Accelerating Adult Clear Aligner Therapy Using Leading-Edge Technology With Remote Oversight

The demand for clear aligner orthodontic treatment continues to rise, and data shows this trend is primarily driven by adults.¹ The adult patient introduces several challenges not present when treating a growing adolescent. One notable challenge is that there is no more opportunity to guide skeletal development critical for achieving class I molar relationship and proper occlusion.^2,3 Also, as adults age, bone metabolism slows down,^4,5 resulting in teeth that do not move as easily or predictably. Adults often present with restorative work, such as crowns, that makes composite attachment placement more difficult as well as implants and ankylosed teeth, which make certain movements more challenging.^6,7

Moreover, many adults are employed in careers that require frequent travel, which can interfere with scheduling and attending routine office visits necessary with traditional orthodontic therapy. In general, the often frenetic pace of contemporary work and recreation places a significant value on the concept of "time" when treating adult orthodontic patients. With remote-monitored clear aligner treatment, the dental profession has an opportunity to redeem that valuable time for patients and practitioners. The following case report demonstrates how advancements in remote monitoring allow oversight and clinical supervision of an adult orthodontic patient during treatment virtually.

Case Report

A 37-year-old male patient presented as a new patient to the author's practice wanting to "fix my crooked [crowded] teeth." The patient's medical history showed no concerns or contraindications for dental treatment. Upon evaluation, the patient had previously had all third molars extracted. Periodontal conditions were within normal limits with no bleeding on probing and no pockets in excess of 3 mm. X-rays showed healthy roots with a ceramic crown (non-radiopaque) that included a buildup on tooth No. 18 and a potential periapical lesion on tooth No. 19. The patient was Angle class I with narrow V-shaped arches and a high vaulted palate. The temporomandibular joint (TMJ) complex was healthy with no signs or symptoms of TMJ dysfunction. The patient's primary concern was the moderate to severe crowding (>6 mm) of the mandible resulting in super-eruption of teeth Nos. 24 and 25, incisal wear on teeth Nos. 8, 9, 23, 24, and 25, and uneven gingival heights on mandibular anterior teeth.

Treatment Plan

The author discussed multiple treatment options with the patient, including orthodontic correction and/or restorative treatment. Veneers and/or crowns were presented as possibilities to ensure full disclosure and consent, as some patients' timelines or preferences may dictate accelerated treatment options. A restorative-only strategy was highly discouraged, as it would have required inappropriate gross reduction of healthy tooth structure and created potential future endodontic concerns. Clear aligner therapy with minor restorative treatment was presented as the most conservative approach. Treatment goals included leveling, aligning, and addressing both crowded V-shaped arches while attempting to minimize the need for interproximal tooth reduction (IPR).

Initially, the patient declined orthodontic treatment due to his inability to schedule and attend routine orthodontic visits because of his frequent impromptu work-related travel. When presented with the opportunity to have his treatment monitored remotely through the use of a scanbox device and his mobile phone he decided to move forward with treatment. The clear aligner system chosen was CandidPro (Candid Care Co., candidco.com) based on its ability to provide continuous clinical oversight while eliminating the need for routine in-person aligner check visits. After reviewing the monitoring system and downloading the app (ProMonitoring app, Candid Care Co.) to his phone, the patient signed consent to treatment as long as the plan did not include any composite attachments. Orthodontic records were taken, including panoramic and full-mouth radiographs, a digital intraoral scan, and a standard orthodontic array of extra- and intraoral photographs (Figure 1 through Figure 6).

The clinician submitted the case through the mobile device clinician portal (Doctor Dashboard, Candid Care Co.) with treatment instructions to address the chief concern of crowding using a 7-day aligner exchange interval. A digital treatment plan (ProCheck, Candid Care Co.) was formulated, reviewed, and refined by a US-based orthodontic specialist and sent back to the clinician. Expansive movement of all teeth in both arches was planned to maximize arch length and address the crowding without the need for IPR and with no attachments as requested. Three degrees of mesial root torque spread out over the full aligner series was planned for tooth No. 9. The mandibular anterior teeth (Nos. 24 and 25) included 4 mm of programmed relative and absolute intrusion with the transverse movements. A total of 36 aligners were approved by the treating clinician and manufactured, and the initial aligners delivery box was shipped to the practice address within 2 weeks.

Treatment Delivery

The standard operating procedure for initial aligner delivery was performed. This included review of the digital orthodontic treatment plan, the patient-facing app, care and use of the aligners including insertion and removal, as well as explaining resource locations and answering patient questions. The patient left the delivery appointment with an appropriately esthetic initial treatment box containing all numbered aligners, a scanbox device, cheek retractors, an aligner seating tool, a travel case, and whitening foam. The initial delivery of the aligners exhibited excellent fit and esthetics using the patient home monitoring scanbox device (Scan Box, Candid Care Co.) (Figure 7 and Figure 8).

At aligner stage 3 the patient notified the clinician through the monitoring app that his employer was transferring him to Texas. The clinician presented the patient the option to either transfer his case to a qualified doctor in Texas or continue having the clinician monitor his treatment remotely. The patient elected to continue treatment under the same doctor. Note that remote monitoring eliminates the need for multiple evaluation and adjustment visits.

At aligner stage 8, the patient submitted his first scan remotely from Texas. Aligner tracking, hygiene, and compliance indicated "No Issues Detected," and the patient received a prompt through the app to proceed forward to the next set of aligners (Figure 9). Over the ensuing weeks, the patient continued to demonstrate excellent aligner wear, hygiene, and scan compliance with remote clinician oversight of each aligner stage.

At aligner stage 27, the patient performed and submitted a remote scan again using the scanbox device and patient app. The remote monitoring system's artificial intelligence (AI) detected aligner lag during the programmed rotation of tooth No. 22 and buccal translation of tooth No. 21. Based on the protocol prescribed, this deviation from planned movement triggered a "No-Go" in which the patient was instructed, via a push message to his mobile device, to continue another week in the same aligner. This in-app communication included prescribed reminders of daily wear requirements and aligner seating tool use (Movemints, dentalmovemints.com) on the specific teeth not tracking to plan. The patient's record in the clinician's monitoring portal was also updated to include this communication.

The following week the patient received a second "No-Go" message and, therefore, continued in aligner 27 for a third week. On the third scan in as many weeks, the challenging movement was detected to have fully expressed and the patient was notified to advance to aligner 28 per the prescribed protocol. Aligner stages 28 through 31 tracked to plan with the patient continuing to demonstrate excellent compliance and tracking.

At aligner stages 32 and 33 the monitoring system detected aligner lag again. On both stages, the patient received two consecutive "No-Go" messages resulting in a total of 21 days in each aligner to allow time for tooth movement to catch up with planned movement.

At aligner 34, three consecutive "No-Gos" occurred (Figure 10). Per the prescribed protocol, the clinician automatically received an email and portal dashboard notification, requiring intervention. The clinician elected to order a refinement from the most recent remote monitoring scan taken by the patient. The photo scan was converted to an .STL file through a Smart STL process (DentalMonitoring, dentalmonitoring.com) (Figure 11), and a new set of aligners was manufactured and shipped directly to the patient with no office visit required.

Based on the first series of aligners achieving the majority of the planned expansion and arch form development, the refinement series consisted of a total of 10 aligners. The maxillary arch plan included a minor rotation of tooth No. 7. The mandibular arch was planned to maximize dentoalveolar expansion within the defined limits of the buccal cortical boundary to facilitate better occlusal interdigitation. The objective was to resolve the minimal remaining crowding, complete the anterior intrusion, and derotate mandibular bicuspids Nos. 20, 21, and 28 as much as possible based on patient preference for no attachments. Full derotation of lower bicuspids was not programmed to avoid creating any open contact areas.

The refinement series tracked smoothly with scan compliance, tracking, and hygiene all demonstrating an engaged and motivated patient. Final results showed the patient's chief concern of "fixing" his "crooked teeth" to be fully resolved (Figure 12 through Figure 16). Ideally, the mandibular bicuspids could have been derotated a few more degrees, but the patient was satisfied with the results and a temporary retainer was fabricated from a ProMonitoring scan (ProMonitoring, promonitoring.ai) using the Smart STL method eliminating any need for patient travel. A final visit for equilibration, minor restorative treatment, enameloplasty, and a permanent retainer scan was scheduled for the patient's next return visit to the clinician's office (in Washington D.C.)

Discussion

Almost any clear aligner case can develop a tracking issue, particularly one with 30 or more aligners in the series.⁸ The author typically sees four causes associated with a lack of clear aligner tracking: patient compliance, space, force, and/or science (the latter of which is described in the paragraph below). From a compliance standpoint, clinicians rely on their patient engaging in the treatment and following treatment instructions. In the present case, patient engagement was verified at each aligner stage using AI-powered monitoring (ProMonitoring) to evaluate compliance with scheduled scans and oral hygiene instructions. Secondly, from a space perspective, digital treatment plans must be free from any programmed tooth collisions.⁹ Considering this treatment plan had been meticulously reviewed by an orthodontist clear aligner specialist, tooth collision (or lack of room to align) was likely not the culprit. Thirdly, from a force perspective, the aligner material used must be able to deliver light continuous forces for the duration of the planned movement.¹⁰ The patient in this case was being treated with Zendura^™ FLX (Bay Materials LLC, zenduradental.com). This advanced aligner material is particularly suited for a remote-monitored patient occasionally experiencing extended wear intervals, allowing time for the movement to fully express as programmed.^11,12

Finally, the science of predictable tooth movement is simultaneously dependent on both a biomechanically sound treatment plan as well as a biological response within normal parameters to the programmed mechanical forces.¹⁰ Whether a tracking issue is related to lack of compliance, challenging movements, biological response, or a combination of factors, proceeding ahead without full expression of tooth movement will result in aligner misfit. In non-monitored aligner cases, proceeding forward can completely derail the case. This patient did not continue to arbitrarily advance aligners and thereby compound the aligner lag until the next scheduled aligner check visit. Had he done so, it would have resulted in lost time and significant discomfort and dampened his motivation. The ProMonitoring app helped keep the patient on track by "holding" him in an aligner for any extended time needed to ensure that all tooth movements were expressed. A single mid-course correction or unnecessary refinement may add months to a typical aligner case.

The monitoring system used in this case allowed clinician oversight of patient engagement, oral tissues, and aligner tracking at every aligner stage. The clinician was able to message the patient through the app when needed without scheduling or waiting for an office visit. This new paradigm in orthodontic treatment oversight has demonstrated effectiveness with no statistical difference in treatment outcomes as compared with traditional in-office oversight.⁹

Conclusion

This case demonstrates the effective use of modern advancements in clear aligner technology enabling the delivery of excellent results to an adult patient in a remotely monitored environment in only three office visits and with continuous 24/7 clinical oversight.

Disclosure

Dr. Gray is Chief Clinical Officer of CandidPro Clear Aligner Company. He has no other conflicts. This article was commercially supported by CandidPro.

About the Author

Brian Gray, DDS
Private Practice, Washington, D.C.; Dr. Gray has trained 31,000+ doctors over 25 years of teaching clear aligner therapy.

Figures and Images

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11

Figure 12

Figure 13

Figure 14

Figure 15

Figure 16

Figure 1

Fig 1 through Fig 6. Initial records included an array of pretreatment extra- and intraoral photographs, including extraoral view of patient’s smile (Fig 1).

Figure 2

Fig 1 through Fig 6. Initial records included an array of pretreatment extra- and intraoral photographs: including maxillary occlusal view (Fig 2).

Figure 3

Fig 1 through Fig 6. Initial records included an array of pretreatment extra- and intraoral photographs, including mandibular occlusal view (Fig 3).

Figure 4

Fig 1 through Fig 6. Initial records included an array of pretreatment extra- and intraoral photographs, including right lateral view (Fig 4).

Figure 5

Fig 1 through Fig 6. Initial records included an array of pretreatment extra- and intraoral photographs, including frontal view (Fig 5).

Figure 6

Fig 1 through Fig 6. Initial records included an array of pretreatment extra- and intraoral photographs, including left lateral view (Fig 6.

Figure 7

Fig 7. Remote scan box with smart phone showing excellent aligner fit.

Figure 8

Fig 8. Pretreatment extraoral frontal view.

Figure 9

Fig 9. Remote monitoring doctor dashboard revealing delivery and compliance schedule. Photograph and video images (not shown) are also part of the dashboard.

Figure 10

Fig 10. Remote oversight of tracking issue detected at stage 34 of 39.

Figure 11

Fig 11. The Smart STL process eliminates office visits and intraoral scanning.

Figure 12

Fig 12 through Fig 16. Final results, demonstrating beautiful form and function in two office visits: maxillary occlusal view (Fig 12); mandibular occlusal view (Fig 13); right lateral view (Fig 14); frontal view (Fig 15); left lateral view (Fig 16).

Figure 13

Fig 12 through Fig 16. Final results, demonstrating beautiful form and function in two office visits: maxillary occlusal view (Fig 12); mandibular occlusal view (Fig 13); right lateral view (Fig 14); frontal view (Fig 15); left lateral view (Fig 16).

Figure 14

Fig 12 through Fig 16. Final results, demonstrating beautiful form and function in two office visits: maxillary occlusal view (Fig 12); mandibular occlusal view (Fig 13); right lateral view (Fig 14); frontal view (Fig 15); left lateral view (Fig 16).

Figure 15

Fig 12 through Fig 16. Final results, demonstrating beautiful form and function in two office visits: maxillary occlusal view (Fig 12); mandibular occlusal view (Fig 13); right lateral view (Fig 14); frontal view (Fig 15); left lateral view (Fig 16).

Figure 16

Fig 12 through Fig 16. Final results, demonstrating beautiful form and function in two office visits: maxillary occlusal view (Fig 12); mandibular occlusal view (Fig 13); right lateral view (Fig 14); frontal view (Fig 15); left lateral view (Fig 16).