2176 9451 Dpjo 25 04 85

special article
Space closure using aligners

Ricardo Martins Machado1
DOI: https://doi.org/10.1590/2177-6709.25.4.085-100.sar
Introduction: Due to the search for more aesthetic and comfortable alternatives to perform orthodontic treatments and
to the great technological development, orthodontic aligners have assumed great importance. More and more complex
treatments have been carried out with these appliances without, however, having all aspects involved in their use being
studied in depth. Its biomechanical planning requires different approaches than those used in fixed orthodontics, as the
force systems involved in movements, responses and side effects are distinct, and the professional must be prepared when
opting for the technique. Objective: The objective of this article is to perform an evaluation of the force systems created
on the space closure with aligners, its characteristics, and problems, as well as make some suggestions to overcome the
difficulties inherent to its use. Conclusion: Space closure with aligners is possible, but depends on the correct selec-
tion of the patient, in addition to requiring the proper planning of the applied forces. The use of auxiliary resources and
overcorrections to address the deficiencies of the aligner systems should always be considered. Digital planning should be
used as a map of the force systems that will be applied, and not just as a marketing tool, keeping in mind that determin-
ing the objectives and the way to achieve them is the responsibility of the orthodontist, and that treatment plans must be
individualized for each situation, following appropriate biomechanical precepts.
Keywords: Esthetic aligners. Invisalign. Removable orthodontic appliances. Clear dental appliances.
Introdução: Devido à busca por alternativas mais estéticas e confortáveis para realizar tratamentos ortodônticos e ao grande
desenvolvimento tecnológico, os alinhadores ortodônticos assumiram uma grande importância. Tratamentos cada vez mais
complexos vêm sendo realizados com esses dispositivos sem que, no entanto, sejam estudados em profundidade todos os as-
pectos envolvidos na sua utilização. Seu planejamento biomecânico requer abordagens diferentes da Ortodontia fixa, pois os
sistemas de forças envolvidos nas movimentações, respostas e efeitos colaterais são distintos, e o profissional deve estar preparado
ao optar por essa técnica. Objetivo: O objetivo deste artigo é fazer uma avaliação dos sistemas de forças envolvidos no fecha-
mento de espaços com alinhadores, suas características e problemas, bem como apresentar algumas sugestões para contornar as
dificuldades decorrentes de seu uso. Conclusão: O fechamento de espaços com alinhadores é possível, mas depende da correta
seleção do paciente, além de exigir o adequado planejamento das forças aplicadas. O uso de recursos auxiliares e sobrecorreções
para suprir as deficiências dos sistemas de alinhadores deve ser sempre considerado. O planejamento digital deve ser usado
como um mapa dos sistemas de forças que serão aplicados, e não apenas como ferramenta de marketing, tendo em mente que a
determinação dos objetivos e da maneira de atingi-los é de responsabilidade do ortodontista e que os planejamentos devem ser
individualizados para cada situação, seguindo preceitos biomecânicos adequados.
Palavras-chave: Alinhadores estéticos. Invisalign. Aparelhos ortodônticos removíveis. Alinhadores transparentes.
1
Universidade Federal do Rio de Janeiro (Rio de Janeiro/RJ, Brazil). » Patients displayed in this article previously approved the use of their facial and in-
traoral photographs.
How to cite: Machado RM. Space closure using aligners. Dental Press J Or-
thod. 2020 July-Aug;25(4):85-100.
Submitted: July 22, 2020 - Revised and accepted: August 02, 2020 DOI: https://doi.org/10.1590/2177-6709.25.4.085-100.sar
» The author reports no commercial, proprietary or financial interest in the products Contact address: Ricardo Machado
or companies described in this article. E-mail: [email protected]
© 2020 Dental Press Journal of Orthodontics 85 Dental Press J Orthod. 2020 July-Aug;25(4):85-100
special article Space closure using aligners
INTRODUCTION market, presented as the best solution for all problems.

Since the first vacuum-formed plastic orthodontic Seduced by all the positive aspects massively highlight-
device for dental alignment was proposed by Kesling1, ed by the developers, professionals start to try to use it
there has been a great advance in the possibilities of in some situations. The use of the technology experi-
treatment with this type of appliance. This idea was put ments a dramatic increase. The manufacturing com-
aside for many years until it was taken up by Ponitz,2 in panies then start to invest more and more in publicity.
1971, who suggested the making of vacuum appliances Stories of success begin to pop up on various fronts,
made with transparent material on plaster setups. Fol- making other professionals feel confident to start using
lowing a similar principle, McNamara et al3 suggested it as well, hoping for wonderful outcomes. This phase
tooth movement with aligners; and in 1993, Sheridan4 is called peak of inflated expectations. As it is used
introduced the Essix system, which uses the technique without thorough evaluation and concern to the re-
of bubbles and bumps, created with reliefs and defor- strictions in its indications of use, failures to achieve
mations in the models, made with heated special pliers, the expected outcomes begin to be reported, because
to move teeth. In 1997, two Stanford MBA students, the limits of the technique are still uncertain. At this
without any dental training, applied their knowledge point, a feeling of disillusionment begins to set in and
in computing and CAD/CAM technology to develop many abandon its use. It is called the through of disil-
and launch the Invisalign system of aligners based on lusionment. We then enter a slope of enlightenment,
digital technology. Since its creation, encouraged by the where more scientific studies and trials are made,
success of Invisalign and the easier access to this kind bringing better understanding of the actual pros and
of technology, several other aligner systems have been cons of the technique and, after a period of maturation
created by other companies, using the same principle. where the limitations and methods are better defined,
The current market presents a huge variety of digitally the technique finds its place among the tools of regular
produced systems, with great appeal to the public. use by the professionals, who will be able to use it in all
Plastic aligners have great esthetic advantage, more its potential on the proper situations, taking the neces-
comfort and make it a lot easier to keep a good oral sary precautions to achieve the best results. This phase
hygiene, when compared with traditional fixed appli- is called the plateau of productivity. This sequence of
ances,5 with ease of feeding and chewing being the most events is known as the Gartner’s Hype Cycle for new
highlighted qualities referred on studies6. Previously technologies,9 as shown in Figure 1.
having it’s use restricted to simple movements to align This situation can be verified in the adoption of
incisors, the plastic aligners have been broadening its the aligners. The planning of orthodontic movements
applications and are now used to treat almost every kind must be made differently if compared to fixed ortho-
of malocclusion, including more complex cases, with
good esthetic and functional outcomes.7 In many situa-
tions aligners can be as efficient as fixed appliances, even
though in other cases they still lack some improvement,
Peak of Inflated
like torque control or proper occlusal settlement.8 Expectations
In this scene, the companies that produce those align-

ers have been funding lots of researches for development
Plateau
of new materials and technologies to supply the ortho- of productivity
Expectations
dontists needs. The great evolution of software for digital

Slope of
planning allied with the use of artificial intelligence and enlightenment
more sophisticated algorithms allow more precise and

predictable outcomes of the force systems generated by
these devices, proposing more reliable solutions. Innovation
trigger
Through of
disillusionment
In the introduction of any new technology a se-
Time
quence of events can be observed. The first phase is
the trigger of the innovation, when it appears on the Figure 1 - Gartner’s Hype Cycle for new technologies.6
Machado RM special article
dontics, and the desired and undesired effects of each with aligners the orthodontist has the activations pre-
force system will depend on other factors. Because of determined and all the compensations must be created
that, orthodontists with traditional background on before the movements are made. For this reason, it is
fixed orthodontics will need to adapt, if they wish to of utmost importance a deep knowledge of the system
use the aligners and achieve results as they are used to. characteristics and all the effects of intended biome-
Thus, the objective of this article is to perform an eval- chanics. Just as individualization on bracket placement
uation of the force systems created on the space closure and archwire sequences on fixed appliances accord-
with aligners, its characteristics and problems, as well ing to the objectives of the treatment, with aligners
as make some suggestions to overcome the difficulties we should be able to clearly visualize where to go and
inherent to its use. how to fulfil each step of the treatment to correctly
prescribe the movements and auxiliary resources, as
PATIENT SELECTION AND ORTHODONTIST’S well as understand the limitations of each case. That is
ATTITUDE why, despite the smaller chair time during treatment,
Regardless of all the high technology behind clear the time invested in the construction of the treatment
aligners, the most important criteria for success in the plan tends to be bigger and demands great dedication.
treatments falls under properly choosing the patient.
Some clinical conditions, such as dental open bites, are DIGITAL SETUPS
more prone to be successfully treated by aligners, while The first dental movements made with aligners were
others, like deep bites associated to spacing, are more made over physical setups or small sequential modifi-
difficult to be treated, but above it all, the orthodontist cations on plaster models, on which the aligners were
must be able to correctly evaluate the psychological and vacuum-pressed. Activations could be done also by spe-
behavioral profile of the patient, to identify the degree of cial pliers causing controlled deformations on the align-
engagement and motivation. Since aligners are remov- ers to create pressure points that would cause the desired
able appliances that need to be worn continuously, the tooth movement. These techniques were very laborious
treatment demands high level of discipline and com- and had very little precision. The introduction of the
mitment to achieve the objectives planned. A perfect digital models in orthodontics had a very important role
biomechanical planning and all the technology involved in the dissemination of aligners. Its precision and accu-
have no use if the patient is not adherent to the treat- racy have already been proved in many studies10,11 and
ment and the aligners are not correctly used. It is very they have been gradually replacing the plaster models.
important that the communication between orthodon- Every treatment with aligners is based on movements
tist and patient is extremely clear, and that the patient made on digital models, that are divided in stages by
take co-responsibility for the success of the treatment, software specifically designed for that purpose, which is
considering that a great part of it depends on that. made respecting the physical properties of the material
Maybe this last issue is the main reason why ortho- of which the aligner is made and the limits of the bio-
dontist resist to adopt aligners as a routine option, since logical response of the patient. The planning systems are
they consider having less control over the results, when becoming more sophisticated, using the huge databases
compared to fixed appliances, which depend less of pa- created by the initial, follow-up and final records of mil-
tient collaboration. lions of cases treated worldwide, to harvest lots of in-
The orthodontist who decides to start using align- formation over the tooth movements and the responses
ers must have in mind that, besides having to motivate to activations. Using artificial intelligence and machine
the patient during the treatment, will have to take a learning resources to treat these data and feed the al-
more proactive attitude while planning, anticipating gorithms, the treatment plans provided are becoming
the possible side effects of the chosen biomechan- more and more reliable.
ics. Differently from the fixed appliances, where they One of the greatest indirect advantages of the mas-
have the possibility to be more reactive and correct it sification of the aligners use was the dissemination of the
at each visit, depending on the response to activations use of digital setups, imperative for their manufacturing.
made on the previous appointment, on the treatment Different companies have different resources to perform
aligners staging, and this interface became a high value predictability of the planned movements, because the
asset for the elaboration of the treatment plans and to undesired side effects will be reduced.
the communication between the orthodontist and the
team that produces the aligners, but it can also be used, PECULIARITIES OF ALIGNER’S BIOMECHANICS
in many situations, for fixed orthodontics cases, like When putting together a force system for any orth-
in trays for indirect bonding, for instance. The digital odontic movement, a series of factors have to be taken
setups can also be used to improve the communication into consideration, such as: the point of application of the
between orthodontist and patient, providing a way to force, the force magnitude, the velocity of application, it’s
visualize the treatment goals and its phases. But is this direction, the duration and the effects it will produce.12
last one the best way to face these softwares? As simply These questions are only some that can emerge and,
a marketing and communication tool? When ortho- when treating with aligners, will have different answers, if
dontists take that attitude, one of the greatest powers compared to fixed appliances. An example of these differ-
of this tool, which is the possibility of constructing a ences can be seen in Figure 2, which shows a clinical case
detailed map of all the force system that will be applied considered simple for treatment with fixed orthodontics,
during the treatment and the anticipation of its effects, but that represents a great challenge to be treated with
gets set aside. The possibility to test in a practical and aligners. The patient had good posterior intercuspation,
fast way many treatment possibilities, makes the ortho- diastemas in the maxillary arch, accentuated overbite and
dontist's choice of one treatment plan over another more good incisors exposure. The vertical control and control
conscious and safe. This visual analysis, paired with the of buccal-lingual inclination of the incisors during the
clinical experience of the clinician, allows the planning anterior retraction for space closure is a great difficulty of
of overcorrections, preparations, compensations, and the aligner systems, as it causes lingual inclination of the
anticipation of undesired side effects that may occur incisors, increasing the overbite and incisors exposure.
as consequence of the chosen biomechanics. By doing In a case like this, the results of treatment with aligners
this, the digital treatment plan helps to minimize errors would be very unfavorable and difficult to achieve.
and makes treatments safer and more precise.
By the deep knowledge of the biomechanics char- POINT OF APPLICATION
acteristics of the appliances and dental movements, Instead of having the force applied to one single point
one can use many resources to achieve the planned at the buccal or lingual surface of the tooth, as happens
outcomes. The results observed on aligner treatments in fixed orthodontics, there will be a plastic surface em-
are improving by their association with auxiliary tools, bracing the whole crown of the tooth (Fig 3).
like elastics, skeletal anchorage, binaries with elastics The decomposition of forces must take into consid-
and even the use of brackets in some segments of the eration all the tooth surface to determine the resulting
arch — the hybrid treatments. By correctly using these force on that system. Besides that, on fixed appliances,
tools, it is possible to overcome some of the limitations the wire is tied to the brackets and delivers the forces
of the aligners and, according to the learning curve of by pulling or pushing the teeth (Fig 3B), while with
each professional, optimize treatments and improve the aligners, where there is no fixed structure connecting
Figure 2 - Patient presenting diastemas with exaggerated overbite, good posterior intercuspation and good incisors exposure - example of a situation
where what seems to be simple for planning with fixed orthodontics becomes a complex treatment to be performed with aligners, due to the limitations
of the technique.
A B C
Figure 3 - Examples of the difference in points of application of forces between fixed appliances and plastic aligners during intrusion (A). The brackets and wires
system push teeth toward the wire (B) while aligners pull the teeth to the desired direction (C).
the appliance and the tooth, the force is delivered by the manufacturer, tooth anatomy and movement intended,
contact of the plastic with the crown, pulling it to the as can be observed on Figures 4 and 5.
desired position (Fig 3C). The proper selection of attachments may be a deci-
Because of this characteristics, dental crown anatomy sive factor on the predictability of the treatment, even
will have a great impact on the response of some tooth though they are not indispensable to tooth movements
movements. Teeth with short expulsive crown shapes, in most cases. When the orthodontist chooses a specific
that will have less contact surface with the plastic of the aligner system, the algorithms in the software will have
aligner, tend to express some movements less efficient- internally predefined parameters to, depending on the
ly than teeth with larger and more retentive crowns. movements needed, suggest which attachments to use.
For this reason extrusion is an example of a unfavorable However, this selection won’t always follow the same
movement to be done with aligners,13 while it’s a simple line of thought of the orthodontist, and may prioritize
movement to be done with fixed appliances. Canines ro- different movements from the ones desired to fulfill the
tation is another movement with very low predictability planned outcomes. Those algorithms work according
and must be overcorrected.14 to a certain hierarchy of movements that will determine
the automatic selection of attachments, normally based
ATTACHMENTS on the difficulty of the movement, and not necessarily
The attachments are resources normally used to ad- on its relevance to the final results. If the case have, for
dress this issue. By adding little amounts of composite instance, a tooth that needs to be intruded and rotat-
with specific designs to specific areas of the crown, the ed, the software will prioritize the rotation and suggest
dental anatomy is changed to improve the retainability one attachment that favors the rotation over the intru-
and create more favorable shapes and contact surfaces to sion, because the rotation is a more difficult movement
deliver the desired force. This allows that these move-
ments occur more effectively and predictably. Unfortu-
nately, these resources present a negative effect as well,
especially in the anterior region of the dental arch, be-
cause it worsens the esthetics of the aligners, making it
even worse than the esthetics of ceramic appliances.15
Attachments may function as retention auxiliaries,
whose only intention is to keep the aligner in place,
or they can be active, when the contact of the plastic
with the tooth surface is supposed to deliver some force
component in a specific direction. In this case, attach-
ments have plan surfaces positioned in a way that favors
the application of these forces. There is a great variety Figure 4 - Examples of attachments: (A) passive or retention, (B) optimized for
extrusion and (C) optimized for root inclination. The optimized attachments
of shapes and sizes of attachments, according to each show active surfaces for specific movements.
Figure 5 - Examples of the great variety of attachments and resources existing in the Invisalign system, which is only one of the many options available.16
to be done, even if the intrusion is a more important an excellent adaptation to be able to work properly.
movement to the resolution of the main problem. This There are variations in size and shape of the attachment
is where the orthodontist must have an active role in templates and the active aligners, so replacement of lost
the attachment selection, and not only passively accept attachments or adjustments to worn out ones must be
the suggestions given by the system. In many cases, it is done on the provided template, never directly on the
necessary to change the attachments’ design, dimension aligner. Another factor that should be taken into con-
and position to get the desired force system. sideration is the proper attachment placement tech-
Another factor that must be taken into consideration nique. The templates must be perfectly adapted, and the
is the attachment building technique. They must have slots completely filled with the composite of choice, but
without excesses, because it could prevent the aligner to sumed with anterior retraction; reciprocating move-
seat properly in place, affecting the movement intended. ment, where part of the space will be used for anterior
If there are excesses, it is important that they are com- retraction and the rest of it will be closed by mesial
pletely removed before placing the aligners on. movement of the posterior segment; or it can be closed
mostly with mesial movement of posterior teeth with-
TREATING CASES WITH EXTRACTIONS out any anterior retraction, just by solving some anterior
The boundaries of aligners treatments without teeth crowding, for example. On the next paragraphs, we will
extractions is similar to the ones with fixed orthodon- analyze the first and second situations.
tics. Severe crowding over 6 millimeters will probably
cause great incisors protrusion and need significative 1 – CASES OF MAXIMUM ANCHORAGE CONTROL
expansion of the dental arches,17 which may compro- On the situations where the space closure must be
mise the stability of the results as well as the patient’s done exclusively by retraction of anterior teeth, the cli-
periodontal health in the long run. In these cases, it may nician must take extra care. The anchorage control must
be recommended to work with teeth extractions, nor- be planned thoroughly and the use of resources such as
mally first premolars, which can be challenging when miniplates or mini-screws should be taken into consid-
the clinician decides to work with aligners.18 Other ex- eration as a valuable ally. They would help not only in
amples of cases that will have to deal with space closure the sagittal direction, but also help control the vertical
are the ones with other extractions and surgically assist- movements. If the clinician chooses not to use those re-
ed palatal expansion (SARPE), where a great diastema is sources, he should be even more careful.
formed on the anterior portion of the upper arch. The elastic properties of clear aligners, similar to what
It is very common to find in the literature case reports would happen if, with fixed appliances, anterior retraction
of successful cases of extractions where premolars have was made on a thin NiTi wire, would generate a clock-
been removed because of severe crowding, but these cas- wise force moment in the anterior part of the arch that
es normally do not need much retraction of the anterior would cause the incisors to incline lingually and extrude.
teeth. The torque control of the incisors during retraction, The middle part of the arch will receive intrusive force
a critical point in any retraction, even with fixed applianc- components, that will tend to intrude the premolar and
es, poses an even tougher challenge in aligner therapy, due cause the molar to tip forward, due to the counterclock-
to its physical properties. Some studies suggested that side wise force moment in the posterior segment. With the
effects of treatments with extractions, more specifically extrusion of the incisors, interferences are created in the
the tipping of the teeth adjacent to the extraction spaces, anterior area and a posterior open bite is set.
should be corrected with fixed appliances, what would This happen because the plastic will suffer horizontal
considerably increase treatment time.19 deformation, like a wooden arch whose tips are connected
When considering space closure, some possibilities by a wire and pulled towards each other. The fact that, due
may be present. The space closure can happen with: to the extraction site, the aligner has a segment without
maximum anchorage, where all the space will be con- tooth support, it is even more prone to deflect (Fig 6).
Figure 6 - Force diagram showing the bow effect

that happens during the anterior segment retraction
with aligners, causing intrusion of the middle seg-
ment, mesial inclination of molars and extrusion with
lingual tipping of the incisors.
As a result, if no action is taken to prevent that, the b) Use movement staging

overbite will increase considerably while an open bite is To gain more control over movements, they can
settled in the posterior segment. When working with be divided in stages. For instance, we can alternate
fixed appliances, similar effects could happen if the re- between periods of distalization and periods of pure
traction was made with thin elastic wires, and the solu- extrusion of the canines during retraction, reducing
tion would be working with thicker and stiffer wires, to the chance of tracking loss, because in between dis-
avoid the bow arch effect. With aligners, the material is tal movements the aligner has the time to express the
the same through all the phases of treatment, so the only movement of crown versus root tipping and the vertical
resource left to be used is to vary the way the forces are control. Taking a closer look at this approach, it mim-
applied. With this in mind, the dentist can use some of ics what happens in the interaction between the wire
the following strategies: and the brackets during sliding mechanics. At first, a
crown inclination will occur and the binding gener-
a) Add curves of Spee ated between the bracket and the wire will generate
Following the same logic used in fixed appliances, one a force moment that will move the root and upright
can plan a reverse curve of Spee on the lower arch and an the canine during the time between activations. Af-
exaggerated curve of Spee on the upper arch during the ter a period of this alternation of movements, a bodily
movements. This is made by planning some extrusion of movement will be achieved. With aligners there will
the premolars, buccal inclination of the incisors’ crowns, be first a tendency to tooth inclination and intrusion
intrusion of the incisors and distal tipping of the molars. (due to the bow arch effect), but if this tooth is kept
Since an intrusive effect will be planned for the inci- without a new activation for distalization, it will have
sors, the aligners won’t tend to lose tracking on those time to express only the compensatory movement,
teeth; but in the middle section of the arch, where the while another segment of the arch can be activated.
premolars will be the vertical anchorage for the incisors The inclination control can also benefit from this
movement, the extrusive force might cause the aligners alternation of active and inactive distalization periods.
to lose grip, damaging the expected results. Besides be- For that to happen, the use of attachments on the teeth
ing the anchorage, some extra extrusion will be planned to be moved will be of great help. When the first incli-
to compensate the bow arch effect. As discussed before, nation occurs, the little unsettling that will take place
extrusive movements are difficult to be made by aligners inside the attachments pod of the aligner will create
because of the expulsive shape of teeth crowns. On this additional forces that will tend to upright the tooth.
matter, the use of attachments can considerably improve Some companies provide active attachments with this
the retention of the aligners and allow the movements to goal, but a similar effect can be achieved with regular at-
happen as planned. tachments properly placed, since the elastic force of the
Another possibility that can be adopted alone or com- aligner mismatch will make it active.
bined with the attachments, depending on the tooth anat- As said before, between the activations for distaliza-
omy, is to use a vertical intermaxillary elastic on the maxil- tion of the canines, we can work on other aspects of the
lary and mandibular premolar, over bonded buttons. The movements in a synergistic way, like the intrusion and
extrusive force of the elastics will oppose the intrusive force the buccal inclination of the incisors, the distal inclina-
generated by the aligner, balancing the force system and tion of the molars, or, if that is the case, the resolution of
keeping the aligner well adapted. Some authors recom- anterior crowding that might be present.
mend the use of bite ramps on the lingual surfaces of the The professional can work dividing all the anterior
maxillary incisors to help the intrusive effect on the man- retraction in periods of canine distalization combined
dibular incisors; but, during anterior retraction, where the with incisors intrusion and protraction, alternated with
lingual inclination of the incisors is already challenging, the partial retraction of the incisors. This approach, depend-
occlusal contact on those bite ramps would generate a force ing on the needs of each case, could be associated with
applied lingually to the center of resistance of the incisors, the use of intermaxillary elastics, which would provide
that would cause a force moment that would make them more control of the undesired effects that may appear,
tip lingually, worsening the final outcome. therefore, making the movements more predictable.
Clinical case 1 After a first set of 43 aligners, the patient, who was
On Figure 7, we can see a patient with severe crowd- extremely compliant with the aligners use, had the ex-
ing on both arches, increased overjet, good molar re- tractions spaces closed, but with open bite on both sides
lationship, mandibular deficiency, and vertical pattern. on the premolars and first molar areas, and very increased
She had a 20% overbite and good periodontal health. overbite (Fig 8). The molars’ crowns were tipped mesi-
The main indication was an orthognathic surgery with ally and, due to the excessive overbite, all lateral move-
mandibular advance, which she refused. It was then de- ments had major interference of the incisors.
cided to perform a compensatory treatment with align- A new set of 37 aligners was planned, for maxillary and
ers — a demand of the patient — with the extraction of mandibular incisors intrusion, premolar extrusion, correc-
the four first premolars. The space would be used for tion of the molars crown tipping, lower midline correction
resolution of the crowding and incisors retraction on both to the right and mesialization of the left posterior man-
maxillary and mandibular arches. Despite the weaker facial dibular segment. Cuts for Class II elastic on the left side
esthetic result, this was the option chosen by the patient, were made on the six last aligners to help lower midline
who refused any orthognathic surgical approach. correction and improve the molars and canines relation.
Figure 7 - Female patient, 24 years of age, with

bimaxillary protrusion and severe crowding on
both arches, who chose to be treated with four
first premolars extraction and compensation
with aligners.
Figure 8 - Situation at the end of the first aligners sequence. The curve of Spee was deepened with incisors extrusion and mesial inclination of molars and pos-
terior open bite.
Figure 9 - Force system planned for the second set

of aligners.
The force system planned for this set is represented on Fig- Going through cephalometric superimpositions, we
ure 9. The patient, although very compliant with the use can verify that there was no mesial movement of the
of the aligners, did not use the elastics as recommended. maxillary posterior segment, but a slight mesial move-
The final result showed good occlusal relations, ment of the mandibular molars. The incisors became
with good root parallelism, 50% overbite, complete more vertical and the mandibular incisors were intruded.
closure of the overjet and complete space closure. De- The compensatory retraction of the maxillary incisors
spite the incisors intrusion did not happen complete- caused a relative extrusion, due the lingual inclination of
ly as planned, the protrusive and lateral movements the crowns, as expected (Fig 11).
guidances were correctly established, as can be veri-
fied in Figure 10. This case showed good finishing C) Use of auxiliary mechanics
parameters and was presented and approved by the The aligners systems alone still need further develop-
Brazilian Board of Orthodontics. ments to treat more complex malocclusions, such as ex-
Figure 10 - Final photographs of the patient, after the second set of aligners.
tractions cases.18 That is why the auxiliary resources are so the mandibular first molars and on the maxillary ca-
important. As an example, we can take the use of skeletal nines during their distal movement can be an excellent
anchorage on cases where you cannot afford to have any alternative to reduce the bow arch effect. The vertical
mesial movement of molars. It would make the outcome component of force generated by the elastic would help
much more predictable. Miniscrews or miniplates would control the tendency of intrusion in the middle section
favor the distalization of the anterior segment without any of the arch. The use of elastics can be started at any point
anchorage loss, having the option of using power arms on during the treatment, but, if it’s present during the dis-
the canines to better control the moment of force created, talization of the canines, we have the advantage of force
and reduce the undesired effects on the anterior segment. component that pulls the tooth towards the aligner,
The use of intermaxillary elastics can also provide making it harder to lose tracking. Similar to what hap-
more control during space closure. On cases where you pens on fixed appliances treatments, the intermaxillary
have a good mandibular arch but extractions are needed elastics can also be used for better anchorage control,
on the maxilla, the use of Class II elastics supported on avoiding mesial movement of the posterior teeth.
Figure 11 - Final panoramic and cephalometric radiographs with superimpositions.
On space closure between teeth with divergent the excessive inclination of the incisors and allowed a
roots, or in the need for uprighting an inclined tooth, more controlled space closure.
the power arms can be an excellent alternative, since As discussed earlier, the virtual setup will allow us
they will balance the moments generated by the align- to analyze the force system step by step and will help us
ers. On Figure 12, a case of space closure after a surgi- draw a clear map of the biomechanics applied to each
cal-assisted rapid palatal expansion (SARPE). One can step of the treatment. On cases with great incisor retrac-
notice that, in spite of the presence of attachments tion, at the end of the planning, the setup will display an
meant to control the root movement, the space closure anterior open bite, with proclined incisors and molars
between the central incisors was happening mainly by with distal tipping. These overcorrections are impor-
mesial inclination of the crowns, causing massive track- tant to be added but, by adding them, the final setup
ing loss of the aligners. In order to revert this situation, won’t be a reflection of the final occlusion planned by
power arms made of stainless steel 0.020-in wires were the orthodontist, which may raise, if the orthodontist
bonded on the lingual surface of the central incisors and decide to show this setup to the patient, some doubts
a cut was made on the aligners. These power arms were and insecurities related to treatment outcomes. If the
divergent and were activated by a chain elastic pulling orthodontist or the patient thinks it is imperative to see
them together. Since the power arms raised above the the final outcome planned, it can be a good solution to
center of resistance of the incisors, it created compensa- create an ideal setup, with the final occlusion planned
tory moments, contrary to the ones created by the align- just to explain to the patient the treatment objectives
ers, who were inclining the teeth mesially. It corrected and promote better communication and understanding.
A B C
D E F
Figure 12 - A) Patient after SARPE, starting treatment with aligners. B) Tracking loss due to excessive me-
sial inclination of the crowns of the incisors. C) Divergent roots. D) Power arms placed to be used along
with the aligners. E) Detail of active power arms. F) Improvement of tracking. G) By the end of the aligner
G set (a new set of aligners was planned then for better finishing).
2 – CASES WITH RECIPROCAL SPACE CLOSURE treatment, it was necessary three aligner sequences.
On cases where some mesialization of the posterior seg- The first set had 51 pairs of aligners, where only verti-
ment simultaneous with the anterior retraction is desirable, cal attachments on canines and premolars were used to
the movements in the sagittal plane work synergistically, avoid crown tipping during the space closure. Since the
meaning that the reciprocal anchorage would tend to favor staging of the movements was not properly done, the
both movements, optimizing the treatment. Even though this side effects discussed earlier were present and intense,
is true, there is also the risk of some of the side effects are po- especially with molars and premolars inclination, deep
tentiated due to the high elasticity of the aligners. bite, extrusion, and lingual inclination of the incisors.
The moment of force created by the mesialization of On the mandibular arch, where there was more ante-
the molars tends to cause intrusion of their mesial cusps, rior retraction, the negative effects on the incisors were
with consequent mesial inclination of the crowns. The ef- more evident. On the maxillary arch, since there was
fect on incisors is also similar to the described earlier for more mesialization of molars to correct the molar rela-
maximum anchorage cases. Being so, the same precau- tionship, their inclination and intrusion was much more
tions can be made with some minor adjustments. noticeable, which can be seen in Figure 13B.
A second sequence of 16 pairs of aligners was ordered
Clinical case 2 to correct these problems and improve the case finish-
Figure 13 displays a case where, specially on the ing. By that time, the provider released optimized at-
maxillary arch, the movement was made in a recipro- tachments for root control, such as the ones described in
cal way. The patient showed Class III molar relation- Figure 4C, for root control, so it was decided to make an
ship, anterior open bite, spacing and biprotrusion, being attempt of correcting the teeth inclinations with these at-
these last two his main complaints (Fig 13A). For the tachments, instead of the vertical ones used in the first set.
Figure 13 - Clinical evolution of a reciprocal space closure, from initial condition (A); to the end of the first set of 51 aligners (B); after the second set of 16 align-
ers (C); and the final result, after the last sequence of 21 aligners.
The results were not satisfactory, as it can be seen on learning curve with aligners and makes it very clear why
Figure 13C, and a third set with 21 pairs of aligners was or- the professional must have a deep knowledge of the align-
dered, but this time with cuts for buttons bonded on the first ers biomechanics, the effects of its resources and be much
molars for intermaxillary elastic use simultaneously with the more proactive during the treatment planning and antici-
aligners. The use of vertical elastics was kept for 45 days after pate the possible side effects of the chosen biomechanics.
the removal of the aligners for better settling of the occlu- If the orthodontist waits until the end of the aligners set to
sion, after which, treatment was finished with proper molar see what went down different from planned, and only then
relationship and better inclination of incisors. The overbite take corrective actions, this will make treatments with high
was still deeper than the ideal, even though there was no in- risks of side effects much longer. If we consider that aligners
terference with lateral or protrusive disocclusion guidances. treatments are completely reliant on patient compliance, in
Figure 14 displays the initial and final cephalometric radio- longer treatments we risk having this cooperation worn out
graphs and superimpositions. and the compliance reduced.
Further improvement of the deep bite would demand a When used only as anchorage units, the molars will al-
new set of aligners, which was refused by the patient, claim- ready tend to incline mesially during retraction of canines and
ing to be completely satisfied with that result, both estheti- incisors. On cases where there will be a force to move molars
cally and functionally. This situation is common during the mesially, this tendency will be even bigger. That is why it is
Figure 14 - Final panoramic, initial and final radiographs, with cephalometric superimpositions.
recommended some distal inclination to the crown of these the cervical buccal surface and on the incisal lingual surface.
molars, similar to the tip-back bends made on anchorage on This force arrangement may cause the aligner to disadapt,
Tweed-Merrifield technique. A six-degree distal inclination so, to avoid that, it is suggested that a retention attachment is
on the molars was suggested to compensate this tendency.20 added at the buccal surface. It will prevent the aligner from
By doing this, notice that the aligner will tend to disadapt on disadapting and the movement will be better expressed.
the mesial cusp, so it is important to increase the retention It has been suggested that several movements need
of the aligner by adding an attachment on the mesial cusp or to be overcorrected when planning aligner treatments,
bonding buttons to use vertical elastics. These precautions considering that not every movement planned will be
will make it more likely that the aligner keeps the tracking expressed to the full extent. Some movements have
the whole movement. been verified to respond from 28 to 56%, with an av-
If we consider the bow arch effects of the aligners and erage of 50% of what was planned.21
the root volume of the molars, the chance of having heavy A good strategy related to overcorrections of some iso-
side effects of lingual inclination and extrusion of the inci- lated movements, such as rotations or intrusions, is to ask
sors is even bigger. To compensate for that, buccal crown that the movement is done normally during the aligner se-
inclination of 10 degrees must be added as an overcorrec- quence, but the overcorrection to be done alone, at the end
tion, as well as a marked intrusion on the incisors.20 In case of the sequence. This way, if the initially planned movement
it is necessary to compensate exclusively by adding buccal is enough and the overcorrection is not needed, the profes-
inclination, if, for some reason it is not possible to add intru- sional can just skip these aligners and interrupt the treatment
sion on incisors, it will be made by adding pressure areas on sooner. It is important though not to skip overcorrections
in movements that tend to be unstable, with high risk of CONCLUSION

relapse, because it will be important for long term stability, It is possible to treat complex cases with aligners. How-
even if the tooth respond well. ever, to obtain good aesthetic and functional results, it is
In cases of reciprocal space closure, the use of other necessary that the orthodontist:
auxiliary resources may be less critical if skeletal anchorage » Select the patient's degree of motivation and collabora-
is associated with the aligners, but can still be very help- tive profile.
ful in the prevention of side effects. Power arms, for ex- » Invest a good amount of time in training, to better un-
ample, can improve dramatically the root control and keep derstand the characteristics of the appliances and the limita-
root parallelism during distalization of the canines and tions of the technique.
mesialization of molars. Despite moments created using » Prepare an individualized planning, having full aware-
vertical or optimized attachments to this end, it was clear ness and control of the forces to be applied; anticipate and
on Figures 9 and 13 that these resources alone may not implement mechanisms to control their side effects.
be enough. Vertical intermaxillary elastics on the medium » Consider the need to use auxiliary resources and over-
segment of the arch on buttons bonded to the teeth may corrections to address deficiencies in the aligner systems.
be a more predictable strategy to reduce the bow arch ef-
fect. The use of box elastics, even after the removal of the Digital planning and the use of aligners can be great allies
aligners, helps improve the final settling of the occlusion, for orthodontists, as well as can induce them to prescribe
compensating these inclination effects on molars with its very unpredictable movements, since the virtual environ-
extrusive force components caused by the elastics. ment does not necessarily reflect in vivo conditions.
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special article

Space closure using aligners

Palavras-chave: Alinhadores estéticos. Invisalign. Aparelhos ortodônticos removíveis. Alinhadores transparentes.

INTRODUCTION market, presented as the best solution for all problems.

In this scene, the companies that produce those align-

dontists needs. The great evolution of software for digital

more sophisticated algorithms allow more precise and

Figure 6 - Force diagram showing the bow effect

As a result, if no action is taken to prevent that, the b) Use movement staging

Figure 7 - Female patient, 24 years of age, with

Figure 9 - Force system planned for the second set

Figure 11 - Final panoramic and cephalometric radiographs with superimpositions.

in movements that tend to be unstable, with high risk of CONCLUSION

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