Case Reports

Orthodontic treatment with a series of vacuum-formed

removable appliancescase report
EDDIE HSIANG-HUA LAI
CHUNG-CHEN JANE YAO
JENNY ZWEI-CHIENG CHANG

YI-JANE CHEN

School of Dentistry, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC.
Division of Orthodontics, Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan, ROC.

This case report focuses on the treatment of a patient with moderate crowding and a maxillary right
lateral incisor crossbite. A treatment plan of moving the teeth through the use of setup models and
vacuum-formed plastic appliances manually fabricated for the tooth movements was proposed to the
patient. Resin attachments were bonded to the labial surface of the maxillary right lateral incisor to
facilitate extrusive movement. A desktop mechanical 3D digitizer was used to measure the amount of
movement of the maxillary and mandibular teeth during each stage. Evidence showed that these plastic
appliances could move a tooth at most 1 mm in each stage, and that resin attachments combined with
elastics could achieve complex extrusion within 3 weeks. J Dent Sci, 3(3)167-173 , 2008
Key words: vacuum-formed orthodontic appliances, resin attachment, 3D digitizer.

The practice of orthodontics is facing new trends.

Adults are increasingly aware of the influence of
appearance in their personal and professional lives1.
Two determinants of receiving orthodontic treatment
for adult patients are esthetics and speed. Lingual
brackets and clear brackets have met the esthetic
demands to a certain extent, but some patients want
even less-visible treatment modalities2.
Teeth movement being conducted without the use
of bands, brackets, or wires was described as early as
1945 by Kesling3, who reported on the use of a
flexible tooth-positioning appliance. Later, Nahoum4
and others5-8 wrote about various types of clear plastic
overlay appliances such as invisible retainers. Minor
tooth movements can be achieved by manually setting
up the teeth on a plaster model and fabricating an

Received: June 16, 2008

Accepted: August 13, 2008
Reprint requests to: Dr. Jenny Zwei-Chieng Chang, Division of Orthodontics, Department of Dentistry, National Taiwan
University Hospital, No.1, Chang-Te Street, Taipei,
Taiwan 10048, ROC.

J Dent Sci 2008Vol 3No 3

overlay appliance for each stage of treatment. The

major limitation of these described methods is
perceived as only relatively small magnitudes of
possible changes because of the technical difficulty of
evenly dividing larger overall movements into small,
precise stages manually9.
Align Technology (Santa Clara, CA, USA),
developed the Invisalign system in 1997. Invisalign
takes the principles of Kesling, Nahoum, and others
using 3-dimensional (3D) digital technologies combined with laboratory techniques to fabricate a series
of custom appliances that are esthetic and removable,
and that can move teeth from beginning to end in a
series of precise movements of 0.15~0.25 mm. The
Invisalign system does have some limitations. Severe
rotations, complex extrusions, and large translations
are less predictable with Invisalign alone and might
require auxiliary treatment9.
The model setup and fabrication of vacuumformed plastic appliances can be done with manual
labor to carry out the planned tooth movement. For
more than 5 years, we have successfully applied this
type of treatment to treat patients who need minor
tooth movement. Herein, we present the treatment of
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E. H.H. Lai, C.C. J. Yao, Y.J. Chen, et al.

an adult patient with moderate anterior tooth crowding

and a palatal crossbite of the upper right lateral
incisor.

CASE PRESENTATION
The patient was a 22-year-old female whose
chief concern was upper and lower anterior tooth
crowding. Her medical history was noncontributory.
She had an overall well-proportioned and balanced
facial pattern with a straight profile (Figure 1). The
maxillary right lateral incisor was in crossbite with the
mandibular right lateral incisor. Both the upper and
lower dental midlines were slightly deviated to the
right side. Crowding was moderate with 4 mm in the
maxillary arch and 6 mm in the mandibular arch. She
had a Class I molar and canine relationship on both
sides. A panoramic radiograph revealed symmetric
condylar heads and no sign of pathology. Fixed
restorations were evident on many posterior teeth.
Treatment was aimed at expanding the upper and
lower arches, especially in the canine and premolar
regions, to relieve anterior crowding. Interproximal
reduction was not planned due to the slender crown
shape. Local treatment with a conventional fixed

appliance was proposed to the patient. However, she

preferred more-esthetic means. Fixed lingual
appliance treatment was proposed. However, she was
concerned about the difficulty with hygiene care
and interference with pronunciation. Thus, tooth
movements were planned through the use of plastic
appliances fabricated on setup models by a pressure
molding machine.
Alginate impressions were taken of the upper and
lower dental arches. After the dental casts were poured
and trimmed, they were occluded and checked for any
rotations or other dental irregularities. The anterior
teeth were cut and reset into the proposed position.
Only 0.50~1.0 mm of dental movement for each tooth
in each stage was allowed. A Biostar positive-pressure
thermal forming machine (Great Lakes Orthodontic
Products, Tonawanda, NY, USA) was used to fabricate
the aligners. The appliance was thermoformed
according to the manufacturers instructions.
The patient was asked to wear the appliance 24
hours a day except during meals, brushing, and
flossing. Since greater tooth movements (0.5~1.0 mm)
in each stage were designed than those proposed by
Invisalign (0.15~0.25 mm), the patient was aware
that each appliance would only become fully seated in
place in 3~4 days after delivery. The appointment

Figure 1. Pretreatment photographs.

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interval was 2 weeks. Impressions were taken, and a

new appliance was fabricated until the ideal tooth
position was achieved.
With good compliance in wearing the appliances,
this patient achieved properly aligned maxillary
teeth after 5 sets of consecutive appliances worn as
instructed (Figure 2). Lower teeth alignment was
achieved after 7 sets of consecutive appliances. A
slight anterior open-bite of the upper right lateral
incisor occurred. The sixth appliance for the upper
arch was designed and combined with composite resin
attachments to correct this localized vertical problem.
The resin attachment was bonded to the upper right
lateral incisor near the cervical region as the active
component (Figure 3A), and on the appliance near the
incisive portion of the upper right central incisor and
upper right canine as the reactive component (Figure
3B). A reservoir space was intentionally provided
between the appliance and the upper right lateral
incisor to facilitate extrusion of this tooth with the use
of elastics. Three weeks later, a positive overbite was
achieved (Figure 3C). The wearing of elastics was
reduced to nighttime only for retention.
The overall orthodontic treatment time for this
patient was 6 months, and the appliances used
consisted of 6 maxillary aligners and 7 mandibular
aligners. The final treatment result was satisfactory.
Class I molar and canine relationships were maintained, and the anterior teeth were aligned. Mild lip

incompetence remained. Fixed lingual retainers were

bonded onto the maxillary and mandibular anterior
teeth (Figure 4). Upper and lower vacuum- formed
retainers were fabricated to maintain the transverse
correction. At 1.5 years after treatment, the fixed
retainers are still intact. The results appear to be very
stable, and the long-term prognosis is good.
Three-dimensional tooth movements on maxillary and mandibular casts of this patients were
analyzed with a desktop mechanical digitizer (Microscribe 3DX, Immersion Corporation, San Jose, CA,
USA), which collects 3D data of dental casts through
a stylus tip10,11. The Rhinoceros software program
(National Instruments, Austin, TX, USA) was used
to read the serial port communications from the
digitizer and compute the X, Y, and Z coordinate
locations. Maxillary and mandibular pretreatment and
posttreatment casts were fixed to the flat desktop
work surface with fixture putty. In total, 32 points
were digitized for each maxillary cast and 30 points
for each mandibular cast. The 3D data from the
study models were oriented in a spatial coordinate
system for easier perception of tooth movements.
Pretreatment and posttreatment study casts were
placed in the same coordinate system via superimposition to analyze changes in tooth positions
during treatment. Palatal ruga points and mandibular
molars were used as the registration landmarks.
Results revealed that during the alignment period,

Figure 2. Intraoral photographs after initial alignment.

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E. H.H. Lai, C.C. J. Yao, Y.J. Chen, et al.

Figure 3. (A)Attachments bonded onto the maxillary right lateral incisor and the
aligner. (B) Reservoir space was provided and elastics were worn for extrusion of the
upper right lateral incisor. (C) A total of 2.5 mm of extrusion was achieved.

Figure 4. Posttreatment photographs.

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mesial-outrotation with 3.1 mm of labial movement at

the mesial aspect of the incisal edge and 1.7 mm at the
distal edge were noted for the maxillary right lateral
incisor (Figure 5). The maxillary central incisors were
slightly retracted by about 0.6 mm. The upper left
canine and premolars were buccally expanded. The
upper dental midline was moved to the left side by
about 1 mm and became more coincident with the
facial midline. The maxillary right lateral incisor
extruded about 2.5 mm, while the maxillary central
incisors and canine maintained their original vertical
positions. Buccal expansion was achieved in the
mandibular canine and premolar areas, thus creating
space to relieve the mandibular anterior crowding
without proclining the lower incisors (Figure 6). The
lower left canine was moved buccally and distally
about 2.4 mm. Distal-outrotation with 2.7 mm of
labial movement at the distal aspect of the incisal edge
and 1.8 mm at the mesial aspect were noted for the
mandibular right canine. The lower dental midline was
moved 1 mm to the left side and was brought into
coincidence with the upper dental midline.

DISCUSSION
In 1945, Kesling published the first article on the

use of clear plastic overlays to achieve minor tooth

movements3. Although the results of those devices
were satisfactory, manual work is required, which is
thought to be impractical due both to laboratory costs
and technical difficulties of evenly dividing a larger
overall movement into small, precise stages manually.
To reduce manual labor, we allowed 0.50~1.0 mm of
tooth movement for each stage, which allowed the
treatment to progress more efficiently. With this
modality, the treatment cost was far less than that
using the Invisalign system.
Align Technology sequences tooth movements
into a series of evenly divided, 0.15~0.25-mm
movements, because they propose that this threshold
of movement reflects the maximum amount of
activation possible, given the virtual tooth position,
modulus of elasticity of the material, and thickness9.
We found that satisfactory results could be achieved
even with 0.5~1.0 mm of movement in each step,
although the appliance would not completely fit
initially, due to the larger dental movements planned.
The patient was educated to always fully seat the
posterior portion of the appliance, which served as the
anchorage portion of the appliance. The anterior
portion of the appliance could be fully seated in place
within a few days. Comparative cases treated with
Invisalign took a longer time because smaller tooth

Figure 5. Superimposition of the pretreatment and posttreatment maxillary dental casts.

Red dots indicate the initial position and blue dots the final position.

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Figure 6. Superimposition of pretreatment and posttreatment mandibular dental casts. Red

dots indicate the initial position and blue dots the final position.

movements (0.15~0.25 mm) were planned for each

step12. The total treatment time for this patient was
only 6 months with 6 appliances for the upper arch
and 7 for the lower arch. The orthodontic treatment
duration was far less than treatment with Invisalign.
Currently complex extrusions are less predictable
with the Invisalign system alone and might require
auxiliary treatment1,9. Attachments are required to be
bonded onto teeth to facilitate extrusive movements.
The Invisalign system should always engage the
undercut area of the attachment, and should always be
fully seated to achieve extrusive movement, which is
rather difficult due to the nature of the material of the
appliance. Therefore, only a small amount of tooth
movement can be planned to allow full engagement of
the attachment. In our treatment regimen, we bonded
attachments onto the appliance and the tooth that
required extrusion. The appliance did not have to fully
engage the undercut area of the attachments; instead,
it had to be trimmed away from the attachment on the
tooth, and a reservoir was intentionally provided to
allow continuous vertical tooth movement until the
reservoir space was eliminated. Although this might
be less esthetically pleasing, it proved to be quite
efficient for extruding the teeth. Results showed that
as much as 2.5 mm of extrusion could be achieved
within 3 weeks.
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Using clear removable appliances to treat

patients is advantageous because it eliminates the
difficulty of bonding fixed appliances to multiple
crowns. In addition, the bulk of tooth movement can
be concentrated in a specific region while minimizing
unwanted tooth movements in other regions. As in this
case, unilateral expansion of the left upper canine and
premolar area was achieved without alteration of
the right upper posterior segment. One major disadvantage of the Invisalign system is that once
treatment has begun, changes to the treatment may
require additional time and documentation. Alteration
of the original restorations may cause a poor fit of the
Invisalign appliances leading to treatment failure.
Orthodontic tooth movements achieved by plastic
appliances fabricated on setup models eliminate this
problem. Since a new alginate impression is taken to
fabricate the subsequent aligner, alterations of the
previous dental restorations will not interrupt the
original treatment sequence.
It is important to note that some conditions can
be difficult to treat with clear removable appliances.
Such conditions include centric-relation and centricocclusion discrepancies, large skeletal anteriorposterior discrepancies, and severely rotated teeth.
Thus, careful case selection is mandatory. The present
case had a solid Class I molar relationship and a
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stable posterior occlusion with no centric-relation

or centric occlusion discrepancies, and thus would
benefit from treatment with clear removable appliances.
In this case report, a patient with moderate
crowding and a maxillary lateral incisor crossbite was
treated with a series of removable plastic appliances,
which were fabricated on consecutive setup models.
For each stage, 0.5~1.0 mm of tooth movement was
achieved. Specially designed resin attachments with
the wearing of elastics achieved complex extrusion
within 3 weeks. Three-dimensional data obtained from
selected landmarks on serial dental models were
superimposed to detect tooth movements during
treatment. Crowding was relieved and midlines
corrected via differential expansion of both arches
instead of interproximal reduction.

REFERENCES
1. Womack WR, Ahn JH, Ammari Z, Castillo A. A new
approach to correction of crowding. Am J Orthod Dentofacial
Orthop, 22: 310-316, 2002.
2. Owen AH. Accelerated Invisalign treatment. J Clin Orthod, 35:
381-385, 2001.

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3. Kesling HD. The philosophy of the tooth positioning

appliance. Am J Orthod, 31: 297-304, 1945.
4. Nahoum HI. The vacuum formed dental contour appliances.
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5. Pontiz RJ. Invisible retainers. Am J Orthod, 59: 266-271,
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