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Correction of Class III Posterior Cross-bite with Maxillary Midline Diastema in an Adult Patient using Invisalign®: Report of two cases

Correction of Class III malocclusions with maxillary deficiency and posterior cross bites in adults can be challenging. Depending upon the severity of the malocclusion treatment options include comprehensive orthodontic treatment with or without surgical aid. With advent of clear aligners systems as Invisalign many patients are seeking orthodontic treatment as an alternative to comprehensive orthodontic treatment with traditional fixed braces.

Two cases with posterior cross-bites are presented here. The first case of a 17-year-old female illustrates the difficulty in correcting posterior cross-bites and the second case of a 35-year-old female demonstrates the treatment of posterior cross-bite and maxillary midline diastema using clear aligners (Invisalign®).

The exploration of using Invisalign® combined with palatal expanders in conjunction with removable elastics to gain desired results was shown to be a useful device for orthodontic correction.

It is described to aid the clinician in the management of maxillary transverse deficiency in skeletally mature patients who desire non-traditional methods.

|| Introduction

Malocclusion is commonly found in adults and observed in equal or greater frequency than in children and adolescents.[1] Some of the most common problems in adults are crowding, affecting about 24% of women and 14% of men, and spacing, affecting 8% of women and 13% of men. Typically those treated by fixed orthodontics show an increase in gingivitis and plaque, while some even experience irreversible bone loss and decalcification. However, when clinicians select the appropriate appliance that produces the right force to correct the malocclusion, many enjoy the benefits of orthodontic treatment. Adults are often reluctant to wear fixed appliances despite their need for orthodontic treatment. But with the increased awareness of patients of the need for good oral health and the increase in aesthetic requirement from society, the demand of orthodontic treatment to correct malocclusions without fixed appliances have increased. In an aesthetically agreeable approach, the Invisalign® system makes it possible for adult patients requiring orthodontic treatment.

The use of clear aligners to move teeth is documented in various articles. In particular, the Invisalign® appliances for treating malocclusions have recently been described by several different authors whose cases involve extractions, deep bites, anterior and posterior cross-bites, and periodontal complications. In these patients, the appearance of the smile is their main treatment goal. This article describes the treatment of a unilateral posterior cross-bite with maxillary midline diastema with the Invisalign® system in conjunction with palatal expander and class III elastics. It describes two similar cases of posterior crossbite, similar malocclusion but with varying results.

A posterior cross-bite can be dysfunctional and unaesthetic as it is a lateral misalignment of the dental arch, where the maxillary posterior dentition is lingual in relation to the mandibular dentition. In a unilateral posterior cross-bite due to shift, one side of the dentition is affected and in order for the posterior dentition to meet together, the lower jaw will have a centric relation-centric occlusion lateral functional shift. This abnormal transverse maxillary/mandibular constriction is a major factor in several malocclusions.

Several methods have been employed to correct a maxillary transverse deficiency in patients including widening the maxilla, surgically or non-surgically. Other methods may include treating the cause of the cross-bite (e.g. thumb sucking habits, tongue thrust). Although the correction of posterior cross-bite can be complex, maxillary expansion is a common orthodontic treatment used for the correction of cross-bites resulting from reduced maxillary width. Correction of maxillary transverse deficiency is routinely done in young patients; however, in a skeletally mature patient the osseous articulations of the maxilla with the adjoining bones make it more challenging to treat. Hence, once the patient has been properly diagnosed, it is necessary to select the appropriate modality and to determine when adequate expansion has been achieved and how to retain it.

The fundamental basis for deciding between surgical vs non-surgical expansion for the correction of reduced maxillary widths, by most clinicians, has been the patient’s chronological age, as well as their skeletal age. It is possible that a chronologically advanced patient is skeletally immature, or vice versa, making skeletal age a very important parameter for case selection. For the predictable correction of posterior cross-bite in adults, it ideally requires surgical expansion; however, these can be associated with certain complications that include significant hemorrhage, gingival recession pain, root resorption maxillary nerve injury, infection, periodontal breakdown, sinus infection, and asymmetrical expansion.

Non-surgical expansion using the Haas/Hyrax rapid palatal expansion (RPE) has been, for the most part, limited to growing patients. However, a few articles state that non-surgical expansion is as successful in adults as it is in children. Most of the correction of maxillary transverse deficiency in an adult occurs at the lateral alveolar process rather than at the skeletal base of the maxilla, producing a combination of dentoalveolar modification and dental tipping to correct posterior cross-bite. Although less invasive than surgical expansion, palatal expanders do pose potential complications including pain, tissue swelling, posterior teeth tip, mandibular rotation, and gingival recession.

The attempt to correct posterior cross-bites with removable elastics is often limited to buccal flaring of the teeth as well and can cause chronic imbalance of the posterior dentition where the lingual cusps strike the mandibular teeth first. Therefore, in the case of adults, surgical expansion may be required or compromise accepted with flare.

Invisalign® might not be as effective as fixed braces for a few reasons. Primary among them is compliance. It is generally a disadvantage to the clinician where treatment efficacy lies in the hands of the patient, as the appliance can be easily removed. Removable appliances produce intermittent forces, and if not continued for enough hours of the day, they don’t have significant effects on tooth movement. When the removable appliance is taken out, intermittent forces drop to zero and only when the appliance is reinserted into the mouth do the forces return.

The optimum force for traditional orthodontic tooth movement is 10-100g, where the values depend on the type of movement and size of the tooth. These forces are not affected by the patient and produce more tooth movement than removable appliances unless the removable appliance is continuously present. Decreased tooth movement is observed when these removable appliances are worn for shorter durations of time.

Another reason Invisalign® fails is that the occlusion is minimally addressed. According to Vlaskalic and Boyd, while assessing Invisalign® occlusal outcome, it became apparent to them that similar results could have been reached with traditional braces in less time. They concluded that the most important aspects of Invisalign® over braces are that they are aesthetically pleasing, comfortable, and removable, and they reduced plaque accumulation resulting in improved periodontal health. However, there are no biomechanical advantages.

Case Report : Case 1 Diagnosis and Treatment Objectives
A 17-year-old female presented with a bilateral, symmetrically constricted posterior cross-bite (Fig. 1). She was concerned with her bite, as well as crowding of her teeth. Her facial proportions were well-balanced and intraoral examination revealed dental arches with moderate crowding. Class III molar relationships were detected and the patient admitted heavy clenching. Third molars had been extracted prior to treatment. The patient did not want traditional fixed appliances and expressed interest in the use of clear aligners (Invisalign®).

The objective of the treatment was to align the lower anterior teeth and eliminate the bilateral cross-bite. Pre-treatment, the patient was advised of the difficulty of correcting her bilateral posterior cross-bite with the Invisalign® system. However, the patient insisted on using clear aligners and not traditional fixed appliances.

Treatment Progress

The patient was prescribed 15 aligners, upper and lower and a total of 2.5 mm Interproximal Reduction (IPR) mesial to the first molars to correct the Bolton discrepancy. IPR was completed within the first two months of treatment. The patient was compliant with aligners. After completion of the 15 sets, the patient’s lower anterior teeth were well aligned but there was no change to her posterior cross-bite. Refinement impressions were taken and the patient was prescribed an additional 14 aligners for the upper and 5 aligners for the lower. At the end of refinement the patient’s poster occlusion was still not corrected. ClinCheck projection (Fig. 2) showed an improvement of her malocclusion with satisfactory resolution of her cross-bite and alignment of her teeth in both arches. Regular appointments were made in 4-6 week intervals to assess her aligner fit, patient compliance, and tooth movement.

Treatment Results The patient’s occlusion made minimal changes. The mandibular crowding was resolved; however the bilateral posterior cross-bite showed little to no improvement despite ClinCheck projections. Invisalign cannot fix posterior cross-bite as expanders can due to the lack of anchorage. Post-treatment results overall showed incomplete correction of her malocclusion (Fig. 3).

Case 2 : Diagnosis and Treatment Objective
A 35-year-old female presented with chief complaint of spacing between her front teeth and biting issues. Pre-treatment photographs, panoramic and cephalometric radiographs (Fig. 4-6) were taken along with initial records. The patient was diagnosed with class III dental and skeletal with symmetrically constricted posterior cross-bite with shift, anterior cross-bite and maxillary midline diastema. The patient was presented with multiple treatment options, including surgical expansion and comprehensive orthodontic treatment. The treatment objective was to use a Hyrax palatal expander to correct the posterior cross-bite. A Hyrax palatal expander was used to correct the posterior cross-bite followed by use of the Invisalign system to close spaces, improve class III dental relation and obtain ideal overjet and overbite.

Treatment Progress
The expander was turned once every third day for approximately 13 weeks, for a total of 6 mm at the screw. The expander after deactivation was left a month to stabilize with expander in place and subsequently removed and post-expansion records were taken (Fig.7). Invisalign ClinCheck superimpositions of predicted outcome were assessed (Fig. 8). The amount of interproximal reduction performed to correct the Bolton discrepancy was a total IPR of 0.2 mm in the upper arch and a total IPR of 3.4 mm in the

Exploring the Uses and Benefits of Laser-Activated Orthodontics According to Joseph Kunnel

People who have had braces in the past are all too familiar with the discomfort with adjustments. To move the teeth, pressure must be exerted, and this is usually accomplished by adding elastics or tightening wires. Since the age of braces patients is steadily becoming younger, orthodontists are interested in finding ways to minimize their discomfort and make their treatment faster and more effective.
Orthodontist Joseph Kunnel of Skokie, Illinois, shares the importance of a
a newer technique called laser-activated orthodontics, naming how it enhances orthodontic treatment.

What is Laser-Activated Orthodontics?
Laser-activated orthodontics refers to several minimally invasive procedures that help dentists care for the teeth and gums of a patient undergoing treatment. In laser-activated orthodontics, a gentle laser is used to excise tissue, break it down, and perform other procedures.

How Does it Work?
Typically, diode lasers are used in laser-assisted orthodontics. Diode lasers are cut with a hot tip and do not interact with healthy teeth. Contact cutting enables orthodontists to see the site of their procedure without excess bleeding that can get in the way.

What are its Benefits?
Following are seven major benefits of using lasers in orthodontic treatment:

  1. Easier Access
    Children and young people who have braces are likely to fall into poor oral care habits due to difficulty accessing teeth and gums. Lasers can help clean up the areas that children are having difficulty with and provide a healthier appearance and protect against tooth decay and infection.
  2. Easy Bracket Debonding
    The removal of orthodontic brackets can be uncomfortable for patients. Lasers can help to remove the bracket and make the process easier for the patient and orthodontist.
  3. Quicker Healing
    Lasers produce quicker healing than traditional methods like cutting the gums with a scalpel. The laser cauterizes tissue as it goes, so there are few wounds to heal after the treatment has been completed. Patients who have received laser-activated orthodontic treatments are more likely to report an easier recovery from their procedures.
  4. Precise Tooth Positioning
    Sometimes connective tissue can get in the way of the proper placement of teeth during orthodontic treatment. Lasers can ablate these tissues and make the teeth move into the desired area for an ideal result when treatment is completed.
  5. Tissue Removal
    Poor hygiene among patients with braces can also lead to gum tissue growing over the teeth. This means that the line of the gums is not aesthetically pleasing to the patient, parent, and orthodontist. Laser therapy can help to smooth out the gum line and make the teeth appear more regular and even. Lasers make it easy to remove this tissue and keep the procedure from being long and arduous. This helps keep patients more comfortable and lessens discomfort during orthodontic treatment.
  6. Reduction in Discomfort
    Lasers can be used to break down the tissue around the areas where the braces will be tightened. This means less discomfort for the patient. Lasers can also be used for dental analgesia. Laser beams help stabilize the nerves and decrease the pain transmitted to the patient’s brain. In most cases, the patient can be numbed before the laser treatment with just a topical anesthetic and no needles. This is especially helpful for pediatric patients.
  7. Fewer Infections
    Since the laser disinfects as it treats, it is much less likely that patients will experience infections.

Potential Risk Factors
Laser-activated orthodontics are generally safe, but there are a few risk factors that patients and their parents should know about. Patients and orthodontists must wear special eyewear to prevent damage to their eyes. If a young patient cannot keep the eyewear on, they are not recommended to receive laser treatment. The laser could damage tissue around the teeth, but typically, this damage heals easily. Further treatment may be necessary.
Rarely, laser treatment can disrupt large blood vessels. This can happen under the tongue as well as in other areas. This may result in the need for other medical treatment.

Taking Advantage of Laser Treatment
When patients and their parents look for safe, effective, and efficient orthodontic treatment, they should consider going to a practitioner like Joseph Kunnel, who uses lasers in their work. Laser treatment has a host of benefits for a patient’s successful outcome, but the risk factors should also be considered before deciding to receive treatment. Patients should be assured that the risks of laser treatment for orthodontia are frequently fewer than those associated with traditional treatment.

Lasers make treatment easier and reduce discomfort. They can visually enhance the look of teeth and gums and address important areas of dental hygiene. Orthodontists like Joseph Kunnel can help you or your child achieve a beautiful, healthy smile.

Joseph Kunnel Describes The Problem of TMJ Disorders and Possible Orthodontic Treatments

TMJ or temporomandibular joint syndrome affects over 10 million Americans every year. More women than men suffer from TMJ dysfunction. TMJ covers a variety of disorders that cause the jaw joint to function improperly and cause pain in the muscles that control the jaw.

Many people experience TMJ problems occasionally, but they frequently come in cycles and resolve themselves. If you believe that you have a TMJ disorder interfering with your life, it is time to consult with an orthodontist.
Joseph Kunnel, a Skokie, Illinois resident and experienced orthodontist,
explores the causes and ramifications of TMJ and the possibilities for treatment.
The Temporomandibular Joint
TMJ affects how the lower jaw (the mandible) is connected to the bones in the side of the head, known as the temporal bones. These joints have a great deal of flexibility, meaning that we can yawn, talk, and chew freely.

Since this joint combines hinge and sliding motions, it is one of the most
complex in the entire body. If something goes wrong, it can be extremely challenging to correct.

The complexity of the TMJ joint means that patients should visit orthodontists who specialize in correcting the disorder. Not all orthodontists are qualified to work on TMJ-related problems, and it pays to do prior research before visiting any practitioner.

TMJ Disorders
TMJ disorders fall into three broad categories. The first is the experience of
myofascial pain. This involves pain and discomfort in the muscles controlling the function of the jaw.
An internal displacement of the joint can involves displaced discs, dislocated jawbones, or injury.
Finally, TMJ can be caused by arthritis. One or more of these conditions may
happen together, making treatment even more complex.

Causes of TMJ
It is largely unknown what causes TMJ to begin. In some cases, trauma to the jaw or muscle could start the problem. While it is popularly believed that a poor bite or orthodontic braces can trigger TMJ, research does not bear this out. Tooth
grinding and general stress also do not cause TMJ, though many believe this is the case.
Poor posture can contribute to TMJ symptoms. Sitting at a computer in a
non-ergonomic position can cause problems because the patient needs to hold their head forward.

Home Care for TMJ
There are actions that TMJ patients can take at home to improve their pain. The first option is jaw exercises. Orthodontists will explain these exercises to the patient and share how they can be used when TMJ is flaring up.

Heat and cold therapy can also be helpful. Ice packs and warm washcloths
should be alternated for the best results. This procedure can be done a few
times per day.
When TMJ is flaring up, it is important to ensure that the patient does not eat crunchy, chewy, or hard foods. Soft foods like scrambled eggs and yogurt are best. Avoid apples, caramels, bagels, and gum, among many other foods.

Extreme jaw movements like biting into a large burger, singing, and yelling
should be avoided. Caffeine should be limited, and magnesium supplements
should be tried.

Orthodontic Treatments for TMJ
Fortunately for the many patients who suffer from TMJ, there are a variety of solutions available for their pain. An experienced orthodontist like Joseph Kunnel can help to walk patients through their treatment options and help them decide which is the best path to follow toward a pain-free life.

Correcting the Alignment of the Jaw
Orthodontists who specialize in TMJ do not always correct the bite to that which is commonly accepted. Orthodontists specializing in this disorder are more concerned with realigning the jaw and muscles to produce a better result and freedom from TMJ pain.

The relationship between the teeth and the temporomandibular joint is carefully examined. Specialist orthodontists like Joseph Kunnel can create treatment plans that help to improve the function of the temporomandibular joint and produce excellent results.

While not all practitioners believe that mouthguards are effective in the fight against TMJ, many patients find that these appliances can reduce the poor alignment of their jaw that causes flare-ups.

Effects of TMJ
TMJ can severely impact a patient’s quality of life. Understandably, they would seek any means of treatment necessary to find a solution to their problem. Correcting their posture, bite, and jaw alignment are a few ways in which TMJ disorders can be treated.

Working with an Orthodontist

Orthodontists like Joseph Kunnel are interested in helping patients overcome the pain and discomfort associated with TMJ disorders. Their advanced methods can help patients rest easier and experience the joy of being pain-free. Contact a local orthodontist today if you believe you are having problems with TMJ. A qualified orthodontist can help to diagnose your problem, recommend proper treatment, and help you move forward to a pain-free future.

Joseph Kunnel Explores How Orthodontic Treatment Can Help Sleep Apnea Patients

Sleep apnea is a damaging condition that can contribute to daytime fatigue, high blood pressure, heart problems, Type 2 diabetes, and metabolic syndrome. If patients find that they snore loudly and are exhausted after a full night’s sleep, they may exhibit sleep apnea signs.
There are many treatment options for sleep apnea, including CPAP machines and other breathing apparatus. However, a less invasive method may also be used to treat sleep apnea. In some cases, especially in children, airway obstruction is caused by misaligned teeth.
Joseph Kunnel, an experienced orthodontist from Skokie, Illinois, shares how orthodontic treatment can help sleep apnea patients sleep better and live healthier lives.

What is Sleep Apnea?
There are three main types of sleep apnea: obstructive sleep apnea, where throat muscles relax too much; central sleep apnea, where the brain does not send the proper breathing signals; and complex sleep apnea syndrome, a combination of obstructive and central sleep apnea.

Sleep apnea causes a person to start and stop breathing frequently throughout the night. They typically disturb their family members who are trying to sleep at night. This is often the first sign that a person needs treatment for sleep apnea.

Causes of Sleep Apnea
Following are the major causes for the two primary types of sleep apnea. Obstructive sleep apnea is the type most commonly treated through orthodontic intervention.

Obstructive Sleep Apnea
Obstructive sleep apnea happens when the muscles sited in the back of the throat relax too much. The muscles support the uvula, the soft palate, the tonsils, the tongue, and the inside walls of the throat. When these muscles relax, the airway closes or narrows as the patient breathes in. This can cause a lack of oxygen in the brain, prompting the brain to wake the patient up enough to reopen their airway.

Central Sleep Apnea
Central sleep apnea happens when the brain does not transmit the right message to the muscles. The body makes no effort to breathe for short periods of time.

Orthodontic Solutions
Orthodontists like Joseph Kunnel are often the first professionals to recognize that an adult or child patient has sleep apnea. They regularly perform screenings for this condition in the course of a patient’s treatment.

If a patient is found to have sleep apnea, they would be referred to a specialist physician. The physician may recommend that the patient receive orthodontic treatment to keep the airways open during sleep.

Orthodontists use oral appliances to keep patients’ airways open during sleep. These devices include mandibular advancing oral appliances and tongue retaining devices. Mandibular advancing appliances hold the jaw and other tissues forward. This helps to keep the upper airway open.

Tongue retaining devices keep the tongue and other soft tissues from relaxing and obstructing the airway. Tongue retaining devices are approximately as effective as mandibular advancing oral appliances. This can mean that a tongue retaining device could be a less expensive and less invasive option than a CPAP machine.

Surgical Solutions
If patients have severe obstructive sleep apnea, they may be candidates for mandibular advancement surgery. This could be an excellent alternative for patients who cannot tolerate oral appliances at night and cannot adhere to CPAP treatment.

Orthodontic Treatment of Obstructive Sleep Apnea in Children There are many options for treating child sleep apnea patients through orthodontic intervention. Early orthodontic treatment may help with abnormalities around the bony structures surround the airway. Early treatment could reverse the causes of obstructive sleep apnea in children as well as adults and adolescents.

Mandibular advancement surgery can also be used in children. Slow or rapid maxillary expansion surgery can also help expand the airway and reduce the risk of problems caused by obstructive sleep apnea.

Benefits of Treatment
The primary benefit of orthodontic treatment for obstructive sleep apnea is that patients can relax into deep and restorative sleep. Interrupted sleep and lack of oxygen can cause many serious problems, and when sleep apnea is treated, people can move forward with a healthier life.

Potential Risks
As with all orthodontic treatments, movement of the teeth will occur with oral appliances. This may cause an undesired appearance in the mouth. A properly trained orthodontist will be able to help the patient compensate for these problems with further treatment.

Choosing the Right Orthodontist
When searching for an orthodontist who can help treat them or their children for sleep apnea, they should make sure that they find an experienced practitioner like Joseph Kunnel. These orthodontists work closely with sleep specialists and surgeons to help design a treatment plan to support healthy sleep in their patients.

Potential Risks
Oral appliances may cause teeth to move. Non-orthodontic providers may not know about the unwanted effects of oral appliances on their patient’s teeth in the long term. Orthodontists can help manage the alignment of the teeth and make sure that unwanted side effects do not occur or can be repaired.