WHAT WE KNOW ABOUT CLEAR ALIGNERS

What_We_Know_About_Clear_Alignersapak

TREATMENT OF VERTICAL MALOCCLUSIONS WITH CLEAR ALIGNERS: CLINICAL CONSIDERATIONS AND APPLICATIONS

Esra Ekizer

Nevşehir Hacı Bektaş Veli University, Faculty of Dentistry, Department of Orthodontics, Nevşehir, Türkiye

Ekizer E. Treatment of Vertical Malocclusions with Clear Aligners: Clinical Considerations and Applications. In: Hancıoğlu Kırcelli B, editor. What We Know About Clear Aligners 1st ed. Ankara: Türkiye Klinikleri; 2025. p.89-104.

ABSTRACT

Deep bite is a malocclusion characterized by excessive vertical overlap of the upper incisors over the lower ones. It can result from skeletal, dental, or combined factors. Treatment involves intrusion of upper and/or lower incisors, extrusion of posterior teeth, and leveling of the curve of Spee. Clear aligners offer advantages over braces, such as occlusal protection, but may have limitations in achieving posterior extrusion. Innovations like bite ramps and pressure areas have improved treatment predictability. Bite ramps apply intrusive forces to lower incisors while disoccluding posterior teeth. Treatment planning must consider the patient’s skeletal pattern; for example, premolar extrusion may benefit brachyfacial patients, while vertical skeletal patterns require caution with posterior extrusion. Digital setup planning focuses on leveling the curve of Spee in three dimensions. Attachments are crucial for vertical anchorage, especially during mandibular incisor intrusion. Class II elastics can aid mandibular rotation. Balancing anterior intrusion and posterior extrusion is key to achieving stable results. Open bite is defined by a lack of vertical overlap between the upper and lower teeth. It can be skeletal or dental in origin and is challenging to treat due to its multifactorial etiology and relapse tendency. Treatment strategies include extrusion of anterior teeth, intrusion of posterior teeth, and retroclination of proclined incisors. Clear aligners are beneficial for open bite correction as they facilitate posterior intrusion and avoid extrusive forces on posterior teeth seen with braces. Optimized attachments enhance anterior extrusion efficiency. Treatment planning should avoid excessive anterior extrusion, especially in patients with gummy smiles, and prioritize posterior intrusion. In vertical skeletal patterns, maxillary molar intrusion encourages forward and upward mandibular rotation, aiding bite closure. Digital planning involves careful attachment selection and staging. For open bites caused by excessive incisor proclination, retroclination and relative extrusion are recommended. Overcorrection to at least 2 mm overbite is crucial for stability. Vacuum-formed retainers are recommended post-treatment to prevent posterior tooth re-eruption. Both deep bite and open bite treatments require meticulous digital planning, biomechanical considerations, and the use of advanced aligner features to achieve predictable and stable outcomes. Deep bite correction focuses on anterior intrusion, posterior extrusion, and leveling the curve of Spee, while open bite correction emphasizes anterior extrusion and posterior intrusion. The integration of bite ramps, pressure areas, and optimized attachments has significantly improved the predictability of aligner therapy. Additionally, Class II elastics and temporary anchorage devices (TADs) can be used to enhance treatment outcomes in complex cases. Proper staging and overcorrection are essential for achieving long-term stability. Overall, clear aligners provide a versatile and effective solution for treating vertical malocclusions, but success depends on careful planning and execution.

Keywords: Orthodontic appliances; Removable; Overbite; Open bite; Malocclusions; Orthodontics

Referanslar

  1. Danz JC, Greuter C, Sifakakis I, Fayed M, Pandis N, Katsaros C. Stability and relapse after orthodontic treatment of deep bite cases-a long-term follow-up study. Eur J Or thod. 2014;36(5):522-30. [Crossref]  [PubMed]
  2. Pasciuti E, Coloccia G, Inchingolo AD, Patano A, Ceci S, Bor dea IR, Cardarelli F, et al. Deep Bite Treatment with Aligners: A New Protocol. Applied Sciences. 2022;12(13):6709. [Crossref]  [PubMed]
  3. Blundell HL, Weir T, Meade MJ. Deep overbite reduction in adolescent patients treated with Invisalign: A retrospective analysis. Am J Orthod Dentofacial Orthop. 2024;166(6):515-523. [Crossref]  [PubMed]
  4. Khosravi R, Cohanim B, Hujoel P, et al. Management of overbite with the Invisalign appliance. Am J Orthod Dentofacial Orthop. 2017;151(4):691-699.e2. [Crossref]  [PubMed]
  5. Kravitz ND, Moshiri M, Nicozisis J, Miller S. Mechanical considerations for deep-bite correction with aligners. Seminars in Orthodontics. 2020;26(3):134-8. [Crossref]  [PubMed]
  6. Shroff B, Yang IIH, Jenkins TS. Deep overbite correction: Biomechanics and clinical implications. Seminars in Orthodontics. 2020;6(3):126-33. [Crossref]  [PubMed]
  7. Sarver DM. The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop. 2001;120(2):98-111. [Crossref]  [PubMed]
  8. Tai S. Clear Aligner Technique. Batavia: Quintessence Publishing Co; 2018.
  9. Husain F, Riccardi J, Alletto L, Stellrecht E, Bejehmir AP, Al-Jewair T. Effectiveness and accuracy of clear aligners in treatment of deep bite: a systematic review. Clin Oral Investig. 2025;29(6):306. Published 2025 May 21. [Crossref]  [PubMed]
  10. Giancotti A, Mampieri G, Greco M. Correction of deep bite in adults using the Invisalign system. J Clin Orthod. 2008;42(12):719-26. [Crossref]  [PubMed]  [PMC]
  11. Greco M, Rombola A. Precision bite ramps and aligners: An elective choice for deep bite treatment. J Orthod. 2022;49(2):213-20. [Crossref]  [PubMed]
  12. Rossini G, Parrini S, Castroflorio T, Deregibus A, Debernardi CL. Efficacy of clear aligners in controlling orthodontic tooth movement: a systematic review. Angle Orthod. 2015;85(5):881-9. [Crossref]  [PubMed]  [PMC]
  13. Henick D, Dayan W, Dunford R, Warunek S, Al-Jewair T. Effects of Invisalign (G5) with virtual bite ramps for skeletal deep overbite malocclusion correction in adults. Angle Orthod. 2021;91(2):164-70. [Crossref]  [PubMed]  [PMC]
  14. Invisalign G5 Innovations for Deep Bite. Available from:  [Link]
  15. Kravitz ND, Kusnoto B, BeGole E, Obrez A, Agran B. How well does Invisalign work? A prospective clinical study eval uating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop. 2009;135(1):27-35. [Crossref]  [PubMed]
  16. Moshiri M, Kravitz ND, Nicozisis J, Miller S. Invisalign eighth-generation features for deep-bite correction and posterior arch expansion. Semin Orthod. 2021;27(3):175-178. [Crossref]  [PubMed]
  17. Zhu Y, Hu W, Li S. Force changes associated with differential activation of en-masse retraction and/or intrusion with clear aligners. Korean J Orthod. 2021;51(1):32-42. [Crossref]  [PubMed]  [PMC]
  18. Al-Balaa M, Li H, Ma Mohamed A, Xia L, Liu W, Chen Y, et al. Predicted and actual outcome of anterior intrusion with Invisalign assessed with cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2021;159(3):e275-e80. [Crossref]  [PubMed]
  19. Nanda R, Castroflorio T, Garino F, Ojima K. Principles and Biomechanics of Aligner Treatment. Elsevier Inc. 2022. [Crossref]  [PubMed]
  20. Karalikkattil TL, Batra N, Vivek CR, Reddy V, Manimegalan P, Tom A. Effectiveness of Invisalign Treatment on Open Bite Correction. J Pharm Bioallied Sci. 2024;16 (Suppl 1):S850-S2. [Crossref]  [PubMed]  [PMC]
  21. Finkleman S, Cohanim B, Tai SK, Khosravi R, Huang G. Does planned molar intrusion with aligners assist with closure of anterior open bite? Am J Orthod Dentofacial Orthop. 2024;166(4):330-49 e1. [Crossref]  [PubMed]
  22. Wen Y, Qiannan N, Wang A, Yang H, Wang H, Jin Z. Clear aligner treatment for an adult with severe anterior open bite malocclusion. Am J Orthod Dentofacial Orthop Clin Companion. 2022;2:409-17. [Crossref]  [PubMed]
  23. Abdelkader F, Rjili R, Amor WB, Dallel I, Tobji S, Amor AB. Efficiency of Aligners in Correcting Anterior Open Bite: A Systematic Literature Review. Saudi J Oral Dent Res. 2023;8(12):380-90. [Crossref]
  24. Olteanu ND, Romanec C, Cernei ER, Karvelas N, Nastri L, Zetu IN. Scoping Review-The Effectiveness of Clear Aligners in the Management of Anterior Open Bite in Adult Patients. Medicina (Kaunas). 2025;61(6):1113. [Crossref]  [PubMed]  [PMC]
  25. Weir T. Clear aligners in orthodontic treatment. Aust Dent J. 2017;62 Suppl 1:58-62. [Crossref]  [PubMed]
  26. Boyd RL. Esthetic orthodontic treatment using the invisalign appliance for moderate to complex malocclusions. J Dent Educ. 2008;72(8):948-67. [Crossref]  [PubMed]
  27. Burashed H. The efficacy of anterior open bite closure when using Invisalign’s optimized extrusion versus conventional attachments. J World Fed Orthod. 2023;12(3):112-7. [Crossref]  [PubMed]
  28. Harris K, Ojima K, Dan C, Upadhyay M, Alshehri A, Kuo CL, et al. Evaluation of open bite closure using clear aligners: a retrospective study. Prog Orthod. 2020;21(1):23. [Crossref]  [PubMed]  [PMC]
  29. Correa E, Michelogiannakis D, Barmak AB, Rossouw PE, Javed F. Efficacy of Clear Aligner Therapy for the Treatment of Anterior Open Bite in Adults: A Systematic Review and Meta-Analysis. Orthod Craniofac Res. 2025;28(2):261-270. [Crossref]  [PubMed]
  30. Bichu YM, Alwafi A, Liu X, Andrews J, Ludwig B, Bichu AY, et al. Advances in orthodontic clear aligner materials. Bioact Mater. 2023;22:384-403. [Crossref]  [PubMed]  [PMC]
  31. Giancotti A, Garino F, Mampieri G. Use of clear aligners in open bite cases: an unexpected treatment option. J Orthod. 2017;44(2):114-25. [Crossref]  [PubMed]
  32. Upadhyay M, Arqub SA. Biomechanics of clear aligners: hidden truths & first principles. Journal of the World Federation of Orthodontists. 2022;11:12-21. [Crossref]  [PubMed]