Dora Morocz is an orthodontist and clinical mentor for the Aligner Dental Academy. Here she shares her top tips for orthodontic treatment, including managing crowding and the most useful tools.
On the forum, we receive thousands of questions about orthodontic treatment, and I’ve noticed certain topics come up repeatedly. One of the most frequently discussed areas is crowding cases and how to create space effectively.
Tips on crowding
Invisalign is an excellent tool for treating crowding, but careful planning is essential. Here are key considerations when managing these cases.
1. Space creation
To resolve crowding, space must be created. The method chosen depends on the patient and a thorough SAFE assessment. A SAFE assessment provides a comprehensive evaluation of your patient, considering aesthetics, function, structure, and biology. Discover more about the SAFE assessment here.
Before deciding on an approach, I always look at the treatment aims, the patient’s starting position, periodontal considerations such as bone loss and existing recessions, and whether they have had previous orthodontic treatment with IPR (interproximal reduction).
2. IPR
Interproximal reduction is a safe and effective way to create space between teeth. It can be done using strips, burs or discs. If you’re looking for further insights, I highly recommend checking out Dr Raman Aulakh’s TED Talk on IPR.
Timing is crucial. If you try to perform IPR too early when crowding is still present, accessing the contacts can be difficult. Instead, you can delay the IPR to a later stage when the teeth are better aligned. Remember though that this is essentially round-tripping, so make sure your patient has the gingival biotype and bone support to handle the temporary expansion instead.
3. Expansion
Expanding the arch form can also create space, but it’s important to differentiate between buccal crown tipping and bodily movement of the teeth. Over-expansion can lead to recession, so I always carefully assess the biotype and reduce expansion if needed. While up to 2mm of expansion per side is generally predictable, whether it is safe depends on the individual patient.
4. Extractions
For moderate to severe crowding, removing a lower central incisor (which is about 5.5mm wide) can sometimes be a better alternative to excessive IPR or expansion. Carefully assess the angulation of the teeth on either side of the incisor you are planning to extract – ideally you’d want converging roots to then be able to take advantage of the mesial crown tipping when closing the space.
Consequences of resolving crowding
When resolving crowding, there are some important factors to keep in mind:
- Black triangles: if the teeth are triangular or overlapping, aligning them can result in black triangles. I always make sure to show patients photos of potential outcomes so they understand what may happen. If needed, black triangles can be minimised with IPR or resolved with restorative techniques post-treatment
- Recession risk: expansion increases the risk of recession, so I closely monitor patients undergoing expansion and make sure to include this risk when going through the consent pre treatment
- Round tripping: this occurs when anterior teeth temporarily procline forward to make space for IPR before moving back. While round tripping can be helpful in some cases, it’s not ideal for patients with recession or a thin biotype.
Utilising ClinCheck tools
ClinCheck tools are invaluable in planning and refining treatment. I recommend using the superimposition tool to visualise movement predictability and checking the tooth movement table to assess feasibility. If in doubt, I create multiple ClinChecks – one with maximum IPR and expansion, and another considering a lower incisor extraction – to compare different approaches.
This also helps patients understand their options during the consent process.
Have more questions?
I hope you found this information useful. If you have any further questions, I encourage you to engage with our expert community on the Aligner Dental Academy (ADA) forum. As an ADA member, you have access to a wealth of knowledge and real-world case discussions.
Whether you need advice on a specific case, insights into ClinCheck planning or guidance on treatment approaches, the forum is the perfect place to seek support and share your experiences. I look forward to seeing your questions and continuing the discussion!
Find more information about joining the Aligner Dental Academy here.
This article is sponsored by the Aligner Dental Academy.
