Dentaltown July 2017 - 69

Fig. 1

orthodontic treatment using
braces.
3. Patient enthusiasm and
compliance with braces decreased dramatically during the
later stages of treatment.
I realized that, as an orthodontic specialist with a variety of
tools at hand, I should be recommending that we take advantage
of the best aspects of each one: Treat with braces for a short time
to level and align the lower teeth, then follow with clear aligners
to detail the teeth and finish the occlusion.
Many of our adult patients have been completely leveled and
aligned in their first two wires using braces, so we began promoting
our combination treatment, which involves four to five months of
braces on the lower teeth and Invisalign on the upper teeth, followed
by full Invisalign treatment for the remainder of the treatment
(usually 12 months).
Here are three examples of patients in which we've used our
combination treatment to take advantage of the best aspects of each
modality. The first two cases were switched from lower Invisalign
to braces because the patients had poor compliance and expressed
frustration with slow visible changes. The third case, meanwhile,
was presented as a combo case from the onset.

Fig. 2

and then we could return to clear aligners and finish in a reduced
amount of time.
We placed American Orthodontics Empower braces on the
lower 7-7 with an 0.014 nickel titanium wire. The patient chose
not to wear his upper aligners at all, saying that he would pick up
usage again after we finished the lower arch.
The changes in the lower arch can be seen from his initial photo
(Fig. 1) to the day we removed the lower braces (Fig. 2). We used
three NiTi wires: 0.014, 0.018, and 20x20. The process took five
appointments over the course of five months, including bonding, two
emergency appointments to clip long wires, and removal of braces.
On the day we removed braces, we scanned for an Invisalign
refinement and placed a lower 3-3 bonded retainer to hold the

Patient 1:

Frustrated by fit,
Bad at compliance
The first patient was a 44-year-old who began treatment as
a full upper and lower clear-aligner case. (I had recommended
partial braces for his treatment, but he explicitly declined during
the consultation.) At later appointments it was noted that he had
been inconsistent about wearing his aligners, so I asked him to
describe his biggest obstacles to getting 20 hours of daily wear. He
said that after a spurt of wearing the aligners frequently, he hoped
and expected to see some visible changes. When there were no
observable changes, he'd get frustrated and stop wearing them for
a few days. With that wear schedule, the fit of his aligners would
get worse, which caused him even more frustration.
I recommended that we boost his treatment by placing braces
on only the lower teeth-the more complicated ones for aligners to
improve because of the patient's severe crowding and rotations. I
promised that the braces would be on for only four to five months,

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