A T E Best Practices Clinical Protoco Compressed

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A T E Best Practices Clinical Protoco Compressed

  1. 1. Invisalign Clinical Best Practices Protocol Ask the Expert Call Dr. René Sterental March 30 th , 2007
  2. 2. What is the Clinical Best Practices Protocol? <ul><li>The objective of the BP Protocol is to offer customers the best of what Align knows of how to treat cases with Invisalign.  </li></ul><ul><li>The protocol is the result of combining the consensus opinions of leading edge user-doctors, research studies, and over 500K cases in treatment.  </li></ul><ul><li>Implementation of the elements of this protocol through software automation renders them available to all user-doctors in a manner that is repeatable and scalable.   </li></ul>
  3. 3. Elements of Invisalign Clinical Best Practices Protocol <ul><li>New Staging Protocol </li></ul><ul><li>New Attachment Protocol </li></ul>
  4. 4. New Staging Protocol Sequential Staging (Old Protocol) Simultaneous Staging (New Protocol)
  5. 5. Sequential Staging (Old protocol) <ul><li>Individual Teeth: </li></ul><ul><ul><li>Complex movements required by one tooth (i.e. rotation + extrusion) are performed separately, with the less predictable movement staged at the end of the treatment. </li></ul></ul><ul><li>Staging of multiple teeth per arch : </li></ul><ul><ul><li>Some teeth start moving earlier in the setup and other teeth start moving later. </li></ul></ul><ul><ul><li>Intended to enhance intra-arch anchorage and/or to avoid collisions between the teeth as they move. </li></ul></ul>
  6. 6. Sequential Staging considerations (Old protocol) <ul><li>Difficult movements are often left to the end of treatment and may be accelerated beyond the ideal clinical rate of movement required – applies to root movements. </li></ul><ul><li>Difficult for the clinician to estimate and request optimal velocity – can lead to request an excessive number of aligners by indiscriminate requests to reduce the velocity by increasing the overall number of stages. </li></ul>
  7. 7. Simultaneous Staging (New protocol) <ul><li>Different movements on individual teeth: </li></ul><ul><ul><li>Complex movements required by one tooth (i.e. rotation + root uprighting) are performed at the same time. </li></ul></ul><ul><ul><li>This usually ensures that the less predictable root movement is performed at a reduced velocity since it is taking place along the greater number of stages required by the easier crown movement. </li></ul></ul>
  8. 8. Simultaneous Staging (New protocol) <ul><li>Staging of multiple teeth per arch: </li></ul><ul><ul><li>All the teeth within each arch are moved together from the initial stage through the final stage. </li></ul></ul><ul><ul><li>The tooth that moves the most dictates the overall number of stages based on the maximum allowable tooth velocity. </li></ul></ul><ul><ul><li>Moving the other teeth simultaneously from the first to last stage reduces the velocity for all the other movements and increases their predictability without increasing the overall number of aligners. </li></ul></ul>
  9. 9. Tooth moving the most determines treatment length.
  10. 10. Upper Arch example Initial Final
  11. 11. Sequential Staging - Velocity (Old protocol)
  12. 12. Simultaneous Staging - Velocity (New protocol) 25% reduction in the number of stages!
  13. 13. Lower arch example Initial Final
  14. 14. Sequential Staging - Velocity (Old protocol)
  15. 15. Simultaneous Staging - Velocity (New protocol) 50% reduction in the number of stages!
  16. 16. Automatically handling of collisions, binding and IPR <ul><li>Movement is not allowed if software does not detect space. </li></ul><ul><li>IPR is programmed only on interproximal contacts. </li></ul><ul><li>Expansion and proclination are considered before IPR </li></ul>
  17. 17. Old IPR Staging Original position If IPR is done at this time, it will remove part of the lingual face in UL1(black mark) Final position – Lingual area that would be have to be removed by IPR needlessly since it keeps shifting as the teeth are rotating.
  18. 18. New IPR Staging Original position Proclination to place the interproximal contacts in a better relationship before IPR is allowed Same final position after doing the IPR and retracting the teeth
  19. 19. New Attachment Protocol
  20. 20. Attachments can be… <ul><li>Passive – Tooth doesn’t move: </li></ul><ul><li>Intrusion Anchorage </li></ul><ul><li>Aligner Retentiveness </li></ul><ul><li>Active – Tooth moves: </li></ul><ul><li>Rotations of round teeth </li></ul><ul><li>Root Control </li></ul><ul><li>Extrusion </li></ul>
  21. 21. Types of Attachments <ul><li>Align Technology has three type of attachments for commercial use: </li></ul>Beveled Ellipsoid Rectangular
  22. 22. Horizontal Ellipsoid Attachment <ul><li>Default for extrusions of anterior teeth </li></ul><ul><li>1 mm thick </li></ul><ul><li>Doctor can request on any tooth </li></ul>
  23. 23. Incisor Extrusions <ul><li>1 mm thick horizontal ellipsoid attachments on any anterior tooth that needs to be extruded </li></ul>
  24. 24. Vertical Rectangular Attachment <ul><li>Default for rotations of cuspids and bicuspids </li></ul><ul><li>Default for root control on extraction cases </li></ul><ul><li>1 mm thick </li></ul><ul><li>3 mm (default), 4 mm or 5 mm long </li></ul><ul><li>2 mm wide </li></ul><ul><li>Doctor can request on any tooth – very retentive </li></ul><ul><li>Doctor can request beveled option </li></ul>
  25. 25. Cuspid & Bicuspid Rotation <ul><li>1 mm thick vertical rectangular attachments on cuspids and bicuspids that are rotating </li></ul><ul><li>Optional on other teeth </li></ul>
  26. 26. <ul><li>1 mm thick vertical rectangular attachments on the two teeth adjacent to the extraction site </li></ul>Lower Incisor Extraction
  27. 27. Bicuspid Extraction 1 mm thick vertical rectangular attachments on the two teeth distal and one tooth mesial to the extraction site
  28. 28. Rectangular Attachments <ul><li>Problems with rectangular attachment </li></ul><ul><ul><li>They don’t always engage as intended </li></ul></ul>Unintended forces
  29. 29. <ul><li>Optional vertical beveled attachment for rotation (Doctor request) </li></ul>Beveled Attachment concept
  30. 30. Horizontal Beveled Attachment <ul><li>Default on first bicuspids as anchorage for anterior intrusion </li></ul><ul><li>Beveled incisally (default) </li></ul><ul><li>Doctor can request on any tooth for aligner retentiveness or extrusion </li></ul><ul><li>Easier to insert and remove aligner </li></ul>
  31. 31. Anterior Intrusion Anchorage Anterior Intrusion Anchorage provided by horizontal beveled attachment on first bicuspids Horizontal beveled attachments bilaterally on the first bicuspids to provide anchorage for anterior intrusion
  32. 32. If bicuspids are rotated… Vertical rectangular attachments will be used instead on both bicuspids to provide anchorage for anterior intrusion if they are rotated Anterior Intrusion Anchorage provided by vertical rectangular attachment on rotated bicuspids
  33. 33. <ul><li>Beveled incisally </li></ul><ul><li>(Default) </li></ul>Horizontal Beveled - Orientation Beveled gingivally (Doctor request) 1 mm 0.25 mm 0.25 mm 1 mm
  34. 34. <ul><li>Vertical Rectangular 1mm prominence </li></ul><ul><li>Placement on two teeth distal and one mesial to the extraction site </li></ul><ul><li>Vertical Rectangular 1mm prominence </li></ul><ul><li>Placement on two teeth adjacent to the extraction site </li></ul><ul><li>Horizontal ellipsoid 1mm of prominence </li></ul><ul><li>Default position for extrusion attachments is between the cervical and middle third of the tooth </li></ul><ul><li>Horizontal beveled incisally 1 mm prominence </li></ul><ul><li>Attachments will be placed bilaterally on the first bicuspids </li></ul><ul><li>Vertical Rectangular is placed instead if bicuspid is also rotating </li></ul><ul><li>Vertical Rectangular 1mm prominence </li></ul>Description for default size and placement Bicuspid extractions Rotations of cuspids & bicuspids Anterior intrusions Lower incisor extractions Anterior extrusions Situation: Default Attachment Placement Summary Always review ClinCheck using the Superimposition Tool to determine if attachments are placed on teeth that might need them
  35. 35. By Doctor Request ONLY! Doctor may request 1 mm thick Vertical Rectangular attachment for mesio-distal root tip. Root Tip Doctors may request attachments when retention/anchorage is a concern during certain movements or conditions i.e. expansion or short clinical crowns More than two vertical rectangular attachments per quadrant may provide too much aligner retention. Aligner Retentiveness Doctors may request attachments be added starting at stage 2 so the patient can first get comfortable in placing and removing aligners with first set without the added retention the attachments provide. Patient Comfort Align does not place attachments on all extrusions by default. Doctor may request attachments for extrusions not included in default. Extrusions of other teeth Doctor may request attachments for rotations not included in default. Incisors generally do not need attachments for rotation. Rotation of other teeth Description Situation Doctor may request Horizontal Beveled attachments placed on the incisal third of upper anterior teeth for bucco-lingual root torque to prevent aligner dislodgment. Root Torque Always review ClinCheck using the Superimposition Tool to determine if attachments are placed on teeth that might need them
  36. 36. Making Invisalign work better… Clean up your Treatment Preferences in order to get consistent quality setups!
  37. 37. Clean up your Tx preferences! <ul><li>Old Treatment preferences often conflict with the automated Best Practices Clinical Protocols. </li></ul><ul><li>View the initial ClinCheck set up with automated protocols for consistent quality. </li></ul><ul><li>If needed, modify the initial ClinCheck to address specific problems or preferences. </li></ul><ul><ul><li>Technicians will tend to use automated protocols instead of complicated Tx preferences for initial setups. </li></ul></ul>
  38. 38. Thank you!

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