Invisalign in Pediatric Dentistry: A Guide

INVISALIGN IN
PEDIATRIC DENTISTRY
Dr Ramesh R
Dept of Pedodontics &
Preventive Dentistry

REFERENCES
1. Mcdonald & Avery dentistry for child & adolescence 10th edition
2. Clear aligner technique, Sandra tai, 2018, quintessence publishing co, inc
3. Orthodontics current principles and techniques –Graber, Varnsdall,vig
4. Textbook of orthodontics- William R profitt
5. Pediatric dentistry infancy through adolescence, Cassamassimo, 5th edition
6. Pediatric dentistry A clinical approach, 2nd edition, Goran koch & Sven
poulsen
7. Pediatric dentistry, Richard welbury & Monty duggal, 5th edition
8. The insiders guide to Invislign treatment- Barry J glasser
9. Drastic plastic: Enhancing the predictability of clear aligners- S. Jay
bowman
10. Invisalign instruction manual –Mcgill university
11. Aligner Bio-mechanics - Orthodontic clinical education corp.
12. Web reference: www.Alignerinsider.Com

CONTENTS
1. Introduction
2. Definition
3. History of the orthodontic appliance
4. Indication
5. Contraindication
6. Advantages
7. Disadvantages
8. Biomechanics of clear aligners
9. Steps in clear aligner treatment
10. Case selection for clear aligner treatment
11. Clincheck software design
12. Digital workflow and monitoring
treatment
13. Finishing, and retention
14. Resolution of crowding
15. Journals

INTRODUCTION
1. Clear aligner technique, Sandra tai, 2018, quintessence publishing co, inc
2. Orthodontics current principlesand techniques–Graber, Varnsdall,vig

DEFINITION
Orthodontic treatment method based on the usage of custom made,
removable, clear, semielastic polyurethane aligners that needs to be
interchanged every two weeks for a period of six to eighteen months
Introduced by Align Technology, Santa Clara, Calif.
Invisalign takes the principals of kesling and raintree essix even further,
using CAD CAM technology compared with laboratory techniques
Meier B, Wiemer KB, Miethke RR. Invisalign: patient profiling— analysis of a prospective survey. J Orofac Orthop
2003;64(5):352-8

HISTORY
• 1945, Peter kesling suggested moving of teeth without bands, brackets and
wires using thermoplastic tooth positioners
• 1964, Nahoum - vaccum formed dental contour appliance
• 1971, Pontiz & 1985, Mcnamara wrote about types of overlay appliances
such as invisible retainer
• 1993 a technique developed by raintree essix, New orleans, la - minor
tooth movements.
Mcdonald & Avery dentistry for child & adolescence 10th edition

ESSIX RETAINER
• This technique uses clear aligners
formed on plaster models of teeth
• The aligners are modified with “devots”
by special heated pliers which produce
forces to push on individual teeth, and
windows to create space for the teeth to
move.
• This type of appliance can correct only
mild discrepancies

 Scheau et al proposed the first thermoforming machine to synthesize
orthodontic appliances in 1966.
Currently 2 types of thermoforming machines:-
The Ministar and Biostar (Scheau Dental)

Kesley wirth and Zia chisti, two MBA students from Stanford university, founded
Align Technology in April 1997.
Today the company is based in Santa clara, California, employs over 800 employees
and has subdivisions in Europe, Mexico and Costa rica

• In 1997, clear aligners from align technology made of a new tripolymer plastic and
make use of optimized attachments used 3D computer imaging graphics to the field
of orthodontics.
• Clear aligner technology represents a revolutionary, transformational change in
orthodontics that challenges the conventional thinking of how orthodontists move teeth.
• Clear aligners have already evolved since they were released to the market in 1999.
• At beginning these were considered for the treatment of class i cases with minor
crowding, resolved primarily with interproximal reduction.
• However, in this 21st century of digital technology, the clinician must now learn to
apply principles of orthodontics to the field of clear aligner technique.
Align Technology, Inc. http://www.aligntech.com/. Accessed 5 February 2018

• The teeth are moved according to sophisticated computer algorithms developed
in the software program.
• There are many clear aligner systems being developed all over the world, and it is
evident that this will be the future of orthodontics.
• It is important to understand that clear aligner treatment is a technique, not a
product.
• There is a common misconception that clear aligners are a “compromise”
orthodontic appliance that is only capable of minor tooth movement.
•
• However, the clear aligner system of today is a comprehensive orthodontic
appliance, capable of treating a wide range of malocclusions.
Ali SA, Miethke HR. Invisalign, an innovative invisible orthodontic appliance to correct malocclusions: Advantages and
limitations. Dent Update 2012;39:254– 256,258–260.

• Before a single tooth is moved, the correction of the malocclusion is
visualized through a series of tooth movements made on a software
program and the final occlusion designed into the treatment
outcome.
• This requires a paradigm shift in the thought process from being a
reactive pediatric orthodontist to being a proactive pedodontists.
1. Li W, Wang S, Zhang Y. The effectiveness of the Invisalign appliance in extraction cases using the ABO model grading
system: A multicenter randomized controlled trial. Int J Clin Exp Med 2015;8:8276–8282.
2. Djeu G, Shelton C, Maganzini A. Outcome assessment of Invisalign and traditional orthodontic treatment compared
with the American Board of Orthodontics objective grading system. Am J Orthod Dentofacial Orthop 2005;128:292–
298.

INDICATION
1. Class I spacing with minor/moderate crowding and existing good buccal
occlusion
2. Class II malocclusion with minor crowding
3. Class III with minimal overbite/overjet non-extraction cases
4. Skeletal & dental anterior open bite
5. Deep bite
6. Posterior cross bite
7. Highly placed canine/ palataly locked canine
8. Lower incisor extraction
9. Bimaxillary protrusion
10. Premolar extractions with minor crowding

CONTRAINDICATION
High risk caries individual
Lack of self motivation in wearing the appliance

ADVANTAGES
• Esthetics
• Comfort
• Detachable
• No bonding to enamel defects
• No root resorption
• Less pain and discomfort
• Better hygiene
• Can be used with any restoration
or crown
• Doesn't alter speech
• Less chair time and
armamentarium
• Good vertical control
• Precise control of each tooth
• Controls bruxism
• Bleaching during treatment

DISADVANTAGES
• Inconsistency between computer prediction and actual tooth
movement in Invisalign treatment always limits clinical judgment
• Long terms studies including clinical controlled trials & RCTs are
lacking evaluating the strength, performance and longevity of the
appliance.
• Very high cost
• Inter proximal reduction
• Need for clinical experience
Tsai MH, Chen SS, Chen YJ, Yao JC. Treatment Efficacy of Invisalign: Literature Review Update. Taiwanese Journal of Orthodontics.
2020;32(2):1.

STEPS FOLLOWED:
1. Obtain impression /intraoral scan
2. Clin check software diagnosis & treatment planning
3. Evaluate staging of treatment
4. Delivery of set of trays
5. Monthly check up
6. Refinement
7. Retention

IMPRESSION
ADDITION SILICONE 3 M TRIOS INTRAORAL SCANNER

BIO MECHANICS OF ALIGNERS
• FORCE
• ENGEGEMENT
• ANCHORAGE
• EXTRUSION
• INTRUSION
• TORQUE
• ROOT INCLINATION

COMPARISON BETWEEN EDGEWISE APPLIANCES
AND CLEAR ALIGNERS

FORCE, ENGAGEMENT, AND ANCHORAGE
FORCE
• Fixed appliance exert pull on teeth
while clear aligners push on teeth.

FIXED APPLIANCE CLEAR ALIGNERS
FORCE DEPENDS ON
FLEXIBILTY OF ARCH WIRE
& AMOUNT OF DEFLECTION
ALIGNERS DEFORMS OVER
THE TOOTH & ELASTICITY
OF IT PUSHES TOOTH IN
POSITION
ELASTOMERIC CHAIN
CONTRACTS & REBOUNDS
– SPACE CLOSURE
OPTIMIZED ATTACHMENTS
PROVIDE AN ACTIVE, FLAT
SURFACE THAT PUSH
AGAINST TO EFFECT TOOTH
MOVEMENTS
Gomez JP, Peña FM, Martínez V, Giraldo DC, Cardona CI. Initial force systems during bodily tooth movement with plastic
aligners and composite attachments: A three-dimensional finite element analysis. Angle Orthod 2015;85:454–460.

ENGAGEMENT
FIXED APPLIANCE CLEAR ALIGNER
Engage teeth via an archwire ligated into the
bracket slot
Engage teeth by having aligner material
wrapped around teeth.
Thicker and more rigid the archwire, the
better the engagement
More aligner material wrapped around a tooth,
the better the engagement
Archwire that approximates the size of the
bracket slot, the tip, torque, and in-and-outs that
are built into the bracket slot
Long clinical crowns and larger surface area,
there is better engagement and therefore better
expression of tooth movement & vice versa
Increase the engagement of the aligner onto
teeth with small morphology—for example,
peg-shaped lateral incisors—is to place an
attachment on the tooth.

ANCHORAGE
FIXED APPLIANCE CLEAR ALIGNER
Reciprocal anchorage based on newton third
law of motion
Anchorage segment predetermined and change
at each stage of treatment
1 segment of teeth act as anchorage unit for
other
Offer extremely good control of anchorage
because the anchorage teeth made immovable at
different stages of treatment.
Premolar extraction case- root surface area of
post teeth more than ant so ant segment retarct
more than post. If post teeth move forward
than ant-loss of anchorage
In the staging of sequential distalization of the
maxillary arch, only the second molars are
distalized in the initial stages of treatment.
In extraction cases this loss of anchorage taken
into account by the clinician when treatment
planning extraction cases to ensure that the
buccal occlusion finishes in a cusp-to-fossa
relationship in the final occlusion.
The remaining teeth in the arch from first molar
to first molar do not move in the initial stages
and act as an anchorage segment to push the
second molars distally for anteroposterior
correction

• In this respect, clear aligners offer extremely good control of
anchorage because the anchorage teeth may be made immovable at
different stages of treatment. For example, (Fig 2-6)

• In the first premolar extraction
protocol (Align Technology), for
maximum anchorage, only the canines
and posterior teeth move in the initial
stages of treatment.
• The incisors do not move, and they act
as an anterior anchorage segment to
distalize the canine into the extraction
site for space closure.
• At a certain stage in treatment, the
second premolar and molars stop
moving, and they become the posterior
anchorage segment as the canines and
incisors are retracted for the remainder
of the extraction site closure

EXTRUSION, INTRUSION, TORQUE, AND
ROOT INCLINATIONS

• Extrusion of a single tooth is a
moderately difficult tooth
movement for clear aligners.
• Auxiliary treatment such as buttons
and elastics have to be placed to
assist with single-tooth extrusion.
• Extrusion of groups of teeth can be
performed successfully with clear
aligners

INTRUSION
• In clear aligner treatment, entire
segments of teeth may be
intruded successfully, or selective
intrusion of individual teeth be
programmed to correct an occlusal
cant or level out gingival margins.
• This may be performed without
concurrent extrusion of the
posterior segments if so desired.
• As a result, clear aligners offer
extremely good vertical control.

Anterior intrusion is programmed to level out the curve of spee in the
mandibular arch to correct a deep bite

Posterior intrusion is programmed to create occlusal clearance after the
posterior teeth have hypererupted.

TORQUE
• Clear aligners very efficient in manging
torque
• power ridge feature for lingual root
torque
• Excessive torque undesirable in cases with
mild incisor protrusion. (non extraction
case)
• Additional torque – extraction case
Archambault A, Lacoursiere R, Badawi H, Major PW, Carey J, Flores-Mir C. Torque expression in stainless steel orthodontic
brackets. A systematic review. Angle Orthod 2010;80:201–210.

ROOT INCLINATIONS
• Long, vertical rectangular
attachments will offer control of root
inclinations as well.
• In lower incisor or premolar extraction
cases, virtual gable bends ensure
careful management of root
inclinations as the extraction spaces
are closed

 Optimized root control attachments offer control of root
inclinations
Cai Y, He B, Yang X, Yao J. Optimization of configuration of attachment in tooth translation with transparent tooth correction
by appropriate moment-to-force ratios: Biomechanical analysis. Biomed Mater Eng 2015; 26(suppl 1):S507–S517.

INCISOR INCLINATION
• Excellent control of incisor inclination.
•
• ClinCheck prescription form - no
proclination is desired can be included
• The labiolingual pre- and posttreatment
positions of the maxillary and
mandibular incisors will be monitored
using the superimposition tool in the
posttreatment occlusion
Isaacson RJ, Lindauer SJ, Davidovitch M. On tooth movement. Angle Orthod 1993;63:305–309.

VERTICAL CONTROL
• Excellent vertical control in cases with
minimal overbite and overjet.
• The occlusal coverage of the aligners on
teeth as well as the ability to program
intrusive mechanics into the treatment
plan allow for leveling and alignment
with excellent control of the vertical
dimension.

MIDLINE CORRECTION
• Midline correction with clear
aligners is more predictable
• Interproximal reduction(IPR)
is commonly incorporated into
the treatment plan to correct the
dental midlines.
Isaacson RJ, Lindauer SJ, Davidovitch M. On tooth movement.
Angle Orthod 1993;63:305–309.

TOOTH SIZE DISCREPANCY
• In clear aligner treatment, the
treatment planning software
accurately calculates the tooth
size discrepancy and will resolve
it according to the clinician’s
preference
• Either by leaving space around
the lateral incisors
• By including interproximal
reduction in the opposing arch.
• This is decided at the treatment-
planning stage and built into the
final occlusion

CASE SELECTION FOR CLEAR ALIGNER
TREATMENT
1. Arch Length Discrepancies
2. Vertical Discrepancies
3. Transverse Discrepancies
4. Anteroposterior Discrepancies
5. Indications for Clear Aligner Treatment

TREATMENT OPTIONS RANGE FROM SIMPLE TO
COMPLEX WITH AN INCREASING LEVEL OF DIFFICULTY
• Mild crowding may be simple to resolve
• As the degree of crowding increases, the degree of difficulty in
treating the case also increases.
• Premolar extraction treatment is an advanced case with clear aligner
treatment

1. Pediatric dentistry infancy through adolescence, Cassamassimo, 5th edition
2. Pediatric dentistry A clinical approach, 2nd edition, Goran koch & Sven poulsen

CLEAR ALIGNER WITH HORSE JET APPLIANCE
FOR DISTALIZATION

The Horseshoe Jet is a miniscrew-supported
maxillary molar distalization appliance.
Miniscrews, inserted in the palatal alveolus,
provide anchorage for compressed coil springs to
push molars posteriorly without any anchorage
loss.
After distalization is complete, the setscrews are
tightened to stop further molar movement and the
appliance now serves as a miniscrew-supported
holding arch for subsequent retraction of the
remaining teeth.
BOWMAN et al, Adjuncts SA. Creative Adjuncts for Clear Aligners.

We can correct deep bites with the following:
1. Anterior intrusion
2. Posterior extrusion
3. A combination thereof
Clincheck list for guidance on criteria to correct this

• INCISAL DISPLAY —
intrusion of the upper anterior
teeth would be indicated in deep-
bite cases with super-eruption of
the upper incisors, but would be
contra-indicated in deep-bite
cases with insufficient incisal
display.
• GINGIVAL DISPLAY —
similar to incisal display, upper
anterior intrusion may be
beneficial in patients with
vertical maxillary excess (VME)
to reduce gummy smiles

• Gingival margins — intrusion or extrusion of key teeth improve the symmetry of
gingival margins. In patients with incisal wear and super-eruption of the worn
tooth, anterior intrusion would be indicated to level the gingival margins prior to
restoration of the tooth
• Smile arc — when working up Invisalign treatment plans, we endeavor to create
pleasing smile arcs where the curvature of the upper anterior incisal edges follows
the curvature of the lower lip. Anterior intrusion or extrusion is a primary
consideration in these cases
• Lower Curve of Spee — lower incisor intrusion and/or posterior extrusion are
key components to correcting deep over bites. Some deep-bite cases requiring bite
opening via posterior extrusion.
For example, in patients with:
Short lower facial heights
Restorative cases with loss of vertical dimension
Hypodivergent, skeletal deep bites CLII div.2 malocclusion

In cases where you deem deep overbite correction to have priority over
premolar rotation, substitute 4mm-wide, occlusally- beveled rectangular
attachments on the lower first and second premolars
These attachments provide additional “grip” to prevent the aligners from
lifting off posteriorly, and are very effective at supporting the intrusion of
the lower incisors.

• In deep-bite cases requiring posterior extrusion precision bite ramps act like
mini “bite plates” to disocclude the posterior teeth when wearing the aligners.
• If there is over-jet >3mm bite ramps are not effective — the lower incisors will
bite behind them
Deep-bite cases requiring posterior extrusion
1. levelling the lower curve of spee
2. Class ii, division 2 cases
3. Bite plate effect — another place to use precision bite ramps is as a bite
plate to facilitate correction of dental cross-bites. It may help to reduce the
trauma to the tooth in cross-bite as it’s moving through the zone of heavy
contact with the opposing dentition
• High angle case/long facial height and an excessive gingival display upon
smiling is not a candidate for precision bite ramps

OPEN BITE
We can correct Open Bite with the following:
1. Extrude the anterior teeth
2. Intrude the posterior teeth, or
3. A combination of the two.

Incisal display
anterior open-bite cases with insufficient incisal display may benefit esthetically from anterior extrusion,
patients with normal incisal display benefit from closure of the open bite via posterior intrusion.
Gingival display
anterior open-bite cases with insufficient gingival display would benefit esthetically from upper anterior
extrusion
Gingival margins
leveling gingival margins may be required in extrusion.
Smile arc
when an anterior open bite is related to a habit, the resultant reverse smile arc corrected with anterior
extrusion.

RELATIVE EXTRUSION OR INTRUSION
• These are predictable movements“invisalign free ride”
• Don’t need any specific attachments or major clincheck plan
modifications to achieve relative extrusion or intrusion.
• Relative extrusion achieved it by simply tipping teeth lingually; same
goes for relative intrusion
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;85:881–889.

ABSOLUTE EXTRUSION/INTRUSION
• More challenging movements with Invisalign treatment
• Evaluate Clincheck plan and recognize teeth that are absolutely
extruding or intruding.
In certain cases, absolute extrusion requires specific:
1. Attachment substitutions
2. Auxiliaries

Modified 4mm-long, gingivally-beveled,
rectangular attachment can be useful for
extrusion
Optimized extrusion
attachment.
ATTACHMENTS

Gingival - if we bevel attachments
gingivally less chance to encounter
failure mode.
Incisal - more “grip” where there will be a
90° ledge at the gingival aspect that will
engage the aligner.

AUXILIARIES
• Miniscrews and elastics in a
“sling” arrangement.
• Miniscrews were placed into the
maxillary dentoalveolus on both
the buccal and palatal and elastics
were worn across the aligners from
one anchor to the other to generate
posterior intrusion.
• Miniscrews were also placed in the
buccal alveolus in mandible and
buttons were bonded on the lingual
of the 1st molars.
• Elastics were “slung” from the
buttons to the miniscrews to assist
with aligner-directed intrusion

CASE REPORT 1
• 12-year-old female in the
late mixed dentition.
• Class ii, division i
malocclusion;
• Deep bite;
• Upper and lower crowding
and
• Severe lingual inclination of
the upper and lower anterior
teeth
• Lower incisor crowding.
• Her right and left lower
incisors are blocked out to
the lingual.
The insiders guide to Invislign treatment- Barry J glasser

Within normal limits
Mild hypodivergent skeletal pattern
Upright upper and lower incisors

TREATMENT PLAN
• Emma is a growing teen, and her Class II, Division I malocclusion was
corrected with Class II elastics.
• Her crowding resolved through a combination of posterior expansion and
anterior proclination.
• Transverse expansion was done resolve her crowding
• Expansion in the transverse dimension to gained arch length to resolve
her crowding, without the need to program any posterior buccal root
torque.
• The deep overbite correction was achieved via predictable relative
intrusion

CLINCHECK TREATMENT PLAN
• Precision-cut elastic hooks on lower 6’s,
and 3mm wide rectangular occlusally
beveled attachments on the lower 6’s for
retention
• The deep overbite was managed with
predictable relative anterior intrusion
achieved with proclination of the upper and
lower anterior teeth.
• The crowding was resolved through a
combination of anterior proclination and
posterior expansion
• These movements are predictable tipping
movements with invisalign clear aligners.

• Precision cut elastic hooks running off her upper 4’s because her upper
3’s were insufficiently erupted to place a precision cut.
• It would have weakened the aligner so placed on the 4’s.
• Class II elastics from upper 4 to lower 6 instead of upper 3 to lower 6
— it works just the same.

RESULTS
• At the end of treatment, well-aligned arches and malocclusion corrected to
Class I
• The final panoramic radiograph is within normal limits and her cephalometric
superimposition shows the planned proclination of the upper and lower
incisors
DISCUSSION
• As ,mentioned by Janson et.al. in systematic review maxillary first molar tends
to stay relatively the same antero-posteriorly as point A.
• The superimposition shows the “headgear effect” which may be achieved
with Class II elastics, growth of the mandible showing forward positioning of
pogonion and reduction of facial convexity.
• SUMMARY: Treatment time was 28 months, with two refinements and the
use of 2 oz. Class 2 elastics

Case 2
• A patient 14 years old presented with
a posterior dental cross bite on the
upper-right side.
• His arch was constricted with upper
anterior cross bite
Krishnan V. The insider's guide to Invisalign® Treatment
(2017). Journal of the World Federation of Orthodontists.
2017 Sep 1;6(3):139-40.

ClinCheck plan
• In cases anchor teeth there on either
side of the cross bite that are not in
cross bite
• for example, the UR7 and the UR3,
those teeth provide anchorage to move
the collapsed portion of the arch.

DISCUSSION
 Skeletal cross bites are a big red flag,
particularly in adults; they are unpredictable
to treat orthodontically non-surgically,
regardless of the appliance used.
 It is not recommended to correct a skeletal
cross bite on an adult patient with invisalign.
 Transverse discrepancy is corrected before
the patient enters into invisalign treatment
 In a prepubescent child pre-invisalign
rapid palatal expansion (rpe) is quite
predictable ie, before the onset of the pubertal
growth spurt, conventional phase 1 treatment
with rapid palatal expansion can pave way for
a more predictable invisalign result.

• In this case cross elastics to helped
with that movement.
• The clincheck plan depicted might be
a typical setup; here is a patient who
has a posterior cross bite on the right
side,
• button cutouts on the lower surfaces
of the LR6 and LR7, as well as on
the palatal surfaces of the UR6 and
UR7.
• Bond buttons on those surfaces as
well as the lower arch

For transverse dimension problems being
treated with invisalign clear aligners is over-
treatment is final consideration.
Over-treatment of the expansion from
mandibular constriction in the arch and
additional expansion in the maxillary arch.
A good rule of thumb in a case with a
unilateral cross bite would be 3mm of
additional expansion past ideal
Patient is now set up for success for two
reasons:
1. We use cross elastics to aid in the
movement.
2. We have overtreated the clincheck plan to
place additional forces on the teeth to achieve
the desired result
FINAL CLINCHECK STAGE

RESULT
 Shows very predictable movement and
good correction of the dental cross bite
on the upper-right side.
 When it comes to treating transverse
problems with Invisalign clear aligners, that
correction of dental cross bites is more
predictable than skeletal cross bites.
 The use of cross elastics and 2mm of
expansion over treatment will increase
the predictability of correction of transverse
dimension problems, reduce the number of
case refinements, and help achieve
excellent results.

1. Distalization of the upper posterior teeth.
2. Class II Elastic Jump - ClinCheck plan to simulate the effects of elastics on growing teen
patient.
3. Extraction of teeth, typically upper first premolars, to correct Class II Malocclusion.
4. IPR - performed in the upper buccal segments to create space for canine retraction into
Class I coupling of the incisors when the patient presents with overjet

Class III CORRECTION
• The non-surgical methods for CL III correction are elucidated on the
SAGITTAL section of the ClinCheck list:
CASE NO 3
Drastic plastic: Enhancing the predictability of clear aligners- S. Jay bowman

A 12-year-old female with Class III
Malocclusion, moderate upper and
lower crowding and traumatic occlusion
to her lower anterior teeth with anterior
cross bite.
Her treatment plan revolves around
treating her upper and lowers incisors to
Steiner’s Acceptable Compromise, to
compensate for the Class III skeletal
pattern.
additional proclination to the upper
incisors and allowed for additional
lingual tipping of the lower incisors to
compensate for the Class III skeletal
pattern, supported with CLIII elastics

Normal limits Class III skeletal pattern

CLINCHECK TREATMENT PLAN
• Square arch form in the maxilla and a v-
shaped arch form in the mandible.
• The occlusal view of the final clincheck stage
shows the coordination of the upper and lower
arch forms.
• Shows the anticipated improvement in the
occlusion via arch form change only,
without the need for a bite jump.
• Virtual bite turbos on LR1 and LL1. Virtual
bite turbos are conventional bite ramps built
into the aligners that helped disocclude the
anterior teeth to ease the jumping of the
anterior cross bite

PROGRESS
• After 8 months of treatment, her
occlusion has greatly improved,
• Significant improvement to her
anterior relationship.
• Upper incisors are still too upright
• she is displaying a posterior open-
bite because of heavy occlusal
contact in the anterior.
• No need to close the posterior open
bite by running posterior vertical
elastics —the reason she is
manifesting a posterior open bite is
because of heavy anterior contact.

REFINEMENT I
Additional 30-degrees of palatal root
torque on U2112 to relieve the heavy
occlusal contact
Precision-cut elastic hooks for cl iii
elastics
These two clincheck moves eliminate
the heavy anterior contact and
eliminate the posterior open bite

RESULTS
• Occlusal change comes from retraction
of her lower incisors into the leeway
space and proclination of her upper
incisors.
• These movements were enhanced by
light 2 oz. CL III elastics.
• The final occlusion was solid class 1.
• She also has nice tissue response on the
lower incisors by removing the
traumatic inclusion.

1. Cephalometric superimposition shows
2. Proclination of the upper incisors
3. Lingual tipping of the lower incisors, which is consistent
with her CL III skeletal pattern
 Three years into retention, there has been a small
degree of asymmetrical mandibular growth to the
left, but her occlusion is still holding up good

SUMMARY:
• Total treatment time was 19 months, 1 refinement, and 2 oz. elastics
LONG TERM FOLLOW UP:
• Three years into retention, there has been a small degree of
asymmetrical mandibular growth to the left, but her occlusion is good

INTERPROXIMAL REDUCTION
• The practice of mechanically removing enamel from between the teeth
to achieve orthodontic ends so as to correct crowding or reshape the
contact area between the teeth
• It is now widely accepted that 50% of the enamel is the maximum
amount that can be stripped without any dental and periodontal injury.
Pinheiro M, Martinho LR. Interproximal enamel reduction. World Journal of Orthodontics. 2002 Sep 1;3(3).

• Jhon Sheridan suggests that if 50% of inter-proximal enamel was removed
• 6.4mm of space could be generated from 8 buccal posterior contacts
(0.8mm/contact)
• 2.5mm of space could be created from 5 anterior contacts (0.5mm/contact)
• so the total space gained 8.9mm within the arch

• John Sheridan advocated air-rotor striping by use of 699L small
tapered crosscut fissure carbide bur with an extended cutting area.
• Finshing is done by polishing with carbide finshing burss,,finshing
diamond, polshing disc of hand held finshing strips

• Steiner states that for each millimeter of protrusion, the discrepancy is
reduced by 2 mm.
• Torque enlargement without protrusion permits a gain of 1 mm per 5°
of radicular palatal torque enlargement.

TYPES OF IPR AVAILABLE
1. Abrasive strips (Hudson et al)
1. Flex-view TM interproximal strips
2. Interproximal serrated strips:
2. Single/double sided diamond disc
(Paskow et al)
3. Flex-view TM snap-on finishing
discs
4. Single/double sided abrasive steel
strip (peck & peck et al)
5. Flexible solid honeycomb
6. Flex-viewTM mesh discs
7. Flexible diamond disc (Zachirsson
et al)
8. Air-rotor striping (john Sheridan)
1. Safe-tipped air-rotor stripping
(STARSTM) burs
9. Tooth stripper kit :
10. Incremental thickness gauge
11. Sheridan interdental space
measuring gauge
12. Contouring kit
13. Mini stripper
14. Cello stripper
15. Manual microcut

ARMAMENTARIUM
• Hand proximal strips
• Proximal slicing disc/ strips
Strauss TR 11 EF/TC 26EF/CD 57 F
• Guage
• Polishing stripes
• Fluoride gel

CLINCHECK SOFTWARE DESIGN
• The Evolution of Software Design and Attachments
• Attachments
• ClinCheck Plan Review
• Tips for Communication with the Technician
• Staging Tooth Movements in the ClinCheck Software
• Making Difficult Tooth Movements Clinically Predictable

EVOLUTION OF SOFTWARE DESIGN
• Simulates the tooth movement sequence into the final occlusion.
• Clear aligners, powerful digital treatment-planning tool utilize digital treatment planning
in a software program before a single tooth is moved.
• It requires a paradigm shift in the mindset of the clinician, who must now “begin with
the end in mind.”
• Digital treatment planning allows different treatment options to be set up in the software
program (eg, extraction vs nonextraction, leaving space open vs closing space, surgical
vs nonsurgical).
• Each treatment option may be visualized in terms of length of treatment time, degree of
difficulty of tooth movements, and treatment outcome.
• Additionally, the ability to visualize the treatment outcome is invaluable in orthodontic-
restorative treatment plans that require interdisciplinary management.
• In the early days of clear aligner technology 20 years ago, most clinicians understood
clear aligners to be capable of simple tooth movements that required interproximal
reduction (ipr) to resolve crowding and align the dentition.

ATTACHMENTS
The principle of aligner engagement is aligner material wrapped around
teeth. If the tooth is fully registered on the digital scan or impression, then
aligner material covering the occlusal, buccal, lingual, mesial, and distal
aspects of the tooth will engage the tooth and cause it to move.
Attachments may be classified into two categories:
(1) Conventional attachments and
(2) Optimized attachments

OPTIMIZED ATTACHMENTS
• Automatically placed by the software when it detects certain thresholds of
tooth movement to control the point of application of force, the direction of
the force, and the amount of force applied, which is customized for each
individual tooth.
• Have an active surface that varies in geometry based on the unique
morphology of each tooth.
• Aligner is designed at a more acute angle than the active surface on the
attachment in order to exert a force on the active surface to move the tooth
in the desired direction.

• Therefore, the size of the attachment on the tooth will be different than the size of
the space in the aligner for the attachment.
• For this reason, if an optimized attachment needs to be replaced midway through
treatment, the clinician will have to use the original attachment template or order a
replacement attachment template to rebond the attachment as opposed to using the last
aligner
• Are customized individually for each tooth using the concept of biomechanics.
• Are engineered for a variety of tooth movements, and they are placed automatically by
the software.
• It is important to note that they cannot be requested.

OPTIMIZED ROTATION ATTACHMENTS
• Are optimized attachments for
rotation of canines and premolars.
• In case of a rotated maxillary canine,
there is an optimized rotation
attachment placed on the canine
with the active surface of the
attachment oriented to allow the
aligner to place the correct force
system to achieve correction of the
rotation.

• The active surface is oriented in the
proper direction so the aligner can place
the appropriate forces on this tooth to
achieve the desired movement, which in
this case is distal-in rotation along with
distal root tip
• The aligner shape is activated, which
means it changes at each stage to
maintain the force system at the
appropriate levels
• Achieved effective rotation with the use
of optimized rotation attachments.

OPTIMIZED EXTRUSION ATTACHMENTS.
• In case of anterior open bite where absolute extrusion of the upper incisors needed.
• The active surface of this attachment is oriented in such a way as to allow the force
system of that aligner to be perpendicular to the active surface of the attachment to
achieve extrusion of these teeth and closure of the open bite.
• May be on single teeth or groups of teeth when multiple extrusions are required
Web reference: www.Alignerinsider.Com

OPTIMIZED ATTACHMENT FOR ROOT CONTROL
• OPG reveals congenitally missing
the UL2.
• The treatment plan revolves around
distalizing the upper canine to
prepare a space for an implant.
• This movement is challenging, and
have crown and root movement at
the same time.
• Will help put the appropriate force
system on the ul3 to achieve bodily
movement to prepare a space for a
future implant.

• The force systems being applied to the
UL3 are not a couple, meaning that the
aligner is not placing equal and opposite
forces on this attachment.
• The forces are modulated to give the
desired tooth movement.
• the larger distal force is acting on the
gingival attachment and a smaller mesial
counter force is acting on the incisal
attachment
• These forces are adjusted automatically
to achieve bodily movement or root
movement depending on the case.

MULTIPLANE
• Attachments on maxillary lateral incisors when root movement and extrusion
are simultaneously required

SUPPORT
Invisalign G5 introduced optimized deep-bite attachments for premolar
teeth to support leveling of the lower curve of spee.
Invisalign G7 introduced optimized maxillary lateral support
attachments when absolute intrusion of either the maxillary central incisors
or maxillary canines is required.

CONVENTIONALATTACHMENTS
Passive attachments that increase the engagement of the aligner onto the tooth.
 Act as handles for the aligners to move teeth.
 Attachments may be placed on teeth by default through the software, by written request to
the software technician, or by using the “drag and drop” feature on the 3D controls.
TYPES
1. Ovoid,
2. Rectangular,
3. Beveled or non-beveled, and
4. Oriented horizontally or vertically.
USES
1. Aligner retention and anchorage,
2. To support intrusion,
3. Extrusion or
4. Root torque control.

RECTANGULAR ATTACHMENTS
are passive attachments and may be vertical or horizontal
VERTICAL RECTANGULAR
• Useful for root control
• used in lieu of optimized root control
attachments where the software is
unable to place them due to conflicts in
the software program.
• By default, the software program does
not place attachments on the
mandibular incisors for root control,
except in lower incisor extraction cases.
• Significant root tip to correct root
inclinations on the mandibular
incisors
HORIZONTAL RECTANGULAR
• Used for root control,
• Particularly in the buccolingual
dimension to correct buccal root
torque on molars.
• Used where a short clinical crown or
occlusal interference does not allow
placement of a vertical rectangular
attachment

BEVELED ATTACHMENTS
• Both the vertical and horizontal attachments can be beveled.
• The beveled surface is the active surface.
• The bevel provides a flat surface for the aligner to push against to effect
the desired tooth movement.
• For extrusive tooth movements on posterior molars, a horizontal
attachment that is beveled on the gingival will be effective.
• For intrusion, use a horizontal attachment beveled on the occlusal

 GINGIVALLY BEVELED RECTANGULAR
The bevel is sloping toward the gingival aspect of the tooth.

OCCLUSALLY BEVELED
The bevel is slanting toward the occlusal surface.
1. This type of attachment is used for aligner retention
2. To support leveling of the curve of spee
3. To support absolute extrusion on posterior teeth

VERTICAL ATTACHMENTS
• Can be beveled either mesially or distally
• Used for root control.

RECTANGULAR ATTACHMENTS
• Can be placed vertically or horizontally.
• These conventional attachments acted
as “handles”
• To increase aligner engagement to
move teeth or control root inclinations

ELLIPSOID ATTACHMENTS
• Only attachments available were
ellipsoidal in shape
• When the tooth surface area is
limited
• Labial surface of maxillary lateral
incisors or the lingual surface of a
lingually inclined mandibular
second molar
• Primarily for anchorage purposes.

CUSTOMIZED CONVENTIONALATTACHMENTS
• Resized attachments by either 3, 4 or 5mm in length.
• Change the orientation of the attachment either by rotating the
attachment in any direction we want.
• Push the attachment into the tooth by clicking on it
• Grabbing the black line to push the attachment in or out of the tooth to
change the orientation of the attachment through rotation.

RULES OF THUMB
• Here are two important rules of thumb when placing conventional
attachments on teeth:
1. Horizontal attachments for vertical movements - use these
attachments when placing attachments for vertical tooth movements
Drastic plastic: Enhancing the predictability of clear aligners- S. Jay bowman

2. Vertical attachments for horizontal movements
• These attachments will support the horizontal translation of the teeth.
• When horizontal movement is desired, think vertical attachment

RETENTIVE ATTACHMENTS
• For additional aligner retention
• For example, when treating with class II elastics off precision-cut elastic
hooks on the lower first molars
• Placement of an occlusally beveled rectangular attachment on the
mesial surface of the molar provides additional retention to prevent the
aligner from dislodging as a result of the vertical vector of force from
the class 2 elastic

CLINCHECK SOFTWARE PLAN
REVIEW
• The ClinCheck software plan is generated when the clinician evaluates the
orthodontic records, makes a diagnosis of the malocclusion, and formulates a
treatment plan.
• The treatment plan for that individual patient is then communicated to the
software technician by filling in a prescription form that prescribes the tooth
movements and treatment objectives for that individual patient.
• The software program then generates a simulation of the tooth movements into
the final occlusion.
• The clinician reviews the ClinCheck software plan, makes modifications to the
plan, and then approves the final plan. Upon approval, the aligners are
manufactured. The clinician then has to clinically execute the plan to treat the
case to the planned final occlusion
• The ClinCheck plan may be reviewed systematically in the following manner
Aligner Bio-mechanics- Orthodontic clinical education corp.

• The software used by the orthodontist in the office is called clin
check.
• It allows the orthodontist to view the treatment in all the aspects as
well as superimpose one stage of treatment over another to visualize
individual tooth movements so as to gauge the probability of
accomplishing the desired movement that will be biologically
feasible.

powerful digital treatment-planning tool

MONITORING TREATMENT
Checklist for the clear aligner adjustment appointment:
1. Patient compliance
2. Oral hygiene
3. Tooth tracking
4. Interproximal contacts
5. Actions required for this appointment
6. Fit of next aligner
7. Appointment conclusion
Invisalign instructionmanual –Mcgill university

FINISHING TECHNIQUES
• Clear aligner cases should be finished to the same standard of
excellence as those treated with fixed edgewise appliances.

DIMPLE AND THERMAL PLIERS
• Due to a lag in tooth movement
result in a difference between the
intraoral position of the tooth and the
tooth position in the aligner.
• The elasticity of the aligner material
also sometimes leads to distortions in
the aligner itself, resulting in less
pressure on the tooth to move it
into position in the final stages of
treatment.
• Align technology has a simple
detailing plier that creates pressure
points or dimples in the aligner that
will nudge teeth into positions already
built into the aligner

• Horizontal plier is an instrument
designed to accent labial or lingual
torque for individual teeth, and it
can also be used to simply increase
the retentiveness of clear aligners or
retainers.
• Horizontal plier is used to reduce
“lag” by accenting extrusive or
intrusive movement by applying
contact points immediately adjacent
to composite attachments

• In the last 3 stages of treatment, the clinician should be able to assess if
treatment will be finished after aligner wear is completed or if the
patient will require additional aligners
• In certain cases, finishing bends in the last few aligners may finish the
case without the need for additional aligners.
• Therefore, it is recommended that patients be seen when they have
approximately three aligners left in active treatment so that finishing
bends may be made in these last few aligners, if necessary to complete
treatment

• Raintree Essix also has a series of
pliers that make various
indentations into the aligner for
tooth movement.
• These pliers require preheating to
175°F to 200°F prior to use
•
• Hu-Friedy has a series of four
pliers that enable the clinician to
make precision-cut hooks, button
cutouts, vertical indentations, and
horizontal indentations in the
aligner

VIRTUAL C-CHAINS
• Virtual c-chains tighten anterior contacts from canine to canine only
• Virtual c-chains set as a preference under Global Clinical Preferences in the
ClinCheck software program, every patient receives 3 virtual c-chain aligners at
the end of active treatment.
• If there are open posterior contacts, particularly in extraction cases, then full-arch
virtual c-chains ordered to tighten up these posterior contacts.
• If the last aligner fits well, virtual c-chains can be ordered as additional aligners
without taking a new digital scan or impression

RETENTION
• If Vivera (Align Technology) is the
retainer of choice, they may be
ordered online without a new digital
scan or impression if the last aligner
fit well.
Retainers may be fixed or removable.
1. Removable retainers include
Hawley retainers, clear vacuum-
formed retainers, and Vivera
retainers.
• Clear vacuum-formed retainers
with full palatal coverage considered
in cases where there has been
maxillary arch expansion.

WEAR TIMING
Carroll KM. Investigation into the significance of daily Invisalign tray
wear duration
(Doctoral dissertation, The Ohio State University).
Decreasing wear time led to decreases in certain incisor movements.
Wearing aligners for 22 h daily seems to be the best protocol to
maximize achieving planned tooth movement.

2. Fixed retainers are usually wires bonded on the lingual surfaces of
the maxillary and/or mandibular anterior teeth
A general guideline may be that the longer the treatment time, the
greater the stability.
• If the orthodontic treatment completed in short time - full-time retainer
• If the orthodontic treatment was completed over several years - part-
time retainer wear
• The clinician should monitor to ascertain the individual patient’s
potential for relapse and the stability of the final occlusion

INSTRUCTIONS TO PATIENT
• Insert using finger pressure.
• Bite all around with chewie or bite stick.
• Massage gum lines all around to ensure no visual gap or saliva bubbles between
Flexalign and teeth.
• Remove aligner always from the back, preferably from tongue side.
• Apply direct up or downward pulling force cautiously to remove the aligner.
• Avoid twisting force.

• Wear Felxalign for minimum 22 hours /day
• Remove Flexalign when eating or after sugary beverages
• Clean or rinse teeth before wearing them
• When Flexalign do not fit properly(visual gap or bubbles), even after
wearing cycle has finished , wear for 1 more week
• If Flexalign don’t fit properly come with last fitting aligner and next few
aligners

ALTERNATIVES AVAILABLE IN INDIA
1. Clear path Dental
2. Clear bite aligners
3. Flexalign

USE OF CLEAR ALIGNERS IN OPEN BITE CASES: AN
UNEXPECTED TREATMENT OPTION
Giancotti et al
JOURNAL OF ORTHODONTICS, 2017
http://dx.doi.org/10.1080/14653125.2017.131144
CASE NO 4

INTRODUCTION
• In recent years, the introduction of temporary anchorage devices (tads)
has expanded the possibilities of orthodontic treatment beyond
traditional limitations of tooth movement and has made it possible to
correct anterior open bites with orthodontic treatment alone
• In this case report how, through a proper diagnosis and a good
knowledge of biomechanics, it is possible to correct an anterior open
bite by using aligners without surgery, tads, or fixed appliances.

• A 14-year-old female patient was referred
with a chief complaint of anterior open
bite.
• She had been previously treated by
orthodontic fixed appliance without
achieving any satisfactory results in terms
of open bite resolution.
• The clinical examination showed bilateral
molar and canine class ii relationship and
an anterior open bite
• Moreover, she presented with proclination
of the upper incisors with increased
overjet, slight excess of posterior dento-
alveolar heights as well as downward and
backward mandibular rotation
• Upper and lower midlines were
coincident.

Lat Ceph
1. The patient was diagnosed with a
class II dento-skeletal malocclusion
(a-n-pg 6°)
2. Skeletal open bite (SN/GO-GN
34°),
3. Excessive lower anterior facial
height
4. Short upper anterior facial height.
5. Convex profile
6. Incompetent lips at rest
7. Mentalis and lip strain

TREATMENT OBJECTIVES
1. To close the anterior open bite by counter clockwise rotation of the
mandible
2. To improve dental exposure by correcting upper incisor inclination
3. To reach a class I molar and canine relationship as well as a normal
overjet
4. To balance the facial profile

• Given the mild skeletal discrepancy, a combination of orthodontic and
orthognathic surgical treatment was not considered.
• Another option could have been through intrusion of the posterior
maxillary dentition using TADs as skeletal anchorage, allowing maxillary
molar distalisation to correct the Class II malocclusion with fixed appliances.
• The selected treatment involved the use of clear aligners combined with
Class II mechanics.
• Moreover, the patient was informed of the fact that her cooperation would be
a critical factor to achieve success with the aligner treatment.

In order to reach a correct anterior relationship and to close the bite, the
treatment plan was based on the following three pivotal points:
1. align and level both the arches;
2. maintain the vertical position of upper molars and promote the
counter clockwise rotation of the mandible;
3. correct the Class II molar relationship by means of derotation of the
upper molars and Class II elastic

• A series of 40 aligners for the upper arch
and 18 for the lower one were planned
• After initial alignment,
• Correction of mesial rotation of the first and
second upper molars to gain 2 mm of space.
• Second planned step was the expansion of
the maxillary arch to distalisation of the
bicuspids and cuspids into Class I
relationships, in addition to arch form
coordination.
• The third step was based on sequential
distalisation by using the force of the
aligners and mechanics of Class II inter-
maxillary elastics, from the first lower
molars to upper canines, to ‘push’ the
molars, bicuspids and canines towards a
Class I relationship.
• A ‘relative’ extrusion of front teeth
occurred during their retraction and
favoured the overbite normalisation

• Class II correction in a growing patient is derived primarily from the
interruption of dentoalveolar compensation (whether from headgear,
elastics, functional appliances, or distalization)
• Sequential molar distalization supported by elastics, as advocated by
Daher, is a logical strategy that has proven successful with aligners
Daher, S.: Dr. Sam Daher’s techniques for Class II correction with Invisalign and elastics, Align Technology, Santa Clara, CA, 2011
[cited July 1, 2013], s3.amazonaws.com/learninvisalign/docs/06840000000GHgmAAG.pdf

• The treatment was completed after 24 months.
• The patient was seen every 6 weeks to check
aligner fit, attachment stability and compliance.
• The final result showed good alignment and
occlusion
• After 24 months of therapy, treatment objectives
set in the pre-treatment plan were achieved.
• The superimposition of the initial and final
cephalometric tracing showed a counter clockwise
rotation of the mandible responsible for the
correction of anterior open bite and Class II
malocclusion.
• The pre/post cephalometric superimposition
showed that treatment had maintained the vertical
position of maxillary molars, thus favouring a
counter clockwise rotation of the mandible,
promoting the Class II and anterior open bite
correction.
• The skeletal Class II jaw base relationship
changed to a Class I relationship, and the
mandibular plane angle was maintained
• After active treatment, the patient also featured a
harmonious straight type profile a Class I molar
relationship had been established.

DISCUSSION
• Clinicians have always thought that aligners, for their biomechanical
characteristics, are not the ideal tools for treating open bite.
• Yet, this paper shows that it is possible to correct dental–skeletal open bite
by using aligners with a proper diagnosis and treatment planning.
• Aligners allow an optimal vertical control and can determine molar
intrusion by bite-block effect of two layers of aligner material between
the dentition for 22 hours/day for 18–24 months and thereby subsequent
minimal autorotation of the mandible and improvement of skeletal open
bite.
• The maxillary superimposition shows the reduction of proclination and
moderate extrusion of the incisors that were initially above the
maxillary plane of occlusion

CONCLUSION
• Orthodontic treatment in patients with open bite can be successfully
treated by using clear aligners.
• Some aspects inherent to the biomechanics of aligners, such as the
vertical control and possible mandible counter clockwise rotation,
have positive effects on the anterior open bite correction.

Correction of Class II Malocclusions in Growing Patients by Using the
Invisalign® Technique: Rational Bases and Treatment Staging
Giancotti*
Journal of Orthodontics & Endodontics, 2017, Vol. 3, No. 4: 12
ISSN 2469-2980
Case 5

INTRODUCTION
• In literature, a number of scientific articles including case reports show
proper correction of Class II malocclusions by using aligners.
• However, treatment protocols are not so clearly evidenced at times so as
to allow for a standardization and simplification of such orthodontic
treatments, which would implement success rate.
• The aim of this case report is to show how it is possible to treat Class II
malocclusions by means of aligners.

• A 13-year-old male patient came to the
orthodontic clinic with a severe Class
II div. 2, deep bite and mild
crowding in both arches.
• The radiographic and clinical
examinations of the temporo-
mandibular joints showed no
alterations.
• The patient was diagnosed with a
dento-skeletal Class II div. 2
malocclusion, dental deep bite and a
mandibular retrusion.
• He reported bilateral molar and canine
Class II, -5 mm of deep bite, no
overjet, severe palatal inclination of
the upper incisors and coincident
midlines.
• His facial features consisted of:
concave profile for an evident
retrusion of both maxilla and
mandible.

TREATMENT OBJECTIVES:
1. to correct the Class II dento-skeletal relationship
2. to obtain an ideal overbite and overjet
3. to promote an anterior repositioning of the mandible.
Additional treatment goals included:-
4. Leveling and aligning,
5. Optimizing the posterior occlusion,
6. To obtain class I molar and canine relationship,
7. Improving the facial profile and
8. Obtaining a natural lip position

TREATMENT PLAN:
• The Invisalign® option was selected for comfort and aesthetic advantages.
• Treatment started with the correction of any mesial rotation of upper 1st and
2nd molars and an expansion of both arches to allow coordination between
arches and to favor bicuspids and canines into Class I relationships.
• The attachments in the upper arch were programmed to perform the anchorage
unit necessary to allow the torque correction of the upper incisors.
• Furthermore, the attachments in both arches were designed to modify the
tipping of bicuspids in order to improve the occlusion.
• During the first phase of treatment, Class II elastics were tied from a hook in
the upper aligner to the bonded metal button on the buccal surface of the lower
first molars with 4 oz, 3/16 size elastics, to improve upper molars’ distal
rotation.
• Upon refinement phase, in order to allow the mandible’s anterior repositioning,
Class II elastics were tied from a clear bonded button onto the surface of the
upper canines to the metal button on the lower first molars.

TREATMENT PROGRESS:
• Digital models were taken by ITERO® scanner and the case was
submitted for Invisalign Full®.
• The correction occurred by means of a first phase of 14 aligners and a
finishing stage with 10 aligners.
• In phase one, the initial correction was achieved by means of distal
rotation of upper molars, expansion of both arches and upper
incisors’ torque modification.
• Upon the refinement phase, the upper arch expansion, together with the
correction of the incisors’ torque, allowed the coordination of both arches
and anterior mandibular repositioning, successfully correcting the Class II
malocclusion.

TREATMENT RESULTS:
• After 13 months of therapy, treatment objectives set in the pretreatment
plan were achieved.
• The Class II malocclusion had been completely corrected; proper
overbite and overjet were achieved.
• In particular, the overbite was reduced from 5 to 2 mm.
• Moreover, this treatment enables us to observe how the virtual jump
programmed in the ClinCheck® simulation with the aid of the Class
II elastics was actually clinically achieved.

The pre and posttreatment cephalometric superimposition shows an evident
change of the upper incisors’ torque confirming the effectiveness of
Power Ridge® auxiliary in the aligners: the maxillary incisors’
inclination on the ANS-PNS plan changed from 104° to 115° and the
mandibular incisors’ inclination on Go-Gn increased from 93° to 101°.
The Interincisal Angle changed from 145° to 128°. Such dental
movement resulted in a mandibular anterior repositioning, mainly
responsible for the correction of the Class II malocclusion as the pre and
post-cephalometric superimposition shows.
The mandibular position SN/Pg changed from 78° to 82° and the NA/ Pg
sagittal jaw relationship was modified from 4° to 1°.
The facial growth was favorable and contributed to the correction of the
malocclusion.

DISCUSSION
• Orthodontic treatment with fixed appliances implies drawbacks including increased oral
bacteria, dental and soft-tissue discomfort, and poor esthetics.
• Adolescents particularly reluctant to undergoing fixed-appliance treatment for social
reasons
• Moreover, Invisalign® treatment provides some advantages over fixed appliances in
specific cases.
• In the presented cases, treatment duration (18 months) was highly satisfactory, because
the Class II elastics were worn upon initial delivery.
• By contrast, when using Class II elastics along with fixed appliances, it generally takes
several months to be able to utilize wires that are of sufficient size and strength.
• Also, when using Class II elastics along with fixed appliances, there can be canting of
the occlusal plane because of the resulting vertical component of force.
• Since the occlusal surfaces are completely covered, Invisalign® allows for the elimination
or reduction of the typical “Class II elastic effect”

CONCLUSION
• Orthodontic correction of Class II malocclusion by aligners, clinicians
can achieve excellent results by adopting the same treatment protocol
currently used with conventional fixed appliances.
• At the beginning of the “digital era,” the majority of orthodontists
thought that aligners were not the ideal tool for treating Class II
malocclusions.
• After 10 years of experience, this article intends to show how it can be
performed in a simple and predictable way.
• This treatment method is not merely limited to the re-alignment of
malposed teeth, but successfully correct Class II occlusal relationships.

A comparison of treatment impacts between Invisalign aligner and
fixed appliance therapy during the first week of treatment.
Miller et al , Am J Orthod 2007 March
• Aim of this study was to evaluate different life impacts between
subjects
• Invisalign group showed less impact in each quality of life –functional,
psychosocial and pain

Ojima K, Dan C, Kumagai Y, Schupp W.
Invisalign treatment accelerated by photobiomodulation.
J. Clin. Orthod. 2016 May 1;50:309-17.
Accelerated orthodontic treatment using photobiomodulation (PBM), a
low-level light therapy that has been shown to accelerate bone and
connectivetissue metabolism for wound healing in medicine.
One commercially available pbm device, orthopulse,* uses light-emitting
diodes (leds) that produce 850 nanometers of light (very near the infrared
spectrum), offering a safer mode of treatment than with laser light
Patient’s ability to change aligners every three days improved her
compliance
Originally planned for 92 weeks (46 sets of aligners) was completed in six
month

Cytotoxic evaluation of directly 3D printed aligners and Invisalign
S Fayyaz Ahmed et al
European journal of molecular & clinical medicine, 2020, volume 7, issue
5, pages 1129-1140
Smarttrack invisalign material (polyurethane) was found to be more
biocompatible, followed by directly printed aligner materials
(polymethylmethacrylate).
Cytotoxicity was found to be more on the first day for all materials and
gradually decreases as day’s progress.
The results indicate the increased leaching of material during the initial
period of use though the level of cytotoxicity is slight.

Effect of 10% Carbamide Peroxide on Tooth Shade, Plaque Index
and Gingival Index during Invisalign Treatment
Dentistry Journal. 2021 May;9(5):48.
Dalia Saleem
10% CP had significant change in tooth shade over the 2- and 4-weeks
periods (p < 0.05) and significantly reduced plaque and gingival indices
(p < 0.05), with minimal to no relapse after 2 weeks post-op.
Thus, applying CP at 10% may be a useful application during Invisalign
treatment in improving teeth shade and overall gingival health.

CONCLUSION
All in all Invisalign is a great alternative to braces, owing to its
comfort level and ease of use.
Though its not very cost effective, newer technology and materials
will make it more affordable.
More research in the field of complex tooth movement is still needed,
but apart from that, Invisalign has the potential to replace conventional
orthodontic appliances

Invisalign in Pediatric Dentistry: A Guide

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Invisalign in Pediatric Dentistry: A Guide

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