Clear Aligners in Orthodontics.pptx

Clearaligners
Presented by : Safa Basiouny
MSc, PhD Orthodontics
Lecturer of Orthodontics, Faculty of
Dentistry, Tanta University

CONTENTS
Fabricationand
technique
Biomechanics
INTRODUCTION ClearCollection
instruments
2 3 4
1 3
5
Classificationofinvisalignsystem
6
Transientfixedappliance&Comprehensive
alignertherapy
7
oral-hygieneprotocol&
Periodontalconsiderations

INTRODUCTION
1
o Definition
o History
o Advantages
o Disadvantages
o Applicability

Definition:
Clear aligner is an orthodontic technique that uses a series of computer-generated custom plastic aligners to guide
the teeth gradually into their proper alignment
History:
Kesling in 1946: A rubber positioner prepared in lab,
used in mouth which moved the teeth to predefined
positions according to diagnostic set-up. The appliance
could be used as a retainer or an appliance to recover
the minor relapse after orthodontic treatment
Nahoum in 1964: built on Kesling’s idea by creating a
method using thermoformed plastic sheets to move
teeth ("The Vacuum Formed Dental Contour
Appliance"). The process was limited because of the
difficulty found in evenly dividing larger movements
into small precise stages.
Sheridan (1985,87): introduced the technique of interproximal tooth reduction (IPR) for resolution of the lower
incisor crowding and alignment of teeth with the help of labio-lingual clear plastic retainer: the Essix
appliance. surface of the tooth to be moved is altered by sequential addition of small layers of composite on the
tooth surface to be pushed and trimming the appliance to create space for the tooth movement
Zia Chishti and Kelsey Wirth in 1997, two MBA students put
together a business plan for what would later become Invisalign.

Unique Features of Clear Aligners
1. Prediction of the treatment results using the digital treatment plan software e.g Clincheck
2. Allow the patients to eat sticky or hard food and better oral hygiene compared with traditional fixed orthodontic braces
3. In cases of noncompliant patients, if relapse occurs, they may be able to re-use their old aligners that can reprogram
their treatment towards the initially planned finished occlusion.
4. Clear aligners cover the occlusal surface of the teeth → disengages the occlusion that allows for free teeth movement
5. In open bite cases, the occlusal coverage of the posterior teeth works as posterior bite plate that can help in controlling the
vertical dimension
6. Clear aligners are more hygienic and less gingival or periodontal problems are encountered with clear aligners when
compared to either buccal or lingual fixed orthodontic appliances.
7. The improved gingival and periodontal health can also help decrease pain with clear aligners compared to fixed orthodontic
treatment.
8. Clear aligners may be used as fluoride application trays should decalcification occur during treatment due to bad oral
hygiene.

Advantages
• Esthetics
• Comfort
• Removability
• Avoidance of bonding problems
• Decreased incidence of root resorption
• Hygiene
• Less chair time and armamentarium, and Fewer emergencies
• Good vertical control??
• Precise control of each tooth (at each stage certain teeth are allowed to move)
• Bleaching during treatment
• Fluoride application trays
• Can be used with any restoration or crown

Disadvantages and limitations
• Cannot treat all types of malocclusions (weak evidence)
• Extraction cases are difficult to treat
• Patient with skeletal discrepancy
• Interproximal enamel reduction (IPR) to obtain space for aligning crowded teeth often is part of the treatment plan
• Patient compliance
• Very high cost
• Changing treatment plan (No “on-the-fly” changes to treatment)
• Need for clinical experience
• More chance of damage if the patient has poor oral hygiene habits and/or eating disorder

Applicability
CAT Performs Well
CAT Does Not Perform
Well
1. Mild-moderate crowding (1-5mm)
with interproximal enamel
reduction (IPR) or expansion
2. Posterior dental expansion
3. Close mild-moderate spacing (1-5
mm)
4. Absolute intrusion (1 or 2 teeth
only)
5. Lower incisor extraction for
severe crowding
6. Tip molar distally
1. Dental expansion for blocked-out teeth
2. Extrusion of incisors (w/o attachments)
3. High canines
4. Severe rotations (particularly of round
teeth)
5. Leveling by relative intrusion
6. Molar uprighting (any teeth with large
undercuts)
7. Translation of molars (w/o
attachments)
8. Closure of premolar extraction spaces
(w/o attachments)

Fabricationandtechnique
2
o Role of orthodontist
o Role of technician
o Manufacturing process
o Clinchick software
o Staging of Tooth movement
in Clincheck

Role of Orthodontist (Clinical Procedures):
• History and clinical examination
• Treatment submission (impressions + records)
• Clincheck revision, modification or approval
• treatment monitoring
• finishing
Role of technician (Laboratory procedures)
• Impressions scanning and Preparation of virtual dental
models
• Tooth separation (on the virtual models)
• Staging of tooth movements
• Elaboration of Clincheck
• Aligners production and delivery

ProcessofInvisalignmanufacturing

 What is clincheck software?
-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.
-it can be used as a tool for therapeutic diagnosis (non extraction treatment outcome can be compared with extraction
treatment out come by superimposition of each treatment plane on the other)

 Staging of Tooth movement in Clincheck
Staging: is the sequence in which and speed at which the teeth are moved with aligners.
1. Segmented staging:
 Based on the classic notion of anchorage in which one group of teeth is held stationary while a smaller group
of teeth is moved (more closely mimics fixed appliance treatment).
 Difficult movements are often left to the end of the treatment.
 Prolonged treatment time

2. Simultaneous staging:
 Adopted by Align technology since 2007.
 Also referred to X staging pattern.
 The basis for simultaneous staging is that all teeth within each arch are
moved together from the initial stage through the final stage.
 The rate limiting tooth: is the tooth that moves the most and dictates the
overall number of stages.
 The rate limiting determinants are:
o Linear movement 0.25 mm per stage
o Rotational movement: 2 degrees per stage

3. V staging pattern (maxillary arch only)
 In distalization of maxillary arch starting with molars, followed by premolars and ending with retraction of
anterior teeth

4. A staging pattern (Both arches)
 Opposite of V staging (Mesialization of the arch)
 Anterior teeth move anteriorly followed by posterior teeth moving anteriorly

5. M staging pattern
 For premolar extraction treatment
 Starts by closing the extraction space, followed by alignment of anterior teeth and finishing with molar movement

6. Custom staging
 Orthodontist can request custom staging when he/she feels it is necessary to improve treatment outcomes.
 Some orthodontists prefer to increase the number of aligners (by decreasing amount of tooth movement per
aligner) to deliver fresh aligners on a weekly basis with more consistent force and less force diminution between
aligner changes.

Biomechanics
3
• Invisalign Materials
• Attachments Design in Invisalign System
• Power Ridges and Pressure Areas
• Auxiliaries and Invisalign (elastics/
miniscrew/ bite ramps)
• Aligners in Different Tooth Movements
• Aligners in Different Malocclusion
• IPR and Invisalign
• Wearing of Invisalign

InvisalignMaterial:
The plastic used to make clear aligners known as Exceed 30
which is viscoelastic. The force delivered with an aligner made
from Exceed 30 is 200 g initially and decays to essentially a
constant level of 40 g within around 48 hours.
The newly introduced material called " Smart Track ™"
developed to address tis problem. Its resistance to
deformation is high so, maintains lighter and more constant
force over longer period of time.

AttachmentDesigninInvisalignsystem
small pieces of light cured composite resins bonded temporarily on the tooth surface.
Reasons for attachments:
 Passive attachment: enhance aligner retention (Attachments provide a ledge for the aligner to grip that is
perpendicular to the direction of displacement) and anchorage for intrusion
 Active attachment: facilitate specific tooth movement (rotations, extrusion and root correction)

AttachmentDesigninInvisalignsystem
Attachment designs:
•Ellipsoid and Circular: least effective (due to small size, and lack
of defined active surface), easiest for insertion and removal.
•Rectangular, Square, and Triangular: can be used for moderate
or difficult movement, but it is difficult to insert or remove aligner
•Beveled: easier for insertion and removal than rectangular, and it
combines both advantages of ellipsoid and rectangular attachments
Attachments could be computer designed (optimized) or
manually placed (physician prescribed). The orthodontist can
place, remove, orient, alter the bevel, change the size (3, 4, or 5
mm)

 Virtual Invisalign Laboratory Series of software tools that enable the evaluation of the expected clinical
responses to various attachment designs and placements. It has 3 parts: virtual modeling, in vitro testing,
and clinical evaluation.
 The term SmartForce has been patented by Align Technology to describe the computer-generated
attachment designs that are generated by Align Technology’s Treat software. Each optimized attachment
is now custom designed for a specific movement on a specific tooth for an individual patient. The optimized
attachments are automatically generated by the Treat software.
 The orthodontist is responsible for moving each tooth to the desired position using Clincheck Pro. The tooth
movements prescribed by the orthodontist are measured in all three planes of space, when a default in any one
direction is exceeded, the Treat software will place the SmartForce attachment on the tooth on the correct
location to create the required force system to cause the tooth to move as depicted in the Clincheck
 Site: away from gingival margin as the aligner relax with time and its gingival part become less retentive. The
table below shows the default attachments that are placed for Invisalign treatments unless otherwise specified
by the orthodontist in Clinical Preferences or on a prescription form for a specific patient.
Attachment Protocol Summary:

PowerridgesandPressureAreas
Power ridge: is a feature on the aligners that delivers force on a tooth at a
specified position. They are engineered corrugations placed at specific
locations to enhance the undercut near the labial gingival margin of teeth
undergoing torqueing movements.
Reasons for use:
•Accomplish an in and out tipping of the front teeth.
• Add torque (provide additional force as close to the gingival
margin) to move the root and the crown of the tooth and push the
teeth into their planned position.
•to stiffen the gingival third of the aligner to make it more resilient;

PowerridgesandPressureAreas
Advantage:
 attachments need not be placed or removed,
 they are more aesthetically acceptable to the patient
Disadvantages:
 they cannot be combined with any other attachment or SmartForce feature.
For the force system to work as designed, the two points where the aligner places
pressure on the tooth should be separated by as large a distance as possible ,
without interference from any other force system.
 they can create irritation of the buccal tissues attributable to the protrusion of
the margin of the aligner.

AuxiliariesandInvisalign
•Class II and Class III elastics:
One can directly attach the elastics either to the aligner
directly or to the buttons bonded to the teeth (aligner
trimmed around button).
If the elastics are directly attached to the aligner:
•attachments are generally required to prevent
displacement of the aligner.
•Precision hooks and button cut-outs are manufactured
into the aligner.

Miniscrews can be used with aligners alone or in
combination with other auxiliaries (button) to simplify
the movements the aligners are required to accomplish.
The two most common uses of miniscrews with aligners
are for vertical and sagittal movements.
Examples:
•One such example is the extrusion of an upper canine.
•Miniscrews:

•Miniscrews:
•Another vertical movement that is easily enhanced with
miniscrews is the intrusion of molars that have supererupted
into an edentulous space. The patient wears an elastic from one
miniscrew over the top of the aligner to the other miniscrew.

•Miniscrews:
Another application of miniscrews with aligners is correcting an arch asymmetry by enhancing the distalization
of one side. This correction can be accomplished by placing a miniscrew in the retromolar area, bonding
buttons on the facial and lingual aspects of the upper first or second molar, and then connecting an elastic chain
from the buttons to the miniscrew. If the intended movement is planned into the aligner treatment, then the
miniscrew provides the anchorage and allows simultaneous movement in the ClinCheck to reduce treatment
time.

•Invisalign bite ramps:
leveling the curve of Spee has now been made significantly easier with the addition of the
virtual bite plane being added to the lingual aspect of the upper incisors. This
addition was released in 2014 to address deep bite treatment.

AlignersinDifferentToothMovements
Simple Versus Difficult Movements:
• Simple orthodontic tooth movements to be achieved using aligners include tipping, intrusion,
and bodily movements
• Difficult movements include extrusion, torque, rotation, and root parallelism.

•Extrusion
Problem: The aligner is incapable of elastic deformation in the direction needed for
effective extrusion, the aligner cannot stretch within the plastic itself.
Solution:
•addition of optimized attachments (gingival beveled attachment) to provide a
longer surface area that can be elastically deformed and provide an extrusive force
on the tooth. The default that causes the attachment to be added to the virtual plan
is extrusion of more than 0.50 mm down the long axis of the tooth. movements
less than this are expected to occur unaided
An additional SmartForce feature improves the tracking of anterior teeth extrusion when all
four upper incisors are individually extruding more than 0.50 mm. This additional feature
alters the digital model to create a pressure area at the bases of the optimized attachment
on the upper lateral incisors. This pressure area produces a higher force on the optimized
attachment to keep the teeth fully engaged in the aligner. The addition of optimized
attachments for extrusion and pressure areas on the upper lateral incisors has made Invisalign
the preferred appliance for treatment of mild to moderate anterior open bite treatment.
Extrusion Auxiliaries:
• Bond bracket/button on the labial/lingual surface of the tooth… Cut Aligner
for bracket/button… Run elastic over the bracket/button
• Toe nail clippers can be used to cut slits in the aligners for elastic placement.

Intrusion
Intrusion normally does not require attachments on the teeth to be intruded, however
anchorage teeth (lower premolars for example in case of intruding lower incisors) need to be fitted with
horizontal beveled rectangular attachments for anchorage and relative extrusion of these
premolars as well. If no attachments were placed, the anterior intrusive force would cause the posterior of the
aligner to lift off the teeth which would result in little, if any, intrusive force applied

Proclination/Retroclination:
Anteroposterior teeth movement by clear aligners is not difficult when we consider tipping of
the crowns. However, it would seem challenging moving the incisors by bodily movement.

Bucco-lingual Tooth Movement
Moving posterior teeth buccally or lingually using clear aligners is not challenging as long as there is a clear
freeway space or inter-occlusal clearance that allows the posterior teeth to move bucco-lingually.
Problem: if the tooth intended to be moved lingually or buccally is overerupted beyond the occlusal
plane, like in cases of buccal cross bite, it would be more difficult to move such a tooth buccally or lingually as it
would require to have more inter-occlusal clearance than the freeway space, which is not possible or not
comfortable for the patients sometimes.
Solution: initially intrude such an over erupted tooth then move it bucco-lingually (but this make the
tooth movement very time consuming)

•Root Torque
•Align technology introduced power ridges and pressure point in order to produce couple
that can produce root movement in the bucco-lingual direction.
• A second method of producing torque is to constrain the crown position while tending to move the
crown in an opposite direction to the direction of root movement. An example if we constrain lower
incisors by a fixed archwire or clear aligner and try to move upper incisors lingually while there is an
adequate overbite, lingual movement of upper incisors would torque lower incisors roots labially
• A third possible way to torque roots with clear aligners is to move the crowns initially in the opposite
direction of the intended direction of root torque. For example, if we need to torque upper incisors’
roots palatally, we would move the crown labially first (counter moment first) and then moving the whole
tooth palatally. This is similar to the traditional way of dealing with class II division 2 cases, where it is
always recommended to procline upper incisors labially first (providing adequate torque) and then moving
the upper incisors afterwards palatally.

Rotational Tooth Movement
Problem 1: Correcting rotations with aligners can be problematic because
the aligner material is incapable of being distorted in a manner that can
produce significant rotational movement.
Solution:
 Beveled attachments with the bevel turned 90 degrees (i.e.,
mesiodistal) would provide a surface that allows the aligner to rotate
teeth.
 Auxiliaries can be used before, during or after aligner ttt
Problem 2: the tooth root is not a cylinder. Because of dilacerations and root surface
variations, the computer software cannot adequately estimate the true rotational long axis and
estimating the proper rate of tooth movement becomes impossible. The result is either no
movement or undesirable tooth movements.
Solution: With the advent of the newer optimized attachments, the predictability of rotational
movements have significantly improved. Optimized attachments are now available for all
bicuspids and cuspids. The default for the bicuspids and cuspids is rotation correction greater
than 5 degrees in either direction. Molars and incisors do not have engineered rotation
attachments to date. (Note that the upper lateral incisor attachment is not a rotation correction
attachment; rather, it is designed for extrusion in combination with root or crown tip.)

Mesiodistal Root Movement (root parallism)
•Closure of extraction spaces presents the challenge to finish with parallel roots.
Align technology also introduced mesiodistal root movement attachments
that produce couple. The active surface on each attachment is pushed by the
aligners to produce the necessary couple needed to move the teeth roots
mesiodistally.
•Power arms can be added with Invisalign to make force closer to the center of
resistance of canine in extraction ttt but limited clinical application because
molar root control is more difficult than canine
Problem: Unfortunately, often canines remain upright during retraction into
premolar spaces, while the molars, especially maxillary molars, tend to tip
mesially This is frequently referred to as “dumping”.
Solution: place two attachment 2-mm × 2-mm × 2-mm on the upper first or
second molars. This appears to offer significant benefits, possibly by providing
a means to have a couple on the molar crown itself
 Use aligners in combination with fixed appliances
 TADs to eliminate unnecessary forces on anchorage. Choi etal. describes a unique method using a segmental
aligner for the anterior teeth and using TADs to retract this segment
 Attachments when a molar needs to be moved mesial to close an extraction space or when roots are long which
increases the probability of tipping

AlignersinDifferentMalocclusion
Open bite:
 anterior open bites can be addressed by either intrusion of posterior teeth to allow the mandible to rotate
closed, or by extrusion of the anterior teeth, or a combination of both.
 Extrusion of anterior teeth can be accomplished with optimized attachments (discussed previously)
 Advantage of using aligners for treatment:
posterior intrusive affect that the aligners will have on the posterior teeth which also facilitates closure of
the anterior open bite
prevent forces of the tongue from acting on the lingual surface of upper incisors
 If need a greater force (particularly for posterior intrusion)…..TADs have been used to facilitate both
types of movements

Deep bite
Deep bites are generally treated by anterior intrusion which can be difficult with aligners. To facilitate this
movement:
 Invisalign uses attachments on the premolars for anchorage while an active intrusive force is placed on the
incisors.
 Bite ramps built into the lingual of the aligner of the upper anterior teeth that act as a bite plane
 Use of TADs. Bowman et al., show a very nice method to intrude upper incisors by cutting a notch on the
buccal surface of the aligner then vertical elastics are then used from the notched aligner to TADs placed in
the anterior buccal vestibule to provide the intrusive force

Crossbites
 Minor anterior or posterior crossbites with a bite depth up to about10% are usually not difficult to treat
with just the usual aligner treatment.
 Anterior or posterior crossbites with a bite depth greater than approximately10% usually requires some
other considerations to open the vertical to allow the tooth in crossbite to clear the opposing teeth such as
anterior bite ramps that are available on the Invisalign aligners or placing cold-cure acrylic on the occlusal
surface of the aligners while the crossbite is being jumbed.
 The aligners may need to be worn full-time including while eating until the crossbite is jumped.
 Crossbite correction of posterior teeth may be facilitated by placing attachments on the lingual and/or using
crossbite elastics

Class II correction
Treatment options range from distalization of the upper dentition to protraction of the lower dentition or a
combination of both.
 Fischer presented several cases where he used attachments on molars and premolars to sequentially distalize
the maxillary dentition to a Class I without the use of Class II elastics. This movement can be difficult with
aligners due to force necessary to create the moment that will distalize the root. In addition, anchorage for the
distalization comes from the anterior teeth and flaring or anterior movement may occur. This is usually controlled
by using the lower arch for anchorage with Class II elastics which can then also assist in distalizing the upper
dentition
 TADs placed either in the buccal or the palate can be used as anchorage to distalize the upper dentition to Class I or
to retract the anterior teeth after extraction of upper first premolars.
Both the Carriere Distalizer and the Mara appliance have been used to initially
create a Class I molar followed by treatment with aligners to finish the case.
•Arreghini et al., described treating a patient with a Runner which is a series of
aligners with ramps build on the occlusal surfaces that resemble Twin Block and
are meant to advance the mandible and mandibular dentition.

Class III
Class III elastics and either maintaining dental compensations or creating dental compensations are often done
when a Class III malocclusion is treated by orthodontics only. When surgery is a consideration, the case is
decompensated prior to surgery. TADs have been used to distalize the lower dentition in an effort to minimize
some compensation

Interproximalreduction(IPR)AndAlignertreatment
Early in the development of the Invisalign technique, there was a perception that most patients treated with
aligners required IPR. That was because most ClinChecks that were returned to the orthodontist had
significant amounts of IPR recommended by Align Technology setup technicians. There were two basic
reasons for such recommendations:
1. The first that many patients treated with Invisalign were patients who had undergone orthodontic
relapse and thus had minor lower anterior crowding. The technicians were taught that in doing a setup
they should never expand lower canines and never flare lower incisors anteriorly. That only left them one
alternative, and that was to reduce tooth mass, either by IPR or extraction of a single lower incisor.
2. The second was to avoid the side effect of virtual collisions. Virtual collisions
occur whenever the setup technician attempts to move teeth in such a manner that one
interproximal surface virtually passes through the adjacent tooth’s interproximal
surface, which is impossible in the physical world. To allow the intended tooth
movement to take place, the setup technician would request that the orthodontist
remove the amount of tooth structure that was involved in the virtual collision.
NOTE: any collision less than 0.05 mm is considered insignificant in that the
aligner can theoretically stretch that much and not cause any problems with treatment.

WearingofInvisalign
 The first aligner is checked for any discomfort and freedom of freni or soft tissue impingement
 Patient is seen two weeks later where aligners 2 and 3 are received
 Each aligner works for 2 weeks and the patient is seen every 4 weeks to check treatment progress
 The appliance is removed during eating and drinking hot liquids.
 The number of aligners for a patient varies according to type of malocclusion
 Each aligner is designed to move the teeth a maximum of about 0.25 to 0.3mm over a 2-week period, and is
worn in a specific sequence
 Aligners are worn for at least 20:22 hours a day to reach the desired maximum effectiveness

The Tear Drop
The Tear Drop pliers was created to produce a notch in clear
aligner plastic to facilitate the application of orthodontic elastics

The Hole Punch
The Hole Punch pliers was created to produce a half-moon cutout to permit the addition of
bonded buttons or brackets
The Hole Punch pliers can be used to relieve plastic impingement of gingival tissues
anywhere along the aligners

Aligner Chewies
If certain teeth are not “tracking” or are lagging behind (i.e., not fitting into the tray) Aligner
Chewies™ are employed. Patients are asked to hold the Chewie between the teeth in question and
squeeze 10-15 seconds, release, and repeat for 5 minutes, 2-3 times per day.
-In addition, Chewies are routinely used for the first few days when patients switch to a
new pair of aligners to help them seat more completely

Bootstrap mechanics
Mechanics to forcibly erupt a “lagging” tooth other than use of aligner chewers. By adding elastics to forcibly
erupt the teeth into the aligner tray. There are several methods to generate so-called “bootstrap mechanics”:
1. An orthodontic elastic is stretched over the plastic aligner to connect to a combination of bonded buttons on both
lingual and buccal of the tooth.
2. The Hole Punch is employed to clear aligner plastic to permit the addition of bonded buttons. The Tear Drop is
used to cut notches in mesial and distal embrasures. elastic hooked from the buccal notches and stretched over the
aligner tray to the button to produce an extrusive force
Aligner “lag” or lost tracking is most often characterized as an “air gap” between the
incisal or occlusal of teeth and the plastic, indicating teeth are not following the
prescribed tooth movement

The Vertical plier
used to accent rotational tooth movement. The shallow indentations are produced
without heating the pliers.

The Horizontal plier
Designed to accent labial or lingual torque for individual teeth,
-It can also be used to simply increase the retentiveness of clear aligners or retainers
-In addition, the Horizontal is used to reduce “lag” by accenting extrusive or intrusive
movement by applying contact points immediately adjacent to composite attachments

Classificationof
invisalignsystem
5

Classificationofinvisalignsystem(Malek2013)
Maximum
flexibility in
treatment of a
wide range of
malocclusions
Treatment limited to moving
upper and lower anterior
teeth (canine to canine) with
crowding or spacing of 4 mm
or less per arch
● Treatment for minor
crowding or spacing /
orthodontic relapse
● Only allows use of 14
aligners or less
Treatment for
teenager patients
InvisalignFull InvisalignTeen
Invisalign
Anterior
Invisalign
Lite
Vivera
Retainers

InvisalignTeen
Originally, Invisalign was anticipated for use with individuals with a fully erupted permanent dentition. It soon
became apparent, however, that being able to treat the late mixed dentition with aligners provided certain benefits
as well.
Drawbacks and How to overcome?
•Anticipating tooth eruption of one or more permanent teeth,
•Eruption tabs (figure) are used to prevent supereruption of unerupted second
molars.
•Tooth forms of approximate anticipated crown size are used to both create and hold
room and to guide eruption of actively erupting teeth
•Planning for refinement aligners with proper fit once the teeth are adequately
erupted to capture properly the crowns in the impression.

InvisalignTeen
as well.
•Being able to monitor patient compliance to discuss the progress with
parents
Wear indicators are placed on the facial surfaces of the first molars. Two
different types of chemical indicators are available that turn from dark
blue to clear as the aligners are worn to evaluate patient compliance
(compliance indicators).

InvisalignTeen
as well.
proper control of torque without the need for attachments when crowns were not yet fully exposed,
 All SmartForce enhancements, including optimized attachments, pressure points, and pressure areas that are
previously discussed were developed for the Invisalign Teen product and are a routine part of the feature set.

InvisalignTeen
as well.
Avoiding practice management issues over lost aligners.
 Align Technology charges a premium and provides free replacements for lost aligners. In reality, the patient
prepays for the privilege of having them replaced if lost. Many adults can benefit from the features in
Invisalign Teen, and it is perfectly acceptable to order the Invisalign Teen product for an adult to access any of
the unique product features.

Transientfixedappliance
&Comprehensivealigner
therapy
6

This brief period of fixed appliances will be followed by comprehensive treatment with aligners.
Indications:
 to treat severe rotations,
 to align divergent roots, or
 to close significant spaces.
Advantages:
 decrease in overall treatment time,
 better results for difficult malocclusions.
Success depends on patient demands and expectations, as well as the orthodontist’s comfort with combining the
two treatment modalities.

Recommendedoral-hygieneprotocol
andPDLconsiderations
7

1. Absolutely never eat with the aligners in place.
2. Brush the inside of the aligners with water and toothpaste every time the teeth are brushed, paying special attention to the cusp-
tip areas and the attachment wells. N.B. Regular cleaning with a soapy cotton-tip swab and/or a proprietary cleaning agent has
been recommended.
3. Brush the teeth for two minutes with a soft toothbrush and 2cm of toothpaste three times per day, followed each time by a
“toothpaste slurry” rinse: take a small sip of water and swish the mixture around the mouth, filtering between the teeth, then
expectorate the mixture, but do not rinse further. (This method leaves some fluoride on the teeth.) Place the clean aligners back
in the mouth immediately.
4. At night, supplement the normal brushing routine with flossing and a one-minute fluoride mouthwash rinse, then place the
aligners back in immediately.
5. Any white matter that accumulates in the aligners is plaque and should be removed. Use of an ultrasonic retainer bath or the
Invisalign Cleaning System* with cleaning crystals several times per week will cleanse areas where a toothbrush may not reach
adequately, such as the cusp tips. (Note: Invisalign specifically advises that denture cleaners should not be used to clean
aligners due to FDA warnings about the risk of allergic reaction to persulfate, an ingredient in most denture cleaners.)
6. Follow up with the general dentist for professional cleanings and examinations as recommended.

 Periodontal considerations
 There is a body of evidence growing that orthodontic treatment with aligners has less detrimental
periodontal impact than that of fixed appliances.
 Miethke and Vogt and Miethke and Brauner compared the periodontal health of the patients who underwent the
treatment with aligners to that of patients who underwent treatment with both labial and lingual fixed
appliances They found that periodontal health could actually improve during the course of the treatment in
cases treated with aligners.
 Boyd found that periodontal health could actually improve during the course of treatment with Invisalign.
He attributed this to the patient’s ability to remove the appliances and spend more time brushing and flossing
their teeth and to maintain an invisible appearance to the appliances.

● Graber, TM., & Vanarsdall, RL. Orthodontics: Current principles and techniques.6th ed. St. Louis: Mosby.2017
● Proffit, WR., Fields, H. W., & Sarver, D. M. Contemporary orthodontics. 6th ed. St. Louis: Mosby.2019
● Basavaraj Subhashchandra Phulari - Orthodontics _ principles and practice (2017, Jaypee Brothers Medical
Publishers (P) Ltd) - libgen.lc
● Om Prakash Kharbanda. Orthodontics Diagnosis and Management of Malocclusion and Dentofacial
Deformities. First Edition 2009
● Jeryl English Sercan Akyalcin Timo Peltomaki Kate Litschel. Mosby's Orthodontic Review.1st Edition.2009
● Gierie WV. Clear Aligner Therapy: An Overview. J Clin Orthod.2018; 52 (12): 665-674
● Wheeler T. Orthodontic clear aligner treatment. SeminOrthod. 2017; 23:83–89.
● Arreghini A, et al., Class II treatment with the Runner in adolescent patients: Combining Twin Block efficiency
with aligner aesthetics, Journal of the World Federation of Orthodontists (2014)
Refrences

Clear Aligners in Orthodontics.pptx

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