Clear Techniques II

How has the development process improved Align’s outcomes?

Invisalign’s advantages over braces:
• Have a diagnostic set-up on every patient
• Only move the teeth you want to move
• Interocclusal plastic ideal for crossbite correction
• Posterior intrusive effect ideal for anterior open bite
• Not dependent of bracket placement- human error
• Less unwanted side effects when using elastics
• No round tripping of teeth
• Interocclusal plastic aids in AP correction
• Less emergencies to slow treatment

The Biggest Advantage!!
•The reason that fixed appliances generally take
about 24 months to treat is that it takes 12
months to correct the problems that we created
through the various effects of our
mechanotherapy

Invisalign, like braces, is an imperfect process
• Inaccuracy of predicted movements
• The process of IPR and software inaccuracy
• Biological variations in orthodontic movement
between patients
• Aligner manufacturing errors
• We use refinements in about 75% of patients to detail
and finish the case; otherwise, 2nd to final tray used
for one month as a finishing appliance
• MCC in about 10%

Orthodontic Movements
• Tipping?- Yes, both crown and root (**attachment
considerations)
• Rotations?- Yes (**attachment considerations)
• Extrusion?- Yes, BUT preferably combined with retraction to
increase predictability (**attachment considerations)
• Intrusion?- Yes, but slow down movements to apply less
force over-engineer (esp. deep OB and ant. intrusion)
• Torque?- Yes, but also need to over-engineer and possibly use
other aligner auxillaries

Malocclusions treated?
Which malocclusions are best treated with Invisalign… in our practice?
Class I with good OB, lower ant. relapse, mild-mod. crowding/spacing and rotations
Pseudo class III/ edge-to-edge malocclusions with mild-mod. crowding
Mild-mod anterior open bite with mild-mod. crowding and mild-mod OJ
End-on class II division I or Div. II , with mild-moderate OB/OJ, mild-mod. crowding
Class I deep OB / Class II div. II severe deep OB patients with minimal crowding or spacing

Variables for Invisalign Clinical Predictability
• 1) Diagnosis-
• i.e. etiology of the malocclusion , cephalometric analysis,
TSD, growth and development, etc
• 2) Set-up of the ClinCheck-
• THOROUGH evaluation of the ClinCheck and understanding
the plausibility and/or limitations of the movements
occurring… being a constant student
• 3) Proper clinical technique- i.e. IPR, anchorage, etc
• 4) Patient selection and Psychology ~ compliance
• 5) Proper team training and systems

Reviewing the ClinCheck
Initial Bite Set
Understanding any Tooth Size Discrepancy
Assess Predictability of Movements
Add/Change Attachments
Anchorage Consideration/Anticipation of Elastics
Address TSD via Interproximal Space/IPR
Interincisal Angle Evaluation

Records
• Great composite photos, perpendicular buccal shots,
***articulation markings (Align does not use bite
records unless requested for CR registrations)

Possible consequences from an
inaccurate bite set:
• 1) Midline shift
• 2) Arch asymmetry and lack of coordination
• 3) Unnecessary IPR

Records continued…
• A traced cephalometric x-ray
– Evaluation of skeletal relationships
– ***Evaluation of incisor angulations
– ***Evaluation of mandibular plane angles

Bolton discrepancy- aka tooth size discrepancy
A proper balance should exist between the mesio-distal
tooth size of the maxillary and mandibular arches to
ensure proper interdigitation, overjet, and overbite at the
completion of orthodontic treatment.

TSD continued…
• This is an often underappreciated and overlooked aspect
of orthodontic diagnosis. Lack of attention to a TSD may:
• 1) less than ideal occlusion instability and relapse
• 2) compromised esthetics
• 3) lead to a posterior open bite

91.3%
77.2%
• Bolton’s OR = 91.3%
If the value obtained is <91.3%, the discrepancy (excess) is in maxillary teeth.
• Bolton’s AR= 77.2 %
If the value obtained is <77.2%, the discrepancy (excess) is in maxillary teeth.
• i.e. if the sum of mandibular 6 anterior=41.5mm, sum of maxillary 6
anterior=48mm
41.5/48*100=86.45% mandibular excess (or maxillary deficiency)
x/48*100=77.2% x=37.05, ideal mandibular anterior total width
41.5-37.05= 4.45mm, amount of mandibular excess
41.5/x * 100= 77.2% x-=53.5, ideal max. ant. total width
53.5- 48= 5.5mm, amount of maxillary deficiency

Reviewing the ClinCheck
Initial Bite Set
Understanding any Tooth Size Discrepancy
Assess predictability of movements
Add/Change Attachments
Anchorage Consideration/Anticipation of Elastics
Address TSD via interproximal space/IPR
Interincisal Angle/ Centric Contact Evaluation

How do you address the TSD,
+ , - or both?
• Depth of Bite
• Periodontal status
• Anterior guidance
• Esthetics- golden proportions
• Lip support
• To aid in detailing of a particular malocclusion

IPR
-It is always good practice to check crowded
interproximal contacts with floss at every patient
appointment and lighten any tight contacts with
diamond strips, even if IPR is not indicated for
that area
-This is because even the slightest 1/100th mm of
binding can impede a tooth’s movement towards
the desired goal

Mild-Moderate Class II Patients

•TSD- the most common cause of
malocclusion ***
•Start elastics early and often

Tip: How to address TSD for Class II malocclusions
• Mandibular excess, maxillary deficiency:
–Distalize buccal segment to full class I, build up upper
laterals
–Use ipr lower to mesialize lower buccal segment and
eliminate heavy anterior interferences
• Maxillary excess:
–Establish class I molar, then use IPR to distalize/detail
remaining buccal occlusion and reduce overjet as
needed
**Pay attention to lingual root torque anterior 2-2**

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Clear Techniques II

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