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 Introduction
 Kesling’s Setup
 Essix Retainers
- Introduction
- Current Retainer Designs
- Fabrication
- Appliance Delivery
- Telephone Supervision
- Conclusion
 Active Tooth Movement With Essix Based
Appliance
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 Invisalign
- In a Nutshell
- Mechanism of Action
- In Detail
- Retention and Stability
- Advantages
- Disadvantages
- Summary
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 Movement of teeth without the use of bands,
brackets, or wires was described as early as 1945
by Dr Kesling, who reported on the use of a
flexible tooth positioning appliance.
 Later, Nahoum (Vacuum formed dental contour
appliance, 1964) and others (Pontiz, 1971;
McNamara, 1985) wrote about various types of
overlay appliances such as invisible retainers.
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 Minor tooth movements have also been achieved
with a technique developed by Raintree Essix
(New Orleans, La).
 This technique uses clear aligners formed on
plaster models of the teeth.
 The aligners are then modified with “divots,”
which create a force to push on the individual
teeth, and “windows,” which create the space for
teeth to move into.
 This type of appliance can be effective in
correcting mild discrepancies in the alignment of
teeth.
 However, movements are limited to 2 to 3 mm;
beyond this range, another impression and a new
appliance are needed.www.indiandentalacademy.com
 Align Technology, Inc (Santa Clara, Calif),
in-troduced the Invisalign system several
years ago.
 Invisalign takes the principles of Kesling,
Nahoum, others, and Raintree Essix even
further, using computer-aided-design–
computer-aided-manufacture (CAD-CAM)
technology combined with laboratory
techniques to fabricate a series of custom
appliances that are esthetic and removable,
and that can move teeth from beginning to
end.
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 The diagnostic setup was first proposed by
Kesling in 1945.
 P.R. Begg does not use tooth positioners,
because they are not readily available in
Australia.
 However, Kesling uses a tooth positioner as a
finishing appliance on each case.
 Not only are the tooth positioners the best post
treatment retention appliance, but they are the
best form of working retainer.
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 It is possible to obtain more accurate final tooth
positions generally and more accurate final
occlusal relations with tooth positioners than with
any other orthodontic appliance now employed.
 At the present time, it is impossible to position
teeth with arch wires and tooth bands with such
final accuracies as can be done with post
treatment use of tooth positioners regardless of
the particular active orthodontic treatment
technique that is used.
 The tooth positioners, as being described by
Kesling in 1945, is a one piece, resilient appliance
made from rubber or plastic that fills the free-way
space and covers the clinical crowns of the teeth
plus the portion of the gingival, both buccal and
lingual.
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 No other appliance has the flexibility to conform to
the discrepancy, and yet has the ability to carry the
teeth to their desired relations- all with no
adjustments required.
 The skills required of the orthodontist in
positioner therapy are those of diagnosis and
judgment of the patients willingness or ability to
cooperate, not of manual dexterity.
 The positioner is constructed over a per-
determined pattern- the set-up.
 Teeth that are to be positioned in the patients
mouth are removed from the patients model and
replaced in the desired positions. The gum area of
the set-up is then contoured to normal form after
changing the teeth.
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 The positioner is then formed of an elastic
material about the arches in rest position.
 This results in the upper and lower teeth slightly
separated, and the lower arch slightly distal to the
upper.
 Space closure within reason can be accomplished
with a tooth positioner, especially spaces manifest
during treatment, as in anterior segments.
 Within limitations the positioners can be used to
help maintain or change the amount of anterior
overbite.
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 Labiolingual axial inclination of upper and
lower anteriors can be influenced by a
positioner, however, these teeth should be
uprighted over basal bone as well as possible
with appliances.
 One must be realistic for the correction to be
achieved
 The positioner can achieve the perfection
possible in the set up only when that perfection
has been approached in the mouth with
conventional treatment.
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 Patients were treated until the correct tooth
relations were achieved.
 Tooth positioner has the ability to quickly achieve
the final detailed finishing that is often required.
 When the positioner is to be used there is no need
to place finishing arches or to consider a stage 4.
 After the teeth have been brought to their
approximate final positions with the proper axial
inclinations, the positioner will close all spaces,
correct slight errors in arch form and develop ideal
occlusion as predetermined by the set up.
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 The control model made at the time of the
appliance were removed, was duplicated and the
teeth were cut from the model and repositioned in
the set up.
 In the set up all the spaces have been closed, arch
form has been corrected and the normal amount of
anterior over bite has been created along with text
book normal occlusion in the posterior segment.
 Tooth positioner was fabricated over the setup.
 The patient then exercised into the positioner four
hours a day and wore it while sleeping.
 Results desired by the set up were achieved in two
weeks.
 At that time the exercise wearing was reduced to
three hours a day.
 After four months, the patient just wore thewww.indiandentalacademy.com
 The cast is cut using a fretsaw blade to separate
individual teeth.
 A horizontal cut is made three mm apical to
gingival margin.
 Vertical cuts are made to separate individual
teeth and the individual teeth are set in desire
position using red wax.
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1. In visualizing and testing the effect of
complex tooth movements and extractions
on the occlusion.
2. The patient can be motivated by simulating
the various corrective positions on the cast.
3. Tooth size – arch length discrepancies can be
visualized by means of a setup.
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INTRODUCTION
 Orthodontists' concept of retention is moving
toward the idea that teeth will move unless
retained indefinitely.
 However, permanent retention implies permanent
supervision, and that is where reality clashes with
stability.
 An orthodontic practice basically consists of
treatment of active cases, which consume the most
time and generate the most income, and
supervision of retention cases, which takes less
time and produces minimal, if any, income. This
balance has been workable because, in due course,
retention patients either are dismissed with
wishes of good luck or simply fade away.www.indiandentalacademy.com
 When permanent retention is emphasized,
the equilibrium is upset.
 As an example, if 200 patients per year are
given permanent retainers and seen twice a
year, after 10 years this will add up to 4,000
retention appointments per year. At 10
minutes per visit, that would take up about
three months' worth of appointments.
 The cornerstone of Essix permanent
retention is the complete delegation of
responsibility to the patient.
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 Essix retainers have nothing to adjust; the only
thing that could be done on a recall visit would
be to check the patient's compliance and listen
to any comments.
 Telephone supervision is a time-and-money-
saving service to our patients and is sincerely
appreciated.
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 Fixed retainers must be systematically
monitored, not only for displacement, but
for hygiene problems that can be induced by
the accumulation of plaque and calculus.
 Although well-aligned teeth should be
easier to clean, the presence of a bonded
retainer makes cleaning more difficult.
 Removable appliances don't interfere with
hygiene, but are at best only adequate
retention mechanisms.
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 The Hawley-type retainer, which dates
from the 1920s, was originally used to move
teeth, not for retention.
 The retaining component for the anterior
teeth— a point contact of wire on the labial
surface and a mass of acrylic approximating
the lingual cervix— is insufficient.
 When the appliance becomes loose, the
mechanical constraints are lessened and the
teeth can shift.
 In addition, most of the acrylic simply
anchors wire elements that are not critical to
the essence of retention— the stabilization of
the teeth.
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 Clear, full-arch, vacuum-formed plastic devices
are only marginally esthetic, are removable, and
are difficult to work with.
 As in Hawley-type retainers, the bulk of the
appliance is distal to the cuspids, covering and
retaining posterior teeth.
 These buccal sections tend to fracture, make the
appliance bulky, and are usually the cause of
complaints of awkwardness of bite.
 The limitations of conventional mechanisms,
which may be adequate for limited retention,
explain some of the dismal results that have been
achieved with permanent retention.
 These devices are too bulky or unhygienic for the
long term, and sooner or later the patient's
enthusiasm wanes.www.indiandentalacademy.com
 Essix thermoplastic copolyester retainers change the
rules of permanent retention.
 They are a thinner, but stronger, cuspid-to-cuspid version
of the full-arch, vacuum-formed devices.
 Advantages include:
• The ability to supervise without office visits.
• Absolute stability of the anterior teeth.
• Durability and ease of cleaning.
• Low cost and ease of fabrication.
• Minimal bulk and thickness (.015").
• The brilliant appearance of the teeth caused by light
reflection.
 If compliance with permanent retention is to be achieved,
the orthodontist must provide duplicate retainers. Essix
retainers can be produced in the office for only a few
dollars each, and the cost to the patient, with a
replacement retainer included, is about one-third that of a
conventional retainer.www.indiandentalacademy.com
 Since only the anterior teeth are retained, a
universal perforated plastic tray works well
for both arches.
 Vinyl polysiloxane is the impression material
of choice. A combination of the light and
heavy (putty) types is preferred.
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Heavy and light vinyl
polysiloxane impression
materials in Universal
perforated plastic tray.
Impression has been cut
distal to cuspids with scalpel.
 Pour the impression with a high-quality die stone
that has been mixed in a vacuum spatulator.
 If the undercuts gingival to the contact points are
extreme, creating three-cornered spaces, they
must be reduced to a more normal contour.
 It is imperative that adequate undercuts remain to
insure a positive fit of the appliance.
 Apply a coating of a separating medium before
thermoforming.
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 A pressure-type thermoforming unit such as a
Biostar is superior to a suction device in
recording the critical interproximal undercuts.
 Essix 0.75mm (0.030") thermoplastic copolyester
is mandatory for the fabrication of Essix
retainers.
 Thinner, 0.5mm material is too flimsy, while
thicker, 1 mm material lacks flexibility.
 Copolyester, unlike polycarbonates, does not
require heat treatment before thermoforming.
 It is much stronger, clearer, and resistant to
abrasion than acrylic sheet, and thus produces
thinner yet sturdier appliances.
 During the thermoforming, the thickness of the
plastic is reduced from .030" to .015".www.indiandentalacademy.com
 Store the cast in the patient's model box in case it
is needed for future construction of duplicate
retainers.
 Cut the retainer from the plastic sheet and trim
the edges to the proper form with a curved pair
of Mayo scissors.
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 Pay particular attention to these details:
 • Do not scallop the labial flange of the retainer to
conform to the cervical line. Extend it 2-3mm into the
labial gingiva, and trim it to make a gentle,
continuous curve.
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 • Trim the lower lingual flange similarly. Trim the
upper lingual flange in a straight line across the
palate, from cuspid to cuspid. If chairside
adjustment is necessary, trim with a scissor,
ligature cutter, or scalpel.
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 • Cut a small space at each cuspid between the
gingival margin and the distogingival edge of the
appliance, allowing the patient to remove the
appliance with a fingernail along the long axis of the
incisors.
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 Essix retainers can be placed the same day
fixed appliances are removed.
 The vinyl polysiloxane impression is taken
immediately after debonding.
 Minor incisor rotations can be corrected by
altering the cast, since the teeth will be
slightly mobile.
 In no case, however, should more than two
days elapse between appliance removal and
retainer delivery.
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 Furthermore, if the patient does not brux, the
retainers should last for years.
 With heavy bruxing, retainers need to be
replaced once or twice a year, but that is still an
attractive alternative to irreversible dental
attrition.
 A single-arch Essix retainer should be worn 24
hours a day (except for cleaning) for two weeks,
and then at night only.
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 If both upper and lower retainers are placed, the
patient should wear the lower during the day and
the upper at night for four weeks, then both at
night only.
 The material is so thin that accommodation to
speaking and eating is not a problem.
 The retainers should be cleaned with a soapy
cotton-tip swab; brushing with toothpaste dulls
their brilliance.
 If the patient chews gum, a brand that does not
stick to dental appliances should be recommended.
 For caries control, we prescribe a fluoride rinse
every night and a fluoride gel once a week.
 The retainers make excellent delivery trays.
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 Attractive, soft retainer cases can be used instead
of the hard, bulky plastic types, since Essix
retainers are nearly impervious to fracture or
distortion. Soft cases do not interfere with the line
of jeans or business clothes, and the clinician's
address and phone number can be printed on the
cases to aid in recovery if they are lost.
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A. Soft cloth Essix retainer case usually preferred by adults.
B. More colorful case preferred by adolescents.
 Patients are routinely contacted by phone to
confirm appointments; retention monitoring
is merely an extension of this procedure.
 The task can be delegated to a staff member
with a personable telephone manner.
 Calls should be made when it is most
convenient for the patient— home or work,
daytime or evening.
 Calls can be scheduled 30 days after
delivery of retainers, and every four to six
months thereafter.
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 Essix retainers have
proven quite versatile.
 Their flexibility and
positioner effect make
them an alternative to
spring retainers in
correcting minor
tooth movements.
 They can be used to
reduce occlusal forces
from the opposing
arch when moving
posterior teeth with
air-rotor strippingwww.indiandentalacademy.com
Essix retainer placed on upper arch
to reduce occlusal forces against
lower arch during air-rotor
stripping mechanics.
 They can serve as a
temporary bridge for a
missing anterior tooth,
when thermoformed
over a pontic placed in
the edentulous space
on the cast.
 They can also act as
night guards for
bruxism and as bite
planes-to relieve
bracket impingement
until the bite can be
opened.
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 The use of Essix retainers, in combination
with telephone monitoring, opens the way
to a practical, patient-friendly method of
true permanent retention.
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 Sheridan has described two methods for
moving teeth.
 One, by the use of windows and divots
whereby minor tooth malalignments, such as
bucco-lingual and mesio-distal malpositions
and rotations. (JCO 1994)
 Secondly, with the help of thermosealing. (JCO
1995)
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Trimmed working cast
for thermoforming Essix
retainer.
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Finishing window
border with scalpel
Cutting window in
thermoformed
appliance with
acrylic bur
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Heating shaft of Divoter
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Monitoring inside of
appliance for divot depth
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Removing residual plastic
debris from heating shaft
prior to use
A. Incisal placement of divot produces
more tipping.
B. Gingival placement produces more
bodily movement
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A. Distal placement of divot produces
mesial rotation.
B. Mesial placement produces distal
rotation.
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Mesial contact point of lateral
incisor locked within Essix
appliance while divot induces
facial rotation of out-of-line distal
surface.
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Divot-induced moments create torquing
couple
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Incisal cap produces pure
root torque
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Case 1.
A. Incisor alignment
before treatment.
B. After four months
of wearing Essix
appliance with
successive 1mm
divots.
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Case 2.
A. Incisor alignment
after debonding.
B. After two weeks of
Essix appliance
with 1mm divot to
align lower right
lateral incisor.
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 By thermosealing we can selectively increase
the thickness of the appliance either
anteriorly or posteriorly by incorporating
layer of composite or light cure acrylic
between two sheet of the Essix plastic.
 By thermosealing we can use Essix
appliance as a bite plane, habit breaking
appliance, molar uprighting appliance or
space maintainer.
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A. Essix plastic sheets with light-cured
acrylic between them.
B. Plastic sheets thermosealed to
encapsulate acrylic layer
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Full-arch working cast made to Essix
standards
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Base sheet with center section and
peripheral excess cut away
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Prying distal ends of base appliance
with thin-bladed instrument to
remove it from cast
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Anterior section of base appliance cut away,
and remainder of appliance replaced on cast
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Bead of light-cured acrylic applied to
palatal area of base appliance
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Heat Gun used to prepare base
appliance for second thermosealing
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Base and second plastic sheets
thermosealed with light-cured acrylic
between them
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Bulk of plastic cut away with acrylic disk
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Finished "full Essix" appliance after
trimming
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Barrier wire tacked to base appliance
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Light-cured acrylic placed in palatal
area and covering base of wire barrier
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Finished habit appliance after trimming
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Active element of uprighting spring
tacked to cast with composite.
Retentive element of spring placed on
base appliance
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Palatal acrylic covering
retentive element of
uprighting spring
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Finished molar uprighting
appliance after trimming
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Thermosealed rigid plastic bar between
two abutment teeth
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Finished space maintainer after trimming
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Finished bite plane after trimming
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 Drs. Rinchuse and Rinchuse successfully
used Essix based appliance to carry out
active tooth movements for correcting single
tooth anterior cross bite and lingually
displaced canine (using finger springs), and
aligning ectopically positioned canine (using
bonded bracket, metal attachments to the
appliance and various elastics) and for
expansion of maxilla (using a hybrid Essix-
nickel titanium removable palatal
expander).
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 Align Technology, Inc. developed Invisalign
appliance for orthodontic tooth movement
in the USA in 1998.
 This appliance was the first orthodontic
treatment method to be based solely on 3-D
digital technology.
 Through the use of computer programmes
that can manipulate 3-D images of
individual malocclusions, a series of
algorithmic stages is produced which can
move the teeth in a series of precise
movements (0.15 – 0.25 mm), or stages.
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 Invisalign braces are a new revolutionary
way to straighten teeth without metal.
 A series of clear, removable aligners are used
to gradually straighten teeth, without metal
or wires.
 Aligners are made of clear, strong medical
grade plastic that is virtually invisible when
worn.
 Aligners look similar to clear tooth-whitening
trays, but are custom-made for a better fit to
move teeth.
 Some dentists have referred to Invisalign
braces as "contact lenses for teeth."
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 Like brackets and archwires, Invisalign
braces move teeth through the appropriate
placement of controlled force on the teeth.
 The principal difference is that Invisalign
braces not only control forces, but also
control the timing of the force application.
 At each stage, only certain teeth are allowed
to move, and these movements are
determined by the orthodontic treatment
plan for that particular stage.
 This results in an efficient force delivery
system.
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 You wear each set of aligners for about 2 weeks,
removing them only to eat, drink, brush, and
floss.
 As you replace each aligner with the next in the
series, your teeth will move – little by little, week
by week – until they have straightened to the
final position your dentist has prescribed.
 You’ll visit your dentist about once every 6
weeks to ensure that your treatment is
progressing as planned.
 Total treatment time averages 9-15 months and
the average number of aligners worn during
treatment is between 18 and 30, but both will
vary from case to case.www.indiandentalacademy.com
 For each patient, the orthodontist submits a
set of polyvinyl siloxane impressions, a
centric occlusion bite registration, a
panoramic radiograph, a lateral
cephalometric radiograph, and photographs
to Align Technology.
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 Vinyl polysiloxane,
- considered the most accurate of impression
materials,
- has excellent elastic recovery,
- minimal permanent deformation, and
- superior tear strength.
 Impressions can be stored for as long as a
week without significant loss of accuracy
and can be disinfected and repoured
multiple times.
 The material is available in several
viscosities that bond to one another,
allowing flexibility in impression technique.
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 The impressions are poured up in dental
plaster and then placed in a tray and encased
with epoxy and urethane.
 The tray is placed into a destructive scanner;
the scanner’s rotating blade makes numerous
passes over the epoxy-encased models,
removing a thin layer with each pass.
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 A computer linked
with the scanner
then assembles the
scanned
information to
create a 3-
dimensional
rendering of the
models.
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 After the bite has been established, the
Invisalign virtual orthodontic technician
(VOT) uses software to “cut” the virtual
models and separate the teeth, allowing
them to be moved individually.
 A virtual gingiva is placed along the
gingival line of the clinical crown to serve as
the margin for the manufacturing of the
aligners.
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Cutters separate teeth Placement of virtual gingiva
 The orthodontist’s prescription is followed
in positioning the teeth and the bite to
proper alignment virtually on the computer
with the company’s Treat software (Align
Technology, Santa Clara, Calif).
 Once the final setup has been done, tooth
movements are staged so that there are no
occlusal and interproximal interferences,
and the velocity of the movements is within
the criteria set by the company.
 The number of stages necessary depends on
the amount and complexity of the
movement.
 The VOT can now send the data to the
referring orthodontist so that he or she can
check the proposed treatment (referred to aswww.indiandentalacademy.com
 When the orthodontist has approved the
treatment plan, the aligners will be
manufactured so that the movements seen
on the computer screen can be transferred
clinically to the patient.
 The computer images are converted to
physical models by using a process called
stereolithography.
 These models are then used to fabricate the
aligners on a Biostar pressure molding
machine (Great Lakes Orthodontic Products,
Tonawanda, NY).
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Stereolithography
machines
Stereolithography
models
Aligners
 Align Technology engineers have
formulated a proprietary material for use in
the aligners.
 The aligners are trimmed and laser-etched
with the patient’s initials, case number,
aligner number, and arch (upper or lower).
 They are then disinfected, packaged, and
shipped to the doctor’s office.
 The entire process of making the Invisalign
aligners is a marvel of modern technology.
 Without the aid of computers and
technologically advanced machinery, it
would be impossible to fabricate aligners in
such large numbers and with such great
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 Fabricating these aligners in an orthodontic
office would be a very time-consuming and
labor-intensive process that probably would
not be practical for everyday treatment.
 The Invisalign technique gives patients an
esthetic choice in their orthodontic treatment
that all orthodontists can easily implement in
their offices.
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 At present, retention protocol with this
appliance is similar to that used with other
types of appliances.
 Usually the final appliance or a thicker
version (0.04 inch) of it is worn full time for
six months, followed by night time wear
indefinitely.
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1. You can straighten your teeth without anyone
knowing.
2. An Invisalign patient can eat and drink anything
while being treated along with being able to
brush and floss normally to maintain good oral
hygiene. This is not possible while wearing
traditional braces.
3. Another advantage is that the teeth can be
bleached with the appliance at the beginning of,
and during treatment.
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4. Invisalign braces are comfortable. There
are no metal brackets or wires to cause
mouth irritation.
5. No metal or wires also means you spend
less time in the doctor's chair getting
adjustments and in some cases a patient
only needs to see the dentist half as often as
with traditional braces.
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1. Only relatively small magnitudes of change are
possible because of the technical difficulty of evenly
dividing larger overall movements into small
precise stages manually.
2. Most people experience temporary, minor
discomfort for a few days at the beginning of each
new stage of treatment. This is normal and is
typically described as a feeling of pressure. It is a
sign that the Invisalign braces are working -
sequentially moving your teeth to their final
destination. This discomfort typically goes away a
couple of days after you insert the new Aligner in the
series.
www.indiandentalacademy.com
3. Like all orthodontic treatments, Invisalign
braces may temporarily affect the speech of
some people, and you may have a slight lisp for
a day or two. However, as your tongue gets
used to having Aligners in your mouth, any lisp
or minor speech impediment caused by the
Aligners should disappear.
4. Open bite.
www.indiandentalacademy.com
 A new system of orthodontic tooth movement
using established methods for minor correction
to achieve greater magnitudes of correction has
been introduced.
 The major advantage of the system is the
esthetic, hygiene, low discomfort and
removable nature of the appliance.
www.indiandentalacademy.com
 The current limitations are in terms of case
selection, increased cost, experience required for
computer treatment planning, difficulty
obtaining certain tooth movements, and the lack
of potential in teeth involving mixed dentition
or impacted teeth.
 The clinician must have an in-depth
understanding of biomechanics, biology,
periodontal concerns, and optimal therapeutic
occlusion achieved during orthodontic
treatment to successfully plan and use this
appliance.
www.indiandentalacademy.com
 In future, we may see the replacement of PVS
impressions with emerging intraoral scanning
devices and the recording of treatment changes
or modifications immediately in a digital format.
 Adding the other 3 D compartments (skeletal,
facial, jaw movement and animation to the
surface map of the teeth) will greatly enhance
the diagnostic and treatment capabilities of this
new appliance.
www.indiandentalacademy.com
www.indiandentalacademy.com

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Invisalign -invisible aligners course in india

  • 2.  Introduction  Kesling’s Setup  Essix Retainers - Introduction - Current Retainer Designs - Fabrication - Appliance Delivery - Telephone Supervision - Conclusion  Active Tooth Movement With Essix Based Appliance www.indiandentalacademy.com
  • 3.  Invisalign - In a Nutshell - Mechanism of Action - In Detail - Retention and Stability - Advantages - Disadvantages - Summary www.indiandentalacademy.com
  • 4.  Movement of teeth without the use of bands, brackets, or wires was described as early as 1945 by Dr Kesling, who reported on the use of a flexible tooth positioning appliance.  Later, Nahoum (Vacuum formed dental contour appliance, 1964) and others (Pontiz, 1971; McNamara, 1985) wrote about various types of overlay appliances such as invisible retainers. www.indiandentalacademy.com
  • 5.  Minor tooth movements have also been achieved with a technique developed by Raintree Essix (New Orleans, La).  This technique uses clear aligners formed on plaster models of the teeth.  The aligners are then modified with “divots,” which create a force to push on the individual teeth, and “windows,” which create the space for teeth to move into.  This type of appliance can be effective in correcting mild discrepancies in the alignment of teeth.  However, movements are limited to 2 to 3 mm; beyond this range, another impression and a new appliance are needed.www.indiandentalacademy.com
  • 6.  Align Technology, Inc (Santa Clara, Calif), in-troduced the Invisalign system several years ago.  Invisalign takes the principles of Kesling, Nahoum, others, and Raintree Essix even further, using computer-aided-design– computer-aided-manufacture (CAD-CAM) technology combined with laboratory techniques to fabricate a series of custom appliances that are esthetic and removable, and that can move teeth from beginning to end. www.indiandentalacademy.com
  • 7.  The diagnostic setup was first proposed by Kesling in 1945.  P.R. Begg does not use tooth positioners, because they are not readily available in Australia.  However, Kesling uses a tooth positioner as a finishing appliance on each case.  Not only are the tooth positioners the best post treatment retention appliance, but they are the best form of working retainer. www.indiandentalacademy.com
  • 8.  It is possible to obtain more accurate final tooth positions generally and more accurate final occlusal relations with tooth positioners than with any other orthodontic appliance now employed.  At the present time, it is impossible to position teeth with arch wires and tooth bands with such final accuracies as can be done with post treatment use of tooth positioners regardless of the particular active orthodontic treatment technique that is used.  The tooth positioners, as being described by Kesling in 1945, is a one piece, resilient appliance made from rubber or plastic that fills the free-way space and covers the clinical crowns of the teeth plus the portion of the gingival, both buccal and lingual. www.indiandentalacademy.com
  • 9.  No other appliance has the flexibility to conform to the discrepancy, and yet has the ability to carry the teeth to their desired relations- all with no adjustments required.  The skills required of the orthodontist in positioner therapy are those of diagnosis and judgment of the patients willingness or ability to cooperate, not of manual dexterity.  The positioner is constructed over a per- determined pattern- the set-up.  Teeth that are to be positioned in the patients mouth are removed from the patients model and replaced in the desired positions. The gum area of the set-up is then contoured to normal form after changing the teeth. www.indiandentalacademy.com
  • 10.  The positioner is then formed of an elastic material about the arches in rest position.  This results in the upper and lower teeth slightly separated, and the lower arch slightly distal to the upper.  Space closure within reason can be accomplished with a tooth positioner, especially spaces manifest during treatment, as in anterior segments.  Within limitations the positioners can be used to help maintain or change the amount of anterior overbite. www.indiandentalacademy.com
  • 11.  Labiolingual axial inclination of upper and lower anteriors can be influenced by a positioner, however, these teeth should be uprighted over basal bone as well as possible with appliances.  One must be realistic for the correction to be achieved  The positioner can achieve the perfection possible in the set up only when that perfection has been approached in the mouth with conventional treatment. www.indiandentalacademy.com
  • 12.  Patients were treated until the correct tooth relations were achieved.  Tooth positioner has the ability to quickly achieve the final detailed finishing that is often required.  When the positioner is to be used there is no need to place finishing arches or to consider a stage 4.  After the teeth have been brought to their approximate final positions with the proper axial inclinations, the positioner will close all spaces, correct slight errors in arch form and develop ideal occlusion as predetermined by the set up. www.indiandentalacademy.com
  • 13.  The control model made at the time of the appliance were removed, was duplicated and the teeth were cut from the model and repositioned in the set up.  In the set up all the spaces have been closed, arch form has been corrected and the normal amount of anterior over bite has been created along with text book normal occlusion in the posterior segment.  Tooth positioner was fabricated over the setup.  The patient then exercised into the positioner four hours a day and wore it while sleeping.  Results desired by the set up were achieved in two weeks.  At that time the exercise wearing was reduced to three hours a day.  After four months, the patient just wore thewww.indiandentalacademy.com
  • 14.  The cast is cut using a fretsaw blade to separate individual teeth.  A horizontal cut is made three mm apical to gingival margin.  Vertical cuts are made to separate individual teeth and the individual teeth are set in desire position using red wax. www.indiandentalacademy.com
  • 15. 1. In visualizing and testing the effect of complex tooth movements and extractions on the occlusion. 2. The patient can be motivated by simulating the various corrective positions on the cast. 3. Tooth size – arch length discrepancies can be visualized by means of a setup. www.indiandentalacademy.com
  • 16. INTRODUCTION  Orthodontists' concept of retention is moving toward the idea that teeth will move unless retained indefinitely.  However, permanent retention implies permanent supervision, and that is where reality clashes with stability.  An orthodontic practice basically consists of treatment of active cases, which consume the most time and generate the most income, and supervision of retention cases, which takes less time and produces minimal, if any, income. This balance has been workable because, in due course, retention patients either are dismissed with wishes of good luck or simply fade away.www.indiandentalacademy.com
  • 17.  When permanent retention is emphasized, the equilibrium is upset.  As an example, if 200 patients per year are given permanent retainers and seen twice a year, after 10 years this will add up to 4,000 retention appointments per year. At 10 minutes per visit, that would take up about three months' worth of appointments.  The cornerstone of Essix permanent retention is the complete delegation of responsibility to the patient. www.indiandentalacademy.com
  • 19.  Essix retainers have nothing to adjust; the only thing that could be done on a recall visit would be to check the patient's compliance and listen to any comments.  Telephone supervision is a time-and-money- saving service to our patients and is sincerely appreciated. www.indiandentalacademy.com
  • 20.  Fixed retainers must be systematically monitored, not only for displacement, but for hygiene problems that can be induced by the accumulation of plaque and calculus.  Although well-aligned teeth should be easier to clean, the presence of a bonded retainer makes cleaning more difficult.  Removable appliances don't interfere with hygiene, but are at best only adequate retention mechanisms. www.indiandentalacademy.com
  • 21.  The Hawley-type retainer, which dates from the 1920s, was originally used to move teeth, not for retention.  The retaining component for the anterior teeth— a point contact of wire on the labial surface and a mass of acrylic approximating the lingual cervix— is insufficient.  When the appliance becomes loose, the mechanical constraints are lessened and the teeth can shift.  In addition, most of the acrylic simply anchors wire elements that are not critical to the essence of retention— the stabilization of the teeth. www.indiandentalacademy.com
  • 22.  Clear, full-arch, vacuum-formed plastic devices are only marginally esthetic, are removable, and are difficult to work with.  As in Hawley-type retainers, the bulk of the appliance is distal to the cuspids, covering and retaining posterior teeth.  These buccal sections tend to fracture, make the appliance bulky, and are usually the cause of complaints of awkwardness of bite.  The limitations of conventional mechanisms, which may be adequate for limited retention, explain some of the dismal results that have been achieved with permanent retention.  These devices are too bulky or unhygienic for the long term, and sooner or later the patient's enthusiasm wanes.www.indiandentalacademy.com
  • 23.  Essix thermoplastic copolyester retainers change the rules of permanent retention.  They are a thinner, but stronger, cuspid-to-cuspid version of the full-arch, vacuum-formed devices.  Advantages include: • The ability to supervise without office visits. • Absolute stability of the anterior teeth. • Durability and ease of cleaning. • Low cost and ease of fabrication. • Minimal bulk and thickness (.015"). • The brilliant appearance of the teeth caused by light reflection.  If compliance with permanent retention is to be achieved, the orthodontist must provide duplicate retainers. Essix retainers can be produced in the office for only a few dollars each, and the cost to the patient, with a replacement retainer included, is about one-third that of a conventional retainer.www.indiandentalacademy.com
  • 24.  Since only the anterior teeth are retained, a universal perforated plastic tray works well for both arches.  Vinyl polysiloxane is the impression material of choice. A combination of the light and heavy (putty) types is preferred. www.indiandentalacademy.com Heavy and light vinyl polysiloxane impression materials in Universal perforated plastic tray. Impression has been cut distal to cuspids with scalpel.
  • 25.  Pour the impression with a high-quality die stone that has been mixed in a vacuum spatulator.  If the undercuts gingival to the contact points are extreme, creating three-cornered spaces, they must be reduced to a more normal contour.  It is imperative that adequate undercuts remain to insure a positive fit of the appliance.  Apply a coating of a separating medium before thermoforming. www.indiandentalacademy.com
  • 26.  A pressure-type thermoforming unit such as a Biostar is superior to a suction device in recording the critical interproximal undercuts.  Essix 0.75mm (0.030") thermoplastic copolyester is mandatory for the fabrication of Essix retainers.  Thinner, 0.5mm material is too flimsy, while thicker, 1 mm material lacks flexibility.  Copolyester, unlike polycarbonates, does not require heat treatment before thermoforming.  It is much stronger, clearer, and resistant to abrasion than acrylic sheet, and thus produces thinner yet sturdier appliances.  During the thermoforming, the thickness of the plastic is reduced from .030" to .015".www.indiandentalacademy.com
  • 27.  Store the cast in the patient's model box in case it is needed for future construction of duplicate retainers.  Cut the retainer from the plastic sheet and trim the edges to the proper form with a curved pair of Mayo scissors. www.indiandentalacademy.com
  • 28.  Pay particular attention to these details:  • Do not scallop the labial flange of the retainer to conform to the cervical line. Extend it 2-3mm into the labial gingiva, and trim it to make a gentle, continuous curve. www.indiandentalacademy.com
  • 29.  • Trim the lower lingual flange similarly. Trim the upper lingual flange in a straight line across the palate, from cuspid to cuspid. If chairside adjustment is necessary, trim with a scissor, ligature cutter, or scalpel. www.indiandentalacademy.com
  • 30.  • Cut a small space at each cuspid between the gingival margin and the distogingival edge of the appliance, allowing the patient to remove the appliance with a fingernail along the long axis of the incisors. www.indiandentalacademy.com
  • 31.  Essix retainers can be placed the same day fixed appliances are removed.  The vinyl polysiloxane impression is taken immediately after debonding.  Minor incisor rotations can be corrected by altering the cast, since the teeth will be slightly mobile.  In no case, however, should more than two days elapse between appliance removal and retainer delivery. www.indiandentalacademy.com
  • 32.  Furthermore, if the patient does not brux, the retainers should last for years.  With heavy bruxing, retainers need to be replaced once or twice a year, but that is still an attractive alternative to irreversible dental attrition.  A single-arch Essix retainer should be worn 24 hours a day (except for cleaning) for two weeks, and then at night only. www.indiandentalacademy.com
  • 33.  If both upper and lower retainers are placed, the patient should wear the lower during the day and the upper at night for four weeks, then both at night only.  The material is so thin that accommodation to speaking and eating is not a problem.  The retainers should be cleaned with a soapy cotton-tip swab; brushing with toothpaste dulls their brilliance.  If the patient chews gum, a brand that does not stick to dental appliances should be recommended.  For caries control, we prescribe a fluoride rinse every night and a fluoride gel once a week.  The retainers make excellent delivery trays. www.indiandentalacademy.com
  • 34.  Attractive, soft retainer cases can be used instead of the hard, bulky plastic types, since Essix retainers are nearly impervious to fracture or distortion. Soft cases do not interfere with the line of jeans or business clothes, and the clinician's address and phone number can be printed on the cases to aid in recovery if they are lost. www.indiandentalacademy.com A. Soft cloth Essix retainer case usually preferred by adults. B. More colorful case preferred by adolescents.
  • 35.  Patients are routinely contacted by phone to confirm appointments; retention monitoring is merely an extension of this procedure.  The task can be delegated to a staff member with a personable telephone manner.  Calls should be made when it is most convenient for the patient— home or work, daytime or evening.  Calls can be scheduled 30 days after delivery of retainers, and every four to six months thereafter. www.indiandentalacademy.com
  • 36.  Essix retainers have proven quite versatile.  Their flexibility and positioner effect make them an alternative to spring retainers in correcting minor tooth movements.  They can be used to reduce occlusal forces from the opposing arch when moving posterior teeth with air-rotor strippingwww.indiandentalacademy.com Essix retainer placed on upper arch to reduce occlusal forces against lower arch during air-rotor stripping mechanics.
  • 37.  They can serve as a temporary bridge for a missing anterior tooth, when thermoformed over a pontic placed in the edentulous space on the cast.  They can also act as night guards for bruxism and as bite planes-to relieve bracket impingement until the bite can be opened. www.indiandentalacademy.com
  • 38.  The use of Essix retainers, in combination with telephone monitoring, opens the way to a practical, patient-friendly method of true permanent retention. www.indiandentalacademy.com
  • 39.  Sheridan has described two methods for moving teeth.  One, by the use of windows and divots whereby minor tooth malalignments, such as bucco-lingual and mesio-distal malpositions and rotations. (JCO 1994)  Secondly, with the help of thermosealing. (JCO 1995) www.indiandentalacademy.com
  • 41. www.indiandentalacademy.com Finishing window border with scalpel Cutting window in thermoformed appliance with acrylic bur
  • 45. A. Incisal placement of divot produces more tipping. B. Gingival placement produces more bodily movement www.indiandentalacademy.com
  • 46. A. Distal placement of divot produces mesial rotation. B. Mesial placement produces distal rotation. www.indiandentalacademy.com
  • 47. Mesial contact point of lateral incisor locked within Essix appliance while divot induces facial rotation of out-of-line distal surface. www.indiandentalacademy.com
  • 48. Divot-induced moments create torquing couple www.indiandentalacademy.com
  • 49. Incisal cap produces pure root torque www.indiandentalacademy.com
  • 50. Case 1. A. Incisor alignment before treatment. B. After four months of wearing Essix appliance with successive 1mm divots. www.indiandentalacademy.com
  • 51. Case 2. A. Incisor alignment after debonding. B. After two weeks of Essix appliance with 1mm divot to align lower right lateral incisor. www.indiandentalacademy.com
  • 52.  By thermosealing we can selectively increase the thickness of the appliance either anteriorly or posteriorly by incorporating layer of composite or light cure acrylic between two sheet of the Essix plastic.  By thermosealing we can use Essix appliance as a bite plane, habit breaking appliance, molar uprighting appliance or space maintainer. www.indiandentalacademy.com
  • 53. A. Essix plastic sheets with light-cured acrylic between them. B. Plastic sheets thermosealed to encapsulate acrylic layer www.indiandentalacademy.com
  • 54. Full-arch working cast made to Essix standards www.indiandentalacademy.com
  • 55. Base sheet with center section and peripheral excess cut away www.indiandentalacademy.com
  • 56. Prying distal ends of base appliance with thin-bladed instrument to remove it from cast www.indiandentalacademy.com
  • 57. Anterior section of base appliance cut away, and remainder of appliance replaced on cast www.indiandentalacademy.com
  • 58. Bead of light-cured acrylic applied to palatal area of base appliance www.indiandentalacademy.com
  • 59. Heat Gun used to prepare base appliance for second thermosealing www.indiandentalacademy.com
  • 60. Base and second plastic sheets thermosealed with light-cured acrylic between them www.indiandentalacademy.com
  • 61. Bulk of plastic cut away with acrylic disk www.indiandentalacademy.com
  • 62. Finished "full Essix" appliance after trimming www.indiandentalacademy.com
  • 63. Barrier wire tacked to base appliance www.indiandentalacademy.com
  • 64. Light-cured acrylic placed in palatal area and covering base of wire barrier www.indiandentalacademy.com
  • 65. Finished habit appliance after trimming www.indiandentalacademy.com
  • 66. Active element of uprighting spring tacked to cast with composite. Retentive element of spring placed on base appliance www.indiandentalacademy.com
  • 67. Palatal acrylic covering retentive element of uprighting spring www.indiandentalacademy.com
  • 68. Finished molar uprighting appliance after trimming www.indiandentalacademy.com
  • 69. Thermosealed rigid plastic bar between two abutment teeth www.indiandentalacademy.com
  • 70. Finished space maintainer after trimming www.indiandentalacademy.com
  • 71. Finished bite plane after trimming www.indiandentalacademy.com
  • 72.  Drs. Rinchuse and Rinchuse successfully used Essix based appliance to carry out active tooth movements for correcting single tooth anterior cross bite and lingually displaced canine (using finger springs), and aligning ectopically positioned canine (using bonded bracket, metal attachments to the appliance and various elastics) and for expansion of maxilla (using a hybrid Essix- nickel titanium removable palatal expander). www.indiandentalacademy.com
  • 73.  Align Technology, Inc. developed Invisalign appliance for orthodontic tooth movement in the USA in 1998.  This appliance was the first orthodontic treatment method to be based solely on 3-D digital technology.  Through the use of computer programmes that can manipulate 3-D images of individual malocclusions, a series of algorithmic stages is produced which can move the teeth in a series of precise movements (0.15 – 0.25 mm), or stages. www.indiandentalacademy.com
  • 74.  Invisalign braces are a new revolutionary way to straighten teeth without metal.  A series of clear, removable aligners are used to gradually straighten teeth, without metal or wires.  Aligners are made of clear, strong medical grade plastic that is virtually invisible when worn.  Aligners look similar to clear tooth-whitening trays, but are custom-made for a better fit to move teeth.  Some dentists have referred to Invisalign braces as "contact lenses for teeth." www.indiandentalacademy.com
  • 75.  Like brackets and archwires, Invisalign braces move teeth through the appropriate placement of controlled force on the teeth.  The principal difference is that Invisalign braces not only control forces, but also control the timing of the force application.  At each stage, only certain teeth are allowed to move, and these movements are determined by the orthodontic treatment plan for that particular stage.  This results in an efficient force delivery system. www.indiandentalacademy.com
  • 76.  You wear each set of aligners for about 2 weeks, removing them only to eat, drink, brush, and floss.  As you replace each aligner with the next in the series, your teeth will move – little by little, week by week – until they have straightened to the final position your dentist has prescribed.  You’ll visit your dentist about once every 6 weeks to ensure that your treatment is progressing as planned.  Total treatment time averages 9-15 months and the average number of aligners worn during treatment is between 18 and 30, but both will vary from case to case.www.indiandentalacademy.com
  • 77.  For each patient, the orthodontist submits a set of polyvinyl siloxane impressions, a centric occlusion bite registration, a panoramic radiograph, a lateral cephalometric radiograph, and photographs to Align Technology. www.indiandentalacademy.com
  • 78.  Vinyl polysiloxane, - considered the most accurate of impression materials, - has excellent elastic recovery, - minimal permanent deformation, and - superior tear strength.  Impressions can be stored for as long as a week without significant loss of accuracy and can be disinfected and repoured multiple times.  The material is available in several viscosities that bond to one another, allowing flexibility in impression technique. www.indiandentalacademy.com
  • 79.  The impressions are poured up in dental plaster and then placed in a tray and encased with epoxy and urethane.  The tray is placed into a destructive scanner; the scanner’s rotating blade makes numerous passes over the epoxy-encased models, removing a thin layer with each pass. www.indiandentalacademy.com
  • 81.  A computer linked with the scanner then assembles the scanned information to create a 3- dimensional rendering of the models. www.indiandentalacademy.com
  • 82.  After the bite has been established, the Invisalign virtual orthodontic technician (VOT) uses software to “cut” the virtual models and separate the teeth, allowing them to be moved individually.  A virtual gingiva is placed along the gingival line of the clinical crown to serve as the margin for the manufacturing of the aligners. www.indiandentalacademy.com
  • 84.  The orthodontist’s prescription is followed in positioning the teeth and the bite to proper alignment virtually on the computer with the company’s Treat software (Align Technology, Santa Clara, Calif).  Once the final setup has been done, tooth movements are staged so that there are no occlusal and interproximal interferences, and the velocity of the movements is within the criteria set by the company.  The number of stages necessary depends on the amount and complexity of the movement.  The VOT can now send the data to the referring orthodontist so that he or she can check the proposed treatment (referred to aswww.indiandentalacademy.com
  • 85.  When the orthodontist has approved the treatment plan, the aligners will be manufactured so that the movements seen on the computer screen can be transferred clinically to the patient.  The computer images are converted to physical models by using a process called stereolithography.  These models are then used to fabricate the aligners on a Biostar pressure molding machine (Great Lakes Orthodontic Products, Tonawanda, NY). www.indiandentalacademy.com
  • 87.  Align Technology engineers have formulated a proprietary material for use in the aligners.  The aligners are trimmed and laser-etched with the patient’s initials, case number, aligner number, and arch (upper or lower).  They are then disinfected, packaged, and shipped to the doctor’s office.  The entire process of making the Invisalign aligners is a marvel of modern technology.  Without the aid of computers and technologically advanced machinery, it would be impossible to fabricate aligners in such large numbers and with such great www.indiandentalacademy.com
  • 88.  Fabricating these aligners in an orthodontic office would be a very time-consuming and labor-intensive process that probably would not be practical for everyday treatment.  The Invisalign technique gives patients an esthetic choice in their orthodontic treatment that all orthodontists can easily implement in their offices. www.indiandentalacademy.com
  • 89.  At present, retention protocol with this appliance is similar to that used with other types of appliances.  Usually the final appliance or a thicker version (0.04 inch) of it is worn full time for six months, followed by night time wear indefinitely. www.indiandentalacademy.com
  • 90. 1. You can straighten your teeth without anyone knowing. 2. An Invisalign patient can eat and drink anything while being treated along with being able to brush and floss normally to maintain good oral hygiene. This is not possible while wearing traditional braces. 3. Another advantage is that the teeth can be bleached with the appliance at the beginning of, and during treatment. www.indiandentalacademy.com
  • 91. 4. Invisalign braces are comfortable. There are no metal brackets or wires to cause mouth irritation. 5. No metal or wires also means you spend less time in the doctor's chair getting adjustments and in some cases a patient only needs to see the dentist half as often as with traditional braces. www.indiandentalacademy.com
  • 92. 1. Only relatively small magnitudes of change are possible because of the technical difficulty of evenly dividing larger overall movements into small precise stages manually. 2. Most people experience temporary, minor discomfort for a few days at the beginning of each new stage of treatment. This is normal and is typically described as a feeling of pressure. It is a sign that the Invisalign braces are working - sequentially moving your teeth to their final destination. This discomfort typically goes away a couple of days after you insert the new Aligner in the series. www.indiandentalacademy.com
  • 93. 3. Like all orthodontic treatments, Invisalign braces may temporarily affect the speech of some people, and you may have a slight lisp for a day or two. However, as your tongue gets used to having Aligners in your mouth, any lisp or minor speech impediment caused by the Aligners should disappear. 4. Open bite. www.indiandentalacademy.com
  • 94.  A new system of orthodontic tooth movement using established methods for minor correction to achieve greater magnitudes of correction has been introduced.  The major advantage of the system is the esthetic, hygiene, low discomfort and removable nature of the appliance. www.indiandentalacademy.com
  • 95.  The current limitations are in terms of case selection, increased cost, experience required for computer treatment planning, difficulty obtaining certain tooth movements, and the lack of potential in teeth involving mixed dentition or impacted teeth.  The clinician must have an in-depth understanding of biomechanics, biology, periodontal concerns, and optimal therapeutic occlusion achieved during orthodontic treatment to successfully plan and use this appliance. www.indiandentalacademy.com
  • 96.  In future, we may see the replacement of PVS impressions with emerging intraoral scanning devices and the recording of treatment changes or modifications immediately in a digital format.  Adding the other 3 D compartments (skeletal, facial, jaw movement and animation to the surface map of the teeth) will greatly enhance the diagnostic and treatment capabilities of this new appliance. www.indiandentalacademy.com