removable clear appliances, history, Kesling retainer, potiz retainer, Essix retainer, and Invisalign retainer, how clear appliances work, and patient compliances.

1. Removable clear appliance
Dr. Shweta A. Kolhe
BDS. MDS. PhD (scholar)

2. History
• Patients seeking orthodontic treatment are increasingly
demanding more aesthetic options.
• Use of ceramic and lingual braces to a large extent satisfied the
aesthetic demand of many patients.
• Thermoformed appliances or clear plastic appliances are used to
bring about active orthodontic treatment.

3. • Kesling (1945) introduced a tooth positioner for refining the final
stage of orthodontic treatment after debanding.
• A positioner was a rubber appliance fabricated on the idealized
wax set-ups for patients whose basic treatment was complete.
• Advantage- positioner include ability to position teeth esthetically.
- To retain the alignment of the teeth achieved.

4. • Ponitz (1971) introduced invisible retainer, made of a thin thermoplastic
acrylic sheet.
• Used - as retainer after active phase of orthodontic treatment.
- for bringing about minor tooth movement.
- to treat minor relapses .
- for detailing of the occlusion.
• Appliance is accomplished by resetting teeth in the working model an then
fabrication of the appliance.

5. • Essix retainer (1993) – similar to the invisible retainer, made up of a
clear thin material that snap-fits over the dentition.
• Essix system can be modified by the orthodontist to bring about
minor tooth movements.

6. • Invisalign appliance (1997) introduced by Align
technology.
• This system made use of computer – aided – design and
computer-aided-manufacturing (CAD-CAM) technology to
fabricate a series of positioners (aligners) that can move
teeth in small increments of about 0.25 to 0.3 mm.
• This system revolutionized the use of clear esthetic plastic
appliances to effectively bring about tooth movement
without the need for making successive model setups to
fabricate the appliances.

7. Invisalign System
• The Invisalign system makes use of a series of aligners made from a thin,
transparent, thermoplastic plastic material formed with CAD-CAM
techniques.
• These aligners are similar to the invisible retainers and cover the clinical
crowns and the marginal gingiva.
• Each aligner is designed to move the teeth a maximum of about 0.25 to 0.3
mm over a 2 week period.
• The aligners are worn in a specific sequence each bringing about 0.25 to 0.3
mm of tooth movement.

8. • Patient compliance :
- Invisalign, removable appliance.
- Patient motivation and compliance are critical in achieving the desired
result.
- Patient must wear it for 20 to 22 hours a day.
- Each aligner should be worn 400 hours to be effective.
- They may remove it only when eating, when drinking hot drinks or
beverages that contain sugar and when brushing and flossing.

9. • Indications of Invisalign -
1. Crowding of 1-6 mm.
2. Mild to moderate spacing of 1-6 mm
3. Constricted arches of non-skeletal nature.
4. Mild relapse cases after fixed appliance therapy.
( Treating mid to moderate malocclusions: space closure, tooth
alignment, limited dental expansion, incisor advancement and limited
distalization of teeth)

10. • Contraindications of Invisalign-
1. Crowing and spacing over 5 mm.
2. Skeletal anterior-posterior discrepancies of more than 2 mm.
(Include class II and class III cases.)
1. Centric-relation and centric-occlusion discrepancies.
2. Severely rotated teeth (more than 200)
3. Open bites (anterior and posterior) that need to be closed.
4. Patients who require extractions.
5. Severe deep bite
6. Extrusion of teeth
7. Severely tipped teeth (more than 450)
8. Teeth with short clinical crowns.
9. Arches with multiple missing teeth.

11. Steps In Treatment With Invisalign
1. Pre-appliance requirements
2. Patient records, diagnosis and treatment plan
3. Records submission
4. 3-D Computer modeling
5. The doctor reviews and approves Clincheck
6. Aligner manufactured and shipped to practitioner for delivery to
patient
7. Monitoring treatment, obtaining desired results and retention.

12. 1. Pre-appliance requirements
• Prior to the initiation of this treatment all necessary restorative treatment
must be competed.
• An important prerequisite is that the patient should not exhibit active
periodontal disease.
• Informed consent should be completed before treatment begins.

13. 2. Patient records, diagnosis and treatment plan
• As with any orthodontic treatment including fixed – appliance
therapy, a through patient history, clinical examination, diagnosis and
a treatment plan is mandatory.
• A comprehensive evaluation of the patient is advised.

14. 3. Records submission
• The most important step in fabricating aligners is obtaining accurate
Polyvinyl siloxane (PVS) upper and lower impressions.
• A Polyvinyl siloxane (PVS) bite registration should also be made.
• Eight photographs are required to be submitted :-
1. Extraoral: frontal smiling
2. Frontal repose
3. Lateral profile repose
4. Intraoral anterior
5. intraoral right and left buccal
6. Intraoral maxillary and mandibular occlusal.

15. • A prescription form is to be filled containing the patient’s diagnostic data.
• Doctors can register their general priorities and preferences for the
treatment.
• Align technology provides disposable impression trays and boxes for
packing and postage of the impressions and bite registration.
• The patient’s diagnostic data can be submitted online

17. 4. 3-D Computer modeling
• Once the records including the impressions and bite reach Align
Technology, the patient’s PVS impressions are transformed into 3-D images
to prepare a three – dimensional computer graphic image of the patient’s
teeth and associated tissues.
• The ClinCheck software uses the practitioner’s treatment form and stated
preferences to generate a computerized final status of the dentition.
• It also generates stages between the start and finish to bring about
approximately 0.25 mm of movement anticipated in each increment.

18. 5. The Doctor Reviews And Approves Clincheck
• After computerized pan of treatment, the dentist is notified that the
case is ready for review of its ClinCheck.
• Careful review of Clincheck is essential to achiee the best possible
results.
• Clinicians can request modification at this time if he fees it is
required.

19. 6. Aligner manufactured and shipped to practitioner
for delivery to patient
• After ClinCheck is approved by the dentist, Align Technology uses the
sequence of graphical images combined with CAD/CAM to produce clear,
lightweight aligners and posts them to the Dentist.
• If attachments are part of the plan of treatment, an “attachment
template” is sent with the aligners and bonded to teeth by the dentist at
the beginning of treatment.
• Attachments serve as “handles” used to assist in the retention of the
appliance or specific types of movements.

20. 7. Monitoring treatment, obtaining desired
results and retention
• Careful treatment monitoring helps to identify problems.
• At each patient visit, check the occlusion and verify fitting of aligner and
compare the treatment progress to the CinCheck simulation at three-
month intervals.
• If teeth do not seem to be tracking well in the aligners then treatment
needs to be modified.
• After case completion, the final aligner should not sere as a long term
retainer
• An invisible retainer can be an excellent choice after active phase of
treatment is completed using Invisalign.

22. How does the Invisalign system work?
• The Invisalign system is force-driven
• The Invisalign aligner, formed in a shape that is
intended to impart specific forces to the tooth
crown, resulting in the desired tooth movement.
• By applying a range of M/F values, different types of
tooth movement can be accomplished.
• Force systems are measurable. Invisalign aligners are
designed with precise control of the force system to
provide excellent control of tooth movement.

23. Lingual root torque
• The Power Ridge feature is a change in the shape of
the aligner
• designed to apply a lingual force to the tooth and to
control the
• distortion of the aligner near the lingual incisal
edge. Treatments for
• lingual root torque with retraction result in removal
of the contact
• on the lingual incisal edge that is required for
control of the root; the
• lingual Power Ridge feature is designed to restore
the contacts in these
• treatments.

24. Extrusion • An Optimised Attachment changes the shape of the tooth so
forces can be applied in the correct direction.
• The Optimised Extrusion Attachment provides a flat planar
“active surface”, on which the aligner imparts force. It is the
only surface engaged by the aligner.
• The rest of the attachment material exists only to hold the
active surface in place.
• This force system is considered to provide more successful
extrusion of all incisors as a unit and is being used effectively
in the treatment of open bite.

25. Root tip control
• Optimised Root Control Attachments are
customized for each patient’s morphology
and provide mesiodistal root tip control.
• Clinical applications include space closure,
mesiodistal uprighting, and bodily
movement

26. Rotation • Rotation of a tooth around its long axis,
considered difficult to achieve with
aligners.
• More predictable rotation of canines
and premolars can be accomplished
using Optimised Rotation Attachments.
• The active surface of the attachment is
automatically positioned on the buccal
surface, as far from the long axis of the
tooth as possible, and designs the
aligner to apply force to this surface.

27. SmartForce features
• The Invisalign system is the only clear aligner system that combines multiple
Smart innovations. It is designed specifically for the treatment of more difficult
malocclusions such as open bite, deep bite, or first premolar extraction
(planned for maximum anchorage).
• Proprietary ClinCheck treatment planning software analyses tooth movements
to determine the optimal force required and automatically places attachments
and features to achieve the desired movement based on specific tooth size and
shape.
• Therefore, it’s the force-driven system that applies the right amount of force
necessary to move the teeth, and not through manual placement.
• With SmartForce Aligner Activation, specific areas on the aligner surfaces are
now contoured to apply forces onto the tooth surface in the proper direction to
produce the desired movement and minimize unwanted movements

28. The Essix System
• Essix system unlike the Invisalign system utilizes the skill of
the dentist in the fabrication and realization of the treatment
objectives.
• The appliance is made up of a thin, durable thermoplastic
material that is practically invisible.
• Most treatment is accomplished by modifying the appliance
a number of times during the course of treatment.

29. The Essix System
• How the system works :
- The Essix system can be used to bring about tooth
movement in all planes of space.
- Whenever a tooth movement is planned using the thin
plastic appliance, provision should be made for the
application of force and also a space should be planned
in the appliance in the direction of the moving tooth.
- E.g. if a tooth is moved palatally, force should be
applied by the appliance on the labial aspect and a
space should exist on the palatal aspect of the
appliance for the tooth to move palatally.

30. • Creating space within the appliance:
- Space can be planned in the appliance in the direction of the moving
tooth.
- Done by blocking out an area on the working model using composites.
- The amount of block-out used should be proportional to the intended
amount of tooth movement.
- Once the appliance is fabricated we would observe a space in the
direction of the tooth movement.

31. Deep-Bite Correction

32. - An alternate way to create a space is by cutting
out a window in the appliance in the direction
of tooth movement.
- This can be made using plastic trimming burs
at a slow speed.
- The size of the window should be large enough
for the intended tooth to move through.

33. • Including tooth moving forces in the appliance :
There are two method of including a force using the Essix system.
1. First method is by the use of Hilliard thermopiler which induces a spot
projection in the appliance in the direction of the desired force.
2. The second method of inducing a force on the appliance is by placing a
small mound of composite on the tooth where the force needs to be
applied.

34. 1. The first method is by the use of Hilliard thermopliers
which induces a spot projection in the appliance in the
direction of the desired force.
- The plier tip is heated to 2000F and is used on the appliance
at the planned spot by gripping it.
- This produces projection in the appliance that produces the
desired force to move the tooth.
- Another method that can be used is to create a small notch
on the working model which would produce a small
projection on the appliance in the area where the force is
desired.

35. 2. The second method of inducing a force on the
appliance is by placing a small mound of
composite on the tooth where the force needs
to be applied.
- If additional tooth movement is desired more
composite can be added.
- The area where the composite mound is placed
can be altered during the treatment to bring
about the desired movement of tooth

36. Compliance With Removable Clear Appliances
• Patient motivation is critical in achieving the desired results when using
removable clear appliances.
• Patients must wear it at least 22 hours a day for these appliance to be
effective.
• They need to be removed when eating; drinking hot beverages that may
cause warping or staining or beverages that contain sugar and when
brushing and flossing.
• Transparency of this appliance may increase the likelihood of its being
misplaced when it is removed.

37. Thank you