Kitabı oku: «Aligner Techniques in Orthodontics»

Table of Contents

1  Cover

2  Title Page

3  Copyright Page

4  Preface

5  About the Authors

6  Acknowledgements

7  About the Companion Website

8  1 History, Present and Future of Aligners 1.1 History of Clear Aligners 1.2 Origins of Align Technology 1.3 Early Clear Aligner Manufacturers 1.4 Align Technology Development 1.5 Current Situation and Future of Aligners 1.6 Promising Aligner Initiatives 1.7 Future of Clear Aligners

9  2 Basic Principles with Aligners 2.1 Forces 2.2 Engagement 2.3 Anchorage 2.4 Case Selection to Start with Aligners Technique

10  3 Why Invisalign? 3.1 Why Did We Begin Prescribing Invisalign in Our Practice? 3.2 Our Motivation

11  4 Patient Communication Skills 4.1 Invisalign Equates to Health, Wellness and Outstanding Results 4.2 Effective Patient Communication

12  5 Keys to Practice Growth 5.1 How to Get the Best Results with Invisalign

13  6 Patient Selection

14  7 Predictability of Movement 7.1 Treatments to Gain Familiarity with the Technique

15  8 Types of Treatments with Invisalign

16  9 Pillars of the Invisalign Technique 9.1 Aligners 9.2 ClinCheck Software 9.3 Attachments and Features of SmartForce 9.4 Auxiliary Techniques 9.5 Technician (CAD Designer)

17  10 Conventional Attachments

18  11 Clinical Preferences

19  12 Attachments Bonding and Interproximal Reduction 12.1 Bonding Attachments Protocol 12.2 Interproximal Reduction Procedure

20  13 Digital Workflow 13.1 Records 13.2 Creating a New Patient Record

21  14 ClinCheck Software 14.1 The Perfect ClinCheck Review in 10 Steps 14.2 Communication with the Technician

22  15 Treatment Monitoring and Appointments Protocol 15.1 Tracking Treatment Progress 15.2 Appointments Protocol for Invisalign Patient

23  16 Troubleshooting and Retention 16.1 Auxiliary Techniques 16.2 Finishing Techniques 16.3 Retention

24  17 Arch Length Discrepancies 17.1 Spacing 17.2 Crowding

25  18 Growing Patients 18.1 First Treatment 18.2 Teenage Patients

26  19 Transversal Problems: Symmetric and Asymmetric Expansion 19.1 Things to Consider in Expansion Cases 19.2 Symmetric Expansion 19.3 Asymmetric Expansion 19.4 Tips for Transversal Arch Compensation

27  20 Sagittal Discrepancies 20.2 Class II Cases 20.3 Class III 20.4 Dentoalveolar Protrusion Skeletal Class II

28  21 Vertical Problems 21.1 Open Bite 21.2 Deep Bite: Classification According to Complexity Bibliography

29  22 Asymmetries 22.1 Growing Patients with Asymmetry 22.2 Non‐growing Patients with Asymmetry

30  23 Extraction Cases 23.1 Incisor Extraction 23.2 Extraction of Premolars

31  24 Multidisciplinary Cases: Implants 24.1 TADs to Intrude Upper Molars 24.2 Upper Midline Shift 24.3 Posterior Bite Collapse 24.4 Posterior Bite Collapse with Deep Bite 24.5 Biomechanics of the Locatelli for Mesialization of the Lower Dental Arch Opening Space for Implants 24.6 Gingivectomy, Passive Eruption Case 24.7 Anterior Intrusion Anchored on Dental Implant 24.8 Anterior Torque Anchored on Dental Implant

32  25 Prerestorative Orthodontics: Veneers 25.1 Bleaching 25.2 Veneers to Solve Lateral Bolton Discrepancy in a Class III Patient 25.3 Space Opening for Anterior Crowns and Implants 25.4 Anterior Intrusion for Two Central Incisor Veneers 25.5 Edge‐to‐Edge Bite Preparation for Veneers

33  Index

34  End User License Agreement

List of Tables

1 Chapter 20Table 20.1 Extra resources for class II patientsTable 20.2 Protocol when treating a growing patient with class II

List of Illustrations

1 Chapter 1Fig. 1.1 Remensnyder patent file.Fig. 1.2 Kesling patent file.Fig. 1.3 Schwartz and Sheridan patent file.Fig. 1.4 Align Technology logo.Fig. 1.5 Align Technology annual revenue.Fig. 1.6 Align Technology stereolithographic has been heavily awarded.Fig. 1.7 Models and aligners by Clear Correct.Fig. 1.8 Optimized attachments for anterior open bite.Fig. 1.9 Passive attachments for anterior intrusion.Fig. 1.10 Results in PubMed for ‘orthodontics’.Fig. 1.11 Results in PubMed for ‘invisalign’ from 1999 to 2019.Fig. 1.12 ClearCorrect aligner retention chart.Fig. 1.13 SureSmile aligner software combined with CBCT.Fig. 1.14 F22 chromatic stability.Fig. 1.15 3M superimposition for treatment evolution.Fig. 1.16 Ormco results for their TruGEN plastic against SmartTrack (data on fil...Fig. 1.17 Distalizer inserted in an in‐practice aligner.Fig. 1.18 Irok is focused on digital models that can serve different purpose...Fig. 1.19 A6 mandibular advancement launched in 2015.Fig. 1.20 LineDock software.Fig. 1.21 SmileDirectClub self‐polyvinyl siloxane (PVS) ‐impression kit.Fig. 1.22 CANDID aligners process.Fig. 1.23 CANDID aligners set.

2 Chapter 2Fig. 2.1 Forces will be delivered through the combination of plastic and att...Fig. 2.2 Optimized attachments provide an active, flat surface that the alig...Fig. 2.3 These crowns allow enough contact from plastic to exert desired for...Fig. 2.4 Short clinical crowns might reduce movement predictability.Fig. 2.5 Quantification of variable aligner material on retention. (Left) Ve...Fig. 2.6 Brackets have a strong small contact point in comparison with a sof...Fig. 2.7 While second molars are moving, the rest of the teeth are considere...Fig. 2.8 This figure shows a horizontal ‘V’ movement pattern.Fig. 2.9 The second quadrant is being expanded using the first quadrant as a...Fig. 2.10 G6 first premolar extraction has a standardized movement sequence....Fig. 2.11 In this G6 protocol extraction of 14 (from left to right), the pos...

3 Chapter 4Fig. 4.1 Let’s talk about aligner treatment with our patients.Fig. 4.2 The more Invisalign patients you have, the more Invisalign referral...Fig. 4.3 A treatment coordinator is a key success driver for Invisalign.

4 Chapter 5Fig. 5.1 If we plan our growth in advance, we will reach our goals.

5 Chapter 6Fig. 6.1 Invisalign evaluation tool.

6 Chapter 7Fig. 7.1 All treatment predictability can be checked with the Invisalign eva...

7 Chapter 8Fig. 8.1 Align Technology’s 2021 portfolio

8 Chapter 10Fig. 10.1 Ellipsoid attachments. Fig. 10.2 Horizontal attachments have great clinical effects on transverse p...Fig. 10.3 Conventional attachments are selected whenever there are no optimi...Fig. 10.4 Extrusion attachments are placed on teeth adjacent to the ones to ...Fig. 10.5 Vertical attachments bevelled to mesial (left) and distal (right)....Fig. 10.6 Conventional attachments might be placed to achieve similar moveme...Fig. 10.7 Research and development investment has led to a very powerful bio...Fig. 10.8 Conventional dental composite is the material chosen for attachmen...Fig. 10.9 Placement on canines and premolars. Fig. 10.10 Placement on incisor. Fig. 10.11 Placement on premolar.Fig. 10.12 The right side shows how anterior extrusion attachments help to c...Fig. 10.13 The figure on the right shows how optimized root control attachme...Fig. 10.14 Pressure points are usually associated with attachments whenever ...Fig. 10.15 Combination of attachments and lingual pressure points help creat...Fig. 10.16 Sometimes attachments are designed for support instead of movemen...Fig. 10.17 Attachments for molars are relatively new and provide improved ro...Fig. 10.18 Mesiobuccal rotation combined with extrusion.Fig. 10.19 Mesiobuccal rotation combined with intrusion.Fig. 10.20 Molar extrusion.Fig. 10.21 Optimized support attachments are commonly used in first treatmen...Fig. 10.22 Power Ridges are plastic bends exerting ‘push’ forces.Fig. 10.23 Activation exerts forces translated to crown or root.Fig. 10.24 Effect of pressure point on the tooth.Fig. 10.25 Precision Ramps are much comfortable for the patient than convent...Fig. 10.26 Clinical view of Precision Wings in a growing patient.

9 Chapter 11Fig. 11.1 Dedicate time to setting up clinical preferences.

10 Chapter 12Fig. 12.1 Have materials and equipment ready before any appointment.Fig. 12.2 (a) Place composite on template and (b) ensure there is no composi...Fig. 12.3 A metal interproximal reduction strip is the most common type used...Fig. 12.4 A high‐speed bur interproximal reduction (IPR) is suggested for 0....Fig. 12.5 Interproximal reduction and attachments removal bur set is ideal f...Fig. 12.6 Interproximal reduction has to be carefully planned and performed....

11 Chapter 13Fig. 13.1 Frontal, smile and lateral photographs.Fig. 13.2 90 degrees pictures are mandatory both in right (a) and left (b) i...Fig. 13.3 Intraoral frontal (a) and overjet (b) pictures will help create a ...Fig. 13.4 Blue or red ink on both upper (a) and lower (b) occlusal pictures ...Fig. 13.5 Polyvinyl siloxane (PVS) material placement.Fig. 13.6 Inserting tray with polyvinyl siloxane (PVS) material into the pat...Fig. 13.7 Upper (left) and lower (right) impressions.Fig. 13.8 iTero scanner has several advantages, such as the Outcome Simulato...Fig. 13.9 Lateral and panoramic X‐rays.

12 Chapter 14Fig. 14.1 ClinCheck software on‐screen.Fig. 14.2 Compare ClinCheck with pictures on the same plane before start pla...Fig. 14.3 Distortions of the impression might affect aligner coverage, so it...Fig. 14.4 Anterior view.Fig. 14.5 Overjet view.Fig. 14.6 Buccal right view.Fig. 14.7 Buccal left view.Fig. 14.8 Occlusal view: maxillaryFig. 14.9 Occlusal view: mandibular.Fig. 14.10 Posterior view.Fig. 14.11 Mandibular advancement.Fig. 14.12 Treatment overview helps us understand general structure of the t...Fig. 14.13 Reviewing occlusal views.Fig. 14.14 Analysis of the force vectors: in simultaneous distalization, if ...Fig. 14.15 Anterior positive torque (left) allows pure intrusion to resolve ...Fig. 14.16 The sequence will always be based on three steps: (1) procline in...Fig. 14.17 Staging is mandatory to help achieving desired final position.Fig. 14.18 Checking every stage on anterior sector will prevent from unaesth...Fig. 14.19 Round tooth rotations (canines and premolars) require perfectly s...Fig. 14.20 Ask the technician to perform the extrusion of the canine simulta...Fig. 14.21 The pearl necklace effect explains how to use these mechanics in ...Fig. 14.22 Simultaneous expansion for reduction in arch length (incisor retr...Fig. 14.23 Expansion leads to arch depth loss and anterior retraction.Fig. 14.24 Whenever possible, simultaneous anterior intrusion and posterior ...Fig. 14.25 Superimposition tool.Fig. 14.26 Black dots indicate complex movements.Fig. 14.27 Blue dots indicate moderate movements.Fig. 14.28 Attachments.Fig. 14.29 White boxes indicating interproximal reduction turn yellow at the...Fig. 14.30 Treatment overview also addresses interproximal reduction needs....Fig. 14.31 Buttons and hooks: the biomechanical difference between button cu...Fig. 14.33 Button cutouts will allow composite or metal butons to be bonded ...Fig. 14.34 Upper hook will affect upper anterior torque.Fig. 14.35 Upper cutout for bonded button will have less effect on anterior ...Fig. 14.36 Treatment overview also refers to hooks or button cutouts.

13 Chapter 16Fig. 16.1 An example of poor fitting.Fig. 16.2 Fitting can improve with ‘fitters’ chewing.Fig. 16.3 Detailing pliers are helpful for case finishing.Fig. 16.4 Auxiliary technique to recapture a rotated lower canine with butto...Fig. 16.5 Buccal (left) and palatal (right) view of a lateral incisor extrud...Fig. 16.6 Ectopic canines not covered by the aligner.Fig. 16.7 Uprighting a premolar root.Fig. 16.8 This patient had a distal tipping of the second premolar root. A P...Fig. 16.9 In this case goal was to mesialize 47 and 48 in order to close 46 space.Fig. 16.10 Patient with missing 46.Fig. 16.11 The patient had missing 36 and 46.Fig. 16.12 A Locatelli helps to open space.Fig. 16.13 Temporary anchorage devices help intruding teeth in severe deep b...Fig. 16.14 Posterior extrusion is achieved here with auxiliary buttons and e...Fig. 16.15 Auxiliary buttons and elastics help derotating teeth.Fig. 16.16 Change in smile after expansion of upper arch and offset and rota...Fig. 16.17 Mesial‐in rotation of the canine.Fig. 16.18 Mesial‐out rotation of the canine.Fig. 16.19 Finishing bends.Fig. 16.20 Fixed retention from lateral to lateral.Fig. 16.21 Vivera retainers are manufactured by Align Technology.

14 Chapter 17Fig. 17.1 Interproximal reduction has to be performed carefully in order to ...Fig. 17.2 Interproximal reduction might improve the shape and size of teeth,...Fig. 17.3 Interproximal reduction in cases of crowding might improve contact...Fig. 17.4 Spacing cases are usually related to abnormal tooth size, which le...Fig. 17.5 Palatal root torque is seen on the ClinCheck Pro as blue areas on ...Fig. 17.6 Skeletal class I with spacing.Fig. 17.7 Pretreatment views.Fig. 17.8 Pretreatment panoramic X‐ ray, teleradiograph and cephalometry.Fig. 17.9 Upper CC superimposition and instructions to CAD designer.Fig. 17.10 Lower CC superimposition and instructions to CAD designer.Fig. 17.11 Front CC view.Fig. 17.12 Front intraoral picture.Fig. 17.13 Right ClinCheck view, initial situation.Fig. 17.14 Left ClinCheck view, initial situation.Fig. 17.15 Post‐treatment views.Fig. 17.16 Pretreatment and final smile.Fig. 17.17 Post‐treatment panoramic and lateral X‐rays.Fig. 17.18 Skeletal class I with spacing.Fig. 17.19 Intraoral views left, front, right, upper, lower.Fig. 17.20 Smile and pretreatment panoramic X‐ray.Fig. 17.21 Pretreatment Clinchecks.Fig. 17.22 Refinement: intraoral views, left, front, and rightFig. 17.23 Refinement ClinChecks.Fig. 17.24 Final intraoral views left, front, right, upper, lower.Fig. 17.25 Before and after smile.Fig. 17.26 Final panoramic and lateral X‐rays.Fig. 17.27 Skeletal class III with upper maxillary compression and anterior ...Fig. 17.28 Pretreatment views.Fig. 17.29 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 17.30 Planned IPR on midline can be seen in several areas of the ClinCh...Fig. 17.31 Upper CC superimposition and instructions to CAD designer.Fig. 17.32 Lower CC superimposition and instructions to CAD designer.Fig. 17.33 Right ClinCheck view, initial situation.Fig. 17.34 Left ClinCheck view, initial situation.Fig. 17.35 Post‐treatment images (right, front, left, upper, lower).Fig. 17.36 Pretreatment smile.Fig. 17.37 Final smile.Fig. 17.38 Upper crowding and anterior crossbite ‘Lite’ treatment in a class...Fig. 17.39 Pretreatment extraoral and intraoral (right, front, left, upper, ...Fig. 17.40 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 17.41 Upper CC superimposition and instructions to CAD designer.Fig. 17.42 Lower CC superimposition and instructions to CAD designer.Fig. 17.43 Right ClinCheck view, initial situation.Fig. 17.44 Left ClinCheck view, initial situation. Fig. 17.45 Planned IPR on midline can be seen in several areas of the ClinCh...Fig. 17.46 Initial intraoral views.Fig. 17.47 Final intraoral views.Fig. 17.48 Initial and final occlusal (upper and lower).Fig. 17.49 Pretreatment smile and overjet.Fig. 17.50 Final Smile and overjet.Fig. 17.51 Upper and lower crowding with anterior crossbite of 22.Fig. 17.52 Pretreatment: extraoral and intraoral (right, front, left, upper,...Fig. 17.53 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 17.54 Upper and lower CC superimposition and instructions to CAD design...Fig. 17.55 Right and left ClinCheck view, initial situation and instructions...Fig. 17.56 Interproximal reduction after improving contact surface between i...Fig. 17.57 Evolution in month 13 of treatment.Fig. 17.58 Evolution in month 17 of treatment.Fig. 17.59 Final intraoral (right, front, left, upper, lower) views.Fig. 17.60 Initial and final smile and overjet.Fig. 17.61 Final panoramic and lateral X‐rays.Fig. 17.62 Skeletal class I with crowding.Fig. 17.63 Protocol excludes crisscross elastics to solve premolar crossbite...Fig. 17.64 Extra palatal root torque premolars, selecting multiple teeth wit...Fig. 17.65 Pretreatment intraoral views (left, front, right).Fig. 17.66 Initial panoramic and lateral X‐rays.Fig. 17.67 Pretreatment ClinChecks with interproximal reduction to avoid exp...Fig. 17.68 Refinement: intraoral views (right, front and left).Fig. 17.69 Refinement ClinCheck: right, front and left (in this set, 37 is i...Fig. 17.70 Final intraoral views (left, front, right).Fig. 17.71 Final panoramic‐X‐ray.Fig. 17.72 Final extraoral views.

15 Chapter 18Fig. 18.1 Skeletal growth pattern has to be carefully evaluated in growing p...Fig. 18.2 Upper temporary spacing is 3 mm, on average, while tooth discrepan...Fig. 18.3 Severe crowding on temporary teeth leads to future extractions or ...Fig. 18.4 Disjunction and protraction should be performed on EC1, while mand...Fig. 18.5 Anterior crossbite management should be addressed early.Fig. 18.6 Skeletal class II can be achieved before than usual if overjet is ...Fig. 18.7 More simple devices can achieve less objectives than aligners.Fig. 18.8 Upper compression with posterior and anterior crowding.Fig. 18.9 Views with the Hyrax before Invisalign First.Fig. 18.10 Panoramic X‐ray before Hyrax.Fig. 18.11 After the Hyrax and before Invisalign First (10‐year‐old patient)...Fig. 18.12 Panoramic X‐ray before Invisalign First.Fig. 18.13 Upper CC superimposition and instructions to CAD designer.Fig. 18.14 Lower CC superimposition and instructions to CAD designer.Fig. 18.15 Right ClinCheck view, initial situation.Fig. 18.16 Left ClinCheck view, initial situation.Fig. 18.17 Attachments can be seen in several areas of the ClinCheck softwar...Fig. 18.18 Pretreatment intraoral views (left, front, right) before Invisali...Fig. 18.19 Intraoral views (left, front, right) with first aligner.Fig. 18.20 Actual situation in additional aligners.Fig. 18.21 Initial and final occlusal (upper and lower).Fig. 18.22 Initial and final smile.Fig. 18.23 Severe crowding impeding proper lateral incisor eruption both in ...Fig. 18.24 Taking advantage of aligner biomechanics by distalizing the secon...Fig. 18.25 Pretreatment intraoral views (right, front, left, upper, lower)....Fig. 18.26 Pretreatment panoramic X‐ray showing current dentition status and...Fig. 18.27 Initial extraoral views.Fig. 18.28 Pretreatment Clinchecks (right, front, left, upper, lower).Fig. 18.29 Refinement: (left) 32 has erupted and does not fit in the aligner...Fig. 18.30 Refinement: panoramic X‐rays show the evolution of the sagittal m...Fig. 18.31 Refinement development: Both available arch space and transverse ...Fig. 18.32 Refinement: 12, 22 have erupted but their clinical crowns are not...Fig. 18.33 Final Intraoral views (right, front, left, upper, lower) showing ...Fig. 18.34 Final and final smile views show an improvement in arch developme...Fig. 18.35 Lateral X‐ray shows incisor proclination as a result of the mecha...Fig. 18.36 Class II growing patient, Lite treatment.Fig. 18.37 Pretreatment views before phase 1 with Hyrax and D‐gainer.Fig. 18.38 Lateral and panoramic X‐rays before phase 1 with Hyrax and D‐gain...Fig. 18.39 Extraoral and intraoral (right, front, left, upper, lower) views ...Fig. 18.40 Panoramic X‐ray, teleradiograph and cephalometry before Invisalig...Fig. 18.41 Upper CC superimposition and instructions to CAD designer.Fig. 18.42 Lower CC superimposition and instructions to CAD designer.Fig. 18.43 Right ClinCheck view, initial situation.Fig. 18.44 Left ClinCheck view, initial situation.Fig. 18.45 Attachments and IPR can be seen in several areas of the ClinCheck...Fig. 18.46 Intraoral views (right, front, left, upper, lower).Fig. 18.47 Intraoral views (right, front, left, upper, lower).Fig. 18.48 Initial and final occlusal views (upper and lower).Fig. 18.49 Pretreatment and final smile and overjet.Fig. 18.50 Initial and final profiles.Fig. 18.51 Final panoramic and lateral X‐rays.Fig. 18.52 Initial intraoral picture.Fig. 18.53 Pretreatment views.Fig. 18.54 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 18.55 Upper CC superimposition and instructions to CAD designer.Fig. 18.56 Lower CC superimposition and instructions to CAD designer.Fig. 18.57 Interproximal reduction necessary to upright lower incisors befor...Fig. 18.58 Right ClinCheck view, initial situation.Fig. 18.59 Left ClinCheck view, initial situation.Fig. 18.60 Pretreatment intraoral views (left, front, right).Fig. 18.61 Month 6 of evolution: intraoral views (left, front, right).Fig. 18.62 Refinement: month 15 of evolution; intraoral views (left, front, ...Fig. 18.63 Final intraoral views (right, front, left, upper, lower).Fig. 18.64 Pretreatment and final smile.Fig. 18.65 Final panoramic and lateral X‐rays.Fig. 18.66 Class III growing patient comprehensive treatment, with 23 includ...Fig. 18.67 Intraoral views (right, front, left, upper, lower).Fig. 18.68 Panoramic X‐ray, teleradiograph, cephalometry.Fig. 18.69 Upper CC superimposition and instructions to CAD designer.Fig. 18.70 Lower CC superimposition and instructions to CAD designer.Fig. 18.71 Right ClinCheck view, initial situation.Fig. 18.72 Left ClinCheck view, initial situation.Fig. 18.73 Interproximal reduction in lower arch to create positive overjet....Fig. 18.74 Opening space for 15 (lateral view).Fig. 18.75 Opening space for 15 (occlusal view).Fig. 18.76 Locatelli to open space for 15 and 23.Fig. 18.77 Situation at the end of first set of aligners.Fig. 18.78 (a–f) Transversal development of the arches.Fig. 18.79 Month 18 of evolution, intraoral views.Fig. 18.80 Final views with15 and 23 in place.Fig. 18.81 By labial.Fig. 18.82 By lingual.Fig. 18.83 Class I deep bite Lite treatment.Fig. 18.84 Pretreatment views (right, front, left, upper, lower).Fig. 18.85 Upper CC superimposition and instructions to CAD designer.Fig. 18.86 Lower CC superimposition and instructions to CAD designer.Fig. 18.87 Attachments and IPR can be seen in several areas of the ClinCheck...Fig. 18.88 Left ClinCheck view, initial situation.Fig. 18.89 Right ClinCheck view, initial situation.Fig. 18.90 Pretreatment panoramic X‐ray, teleradiography and cephalometry.Fig. 18.91 Pretreatment (upper) and final (lower) results.Fig. 18.92 Initial and final occlusal (upper and lower).Fig. 18.93 Pretreatment and final smiles and overjets.Fig. 18.94 Final panoramic and lateral X‐rays.Fig. 18.95 Ectopic palatal canine.Fig. 18.96 Initial intraoral views (right, front, left, upper, lower).Fig. 18.97 Initial extraoral views.Fig. 18.98 Initial intraoral views: traction 1, 2, 3.Fig. 18.99 Initial lateral and panoramic X‐rays.Fig. 18.100 Refinement: intraoral views (right, front, left, upper, lower)....Fig. 18.101 ClinChecks: right, front, left, upper, lower.Fig. 18.102 Traction 4 and 5. Initial traction was delivered with constant f...Fig. 18.103 Refinement 2: intraoral views (right, front, left, upper, lower)...Fig. 18.104 Smile at refinement 2.Fig. 18.105 Refinement 2 ClinChecks (right, front, left, upper, lower).Fig. 18.106 Final intraoral views.Fig. 18.107 Final smile view.Fig. 18.108 Current cephalometric measurements.Fig. 18.109 Ortopantomographs (OPG) 0, 1, 2, 3. Evolution of the canine with...Fig. 18.110 Temporary 52.Fig. 18.111 Initial intraoral views (right, front, left, upper, lower).Fig. 18.112 Pretreatment panoramic X‐ray with wisdom teeth present.Fig. 18.113 Final intraoral views (right, front, left, upper, lower).Fig. 18.114 Initial and final panoramic X‐rays. Right class I was achieved e...Fig. 18.115 Final lateral X‐ray and cephalometric analysis.

16 Chapter 19Fig. 19.1 Classic NiTi archwires were only available on standard sizes and s...Fig. 19.2 Expansion can be defined in a precise way, with the decision about...Fig. 19.3 Expansion with aligners can be defined in between Fa point (blue l...Fig. 19.4 Dentoalveolar expansion can be achieved with aligners, as with bra...Fig. 19.5 In this situation, if we ask for the same amount of expansion in b...Fig. 19.6 Check smile In unilateral masticatory side the patient will expose...Fig. 19.7 Asymmetric expansion.Fig. 19.8 Blue arrows indicate proper posterior torque, white ones show arch...Fig. 19.9 Pearl necklace effect.Fig. 19.10 Smile picture.Fig. 19.11 Symmetric compression causing anterior open bite.Fig. 19.12 Pretreatment extraoral and intraoral views.Fig. 19.13 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 19.14 Interproximal reduction.Fig. 19.15 Upper superposition.Fig. 19.16 Lower superposition.Fig. 19.17 Initial right ClinCheck view, with CAD designer instructions.Fig. 19.18 Initial left ClinCheck view, with CAD designer instructions.Fig. 19.19 Comparison of initial and final occlusion.Fig. 19.20 Comparison of initial and final occlusal.Fig. 19.21 Comparison of initial and final smile overjets.Fig. 19.22 Comparison of initial and final smiles.Fig. 19.23 Final panoramic X‐ray and teleradiograph.Fig. 19.24 Edge to edge bite with open bite tendency.Fig. 19.25 Pretreatment intraoral views (right, front, left, upper, lower)....Fig. 19.26 Initial extraoral view: short display.Fig. 19.27 Pretreatment panoramic and lateral X‐rays.Fig. 19.28 Pretreatment ClinChecks (right, front, left, upper, lower).Fig. 19.29 Refinement intraoral views (right, front, left, upper, lower).Fig. 19.30 Refinement smile.Fig. 19.31 Refinement ClinChecks (right, front, left, upper, lower).Fig. 19.32 Final intraoral views (right, front, left, upper, lower).Fig. 19.33 Final smile picture and lateral X-ray.Fig. 19.34 Symmetric compression.Fig. 19.35 Pretreatment intraoral views (right, front, left, upper, lower)....Fig. 19.36 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 19.37 Upper CC superimposition and instructions to CAD designer.Fig. 19.38 Lower CC superimposition and instructions to CAD designer.Fig. 19.39 Attachments and IPR can be seen in several areas of the ClinCheck...Fig. 19.40 Right ClinCheck view, initial situation.Fig. 19.41 Left ClinCheck view, initial situation.Fig. 19.42 Views before starting refinement.Fig. 19.43 Final views.Fig. 19.44 Comparison of initial and final occlusal (upper and lower).Fig. 19.45 Final expansion reducing buccal corridors.Fig. 19.46 Final Panoramic X‐ray and teleradiography.Fig. 19.47 Symmetric compression with loss of attachment.Fig. 19.48 Pretreatment extraoral and intraoral views.Fig. 19.49 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 19.50 Upper CC superimposition and instructions to CAD designer.Fig. 19.51 Lower CC superimposition and instructions to CAD designer.Fig. 19.52 Interproximal reduction is necessary to upright lower incisors.Fig. 19.53 Right and left ClinCheck view, initial situation.Fig. 19.54 Comparison of pretreatment (upper) and final (lower) views.Fig. 19.55 Comparison of initial and final occlusal.Fig. 19.56 Comparison initial of and final smile and overjet.Fig. 19.57 Posterior bilateral crossbite.Fig. 19.58 Initial extraoral views.Fig. 19.59 Initial intraoral views (right, front, left, upper, lower).Fig. 19.60 Pretreatment Clinchecks: right, front, left, upper, lower.Fig. 19.61 Refinement: intraoral views (right, front, left, upper, lower).Fig. 19.62 Refinement ClinChecks: right, front, left, upper, lower.Fig. 19.63 Refinement 2: intraoral views (right, front, left, upper, lower)....Fig. 19.64 Refinement 2 ClinChecks: right, front, left, upper, lower.Fig. 19.65 Final intraoral views (right, front, left, upper, lower).Fig. 19.66 Pretreatment and final smile.Fig. 19.67 Posterior bilateral compression.Fig. 19.68 Initial intraoral views (right, front, left, upper, lower).Fig. 19.69 Initial intraoral views (right, front, left, upper, lower).Fig. 19.70 Pretreatment ClinChecks: right, front, left, upper, lower. Fig. 19.71 Refinement: intraoral views (right, front, left, upper, lower). Fig. 19.72 Refinement ClinChecks: right, front, left, upper, lower.Fig. 19.73 Refinement ClinChecks: right, front, left, upper, lower.Fig. 19.74 Check first column on both charts to see how much expansion was a...Fig. 19.75 Refinement 2: intraoral views (right, front, left, upper, lower)....Fig. 19.76 Final intraoral views: right, front, left, upper, lower.Fig. 19.77 Pretreatment and final smile.Fig. 19.78 Final lateral, cephalometric analysis and panoramic X-ray.Fig. 19.79 patient with severe periodontal disease.Fig. 19.80 Pretreatment views. Note the critical periodontal situation of up...Fig. 19.81 Initial panoramic X-ray, teleradiograph and cephalometry.Fig. 19.82 Problem list.Fig. 19.83 Treatment plan.Fig. 19.84 It is important to relate clinical view to the Clincheck.Fig. 19.85 Upper and lower CC superimposition and instructions to CAD design...Fig. 19.86 Goal of treatment. Open space by asymmetric upper expansion on th...Fig. 19.87 Right ClinCheck view, initial situation.Fig. 19.88 Left ClinCheck view, initial situation.Fig. 19.89 Pontic to open space for a second upper right canine.Fig. 19.90 Views before refinement.Fig. 19.91 Comparison of initial (upper) with final (lower) occlusion. Compo...Fig. 19.92 Comparison of initial and final occlusal.Fig. 19.93 Comparison of initial and final smile and overjet.Fig. 19.94 Comparison of initial (left) and final panoramic x‐rays (right). ...Fig. 19.95 Final teleradiograph.Fig. 19.96 Asymmetric compression.Fig. 19.97 Pretreatment views.Fig. 19.98 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 19.99 left‐side deviation of lower jaw.Fig. 19.100 Upper and lower CC superimposition and instructions to CAD desig...Fig. 19.101 Interproximal reduction is necessary to reduce the lower dental ...Fig. 19.102 Initial views before refinement. The posterior open bite on left...Fig. 19.103 Goal of treatment: correct posterior crossbite from 23 to 27.Fig. 19.104 Initial and final design of the asymmetric expansion of the uppe...Fig. 19.105 Comparison of initial and final occlusion.Fig. 19.106 Final occlusion. Both midlines centred. Unilateral posterior cro...Fig. 19.107 Improvement in the smile and in the final torque of upper inciso...Fig. 19.108 Improvement in the profile by clockwise rotation of the mandible...Fig. 19.109 Posterior crossbite with anterior crowding.Fig. 19.110 Careful diagnosis of the crossbite origin will lead to a great r...Fig. 19.111 Cone beam computed tomography: three dimensional radiological ex...Fig. 19.112 Pretreatment intraoral views (right, front, left, upper, lower)....Fig. 19.113 Pretreatment smile and lateral X‐ray.Fig. 19.114 Pretreatment ClinChecks: right, front, left, upper, lower.Fig. 19.115 Refinement: intraoral views (right, front, left, upper, lower)....Fig. 19.116 Smile after first set of aligners.Fig. 19.117 Refinement ClinChecks: right, front, left, upper, lower.Fig. 19.118 Final intraoral views: right, front, left, upper, lower.Fig. 19.119 Pretreatment and final smile: we can observe how posterior expan...Fig. 19.120 Cone beam computed tomography sections. From left (pretreatment)...Fig. 19.121 Posterior crossbite, with anterior crossbite and edge‐to‐edge oc...Fig. 19.122 Smile and upper and lower arch view.Fig. 19.123 Panoramic and lateral X‐rays.Fig. 19.124 Measurements were performed after iTero scanning and OrthoCad so...Fig. 19.125 Skeletal compression has to be approached with a surgical proced...Fig. 19.126 First phase: initially, the patient had a gingivectomy performed...Fig. 19.127 First phase: initially, the patient had a gingivectomy performed...Fig. 19.128 Upper pre‐miniscrew‐assisted rapid palatal expander (MARPE): pos...Fig. 19.129 Right, Front, Left Post miniscrew‐assisted rapid palatal expande...Fig. 19.130 Second phase. Measurements were performed after iTero scanning a...Fig. 19.131 Second phase ClinChecks (front, upper, lower).Fig. 19.132 Third phase: intraoral views (front and upper).Fig. 19.133 After 16 aligners space was closed, palatal suture was still ope...Fig. 19.134 Third phase ClinChecks (front, upper, lower).Fig. 19.135 Final intraoral views: front, upper, lower.Fig. 19.136 Pretreatment and final smile.Fig. 19.137 Initial and final cephalometric measurements, with the final pos...Fig. 19.138 Final panoramic X‐ray. Patient smile was widened and skeletal ba...

17 Chapter 20Fig. 20.1 Precision cuts and button cutouts: to hold the intermaxillary elas...Fig. 20.2 Precision hooks would equal to archposts in fixed appliances.Fig. 20.3 Button cutouts allow bonding a metal/ceramic button.Fig. 20.4 Class II, division 2 will benefit from two button cutouts for clas...Fig. 20.5 Class II, division 1 will benefit from canine hook and molar butto...Fig. 20.6 Mesial‐in rotation of the canine.Fig. 20.7 Mesial‐out rotation of the canine.Fig. 20.8 Whenever a lingual button is placed on the lingual surface of the...Fig. 20.9 Occlusal view of lingual buttons on upper canines.Fig. 20.10 Pontic to cover missing 34.Fig. 20.11 Traction of impacted canine using elastic from button in canine t...Fig. 20.12 Interproximal reduction can be performed on upper premolars to di...Fig. 20.13 With class II or class III elastics use, visualization will be sh...Fig. 20.14 From a ‘left 90 degrees view’ the sequential distalization is see...Fig. 20.15 Sequential distalization increases surface contact with molars on...Fig. 20.16 Effect of a coil spring opening space is similar to sequential di...Fig. 20.17 Effect of a coil spring opening space would lead to lack of torqu...Fig. 20.18 Effect of a coil spring opening space would lead to anterior proc...Fig. 20.19 Posterior Powerwings on aligner help advancing mandible on growin...Fig. 20.20 Class II profiles will benefit from this feature.Fig. 20.21 Class II, division 2 incisors need treatment sequence like this: ...Fig. 20.22 Class II, division 2 incisors need a treatment sequence such as: ...Fig. 20.23 Upper expansion leads to higher arch depth reduction and resolvin...Fig. 20.24 Clinchecks: a 45 degree upper molar derotation solves up to 1 mm ...Fig. 20.25 Intraoral views: a 45 degree upper molar derotation solves up to ...Fig. 20.26 Lower mesialization is represented in yellow, and results from th...Fig. 20.27 Biomechanics is the basis of an orthodontic treatment, regardless...Fig. 20.28 Distalization should start just after wisdom tooth extraction so ...Fig. 20.29 Growth has to be carefully checked before a mandibular advancemen...Fig. 20.30 Eruption compensator in a canine.Fig. 20.31 Any contact over 12 g will interrupt the tooth eruption.Fig. 20.32 Terminal molar tabs prevent molars supra‐eruption creating poster...Fig. 20.33 Initial intraoral view.Fig. 20.34 Pretreatment extraoral and intraoral views.Fig. 20.35 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.36 Intraoral situation after Herbst appliance. After the first phase...Fig. 20.37 Upper and lower ClinCheck views.Fig. 20.38 Comparison of initial (upper row) with final result (lower row)....Fig. 20.39 Initial (left) and final occlusal(right).Fig. 20.40 Initial (left) and final overjet (right).Fig. 20.41 Mandibular changes.Fig. 20.42 Changes in profile.Fig. 20.43 Initial smile (left), smile at the end of first phase (middle) an...Fig. 20.44 Initial and final lateral X‐rays.Fig. 20.45 Intraoral initial picture.Fig. 20.46 Initial extraoral and intraoral views.Fig. 20.47 Occlusal contact at the beginning of the treatment.Fig. 20.48 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.49 Initial upper and lower ClinCheck views.Fig. 20.50 Initial right and left ClinCheck views.Fig. 20.51 Initial frontal Clincheck view.Fig. 20.52 Goal of treatment: mandibular advancement into a bilateral class ...Fig. 20.53 Initial occlusion (upper), month 6 of evolution (middle), with al...Fig. 20.54 Mandibular advancement in the first six months of treatment.Fig. 20.55 New ClinCheck, asking to level the curve of Spee before continuin...Fig. 20.56 Aligner 17 of additional aligners using class II elastics.Fig. 20.57 Position of class II elastics (from lingual of upper first premol...Fig. 20.58 Situation at the end of mandibular advancement phase, before aski...Fig. 20.59 Comparison between initial (upper) and final occlusion (lower).Fig. 20.60 Final arch development.Fig. 20.61 Comparison initial and final overjet.Fig. 20.62 Comparison of initial and final smile.Fig. 20.63 Mandibular changes after 18 months of treatment.Fig. 20.64 Comparison in chin projection between initial, before additional ...Fig. 20.65 Final lateral X‐ray.Fig. 20.66 Initial intraoral view.Fig. 20.67 Pretreatment extraoral and intraoral views.Fig. 20.68 Lower skeletal asymmetry. Normal upper incisors exposure at rest ...Fig. 20.69 Initial panoramic X‐ray, teleradiograph and cephalometry. The AimFig. 20.70 Initial upper and lower ClinCheck views.Fig. 20.71 Lateral ClinCheck views.Fig. 20.72 Initial frontal Clincheck view.Fig. 20.73 Comparison between initial (upper) and final occlusion (lower).Fig. 20.74 Initial (left) and final occlusal (right).Fig. 20.75 Initial and final smile.Fig. 20.76 Panoramic and lateral X‐rays.Fig. 20.77 Initial intraoral view.Fig. 20.78 Pretreatment extraoral and intraoral views.Fig. 20.79 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.80 Initial upper and lower ClinCheck viewsFig. 20.81 Initial right and left ClinCheck views.Fig. 20.82 Initial front ClinCheck view.Fig. 20.83 Upper sequential distalization and lower sequential mesialization...Fig. 20.84 Comparison between initial (upper) and final (lower) occlusion.Fig. 20.85 Before (left) and after (right) lower occlusal views.Fig. 20.86 Initial and final smile and overjet.Fig. 20.87 Final panoramic and lateral X‐rays.Fig. 20.88 Initial intraoral view.Fig. 20.89 Pretreatment extraoral and intraoral views.Fig. 20.90 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.91 Upper and lower occlusal ClinCheck views.Fig. 20.92 Right and left ClinCheck views.Fig. 20.93 Front ClinCheck view.Fig. 20.94 Treatment interproximal reduction.Fig. 20.95 Sequential upper distalization pattern.Fig. 20.96 Before (upper) and after (lower) intraoral views.Fig. 20.97 Initial (left) and final (right) occlusal.Fig. 20.98 Initial and final smile and overjet.Fig. 20.99 Final panoramic and lateral X‐rays.Fig. 20.100 Initial intraoral view.Fig. 20.101 Pretreatment extraoral and intraoral views.Fig. 20.102 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.103 Superimposition, upper occlusal ClinCheck view.Fig. 20.104 Superimposition, lower occlusal ClinCheck view.Fig. 20.105 Biomechanics for simultaneous distalization.Fig. 20.106 Clincheck view.Fig. 20.107 Right and left ClinCheck views.Fig. 20.108 Initial views (upper), before additional aligners (middle) and f...Fig. 20.109 Before (left) and after (right) occlusal views.Fig. 20.110 Simultaneous distalization pattern.Fig. 20.111 Before and after treatment smile.Fig. 20.112 Final panoramic and lateral X‐rays.Fig. 20.113 Distalization from 3 to 7 in a row pattern.Fig. 20.114 Extraoral analysis: mandibular asymmetry.Fig. 20.115 Initial intraoral views.Fig. 20.116 Scissor bite on left side.Fig. 20.117 Scissor bite on left side.Fig. 20.118 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.119 ClinCheck upper occlusal view. Correct class II by simultaneous ...Fig. 20.120 ClinCheck lower occlusal view.Fig. 20.121 Interproximal reduction.Fig. 20.122 Lateral views: Class II elastics from upper 4 to lower 7.Fig. 20.123 Evolution after 13 months.Fig. 20.124 Rein horse to distalize upper molars from TADs in the tuberosity...Fig. 20.125 Evolution after 17 months.Fig. 20.126 Correction of scissor bite.Fig. 20.127 Initial (upper) and final occlusion (lower).Fig. 20.128 Before (left) and after (right) occlusal.Fig. 20.129 Comparison of before (left) and after smile (right).Fig. 20.130 Before (left) and after (right) profile.Fig. 20.131 Final panoramic and lateral X‐rays.Fig. 20.132 Simultaneous distalization from 5 to 5 pattern.Fig. 20.133 Pretreatment extraoral and intraoral views.Fig. 20.134 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.135 Initial upper and lower ClinCheck views.Fig. 20.136 Interproximal reduction from 33 to 43 to upright lower incisors....Fig. 20.137 Right and left ClinCheck views.Fig. 20.138 Intra‐arch Powerchain from upper canine to first molar to guide ...Fig. 20.139 Initial (upper) and final (lowe) intraoral views.Fig. 20.140 Occlusal before (left) and after (right) treatment.Fig. 20.141 Final occlusal contact.Fig. 20.142 Initial (left) and final smile (right).Fig. 20.143 Final panoramic and lateral X‐rays: maintenance of lower incisor...Fig. 20.144 Top jet appliance.Fig. 20.145 Pretreatment extraoral and intraoral views.Fig. 20.146 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.147 Distalization with top‐jet before Invisalign treatment.Fig. 20.148 Sequential distalization with class II elastics.Fig. 20.149 Upper and lower ClinCheck views.Fig. 20.150 Lateral ClinCheck views.Fig. 20.151 Comparison of initial (upper) and final (lower) intraoral views....Fig. 20.152 Initial (left) and final (right) occlusal.Fig. 20.153 Initial (right) and final overjet (left).Fig. 20.154 Initial and final smile.Fig. 20.155 Final panoramic and lateral X‐rays.Fig 20.156 Initial intraoral view.Fig 20.157 Deferred sequential distalization, in which some teeth move ‘alon...Fig. 20.158 Initial intraoral views (right, front, left, upper, lower). Pati...Fig. 20.159 Initial extraoral pictures and cephalometric analysis.Fig. 20.160 Initial Clinchecks.Fig. 20.161 Intraoral pictures at refinement.Fig. 20.162 Refinement Clinchecks.Fig. 20.163 Final: intraoral pictures showing improvement of the lower incis...Fig. 20.164 The cone beam computed tomography comparisons show how lower the...Fig. 20.165 Final comparison of lateral X‐rays.Fig. 20.166 Comparison of before and after smile.Fig. 20.167 Extraoral profile views.Fig. 20.168 Initial intraoral view.Fig. 20.169 Manual precision cut on 13 allows optimized attachment on this t...Fig. 20.170 Initial intraoral views (right, front, left, upper, lower).Fig. 20.171 Initial panoramic and lateral X‐rays.Fig. 20.172 Initial Clinchecks.Fig. 20.173 Refinement: initial intraoral views (right, front, left, upper, ...Fig. 20.174 Refinement Clinchecks.Fig. 20.175 Final intraoral views (right, front, left, lower, upper).Fig. 20.176 Final panoramic and lateral X‐rays.Fig. 20.177 Before and after smiles, before aesthetic anterior restoration....Fig. 20.178 Initial intraoral view.Fig. 20.179 Initial intraoral views (right, front, left, upper).Fig. 20.180 Initial intraoral models to check class II relationship before 1...Fig. 20.181 Pretreatment panoramic and lateral X‐rays and cephalometry.Fig. 20.182 Initial extraoral views.Fig. 20.183 Initial Clinchecks (right, front, left, upper, lower).Fig. 20.184 Intraoral refinement (right, front, left, upper, lower).Fig. 20.185 Refinement Clinchecks: right, front, left, upper, lower.Fig. 20.186 Final intraoral views: right, front, left, upper with tongue tam...Fig. 20.187 Before and after smile, showing improvement in upper incisor dis...Fig. 20.188 Final cephalometric measurements (before and after).Fig. 20.189 Final panoramic X‐ray.Fig. 20.190 Posterior interproximal reduction will help create space (before...Fig. 20.191 Posterior interproximal reduction might be up to 1 mm per contac...Fig. 20.192 Sequential lower distalization is meant to be predictable up to ...Fig. 20.193 In class III cases, anchorage is extremely important. The anchor...Fig. 20.194 Temporary implant supported crowns help create posterior anchora...Fig. 20.195 Initial intraoral view.Fig. 20.196 Pretreatment extraoral and intraoral views.Fig. 20.197 Implant placement on 47 before starting Invisalign treatment.Fig. 20.198 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.199 Initial front view.Fig. 20.200 Initial ClinCheck front view..Fig. 20.201 Initial occlusal contact.Fig. 20.202 Sagittal priority of movements to solve the anterior crossbite. ...Fig. 20.203 Upper and lower ClinCheck views.Fig. 20.204 Initial (upper), evolution (middle) and situation after 12 month...Fig. 20.205 Arch evolution after treatment for 12 months.Fig. 20.206 Right and left initial ClinCheck views.Fig. 20.207 Arch development after 12 months.Fig. 20.208 Initial and final overjet and smile.Fig. 20.209 Initial intraoral picture.Fig. 20.210 Pretreatment extraoral and intraoral views.Fig. 20.211 Initial X‐ray: panoramic, teleradiograph and cephalometry.Fig. 20.212 Interproximal reduction.Fig. 20.213 Simultaneous movement pattern.Fig. 20.214 Extrusion of 27 owing to missing 47.Fig. 20.215 Anterior cross bite of 12.Fig. 20.216 Initial superimposition, ClinCheck upper and lower occlusal view...Fig. 20.217 Comparison of initial (upper) and final occlusion (lower).Fig. 20.218 Comparison of initial (left) and final occlusal (right).Fig. 20.219 Initial and final smile.Fig. 20.220 Final panoramic and lateral X‐rays.Fig. 20.221 Initial intraoral view.Fig. 20.222 Initial intraoral views.Fig. 20.223 Initial extraoral views.Fig. 20.224 Initial cone beam computed tomography and panoramic X‐ray.Fig. 20.225 Initial lateral X‐ray and cephalometric analysis.Fig. 20.226 Initial ClinChecks.Fig. 20.227 Refinement: intraoral views.Fig. 20.228 Refinement: extraoral views.Fig. 20.229 Current intraoral views.Fig. 20.230 Current smile.Fig. 20.231 Current cephalometric measurements.Fig. 20.232 Cone beam computed tomography measurements, before and after tre...Fig. 20.233 Final smile.Fig. 20.234 Initial intraoral view.Fig. 20.235 Initial smile.Fig. 20.236 Initial panoramic and lateral X‐rays.Fig. 20.237 Refinement: initial views after 6 months, when the patient decid...Fig. 20.238 The palatal suture is broken with the same anaesthesia that that...Fig. 20.239 The palatal suture is broken with the same anaesthesia that will...Fig. 20.240 After 2 weeks, the 8 mm screw is fully opened. The palatal surfa...Fig. 20.241 Refinement ClinChecks.Fig. 20.242 Second refinement: intraoral views.Fig. 20.243 Second refinement Clinchecks.Fig. 20.244 Final Intraoral views.Fig. 20.245 Final smile.Fig. 20.246 Final cephalometric examination.Fig. 20.247 Final panoramic X‐ray.Fig. 20.248 Initial frontal intraoral view.Fig. 20.249 Initial intraoral views.Fig. 20.250 Initial panoramic and lateral and X‐rays and cephalometry.Fig. 20.251 Initial extraoral view.Fig. 20.252 Initial Clinchecks.Fig. 20.253 Refinement: intraoral views.Fig. 20.254 Refinement ClinChecks.Fig. 20.255 Extraoral view after refinement.Fig. 20.256 Final intraoral views.Fig. 20.257 Final smile.Fig. 20.258 Initial and post‐treatment cephalometric analysis.Fig. 20.259 Initial intraoral view.Fig. 20.260 Pretreatment extraoral and intraoral views.Fig. 20.261 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.262 Simultaneous distalization pattern in upper and lower arches.Fig. 20.263 Upper and lower ClinCheck views.Fig. 20.264 interproximal reduction necessary in order not to procline lower...Fig. 20.265 Lateral ClinCheck views.Fig. 20.266 Rein horse with Powerchain to temporary anchorage devices in the...Fig. 20.267 Simultaneous upper distalization using temporary anchorage devic...Fig. 20.268 Simultaneous lower distalization using temporary anchorage devic...Fig. 20.269 Initial occlusion (upper) and situation at month 17 of treatment...Fig. 20.270 Arch development in 23 months. Powerchain from first upper and l...Fig. 20.271 Pretreatment and final smile and overjet.Fig. 20.272 Final panoramic and lateral X‐rays.

18 Chapter 21Fig. 21.1 Vertical cause, excess posterior facial height.Fig. 21.2 Dentoalveolar cause (protrusion).Fig. 21.3 Transversal cause, lingual torque of posterior teeth.Fig. 21.4 The amount of lingual tipping of upper and lower incisors helps to...Fig. 21.5 Gummy smile.Fig. 21.6 Low smile, short display.Fig. 21.7 The facial lower third determines whether to intrude or not to int...Fig. 21.8 Anchorage attachments.Fig. 21.9 Chewies or fitters are good for minor open bite cases.Fig. 21.10 Miniscrews used for absolute posterior intrusion greater than 3 m...Fig. 21.11 Open bite requires careful biomechanics planning.Fig. 21.12 Optimized anterior extrusion is mostly predictable if it is plann...Fig. 21.13 Posterior intrusion will have saggital effects as a result of man...Fig. 21.14 We have to face predictability of vertical movements in order to ...Fig. 21.15 Single optimized attachment for extrusion.Fig. 21.16 Optimized anterior extrusion is mostly predictable if it is plann...Fig. 21.17 Posterior open bite is a good overcorrection in this case.Fig. 21.18 Unpredictable posterior intrusion is assisted by upper and lower ...Fig. 21.19 Open bite solved with LITE treatment.Fig. 21.20 Initial extraoral and intraoral views.Fig. 21.21 Initial occlusal contact.Fig. 21.22 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.23 Initial upper and lower ClinCheck views.Fig. 21.24 Initial right and left ClinCheck views.Fig. 21.25 Interproximal reduction necessary for relative extrusion of upper...Fig. 21.26 Initial intraoral views (upper) and views before refinement (lowe...Fig. 21.27 Final intraoral views.Fig. 21.28 Initial (left) and final occlusal (right).Fig. 21.29 Initial and final smile.Fig. 21.30 Final panoramic and lateral X‐rays.Fig. 21.31 Initial intraoral view.Fig. 21.32 Initial extraoral and intraoral views.Fig. 21.33 Panoramic X‐ray.Fig. 21.34 Teleradiograph: proclination of upper and lower incisors, narrow ...Fig. 21.35 Initial upper and lower ClinCheck views.Fig. 21.36 Interproximal reduction to create relative extrusion of incisors....Fig. 21.37 Palatal attachments prevent upper incisors from intrusion during ...Fig. 21.38 Initial right and left intraoral ClinCheck views.Fig. 21.39 Triangular elastics in class II. The technician was required to e...Fig. 21.40 reciprocal movement of anterior extrusion and posterior intrusion...Fig. 21.41 Sequential distalization.Fig. 21.42 Initial (upper) and final (lower) views.Fig. 21.43 Initial (left) and final occlusal (right).Fig. 21.44 Initial and final smiles and overjet.Fig. 21.45 Final panoramic and lateral X‐rays.Fig. 21.46 Initial intraoral view.Fig. 21.47 Initial extraoral and intraoral views.Fig. 21.48 Goal of treatment: close open bite by upper and lower distalizati...Fig. 21.49 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.50 Mechanics of simultaneous distalization from temporary anchorage ...Fig. 21.51 Temporary anchorage devices in left tuberosity failed. It was cha...Fig. 21.52 Mechanics with temporary anchorage device in the tuberosity.Fig. 21.53 Mechanics for upper and lower simultaneous distalization. Opening...Fig. 21.54 Simultaneous distalization of lower arch using temporary anchorag...Fig. 21.55 Initial views before refinement. Opening space for missing 13, up...Fig. 21.56 Final panoramic X‐ray, after placing the implant for 13 and remov...Fig. 21.57 Initial and final intraoral images with composite veneer for 13 i...Fig. 21.58 Initial (left) and final (right) occlusal (composite veneer in 13...Fig. 21.59 Initial and final smile. Correction of the open bite without crea...Fig. 21.60 Initial intraoral view.Fig. 21.61 Initial intraoral views: right, front, left, upper, lower.Fig. 21.62 Initial panoramic X‐ray.Fig. 21.63 Initial extraoral views.Fig. 21.64 Initial Clinchecks (right, front, left, upper, lower).Fig. 21.65 Refinement intraoral views (right, front, left, upper, lower).Fig. 21.66 Refinement Clinchecks: right, front, left, upper, lower.Fig. 21.67 Refinement: extraoral views.Fig. 21.68 Refinement: a third set of aligners was ordered for final settlem...Fig. 21.69 Lateral and panoramic X‐rays showing final situation, and wisdom ...Fig. 21.70 Final intraoral views (right, front, left, upper, lower).Fig. 21.71 Before and after smiles.Fig. 21.72 Initial intraoral view.Fig. 21.73 Initial intraoral views (right, front, left, upper, lower).Fig. 21.74 Initial smile: short incisor display required aesthetic improveme...Fig. 21.75 Initial panoramic and lateral X‐rays.Fig. 21.76 Initial Clinchecks (right, front, left, upper and lower).Fig. 21.77 Refinement: intraoral views (right, front, left, upper and lower)...Fig. 21.78 Refinement Clinchecks (right, front, left, upper and lower).Fig. 21.79 Final intraoral views (right, front, left, upper with tongue tame...Fig. 21.80 Smile before and after treatment.Fig. 21.81 Final lateral X‐rays.Fig. 21.82 Initial intraoral view.Fig. 21.83 TheOrthopulse device was used by the patient to accelerate treatm...Fig. 21.84 Initial set of intraoral views (right, front, left, upper and low...Fig. 21.85 Initial panoramic and lateral X‐rays and cephalometric measuremen...Fig. 21.86 Initial extraoral views.Fig. 21.87 Initial ClinChecks (right, front, left, upper and lower) with vir...Fig. 21.88 Refinement: intraoral views (right, front, left, upper and lower)...Fig. 21.89 Refinement: lateral and panoramic X‐rays.Fig. 21.90 Refinement: profile and smile.Fig. 21.91 Refinement ClinChecks (right, front, left, upper and lower).Fig. 21.92 Current intraoral views (right, front, left, upper and lower).Fig. 21.93 Current lateral and panoramic X‐rays and cephalometry.Fig. 21.94 Final smile.Fig. 21.95 Predictability of vertical movements is important in order to pla...Fig. 21.96 Optimized pressure areas help intruding anterior teeth by combini...Fig. 21.97 Optimized extrusion attachments on premolars create a counterforc...Fig. 21.98 Precision bite ramps are designed to dissoclude posterior sectors...Fig. 21.99 Optimized support attachments are designed to help intruding uppe...Fig. 21.100 Patient with a gummy smile and deep bite. Expand + procline inci...Fig. 21.101 This patient (before and after views) presented low smile with d...Fig. 21.102 When anterior torque is negative relative intrusion might be eas...Fig. 21.103 When pure intrusion is needed, interproximal reduction will help...Fig. 21.104 Incisors protocol in deep bite is: procline crown, intrude, then...Fig. 21.105 Anterior temporary anchorage devices will help with this case.Fig. 21.106 Suggested torque for upper (+17 degrees) and lower incisor (–1 d...Fig. 21.107 Hypercorrection of the curve of Spee usually creates an open bit...Fig. 21.108 A single buccal or palatal power ridge (left and middle) creates...Fig. 21.109 Posterior extrusion might be achieved with optimized extrusion a...Fig. 21.110 Initial intraoral view.Fig. 21.111 Initial extraoral and intraoral views.Fig. 21.112 Initial panoramic and lateral X‐rays and cephalometry.Fig. 21.113 Initial occlusal upper and lower superimposition ClinCheck views...Fig. 21.114 Initial right and left ClinCheck views.Fig. 21.115 Interproximal reduction.Fig. 21.116 Initial (upper) and final intraoral views (lower).Fig. 21.117 Initial (left) and final occlusal (right).Fig. 21.118 Final panoramic and lateral X‐rays.Fig. 21.119 Initial intraoral view.Fig. 21.120 Initial extraoral and intraoral views.Fig. 21.121 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.122 Initial upper and lower ClinCheck views.Fig. 21.123 Initial right and left ClinCheck views.Fig. 21.124 On the additional aligners set, distal tipping of the crown in 3...Fig. 21.125 Evolution in last aligner before refinement.Fig. 21.126 Initial (upper) and final (lower) intraoral views.Fig. 21.127 Initial (left) and final (right) occlusals.Fig. 21.128 Before and after smile.Fig. 21.129 Final panoramic and lateral X‐rays.Fig. 21.130 Initial intraoral view.Fig. 21.131 Initial extraoral and intraoral views.Fig. 21.132 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.133 Initial upper occlusal superimposition ClinCheck view.Fig. 21.134 Initial lower occlusal superimposition ClinCheck view.Fig. 21.135 Initial right and left ClinCheck view.Fig. 21.136 Initial front ClinCheck view with interproximal reduction.Fig. 21.137 Initial views (upper) and evolution after 12 months (lower).Fig. 21.138 Final intraoral views.Fig. 21.139 Initial (left) and final occlusal (right).Fig. 21.140 Occlusal contact point at the end of the treatment.Fig. 21.141 Initial and final smile.Fig. 21.142 Final panoramic and lateral X‐rays.Fig. 21.143 Initial intraoral view.Fig. 21.144 Initial extraoral and intraoral views.Fig. 21.145 Initial occlusal contact.Fig. 21.146 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.147 Initial upper occlusal superimposition ClinCheck view.Fig. 21.148 Initial lower occlusal superimposition ClinCheck view.Fig. 21.149 Interproximal reduction is only needed mesial and distal to 22 t...Fig. 21.150 Initial right and left ClinCheck view.Fig. 21.151 Temporary anchorage devices to provide enough posterior anchorag...Fig. 21.152 Evolution at the end of additional aligners. Intermaxillary elas...Fig. 21.153 Initial (upper) and final (lower) intraoral views.Fig. 21.154 Initial left) and final (right) occlusal.Fig. 21.155 Initial and final overjet and final correction of the deep bite....Fig. 21.156 Initial and final smile.Fig. 21.157 Final panoramic and lateral X‐rays with an appropriate inclinati...Fig. 21.158 Initial intraoral view.Fig. 21.159 Initial intraoral pictures (right, front, left, upper and lower)...Fig. 21.160 Initial panoramic and lateral X‐rays.Fig. 21.161 Initial smile.Fig. 21.162 Initial Clinchecks (right, front, left, upper and lower).Fig. 21.163 Refinement 1: intraoral views (right, front, left, upper and low...Fig. 21.164 Refinement 1 Clinchecks (right, front, left, upper and lower). A...Fig. 21.165 Refinement 2 (aligner): st the end of first refinement, the alig...Fig. 21.166 Refinement 2 (aligner: right, front, left, upper and lower). Ali...Fig. 21.167 Refinement 2 ClinChecks (right, front, left, upper and lower). A...Fig. 21.168 Final intraoral pictures: right, front, left, upper and lower. D...Fig. 21.169 The smile has widened but still gummy, as initially predicted.

19 Chapter 22Fig. 22.1 Asymmetries can be managed with specific aligner biomechanics.Fig. 22.2 Initial view.Fig. 22.3 Class II subdivision right, deviation of both midlines equal to th...Fig. 22.4 Pretreatment intraoral views.Fig. 22.5 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 22.6 Initial frontal Clincheck view.Fig. 22.7 Upper and lower ClinCheck archshape changes and instructions to CA...Fig. 22.8 Upper and lower CC superimposition and instructions to CAD designe...Fig. 22.9 Lateral ClinCheck views.Fig. 22.10 Final intraoral views.Fig. 22.11 Initial and final smile and overjet.Fig. 22.12 Final panoramic and lateral X‐rays.Fig. 22.13 Initial intraoral view.Fig. 22.14 Pretreatment extraoral and intraoral views.Fig. 22.15 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 22.16 Upper and lower CC superimposition and instructions to CAD design...Fig. 22.17 Lateral ClinCheck views.Fig. 22.18 Initial frontal Clincheck view.Fig. 22.19 Intermaxillary elastics to correct asymmetric mandibular growth. ...Fig. 22.20 Final occlusion.Fig. 22.21 Initial and final smile.Fig. 22.22 Final panoramic and lateral X‐ray.Fig. 22.23 Patient with maxillomandibular asymmetry.Fig. 22.24 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 22.25 Pretreatment extraoral views.Fig. 22.26 Occlusion in centric occlusion (CO).Fig. 22.27 Occlusion in centric relation (CR). In this situation, photograph...Fig. 22.28 iTero occlusion analysis.Fig. 22.29 The goal of treatment is asymmetric expansion of the maxilla to c...Fig. 22.30 A temporary anchorage device on the tuberosity will assist the mo...Fig. 22.31 Lower arch molar straightening will be assisted with a Lower arch...Fig. 22.32 Occlusal ClinCheck views.Fig. 22.33 Lateral ClinCheck views.Fig. 22.34 Frontal ClinCheck view.Fig. 22.35 Interproximal reduction.Fig. 22.36 Evolution in the occlusal contact.Fig. 22.37 Arch development.Fig. 22.38 Initial (upper) views and evolution at month 18 of treatment (low...Fig. 22.39 Initial (upper), after Invisalign and before prothesis (middle) a...Fig. 22.40 Final occlusal.Fig. 22.41 Comparison of initial and final smile and overjet.Fig. 22.42 Final panoramic and lateral X‐rays.Fig. 22.43 Initial intraoral view.Fig. 22.44 Pre‐treatment extraoral and intraoral views.Fig. 22.45 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 22.46 Lateral sectional wire applied based on a temporary achorage devi...Fig. 22.47 Lateral ClinCheck views showing forces applied.Fig. 22.48 Lateral ClinCheck view showing forces applied with the temporary ...Fig. 22.49 Upper ClinCheck view superimposition.Fig. 22.50 Lower ClinCheck view superimposition.Fig. 22.51 Second set of aligners. Frontal ClinCheck view.Fig. 22.52 Second set of aligners. Lateral ClinCheck views.Fig. 22.53 Second set of aligners. Frontal ClinCheck view.Fig. 22.54 Initial occlusion.Fig. 22.55 Evolution at 3 months with sectional wire to anchor 36 and 46 to ...Fig. 22.56 When the lower incisors are in their final position, mesialize pr...Fig. 22.57 Completing mesialization of second lower molar.Fig. 22.58 Settle the occlusion with elastics.Fig. 22.59 Initial (upper) and final occlusion (lower) views. The full class...Fig. 22.60 Initial (left) and final (right) occlusal.Fig. 22.61 Initial, smile in 22 months and final smile.Fig. 22.62 Initial and final overjet (right and left side).Fig. 22.63 Initial intraoral view.Fig. 22.64 Initial intraoral views.Fig. 22.65 Initial extraoral views.Fig. 22.66 Initial lateral and panoramic X‐ray and cephalometric analysis.Fig. 22.67 Initial Clinchecks: the left side should be in a Class II relatio...Fig. 22.68 After 10 months of treatment, the intraoral situation was good, b...Fig. 22.69 Extraoral view after 10 months.Fig. 22.70 After 10 months, the ClinCheck had vertical overcorrection and vi...Fig. 22.71 Current views after 20 months of treatment, but expected at 24 mo...Fig. 22.72 Pretreatment and current X‐rays.Fig. 22.73 Extraoral pictures after treatment.

20 Chapter 23Fig. 23.1 First premolar extraction, G6 protocol.Fig. 23.2 Lower incisor extraction, with vertical attachments on the remaini...Fig. 23.3 Powerchain helps close final spacing.Fig. 23.4 Perfect root parallelism after tooth extraction commonly needs the...Fig. 23.5 Initial intraoral view.Fig. 23.6 Pretreatment extraoral and intraoral views.Fig. 23.7 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 23.8 Upper and lower CC superimposition and instructions to CAD designe...Fig. 23.9 Attachments can be seen in several areas of the ClinCheck software...Fig. 23.10 Lateral ClinCheck views.Fig. 23.11 Intraoral view.Fig. 23.12 Initial (upper)and final (lower) views.Fig. 23.13 Initial and final occlusal.Fig. 23.14 Initial and final smile.Fig. 23.15 Final panoramic and lateral X‐rays: good final parallelism betwee...Fig. 23.16 Initial intraoral view.Fig. 23.17 Initial extraoral and intraoral views.Fig. 23.18 Occlusal contact at the beginning of the treatment.Fig. 23.19 Periodontal bone loss in upper incisors.Fig. 23.20 Initial teleradiograph and cephalometry.Fig. 23.21 Upper occlusal interproximal reduction to avoid excessive proclin...Fig. 23.22 Pontic for extracted 42. Bevelled attachment on lateral incisors ...Fig. 23.23 Interproximal reduction of upper arch and lower incisor extractio...Fig. 23.24 Lateral ClinCheck views.Fig. 23.25 Initial (upper) and evolution 11 months of treatment (lower).Fig. 23.26 Finishing refinement. Posterior elastic is used to settle the occ...Fig. 23.27 Initial (upper) and final occlusion (lower). Adequate parallelism...Fig. 23.28 Occlusal contact point at the end of the treatment.Fig. 23.29 Initial and final occlusal.Fig. 23.30 Initial and final smile and overjet.Fig. 23.31 Final panoramic and lateral X‐rays.Fig. 23.32 The canine and second premolar in this picture would be ideal for...Fig. 23.33 Extraction of first premolars, absolute anchorage: 0 mm posterior...Fig. 23.34 Extraction of first premolars, maximum anchorage: 0–2 mm posterio...Fig. 23.35 G6 protocol is considered a full system for space closure, theref...Fig. 23.36 Moderate anchorage protocol will start with canine and posterior ...Fig. 23.37 Moderate anchorage protocol will start with canine and second pre...Fig. 23.38 A popular pattern in Asia for extraction space closure.Fig. 23.39 The selection of bonding hooks or buttons has to be carefully pla...Fig. 23.40 Extraction of 5s with minimum anchorage.Fig. 23.41 With the double vertical attachment in molars the intrusion of th...Fig. 23.42 With the Powerarm attachment in molars at the final aligners we c...Fig. 23.43 Staggered technique for second premolar extraction.Fig. 23.44 Staggered technique for first molars extraction.Fig. 23.45 Retroclined incisors might mean increased overbite and need root ...Fig. 23.46 Powerarms are great auxiliaries in achieving root parallelism.Fig. 23.47 Undesired effects of brackets and wires are quite similar to the ...Fig. 23.48 Absolute anchorage with temporary anchorage devices.Fig. 23.49 Pretreatment extraoral and intraoral views.Fig. 23.50 Initial panoramic and lateral X‐rays, and cephalometry.Fig. 23.51 Upper CC superimposition and instructions to CAD designer.Fig. 23.52 Lower CC superimposition and instructions to CAD designer.Fig. 23.53 Lateral Clinchecks.Fig. 23.54 Front ClinCheck view in which we can check deep bite and midline ...Fig. 23.55 Asymmetry is clear from both a vertical and saggital perspective....Fig. 23.56 Pure intrusion of lower incisors from TADs (right, front and left...Fig. 23.57 Treatment evolution.Fig. 23.58 Evolution with aligners. Initial (left) and evolution at 3 months...Fig. 23.59 Posterior teeth have distal root tipping movement planned.Fig. 23.60 TADs are included in the doctor’s treatment plan with these diagr...Fig. 23.61 Initial frontal view.Fig. 23.62 Initial intraoral views.Fig. 23.63 Initial extraoral views.Fig. 23.64 Initial Clinchecks.Fig. 23.65 Refinement: intraoral views after first set of aligners.Fig. 23.66 Refinement: extraoral views after first set of aligners.Fig. 23.67 Refinement Clinchecks.Fig. 23.68 Intraoral views of smile at the end of treatment.Fig. 23.69 Final panoramic X‐ray to check final root paralellism between 13 ...Fig. 23.70 initial frontal view.Fig. 23.71 Initial intraoral views.Fig. 23.72 Initial extraoral views.Fig. 23.73 Initial teleradiograph, and lateral and panoramic X‐rays.Fig. 23.74 Initial Clinchecks.Fig. 23.75 Refinement: intraoral views showing exact position predicted on C...Fig. 23.76 Refinement: Clinchecks showing space mesial to 18.Fig. 23.77 Second refinement: intraoral pictures after two sets of aligners....Fig. 23.78 Second refinement: smile after two sets of aligners.Fig. 23.79 Second refinement: extraoral views after two sets of aligners.Fig. 23.80 Refinement: Clinchecks showing final vertical engagement.Fig. 23.81 Intraoral views after treatment.Fig. 23.82 Final teleradiograph and panoramic X‐ray showing improvement in p...Fig. 23.83 Current extraoral pictures.Fig. 23.84 Initial frontal view.Fig. 23.85 Initial Intraoral views.Fig. 23.86 Initial panoramic X‐ray and teleradiograph.Fig. 23.87 Initial smile.Fig. 23.88 Initial Clincheck with posterior spacing.Fig. 23.89 Refinement: Clincheck with posterior residual spacing, it can be ...Fig. 23.90 Refinement: the midline has been centred and exposure increased; ...Fig. 23.91 Refinement Clinchecks.Fig. 23.92 Second refinement: intraoral views.Fig. 23.93 Second refinement: space distal to 17 can be observed on the pano...Fig. 23.94 Second refinement: space distal to 17 can be observed, as well as...Fig. 23.95 Second refinement Clinchecks.Fig. 23.96 Intraoral views with Powerarms to straighten roots for 13 and 15 ...Fig. 23.97 Current intraoral views pending 5 aligners to the end of treatmen...Fig. 23.98 Initial and final lateral and panoramic X‐ray showing profile cha...Fig. 23.99 Comparison of pretreatment and final smiles.Fig. 23.100 Initial frontal view.Fig. 23.101 Initial intraoral situation.Fig. 23.102 Initial extraoral views.Fig. 23.103 Initial lateral and panoramic X‐rays and cephalometric analysis....Fig. 23.104 Initial Clinchecks.Fig. 23.105 Intraoral views when anterior misfitting was detected.Fig. 23.106 Refinement: intraoral views.Fig. 23.107 Refinement Clincheck.Fig. 23.108 Refinement: extraoral views.Fig. 23.109 A Powerchain was used to reduce rotations resulting from a lack ...Fig. 23.110 Space distribution equal to final ClinCheck position, and patien...Fig. 23.111 Lateral and panoramic X‐rays taken before aesthetic restoration....Fig. 23.112 Current extraoral views.Fig. 23.113 Smile before and after treatment.Fig. 23.114 Initial frontal view.Fig. 23.115 Initial intraoral views.Fig. 23.116 Initial extraoral views.Fig. 23.117 Initial ClinChecks.Fig. 23.118 Refinement: intraoral situation after first set of aligners.Fig. 23.119 Refinement: initial extraoral views.Fig. 23.120 Final views with veneers bonded (aesthetic treatment performed b...Fig. 23.121 Views at start and after refinement with veneers.Fig. 23.122 Final cephalometric measurements.

21 Chapter 24Fig. 24.1 Initial intraoral view.Fig. 24.2 Pretreatment extraoral and intraoral views.Fig. 24.3 Initial: teleradiograph, cephalometry and panoramic X‐rays.Fig. 24.4 Initial occlusal contact point.Fig. 24.5 Occlusal ClinCheck views.Fig. 24.6 Lateral ClinCheck views.Fig. 24.7 Interproximal reduction was not planned in the ClinCheck, but was ...Fig. 24.8 Initial frontal Clincheck view.Fig. 24.9 Situation before additional aligners. Results after the first set ...Fig. 24.10 Initial (upper) and final (lower) occlusion. Final result after r...Fig. 24.11 Initial (left) and final (right) occlusals.Fig. 24.12 Initial and final smile.Fig. 24.13 Final panoramic and lateral X‐rays.Fig. 24.14 Initial intraoral view.Fig. 24.15 Pretreatment extraoral and intraoral views.Fig. 24.16 Initial occlusal contact.Fig. 24.17 Panoramic and lateral X‐rays. Cephalometric analysis.Fig. 24.18 Opening space for missing 23.Fig. 24.19 interproximal reduction 3 to 3 to allow lower incisors retraction...Fig. 24.20 Initial lateral ClinCheck views.Fig. 24.21 Powerarm to make roots of 25 and 24 closer.Fig. 24.22 Evolution at 12 months.Fig. 24.23 Evolution after using additional aligners.Fig. 24.24 Final views with implant for 13.Fig. 24.25 Initial (left) and final (right) occlusal.Fig. 24.26 Initial and final overjet.Fig. 24.27 Evolution of the patient’s smile (from left): initial, before add...Fig. 24.28 Final panoramic X‐ray with implant for 23.Fig. 24.29 Final teleradiograph with overjet corrected.Fig. 24.30 Initial left intraoral view.Fig. 24.31 Pretreatment extraoral views.Fig. 24.32 Pretreatment intraoral views.Fig. 24.33 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 24.34 Initial views and views after placing provisional crowns over the...Fig. 24.35 Initial occlusal ClinCheck views.Fig. 24.36 Initial lateral ClinCheck views.Fig. 24.37 Initial front ClinCheck view.Fig. 24.38 Biomechanics applied to the treatment plan.Fig. 24.39 Initial (upper) and final (lower) views: the incisal edges were r...Fig. 24.40 Initial (left) and final occlusal (right).Fig. 24.41 Initial and final panoramic X‐rays: levelling of the occlusal pla...Fig. 24.42 Initial and final smile.Fig. 24.43 Initial frontal intraoral view.Fig. 24.44 Initial extraoral and intraoral views.Fig. 24.45 Initial panoramic X‐ray, teleradiograph and cephalometry: upper m...Fig. 24.46 Mock up to estimate vertical dimension.Fig. 24.47 These are the intraoral views when the case was sent to Align Tec...Fig. 24.48 Initial upper ClinCheck.Fig. 24.49 Initial lower ClinCheck.Fig. 24.50 Initial lateral ClinChecks.Fig. 24.51 Initial frontal Clincheck.Fig. 24.52 class II elastic from upper canine to lower first molar (night us...Fig. 24.53 Initial and final occlusion.Fig. 24.54 Final panoramic and lateral X‐rays.Fig. 24.55 Comparison of initial and final smile and overjet.Fig. 24.56 Simulation of force vectors applied by a Locatelli spring.Fig. 24.57 Locatelli to open space for implanting 35 and 45.Fig. 24.58 Distalization of molars from temporary anchorage devices and mesi...Fig. 24.59 The sequence of opening space for implants of 35 and 45, helping ...Fig. 24.60 Initial intraoral view.Fig. 24.61 Pretreatment intraoral views.Fig. 24.62 X‐ray analysis (panoramic, teleradiograph and cephalometry): norm...Fig. 24.63 Initial occlusal, upper and lower ClinCheck views.Fig. 24.64 Initial left and right ClinCheck views.Fig. 24.65 Initial front ClinCheck view.Fig. 24.66 Intraoral views: right, upper, lower with the Locatelli and the a...Fig. 24.67 Intraoral views: right, front, left with the Locatelli.Fig. 24.68 Intraoral views at the beginning and after placing the implants....Fig. 24.69 Intraoral views after loading implants.Fig. 24.70 Intraoral views before and after treatment (upper and lower occlu...Fig. 24.71 Comparison of smile and overjet before and after treatment.Fig. 24.72 Final panoramic and lateral X‐ray.Fig. 24.73 Skeletal Class I with spacing.Fig. 24.74 Extra palatal root torque to anterior sector, selecting multiple ...Fig. 24.75 Initial intraoral views.Fig. 24.76 Initial Clinchecks.Fig. 24.77 Refinement: after first set of aligners, gingivectomy was perform...Fig. 24.78 Refinement: intraoral images taken before scanning for additional...Fig. 24.79 Refinement: extraoral views.Fig. 24.80 Refinement ClinChecks.Fig. 24.81 Intraoral views and smile at the end of treatment.Fig. 24.82 Intraoral view.Fig. 24.83 Initial intraoral views.Fig. 24.84 Initial panoramic and lateral X‐rays.Fig. 24.85 Initial Clinchecks.Fig. 24.86 Final Intraoral views.Fig. 24.87 Pretreatment and final smile.Fig. 24.88 Final: anterior intrusion is visible on comparison of panoramic X...Fig. 24.89 Intraoral view.Fig. 24.90 Initial cephalometric measurements.Fig. 24.91 Initial intraoral views.Fig. 24.92 Initial Clinchecks.Fig. 24.93 Refinement: intraoral views.Fig. 24.94 Refinement: change of scan to include molars and increased anchor...Fig. 24.95 Refinement Clinchecks.Fig. 24.96 Final intraoral views.Fig. 24.97 Final smile.

22 Chapter 25Fig. 25.1 Aesthetic protocol for veneers preparation with aligners.Fig. 25.2 Anterior teeth width has to be determined carefully in order to en...Fig. 25.3 This bilateral full Class II case has an abnormal 11 size and shap...Fig. 25.4 Auxiliary buttons and Powerchains are used to help with a severe 9...Fig. 25.5 Mesial and distal spacing is planned at the end of the case for a ...Fig. 25.6 The left image is complex if we have to create anterior spacing fo...Fig. 25.7 Transverse space planning is made with protrusion, leaving 0.2 mm ...Fig. 25.8 After no space‐making mesial or distal to affected toot, transvers...Fig. 25.9 After 1.3 mm space planning, this only happens in the lateral with...Fig. 25.10 After attachment and threefold overcorrection, nonpredictable ant...Fig. 25.11 Align’s overjet concept might be different from the one the pract...Fig. 25.12 Natural arch depth loss owing to large posterior expansions has t...Fig. 25.13 In this patient, if 11 is in a proper incisal position we might p...Fig. 25.14 Incisors and canines have usually higher gingival margins than la...Fig. 25.15 This spacing is an example of how final gingivectomy might help i...Fig. 25.16 Incisors and usually canines have higher gingival margins than la...Fig. 25.17 This patient had a selective whitening treatment, focusing more o...Fig. 25.18 Patients habits, included smoking and drinking coffee on a daily ...Fig. 25.19 Bolton discrepancy in upper incisors as well as a maxillary skele...Fig. 25.20 Initial intraoral views.Fig. 25.21 Initial extraoral pictures.Fig. 25.22 Initial lateral and panoramicX‐rays.Fig. 25.23 Initial Clinchecks.Fig. 25.24 MARPE: the design was made considering that aligners would be tri...Fig. 25.25 MARPE: iTero software occlusal analysis.Fig. 25.26 Cone beam computed tomography and panoramic X‐ray and after MARPE...Fig. 25.27 Refinement: after 11 months the patient had the MARPE removed. Th...Fig. 25.28 Refinement Clinchecks.Fig. 25.29 Intraoral and extraoral views of smile before and after treatment...Fig. 25.30 Intraoral views before and after treatment.Fig. 25.31 Final extraoral views.Fig. 25.32 Final panoramic and lateral X‐rays.Fig. 25.33 Initial and final cephalometric analysis.Fig. 25.34 Previous cantilever bridge provided smile aesthetics that were un...Fig. 25.35 The Bolton tool was used to set space neededFig. 25.36 Initial intraoral views.Fig. 25.37 Initial Clinchecks.Fig. 25.38 Initial smile.Fig. 25.39 Refinement: intraoral views.Fig. 25.40 Refinement Clinchecks.Fig. 25.41 Final intraoral views before fitting veneers.Fig. 25.42 Final X‐ray views.Fig. 25.43 Change in smile after ceramic restoration (Dr Ignacio Vázquez Nat...Fig. 25.44 Tooth wear on anterior teeth led to severe attrition of 11–21.Fig. 25.45 Initial intraoral views.Fig. 25.46 Initial lateral and panoramic X‐rays and cephalometric analysis....Fig. 25.47 Initial Clinchecks.Fig. 25.48 Final intraoral views.Fig. 25.49 Final panoramic and lateral X‐rays.Fig. 25.50 Final smile after veneer bonding (work performed by Dr Ignacio Va...Fig. 25.51 Patient wanted to improve smile aesthetics with veneers, for whic...Fig. 25.52 Lower/upper cone beam computed tomography.Fig. 25.53 Bolton analysis showed possibility for lower premolar interproxim...Fig. 25.54 Initial intraoral views.Fig. 25.55 Initial cephalometric analysis.Fig. 25.56 Initial ClinChecks.Fig. 25.57 Refinement: the second Clincheck showed change from edge‐to‐edge ...Fig. 25.58 Refinement: intraoral views and cone beam computed tomography bon...Fig. 25.59 Good final results were achieved thanks to detailed multidiscipli...Fig. 25.60 Final extraoral views.

Guide

1  Cover Page

2  Title Page

3  Copyright Page

4  Preface

5  About the Authors

6  Acknowledgements

7  About the Companion Website

8  Table of Contents

9  Begin Reading

10  Index

11  WILEY END USER LICENSE AGREEMENT

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Aligner Techniques in Orthodontics

Susana Palma Moya Javier Lozano Zafra

This edition first published 2021

© 2021 by John Wiley & Sons Ltd

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The right of Susana Palma Moya and Javier Lozano Zafra to be identified as the authors of this work has been asserted in accordance with law.

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Library of Congress Cataloging‐in‐Publication Data

Names: Lozano Zafra, Javier, author. | Palma Moya, Susana, author.

Title: Aligner techniques in orthodontics / Javier Lozano Zafra, Dr Susana Palma Moya.

Description: Hoboken, NJ : Wiley‐Blackwell, 2020.

Identifiers: LCCN 2020024180 (print) | LCCN 2020024181 (ebook) | ISBN 9781119607229 (paperback) | ISBN 9781119607212 (adobe pdf) | ISBN 9781119607236 (epub)

Subjects: MESH: Malocclusion–therapy | Orthodontics, Corrective–methods | Orthodontic Appliance Design–methods

Classification: LCC RK523 (print) | LCC RK523 (ebook) | NLM WU 440 | DDC 617.6/43–dc23

LC record available at https://lccn.loc.gov/2020024180 LC ebook record available at https://lccn.loc.gov/2020024181

Cover Design: Wiley

Cover Image: Courtesy of Javier Lozano Zafra

Preface

I started to work with aligners in 2001 and immediatly I realized that they had a huge potential. It was easy for me to get familiar with the whole idea because I used to work with dental positioners at that time. In contrast, most of my colleagues were quite skeptical and did not consider aligners as a real orthodontic system.

Reviewing the literature we can see how the possibilities of the aligners have increased over the years. In 2001, there were limited tools available to solve mild crowded Class I malocclusions; however, several years after, we started to speak about extraction cases, Class II malocclusions, and open bites, which were treated more successfully each time. This situation was due to two factors: on the one hand, the continuous feedback the manufacturers use to make constant improvements, and on the other hand, the tremendous effort by many orthdontists who have been triyng to understand and explain what we call “the plastic biomechanics.” Therefore, the perception of using the aligners as an effective orthodontic method is improving due to the irrefutable fact that the results are getting better and better and, in many cases, they overtake the outcomes achieved by conventional orthodontics.

We are only beginning to understand how the aligners move teeth, and the learning curve is slower than we thought. Those are the reasons why their effectiveness is indisputably attached to academic training and experience. The professionals with greater knowledge and greater number of treated cases will achieve better results. This is no surprise as this is what happens when a new technique is introduced.

For all these reasons, as professionals, we are the ones who still establish our treatment goals. Aesthetics and the patient’s comfort should not conflict with the quality of the treatment results. This means that in quite a few situations, we need to use auxiliary techniques to complement the aligners deficiencies. It also means on the part of the practitioner a greater effort and dedication than usual to the occlusal and functional treatment finishing, and especially to training. I understand that leaving the comfort zone is not easy for those who have been treating patients the same way their whole life. This is where Dr. Palma and Dr. Lozano are absolutely exactly correct. This book fills a gap in our interpretation of the orthodontic movement with aligners. It offers a great number of essential keys to the understanding of the aligners biomechanics. It is the right publication at the right moment, with guides to treat different malocclusions with confidence, predictability, and quality. Following their solid biomechanics knowledge and experience‐based advice, the reader will be introduced to the treatment of more and more difficult cases, always keeping the traditional occlusal standards.

The book covers all the different malocclusions from the easiest mild crowding cases to the complex pre‐prosthetic treatments. It is written like an atlas, with specific cases fully explained step by step. The reader will also find an innovative and attractive video format of each treatment. For all these reasons, this book is a wonderful and easy tool for references suitable for beginners, but also for orthodontists well trained in aligners. Moreover, for the skeptical ones, the book, at least, will peak their curiosity. Is it really possible to perform a good quality orthodontics with aligners? This book will provide answers, and without doubt, many arguments for discussion.

We are at the beginning of a new technique. Previous and complete case planification through a powerful software has radically changed the way we work. This means we have to go back to school, but we have never had so many possibilities to train ourselves like today. In this way, the professional is able to become as competent as he or she wishes. However, it seems that some things never change; and I do not just mean the huge reluctance to accept new concepts or techniques (that is really frequent in our profession), I also mean the small percentage of people such as Dr. Palma and Dr. Lozano, whose great desire for self‐improvement and progress gives as a result the finding of new knowledge. The knowledge that they generously share serves as an example and guide for many people.

Dr. Arturo Vela Hernandez

About the Authors

Dr Susana Palma Moya is an Orthodontist running a private practice in Ciudad Real, Spain. She obtained her postgraduate degree in Orthodontics and PhD in Dentofacial Orthopaedic and Orthodontics from the University of Madrid in 2002.

 Was among the first group of Spanish Invisalign Providers in 2001.

 International Invisalign Speaker since 2015.

 Assistant professor for the postgraduate's program in orthodontics at U.C.M University in Madrid from 2003 to 2007, and currently teaching orthodontics at Salamanca University.

 University degree in Orthodontics with Surfery from the International University of Cataluña UIC 2007

 University degree in lingual Orthodontics by Valencia University 2009‐ 2011

 Invisalign peer award 2015 (first international Award) and Invisalign peer award 2017(second European Award).

 Member of the EMEA teen global group and member of Ortodoncis group in Spain

 Invisalign Diamond II practitioner since 2015 and lectured in Invisalign treatment throughout Spain and Europe.

Dr Javier Lozano Zafra is an Orthodontist running a private practice in Murcia, Spain.

 Degree in Dentistry, Murcia University

 PhD, Murcia University

 Postgraduate programme in Orthodontics, San Pablo CEU University

 Honorary lecturer, Seville University, Spain

 Invisalign International Speaker

 Invisalign Diamond Practitioner

 Honorary Member of the French Society of Aligners

 Member of the Invisalign TEEN global group and member of Ortodoncis group in Spain

Acknowledgements

My thanks must go first to my husband Paco who has worked just as much as I on the preparation of this book. He has worked tirelessly in gathering together the evidence from videos and other photographic material required. I also want to thank him for his love and understanding which have given me the inspiration and strength to write it.

To my children Marta and Paco for the time I have stolen from them and the continuous inspiration and strength they provide to enable me to get the best from myself: thank you.

To my parents, Mercedes and Paco, whose love and effort encouraged me to become an orthodontist and who have been pillars of strength throughout my life.

To Align Technology for believing in me and giving me the opportunity to share my orthodontic experience with other practitioners from 2015 onwards.

I also want to thank all my orthodontics team, because without them we could not get the results we see today, which we are able to demonstrate in the book.

I want to thank my good friend and partner, Dr Javier Lozano, not only because it has been a pleasure sharing our time working on making the book (and ultimately helping many students master the aligner technique in Aligners Academy), but also because his friendship has led to a tipping point in my life.

And finally, my thanks go to the entire Wiley team for their help in producing this book.

Dr. Susana Palma Moya

To Susana and Paco,

You both take me to the ‘next level’ every day, inspire my work and my life.

I do not know where I will be in 10 or 20 years’ time but, of this I am sure, our friendship will remain one of the most important pillars of life to me.

Thanks for trusting me, for taking care of me, for having me as a friend: I hope life brings you as much happiness as I think you deserve.

To Dani,

Your smile is the most important thing to me.

Dr. Javier Lozano Zafra

About the Companion Website

This book is accompanied by a companion website:

Companion website: www.wiley.com/go/lozano‐zafra/aligner‐techniques

The website includes:

 ClinCheck videos of every treatment in the book. Watch them simultaneously to every chapter, in order to fully understand biomechanics and staging used in every treatment.

 Patient Cases

1 History, Present and Future of Aligners
1.1 History of Clear Aligners
1.1.1 Early Beginning

Recent advances in technology have allowed many inventions that were previously only thought of to become a reality. Such is the case with clear aligners whose history began at the start of the 20th century.

These early retainers were developed by Hawley and others and made from Vulcanite and gold.

Rubber was first used in 1924, when Orrin Remensnyder developed the ‘Flex‐o‐Tite’,¹ a device that was meant to stimulate gums through home use combined with toothpaste, and was therefore convenient for periodontally compromised patients.

Fig. 1.1 Remensnyder patent file.

On approval the patent, Remensnyder described that the device might cause small teeth movements, using the expression ‘orthodontic appliance’ to describe it on his second patent for the device.²

Twenty years later, in 1946, Harold Kesling was responsible for developing what he called the ‘Tooth Positioner’, a device made from Vulcanite meant to prevent relapse after orthodontic treatment.

Fig. 1.2 Kesling patent file.

This, alongside variations from other orthodontists, was considered a gold standard for several years, in which black vulcanite was the preferred option.

By using the tooth positioner, Kesling suggested ‘major tooth movements could be accomplished with a series of positioners by changing the teeth on the setup slightly as treatment progresses. At present this type of treatment does not seem to be practical. It remains a possibility, however, and the technique for its practical application might be developed in the future’.

In 1963 when Shanks developed a technique for producing mouth guard style transparent retainers, with a machine capable of producing them. In 1964 Nahoum patented his ‘vacuum formed dental contour appliance’, while other orthodontists such as Ponitz³ faced problems in different designs such as heating capability or plastic needs.

Up to this time these devices were used to stabilize the results of previous orthodontic treatment but were also used for minor corrections to the position of the teeth.

At the end of the 1980s, Elasto devices were developed that were made from highly flexible silicon that could be used for either one or two teeth quadrants.⁴ Tooth movements were possible thanks to several set‐ups that were built in different plastics, depending on the clinician’s needs, after fixed appliances.

In 1994, Sheridan developed an aligner system,⁵ which he called ESSIX, using clear, polymeric shell appliances with thermoplastic divots to reposition teeth, which was meant to solve minor anterior malpositions. In 1997, together with Schwartz, they standardized this by patenting a system that would be implemented in many dental offices until now, an ‘in‐office’ vacuum system.

Fig. 1.3 Schwartz and Sheridan patent file.

1.2 Origins of Align Technology

At the end of the 1990s a computerized aligner system was developed in the USA with promising features: namely, Invisalign, created by two Stanford students, Zia Chishti and Kelsey Wirth.

Zia Chishti was an orthodontic patient that found out that his own clear retainer might be applicable to the whole orthodontic treatment, as it might be able also to move teeth and avoid metal braces. This reasoning led to why they both started the Company, partnered with some other students in their campus, Apostolos Lerios and Brian Freyburger, who were responsible for the Computer Aid Design part of this start‐up.

They then developed a software to design incremental stages of retainers to straighten teeth in a campus laboratory. In 1998, they got Food and Drug Administration (FDA) approval, and were then able to sell their product to the orthodontic community, which was resistant to this radical change, mostly owing to the lack of orthodontic experience of its founders.

In 2000, they raised $140M from venture capital companies and this allowed them to start a $31 million TV campaign that same year. In 2001, the Company went public, raising an additional $128M on NASDAQ.⁶

Fig. 1.4 Align Technology logo.

During this time, consumers drove more than 70% of the American Orthodontists to be trained in the system.⁷ That same year, Align Technology made Invisalign available to general dental practitioners, arguing that offering it only to orthodontists would be considered unfair competition by dentists.

By then, Align Technology was spending most of its revenues on advertising, and losing about $18 million per year,⁸ which led cofounders Wirth and Chishti to resign from Align Technology before 2003.

Fig. 1.5 Align Technology annual revenue.

After a cut in advertising to one‐third of the original, the company grew from 80,000 patients treated in 2002 to 175,000 in 2004, while receiving awards for its stereolithography techniques, medical design and fast growth. In addition, the company finally achieved a profit for the first time in 2003.

In 2004 the FDA cleared expanded labelling for Invisalign and removed the permanent dentition requirement, making possible the launching of Invisalign TEEN and widening clinical applicability to include more complex cases and increase the age band for treatment.

Fig. 1.6 Align Technology stereolithographic has been heavily awarded.

In 2005, the Harvard School of Dental Medicine required for the first time that its orthodontic graduate students complete Invisalign certification before they graduated.⁹

1.3 Early Clear Aligner Manufacturers

Although most patented innovations have been developed by Align Technology, other companies have been working on new functionalities since the beginning of the century.

Orthoclear

 Founded in 2005 by Zia Chishti, one of the Invisalign system founders, based in Pakistan, ended its operations in 2006 after a corporate agreement with Align Technology that followed litigations related to trademark.

ClearCorrect

 Founded in 2006 in Texas, it was developed by one of the practitioners using Orthoclear, after it ended its operations, to be able to finish his patient treatments not using the Invisalign system, offered to old Orthoclear customers.

 This was made in collaboration with a technician working with plaster models. In 2008 they digitalized the process and were able to produce larger series of aligners, which they sent to the orthodontists together with the plastic models made for every movement.

 The Company was acquired in 2008 by Straumann group, together with some other companies with previous experience in the field to build an aligner system driven by this international holding.

Fig. 1.7 Models and aligners by Clear Correct.

Orthocaps

 Founded in 2006 in Germany by Khan, this system has a ‘method of combining two different soft aligners for day and night time use’. These two types differ from one another in both their composition and the amount of pressure they exert. This innovation is called the TwinAligner system.

Inman aligner

 Developed by a dental technician, Donal P. Inman in 2000 in Florida, it was initially for minor alignments and finally widely used by general practitioners for veneer preparation in a simple and more affordable way than other aligner brands.

1.4 Align Technology Development

Align Technology claims an investment over $1000M, which has made them a leader the clear aligner market over 20 last years, with more than 900 patents currently issued at the time of writing.

This progress has been possible thanks to an increasing clinical and engineering team that has been involved with many innovations over the years, such as:

 Invisalign 1.5: this included initial SmartForces and attachments, which are attachments combined with three dimensional (3D) activations on the aligner material (by then, EX30) that help creating counterforces to achieve desired movement.

 Invisalign G3: this included passive aligners on the arch with less movement to allow class II and III elastics on patients with A‐P correction needed, as well as laser cut precision cuts or hooks.

 Invisalign G4: Optimized attachments for root control movements, open bite, and pressure points on aligners on teeth with small clinical crowns that could not accommodate double attachments.

Fig. 1.8 Optimized attachments for anterior open bite.

 SmartTrack: Align Technology’s proprietary material for aligners, launched for its increased fitting and elasticity.

 Invisalign G5: mostly for vertical malocclusions treatment, including specific protocols for Spee curve intrusion, passive attachments or precision ramps to help disoccluding posterior sectors.

Fig. 1.9 Passive attachments for anterior intrusion.

 Invisalign G6: specific movement protocol for premolars extraction as well as exclusive attachments group designed to fulfil the best outcome in these cases.

 Invisalign G7: designed for improved finishing with functionalities such as specific lateral incisors attachments.

 One week wear: an aspect that helped to reduce the treatment length resulting from changing the aligners every 7 days instead of 14, as had previously been the case (after an internal clinical study).

 Mandibular advancement: this is one of the features that has further increased the range of cases treated, as it includes not just orthodontic treatments, but functional ones, substituting classical twin blocks or mandibular advancements for power wings.

These, together with further functionalities covered in this book can help the orthodontist to achieve the same results as with braces, and combined with auxiliary techniques such as TADs, intermaxillary elastics, buttons, surgery: any malocclusion can now be solved with aligners.

1.5 Current Situation and Future of Aligners

Since the beginning of the twentieth century there have been vast improvements in the field of orthodontics. These range from edgewise appliances to the latest straightwise ones and self‐ligating braces.

If we were to search ‘orthodontics’ in PubMed, we would now find more than 70,000 entries, indicating that the profession is becoming more and more relevant for a global population that is demanding both health and aesthetics in their smile.

Fig. 1.10 Results in PubMed for ‘orthodontics’.

As seen in the history of clear aligners, it is clear that the number of papers published on aligners is much lower than in the entire field of orthodontics, likely because of its relatively newness, with developments only coming in the last 5–10 years. The requirements for publishing a paper in a peer‐reviewed journal can make it very difficult to fully appreciate their growth in the orthodontic community.

That being said, what we can see is that the popularity of aligners has been powered by Align Technology over the last 20 years, given that the majority of papers published have referred directly to the ‘Invisalign’ technique, and it has only been relatively recently that other brands have attempted to enter the market.

Fig. 1.11 Results in PubMed for ‘invisalign’ from 1999 to 2019.

It is for this reason that the patients mentioned in this book have been treated entirely using aligners produced by Align Technology; however, the biomechanical approach can be extended to any brand that, in the future, is able to develop a reliable product to treat any malocclusion using aligners and auxiliary techniques.

We constantly aim to analyse, study and understand what is happening within the field of orthodontics and strive to be on the edge of innovation, always one step ahead in order to provide our patients with the best solution for the situation that they face. We have focused on the most promising aligner brands available at this moment but we are aware that with technological advances everything may change very quickly.

1.6 Promising Aligner Initiatives
1.6.1 ClearCorrect by Straumann

Straumann is one of the larger dental companies in the world, and is known for dental implants. With the acquisition of ClearCorrect in 2019, a company founded in Texas in 2006, they entered the Aligner marketplace offering the following:

 Two aligner options: unlimited or individual (including just a single aligner), a flexible option to suit each practitioners needs.

 Free treatment setup (you do not pay for anything except the aligners).

 Polyurethane aligners, 0.3 inches (approx. 7.5 mm) thick, a very common material.

Unscalloped trim line extended past the gingival margin, intended to increase retention over scalloped aligners, therefore reducing the need for attachments and improving aesthetics.

Fig. 1.12 ClearCorrect aligner retention chart.

From: Cowley DP, Mah J, O'Toole B. The effect of gingival‐margin design on the retention of thermoformed aligners. J Clin Orthod 2012; 46(11): 697–702.

None of these aspects have been followed through a clinical study or published in a journal, so although this seems promising, we will have to wait to see how the system develops in the future.

1.6.2 SureSmile by Dentsply

Dentsply is the largest dental company in the world, with an extensive portfolio of dental products. Although initially focused on restorative dentistry they have recently incorporated dental implants and clear aligners. The acquisition of SureSmile from Orametrix in 2018 allowed them to enter the aligner market with a system displaying the following characteristics.

 The only aligner system linking cone beam computed tomography (CBCT) with cephalometric X‐ray and virtual simulation of movement.

 Hybrid treatment, being able to mix braces and aligners.

 In‐practice produced aligners, where the practitioner is sent the files to print three‐dimensional models that are used to vacuum‐form aligners with Essix plastics.

Fig. 1.13 SureSmile aligner software combined with CBCT.

1.6.3 F22 by Sweden and Martina

Sweden and Martina is a dental implant company from Italy that developed an aligner system alongside Prof. Siciliani from the University of Ferrara. The system has the following characteristics:

 Mentoring from a member of the University of Ferrara throughout the duration of the treatment.

 Chromatic stability, owing to less pigment retention from the plastic material used for the aligners, and proven through clinical study by the university.

 Optimal fitting, leaving a space smaller than 40 μm between the aligner and the teeth.

 20% lighter force transmission than other aligner materials, according to one study by the university.

 Increased comfort, as a result of the university’s trimming protocol.

 Increased retention, as a result of a design based on a paper published by Cowley¹⁰ suggesting higher values of retention are obtained when aligners are cut regularly and straight at the level of the gingival margin zenith.

Fig. 1.14 F22 chromatic stability.

From Lombardo et al. Optical properties of orthodontic aligners—spectrophotometry analysis of three types before and after aging. Prog Orthod 2015;16:41.

1.6.4 Clarity by 3M

The MBT prescription, developed by McLaughlin, Bennett and Trevisi, was successfully marketed by 3M, based in Germany, having developed many innovations in the orthodontic field and including the proprietary Incognito lingual braces system.

In 2018 they launched their Clarity aligners, with the same name they give to their aesthetic braces system, claiming:

 Advanced analytics and software planning tools.

 Open platform accessible with any scanner.

 3M Treatment Tracking patient App.

 Accessibility from PC and MAC.Fig. 1.15 3M superimposition for treatment evolution.

 From November 2019, the only information published in regard to this were two clinical cases published on their website, both for aligning anterior teeth, but with no A/P correction or vertical component in the treatment.

1.6.5 Spark, by Ormco

Ormco is one of the leading brackets and wires manufacturers in the world, which started offering its own aligners brand in 2019, claiming the following (data on file from the Company that we cannot access at this time):

 TruGEN plastic aligner is clearer than the leading aligner (AKA Invisalign).

 TruGEN plastic aligner produces higher sustained force retention in order to reach treatment goals faster than the leading aligner (AKA Invisalign).

 Hand trimmed aligners, with scalloped edges that are meant to be more comfortable for the patient.

Apart from this, their product portfolio is similar to the one developed by Align Technology, with 3 treatment options (10, 20 or unlimited aligners), based on a 7 day wearing period of the aligners. They have as an advantage, the ability to perform single arch treatments using the unlimited aligners product, which is not available for Invisalign aligners.

In regards to their proprietary software, it has different functionalities than ClinCheck software, the most significant being the simulation of roots. None of this has been through a clinical study or published in any journal so, even though these aspects are promising, we will have to wait to see how it develops in the future.

Fig. 1.16 Ormco results for their TruGEN plastic against SmartTrack (data on file).

1.6.6 CA Clear Aligner by Scheu

This German aligner system enables clinicians to fully take control of aligner production, provided that there is a dental technician in the team responsible for developing models and manufacturing in‐office vacuum aligners that offer several advantages:

 Integration of auxiliaries, such as expansion screws or distalizers

 Scheu biocompatible material

 Individual fabrication for each treatment step

 Three thicknesses available (0.5, 0.65 and 0.75 mm) to be changed selectively in order to exert certain forces

Fig. 1.17 Distalizer inserted in an in‐practice aligner.

This is one of the segments that might grow in the near future when 3D printing allows direct aligner printing in the practice, thereby reducing the need for vacuum models, saving both time and money and making it cheaper to produce aligners. This will improve the affordability of the treatments for patients, as this option already provides a fit equal to that of any other aligner brand.¹¹

1.6.7 Irok

This US Company is focused on the printing of digital models for aligners design, but also for retainers, indirect braces bonding.

Fig. 1.18 Irok is focused on digital models that can serve different purposes.

Its unique characteristic is that it provides the possibility of aligning in combination with dental implant software, based on the implant’s final position, and it can be placed with a surgical 3D splint.

1.6.8 Angelalign

Founded in 2001 by Li Haumin in conjunction with Tsinghua University and Beijing Capital, Angelalign is the largest provider of transparent teeth aligners in China.

Since 2006 they have been granted 80 patents relating to processes, aligners, manufacturing and 3D technology and, for these reasons, they can offer a product with several technological advancements and functionalities through their iOrto platform:

 masterMulti, offering the opportunity to using different aligner thickness

 Mandibular advancement device, first launched globally, in 2015

 a7 extraction technology, tested over 15 years

Together with other Asian companies such as Smartee, for whom there is currently little information in Europe, Angelalign will probably become an important stakeholder in aligners development.

Fig. 1.19 A6 mandibular advancement launched in 2015.

1.6.9 Alineadent

This Spanish aligner Company has its origins in a dental laboratory specializing in orthodontic functional appliances, which led to the development of this aligner brand. Its characteristics are:

 Open system, compatible with any scanner brand

 Immediate validation from a dental technician

 Planning within 72 hours

 Production within 72 hours

 LineDock software for case management

Unfortunately, there is no evidence available with regard to its capability in the management of complex cases, as with some other dental companies manufacturing aligners. Their ability to improve this may rely on their approach to practitioners that may choose to use them in cases of minor tooth movements.

Fig. 1.20 LineDock software.

1.6.10 Remote Aligner Companies

It is important to mention direct to consumer aligners, or remote aligners initiatives, especially as Candid, one of these companies, has raised $78.4M in venture capital funds, and SmileDirectClub already has more than 300 locations in the US, UK and Australia and has treated more than 650,000 patients since its foundation in 2014.

Fig. 1.21 SmileDirectClub self‐polyvinyl siloxane (PVS) ‐impression kit.

They all are based on the following workflow:

 Scanning in a company facility similar to a store or self‐taking a polyvinyl siloxane (PVS) impression at home with a kit sent from a remote aligner company, and sending it back to its headquarters

 Validating the case at the company aligners production facility

 Patients receive the aligners

Fig. 1.22 CANDID aligners process.

In an era when people are used to a one‐click‐buy, particularly through their Smartphone, and when telemedicine is on the rise as a result of the growth of the internet and wearables that are part of our daily routines, this might sound ‘good’ for patients who want to have a cheaper treatment option, as they are usually three to four times cheaper than an average comprehensive treatment performed by an orthodontist.

There have been several blocks to the success of these companies: for, example SmileDirectClub were forced to pull out of the Spanish market after the Spanish Ministry of Health warned that their system was against Spanish Law, and the American Association of Orthodontists filed complaints with 36 state dental boards and attorney generals alleging specific statutory and regulatory violations.

These systems may lead to health problems in the future for some of their users owing to poor, improper treatment. This may lead to problems that need to be resolved in‐house, resulting a furhter treatment cost on top of the impact on their health.

Fig. 1.23 CANDID aligners set.

1.7 Future of Clear Aligners

The future of clear aligners is, as with everything, unpredictable, but it likely that there will be a strong focus on:

 In‐practice aligners, thanks to the development of 3D printing

 Integration of CBCT with treatment planning software

 Increasing number of laboratories and aligners companies

 Price reduction

What is clear is that, thanks to this, before 2030 100% of the orthodontic treatments will be performed with aligners in every practice in the world, as it is currently in ours.

We should aim to ensure that as orthodontists we are ahead of these changes and share our views and clinical experience with the orthodontic community as a whole so we may help to improve the smiles of everyone.

Notes

1 1 Remensnyder, O. A gum‐massaging appliance in the treatment of pyorrhea. Dent Cosmos. 1926; 48: 381–384.

2 2 Remonsnyder, O. United States Patent 2,479,780, Orthodontic Appliance, Aug. 23, 1949.

3 3 Ponitz, R. Invisible retainers. Am J Orthod. 1971 59(3): 266–272.

4 4 Hinz R. Elasto‐orthodontic system – a development of the positioner. Prakt Kieferorthop. 1991;5(3):179‐88.

5 5 Sheridan JJ, McMinn R, LeDoux W. Essix thermosealed appliances: various orthodontic uses. J Clin Orthod. 1995;29(2):108–13.

6 6 Feder, BJ. ‘Orthodontics Via Silicon Valley; A Start‐Up Uses Computer Modeling And Venture Capital to Reach Patients’. The New York Times, 18 August 2000: p. 1.

7 7 Bush, J. ‘Stealth Braces’. YT Regional Newspapers (August 14, 2001). Retrieved January 9, 2013.

8 8 Lau, G. ‘It has a bracing impact on patients; Align Technology’ May 3; 2004.

9 9 Antelman G. International Directory of Company Histories. St James Press. 2008; 94: pp. 15–18.

10 10 Cowley, DP., Effect of Gingival Margin Design on Retention of Thermoformed Orthodontic Aligners (2012). UNLV Theses, Dissertations, Professional Papers, and Capstones. 1662. https://digitalscholarship.unlv.edu/thesesdissertations/1662.

11 11 Mantovani E et al. Scanning electron microscopy analysis of aligner fitting on anchorage attachments. J Orofac Orthop. 2019;80(2):79–87.

2 Basic Principles with Aligners

Invisalign treatment is an orthodontic technique, not just a product. As such, orthodontic principles of force application, engagement, anchorage and biomechanics need to be applied. However, aligners move teeth differently than fixed appliances do. In order to understand this we need to have a look at how aligners work.

2.1 Forces

Aligners move teeth by exerting a push force. When the aligner is inserted over teeth, the aligner deforms over the teeth and the elasticity in the aligner material pushes the teeth into position.

Fig. 2.1 Forces will be delivered through the combination of plastic and attachments.

Optimized attachments provide an active, flat surface that the aligner may push against to provide effective tooth movements.

Fig. 2.2 Optimized attachments provide an active, flat surface that the aligner may push against to provide effective tooth movements.

2.2 Engagement

Aligners engage teeth by enclosing the tooth in aligner material. The more material wrapped around a tooth, the better the engagement. In teeth with a long clinical crown and larger surface area, there will be better engagement and therefore better expression of tooth movement. In contrast, in teeth with short clinical crowns and less surface area, there is less engagement and less expression of tooth movement.

Fig. 2.3 These crowns allow enough contact from plastic to exert desired forces.

Fig. 2.4 Short clinical crowns might reduce movement predictability.

One way to increase the engagement of the aligner onto teeth with short or small clinical crowns (for example, peg‐shape lateral incisors) is to place an attachment on the tooth.

Fig. 2.5 Quantification of variable aligner material on retention. (Left) Vertical displacement forces (Newtons) of each aligner material during removal from the control cast containing no attachments. (Right) Vertical displacement forces of each aligner material during removal from the cast containing ellipsoid attachments. (Right) Vertical displacement forces of each aligner material during removal from the cast containing bevelled attachments. Each column represents one of the aligner materials tested (CA soft, medium, hard; Essix ACE).¹

This is a different approach from the that with braces, which had ‘contact points’ instead of a full surface contact and this should be kept this in mind for a treatment plan to achieve the same results that can be achieved with brackets and wires.

Fig. 2.6 Brackets have a strong small contact point in comparison with a soft big contact surface between aligner and teeth.

2.3 Anchorage

Aligners offer extremely good control of anchorage because the anchoring teeth can become immovable at different stages of treatment. For example, in asymmetric expansion, one side of the mouth can be used to expand the other. Alternatively, in sequential distalization of the maxillary arch, only the second molars in the initial stages of treatment can be distalized, while the remaining teeth in the arch from first molar to first molar do not move in the initial stages and act as an anchorage segment to push the second molar distally for anteroposterior correction.

Fig. 2.7 While second molars are moving, the rest of the teeth are considered as anchorage.

Fig. 2.8 This figure shows a horizontal ‘V’ movement pattern.

Fig. 2.9 The second quadrant is being expanded using the first quadrant as anchorage.

In the G6 first premolar extraction protocol (Align technology), for maximum anchorage, only the canines and posterior teeth are moved in the initial stages of treatment (if anchorage loss is needed to achieve class I, but only up to 2 mm, otherwise the G6 protocol does not apply). The incisors do not move, and they act as an anterior anchorage segment to distalize the canine into the extraction site for space closure. After using some aligners, the second premolar and molars stop moving, and they become the posterior anchorage segment. Canines will move up to one‐third of their total movement and, at that point, incisors retraction will start.

Fig. 2.10 G6 first premolar extraction has a standardized movement sequence.

Fig. 2.11 In this G6 protocol extraction of 14 (from left to right), the posterior sector and canine move first; when the canine has achieved 1/3 of its total movement, incisors can start retruding.

2.4 Case Selection to Start with Aligners Technique

Invisalign is an orthodontic technique that can be used to treat all malocclusions that were previously addressed with brackets. However, in order to develop confidence with the technique, it is paramount in the beginning to follow a suitable learning curve to allow familiarization with the system and working with the following malocclusions is recommended:

 Class I with minor or moderate crowding or spacing

 Half‐cusp Class II with minor crowding

 Class III with minimal overbite/overjet non‐extraction cases

 Deep bite that can be solve by proclination and anterior intrusion (without posterior extrusion)

 Open bite that can be solved by retroclination and anterior extrusion (without posterior intrusion)

 Lower incisors extractions

However, if we are already comfortable and secure treating all types of malocclusions successfully with braces, then why should we change to aligners?

Note

1 1 Dasy H, Dasy A, Asatrian G, Rózsa N, Lee H‐F, Kwak JH. Effects of variable attachment shapes and aligner material on aligner retention. Angle Orthodontist 2015;85(6):934–940.

3 Why Invisalign?

We will explain why we decided to change ouro patients from braces to aligners and the advantages this brought to the growth of our practices and for ourselves.

3.1 Why Did We Begin Prescribing Invisalign in Our Practice?

Our reasons for prescribing Invisalign in our practice are:

 Differentiation: we wanted to be different from other practices that only offered brackets to their patients. Our goal was to have more contented patients in our offices, leading to more positive feedback and producing patients that would become our best ambassadors for referrals.

 Reputation: currently, and especially in Spain, the state‐of‐the‐art treatment within orthodontics is Invisalign, so patients might believe that if you are not confident in Invisalign, then you might not be a good orthodontist.

 Efficiency in our practice:fewer (and shorter) appointmentsfewer emergenciesappointments planned ahead, so staff can use our protocols and reduce chair timefewer staff members needed to attend the same number of patientseasier training for new staff (compared with using brackets and wires).

It was considered that all these elements would result in a more efficient workflow, and they did!

 Aesthetics: patients seek an aesthetic pleasing look, but not just at the end of treatment, as occurs with brackets and wires, so it is much better for them if we can offer those aesthetics during the entire treatment using an almost invisible plastic appliance.

 Up‐to‐date image of practice: it is easier if you show your treatment plan using digital tools and 3D planning using an iTero (intraoral) scanner, the outcome simulator and ClinCheck, especially compared with practitioners who are still showing their treatment plan with pictures and plaster models.

 For the future: this is our real motivation and the most important one for us.

3.2 Our Motivation

Our prime motivation is that we strongly believe that in the not too distant future, Orthodontics will be exclusively based on aligners. Therefore, what we aim to do right now is offer our patients the treatments most practitioners will be offering in a few years’ time. So, why wait if technological advances let us offer this treatment with the same goals and results as brackets and wires? We also believe this will lead us to being considered lead practitioners, further improving our practices.

The first smartphones became available just a decade ago, and it already seems as though they have been with us for a lifetime. Technology is advancing so rapidly that we will experience radical changes in society. As we undergo this rapid change, our old treatments using braces will no longer apply. Technology is creating a new set of rules that will change everything in our way of working: everything that can be digitized and customized will be. We firmly believe that soon no patients will be using braces for orthodontic treatment so, ‘The sooner we transform all our patients into aligner patients, the sooner we will find the right path for our practice growth’.

4 Patient Communication Skills

The first element in our practice driving growth was word of mouth. For this, we developed a communication plan to explain that Invisalign is not just an aesthetic treatment, it is a lifestyle.

4.1 Invisalign Equates to Health, Wellness and Outstanding Results

We focused on communicating to our current patients that we were using a new technique to align the teeth without braces. For this we used the following channels:

Fig. 4.1 Let’s talk about aligner treatment with our patients.

 Verbal in‐office communication

 Digital and paper newsletter

 Social media

After this, we provided them with a change in mindset:

 For parents: health, wellness and guarantee of results

 For teenagers: change everything in your smile without changing your lifestyle

Fig. 4.2 The more Invisalign patients you have, the more Invisalign referrals you will have.

4.2 Effective Patient Communication

As in‐office communication is crucial and the best chance to interact with patients, we suggest having an Invisalign treatment coordinator in any office. Ideally, this would be a dental hygienist who:

 Addresses the patient’s doubts about the treatment.

 Explains the whole process (the patient journey).

 Assists the patient from the moment they are given the treatment plan and quotation until they finish their treatment.

Fig. 4.3 A treatment coordinator is a key success driver for Invisalign.

5 Keys to Practice Growth

The ‘four Ps’ are the main growth drivers for Invisalign in our practices:

 Progress: this technique is more advanced than any other in orthodontics – it is a 100% digital and customized technique.

 Predictability: the chance of having selective anchorage during the treatment makes our movements more predictable.

 Possibility of treating every malocclusion, even in mixed dentition.

 Profitability: treat more patient with less chair time and fewer staff needed.

Fig. 5.1 If we plan our growth in advance, we will reach our goals.

5.1 How to Get the Best Results with Invisalign

We have come to the conclusion that the keys for success with Invisalign rely on:

 Adequate patient selection (motivate the patient, show them in every appointment the results he or she is obtaining due to the use of the aligners)

 Clear goals of treatment in every plane: transversal, sagittal and vertical.

 Being very specific with the technician (in your instructions): communicate not only what you want to achieve but also how you want to obtain your treatment goals and the staging of movements needed for this particular malocclusion.

 A thorough dynamic evaluation of the ClinCheck, considering staging, differential anchorage, looking for predictable movements while avoiding those outside the predictability range of the aligners shown as black dots on the tooth movement assessment tool (TMA).

6 Patient Selection

The Invisalign selection tool is a guide provided by Align Technology to help choose between the different treatment options that Invisalign provides, according to the patient malocclusion. This is a tool that might be used before sending the case in order to assess the predictability of the case (simple, green/moderate, blue/difficult, black) as well as the treatment option from the Align portfolio. During the learning curve, clinicians usually do this evaluation ‘automatically’, but we still think it is useful for beginners.

Based on Align’s ‘big data’ it is possible to predict accurately the outcomes from every tooth movement. This is really important in order to achieve excellent results, as the practitioner will need to understand how to make movements possible using auxiliary techniques (which relies on experience), alongside aligners or attachments (which is what this tool ‘analyses’).

Fig. 6.1 Invisalign evaluation tool.

7 Predictability of Movement

Movements are classified into three colours, according to their predictability:

Fig. 7.1 All treatment predictability can be checked with the Invisalign evaluation tool before sending the case.

7.1 Treatments to Gain Familiarity with the Technique

Class I < 6 mm spacing or crowding.

 Deep bite < 4 mm

 Open bite < 2,5 mm

 Class II < 4 mm

 Class III < 2 mm (distalization of lower molars by tipping the lower molars Crown to distal without moving the roots)

 Midlines shift < 3 mm

8 Types of Treatments with Invisalign

Currently, although this may change in different parts of the world and in the future as a result of Align Technology commercial policies, the different options that Align provides according to the malocclusion of our patients are indicated in Fig. 8.1.

Fig. 8.1 Align Technology’s 2021 portfolio.

9 Pillars of the Invisalign Technique

The Invisalign system is not just a set of aligners, as other resources are needed to achieve success in each case. Based on this, we describe five pillars of the technique, which are:

 Aligners

 ClinCheck software

 Attachments and features of SmartForce

 Auxiliary techniques

 Technicians

9.1 Aligners

Aligners are made from SmartTrack material, a patented plastic formula exclusively designed this purpose, while attachment templates are made with EX 15 and Vivera retainers with EX 40.

Characteristics of the SmartTrack technology:¹

 Creates a soft and constant force.

 Is more elastic than other aligner materials, which results in a longer working period.

 Better adjustment to the teeth than any other alternative.

 Easier to use and provides an easier way of placing and removing the aligner.

Every aligner makes:

 0.25 mm of lineal movement

 2 degrees of angular movement to correct rotations

 1 degree of torque movement (lingual–root torque or labial–root torque)

In cases where we want to slow down the amount of movement, this can be requested from the technician, which will change Align’s default parameters to 50% (half of the movements indicated above).

Aligners are created to be used 22 hours per day, with changes depending on the amount of movement every 7, 10 or 14 days.

9.2 ClinCheck Software

This application, created by Align Technology, was designed specifically for practitioners. ClinCheck provides a 3D virtual representation of a treatment plan derived from the orthodontic prescription.

Each practitioner is able to send information back and forth with Align as changes are made to the treatment plan, and then aligners are manufactured in accordance with the finalized plan and sent directly to the practitioner to begin the patient’s treatment.

9.3 Attachments and Features of SmartForce

These are attachments composite structures that are bonded to the patient’s teeth in order to help achieve the movements previously planned on the ClinCheck software. They can be ‘conventional’, with standardized shapes and sizes, or optimized, where a shape and size is determined by the software based on each patient and tooth. They are bonded throughout the treatment and will be removed at the end of it.

In 2013, Align Technology developed the Smartforce Features in order to create the optimal forces to move the teeth in a predictable way. They can be placed.

 On teeth, as optimized attachments

 On the aligner, as pressure points or power ridges

Full information of these will be delivered in later sections of this book.

9.4 Auxiliary Techniques

As stated previously, clear aligner therapy needs other forms of auxiliary techniques, such as elastics, buttons, Powerchains, Temporary Anchorage Devices (TADs) and others, just as we do with fixed appliances in order to make treatments more predictable and more efficient.

We will explain some of these auxiliary technique in the troubleshooting and auxiliary techniques section but it must always kept in mind that a great result with aligners needs a great practitioner using the five pillars: it is not just a matter of plastic and elastic, but an orthodontic treatment based on mechanics, forces and a detailed treatment plan that has to include every tool in our ‘ortho’ arsenal.

9.5 Technician (CAD Designer)

ClinCheck software allows practitioners to plan occlusion and tooth position but other changes, such as staging and teeth extraction still need collaboration from an Invisalign CAD designer. This makes these individuals really important to the treatment outcome and requires practitioners to adapt to the ‘technician language’ in order to achieve the best result from the aligner technique.

Note

1 1 Bräscher AK, Zuran D, Feldmann RE Jr, Benrath J . Patient survey on Invisalign® treatment comparen the SmartTrack® material to the previous aligner material. J Orofac Orthop. 2016; 77(6):432–438. Epub October 24, 2016.

10 Conventional Attachments

Conventional attachments are passive attachments that increase the engagement of the aligner onto the tooth. They act as a handle for the aligners to move teeth. They can be placed via written request to the technician or by using the drag and drop feature on the 3‐D controls.

There are three types of conventional attachments:

 Ellipsoid attachments: Used for retention or anchorage when the tooth surface area is limited, for example for peg‐shape lateral incisors or the lingual surface of a lingually inclined mandibular second molar.Fig. 10.1 Ellipsoid attachments.

 Rectangular attachments: These are passive attachments that can be vertical or horizontal. By default, they are placed in the middle of the tooth crown, but can be moved to any desired position to facilitate the mechanics that have been planned for the case.Horizontal: can be used for root control, especially for labial root torque on the molars. These can also be used in short crowns in order to increase the retention of the aligners, which is part of the standard Align’s protocols for patients that are still growing in interventions such as mandibular advancement or first protocols (similar to this, but optimized). In unilateral crossbites, horizontal rectangular attachments are used in the side without the crossbite in order to provide anchorage to correct the unilateral posterior crossbite on the contralateral side. This will be explained in Chapter 17, but they help to control the root torque so as to create an ‘en masse’ movement of not just the crown but of the whole tooth body.Fig. 10.2 Horizontal attachments have great clinical effects on transverse plane. Ellipsoid attachments.Vertical: these are used for root control when the software cannot place optimized root control attachments, such as mandibular incisors in cases involving the extraction of one lower incisor.Fig. 10.3 Conventional attachments are selected whenever there are no optimized ones available.

 Bevelled attachments: both horizontal and rectangular vertical attachments can be bevelledHorizontal attachments can be bevelled to the occlusal (HBO) or to gingival (HBG) to help with intrusion or extrusion movements:For extrusive tooth movements on posterior molars, a horizontal attachment bevelled to gingival can be usedFor intrusion, use the horizontal attachment bevelled on the occlusal on the teeth adjacent to the one that has to be intrudedFig. 10.4 Extrusion attachments are placed on teeth adjacent to the ones to be intruded, so as to create a counter‐movement that will lead to a force couple. This is a great example of how biomechanics are applied on aligners.Vertical attachments can be bevelled to mesial (VBM) or to distal (VBD): for rotation movements when the software has not placed optimised rotation attachments, for example when correcting first molar rotation. The bevelled surface is the active one, as the bevel provides a flat surface for the aligner to push against to achieve the desired tooth movement.Fig. 10.5 Vertical attachments bevelled to mesial (left) and distal (right).

 Conventional and optimized attachments might have similar functions:Double root control attachment: AT conventional rectangular verticalOptimized rotation attachment: AT conventional rectangular vertical bevelled to mesial VBM or distal VBDOptimized extrusion attachment: AT conventional horizontal bevelled to gingival HBGFig. 10.6 Conventional attachments might be placed to achieve similar movements to the optimized ones.

10.1 Features of SmartForce
10.1.1 Optimized Attachments

These area attachments with different characteristics from the conventional ones. They are:

 Designed to provide optimal force to achieve a more predictable movement

 Tailor‐made for each tooth’s width, long axis and contour

 Positioned precisely to deliver the forces while simultaneously eliminating interferences

All these characteristics are defined by the ClinCheck software and do not permit changes by the practitioner, a feature that may change in the future.

Fig. 10.7 Research and development investment has led to a very powerful biomechanical system.

Optimized attachments provide SmartForces applied to the teeth. They provide the amount of force necessary to create the ideal movement of the tooth. In addition:

 They are automatically placed by the software when it detects certain thresholds of tooth movement. They are designed to control the point of application of the force, the direction of the force and the amount of force applied. Every optimized attachment is customized to each individual tooth.

 They have an active surface that contacts with the aligner. Its active surface varies in geometry based on the unique morphology of each tooth. The aligner is designed at a more acute angle than the active surface on the attachment in order to exert a force on the active surface to move the tooth in the desired direction. As a result of this, the size of the attachment on the tooth will differ from the size of the space in the aligner for attachment (reservoirs).

 If an optimized attachment needs to be replaced midway through treatment, the clinician will need to use the attachment template to re‐bond the attachment, instead of using the last aligner.Fig. 10.8 Conventional dental composite is the material chosen for attachments.

In the past, the practitioner could not ask the technician to place an optimized attachment, but could ask for the movement so the software would place them. For example, if an optimized extrusion attachment on a certain tooth was required, we would ask for more than 0.5 mm of extrusion in that tooth and the software would place the attachment. However, it is now possible to ask for optimized attachments even if the movement is not supposed to happen (or it is under the threshold), which could prove helpful for certain situations (lower premolar anchorage to level lower Spee curve by incisor intrusion). It should be noted that:

 They are individualized for the tooth and for the specific movement that particular tooth needs

 Their position, shape or size cannot be changed

 They cannot be placed lingually

 They are not compatible with other lingual attachments or SmartForces

Currently available optimized attachments include:

 Optimized rotation attachment (for rotation movements in canines and premolars)

 Optimized extrusion attachment (for extrusion movements in incisors, canines and premolars)

 Optimized root control attachment (for root control in incisors, canines and premolars)

 Optimized attachment for upper lateral incisorsMultiplane attachment (for lateral incisors with rotation and vertical movement)Optimized support attachment (to support lateral incisors when there is an intrusion movement on adjacent canine or central incisors); deep bite correction.

 Optimized attachments on molars:Multiplane attachment (for molars with rotation + vertical movement)Extrusion optimized attachments (for extrusion movements on molars)

 Optimized support attachments: to provide support for predictable dental arch expansion in mixed dentition.

Optimized Rotation Attachment

These are placed for rotation of canines and premolars greater than 5 degrees:

Fig. 10.9 Placement on canines and premolars.

 Placed when more than 5 degrees of rotation is needed.

 The predictable rotation is between 30 and 45 degrees.

 If one needs to be replaced for a conventional one, it will be a vertical rectangular attachment bevelled to mesial or distal.

Optimized Extrusion Attachment

Designed for extrusion of incisors, canines and premolars, these attachments are bonded in the middle of the crown:

 They are placed when the extrusion is more than 0.5 mm and have a wedge shapeFig. 10.10 Placement on incisor.Fig. 10.11 Placement on premolar.

 When they are placed on lower premolars, they are used as an anchorage for the anterior intrusion of the incisors and they have a different shape

 They can also be activated to provide an extrusion force on the premolars during the anterior intrusion

 When extrusion of the four upper incisors is greater than 0.5 mm the four teeth will act as a single unit

We will look at these attachments in more detail later, but note that they are mandatory when an anterior open bite is part of the patient’s malocclusion, otherwise the aligner will not be able to apply a clean extrusion vector.

Fig. 10.12 The right side shows how anterior extrusion attachments help to create a counterforce to posterior intrusion, achieving predictable movements.

Optimized Root Control Attachments

These are are designed for upper central upper incisors and lower canines, where they will control root movement, for tipping management and ‘en masse’ translation:

 They have two active surfaces and are placed when there is a translation of the tooth centre of resistance greater than 0.75 mmFig. 10.13 The figure on the right shows how optimized root control attachments create a couple of forces to improve root tipping.

 These are not available for lower incisors

 They can be placed in two ways:In opposite orientations on both central incisors (like a mirror image): they are used to close a diastema (mesial root tipping of 11 and 21 to close the diastema)Parallel to each other on both central incisors (they are placed in the same directions in both central incisors). In this case they are used to move the upper midline in one direction

 They are automatically placed by the software:When the centre of the root on upper and lower canines and premolars moves more than 0.5 mmWhen the centre of the root on upper central incisors moves more than 0.75 mmThey can also be placed in lateral incisors and premolars, but because of the short crown, instead of a ‘double attachment’ it is sometimes shown as a half‐moon and a pressure point applied on the aligner’s lingual surfaceFig. 10.14 Pressure points are usually associated with attachments whenever short clinical crowns are detected.

Optimized Attachments for Lateral Incisors
Multiplane Attachment

 Placed when the lateral incisors need intrusion or extrusion while simultaneously requiring rotation, torque or tipping movements

 They have an active surface on the attachment and a lingual pressure pointFig. 10.15 Combination of attachments and lingual pressure points help creating an excellent force system.

Optimized Support Attachment

 Placed on lateral incisors when 1 mm or more of intrusion is planned on adjacent canine or central incisors, similar to the example given for posterior intrusion, but with characteristics adapted to lateral teeth clinical crowns

 The aim of these attachments is to prevent tracking problems on the lateral incisors during the vertical correction of the central incisors and the caninesFig. 10.16 Sometimes attachments are designed for support instead of movement.

Optimized Attachments for Molars

These are automatically placed by the software for anchorage purpose and to assist the molars to move in different planes of space.

Fig. 10.17 Attachments for molars are relatively new and provide improved root movement.

Multiplane Attachments for Molars

 Optimized multiplane attachments are designed for molars that require rotation correction and a vertical correction of intrusion or extrusion at the same time.

 For extrusion + rotation, equal to or more than 0.5mm extrusion and 5 degrees of rotation about the long axis of the tooth.

 For extrusion/intrusion, between 0.5 mm intrusion/extrusion and more than 5 degrees of rotation about the long axis of the tooth.Fig. 10.18 Mesiobuccal rotation combined with extrusion.

 For intrusion, equal to or less than 0.5mm intrusion and 5 degrees of rotation about the long axis of the tooth.Fig. 10.19 Mesiobuccal rotation combined with intrusion.

Optimized Extrusion Attachments for Molars

These help with the extrusion of the molars, for extrusion + rotation, more than 0.5mm extrusion and less than 5 degrees of rotation about the long axis of the tooth.

Fig. 10.20 Molar extrusion.

10.2 Optimized Support Attachments

These provide support for predictable dental arch expansion.

Fig. 10.21 Optimized support attachments are commonly used in first treatments.

10.2.1 SmartForces

There are other types of SmartForce attachments, such as those placed on the aligners (not on the teeth, as attachments) to help achieve the desired movement, which have been developed after more than a decade of research and development from Align Technology.

Power Ridges

They might be placed alone, and are not compatible with attachments, usually stablishing a force couple, for example, for incisors torque:

 BuccalAvailable on upper and lower incisorsThey produce lingual root torque (LRT)Threshold for placement is 3 degrees LRT1 degree/alignerFig. 10.22 Power Ridges are plastic bends exerting ‘push’ forces.

 Buccal + lingualAvailable on upper incisorsThey produce LRT + incisor retractionThreshold for placement is 3 degrees LRT + anterior retraction1 degree/aligner +0.25mm retractionFig. 10.23 Activation exerts forces translated to crown or root.

Pressure Points

As previously stated, they can be placed in combination with attachments, for example, to promote teeth rotation or intrusion.

Fig. 10.24 Effect of pressure point on the tooth.

Precision Ramps

These are usually dynamic, changing on every aligner, adapting to tooth movement, and constitute a differential aspect to braces, which can only change when the practitioner has the patient in office.

This is especially useful for precision bite ramps which, in contrast to fixed turbo bites help create only the required tooth disocclusion, being more comfortable for the patient’s TMJ and, as they ‘disappear’ whenever the patient removes the aligner to eat, improve their quality of life.

Fig. 10.25 Precision Ramps are much comfortable for the patient than conventional bite ramps.

Precision Wings

This is the latest innovation from Align Technology on SmartForces applied to the aligners, developed for Mandibular Advancement Features. They help the patient by advancing the mandible on a preset basis, which is now the gold standard whenever mandibular hypoplasia is found on young, growing patients.

Fig. 10.26 Clinical view of Precision Wings in a growing patient.

11 Clinical Preferences

The software and the technician (CAD designer) will work on the ClinCheck based on your clinical preferences. They can be modified when desired or for a specific patient. However, it is important to dedicate time to specify what expectations are for each treatment as this will help save time and produce more accurate results in the years to come.

Fig. 11.1 Dedicate time to setting up clinical preferences.

Treatment software will act automatically based on ‘Clinical Preferences’ to create ClinCheck Treatment Plans. However, every time the clinician submits a new patient they can, if needed, modify the clinical preferences exclusively for this patient.

12 Attachments Bonding and Interproximal Reduction
12.1 Bonding Attachments Protocol

The following Align Technology recommendations are suggested for a bonding attachments protocol, as summarized below and in Fig. 12.1.

Fig. 12.1 Have materials and equipment ready before any appointment.

 Check the adjustment of the attachment template

 Isolate with Nola dry field cheek retractor and prepare teeth: apply etching for 30 s, wash the surface carefully and then dry until the surface of the teeth become completely white.

 Use the bond on the surface of the teeth and cure it following manufacturer’s instructions.

 Apply the composite roughly in the attachment template. Clinician must use one of the composites recommended by Align Technology to prevent erosion of the attachment or debonding. SmartForces are only guaranteed with certain composites, as attachments might change their shape or surface easily if made with different brands from those tested (refer to the Invisalign Doctor Site to check suggested composite brands).

 Place the template in the mouth and apply pressure while curing the attachments.

 Remove template and remove excess composite with a bur.

 Test first aligner fit. The active bevel of the attachment must be in contact with the aligner.

Repeat the same process in the other arch.

Show the patient how to insert and remove the first aligner.

Fig. 12.2 (a) Place composite on template and (b) ensure there is no composite excess. (c) Bonding is best performed by two operators and (d) start from distal to mesial to avoid unexpected light‐curing.

Following Align Technology’s instructions on composites is strongly advised, as they have been previously tested, and results optimised, which cannot be ensured when using other brands.¹

12.2 Interproximal Reduction Procedure

Interproximal reduction (IPR) is the term usually applied to the Invisalign technique for stripping. This is a clinical procedure characterized by the interproximal enamel reduction of the teeth.

When applied to orthodontics, the space created is used for tooth alignment in cases of crowding² and the camouflage of class II/III malocclusions with an overjet excess/lack,³ as well as improving dental aesthetics by teeth recontouring.⁴

It is important to develop a good technique as enamel irregularities/scratches, resulting from an inadequate technique could increase the susceptibility of these teeth to the accumulation of plaque. That said, it should be stressed that both clinical teams from Craig and Sheridan⁵ and Sheridan and Ledoux⁶ concluded that posterior teeth whose interproximal enamel were stripped were not more susceptible to decay or periodontal disease, so it can be considered a safe and convenient procedure.

Fig. 12.3 A metal interproximal reduction strip is the most common type used.

Any IPR should be performed upon the practitioner’s criteria, usually using any of the most common techniques:

 Manual diamond stripParticularly effective for <0.2 mm IPR, mostly on anterior teethStart with the thinnest stripPatient’s gums should be protected with any retraction technique

 Slow speed diamond diskFirst break tight contacts using diamond stripsTo isolate, use interproximal wedges to loosen contactsPatient’s soft tissues can be protected using a dental mirror

 High speed burSuggested for 0.5 mm IPRTo isolate, use interproximal wedges to loosen contactsBe careful around cervical regions to avoid ledgesUse water spray to reduce clogging and overheating

Fig. 12.4 A high‐speed bur interproximal reduction (IPR) is suggested for 0. 5mm IPR, using both interproximal bur (a) and (b) edge rounding one.

 Oscillating techniqueSingle/double sided disks used in conjunction with oscillating hand pieces for enamel reductionStart with the thinnest diskUse water spray

Suggested IPR Protocol

Anterior IPR:

 <0.4 mm: oscillating technique

 >0.4 mm: diamond disk + oscillating technique

Posterior IPR:

 <0.4 mm: oscillating technique

 >0.4 mm: diamond bur + oscillating technique

Fig. 12.5 Interproximal reduction and attachments removal bur set is ideal for an Invisalign practice.

Suggested IPR Procedure

 Check space between teeth to decide if IPR is required

 Check that the clinical situation is equal to the ClinCheck

 If the space is less than 0.4 mm, protect soft tissue with wet jet. Use 0.15 mm metal strip (both sides) to break the contact point. After breaking the contact point with this strip, use the oscillating technique from thinner to thickest until the desired measurement is achieved.

 If the IPR is more than 0.4 mm, rotatory instruments are necessary:Use drill with a high‐speed bur for posterior teethContra‐angle with diamond disk for anterior teeth, while always protecting the soft tissue

 Measure with gauges. Do not use pressure to insert the gauge. After 3 minutes, check it again as the resilience of the periodontal tissue can tend to close this space again.

 Polish and verify: polish with a polishing strip, apply fluoride varnish to prevent sensibility and note down in the patient file the amount of IPR done.

In our clinical template we register:

 IPR, in what stage of treatment this has to be done and between which teeth

 When we have to begin using elastics

 If we need to use any extra auxiliary techniques and in what stages

 If any attachment appears or disappear during the treatment

 Note potential problem teeth (the chief complaint of the patient and the black movement of the ClinCheck)

 The number of aligner we are on, and the next appointment with us

Fig. 12.6 Interproximal reduction has to be carefully planned and performed.

Notes

1 1 Barreda GJ, Dzierewianko EA, Muñoz KA, Piccoli GI. Surface wear of resin composites used for Invisalign® attachments. Acta Odontol Latinoam. 2017;30(2):90–95.

2 2 Betteridge MA. The effects of interdental stripping on the labial segments. Br J Orthod. 1981;8:193–7.

3 3 Vanarsdall RL, Jr. Periodontal‐orthodontic relationships. In: Graber TM, Vanarsdall RL JR, eds. Orthodontics: Current Principles and Techniques. 2000: pp. 801–38.

4 4 Zachrisson BU. Zachrisson on excellence finishing. Part I. J Clin Orthod 1986;20:460–82.

5 5 Craig G, Sheridan JJ. Susceptibility to caries and periodontal disease after posterior air‐rotor stripping. J Clin Orthod. 1990;24:84–5.

6 6 Sheridan JJ, Ledoux PM. Air rotor stripping and proximal sealants: an SEM evaluation. J Clin Orthod. 1989;23:790–4.

13 Digital Workflow

With any orthodontic technique, as with clear aligners, records routinely include study casts, intraoral and extraoral photographs, and panoramic and lateral cephalometric radiographs.

Additional diagnostic records may include a 3D cone beam computed tomography (CBCT) scan, periapical radiographs and any other diagnostic records necessary to begin the case.

One of the main advantages with clear aligners is that the whole procedure can be performed digitally, tracking every single movement and it is possible to ‘time lapse’ it.

13.1 Records
13.1.1 Photographs
Extraoral

Extraoral pictures should be taken with the following parameters on your camera:

 Manual mode

 F5.6

 1/125

 ISO 100

 Flash ¼ (ring flash is strongly adviced)

Fig. 13.1 Frontal, smile and lateral photographs.

A plain white background is recommended to avoid distortion on the images.

Intraoral

Lateral pictures must be exactly at 90 degrees: if lateral photos with any other angulation are sent, it will not be possible to check if the technician has set the occlusion for the real patient situation. For this, note that ‘teeth’ will be set up by the system with the pictures, so a poor quality picture might lead to a ‘false’ initial occlusion and, if this was not identified from the very beginning, it would lead to a ‘false’ or inappropriate treatment plan.

Fig. 13.2 90 degrees pictures are mandatory both in right (a) and left (b) intraoral views.

It is important to send an overjet photograph. In the intraoral frontal view, it is also possible to check the upper and lower midlines.

Fig. 13.3 Intraoral frontal (a) and overjet (b) pictures will help create a good treatment plan.

Occlusal photographs must be sent with articulating paper marks to assist the technician in setting up the initial occlusion.

Fig. 13.4 Blue or red ink on both upper (a) and lower (b) occlusal pictures will help setting initial occlusion.

13.1.2 Impressions: PVS vs Scan
PVS Impressions

Flexitime or Aquasil Ultra are the materials recommended for PVS impressions. It is important also not to use latex gloves to mix the PVS material, as they might interfere with its properties, and to follow the manufacturers’ instructions in regards to the working time of the product.

Choose the size of the tray carefully: in case of doubt, choose a bigger one and check that the third molars are included in the tray.

The impression has to be made in two stages: first the heavy material and second the light material.

Fig. 13.5 Polyvinyl siloxane (PVS) material placement.

Procedure:

 Mix the PVS material with vinyl gloves (do not use latex)

 Place a small amount of PVS material in the tray’s posterior zone

 Insert the tray and press slightly in the molar zone, use a smooth movement

Fig. 13.6 Inserting tray with polyvinyl siloxane (PVS) material into the patient’s mouth.

 Remove the tray immediately and exert pressure on the PVS material to open space for the light PVS silicon.

 Fill the tray with light silicon.

 Insert the tray into the mouth, it must be inserted from back to front in the upper arch and from front to back in the lower arch. Do it slowly to allow air to scape.

 Maintain the tray with no movement until the setting time is over.

A perfect impression is one in which the heavy PVS cannot or can only just be seen, and where we can visualize all the teeth, including the distal part of the second molars; 1–2 mm of gum should also be observed.

As a result of Align’s efforts and investment in research and development, digital detailing is now available to us, which is something that is not available with impressions for lingual appliances, for example, but nevertheless it is still essential to take a really good impression in order to achieve a great digital model.

Fig. 13.7 Upper (left) and lower (right) impressions.

Source: Images from Align Technology database.

Shipping boxes on the IDS Webstore, which will be delivered free of charge to the practice will need to be ordered to send PVS impressions. The impressions and patient prescription are placed in these boxes and sent to Invisalign, and instructions for this are provided the inside the boxes.

iTero Scan

The iTero Element 2 Intraoral Scanner is designed to fit in practice even better than before. Whether a general practitioner or orthodontist, the iTero Element is designed to deliver speed, reliability, intuitive operations and outstanding visualization capabilities that include:

 Next‐generation processor giving reduced scan processing and a faster start‐up time (can perform a full arch scan in as little as 60 seconds)

 Uninterrupted scanning: long‐lasting, rechargeable battery for easy mobility from surgery to surgery without plugging in or rebooting

 Stunning colour imaging: enhanced colour offers a more thorough look at the patient’s oral health

 High‐definition visuals: slim, 21.5‐inch monitor with 16:9 widescreen viewing format and improved resolution for highly detailed images

 Ergonomic wand placement: designed with a centre‐mounted wand cradle for easy ergonomics during scanning

 Smarter scanning: improved wand touchpad is as intuitive as gesturing on a smartphone: the touchpad can be used to switch between scanning segments or rotate the model on screen

Fig. 13.8 iTero scanner has several advantages, such as the Outcome Simulator

X‐rays

It is recommended that, as a minimum, both panoramic and lateral radiographs are submitted.

Fig. 13.9 Lateral and panoramic X‐rays.

13.2 Creating a New Patient Record

To create a new patient record, the facial and intraoral photographs and the X‐rays need to be uploaded. This, together with the patient data: name, surname, date of birth will create a unique profile on the Invisalign Practitioner Site.

Submitting a Prescription Form

 Create a patient

 Take patient's records

 Complete prescription form

 Package records: photos and iTero scan or PVS impression

Prescription Form

From this moment on, the process is entirely digital, as previously stated, this process can be 100% fully digital if a iTero scanner is used instead of PVS impressions.

After adding a new patient, select between the different treatments plans available according to the patient profile, choosing between:

 Adult (20 years or older)

 Teenager (13 to 19 years)

 Growing (6 to 12 years)

Next, select a product type:

 Aligners, for active treatment

 Retainers, for retention phase

 ‘Vivera retainers’ would only be selected at the end of the treatment, but at the start ‘Invisalign Clear Aligners’ will always be selected, which provides us with the following treatment options:

 Comprehensive, for a complex malocclusion

 ‘Lite’, for a simple treatment

 Express, for a relapse or really simple treatment

Finally, the prescription form needs to be filled in step by step depending on the malocclusion of the patient. How to fill in the prescription form is explained for every space plane at the beginning of each chapter.