17 Invisalign® - As Many Answers As Questions - Pocket Dentistry

13/12/2017 17 Invisalign®: as Many Answers as Questions | Pocket Dentistry
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17 Invisalign®: as Many Answers as Questions
17
Invisalign®: as Many Answers as Questions
RainerReginald Miethke
Is Invisalign® new?
How does Invisalign work?
What are the pretreatment considerations?
How does the Invisalign System differ from conventional orthodontics?
What characterizes patients seeking Invisalign treatment?
What is the most favourable approach to resolving crowding in Invisalign patients?
How can the alternatives to IER be evaluated?
What are the problems related to resolution of crowding?
When are extractions indicated?
Does an Invisalign treatment plan differ from a regular orthodontic treatment plan?
How does one take an adequate impression for the Invisalign System?
What is required to be evaluated in ClinCheck®?
What material are aligners made of?
What are aligner attachments?
How are attachments fabricated on the teeth?
What has to be controlled after insertion of aligners?
What are the consequences of good or poor aligner fit?
What if an aligner is lost?
What can be done if a severe discrepancy between ClinCheck® and the clinical situation becomes evident during treatment?
What can be done if a slight discrepancy between ClinCheck® and the clinical situation becomes evident at the end of treatment?
How can complications during treatment with the Invisalign System be avoided?
References
Is Invisalign® New?
https://pocketdentistry.com/17-invisalign-as-many-answers-as-questions/ 1/15
Yes and no! As early as in 1945, Kesling wrote: ‘Major tooth movements could be accomplished with a series of Positioners by changing the teeth on the setup
slightly as treatment progresses.’ From 1971 onwards, several publications on clear appliances appeared. These appliances were mainly used as retainers
because, as active appliances, they lacked precision and required too much work to move teeth into the desired positions (Ponitz 1971; McNamara et al. 1985;
Sheridan et al. 1993; Rinchuse and Rinchuse 1997).
With the computeraided design/computeraided manufacture (CAD/CAM)based Invisalign System introduced in 1997, the idea of moving teeth with clear
plastic appliances took a new turn.
How Does Invisalign Work?
The present text reflects the state of the art in technology and therapeutic possibilities at the time of writing (2006). Align Technology is continuously developing
novel methods to improve the process. Each treatment is based on a complete set of records including extra and intraoral photographs, full Xray status, vinyl
polysiloxane impressions of the dental arches including the alveolar processes and an exact bite registration.
The impressions are scanned by a computed tomography (CT) scanner while rotating in front of an amorphous silicon Xray sensor. From the database a set of
virtual models is generated. The precision of the scanning process is around 100 µm (Lee et al. 2002). Eventual artefacts are corrected by a process of tooth
shaping based on the operator’s knowledge of tooth anatomy and the patient’s photographs.
The occlusion is established based on the bite registration supplemented by the photographs, and a software program for collision control. In addition, the
gingival sulcus is marked and a virtual gingiva is draped over the alveolar processes. This serves to define the margin of the aligners during manufacturing and
to allow a more realistic visual presentation (Fig. 17.1). Proprietary design software (Treat) subsequently enables the operator to separate the crowns of all
teeth from each other (Beers et al. 2003).
Fig. 17.1 Virtual models of a patient with bimaxillary crowding that was corrected by extraction of all four 2nd premolars. Since the patient was an airline
attendant she refused treatment with fixed appliances and was treated with the Invisalign System only; compare with Fig. 17.6.
Every individual tooth is checked for scanning artefacts by comparing it with the existing intraoral photographs, considering normal tooth anatomy. This process
is called ‘tooth shaping’. In a subsequent operation termed ‘staging’, the software technician defines specific landmarks on the enamel surface to construct
reference lines, e.g. the facial crown axis. The technician will then rearrange all the teeth according to the treatment plan submitted by the orthodontist and
determine the sequence by which the individual teeth should be moved (Miller and Derakhshan 2002).
The two basic approaches are:
Simultaneous movement of a group of teeth, called Xpattern due to its graphic representation
Sequential movement of individual teeth as typically in a situation in which posterior teeth are distalized and where the movement of the second molars is
followed by the first molars, the second premolars etc., named Ypattern due to its graphic representation.
During all the movements, occlusal or interproximal interferences should be avoided. Within each stage, the movement can be variously programmed between
0.10 and 0.33 mm. Depending on the complexity of the malocclusion, the sequence and the velocity of movements, the number of necessary aligners required
can reach 70 or even more.
After being prepared in the Align laboratory, the virtual model is sent to the clinician, who can assess the treatment with an animation program called
‘ClinCheck®’. If both clinician and the patient find the simulation satisfactory, the clinician clicks ‘accept’ to let the company know. Patients generally appreciate
active participation in their therapy.
Once the treatment goal has been accepted, Align Technology will transfer the virtual model into a physical resin model using a stereolithographic method (Fig.
17.2). During stereolithography, a laser cures liquid polymer by photoactivation. The cleaned and refined acrylic models will then be loaded into an automat that
heats, pressure forms and laser marks all the raw aligners, which are then transferred to a cutting automat. This machine will trim aligners after which they all
are separated from the stereolithographic model, polished, disinfected, packaged and finally shipped to the respective doctor (Wong 2002; Kuo and Miller 2003)
(Fig. 17.2).
Fig. 17.2 (1) Refined stereolithographically produced resin model of a specific treatment stage, which serves as a working cast to produce the respective
aligner. All of the discernible resin layers are about 0.15 mm thick. (2) Finished aligner made of clear polyurethane with occlusal labelling (patient number,
upper/lower jaw, and aligner stage number).
What Are the PreTreatment Considerations?
Patients frequently arrive in an orthodontic office with the request to be treated with an invisible appliance. In this situation, they can be offered lingual
appliances or Invisalign therapy. Principally, Invisalign therapy is orthodontics with just a different appliance system. Therefore, consultation, record collection,
documentation of existing problems and treatment goals should follow standard orthodontic operational procedures. Align Technology requests the following
records:
Photographs (extraoral: frontal (at rest/smiling) and profile; intraoral: frontal, left/right lateral, maxillary/mandibular occlusal)
Radiographs (panoramic or periapical, optional: cephalogram)
Vinyl polysiloxane impressions (maxillary, mandibular) plus bite registration
Completed treatment form.
Other than the impressions, everything else can be submitted as highresolution records via email.
How Does the Invisalign System Differ from Conventional Orthodontics?
One of the biggest differences is that Invisalign treatment has to be planned from the first to the last movement in all possible details. In contrast to most other
treatment modalities, the sequence, the direction and the amount of any tooth movement can only be changed by a midcourse correction (see ‘What can be
done if during treatment a severe discrepancy between ClinCheck® and the clinical situation becomes evident?’), which implies additional costs and a delay of
progress. This may seem to be disadvantageous, but can also be considered a challenge. The visualization of the anticipated outcome is helpful. Such
visualization can be accomplished by using occlusograms (Melsen 2012), a standard study model setup, or, as in the case of Invisalign, by a virtual setup.
What Characterizes Patients Seeking Invisalign Treatment?
The chief complaint of patients choosing treatment with the Invisalign System includes crowding or spacing, flaring, supra or infraerupted teeth (Vlaskalic and
Boyd 2001; Meier et al. 2003) (Fig. 17.3). Spacing and flaring can generally be resolved without problems and intrusion of overerupted teeth is not a problem
as long as the aligners are not dislodged occlusally from the anchor teeth. Retention can be easily improved by adding socalled attachments to the
neighbouring teeth. Since extrusion of infraerupted teeth cannot be predictably accomplished with the Invisalign System alone it may require additional
measures (see ‘How can complications during treatment with the Invisalign System be avoided?’). Crowding can be treated by: interproximal enamel reduction
(IER), expansion of the dental arch, moving posterior teeth distally or with extractions.
Fig. 17.3 Frequency of occurrence of various malocclusion features in patients enquiring about Invisalign therapy
(data source: Meier et al. 2003).
What Is the Most Favourable Approach to Resolving Crowding in Invisalign Patients?
Crowding is most frequently resolved by IER, primarily because many Invisalign patients had orthodontic treatment previously, specially if the crowding is only
moderate (Miethke and JostBrinkmann 2006) (Fig. 17.4). Extractions would create excessive space and IER is effective in avoiding open gingival embrasures
(Atherton 1970; de Harfin 2000; Kurth and Kokich 2001; Zachrisson 2004), a problem which increases with age especially in patients with advanced periodontal
diseases. IER is also the treatment of choice in the case of a tooth size discrepancy between the two dental arches.
Fig. 17.4 (1) Patient in whom interproximal enamel reduction (IER) was performed before treatment to alleviate crowding; only very limited tooth movements will
be required and no excessive space will remain if the procedure is carried out with due care. (2) Patient with a Class II Division 1 malocclusion in whom distal
movement of the maxillary posterior teeth was indicated. To overcome the reactive protrusive force on the maxillary anterior teeth the patient wore Class II
elastics, which had the positive side effect of facilitating correction of the distal occlusion.
Fundamentally, IER is an imitation of a physiological process because extensive attrition was a feature of the natural human dentition before civilization led to
consumption of increasingly soft food.
How Can the Alternatives to IER Be Evaluated?
An alternative to IER is transverse expansion of the dental arch. However, only 3–4 mm space can be generated and expansion may be unstable (Chenin et al.
2003). This applies especially to the mandible where crowding is most frequently seen. Still, expansion may be indicated as a wider dental arch avoids the
appearance of dark buccal corridors while smiling (Sarver 2001; Womack et al. 2002; Sarver and Ackerman 2003, Moore et al. 2005).
Another alternative to IER would be to move posterior teeth distally to create space for the anterior segment. This approach too is limited to 3–4 mm space gain.
Distal movements can be enhanced by separating the posterior teeth before the vinyl polysiloxane impressions are taken. The preceding separation guarantees
a much better fit of the aligners, especially in the interproximal spaces. The fit can be enhanced further by applying socalled attachments on the teeth to be
moved distally. Since the laws of equilibrium cannot be overlooked, any retrusion of posterior teeth will produce some reciprocal protrusion of the anterior
segments. Therefore, it is advisable to use appropriate interarch elastics simultaneously (Fig. 17.4); also the orthodontist should take care that all distal
movements are programmed sequentially.
Besides the abovementioned limitation, a problem related to lengthening of the dental arch is that it is time consuming to gain the necessary space before the
crowding of the anterior segment can be alleviated. This may adversely impact on the patient’s cooperation.
Since extraction therapy with Invisalign treatment is still controversial, it will be dealt with in a separate section below.
What Are the Problems Related to Resolution of Crowding?
The malocclusion features related to crowding are labiolingual malpositions, rotations and deviations from normal angulation. Positional irregularities do not
create any difficulties as correction usually only requires tipping or small bodily movements.
While rotations of relatively flat teeth such as incisors do not pose a problem, rotation of relatively cylindrical teeth as canines and premolars cannot generally
be resolved with standard aligners. Any aligner which is programmed to derotate one of those teeth by no more than 2° will only contact the tooth surface in a
few spots and most likely deliver more vertical than rotational forces (Fig. 17.5). Rotation of molars is also a problem due to resistance by the root surface to
such a movement.
Fig. 17.5 (1) Graphic representation of the fit between tooth and aligner. If the tooth is rotated 15° anticlockwise the aligner (white mesh) contacts the enamel
only in the areas indicated by the red arrows, whereas is stands away from the remaining tooth surfaces. Please notice that the average rotation programmed
by Align is between 2–5°, which results into a mean 0.2 mm movement of the distal/mesial proximal surface depending on the mesiodistal width of the
respective tooth. (2) The result of the imperfect fit is a premature contact which could eventually lead to a completely different movement (intrusion) than
originally intended (rotation); notice the extensive void areas between the aligner (white mesh) and the tooth.
Correction of angulations may also be a problem. It is easy to envision that it is difficult for an aligner with its smooth surface to move a tooth with a likewise
smooth surface and hardly any natural undercuts. This problem can be overcome by bonding rectangular attachments to the respective teeth.
When Are Extractions Indicated?
Since basic orthodontic principles also apply to Invisalign, indications for extractions are no different for these treatments. When extractions of premolars (Fig.
17.6) are indicated, although such extraction spaces could be closed with aligners, paralleling the roots of all teeth would be difficult, especially in a mandibular
arch with a deep curve of Spee.
Fig. 17.6 Same patient as depicted in Figure 17.1; occlusal and lateral views before (1–4) and after treatment (5–8) involving extraction of maxillary first and
mandibular second premolars; 46 aligners were used in the maxilla and 49 in the mandible. The result is satisfactory apart from some mesial tipping of the
molars. This may be improved during case refinement, which would require additional aligners manufactured using either original or new impressions.
Extraction of mandibular incisors is only indicated if the lack of space exceeds 5.0 mm. It may be difficult to parallel the roots, and a midline discrepancy
between the two dental arches will remain (Fig. 17.6). The main objection to extractions, especially in adult patients with a certain degree of gingival recession,
is that removal of teeth will almost inevitably lead to open gingival embrasures (Fig. 17.6). Extractions should be considered as the last choice for resolution of
crowding during therapy with the Invisalign System, and such treatment may require the use of appropriate attachments and even specific adjuncts (Miller et al.
2002).
Fig. 17.6 (9,10) Patient in whom the mandibular right central incisor and the maxillary first premolars were extracted because of severe crowding. Note that
already before treatment the periodontal condition of the mandibular left central and right lateral incisors was compromised. At the end of the first phase of
Invisalign treatment and before case refinement the periodontal situation has deteriorated although a free gingival graft was performed. (11,12) Patient in whom
the mandibular right central incisor was extracted because of the existing crowding and a rather favourable angulation of the remaining front teeth. The result
was to the patient’s satisfaction; however, the reduction of vertical overbite could be criticized and even more so the open gingival embrasures. These were
already existing but not visible at the beginning of treatment as the interproximal spaces were filled with calculus.
Does an Invisalign Treatment Plan Differ from a Regular Orthodontic Treatment Plan?
The answer to some degree depends on the school of thought to which the orthodontist belongs. Frequently, a standard treatment plan for removable or/and
fixed appliances only comprises a general treatment outline, with no specification of any individual mechanical approach.
In the case of the Invisalign System, it is advisable to be as specific as possible. This is to some degree guaranteed by the fact that the orthodontist is expected
to go through a six pages long treatment planning form which will not allow moving to the next page before every aspect of the current page has been
sufficiently covered. Several pages have spaces for additional comments. The orthodontist can define:
The order in which the treatment should be started (maxilla versus mandible).
The sequence in which the individual teeth have to be moved.
How many teeth are to be moved at a given time (active versus passive units).
The movements in millimetres (0.10–0.33 mm) or in degrees.
The type of movement (tipping versus bodily movement).
Shape/size/number/position of attachments
Inclusion of overcorrections required (in millimeters and degrees).
As far as overcorrections are concerned, the orthodontist has to make sure whether they are possible or will lead to occlusal interferences and thus instability.
How Does One Take an Adequate Impression for the Invisalign System?
The only impression compound acceptable at this point is vinyl polysiloxane, socalled asilicone. The main reasons are that this is the only material that
reproduces details with enough precision (<3 µm) and adequate longterm dimensional stability (∼3 months). The impression is taken in a twostep procedure
following the guidelines below:
All impressions must be taken with perforated plastic trays supplied by Align Technology (Fig. 17.7). They come in different sizes and can be customized by
trimming them with a bur, by reshaping them under heat or extending them with the heavybodied component of the impression material.
Severe undercuts, for instance bridges, must be blocked out with wax.
Any material must be handled according to the manufacturer’s specification; components of different product families should not to be mixed with each other.
Contact between impression material and latex (gloves) should be avoided.
The first, heavybodied material impression should include all the teeth with all their surfaces and the surrounding alveolar processes.
Space for the lightbodied material is created by blocking out the teeth and the alveolar process of the study model with a sheet of wax approximately 2 mm
thick before the impression is taken on the cast (Fig. 17.7).
Still, the heavybodied impression should be checked in order to verify whether there is enough space for the lightbodied material, i.e. the heavybodied
material is not in contact with any teeth or parts of the alveolar process; if this is the case the heavybodied material must be trimmed away.
Fig. 17.7 (1) Perforated plastic impressions trays, which can be scanned without producing unwanted side effects. These trays come in different sizes and can
be customized by trimming, heating or adding extensions of heavy body impression material. (2) Study model with an approximately 2 mm thick layer of wax
over the dental arch. This guarantees that there is sufficient space for the lightbodied material which will replicate all details of the teeth and the surrounding
alveolus. (3) Impression with no voids/bubbles that replicates all teeth and their adjacent alveolar process in great detail. The heavy body material shows
through only slightly in those areas that are irrelevant for treatment planning and aligner production.
All of the abovelisted procedures can be performed on the patient’s study model to shorten chair time.
Before the tray with the light bodied material is inserted in the mouth all teeth have to be thoroughly dried.
The lightbodied material is injected bubblefree into the impression tray and some extra material is dispensed over the teeth, especially on the distal surfaces
of the terminal teeth.
After the lightbodied material has set, the impression should be removed with a quick snap because slow removal would lead to unacceptable distortion.
The subsequent inspection should reveal no voids/bubbles (Fig. 17.7). A perfect impression will replicate all tooth surfaces including the interproximal spaces
and the adjacent alveolar process in all details. The heavybodied material should not show or only slightly show through the lightbodied component to avoid
distortions.
Finally, a bite registration has to be taken preferably also with a fastsetting vinyl polysiloxane.
The main disadvantage of asilicone impressions is that they are costly – at least in comparison to standard alginate impressions.
What Is Required to Be Evaluated in ClinCheck®?
About 1–2 weeks after all necessary records are submitted, the orthodontist will be informed, on his personal VIP (Virtual Invisalign Practice) site, that the
ClinCheck® is ready for inspection and possible acceptance. The first step of the evaluation should ensure that the morphology of all teeth and the occlusion
reflect the correct intraoral situation. An improper occlusion of the virtual model can for instance indicate an impression failure (Fig. 17.8)).
Fig. 17.8 (1) Frontal view of a patient with an open bite before treatment with the Invisalign System. (2) Frontal view of the respective ClinCheck®. Note
difference in severity of open bite, which is due to a deviation in the bite setting, but also may be due to an incorrect impression technique. (3) Reproximation
chart of a patient in whom IER of 0.7–0.9 mm was suggested possibly due to the presence of interferences. According to Shillingburg and Grace (1973) the
enamel thickness between both maxillary central incisors, between the central and lateral incisors and between lateral incisors and canines allows on average
only 0.6 mm IER. Only with an orthoradial periapical radiograph can the individual enamel thickness be quantified to permit for more IER. In this patient the
ClinCheck® was rejected and reformulated. (4) Vertically and horizontally placed ellipsoid and rectangular attachments as they appear in a patient’s
ClinCheck®. (5) The same attachments as they appear in the patient’s mouth; the horizontal attachment on tooth 11 was requested for the intrusion of this
tooth. (6) To prepare the relevant tooth surfaces, etching gel is applied in the same shape as the configuration of the subsequent attachments and the loaded
attachment template is carefully placed onto the dentition after the prerequisite procedures are concluded. (7) Each attachment is adapted by firmly pressing the
loaded tray with a ball end burnisher against the respective tooth before light curing is initiated. (8) After polymerization and removal of the thin shell template,
all excess composite material is trimmed off with finishing burs and finally with polishing discs until all attachments have a wellfined configuration. (9) Situation
immediately after insertion of the first aligner in the maxilla. The fit is as good as it can be expected.
The orthodontist should then compare his/her treatment plan including any annotated remarks with the virtual treatment plan. There may be differences either
because the IT technician overlooked some information or realized during the virtual setup that interferences, which could impede with the progress of
treatment, had occurred. If the treatment plan has to be modified, the ClinCheck® is rejected. It is then altered until it is acceptable to the orthodontist and
eventually the patient. Acceptance will be followed by production of all the aligners and a subsequent invoice.
Every ClinCheck® is supplemented by a reproximation chart, an attachment form and a sheet with general comments, which likewise ought to be checked. The
reproximation chart will indicate how much enamel needs to be removed at which specific stage according to interferences detected by the software (Fig. 17.8).
The attachment form states which attachments need to be bonded in particular treatment phases. The overall comment sheet contains general information from
the Align IT technician about attachments, necessary IER, number of aligners, and possible overcorrections or warnings of potential complications.
What Material Are Aligners Made Of?
Aligners are made of 0.75 mm thick foils composed of polyurethane with methylene diphenyl diisocyanate and 1.6 hexanediol (EX 40). This material has
sufficient viscoelasticity to allow some elastic deformation. The actual force system has as yet not been evaluated (Boyd and Vlaskalic 2001), but seems to be
within physiological range on the basis of the following three observations:
The amount (in mm) of every tooth movement is well defined and can be tailored to the assessed periodontal condition of each individual patient.
Aligners are not fixed appliances and thus they can be taken out of the mouth to periodically allow the periodontium to recover.
Final radiographs do not reveal excessive root resorption.
Theoretically, aligners contact all tooth surfaces and thus they should allow all types of tooth movement, even root movements and rotations. However, because
the elasticity of the material is limited, premature contacts can occur between the aligner and the tooth to be moved. The consequence could be an unwanted
movement, as for instance intrusion. Therefore, such socalled less predictable tooth movements should at best be dealt with separately (see ‘How can
complications during treatment with the Invisalign System be avoided?’).
As mentioned before, the efficacy of any aligner depends on a firm fit to every tooth surface. Since this is difficult to accomplish in flat teeth with a minimum of
undercuts, e.g. mandibular incisors, or when there is an extrusive counter force that acts to dislodge the aligner during attempts to intrude teeth, the retention of
the appliance should be improved by application of socalled attachments.
What Are Aligner Attachments?
Aligner attachments are small custommade composite additions, which are bonded onto selected teeth. There are two types of attachments: ellipsoid and
rectangular. Ellipsoid attachments are 3.00 mm long, 2.00 mm wide and 0.75 mm high, rectangular attachments are 2.00 mm wide, 0.50 or 1.00 mm high and
0.30, 0.40 or 0.50 mm long (Fig. 17.8). Both attachment types can be placed parallel to the long axis of the tooth or parallel to the occlusal plane. They can be
attached to the buccal as well as to the palatal tooth surfaces. As a norm, the orthodontist should decide where which type of attachment should be placed.
For novices, it might appear difficult to decide about all these aspects. However, decisionmaking can be facilitated by comparing Invisalign treatment with fixed
appliances therapy where it has to be decided whether a bracket on a specific tooth is needed. In general, appliance retention is enhanced significantly with the
addition of attachments. Too many attachments will, however, complicate aligner removal from the acrylic model during production as well as from the dentition
later during treatment. Still, sufficient attachments should be included in the plan since they cannot be added later on. Not every virtual attachment has to be
fabricated in the patient’s mouth, at least not initially. Because of the system’s versatility, it is possible to bond a programmed attachment at any stage of
therapy.
The need for attachments is less for teeth with sufficient undercuts, for instance teeth with long crowns, whereas they are definitively needed in patients who
have short clinical crowns and shallow undercuts. If a doctor is uncertain regarding attachments he/she can talk to the Align customer agent who may suggest
useful attachments.
How Are Attachments Fabricated on the Teeth?
The actual fabrication is assisted by a socalled thin shell template, which is a 0.25 mm thick aligner with respective concavities. These are loaded with a strong
lightcuring microfilled composite, preferably one that comes in various tooth colour shades. The tooth surface has to be prepared as for a typical acid etch
bonding procedure. The loaded attachment template is carefully placed onto the teeth (Fig. 17.8); the tray is firmly adapted with e. g. a ball end burnisher (Fig.
17.8) and finally all attachments are light cured. After polymerization, the template is carefully removed and the excess composite material is ground off with an
appropriate finishing bur (Fig. 17.8). After this cleanup, the attachment should be well defined.
Attachment bonding is facilitated when it is done after the first aligner has been worn intensively for about 1 week (Fig. 17.8). Then, all teeth will be slightly

mobile, which enhances the adaptation of the bonding template. Further, the patient is by now sufficiently adept at handling his/her aligner effortlessly and so
the risk of damaging an attachment or an aligner is minimized.
If an attachment is lost or damaged during treatment, it can be refitted. This can be accomplished with either the current aligner or the respective part (tooth) of
the original thin shell template. If the respective area is cut out, the attachment can be bonded to a specific tooth. The same course of action should be followed
if an attachment was not fabricated initially but seems to be needed later on. In addition, if many attachments have to be placed, it might be practical to cut the
thin shell template into segments to facilitate the bonding.
What Has to Be Controlled After Insertion of Aligners?
Before the insertion, the aligners are briefly immersed into water to counteract their hydrophilic nature. Afterwards, the orthodontist will check whether the
aligner can be inserted and taken out with adequate force thus avoiding distortion or damage. In addition, the aligner fit is controlled and demonstrated to the
patient using a hand mirror. The fit is acceptable if all teeth are fully covered by the aligner material. Further, no gingival impingement should be noticeable.
Finally, all margins should be smooth and fit close to the alveolus (Miethke and Vogt 2005) (Fig. 17.9). In any case, the patient is given wax to protect against
sharp edges or roughness detected later on; chewing gum may be used instead of wax. Before leaving the office, the patient should be taught:
How to remove and insert the aligners with the same ease as the orthodontist,
How to clean the aligners thoroughly at least once a day, preferably with a brush with long bristles,
How often the aligners have to be worn. Principally, that is as close to 24 hours/day as possible, i.e. all the time except when brushing the teeth, eating and
drinking any fluids that might stain (for instance red wine) or sugarcontaining liquids.
Fig. 17.9 (1) Intraoral situation immediately after insertion of first aligner. Obviously, the aligner margins in certain areas are not as close to the alveolus as
should usually be the case. A possible explanation could be that the volume of the gingiva decreased, although this is unlikely. Another possibility could be
impression inaccuracy. In any case, the edges must be smoothened; subsequent aligners have to be checked for the same problem. (2) Clinical situation after
nine aligners. The intended distal movement and derotation of the maxillary right lateral incisor did not occur as indicated by the void between appliance and
tooth surface. It was planned to gain the necessary space for derotation by correcting the rotations of the posterior teeth on the right side. Since these
movements failed, the alignment of tooth 12 also fell short. (3) In this clinical situation, neither could tooth 42 be proclined nor could tooth 41 be derotated
because with the Invisalign System, teeth can only move in a straight line. The bend in the course of the dental floss indicates clearly that the path of movement
is impeded, i.e. IER should be performed.
The advantage of the appliance being removable may also be a disadvantage because patients may not follow the prescription (Boyd et al. 2000). To minimize
this problem patients must be motivated again and again (Nedwed and Miethke 2005) along with cautioning about the possible lengthening of wear of every
single aligner up to 4 weeks.
On an average, aligners are changed every 2 weeks (Owen 2001; Bollen et al. 2003; Clements et al. 2003). When the patient returns for his/her second visit
about 14 days later, the fit and the cleanness of the appliance are checked. At the same time, the patient is requested to give a report on his/her experiences
and any inconveniences in relation to the Invisalign treatment. On the patient’s ClinCheck® the doctor can see which tooth/teeth in which plane of space will be
moved with the second/third, etc. aligner (Fig. 17.9). Also, the reproximation chart, the attachment form and the comment sheet should be checked for any
necessary interventions.
The procedure described above should be followed at all subsequent appointments. The reproximation chart might recommend IER at a specific stage due to
an overlap of two adjacent teeth, as calculated by the software; however, this interference may only be virtual. Therefore, the orthodontist should verify a lack of
space intraorally first, because indiscriminate IER can lead to unwanted gaps between the teeth at the end of treatment. The safest way of finding out whether
enough space for tooth movement is available, is to take a piece of dental floss and push it between the two teeth that are possibly overlapping. If the thread
glides down smoothly and in a straight line without any bend, the path of movement is unimpeded, i.e. the intended movement can occur (Fig. 17.9).
What Are the Consequences of Good or Poor Aligner Fit?
The presence of saliva bubbles between the tooth and the inner aligner surface (Fig. 17.10) indicates an inadequate aligner fit. Other indications are: void
spaces predominantly occlusally/incisally and – after attachment bonding – discrepancies between these composite shapes and the respective aligner
concavities. Such incongruities become evident especially to the patient if the attachment is marked before the aligner is replaced (Fig. 17.10). In case of poor
aligner fit, the cause must be detected. Most likely, it will be lack of patient cooperation or lack of tooth movement. In the latter case, almost certainly it will be a
movement which is considered less predictable within the Invisalign System (Joffe 2003; Miller et al. 2003; Miethke and Vogt 2005). Examples of such
movements are:
Rotations of cylindrical teeth
Extrusions
Translations over larger distances e.g. after extractions of premolars
Pure root movements.
Fig. 17.10 (1) Most likely, the main cause for the poor fit of these aligners is that they are too short and do not cover the clinical crowns sufficiently. Therefore the
programmed movements did not occur. The two most plausible explanations for the improper fit of the aligners are an impression error or a miscalculation
during the virtual definition of the cementogingival junction. Retraction of the gingiva or reduction of its volume due to healing following inflammation is rather
unlikely in a 22yearold female patient with a good oral hygiene. (2) For illustrative purposes, the attachment on tooth 13 of this patient was painted red. (3) The
respective concavity in the aligner was coloured blue. After insertion of the aligner, the discrepancy is obvious.
The phrase ‘less predictable’ indicates that it is dubious that such movements can be generated. If a lack of space is the likely cause of improper aligner fit, IER
is performed and the aligner is worn for another week or even 2 more weeks. Extension of appliance wear is also prescribed if poor cooperation led to reduced
aligner fit. It should be kept in mind, however, that continued wear of a specific aligner is not the correct solution to this problem because the physical properties
of the material change as it ages (Schuster et al. 2004; Eliades and Bourauel 2005).
If after use of several aligners, some teeth seem to lag behind others, this should not be ignored. Three alternative actions may be taken: first, every previous
aligner should be tested in reversed sequence until the one that fits best is found. From there on, the treatment would restart with a respective lengthening of its
duration. A second alternative could be to choose a socalled midcourse correction, a procedure, which will be described in detail below. Midcourse correction
might include modified treatment goals. Thirdly, adjuncts such as buttons on the aligners for powerchains or elastics could be introduced to move the lagging
tooth until it is most perfectly aligned within the patient’s present aligner.
If at the second appointment, the first aligner fits well, the second one is handed out to the patient maybe together with the third one. Hence, the patient can
change aligners without visiting the doctor’s practice. If after 4–6 weeks, the third aligner is fitting satisfactorily, the fourth, fifth and sixth are delivered to the
patient. Though the patient will appreciate savings of time by not having to see the doctor for every aligner insertion, it is not advisable to deliver more than two
aligners for independent change. Leaving the patient with more than two aligners, may result in the treatment getting out of control even when the patient seems
to have a full understanding of the therapy.
What If an Aligner Is Lost?
The answer depends on how soon after the loss the patient sees his/her doctor and how long the aligner was worn up to this point. If the patient shows up soon
enough, there are two possibilities: one is to assume that the lost aligner had accomplished almost all programmed movements because the wearing time was
sufficient. In that case, the patient receives his/her next aligner, which might fit tighter than normally and should be worn a little longer than usual. The second
option is to order a replacement for the lost aligner from Align Technology. This is unproblematic because all necessary data exist in the patient’s Treat software.
Until the substitute aligner is delivered within approximately 2 weeks, the patient is put ‘on hold’, i.e. he/she receives an ad hoc made retainer, preferably of the
same make as the lost aligner, or he/she wears the previous aligner. To cover this possibility, it is mandatory to keep all used aligners, which is best guaranteed
if the orthodontist keeps them.
If a longer period has passed and the patient did not have the previous aligner at the time of loss, it can be assumed that a partial relapse has occurred. The
doctor should try to find the best fitting aligner out of all the aligners that the patient has worn in the past and then progress as described previously. In the
meantime, the lost aligner could be reordered or it could be attempted to ‘jump’ from the aligner used before the lost one to the one following it. Another
alternative would be to start a midcourse correction, which is dealt with in the next paragraph.
What Can Be Done If a Severe Discrepancy between ClinCheck® and the Clinical Situation Becomes Evident During Treatment?
In case of a discrepancy between ClinCheck® and the clinical situation, a socalled midcourse correction is indicated. Such a ‘reboot’ is similar to starting a new
patient. It means that all the abovelisted records must be taken again and submitted to Align Technology together with a new treatment plan. Most probably, the
course of treatment and/or its goals will need to be changed because there was a clear reason why the first approach failed. Overall, a midcourse correction
requires extra time, efforts, and costs. To limit the financial loss, Align Technology offers a type of insurance to cover a restart.
What Can Be Done If a Slight Discrepancy between ClinCheck® and the Clinical Situation Becomes Evident at the end of Treatment?
In this situation the socalled case refinement is indicated. Case refinement implies that even though all aligners were worn, not every one of the intended
movements has materialized to the patient’s and/or doctor’s satisfaction. In this case, generally new impressions have to be submitted, supplemented by
respective special instructions; current intraoral photographs would be advantageous. Case refinement might also be considered to counteract an apparent
relapse tendency. Under these circumstances, no new impressions are needed because the original ClinCheck® can be used to fabricate additional aligners to
accomplish the respective overcorrections.
How Can Complications During Treatment with the Invisalign System Be Avoided?
The three most common causes for complications are lack of space and cooperation as well as nonoccurrence of less predictable tooth movements. Space
problems are easy to resolve with IER. In contrast, lack of cooperation cannot always be foreseen and thus remains a possible risk. Finally, difficulties with less
predictable tooth movements can be anticipated and they should be dealt with while developing the treatment plan for a given patient. As rotations of cylindrical
teeth poses a problem, there are four possible options to overcome it. Derotations can be:
Accomplished before Invisalign treatment (Fig. 17.11),
Programmed for the first stages of Invisalign therapy,
Programmed for the last stages of Invisalign treatment (Fig. 17.11),
Dealt with after Invisalign therapy is finished (Fig. 17.11).
Fig. 17.11 (1–4) This patient was previously treated orthodontically with extraction of both first premolars on the left side. Her chief complaints were bimaxillary
crowding, large overjet and maxillary midline deviation. She refused any correction of the malocclusion features on the left side. Since derotation of tooth 33
was less predictable, it was decided to accomplish this before aligner treatment. Therefore, the patient received a custommade splint with two hooks (5). It
would have been preferable to place the hook next to tooth 42 on the lingual side because the labial position would lead to some buccal displacement. The
treatment was finished to the patient’s satisfaction (6–9). To assist derotation at the end of treatment, detailing pliers can be used to introduce pressure points
by deforming the aligner material (10). One arm of the pliers has a pointed tip of a different size while the other arm has a hole. When the arms are pressed
together, the semirigid material will be forced slightly into the hole, producing a concavity. This activation can assist in accomplishing movement not expressed
by the aligner alone. Careful activation requires slight heating of the pliers. (11,12) This patient’s chief complaint was bimaxillary crowding. (13) Uprighting and
rotating tooth 33 is to be considered a less predictable movement. (14) The situation after Invisalign treatment. At that time tooth 33 needed more uprighting,
some extrusion and minimal lingual tipping. To solve all these problems within a reasonable timeframe, a ceramic bracket was bonded to tooth 33 and a
customized splint inserted in which a tube in the region of tooth 36 was embedded. A cantilever extending from tooth 36 to tooth 33 was used to perform the
correction. The patient was supplied with some hemostats so she could ligate the cantilever into the bracket with an elastic. Thus, the appliance was removable
while this treatment phase was rather invisible at the same time. The treatment was finished to the patient’s satisfaction (15–17).
Derotation during the first stages of Invisalign treatment seems questionable because if it does not materialize, a midcourse correction becomes necessary,
which likely challenges the confidence and patience of the affected patient. If derotations are postponed to the final stages and are not accomplished, the
patient might develop the same negative reactions as described above.
Thus, it seems to be best to discuss such a problem with the patient before Invisalign treatment is initiated and to correct less predictable tooth movements
before Invisalign therapy. This could mean using a few (clear) brackets and cantilevers to achieve the necessary positional change. Another possibility could be
a combination of a clear plastic splint retainer with Class I elastics attached to any kind of adjuncts, such as buttons, cleats, etc. (Fig. 17.12) on respective teeth
(Vlaskalic and Boyd 2002; Boyd 2005).
In any case the orthodontist must draw on his/her creativity to deal with any movement that might not be generated by Invisalign therapy, thus satisfying the
patient’s expectations to be treated with an invisible appliance.
Fig. 17.12 Pretreatment study model of a patient with bimaxillary crowding, crossbite on the left side and between the teeth 12, 43; note the differences in the
level of the incisal edges of the maxillary central and lateral incisors (1). This difference increased significantly after correction of the crossbite by expansion of
the maxilla and correction of the bimaxillary crowding by protrusion of all front teeth (2). To resolve this problem predictably some clear buttons were applied on
the labial surfaces of the lateral incisors close to the gingiva. After imitation of the intended extrusion on a setup model an alignerlike splint was fabricated with
two pairs of hooks on the palatal side (3). Elastics facilitated a predictable extrusion with forces which could be adjusted freely by choosing different elastics.
Situation after the intended extrusion was completed (4).
References
Atherton JD (1970) The gingival response to orthodontic tooth movement. Am J Orthod 58, 179–186.
Beers AC, Choi W and Pavlovskaia E (2003) Computerassisted treatment planning and analysis. Orthod Craniofac Res 6 Suppl 1, 117–125.
Bollen AM, Huang G, King G, Hujoel P and Ma T (2003) Activation time and material stiffness of sequential removable orthodontic appliances. Part 1: Ability to
complete treatment. Am J Orthod Dentofacial Orthop 124, 496–501.
Boyd RL (2005) Surgicalorthodontic treatment of two skeletal Class III patients with Invisalign and fixed appliances. J Clin Orthod 39, 245–258.
Boyd R and Vlaskalic V (2001) Threedimensional diagnosis and orthodontic treatment of complex malocclusions with the Invisalign appliance. Sem Orthod 7,
274–293.
Boyd R, Miller RJ and Vlaskalic V (2000) The Invisalign system in adult orthodontics: Mild crowding and space closure cases. J Clin Orthod 34, 203–212.
Chenin DA, Trosien AH, Fong PF, Miller RA and Lee RS (2003) Orthodontic treatment with a series of removable appliances. J Am Dent Assoc 134, 1232–
1239.
Clements KM, Bollen AM, Huang G, King G, Hujoel P and Ma T (2003) Activation time and material stiffness of sequential removable orthodontic appliances.
Part 2: Dental improvements. Am J Orthod Dentofacial Orthop 124, 502–508.
de Harfin JF (2000) Interproximal stripping for the treatment of adult crowding. J Clin Orthod 34, 424–433.
Eliades T and Bourauel C (2005) Intraoral aging of orthodontic materials: the picture we miss and its clinical relevance. Am J Orthod Dentofacial Orthop 127,
403–412.
Joffe L (2003) Invisalign: early experiences. J Orthod 30, 348–352.
Kuo E and Miller RJ (2003) Automated custommanufacturing technology in orthodontics. Am J Orthod Dentofacial Orthop 123, 578–581.
Kurth JR and Kokich VG (2001) Open gingival embrasures after orthodontic treatment in adults: prevalence and etiology. Am J Orthod Dentofacial Orthop 120,
116–123.
Lee HF, Wu B and Ting K (2002) Preliminary study on Invisalign tray fabrication. Am J Orthod Dentofacial Orthop 122, 678.
McNamara JA, Kramer KL and Juenker JP (1985) Invisible retainers. J Clin Orthod 19, 570–578.
Meier B, Wiemer KB and Miethke RR (2003) Invisalign–patient profiling. Analysis of a prospective survey. J Orofac Orthop 64, 352–358.
Melsen B (2012) Chapter 5 by B Melsen et al. In Melsen B (ed.) Adult Orthodontics. Oxford: Blackwell Publishing Ltd.
Miethke RR and Vogt S (2005) A comparison of the periodontal health of patients during treatment with the Invisalign® system and with fixed orthodontic
appliances. J Orofac Orthop 66, 219–229.
Miethke RR and JostBrinkmann PG (2006) Interproximal enamel reduction. In Tuncay OC (ed.) The Invisalign System, 1st edn. Berlin: Quintessence.
Miller RJ and Derakhshan M (2002) The Invisalign system: case report of a patient with deep bite, upper incisor flaring and severe curve of Spee. Semin Orthod
8, 43–50.
Miller RJ, Duong TT and Derakhshan M (2002) Lower incisor extraction treatment with the Invisalign system. J Clin Orthod 36, 95–102.
Miller RJ, Kuo E and Choi W (2003) Validation of Align Technology’s Treat III digital model superimposition tool and its case application. Orthod Craniofac Res 6
Suppl 1, 143–149.
Moore T, Southard KA, Casko JS, Qian F and Southard TE (2005) Buccal corridors and smile esthetics. Am J Orthod Dentofacial Orthop 127, 208–213.
Nedwed V and Miethke RR (2005) Motivation, acceptance and problems of Invisalign patients. J Orofac Orthop 66, 162–173.
Owen AH III (2001) Accelerated Invisalign treatment. J Clin Orthod 35, 381–385.
Ponitz RJ (1971) Invisible retainers. Am J Orthod 59, 266–272.
Rinchuse DJ and Rinchuse DJ (1997) Active tooth movement with Essixbased appliances. J Clin Orthod 31, 109–112.
Sarver DM (2001) The importance of incisor positioning in the esthetic smile: the smile arc. Am J Orthod Dentofacial Orthop 120, 98–111.
Sarver DM and Ackerman MB (2003) Dynamic smile visualization and quantification: Part 2. Smile analysis and treatment strategies. Am J Orthod Dentofacial
Orthop 124, 116–127.
Schuster S, Eliades G, Zinelis S, Eliades T and Bradley TG (2004) Structural conformation and leaching from in vitro aged and retrieved Invisalign appliances.
Am J Orthod Dentofacial Orthop 126, 725–728.
Sheridan JJ, LeDoux W and McMinn R (1993) Essix retainers: fabrication and supervision for permanent retention. J Clin Orthod 27, 37–45.
Shillingburg HT and Grace CS (1973) Thickness of enamel and dentin. J South Calif Dent Assoc 41, 33–36.
Vlaskalic V and Boyd R (2001) Orthodontic treatment of a mildly crowded malocclusion using the Invisalign system. Aust Orthod J 17, 41–46.
Vlaskalic V and Boyd R (2002) Clinical evaluation of the Invisalign appliance. J Calif Dent Assoc 30, 769–776.
Womack WR, Ahn JH, Ammari Z and Castillo A (2002) A new approach to correction of crowding. Am J Orthod Dentofacial Orthop 122, 310–316.
Wong BH (2002) Invisalign A to Z. Am J Orthod Dentofacial Orthop 121, 540–541.
Zachrisson BU (2004) Actual damage to teeth and periodontal tissues with mesiodistal enamel reduction (‘stripping’). World J Orthod 5, 178–183.
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January 1, 2015 biomechanics, planning and treatment January 1, 2015
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17 Invisalign®: as Many Answers as Questions

Attachment bonding is facilitated when it is done after the first aligner has been worn intensively for about 1 week (Fig. 17.8). Then, all teeth will be slightly

12: The Invisalign System Aligner orthodontics: Diagnostics, 34 Clear aligners

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