THE INVISALIGN\u00ae SIX-STEP PROCESS<\/strong>
\nBefore initiating Invisalign\u00ae, all necessary basic restorative treatment must be completed, the patient should exhibit no active periodontal disease, and the patient should have fully erupted second molars. As with fixed-appliance orthodontic treatment, a thorough clinical examination, patient history, diagnosis, case presentation including alternative treatment plans, if appropriate, and informed consent should be completed before treatment begins. Treatment using Invisalign\u00ae involves a process of at least six steps (Figure 2). They include:
\nStep 1: Patient records, diagnosis, and treatment plan submission
\nStep 2: Records submission
\nStep 3: 3-D computer modeling
\nStep 4: Review of ClinCheck\u00ae by doctor
\nStep 5: Manufacturing of aligners, initiation of treatment, and aligner delivery
\nStep 6: Treatment, midcourse correction, refinements, and retention<\/p>\nStep 1: Diagnosis and Treatment Plan Written by Doctor When all necessary preliminary restorative treatment has been completed and the patient is free of active periodontal disease, the patient can be evaluated further to assess the orthodontic needs. As with any orthodontic treatment, a comprehensive evaluation of the patient is advised. Not all records from this evaluation need to be submitted to Align Technology, if treatment with Invisalign\u00ae is feasible. Eight photographs are required for submission: Extraoral: frontal smiling (1), frontal repose (2), lateral profile repose (3); Intraoral: anterior (4), right and left buccal (5,6), and maxillary and mandibular occlusal (7,8). The patient should also have fully erupted second molars, which limits the care of many adolescents. Good candidates for Invisalign\u00ae treatment include patients with:<\/p>\n
Generalized spacing
\nGeneralized mild to moderate crowding
\nEvidence of orthodontic relapse<\/p>\n
A moderately deep bite
\nA need for combined restorative\/orthodontic treatment
\nA need for posterior dental expansion of
\n1 to 2 mm per quadrant
\nDiastemas
\nLate-onset lower crowding (adults)<\/p>\n
Step 2: Records Submission
\nThe minimal needs for submission to Align Technology are original Polyvinyl Siloxane (PVS) upper and lower impressions, an original PVS bite registration, photographs, and a prescription form (Figure 3a). When the technique was first available, duplicate X-rays were also necessary but currently are not required. With the exception of the impressions and bite registration, the patient\u2019s diagnostic data can be submitted online, along with the provider\u2019s preferences as to how each case should be managed.
\nFor example, in a case that exhibits crowding, the provider may want to use interproximal enamel reduction, dental expansion, or incisor proclination to alleviate the crowding. Doctors can register their general priorities and preferences for case treatment in their personal data record on the Align Technology Web site. This record will serve as a general guide to the Align technician for all of the doctors\u2019 cases.
\nBefore submitting records, practitioners should have a clear idea of their specific objectives for treatment. When cases are submitted, new disposable trays, submission forms and boxes are supplied by the company. Prepaid mailing boxes are provided by Align Technology. Different types of prescription forms can be submitted. The first is the more traditional FULL-Prescription and Diagnosis Form, which is used for aligners fabricated to treat the full arch and includes three refinements (additional aligners or slight modifications), if necessary, at no additional charge. Midcourse corrections are also available and will be described later in this article. The second is the Anterior Prescription and Diagnostic Form, which is used for aligners fabricated to treat only anterior teeth, canine to canine, with no extractions (this includes three refinements, if necessary, and midcourse corrections are also available). Finally, there is the Invisalign\u00ae Express Form, which is used for single- or dual-arch treatment for very minor cases of crowding and spacing that meet the Invisalign\u00ae Express criteria and require 10 aligners or less to complete the patient\u2019s treatment. One refinement and one detailing set (fine, finishing movements) can be requested for an Invisalign\u00ae Express case, but no midcourse corrections can be ordered.
\nInvisalign\u00ae Express is an orthodontic treatment for patients with very minor malocclusions. Treatments must meet the Invisalign\u00ae Express criteria and be 10 or fewer stages. Invisalign\u00ae Express delivers similar esthetic benefits to patients, with limited orthodontic needs. The clinical criteria for Invisalign\u00ae Express include: spacing or crowding of less than 2 mm per arch, rotation of canines\/bicuspids that are less than 10 degrees, rotation of incisors less than 15 degrees, less than 1.5 mm dental expansion per arch, less than 2 mm midline correction, no mesial or distal movement of the molars or premolars and less than 1 mm distal movement of any canine, and no extrusions.
\nAside from determining the proper diagnosis and treatment plan, the most critical step in fabricating aligners is obtaining accurate PVS impressions. Attention to detail is of the utmost importance.<\/p>\n
Step 3: 3-D Computer Modeling
\nOnce records are submitted, Align Technology transforms the patient\u2019s PVS impressions into 3-D images to prepare a three-dimensional computer graphic image of the patient\u2019s teeth and associated tissues. Later, additional models are used to validate the orthodontist\u2019s diagnosis and treatment plan. The PVS impressions are archived for model duplication or replacement.
\nClinCheck\u00ae is a three-dimensional representation of the planned orthodontic tooth movement in increments or stages. The ClinCheck\u00ae software uses the practitioner\u2019s treatment form and stated preferences to generate a computerized final status, which includes stages in between the start and finish. Planned movements of teeth are projected at two-week intervals with approximately 0.25 mm of movement anticipated for anterior tooth movement. After this computerized plan of treatment is projected, the doctor is notified that the case is ready for review of its ClinCheck\u00ae.<\/p>\n
Step 4: The Doctor Reviews and Approves ClinCheck\u00ae There are five basic steps that Align Technology recommends for reviewing ClinCheck\u00ae. A \u201cClinCheck\u00ae Review Guide\u201d is available on the Web site. Careful review of ClinCheck\u00ae is essential to achieve the best possible results. If tooth movement is not planned properly in ClinCheck\u00ae treatment, results may be disappointing.
\nWhen first viewing ClinCheck\u00ae, it is important to verify that the interocclusal relationship is correct. If it is not, the practitioner must communicate with the Align technician and have the occlusion reset in its proper position.<\/p>\n
The areas to review are:<\/p>\n
1. The final positions of the teeth as viewed from the anterior, overjet, occlusal, buccal, and lingual perspectives. Basically, the doctor must have his or her specific goals and objectives for the case represented in the CliniCheck\u00ae simulation.<\/p>\n
2. Interproximal reduction (IPR): recommendations regarding the quantity, location, and timing of the enamel reduction. Interproximal reduction of enamel [also referred to as Air-Rotor Stripping (ARS)], reproximation, slenderizing, stripping, or interproximal recontouring are often necessary and integral parts of Invisalign\u00ae treatment. Any case requiring interproximal reduction will have an IPR form indicating when, where, and how much is required.9 IPR is performed where additional space needs to be established to alleviate crowding. IPR is usually done during treatment, but it can be done before the PVS impression, as long as the space is retained until aligners are delivered. If performed during treatment, properly adhering to the IPR instructions is important to achieve the predicted treatment outcome. If the IPR is inadequate, crowded teeth will not be able to align properly and treatment will not progress or come to a successful completion.<\/p>\n
3. Staging is the process of determining the sequence, timing, and rate of tooth movement from the initial to the final occlusal position. Each stage represents one aligner. Aligners are fabricated to move teeth 0.25 mm per tooth per stage. However, the practitioner may choose to provide movement speeds different from those recommended in the proposed protocol in certain cases. More difficult and less predictable movements may be slowed and staged over a longer period to better express the movement.<\/p>\n
4. Attachments and pontics. Align Technology defines attachments as three-dimensional shapes added to tooth geometry to enhance the interaction between an aligner and the teeth. These are represented by red shapes on the ClinCheck\u00ae. Attachments are tooth-colored composite forms that are bonded onto the teeth using a template and a restorative composite (Figure 6). Attachment can be used to anchor aligners for better retention, to modify force delivery, or to improve specific tooth movements. The most commonly used attachments are rectangular or elliptical shapes and may be oriented either horizontally or vertically, depending on their function. Pontics are spaces built into the aligner that narrow over the course of treatment as the spaces are closed. In the ClinCheck\u00ae, pontics are represented as half a tooth with a retention dimple.<\/p>\n
5. Overcorrection is planning tooth movement beyond ideal to anticipate tooth relapse. However, trying to predict before treatment begins which teeth may need overcorrection is difficult and unreliable. It is recommended that overcorrection be done as part of refinement. If overcorrection of specific teeth has been requested as part of your treatment plan, try to be as precise as possible in prescribing the amount (in millimeters or degrees) and direction of movements.<\/p>\n
Step 5: Aligners Manufactured and Shipped to Practitioner for Delivery to Patient.
\nAfter ClinCheck\u00ae approval of the treatment plan, Align Technology uses the sequence of graphical images combined with CAD\/CAM to produce clear, lightweight aligners. Within 10 business days of the ClinCheck\u00ae approval, Align Technology ships the aligners to the doctor\u2019s office. If attachments are part of the plan of treatment, an \u201cattachment template\u201d is sent with the aligners.
\nAfter any necessary attachments are placed, the aligners are delivered to the patient with a starter kit, and written and verbal instructions are provided as well. Patients are generally instructed to wear the aligners full time, except for eating and drinking. The patient wears each set of aligners for two-week intervals until treatment is complete. Monitoring the treatment occurs as the patient visits the doctor every six to eight weeks or as otherwise instructed.
\nThe attachments referred to previously are composite forms bonded to a tooth surface or surfaces to aid in movement of the teeth. They serve as \u201chandles\u201d used to assist in the retention of the appliance or specific types of movements.
\nThese composite attachments are bonded to teeth by the doctor at the beginning of treatment using a ready-made template. They are placed to assist in: (1) retention of the aligner, (2) intrusion, (3) rotations of teeth, (4) limited uprighting, and (5) space closure. The attachment
\ntemplates can be made in different shapes, as prescribed by the practitioner.<\/p>\n
Step 6: Monitoring Treatment, Obtaining Desired Results, and Retention.
\nCareful treatment monitoring will help identify problems and issues before they become major issues that may limit the success of the planned treatment. When monitoring a patient\u2019s treatment, it is important to make sure that the teeth are tracking (fitting intimately within the aligner), as planned in the appliance. Sometimes, one or more teeth do not track according to the plan mapped out in the ClinCheck\u00ae. This may occur for a variety of reasons, including a lack of patient compliance, inadequate IPR, excessively tight proximal contacts, or planned tooth movement that exceeds the capability of the aligner.
\nAn important routine procedure in any Invisalign\u00ae treatment is to check the tightness of interproximal contacts with a thin piece of dental floss at each visit and to relieve tight contacts in areas of planned tooth movement.
\nAt each patient visit, check the occlusion and verify that aligners are fitting and tracking properly, perform IPR as planned, and check the condition of the attachments. It is advisable to compare treatment progress to the ClinCheck\u00ae simulation at three-month intervals to evaluate that the treatment is proceeding appropriately and according to plan. If teeth do not seem to be tracking well in the aligners or treatment needs to be modified, some type of midcourse correction or \u201crefinement\u201d may be necessary. REFINEMENTS AND MIDCOURSE CORRECTIONS
\nDuring treatment, it may be necessary to revise the original plan or augment it with additional or slightly modified aligners. When additional aligners are needed to move teeth closer to the desired final position originally approved in the ClinCheck\u00ae setup, a refinement may be requested.
\nA midcourse correction is an option to order new aligners during treatment if clinical results have deviated to such an extent that the aligner(s) no longer fit(s). It is advisable to take new PVS impressions for such refinements and midcourse corrections.<\/p>\n
Auxiliary Treatment<\/strong>
\nUsing other supplemental appliances along with Invisalign\u00ae is considered \u201cauxiliary\u201d treatment. Buttons, elastics or other techniques, including brackets and bands, before, after or in combination with aligners may be required to achieve certain tooth movements or occlusal seating. Auxiliary treatment may also include the use of more traditional fixed appliances in one arch or the use of traditional fixed appliances, as needed, for surgery patients.<\/p>\nRetention<\/strong>
\nWhen the case has been completed, the patient goes into retention. The final aligner should not serve as a long-term retainer as the material is not as durable as other available retainers. A retainer may be fabricated by Align Technology, but the practitioner may elect to design and fabricate the retainer elsewhere. Align Technology does not accept work models or additional impressions to make retainers. Retainers are only created from initial or case refinement ClinCheck\u00ae plans. In retention all of the more complex restorative procedures that could not be completed before or during treatment can now be accomplished.<\/p>\n![\"\"](\"https:\/\/i0.wp.com\/orthodontist-sandiego.com\/wp-content\/uploads\/2011\/02\/invisalign1.jpg?resize=290%2C65\" "\\"invisalign1\\"")
<\/a><\/p>\nAn Overview of Invisalign\u00ae Treatment courtesy of Stuart D. Josell, DMD, MDent Sc, Chair of the Department of Orthodontics at the University of Maryland Dental School and Steven M. Siegel, DMD, Clinical assistant professor in the Department of Orthodontics in private practices in Glen Burnie, Reisterstown, and Owings Mills, Md.<\/p>\n","protected":false},"excerpt":{"rendered":"
What is Invisalign\u00ae? Invisalign\u00ae invisible braces are just that: invisible. The Invisalign\u00ae system utilizes clear aligners that are designed to fit discreetly over the teeth and gradually straighten them. Because the aligners are constructed from clear material, they are virtually imperceptible to the eye, no braces or wires are used. Invisalign\u00ae vs. Traditional Orthodontics Invisalign\u00ae […]<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":28,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"ngg_post_thumbnail":0,"footnotes":""},"aioseo_notices":[],"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages\/383"}],"collection":[{"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/comments?post=383"}],"version-history":[{"count":27,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages\/383\/revisions"}],"predecessor-version":[{"id":1318,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages\/383\/revisions\/1318"}],"up":[{"embeddable":true,"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/pages\/28"}],"wp:attachment":[{"href":"https:\/\/orthodontist-sandiego.com\/wp-json\/wp\/v2\/media?parent=383"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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