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Author’s Accepted Manuscript

The Invisalign® appliance today: A thinking


person’s orthodontic appliance

Eugene Chan, M. Ali Darendelilier

www.elsevier.com/locate/ysodo

PII: S1073-8746(16)30059-7
DOI: http://dx.doi.org/10.1053/j.sodo.2016.10.003
Reference: YSODO480
To appear in: Seminars in Orthodontics
Cite this article as: Eugene Chan and M. Ali Darendelilier, The Invisalign®
appliance today: A thinking person’s orthodontic appliance, Seminars in
Orthodontics, http://dx.doi.org/10.1053/j.sodo.2016.10.003
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The Invisalign® appliance today: A thinking person’s
orthodontic appliance.

Eugene Chan, BDS, MDSc (Orthodontics), MRACDS (Ortho), M Orth RCS Ed, PhD

Honorary Lecturer1 and Specialist Orthodontist in Private Practice2


1
Department of Orthodontics.

Faculty of Dentistry

University of Sydney, Australia


2
Orthoworx, Sydney, Australia

M Ali Darendelilier, BDS, PhD, Dip Ortho, Certif. Orth, Priv. Doc

Professor and Chair

Department of Orthodontics.

Faculty of Dentistry

University of Sydney, Australia

Corresponding Author:

M Ali Darendelilier,

Discipline of Orthodontics

Faculty of Dentistry

University of Sydney

Level 2, 2 Chalmers Street

Surry Hills NSW 2010 Australia


Phone +61 2 9351 8314

Email: ali.darendeliler@sydney.edu.au

Abstract

Since its induction in 1997, the Invisalign® appliance has vastly evolved
through the years. Having used this appliance since inception to its current
form, we have learnt much through trial and error and accumulated much
experience. The product had advanced substantially since the days of only
treating simple Class I malocclusions. It is now possible to treat multiple
extraction cases, skeletal asymmetries, as well as, surgical and non-surgical
camouflage cases. This paper summarizes the experiences of 2 specialist
orthodontists who had spent time to perfect the system through
understanding the biology of tooth movement and also utilizing smart
biomechanics to bypass the inadequacies and further enhance the patient and
clinician’s experience in using the appliance.
Introduction

Orthodontics has a strong history of individual opinions; from the individual


orthodontist to the orthodontic guru. However, the global trend is to gradually move
towards a focus on evidence-based rather than opinion-based decisions.1

If treatment is needed, how do we decide what sort of treatment to use? Treatment


procedures should be chosen on the basis of clear evidence and the most
successful approach. Usually the better the evidence, the easier the decision. Yet,
there are some innate problems with evidence-based orthodontics. Unlike in
medicine, we are not dealing with a disease or diseased tissues. In order to treat a
presented malocclusion, we primarily establish an individualized treatment goal and
proceed to formulate a set of treatment plan(s). In order to obtain these goals, our
mechanical procedures can be very different for any given patient; hence, unlike
medicine, the endpoint, akin to the elimination of disease, may not be as precise.

Twenty years ago, less than three percent of the world’s population had a mobile
phone. Today, two-thirds of the world’s population has a mobile phone of some sort.
The digital technology around us have pushed us to learn and adapt to new gadgets
and methods in the world of orthodontics. From digital records, treatment planning,
appliance design and manufacture, digital monitoring of treatment, computer aided
orthodontic treatment has finally arrived. However, there are roadblocks and
clinicians need to be fully aware of such consequence before embracing this
technology fully, and blindly.

Diagnostics

Training clinicians to use the Invisalign appliance has long been largely based on
anecdotal evidence. There is an urgent need for systemic reviews and meta
analyses to be conducted. We were able to collect data on 400 consecutively
treated Invisalign cases by one clinician, and subsequently analyse them. 2 These
cases were classified under respective age groups, gender, type of dental
malocclusions and treatment therapies (extraction or non-extraction). The treatment
duration and total number of appointments required were also noted.

The following report draws evidence from the above findings.

Identifying road blocks.


The common feedback from new clinicians include the following: “I have followed all
the instructions given by the technicians, I have placed all the necessary
attachments, and done all the necessary prescribed interproximal reduction (IPR).
My patient wore all the aligners and used the Chewies as prescribed. They all wore
them “more than” 20 hours per day but the result still differs from the ClinCheck
plans. The product just “does not” work!”

Years of experience using the Invisalign appliance let us to conclude treatment


progress is indeed not as easy and predictable as the computer animation dictates.
There has to be some understanding of the biology and mechanical involvement of
the aligners in order to produce repeatable, good clinical outcomes. The Invisalign
product itself has evolved through time to make it more user friendly. Have we, the
clinicians, evolved to understand its advanced applications too? The Invisalign
appliance has indeed become a thinking persons’ orthodontic appliance.

The one difficulty which new Invisalign users face while using this appliance is the
ability to identify the challenging cases. The common factors affecting the
predictability of treatment are (i) understanding the anatomy of dentition, (ii) knowing
the growth potential of the patient (or the lack of), (iii) the ability to place attachments
(based on aesthetic and biomechanical requirements), and (iv) identifying difficult
dental movements and how to plan for contingencies.

Case 1

Case 1 is an adult female of Asian extraction (Figure 1A). She first presented with
chief concerns of an uneven bite, crooked front teeth and some dental spacing. She
was diagnosed as a Class-II dental malocclusion with skeletal Class-I pattern, with a
normal to horizontal direction of growth. Radiographic examination was nondescript.

The road blocks treating this patient with the Invisalign appliance were: (i) she had
some degree of microdontia with short clinical crown heights, (ii) she was a non-
growing Class-II dental malocclusion with upper crowding, and lower spacing, (iii) the
antero-posterior (AP) correction would require good compliance with Class II
traction, and (iv) she also has a horizontal growth pattern with a tendency of her bite
deepening as treatment progresses.
A key to successful treatment with the Invisalign appliance is to ensure good surface
area contacts between the aligner material and the dentition. Therefore, the
successful planning and treatment of this case with short clinical crown heights
involved (i) choosing the correct attachments, (ii) have them appropriately placed,
(iii) decrease the velocity of the movement of the dentition whilst designing the
ClinCheck plans, (iv) the patient also has to understand the importance of using
Class-II elastics, (v) be prepared for refinement/additional aligners, and (vi) ensure
good patient compliance.

The first ClinCheck plans presented a treatment plan with 15 aligners and
attachment design as shown (Figure1B).

The ClinCheck plans were modified to reduce the treatment velocity and a different
attachment design (Figure 1C).

The case treated out well in 21 months using a total of 46 (29+17) aligners with one
refinement (Figure 1D, E).

Case 2

Case 2 is an adult female Caucasian who is extremely concerned with the aesthetics
of the appliance she wanted (Figure 2A). Her chief concern was the rotated upper
lateral incisors with a lateral open bite on the left side. She is a Class-I dental
malocclusion over a skeletal Class-I base with a normal direction of growth. There
were no soft tissue parafunctions and radiographic examination was nondescript.

Previous experiences with moving lateral incisors has noted it to be a great


challenge. The necessity of placing an optimised extrusion attachment in this case is
almost imminent. The clear appliance that is Invisalign is a natural choice for the
patient provided it was capable of executing the biomechanical forces necessary to
extrude the lateral incisor and close down the lateral open bite successfully.
Although matching tooth-coloured composite attachments may be selected, and if
well placed and polished, almost invisible upon close scrutiny, when the actual
aligner with the pushed out outline of the attachment is placed on the dentition, the
visibility of the attachment highly increases. Out of social embarrassment, this often
result in patients not wearing the aligners for the prescribed number of hours and
hence disrupting the biomechanical forces and not obtaining the desired results.
The road block of treating this case with the Invisalign appliance includes meeting
the patient’s expectations in terms of aesthetics and treatment outcomes. If
attachments were to be placed on the buccal surfaces of the teeth, there might be a
high chance that the patient might not fulfil the prescribed hours of aligner wear. Is
there any other way to design the ClinCheck plans and attachments? How do we
extrude the dentition and close the lateral open bite on the left side? Would we
require the need for elastic bands?

The first ClinCheck plan presented a treatment plan with upper 18 and lower 12
aligners and attachments on the buccal surfaces of the upper anterior teeth (Figure
2B).

The ClinCheck plan was modified to place vertical rectangular attachments on the
lingual surfaces of the upper lateral incisors instead. The velocity of the tooth
movement was also reduced (Figure 2C). No elastic bands were necessary and the
patient’s compliance was excellent throughout the treatment duration.

The case treated out well in 15 months using a total of 32 (25+7) aligners with one
refinement (Figure 2D, E).

Case 3

Case 3 is an adult Asian patient with initial concerns of crooked front teeth and
impacted lower second premolars (Figure 3A). Radiographic examination was
nondescript.

She was a Class-II division 2 dental malocclusion on a skeletal Class-I base with a
normal direction of growth. The road block in this case hinges mainly on the
disengagement of the lower second premolar teeth, and extruding them. There is a
high chance that we would require the use of auxiliaries to assist in these extrusion
movements.

Prior to onset of treatment the patient gave her informed consent that she fully
understands that there would be a high chance of using sectional fixed appliances
on the lower quadrants to assist in the dental movements. The initial ClinCheck plan
set up by the technician had recognised the difficulty in these extrusive movements
and have decided to not extrude the lower second premolars at all (Figure 3B). This
treatment plan successfully improves the tracking rate of the case as the difficult
movements will be dealt with at a second, later stage. However, this will lengthen the
total treatment duration and may not be of the best interest of the patient. Moreover,
when the sectional fixed appliances are placed, the original alignment achieved on
the lower anterior segments may be lost as relapse quickly sets in. Some sort of
retainers will have to be designed to prevent this.

The ClinCheck plans were subsequently modified to allow expansion of the dental
arch forms, increasing the dental arch perimeter to allow sufficient space for the
extrusion of the lower second premolars (Figure 3C). Appropriate attachments were
placed to assist in the extrusion of the premolars and the contingency plan was that
once the lower impacted premolar teeth are not tracking, sectional fixed appliances
would be placed on the lower first premolars, second premolars and first molars. The
existing, remaining aligners will also be cut and adjusted to fit around these fixed
appliances. The patient will still be changing her aligners every two weeks as
previously planned. In this way, the extrusion with the fixed appliances are planned
within the boundaries of the aligner movement and there will be “space” to allow this
extrusive movement to occur with the usual aligner wear. There will be no need to
have any interim retainers.

Some other considerations in this case include appropriate attachment designs in


order to successfully extrude these premolars, and clinical monitoring on sufficient
spacing, light IPR where necessary to allow the movements planned to occur.
Patient compliance has to be reinforced as well.

The case treated out well in 26 months using a total of 58 (40+18) aligners with one
refinement and Class II elastics, (Figure 3D) surprisingly, without the need for any
sectional braces.

ClinCheck treatment plans

A ClinCheck treatment plan allows us to visualize the treatment progress and


treatment outcome virtually. It is however strongly guided by software defaults and
limitations. Trained align technicians are often unaware of biology of tooth
movement, biomechanics, and other clinical limitations and/or variations.

Therefore, common trouble situations are often reported: (i) difficulty in obtaining the
correct amount of dental expansion (Figures 4A, B, and C), (ii) inability to achieve
sufficient anterior torque in premolar extraction cases (Figures 5A, B, and C), (iii)
inability to fully correct deep overbite dental malocclusions (Figures 6A, B, and C),
and (iv) inability to resolve severe dental crowding without multiple refinements
(Figures 7A, B, and C).

Recovery techniques therefore are formulated to overcome these situations.


Sectional or full arch fixed appliances, fixed bonded power arms incorporated with
power chains and/or pull coils, button and elastics etc. are often the `get out of
trouble` consequence. Clinicians have to spend more time and overhead to prepare
and plan for such situations. Patients who are not pre-warned of such situations are
often not impressed with the prolonged treatment duration, extra costs involved and
the placement of a more visible appliance in order to complete the case to
perfection.

We strive to achieve repeatable, outstanding results without the need for such
predicaments. We can come close to avoiding such situations by going back to the
basics: through understanding the true biology of tooth movement, and relating it
back to aligner treatment and biomechanics.

Planning and execution

With an expansive market within the field of dentistry, Invisalign has made
orthodontics easily available for the masses. As the product evolves into the
cosmetic dental environment, the science behind dental movement is slowly eroded.

“Is Invisalign orthodontics?”

Using pre-set defaults within the ClinCheck software and allowing technicians to
dictate clinical treatment may allow the new clinician to get away with treating simple
Class-I cases. However, when faced with more complex situations, the age-old
debate comes about: “how much orthodontics should you know before using the
Invisalign appliance?”

Age related treatment

(a) Molar distalisation or elastic simulation

The decision making in the type of orthodontic correction required in Class-II and/or
Class-III dental malocclusions relate closely to the growth potential of the patient.
Differential growth spurts and velocities in the growth of adolescences have been
previously described.3 It is noted that girls have their growth spurt up to two years
earlier than boys. However early maturing boys will reach puberty before slow
maturing girls. Therefore, it is essential to note the growth patterns and
characteristics of each individual patient during consultation appointments. The
Burlington growth studies done in the early 70’s looked at the various growth time
points of children.4 The increments of mandibular length was also noted annually.

Therefore, when it comes to the decision on whether the molar dental relationship
should be corrected with “molar distalisation” or an “elastic simulation”, this
understanding of the growth potential of the patient becomes rather important.

(i) Sequential staging pattern.

This is one of the default staging patterns in the correction of molar dental
relationships with the Invisalign appliance.

Case 4

Case 4 is a Caucasian non-growing adult female with a Class-II dental malocclusion


(Figure 8A). She had undergone previous orthodontic treatment with a single upper
and lower premolar tooth extracted in quadrants one and four. This has resulted in a
deviated upper dental midline, moderate upper and lower dental crowding, rather
constricted upper and lower dental arch forms, a deep dental overbite, and a Class II
dental molar relationship. Her panoramic (OPG) radiograph demonstrates normal
dental root anatomy, normal dento-alveolar bone heights and normal bony density
(Figure 8B). The wisdom teeth on the left side have all been previously removed.

The ClinCheck plans reveals a “staggered” staging pattern (Figure 8C) which
indicates a sequential staging treatment plan. The default staging pattern is as such:
the upper terminal molars are usually distalised from stage 1 for approximately 8
stages before the first molar starts distalising for another 8 stages and subsequent
teeth distalised individually thereafter. The upper anterior teeth are usually stationary
all this time while the molar distalisation is occurring.
Although this staging pattern is predictable in non-growing patients, the treatment
duration is usually prolonged. Moreover, the upper anterior crowding is usually not
resolved till the later part of the treatment. Patients with anterior crowding as a chief
concern would not like such a treatment plan.

There are however several ways to overcome this staging problem.


 The digital ClinCheck plans do not take into considerations any inter arch
anchorage augmentation. The use of Class-II elastics in such treatment highly
improves the predictability of the treatment. The sequential staging of the upper
molars may then be successfully reduced to every 4 stages instead of 8. This
reduces the total number of active aligners significantly.
 The ClinCheck plans may also be modified to allow early upper anterior
alignment to alleviate the patients’ chief concerns. This usually involves, if
allowed, an expansion and/or proclination movement of the upper anterior teeth
allowing an early aesthetic improvement. The upper anterior teeth will
subsequently be retracted back once the molar distalisation has created sufficient
space.

The case treated out well in 18 months using a total of 43 (39+4) aligners with one
refinement (Figures 8D, E).

This staging pattern is predictable and suitable for adult non-growing patients with up
to half unit A-P correction. The patient would require good clinical crown heights,
good compliance with aligner wear and dental elastics. There should not be any
wisdom teeth present on the arch which we are distalising. However, treatment
duration may be longer and anterior teeth may not be fully corrected till the later part
of the treatment.

(ii) En masse distalisation

With the sequential staging pattern taking up a longer treatment duration, there will
be certain cases that will allow “en masse distalisation” pattern. This staging pattern
is not an “elastic simulation” but rather right from the commencement of treatment,
the whole dental arch distalises and achieves the desired AP correction.

Case 5
Case 5 is an adult Caucasian non-growing adult patient with a Class-II dental
malocclusion (Figures 9A, B). She had previous orthodontic treatment and four
premolar teeth were previously extracted. Her upper and lower dental arches have
collapsed and constricted over time with upper and lower mild to moderate degrees
of crowding noted. There is an increased overjet and a quarter unit Class II dental
relationship.

Attachments were placed from stage 4, Class-II elastics were also applied then. This
staging pattern is demonstrated in the ClinCheck plans as the upper arch is
completely distalised as if via “an invisible” force. This could be applied either
through inter arch elastics or placement of temporary anchorage devices (TADs) at
the appropriate areas.

The en masse staging pattern allows simultaneous correction of the patients’ dental
crowding as well as addressing the AP correction at the same time. The treatment
duration, however, is much shorter. And clinical tracking may be slightly trickier.
When the patient returns for a review/adjustment appointment, it is imperative to not
only check the fit of the aligners, but also remove the aligners, get the patient to bite
into a maximum intercuspation to check for inter arch relationships and adjust the
anchorage control with Class-II elastics as required.

The case treated out well in 12 months using a total of 27 (18+9) aligners with one
refinement (Figure 9C).

This staging pattern is predictable and suitable for adult non-growing patients with
previous premolar extractions, and up to half unit AP correction. The presence of
maxillary wisdom teeth may sometimes make the correction difficult when we are
performing en masse distalising and it is highly recommended that they be removed.
The patient would require good clinical crown heights, excellent compliance with
aligner wear and dental elastics. Otherwise, four to five millimetre attachments on
the premolars may be required to increase the surface area contacts between the
aligner and the dentition.

(iii) Elastic simulation

Using inter arch elastic traction to correct Class-II dental malocclusion is quite the
“norm” in conventional orthodontics. Especially in growing children with the potential
for vertical dento-alveolar growth. In contrast, correcting a full Class-II dental
malocclusion using elastics in an adult patient is like asking a toddler to cross
walking the Sydney Harbour Bridge.

Case 6

Case 6 is an adolescent Asian male with concerns of deviated upper and lower
dental midlines, retroclined anterior teeth with moderate upper and lower dental
crowding. He was diagnosed as a Class II subdivision dental malocclusion on a mild
skeletal 2 base (Figure 10A).

The elastic simulation staging pattern is an efficient staging pattern to achieve


alignment, space closure and vertical correction in growing patients. In such cases, it
is essential to have good attachments placed due to their shorter clinical crown
heights, and their passive eruption. In the ClinCheck plan, the staging pattern
demonstrates a simultaneous movement of all teeth with a last aligner `jump` at the
end, just before the overcorrection aligners (if any were planned). It does not matter
which arch does the jump as in the ClinCheck plans, dental movement occur in
space. The default has set the arch with the most aligners to jump (Figure 10B).
However, it has to be taken into account that the success of the treatment also relies
heavily on the severity of the Class II discrepancy, growth potential and patient
cooperation.

It is important to understand that although elastic simulation was performed at the


last aligner, it is imperative to have the inter-arch dental elastics worn from the very
early part of the treatment to have the desired treatment outcome. The strength and
duration of the elastic wear will depend greatly on the severity of the discrepancy.

The case treated out well in 22 months using a total of 58 (39+12+7) aligners with
two refinements (Figure 10C, D). Refinement aligners were changed weekly.

This staging pattern is rather predictable and suitable for growing patients with up to
half unit AP correction. Dental crowding is usually resolved early and simultaneous
staging pattern keeps the treatment duration short. The patient would require good
clinical crown heights, excellent compliance with aligner wear and dental elastics.

(b) Dental arch expansion


Dental arch expansion in growing and non-growing patients using removable
appliances has previously been established.5,6 Studies on cadaver material have
noted the cessation of growth and fusion of the palatal and pterygopalatine sutures
at around thirteen to fifteen years of age.7 Accordingly, in the treatment of adult
patients using the Invisalign appliance, one cannot expect skeletal transverse
changes unless surgery is incorporated.

Dental arch expansion in adults using the Invisalign appliance is predictable and
successful (Figures 11A, B, C, and D). However, there are limitations to how much
expansion is achievable and it has to occur within the dento-alveolus.8 Cases with
thin gingival biotype and evident recession should be avoided (Figure 12A). On the
other hand, try to select cases with lingually tipped buccal segments, with thick
gingival biotype with minimal or no recession (Figure 12B).

During dental arch expansion of the maxilla, the centre of rotation of the expansion is
much higher than the palatal bone structures itself (Figure 13). One of the worst side
effect during this dental expansion is that the palatal cusps of the posterior teeth will
extrude and hang down due to the tipping movement of the dentition. The strong soft
tissue resistance during expansion also does not allow sufficient expansion clinically
as planned. Understanding these side effects is therefore necessary in order to
design a successful ClinCheck plan.

It is quite a common diagnostic error during the evaluation of the transverse


discrepancy that the clinician only considered the dimensions of the upper dental
arch, but has not considered if the lower arch was too wide instead. This transverse
discrepancy can be corrected by not just expanding the upper arch, but with a
combination with the constriction of the lower arch if necessary. This will reduce the
amount of upper arch expansion and make the treatment more predictable.

It is vital to have these following movements designed into the ClinCheck plan: (i)
intrude and increase the buccal root torque of the upper posterior teeth, (ii) place
appropriate attachments in order to increase the surface area contact between the
dentition and aligner material, (iii) over expansion of up to twenty percent of the
required distance (Figure 14).

(c) Treatment in teenagers


Using the Invisalign appliance in the orthodontic treatment of teenagers has been
met with resistance. The number of Invisalign Teen cases shipped globally have
stagnated at about 24% over the last three years.9 The usual roadblocks include (i)
the lack of patient compliance (despite the presence of compliance indicators), and
(ii) short clinical crown heights disallowing good three dimensional control. However,
the physiology of teenage patients has been shown to respond better to various
orthodontic appliances as compared to adults.10,11 The Ann Arbour Michigan Centre
of Human Growth and Development published data on the average changes in
mandibular molar and canine widths over the children’s’ growing years. Maximum
growth rates tend to peak just before the age of twelve and the trend decreases
thereafter. Therefore, while we are planning for a younger patient using the Invisalign
appliance, we cannot forget the fact that the patient’s growth is assisting the
treatment while we are also enhancing the growth potential of the child.

Case 7

Case 7 is an adolescent female patient of Asian descent with chief concerns of


dental crowding. She was diagnosed as a Class-I dental malocclusion on a skeletal
1 base with a normal direction of growth. She presented with severe upper and lower
dental crowding with her upper and lower dental arch forms rather constricted, and a
minimum dental overbite (Figure 15A).

A non-extraction therapy was planned with dental arch expansion, IPR and
alignment of the dentition performed (Figure 15B). The initial twenty-four aligners
achieved a rather good result despite less than ideal compliance; as expected from a
typical teenager (Figure 16C). The case treated out well in 14 months using a total of
38 (24+14) aligners with one refinement (Figure 16D).

Case 8

Case 8 is an adolescent female patient of Caucasian decent. She was diagnosed as


a Class-II dental malocclusion on a mild skeletal Class-II base with a normal to
horizontal direction of growth. She presented with a deep dental overbite, unilateral
posterior cross bite and lower midline deviation to the right side (Figures 16A, B, and
C). The ClinCheck plan included the use of both optimised and conventional
attachments. Simultaneous staging was planned with an elastic simulation. Class-II
elastics were worn from the upper canines to the lower first molars using a button-to-
button method (Figure 16D).

The case treated out well under 21 months using a total of 45 (33+12) aligners with
one refinement (Figure 16E).

Shape driven orthodontics

The essence of orthodontic treatment is the application of forces and force systems
to alter tooth positions or to produce physiologic bony changes. The application of
scientific biomechanics improves the quality of treatment and treatment efficiency.
However, biomechanics didn't originate with orthodontics. It is based upon the
pioneers of physics like Galileo and Newton. Recent research also included material
science, mechanics of materials, beam theory, finite-element and computer science,
to get to where we are today. In orthodontics, we build on the foundation from these
basic sciences of engineering and physics. In the biological system, we are dealing
with constant bone resorption and bone remodelling through the periodontal ligament
within the periodontium. The tooth itself becomes the subject of interest as it
traverses through the dentoalveolar bone.

Historically, orthodontic appliances were developed, described, and taught as shape-


driven. In the era of shape-driven appliances, we were taught how to bend or twist a
wire or how to properly position a bracket. That is all geometry and driven by shape.

The best approach is to first determine our orthodontic goal, what we want to
achieve, and then determine the force system that is required to produce that result.
Subsequent to that can we then design our appliance. It is important to have a
shape, but it is more important that the shape produces the desired force system.
Often, that resultant shape will look nothing like the ideal finish.

Compensatory movements

Understanding the side effects and the inadequacies of the aligner system is
extremely important in treating of complex cases. As Invisalign is also a removable
appliance, the degree of `play` between the appliance and the dentition affects the
true tracking of the appliance.
Managing premolar extraction cases using the Invisalign appliance is challenging.
Extraction cases in younger patients contribute to a greater challenge due to the lack
of absolute three-dimensional control of the dental movements with shorter clinical
crown heights and less than ideal patient compliance. However, through good case
selection, proper planning and design, premolar extractions in teenagers can be
executed well.

In such cases, not only good and sufficient attachments need to be selected,
compensatory movements also need to be planned.

These are some of the compensatory movements required in handling such


extraction cases. (i) Increase upper anterior lingual root torque, further intrude the
lower incisors: often an anterior open bite is seen in the final ClinCheck plans. During
dental space closure, the anterior teeth are often extruded and retroclined
contributing to an increase of dental overbite often leading to an anterior interference
and posterior open bite. These two compensatory movements will prevent the
`dumping` of the anterior teeth as the dental spaces are closed. G5 precision bite
ramps should be included on the upper anterior teeth to assist in the control of the
vertical dimension as space closes. (ii) Teeth mesial to the extraction site need
increased distal root tip movements while teeth distal to the site require increased
mesial root tip movements. Essentially, we are trying to counteract the crown
`dumping` of the abutment teeth as the extraction spaces are closed. Due to the
damping effect of the aligner system, the further away from the extraction space, the
less of these increased tipping movement is required.

This concept is further explained using the following two cases.

Case 9

Case 9 is an adolescent Asian female with a Class-II division 1 dental malocclusion


with a skeletal 1 pattern and a vertical to normal direction of growth (Figures 17A, B,
and C). Her chief concerns were that her upper front teeth stuck out and she wanted
to have them retracted with an improvement with her dento-facial profile. She also
presented with severe upper and moderate lower dental crowding, a deep lower
Curve of Spee and incompetent lips. Her dental midlines were non-coincident.
The upper first premolar teeth were extracted and Invisalign Teen was prescribed.
The ClinCheck plans with conventional attachment designs and staging patterns are
shown (Figure 17D). Class II dental elastics were also used to control the anchorage
during space closure. Precision buccal cut outs were designed and buttons were
placed to enable controlled retraction and space closure.

The compensatory movements planned in this case were: increased lower incisor
intrusion by 0.8mm, increased distal root tip of the upper canines 6 degrees,
increased mesial root tip of the upper second premolars and first molars 8 degrees
and 6 degrees respectively.

The case treated well in 24 months with a total of 51 (37+14) aligners with one
refinement (Fig. 17E, F, and G).

Case 10

Case 10 is an adolescent male patient with a mixed Asian and Caucasian ethnicity.
He was a Class I dental on a skeletal 2 base with a horizontal direction of growth.
His chief concerns were a mildly recessive chin and lower dental crowding (Figures
18A, B, and C).

Due to his insufficient horizontal projection of his chin and a deficient mandible, a
functional twin block appliance was prescribed. Active treatment lasted seven
months and brought him into a reversed dental overjet and an improved facial
appearance (Figure 18D).

Subsequently lower first premolars were extracted and the Invisalign Teen appliance
was prescribed. The treatment plan was to complete the case in a Class I canine
and a Class III molar dental relationship. The ClinCheck plans demonstrate the use
of optimised as well as conventional attachments in a simultaneous staging pattern
(Figure 18E). After obtaining a positive overjet and overbite at stage 23, night use of
Class II dental elastics was used to maintain the anchorage. 12 An early refinement
was performed at stage 31 (Figure 18F) and posterior triangular elastics was used to
settle the bite during these refinement stages.

The compensatory movements planned in this case were: increased lower incisor
intrusion by 0.8mm, increased distal root tip of the lower canines 8 degrees,
increased mesial root tip of the lower second premolars and first molars 8 degrees
and 6 degrees respectively.

The case treated well in 17 months with a total of 42 (31+11) aligners with one
refinement (Figure 18G, H, I, and J). The total active orthodontic treatment was 24
months.

Despite reported difficulties from new clinicians in obtaining repeatable good results
using the Invisalign appliance in younger patients, the most common mistakes are
that they have either not planned the treatment around the patients existing growth
potential, or that they have failed to fully understand and counteract the side effects
of tooth movement with aligner appliances.

Favourable physiology and good growth potential in younger patients allow


orthodontic treatment to be more “forgiving”. We could often achieve a reasonable
result despite less than ideal compliance, and even more overwhelming results with
excellent growth potential and compliance.

(d) AP correction

Understanding the shortcoming of any orthodontic appliance allow us to think outside


the usual treatment plans in order to achieve the desired result within a prescribed,
limited range.

The anterior-posterior correction of dental malocclusion using the Invisalign


appliance will be described under the following subheadings:

(i) Opening spaces

Case 11

Case 11 is an adult Caucasian male who lived many years with an absent upper
right lateral incisor (Figures 19A, B). His chief concerns were that his smile was
asymmetrical, has an “underbite”, would like to have his smile improved, and missing
dentition restored. He presented with a Class-III dental malocclusion on a skeletal 1
pattern with a normal direction of growth. The upper dental midline was deviated to
the right due to the missing upper right lateral incisor. There was a reversed overjet,
an anterior functional shift, with increased wear and attrition to his anterior teeth. The
patient also presented with a Bolton’s’ discrepancy with the upper left lateral incisor
slightly diminished in size. As he was reluctant to have that built up, it was than quite
a challenge to allow a full dental implant to be placed in the site where the missing
tooth was.

The ClinCheck plan was designed with simultaneous staging. An elastic simulation
was prescribed in order to achieve the Class-I occlusion after the elimination of the
functional shift (Figure 19C). Class-III dental elastics were used clinically to achieve
the AP correction.

The final occlusion and dental space for the upper right lateral incisor was achieved
after 13 months of active treatment with 27 (17+10) aligners, one refinement (Figures
19D, E). The dental implant was successfully placed and the final restoration
subsequently installed (Figures 19F, G).

Treatment planning in adults is challenging as patients do not often present with a


full set of complete dentition. However, ClinCheck treatment planning is the best tool
for such patients requiring interdisciplinary contribution. The precise virtual prediction
of dental movements and implant site preparation allows the case to be prepared
and modified where necessary with the input from the orthodontist, periodontist,
prosthodontist and also the patient him/herself. The same applies for orthognathic
surgery cases in terms of arch coordination and anchorage management.

Case 12

Case 12 is an adult Caucasian female who had her lower left first premolar tooth
previously extracted. The dental space had since closed resulting in the lower dental
midline shifting completely to the left side (Figures 20A, B). Her chief concern was
that she had a narrow smile and crooked front teeth.

Multiple orthodontic plans for her were discussed. We could extract three more
premolar teeth (one from each other quadrant) to balance the occlusion, or remove
two upper premolar teeth and IPR the lower arch, or perform a non-extraction plan
and IPR the upper arch and keep the dental midlines uncorrected.
As the patient was also concerned with her narrow smile, the examination of her
supporting periodontal tissues led us to a fourth treatment option. A non-extraction
treatment was planned with the re-establishment of a dental space where the lower
left first premolar was. This treatment would require the patient to have a dental
implant placed post orthodontic treatment. The ClinCheck plans with the attachment
design (Figure 20C), simultaneous staging pattern and use of Class II elastics on the
left side was prescribed.

The implant space was favourably opened after the initial lot of 40 (31+9) aligners
(Figure 20D). The stage I dental implant was placed while the patient was still
undergoing active treatment with refinement aligners (Figure 20E). This allowed no
down time as osteointegration occurred.

The final restoration was placed (Figures 20F, G) after a total of 51 aligners.

Case 13

Case 13 is an adult male Caucasian patient with his dental spacing as his chief
concern. He had a Class-II dental malocclusion with a skeletal Clss-I facial pattern
and a horizontal direction of growth (Figures 21A, B, and C). He also presented with
a mild degree of microdontia, a deep bite tendency, and noted wear and attrition on
his dentition in general.

Few treatment options were discussed and many included the closure of the dental
spaces, fixed appliances with fixed functional appliances such as a Herbst. After
considering his dento-facial profile and his preferred choice of appliance, the final
treatment plan was to use the Invisalign appliance to open a third premolar space on
each of the lower quadrants, leaving the molars in full Class-II but canines in Class-I
dental relationship. These spaces will then be restored with prosthodontic
replacements, likely dental implants.

Opening of a third premolar space in the lower arch to treat a Class II dentition
orthodontically is not common. However, the distraction of the periodontium provides
good dental bony structures to allow implant placement. But it is necessary to
examine if the surrounding supporting periodontal tissues are able to contain the
dental movements required to achieve the desired end result. With the Invisalign
system, ClinCheck plans allow the visualisation of the dental movements, either
expansion and/or proclination (in this case), and exact measurements and
anchorage considerations can be made. Computer aided treatment decisions can
then be made more precisely as such.

A prosthodontist and periodontist were consulted and radiographs inspected. In


order to keep the option of a dental implant placement open, the position of the
mental nerve and its canal had to be considered. In this case, we decided to open a
single premolar dental space between the lower first and second premolar teeth
(Figure 21D).

Treatment was supported with optimised and conventional attachments, and Class-II
elastics. Treatment was completed in 21 months with 45 (26 + 19) aligners and one
refinement (Figures 21E, F, and G).

Case 14

Case 14 is an adult Caucasian female with chief concerns of dental spacing. She
presented as a Class-I dental on a skeletal Class-I horizontal base. She had a
certain degree of microdontia with upper and lower dental spacing. She also had a
deep bite tendency, retroclined upper and lower anterior teeth with deviated dental
midlines . Her dental profile was concaved and did not allow full dental space closure
without either dishing in her profile further, or involving bimaxillary orthognathic
surgery.

After considering various treatment options using the virtual ClinCheck treatment
plans , it was decided to have four premolar spaces opened up for prosthodontic
replacement, one in each quadrant. On the upper arch, the third premolar spaces
were to be opened between the upper first and second premolars. Whereas on the
lower arch, the third premolar spaces were to be opened between the lower canines
and the lower first premolars.

Both Class-II and Class-III elastics were used to control the anchorage and midline
correction. The completed dental occlusion was a Class-I canine and molar dental
relationship . The consolidation of dental spaces, closing of the anterior spacing and
establishing a full premolar space in this case has allowed an aesthetic outcome with
the preservation of the patient’s dento-facial profile .

The treatment duration was 15 months with a total of 31 (22+9) aligners and one
refinement.

(ii) Closing spaces

Premolar extraction cases in non-growing patients using the Invisalign appliance


maintain a tough challenge to the new clinician. The same principles on
compensatory movements mentioned as before are also applied. The increased
difficulty in adult treatment is the lack of vertical dentoalveolar growth and often
treatment duration could be longer.

Case 15

Case 15 is an adult female patient of Asian descent. Her chief concerns were her
crowded dentition. She presented as a Class-III dental on a skeletal 3 pattern with a
vertical growth pattern. She had bilateral posterior and anterior crossbites,
moderately severe upper and lower dental crowding, minimal over bite and overjet
with deviated dental midlines .

A camouflage treatment plan was designed with the extraction of the lower left first
and lower right second premolars. The ClinCheck plans shows a mixture of
optimised and conventional attachment designs, IPR and simultaneous staging .

Compensatory movements were planned with increased mesial root tip of the
immediate dentition distal to the extraction spaces and increased distal root tip of the
immediate dentition mesial to the extraction spaces . Class-III elastics was used to
control the anchorage. The plan was to complete the occlusion with a Class I canine
and Class III molar dental relationship.

The treatment duration was 22 months with 47 (32+15) active aligners with one
refinement .

Case 16
Case 16 is an adult male patient of Asian background. He presented with a
bimaxillary protrusive Class-I dental malocclusion on a skeletal 1 base with a normal
direction of growth. He had a protrusive dental profile, incompetent lips, an anterior
crossbite with minimal overjet and overbite .

The treatment plan was to have four first premolars extracted. The Invisalign
ClinCheck treatment plan was set up with both optimised and conventional
attachments with simultaneous staging. A vertical rectangular attachment was
placed on the lingual surface of the upper right instanding lateral incisor for aesthetic
reasons .

The compensatory movements in this case included an increased upper incisor


lingual root torque of 4 degrees, further intrusion of the lower incisors of 0.6mm,
increased mesial and distal root tip of the abutment teeth distal and mesial to the
extraction sites respectively of between 4-8 degrees .

Class II elastics were used initially to allow anchorage control and also to maintain a
Class I canine relationship. During the refinement stages, posterior box elastics
were used in corporation with the upper anterior precision bite ramps (G5 feature) in
order to control the vertical settling of the occlusion .

The total treatment duration was 26 months with 83 aligners (30+17+12+24) and 3
refinements . The refinement aligners were changed weekly.

Adult orthodontic treatment often constitutes dentitions with missing or absent teeth.
While prosthodontic replacements are more common now, there remains additional
surgical involvement and costs. Closure of large edentulous spaces with the
Invisalign appliance alone is challenging and should be discouraged. However, the
appliance could be incorporated with partial fixed appliances and TADs to enable us
to dictate the dental movements required.

Case 17

Case 17 is an adult male patient with an Asian background. He had a missing lower
left first molar and wanted to have it closed orthodontically to avoid the placement of
a dental implant. He was a mutilated Class-I dental malocclusion on a skeletal Class-
I base with a normal direction of growth. He presented with a congenitally missing
lower incisor, non-coincident dental midlines, missing upper right first molar (space
almost all closed up) and lower left first molar, proclined upper incisors with mild
upper and lower anterior crowding .

The treatment plan was to use a TAD on the lower left quadrant, in concurrent with
partial fixed appliance to close the lower left edentulous space; and do the rest of the
other orthodontic movements with the Invisalign appliance.

The ClinCheck plans demonstrated the use of optimised and conventional


attachments with an initial upper 30 and lower 40 active aligners . We allowed mesial
movement of the lower left molars within the first 30 active aligners as the upper
dental treatment progressed. At the end of the first 30 aligners, partial braces and a
TAD were placed and refinement aligners were ordered to complete all the dental
movements required .

In the refinement ClinCheck plans, precision cuts were designed to incorporate the
partial fixed appliances and triangular elastics with elastomeric chains were also
used to close the dental spaces as well as to settle the occlusion vertically . Although
the movement of the lower left molars were achieved with the partial fixed appliance,
mesial movements were also planned in the ClinCheck treatment to facilitate the
tracking of the dentition. Other finishing orthodontic movements were occurring in
concurrent with the partial fixed appliances.

The treatment duration was 28 months with 61 (30 + 31) active aligners and one
refinement .

(iii) Orthognathic surgery

Further AP correction in adult treatment that extends beyond the boundaries of the
dento-alveolar segment will require the involvement of orthognathic surgery. More
often than not, oral surgeons involved in the treatment planning and execution of
these cases treated with Invisalign would still prefer to have fixed appliances placed
a couple of months before the surgery is performed.

The decompensatory, pre-surgical movements are clearly visualised and well


executed by the Invisalign appliance. It is predictable and the patients and surgeons
appreciate the `forecast` of dental movements prior to the actual commencement of
treatment. Surgical movements can be better planned as such.
Case 18

Case 18 is an adult Caucasian female patient that presented with an uneven bite.
She was a Class III dental and skeletal 3 base with a vertical growth pattern. There
were mild degrees of upper and lower dental crowding, the lower midline and
mandible were both deviated to the right side with anterior and posterior crossbites
evident .

The strength of the virtual ClinCheck treatment plan allows us to view the pre-
surgical decompensatory movements clearly and plan the vertical and transverse
corrections digitally prior to the commencement of treatment. Marginal ridge
discrepancies, palatal cusps interferences and transverse inter arch discrepancies
can all be eliminated early and efficiently. Optimised and conventional attachments
were used, a simultaneous staging pattern was planned with a surgical simulation at
the end of the active aligners .

Treatment proceed with initial prescription with the Invisalign appliance. Two months
prior to the surgical date, fixed appliances were placed. The fixed appliances were
removed two months after the completion of the orthognathic surgery and refinement
aligners were ordered to complete the treatment. The surgical movements executed
were: maxillary advancement and posterior impaction, asymmetrical bilateral sagittal
split osteotomy (BSSO), and autorotation of the mandible.

After the first 17 aligners, fixed orthodontic appliances were placed and a surgical
date was set. Model surgery and surgical splints were fabricated as usual, and the
final surgical movements were confirmed. After two months post orthognathic
surgery, the fixed orthodontic appliances were removed and refinement aligners
were ordered . During the refinement stages, precision cuts were planned to allow
further correction of the malocclusion and dental midlines .

The treatment was completed in 17 months with 4+ months of fixed appliances and
27 (17+10) active aligners with one refinement .
Discussion

Pre-treatment evaluation, case selection and planning is of paramount importance in


using the Invisalign appliance. The study of the anatomy of the dentition, biology of
the subject and part psychological evaluation of the patient is the key to a smooth
treatment.

Age related treatment plans using the Invisalign appliance should be no different
from using conventional orthodontic appliances. Considerations of treatment include
the following.

 Sutural maturity.
 Biological age of the patient.
 Avoiding movement of teeth beyond the physiological boundaries of the
dento-alveolar segments.
 Examine the periodontal support of the dentition. One of the advantages of
using the Invisalign system is the ability to selectively orchestrate the dental
movements. The velocities of every tooth can be dictated and monitored as
treatment is planned and executed. Periodontally compromised teeth can also
be almost left stationary during treatment with minimum and/or no mechanical
pressure.
 Examine if the soft tissues can hold up against camouflage treatment.
 Examine for sufficient clinical crown heights for aligner adaptation.
 Decide if it is necessary to have extractions.
 Plan for sufficient and appropriate attachments.
 Plan for compensatory movements to overcome the side effects of the dental
movements.
 Do not hesitate to use any other orthodontic auxiliaries to facilitate your
aligner treatment plans.
 Examine the need and extra costs involved if prosthodontic and orthognathic
work were to be included.
 Examine stability of the result achieved and plan for long term retention where
necessary.
Conclusion

With digital treatment planning and automated manufacturing, many traditional


barriers of orthodontic treatment are removed. The three-dimensional visualization of
the treatment outcomes, differential treatment plans and/or extraction/non-extraction
treatment plans, and foreseeing Bolton’s’ discrepancies, assist the clinician in the
orthodontic office. However, many new clinicians tend to forget that the diagnosis
and treatment planning still lies well within our responsibilities.

Computer aided treatment planning does not understand dental anatomy, biology of
tooth movement, biomechanics and material properties as well as we do. The
complete reliance on it will lead to undesirable treatment outcomes. We are
ultimately responsible for the treatment of our patients and we must understand the
strength and weaknesses of the appliance in order to exploit the best out of what is
available, and offer our patients the best treatment modality possible.

As with any new appliance, treating complex cases using the Invisalign system
would have a learning curve. However, thoroughly understanding the limitations of
the appliance and defaults of the ClinCheck software, outstanding results can often
be achieved predictably. Clear appliance therapy is here to stay. Embracing
technology without first applying basic orthodontic concepts is a dangerous affair and
should be discouraged. Lateral thinking and often, thinking outside the common box
allows us to further our art and achieve quality treatment results, more efficiently.
Reference

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Figures

Figure 1A. Pre-treatment images of case 1.

Figure 1B. Initial ClinCheck plans with only 15 active aligners and an elastic simulation. Precision
cuts for elastic wear were not available as case was treated pre G3.
Figure 1C. Final ClinCheck plans with slower velocity and modification of attachment designs.
Precision cuts for elastic wear were not available as case was treated pre G3.

Figure 1D. Completion images of case 1.


Figure 2A. Pre-treatment images of case 2

Figure 2B. Initial ClinCheck plans with only 18 upper active aligners and 12 lower active aligners.
Optimised attachments are placed on the upper anterior teeth.
Figure 2C. Final modified ClinCheck plans with 25 active aligners and vertical rectangular
attachments placed on the lingual surfaces of the upper anterior teeth.

Figure 2D. Completion images of case 2.


Figure 3A. Pre-treatment images of case 3.

Figure 3B. Initial ClinCheck plans with uncorrected impacted lower second premolars.
Figure 3C. Final modified ClinCheck plans with 40 active aligners and corrected lower second
premolar positions.

Figure 3D. Completion images of case 3.


Figure 4A. Pre-treatment images of case 4.

Figure 4B. ClinCheck plans showing sequential “staggered” staging pattern.


Figure 4C. Clinical images showing sequential molar distalisation augmented by using Class II
elastics.

Figure 4D. Completion images of case 4.


Figure 5A. Pre-treatment images of case 5

Figure 5B. Images showing the ClinCheck plans and staging pattern of case 5.
Figure 5C. Completed images of case 5.

Figure 6A. Pre-treatment images of case 6.


Figure 6B. ClinCheck plans for case 6.

Figure 6C. Completed images of case 6.


(A) (B)

(C) (D)

Figure 7. Pre and post dental arch expansion in adults using the Invisalign appliance. Case I
(A, B) and Case II (C, D).

(A) (B)

Figure 8. Dental arch expansion. (A) cases to avoid. (B) cases to select.
Figure 9. Dental arch expansion: showing the centre of rotation and the expansion arc.
(Image source: Wikimedia commons, free media repository)

Figure 10. Overcoming the side effects of dental arch expansion: intruding and increasing
the buccal root torque, placement of attachments, and over expansion. (Image source:
Wikimedia commons, free media repository)
Figure 11A. Pre-treatment images of case 7.

Figure 11B. Pre-treatment OPG and lateral ceph of case 7.


Figure 11C. ClinCheck plans for case 7.

Figure 11D. Completed images of case 7.


Figure 11E. Completed OPG and lateral ceph of case 7.

Figure 11F. Overall and regional superimposition of case 7.


Figure 12A. Pre-treatment images of case 8.

Figure 12B. Pre-treatment OPG and lateral ceph of case 8.


Figure 12C. ClinCheck plans for case 8.

Figure 12D. Completed images of case 8.


Figure 12E. Completed OPG and lateral ceph of case 8.

Figure 12F. Overall and regional superimposition of case 8.


Figure 13A. Pre-treatment images of case 9.

Figure 13B. Pre-treatment OPG and lateral ceph of case 9.


Figure 13C. Post twin block treatment images of case 9.

Figure 13D. ClinCheck treatment plans of case 9.


Figure 13E. Completion images of case 9.

Figure 13F. Completion OPG and lateral ceph of case 9.


Figure 13G. Overall and regional superimposition of case 9.

Figure 14A. Pre-treatment images of case 10.


Figure 14B. Pre-treatment OPG of case 10.

Figure 14C. ClinCheck plan for case 10 showing simultaneous staging and an elastic
simulation.
Figure 14D. Completed images of case 10.

Figure 14E. Completed OPG of case 10.


Figure 14F. Final restoration placed for case 10.

Figure 14G. Periapical radiographs of implant and final restoration for case 10.
Figure 15A. Pre-treatment images of case 11.

Figure 15B. Pre-treatment OPG of case 11.


Figure 15C. ClinCheck plans for case 11.

Figure 15D. Images of case 11 after the 31+9 aligners. Images taken at refinement 2.
Figure 15E. Completed images of case 11 after the placement of final restoration.

Figure 15F. Completed OPG of case 11 after the placement of final restoration.
Figure 16A. Pre-treatment images of case 12.

Figure 16B. Pre-treatment OPG and lateral ceph for Case 12.
Figure 16C. ClinCheck plans for case 12.

Figure 16D. Completed images and CT scan of mandible of case 12.


Figure 17A. Pre-treatment images of case 13.

Figure 17B. Pre-treatment OPG of case 13.


Figure 17C. ClinCheck plans showing the establishment of four premolar spaces.

Figure 17D. Completion images of case 13.


Figure 17E. Comparison of pre and post treatment profiles of case 13.

Figure 18A. Pre-treatment images of case 14.


Figure 18B. Pre-treatment OPG and lateral ceph of case 14.

Figure 18C. ClinCheck plans of case 14.


Figure 18D. Compensatory movements planned for case 14.

Figure 18E. Completion images of case 14.


Figure 18F. Completion OPG and lateral ceph of case 14.

Figure 18G. Overall and regional superimposition of case 14.


Figure 19A. Pre-treatment images of case 15.

Figure 19B. Pre-treatment OPG and lateral ceph of case 15.


Figure 19C. ClinCheck plans of case 15.

Figure 19D. Compensatory movements planned for case 15.


Figure 19E. Posterior box elastics with G5 precision bite ramps on the upper incisors.

Figure 19F. Completion images of case 15.


Figure 19G. Completion OPG and lateral ceph of case 15.

Figure 19H. Overall and regional superimposition of case 15.


Figure 20A. Pre-treatment images of case 16.

Figure 20B. Pre-treatment OPG of case 16.


Figure 20C. Images at refinement, placement of partial fixed appliances and TAD.

Figure 20D. ClinCheck plans at refinement of case 16.


Figure 20E. Completion images of case 16.

Figure 20F. Completion OPG of case 16.


Figure 21A. Pre-treatment images of case 17.

Figure 21B. Pre-treatment OPG and lateral ceph of case 17.


Figure 21C. ClinCheck plans of case 17.

Figure 21D. Refinement arch co-ordination with precision cuts and elastic bands.
Figure 21E. Completion images of case 17.

Figure 21F. Completion OPG and lateral ceph of case 17.


Figure 21G. Overall and regional superimposition of case 17.