9/16/2011 GP Managing Aligner Tracking Issues: Tips and …€¦ ·  · 2015-08-31Tips and Techniques for keeping treatment on course invisalign® Aligner Tracking Issues ... Recent

9/15/2011

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Managing

Tips and Techniques for keeping treatment on course

invisalign® Aligner Tracking Issues

• Dr. Karol Miranda

● DDS Universidad Latino Americana de Ciencia y Tecnología, (ULACIT), Costa Rica.

● Private Practice for 6 years

● Actively treating Invisalign patients

● Associated professor at the ULACIT, College of Dentistry

● Presently working with Align Technology, and involved in clinical education at the Treat Facility in Costa Rica

The statements, views and opinions expressed in this program and related course materials are those of

the speaker.

Align Technology, Inc. may not endorse such statements, views or opinions.

Attendees are responsible for legal and regulatory compliance of any marketing and referral programs.

Unplanned reaction

Not on course

Probable Root causes

1. Lack of inter-proximal space

2. Attachment disengaged

3. Moving to quickly

Possible Reactions

1. Buttons and elastics

2. Go back to the best seating aligner

3. Mid course correction

Regardless of which decision you

make… it’s inconvenient and costly

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Research indicates that 90% of the time clinicians after trying the other two methods* still need a

Mid-Course Correction for the same issue

90%

*Buttons/elastics and/or back to best seating aligner

Being efficient… time management

GROWTH

Planning to avoid and/or lessen the impact of the bumps along the road Today’s lecture will focus on being proactive

instead of reactive to Invisalign® aligner fitting

issues. For more information on individual

situations in which the aligners stop tracking;

please refer to the attached PDF file.

Please note!!!

Built into the ClinCheck® Treatment Plan

Planned reaction (Class II elastics)

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Built into the ClinCheck® Treatment Plan

Planned reaction (IPR and attachments)

To be proactive you need to understand these tooth movement

principles of invisalign® aligners

1. Apply a pushing force on unlimited tooth surfaces… as required

2. Multiple tooth movements can be performed at one time… torque + rotation + leveling

3. Force levels are calculated and adjusted as needed for each tooth and/or multiple teeth within optimal biological levels

1. Apply a pushing force on the available tooth surface(s) … as required

2. Multiple tooth movements can be performed at one time… torque + rotation + leveling

3. Force levels are calculated and adjusted as needed for each tooth and/or multiple teeth within optimal biological levels

Bench tested with the Force Measurement

Apparatus (FMA)

Let’s look at a situation where these principles were programmed

and implemented clinically

Courtesy of Dr. Janice Grossman

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Initial records Initial records

Recent history of fixed orthodontics

Initial ClinCheck®Beginning Initial periapical radiographs

Initial ClinCheck®Projected End

A dynamic representation of the right cuspid root movement

Simulated roots for demonstration purposes… not real

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A dynamic representation of the central incisor root movements

Simulated roots for demonstration purposes… not real Simulated roots for demonstration purposes… not real

A dynamic representation of the left cuspid root movement

Goal was parallel roots, crowns and equal implant spaces

ClinCheck® treatment model was based on the tooth movement principles of Invisalign® aligners

1. Creating surface(s) to push on… Smaller pontics and large attachments

Creating surface(s) to push on…

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2. Multiple tooth movements can be performed at one time… torque + rotation + leveling

Staging

3. Force levels are calculated and adjusted as needed for each tooth and/or multiple teeth within optimal biological levels

Six months progress (½ the way)Initial

Six months progress

Total treatment time 11 months

Before

After

Final position

The root parallelism is very remarkable… no refinements or auxiliary treatment

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Using your best diagnostic and treatment planning tool(s) to help you stay on course

Top 6 things you need to review in your ClinCheck® model to stay on track

Interincisal angleInterproximal space

Attachments

Tooth size discrepancy

Root MovementsInitial Bite Set

Bitesetting

TIPSUse articulating paper

90 degree buccal shots

TIP Compare photos with ClinCheck model The diagnosis and treatment approach is based on what you see!! 45 degrees

60 degrees

90 degrees

Class I or Class II?

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Anterior overjet view helps determine the most anterior

contact(s)

TIP TIPCan send photos of study models with

occlusal marks and scribe lines… if needed to verify the bite

Patient appears to be

biting with the

mandible forward?

Photos with articulated marks verified the patient had

postured forward in the initial photos… bite was reset

There is more inter-occlusal contacts

There are anterior

inter- occlusal stops

Bite set… based on inaccurate photos

Bite set… based on accurate photos

Inaccurate Bite Set

1.Initial bite set

Unnecessary Movements

Occlusal problems

Unnecessary IPR Midline Shift

Possible Clinical Consequences

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Root movement

Understand where and type!!!

Relative movements are more

Predictable

and stable

Relative extrusion Pure extrusion

Use these tools to obtain information on root movements

Which teeth will have

significant root

movement?

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Superimpose Superimpose

Where are the roots moving?

White is the final stage

To help identify root movementDraw imaginary lines

Does the right central need an attachment?

Buccal view is great to evaluate the amount and type of incisor retraction

Can you see that the maxillary

incisors had bodily retraction? For Lingual root

torque the software will add Power Ridges

Using the ClinCheck® to identify root movement

You can see them in the Treatment

Overview

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Do the lower incisors need attachments?

With the long clinical crowns and black triangles… this amount of

incisor root movement shouldn’t need any attachments

The Grid It provides linear measurements

2mm of mesial root uprighting… needs an

attachment

Before After

Tooth Movement Assessment TMA

Another great tool to help identify some significant root movements

TMA helps quantify what you see

… and plan ahead to take care of any challenging tooth movements

challenging tooth

movements

Buttons and elastics for rotation and A-P… a

planned reaction in the Invisalign®aligner

treatment

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CC: Maxillary midline

diastema

History of maxillary first

molar extractions

What you may expect if

the principles of

Invisalign aligner tooth

movement aren’t

followed

Watch the maxillary central incisors!!Progress records… since the maxillary central

incisor crowns were starting to tip mesial

Root cause(s)

Crowns moving mesial from the

beginning

Timing of attachments

Lack of pushing surfaces

Proactive

Different staging

Place attachments from the start

Create space around the teeth

Reactive

Refinement

Auxiliary techniques

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Mandibularexcess 3-3

Mandibular excess 6-6

0.88mm 3.88mm

Teeth 6-7 9-10

Space 0.7mm 0.5mm

Teeth 27-28 28-29 29-30 19-20 20-21

IPR 0.3mm 0.3mm 0.3mm 0.2mm 0.2mm

Auxiliary treatment required to achieve root parallelism

Buttons and C-Chain to tip the roots mesial

An example of before and after with the use of auxiliaries

BEFORE AFTER

We are not going to let

the same result take

place a second time.

Attachments as well as mesial and distal tooth surfaces to push on……

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To help close the maxillary spaces

Did you notice the U/L incisors

had lingual root torque?

Can you see that the U/L

incisors have bodily

retraction?

Identify root movement with imaginary scribe lines & superimposition

Superimpose tool is used to identify

teeth with bodily movement (retraction).

Tooth sizediscrepancy

How important is TSD?

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Where would you say the TSD is? Maxillary lateral incisors are smaller than ideal

Post Splint

Centric Relation Occlusion(CRO)Treatment for 6 months

with the invisalign® System

TSD resolved by creating space around the

undersized maxillary laterals

Harmony established with a combination of

Invisalign and restorations

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What if… Tooth Size Discrepancy is not

considered?

Could result in :

1. Overretraction of the anterior teeth… posterior

openbite.

2. Compromised esthetics

3. Less than ideal occlusion… poor stability

AttachmentsGo Optimized

Add attachments to improve the engagement between the tooth

and the aligner to make root movements more predictable

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If you want to add or remove attachments use the Attachment Interface

The Future is even brighter in the world of attachments

SPACEInteproximal

Create spaces in the direction the teeth are moving this will improve the engagement

between the tooth and the aligner, making the movement more predictable

Stage 0: No space to move the lateral

Stage 3: Space is being created for the lateral

IPR before aligner 15IPR is prescribed when there is adequate clinical

access

ANGLEInterincisal

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Why the inter-incisal angle is so important?

1. There is a close relationship between the inter-incisal angle and the angle of the condylar eminence… affecting the functional occlusion

2. Esthetics

3. Long term stability… retention

Reviewing the ClinCheck® Treatment Plan

Inter-Incisal Angle

The Inter-incisal angle is patient specific

There is no standard Inter-incisal angle it is based on the occlusion

Being proactive at the ClinCheck® treatment planning stage can help keep you and the patient on track

Providing excellent results

It was a Pleasure!!! QUESTIONS?

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