In orthodontic treatment, we are fortunate to have several different resources to address a variety of malocclusion. Since the 1980’s TAD’s (temporary anchor devices) were introduced as a tool in orthodontics. They allow us to use an anchorage system that widens the scope of treatment plans.

Similar to many other tools in orthodontics, TAD’s are primarily used with fixed appliances to facilitate different corrections. Direct or indirect anchorage setups can be combined with braces.  In an aligner practice, the use of TAD’s also becomes an option and can serve to increase the ability of the orthodontist to setup patient care for success.  Consider we can use the force systems and the strengths of a TAD, to enhance aligner therapy.

There are many options for integrating TAD’s with aligner systems. I am not an expert with them, but I want to share my experience in using this orthodontic tool to better serve patients.  I have found TAD’s help broaden the range of applicability in complex, aligner treatment.

Molar Intrusion

TAD’s can be placed and supported by elastics or chain to intrude posterior teeth in combination with an aligner system.  Usually buccal and lingual TAD’s with elastics will support the intrusion.  If lingual TAD’s are considered, add a significant amount of expansion to counteract the lingual component in the intrusion.

Pontics and TAD’s

The use of aligners allows for custom pontics to be placed in edentulous regions. This allows for the pontic and the aligners to be seamlessly integrated with a TAD supported, pontic crown.  The temporary crowns can be used as an anchorage system to facilitate mesial or distal movement where insufficient posterior support is present.

Segmental Treatment

Sometimes, the use of limited, fixed appliances are best suited for significant root movements or tooth translation. Segmental mechanics with a TAD supported appliance allows for challenging movements in localized areas.  A TAD supported pontic with bracket segments can be used along side aligner therapy.

TAD’s and Power Arms

In some cases, tools available in the Invisalign system can be combined with TAD’s to broaden the range of movements. Power arms can be used to support significant mesial movements and root control in an otherwise challenging aligner force system.

These are but a few examples of the integration of TAD’s into aligner therapy. These tools offer many creative options when we allow our imagination to develop treatment plans for our patients.

Compliance is King

When treating adolescents with Invisalign clear aligners, one of the biggest concerns among both parents and orthodontists is the fear that kids aren’t going to wear the aligners and that they lack the responsibility. The irony though is that we often have better leverage over compliance in Invisalign treatment as compared to fixed appliances. With our non-compliant Invisalign patients, there is always the threat of transitioning to braces. However, in teens with braces who fail to adequately brush and who won’t wear their rubber bands, at some point the only thing we have left to bargain with is removing appliances, which to them isn’t much of a threat at all.

Orthodontists who are concerned with teenagers’ compliance feel this way mainly as a result of limited experience versus having actual compliance issues with teens in aligners. Poor compliance leads to a poor outcome no matter how you decide to treat a case. Therefore, it is essential that we anticipate potential stress points that will ultimately have a negative impact on patient motivation, and work to minimize these obstacles by actively steering the family towards the treatment option with the best fit for the patient’s lifestyle. This comes with special emphasis on the patient because the parents’ motivation has not been shown to correlate with the child’s level of cooperation. When the adolescent has bought into the idea of orthodontics, and into the idea of clear aligners, we know compliance will be excellent so we need to make sure the parents’ are on board with the ideal approach.

When parents do have hesitations, they come in a few different flavors:

1. They think braces are less responsibility. Many parents fail to understand that braces require just as much work as Invisalign treatment, but that the required tasks are just different. This sort of objection opens the door to an important discussion about the patient’s role in treatment. Difficulty with hygiene around braces, the dietary restrictions, the need to wear elastics, potential discomfort, etc. can be substantial challenges for patients, so they will really need to be up to the task if we are going to deliver the best outcome. Providing much needed perspective and putting your recommendation within the context of patient motivation and it’s importance to treatment is the best approach to allay these concerns.
2. “What ifs.” Some parents find it hard to trust their child with the investment they are making and get hung up on the “what ifs” of Invisalign treatment. Offering a no cost transition into braces is the easiest way to take this concern off the table and gives you a nice, uncomplicated bargaining when if the patient isn’t living up to their end of the deal.
3. Does it really work? Every now and again you’ll encounter a parent who scratches their head about plastic aligners, and you’ll need to provide reassurance. Some may have even been told by their dentist, a friend, or a less experienced orthodontist that “Invisalign treatment doesn’t work.” A simple explanation that both braces and Invisalign clear aligners do the same things (i.e. straightening teeth) and that the teeth cannot tell the difference puts these concerns to bed.
4. Differences in price. If we know Invisalign treatment is a better fit for that patient, why are you then charging more to make everyone’s life easier? Since we are providing a service and not a product, treatment fees should be based on the complexity of treatment and treatment goals.

Understand Your Patients

When we fail to adequately engage the patient in the decision making process, we see less motivation, poor cooperation, extended treatment times, and compromised results, yet I still see many orthodontists taking patients’ stated desires for “braces” or “colors” at face value instead of looking at the bigger picture. Unless the patient or a sibling has already had treatment, most people don’t have much perspective on what orthodontic treatment will be like and it is up to you to show them what is possible. Don’t abdicate your responsibility to your patients. Be proactive and really listen to what they are telling you about themselves so you can help them make the right choice.

Et monuit

Extraction treatment with aligners is possible and can be effective, but be warned. I regularly warn doctors that more complex treatment plans with aligners do need a minimum level of proficiency. The reason being, that anyone can finish a successful case. The true measure of your skill is how you recover from a case that doesn’t go “by the book”.

Warnings aside, we all will encounter patients that will insist on aligner therapy where an extraction treatment plan is indicated. Some of you like a challenge like I do, and may elect to treat select cases with this technique. I can appreciate that when done properly, cases with extraction treatment can be predictable and a positive experience for both the orthodontic practice and patient.

It’s a different skill

I know many orthodontists who use aligner therapy regularly, who do not do extraction treatment with Invisalign. Depending on your patient demographics, you may never feel the need to use this technique. If you are pulling punches on teen cases, Class I, Class II, deep bites, etc, just stay away. It’s really not funny to see doctors who have treated very few cases jump into aligner extraction treatment. Sometimes they get lucky, but often I see an orthodontist leave with a bad taste for aligner therapy when there are plenty of opportunities to treat other types of cases. Sometimes, you don’t know what you don’t know.

Diagnosis, diagnosis, diagnosis

Are you sure it’s an extraction case? Unlike fixed appliances that expand and procline, Invisalign is a closed system that has to be intentionally designed to procline and expand. From my experience, it’s strength is in retraction and constriction. IPR, expansion, distalization, etc. are tools available in an aligner system if integrated to address various crowding issues.

Measure twice, cut once

Use Clincheck as the diagnostic tool it is designed to be. I enjoy how a patient can be run through various treatment scenarios before even starting to move a single tooth. This is a powerful tool often overlooked. You don’t have to guess, simply setup various plans and see how the outcomes change. Then select the treatment plan that best matches your treatment objectives.

Setup for success

Extraction treatment often caters to the mastery of all 3 dimensions with an aligner system. The most predictable extraction cases present with severe crowding where tipping teeth into the extraction sites leads to a great outcome. Some cases are more challenging when a deep bite is present and when root movements are necessary. Often, the most challenging cases present as bimaxillary protrusion with little to no crowding.

Some of the considerations when planning extraction cases include objectives in anchorage, root control, attachment design, staging, incisor root torque, curve of Spee and AP changes. It is important to control the roots of the canines, bicuspids and molars. Add significant attachments on canines, bicuspids and molars with maximum length from occlusal to gingival, or better yet, optimized designs.

Consider the anchorage in each case (mild, moderate or maximum). G6 protocols should never be used when any mesial movement of the posterior teeth is incorporated and is only effective in maximum anchorage cases. Significant mesial movement of posterior teeth may also require attachment on second molars and more hefty attachments on the first molars.

Don’t jump without a parachute

Especially if you don’t have many cases under your belt. Seek mentorship, learn from all the CE that is available at lectures and online. Don’t forget as  orthodontists there are many tools at our disposal. Inform patients that finishing with fixed appliances is a possibility. It is best to warn than to give excuses.

As a top 1% Elite Provider of Invisalign, who still does all her own “clinchecks”, there is a point where you need to set up a system for managing your “clinchecks.”  Through trial and error, I have figured out a few ways to manage this important aspect of our patient care.

My goal here is to give you a few strategies that you can immediately implement to help you get through your workload and still have time to play with your children, see your patients and have a life!

First strategy is to carve out 30-60 minutes in the course of your daily practice to sit unerupted and evaluate your clinchecks.  Generally for most offices, the 10-12 am times slots can be the toughest to fill.  This would be a great time to have your staff schedule you out of the clinic for 30-60 minutes and give you unerupted time to do your clinchecks.

You will find that as you do more and more Invisalign, your schedule may change. For example, because we have much fewer patients with braces and therefore less full bondings and debondings, our morning ( long appointments) became less needed.  Now most of the week, we start seeing patients at 1 pm and work until 6 pm.  This now gives me time in the morning to manage my clinchecks.

Second strategy goes along with the first, and that would be once you sit down to review your cases, set a timer for x amount of minutes.  Furthermore, set goals for yourself to finish so many cases in the time you have carved out.  This alone is one of the best things I have done to not get “buried” in a clincheck.

The third and final strategy is to stop obsessing over your clincheck.

I see so many doctors who are so focused on the last .25mm of movement in their first clincheck that they modify the case over and over again.  This frustrates them because the case is taking longer than they planned to finalize.

They begin to wonder if all this extra time in front of the computer is worth it!

Let me ask you a few questions.  How many of you are placing brackets on teeth with .25mm precision?

How many of you are placing your brackets with such perfection that you never have to reposition a bracket?

After 31 years of direct bonding, repositioning is alive and well in our practice.  The bottomline is repositioning is an expected part of the process.

Do I get upset with my bonding skills because I have to reposition?

Of course not.  I would prefer to get it right the first time, but that just does not happen the majority of the time.

So look at your clinchecks the same way.  You do not need to get 100% of all the movements perfected in this first order of aligners. My goal is to get 80-90% of the objectives reached and I know that during the refinement stage I can gain the final 10-20%.

It is so much easier and more efficient to manage the remaining movements in refinement than to try to solve all the patient’s orthodontic problems in that first order.

When you have a large inbox of cases to set-up and manage, focusing on the more important or pressing issues first will allow you to work through your case load more efficiently and get to the approval button sooner.

So stop obsessing!  Get the clincheck set-up effectively and efficiently and work within a fixed time frame to manage your schedule.

Follow these strategies and they will make your time in front of your computer more enjoyable and productive and help you manage your clinchecks with minimal stress and maximum efficiency.

The patient demand for aligner therapy has grown over the years, and yet the challenge as orthodontists has been proper case selection and learning what types of patients can be treated with Invisalign. Every appliance we use has limitations, and aligners are no different. The opportunity we have is that technology has advanced the effectiveness of aligner therapy and increased the range of treatable malocclusions from Class I crowding to a range of problems that were once thought to be unachievable.

There are many perceived aligner therapy limitations.  Let’s review some of those areas that are commonly perceived as beyond the reach of aligners, and review a few Invisalign treatments that addressed these malocclusions:

Significant AP Correction

Deep Overbite

Anterior Openbite

Significant Root Movement

Bicuspid Extraction Therapy

There is a common misconception amongst the public and the orthodontic specialty that orthodontists are in the business of braces and wire bending. As patient demand shifts to expecting the same results from orthodontists but in more convenient and comfortable modes of treatment, it is important for us to remember that we are not in the braces business. Our specialty should continue to focus on the results we want to provide patients, and continue to explore modalities that fit into the experience patients desire. Properly implementing aligner therapy into an orthodontic practice does not have to compromise on these expectations.

A common issue seen with aligner therapy is the development of posterior open bites. This problem appears to have become more common place as aligner treatment has increased. More evidence on the occurrence of posterior openbites and the etiology is needed, and most practitioners are having to deal with this pain point.

Some of the theories about posterior open bites come from various anecdotal observations. The most common being that aligners cover the occlusal of the posterior teeth. Therefore, occluding on the aligners, especially in brachyfacial patients, tends to develop this issue. I believe that is a factor in select patients. The most common reasons I have seen posterior open bites develop stem from the lack of occlusal corrections that are not fully incorporated into the virtual treatment plan. Other reasons are related to unfinished corrections that are primary factors in developing anterior interference.

Next time you see a posterior open bite develop, keep a few factors in mind so you can properly address this issue:

Upper Incisor Inclination

Lack of torque on the upper incisors can lead to heavy anterior occlusion that discludes the posterior teeth. Therefore, developing a posterior openbite. Full incorporation of lingual root torque, plus careful incorporation of incisor retraction in the treatment plan are important factors to consider when preparing your clinchecks.

Curve of Spee & Lack of Space

Leveling the curve of Spee in treatment is a very common factor in the appearance of posterior openbites. Deep bite cases should be corrected with proper leveling, which requires additional space in the dental arch. Much like reverse curve arch wires are used in fixed appliances, a reverse curve aligner staging technique that provides sufficient space within the arch is critical to avoid heavy anterior contacts and an open posterior occlusion. This is exacerbated when the patient has a deep bite and undergoes Class II correction. If the leveling is not completed as the overjet decreases, a posterior open bite will worsen.

Clincheck Overjet

The virtual overjet in the clincheck is an area I recommend you focus as you develop your plans. Many doctors want the clincheck to show ideal “anterior coupling” and contact. Since there is a layer of plastic and a variable posture from extended wear of a series of aligners, the virtual treatment plans should be tailored to finish with no anterior occlusion.

AP Correction

Lack of AP correction and minimal overjet that is common in Class III cases will also lead to heavy anterior occlusion and posterior open bites due to the fact that elastics have not been worn or have not completed their correction.  In these cases, continuing elastic wear is important to regain posterior occlusion.  Once overjet is gained, the heavy anterior contacts are resolved and posterior contacts are achieved.

Bolton Discrepancy

In the presence of a tooth-size discrepancy, the resulting lack of overjet can also contribute to a posterior open bite. Addressing this factor via maxillary restorations or mandibular IPR are possible solutions to be considered. As I stated previously, the clincheck should be critiqued to avoid a plan that has minimal to no overjet.

Anterior Extrusion

Many Clinchecks I have reviewed have maxillary anterior extrusion in the presence of a normal or even deep bite. Although a plan to improve the smile line by anterior extrusion may be indicated in some cases, my experience is that this is commonly incorporated into Clinchecks even when this goal is not desired. Carefully monitor the anterior movements in your cases, and remember that the lower incisor intrusion that is necessary to allow for the maxillary teeth to extrude, is not 100% expressed without overcompensation. I have done a “forensic” review of many cases, where a more predictable movement (upper incisor retraction with simultaneous extrusion) is incorporated with a less predictable movement (pure lower incisor and canine intrusion), without proper safeguards to compensate for the varying degrees of expression in this appliance.

Second Molars

Finally, I would like to make a case for the positioning of your second molars. These teeth will impact your posterior occlusion, and I have seen many cases where they were ignored, and molar extrusion was incorporated on the maxillary arch that lead to an occlusion only on the incisors and second molars. When you desire proper posterior occlusion, don’t ignore some of the posterior teeth that contribute to that occlusion.

Using Additional Aligners Effectively

Whether you still call them refinement aligners or midcourse correction, ordering additional aligners for Invisalign treatment should not be considered a treatment failure. In fact, this should often be considered part of the process in aligner therapy. Patients are advised that aligners come in batches, and as such, each batch is meant to achieve certain goals.

In many cases, the first batch is designed to achieve large movements and critical stages in treatment to correct the malocclusion. Sometimes, this is space closure, arch development, vertical changes, expansion, root movements or AP correction. The initial clincheck is designed to treat the most challenging issues and develop a plan that gets the patient closer to the end-goal. Sometimes that initial clincheck gets the final result achieved, but it is common where fine tuning is desired.

In the presence of multiple problems, especially in the three dimensions of space, more finishing is important and we should not dwell on refinement rates. Additional aligners help to finish the case and begin preparation for retention. There are times, when more severe treatment challenges dictate for a differing hierarchy of movements that will require different attachments that cannot perform adequately if everything is expected to be completed in one round of aligners.  This is where one or more sets of additional aligners are required to achieve a comparable result to what we would expect from fixed appliance treatment.

Through efficient use of Invisalign, ordering additional aligners can still keep treatment on track, maintain the expectations of treatment time with the patient, and practice efficiency.