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Table of Contents INTRODUCTION . 2 Getting Quality Clinical Outcomes with Invisalign. 2 Invisalign Applicability . 3 DIAGNOSIS AND TREATMENT OPTIONS 1. Crowding . 4 2. Spacing. 10 3. Narrow Arches . 16 4. Crossbite. 20 5. Deep Bite . 24 6. Open Bite . 28 7. Class II . 32 Invisalign 8. Class III . 38 CLINICAL NOTES Treatment IPR . 5 Tooth Size Discrepancy . 11 Planning Staging . 12 Auxiliary Treatment. 12 Guide Expansion . 17 Attachments. 25 Anchorage . 42 APPENDIX Prescription Form Tips. 44 Glossary . 46 Index. 48 Credits . 54 Invisalign Treatment Planning Guide 1 Align Technology, Inc. Introduction HOW TO USE THIS GUIDE Getting Quality Clinical The guide is organized by patient diagnosis. ABOUT THIS GUIDE Match your patient’s diagnosis to the appropriate Outcomes with Invisalign The goal of this guide is to provide you with a diagnosis decision tree to see some possible treat- decision making tool you can use while selecting ment options. Read the accompanying treatment Successful clinical outcomes with Invisalign and treatment planning your Invisalign cases. notes and evaluate your options given your start with attention to detail during case By outlining typically used Invisalign approaches Invisalign experience level. See Figure A, below. selection and treatment planning. Here are and discussing their complexity and predict- five guidelines for setting up your cases that ABOUT THIS SERIES ability, we hope to make the treatment planning pay great dividends later: This guide is the first in a three-part series options and implications more clear for you of Invisalign patient care references, comple- to evaluate. 1. Submit high quality records. Accurate menting the ClinCheck® Evaluation Guide PVS impressions and clear patient photos and (D4458) and the Invisalign Clinical Monitoring Align Technology is not a provider of medical, radiographs are critical for the creation of your Guide (D4219). dental or healthcare services and does not and ClinCheck treatment plan and the manufactur- cannot practice medicine, dentistry or give med- Collectively, the guides provide the Invisalign ing of the aligners. The number one reason for ical advice. This guide is not a comprehensive clinician with useful tips and insight on the poor aligner fit is an incomplete or distorted volume on orthodontic treatment planning nor entire Invisalign process, from start to finish. PVS impression. a detailed how-to manual on treating Invisalign For additional copies of any of these three cases. As the treating doctor, you are solely guides, please contact your local Invisalign responsible for the treatment of your patients, Sales Representative or Align Customer including but not limited to the outcome of such Support at 888-82ALIGN. treatment or decision to move forward with treatment. You are solely responsible for the treatment of your patients. When in doubt, consult another doctor for further guidance. SUGGESTED INVISALIGN EXPERIENCE LEVELS PATIENT DIAGNOSIS less complex more complex INVISALIGN TREATMENT OPTIONS more comprehensive TREATMENT NOTE NUMBER (FOUND ON FACING PAGE) Figure A. Diagnosis and Treatment Options decision tree less comprehensive Invisalign Treatment Planning Guide 2 Align Technology, Inc. 2. Be detailed when treatment planning. Invisalign Applicability DOCTOR EXPERIENCE AND CASE The more clear and specific your directions are SELECTION on the Invisalign Prescription & Diagnosis form, With experience, doctors can use Invisalign the better your Align technician can provide the to treat a majority of adults and adolescents who As with any orthodontic technique, there is set up that meets your expectations. Remember, want a better smile. Invisalign is effective across a learning curve with Invisalign. If you are an the treatment plan is yours—not Align Technology’s. a broad range of malocclusions. Invisalign Initiator (0–15 Invisalign cases), you may want to select relatively simple cases and 3. Review ClinCheck carefully. ClinCheck is WHAT DOCTORS CAN TREAT WITH INVISALIGN choose more predictable treatment approaches. • Arch length discrepancies the virtual representation of the treatment plan, As you progress to the Experienced (16–50 (Crowding, Spacing) and the model used to fabricate the aligners. Invisalign cases) and Advanced (more than 50 What you approve in ClinCheck is what you’ll • Transverse discrepancies cases) levels, you will want to select more com- get in the aligners. (Narrow arches, Crossbite) plex cases and utilize more advanced treatment 4. Plan to detail. As certain tooth movements • Vertical discrepancies approaches. (Deep bite, Open bite) are less predictable with aligners, you may want Successful treatment outcomes and your personal to integrate auxiliary techniques into your treat- • Sagittal discrepancies satisfaction with Invisalign start with informed ment plan at the start. Regardless of the com- (Class II, Class III) case selection and thoughtful treatment plan- plexity of the case or the movements planned, ning. For more specific information on case WHO DOCTORS CAN TREAT WITH INVISALIGN always be prepared to use auxiliaries to help you selection by suggested Invisalign experience • Adults get the results you want. level, please see each Diagnosis and Treatment • Teens with fully erupted second molars Option section, and look for the following 5. Review your past ClinCheck files and • Pre-surgical patients symbols: treatment outcomes. Regular review of your • Pre-restorative patients past treatment plans and their clinical results will give you greater insight when setting up CONTRAINDICATIONS FOR INVISALIGN Initiator (0–15 cases) • your future Invisalign cases. Active compromised periodontal condition Experienced (16–50 cases) • Mixed dentition • TMJ dysfunction Advanced (more thasn 50 cases) Invisalign Treatment Planning Guide 3 Align Technology, Inc. DIAGNOSIS AND TREATMENT OPTIONS NOTE: The chart below is intended to give you general, high-level information on how each isolated condition might be treated. Not KEY addressed here are the relationships between different conditions Diagnosis 1. Crowding that exist in the majority of patients. Always consider each patient’s individual dental and periodontal condition, restorative needs, facial Treatment options by suggested proportions, and age when you are considering treatment options. Invisalign experience level Initiator (0–15 cases) Experienced (16–50 cases) Crowding Advanced (more than 50 cases) Mild Moderate Severe 1.1 1.2 1.2 Expansion/Proclination/IPR Expansion/Proclination/IPR Expansion/Proclination/IPR See case on p. 6 1.3 1.3 Lower incisor extraction Lower incisor extraction See case on p. 8 1.4 1.4 Distalization Distalization 1.5 Bicuspid extraction with combination treatment Invisalign Treatment Planning Guide 4 Align Technology, Inc. Crowding is a common aspect of malocclusion, which can a full diagnostic setup should be made with these cases to be CLINICAL NOTES manifest itself in varying amounts from mild to moderate to sure the occlusal results will be acceptable before extracting severe. In general, mild crowding can be resolved with some any teeth. It is important to note the amount of interproxi- proclination, rounding out of the arches, or even mild IPR. mal space that is required to close once the tooth is IPR Moderate crowding can be corrected by arch expansion, extracted, and look at the crown and root position of the IPR is a commonly-utilized technique in orthodontics. IPR can proclination, IPR and/or extractions. Severe crowding teeth adjacent to the tooth deciding to extract. The greater be used in the treatment of crowding, especially when there usually requires a combination of expansion, proclination, the space to close and/or the farther positioned the roots is minimal periodontal support and proclination and expan- IPR, extractions, and/or distalization. are away from the extraction site, the greater the potential sion are to be kept to a minimum. IPR can be performed prior for tipping into the extraction site. This may create black to PVS impressions, during aligner delivery, or both. Depending on the arch width and whether crossbites are triangles with insufficient interproximal tissue. Therefore, present or not, the amount of expansion possible will deter- closing of the extraction site needs to be monitored for In general, if more than 3-4 mm of IPR is needed, experienced mine the amount of proclination and/or IPR needed to root parallelism. Consider specifying rectangular attach- clinicians may consider performing it prior to PVS impres- resolve the remaining balance. Extractions can also be used ments to help control tipping. Sectional appliance or sions. Always use a lab set-up to determine the correct to change anterior-posterior (A-P) relationships, minimize auxiliaries may be needed at the end of treatment if amount of removal. If re-contouring teeth prior to the PVS advancing incisors, or changing facial strain. In general, tipping is noticed. This is important to disclose to the impressions, it is also important to hold the position of the a combination of approaches are used to resolve crowding, patient before treatment begins. each amount depending on the facial profile of the patient, teeth with a retainer while waiting for delivery of the aligners. dental positions of the teeth, arch forms, size of teeth, and 1.4 Upper distalization can be used to reduce crowding buccal class relationship of the case. and/or change the AP relationship of the buccal segments. Reproximation with aligner delivery is based upon
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