Comprehensive Orthodontic Diagnosis Align upper and lower arches is not a treatment plan!

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1 Engineering Your Invisalign Treatment Plan To Conquer a Wide Variety of Cases Dr. Willy Dayan drwillydayan@gmail.com Orthodontics is not just Straight Teeth Skeletal Foundation Posterior Interdigitation Anterior Guidance Transverse Relations Vertical Dimension of Occlusion Lip Support Lip Competency Neutral Zone Straight Teeth Smile Lines Comprehensive Orthodontic Diagnosis Align upper and lower arches is not a treatment plan! 4 2 Dr. Willy Dayan DDS ( 1986) and Diploma of Orthodontics from the University of Toronto (1991) Orthodontic practice in Toronto, Canada, focused on Cosmetic and Rehabilitative Orthodontics. Invisalign Super Elite Provider and member of the Aligntech Institute Faculty Lecturer at the University of Toronto, and Guest Lecturer at Tel Aviv University and Hadassah University in Jerusalem Featured speaker at the Pankey Institute, Invisalign Forum and Invisalign Summits, and numerous Align events worldwide. Member of the AAO and CAO, and other dental organizations Married to Ellen Dayan ( Restorative Dentist ), and 4 great children, Laurel, Ariel, Jamie, and Jory Intra-orally Extra-orally Should these people get the same treatment plan and same retainers? Customize our retention the way we customize our treatment plan! Biological Variation! Engineering Your Invisalign Treatment Plan To Conquer a Wide Variety of Cases Outline 1) Diagnosis and Treatment Plan...It Still Matters 2) Understanding Bio-mechanics of Invisalign 3) They are All Invisalign Cases! 6 Orthodontics is not just Straight Teeth Skeletal Foundation Posterior Interdigitation Anterior Guidance Transverse Relations Vertical Dimension of Occlusion Lip Support Lip Competency Neutral Zone Straight Teeth Smile Lines Comprehensive Orthodontic Diagnosis Align upper and lower arches is not a treatment plan! Who is the clinician and who is the technician. Doctor your ClinCheck!

2 Engineering Your Invisalign Treatment Plan To Conquer a Wide Variety of Cases Outline Upper Lateral Incisor Bodily Movement Need 2 points of contact to create a rotational moment. 1) Diagnosis and Treatment Plan...It Still Matters 2) Understanding Bio-mechanics of Invisalign 3) They are All Invisalign Cases! 10 A Review of Bio-Mechanics of Invisalign! Translating Roots Mesially or Distally Willy s Golden Rules of ClinCheck Analysis Controlling Root Tipping. 1) Think Like Plastic and Feel Like a Tooth. 2) Stop watching the video as teeth moving, but think of it as aligners surfaces changing. Focus on the correction of LL2 and LR2 Some Clinical Examples 11 Levelling Deep Curve of Spee Translating Roots Mesially or Distally What the tooth needs to feel, and what we need to see! What if the bicuspids have optimized rotation attachments?!?! 9 12

3 Translating Roots Mesially or Distally Opening Space for a Missing Maxillary Lateral Incisor I tried that and it did not work, so my conclusion could be... Invisalign can t do that!!! But is that true? cc1 Go To ClinCheck 1 A ClinCheck Treatment Plan after the first plan did not work! Progress Xrays cc2 Go To ClinCheck 2 ( instructed by orthoclined.com ) Not finished yet Conclusion: Ask not what Invisalign can do. but ask yourself what you can do with Invisalign!!! Do you see arrows in your Clincheck Video? Start CC1 End CC1 Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics CC1 Start CC2 End CC2 Tracking at End of CC2 Do you see arrows in your Clincheck Video? Start CC1 End CC1 Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics CC1 Start CC2 End CC2 Tracking at End of CC2

4 Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics Anterior Deepbite and Torque Control The Force System! Refnmnt Go to Refinement End of 1 st Order Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics Engineering Your Invisalign Treatment Plan To Conquer a Wide Variety of Cases Outline 1) Diagnosis and Treatment Plan...It Still Matters 2) Understanding Bio-mechanics of Invisalign 3) They are All Invisalign Cases! Refnmnt Go to Refinement Anterior Torque Control They are All Invisalign Cases! 1) Vertical Challenges 2) Sagittal Challenges 3) Crowding, Spacing and Alignment Challenges 4) Cuspid Impactions Plan is to leave some maxillary anterior spaces for restorative finish on maxillary incisors

5 Bite Turbos: Incisors or Cuspids? Vertical Challenges Deep-bite and Openbite The idea is to have the ledges act as a removable anterior bite plane to avoid excessive posterior contact of upper and lower aligners. Go to Cuspid Turbos Clincheck The reality of too much overjet allows mandible to close distal to ledges. Assessing The Vertical Dimension of Occlusion Bite Turbos: Incisors or Cuspids? The idea is to have the ledges act as a removable anterior bite plane to avoid excessive posterior contact of upper and lower aligners. Go to Cuspid Turbos Clincheck The reality of too much overjet allows mandible to close distal to ledges. What does it tell you about the forces on the teeth that have created this equilibrium? Bite Turbos: Incisors or Cuspids? Vertical Challenges: Deep Anterior Overbite The idea is to have the ledges act as a removable anterior bite plane to avoid excessive posterior contact of upper and lower aligners. ClinCheck is not teeth moving, but the force system to get them there. 30

6 Vertical Challenges: Deep Anterior Overbite Vertical Challenges: Deep Anterior Overbite Stage Vertical Challenges: Deep Anterior Overbite Vertical Challenges: Deep Anterior Overbite First ClinCheck Final ClinCheck Stage 36 4 weeks of anterior bite plane Vertical Challenges: Deep Anterior Overbite Vertical Challenges: Deep Anterior Overbite Mx: 38+0=38 Md: 38+0=38 Treatment Appointments: 11 (Including Impressions and debond and retention) +6: Invisalign progress at 9,15,21,27,33,38 +2: Debond Attachments and Retention 36 Mx: 25+0=25 Md: 19+0=19 Treatment Appointments: 8 (Including Impressions and debond and retention) +4: Invisalign progress at 9,15,21,25 +1: Debond Attachments and Retention

7 Vertical Challenges: Deep Anterior Overbite Are they all the same? Vertical Challenges: Deep Anterior Overbite Vertical Challenges: Deep Anterior Overbite Are they all the same? Vertical Challenges: Deep Anterior Overbite Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics Go to Clincheck Deep-bite, with desire to open vertical dimension of occlusion with mandibular posterior eruption. Deepbite, with desire to open vertical dimension of occlusion with mandibular posterior eruption. Prognosis of UL2 and UL3 guarded.

8 Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics Vertical Challenges: Posterior Intrusion During Post-ortho Pre-Resto Post-Resto Post-Orthodontic A pleasure for the Patient...A pleasure for the Dentist! Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics Naturally You! Not.. Extreme Makeover Vertical Challenges: Posterior Intrusion Post-Orthodontic Post-Prosthetic Final Final Mx: 20+9=29 Md: 20+9=29 Treatment Efficiency Treatment Appointments: 9 +5: Invisalign progress and refinement impressions at 9,15,20,2,9 +1: Debond Attachments and Retention Vertical Challenges: Posterior Intrusion Vertical Challenges: Anterior Openbite Initial Records 1 Go to Final ClinCheck 45 48

9 Vertical Challenges: Anterior Openbite and (First Order) Cephs Initial Ceph Tracing Progress Ceph Tracing Selected Posterior Intrusion Mild Anterior IPR Auto-rotation of Mandible No Incisor Extrusion Progress 1 Stage 9 Progress 2 Stage 15 Progress 3 Stage 21 and Superimpositions With Aligners..and ONLY ALIGNERS Openbite closure 42 weeks Progress Summary of Progress Analysis It appears that from initial to progress the upper and lower molars were intruded, and that the mandible has auto-rotated forward into a more closed position. In addition it appears that the lower incisors were extruded Refinement

10 Vertical Challenges: Anterior Openbite Vertical Challenges: Anterior Openbite 3 Years Later Time for New Vivera Retainers Still Coupling..Still Smiling! Selected Posterior Intrusion Mild Anterior IPR Auto-rotation of Mandible No Incisor Extrusion 3 yrs Post-ortho ( no fixed retainers) Treatment Time: 18 months Posterior Intrusion to Establish Anterior Coupling During Aligners Ready for Refinement Final Aligner Numbers Mx: =36 Md: =36 Treatment Appointments: 9 (Including Impressions and debond and retention) +6: Invisalign progress and refinemnt at 9,15,21,28,1,8 +1: Debond Attachments and Retention 56 Treatment Efficiency Mx: 21+6=27 Md: 11+7=18 Treatment Appointments: 9 (Including Impressions and debond and retention +5: Invisalign progress at 9,11,15,21, 6 +1: Debond Attachments and Retention Posterior Intrusion to Establish Anterior Coupling Prior to Refinement End Treatment Working Smarter. Not Harder!! Avoiding the Openbite!!

11 Working Smarter. Not Harder!! Sagittal Challenges: Class II and Class III Treatment Avoiding the Openbite! Aligner tooth movements depend on intra-arch anchorage. They do not replace the need for inter-arch anchorage. They do not replace the need or auxiliary treatment appliances such as: Rapid Palatal Expanders Headgear Functional Appliances Herbst Appliance Orthognathic Surgery Inter-arch elastics Etc.. Comprehensive Diagnosis and Treatment Planning 1 st ClinCheck Later! Working Smarter. Not Harder!! Final If it is too good to be true...it probably is to good to be true!!!! It is still orthodontics. Not magic! Sagital correction...or NOT!! ClinCheck Coaching Request at Time of Refinement. Lets do the math together! Mx: 17+0=32 Md: 17+0=32 Treatment Appointments: 7 (Including Impressions and debond and retention) +2: Invisalign progress at 9,15, +2: Debond Attachments and Retention 65 If it is too good to be true...it probably is to good to be true!!!! Sagittal Challenges Class II and Class III Malocclusions It is still orthodontics. Not magic! Sagital correction...or NOT!! ClinCheck Coaching Request at Time of Refinement. Lets do the math together! 66

12 Sagittal Challenges: Class II Correction What do you like to use for Growth Modification and Molar Distalization? Final ( oops...aligners still on!) 67 Aligner Numbers Mx: =36 Md: =36 70 Sagital Challenges: Class II Correction Sagittal Challenges: Class II Correction: Functional Appliance Initial Records Power Ridges for Anterior Torque Treatment Plan Functional Appliance Stage 1: Procline max incisors followed by functional appliance Stage 2: Invisalign with Class II elastics if required 71 Power Ridges are Effective at Anterior Torque Sagittal Challenges: Class II Correction: Functional Appliance Beginning of First Order End of First Order New Scan for 2 nd Order Refinement 69 Initial Records Treatment Plan Stage 1: : Procline max incisors followed by functional appliance Stage 2: Invisalign with Class II elastics if required Pre-Invisalign Records Treatment Plan Invisalign

13 Sagittal Challenges: Class II Correction: Functional Appliance Sagittal Challenges: Class II Correction: Elastics Class II Elastics: Stage 9 Initial Records Final Records Stage 2: Invisalign Only Mx: = 15 Md: = 15 Progress: Stage 9 73 Sagital Challenges: Class II Correction: Elastics Sagittal Challenges: Class II Correction: Elastics Class II Elastics Treatment Efficiency ( stopped refinement at #5) 74 Mx: 21+4=25 Md: 18+0=18 Treatment Appointments: 9 +5: Invisalign progress and refinemnt at 9,15,21,2,5 +1: Debond Attachments and Retention Class II Correction During Invisalign Sagittal Challenges: Class II Correction: Elastics Initial Final 75 Continuous Staging IPR delayed until stage 21 Bite Jump at end of Clincheck 1 year Retn. Mx:Vivera Nights Md: Fixed Wire Note posterior inter-occlusal space closing slowly. 78

14 Root Control in Extraction Sites. Root Control in Extraction Sites. 79 VP: mxd 44; RF 18 VP: mxd 44; RF 18 Root Control in Extraction Sites. Surgical Class II Case At stage 29 and until stage 44, the extraction sites are closed and remain closed. Transfer of records with request for surgical treatment with Invisalign. Root Control in Extraction Sites. Surgical Class II Case Progress: Pictures at stage15 Progress: Pictures at Stage 25 Last aligners trimmed around selected braces. Ready for Refinement Aligners removed for fabrication of surgical splint, and during surgery. Full time aligner wear, immediately after surgery and with post surgical elastics. Once patient healed and ready for post surgical orthodontics, will decide on detailing Go to Refinement VP: mxd 44; RF with refinement as required.

15 Surgical Class II Case Sagittal Challenges: Class III Correction: IPR in Lower Arch 85 Post Surgical with aligners. Post Surgical without aligners. Refinement Go to Refinement Surgical Class II Case Sagittal Challenges: Class III Correction: IPR in Lower Arch Work Smarter. Not Harder! No Refinement No Repairs Refinement Treatment Efficiency Mx: 13+0=13 Md: 20+0=20 86 Sagittal Challenges: Class III Correction: IPR in Lower Arch Sagittal Challenges: Class III Correction: IPR in Lower Arch Treatment Efficiency Mx: 37+17=54 Md: 26+17=43 Treatment Appointments: 13 (Including Impressions and debond and retention) +9: Invisalign progress at 9,15,21,27,33,37,1,10,17 +1: Debond Attachments and Retention 6 months retention 87

16 Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics Cut-outs Elastic hooks Posterior intrusion Bite jump. Not same patient... Fastest Elastics in the West!! Treatment Plan: Achieve Maxillary Expansion First.. Then Invisalign and Elastics 94 Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics The Expander ( not same patient) Removable Expander 92 Treatment Plan: Achieve Maxillary Expansion First.. Then Invisalign and Elastics 95 Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics Removable Expander Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics Treatment Efficiency 93 Treatment Plan: Achieve Maxillary Expansion First.. Then Invisalign and Elastics Maxillary Removable Expander and then 96 Mx: =25 Md: =25 Treatment Appointments: 12 +4: Removable Expander +4: Invisalign progress at 9,15,21,25 +1: Debond Attachments and Retention

17 Sagittal Challenges: Class III Correction: Lower Incisor Extraction Sagittal Challenges: Class III Correction: Lower Incisor Extraction 97 Final 100 Time for Refinement Aligners for Finishing Details Refinement In Mandible Only 6 Aligners with 0.2mm IPR from 3 to 3 increase overjet. Sagittal Challenges: Class III Correction: Lower Incisor Extraction Sagittal Challenges: Class III Correction: Lower Incisor Extraction Maxillary IPR Lower Incisor Extraction Treatment Appointments: 11 (Including Impressions and debond and retention) +7: Invisalign progress at 9,15,21,27,33, 36,6 +1: Debond Attachments and Retention Mx: =36 Md: =42 Sagittal Challenges: Class III Correction: Lower Incisor Extraction Progress Pictures Crowding, Spacing & Alignment Challenges

18 Spacing Spacing Treatment Efficiency Mx: 25+6=31 Md: 19+0=19 Treatment Appointments: 10 (Including Impressions and debond and retention) +6: Invisalign progress at 9,15,21,25, 1, 6 +1: Debond Attachments and Retention Spacing 1 st Order Spacing Go to Refinement Pictures only. To Close remaining spaces Go to Retainer Refinement Spacing Spacing 1 st Order Go to Refinement Go to Retainer Refinement

19 Spacing Treatment Efficiency Mx: 25+6=31 Md: 19+0=19 Treatment Appointments: 10 (Including Impressions and debond and retention) +6: Invisalign progress at 9,15,21,25, 1, 6 +1: Debond Attachments and Retention What is your first choice? 112 NM:MXD28 No RF! NM:MXD28 No RF! 110 Refinement Staging treatment to expose useful surfaces. What the tooth needs to feel, and what we need to see! 111 She is already too happy! Go to Refinement

20 Final Advantage of New Smart Track and Optimized Attachments Progress 1 Progress 2 ( finish md) With Aligners and maxillary extrusion and rotation of lateral incisors. Mx: 32+4=32 Md: 32+0=32 Treatment Appointments: 11 (Including Impressions and debond and retention) +5: Invisalign progress at 9,15,21,27,32,4 +2: Debond Attachments and Retention 118 Chief Complaint: I don t like my smile and Fronts spaces and twisted teeth. Significant Clinical Findings: Severe rotation of UR2 and UL2 Minimal vertical maxillary incisor display on smile Records: Panoramic Xray: 38 missing. Lateral Cephalometric Xray: WNL Orthodontic Treatment Plan: Align both arches Possibility of inter-arch elastics Erupt/ Extrude maxillary anterior teeth Possibility of bonding of maxillary anteriors post-orthodontics. Final 1 Final Final 120 VT:MXD27/45, MCC30/30 RFMXD10

21 Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics Start MCC. Start RFNMT Final Go to Refinement 121 VT:MXD27/45, MCC30/30 RFMXD10 Go to MCC Go to RFMNT Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics Final Start MCC. Start RFNMT 122 VT:MXD27/45, MCC30/30 RFMXD10 Mx: 20+10=30 Md: 20+10=30 Treatment Appointments: 11 (Including Impressions and debond and retention) +5: Invisalign progress at 9,15,20, 1,9 +2: Debond Attachments and Retention Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics Root Control in Extraction Sites.

22 Root Control in Extraction Sites. Later Atts off for Wedding Go to ClinCheck 40 Aligners Refinement Root Control in Extraction Sites. Refinement Time for Retainer Refinement 51 Aligners Go to Refinement Go to Retainer Refinement Cuspid Impactions

23 Cuspid Impaction 2 consultations have suggested that cannot erupt tooth and to remove the tooth. Begin treatment with customized TPA, and exposure with activation each 3 weeks Periapical progress xray 6weeks into treatment Our plan...3d Scan At 12 weeks into total treatment time, removed palatal activation wire and used buccal wire from UR6 to UR3. 7 months after exposure The Challenges Horizontally impacted UR3 Roots of UR4 in the path of eruption 7 months of activation, all hardware removed, new button on UR3 and fabrication of maxillary holding aligner with boot strap elastic. Even Radiologist missed on first try due to panorex distortions 137 Creative Thinking 90/10 Custom Maxillary TPA with extra arm from TPA and leaning on lateral. Lingual button to rotate UR4 distal to the lingual Buccal Brace on UR4 to tip root distally Expose UR3 and Erupt into space. Later Invisalign to finish. Cuspid Impaction: 90/ First!

24 Cuspid Impaction Back to the Question. Can Invisalign treat a cuspid impaction case?... Class II elastics Right Side It s not the right question...braces or Invisalign do not treat patients!!!! RF RF Progress Back to the Question. Can Invisalign treat a cuspid impaction case?... 90/10 Invisalign Start Invisalign It s not the right question...braces or Invisalign do not treat patients!!!! I am not an Invisalignist... I am an Orthodontist who uses Invisalign. Progress 1 Progress Class II Elastic Custom Hook on UR2 RF Back to the Question. Can Invisalign treat a cuspid impaction case?... Back to the Question. Can Invisalign treat a cuspid impaction case?... It s not the right question...braces or Invisalign do not treat patients!!!! I am not an Invisalignist... I am an Orthodontist who uses Invisalign. So what is the right question... Is a cuspid impaction case an Invisalign candidate? RF RF

25 Back to the Question. Can Invisalign treat a cuspid impaction case?... It s not the right question...braces or Invisalign do not treat patients!!!! I am not an Invisalignist... I am an Orthodontist who uses Invisalign. Cuspid Impaction Case Is an Invisalign Candidate! RF Viewing all Patients as Invisalign Candidates Diagnosis and Treatment Plan...It Still Matters Understanding Bio-mechanics of Invisalign They are All Invisalign Cases! Dr. Willy Dayan 146 drwillydayan@gmail.com Dr. Willy Dayan drwillydayan@gmail.com 147