Managing. Not on course. Unplanned reaction 9/15/2011. Possible Reactions. Probable Root causes. invisalign Aligner Tracking Issues

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1 Managing invisalign Aligner Tracking Issues Tips and Techniques for keeping treatment on course 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 Not on course 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 Probable Root causes 1. Lack of interproximal 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 1

2 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% Being efficient time management *Buttons/elastics and/or back to best seating aligner GROWTH Planning to avoid and/or lessen the impact of the bumps along the road Please note!!! 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. Built into the ClinCheck Treatment Plan Planned reaction (Class II elastics) 2

3 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 3

4 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 4

5 A dynamic representation of the central incisor root movements A dynamic representation of the left cuspid root movement Simulated roots for demonstration purposes not real Simulated roots for demonstration purposes not real 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 5

6 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 Staging Six months progress (½ the way) Initial Total treatment time 11 months Before Six months progress After Final position The root parallelism is very remarkable no refinements or auxiliary treatment 6

7 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 Initial Bite Set Root Movements Tooth size discrepancy Attachments Interproximal space Interincisal angle TIPS Use articulating paper 90 degree buccal shots Bite setting TIP Compare photos with ClinCheck model The diagnosis and treatment approach is 45 degrees based on what you see!! Class I or Class II? 60 degrees 90 degrees 7

8 TIP Anterior overjet view helps determine the most anterior contact(s) TIP Can send photos of study models with occlusal marks and scribe lines if needed to verify the bite Photos with articulated marks verified the patient had postured forward in the initial photos bite was reset There are anterior inter- occlusal stops Patient appears to be biting with the mandible forward? There is more inter-occlusal contacts Bite set based on accurate photos Bite set based on inaccurate photos Inaccurate Bite Set Unnecessary Movements Occlusal problems 1.Initial bite set Possible Clinical Consequences Unnecessary IPR Midline Shift 8

9 Root movement Relative movements are more Predictable and stable Understand where and type!!! Relative extrusion Pure extrusion Use these tools to obtain information on root movements Which teeth will have significant root movement? 9

10 Superimpose Superimpose Where are the roots moving? To help identify root movement Draw imaginary lines White is the final stage Does the right central need an attachment? Buccal view is great to evaluate the amount and type of incisor retraction Using the ClinCheck to identify root movement Can you see that the maxillary incisors had bodily retraction? For Lingual root torque the software will add Power Ridges You can see them in the Treatment Overview 10

11 Do the lower incisors need attachments? The Grid It provides linear measurements With the long clinical crowns and black triangles this amount of incisor root movement shouldn t need any attachments Before After 2mm of mesial root uprighting needs an attachment Tooth Movement Assessment TMA TMA helps quantify what you see Another great tool to help identify some significant root movements 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 11

12 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 Proactive Different staging Reactive Refinement Timing of attachments Place attachments from the start Lack of pushing surfaces Create space around the teeth Auxiliary techniques 12

13 Auxiliary treatment required to achieve root parallelism Mandibular excess mm Mandibular excess mm Teeth Space 0.7mm 0.5mm Teeth IPR 0.3mm 0.3mm 0.3mm 0.2mm 0.2mm Buttons and C-Chain to tip the roots mesial An example of before and after with the use of auxiliaries BEFORE AFTER Attachments as well as mesial and distal tooth surfaces to push on We are not going to let the same result take place a second time. 13

14 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 size discrepancy How important is TSD? 14

15 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 15

16 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 Attachments Go Optimized Add attachments to improve the engagement between the tooth and the aligner to make root movements more predictable 16

17 If you want to add or remove attachments use the Attachment Interface The Future is even brighter in the world of attachments Inteproximal SPACE 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 15 IPR is prescribed when there is adequate clinical access Interincisal ANGLE 17

18 Why the inter-incisal angle is so important? Reviewing the ClinCheck Treatment Plan Inter-Incisal Angle 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 The Inter-incisal angle is patient specific Being proactive at the ClinCheck treatment planning stage can help keep you and the patient on track There is no standard Inter-incisal angle it is based on the occlusion Providing excellent results It was a Pleasure!!! QUESTIONS? 18

19 To obtain your CE certificate for this program please complete a brief survey at: Upon completion of your survey* you will have immediate access to your CE certificate. *This survey is only available to the participants who attend the live presentation via the webinar/phone. Participants who complete the archived program on AligntechInstitute.com need to complete a CE test to obtain their CE certificate. 19

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