Checklist with summary points Question 1: Are your doctor Invisalign preferences on your home page up to date? Go to your doctor home page and open up your doctor preferences pages. Be sure to update item 16, special instructions. Question 2: Is the virtual mount accurate? The virtual mount is the articulation of the dental arches in Clincheck before any tooth movements have occurred. This would be at stage number 0. Compare photos to the clincheck at stage 0 to determine if the technician has mounted the case correctly. Make sure all erupted teeth are covered with plastic. Question 3: Are the dental arches developed properly? Reshaping the arches. Tapered, Omega or Square forms need to be reshaped into ovoid form. Expansion. Expand narrow arches. Average transverse measurement = 33-37mm. Leveling the curve of Wilson. Correct lingual crown tip of posterior teeth. Alignment of teeth. Consider using Hinge Axis (Hinge-out) mechanics for anterior rotations. Create temporary space and delay rotations until this space exists. Leveling the Curve of Spee. Overtreat anterior if intrusion > 2mm. Add posterior attachments to anchor the aligners. Proper position of the upper first molars. Check U6 teeth for mesial in rotation. Perform mesial out rotation in class II cases or cases where you need arch space. Question 4: Is this a deep bite case? If yes, do you want to treat the anterior deep bite? 4 possible components for deep bite correction. Leveling the Curve of Wilson: Upright lingually tipped posterior teeth.
Leveling the Curve of Spee: Overtreat anterior intrusion > 2mm. Posterior aligner anchorage to prevent slippage during anterior intrusion. Proclination of retroclined anterior teeth. Correct anterior lingual crown tip. Question 5: How is the overjet at the final stage in Clincheck? Does the overjet in Clincheck need modification? Incorporate 1-2mm of overjet in cases where: There is a deep anterior bite. There is a lot of anterior intrusion (>2mm) to treat a deep bite. There are retroclined anterior teeth before treatment. In cases where anterior torque is needed to correct, lingual crown tip. You feel there is a risk of premature anterior contacts at finish. You are doing a refinement to resolve a posterior open bite.if IPR is added for the sole reason to create this overjet, add the IPR in the later stages. Then you assess the patient s occlusion and decide if the IPR is needed. Question 6: Is there anterior root torque in this case? If yes, do you want to add additional torque to the Clincheck? Add additional torque in cases where there is noticeable root torque in the Clincheck. These are cases where you see retroclination or proclination before treatment. Add 15-20 degrees of additional root torque. Question 7: If IPR was added by the technician, is it acceptable? Is it staged and located properly? Anterior IPR or posterior IPR? Stage IPR when teeth are aligned. Avoid IPR in sites where there are Emax or Zirconia crowns.
IPR may be used to reduce black triangles. Locate IPR in these sites. Add virtual C Chains to close residual anterior spaces that may exist at the end. Use Virtual Power Chains to close residual posterior spaces that may exist at the end. Question 8: Review the attachments in this Clincheck. Is there a need to change, add or remove any of the attachments? Check tooth movement values to determine if additional attachments are needed. Use Rectangular-Horizontal-Beveled-Gingival attachments for extrusions. Use Rectangular-Horizontal-Beveled-Incisal attachments for anchorage. Use Vertical-Beveled attachments for rotations and crown tip. Upper laterals: make sure you add attachments if you see a lot of rotation or extrusion or crown tip. Avoid attachments on crowned teeth. Use larger attachments whenever you can. Question 9: Do you want bite ramps for this case? Use the G5 bite ramps as your first choice. It is ok to substitute cuspid ramps when G5 ramps are unavailable. Here are indications for using bite ramps: A lot of upper anterior intrusion. When there are posterior extrusions. When you are treating a posterior x-bite. When you performing molar distalization for class II treatment. In cases where there is significant posterior expansion. Question 10: Does your patient have a class II malocclusion? Do you want to treat the class II? Treatment goals for non-growing class II cases:
1. Improve but not necessarily fully correct the molar and cuspid AP relationship. 2. Create arch space for alignment, midline correction, and anterior retraction. 3. Improve function. Protocol options available for class II treatment: 1. Distalization (sequential): Maximum distalization = 4 mm. Perform mesialout rotation of the upper 1st molars. Extract upper wisdom if teeth present. Use class II elastics. Be prepared for long treatment times. 2. IPR: Develop the arches before adding any IPR. Consider posterior IPR before adding distalization. Posterior IPR will improve the cuspid relationship. 3. Elastics: Class II elastics are mandatory for distalization cases. They provide anchorage which will maximize the effect of the distalization. Full-time use as indicated during the distalization process. 4. Bite Ramps: Use virtual bite ramps when performing distalization. If excessive overjet prevents ramps from being used with teeth 7 10, use cuspid ramps. Posterior disocclusion while the aligners are being worn can assist with posterior tooth movements. Miscellaneous points: Do not forget to add cutouts for class II elastics. Either submit a written request to the technician or use the 3-D controls to have them yourself. Use a 5/16 inch 4.5 ounce elastic. A 3/16 inch 3.5 ounce elastic will also work well. Be sure your patient understands the commitment involved in wearing the elastics if you are going to go ahead with distalization. Also, make sure the patient is aware of the longer treatment time.
Question 11: Is there dental spacing? Do you want to close the spacing? There are 3 causing for dental spacing. A correct diagnosis is important. 1. Tooth size discrepancy or small teeth. Generalized? Localized? Are restorations needed in addition to Invisalign? Check patient s profile before retracting the arch(s). 2. Proclined or flared anterior teeth. Use Clincheck to determine if spaces can be closed by correcting flaring. 3. Missing teeth. Are you going to leave space for replacement? Close all spaces? Relocate the space? There are 2 ways to close dental spaces. Some cases may require both. Translation. Mesial-distal movement. The dental arch is not contracted. Apply "Virtual Gable Bend" forces to prevent crown tip after translation is complete. Add Rectangular-Vertical-Beveled attachments if the technician did not add them. Bevel on the push service of the attachment. Retraction. Retraction is the lingual movement of anterior teeth. This movement will make the arches smaller which will close spacing. There are 2 scenarios: Retracting proclined (flared) teeth. Correction occurs by tipping the flared crowns lingual. These cases are usually easier as root torque may not be needed. Need overjet to perform this retraction. Retracting teeth with normal buccal-lingual inclination. Be careful not to over-retract. Check patient s profile and the degree of retraction in Clincheck. Apply constant lingual root torque as retraction occurs. Manage the overjet carefully to avoid premature anterior contacts at finish. Retention. Apply virtual C-chain aligners at the end. Vivera retainers from stage after chains have been used. Carefully check for slight anterior
interferences and perform equilibration. Stress retainer compliance with patient. Question 12: Does this Clincheck address a posterior open bite? Did this develop in the course of treatment? Are you trying to resolve it? Preventing a Posterior Open Bite. A posterior open bite can occur during orthodontic treatment. It is not exclusive to Invisalign. The most common reason is premature anterior occlusal contacts at the end of treatment. There are preventive measures that can be taken when setting up your initial Clinchecks. Another possible reason is posterior intrusion caused by heavy clenching (chewing) on the aligners. The degree of open contacts can vary. Here are some points to consider when setting up your cases: 1. Create some excess overjet in your Clinchecks set ups. Usually 1-2 mm is about right. If any IPR is added for this reason only, add it near the end of treatment. Then you can check the bite clinically and decide if it is needed. I am NOT implying you should finish with excessive clinical overjet. 2. In deep bite cases, "over-treat" the anterior intrusion needed to provide the deep bite relief. This means to add additional intrusion in the regular stages. I like to set the final overbite at.5mm (with centrals) in Clincheck. The reason for this is the clinical lag we see between the actual intrusion as compared to Clincheck. 3. Add additional anchorage attachments on the first molars or second premolars when you see anterior intrusion in deep bite cases. Add 4mm Rectangular-Horizontal-Beveled-Incisal attachments on the buccal surfaces of these teeth. Do not place these on crowned teeth. 4. Over treat torque in cases where you see retroclination or lingual crown tip in the beginning. Request 15 degrees of additional torque. This will compensate for the lag between torque you obtain clinically and what you see in Clincheck. 5. Apply constant lingual root torque when you are retracting anterior teeth. This will prevent retroclination at finish. 6. In spacing cases be careful about collapsing the arches to close the spaces. Consider restorations in addition to Invisalign treatment if there is a tooth size discrepancy.
7. Add bite ramps to patients who have a history of clenching and grinding their teeth. Resolving a Posterior Open Bite. It is much better to prevent a posterior open bite in our cases. Therefore, I highly recommend following the above steps. I have published a tutorial on resolving a posterior open bite. I recommend you view it. You can access it in the "Master's Section" module 12. Click here for a direct link. Here are some summary points to consider: 1. If the posterior open contacts are 1 mm or less, consider allowing time for natural settling. Most orthodontic cases require some settling, even with braces. Natural settling works well especially in young patients. You can cut off the aligners distal to the cuspid teeth. Allow about 4 to 6 weeks of settling and then take records for additional aligners to finish the case. The more settling you see the easier it is to finish the case. 2. If the reason for the posterior open bite is premature anterior contacts, set up the Clincheck to resolve these heavy anterior contacts. Add some over correction into the Clincheck. Usually lingual retraction, lingual root torque, and intrusion will resolve the premature contacts. Lower IPR may be needed. 3. Try and limit the degree and amount of vertical movements of the posterior teeth. For example, if the 2nd molars are hitting prematurely, intrude these teeth rather than extruding all the other teeth. There is a tooth movement table you can access from the "Tools Tab" on the top line of the Clincheck page. This will show you all tooth movements. 4. If there are posterior extrusions, make sure they have attachments. Use Rectangular Horizontal Beveled Gingival attachments on these teeth. If there's a lot of anterior intrusion add additional attachments to the lower 1st molars or to the 2nd premolars. Add Rectangular Horizontal Beveled Incisal attachments. 5. Class III elastics can be a useful adjunct when resolving premature anterior contacts.