The Invisaligns appliance today:

A thinking persons orthodontic appliance

Eugene Chan, and M. Ali Darendeliler

Since its induction in 1997, the Invisaligns appliance has vastly evolved
through the years. Having used this appliance since inception to its current
form, we have learnt much through trial and error and accumulated much
experience. The product had advanced substantially since the days of only
treating simple Class I malocclusions. It is now possible to treat multiple
extraction cases, skeletal asymmetries, as well as, surgical and non-surgical
camouage cases. This article summarises the experiences of two specialist
orthodontists who had spent time to perfect the system through under-
standing the biology of tooth movement, and also utilising smart bio-
mechanics to bypass the inadequacies and further enhance the patient
and clinician's experience in using the appliance. (Semin Orthod 2017;
23:1264.) & 2017 Published by Elsevier Inc.

Introduction the endpoint, akin to the elimination of disease,

may not be as precise.
rthodontics has a strong history of indi-
O vidual opinions; from the individual
orthodontist to the orthodontic guru. However,
About 20 years ago, less than 3% of the world's
population had a mobile phone. Today, two-
thirds of the world's population has a mobile
the global trend is to gradually move towards a
phone of some sort. The digital technology
focus on evidence-based rather than opinion-
around us have pushed us to learn and adapt to
based decisions.1
new gadgets and methods in the world of
If treatment is needed, how do we decide what
orthodontics. From digital records, treatment
sort of treatment to use? Treatment procedures
planning, appliance design and manufacture,
should be chosen on the basis of clear evidence
digital monitoring of treatment, computer aided
and the most successful approach. Usually the
orthodontic treatment has nally arrived. How-
better the evidence, the easier the decision. Yet,
ever, there are road blocks and clinicians need to
there are some innate problems with evidence-
be fully aware of such consequences before
based orthodontics. Unlike the eld of medicine,
embracing this technology fully, and blindly.
we are not dealing with a disease or diseased
tissues. In order to treat a presented maloc-
clusion, we primarily establish an individualised
Diagnostics
treatment goal and proceed to formulate a set of
treatment plan(s). In the pursuit of these goals, Training clinicians to use the Invisalign appli-
our mechanical procedures can be very different ance has long been largely based on anecdotal
for any given patient; hence, unlike medicine, evidence. There is an urgent need for systemic
reviews and meta analyses to be conducted. We
were able to collect data on 400 consecutively
Department of Orthodontics, Faculty of Dentistry, University of
treated Invisalign cases by 1 clinician, and sub-
Sydney, Sydney, Australia; Orthoworx, Sydney, Australia. sequently analyse them.2 These cases were
Address correspondence to M. Ali Darendeliler, BDS, PhD, Dip classied under respective age groups, gender,
Ortho, Certif. Orth, Priv. Doc, Department of Orthodontics, Faculty of type of dental malocclusions, and treatment
Dentistry, University of Sydney, Sydney Dental Hospital, Sydney Local
therapies (extraction or non-extraction). The
Health District, Level 2, 2 Chalmers Street, Surry Hills, New South
Wales 2010, Australia. E-mail: ali.darendeliler@sydney.edu.au treatment duration and total number of
& 2017 Published by Elsevier Inc.
appointments required were also noted.
1073-8746/12/1801-$30.00/0 The following report draws evidence from the
http://dx.doi.org/10.1053/j.sodo.2016.10.003 above ndings.

Seminars in Orthodontics, Vol 23, No 1, 2017: pp 1264 12

 The Invisaligns appliance today 13

Identifying road blocks horizontal growth pattern with a tendency of her

bite deepening as treatment progresses.
The common feedback from new clinicians
A key to successful treatment with the Invis-
include the following: I have followed all the
align appliance is to ensure good surface area
instructions given by the technicians, I have placed all
contacts between the aligner material and the
the necessary attachments, and done all the necessary
dentition. Therefore, the successful planning
prescribed interproximal reduction (IPR). My patient
and treatment of this case with short clinical
wore all the aligners and used the Chewies as prescribed.
crown heights involved (i) choosing the correct
They all wore them more than 20 hours per day but the
attachments, (ii) have them appropriately
result still differs from the ClinCheck plans. The product
placed, (iii) decrease the velocity of the move-
just does not work!
ment of the dentition whilst designing the
Years of experience using the Invisalign
ClinCheck plans, (iv) the patient also has to
appliance have allowed us to conclude that
understand the importance of using Class-II
treatment progress is indeed not as easy and
elastics, (v) be prepared for renement/addi-
predictable as the computer animation dictates.
tional aligners, and (vi) ensure good patient
There has to be some understanding of the
compliance.
biology and mechanical involvement of the
The rst ClinCheck plans presented a treat-
aligners in order to produce repeatable, good
ment plan with 15 aligners and attachment
clinical outcomes. The Invisalign product itself
design as shown in Fig. 1B.
has evolved through time and has become more
The ClinCheck plans were modied to reduce
user friendly. Have we, the clinicians, evolved to
the treatment velocity and a different attachment
understand its advanced applications too? The
design (Fig. 1C).
Invisalign appliance has indeed become a
The case treated out well in 21 months using a
thinking persons orthodontic appliance.
total of 46 (29 17) aligners with 1 renement
One of the difculties that new Invisalign users
(Fig. 1D).
face while using this appliance is the ability to
identify challenging cases. The common factors
affecting the predictability of treatment are (i) Case 2
understanding the anatomy of dentition, (ii)
Case 2 is an adult female Caucasian who is
knowing the growth potential of the patient (or
extremely concerned with the aesthetics of the
the lack of), (iii) the ability to place attachments
treatment appliance (Fig. 2A). Her chief
(based on aesthetic and biomechanical
concerns were the rotated upper lateral
requirements), and (iv) identifying difcult
incisors and also a lateral open bite on the left
dental movements and how to plan for such
side. She is a Class-I dental malocclusion over a
contingencies.
skeletal Class-I base with a normal direction of
growth. There were no soft tissue parafunctions
Case 1
and radiographic examination was nondescript.
Case 1 is an adult female of Asian extraction Previous experiences with moving lateral
(Fig. 1A). She rst presented with chief concerns incisors has noted it to be a great challenge. The
of an uneven bite, crooked front teeth, and some necessity of placing an optimised extrusion
dental spacing. She was diagnosed as a Class-II attachment in this case is almost imminent. The
dental malocclusion on a skeletal Class-I pattern, clear appliance that is Invisalign is a natural
with a normal to horizontal direction of growth. choice for the patient, provided it was capable of
Radiographic examination was nondescript. executing the biomechanical forces necessary to
The road blocks with treating this patient extrude the lateral incisor and close down the
using the Invisalign appliance were as follows: (i) lateral open bite successfully. Although matching
she had some degree of microdontia with short tooth-coloured composite attachments may be
clinical crown heights, (ii) she was a non-growing selected, and if well placed and polished, almost
Class-II dental malocclusion with upper crowd- invisible upon close scrutiny. However, when the
ing, and lower spacing, (iii) the antero-posterior actual aligner with the pushed out outline of the
(AP) correction would require good compliance attachment is placed on the dentition, the visi-
with Class-II traction, and (iv) she also has a bility of the attachment highly increases. Out of
14 Chan and Darendeliler

social embarrassment, this often result in patients
not wearing the aligners for the prescribed
number of hours; and hence, disrupting the
biomechanical forces and not obtaining the
desired results.
The road block of treating this case with the
Invisalign appliance includes meeting the
patients expectations in terms of aesthetics and
treatment outcomes. If attachments were to be
placed on the buccal surfaces of the teeth, there
might be a high chance that the patient might
not full the prescribed hours of aligner wear.
Is there any other way to design the ClinCheck
plans and attachments? How do we extrude the
dentition and close the lateral open bite on the
left side? Would we require the need for
elastic bands?
The rst ClinCheck plan presented a treat-
ment plan with upper 18 and lower 12 aligners
and attachments on the buccal surfaces of the
upper anterior teeth (Fig. 2B).
The ClinCheck plan was modied to place
vertical rectangular attachments on the lingual
surfaces of the upper lateral incisors instead.

Figure 1. (A) Pre-treatment images of case 1. (B) Initial ClinCheck plans with only 15 active aligners and an elastic
simulation. Precision cuts for elastic wear were not available as case was treated pre-G3. (C) Final ClinCheck plans
with slower velocity and modication of attachment designs. Precision cuts for elastic wear were not available as
case was treated pre-G3. (D) Completion images of case 1.
 The Invisaligns appliance today 15

Figure 1. Continued.

The velocity of the tooth movement was also
reduced (Fig. 2C). No elastic bands were
necessary and the patients compliance was
excellent throughout the treatment duration.
The case treated out well in 15 months using a
total of 32 (25 7) aligners with 1 renement
(Fig. 2D).
Case 3
Case 3 is an adult Asian patient with initial
concerns of crooked front teeth and impacted
lower second premolars (Fig. 3A). Radiographic
examination was nondescript.
She was a Class-II division 2 dental maloc-
clusion on a skeletal Class-I base with a normal
direction of growth. The road block in this case
hinges mainly on the disengagement of the lower
second premolar teeth, and extruding them.
There is a high chance that we would require the
use of auxiliaries to assist in these extrusion
movements.
Prior to onset of treatment, the patient gave
her informed consent that there would be a high
16 Chan and Darendeliler

Figure 2. (A) Pre-treatment images of case 2. (B) Initial ClinCheck plans with only 18 upper active aligners and 12
lower active aligners. Optimised attachments are placed on the upper anterior teeth. (C) Final modied
ClinCheck plans with 25 active aligners and vertical rectangular attachments placed on the lingual surfaces of the
upper anterior teeth. (D) Completion images of case 2.

chance of using sectional xed appliances on the
lower quadrants to assist in the dental move-
ments. The initial ClinCheck plan set up by the
technician had recognised the difculty in these
extrusive movements and have decided to not
extrude the lower second premolars at all
(Fig. 3B). This treatment plan successfully
improves the tracking rate of the case as the
difcult movements will be dealt with at a second,
later stage. However, this will lengthen the total
treatment duration and may not be of the best
interest of the patient. Moreover, when the
sectional xed appliances are placed, the
original alignment achieved on the lower
anterior segments may be lost as relapse
quickly sets in. Some sort of temporary
retainers will have to be designed to prevent this.
The ClinCheck plans were subsequently
modied to allow expansion of the dental arch
forms, increasing the dental arch perimeter
to allow sufcient space for the extrusion
of the lower second premolars (Fig. 3C).
 The Invisaligns appliance today 17

Figure 2. Continued.

Appropriate attachments were placed to assist
in the extrusion of the premolars and the
contingency plan was that once the lower
impacted premolar teeth were not tracking,
sectional xed appliances would be placed on
the lower rst premolars, second premolars,
and rst molars. The existing, remaining aligners
will also be cut and adjusted to t around these
xed appliances. The patient will still be changing
her aligners every 2 weeks as previously planned.
In this way, the extrusion with the xed appliances
are planned within the boundaries of the aligner
movement and there will be space to allow this
extrusive movement to occur with the usual aligner
wear. As such, any interim retainers will not be
necessary.
Some other considerations in this case include
appropriate attachment designs in order to
successfully extrude these premolars, clinical
monitoring on sufcient spacing, and light IPR
where necessary to allow the planned movements
to occur. Patient compliance has to be reinforced
as well.
The case treated out well in 26 months
using a total of 58 (40 18) aligners with 1
renement and Class-II elastics (Fig. 3D),
18 Chan and Darendeliler

Figure 3. (A) Pre-treatment images of case 3. (B) Initial ClinCheck plans with uncorrected impacted lower second
premolars. (C) Final modied ClinCheck plans with 40 active aligners and corrected lower second premolar
positions. (D) Completion images of case 3.

surprisingly, without the need for any sectional
braces.
ClinCheck treatment plans
A ClinCheck treatment plan allows us to visualise
the treatment progress and treatment outcome
virtually. However, it is strongly guided by soft-
ware defaults and limitations. Trained align
technicians are often unaware of biology of tooth
movement, biomechanics, and other clinical
limitations and/or variations.
Therefore, the following common trouble
situations are often reported: (i) difculty in
obtaining the correct amount of dental
expansion (ii) inability to achieve sufcient
anterior torque in premolar extraction cases (iii)
inability to fully correct deep overbite dental
 The Invisaligns appliance today 19

Figure 3. Continued.

malocclusions and (iv) inability to resolve
severe dental crowding without multiple
renements.
Recovery techniques therefore are formulated
to overcome these situations. Sectional or full
arch xed appliances, xed bonded power arms
incorporated with power chains and/or pull
coils, button, and elastics etc. are often the get
out of trouble consequence. Clinicians have to
spend more time and overheads to prepare and
plan for such situations. Patients who are not pre-
warned of such situations are often not impressed
with the prolonged treatment duration, extra
costs involved, and the placement of a more
visible appliance in order to complete the case to
perfection.
We strive to achieve repeatable, outstanding
results without the need for such predicaments.
We can come close to avoiding such situations by
going back to the basicsthrough under-
standing the true biology of tooth movement,
and relating it back to aligner treatment and
biomechanics.
Planning and execution
With an expansive market within the eld of
dentistry, Invisalign has made orthodontics easily
20 Chan and Darendeliler

Figure 4. (A) Pre-treatment images of case 4. (B) ClinCheck plans showing sequential staggered staging pattern.
(C) Clinical images showing sequential molar distalisation augmented by using Class-II elastics. (D) Completion
images of case 4.

available for the masses. As the product evolves
into the cosmetic dental environment, the sci-
ence behind dental movement is slowly eroded.
Is Invisalign orthodontics?
Using pre-set defaults within the ClinCheck
software and allowing technicians to dictate
clinical treatment may allow the new clinician to
get away with treating simple Class-I cases. How-
ever, when faced with more complex situations,
the age-old debate comes about how much
orthodontics should you know before using the
Invisalign appliance?
Age-related treatment
(a) Molar distalisation or elastic simulation
The decision making in the type of orthodontic
correction required in Class-II and/or Class-III
dental malocclusions relate closely to the growth
potential of the patient. Differential growth spurts
 The Invisaligns appliance today 21

Figure 4. Continued.

and velocities in the growth of adolescences have
been previously described.3 It is noted that girls
have their growth spurt up to 2 years earlier than
boys. However early-maturing boys will reach pub-
erty before slow maturing girls. Therefore, it is
essential to note the growth patterns and charac-
teristics of each individual patient during
consultation appointments. The Burlington growth
studies done in the early 70s looked at the various
growth time points of children.4 The increments of
mandibular length was also noted annually.
Therefore, when it comes to the decision on
whether the molar dental relationship should be
corrected with molar distalisation or an elastic
22 Chan and Darendeliler

Figure 5. (A) Pre-treatment images of case 5. (B) Images showing the ClinCheck plans and staging pattern of case 5.
(C) Completed images of case 5.

simulation, this understanding of the growth Case 4

potential of the patient becomes rather important.
(i) Sequential staging pattern
This is one of the default staging patterns in
the correction of molar dental relationships with
the Invisalign appliance.
Case 4 is a Caucasian non-growing adult female
with a Class-II dental malocclusion (Fig. 4A). She
had undergone previous dental treatment with a
single upper and lower premolar tooth extracted
in quadrants 1 and 4. This has resulted in a
deviated upper dental midline, moderate upper,
 The Invisaligns appliance today
Figure 5. Continued.
and lower dental crowding, rather constricted
upper and lower dental arch forms, a deep dental
overbite, and a Class-II dental molar relationship.
Her panoramic (OPG) radiograph demonstrates
normal dental root anatomy, normal dento-
alveolar bone heights, and normal bony density
(Fig. 4B). The wisdom teeth on the left side have
all been previously removed.
The ClinCheck plans reveal a staggered
staging pattern (Fig. 4C) that indicates a sequential
staging treatment plan. The default staging pattern
is as such the upper terminal molars are usually
distalised from stage 1 for approximately 8 stages
before the rst molar starts distalising for another
8 stages and subsequent teeth distalised
individually thereafter. The upper anterior teeth
are usually stationary all this time while the molar
distalisation is occurring.
Although this staging pattern is predictable in
non-growing patients, the treatment duration is
usually prolonged. Moreover, the upper anterior
crowding is usually not resolved till the later part of
the treatment. Patients with anterior crowding as a
chief concern would not like such a treatment plan.
There are, however, several ways to overcome
this staging problem.
 The digital ClinCheck plans do not take into
considerations any inter-arch anchorage aug-
mentation. The use of Class-II elastics in such
treatment highly improves the predictability of
23
the treatment. The sequential staging of the
upper molars may then be successfully reduced
to every 4 stages instead of 8. This reduces the
total number of active aligners signicantly.
 The ClinCheck plans may also be modied to
allow early upper anterior alignment to
alleviate the patients chief concerns. This
usually involves, if allowed, an expansion and/
or proclination movement of the upper ante-
rior teeth allowing an early aesthetic improve-
ment. The upper anterior teeth will
subsequently be retracted back once the molar
distalisation has created sufcient space.
The case treated out well in 18 months using a
total of 43 (39 4) aligners with 1 renement
(Fig. 4D).
This staging pattern is predictable and suitable
for adult non-growing patients with up to half unit
A-P correction. The patient would require good
clinical crown heights, good compliance with
aligner wear, and dental elastics. There should not
be any wisdom teeth present on the arch which we
are distalising. However, treatment duration may
be longer and anterior teeth may not be fully
corrected till the later part of the treatment.
(ii) En masse distalisation
With the sequential staging pattern taking up a
longer treatment duration, there will be certain
24 Chan and Darendeliler

Figure 6. (A) Pre-treatment images of case 6. (B) ClinCheck plans for case 6. (C) Completed images of case 6.

cases that will allow en masse distalisation
pattern. This staging pattern is not an elastic
simulation but rather right from the
commencement of treatment, the whole dental
arch distalises and achieves the desired AP
correction.
Case 5
Case 5 is an adult Caucasian non-growing adult
patient with a Class-II dental malocclusion
(Fig. 5A and B). She had previous orthodontic
treatment and 4 premolar teeth were previously
extracted. Her upper and lower dental arches
have collapsed and constricted over time with
upper and lower mild to moderate degrees of
crowding noted. There is an increased overjet
and a quarter unit Class-II dental relationship.
Attachments were placed from stage 4, Class-II
elastics were also applied then. This staging
pattern is demonstrated in the ClinCheck plans
as the upper arch is completely distalised as if via
an invisible force. This could be applied either
through inter-arch elastics or placement of
temporary anchorage devices (TADs) at the
appropriate areas.
 The Invisaligns appliance today 25

Figure 6. Continued.

The en masse staging pattern allows simul-
taneous correction of the patients dental
crowding as well as addressing the AP correc-
tion at the same time. The treatment duration,
however, is much shorter. And clinical tracking
may be slightly trickier. When the patient
returns for a review/adjustment appointment,
it is imperative to not only check the t of the
aligners, but also remove the aligners, get the
patient to bite into a maximum intercuspation
to check for inter-arch relationships and adjust
the anchorage control with Class-II elastics as
required.
The case treated out well in 12 months using a
total of 27 (18 9) aligners with 1 renement
(Fig. 5C).

Figure 7. Pre- and post-dental arch expansion in adults using the Invisalign appliance. Case I (A and B) and Case II
(C and D).
26 Chan and Darendeliler
Figure 8. Dental arch expansion. (A) Cases to avoid and (B) cases to select.
This staging pattern is predictable and suit-
able for adult non-growing patients with pre-
vious premolar extractions, and up to half unit
AP correction. The presence of maxillary wis-
dom teeth may sometimes make the correction
difcult when we are performing en masse
distalising and it is highly recommended that
they be removed. The patient would require
good clinical crown heights, excellent com-
pliance with aligner wear and dental elastics.
Otherwise, 4-5 mm attachments on the pre-
molars may be required to increase the surface
area contacts between the aligner and the
dentition.
(iii) Elastic simulation
Using inter-arch elastic traction to correct
Class-II dental malocclusion is quite the norm
in conventional orthodontics. Especially in
growing children with the potential for vertical
Figure 9. Dental arch expansion: showing the centre
of rotation and the expansion arc. (Image source:
Wikimedia commons, free media repository).
dento-alveolar growth. In contrast, correcting a
full Class-II dental malocclusion using elastics in
an adult patient is like asking a toddler to walk
across the Sydney Harbour Bridge.
Case 6
Case 6 is an adolescent Asian male with concerns
of deviated upper and lower dental midlines,
retroclined anterior teeth with moderate upper
and lower dental crowding. He was diagnosed as
a Class-II subdivision dental malocclusion on a
mild skeletal 2 base (Fig. 6A).
The elastic simulation staging pattern is an
efcient staging pattern to achieve alignment,
space closure and vertical correction in growing
patients. In such cases, it is essential to have good
attachments placed due to their shorter clinical
crown heights, and their passive eruption. In the
ClinCheck plan, the staging pattern demon-
strates a simultaneous movement of all teeth with
a last stage aligner jump at the end, just before
the overcorrection aligners (if any were plan-
ned). It does not matter which arch does the
jump as in the ClinCheck plans, dental move-
ment occur in space. The default has set the arch
with the most aligners to jump (Fig. 6B).
Figure 10. Overcoming the side effects of dental arch
expansion: intruding and increasing the buccal root
torque, placement of attachments, and over expan-
sion. (Image source: Wikimedia commons, free media
repository).
 The Invisaligns appliance today 27

Figure 11. (A) Pre-treatment images of case 7. (B) Pre-treatment OPG and lateral ceph of case 7. (C) ClinCheck
plans for case 7. (D) Completed images of case 7. (E) Completed OPG and lateral ceph of case 7. (F) Overall and
regional superimposition of case 7.

However, it has to be taken into account that the
success of the treatment also relies heavily on the
severity of the Class-II discrepancy, growth
potential and patient cooperation.
It is important to understand that although
elastic simulation was performed at the last
aligner, it is imperative to have the inter-arch
dental elastics worn from the very early part of
the treatment to have the desired treatment
outcome. The strength and duration of the
elastic wear will depend greatly on the severity of
the discrepancy.
The case treated out well in 22 months using a
total of 58 (39 12 7) aligners with 2
renements (Fig. 6C). Renement/additional
aligners were changed weekly.
This staging pattern is rather predictable and
suitable for growing patients with up to half unit
AP correction. Dental crowding is usually
resolved early and simultaneous staging pattern
keeps the treatment duration short. The patient
would require good clinical crown heights,
excellent compliance with aligner wear and
dental elastics.
28 Chan and Darendeliler

Figure 11. Continued.

(b) Dental arch expansion Invisalign appliance is predictable and

Dental arch expansion in growing and
non-growing patients using removable appli-
ances has previously been established.5,6
Studies on cadaver material have noted the
cessation of growth and fusion of the palatal
and pterygopalatine sutures at around 1315
years of age.7 Accordingly, in the treatment of
adult patients using the Invisalign appliance,
one cannot expect skeletal transverse
changes unless surgery is incorporated.
Dental arch expansion in adults using the
successful (Fig. 7AD). However, there are
limitations to how much expansion is
achievable and it has to occur within the
thickness of the dento-alveolus.8 Cases with
thin gingival biotype and evident recession
should be avoided (Fig. 8A). Instead, try to
select cases with lingually tipped buccal
segments, with thick gingival biotype with
minimal or no recession (Fig. 8B).
During dental arch expansion of the
maxilla, the centre of rotation of the
 The Invisaligns appliance today 29

Figure 11. Continued.

expansion is much higher than the palatal
bone structures itself (Fig. 9). One of the
worst side effect during this dental
expansion is that the palatal cusps of the
posterior teeth will extrude and hang down
due to the tipping movement of the
dentition. The strong soft tissue resistance
during expansion also does not allow
sufcient expansion clinically as planned.
Understanding these side effects is therefore
necessary in order to design a successful
ClinCheck plan.
30 Chan and Darendeliler

Figure 12. (A) Pre-treatment images of case 8. (B) Pre-treatment OPG and lateral ceph of case 8. (C) ClinCheck
plans for case 8. (D) Completed images of case 8. (E) Completed OPG and lateral ceph of case 8. (F) Overall and
regional superimposition of case 8.

It is quite a common diagnostic error during
the evaluation of the transverse discrepancy that
the clinician only considered the dimensions
of the upper dental arch, but has not con-
sidered if the lower arch was too wide instead.
This transverse discrepancy can be corrected by
not just expanding the upper arch, but with a
combination with the constriction of the lower
arch if necessary. This will reduce the amount
of upper arch expansion and make the
treatment more predictable.
It is vital to have these following movements
designed into the ClinCheck plan: (i) intrude
and increase the buccal root torque of the
upper posterior teeth, (ii) place appropriate
attachments in order to increase the surface
area contact between the dentition and aligner
material, (iii) over expansion of up to 20% of
the required distance (Fig. 10).
(c) Treatment in teenagers
Using the Invisalign appliance in the
orthodontic treatment of teenagers has
been met with resistance. The number of
Invisalign Teen cases shipped globally have
stagnated at about 24% over the last few
years.9 The usual road blocks include (i) the
 The Invisaligns appliance today 31

Figure 12. Continued.

lack of patient compliance (despite the
presence of compliance indicators), and
(ii) short clinical crown heights disallowing
good three-dimensional control. However,
the physiology of teenage patients has
been shown to respond better to various
orthodontic appliances as compared to
adults.10,11 The Ann Arbour Michigan Centre
of Human Growth and Development
published data on the average changes in
mandibular molar and canine widths over
the childrens growing years. Maximum
growth rates tend to peak just before the
age of 12 years and the trend decreases
thereafter. Therefore, while we are planning
for a younger patient using the Invisalign
appliance, we cannot forget the fact that the
patients growth is assisting the treatment
32 Chan and Darendeliler

Figure 12. Continued.

while we are enhancing the growth potential
of the child as well.
Case 7
Case 7 is an adolescent female patient of Caucasian
decent. She was diagnosed as a Class-II dental
malocclusion on a mild skeletal Class-II base with a
normal to horizontal direction of growth. She pre-
sented with a deep dental overbite, unilateral pos-
terior crossbite and lower midline deviation to the
right side (Fig. 11AC). The ClinCheck plan
included the use of both optimised and
conventional attachments. Simultaneous staging
 The Invisaligns appliance today 33

Figure 13. (A) Pre-treatment images of case 9. (B) Pre-treatment OPG and lateral ceph of case 9. (C) Post-twin
block treatment images of case 9. (D) ClinCheck treatment plans of case 9. (E) Completion images of case 9.
(F) Completion OPG and lateral ceph of case 9. (G) Overall and regional superimposition of case 9.
34 Chan and Darendeliler

Figure 13. Continued.

was planned with an elastic simulation. Class-II The case treated out well under 21 months
elastics were worn from the upper canines to the using a total of 45 (33 12) aligners with 1
lower rst molars using a button-to-button method. renement (Fig. 11DF).
The Invisaligns appliance today 35

Figure 13. Continued.

36 Chan and Darendeliler
Figure 13. Continued.
Shape-driven orthodontics
The essence of orthodontic treatment is the
application of forces and force systems to alter
tooth positions or to produce physiologic bony
changes. The application of scientic bio-
mechanics improves the quality of treatment and
treatment efciency. However, biomechanics did
not originate with orthodontics. It is based upon
the pioneers of physics like Galileo and Newton.
Recent research also included material science,
mechanics of materials, beam theory, nite-ele-
ment, and computer science to get to where we
are today. In orthodontics, we build on the
foundation from these basic sciences of engi-
neering and physics. In the biological system, we
are dealing with constant bone resorption
and bone remodelling through the periodontal
ligament within the periodontium. The tooth
itself becomes the subject of interest as it tra-
verses through the dento-alveolar bone.
Historically, orthodontic appliances were
developed, described, and taught as shape
driven. In the era of shape-driven appliances, we
were taught how to bend or twist a wire or how to
properly position a bracket. That is all geometry
and driven by shape.
The best approach is to rst determine our
orthodontic goal, what we want to achieve, and
then determine the force system that is required
to produce that result. Subsequent to that can we
then design our appliance. It is important to have
a shape, but it is more important that the shape
produces the desired force system. Often, that
resultant shape will look nothing like the ideal
nish.
 The Invisaligns appliance today 37

Figure 14. (A) Pre-treatment images of case 10. (B) Pre-treatment OPG of case 10. (C) ClinCheck plan for case 10
showing simultaneous staging and an elastic simulation. (D) Completed images of case 10. (E) Completed OPG of
case 10. (F) Final restoration placed for case 10. (G) Periapical radiographs of implant and nal restoration for
case 10.

Compensatory movements Managing premolar extraction cases using the

Understanding the side effects and the inad-
equacies of the aligner system is extremely
important in treating of complex cases. As Invis-
align is also a removable appliance, the degree of
play between the appliance and the dentition
affects the true tracking of the appliance.
Invisalign appliance is challenging. Extraction
cases in younger patients contribute to a greater
challenge due to the lack of absolute three-
dimensional control of the dental movements
with shorter clinical crown heights and less than
ideal patient compliance. However, through
good case selection, proper planning and design,
38 Chan and Darendeliler

Figure 14. Continued.

premolar extractions in teenagers can be often leading to an anterior interference and

executed well.
In such cases, not only good and sufcient
attachments need to be selected, compensatory
movements also need to be planned.
These are some of the compensatory move-
ments required in handling such extraction
cases. (i) Increase the upper anterior lingual root
torque, further intrude the lower incisors: often
an anterior open bite is seen in the nal Clin-
Check plans. During dental space closure, the
anterior teeth are often extruded and retroclined
contributing to an increase of dental overbite
posterior open bite. These 2 compensatory
movements will prevent the dumping of the
anterior teeth as the dental spaces are closed. G5
precision bite ramps should be included on the
upper anterior teeth to assist in the control of the
vertical dimension as space closes. (ii) Teeth
mesial to the extraction site need increased distal
root tip movements while teeth distal to the site
require increased mesial root tip movements.
Essentially, we are trying to counteract the crown
dumping of the abutment teeth as the
extraction spaces are closed. Due to the damping
 The Invisaligns appliance today 39

Figure 14. Continued.

effect of the aligner system, the further away from
the extraction space, the less of these increased
tipping movements are required.
This concept is further explained using the
following 2 cases.
Case 8
Case 8 is an adolescent Asian female with a Class-II
division 1 dental malocclusion with a skeletal 1
pattern and a vertical to normal direction of
growth (Fig. 12AB). Her chief concerns were that
her upper front teeth stuck out and she wanted to
have them retracted with an improvement with
her dento-facial prole. She also presented with
severe upper and moderate lower dental crowd-
ing, a deep lower Curve of Spee and incompetent
lips. Her dental midlines were non-coincident.
The upper rst premolar teeth (teeth #14, #24)
were extracted and Invisalign Teen was prescribed.
The ClinCheck plans with conventional attachment
designs and staging patterns are shown (Fig. 12C).
Class-II dental elastics were also used to control the
anchorage during space closure. Precision buccal cut
40 Chan and Darendeliler
Figure 14. Continued.
outs were designed and buttons were placed to enable
controlled retraction and space closure.
The compensatory movements planned in this
case were: increased lower incisor intrusion by
0.8 mm, increased distal root tip of the upper
canines 61, increased mesial root tip of the
upper second premolars, and rst molars 81and
61, respectively.
The case treated well in 24 months with a total
of 51 (37 14) aligners with 1 renement
(Fig. 12DF).
Case 9
Case 9 is an adolescent male patient with a mixed
Asian and Caucasian ethnicity. He was a Class I
dental on a skeletal 2 base with a horizontal
direction of growth. His chief concerns were a
mildly recessive chin and lower dental crowding
(Fig. 13AB).
Due to his insufcient horizontal projection of
his chin and a decient mandible, a functional
twin block appliance was prescribed. Active
treatment lasted 7 months and brought him into
a reversed dental overjet and an improved facial
appearance (Fig. 13C).
Subsequently lower rst premolars (teeth #34
and #44) were extracted and the Invisalign Teen
appliance was prescribed. The treatment plan was
to complete the case in a Class I canine and a Class-
III molar dental relationship. The ClinCheck plans
demonstrate the use of optimised as well as con-
ventional attachments in a simultaneous staging
pattern (Fig. 13D). After obtaining a positive overjet
and overbite at stage 23, night use of Class-II dental
elastics was used to maintain the anchorage.12 An
early renement was performed at stage 31 and
posterior triangular elastics was used to settle the
bite during these renement stages.
The compensatory movements planned in this
case were increased lower incisor intrusion by
0.8 mm, increased distal root tip of the lower
canines 81, increased mesial root tip of the lower
second premolars, and rst molars 81 and 61,
respectively.
The case treated well in 17 months with a total
of 42 (31 11) aligners with 1 renement
(Fig. 13EG). The total active orthodontic
treatment was 24 months.
Despite reported difculties from new clini-
cians in obtaining repeatable good results using
the Invisalign appliance in younger patients, the
most common mistakes are that they have either
not planned the treatment around the patients
existing growth potential, or that they have failed
to fully understand and counteract the side effects
of tooth movement with aligner appliances.
Favourable physiology and good growth
potential in younger patients allow orthodontic
treatment to be more forgiving. We could often
achieve a reasonable result despite less than ideal
compliance, and even more overwhelming results
with excellent growth potential and compliance.
(d) AP correction
Understanding the shortcoming of any
orthodontic appliance allows us to think outside
the usual treatment plans in order to achieve the
desired result within a prescribed, limited range.
The anteriorposterior correction of dental
malocclusion using the Invisalign appliance will
be described under the following subheadings:
(i) Opening spaces
Case 10
Case 10 is an adult Caucasian male who lived
many years with an absent upper right lateral
incisor (Fig. 14AB). His chief concerns were
that his smile was asymmetrical, has an
underbite, would like to have his smile
improved, and missing dentition restored. He
presented with a Class-III dental malocclusion on
a skeletal 1 pattern with a normal direction of
 The Invisaligns appliance today 41

Figure 15. (A) Pre-treatment images of case 11. (B) Pre-treatment OPG of case 11. (C) ClinCheck plans for case
11. (D) Images of case 11 after the 319 aligners. Images taken at renement 2. (E) Completed images of case 11
after the placement of nal restoration. (F) Completed OPG of case 11 after the placement of nal restoration.
42 Chan and Darendeliler

Figure 15. Continued.

growth. The upper dental midline was deviated
to the right due to the missing upper right lateral
incisor. There was a reversed overjet, an anterior
functional shift, with increased wear and attrition
to his anterior teeth. The patient also presented
with a Boltons discrepancy with the upper left
lateral incisor slightly diminished in size. As he
was reluctant to have that built up, it was quite a
challenge to allow a full dental implant to be
placed in the site where the missing tooth was.
The ClinCheck plan was designed with
simultaneous staging. An elastic simulation was
prescribed in order to achieve the Class-I
occlusion after the elimination of the
functional shift (Fig. 14C). Class-III dental
elastics were used clinically to achieve the AP
correction.
The nal occlusion and dental space for the
upper right lateral incisor was achieved after 13
months of active treatment with 27 (17 10)
aligners, 1 renement (Fig. 14DE). The
dental implant was successfully placed and
the nal restoration subsequently installed
(Fig. 14FG).
Treatment planning in adults is challenging as
patients do not often present with a full set of
complete dentition. However, ClinCheck treat-
ment planning is the best tool for such patients
 The Invisaligns appliance today 43

Figure 15. Continued.

requiring interdisciplinary treatment. The pre-
cise virtual prediction of dental movements and
implant site preparation allows the case to be
planned and modied where necessary with the
input from the orthodontist, periodontist, pros-
thodontist, and also the patient him/herself. The
same applies for orthognathic surgery cases in
terms of arch co-ordination and anchorage
management.
Case 11
Case 11 is an adult Caucasian female who had her
lower left rst premolar tooth previously
extracted. The dental space had since closed
resulting in the lower dental midline shifting
completely to the left side (Fig. 15AB). Her
chief concern was that she had a narrow smile
and crooked front teeth.
Multiple orthodontic plans for her were dis-
cussed. We could extract 3 more premolar teeth
(one from each other quadrant) to balance the
occlusion, or remove 2 upper premolar teeth and
IPR the lower arch, or perform a non-extraction
plan and IPR the upper arch and keep the dental
midlines uncorrected.
As the patient was also concerned with her
narrow smile, the examination of her supporting
periodontal tissues led us to a fourth treatment
option. A non-extraction treatment was planned
with the re-establishment of a dental space where
the lower left rst premolar was. This treatment
44 Chan and Darendeliler

Figure 16. (A) Pre-treatment images of case 12. (B) Pre-treatment OPG and lateral ceph for Case 12.
(C) ClinCheck plans for case 12. (D) Completed images and CT scan of mandible of case 12.

would require the patient to have a dental
implant placed post-orthodontic treatment. The
ClinCheck plans with the attachment design
(Fig. 15C), simultaneous staging pattern and use
of Class-II elastics on the left side was prescribed.
The implant space was favourably opened
after the initial lot of 40 (31 9) aligners
(Fig. 15D). The stage I dental implant was
placed while the patient was still undergoing
active treatment with renement aligners. This
allowed no down time as osteointegration
occurred.
The nal restoration was placed (Fig. 15EF)
after a total of 51 aligners.
Case 12
Case 12 is an adult male Caucasian patient with his
dental spacing as his chief concern. He had a Class-
II dental malocclusion with a skeletal Class-I facial
pattern and a horizontal direction of growth
 The Invisaligns appliance today 45

Figure 16. Continued.

(Fig. 16AB). He also presented with a mild degree
of microdontia, a deep bite tendency, and noted
wear and attrition on his dentition in general.
Few treatment options were discussed and
many included the closure of the dental spaces,
xed appliances with xed functional appliances
such as a Herbst. After considering his dento-
facial prole and his preferred choice of appli-
ance, the nal treatment plan was to use the
Invisalign appliance to open a third premolar
46 Chan and Darendeliler

Figure 17. (A) Pre-treatment images of case 13. (B) Pre-treatment OPG of case 13. (C) ClinCheck plans showing
the establishment of 4 premolar spaces. (D) Completion images of case 13. (E) Comparison of pre- and post-
treatment proles of case 13.

space on each of the lower quadrants, leaving the
molars in full Class-II but canines in Class-I dental
relationship. These spaces will then be restored
with prosthodontic replacements, likely dental
implants.
Opening of a third premolar space in the
lower arch to treat a Class-II dentition ortho-
dontically is not common. However, the dis-
traction of the periodontium provides good
dental bony structures to allow implant place-
ment. But it is necessary to examine if the sur-
rounding supporting periodontal tissues are able
to contain the dental movements required to
achieve the desired end result. With the Invis-
align system, ClinCheck plans allow the visual-
isation of the dental movements, either
expansion and/or proclination (in this case),
and exact measurements and anchorage con-
siderations can be made. Computer aided
treatment decisions can then be made more
precisely as such.
A prosthodontist and periodontist were con-
sulted and radiographs inspected. In order to keep
the option of a dental implant placement open,
 The Invisaligns appliance today 47

Figure 17. Continued.

the position of the mental nerve and its canal had Treatment was supported with optimised and
to be considered. In this case, we decided to open conventional attachments, and Class-II elastics.
a single premolar dental space between the lower Treatment was completed in 21 months with 45
rst and second premolar teeth (Fig. 16C). (26 19) aligners and 1 renement (Fig. 16D).
48 Chan and Darendeliler
Figure 17. Continued.
Case 13
Case 13 is an adult Caucasian female with chief
concerns of dental spacing. She presented as a
Class-I dental on a skeletal Class-I horizontal
base. She had a certain degree of microdontia
with upper and lower dental spacing. She also
had a deep bite tendency, retroclined upper and
lower anterior teeth with deviated dental mid-
lines. Her dental prole was concaved and did
not allow full dental space closure without either
dishing in her prole further, or involving
bimaxillary orthognathic surgery (Fig. 17A-B).
After considering various treatment options
using the virtual ClinCheck treatment plans, it
was decided to have 4 premolar spaces opened
up for prosthodontic replacement, one in each
quadrant (Fig. 17C). On the upper arch, the
third premolar spaces were opened between the
upper rst and second premolars. Whereas on
the lower arch, the third premolar spaces were
opened between the lower canines and the lower
rst premolars.
Both Class-II and Class-III elastics were used to
control the anchorage and midline correction.
The completed dental occlusion was a Class-I
canine and molar dental relationship. The
consolidation of dental spaces, closing of the
anterior spacing, and establishing a full premolar
space in this case has allowed an aesthetic out-
come with the preservation of the patients
dento-facial prole (Fig. 17D-E).
The treatment duration was 15 months with a
total of 31 (22 9) aligners and 1 renement.
(ii) Closing spaces
Premolar extraction cases in non-growing
patients using the Invisalign appliance main-
tain a tough challenge to the new clinician. The
same principles on compensatory movements
mentioned as before should also be applied. The
increased difculty in adult treatment is the lack
of vertical dento-alveolar growth and often
treatment duration could be longer.
Case 14
Case 14 is an adult female patient of Asian
descent. Her chief concerns were her crowded
dentition. She presented as a Class-III dental on a
skeletal 3 pattern with a vertical growth pattern.
She had bilateral posterior and anterior cross-
bites, moderately severe upper and lower dental
 The Invisaligns appliance today 49

Figure 18. (A) Pre-treatment images of case 14. (B) Pre-treatment OPG and lateral ceph of case 14. (C) ClinCheck
plans of case 14. (D) Compensatory movements planned for case 14. (E) Completion images of case 14. (F)
Completion OPG and lateral ceph of case 14. (G) Overall and regional superimposition of case 14.

crowding, minimal overbite, and overjet with
deviated dental midlines (Fig. 18A-B).
A camouage treatment plan was designed
with the extraction of the lower left rst and
lower right second premolars (teeth #34 and
#45). The ClinCheck plans show a mixture of
optimised and conventional attachment designs,
IPR, and simultaneous staging (Fig. 18C).
Compensatory movements were planned with
increased mesial root tip of the immediate
dentition distal to the extraction spaces and
increased distal root tip of the immediate den-
tition mesial to the extraction spaces (Fig. 18D).
Class-III elastics were used to control the
anchorage. The plan was to complete the
occlusion with a Class I canine and Class-III
molar dental relationship.
The treatment duration was 22 months with 47
(32 15) active aligners with 1 renement (Fig.
18E-G).
50 Chan and Darendeliler
Figure 18. Continued.
Case 15
Case 15 is an adult male patient of Asian back-
ground. He presented with a bimaxillary pro-
trusive Class-I dental malocclusion on a skeletal 1
base with a normal direction of growth. He had a
protrusive dental prole, incompetent lips, an
anterior crossbite with minimal overjet and
overbite (Fig. 19A-B).
The treatment plan was to have 4 rst pre-
molars extracted (teeth #14, #24, #34 and #44).
The Invisalign ClinCheck treatment plan was set
up with both optimised and conventional
attachments with simultaneous staging. A vertical
rectangular attachment was placed on the lingual
surface of the upper right instanding lateral
incisor for aesthetic reasons (Fig. 19C).
The compensatory movements in this case
included an increased upper incisor lingual root
torque of 41, further intrusion of the lower
incisors of 0.6 mm, increased mesial and distal
root tip of the abutment teeth distal and mesial to
the extraction sites respectively of between 41 and 81
(Fig. 19D).
Class-II elastics were used initially to allow
anchorage control and also to maintain a Class I
canine relationship. During the renement
stages, posterior box elastics were used in cor-
poration with the upper anterior precision bite
ramps (G5 feature) in order to control the ver-
tical settling of the occlusion. (Fig. 19E)
The total treatment duration was 26 months
with 83 aligners (30 17 12 24) and 3
renements. The renement aligners were
changed weekly (Fig. 19F-H).
Adult orthodontic treatment often con-
stitutes dentitions with missing or absent teeth.
While prosthodontic replacements are more
 The Invisaligns appliance today 51

Figure 18. Continued.

common now, there remains additional surgical
involvement and costs. Closure of large eden-
tulous spaces with the Invisalign appliance
alone is challenging and should be discouraged.
However, the appliance could be incorporated
with partial xed appliances and TADs to
enable us to dictate the dental movements
required.
Case 16
Case 16 is an adult male patient with an Asian
background. He had a missing lower left rst molar
and wanted to have it closed orthodontically to
avoid the placement of a dental implant. He was a
mutilated Class-I dental malocclusion on a skeletal
Class-I base with a normal direction of growth. He
presented with a congenitally missing lower incisor,
non-coincident dental midlines, missing upper
right rst molar (space almost all closed up) and
lower left rst molar, proclined upper incisors
with mild upper and lower anterior crowding
(Fig. 20A-B).
The treatment plan was to use a TAD on the
lower left quadrant, in concurrent with partial
xed appliance to close the lower left edentulous
52 Chan and Darendeliler

Figure 18. Continued.

space; and do the rest of the other orthodontic
movements with the Invisalign appliance.
The ClinCheck plans demonstrated the use of
optimised and conventional attachments with an
initial upper 30 and lower 40 active aligners. We
allowed mesial movement of the lower left molars
within the rst 30 active aligners as the upper
dental treatment progressed. At the end of the
rst 30 aligners, partial braces and a TAD were
placed and renement aligners were ordered to
complete all the dental movements required
(Fig. 20C).
In the renement ClinCheck plans, precision
cuts were designed to incorporate the partial
xed appliances and triangular elastics with
elastomeric chains were also used to close the
dental spaces as well as to settle the occlusion
vertically (Fig. 20D). Although the movement of
the lower left molars were achieved with the
partial xed appliance, mesial movements were
also planned in the ClinCheck treatment to
facilitate the tracking of the dentition. Other
nishing orthodontic movements were occurring
in concurrent with the partial xed appliances.
The treatment duration was 28 months with 61
(30 31) active aligners and 1 renement (Fig.
20E-F).
(iii) Orthognathic surgery
Further AP correction in adult treatment that
extends beyond the boundaries of the dento-
alveolar segment will require the involvement of
orthognathic surgery. More often than not, oral
 The Invisaligns appliance today 53

Figure 19. (A) Pre-treatment images of case 15. (B) Pre-treatment OPG and lateral ceph of case 15. (C) ClinCheck
plans of case 15. (D) Compensatory movements planned for case 15. (E) Posterior box elastics with G5 precision
bite ramps on the upper incisors. (F) Completion images of case 15. (G) Completion OPG and lateral ceph of case
15. (H) Overall and regional superimposition of case 15.

surgeons involved in the treatment planning and Case 17

execution of these cases treated with the Invisalign
appliance would still prefer to have xed appli-
ances placed a couple of months before the sur-
gery is performed.
The decompensatory, pre-surgical movements
are clearly visualised and well executed by the
Invisalign appliance. It is predictable and the
patients and surgeons appreciate the forecast
of dental movements prior to the actual com-
mencement of treatment. Surgical movements
can be better planned as such.
Case 17 is an adult Caucasian female patient that
presented with an uneven bite. She was a Class-III
dental and skeletal 3 base with a vertical growth
pattern. There were mild degrees of upper and
lower dental crowding, the lower midline and
mandible were both deviated to the right side
with anterior and posterior crossbites evident
(Fig. 21A-B).
The strength of the virtual ClinCheck treat-
ment plan allows us to view the pre-surgical
54 Chan and Darendeliler

Figure 19. Continued.

decompensatory movements clearly and plan the
vertical and transverse corrections digitally prior
to the commencement of treatment. Marginal
ridge discrepancies, palatal cusps interferences,
and transverse inter-arch discrepancies can all be
eliminated early and efciently. Optimised and
conventional attachments were used; a simulta-
neous staging pattern was planned with a surgical
simulation at the end of the active aligners
(Fig. 21C).
Treatment proceed with initial prescription
with the Invisalign appliance. 2 months before
the surgical date, xed appliances were placed.
The xed appliances were removed 2 months
after the completion of the orthognathic surgery
and renement aligners were ordered to com-
plete the treatment. The surgical movements
executed were maxillary advancement and pos-
terior impaction, asymmetrical bilateral sagittal
split osteotomy (BSSO), and autorotation of the
mandible.
After the rst 17 aligners, xed orthodontic
appliances were placed and a surgical date was
set. Model surgery and surgical splints were
fabricated as usual, and the nal surgical move-
ments were conrmed. 2 months post-
orthognathic surgery, the xed orthodontic
appliances were removed and renement align-
ers were ordered. During the renement stages,
precision cuts were planned to allow further
 The Invisaligns appliance today 55

Figure 19. Continued.

correction of the malocclusion and dental mid-
lines (Fig. 21D).
The treatment was completed in 17 months
with 4 months of xed appliances and 27
(17 10) active aligners with 1 renement (Fig.
21E-G).
Discussion
Pre-treatment evaluation, case selection, and
planning is of paramount importance in using
the Invisalign appliance. The study of the anat-
omy of the dentition, biology of the subject and
part psychological evaluation of the patient is the
key to successful treatment.
Age-related treatment plans using the Invis-
align appliance should be no different from
using conventional orthodontic appliances.
Considerations of treatment include the
followings.
 Sutural maturity.
 Biological age of the patient.
 Avoiding movement of teeth beyond the
physiological boundaries of the dento-
alveolar segments.
 Examine the periodontal support of the
dentition. One of the advantages of using
the Invisalign system is the ability to selectively
orchestrate the dental movements. The veloc-
ities of every tooth can be dictated and
56 Chan and Darendeliler

Figure 19. Continued.

monitored as treatment is planned and exe-
cuted. Periodontally compromised teeth can
also be almost left stationary during treatment
with minimum and/or no mechanical
pressure.
 Examine if the soft tissues can hold up against
camouage treatment.
 Examine for sufcient clinical crown heights
for aligner adaptation.
 Decide if it is necessary to have extractions.
 Plan for sufcient and appropriate attachments.
 Plan for compensatory movements to over-
come the side effects of the dental
movements.
 The Invisaligns appliance today 57

Figure 20. (A) Pre-treatment images of case 16. (B) Pre-treatment OPG of case 16. (C) Images at renement,
placement of partial xed appliances and TAD. (D) ClinCheck plans at renement of case 16. (E) Completion
images of case 16. (F) Completion OPG of case 16.
58 Chan and Darendeliler

Figure 20. Continued.

 Do not hesitate to use any other orthodontic Conclusion

auxiliaries to facilitate your aligner treatment
plans.
 Examine the need and extra costs involved if
prosthodontic and orthognathic work were to
be included.
 Examine stability of the result achieved
and plan for long term retention where
necessary.
With digital treatment planning and automated
manufacturing, many traditional barriers of
orthodontic treatment are removed. The three-
dimensional visualisation of the treatment out-
comes, differential treatment plans and/or
extraction/non-extraction treatment plans, and
foreseeing Boltons discrepancies, assist the
The Invisaligns appliance today 59

Figure 20. Continued.

60 Chan and Darendeliler

Figure 21. (A) Pre-treatment images of case 17. (B) Pre-treatment OPG and lateral ceph of case 17. (C) ClinCheck
plans of case 17. (D) Renement arch co-ordination with precision cuts and elastic bands. (E) Completion images
of case 17. (F) Completion OPG and lateral ceph of case 17. (G) Overall and regional superimposition of case 17.
The Invisaligns appliance today 61

Figure 21. Continued.

62 Chan and Darendeliler

Figure 21. Continued.

 The Invisaligns appliance today
Figure 21. Continued.
clinician in the orthodontic ofce. However,
many new clinicians tend to forget that the
diagnosis and treatment planning still lies well
within our responsibilities.
Computer-aided treatment planning does
not understand dental anatomy, biology of
tooth movement, biomechanics and material prop-
erties as well as we do. The complete reliance on it
will lead to undesirable treatment outcomes. We are
ultimately responsible for the treatment of our
patients and we must understand the strength and
weaknesses of the appliance in order to exploit the
best out of what is available, and offer our patients
the best treatment modality possible.
As with using any new appliance, treating
complex cases using the Invisalign system would
have a learning curve. However, thoroughly
understanding the limitations of the appliance
and defaults of the ClinCheck software, out-
standing results can often be achieved predict-
ably. Clear appliance therapy is here to stay.
63
Embracing technology without rst applying
basic orthodontic concepts is a dangerous affair
and should be discouraged. Lateral thinking, and
often, thinking outside the common box allows
us to further our art and achieve quality treat-
ment results, more efciently.
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