Contents

Introduction

History and Development of Clear Aligners

Advantages and Disadvantages

Indications & Difficult Cases for Clear Aligners

Terminologies in Clear Aligner Therapy

Impression Techniques and Its’ Errors & Solutions

Introduction

• Clear aligners are colourless and nearly invisible

removable appliances that gradually guide teeth

into proper alignment

• They are alternatives to traditional fixed appliances

and do not use wires or brackets

Introduction

• Invisalign® can be said to be the forefront of clear

aligner therapy in the present day

• Having been around for 20 years in the market it:

• Available over 90 countries

• Treated over 4 million patients

History and Development

• The origin of clear aligners dates back to 1945

• H.D. Kesling introduced his ‘diagnostic set-up’

History and Development
Kesling set-up used
in:

Close to the end of

treatment

Treatment planning to visualise

final tooth positions

Evaluate extraction or non-

extraction approach
History and Development
Impressions taken at end of orthodontic treatment

Teeth were separated on plaster models

Appliance was removed

Set up in ideal occlusion

Rubber positioner made in lab according to the set up

Used as retainer or correct minor relapse

History and Development
History and Development
Nahoum (1964) Ponitz (1971)

Introduced thermoformed plastic

Described a method to appliance called ‘invisible
change tooth contours retainer’

Made on master model that

Using thermoformed prepositioned teeth on wax
plastic

Claimed could produce limited

movements
History and Development
Sheridan (1985)

Technique of interproximal tooth reduction

For resolution of lower incisor crowding and

alignment of teeth

With help of labiolingual clear retainer –

Essix retainer
History and Development
Sheridan Required new set of study models for
the appliance
Time consuming for patient and
orthodontist
With Keith Hilliard, used thermoforming
pliers to enhance tooth movements
History and Development
Essix Light invisible removable appliance
Retainer
(Dentsply)
As a retainer after orthodontic treatment

Or for mild crowding

Tooth to be moved by thermoformed pliers

or addition of composite layers
History and Development
Clear Aligner

Essix Retainer Invisalign

Fabricated by
Thermoformed Series of Series of
making
retainers computer aligners
adjustments to
tooth positions generated gradually guide
on models custom plastic teeth into
aligners proper
alignment
History and Development
Invisalign

Proprietary orthodontic
brand and technique

Other commercially available

alternatives

Its growth has spread worldwide and is

commonly used to represent this specific
technique
History and Development
Invisalign

Commercially Brainchild of 2 Stanford University

available since 1998 graduate business students

Zia Chishti Kelsey Wirth

History and Development
Wirth and Chishti were given Essix retainers

To correct minor orthodontic relapse

‘Why couldn’t they have these instead of braces?’

Orthodontists told them it was for minor problems and dismissed

idea for correcting complex malocclusion

Undeterred and unburdened with ‘baggage’ of orthodontic background

Formed Align Technology Inc.

 History and Development
Align Technology

Use CAD-CAM to mass produce aligners to treat

broader range of malocclusions

Lucky to be attracting intest of Dr. Robert Boyd

Chairman of Department of Orthodontics (University of the Pacific)

He assisted by being consultant

He and his residents tested this new technology

Invisalign
Uses principles of Kesling set-up
and CAD-CAM process

Patients’ impressions scanned

Digital virtual occlusion created

Initial malocclusion and final

treatment plan is worked out
Invisalign
Virtual sequential models

Controlled by softwares and laser guided

procedures

Series of clear aligners made

Aligners produce 0.25 to 3mm tooth

movements

Aligner used over a period of 2 weeks

Advantages of Clear Aligners
• Removable

• Easier to maintain oral hygiene

• Comfortable less likely to irritate soft tissues compared to fixed

appliances

• Excellent esthetics for adult patients reluctant for fixed appliances

Advantages of Clear Aligners

• Excellent tool for final correction after orthodontic

correction

• Can realign after relapse of post-orthodontic treatment

• Can prevent tooth wear from bruxism

Disadvantages of Clear Aligners

• Initially difficulty in speech present

• Pain from tooth movement due to aligner changes

• Errors from impressions result in delayed treatment

or mid-course corrections
Disadvantages of Clear Aligners

• Loss of aligners during treatment

• Sores and irritation around gingival region if not

fabricated adequately

• High cost (Average cost £1690)

Indications of Clear Aligners
Mildly crowded
malocclusions (1-5mm) by:
• Slight interproximal reduction
Narrow arches that can be

• Lateral and/or anteroposterior expanded without tipping

expansion teeth much
• Removal of a lower incisor
Indications of Clear Aligners

Deep overbite problems

(e.g. Class II Div. 2)
Spacing problems
(1-5mm) • Overbite reduced by
intrusion and advancement
incisors
Difficult Cases For Clear Aligners

Crowding and Skeletal anteroposterior

spacing more than discrepancies

5mm • Measured cuspid relationships of more

than 2mm

Centric relation and

centric occlusion Severely rotated teeth
discrepancies more than 20⁰
Difficult Cases For Clear Aligners

Openbites (posterior and

anterior) Extrusion of teeth

Severely tipped Arches with Teeth with short

teeth (more than multiple missing clinical crowns
45⁰) teeth
Terminologies in Clear Aligners

Midcourse Temporary pause in treatment while new

impressions are made
Correction
Treatment continued once new aligners are
made

Similar in concept to repositioning brackets

brackets halfway in fixed appliances
Terminologies in Clear Aligners
Restorations making aligner
Lack of patient compliance unacceptable fit due to
morphology change

Midcourse Correction
Reasons

Lack of teeth tracking with

Change in treatment plan aligner affecting the fit of
aligner
Terminologies in Clear Aligners
Refinement

Similar to midcourse correction

Pausing treatment, taking new impressions, ordering

new series of aligners

Takes place near end of treatment when teeth not in

position as desired

Considered like artistic detail bends with fixed appliance

Terminologies in Clear Aligners
Reasons for Refinement

Small amount of permanent distortion

of aligner causing tooth position not to
match virtual treatment plan

Insufficient attention to details

during virtual set-up
Terminologies in Clear Aligners
Interproximal
reduction Removing controlled amounts of tooth structure
interproximally

Attachment
Small composite additions to tooth surfaces

Enhance areas of undercut for retention or for tooth

movement
Impression Techniques

• Treatment success begins with good polyvinyl

siloxane (PVS) impression

• Initially Align Technology used a process called

‘destructive scanning’
Impression Techniques
Destructive Scanning

Models photographed occlusal view

Milled down slightly

Photographed again

Process repeated

Series of photographs to reassemble by layers

Recreate the model by virtual stacking the images

Impression Techniques
Advantage: Disadvantages:
Destructive
• Technician can fix • Time consuming and
Scanning
imperfections in expensive
impression by repairing • Huge amount of plaster
model prior to scanning dust produced

No longer used Align Technology converts impressions

into 3D virtual models with high-
resolution industrial CT Scan
Impression Techniques

Basic Impression
Techniques

One-step impression

Combination
impression technique
Two-step impression
technique
Impression Techniques
One Step Impression

Preferred Higher
Easiest and method; probability if
most likely ‘medium-body’
reduced missing
defective PVS material in
chair time anatomy of
impression Invisalign trays
and one or more
expenses teeth

Especially area distal

to 2nd molars which
ensures fit of aligner
Impression Techniques
Impressions of 2nd molars
Combination
are first captured with PVS
Technique
putty material

To create a
posterior dam
Impression Techniques
To gain more detailed
Medium body used
impression of 2nd molar
over the putty
and rest of dentition

More chairside time but

reduces chances of
unacceptable impression
Impression Techniques
Two-step
Making custom trays and
technique
essix type retainer
‘training aligner’

Models trimmed to
make essix-style retainer

Alginate impression taken

and poured using dental
stone
Impression Techniques
Thermoformed plastic Plastic impression tray
material formed over filled with heavy body
model but not trimmed material
Impression Techniques
Model with untrimmed
thermoformed plastic
inverted and pressed into
impression material
To ensure good visualisation
to produce consistent
thickness of material around
the teeth

Thus creating
perfect
custom tray
Impression Techniques
Thermoformed
Once custom tray is material trimmed in
made typical way to be used
as a ‘training aligner’
Impression Techniques
Final impression when Light body wash placed in the
patient returns custom tray

Once impressions are done, if

patient is interested bleaching
can be used with training
aligners before aligners from
Align arrive
Errors in Impressions
Failure to capture details of areas distal to 2nd molars

No distal surface of terminal molars

Retention of aligner is compromised

It floats on surface of distal molars

When forces applied anterior teeth

Appliance easily dislodged

Avoided by two step technique

Errors in Impressions
Multiple areas of ‘drag’ near gingival margin

Triangular voids caused by seating tray too

quickly in the mouth

Not allowing time for material to flow around

the gingival margins

This causes problems in allowing the aligner to be trimmed for

comfort and effectiveness

Avoided by seating the tray more slowly

Errors in Impressions
Surface air bubbles in
impression

By capturing air in folds of material while loading

tray due to

Moving the syringe

tip in and out of the Seating tray too quickly
material

Trapping air between tooth and

material
Errors in Impressions
If air bubbles immediately below
surface of impression material

It appears to be good quality

When it is scanned, insufficient thickness to

be resolved on image

Tooth will have large area of distortion

Both errors avoided by using proper technique

Errors in Impressions
Seating impression tray too close or far to buccal or lingual
tooth surface

Impression material bleeds through

to tray

Material becomes too thin to be

resolved on CT image

Same problem as an air bubble

Avoided using correct tray size and seating it properly

Invisalign Impression Trays

• They are made of plastic

• Easily customised by heating the tray to form it to

patients arch form

Thank You
References
• Graber LW, Vanarsdall RL, Vig KWL, Huang GJ. Orthodontics:
current principles and techniques. St. Louis, MO: Elsevier; 2017.

• Kharbanda OP. Orthodontics: Diagnosis Of & Management Of

Malocclusion & Dentofacial Deformities. S.L.: Elsevier India; 2011.

• Chan E, Darendeliler MA. The Invisalign ® appliance today: A

thinking person’s orthodontic appliance. Seminars in
Orthodontics. 2017;23(1):12–64.
References

• Morton J, Derakhshan M, Kaza S, Li C. Design of the Invisalign system

performance. Seminars in Orthodontics. 2017;23(1):3–11.

• Kesling H. The philosophy of the tooth positioning appliance. American

Journal of Orthodontics and Oral Surgery. 1945;31(6):297–304.