Dean Steinman, Owner of OrthoMarketing

I have been treating patients with Invisalign® for almost 10 years. Over that time, I have learned a great deal about moving teeth with plastic aligners. In addition, I have also made just about every practice management mistake there is. Here, I have compiled my top 10 Invisalign management pearls that I learned the hard way—by trial and error. I share them with you so perhaps you won’t make the same mistakes I have and can make your day-to-day practice just a little bit less stressful.

 

Handing out an emery board to all new aligner patients is a great way to empower patients and reduce emergency phone calls.
Handing out an emery board to all new aligner patients is a great way to empower patients and reduce emergency phone calls.

 

1. Change attachments to “same color as tooth” before showing ClinCheck to patients.

Attachments, especially optimized attachments, are custom designed to achieve the desired tooth movement. They are absolutely necessary. Nevertheless, I see many orthodontists who are coerced by their patients into removing anterior attachments for aesthetic reasons. Not a good idea! Omitting an attachment, especially on stubborn maxillary lateral incisors, can lead to nontracking issues. To reduce the chance of a patient objecting to attachments when viewing their ClinCheck®, change the attachment to tooth color on the ClinCheck by going to File> Settings>Display>Attachments>Same as Tooth. When viewed on a ClinCheck, tooth-colored attachments are much less noticeable, and patients are less likely to object to their presence.

 

2. Talk about refinements early and often.

Early on in my Invisalign experience, I made the mistake of telling a patient that they would need “a refinement.” No problem, right? Wrong! When I delivered the patient’s refinement aligners, all 12 stages of them, the patient was upset. Why? “You said I would need A refinement!” In the patient’s mind, “A refinement” meant one stage of aligners. I thought about this, and realized that the patient had a good point. Learning from that experience, the possibility of multiple refinement series is discussed with each Invisalign patient at the initial consultation and frequently thereafter. Phrases such as “We get your aligners in batches. You will need multiple batches of aligners during your treatment.” or “At your next visit, you will be getting your next bunch of aligners,” are much more effective, and help to set reasonable expectations for the patient.

 

To reduce patient concerns about IPR, Glaser strongly recommends explaining the entire process on three separate occasions before performing the procedure.
To reduce patient concerns about IPR, Glaser strongly recommends explaining the entire process on three separate occasions before performing the procedure.

 

3. Explain IPR three times.

Patients have lots of concerns about IPR. We explain the entire process on three different occasions—first at the initial consultation, then at the Invisalign scan appointment, and again immediately before performing IPR for the first time. The American Association of Orthodontists has an excellent brochure on IPR you can give to your patients. In addition, with a teen patient, it is especially important to have the parent present in the treatment room right before performing IPR. The number of parents who have no recollection of the prior two conversations always amazes me. The last thing I want to happen is to perform IPR on a child, have them walk out to their parent in the waiting room, with blood possibly in their aligners, and have a parent go ballistic because they didn’t recall our previous two conversations. When it comes to IPR, always “inform before you perform.”

The compliance indicators on Invisalign Teen serve as great “lie detectors” to ensure all patients—adult and teen—wear their aligners properly. Reprinted with permission of Align Technology Inc
The compliance indicators on Invisalign Teen serve as great “lie detectors” to ensure all patients—adult and teen—wear their aligners properly. Reprinted with permission of Align Technology Inc

4. Keep compliance indicators a secret at first.

Compliance indicators, the little blue dots on Invisalign Teen® aligners that gradually fade if the aligners are being worn full time, can be great motivational tools. We like to call them “lie detectors” in our office. It’s one of the best reasons to order Invisalign Teen for ALL patients including adults. Here’s the trick: Don’t tell patients what they are at the first aligner delivery appointment. At the next visit, ask the patient to remove their aligners and inspect the compliance indicators. If they have faded from blue to clear, praise the patient for excellent aligner wear and share in the joy! If, however, the compliance indicators are still bright blue, tell them what the compliance indicators are for and explain to the patient and parent that the aligners are not being worn enough to achieve the desired result. In addition, refer to tip #5 below.

 

5. Don’t give out more aligners if the patient has not been compliant.

You read that correctly. Patients must understand that their teeth will not get straight simply by having aligners handed to them—22 hour per day wear is absolutely critical to achieving good results. In any situation where the teeth do not appear to be tracking and the compliance indicators are not faded from blue to clear, we instruct the patients to continue wearing the same set of aligners and return for an aligner check in 1 week. Is it punishment? We try very hard not to scold, lecture, or denigrate our patients. Nevertheless, they usually get the message. There have been situations in my office where patients become upset, and even insist they have been compliant even though it is obvious they have not been. In these situations, to keep the peace, we say, “Some people’s teeth move slower than others. Let’s have you switch aligners every 3 weeks instead of every 2.” I think it’s a nice way of getting the message across that compliance is necessary without being accusatory. We don’t want those bad Yelp reviews.

 

6. Be suspicious of “I left my aligners in the car” or “I took my aligners out because I knew I had an appointment.”

Patients are repeatedly instructed to always arrive to their appointment wearing their current aligners. We want to check for fit as well as compliance. Any patient who shows up without their aligners? HUGE RED FLAG! More often than not, there’s something fishy going on. Calmly ask the patient to retrieve their aligners from the car because you want to check the fit. More often than not, a most uncomfortable silence will ensue. Typically, the patient will have no choice but to come clean. This is an excellent opportunity for sympathetic education, explaining the importance of consistent aligner wear. Note in the patient’s chart that they forgot their aligners and emphasize that they must have them at their next visit.

 

Seeing a lot of broken aligners? More than likely, patients are flipping them on and off while in the mouth.
Seeing a lot of broken aligners? More than likely, patients are flipping them on and off while in the mouth.

 

7. Aligners broken into several pieces are being flipped on and off in the mouth. Guaranteed!

If a teen patient presents with their aligner in multiple pieces, it is a virtual certainty that they are playing with their aligners—repeatedly flipping them out with their tongue and biting them back into position. This habit will initially distort the aligners, reducing their effectiveness, and rapidly lead to fatigue and failure of the plastic. Instruct the patients that aligners should never be bitten into position; rather they should always be placed with finger pressure to reduce the likelihood of distortion or breakage. In cases where the patient cannot stop the habit, we will order additional aligners with the rate of movement reduced by 50%, and have the patient switch weekly to keep ahead of the breakage. A recent change by Align Technology Inc now allows for unlimited additional aligners for 5 years, so there should be no issue with additional fees.

 

8. Hand out an emery board to all new patients and teach them to sand out rough spots.

Handing out a simple emery board to all new Invisalign patients is a great way to reduce emergency phone calls. We instruct new patients to use the emery board to smooth the aligners in any areas that may feel rough to their cheeks or tongue. These instructions help patients to have realistic expectations regarding aligner comfort, especially at the beginning of treatment, and empower them to handle minor irritations on their own. We always say, “If you can’t resolve the problem on your own, please do not hesitate to give us a call.” This way, the patient does not feel like we are ushering them out the door.

 

9. Give patients unused overcorrection aligners as emergency retainers.

I will routinely prescribe overcorrection aligners for incisor rotations. In some cases, however, the teeth align ideally without the need for overcorrection. In these cases, don’t throw the three overcorrection stages away! Why? They are great emergency retainers, why throw them away? We give the patient the three stages of overcorrection aligners at the same appointment when the final retainers are delivered and instruct them to use them as temporary emergency backup retainers if their final retainers are lost, broken, or if Fido chews them up. This is less important when you use Vivera retainers.

 

10. Order Vivera from first overcorrection stage.

Speaking of Vivera® retainers, from Align Technology Inc, it’s awfully nice to give the patient four sets of retainers, and that’s exactly what you get when you use Vivera. Vivera greatly reduces the number of retainer emergencies, and they happen to be an excellent, durable retainer. Here’s a trick I learned from my friend and fellow Align faculty member William Kotteman, DDS, MS—order your Vivera retainers from the first overcorrection stage. Kotteman follows Zachisson’s concept of “11/10ths” orthodontics, meaning routine 5° overcorrection of incisor rotations in three overcorrection stages of aligners. Once the patient has completed wearing their last set of overcorrection aligners, order the Vivera from the first overcorrection stage—with just a slight hint of overcorrection. As we know, rotational relapse is a frequent issue after completion of orthodontic treatment, and slightly overcorrected Vivera retainers can help keep teeth in the proper position post-treatment, especially if patients are not wearing the retainers as often as we would like.

 

Barry J. Glaser, DMD, received his doctorate in dental medicine from The University of Pennsylvania School of Dental Medicine and earned his Certificate of Advanced Graduate Studies in Orthodontics from Boston University. He served as associate director of orthodontics at Montefiore Medical Center in New York City from 1992 to 1995. He has been in private practice in Cortlandt Manor, NY, since 1994. Glaser was an early adopter of Invisalign Teen and has extensive experience treating teens and adults of all malocclusions with Invisalign.

 

64% of adults feel that their teeth currently have some sort of bite problem or crooked teeth. 44% of all adults said that straightening their teeth would make them feel more confident. However, many adults think braces are unsightly and bulky, so they avoid seeking treatment for crooked teeth. It is important to communicate to adults what Invisalign is and the benefits that Invisalign has over braces, this way instead of showing off braces they can show off their smile in clear aligners.

Check out our infographic for the top 5 benefits that could convince an adult to seek an Invisalign treatment for straighter teeth.

Invisalign Benefits Infographic

 

Published on By Barry J. Glaser, DMD

Invisalign® clear aligner technology is growing in the number of patients treated annually. According to the Align Technology Annual Report, the statistics regarding patient adoption rates worldwide now show over 4 million patients have used Invisalign technology to straighten their teeth. Orthodontists should wisely consider this growing marketplace as an area to expand their practices to take advantage of the immense opportunities, especially as the market becomes ever more competitive.

Your orthodontic practices can greatly benefit from expansion into the Invisalign marketplace. Opening the door for more opportunities to serve the adult and teen market makes it a terrific way to grow your practice.

To do this, you will need education about the latest Invisalign treatment techniques. This knowledge will help you understand Invisalign’s potential value through the technology’s capabilities. It may even inspire you to broaden your orthodontic patient solutions, practices, and methodologies to achieve winning results.

There are many ways to learn more about treating patients with Invisalign clear aligners, including webinars and lectures archived on the Invisalign Doctor Site, as well as live clinical education events. Despite these resources, many doctors still tell me they hesitate to treat more of their patients with Invisalign clear aligners because they don’t understand how to interpret what they see on their 3D ClinCheck® virtual treatment plans, nor do they understand when and where ClinCheck plan modifications are required. What many doctors who are inexperienced at treating patients with Invisalign really need is a personal coach—an Invisalign expert who can guide them through the ClinCheck treatment planning process on a personalized, one-on-one basis. This is exactly what AlignerInsider.com offers. After registering for a membership, you get access to a video library of expert aligner training resources and a walk-through for various Invisalign-based cases as well as educational and professional videos on marketing for your practice.

Glaser_Coach_Book

Inside the Book

Orthodontic Products talks to Barry J. Glaser, DMD, about his new book The Insider’s Guide to Invisalign® Treatment, which will be released in the spring.

OP: What prompted you to write this book?

Glaser: When I set out to write The Insider’s Guide to Invisalign® Treatment, my objective was to develop a user-friendly, systematic guide to virtual treatment planning with Invisalign. Throughout my travels lecturing to doctors about treating patients orthodontically with Invisalign, a common theme I hear is that many doctors don’t “get” Invisalign, meaning they don’t understand how to interpret what they see on a ClinCheck® treatment plan, nor do they understand how to effectively communicate their treatment goals to their technician.

Designed for both the novice as well as the more experienced user, the book features a 10-step systematic guide to virtual ClinCheck treatment planning I call the “ClinCheck List.” Using a wide variety of patients I have successfully treated with Invisalign clear aligners, the book takes the reader through a rational, common sense, step-by-step approach to Invisalign treatment planning. In addition, the reader will learn my many tips and tricks for more efficient treatment as well as trouble-shooting for common problems encountered during clear aligner treatment.

OP: What can the Invisalign skeptic, and the Invisalign expert, learn from this book?

Glaser: I think the skeptic will be surprised to see that excellent results can be achieved predictably with Invisalign treatment even in quite complex malocclusions.  Furthermore, the book will demystify the virtual treatment planning process so that they too can achieve consistently excellent results in their own Invisalign cases.

For the Invisalign expert, I think my unique way of viewing a ClinCheck animation as a depiction of the forces acting upon the teeth rather than a prediction of the final occlusion will help them view their own ClinCheck plans in a completely novel and enlightening way, and will help them treat their own patients in a more efficient and predictable manner.

OP: You were once an Invisalign skeptic. What changed your view about Invisalign?     

Glaser: I was a huge skeptic! But I also recognized that as a practitioner, it was critically important to the success of my practice that I continue to embrace the rapidly changing nature of our profession. To keep up with changing trends, as well as the demands of my own 21st century patients—including teens—or more aesthetic and convenient treatment techniques, it was necessary to offer Invisalign as a treatment option. I quickly realized that if I wanted to offer the very best service to my patients, I had to educate myself. So, I began attending every live Invisalign educational event I could, read all the articles I could get my hands on, and viewed all the educational webinars offered on my Invisalign Doctor Site. Before long, I found myself up at the podium teaching other doctors about excellence in orthodontics with Invisalign.

OP: Besides yourorthocoach.com, what other Invisalign education efforts have you been involved with?

Glaser: Doctors have yet another avenue for Invisalign education right from their computer. I founded AlignerInsider.com as the premier resource for education in excellence with aligner orthodontics. Version 2.0, soon to be released, represents a major upgrade to the original site. In partnership with Willy Dayan, DDS, treatment coordinator and consultant Laura Cafik-Martin, and marketing expert Dean Steinman of OrthoMarketing.com,  alignerinsider.com is a rich resource for further Invisalign education. Featuring a phenomenal library of exclusive educational videos for both doctors and staff that may be viewed 24 hours a day, alignerinsider.com not only helps doctors and their practices achieve better and more efficient results with Invisalign treatment, but it also provides expert marketing tips and staff training. Soon to be released enhancements include exclusive live webinars as well as a “social media” component where doctors and staff around the world will be able to interact online to discuss aligner-related topics.

OP: What do you hope to accomplish with your involvement with these two online-based services?  

Glaser: I highly recommend the book, The 4 Hour Work Week by Tim Ferriss. I am passionate about teaching; however, the demands of my practice and family prevent me from travelling to teach as much as I would like. Virtual, computer-based education via alignerinsider.com and yourorthocoach.com allows me to adopt a “4 Hour Work Week” model, reaching a large audience of doctors literally around the world without ever leaving my home town.

 

As an Align Faculty member, I travel the world teaching doctors about achieving excellence with Invisalign clear aligners for both their adult as well as teen patients. My inbox was flooded with emails from doctors and Invisalign reps looking for individual help with their Invisalign cases. When Dayan approached and asked me to join his team of coaches, I did not hesitate to accept. I immediately recognized this new paradigm of virtual coaching as “technology at its best.” For the first time, I could coach doctors anywhere in the world in a meaningful way from the convenience of my laptop computer.

Using my principles of ClinCheck design, I teach doctors to look at ClinCheck not as a prediction of the final occlusion, but rather as a visual representation of the forces being applied to the teeth by the aligners. Force systems, not teeth. These principles of systematic, common sense ClinCheck treatment planning are featured in my soon-to-be released textbook, The Insider’s Guide to Invisalign® Treatment.

Twenty-first century technology has opened up an exciting arena for computer-based orthodontic education. As computer-assisted orthodontic technologies such as Invisalign clear aligners continue to grow in the orthodontic marketplace, educational opportunities have emerged to capitalize on the virtual treatment planning tools offered via the ClinCheck software. Doctors now have at their disposal the ability to call upon a virtual mentor to personally guide them in the treatment planning process for their Invisalign cases. The educational video lessons from the coaches at yourorthocoach.com are viewable 24 hours a day from your desktop computer, laptop, or mobile device, whether at the office, at home, or on the go. Clinical confidence treating a wider variety of malocclusions with Invisalign clear aligners develops quickly, while treatment outcomes become more predictable and efficient. Ultimately, the doctor as well as the patient benefit. I encourage you to take advantage of this incredible technology to help keep up with rapidly changing trends in orthodontics.

Glaser_headshotBarry J. Glaser, DMD, received his doctorate in dental medicine from The University of Pennsylvania School of Dental Medicine and earned his Certificate of Advanced Graduate Studies in Orthodontics from Boston University. He served as associate director of orthodontics at Montefiore Medical Center in New York City from 1992 to 1995. He has been in private practice in Cortlandt Manor, NY, since 1994. Glaser was an early adopter of Invisalign Teen and has extensive experience treating teens and adults of all malocclusions with Invisalign.

In the United States, only 6% of all teens undergoing orthodontic treatment are being treated with Invisalign®, from Align Technology Inc. Furthermore, a small minority of those patients have Class II malocclusions. For me, these statistics are fascinating for several reasons.

First, teen patients tend to have healthier oral cavities than adults and fewer complicating factors such as missing teeth, periodontal disease, and overly restored teeth. Second, the teeth of teen patients tend to track better than those of adults. Third, teen patients are highly motivated to wear their aligners—they don’t want braces for the prom or class pictures. Finally, there is scientific evidence to suggest that it may be advantageous to treat Class II malocclusions during the pubertal growth spurt.

Barry Glaser Barry J. Glaser, DMD, received his doctorate in dental medicine from The University of Pennsylvania School of Dental Medicine and earned his Certificate of Advanced Graduate Studies in Orthodontics from Boston University. He served as associate director of orthodontics at Montefiore Medical Center in New York City from 1992 to 1995. He has been in private practice in Cortlandt Manor, NY, since 1994. Glaser was an early adopter of Invisalign Teen and has extensive experience treating teens and adults of all malocclusions with Invisalign. ” width=”150″ height=”183″ />

Barry J. Glaser, DMD, received his doctorate in dental medicine from The University of Pennsylvania School of Dental Medicine and earned his Certificate of Advanced Graduate Studies in Orthodontics from Boston University. He served as associate director of orthodontics at Montefiore Medical Center in New York City from 1992 to 1995. He has been in private practice in Cortlandt Manor, NY, since 1994. Glaser was an early adopter of Invisalign Teen and has extensive experience treating teens and adults of all malocclusions with Invisalign.

The Literature

A recent systematic review of 11 studies on the treatment effects of Class II elastics1 found that Class II elastics are safe and effective in correcting Class II malocclusions in growing patients through a combination of 63% dental and 37% skeletal effects. The main skeletal contribution to Class II correction was (1) restraint of maxillary forward growth and (2) an additional 1 to 2 mm of forward mandibular growth. Furthermore, the data suggested that the effects of Class II elastics are similar to those of fixed functional appliances.

With respect to functional appliances, Baccetti, Franchi, McNamara, and associates2 found that patients treated with the Bionator, Activator, and Twin Block appliances had more favorable skeletal effects with regard to mandibular length and ramus height increases when reated at the pubertal peak as compared to patients treated in the mixed dentition, before peak growth velocity. Meanwhile, Frye, Diedrich, and Kinzinger3 found greater reduction in the convexity of the bony profile in patients treated with functional appliances treated during puberty as compared to pre-pubertal patients.

Given that there is evidence to suggest that the effects of functional appliances and Class II elastics are similar, and furthermore that the greatest skeletal effects can be expected during peak growth, the rationale can be made to routinely treat patients with Class II malocclusions using Class II elastics during puberty to maximize the beneficial skeletal effects— in particular, the additional forward growth of the mandible and reduction in facial convexity.

Based on this logic, I developed the following protocol to treat growing Class II teen patients simultaneously with Invisalign Teen® and Class II elastics. This technique is simple, clean, and neat, and does not require additional hardware. Furthermore, multiple phases of treatment are typically unnecessary.

Figure 1: Here is a graphic representation of the basic Class II setup using Invisalign Teen and elastics.using Invisalign Teen and elastics.

Figure 1: Here is a graphic representation of the basic Class II setup using Invisalign Teen and elastics.using Invisalign Teen and elastics.

Let’s start by looking at a graphic representation of the basic Class II setup, as seen in Figure 1. Precision-cut elastic hooks are prescribed for the upper canines and lower first molars. An occlusally beveled horizontal rectangular attachment is placed on the mesial of the lower first molars to retain the aligner and resist the vertical component of force from the Class II elastics. For those doctors who prefer to have a bonded button on the lower first molars, simply substitute a button cutout on the lower first molars in your Clin Check setup.

The typical Class II setup on a teen patient, shown here with an optional incisally beveled, horizontal rectangular attachment on the upper left canine. The attachment was placed for aligner retention.

The typical Class II setup on a teen patient, shown here with an optional incisally beveled, horizontal rectangular attachment on the upper left canine. The attachment was placed for aligner retention.

 

Now in Figure 2, we can see a typical Class II setup on a teen patient. An optional incisally beveled, horizontal rectangular attachment has been placed on the upper left canine. In this case, there were no other attachments in this quadrant and the attachment was placed on the upper left canine for aligner retention.

Tips and Tricks

At the initial aligner delivery appointment, all attachments are placed, and the patient is instructed to wear light 1.8-ounce, ¼-inch elastics (DENTSPLY GAC’s “China”). Any light Class II elastic of approximately 2 ounces in force will suffice. If your typical office procedure is to place attachments at the second visit, delay the start of elastics until attachments are placed to avoid unwanted aligner dislodgement.

Monitor aligner and elastic wear at each visit. The compliance indicators provided for Invisalign Teen cases are extremely useful for this purpose. While most patients are compliant with elastic and aligner wear, it is important to keep teen patients motivated. I always begin with positive motivation; praise good behavior, and use initial photographs to illustrate to the patient and parents good progress. For those patients who are not wearing their aligners and/or elastics properly, the threat of switching to braces and Forsus springs, along with the phrase, “If you don’t want to have braces for the yearbook and the prom, just wear your aligners and elastics,” helps play to a teenager’s sense of vanity and may motivate them to stay on track.

The standard amount of time for the average end-on Class II malocclusion to convert to Class I is approximately 1 year. Please make sure you have sufficient aligner stages in your Clin Check setup to last 1 year—approximately 26 stages. If the patient does not have significant crowding or spacing, and the initial Clin Check indicates fewer than 26 stages, ask your tech to ”Please slow down all movements to last 26 stages.” This way, the patient will have a year’s worth of fresh aligners to attach his/her elastics to.

Figures 3A and 3B: A 16-year-old female patient with a Class II division 1 malocclusion with maxillary and mandibular crowding. Treatment included the insertion of attachments, aligners, and the use of light Class II elastics.

Figures 3A and 3B: A 16-year-old female patient with a Class II division 1 malocclusion with maxillary and mandibular crowding. Treatment included the insertion of attachments, aligners, and the use of light Class II elastics.

Case 1

A 16-year-old female patient presented with a chief complaint of an “overbite.” Clinical exam revealed a significant Class II division 1 malocclusion with maxillary and mandibular crowding (Figures 3A and 3B). The patient was a performer and asked to be treated with Invisalign Teen.

At treatment end, the patient has a bilateral Class I occlusion with normal overbite and overjet. Superimposition shows the correction was the result of mesial movement of the lower dentition and palatal tipping of the upper incisors.

At treatment end, the patient has a bilateral Class I occlusion with normal overbite and overjet. Superimposition shows the correction was the result of mesial movement of the lower dentition and palatal tipping of the upper incisors.

Treatment commenced on July 5, 2011, with the placement of attachments, insertion of the first set of aligners, and placement of 1.8-ounce, ¼-inch Class II elastics. Refinement aligners were inserted on July 16, 2012. On September 24, 2012, the elastic force was increased to 4 ounces per side. Final retainers were placed on May 2, 2013. Total treatment time was 22 months.

The final photographs reveal a bilateral Class I occlusion with normal overbite and overjet (Figures 3C and 3D).

The cephalometric superimposition (Figure 3E) reveals that for this non-growing patient, the correction to Class I was through mesial movement of the lower dentition and palatal tipping of the upper incisors. The final result reveals a solid Class I occlusion.

This case illustrates the effects of Class II elastic wear on a patient where growth is not anticipated. It should be noted that this magnitude of occlusal change would be much more predictable if the patient were at peak growth velocity (see Cases 2 and 3 that follow). As such, the possibility of extraction of upper first premolars was discussed with the patient and parents prior to treatment. Needless to say, the patient was extremely cooperative during treatment, and extractions were ultimately not necessary.

The superimposition also illustrates excellent control of the mandibular plane angle as well as lower incisor proclination, which is typical of patients treated simultaneously with Class II elastics and Invisalign.

Figures 4A and 4B: A 13-year-old male patient exhibits a large Class II division 1 malocclusion, larger overjet, and deep overbite. Mild upper and lower crowding is present.

Figures 4A and 4B: A 13-year-old male patient exhibits a large Class II division 1 malocclusion, larger overjet, and deep overbite. Mild upper and lower crowding is present.

Case 2

A 13-year-old male presented for correction of his “overbite.” Clinical exam revealed a large Class II division 1 malocclusion, larger overjet, and deep overbite. There was mild upper and lower crowding (Figures 4A and 4B).

Figures 4C-4E: A Class I malocclusion was achieved on both sides, along with a significant reduction in overjet and overbite and well-aligned arches. Superimposition shows the predictable skeletal and dental improvements.

Figures 4C-4E: A Class I malocclusion was achieved on both sides, along with a significant reduction in overjet and overbite and well-aligned arches. Superimposition shows the predictable skeletal and dental improvements.

Treatment commenced on March 25, 2013, with the placement of attachments and insertion of the first stage of aligners and 1.8-ounce Class II elastics.

Elastics were discontinued on January 17, 2014, at the time of refinement. Active treatment was completed on December 22, 2014, for a total of 21 months of active treatment.

The final photographs (Figures 4C and 4D) reveal correction to Class I on both sides along with a significant reduction in overjet and overbite and well-aligned arches. The superimposition (Figure 4E) shows the predictable skeletal and dental improvements as documented in the literature.

In addition, excellent oral hygiene was facilitated by use of Invisalign. In my practice, gingival inflammation and enamel demineralization are extremely rare in my Invisalign patients.

Figures 5A and 5B: A 14-year-old male patient has a significant Class II division 1 malocclusion complicated by a severely deep overbite and 
retro-inclination of the upper incisors.

Figures 5A and 5B: A 14-year-old male patient has a significant Class II division 1 malocclusion complicated by a severely deep overbite and 
retro-inclination of the upper incisors.

Case 3

A 14-year-old male patient presented for treatment with a significant Class II division 1 malocclusion complicated by a severely deep overbite and retro-inclination of the upper incisors (Figures 5A and 5B).

Figures 5C-5E: Treatment included placement of attachments, and insertion of aligners and 1.8-ounce Class II elastics. Final photographs here reveal correction to Class I on both sides with improvement in the deep overbite.

Figures 5C-5E: Treatment included placement of attachments, and insertion of aligners and 1.8-ounce Class II elastics. Final photographs here reveal correction to Class I on both sides with improvement in the deep overbite.

Treatment commenced on September 20, 2011, with the placement of attachments, and insertion of aligners and 1.8-ounce Class II elastics. Elastics were discontinued on October 9, 2012, at the time of refinement. Active treatment was completed on February 19, 2013, for a total active treatment time of 17 months. This was an excellent case to use bite ramps on the lingual of the upper central and lateral incisors to facilitate correction of the deep overbite.

The final photographs reveal correction to Class I on both sides with improvement in the deep overbite (Figures 5C and 5D). The cephalometric superimposition (Figure 5E) reveals the typical growth/dental response to Class II elastic wear.At 15 months post-treatment, the occlusion was stable, as shown in Figure 5F.

Summary

As I pointed out at the beginning of this article, only 6% of all teen patients in the United States are being treated with Invisalign. In my suburban New York practice, 75% on my teen patients are being treated with Invisalign Teen. I have found that these patients are often my best patients, and have come to realize that it is not magic—it’s psychology.

Figure 5F: At 15 months post-treatment, the occlusion was stable.

Figure 5F: At 15 months post-treatment, the occlusion was stable.

Teen patients do not want to have school pictures or go to the prom with braces, so they are highly motivated to wear their aligners. If the patient is treated during the peak pubertal growth period, correction to Class I using aligners and Class II elastics is rapid and predictable. Furthermore, there is a body of literature that documents and quantifies the effects of Class II elastics. Basing treatment decisions on evidence-based principles gives me confidence that good results will be predictable and routine.

If you are stuck in the “box” of thinking that teens will be noncompliant, think again. I thoroughly enjoy treating teens with Invisalign and have been very satisfied with the clinical outcomes. If you employ the protocol outlined here, I am confident that you will be pleased with the results as well.

References

  1. Janson G, Sathler R, Fernandes TM, Branco NC, Freitas MR. Correction of Class II malocclusion with Class II elastics: A systematic review. Am J Orthod Dentofacial Orthop. 2013;143:383-392.
  2. Baccetti T, Franchi L, Toth LR, McNamara JA Jr. Treatment timing for Twin Block therapy. Am J Orthod Dentofacial Orthop. 2000;118(2):159-170.
  3. Frye L, Diedrich PR, Kinzinger GS. Class II treatment with fixed functional orthodontic appliances before and after the pubertal growth peak – a cephalometric study to evaluate differential therapeutic effects. J Orofac Orthop. 2009;70(6):511-527.

For the first decade of Barry J. Glaser’s private practice, he was like every other orthodontist around. His practice centered on treating patients with traditional brackets and wires. And those tools dictated not only how he treated patients, but how he did business—from staffing to scheduling.

But in the early 2000s, Glaser heard of a new product that could take the place of traditional brackets and wires. That product wouldn’t necessarily change how he treated patients, but it would change how he ran his business and how successful it would become.

Building a Practice

In 1988, Glaser received his DMD from the University of Pennsylvania School of Dental Medicine and then went on to complete a 1-year residency at Englewood Hospital in New Jersey. From there he accepted a postdoctoral appointment in orthodontics at Boston University (BU), earning his specialty certification in 1992. But he didn’t jump into a private practice from there. Instead, he stayed in academics.

“I had a great opportunity to become a professor early in my career,” he says. “I became associate director of orthodontics at Montefiore Medical Center, where I had the chance to teach and conduct research. I also had a private practice in the hospital one day a week.”

For 3 years, Glaser honed his lecturing and teaching skills before shifting gears and purchasing his current practice in 1995 in the Westchester County suburb of Cortlandt Manor, NY.

During the first few years in practice, Glaser primarily employed the bidimensional technique, which he learned at BU under Professor Anthony Gianelly, DMD, PhD, MD. “Gianelly was truly one of the gods of orthodontics,” Glaser says. But growing the practice in those early years proved to be challenging for Glaser’s private practice.

“From 1995 until 2006, only about 15% of my patients were adults,” he says. While adults wanted and needed straight teeth and healthier occlusions, many were reluctant to consent to wearing traditional braces. “For example, a 50-year-old male who hadn’t smiled his entire adult life came to me for treatment. I told him in 12 to 15 months his teeth would be straight. But the thought of wearing braces proved to be a deal-breaker [for him]. His appearance affected his career and his life, but he couldn’t put up with braces,” Glaser noted. “Even a removable appliance was unacceptable for this patient.” Not only were Glaser’s patients frustrated, but he was as well.

As he considered how to expand his practice, Glaser heard of a new treatment tool: The Invisalign® system, introduced by Align Technology Inc, San Jose, Calif, in 1999. But Gianelly had instilled in him the importance of questioning innovation and seeking proof before accepting new ideas, a lesson he took seriously. “I thought it would be a disaster. I figured I’d let everyone else make mistakes with it,” Glaser says. “I didn’t think you could control the movement of teeth [with aligners] as well as you could with braces.”

By 2006, Invisalign seemed to be gaining acceptance in orthodontic circles, so Glaser decided to test the waters. “I still viewed this as a removable appliance for simple tooth movement, and I was skeptical of the results,” he says.

To his surprise, his adult patients complied with treatment. The absence of metal wires and brackets, coupled with minimal irritation or discomfort, made a difference. “I was surprised and pleased. Gradually, I increased the complexity of the cases I was treating.”

Today, Glaser reports that 99% of his adult patients use Invisalign and typically ask for it by name.

Treating Teens

As for the younger demographic: Glaser treats a significant number of adolescents and teens, and he classifies these younger patients into two different groups. His pre-teen patients—those between 10 and 12 years of age—typically prefer traditional metal braces. “At that age, kids think braces are cool. They want to belong to their peer group. Girls, especially, are excited to have braces.” He explains that the pink and purple colors hold great appeal for this age group. “Some parents who had braces want their children to also have braces,” Glaser adds.

But by the time a youngster reaches the age of 13, he or she may be embarrassed by metal wires and brackets and will instead prefer a more unobtrusive option. Before the dawn of Invisalign, Glaser would use ceramic braces for some teens, but few choose that option nowadays.

In 2008, when Invisalign introduced a teen version of the product, Glaser again expressed skepticism. Although he had success treating adults, he foresaw bigger challenges with his younger patients. “Teens are more independent and question authority. I thought compliance would be an issue,” he says. Still, he decided to give Invisalign Teen® a try.

To his surprise, the teens were often more compliant than the adults. “There was no magic involved. It was a matter of psychology. You have to understand what motivates a patient. A 17-year-old cheerleader does not want to wear braces to her prom or for senior pictures. It’s incredibly motivating for patients like this to wear an invisible aligner.”

And just as Glaser expressed skepticism of these invisible aligners at first, many parents also needed to be convinced that this treatment option would be good for their children. “Parents sometimes have objections to the aligners. We take the time to explain all the benefits of Invisalign and debunk the myths,” Glaser says.

For those parents who remain skeptical—whether it be that they don’t think it’s going to be as effective or they fear their child will lose or forget to wear their aligners and ultimately need to be treated with braces anyway—Glaser makes a deal with them. “I tell parents it won’t cost you a penny [if we need to switch to braces]. If for any reason Invisalign doesn’t work for you or your child, we’ll switch you over to braces at no charge. Crazy? Maybe. But we’ve tracked it, and it happens in less than one-half of 1% of all cases. To me, it’s worth it to get all those other patients into Invisalign. So parents say, ‘OK. Sounds good.’ And lo and behold, those kids are doing great.”

Scientific Evidence

However, Glaser’s complete conversion to Invisalign didn’t occur until 2010, 4 years into using Invisalign, when he attended a 2-day summit in Las Vegas. This particular conference featured John Morton, director of research and technology product innovation at Align Technology, who is largely responsible for the science behind Invisalign.

Up until the summit, Glaser had only been using Invisalign as he would a retainer—for minor tooth movement. “I wasn’t looking to change malocclusions because I didn’t think it could.”

The presentations and scientific evidence featured at the summit impressed Glaser. “For the first time, Align was doing physical measurements and following scientific principles. They developed an electronic typodont, where aligners can be placed on the teeth and they can measure the forces being generated at the level of the roots to produce the desired tooth movements,” he recalls.

Listening to the lectures, Glaser had an a-ha moment that changed everything. “I realized mechanically and biologically that what you could do with Invisalign was the same as what you could do with braces. The only reason I wasn’t addressing patients’ malocclusions with Invisalign was because I didn’t think you could. So once I realized that it’s the same mechanics—that you would set up patients the same way you would with braces—things really started to take off for me.”

Glaser now realized that Invisalign wasn’t a technology he could ignore, no passing fad. For him, it was the future of orthodontics. Given that, he saw an opportunity to differentiate his practice, setting out to become the first Elite Preferred provider in the Westchester area—a status that requires an orthodontist to start 50 Invisalign cases every 6 months.

Transitioning a Business

When any business incorporates a new product into its routine, it is going to have an impact on efficiency and profits. The challenge then is to correctly integrate that new technology so that the impact is positive and helps the business succeed.

Fully diving into Invisalign meant Glaser was taking a risk; the most obvious being the financial investment Invisalign carries, as lab fees and product costs run higher than traditional braces. He also made the decision to invest in an iTero® scanner, as he admits that taking PVS impressions was challenging for him and his staff, while his patients found the experience to be unpleasant.

However, once Glaser grew his number of Invisalign starts, he saw the product cost mitigated with Align Technology’s volume rebates. The financial cost of the iTero scanner was also mitigated with a federal IRS section 179 tax credit that allows a practice to write off the full amount of certain capital expenses in one year. When asked whether he thinks a practice needs to buy the iTero to reap all the benefits of incorporating Invisalign, he answers, “I think it’s worth every penny. The scans are dead-on accurate. The aligners fit better, and you don’t have to deal with rejected impressions. And patients are amazed by the technology. Plus, it is super-efficient. If you are going to look to try and make your appointments and your office as efficient as possible, it’s very helpful.”

Going beyond the initial equipment investment, Glaser had to look at the financial impact from a different angle. As with the integration of any new technology, the reduction in product cost wasn’t going to be what made his practice profitable and successful.

“It dawned on me that profitability in my practice wasn’t just the expense side of the balance sheet—and I think that’s what a lot of orthodontists focus on,” Glaser recalls. “They see the lab fee and think, ‘My lab fee is going to be three times as much with Invisalign. I’m going to make three times less money.’ But what about the other side of the balance sheet? What about staff? What about the number of days you work? What about emergency appointments and all those other inefficiencies? I realized that if I was going to be profitable with Invisalign, I really had to go back and look at what we were doing in the office and clean up everything. I had to streamline the office to be as efficient as possible.”

With Invisalign, patients not only required 40% fewer visits than with braces, they were also less likely to require emergency appointments. Glaser is quick to stress the importance of re-evaluating appointment scheduling to truly maximize the benefit of any new technology that makes appointments more efficient.

“Don’t just keep seeing the patient once a month because that’s what you learned in dental school. You have to really sit down and think about why you do the things you do in your office. I can assure you, if the patients are wearing their aligners well and coming in once a month, they will wear their aligners well coming in every 3 months,” Glaser says. “And I have never had a patient or parent say, ‘I can’t believe we’re only coming in four times a year. You’re ripping us off!’ Parents and kids are super scheduled and super busy. Parents appreciate that.”

With the freeing up of the schedule, Glaser also had to re-evaluate his staffing levels, and he realized he no longer needed to maintain his old numbers. Fortunately, he was able to reduce his staff from six to four through attrition—retirement and career changes—rather than layoffs. In real numbers, between salary and benefits in NY, cutting those two positions resulted in about $120,000 per year in true savings, more than making up the difference in additional lab fees, he says. And the opportunities for the practice to profit from a staff perspective didn’t stop there. Now that they weren’t so busy, staff had time to take on some of the marketing tasks that make a practice successful—from updating the practice’s Facebook page to visiting referring offices.

And there is another marketing angle that comes with a product like Invisalign that goes beyond just having more time in the office to better market the practice. Not only does Align Technology provide users with numerous free or low-cost marketing materials—from brochures and posters for the office to professionally shot patient testimonials for the practice website, it has also positioned Invisalign as a household name with TV and print ads targeting both parents and teens. Patients walk into orthodontic offices asking for it by name.

What’s more, by becoming an Elite provider, Glaser’s practice is listed on the Invisalign website’s Doctor Locator tool, which allows those patients looking specifically for Invisalign to find a doctor in their area who can do it. Glaser has seen this marketing tool pay off for his practice. At least two times a month, he receives an email from a potential patient saying they found him on the Doctor Locator site. “Those patients are real patients,” Glaser says. “That’s 20 to 25 patients per year being driven to my office through the website.”

Moreover, Glaser benefits from being listed as the No 1 provider in his area. He tells the story of a 13-year-old boy who came in with his mother looking for treatment with Invisalign. The mother and son were from a town that was some distance away. “You drove past five orthodontist’s offices to get to my office. What are you doing all the way over here?” he remembers asking. “And the kid looks up at me and says, ‘You’re the No 1 doctor.’ They had seen me on the Doctor Locator. Parents don’t want to go to No 5 for their child. They want to go to No 1.”

As Glaser treated more teens, he soon saw how they were becoming “brand ambassadors,” not just for Invisalign, but also for his practice. “When you think about it, it’s just like anything else. My boys only want to wear the Jordan’s [basketball sneakers]—they have to have the swosh. And I was the same way [as a kid]. I wanted the Levi’s. Kids are, for better or worse, incredibly impressionable, incredibly brand motivated, and incredibly brand loyal. So once Invisalign starts to become a thing, that’s what they want—like any other fashion,” he says.

Glaser adds that, “Only 5% of teens in the United States are currently being treated with Invisalign. As I [speak about it], I emphasize the huge opportunity for orthodontists to market Invisalign to teens and their parents. It has helped keep my practice competitive.”

He has used Invisalign as a way to turn school nurses and hygienists into brand ambassadors as well. “We market a lot to the hygienists, especially [for the hygiene benefits of Invisalign]. They love it. They love that they don’t have to clean between brackets and wires. So, we offer to treat hygienists at a reduced fee because we want them to be our ambassadors. We also sponsor a hygienists’ appreciation breakfast once a year and educate them about the many benefits of Invisalign.”

Beyond having more time for marketing, the reduction in patient visits also meant that there was more time to do patient consults. Prior to Invisalign, there was a 4-week wait list. As a result, many patients called up other orthodontists for an appointment. That wait list has now been reduced to less than 1 week, Glaser says.

And even with the time for more patient consults, Glaser, a married father of two boys, has still been able to reduce his work schedule from 16 to 18 days per month to 12 to 14 days per month. All this freed-up time has had a huge impact on Glaser’s practice and his work life. “With that free time, I could choose to open a satellite office or spend more time with my family or pursuing hobbies. I could use the time to drive the growth of the practice and do things that make you successful, like networking or sponsoring a Lunch and Learn.”

Even though using the free time to open a second office would have upped the profitability potential that came with changing his practice, Glaser decided to spend the additional free time learning to play the guitar, riding his Harley-Davidson motorcycle, and returning to his academic roots by lecturing instead. Since becoming an Elite Invisalign provider, Glaser has been delivering educational lectures about the product first in the northeast and then across North America. Last year, he gave more than 40 talks at a variety of conferences and meetings. “I have been involved with orthodontic education for over 20 years,” Glaser says. “I thoroughly enjoy giving something back to my peers in the orthodontic community.”

Four years after his decision to convert his practice, approximately 75% of Glaser’s current patients opt for the Invisalign system. His decision to take the leap and radically change the way he practiced has been career defining, and, more importantly, successful.

For other orthodontists to experience the same success with Invisalign or with the introduction of any other new technology into their practice, Glaser reiterates the importance of changing the way you think to reap the best rewards. “If you basically use your bracket and wire paradigm with Invisalign, you’re still probably going to be happier because you are going to have an easier day. But if you are looking to make it as profitable as possible, you need to make some simple changes. Think about all those things you do just because that’s what you do. It’s not necessary.”

In the end, an appliance change or adoption of a new technology does not determine success in and of itself. They are merely tools, Glaser emphasizes. “The skill and training you have as a doctor provides the best outcome. My number one priority is to do the best orthodontics on every patient that walks through the door. This helps my practice grow.”

Source: http://www.orthodonticproductsonline.com/2014/06/skeptic-elite

By Barry J. Glaser, DMD

If you are a frequent reader of Orthodontic Products, you already know that I treat approximately 75% of my patients with Invisalign® from Align Technology Inc. What you may not know is that I spend considerable time and effort customizing each and every ClinCheck® plan. Over the past 10 years, I have encountered certain clinical situations where, in my hands, the default optimized attachments don’t always get the job done. In these situations, I substitute attachments of my own design that give me more predictable results.

In this article, I descend from the mountain to bestow upon my readers Dr Glaser’s 10 commandments of attachment design. These 10 simple rules will help to keep your patient’s Invisalign treatment on track. Use them wisely!

1. Thou shalt use 4 mm wide occlusally beveled rectangular retentive attachments on the lower 4’s and 5’s to support leveling of the lower Curve of Spee.

Aligners require posterior retention to effectively intrude the lower incisors to level the Curve of Spee. Why? Think Newton’s Third Law. The “action” force comes from the anterior portion of the aligner pressing down on the lower anterior teeth. The “reaction” is for the distal portion of the aligner to pop off the posterior teeth. Your patient may note that the back of the aligners feels “bouncy.” Herein lies the problem. If the aligner is dislodged from the molars, the intrusion forces to the lower anteriors are diminished or lost completely. Clinically, the patient’s deep overbite will not correct.

This situation can be remedied by placing 4 mm wide occlusally beveled rectangular attachments on the lower 4’s and 5’s (Figure 1). These attachments provide “grip,” so that the aligners stay firmly on the posterior teeth, allowing for effective forces of intrusion. “What about unwanted posterior extrusion?” you ask. While it is true that the reaction force will tend to place extrusion forces against the attachments on the lower 4’s and 5’s, the forces of occlusion effectively block any unwanted posterior extrusion.

2. Thou shalt trash optimized rotation attachments on the lower 4’s and 5’s, and substitute the attachments described in Commandment #1 in situations where leveling the Curve of Spee takes priority over premolar rotation.

Another issue that can interfere with levelling of the lower Curve of Spee is software-related. Optimized rotation attachments are one of many SmartForce® features integrated into the ClinCheck software. All SmartForce features, optimized rotation attachments being one of them, have built-in protocols that place the attachments at certain clinical thresholds. Optimized rotation attachments are placed automatically on the premolars when rotations of 5° or greater are detected. But what happens when you need premolar anchorage to level the lower Curve of Spee? The smaller optimized rotation attachments are not retentive enough to support the intrusion of the lower incisors. When this situation arises, I use 3D controls in ClinCheck Pro to trash the optimized rotation attachments, and substitute the 4 mm wide occlusally beveled rectangular attachments described in Commandment #1. Typically, the larger attachments are more than adequate to gain the desired rotation. If, after the bite has been opened, there is still the need for additional rotation of the premolars, I will allow the placement of optimized rotation attachments during refinement.

3. Thou shalt use 3 mm wide gingivally beveled rectangular attachments when applying palatal root torque U 2112.

Another SmartForce feature is power ridges. Power ridges are designed to place torque on upper and lower incisors. I have encountered a performance issue when there are four power ridges on the upper anterior teeth in situations where I want to add palatal root torque (PRT). A side effect of the torquing force tends to make the aligners slip off the anterior teeth, as depicted in Figure 2. When this situation arises, the aligners do not fully engage the anterior teeth and the torque will not express. Unfortunately, the software will not allow the placement of a retentive attachment on the same tooth as a power ridge. My solution for this problem is to prescribe the desired palatal root torque, but I ask my technician to delete the power ridges and add 3 mm wide gingivally beveled rectangular attachments to keep the aligners fully engaged on the teeth (Figure 3). I still get the torque, but don’t have to worry about the aligners disengaging from the teeth. Try it!

4. Thou shalt not use power ridges, except for single tooth torquing.

Not only do I find the power ridge-related performance issue as described in Commandment #3, there’s another issue my patients have with power ridges: comfort. In general, I hear few complaints from patients regarding aligner comfort. However, power ridges, especially several in a row, can be a source of both lip irritation and speech issues. More frequently in adults than teens, patients who spend their days talking—teachers, for example—have complained about saliva bubbling out around the gingival gap created by the power ridge, as well as significant irritation to the mucosa of the lip. I have heard enough of these complaints to virtually eliminate power ridges from my repertoire, with one exception—applying root torque to a single tooth. Most often encountered in situations where a lower incisor root requires lingual root torque, I will allow placement of a power ridge. I will support this movement with a small rectangular attachment on the adjacent teeth to ensure that the aligner stays fully engaged and the torque expresses. While I still run the risk of causing irritation to the lip, one power ridge doesn’t seem to be as problematic. We also empower our patients to use an emery board to smooth the gingival aspect of the aligner if necessary.

5. Thou shalt use 4 mm wide gingivally beveled rectangular attachments on the upper laterals to support absolute extrusion.

There are two ways to extrude a tooth: 1) relative extrusion and 2) absolute extrusion.

Relative extrusion occurs when a tooth is being tipped lingually. Think habit-induced anterior open bite. Eliminate the habit and the anterior teeth simultaneously retract and relatively extrude; and PRESTO! the bite closes down. Relative extrusion is an “Invisalign free ride.” You don’t need any special attachments or ClinCheck modifications to achieve relative extrusion, and it’s very predictable.

Absolute extrusion—physically grabbing a tooth and extruding it from the alveolus—can be quite challenging to achieve predictably with aligners, especially on pesky maxillary lateral incisors. This is probably the most common area to encounter non-tracking, and it’s not surprising. It has been said that with Invisalign, we are trying to move “slippery teeth with a wet piece of plastic.” In addition, the maxillary lateral incisors are small, with little surface area for the aligners to engage. This is a situation where 3D controls in ClinCheck Pro come in handy. In instances where absolute extrusion of the maxillary incisors is desired, I place a 4 mm wide gingivally beveled attachment to provide additional “aligner grip” (Figure 4). They work quite well, and they’re not as much an aesthetic problem as you would think. I use Flow Tain® from Reliance Orthodontic Products Inc as my attachment material. It’s very translucent and picks up the natural shade of the tooth. We explain to our patients that this attachment is absolutely necessary to achieve a good result, and I don’t negotiate! I would rather settle the issue of attachments with my patients at the beginning of treatment versus running the risk of the dreaded “I spent all this money and my tooth isn’t straight” conversation a year or more into treatment.

6. Thou shalt use 3D controls in ClinCheck Pro to rotate the bevels of these upper lateral attachments so the bevel blends smoothly into the gingival aspect of the tooth.

There is a debate amongst Invisalign educators as to the orientation of the bevel for optimal predictability of absolute extrusion of incisors. One school of thought contends that the bevel should be oriented towards the incisal edge, resulting in a large “ledge” at the gingival aspect of the attachment. This ledge, the thinking goes, provides maximum grip for the aligner and provides the best opportunity to gain absolute extrusion. This rationale makes sense, but there’s a problem. The interface between the ledge of the attachment and the aligner is not very forgiving if the tooth begins to get off track and goes into “failure mode.” If this occurs, even slightly, the aligner will not fit properly over the attachment and may even begin to exert an unwanted lingual force. Unwanted lingual forces are bad, and may lead to the opposite of the desired tooth movement, meaning intrusion rather than extrusion.

The opposing school of thought contends that the bevel should be oriented gingivally. While providing somewhat less grip, the long gingival bevel allows more forgiveness in failure mode. In other words, if the tooth begins to get off track, there is still plenty of engagement between the aligner surface and the bevel.

My personal preference is the latter, beveling the attachment towards the gingival, mimicking the orientation of optimized extrusion attachments, which have been biomechanically tested by Align Technology to be the best orientation for absolute extrusion. By manipulating these attachments using 3D controls, I roll the bevel gingivally and make the attachments 4 mm in length to make a broad flat surface to gain as much surface area as possible, and I find this to work well (Figure 5).

7. Thou shalt use the same attachment as above to support intrusion of the upper central incisors.

Have you ever encountered a situation where you want to intrude UR1 UL1? You set up your ClinCheck to achieve this movement, but clinically you notice that there is gapping (non-tracking) at the level of the maxillary lateral incisors. Your first instinct may be to consider a bootstrap elastic on the laterals to pull them back into the aligner, because it appears the laterals are not tracking. If we analyze this situation more closely, it’s not the laterals that are not tracking; it’s the centrals. Why? Imagine each aligner stage intruding the upper centrals .25 mm per tray. What happens if the centrals don’t intrude? The aligner, when seated, will first contact the incisal edges of the upper centrals, and will not allow full seating of the tray on the adjacent laterals. Clinically, this appears to be lateral non-tracking, but the real culprit is lack of intrusion of the centrals—it’s the centrals not tracking! To reduce the chances of this occurring, place the same attachment as described in Commandment #6, a 4 mm wide gingivally beveled rectangular attachment on the upper laterals to support the intrusion of the centrals. These attachments provide anchorage to keep the aligners engaged on the teeth and transmit the intrusion forces appropriately to the centrals.

8. Thou shalt place a 3 mm wide occlusally beveled rectangular attachment on the mesial of the lower 6’s for aligner retention whilst using Class II elastics.

I treat a lot of teens with Invisalign. Naturally, many of these patients have Class II malocclusions. In a previous article in Orthodontic Products, I described in detail my Class II protocol. In my protocol, I prefer to use precision cut elastic hooks on the lower molars to retain the elastics. To prevent the aligners from dislodging posteriorly from the pull of the elastics, I add a 3 mm wide occlusally beveled rectangular attachment to the mesio-buccal aspect of the lower first molars to provide aligner retention (Figure 6). This works very well and eliminates the need to bond a button or bracket, which can fall off during treatment and cause an unwanted emergency appointment.

9. Thou shalt trash optimized attachments on the upper 3’s and place a standard attachment when a precision cut elastic hook is needed on the upper 3’s.

Similarly, I use precision cut elastic hooks on the upper 3’s to retain the Class II elastics. You may have encountered situations where your technician informs you that an optimized attachment cannot be placed on the same tooth as a precision cut. If this occurs, trash the optimized attachment and place a standard attachment that best approximates the shape and orientation of the optimized attachment. This way, you can have your elastic hook and an attachment on the same tooth.

10. Thou shalt place 4 mm wide occlusally beveled rectangular attachments on the upper 4’s and 5’s to support intrusion of the upper molars in thy open bite cases.

Treating open bites with Invisalign can be incredibly gratifying, especially in cases where upper molar intrusion is desired. Once again, we need to look at Newton’s Third Law. In this case, the “action” force is intrusion of the upper molars. The “reaction” is the dislodgement of the aligner in the region of the upper premolars. If the aligner is allowed to dislodge on the premolars, the intrusion forces are diminished or lost completely to the molars and the open bite won’t close. To prevent this from happening, place 4 mm wide occlusally beveled rectangular attachments on the upper 4’s and 5’s to support the intrusion of the molars (Figure 7). Here’s one more tip—overtreat the intrusion of the molars to a 2 mm posterior open bite, as aligners can routinely underperform in this area.

Source: http://www.orthodonticproductsonline.com/2016/03/dr-glasers-10-commandments-attachment-design