Post on 07-Mar-2020
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Ortho Summit 2012
Dr. Willy Dayandrwillydayan@gmail.com
www.orthoclined.com
Engineering Your Invisalign Treatment PlanTo
Conquer a Wide Variety of Cases
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• DDS ( 1986) and Diploma of Orthodontics from the University of Toronto (1991)
• Orthodontic practice in Toronto, Canada, focused on Cosmetic and Rehabilitative Orthodontics.
• Invisalign Super Elite Provider and member of the Aligntech Institute Faculty
• Lecturer at the University of Toronto, and Guest Lecturer at Tel Aviv University and Hadassah University in Jerusalem
• Featured speaker at the Pankey Institute, Invisalign Forum and Invisalign Summits, and numerous Align events worldwide.
• Member of the AAO and CAO, and other dental organizations
• Married to Ellen Dayan ( Restorative Dentist ), and 4 great children, Laurel, Ariel, Jamie, and Jory
Dr. Willy Dayan
1) Diagnosis and Treatment Plan.....It Still Matters
2) Understanding Bio-mechanics of Invisalign
3) They are All Invisalign Cases!
Engineering Your Invisalign Treatment Plan To Conquer a Wide Variety of Cases
Outline
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Orthodontics is not just Straight Teeth
Comprehensive Orthodontic Diagnosis
•Skeletal Foundation•Posterior Interdigitation•Anterior Guidance•Transverse Relations•Vertical Dimension of Occlusion•Lip Support•Lip Competency•Neutral Zone•Straight Teeth•Smile Lines
Align upper and lower arches is not a treatment plan!
Should these people get the same treatment plan and same retainers?Customize our retention the way we customize our treatment plan!
AfterBeforeIntra-orally Extra-orally
BiologicalVariation!
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Orthodontics is not just Straight Teeth
Comprehensive Orthodontic Diagnosis
•Skeletal Foundation•Posterior Interdigitation•Anterior Guidance•Transverse Relations•Vertical Dimension of Occlusion•Lip Support•Lip Competency•Neutral Zone•Straight Teeth•Smile Lines
Align upper and lower arches is not a treatment plan!
•Who is the clinician and who is the technician.
•Doctor your ClinCheck!
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Ortho Summit 2012
1) Diagnosis and Treatment Plan.....It Still Matters
2) Understanding Bio-mechanics of Invisalign
3) They are All Invisalign Cases!
Engineering Your Invisalign Treatment Plan To Conquer a Wide Variety of Cases
Outline
A Review of Bio-Mechanics of Invisalign!
Willy’s Golden Rules of ClinCheck Analysis
1) Think Like Plastic and Feel Like a Tooth.
2) Stop watching the video as teeth moving, but think of it as aligners surfaces changing.
Some Clinical Examples
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Levelling Deep Curve of Spee
What if the bicuspids have optimized rotation attachments ?!?!
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Upper Lateral Incisor Bodily Movement
Need 2 points of contact to create a rotational moment.
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Translating Roots Mesially or Distally
Controlling Root Tipping.
Focus on the correction of LL2 and LR2
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Translating Roots Mesially or Distally
What the tooth needs to feel, and what we need to see!
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Translating Roots Mesially or Distally
Do you see arrows in your Clincheck Video?
Before Start CC1 End CC1
After CC1 Start CC2 End CC2
Tracking atEnd of CC2
Do you see arrows in your Clincheck Video?
Before Start CC1 End CC1
After CC1 Start CC2 End CC2
Tracking atEnd of CC2
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Opening Space for a Missing Maxillary Lateral Incisor
A ClinCheck Treatment Plan after the first plan did not work!
Go To ClinCheck 1
Go To ClinCheck 2( instructed by orthoclined.com )
Before After cc1
Progress Xrays cc2
I tried that and it did not work, so my conclusion could be......Invisalign can’t do that!!! But is that true?
Conclusion:Ask not what Invisalign can do….but ask yourself what you can do with Invisalign!!!
Not finishedyet
Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Go to Clincheck
Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Go to Clincheck
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Ortho Summit 2012
Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Before
Refnmnt
Go to RefinementGo to Clincheck
Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Before
Refnmnt
Go to Clincheck Go to Refinement
Go to ClinCheck
Anterior Torque Control
Plan is to leave some maxillary anterior spacesfor restorative finish on maxillary incisors
Anterior Deepbite and Torque Control
Before
End of1st Order
The ForceSystem!
1) Diagnosis and Treatment Plan.....It Still Matters
2) Understanding Bio-mechanics of Invisalign
3) They are All Invisalign Cases!
Engineering Your Invisalign Treatment Plan To Conquer a Wide Variety of Cases
Outline
They are All Invisalign Cases!
1) Vertical Challenges
2) Sagittal Challenges
3) Crowding, Spacing and Alignment Challenges
4) Cuspid Impactions
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Vertical Challenges
Deep-bite and Openbite
Assessing The Vertical Dimension of Occlusion
What does it tell you about the forces on the teeth that havecreated this equilibrium?
Bite Turbos: Incisors or Cuspids?
The idea is to have the ledges act as a removable anterior bite plane to avoid excessive posterior contact of upper and lower aligners .
Bite Turbos: Incisors or Cuspids?
The idea is to have the ledges act as a removable anterior bite plane to avoid excessive posterior contact of upper and lower aligners .
The reality of too much overjetallows mandible to close distal to ledges .
Go to Cuspid “Turbos” Clincheck
Bite Turbos: Incisors or Cuspids?
The idea is to have the ledges act as a removable anterior bite plane to avoid excessive posterior contact of upper and lower aligners .
The reality of too much overjetallows mandible to close distal to ledges .
Go to Cuspid “Turbos” Clincheck
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Vertical Challenges: Deep Anterior Overbite
Before
ClinCheck is not teeth moving, but the force system to get them there.
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Vertical Challenges: Deep Anterior Overbite
Stage 36Before
Vertical Challenges: Deep Anterior Overbite
Before
After
Stage 36
4 weeks ofanterior bite plane
Vertical Challenges: Deep Anterior Overbite
Before
After
Aligner NumbersMx: 38+0=38Md: 38+0=38
Treatment Appointments: 11(Including Impressions and debond and retention)
+1: Impression+2: Insert Aligners and attachments+6: Invisalign progress at 9,15,21,27,33,38+2: Debond Attachments and Retention
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Vertical Challenges: Deep Anterior Overbite
Go to Clincheck
Vertical Challenges: Deep Anterior Overbite
First ClinCheck Final ClinCheck
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Vertical Challenges: Deep Anterior Overbite
Aligner NumbersMx: 25+0=25Md: 19+0=19
Treatment Appointments: 8(Including Impressions and debond and retention)
+1: Impression+2: Insert Aligners and attachments+4: Invisalign progress at 9,15,21,25+1: Debond Attachments and Retention
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Vertical Challenges: Deep Anterior OverbiteAre they all the same?
Vertical Challenges: Deep Anterior OverbiteAre they all the same?
Vertical Challenges: Deep Anterior Overbite
Before
Deep-bite, with desire to open vertical dimension of occlusion with mandibular posterior eruption.
Vertical Challenges: Deep Anterior Overbite
Go to ClinCheck
Before After
Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Go to Clincheck
Deepbite, with desire to open vertical dimension of occlusion with mandibularposterior eruption.
Prognosis of UL2 and UL3 guarded.
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Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Before
During
Post-orthoPre-Resto
Post-Resto
A pleasure for the Patient....A pleasure for the Dentist!
Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Before
Final
Naturally You!
Not …….. Extreme Makeover
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Vertical Challenges: Posterior Intrusion
Go to ClinCheck
Vertical Challenges: Posterior Intrusion
Before
Post-Orthodontic
Aligner NumbersMx: 20+9=29Md: 20+9=29
Treatment Appointments: 9
+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress and refinement impressions at
9,15,20,2,9+1: Debond Attachments and Retention
Treatment Efficiency
Before Post-Orthodontic Post-Prosthetic Final
Vertical Challenges: Posterior Intrusion
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Vertical Challenges: Anterior Openbite
InitialRecords
Go to Final ClinCheck
Go to Clincheck 1
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Vertical Challenges: Anterior Openbite
Selected Posterior IntrusionMild Anterior IPRAuto-rotation of MandibleNo Incisor Extrusion
BeforeProgress 1Stage 9
Progress 2Stage 15
Progress 3Stage 21
With Aligners…..and ONLY ALIGNERS
Openbite closure42 weeks
Before Progress
Initial Ceph Tracing Progress Ceph Tracing
Before and After (First Order) Cephs
Before and After Superimpositions
Summary of Progress Analysis
•It appears that from initial to progress the upper and lower molars were intruded, and that the mandible has auto-rotated forward into a more closed position.
•In addition it appears that the lower incisors were extruded
Go to Clincheck Refinement
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Vertical Challenges: Anterior Openbite
Selected Posterior IntrusionMild Anterior IPRAuto-rotation of MandibleNo Incisor Extrusion
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Before AfterTreatment Time: 18 months
Mx: 28 + 8 =36Md: 28 + 8 =36
Aligner Numbers
Treatment Appointments: 9(Including Impressions and debond and retention)+1: Impression+2: Insert Aligners and attachments+6: Invisalign progress and refinemnt at 9,15,21,28,1,8+1: Debond Attachments and Retention
Before End TreatmentPrior to Refinement
Posterior Intrusion to Establish Anterior Coupling
Vertical Challenges: Anterior Openbite
Before
After
3 yrs Post-ortho
( no fixed retainers)
3 Years Later Time for New Vivera Retainers
Still Coupling…..Still Smiling!
Before During Aligners Ready for Refinement Final
Posterior Intrusion to Establish Anterior Coupling
Treatment Efficiency
Aligner NumbersMx: 21+6=27Md: 11+7=18
Treatment Appointments: 9(Including Impressions and debond and retention
+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress at 9,11,15,21, 6+1: Debond Attachments and Retention
Go to ClinCheck
Working Smarter …. Not Harder!!
Avoiding the Openbite!!
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Go to ClinCheck
Working Smarter …. Not Harder!!
Avoiding the Openbite!
Before Final
Aligner NumbersMx: 17+0=32Md: 17+0=32
Treatment Appointments: 7(Including Impressions and debond and retention)
+1: Impression+2: Insert Aligners and attachments+2: Invisalign progress at 9,15,+2: Debond Attachments and Retention
Working Smarter …. Not Harder!!
Sagittal Challenges
Class II and Class III Malocclusions
Sagittal Challenges: Class II and Class III Treatment
•Aligner tooth movements depend on intra-arch anchorage.
•They do not replace the need for inter-arch anchorage.
•They do not replace the need or auxiliary treatment appliances such as:
•Rapid Palatal Expanders•Headgear•Functional Appliances•Herbst Appliance•Orthognathic Surgery•Inter-arch elastics•Etc…..
•Comprehensive Diagnosis and Treatment Planning 1st……ClinCheck Later!
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If it is too good to be true......it probably is to good to be true!!!!
It is still orthodontics….Not magic!
Sagital correction......................OR NOT!!ClinCheck Coaching Request at Time of Refinement.
Lets do the math together!
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If it is too good to be true......it probably is to good to be true!!!!
It is still orthodontics….Not magic!
Sagital correction......................OR NOT!!ClinCheck Coaching Request at Time of Refinement.
Lets do the math together!
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Sagittal Challenges: Class II Correction
What do you like to use for Growth Modificationand Molar Distalization?
Sagital Challenges: Class II Correction
Power Ridges forAnterior Torque
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Beginning of First Order
End ofFirst Order
New Scan for2nd Order
Power Ridges are Effective at Anterior Torque
Go to Clincheck Refinement
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Before Final
Mx: 25 + 11 =36Md: 25 + 11 =36
Aligner Numbers
( oops....aligners still on!)
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Sagittal Challenges: Class II Correction: Functional Appliance
Functional Appliance
Initial Records
Treatment Plan
•Stage 1: Procline max incisors followedby functional appliance
•Stage 2: Invisalign with Class IIelastics if required
Initial Records
Treatment Plan•Stage 1: : Procline max incisors followed
by functional appliance•Stage 2: Invisalign with Class II
elastics if required
Sagittal Challenges: Class II Correction: Functional Appliance
Pre-Invisalign RecordsTreatment Plan•Invisalign
Go to ClinCheck
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Final RecordsInitial Records
Aligner NumbersMx: 15 + 0 = 15Md: 15 + 0 = 15
Stage 2: Invisalign Only
Sagittal Challenges: Class II Correction: Functional Appliance
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Sagital Challenges: Class II Correction: Elastics
Class II Elastics
Go to Clincheck
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Class II Correction During Invisalign
•Continuous Staging•IPR delayed until stage 21•Bite Jump at end of Clincheck
Sagittal Challenges: Class II Correction: Elastics
Before
Class II Elastics: Stage 9
Progress: Stage 9
Before After
Treatment Efficiency ( stopped refinement at #5)
Aligner NumbersMx: 21+4=25Md: 18+0=18
Treatment Appointments: 9+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress and refinemnt at 9,15,21,2,5+1: Debond Attachments and Retention
Sagittal Challenges: Class II Correction: Elastics
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Initial
Final
1 year Retn.Mx:Vivera NightsMd: Fixed Wire
Note posterior inter-occlusalspace closing slowly.
Sagittal Challenges: Class II Correction: Elastics
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79Go to ClinCheckVP: mxd 44; RF 18
Root Control in Extraction Sites.
Root Control in Extraction Sites.
At stage 29 and until stage 44, the extraction sites are closed and remain closed.
Before
Progress: Pictures at stage15
Progress: Pictures at Stage 25
Ready forRefinement
Root Control in Extraction Sites.
Go to RefinementVP: mxd 44; RF 18
VP: mxd 44; RF 18
Root Control in Extraction Sites.
Go to ClinCheck
Surgical Class II Case
Transfer of records with request for surgical treatment with Invisalign.
84
Surgical Class II Case
•Last aligners trimmed around selected braces.
•Aligners removed for fabrication of surgical splint, and during surgery.
•Full time aligner wear, immediately after surgery and with post surgical elastics.
•Once patient healed and ready for post surgical orthodontics, will decide on detailing
with refinement as required.
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Post Surgicalwith aligners.
Post Surgicalwithout aligners.
Surgical Class II Case
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Surgical Class II Case
No RefinementNo Repairs
Aligner NumbersMx: 13+0=13Md: 20+0=20
Work Smarter….Not Harder!
Treatment Efficiency
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Sagittal Challenges: Class III Correction: IPR in Lower Arch
Go to ClinCheck
Go to Clincheck Go to Refinement
Before Refinement
Sagittal Challenges: Class III Correction: IPR in Lower Arch
Before Refinement
After
Sagittal Challenges: Class III Correction: IPR in Lower Arch
Before After
Treatment Efficiency
Aligner NumbersMx: 37+17=54Md: 26+17=43
Treatment Appointments: 13(Including Impressions and debond and retention)
+1: Impression+2: Insert Aligners and attachments+9: Invisalign progress at 9,15,21,27,33,37,1,10,17+1: Debond Attachments and Retention
After 6 monthsretention
Sagittal Challenges: Class III Correction: IPR in Lower Arch
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Before
Treatment Plan: Achieve Maxillary Expansion First…..Then Invisalign and Elastics
Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics
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Before
Treatment Plan: Achieve Maxillary Expansion First…..Then Invisalign and Elastics
Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics
The Expander ( not same patient)
93
Before
Treatment Plan: Achieve Maxillary Expansion First…..Then Invisalign and Elastics
Go to ClinCheck
After Removable Expander
Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics
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•Cut-outs
•Elastic hooks
•Posterior intrusion
•Bite jump.
Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics
Not same patient....Fastest Elastics in the West!!
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Before After Removable Expander
After
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After
Before
Treatment Efficiency
Aligner NumbersMx: 25 + 0=25Md: 25 + 0=25
Treatment Appointments: 12+4: Removable Expander+1: Impression+2: Insert Aligners and attachments+4: Invisalign progress at 9,15,21,25+1: Debond Attachments and Retention
Maxillary Removable Expander and then
Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics
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Sagittal Challenges: Class III Correction: Lower Incisor Extraction
Go to ClinCheck Final
Sagittal Challenges: Class III Correction: Lower Incisor Extraction
Maxillary IPRLower Incisor Extraction
Progress Pictures
Sagittal Challenges: Class III Correction: Lower Incisor Extraction
100
Refinement In Mandible Only
6 Aligners with 0.2mm IPR from 3 to 3 increase overjet.
Time for Refinement Aligners for Finishing Details
Sagittal Challenges: Class III Correction: Lower Incisor Extraction
Aligner NumbersMx: 36 + 0=36Md: 36 + 6=42
Treatment Appointments: 11(Including Impressions and debond and retention)
+1: Impression+2: Insert Aligners and attachments+7: Invisalign progress at 9,15,21,27,33, 36,6+1: Debond Attachments and Retention
Before
After
Sagittal Challenges: Class III Correction: Lower Incisor Extraction
Crowding, Spacing&
Alignment Challenges
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Go to Clincheck
Spacing
Spacing
Go to Clincheck
Before After 1st Order
Go to Refinement•Pictures only.•To Close remaining spaces
Spacing
Go to Clincheck
Before
After1st Order
Go to Refinement
After
Before
Treatment Efficiency
Aligner NumbersMx: 25+6=31Md: 19+0=19
Treatment Appointments: 10(Including Impressions and debond and retention)
+1: Impression+2: Insert Aligners and attachments+6: Invisalign progress at 9,15,21,25, 1, 6+1: Debond Attachments and Retention
SpacingAfter
Go to Clincheck
Spacing
Go to Retainer Refinement
Go to Clincheck
Spacing
Go to Retainer Refinement
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SpacingBefore
Treatment Efficiency
Aligner NumbersMx: 25+6=31Md: 19+0=19
Treatment Appointments: 10(Including Impressions and debond and retention)
+1: Impression+2: Insert Aligners and attachments+6: Invisalign progress at 9,15,21,25, 1, 6+1: Debond Attachments and Retention
After
Go to ClinCheck
110 NM:MXD28 No RF!
111
What the tooth needs to feel, and what we need to see!
Staging treatment to expose useful surfaces.
Before
After
112 NM:MXD28 No RF!
What is yourfirst choice?
Go to ClinCheck
Go to ClinCheck Go to RefinementShe is already too happy!
Before Refinement
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Before Final
Aligner NumbersMx: 32+4=32Md: 32+0=32
Treatment Appointments: 11(Including Impressions and debond and retention)
+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress at 9,15,21,27,32,4+2: Debond Attachments and Retention
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Chief Complaint: •I don’t like my smile and •Fronts spaces and twisted teeth.Significant Clinical Findings: •Severe rotation of UR2 and UL2•Minimal vertical maxillary incisor display on smileRecords: •Panoramic Xray: 38 missing. •Lateral Cephalometric Xray: WNL
Orthodontic Treatment Plan: •Align both arches•Possibility of inter-arch elastics•Erupt/ Extrude maxillary anterior teeth•Possibility of bonding of
maxillary anteriors post-orthodontics.
Go to Clincheck FinalGo to Clincheck 1
Go to Clincheck Final
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Before Progress 1 Progress 2 ( finish md)
With Aligners and maxillary extrusion and rotation of lateral incisors.
Advantage of New Smart Track and Optimized Attachments
119
Before Final
Go to ClinCheck120 VT:MXD27/45, MCC30/30 RFMXD10
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StartRFNMT
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Before
StartMCC.
VT:MXD27/45, MCC30/30 RFMXD10
After
Go to MCC Go to RFMNTGo to ClinCheck
StartRFNMT
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Before
StartMCC.
VT:MXD27/45, MCC30/30 RFMXD10
After
Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Go to Clincheck
Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Before
Final
Go to RefinementGo to Clincheck
Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics
Before Final
Aligner NumbersMx: 20+10=30Md: 20+10=30
Treatment Appointments: 11 (Including Impressions and debond and retention)
+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress at 9,15,20, 1,9+2: Debond Attachments and Retention
Go to Clincheck
Root Control in Extraction Sites.
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Root Control in Extraction Sites.
Before
Later
Atts off forWedding
Refinement
Root Control in Extraction Sites.
Before Refinement
Go to Clincheck Go to Refinement 51 Aligners
Go to ClinCheck
Go toClinCheck
40 Aligners
Go to ClinCheck Go to RetainerRefinement
Before Time for Retainer Refinement
Cuspid Impactions
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Cuspid Impaction
•2 consultations have suggestedthat cannot erupt tooth andto remove the tooth.
Our plan......3D Scan
The Challenges
•Horizontally impacted UR3•Roots of UR4 in the path
of eruption
Even Radiologist missed on first try due to
panorex distortions
135
Creative Thinking 90/10
•Custom Maxillary TPA with extra arm from TPA and leaning on lateral.
•Lingual button to rotate UR4 distal to the lingual•Buccal Brace on UR4 to tip root distally•Expose UR3 and Erupt into space.•Later Invisalign to finish.
136
Periapicalprogress xray6weeks into treatment
At 12 weeks into total treatment time, removed palatal activation wire and usedbuccal wire from UR6 to UR3.
7 months after exposure.
Begin treatment with customized TPA, and exposure with activation each 3 weeks
137
After 7 months of activation, all hardware removed, new button on UR3and fabrication of maxillary holding aligner with boot strap elastic.
138
Cuspid Impaction: 90/10....10 First!
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RF
Cuspid Impaction
Class II elasticsRight Side
140
Progress
Progress 2
Start Invisalign
Progress 1
Before
90/10 Before Invisalign
Class II ElasticCustom Hook on UR2
Before
RF
Back to the Question….
Can Invisalign treat a cuspid impaction case?.........
Before
RF
Back to the Question….
Can Invisalign treat a cuspid impaction case?.........
It’s not the right question....Braces or Invisalign do not treat patients!!!!
Before
RF
Back to the Question….
Can Invisalign treat a cuspid impaction case?.........
It’s not the right question....Braces or Invisalign do not treat patients!!!!
I am not an Invisalignist .... I am an Orthodontist who uses Invisalign.
Before
RF
Back to the Question….
Can Invisalign treat a cuspid impaction case?.........
It’s not the right question....Braces or Invisalign do not treat patients!!!!
I am not an Invisalignist .... I am an Orthodontist who uses Invisalign.
So what is the right question.........
Is a cuspid impaction case an Invisalign candidate?
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Before
RF
Back to the Question….
Can Invisalign treat a cuspid impaction case?.........
Cuspid Impaction Case…Is an Invisalign Candidate!
It’s not the right question....Braces or Invisalign do not treat patients!!!!
I am not an Invisalignist .... I am an Orthodontist who uses Invisalign.
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Viewing all Patients as Invisalign Candidates
• Diagnosis and Treatment Plan.....It Still Matters
• Understanding Bio-mechanics of Invisalign
• They are All Invisalign Cases!
Dr. Willy Dayan
•drwillydayan@gmail.com
•www.orthoclined.com
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Dr. Willy Dayan
•drwillydayan@gmail.com
•www.orthoclined.com