Table of Contents

1  Cover

2  Title Page

3  Copyright Page

4  Preface

5  About the Authors

6  Acknowledgements

7  About the Companion Website

8  1 History, Present and Future of Aligners 1.1 History of Clear Aligners 1.2 Origins of Align Technology 1.3 Early Clear Aligner Manufacturers 1.4 Align Technology Development 1.5 Current Situation and Future of Aligners 1.6 Promising Aligner Initiatives 1.7 Future of Clear Aligners

9  2 Basic Principles with Aligners 2.1 Forces 2.2 Engagement 2.3 Anchorage 2.4 Case Selection to Start with Aligners Technique

10  3 Why Invisalign? 3.1 Why Did We Begin Prescribing Invisalign in Our Practice? 3.2 Our Motivation

11  4 Patient Communication Skills 4.1 Invisalign Equates to Health, Wellness and Outstanding Results 4.2 Effective Patient Communication

12  5 Keys to Practice Growth 5.1 How to Get the Best Results with Invisalign

13  6 Patient Selection

14  7 Predictability of Movement 7.1 Treatments to Gain Familiarity with the Technique

15  8 Types of Treatments with Invisalign

16  9 Pillars of the Invisalign Technique 9.1 Aligners 9.2 ClinCheck Software 9.3 Attachments and Features of SmartForce 9.4 Auxiliary Techniques 9.5 Technician (CAD Designer)

17  10 Conventional Attachments

18  11 Clinical Preferences

19  12 Attachments Bonding and Interproximal Reduction 12.1 Bonding Attachments Protocol 12.2 Interproximal Reduction Procedure

20  13 Digital Workflow 13.1 Records 13.2 Creating a New Patient Record

21  14 ClinCheck Software 14.1 The Perfect ClinCheck Review in 10 Steps 14.2 Communication with the Technician

22  15 Treatment Monitoring and Appointments Protocol 15.1 Tracking Treatment Progress 15.2 Appointments Protocol for Invisalign Patient

23  16 Troubleshooting and Retention 16.1 Auxiliary Techniques 16.2 Finishing Techniques 16.3 Retention

24  17 Arch Length Discrepancies 17.1 Spacing 17.2 Crowding

25  18 Growing Patients 18.1 First Treatment 18.2 Teenage Patients

26  19 Transversal Problems: Symmetric and Asymmetric Expansion 19.1 Things to Consider in Expansion Cases 19.2 Symmetric Expansion 19.3 Asymmetric Expansion 19.4 Tips for Transversal Arch Compensation

27  20 Sagittal Discrepancies 20.2 Class II Cases 20.3 Class III 20.4 Dentoalveolar Protrusion Skeletal Class II

28  21 Vertical Problems 21.1 Open Bite 21.2 Deep Bite: Classification According to Complexity Bibliography

29  22 Asymmetries 22.1 Growing Patients with Asymmetry 22.2 Non‐growing Patients with Asymmetry

30  23 Extraction Cases 23.1 Incisor Extraction 23.2 Extraction of Premolars

31  24 Multidisciplinary Cases: Implants 24.1 TADs to Intrude Upper Molars 24.2 Upper Midline Shift 24.3 Posterior Bite Collapse 24.4 Posterior Bite Collapse with Deep Bite 24.5 Biomechanics of the Locatelli for Mesialization of the Lower Dental Arch Opening Space for Implants 24.6 Gingivectomy, Passive Eruption Case 24.7 Anterior Intrusion Anchored on Dental Implant 24.8 Anterior Torque Anchored on Dental Implant

32  25 Prerestorative Orthodontics: Veneers 25.1 Bleaching 25.2 Veneers to Solve Lateral Bolton Discrepancy in a Class III Patient 25.3 Space Opening for Anterior Crowns and Implants 25.4 Anterior Intrusion for Two Central Incisor Veneers 25.5 Edge‐to‐Edge Bite Preparation for Veneers

33  Index

34  End User License Agreement

List of Tables

1 Chapter 20Table 20.1 Extra resources for class II patientsTable 20.2 Protocol when treating a growing patient with class II

List of Illustrations

1 Chapter 1Fig. 1.1 Remensnyder patent file.Fig. 1.2 Kesling patent file.Fig. 1.3 Schwartz and Sheridan patent file.Fig. 1.4 Align Technology logo.Fig. 1.5 Align Technology annual revenue.Fig. 1.6 Align Technology stereolithographic has been heavily awarded.Fig. 1.7 Models and aligners by Clear Correct.Fig. 1.8 Optimized attachments for anterior open bite.Fig. 1.9 Passive attachments for anterior intrusion.Fig. 1.10 Results in PubMed for ‘orthodontics’.Fig. 1.11 Results in PubMed for ‘invisalign’ from 1999 to 2019.Fig. 1.12 ClearCorrect aligner retention chart.Fig. 1.13 SureSmile aligner software combined with CBCT.Fig. 1.14 F22 chromatic stability.Fig. 1.15 3M superimposition for treatment evolution.Fig. 1.16 Ormco results for their TruGEN plastic against SmartTrack (data on fil...Fig. 1.17 Distalizer inserted in an in‐practice aligner.Fig. 1.18 Irok is focused on digital models that can serve different purpose...Fig. 1.19 A6 mandibular advancement launched in 2015.Fig. 1.20 LineDock software.Fig. 1.21 SmileDirectClub self‐polyvinyl siloxane (PVS) ‐impression kit.Fig. 1.22 CANDID aligners process.Fig. 1.23 CANDID aligners set.

2 Chapter 2Fig. 2.1 Forces will be delivered through the combination of plastic and att...Fig. 2.2 Optimized attachments provide an active, flat surface that the alig...Fig. 2.3 These crowns allow enough contact from plastic to exert desired for...Fig. 2.4 Short clinical crowns might reduce movement predictability.Fig. 2.5 Quantification of variable aligner material on retention. (Left) Ve...Fig. 2.6 Brackets have a strong small contact point in comparison with a sof...Fig. 2.7 While second molars are moving, the rest of the teeth are considere...Fig. 2.8 This figure shows a horizontal ‘V’ movement pattern.Fig. 2.9 The second quadrant is being expanded using the first quadrant as a...Fig. 2.10 G6 first premolar extraction has a standardized movement sequence....Fig. 2.11 In this G6 protocol extraction of 14 (from left to right), the pos...

3 Chapter 4Fig. 4.1 Let’s talk about aligner treatment with our patients.Fig. 4.2 The more Invisalign patients you have, the more Invisalign referral...Fig. 4.3 A treatment coordinator is a key success driver for Invisalign.

4 Chapter 5Fig. 5.1 If we plan our growth in advance, we will reach our goals.

5 Chapter 6Fig. 6.1 Invisalign evaluation tool.

6 Chapter 7Fig. 7.1 All treatment predictability can be checked with the Invisalign eva...

7 Chapter 8Fig. 8.1 Align Technology’s 2021 portfolio

8 Chapter 10Fig. 10.1 Ellipsoid attachments. Fig. 10.2 Horizontal attachments have great clinical effects on transverse p...Fig. 10.3 Conventional attachments are selected whenever there are no optimi...Fig. 10.4 Extrusion attachments are placed on teeth adjacent to the ones to ...Fig. 10.5 Vertical attachments bevelled to mesial (left) and distal (right)....Fig. 10.6 Conventional attachments might be placed to achieve similar moveme...Fig. 10.7 Research and development investment has led to a very powerful bio...Fig. 10.8 Conventional dental composite is the material chosen for attachmen...Fig. 10.9 Placement on canines and premolars. Fig. 10.10 Placement on incisor. Fig. 10.11 Placement on premolar.Fig. 10.12 The right side shows how anterior extrusion attachments help to c...Fig. 10.13 The figure on the right shows how optimized root control attachme...Fig. 10.14 Pressure points are usually associated with attachments whenever ...Fig. 10.15 Combination of attachments and lingual pressure points help creat...Fig. 10.16 Sometimes attachments are designed for support instead of movemen...Fig. 10.17 Attachments for molars are relatively new and provide improved ro...Fig. 10.18 Mesiobuccal rotation combined with extrusion.Fig. 10.19 Mesiobuccal rotation combined with intrusion.Fig. 10.20 Molar extrusion.Fig. 10.21 Optimized support attachments are commonly used in first treatmen...Fig. 10.22 Power Ridges are plastic bends exerting ‘push’ forces.Fig. 10.23 Activation exerts forces translated to crown or root.Fig. 10.24 Effect of pressure point on the tooth.Fig. 10.25 Precision Ramps are much comfortable for the patient than convent...Fig. 10.26 Clinical view of Precision Wings in a growing patient.

9 Chapter 11Fig. 11.1 Dedicate time to setting up clinical preferences.

10 Chapter 12Fig. 12.1 Have materials and equipment ready before any appointment.Fig. 12.2 (a) Place composite on template and (b) ensure there is no composi...Fig. 12.3 A metal interproximal reduction strip is the most common type used...Fig. 12.4 A high‐speed bur interproximal reduction (IPR) is suggested for 0....Fig. 12.5 Interproximal reduction and attachments removal bur set is ideal f...Fig. 12.6 Interproximal reduction has to be carefully planned and performed....

11 Chapter 13Fig. 13.1 Frontal, smile and lateral photographs.Fig. 13.2 90 degrees pictures are mandatory both in right (a) and left (b) i...Fig. 13.3 Intraoral frontal (a) and overjet (b) pictures will help create a ...Fig. 13.4 Blue or red ink on both upper (a) and lower (b) occlusal pictures ...Fig. 13.5 Polyvinyl siloxane (PVS) material placement.Fig. 13.6 Inserting tray with polyvinyl siloxane (PVS) material into the pat...Fig. 13.7 Upper (left) and lower (right) impressions.Fig. 13.8 iTero scanner has several advantages, such as the Outcome Simulato...Fig. 13.9 Lateral and panoramic X‐rays.

12 Chapter 14Fig. 14.1 ClinCheck software on‐screen.Fig. 14.2 Compare ClinCheck with pictures on the same plane before start pla...Fig. 14.3 Distortions of the impression might affect aligner coverage, so it...Fig. 14.4 Anterior view.Fig. 14.5 Overjet view.Fig. 14.6 Buccal right view.Fig. 14.7 Buccal left view.Fig. 14.8 Occlusal view: maxillaryFig. 14.9 Occlusal view: mandibular.Fig. 14.10 Posterior view.Fig. 14.11 Mandibular advancement.Fig. 14.12 Treatment overview helps us understand general structure of the t...Fig. 14.13 Reviewing occlusal views.Fig. 14.14 Analysis of the force vectors: in simultaneous distalization, if ...Fig. 14.15 Anterior positive torque (left) allows pure intrusion to resolve ...Fig. 14.16 The sequence will always be based on three steps: (1) procline in...Fig. 14.17 Staging is mandatory to help achieving desired final position.Fig. 14.18 Checking every stage on anterior sector will prevent from unaesth...Fig. 14.19 Round tooth rotations (canines and premolars) require perfectly s...Fig. 14.20 Ask the technician to perform the extrusion of the canine simulta...Fig. 14.21 The pearl necklace effect explains how to use these mechanics in ...Fig. 14.22 Simultaneous expansion for reduction in arch length (incisor retr...Fig. 14.23 Expansion leads to arch depth loss and anterior retraction.Fig. 14.24 Whenever possible, simultaneous anterior intrusion and posterior ...Fig. 14.25 Superimposition tool.Fig. 14.26 Black dots indicate complex movements.Fig. 14.27 Blue dots indicate moderate movements.Fig. 14.28 Attachments.Fig. 14.29 White boxes indicating interproximal reduction turn yellow at the...Fig. 14.30 Treatment overview also addresses interproximal reduction needs....Fig. 14.31 Buttons and hooks: the biomechanical difference between button cu...Fig. 14.33 Button cutouts will allow composite or metal butons to be bonded ...Fig. 14.34 Upper hook will affect upper anterior torque.Fig. 14.35 Upper cutout for bonded button will have less effect on anterior ...Fig. 14.36 Treatment overview also refers to hooks or button cutouts.

13 Chapter 16Fig. 16.1 An example of poor fitting.Fig. 16.2 Fitting can improve with ‘fitters’ chewing.Fig. 16.3 Detailing pliers are helpful for case finishing.Fig. 16.4 Auxiliary technique to recapture a rotated lower canine with butto...Fig. 16.5 Buccal (left) and palatal (right) view of a lateral incisor extrud...Fig. 16.6 Ectopic canines not covered by the aligner.Fig. 16.7 Uprighting a premolar root.Fig. 16.8 This patient had a distal tipping of the second premolar root. A P...Fig. 16.9 In this case goal was to mesialize 47 and 48 in order to close 46 space.Fig. 16.10 Patient with missing 46.Fig. 16.11 The patient had missing 36 and 46.Fig. 16.12 A Locatelli helps to open space.Fig. 16.13 Temporary anchorage devices help intruding teeth in severe deep b...Fig. 16.14 Posterior extrusion is achieved here with auxiliary buttons and e...Fig. 16.15 Auxiliary buttons and elastics help derotating teeth.Fig. 16.16 Change in smile after expansion of upper arch and offset and rota...Fig. 16.17 Mesial‐in rotation of the canine.Fig. 16.18 Mesial‐out rotation of the canine.Fig. 16.19 Finishing bends.Fig. 16.20 Fixed retention from lateral to lateral.Fig. 16.21 Vivera retainers are manufactured by Align Technology.

14 Chapter 17Fig. 17.1 Interproximal reduction has to be performed carefully in order to ...Fig. 17.2 Interproximal reduction might improve the shape and size of teeth,...Fig. 17.3 Interproximal reduction in cases of crowding might improve contact...Fig. 17.4 Spacing cases are usually related to abnormal tooth size, which le...Fig. 17.5 Palatal root torque is seen on the ClinCheck Pro as blue areas on ...Fig. 17.6 Skeletal class I with spacing.Fig. 17.7 Pretreatment views.Fig. 17.8 Pretreatment panoramic X‐ ray, teleradiograph and cephalometry.Fig. 17.9 Upper CC superimposition and instructions to CAD designer.Fig. 17.10 Lower CC superimposition and instructions to CAD designer.Fig. 17.11 Front CC view.Fig. 17.12 Front intraoral picture.Fig. 17.13 Right ClinCheck view, initial situation.Fig. 17.14 Left ClinCheck view, initial situation.Fig. 17.15 Post‐treatment views.Fig. 17.16 Pretreatment and final smile.Fig. 17.17 Post‐treatment panoramic and lateral X‐rays.Fig. 17.18 Skeletal class I with spacing.Fig. 17.19 Intraoral views left, front, right, upper, lower.Fig. 17.20 Smile and pretreatment panoramic X‐ray.Fig. 17.21 Pretreatment Clinchecks.Fig. 17.22 Refinement: intraoral views, left, front, and rightFig. 17.23 Refinement ClinChecks.Fig. 17.24 Final intraoral views left, front, right, upper, lower.Fig. 17.25 Before and after smile.Fig. 17.26 Final panoramic and lateral X‐rays.Fig. 17.27 Skeletal class III with upper maxillary compression and anterior ...Fig. 17.28 Pretreatment views.Fig. 17.29 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 17.30 Planned IPR on midline can be seen in several areas of the ClinCh...Fig. 17.31 Upper CC superimposition and instructions to CAD designer.Fig. 17.32 Lower CC superimposition and instructions to CAD designer.Fig. 17.33 Right ClinCheck view, initial situation.Fig. 17.34 Left ClinCheck view, initial situation.Fig. 17.35 Post‐treatment images (right, front, left, upper, lower).Fig. 17.36 Pretreatment smile.Fig. 17.37 Final smile.Fig. 17.38 Upper crowding and anterior crossbite ‘Lite’ treatment in a class...Fig. 17.39 Pretreatment extraoral and intraoral (right, front, left, upper, ...Fig. 17.40 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 17.41 Upper CC superimposition and instructions to CAD designer.Fig. 17.42 Lower CC superimposition and instructions to CAD designer.Fig. 17.43 Right ClinCheck view, initial situation.Fig. 17.44 Left ClinCheck view, initial situation. Fig. 17.45 Planned IPR on midline can be seen in several areas of the ClinCh...Fig. 17.46 Initial intraoral views.Fig. 17.47 Final intraoral views.Fig. 17.48 Initial and final occlusal (upper and lower).Fig. 17.49 Pretreatment smile and overjet.Fig. 17.50 Final Smile and overjet.Fig. 17.51 Upper and lower crowding with anterior crossbite of 22.Fig. 17.52 Pretreatment: extraoral and intraoral (right, front, left, upper,...Fig. 17.53 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 17.54 Upper and lower CC superimposition and instructions to CAD design...Fig. 17.55 Right and left ClinCheck view, initial situation and instructions...Fig. 17.56 Interproximal reduction after improving contact surface between i...Fig. 17.57 Evolution in month 13 of treatment.Fig. 17.58 Evolution in month 17 of treatment.Fig. 17.59 Final intraoral (right, front, left, upper, lower) views.Fig. 17.60 Initial and final smile and overjet.Fig. 17.61 Final panoramic and lateral X‐rays.Fig. 17.62 Skeletal class I with crowding.Fig. 17.63 Protocol excludes crisscross elastics to solve premolar crossbite...Fig. 17.64 Extra palatal root torque premolars, selecting multiple teeth wit...Fig. 17.65 Pretreatment intraoral views (left, front, right).Fig. 17.66 Initial panoramic and lateral X‐rays.Fig. 17.67 Pretreatment ClinChecks with interproximal reduction to avoid exp...Fig. 17.68 Refinement: intraoral views (right, front and left).Fig. 17.69 Refinement ClinCheck: right, front and left (in this set, 37 is i...Fig. 17.70 Final intraoral views (left, front, right).Fig. 17.71 Final panoramic‐X‐ray.Fig. 17.72 Final extraoral views.

15 Chapter 18Fig. 18.1 Skeletal growth pattern has to be carefully evaluated in growing p...Fig. 18.2 Upper temporary spacing is 3 mm, on average, while tooth discrepan...Fig. 18.3 Severe crowding on temporary teeth leads to future extractions or ...Fig. 18.4 Disjunction and protraction should be performed on EC1, while mand...Fig. 18.5 Anterior crossbite management should be addressed early.Fig. 18.6 Skeletal class II can be achieved before than usual if overjet is ...Fig. 18.7 More simple devices can achieve less objectives than aligners.Fig. 18.8 Upper compression with posterior and anterior crowding.Fig. 18.9 Views with the Hyrax before Invisalign First.Fig. 18.10 Panoramic X‐ray before Hyrax.Fig. 18.11 After the Hyrax and before Invisalign First (10‐year‐old patient)...Fig. 18.12 Panoramic X‐ray before Invisalign First.Fig. 18.13 Upper CC superimposition and instructions to CAD designer.Fig. 18.14 Lower CC superimposition and instructions to CAD designer.Fig. 18.15 Right ClinCheck view, initial situation.Fig. 18.16 Left ClinCheck view, initial situation.Fig. 18.17 Attachments can be seen in several areas of the ClinCheck softwar...Fig. 18.18 Pretreatment intraoral views (left, front, right) before Invisali...Fig. 18.19 Intraoral views (left, front, right) with first aligner.Fig. 18.20 Actual situation in additional aligners.Fig. 18.21 Initial and final occlusal (upper and lower).Fig. 18.22 Initial and final smile.Fig. 18.23 Severe crowding impeding proper lateral incisor eruption both in ...Fig. 18.24 Taking advantage of aligner biomechanics by distalizing the secon...Fig. 18.25 Pretreatment intraoral views (right, front, left, upper, lower)....Fig. 18.26 Pretreatment panoramic X‐ray showing current dentition status and...Fig. 18.27 Initial extraoral views.Fig. 18.28 Pretreatment Clinchecks (right, front, left, upper, lower).Fig. 18.29 Refinement: (left) 32 has erupted and does not fit in the aligner...Fig. 18.30 Refinement: panoramic X‐rays show the evolution of the sagittal m...Fig. 18.31 Refinement development: Both available arch space and transverse ...Fig. 18.32 Refinement: 12, 22 have erupted but their clinical crowns are not...Fig. 18.33 Final Intraoral views (right, front, left, upper, lower) showing ...Fig. 18.34 Final and final smile views show an improvement in arch developme...Fig. 18.35 Lateral X‐ray shows incisor proclination as a result of the mecha...Fig. 18.36 Class II growing patient, Lite treatment.Fig. 18.37 Pretreatment views before phase 1 with Hyrax and D‐gainer.Fig. 18.38 Lateral and panoramic X‐rays before phase 1 with Hyrax and D‐gain...Fig. 18.39 Extraoral and intraoral (right, front, left, upper, lower) views ...Fig. 18.40 Panoramic X‐ray, teleradiograph and cephalometry before Invisalig...Fig. 18.41 Upper CC superimposition and instructions to CAD designer.Fig. 18.42 Lower CC superimposition and instructions to CAD designer.Fig. 18.43 Right ClinCheck view, initial situation.Fig. 18.44 Left ClinCheck view, initial situation.Fig. 18.45 Attachments and IPR can be seen in several areas of the ClinCheck...Fig. 18.46 Intraoral views (right, front, left, upper, lower).Fig. 18.47 Intraoral views (right, front, left, upper, lower).Fig. 18.48 Initial and final occlusal views (upper and lower).Fig. 18.49 Pretreatment and final smile and overjet.Fig. 18.50 Initial and final profiles.Fig. 18.51 Final panoramic and lateral X‐rays.Fig. 18.52 Initial intraoral picture.Fig. 18.53 Pretreatment views.Fig. 18.54 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 18.55 Upper CC superimposition and instructions to CAD designer.Fig. 18.56 Lower CC superimposition and instructions to CAD designer.Fig. 18.57 Interproximal reduction necessary to upright lower incisors befor...Fig. 18.58 Right ClinCheck view, initial situation.Fig. 18.59 Left ClinCheck view, initial situation.Fig. 18.60 Pretreatment intraoral views (left, front, right).Fig. 18.61 Month 6 of evolution: intraoral views (left, front, right).Fig. 18.62 Refinement: month 15 of evolution; intraoral views (left, front, ...Fig. 18.63 Final intraoral views (right, front, left, upper, lower).Fig. 18.64 Pretreatment and final smile.Fig. 18.65 Final panoramic and lateral X‐rays.Fig. 18.66 Class III growing patient comprehensive treatment, with 23 includ...Fig. 18.67 Intraoral views (right, front, left, upper, lower).Fig. 18.68 Panoramic X‐ray, teleradiograph, cephalometry.Fig. 18.69 Upper CC superimposition and instructions to CAD designer.Fig. 18.70 Lower CC superimposition and instructions to CAD designer.Fig. 18.71 Right ClinCheck view, initial situation.Fig. 18.72 Left ClinCheck view, initial situation.Fig. 18.73 Interproximal reduction in lower arch to create positive overjet....Fig. 18.74 Opening space for 15 (lateral view).Fig. 18.75 Opening space for 15 (occlusal view).Fig. 18.76 Locatelli to open space for 15 and 23.Fig. 18.77 Situation at the end of first set of aligners.Fig. 18.78 (a–f) Transversal development of the arches.Fig. 18.79 Month 18 of evolution, intraoral views.Fig. 18.80 Final views with15 and 23 in place.Fig. 18.81 By labial.Fig. 18.82 By lingual.Fig. 18.83 Class I deep bite Lite treatment.Fig. 18.84 Pretreatment views (right, front, left, upper, lower).Fig. 18.85 Upper CC superimposition and instructions to CAD designer.Fig. 18.86 Lower CC superimposition and instructions to CAD designer.Fig. 18.87 Attachments and IPR can be seen in several areas of the ClinCheck...Fig. 18.88 Left ClinCheck view, initial situation.Fig. 18.89 Right ClinCheck view, initial situation.Fig. 18.90 Pretreatment panoramic X‐ray, teleradiography and cephalometry.Fig. 18.91 Pretreatment (upper) and final (lower) results.Fig. 18.92 Initial and final occlusal (upper and lower).Fig. 18.93 Pretreatment and final smiles and overjets.Fig. 18.94 Final panoramic and lateral X‐rays.Fig. 18.95 Ectopic palatal canine.Fig. 18.96 Initial intraoral views (right, front, left, upper, lower).Fig. 18.97 Initial extraoral views.Fig. 18.98 Initial intraoral views: traction 1, 2, 3.Fig. 18.99 Initial lateral and panoramic X‐rays.Fig. 18.100 Refinement: intraoral views (right, front, left, upper, lower)....Fig. 18.101 ClinChecks: right, front, left, upper, lower.Fig. 18.102 Traction 4 and 5. Initial traction was delivered with constant f...Fig. 18.103 Refinement 2: intraoral views (right, front, left, upper, lower)...Fig. 18.104 Smile at refinement 2.Fig. 18.105 Refinement 2 ClinChecks (right, front, left, upper, lower).Fig. 18.106 Final intraoral views.Fig. 18.107 Final smile view.Fig. 18.108 Current cephalometric measurements.Fig. 18.109 Ortopantomographs (OPG) 0, 1, 2, 3. Evolution of the canine with...Fig. 18.110 Temporary 52.Fig. 18.111 Initial intraoral views (right, front, left, upper, lower).Fig. 18.112 Pretreatment panoramic X‐ray with wisdom teeth present.Fig. 18.113 Final intraoral views (right, front, left, upper, lower).Fig. 18.114 Initial and final panoramic X‐rays. Right class I was achieved e...Fig. 18.115 Final lateral X‐ray and cephalometric analysis.

16 Chapter 19Fig. 19.1 Classic NiTi archwires were only available on standard sizes and s...Fig. 19.2 Expansion can be defined in a precise way, with the decision about...Fig. 19.3 Expansion with aligners can be defined in between Fa point (blue l...Fig. 19.4 Dentoalveolar expansion can be achieved with aligners, as with bra...Fig. 19.5 In this situation, if we ask for the same amount of expansion in b...Fig. 19.6 Check smile In unilateral masticatory side the patient will expose...Fig. 19.7 Asymmetric expansion.Fig. 19.8 Blue arrows indicate proper posterior torque, white ones show arch...Fig. 19.9 Pearl necklace effect.Fig. 19.10 Smile picture.Fig. 19.11 Symmetric compression causing anterior open bite.Fig. 19.12 Pretreatment extraoral and intraoral views.Fig. 19.13 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 19.14 Interproximal reduction.Fig. 19.15 Upper superposition.Fig. 19.16 Lower superposition.Fig. 19.17 Initial right ClinCheck view, with CAD designer instructions.Fig. 19.18 Initial left ClinCheck view, with CAD designer instructions.Fig. 19.19 Comparison of initial and final occlusion.Fig. 19.20 Comparison of initial and final occlusal.Fig. 19.21 Comparison of initial and final smile overjets.Fig. 19.22 Comparison of initial and final smiles.Fig. 19.23 Final panoramic X‐ray and teleradiograph.Fig. 19.24 Edge to edge bite with open bite tendency.Fig. 19.25 Pretreatment intraoral views (right, front, left, upper, lower)....Fig. 19.26 Initial extraoral view: short display.Fig. 19.27 Pretreatment panoramic and lateral X‐rays.Fig. 19.28 Pretreatment ClinChecks (right, front, left, upper, lower).Fig. 19.29 Refinement intraoral views (right, front, left, upper, lower).Fig. 19.30 Refinement smile.Fig. 19.31 Refinement ClinChecks (right, front, left, upper, lower).Fig. 19.32 Final intraoral views (right, front, left, upper, lower).Fig. 19.33 Final smile picture and lateral X-ray.Fig. 19.34 Symmetric compression.Fig. 19.35 Pretreatment intraoral views (right, front, left, upper, lower)....Fig. 19.36 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 19.37 Upper CC superimposition and instructions to CAD designer.Fig. 19.38 Lower CC superimposition and instructions to CAD designer.Fig. 19.39 Attachments and IPR can be seen in several areas of the ClinCheck...Fig. 19.40 Right ClinCheck view, initial situation.Fig. 19.41 Left ClinCheck view, initial situation.Fig. 19.42 Views before starting refinement.Fig. 19.43 Final views.Fig. 19.44 Comparison of initial and final occlusal (upper and lower).Fig. 19.45 Final expansion reducing buccal corridors.Fig. 19.46 Final Panoramic X‐ray and teleradiography.Fig. 19.47 Symmetric compression with loss of attachment.Fig. 19.48 Pretreatment extraoral and intraoral views.Fig. 19.49 Pretreatment panoramic X‐ray, teleradiograph and cephalometry.Fig. 19.50 Upper CC superimposition and instructions to CAD designer.Fig. 19.51 Lower CC superimposition and instructions to CAD designer.Fig. 19.52 Interproximal reduction is necessary to upright lower incisors.Fig. 19.53 Right and left ClinCheck view, initial situation.Fig. 19.54 Comparison of pretreatment (upper) and final (lower) views.Fig. 19.55 Comparison of initial and final occlusal.Fig. 19.56 Comparison initial of and final smile and overjet.Fig. 19.57 Posterior bilateral crossbite.Fig. 19.58 Initial extraoral views.Fig. 19.59 Initial intraoral views (right, front, left, upper, lower).Fig. 19.60 Pretreatment Clinchecks: right, front, left, upper, lower.Fig. 19.61 Refinement: intraoral views (right, front, left, upper, lower).Fig. 19.62 Refinement ClinChecks: right, front, left, upper, lower.Fig. 19.63 Refinement 2: intraoral views (right, front, left, upper, lower)....Fig. 19.64 Refinement 2 ClinChecks: right, front, left, upper, lower.Fig. 19.65 Final intraoral views (right, front, left, upper, lower).Fig. 19.66 Pretreatment and final smile.Fig. 19.67 Posterior bilateral compression.Fig. 19.68 Initial intraoral views (right, front, left, upper, lower).Fig. 19.69 Initial intraoral views (right, front, left, upper, lower).Fig. 19.70 Pretreatment ClinChecks: right, front, left, upper, lower. Fig. 19.71 Refinement: intraoral views (right, front, left, upper, lower). Fig. 19.72 Refinement ClinChecks: right, front, left, upper, lower.Fig. 19.73 Refinement ClinChecks: right, front, left, upper, lower.Fig. 19.74 Check first column on both charts to see how much expansion was a...Fig. 19.75 Refinement 2: intraoral views (right, front, left, upper, lower)....Fig. 19.76 Final intraoral views: right, front, left, upper, lower.Fig. 19.77 Pretreatment and final smile.Fig. 19.78 Final lateral, cephalometric analysis and panoramic X-ray.Fig. 19.79 patient with severe periodontal disease.Fig. 19.80 Pretreatment views. Note the critical periodontal situation of up...Fig. 19.81 Initial panoramic X-ray, teleradiograph and cephalometry.Fig. 19.82 Problem list.Fig. 19.83 Treatment plan.Fig. 19.84 It is important to relate clinical view to the Clincheck.Fig. 19.85 Upper and lower CC superimposition and instructions to CAD design...Fig. 19.86 Goal of treatment. Open space by asymmetric upper expansion on th...Fig. 19.87 Right ClinCheck view, initial situation.Fig. 19.88 Left ClinCheck view, initial situation.Fig. 19.89 Pontic to open space for a second upper right canine.Fig. 19.90 Views before refinement.Fig. 19.91 Comparison of initial (upper) with final (lower) occlusion. Compo...Fig. 19.92 Comparison of initial and final occlusal.Fig. 19.93 Comparison of initial and final smile and overjet.Fig. 19.94 Comparison of initial (left) and final panoramic x‐rays (right). ...Fig. 19.95 Final teleradiograph.Fig. 19.96 Asymmetric compression.Fig. 19.97 Pretreatment views.Fig. 19.98 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 19.99 left‐side deviation of lower jaw.Fig. 19.100 Upper and lower CC superimposition and instructions to CAD desig...Fig. 19.101 Interproximal reduction is necessary to reduce the lower dental ...Fig. 19.102 Initial views before refinement. The posterior open bite on left...Fig. 19.103 Goal of treatment: correct posterior crossbite from 23 to 27.Fig. 19.104 Initial and final design of the asymmetric expansion of the uppe...Fig. 19.105 Comparison of initial and final occlusion.Fig. 19.106 Final occlusion. Both midlines centred. Unilateral posterior cro...Fig. 19.107 Improvement in the smile and in the final torque of upper inciso...Fig. 19.108 Improvement in the profile by clockwise rotation of the mandible...Fig. 19.109 Posterior crossbite with anterior crowding.Fig. 19.110 Careful diagnosis of the crossbite origin will lead to a great r...Fig. 19.111 Cone beam computed tomography: three dimensional radiological ex...Fig. 19.112 Pretreatment intraoral views (right, front, left, upper, lower)....Fig. 19.113 Pretreatment smile and lateral X‐ray.Fig. 19.114 Pretreatment ClinChecks: right, front, left, upper, lower.Fig. 19.115 Refinement: intraoral views (right, front, left, upper, lower)....Fig. 19.116 Smile after first set of aligners.Fig. 19.117 Refinement ClinChecks: right, front, left, upper, lower.Fig. 19.118 Final intraoral views: right, front, left, upper, lower.Fig. 19.119 Pretreatment and final smile: we can observe how posterior expan...Fig. 19.120 Cone beam computed tomography sections. From left (pretreatment)...Fig. 19.121 Posterior crossbite, with anterior crossbite and edge‐to‐edge oc...Fig. 19.122 Smile and upper and lower arch view.Fig. 19.123 Panoramic and lateral X‐rays.Fig. 19.124 Measurements were performed after iTero scanning and OrthoCad so...Fig. 19.125 Skeletal compression has to be approached with a surgical proced...Fig. 19.126 First phase: initially, the patient had a gingivectomy performed...Fig. 19.127 First phase: initially, the patient had a gingivectomy performed...Fig. 19.128 Upper pre‐miniscrew‐assisted rapid palatal expander (MARPE): pos...Fig. 19.129 Right, Front, Left Post miniscrew‐assisted rapid palatal expande...Fig. 19.130 Second phase. Measurements were performed after iTero scanning a...Fig. 19.131 Second phase ClinChecks (front, upper, lower).Fig. 19.132 Third phase: intraoral views (front and upper).Fig. 19.133 After 16 aligners space was closed, palatal suture was still ope...Fig. 19.134 Third phase ClinChecks (front, upper, lower).Fig. 19.135 Final intraoral views: front, upper, lower.Fig. 19.136 Pretreatment and final smile.Fig. 19.137 Initial and final cephalometric measurements, with the final pos...Fig. 19.138 Final panoramic X‐ray. Patient smile was widened and skeletal ba...

17 Chapter 20Fig. 20.1 Precision cuts and button cutouts: to hold the intermaxillary elas...Fig. 20.2 Precision hooks would equal to archposts in fixed appliances.Fig. 20.3 Button cutouts allow bonding a metal/ceramic button.Fig. 20.4 Class II, division 2 will benefit from two button cutouts for clas...Fig. 20.5 Class II, division 1 will benefit from canine hook and molar butto...Fig. 20.6 Mesial‐in rotation of the canine.Fig. 20.7 Mesial‐out rotation of the canine.Fig. 20.8 Whenever a lingual button is placed on the lingual surface of the...Fig. 20.9 Occlusal view of lingual buttons on upper canines.Fig. 20.10 Pontic to cover missing 34.Fig. 20.11 Traction of impacted canine using elastic from button in canine t...Fig. 20.12 Interproximal reduction can be performed on upper premolars to di...Fig. 20.13 With class II or class III elastics use, visualization will be sh...Fig. 20.14 From a ‘left 90 degrees view’ the sequential distalization is see...Fig. 20.15 Sequential distalization increases surface contact with molars on...Fig. 20.16 Effect of a coil spring opening space is similar to sequential di...Fig. 20.17 Effect of a coil spring opening space would lead to lack of torqu...Fig. 20.18 Effect of a coil spring opening space would lead to anterior proc...Fig. 20.19 Posterior Powerwings on aligner help advancing mandible on growin...Fig. 20.20 Class II profiles will benefit from this feature.Fig. 20.21 Class II, division 2 incisors need treatment sequence like this: ...Fig. 20.22 Class II, division 2 incisors need a treatment sequence such as: ...Fig. 20.23 Upper expansion leads to higher arch depth reduction and resolvin...Fig. 20.24 Clinchecks: a 45 degree upper molar derotation solves up to 1 mm ...Fig. 20.25 Intraoral views: a 45 degree upper molar derotation solves up to ...Fig. 20.26 Lower mesialization is represented in yellow, and results from th...Fig. 20.27 Biomechanics is the basis of an orthodontic treatment, regardless...Fig. 20.28 Distalization should start just after wisdom tooth extraction so ...Fig. 20.29 Growth has to be carefully checked before a mandibular advancemen...Fig. 20.30 Eruption compensator in a canine.Fig. 20.31 Any contact over 12 g will interrupt the tooth eruption.Fig. 20.32 Terminal molar tabs prevent molars supra‐eruption creating poster...Fig. 20.33 Initial intraoral view.Fig. 20.34 Pretreatment extraoral and intraoral views.Fig. 20.35 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.36 Intraoral situation after Herbst appliance. After the first phase...Fig. 20.37 Upper and lower ClinCheck views.Fig. 20.38 Comparison of initial (upper row) with final result (lower row)....Fig. 20.39 Initial (left) and final occlusal(right).Fig. 20.40 Initial (left) and final overjet (right).Fig. 20.41 Mandibular changes.Fig. 20.42 Changes in profile.Fig. 20.43 Initial smile (left), smile at the end of first phase (middle) an...Fig. 20.44 Initial and final lateral X‐rays.Fig. 20.45 Intraoral initial picture.Fig. 20.46 Initial extraoral and intraoral views.Fig. 20.47 Occlusal contact at the beginning of the treatment.Fig. 20.48 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.49 Initial upper and lower ClinCheck views.Fig. 20.50 Initial right and left ClinCheck views.Fig. 20.51 Initial frontal Clincheck view.Fig. 20.52 Goal of treatment: mandibular advancement into a bilateral class ...Fig. 20.53 Initial occlusion (upper), month 6 of evolution (middle), with al...Fig. 20.54 Mandibular advancement in the first six months of treatment.Fig. 20.55 New ClinCheck, asking to level the curve of Spee before continuin...Fig. 20.56 Aligner 17 of additional aligners using class II elastics.Fig. 20.57 Position of class II elastics (from lingual of upper first premol...Fig. 20.58 Situation at the end of mandibular advancement phase, before aski...Fig. 20.59 Comparison between initial (upper) and final occlusion (lower).Fig. 20.60 Final arch development.Fig. 20.61 Comparison initial and final overjet.Fig. 20.62 Comparison of initial and final smile.Fig. 20.63 Mandibular changes after 18 months of treatment.Fig. 20.64 Comparison in chin projection between initial, before additional ...Fig. 20.65 Final lateral X‐ray.Fig. 20.66 Initial intraoral view.Fig. 20.67 Pretreatment extraoral and intraoral views.Fig. 20.68 Lower skeletal asymmetry. Normal upper incisors exposure at rest ...Fig. 20.69 Initial panoramic X‐ray, teleradiograph and cephalometry. The AimFig. 20.70 Initial upper and lower ClinCheck views.Fig. 20.71 Lateral ClinCheck views.Fig. 20.72 Initial frontal Clincheck view.Fig. 20.73 Comparison between initial (upper) and final occlusion (lower).Fig. 20.74 Initial (left) and final occlusal (right).Fig. 20.75 Initial and final smile.Fig. 20.76 Panoramic and lateral X‐rays.Fig. 20.77 Initial intraoral view.Fig. 20.78 Pretreatment extraoral and intraoral views.Fig. 20.79 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.80 Initial upper and lower ClinCheck viewsFig. 20.81 Initial right and left ClinCheck views.Fig. 20.82 Initial front ClinCheck view.Fig. 20.83 Upper sequential distalization and lower sequential mesialization...Fig. 20.84 Comparison between initial (upper) and final (lower) occlusion.Fig. 20.85 Before (left) and after (right) lower occlusal views.Fig. 20.86 Initial and final smile and overjet.Fig. 20.87 Final panoramic and lateral X‐rays.Fig. 20.88 Initial intraoral view.Fig. 20.89 Pretreatment extraoral and intraoral views.Fig. 20.90 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.91 Upper and lower occlusal ClinCheck views.Fig. 20.92 Right and left ClinCheck views.Fig. 20.93 Front ClinCheck view.Fig. 20.94 Treatment interproximal reduction.Fig. 20.95 Sequential upper distalization pattern.Fig. 20.96 Before (upper) and after (lower) intraoral views.Fig. 20.97 Initial (left) and final (right) occlusal.Fig. 20.98 Initial and final smile and overjet.Fig. 20.99 Final panoramic and lateral X‐rays.Fig. 20.100 Initial intraoral view.Fig. 20.101 Pretreatment extraoral and intraoral views.Fig. 20.102 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.103 Superimposition, upper occlusal ClinCheck view.Fig. 20.104 Superimposition, lower occlusal ClinCheck view.Fig. 20.105 Biomechanics for simultaneous distalization.Fig. 20.106 Clincheck view.Fig. 20.107 Right and left ClinCheck views.Fig. 20.108 Initial views (upper), before additional aligners (middle) and f...Fig. 20.109 Before (left) and after (right) occlusal views.Fig. 20.110 Simultaneous distalization pattern.Fig. 20.111 Before and after treatment smile.Fig. 20.112 Final panoramic and lateral X‐rays.Fig. 20.113 Distalization from 3 to 7 in a row pattern.Fig. 20.114 Extraoral analysis: mandibular asymmetry.Fig. 20.115 Initial intraoral views.Fig. 20.116 Scissor bite on left side.Fig. 20.117 Scissor bite on left side.Fig. 20.118 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.119 ClinCheck upper occlusal view. Correct class II by simultaneous ...Fig. 20.120 ClinCheck lower occlusal view.Fig. 20.121 Interproximal reduction.Fig. 20.122 Lateral views: Class II elastics from upper 4 to lower 7.Fig. 20.123 Evolution after 13 months.Fig. 20.124 Rein horse to distalize upper molars from TADs in the tuberosity...Fig. 20.125 Evolution after 17 months.Fig. 20.126 Correction of scissor bite.Fig. 20.127 Initial (upper) and final occlusion (lower).Fig. 20.128 Before (left) and after (right) occlusal.Fig. 20.129 Comparison of before (left) and after smile (right).Fig. 20.130 Before (left) and after (right) profile.Fig. 20.131 Final panoramic and lateral X‐rays.Fig. 20.132 Simultaneous distalization from 5 to 5 pattern.Fig. 20.133 Pretreatment extraoral and intraoral views.Fig. 20.134 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.135 Initial upper and lower ClinCheck views.Fig. 20.136 Interproximal reduction from 33 to 43 to upright lower incisors....Fig. 20.137 Right and left ClinCheck views.Fig. 20.138 Intra‐arch Powerchain from upper canine to first molar to guide ...Fig. 20.139 Initial (upper) and final (lowe) intraoral views.Fig. 20.140 Occlusal before (left) and after (right) treatment.Fig. 20.141 Final occlusal contact.Fig. 20.142 Initial (left) and final smile (right).Fig. 20.143 Final panoramic and lateral X‐rays: maintenance of lower incisor...Fig. 20.144 Top jet appliance.Fig. 20.145 Pretreatment extraoral and intraoral views.Fig. 20.146 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.147 Distalization with top‐jet before Invisalign treatment.Fig. 20.148 Sequential distalization with class II elastics.Fig. 20.149 Upper and lower ClinCheck views.Fig. 20.150 Lateral ClinCheck views.Fig. 20.151 Comparison of initial (upper) and final (lower) intraoral views....Fig. 20.152 Initial (left) and final (right) occlusal.Fig. 20.153 Initial (right) and final overjet (left).Fig. 20.154 Initial and final smile.Fig. 20.155 Final panoramic and lateral X‐rays.Fig 20.156 Initial intraoral view.Fig 20.157 Deferred sequential distalization, in which some teeth move ‘alon...Fig. 20.158 Initial intraoral views (right, front, left, upper, lower). Pati...Fig. 20.159 Initial extraoral pictures and cephalometric analysis.Fig. 20.160 Initial Clinchecks.Fig. 20.161 Intraoral pictures at refinement.Fig. 20.162 Refinement Clinchecks.Fig. 20.163 Final: intraoral pictures showing improvement of the lower incis...Fig. 20.164 The cone beam computed tomography comparisons show how lower the...Fig. 20.165 Final comparison of lateral X‐rays.Fig. 20.166 Comparison of before and after smile.Fig. 20.167 Extraoral profile views.Fig. 20.168 Initial intraoral view.Fig. 20.169 Manual precision cut on 13 allows optimized attachment on this t...Fig. 20.170 Initial intraoral views (right, front, left, upper, lower).Fig. 20.171 Initial panoramic and lateral X‐rays.Fig. 20.172 Initial Clinchecks.Fig. 20.173 Refinement: initial intraoral views (right, front, left, upper, ...Fig. 20.174 Refinement Clinchecks.Fig. 20.175 Final intraoral views (right, front, left, lower, upper).Fig. 20.176 Final panoramic and lateral X‐rays.Fig. 20.177 Before and after smiles, before aesthetic anterior restoration....Fig. 20.178 Initial intraoral view.Fig. 20.179 Initial intraoral views (right, front, left, upper).Fig. 20.180 Initial intraoral models to check class II relationship before 1...Fig. 20.181 Pretreatment panoramic and lateral X‐rays and cephalometry.Fig. 20.182 Initial extraoral views.Fig. 20.183 Initial Clinchecks (right, front, left, upper, lower).Fig. 20.184 Intraoral refinement (right, front, left, upper, lower).Fig. 20.185 Refinement Clinchecks: right, front, left, upper, lower.Fig. 20.186 Final intraoral views: right, front, left, upper with tongue tam...Fig. 20.187 Before and after smile, showing improvement in upper incisor dis...Fig. 20.188 Final cephalometric measurements (before and after).Fig. 20.189 Final panoramic X‐ray.Fig. 20.190 Posterior interproximal reduction will help create space (before...Fig. 20.191 Posterior interproximal reduction might be up to 1 mm per contac...Fig. 20.192 Sequential lower distalization is meant to be predictable up to ...Fig. 20.193 In class III cases, anchorage is extremely important. The anchor...Fig. 20.194 Temporary implant supported crowns help create posterior anchora...Fig. 20.195 Initial intraoral view.Fig. 20.196 Pretreatment extraoral and intraoral views.Fig. 20.197 Implant placement on 47 before starting Invisalign treatment.Fig. 20.198 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.199 Initial front view.Fig. 20.200 Initial ClinCheck front view..Fig. 20.201 Initial occlusal contact.Fig. 20.202 Sagittal priority of movements to solve the anterior crossbite. ...Fig. 20.203 Upper and lower ClinCheck views.Fig. 20.204 Initial (upper), evolution (middle) and situation after 12 month...Fig. 20.205 Arch evolution after treatment for 12 months.Fig. 20.206 Right and left initial ClinCheck views.Fig. 20.207 Arch development after 12 months.Fig. 20.208 Initial and final overjet and smile.Fig. 20.209 Initial intraoral picture.Fig. 20.210 Pretreatment extraoral and intraoral views.Fig. 20.211 Initial X‐ray: panoramic, teleradiograph and cephalometry.Fig. 20.212 Interproximal reduction.Fig. 20.213 Simultaneous movement pattern.Fig. 20.214 Extrusion of 27 owing to missing 47.Fig. 20.215 Anterior cross bite of 12.Fig. 20.216 Initial superimposition, ClinCheck upper and lower occlusal view...Fig. 20.217 Comparison of initial (upper) and final occlusion (lower).Fig. 20.218 Comparison of initial (left) and final occlusal (right).Fig. 20.219 Initial and final smile.Fig. 20.220 Final panoramic and lateral X‐rays.Fig. 20.221 Initial intraoral view.Fig. 20.222 Initial intraoral views.Fig. 20.223 Initial extraoral views.Fig. 20.224 Initial cone beam computed tomography and panoramic X‐ray.Fig. 20.225 Initial lateral X‐ray and cephalometric analysis.Fig. 20.226 Initial ClinChecks.Fig. 20.227 Refinement: intraoral views.Fig. 20.228 Refinement: extraoral views.Fig. 20.229 Current intraoral views.Fig. 20.230 Current smile.Fig. 20.231 Current cephalometric measurements.Fig. 20.232 Cone beam computed tomography measurements, before and after tre...Fig. 20.233 Final smile.Fig. 20.234 Initial intraoral view.Fig. 20.235 Initial smile.Fig. 20.236 Initial panoramic and lateral X‐rays.Fig. 20.237 Refinement: initial views after 6 months, when the patient decid...Fig. 20.238 The palatal suture is broken with the same anaesthesia that that...Fig. 20.239 The palatal suture is broken with the same anaesthesia that will...Fig. 20.240 After 2 weeks, the 8 mm screw is fully opened. The palatal surfa...Fig. 20.241 Refinement ClinChecks.Fig. 20.242 Second refinement: intraoral views.Fig. 20.243 Second refinement Clinchecks.Fig. 20.244 Final Intraoral views.Fig. 20.245 Final smile.Fig. 20.246 Final cephalometric examination.Fig. 20.247 Final panoramic X‐ray.Fig. 20.248 Initial frontal intraoral view.Fig. 20.249 Initial intraoral views.Fig. 20.250 Initial panoramic and lateral and X‐rays and cephalometry.Fig. 20.251 Initial extraoral view.Fig. 20.252 Initial Clinchecks.Fig. 20.253 Refinement: intraoral views.Fig. 20.254 Refinement ClinChecks.Fig. 20.255 Extraoral view after refinement.Fig. 20.256 Final intraoral views.Fig. 20.257 Final smile.Fig. 20.258 Initial and post‐treatment cephalometric analysis.Fig. 20.259 Initial intraoral view.Fig. 20.260 Pretreatment extraoral and intraoral views.Fig. 20.261 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 20.262 Simultaneous distalization pattern in upper and lower arches.Fig. 20.263 Upper and lower ClinCheck views.Fig. 20.264 interproximal reduction necessary in order not to procline lower...Fig. 20.265 Lateral ClinCheck views.Fig. 20.266 Rein horse with Powerchain to temporary anchorage devices in the...Fig. 20.267 Simultaneous upper distalization using temporary anchorage devic...Fig. 20.268 Simultaneous lower distalization using temporary anchorage devic...Fig. 20.269 Initial occlusion (upper) and situation at month 17 of treatment...Fig. 20.270 Arch development in 23 months. Powerchain from first upper and l...Fig. 20.271 Pretreatment and final smile and overjet.Fig. 20.272 Final panoramic and lateral X‐rays.

18 Chapter 21Fig. 21.1 Vertical cause, excess posterior facial height.Fig. 21.2 Dentoalveolar cause (protrusion).Fig. 21.3 Transversal cause, lingual torque of posterior teeth.Fig. 21.4 The amount of lingual tipping of upper and lower incisors helps to...Fig. 21.5 Gummy smile.Fig. 21.6 Low smile, short display.Fig. 21.7 The facial lower third determines whether to intrude or not to int...Fig. 21.8 Anchorage attachments.Fig. 21.9 Chewies or fitters are good for minor open bite cases.Fig. 21.10 Miniscrews used for absolute posterior intrusion greater than 3 m...Fig. 21.11 Open bite requires careful biomechanics planning.Fig. 21.12 Optimized anterior extrusion is mostly predictable if it is plann...Fig. 21.13 Posterior intrusion will have saggital effects as a result of man...Fig. 21.14 We have to face predictability of vertical movements in order to ...Fig. 21.15 Single optimized attachment for extrusion.Fig. 21.16 Optimized anterior extrusion is mostly predictable if it is plann...Fig. 21.17 Posterior open bite is a good overcorrection in this case.Fig. 21.18 Unpredictable posterior intrusion is assisted by upper and lower ...Fig. 21.19 Open bite solved with LITE treatment.Fig. 21.20 Initial extraoral and intraoral views.Fig. 21.21 Initial occlusal contact.Fig. 21.22 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.23 Initial upper and lower ClinCheck views.Fig. 21.24 Initial right and left ClinCheck views.Fig. 21.25 Interproximal reduction necessary for relative extrusion of upper...Fig. 21.26 Initial intraoral views (upper) and views before refinement (lowe...Fig. 21.27 Final intraoral views.Fig. 21.28 Initial (left) and final occlusal (right).Fig. 21.29 Initial and final smile.Fig. 21.30 Final panoramic and lateral X‐rays.Fig. 21.31 Initial intraoral view.Fig. 21.32 Initial extraoral and intraoral views.Fig. 21.33 Panoramic X‐ray.Fig. 21.34 Teleradiograph: proclination of upper and lower incisors, narrow ...Fig. 21.35 Initial upper and lower ClinCheck views.Fig. 21.36 Interproximal reduction to create relative extrusion of incisors....Fig. 21.37 Palatal attachments prevent upper incisors from intrusion during ...Fig. 21.38 Initial right and left intraoral ClinCheck views.Fig. 21.39 Triangular elastics in class II. The technician was required to e...Fig. 21.40 reciprocal movement of anterior extrusion and posterior intrusion...Fig. 21.41 Sequential distalization.Fig. 21.42 Initial (upper) and final (lower) views.Fig. 21.43 Initial (left) and final occlusal (right).Fig. 21.44 Initial and final smiles and overjet.Fig. 21.45 Final panoramic and lateral X‐rays.Fig. 21.46 Initial intraoral view.Fig. 21.47 Initial extraoral and intraoral views.Fig. 21.48 Goal of treatment: close open bite by upper and lower distalizati...Fig. 21.49 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.50 Mechanics of simultaneous distalization from temporary anchorage ...Fig. 21.51 Temporary anchorage devices in left tuberosity failed. It was cha...Fig. 21.52 Mechanics with temporary anchorage device in the tuberosity.Fig. 21.53 Mechanics for upper and lower simultaneous distalization. Opening...Fig. 21.54 Simultaneous distalization of lower arch using temporary anchorag...Fig. 21.55 Initial views before refinement. Opening space for missing 13, up...Fig. 21.56 Final panoramic X‐ray, after placing the implant for 13 and remov...Fig. 21.57 Initial and final intraoral images with composite veneer for 13 i...Fig. 21.58 Initial (left) and final (right) occlusal (composite veneer in 13...Fig. 21.59 Initial and final smile. Correction of the open bite without crea...Fig. 21.60 Initial intraoral view.Fig. 21.61 Initial intraoral views: right, front, left, upper, lower.Fig. 21.62 Initial panoramic X‐ray.Fig. 21.63 Initial extraoral views.Fig. 21.64 Initial Clinchecks (right, front, left, upper, lower).Fig. 21.65 Refinement intraoral views (right, front, left, upper, lower).Fig. 21.66 Refinement Clinchecks: right, front, left, upper, lower.Fig. 21.67 Refinement: extraoral views.Fig. 21.68 Refinement: a third set of aligners was ordered for final settlem...Fig. 21.69 Lateral and panoramic X‐rays showing final situation, and wisdom ...Fig. 21.70 Final intraoral views (right, front, left, upper, lower).Fig. 21.71 Before and after smiles.Fig. 21.72 Initial intraoral view.Fig. 21.73 Initial intraoral views (right, front, left, upper, lower).Fig. 21.74 Initial smile: short incisor display required aesthetic improveme...Fig. 21.75 Initial panoramic and lateral X‐rays.Fig. 21.76 Initial Clinchecks (right, front, left, upper and lower).Fig. 21.77 Refinement: intraoral views (right, front, left, upper and lower)...Fig. 21.78 Refinement Clinchecks (right, front, left, upper and lower).Fig. 21.79 Final intraoral views (right, front, left, upper with tongue tame...Fig. 21.80 Smile before and after treatment.Fig. 21.81 Final lateral X‐rays.Fig. 21.82 Initial intraoral view.Fig. 21.83 TheOrthopulse device was used by the patient to accelerate treatm...Fig. 21.84 Initial set of intraoral views (right, front, left, upper and low...Fig. 21.85 Initial panoramic and lateral X‐rays and cephalometric measuremen...Fig. 21.86 Initial extraoral views.Fig. 21.87 Initial ClinChecks (right, front, left, upper and lower) with vir...Fig. 21.88 Refinement: intraoral views (right, front, left, upper and lower)...Fig. 21.89 Refinement: lateral and panoramic X‐rays.Fig. 21.90 Refinement: profile and smile.Fig. 21.91 Refinement ClinChecks (right, front, left, upper and lower).Fig. 21.92 Current intraoral views (right, front, left, upper and lower).Fig. 21.93 Current lateral and panoramic X‐rays and cephalometry.Fig. 21.94 Final smile.Fig. 21.95 Predictability of vertical movements is important in order to pla...Fig. 21.96 Optimized pressure areas help intruding anterior teeth by combini...Fig. 21.97 Optimized extrusion attachments on premolars create a counterforc...Fig. 21.98 Precision bite ramps are designed to dissoclude posterior sectors...Fig. 21.99 Optimized support attachments are designed to help intruding uppe...Fig. 21.100 Patient with a gummy smile and deep bite. Expand + procline inci...Fig. 21.101 This patient (before and after views) presented low smile with d...Fig. 21.102 When anterior torque is negative relative intrusion might be eas...Fig. 21.103 When pure intrusion is needed, interproximal reduction will help...Fig. 21.104 Incisors protocol in deep bite is: procline crown, intrude, then...Fig. 21.105 Anterior temporary anchorage devices will help with this case.Fig. 21.106 Suggested torque for upper (+17 degrees) and lower incisor (–1 d...Fig. 21.107 Hypercorrection of the curve of Spee usually creates an open bit...Fig. 21.108 A single buccal or palatal power ridge (left and middle) creates...Fig. 21.109 Posterior extrusion might be achieved with optimized extrusion a...Fig. 21.110 Initial intraoral view.Fig. 21.111 Initial extraoral and intraoral views.Fig. 21.112 Initial panoramic and lateral X‐rays and cephalometry.Fig. 21.113 Initial occlusal upper and lower superimposition ClinCheck views...Fig. 21.114 Initial right and left ClinCheck views.Fig. 21.115 Interproximal reduction.Fig. 21.116 Initial (upper) and final intraoral views (lower).Fig. 21.117 Initial (left) and final occlusal (right).Fig. 21.118 Final panoramic and lateral X‐rays.Fig. 21.119 Initial intraoral view.Fig. 21.120 Initial extraoral and intraoral views.Fig. 21.121 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.122 Initial upper and lower ClinCheck views.Fig. 21.123 Initial right and left ClinCheck views.Fig. 21.124 On the additional aligners set, distal tipping of the crown in 3...Fig. 21.125 Evolution in last aligner before refinement.Fig. 21.126 Initial (upper) and final (lower) intraoral views.Fig. 21.127 Initial (left) and final (right) occlusals.Fig. 21.128 Before and after smile.Fig. 21.129 Final panoramic and lateral X‐rays.Fig. 21.130 Initial intraoral view.Fig. 21.131 Initial extraoral and intraoral views.Fig. 21.132 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.133 Initial upper occlusal superimposition ClinCheck view.Fig. 21.134 Initial lower occlusal superimposition ClinCheck view.Fig. 21.135 Initial right and left ClinCheck view.Fig. 21.136 Initial front ClinCheck view with interproximal reduction.Fig. 21.137 Initial views (upper) and evolution after 12 months (lower).Fig. 21.138 Final intraoral views.Fig. 21.139 Initial (left) and final occlusal (right).Fig. 21.140 Occlusal contact point at the end of the treatment.Fig. 21.141 Initial and final smile.Fig. 21.142 Final panoramic and lateral X‐rays.Fig. 21.143 Initial intraoral view.Fig. 21.144 Initial extraoral and intraoral views.Fig. 21.145 Initial occlusal contact.Fig. 21.146 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 21.147 Initial upper occlusal superimposition ClinCheck view.Fig. 21.148 Initial lower occlusal superimposition ClinCheck view.Fig. 21.149 Interproximal reduction is only needed mesial and distal to 22 t...Fig. 21.150 Initial right and left ClinCheck view.Fig. 21.151 Temporary anchorage devices to provide enough posterior anchorag...Fig. 21.152 Evolution at the end of additional aligners. Intermaxillary elas...Fig. 21.153 Initial (upper) and final (lower) intraoral views.Fig. 21.154 Initial left) and final (right) occlusal.Fig. 21.155 Initial and final overjet and final correction of the deep bite....Fig. 21.156 Initial and final smile.Fig. 21.157 Final panoramic and lateral X‐rays with an appropriate inclinati...Fig. 21.158 Initial intraoral view.Fig. 21.159 Initial intraoral pictures (right, front, left, upper and lower)...Fig. 21.160 Initial panoramic and lateral X‐rays.Fig. 21.161 Initial smile.Fig. 21.162 Initial Clinchecks (right, front, left, upper and lower).Fig. 21.163 Refinement 1: intraoral views (right, front, left, upper and low...Fig. 21.164 Refinement 1 Clinchecks (right, front, left, upper and lower). A...Fig. 21.165 Refinement 2 (aligner): st the end of first refinement, the alig...Fig. 21.166 Refinement 2 (aligner: right, front, left, upper and lower). Ali...Fig. 21.167 Refinement 2 ClinChecks (right, front, left, upper and lower). A...Fig. 21.168 Final intraoral pictures: right, front, left, upper and lower. D...Fig. 21.169 The smile has widened but still gummy, as initially predicted.

19 Chapter 22Fig. 22.1 Asymmetries can be managed with specific aligner biomechanics.Fig. 22.2 Initial view.Fig. 22.3 Class II subdivision right, deviation of both midlines equal to th...Fig. 22.4 Pretreatment intraoral views.Fig. 22.5 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 22.6 Initial frontal Clincheck view.Fig. 22.7 Upper and lower ClinCheck archshape changes and instructions to CA...Fig. 22.8 Upper and lower CC superimposition and instructions to CAD designe...Fig. 22.9 Lateral ClinCheck views.Fig. 22.10 Final intraoral views.Fig. 22.11 Initial and final smile and overjet.Fig. 22.12 Final panoramic and lateral X‐rays.Fig. 22.13 Initial intraoral view.Fig. 22.14 Pretreatment extraoral and intraoral views.Fig. 22.15 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 22.16 Upper and lower CC superimposition and instructions to CAD design...Fig. 22.17 Lateral ClinCheck views.Fig. 22.18 Initial frontal Clincheck view.Fig. 22.19 Intermaxillary elastics to correct asymmetric mandibular growth. ...Fig. 22.20 Final occlusion.Fig. 22.21 Initial and final smile.Fig. 22.22 Final panoramic and lateral X‐ray.Fig. 22.23 Patient with maxillomandibular asymmetry.Fig. 22.24 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 22.25 Pretreatment extraoral views.Fig. 22.26 Occlusion in centric occlusion (CO).Fig. 22.27 Occlusion in centric relation (CR). In this situation, photograph...Fig. 22.28 iTero occlusion analysis.Fig. 22.29 The goal of treatment is asymmetric expansion of the maxilla to c...Fig. 22.30 A temporary anchorage device on the tuberosity will assist the mo...Fig. 22.31 Lower arch molar straightening will be assisted with a Lower arch...Fig. 22.32 Occlusal ClinCheck views.Fig. 22.33 Lateral ClinCheck views.Fig. 22.34 Frontal ClinCheck view.Fig. 22.35 Interproximal reduction.Fig. 22.36 Evolution in the occlusal contact.Fig. 22.37 Arch development.Fig. 22.38 Initial (upper) views and evolution at month 18 of treatment (low...Fig. 22.39 Initial (upper), after Invisalign and before prothesis (middle) a...Fig. 22.40 Final occlusal.Fig. 22.41 Comparison of initial and final smile and overjet.Fig. 22.42 Final panoramic and lateral X‐rays.Fig. 22.43 Initial intraoral view.Fig. 22.44 Pre‐treatment extraoral and intraoral views.Fig. 22.45 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 22.46 Lateral sectional wire applied based on a temporary achorage devi...Fig. 22.47 Lateral ClinCheck views showing forces applied.Fig. 22.48 Lateral ClinCheck view showing forces applied with the temporary ...Fig. 22.49 Upper ClinCheck view superimposition.Fig. 22.50 Lower ClinCheck view superimposition.Fig. 22.51 Second set of aligners. Frontal ClinCheck view.Fig. 22.52 Second set of aligners. Lateral ClinCheck views.Fig. 22.53 Second set of aligners. Frontal ClinCheck view.Fig. 22.54 Initial occlusion.Fig. 22.55 Evolution at 3 months with sectional wire to anchor 36 and 46 to ...Fig. 22.56 When the lower incisors are in their final position, mesialize pr...Fig. 22.57 Completing mesialization of second lower molar.Fig. 22.58 Settle the occlusion with elastics.Fig. 22.59 Initial (upper) and final occlusion (lower) views. The full class...Fig. 22.60 Initial (left) and final (right) occlusal.Fig. 22.61 Initial, smile in 22 months and final smile.Fig. 22.62 Initial and final overjet (right and left side).Fig. 22.63 Initial intraoral view.Fig. 22.64 Initial intraoral views.Fig. 22.65 Initial extraoral views.Fig. 22.66 Initial lateral and panoramic X‐ray and cephalometric analysis.Fig. 22.67 Initial Clinchecks: the left side should be in a Class II relatio...Fig. 22.68 After 10 months of treatment, the intraoral situation was good, b...Fig. 22.69 Extraoral view after 10 months.Fig. 22.70 After 10 months, the ClinCheck had vertical overcorrection and vi...Fig. 22.71 Current views after 20 months of treatment, but expected at 24 mo...Fig. 22.72 Pretreatment and current X‐rays.Fig. 22.73 Extraoral pictures after treatment.

20 Chapter 23Fig. 23.1 First premolar extraction, G6 protocol.Fig. 23.2 Lower incisor extraction, with vertical attachments on the remaini...Fig. 23.3 Powerchain helps close final spacing.Fig. 23.4 Perfect root parallelism after tooth extraction commonly needs the...Fig. 23.5 Initial intraoral view.Fig. 23.6 Pretreatment extraoral and intraoral views.Fig. 23.7 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 23.8 Upper and lower CC superimposition and instructions to CAD designe...Fig. 23.9 Attachments can be seen in several areas of the ClinCheck software...Fig. 23.10 Lateral ClinCheck views.Fig. 23.11 Intraoral view.Fig. 23.12 Initial (upper)and final (lower) views.Fig. 23.13 Initial and final occlusal.Fig. 23.14 Initial and final smile.Fig. 23.15 Final panoramic and lateral X‐rays: good final parallelism betwee...Fig. 23.16 Initial intraoral view.Fig. 23.17 Initial extraoral and intraoral views.Fig. 23.18 Occlusal contact at the beginning of the treatment.Fig. 23.19 Periodontal bone loss in upper incisors.Fig. 23.20 Initial teleradiograph and cephalometry.Fig. 23.21 Upper occlusal interproximal reduction to avoid excessive proclin...Fig. 23.22 Pontic for extracted 42. Bevelled attachment on lateral incisors ...Fig. 23.23 Interproximal reduction of upper arch and lower incisor extractio...Fig. 23.24 Lateral ClinCheck views.Fig. 23.25 Initial (upper) and evolution 11 months of treatment (lower).Fig. 23.26 Finishing refinement. Posterior elastic is used to settle the occ...Fig. 23.27 Initial (upper) and final occlusion (lower). Adequate parallelism...Fig. 23.28 Occlusal contact point at the end of the treatment.Fig. 23.29 Initial and final occlusal.Fig. 23.30 Initial and final smile and overjet.Fig. 23.31 Final panoramic and lateral X‐rays.Fig. 23.32 The canine and second premolar in this picture would be ideal for...Fig. 23.33 Extraction of first premolars, absolute anchorage: 0 mm posterior...Fig. 23.34 Extraction of first premolars, maximum anchorage: 0–2 mm posterio...Fig. 23.35 G6 protocol is considered a full system for space closure, theref...Fig. 23.36 Moderate anchorage protocol will start with canine and posterior ...Fig. 23.37 Moderate anchorage protocol will start with canine and second pre...Fig. 23.38 A popular pattern in Asia for extraction space closure.Fig. 23.39 The selection of bonding hooks or buttons has to be carefully pla...Fig. 23.40 Extraction of 5s with minimum anchorage.Fig. 23.41 With the double vertical attachment in molars the intrusion of th...Fig. 23.42 With the Powerarm attachment in molars at the final aligners we c...Fig. 23.43 Staggered technique for second premolar extraction.Fig. 23.44 Staggered technique for first molars extraction.Fig. 23.45 Retroclined incisors might mean increased overbite and need root ...Fig. 23.46 Powerarms are great auxiliaries in achieving root parallelism.Fig. 23.47 Undesired effects of brackets and wires are quite similar to the ...Fig. 23.48 Absolute anchorage with temporary anchorage devices.Fig. 23.49 Pretreatment extraoral and intraoral views.Fig. 23.50 Initial panoramic and lateral X‐rays, and cephalometry.Fig. 23.51 Upper CC superimposition and instructions to CAD designer.Fig. 23.52 Lower CC superimposition and instructions to CAD designer.Fig. 23.53 Lateral Clinchecks.Fig. 23.54 Front ClinCheck view in which we can check deep bite and midline ...Fig. 23.55 Asymmetry is clear from both a vertical and saggital perspective....Fig. 23.56 Pure intrusion of lower incisors from TADs (right, front and left...Fig. 23.57 Treatment evolution.Fig. 23.58 Evolution with aligners. Initial (left) and evolution at 3 months...Fig. 23.59 Posterior teeth have distal root tipping movement planned.Fig. 23.60 TADs are included in the doctor’s treatment plan with these diagr...Fig. 23.61 Initial frontal view.Fig. 23.62 Initial intraoral views.Fig. 23.63 Initial extraoral views.Fig. 23.64 Initial Clinchecks.Fig. 23.65 Refinement: intraoral views after first set of aligners.Fig. 23.66 Refinement: extraoral views after first set of aligners.Fig. 23.67 Refinement Clinchecks.Fig. 23.68 Intraoral views of smile at the end of treatment.Fig. 23.69 Final panoramic X‐ray to check final root paralellism between 13 ...Fig. 23.70 initial frontal view.Fig. 23.71 Initial intraoral views.Fig. 23.72 Initial extraoral views.Fig. 23.73 Initial teleradiograph, and lateral and panoramic X‐rays.Fig. 23.74 Initial Clinchecks.Fig. 23.75 Refinement: intraoral views showing exact position predicted on C...Fig. 23.76 Refinement: Clinchecks showing space mesial to 18.Fig. 23.77 Second refinement: intraoral pictures after two sets of aligners....Fig. 23.78 Second refinement: smile after two sets of aligners.Fig. 23.79 Second refinement: extraoral views after two sets of aligners.Fig. 23.80 Refinement: Clinchecks showing final vertical engagement.Fig. 23.81 Intraoral views after treatment.Fig. 23.82 Final teleradiograph and panoramic X‐ray showing improvement in p...Fig. 23.83 Current extraoral pictures.Fig. 23.84 Initial frontal view.Fig. 23.85 Initial Intraoral views.Fig. 23.86 Initial panoramic X‐ray and teleradiograph.Fig. 23.87 Initial smile.Fig. 23.88 Initial Clincheck with posterior spacing.Fig. 23.89 Refinement: Clincheck with posterior residual spacing, it can be ...Fig. 23.90 Refinement: the midline has been centred and exposure increased; ...Fig. 23.91 Refinement Clinchecks.Fig. 23.92 Second refinement: intraoral views.Fig. 23.93 Second refinement: space distal to 17 can be observed on the pano...Fig. 23.94 Second refinement: space distal to 17 can be observed, as well as...Fig. 23.95 Second refinement Clinchecks.Fig. 23.96 Intraoral views with Powerarms to straighten roots for 13 and 15 ...Fig. 23.97 Current intraoral views pending 5 aligners to the end of treatmen...Fig. 23.98 Initial and final lateral and panoramic X‐ray showing profile cha...Fig. 23.99 Comparison of pretreatment and final smiles.Fig. 23.100 Initial frontal view.Fig. 23.101 Initial intraoral situation.Fig. 23.102 Initial extraoral views.Fig. 23.103 Initial lateral and panoramic X‐rays and cephalometric analysis....Fig. 23.104 Initial Clinchecks.Fig. 23.105 Intraoral views when anterior misfitting was detected.Fig. 23.106 Refinement: intraoral views.Fig. 23.107 Refinement Clincheck.Fig. 23.108 Refinement: extraoral views.Fig. 23.109 A Powerchain was used to reduce rotations resulting from a lack ...Fig. 23.110 Space distribution equal to final ClinCheck position, and patien...Fig. 23.111 Lateral and panoramic X‐rays taken before aesthetic restoration....Fig. 23.112 Current extraoral views.Fig. 23.113 Smile before and after treatment.Fig. 23.114 Initial frontal view.Fig. 23.115 Initial intraoral views.Fig. 23.116 Initial extraoral views.Fig. 23.117 Initial ClinChecks.Fig. 23.118 Refinement: intraoral situation after first set of aligners.Fig. 23.119 Refinement: initial extraoral views.Fig. 23.120 Final views with veneers bonded (aesthetic treatment performed b...Fig. 23.121 Views at start and after refinement with veneers.Fig. 23.122 Final cephalometric measurements.

21 Chapter 24Fig. 24.1 Initial intraoral view.Fig. 24.2 Pretreatment extraoral and intraoral views.Fig. 24.3 Initial: teleradiograph, cephalometry and panoramic X‐rays.Fig. 24.4 Initial occlusal contact point.Fig. 24.5 Occlusal ClinCheck views.Fig. 24.6 Lateral ClinCheck views.Fig. 24.7 Interproximal reduction was not planned in the ClinCheck, but was ...Fig. 24.8 Initial frontal Clincheck view.Fig. 24.9 Situation before additional aligners. Results after the first set ...Fig. 24.10 Initial (upper) and final (lower) occlusion. Final result after r...Fig. 24.11 Initial (left) and final (right) occlusals.Fig. 24.12 Initial and final smile.Fig. 24.13 Final panoramic and lateral X‐rays.Fig. 24.14 Initial intraoral view.Fig. 24.15 Pretreatment extraoral and intraoral views.Fig. 24.16 Initial occlusal contact.Fig. 24.17 Panoramic and lateral X‐rays. Cephalometric analysis.Fig. 24.18 Opening space for missing 23.Fig. 24.19 interproximal reduction 3 to 3 to allow lower incisors retraction...Fig. 24.20 Initial lateral ClinCheck views.Fig. 24.21 Powerarm to make roots of 25 and 24 closer.Fig. 24.22 Evolution at 12 months.Fig. 24.23 Evolution after using additional aligners.Fig. 24.24 Final views with implant for 13.Fig. 24.25 Initial (left) and final (right) occlusal.Fig. 24.26 Initial and final overjet.Fig. 24.27 Evolution of the patient’s smile (from left): initial, before add...Fig. 24.28 Final panoramic X‐ray with implant for 23.Fig. 24.29 Final teleradiograph with overjet corrected.Fig. 24.30 Initial left intraoral view.Fig. 24.31 Pretreatment extraoral views.Fig. 24.32 Pretreatment intraoral views.Fig. 24.33 Initial panoramic X‐ray, teleradiograph and cephalometry.Fig. 24.34 Initial views and views after placing provisional crowns over the...Fig. 24.35 Initial occlusal ClinCheck views.Fig. 24.36 Initial lateral ClinCheck views.Fig. 24.37 Initial front ClinCheck view.Fig. 24.38 Biomechanics applied to the treatment plan.Fig. 24.39 Initial (upper) and final (lower) views: the incisal edges were r...Fig. 24.40 Initial (left) and final occlusal (right).Fig. 24.41 Initial and final panoramic X‐rays: levelling of the occlusal pla...Fig. 24.42 Initial and final smile.Fig. 24.43 Initial frontal intraoral view.Fig. 24.44 Initial extraoral and intraoral views.Fig. 24.45 Initial panoramic X‐ray, teleradiograph and cephalometry: upper m...Fig. 24.46 Mock up to estimate vertical dimension.Fig. 24.47 These are the intraoral views when the case was sent to Align Tec...Fig. 24.48 Initial upper ClinCheck.Fig. 24.49 Initial lower ClinCheck.Fig. 24.50 Initial lateral ClinChecks.Fig. 24.51 Initial frontal Clincheck.Fig. 24.52 class II elastic from upper canine to lower first molar (night us...Fig. 24.53 Initial and final occlusion.Fig. 24.54 Final panoramic and lateral X‐rays.Fig. 24.55 Comparison of initial and final smile and overjet.Fig. 24.56 Simulation of force vectors applied by a Locatelli spring.Fig. 24.57 Locatelli to open space for implanting 35 and 45.Fig. 24.58 Distalization of molars from temporary anchorage devices and mesi...Fig. 24.59 The sequence of opening space for implants of 35 and 45, helping ...Fig. 24.60 Initial intraoral view.Fig. 24.61 Pretreatment intraoral views.Fig. 24.62 X‐ray analysis (panoramic, teleradiograph and cephalometry): norm...Fig. 24.63 Initial occlusal, upper and lower ClinCheck views.Fig. 24.64 Initial left and right ClinCheck views.Fig. 24.65 Initial front ClinCheck view.Fig. 24.66 Intraoral views: right, upper, lower with the Locatelli and the a...Fig. 24.67 Intraoral views: right, front, left with the Locatelli.Fig. 24.68 Intraoral views at the beginning and after placing the implants....Fig. 24.69 Intraoral views after loading implants.Fig. 24.70 Intraoral views before and after treatment (upper and lower occlu...Fig. 24.71 Comparison of smile and overjet before and after treatment.Fig. 24.72 Final panoramic and lateral X‐ray.Fig. 24.73 Skeletal Class I with spacing.Fig. 24.74 Extra palatal root torque to anterior sector, selecting multiple ...Fig. 24.75 Initial intraoral views.Fig. 24.76 Initial Clinchecks.Fig. 24.77 Refinement: after first set of aligners, gingivectomy was perform...Fig. 24.78 Refinement: intraoral images taken before scanning for additional...Fig. 24.79 Refinement: extraoral views.Fig. 24.80 Refinement ClinChecks.Fig. 24.81 Intraoral views and smile at the end of treatment.Fig. 24.82 Intraoral view.Fig. 24.83 Initial intraoral views.Fig. 24.84 Initial panoramic and lateral X‐rays.Fig. 24.85 Initial Clinchecks.Fig. 24.86 Final Intraoral views.Fig. 24.87 Pretreatment and final smile.Fig. 24.88 Final: anterior intrusion is visible on comparison of panoramic X...Fig. 24.89 Intraoral view.Fig. 24.90 Initial cephalometric measurements.Fig. 24.91 Initial intraoral views.Fig. 24.92 Initial Clinchecks.Fig. 24.93 Refinement: intraoral views.Fig. 24.94 Refinement: change of scan to include molars and increased anchor...Fig. 24.95 Refinement Clinchecks.Fig. 24.96 Final intraoral views.Fig. 24.97 Final smile.

22 Chapter 25Fig. 25.1 Aesthetic protocol for veneers preparation with aligners.Fig. 25.2 Anterior teeth width has to be determined carefully in order to en...Fig. 25.3 This bilateral full Class II case has an abnormal 11 size and shap...Fig. 25.4 Auxiliary buttons and Powerchains are used to help with a severe 9...Fig. 25.5 Mesial and distal spacing is planned at the end of the case for a ...Fig. 25.6 The left image is complex if we have to create anterior spacing fo...Fig. 25.7 Transverse space planning is made with protrusion, leaving 0.2 mm ...Fig. 25.8 After no space‐making mesial or distal to affected toot, transvers...Fig. 25.9 After 1.3 mm space planning, this only happens in the lateral with...Fig. 25.10 After attachment and threefold overcorrection, nonpredictable ant...Fig. 25.11 Align’s overjet concept might be different from the one the pract...Fig. 25.12 Natural arch depth loss owing to large posterior expansions has t...Fig. 25.13 In this patient, if 11 is in a proper incisal position we might p...Fig. 25.14 Incisors and canines have usually higher gingival margins than la...Fig. 25.15 This spacing is an example of how final gingivectomy might help i...Fig. 25.16 Incisors and usually canines have higher gingival margins than la...Fig. 25.17 This patient had a selective whitening treatment, focusing more o...Fig. 25.18 Patients habits, included smoking and drinking coffee on a daily ...Fig. 25.19 Bolton discrepancy in upper incisors as well as a maxillary skele...Fig. 25.20 Initial intraoral views.Fig. 25.21 Initial extraoral pictures.Fig. 25.22 Initial lateral and panoramicX‐rays.Fig. 25.23 Initial Clinchecks.Fig. 25.24 MARPE: the design was made considering that aligners would be tri...Fig. 25.25 MARPE: iTero software occlusal analysis.Fig. 25.26 Cone beam computed tomography and panoramic X‐ray and after MARPE...Fig. 25.27 Refinement: after 11 months the patient had the MARPE removed. Th...Fig. 25.28 Refinement Clinchecks.Fig. 25.29 Intraoral and extraoral views of smile before and after treatment...Fig. 25.30 Intraoral views before and after treatment.Fig. 25.31 Final extraoral views.Fig. 25.32 Final panoramic and lateral X‐rays.Fig. 25.33 Initial and final cephalometric analysis.Fig. 25.34 Previous cantilever bridge provided smile aesthetics that were un...Fig. 25.35 The Bolton tool was used to set space neededFig. 25.36 Initial intraoral views.Fig. 25.37 Initial Clinchecks.Fig. 25.38 Initial smile.Fig. 25.39 Refinement: intraoral views.Fig. 25.40 Refinement Clinchecks.Fig. 25.41 Final intraoral views before fitting veneers.Fig. 25.42 Final X‐ray views.Fig. 25.43 Change in smile after ceramic restoration (Dr Ignacio Vázquez Nat...Fig. 25.44 Tooth wear on anterior teeth led to severe attrition of 11–21.Fig. 25.45 Initial intraoral views.Fig. 25.46 Initial lateral and panoramic X‐rays and cephalometric analysis....Fig. 25.47 Initial Clinchecks.Fig. 25.48 Final intraoral views.Fig. 25.49 Final panoramic and lateral X‐rays.Fig. 25.50 Final smile after veneer bonding (work performed by Dr Ignacio Va...Fig. 25.51 Patient wanted to improve smile aesthetics with veneers, for whic...Fig. 25.52 Lower/upper cone beam computed tomography.Fig. 25.53 Bolton analysis showed possibility for lower premolar interproxim...Fig. 25.54 Initial intraoral views.Fig. 25.55 Initial cephalometric analysis.Fig. 25.56 Initial ClinChecks.Fig. 25.57 Refinement: the second Clincheck showed change from edge‐to‐edge ...Fig. 25.58 Refinement: intraoral views and cone beam computed tomography bon...Fig. 25.59 Good final results were achieved thanks to detailed multidiscipli...Fig. 25.60 Final extraoral views.

Guide

1  Cover Page

2  Title Page

3  Copyright Page

4  Preface

5  About the Authors

6  Acknowledgements

7  About the Companion Website

8  Table of Contents

9  Begin Reading

10  Index

11  WILEY END USER LICENSE AGREEMENT

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Aligner Techniques in Orthodontics

Susana Palma Moya Javier Lozano Zafra

This edition first published 2021

© 2021 by John Wiley & Sons Ltd

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions.

The right of Susana Palma Moya and Javier Lozano Zafra to be identified as the authors of this work has been asserted in accordance with law.

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Library of Congress Cataloging‐in‐Publication Data

Names: Lozano Zafra, Javier, author. | Palma Moya, Susana, author.

Title: Aligner techniques in orthodontics / Javier Lozano Zafra, Dr Susana Palma Moya.

Description: Hoboken, NJ : Wiley‐Blackwell, 2020.

Identifiers: LCCN 2020024180 (print) | LCCN 2020024181 (ebook) | ISBN 9781119607229 (paperback) | ISBN 9781119607212 (adobe pdf) | ISBN 9781119607236 (epub)

Subjects: MESH: Malocclusion–therapy | Orthodontics, Corrective–methods | Orthodontic Appliance Design–methods

Classification: LCC RK523 (print) | LCC RK523 (ebook) | NLM WU 440 | DDC 617.6/43–dc23

LC record available at https://lccn.loc.gov/2020024180 LC ebook record available at https://lccn.loc.gov/2020024181

Cover Design: Wiley

Cover Image: Courtesy of Javier Lozano Zafra

Preface

I started to work with aligners in 2001 and immediatly I realized that they had a huge potential. It was easy for me to get familiar with the whole idea because I used to work with dental positioners at that time. In contrast, most of my colleagues were quite skeptical and did not consider aligners as a real orthodontic system.

Reviewing the literature we can see how the possibilities of the aligners have increased over the years. In 2001, there were limited tools available to solve mild crowded Class I malocclusions; however, several years after, we started to speak about extraction cases, Class II malocclusions, and open bites, which were treated more successfully each time. This situation was due to two factors: on the one hand, the continuous feedback the manufacturers use to make constant improvements, and on the other hand, the tremendous effort by many orthdontists who have been triyng to understand and explain what we call “the plastic biomechanics.” Therefore, the perception of using the aligners as an effective orthodontic method is improving due to the irrefutable fact that the results are getting better and better and, in many cases, they overtake the outcomes achieved by conventional orthodontics.

We are only beginning to understand how the aligners move teeth, and the learning curve is slower than we thought. Those are the reasons why their effectiveness is indisputably attached to academic training and experience. The professionals with greater knowledge and greater number of treated cases will achieve better results. This is no surprise as this is what happens when a new technique is introduced.

For all these reasons, as professionals, we are the ones who still establish our treatment goals. Aesthetics and the patient’s comfort should not conflict with the quality of the treatment results. This means that in quite a few situations, we need to use auxiliary techniques to complement the aligners deficiencies. It also means on the part of the practitioner a greater effort and dedication than usual to the occlusal and functional treatment finishing, and especially to training. I understand that leaving the comfort zone is not easy for those who have been treating patients the same way their whole life. This is where Dr. Palma and Dr. Lozano are absolutely exactly correct. This book fills a gap in our interpretation of the orthodontic movement with aligners. It offers a great number of essential keys to the understanding of the aligners biomechanics. It is the right publication at the right moment, with guides to treat different malocclusions with confidence, predictability, and quality. Following their solid biomechanics knowledge and experience‐based advice, the reader will be introduced to the treatment of more and more difficult cases, always keeping the traditional occlusal standards.

The book covers all the different malocclusions from the easiest mild crowding cases to the complex pre‐prosthetic treatments. It is written like an atlas, with specific cases fully explained step by step. The reader will also find an innovative and attractive video format of each treatment. For all these reasons, this book is a wonderful and easy tool for references suitable for beginners, but also for orthodontists well trained in aligners. Moreover, for the skeptical ones, the book, at least, will peak their curiosity. Is it really possible to perform a good quality orthodontics with aligners? This book will provide answers, and without doubt, many arguments for discussion.

We are at the beginning of a new technique. Previous and complete case planification through a powerful software has radically changed the way we work. This means we have to go back to school, but we have never had so many possibilities to train ourselves like today. In this way, the professional is able to become as competent as he or she wishes. However, it seems that some things never change; and I do not just mean the huge reluctance to accept new concepts or techniques (that is really frequent in our profession), I also mean the small percentage of people such as Dr. Palma and Dr. Lozano, whose great desire for self‐improvement and progress gives as a result the finding of new knowledge. The knowledge that they generously share serves as an example and guide for many people.

Dr. Arturo Vela Hernandez

About the Authors

Dr Susana Palma Moya is an Orthodontist running a private practice in Ciudad Real, Spain. She obtained her postgraduate degree in Orthodontics and PhD in Dentofacial Orthopaedic and Orthodontics from the University of Madrid in 2002.

 Was among the first group of Spanish Invisalign Providers in 2001.

 International Invisalign Speaker since 2015.

 Assistant professor for the postgraduate's program in orthodontics at U.C.M University in Madrid from 2003 to 2007, and currently teaching orthodontics at Salamanca University.

 University degree in Orthodontics with Surfery from the International University of Cataluña UIC 2007

 University degree in lingual Orthodontics by Valencia University 2009‐ 2011

 Invisalign peer award 2015 (first international Award) and Invisalign peer award 2017(second European Award).

 Member of the EMEA teen global group and member of Ortodoncis group in Spain

 Invisalign Diamond II practitioner since 2015 and lectured in Invisalign treatment throughout Spain and Europe.

Dr Javier Lozano Zafra is an Orthodontist running a private practice in Murcia, Spain.

 Degree in Dentistry, Murcia University

 PhD, Murcia University

 Postgraduate programme in Orthodontics, San Pablo CEU University

 Honorary lecturer, Seville University, Spain

 Invisalign International Speaker

 Invisalign Diamond Practitioner

 Honorary Member of the French Society of Aligners

 Member of the Invisalign TEEN global group and member of Ortodoncis group in Spain

Acknowledgements

My thanks must go first to my husband Paco who has worked just as much as I on the preparation of this book. He has worked tirelessly in gathering together the evidence from videos and other photographic material required. I also want to thank him for his love and understanding which have given me the inspiration and strength to write it.

To my children Marta and Paco for the time I have stolen from them and the continuous inspiration and strength they provide to enable me to get the best from myself: thank you.

To my parents, Mercedes and Paco, whose love and effort encouraged me to become an orthodontist and who have been pillars of strength throughout my life.

To Align Technology for believing in me and giving me the opportunity to share my orthodontic experience with other practitioners from 2015 onwards.

I also want to thank all my orthodontics team, because without them we could not get the results we see today, which we are able to demonstrate in the book.

I want to thank my good friend and partner, Dr Javier Lozano, not only because it has been a pleasure sharing our time working on making the book (and ultimately helping many students master the aligner technique in Aligners Academy), but also because his friendship has led to a tipping point in my life.

And finally, my thanks go to the entire Wiley team for their help in producing this book.

Dr. Susana Palma Moya

To Susana and Paco,

You both take me to the ‘next level’ every day, inspire my work and my life.

I do not know where I will be in 10 or 20 years’ time but, of this I am sure, our friendship will remain one of the most important pillars of life to me.

Thanks for trusting me, for taking care of me, for having me as a friend: I hope life brings you as much happiness as I think you deserve.

To Dani,

Your smile is the most important thing to me.

Dr. Javier Lozano Zafra

About the Companion Website

This book is accompanied by a companion website:

Companion website: www.wiley.com/go/lozano‐zafra/aligner‐techniques

The website includes:

 ClinCheck videos of every treatment in the book. Watch them simultaneously to every chapter, in order to fully understand biomechanics and staging used in every treatment.

 Patient Cases