Invisalign (GLASER)

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Dr. Barry Glaser is a paid consultant of Align Technology, Inc., however, the views presented herein represent his personal
opinions in his capacity as healthcare professional and do not necessarily reflect the opinions, thoughts, or views of Align
Technology, Inc. Dr. Glaser was not compensated by Align Technology, Inc. in connection with this book.
Copyright ©2017
ISBN: 9780996677677
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, scanning or otherwise, except as permitted under Section 107 or
108 of the 1976 United States Copyright Act, without the prior written permission of the Publisher.
Limit of Liability/Disclaimer of Warranty: While the publisher and the author have used their best efforts in preparing this
book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and
specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created
or extended by sales representatives or written materials. The advice and strategies contained herein may not be suitable for
your situation. You should consult with a professional where appropriate. Neither the publisher nor the author shall be liable for
any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other
damages.

Dedication
To Tracy, Scott and Jake,

La familia es todo

BOOK TESTIMONIALS
“Dr. Glaser, like myself, recognized long ago that his students needed to have an organized way to talk to the teeth with plastic
force systems just as we do with wire and braces. The Insider’s Guide to Invisalign Treatment will set the doctor on the right track
to do just that.
This book is well organized to help the doctor learn the important principles in each case type in an easy-to-read, systematic
format. Each chapter addresses another aspect of correcting malocclusion with Invisalign clear aligners, and guides the reader
through a common-sense approach to virtual treatment planning using the ClinCheck® software. His concept of viewing a ClinCheck
treatment plan as force systems, not teeth compliments my own educational principle of think like plastic and feel like a tooth.
The Insider’s Guide to Invisalign Treatment is a must-read for all doctors looking to up their Invisalign game. I highly
recommend you study this book and keep it next to the computer where you work up your ClinCheck treatment plans. I am confident
that if you follow Dr. Glaser’s methods, you will be delighted with the results!”
– Willy Dayan, DDS, Dip. Ortho, Toronto, ON, Canada
“The current landscape of orthodontic literature regarding Invisalign therapy is replete with text books showing before and after
cases following a review of some distinct advantages aligners have over fixed appliances in regards to orthodontic tooth
movement. The unmet didactic need for the private practitioner is a true ‘how to’ textbook when it comes to treatment planning using
the ClinCheck software. Dr. Barry Glaser’s contribution to the orthodontic literature is the first of its kind towards this endeavor and
readily services a doctor’s unmet need when treatment planning in the privacy of their offices.
“Whether a novice or more experienced, Dr. Glaser’s logical, methodi- cal, and step-by-step approach is exactly what is needed
to streamline the Invisalign treatment planning process so it will become as second nature as it is for fixed appliances.
This body of work will prove to be a timeless addition to your library to be happily referenced often while submitting your
cases. I have removed a text book on fixed appliances to make room for it on my book shelf!”
– Jonathan L. Nicozisis, DMD, MS, Princeton, NJ
“Dr. Glaser has and continues to be a guiding voice in the Invisalign orthodontic community. His commitment to mastering the
art and science of moving teeth with plastic is commendable. This book is a testimony to his passion to all things Invisalign. Its
content is a wonderful resource for us all. Thank you, Barry, for taking the time and energy to compile your ideas, insight, and
experience into this volume. This book is certainly a valuable addition to the wealth of orthodontic knowledge.”
– Bart Iwasiuk, DDS, Burlington, ON, Canada
“If you have been sitting on the fence, thinking about offering Invisalign to your patients, or gaining the confidence to tackle more
challenging cases, then this informative and instructive book from Dr. Glaser will get you started on the right path. Dr. Glaser
brings his personal and extensive experience as an Elite Provider of Invisalign and provides specific detailed strategies to help
you set up your cases with predictable and profitable results.”
– Donna Galante, DMD, Sacramento, CA
“I have had the pleasure of speaking alongside Dr. Barry Glaser, in addition to listening to his lectures and insight on multiple
occasions. His knowledge is invaluable, and important for anyone wanting to treat their Invisalign patients with excellent results.”
– Mazyar Moshiri DMD, MS, FICD, Saint Louis, MO

ACKNOWLEDGMENTS
First, I would not be the person I am today without the brilliant guidance and inspiration of the late Dr. Anthony A. Gianelly. I
will be forever grateful to Dr. Gianelly for accepting me into Boston University’s orthodontic program back in 1990, an event that
changed the arc of my professional life in so many ways. Dr. G, I hope I have made you proud.
To the many Invisalign educators who have inspired me along the way, I would not be where I am today without you. I would be
remiss without making special mention of the giants whose shoulders I have stood upon: Willy Dayan, Gary Brigham, Bill
Kottemann, Johnathan Nicozisis, Donna Galante, Sandra Tai, Maz Moshiri. Your teachings and friendship are a constant source of
inspiration.
Thank you to my amazing staff for not only assisting me in caring for our patients and gathering all the records for this book, but
also enduring the countless schedule changes that allow me to go on my teaching expe- ditions around the world. You guys are the
best!
Michelle Gamble, this book would not be possible without your editing and guidance every step of the way. Who knew I could
write a book? And thank you to Erin Pace-Molina for all the internal layout as well as the fantastic cover graphics.
Thank you to my patients who appear in this textbook for so graciously allowing me to share their success stories with the world.
May your gifts be a source of inspiration for doctors to create healthy, beautiful smiles with clear aligners for millions of patients
around the world.
To my parents, thank you for raising me the right way and for always being there for me. You always tell me how proud you are
of your son the orthodontist, but this is my opportunity to let you know how proud I am of you! I love you both.
Last but not least, this book is dedicated to my wife Tracy and sons Scott and Jake. There is nothing more important to me in the
world than you.

Table of Contents
Preface
A Guide on How to Read This Book
Introduction — Invisalign Offers New Ways to Grow Your Business
Chapter 1 — Principles of Invisalign Treatment Planning
Chapter 2 — An Overview of the ClinCheck list
Chapter 3 — Crowding
Chapter 4 — Spacing
Chapter 5 — Vertical
Chapter 6 — Sagittal.
Chapter 7 — Transverse
Chapter 8 — Attachments
Chapter 9 — IPR and Staging
Chapter 10 — Overtreatment and Overcorrection
Chapter 11 — Troubleshooting
Conclusion
Resources
About the Author

Preface
When I set out to write this book, my objective was to develop a user-friendly, systematic guide to virtual treatment planning
with Invisalign ® treatment. Throughout my travels lecturing to doctors about treating patients orthodontically with Invisalign clear
aligners, as well as consulting with doctors on my educational website AlignerInsider.com, a common theme I hear is that many
doctors don’t “get” Invisalign treatment planning. For example, they don’t understand how to interpret what they see on a
ClinCheck ® treatment plan, nor do they understand how to effectively communicate their treatment goals to their technician.
Based on these observations, I developed a 10-step method to Invisalign treatment planning and ClinCheck design I call the
“ClinCheck list”. The ClinCheck list is a systematic approach to Invisalign treatment planning, providing the doctor with a step-by-
step method to guide them through a rational, common sense thought process to achieve consistently excellent results with
Invisalign.
Whether you are a first-time user or an experienced provider, the principles revealed in this book will help you look at
ClinCheck plans in an entirely new way — as “force systems, not teeth”. By retraining your eyes and mind to view your ClinCheck
setups as the forces exerted upon the teeth by the aligners rather than a depiction of the teeth themselves, you will better understand
how to set up your cases to achieve more predictable results, more efficiently, with fewer refinements.
You may be asking yourself, “Why can’t I just submit my case, push the “Accept” button on my ClinCheck plan, and have
everything track perfectly on every patient?” The short answer is “Because that’s not how orthodontics works.” Orthodontics,
whether performed with fixed appliances or Invisalign, is both art as well as science. The engineers at Align Technology, Inc., the
makers of Invisalign, are continuously innovating their products to achieve more predictable results. SmartForce ® features,
SmartStage TM technology, and SmartTrack ® aligner material continue to evolve as the science of Invisalign advances from year to
year. Nevertheless, just like with “straightwire” pre-adjusted fixed appliances, despite the presence of a prescription in each
bracket for tip, torque and in-out position, we can’t simply “throw in a wire” and have the case treat itself. Wires still need to be
bent, auxiliaries used, and adjustments made to accommodate individual variation from one patient to the next. Tooth anatomy, root
morphology, bone density and genetic differences between patients means that there will always be the need for an orthodontist
treating his or her patient.
It’s the same with Invisalign. While advances in aligner technology will continue to improve treatment outcomes, there will
always be the need for the orthodontist to monitor, adjust and adapt to the patient’s individual needs. That’s what this book is all
about.
It is important to note that the information contained in this book is based on how I approach Invisalign treatment in my own
practice. The views and opinions expressed in this book are mine, and are not necessarily those of Align Technology, Inc. Just like
with fixed appliances, there are many different philosophies and treatment approaches with Invisalign. In this book you will learn
about my unique way of approach- ing Invisalign treatment. This speaks more to the art of orthodontics — there is more than one
way to arrive at an excellent final result. To me, this is one of the joys of orthodontics — each patient presents with new challenges
to solve, and the ability to think my way creatively through a case helps keep my practice fresh and exciting. After more than two
decades in practice I still enjoy coming to the office every day.
I hope you find the information in this book beneficial to both you and your patients, and I wish you the same excitement and
enthusiasm in your practice as I feel for mine.
—Barry J. Glaser, DMD

A Guide On How To Read This Book
When I began this project, my initial temptation was to simply present patients treated with Invisalign and go through a step-by-
step expla- nation of how I treatment planned the case from beginning to end using the ClinCheck list. I quickly realized that this
made for an overwhelming and somewhat disjointed amount of information for the reader to digest. Instead, I decided to break the
body of the book into discreet sections, each dealing with a different clinical aspect of orthodontic treatment using Invisalign.
Each chapter of this book deals with a specific section of the ClinCheck list. As a result, you will see many of the same cases
presented multiple times throughout the chapters along with an in-depth description of a specific element of ClinCheck treatment
planning. For example, the same patient with a CL II div. 1 malocclusion and deep overbite may be presented in both the chapter on
sagittal correction as well the chapter on vertical problems. Therefore, you have several ways you can read this book.
If you are relatively new to Invisalign, reading through each chapter in order would make the most sense. In each chapter, another
element of ClinCheck treatment planning will be presented along with repre- sentative case studies to reinforce the educational
concepts.
Here is my recommended approach for new Invisalign users reading this book:
1. Learn the basics in Chapters 1 and 2 then proceed through the remaining chapters in order. Start off with the most common
orthodontic problems, crowding (chapter 3) and spacing (chapter 4).
2. Progress through more complex problems (vertical, sagittal and transverse) in chapters 5, 6 and 7.
3. Learn the nuances of attachments, IPR and staging in chapters 8 and 9.
4. Discover the importance of over treatment and over correction in chapter 10, then finish up with troubleshooting in chapter
11.
Here is my recommended approach for orthodontists more experienced with Invisalign, but may be having a specific challenge.
For example correcting deep bites:
1. Start off by reviewing the basics presented in Chapters 1 and 2.
2. Then jump directly to Chapter 5, which deals with correcting problems in the vertical dimension.
3. From there, proceed to Chapter 8 to learn more about how attachments help to achieve deep bite correction, Chapter 10
which explores the concepts of over treatment, then Chapter 11 for some helpful tips on troubleshooting.
Finally, here is my approach for those doctors with extensive experience with Invisalign:
1. Start off with a quick read of chapters 1 and 2 to familiarize yourself with the ClinCheck list, then jump to whatever chapter
you see fit.
2. Haven’t treated many CL II teens? Off to chapter 6 you go to take a dive into the deep end of the CL II correction pool!
3. Have some troubleshooting questions? Turn to chapter 11. And so on.
In any event, I strongly suggest you keep this book handy at the computer where you work up your ClinCheck treatment plans.
You can also download a free copy of the ClinCheck list from my educational website, AlignerInsider.com. Use the ClinCheck list
as a guide on every case, and I am confident that you will quickly see your Invisalign cases track better, require fewer refinements,
and finish with consistently excellent results.
—BJG

INTRODUCTION
Invisalign Offers a New Way to Grow Your Practice
Invisalign clear aligner technology is growing in the number of patients treated annually. The statistics regarding patient
adoption rates worldwide now show according to the Align Technology Annual Report that over 4 million patients have used
Invisalign technology to straighten their teeth. Orthodontists should wisely consider this growing marketplace as an area to
expand their practices to take advantage of the immense opportunities, especially as the market becomes ever more competitive.
Not only does clear-aligner technology, led by the innovative compa- ny Align Technology, Inc., enable straightening of teeth in
routine Class I cases, but recent advances in techniques and technology now offers correction of more severe malocclusions. Just 10
years ago, the thought of predictably correcting moderate to severe malocclusions with clear aligners would have seemed far-
fetched. The latest innovations are creating new market opportunities for orthodontists to not only expand adult teeth straightening,
but also teenage cases.
In years past, the adult orthodontic market was limited. Many adults who had severe malocclusions weren’t offered much more
than traditional metal or ceramic or lingual braces. This prevented many adults who didn’t want the stigma of braces from getting
their teeth straightened. Today, the evolving technological innovations coming out of Align Technology, which is the leader in
clear-aligner products, enables a large segment of the adult population to use highly esthetic clear aligners to straighten their teeth.
The clear aligners enable adults to avoid the per- ceived embarrassment of braces and easily persuade them to straighten their teeth
even as senior citizens.
Invisalign also offers orthodontists the opportunity to increase their teen product offerings. Not only can clear aligners now
correct most malocclusions, but also Align Technology addressed parental concerns about lost aligners and teenagers not being
responsible enough with their aligners. Without these new programs, orthodontists were finding it challenging to grow the use of
Invisalign among the teenage market segment. In doing patient evaluations and providing recommendations, orthodontists were
coming up against parental concerns about extra costs due to teenagers losing aligners or not properly wearing their aligners.
Parents were attracted to fixed braces vs. clear-aligners because of these concerns. As a result, clear-aligners weren’t as broadly
adopted by teens.
So Align Technology implemented its Invisalign Teen program to re- sponsively address parental concerns. Now orthodontists
have in their arsenals a great marketing tool to encourage parents to use clear-aligners instead of fixed braces for their teenagers.
The program features and benefits make the orthodontist’s sales job easy.
Invisalign Teen addresses issues such as misplaced or lost aligners by offering free aligner replacements (up to a certain
number). Additionally, Invisalign Teen uses compliance indicators — color-changing markers to indicate for parents whether or not
their teen is properly wearing their aligners. These offers have alleviated parents’ concerns, and as a result the Invisalign Teen
program is rapidly growing in adoption rates.
Your orthodontic practices can greatly benefit from expansion into the Invisalign marketplace. Opening the door for more
opportunities to serve the adult and teen market make it a terrific way to grow your practice.
To do this, you will need education about the latest Invisalign treatment techniques. This knowledge will help you
understand Invisalign’s potential value through the technology’s capabilities. It may even inspire you to broaden your orthodontic
patient solutions using my prescribed principles, practices and methodologies to achieving winning results.
As the author of this book, my intention is to help orthodontists see Invisalign not just as a device to correct malocclusion, but to
understand the science behind the technology. For those of you unfamiliar with Invisalign technology, ClinCheck is the software
application created by Align Technology designed specifically for doctors who register to work with the program. ClinCheck
provides a 3D virtual representation of a treatment plan derived from the doctor’s orthodontic prescription. Each doctor is able to
send information back and forth with Align as changes are made to the treatment plan, and then aligners are manufactured to the plan
and sent to the doctor for the patient’s treatment.
In this book, I will be showing you how to use the ClinCheck software to become a sort of “orthodontic software engineer”. I
will help you understand how to use the software tool to integrate the digital capabilities with the physical practice of moving
and adjusting teeth. I will also uncover the scientific principles and techniques behind the technology that enable practical patient
application.

As we step through this process of using ClinCheck software, you will see how modern orthodontic techniques are applying the
science of innovation and technological evolution to inspire new ideas in orthodontic practice. This book outlines those principles
and science behind clear-aligner treatment to motivate new ways of practical application to achieve beautiful smiles and healthy
occlusions even in some of the most challenging cases.
As I begin this introduction into the new innovations and practical applications of Invisalign technology, I will identify specific
opportunities to apply ClinCheck software to engineer the teeth into place. Yes, I said engineer. You will use ClinCheck to become a
new breed of orthodontic software engineer to figure out how to move teeth using my principles described in the upcoming chapters.
I am going to outline and explain how I use ClinCheck software to essentially “over-engineer” the teeth (I’ll explain what I mean by
“over-engineer” in the following chapters) to correct almost all problems.
As an orthodontist myself I understand the unique challenges we all face to remain competitive in this changing industry. I’ve
learned a lot about Invisalign technology, and I’m going to share my insights and hands-on experience to help you understand and
apply my principles and knowledge to your own patients. Maybe using my techniques, you will even recognize new ways to apply
them yourself. When you learn my tried-and-true techniques how to “over-engineer” and manipulate the teeth using ClinCheck you
will ultimately benefit both your patients and practice. So let’s get started.
— Dr. Barry Glaser

CHAPTER 1
Principles of Invisalign® Treatment Planning
Before I became a Certified Invisalign Provider in 2006, I saw clear-aligner technology as just another in a long line of
frustrating, un- derperforming removable appliances. In my pre-Invisalign days, adult patients would frequently present for
consultation with lower incisor crowding asking for “just a retainer.” Psychologically, adult patients would often underestimate the
magnitude of their orthodontic problem, from both a clinical as well as financial perspective. In their minds, “just a retainer”
would be an inexpensive, easy way to straighten their teeth. In my earliest days of practice, I would welcome these patients, only to
find that these “simple” six-month lower incisor alignment cases weren’t progressing well and were falling way past the estimated
completion date. Ensuing discussions with these patients revealed that despite clear instructions, the retainers were not being worn
full-time as directed. “I can’t wear this thing to work!” was heard in my office more times than I care to admit. The patients weren’t
compliant, the devices weren’t producing straight teeth, and of course it was all my fault. No matter what I tried (spring aligners and
other removable appliances) I simply couldn’t get teeth straightened on a consistent basis without using traditional braces. As a
result of these frustrating experiences, I quickly gave up on removable appliances as an option to straighten teeth. Needless to say, I
was losing this adult cohort of patients to treatment year after year and was missing the opportunity to capitalize on the growing
adult segment of the orthodontic population.
In 1999, Invisalign arrived on the scene. My initial impression was that clear aligner therapy was going to be another in a long
line of failed removable appliances. I was skeptical of the ability of clear aligners to achieve the control I had with fixed
appliances, and I was bruised and bat- tered from the practice management nightmares I had with my previous “just-a-retainer”
patients.
I became Invisalign certified in 2006 as a self-proclaimed skeptic. Initially, I viewed clear-aligner therapy as a minor tooth
moving appliance at best, and I was quite skeptical of both its efficacy as well as patient compliance. I began treating adult mild
crowding and spacing cases — those that I recognized as removable appliance cases. Surprisingly, I found my earliest test cases to
turn out quite nicely. In addition, patients (only adults at this point) seemed to wear the aligners the required 22 hours per day with
little complaint, and in fact, high levels of satisfaction. Before long, patients began to seek me out for Invisalign treatment.
As time went on I started to see gradual changes in the clear-aligner technology, ideas behind it, techniques to apply it, and
practical application of it. As an orthodontist I slowly tried out these practices on patients; however, it wasn’t until 2010 that I
became more educated on the emerging applications of this technology. It was then that I attended the Invisalign Summit for the first
time and learned about the revolutionary Invisalign G3 technology.
At the Summit I started to realize the innovators at Align Technology were working out actual scientific methods on how to get
the aligners to work more predictably. It was also interesting to discover that they were now talking about the techniques in terms of
science — a word I had never heard applied to clear-aligner therapy before. At that moment I resolved to learn all I could about
treating malocclusions with Invisalign, and resolved to fully integrate Invisalign into my practice.
One of my earliest success stories came with using Invisalign on a patient with a Class I malocclusion, complicated by severe
upper and lower crowding. Quite frankly, I didn’t think I could complete the case with aligners alone, and I counselled the patient
that I would have to finish his case in braces. In this case (image 1-1, 1-2), I was able to use Invisalign to correct the problem
without extractions in 25 months of treatment. This case was one of my earliest successes, and I still view this patient as an “index
case” — meaning if I could successfully control his severe crowding with Invisalign, there were a multitude of mild to moderate
cases I should be able to control as well. It was cases like this one that began to help me understand much of what we’re going to
review in this book.
As we delve into this discussion, one of my main goals of this book is to get orthodontists to begin to look at ClinCheck as “force
systems, not teeth.” As you examine ClinCheck, begin to adjust your thinking regarding biomechanics in the process of
straightening teeth. ClinCheck works from the basic concept that defines a new paradigm of virtual treatment planning that
recognizes ClinCheck as not a visual prediction of the final occlusion, but rather a graphic representation of force systems produced
by the aligners acting on teeth. As this chapter reviews the principles and provides explanations, the information will describe,
define and illustrate what is meant about these force systems and the earlier mentioned “over-engineering” principle.

INVISALIGN FUNDAMENTAL PRINCIPLES
So let’s start with the actual principles and then slowly describe and define what I mean by them. The basic fundamental
principles of using Invisalign are as follows:
NO. 1: ALIGNERS ONLY WORK BY PUSHING TEETH; THEY DON’T PULL
NO. 2: MULTIPLE MOVEMENTS AT THE SAME TIME
NO. 3: ANCHORAGE IS REQUIRED FOR EFFICIENT MOVEMENT
NO. 4: OVER-ENGINEERING CLINCHECK IS A MUST
NO. 5: TEETH NEED SPACE TO MOVE
Now let’s break down the principles and walk through the concepts.
PRINCIPLE NO. 1: ALIGNERS ONLY WORK BY PUSHING TEETH; THEY DON’T PULL
What does that mean? Isn’t the idea behind orthodontics that we’re pulling teeth in different directions? In the case of clear-
aligner treatment and what you’re trying to do requires an understanding about one key thing:
Aligners Push
It’s very important to recognize the push surfaces on either the teeth themselves or on the attachments placed on teeth to get the
desired movement. We need the interaction of an aligner surface with the tooth or active surface of an attachment to achieve
movement. Pulling won’t work — an aligner surface that is pulling will simply disengage from the tooth. So remember, we’re
pushing NOT pulling. It’s one of the main reasons that extrusion of maxillary lateral incisors is so challenging — there is
essentially nowhere for the aligner to “grab” on either the labial or palatal surface. We will look at this problem in depth in the
chapter on vertical control of teeth and I will offer solutions to improve maxillary lateral incisor tracking, but the fundamental
concept is this: If you can develop an appropriate push surface on a tooth, the chances of the tooth moving in the desired direction
increase greatly.

So think PUSH, and you are on your way to looking at ClinCheck in an entirely new way.

CASE STUDY NO. 1 — PUSH SURFACE
This was a teen patient treated in one year with no refinements. The teeth tracked very well because of the large push surfaces.
Look at image 1-3 and notice the upper canines. See the broad, flat labial and palatal surfaces? The aligners were able to produce
a set of opposing push forces on each tooth, and the upper canines tracked well (image 1-4)
PRINCIPLE NO. 2: MULTIPLE MOVEMENTS AT THE SAME TIME

The second principle, multiple movements at the same time, speaks to one of the benefits of the Invisalign system — its
efficiency. In the sam- ple ClinCheck (see sequence of photos, images 1-5 through 1-7), you can observe that you can simultaneously
torque teeth, rotate and align them. Let’s take a look at Erin.

CASE STUDY NO. 2 — ERIN
Let’s take an example of what we mean by multiple movements at the same time. In this case study we have a patient named Erin.
She presented with a Class I malocclusion, which you can observe in image 1-8, a deep overbite and cross-bite of the upper-right
canine. Erin’s case illustrates multiple movements being done at the same time. As you can see in the sequence of ClinCheck photos
the work being done is to simultaneously intrude the upper-right and the upper-left central incisors while at the same time correcting
her cross-bite.
The ClinCheck plan actually shows what is happening with this process. Observe intrusion of the two upper-front teeth to level
the smile arc. This procedure is done at the same time that the upper-right canine is being moved buccally out of cross-bite.
The key takeaway: The orthodontist does this all at the same time — and that is what I mean by the efficiency of the
process.
Here is the final picture at the end of Erin’s treatment (image 1-9). She has a normal occlusion, and we have achieved a good
final result.

PRINCIPLE NO 3: ANCHORAGE IS REQUIRED FOR EFFICIENT MOVEMENT
The term “anchorage” is used all of the time with conventional fixed appliances.
I use the term a little differently for the Invisalign system. When I refer to anchorage, a good example of that would be Haley’s
case (image 1-10). Haley presents with a significantly deep overbite. In her case, the goal is to correct the deep overbite with a
combination of 30-percent intrusion of the upper incisors and 70 percent of lower incisors.
Now review the ClinCheck (image 1-11), and a problem presents itself. Start by going back to Principle NO. 1: Aligners only
work by push teeth- ing; they don’t pull. The aligner plastic only works by pushing against the teeth.

Let’s focus in the lower arch. In Haley’s case we want to intrude the lower incisors. Newton’s third law states that for every
action there is an equal and opposite reaction. So in a case like Haley’s, the “action” force is the aligner pushing on the lower
incisors to intrude, while the reaction force tends to want to lift the aligner off the posterior teeth. If the aligners lift off the pos-
terior teeth you’re going to lose the desired push force on the lower incisors. As a result of this lift off, there will be less force to
intrude the teeth. The bite will then remain deep, which is a common clinical problem where posterior aligner anchorage is not
properly set up in the ClinCheck plan.
In a case like Haley’s we apply our Principle NO. 3 and set up anchorage. Look at image 1-11 and notice the attachments on the
lower first and second premolars. They are occlusally beveled rectangular attachments, 4mm in length. The retentive surface of
these attachments is at the gingival aspects. The goal is when Haley snaps the aligner on it’s going to be retentive in the buccal
segments. These attachments are going to prevent the dislodgment of the aligner posteriorly. Imagine the aligner is like a lever arm,
and the lowers incisors are going to feel the force of the intrusion. The results: more predictable bite opening. As you can see from
Haley’s final results (image 1-12), her deep overbite was successfully resolved.
The principle of attachment design and the use of attachments is the area of ClinCheck treatment planning this book will revisit
over and over again.
PRINCIPLE NO. 4: OVER-ENGINEERING CLINCHECK PLAN IS A MUST

Key Point #1: Aligners vs. Braces: Not as different as you think.

What does the term “over-engineering” mean as applied to our ClinCheck process? Let’s make a parallel between braces and
Invisalign — in a lot of ways they are not as different as you would think. These days, most orthodontists use a “pre-adjusted
system” meaning there is a prescription toward first-, second- and third-order movements built into the brackets themselves.
In a Roth Prescription, for example, in the maxillary central incisors there is +12 degrees of palatal root torque built into the
bracket. The Damon System happens to have +15 degrees. MBT +17 degrees. Do we want full expression of all this palatal root
torque? Not always. So why do these prescriptions exist?
We need to over-build our prescriptions in our brackets for a variety of reasons, but for this discussion let’s focus on the play
between the wire and the slot. For every .001” play between the arch wire and slot there is a loss of approximately 4 degrees of
torque. That means a .021” x .025” arch wire in an .022” slot in a Roth prescription will express at most 8 degrees. Think of this as
a “loss factor”.
Modern pre-adjusted straight wire appliances have become very so- phisticated. The orthodontist has a variety of prescriptions
to choose from, in addition to multiple wire configurations and metallurgy. These advances have been beneficial to both orthodontist
and patient. Despite these advances, however, we don’t simply “throw in a wire” and have the cases treat themselves. Each patient
is unique, and as a result wires still need to be bent, auxiliaries employed, brackets repositioned, and adjustments made.
Biological differences from one patient to the next means that the doctor is still in the driver’s seat, managing tooth movement from
beginning to end.
It’s the same with ClinCheck treatment planning. In reality, there is a tremendous amount of science and engineering built into
every ClinCheck treatment plan. The engineers at Align technology have sophisticat- ed algorithms designed to place optimal force
systems along the arch to achieve desired tooth movements. In addition, advances in Smart ForceTM features and aligner materials
(Smart TrackTM) have revolution- ized clear-aligner treatment to the point where, for me, Invisalign is the appliance of choice in
most situations. I make the parallel between ClinCheck and straight-wire appliances only to illustrate a point: that in my experience,
in certain clinical situations, Invisalign, just like straightwire appliances, requires adjustment to compensate for individual dif-
ferences from one patient to another. This is what I mean when I use the term “over-engineering”. We will spend a considerable
amount time in this book looking at four areas requiring over-engineering — deep/open bite, tip, torque and expansion.
Key Point #2: When you look at ClinCheck plan you are not looking at teeth. You are looking at force systems acting on the
teeth.

CASE STUDY NO. 3 — KYLE
Let’s look at Kyle’s case (image 1-13). Imagine he is being treated with fixed appliances. We endeavor to correct his deep over-
bite by leveling the lower Curve of Spee. To accomplish that goal, it would be quite normal to place a reverse curve-arch wire in
the lower arch. I’ll call this reverse-curved arch wire over-engineered, meaning we’ve placed something additional into the wire
that doesn’t exist in the bracket prescription.
If we think about the shape of the reverse curve arch wire, we don’t want the lower arch ultimately to have this curve; but as
orthodontists we have learned that if we place a reverse curved-arch wire into the lower arch it’s going to place a force system that
will flatten the arch. So a curve produces a leveled arch — and thus, it’s the same with a ClinCheck plan.
Let’s go back to Kyle’s case where the patient presents with a deep overbite (image 1-14). We know we need to level the Curve
of Spee. Just like in the use of the reverse curved arch wire, we need to over-engineer our ClinCheck plan. The reverse curve built
into this ClinCheck plan (image 1-15) to achieve the appropriate bite opening. I am not expecting the final result to look like this
image. A ClinCheck plan is not a predictor of the final result of occlusion. It is a graphic depiction of the forces being placed on the
teeth to achieve the required results. It’s force systems, not teeth.
In this ClinCheck plan, there are two areas that have been over-engineered. We have over-engineered the bite opening by
adding additional reverse Curve of Spee to the lower arch. The second place is on the maxillary incisors, which need to be

intruded and retracted. The tendency is for them to be tipped lingually just as if you were retracting these teeth on a round arch wire,
which isn’t the desired result because it’s one of the main causes of posterior open bites — I will elaborate more on the topic of
posterior open bites later in this book.
In Kyle’s case if you look at the upper incisors in the final ClinCheck stage, notice an additional 30 degrees of palatal root torque
(PRT) built in as counter tip. Since the idea is to avoid the upper incisors tipping lingually, this was used as an over-engineering
move in the ClinCheck plan. The point of the information contained in this book teaches doctors to over-engineer their ClinCheck
plans and how to modify them so the teeth ultimately wind up in the proper occlusion (image 1-16). As you can see, the final
position of the teeth does not look like the final ClinCheck stage, and that’s the point. When you look at a ClinCheck plan, you are
looking a graphic representation of the forces being applied to the teeth rather than a prediction of the final tooth positions.
It’s force systems, not teeth.
PRINCIPLE NO. 5: TEETH NEED SPACE TO MOVE

This principle is short and direct but nonetheless fundamental: In order for a tooth to move from A to B it requires space to
move. Binding of teeth is one of the main causes of non-tracking. Always check for tight contacts at the first indication of non-
tracking. Chapter 11 deals with a variety of troubleshooting issues and how to get things back on track.

SUMMARY
Before beginning the next chapter here is one last abbreviated review of what this chapter just explained.
BASIC ALIGNER PRINCIPLES

1. Push only
2. Multiple movements at the same time
3. Anchorage required for efficient movement
4. Over-engineering ClinCheck plan is a MUST
5. Teeth need space to move

CHAPTER 2
What is the ClinCheck list?
The ClinCheck list is a tool we will be referencing throughout the pages of this book. My goal is for you to use the ClinCheck list
as a guide to help you through the process of Invisalign treatment planning and to help properly set up your ClinCheck treatment
plans for each patient to achieve the best results.
As I travel around the world lecturing to doctors about Invisalign treatment, and consult with doctors on my website
AlignerInsider.com, a common theme I hear is that they don’t understand how to interpret what they see graphically represented on
the ClinCheck plan, nor do they understand what areas of their ClinCheck plan require modification. I often make the comment that
“Invisalign isn’t about a technician in Costa Rica telling you how to treat your patients, it’s about you telling the technician what you
want.” It was this observation — that doctors need a systematic way of looking at and modifying their Invisalign treatment plans
— that gave rise to the development of the ClinCheck list.
So what is the ClinCheck list? The ClinCheck list is a systematic approach to ClinCheck design and Invisalign treatment
planning. It provides a step-by-step method for increased efficiency and predictability for your Invisalign treatment and results.
Furthermore, it will help to reduce the number of times you will need to send the ClinCheck plan back to your technician, saving you
precious time.
The ClinCheck list is NOT a cookbook, meaning it is not a “one-size- fits-all” proposition. While it will serve as a guide to
assist you in working up your Invisalign treatment plans, the ClinCheck list allows for individual customization of each ClinCheck
plan, tailored to the specific needs of each patient as well as the individual treatment philosophy of each doctor.
ClinCheck list can be pared down to these concepts:

1. Systematic approach to ClinCheck design
2. Step-by-step method
3. Reduces ClinCheck revisions
4. Increases Invisalign predictability
5. Is NOT a cookbook
ClinCheck software is a customizable virtual treatment-planning tool for each patient’s orthodontic treatment. Within the
ClinCheck list there are 10 Critical Parameters to guide you through customizing your Invisalign treatment plan.
The 10 Critical Parameters are:

1. Crowding
2. Spacing
3. Vertical
4. Sagittal
5. Transverse
6. Attachments
7. IPR
8. Staging
9. Overtreatment
10. Overcorrection
CROWDING AND SPACING

We begin here, thinking through the nuances of aligning teeth in the intra-arch dimension with Invisalign. It’s surprising to me how
many doctors instruct their technicians to simply “Level, align and de-rotate all teeth,” and that’s it! These types of vague, imprecise
instructions place critical treatment decisions in the hands of the technician. While highly skilled at what they do, your technician is
not a doctor, and they do not have the training and experience that you have. One of the beauties of virtual treatment planning with
the ClinCheck software is the ability to control critical parameters such as arch form, expansion, proclination and interproximal
reduction (IPR) before actually treating the patient. To gain a high level of control with Invisalign we must learn to specify exactly

how we want the teeth to move as well as defining the final position of all teeth for optimal esthetics and function. The chapters on
crowding and spacing will teach you how to align malposed teeth, why certain situations are more predictable than others, and when
ClinCheck modifications are necessary.
VERTICAL, SAGITTAL AND TRANSVERSE

The next three parameters: vertical, sagittal and transverse are inter-arch problems where we are looking to solve the
patient’s malocclusion in three planes of space. As I write this I have to laugh, because 10 years ago I would never have believed
that routine correction of malocclusion would be possible with clear aligners. However, as the science of Invisalign treatment has
advanced, so has my understanding of the specific ClinCheck moves required to achieve an excellent final result. We will look at
correction in each of the three planes of space in detail in the corresponding chapters. A word of caution — Invisalign clear align-
ers, like traditional fixed appliances, is effective at treating dento-alveolar problems. In addition, mild skeletal discrepancies may
sometimes be successfully camouflaged with dento-alveolar movements as well. Nevertheless, I do not advocate attempting
correction of moderate to severe skeletal problems with an appliance that is designed to move only teeth. If we plan realistic
correction of malocclusion using sound orthodontic principles, Invisalign treatment for vertical, sagittal and transverse problems
can be very gratifying to both doctor and patient.
ATTACHMENTS, IPR AND STAGING

The next three parameters in the ClinCheck list are attachments, IPR and staging. These fall under what I call “Housekeeping”.
In this respect, housekeeping encompasses frequently overlooked items that can bog treatment down. For example, have you ever
considered when to place new attachments or perform IPR? You should, because staging these events at normal visits helps to
reduce unnecessary appointments and keep treatment as efficient as possible.
This may seem trivial, but these parameters are the areas where many doctors lose a lot of efficiency in treatment. By looking
closely at the following:
Attachment design and placement
IPR location and quantity; and combined that with...
Looking at the staging of our cases
We can then make our ClinCheck treatment plans more efficient as well as make our treatment more efficient with fewer office
visits and refinements.
OVER TREATMENT AND OVER CORRECTION

The final two parameters fall under the concept of over-engineering (mentioned in the first chapter), and they are your
prescription for Invisalign treatment, similar to the prescription built into pre-adjusted brackets.
Over treatment refers to moves we make in our ClinCheck plan to build in additional forces for some specific clinical situations.
Over treatment happens gradually throughout the ClinCheck plan from beginning to end. The four over treatment areas we will
explore are overbite, tip, torque and expansion.
Over correction, on the other hand is represented by three aligner stages at the end of treatment designated with a “+” sign. Over
correction should be routinely prescribed for two specific clinical situations: rotations and ins and outs.
Here are (see example 2-1) of 10 critical parameters. Under each cat- egory we have subheadings. These subheadings are the
areas the doctor will look through for each Invisalign treatment plan. Doctors will check off these boxes and make notations to help
guide them through the treatment. We will explore each of these in detail in the following chapters. When you sign up for
AlignerInsider.com, you will have access to a free download of the ClinCheck list. Now let’s get to those ClinCheck treatment
plans!

CHAPTER 3
Crowding
In this chapter, we are going to review the fundamentals of dental crowding and how to use the ClinCheck list to address the
problem. After reading this chapter, I would hope that the instructions, “Please level, align and de-rotate all teeth” would be a thing
of the past. Furthermore, the notion that the dental arches can be expanded in every case ad libi- tum to the extent that IPR is never
required would be similarly relegated to the trash heap once and for all.
When we want to resolve crowding in a patient, we only have a limited number of options to choose from. Those options are as
follows:
1. Expansion, which refers to lateral widening of the posterior teeth. As they are widened laterally, additional arch
circumference is created to align the teeth. I also include posterior distalization to be a type of expansion treatment.
2. Proclination, which refers to labial movement of the upper and lower incisors, which can also gain arch length to unravel
crowding.
3. Interproximal Reduction (IPR) is judicious removal of enamel between teeth, and by removing enamel we can also create
space to resolve crowding.
4. Extraction of a tooth or several teeth.
The CROWDING section of the ClinCheck list helps guide you through the thought process to resolve the crowding problem.
In cases that present with crowding these four methods are the only four options for resolution. We have to select one or more of
these methods to resolve crowding. Having said this, how does one decide which of these methods to use or which combination of
methods to use?
For each of these approaches there are implications, including:
Periodontal
Esthetic
Functional
Long-term stability
PERIODONTAL IMPLICATIONS
When we are resolving crowding we have to take into account the patient’s periodontal condition. A short list of things to
consider are as follows:
Tissue type — does the patient have thick or thin periodontal tissue? As a rule of thumb patients with thick tissue can withstand
more expansion and more proclination than a patient with thin, friable tissue.
Recession — does the patient present with areas of gingival recession? In these cases, one has to ask, “How far can I move this
tooth labially in the presence of gingival recession before the situation becomes worse?”
Mucogingival Problems — if a patient presents with zones of inad- equate attached gingiva we have to consider whether we can
procline or move teeth labially or expand buccally at all. In these cases, would pretreatment gingival grafting change the treatment
plan?
Fenestrations — could labial movements in the presence of bony fenestration of the labial plate invite disaster? Patients who

present with significant gingival recession on the facial surface of the teeth have the potential for compromised amounts of labial
bone as well. In patients that present with bony fenestration, wanton or unlimited expansion in the posterior or anterior part of the
mouth can be disastrous, leading to worsening of the periodontal issues.
FUNCTIONAL IMPLICATIONS
When we are thinking about resolving crowding we also have to think about how the upper teeth are going to occlude with the
lower teeth. Things we have to consider are setting up patients for:
Incisal guidance
Canine guidance
Fremitus — we want to set up patients so their occlusion has no abnormal fremitus at the end of treatment.
Abfraction — does the patient present with any cervical abfraction lesions, which may be related to abnormal occlusion?
Non-working interferences
Centric relation where in these cases we are looking to create a cen- trically related occlusion.
ESTHETIC IMPLICATIONS
The best way to think of esthetic implications is to consider the denture setup. When denture teeth are being set up, traditionally
the first teeth to be set are the upper central incisors. We have a very good reason for this consideration. We want to set up the upper
incisors for the best esthetics — Incisal display both at rest and while smiling, as well as for lip support. In addition, the upper
incisors are set for ideal phonetics.
In a denture setup as well as an orthodontic setup, we want to accomplish the following:
Set up patients with a pleasing amount of gingival display not either excessive or insufficient.
Gingival margins to be level and symmetric.
The smile arc of the upper incisors should follow the curvature of the lower lip.
Limited amounts of negative space for a full smile.
The position of the anterior teeth should support the upper and lower lips.
It’s no different with Invisalign treatment. The final position of the teeth are dictated by the same esthetic considerations as the
denture set up. Just as if a lab prescription for a denture would be inappropriately worded, “Please set up straight teeth,” the
ClinCheck instructions must be precise and specific to achieve optimal esthetics for the Invisalign patient.
Additionally, when we are treating patients orthodontically, we also want to take into consideration areas of papilla loss/dark
triangles. We will discuss this in detail in the chapter on IPR.
At the beginning of this chapter, I made the statement that the instructions, “Level, align and de-rotate all teeth” should be
eliminated from your lexicon. I hope that the proceding brief discussion of the major implications to consider when resolving a
patient’s dental crowding illustrate this point.
What does “level, align and de-rotate teeth” even mean? To me, these instructions are not only vague and imprecise, they also do
not help your technician to understand how the teeth will align and where they will wind up in their final position. Your technician is
very skilled at setting up your ClinCheck plan, and the more specific your instructions are the better they will be able to produce a
ClinCheck treatment plan to achieve the results you want. It is incumbent upon the doctor to make the critical treatment planning
decisions and then communicate these decisions effectively to the technician. Fundamentally, this is one of the central themes of this
book.
As for planning unlimited expansion and proclination into every ClinCheck treatment plan without IPR, please consider the
following brief literature review.
LONG-TERM STABILITY
In 1997, Burke and Associates published the paper, “A meta-analysis of mandibular inter-canine width in treatment and post-
retention” in The Angle Orthodontist. The authors looked at 26 different studies all essentially asking the same question:
If the distance between the mandibular canines is expanded during orthodontic treatment what happens during retention
and what happens in post-retention?
The authors concluded, “Regardless of treatment modality, if mandibular inter-canine width is expanded during treatment, it

will contract during post-retention and return to the pre-treatment dimension.” Based on these findings, if we endeavor to improve
the chances of long-term stability for our patients, maintenance of the mandibular inter-canine width should be a central component
of the routine ClinCheck set up.
POSTERIOR EXPANSION
What about posterior expansion distal to the canines? In a brief review of the literature, consider these papers:
Walter, American Journal of Orthodontics, 1962
Shapiro, American Journal of Orthodontics, 1974
Gardner and Choconas, Angle Orthodontist 1976
Glenn, Sinclair and Alexander, American Journal of Orthodontics, 1987 These four articles discuss long-term stability where
teeth posterior
These four articles discuss long-term stability where teeth posterior to the canines were expanded. My interpretation of the data
indicates that although all expansion tends to relapse, inter-canine width expansion shows the least stability while expansion of the
premolars and molars shows the potential for less post-retention relapse. Ideally, we don’t want to expand cases at all, but in cases
where we feel compelled to do it, we are going to at least invite the possibility of improved long-term stability when we expand
the teeth posterior to the canines and not expand inter-canine width at all.
If look at your Invisalign Doctor’s Site (IDS) there are “Clinical Preferences” where you can set your default arch expansion
parameters. Go into your Clinical Preferences on the homepage of the Invisalign Doctor’s Site. Here are my recommendations:
Homepage: Click on Clinical Preferences on the far right of the screen
Look at 7. Arch Expansion
Select: Increasing the arch width between premolars and molars only (based on research that shows we have a
fighting chance of better stability there).
8. Expansion per quadrant
Click on: 2+ mm per quadrant

CASE STUDY NO. 1 — JESSICA
Jessica was a teenage patient who presented with a CL I malocclusion, with moderate upper and lower crowding. Note the
severely rotated upper canines. She has moderate lower anterior crowding and a normal profile (images 3-1 through 3-3). I would
consider Jessica to be “Invisalign Teen low-hanging fruit”. She is a high school student who does not want braces for the prom or
class pictures. These patients tend to be very compliant with Invisalign Teen.
Here is the ClinCheck list in reference to Jessica’s crowding.

TREATMENT PLAN
1. I have determined that Jessica will be treated non-extraction.
2. The crowding will be resolved from a combination of the following:
a. Posterior expansion
b. Incisor proclination
c. IPR
One of the beauties of 3D controls in ClinCheck Pro is that the doctor can dial in different amounts of expansion, proclination and
IPR to get the desired results. You have the ability to virtually treat the patient and customize the ClinCheck set up before
treatment begins. This truly revolutionary technology allows you to control the final outcome as well as the path the teeth travel from
beginning to end. In Jessica’s case, I want to maintain her mandibular inter-canine width to try and improve her chances for long-
term stability. Based on this, I made the decision to balance posterior expansion, anterior proclination, and IPR to resolve the
crowding.

CLINCHECK TREATMENT PLAN
Her ClinCheck plan was set up with posterior expansion, proclination of select lingually positioned lower incisors and anterior
IPR from canine to canine to resolve the crowding. If you look at the position (image 3-4) initially of the lower right central incisor
you can note that tooth is placed somewhat labially out of the arch. Since this tooth is too far to the labial, the treatment plan is to
move this tooth lingually during treatment.
As the orthodontist it will be your job to instruct your technician on the particulars to set up the ClinCheck plan to meet the needs
of the patient. This is how those instructions would look:
Instructions to the technician: these instructions are very specific because I want the lower right central incisor to finish
lingually, upright over the basal bone. My instructions to my technician are:
Please allow a maximum of 3mm buccal expansion (1.5mm per side) distal to the canines.
IPR L3-3 maximum of 0.3mm per contact.
The lower right and lower left lateral incisors may procline, but the lower right central incisor must finish 1mm lingual to its
current position.

JESSICA’S CLINCHECK PLAN
Step 1: If you look at where the lower right central incisor is positioned at stage 12 (image 3-5) you will notice that it has
proclined. Why would this happen? It proclines up until stage 12 to improve access for IPR. This is known as “round tripping”.
Once the IPR is performed the LR1 begins to retract. Round tripping can be useful to improve access for IPR.
Step 2: My instructions to the technician are, “Please allow for labial movement of the lower incisors until stage 12 to allow
for access of IPR.” At that point, the teeth retract and the LR1 ends up where I want it, 1mm lingual to its current position (image 3-
6).
Note: The “Superimposition” Tool in ClinCheck Pro is very useful to see the overall movements of the teeth.
These two steps we just described are how we are going to align the lower arch so that the lower-inter-canine width is not
expanded.
Jessica’s Upper Arch

Note the severely rotated maxillary canines (image 3-7). Despite the significant rotation, these teeth are set up for success for
four reasons.

These teeth present with broad, flat push-surfaces on both the buccal and palatal surfaces (basic principle #1, aligners move
teeth by pushing).
There is space present between the canines and adjacent teeth (basic principle #4, teeth need space to move).
There are optimized rotation attachments placed on these teeth to place the appropriate force system to achieve the desired
tooth movement.
Smart TrackTM aligner material works very well to deliver light forces to achieve predictable movement.

RESULTS
Note that the final results (image 3-8) and ClinCheck (image 3-9) agree nicely. The final panoramic radiograph is normal (image
3-10).

Summary: Total treatment time was 12 months. No refinements were needed.
Jessica’s ClinCheck set up can serve as a guide for many of your moderately crowded, non-extraction cases. By balancing
posterior expansion versus anterior proclination versus IPR, you can achieve excellent final alignment in a thoughtful and precise
manner. Please note: If your personal preference is to perform IPR in the premolar region, it would be perfectly acceptable to set
up your ClinCheck plan with posterior IPR.
To illustrate the aforementioned point that Jessica’s case can serve as a template for many moderately crowded, non-extraction
cases, let’s take a look at Lailaa.

CASE STUDY 2 NO. — LAILAA
Lailaa presented with a crowding pattern similar to Jessica’s, with the addition of a crossbite of the upper and lower right
canines (images 3-11 through 3-13).

As you can see, Lailaa’s ClinCheck list is identical to Jessica’s. Her lower arch crowding will be resolved in a similar manner
(images 3-14, 3-15). In the upper arch, however, the instructions to the technician are different: “Please expand the upper arch
sufficiently to allow space for retraction and alignment of the UR1 and UL1.” By slight widening of the arch form in the upper arch,
sufficient space is created to allow for alignment of the protrusive UR1 and UL1 without the need for IPR. Arch form changes such
as this can be helpful to create good alignment in cases such as Lailaa’s (images 3-16, 3-17).

RESULTS
Images 3-18 and 3-19 show Lailaa’s final result as compared to her ClinCheck plan. The final panoramic radiograph is normal
(image 3-20).
Summary: Total treatment time was 22 months.

CASE STUDY NO. 3 — GILBERT
Gilbert presented with a Class I malocclusion, normal overbite, normal overjet, severe upper and lower crowding, challenging
labially misplaced UR2 UL2 incisors, LR3 partially blocked out of arch and a normal profile. Gilbert (images 3-21 through 3-23)
presented with severe crowding and constriction of the dental arches. His maxillary lateral incisors are labially displaced. We
will discuss the management of the maxillary lateral incisors in detail in our discussion of the differences between relative
extrusion vs. absolute extrusion.

TREATMENT PLAN
In Gilbert’s case we are going to resolve his crowding with a combination of the following:
Posterior Expansion
Anterior Proclination
IPR

Gilbert presents with negative space (dark buccal corridors) with collapsed arches on both sides. Posterior expansion of 2-
3mm per side to upright his lingually inclined posterior teeth, will help gain a fuller and more esthetic smile. Nevertheless, I still
want to maintain Gilbert’s mandibular inter-canine width.
Note the initial position of the maxillary lateral incisors. They are proclined labially. This sets up beautifully for Invisalign
treatment since palatal tipping of these teeth will result in relative extrusion.
There are two types of extrusion:
Absolute extrusion
Relative extrusion
Absolute extrusion involves physically “grabbing” a tooth and extruding it in relation to the alveolus, and it can be a
challenging movement with aligners. Relative extrusion is different — it is lingual tipping (image 3-24) in which you can see this
concept on Gilbert’s laterals, which is an “Invisalign free ride”. As the teeth tip lingually they also tend to deepen automatically. It’s
not something that requires any specific ClinCheck modification — and it’s very predictable. As you can see on Gilbert’s ClinCheck
plan, there are optimized extrusion attachments on the maxillary lateral incisors. This indicates that the software detected some
degree of absolute extrusion, and these attachments are automatically placed with the active surface perpendicular to the force
necessary to achieve extrusion. Please refer to chapter 5 for more information on relative vs. absolute extrusion, and chapter 8 for
details on attachments that can be useful in cases where absolute extrusion is desired.

Pro Tip: Relative extrusion of UR2 UL2 is very predictable movement.

In the mandibular arch, we are creating space to resolve the crowding through a combination of posterior expansion, proclination
of the incisors, along with anterior IPR. (see image 3-25). In the maxillary arch, posterior expansion, proclination of the palatally
tipped UR1 and UL1, and anterior IPR create space for alignment as well as palatal tipping of UR2 UL2 (image 3-26).

RESULTS
Images 3-27 and 3-28 show Gilbert’s final results as compared to his ClinCheck plan — his arches are well-aligned; we’ve
maintained the inter-canine width; maxillary arches are well-aligned; maxillary lateral incisors have predictably, relatively
extruded; and we have achieved a functional and esthetic result.
Looking at the superimposition (image 3-29) note the 3-degree proclination of the lower incisors. Also note the maintenance of
the vertical dimension and excellent control of the mandibular plane angle. His final panoramic radiograph is shown in image 3-30.
Thirty months into retention his results are stable and are holding up well (image 3-31).

Summary: Total treatment time was 25 months with two refinements, and he is being retained with Vivera® retainers. I look at
Gilbert’s treatment as an “index case,” meaning that his treatment serves as a guide for many of the lesser-crowded cases that
present in my practice. If I can manage Gilbert’s severe crowding successfully with Invisalign clear aligners, I am confident I can
handle the mild to moderately crowded cases as well. And so can you!
EXTRACTION TREATMENT
For those Invisalign patients requiring extraction of teeth to resolve their crowding (EXTRACTION in the Space Analysis
section under “Crowding” on the ClinCheck list), it is important to revisit two of the fundamental principles of Aligner treatment
discussed in Chapter 1 — Principle #1, Aligners work by pushing, and Principle #4, over treatment is a must. For the management
of extraction spaces, or any spaces where bodily movement is required (see “Bodily Movement” in Chapter 4 — Spacing), it is
most important to develop our ClinCheck setups in such a way as to properly control the position of the roots. We must identify the
push surfaces available on the teeth adjacent to the extraction space that will help achieve bodily movement, as well as over-
engineer the ClinCheck plan to place the appropriate force systems on the key teeth to keep the roots moving along with the crowns.
The three critical factors to examine when designing an extraction ClinCheck treatment plan are:
Virtual Gable Bends
Attachments
Pontics
Virtual Gable Bends (VGB) are an over-engineering ClinCheck move designed to place anti-tip forces on the teeth adjacent to
a space. Since the point of application of orthodontic force is at the level of the crown, some distance away from the center of
rotation of a tooth, the tendency for teeth to tip during space closure must be neutralized. The VGB, as viewed on the ClinCheck
plan, moves the root ahead of the crown to counteract the tendency for these teeth to tip, similar to the use of a gable bend in an arch
wire. However, keep in mind that the ClinCheck plan is a graphic representation of the forces being applied to the teeth by the
aligners rather than a prediction of the final position of the teeth. In other words, the full extent of the VGB does not express
clinically. Force systems, not teeth. For extraction space closure requiring bodily movement, a 30-degree VGB, 15 degrees on
each tooth, is sufficient (images 3-32, 3-33). The before and after panoramic radiographs taken on the same patient depict the well-
controlled position of the roots of the mandibular teeth after extraction of the lower first premolars and subsequent space closure
(images 3-34, 3-35). Note the differences between the final positions of the teeth on the ClinCheck plan as compared to the final
panoramic radiograph.

Attachments provide additional aligner “grip” to help control the movement of the teeth. We examine attachments in detail in
Chapter 8. They may be optimized — placed automatically by the software and engineered to place the specific force systems
necessary to achieve the desired tooth movement, or conventional. Optimized root control attachments are one of many
SmartForce® features automatically placed by the software. In cases where an optimized root control is not triggered, a vertical
rectangular attachment may be used to add additional root control when closing extraction spaces (see previous image 3-33).
Pontics provide esthetic replacement of extracted teeth. In cases where you are closing extraction spaces, I recommend
eliminating them. Why? It’s all about push surfaces. In extraction spaces, the optimal push surfaces for the aligner plastic to provide
anti-tip are the interproximal surfaces, represented by the green shaded area in image 3-36. The more the aligner material that wraps
around the interproximal surfaces, the greater resistance to unwanted tipping. When a pontic is present, there is a void on the
interproximal surfaces — and therefore no interproximal plastic at all. The best opportunity for the aligner material to resist tipping
is lost. Therefore, whenever possible, ask your technician to remove any pontics in areas where extraction spaces will be closed. If
a patient insists on having a pontic, your best bet is to ask for a thin pontic with at least 1mm of space on each side to allow for as
much interproximal plastic as possible.

A new development in extraction treatment is Invisalign G6, which is a solution for maximum anchorage premolar extraction
cases. At the time of this writing, Invisalign G6 innovations are being used throughout the world and along with Invisalign G7
innovations represents the latest evolution in Invisalign treatment.
SUMMARY
Crowding is probably the most common clinical issue to be resolved orthodontically. Use the ClinCheck list to guide you through
the treatment decisions necessary to unravel crowding in a systematic, controlled fashion. The principles and examples outlined in
this chapter will help you to achieve predictable results time and time again!

CHAPTER 4
Spacing
The next item on the ClinCheck list is spacing. Spacing is defined as teeth that have separated and lost proximal contact with
adjacent teeth.
In orthodontics, there are only two ways to solve spacing problems, tipping or bodily movement. The SPACING section of the
ClinCheck list helps guide you through your treatment decision on spacing cases.
Tipping is an “Invisalign free ride”. Since orthodontic forces are applied to the crowns of teeth — a distance away from the
center of rotation — teeth orthodontically tend to tip as they move, something we can capitalize upon with Invisalign treatment
when tipping is desired. When we are planning movements that require tipping, major ClinCheck modifications are not needed, and
these tipping movements are quite predictable.
In cases like this one pictured in image 4-1, where the patient presents with the UR1 and UL1 tipped away from each other,
Invisalign treatment is very predictable, and the final ClinCheck stage is identical to the final clinical presentation (images 4-2, 4-
3).

Tipping may also occur in cases of incisor retraction where the initial presentation is of flared and spaced upper and or lower
incisors (images 4-4, 4-5). For the patient depicted in images 4-6, 4-7, the upper and lower anterior teeth were retracted via
tipping to both close the spaces as well as upright the teeth. Another Invisalign free ride!

CLINICAL CHALLENGE: BODILY MOVEMENT OF TEETH
The second way to close spaces is with bodily movement. Bodily movement is more challenging and the force systems acting
upon the teeth are more complex. There are two ClinCheck modifications to consider when closing spaces via bodily movement:

Attachments — attachments provide additional aligner “grip”. They may be optimized — placed automatically by the software
and engineered to place the specific force systems necessary to achieve the desired tooth movement, or conventional. Note
the attachments on the UR1 and UL1 in this patient (images 4-8, 4-9) who presented with a diastema. On the UR1, there is an
optimized root-control attachment. On the UL1, there is a conventional vertical rectangular attachment. Both attachments
provide additional push surfaces to assist in bodily movement.
Virtual Gable Bends are adjustments we make in the ClinCheck plan as anti-tip. For example, in the aforementioned patient
with a diastema between the UR1 and UL1, we need to move the teeth bodily to close the space — we do not want them to tip.
If the teeth tip as they move, the crowns will tip off axis, the incisal edges will not be aligned, and there will be a dark triangle
between the teeth at the gingival aspect. Clearly not what we want.
Instruction to the Technician: “Please add a 30-degree virtual Gable Bend URI UL1.”
The Virtual Gable Bend (VGB) places forces to the teeth to counteract the tendency to tip, similar to the use of a gable bend in an
arch wire (image 4-10). Fifteen degrees of additional root tip is applied to each tooth, resulting in a total of 30 degrees. In images 4-
11 through 4-14 we see the patient in progress and the teeth are still moving well, the diastema almost closed and the teeth still
upright.

Note at Stage 16, image 4-10: There appears to be more root movement versus crown movement, which is deliberate. We are

placing 30 degrees of mesial root movement into the ClinCheck plan as “anti-tip”. Clinically, however, the full extent of the VGB
does not express. The VGB is an excellent illustration of looking at ClinCheck as force systems, not teeth, which is another central
theme of this book. Clinically at stage 16 the teeth do not look like they are overly tipped — they are still upright.
Case no. 2 (images 4-15 through 4-19): This patient is missing the upper-left lateral incisor. Our treatment plan involves moving
the upper-left canine distally into Class I and opening the space for an implant. If you look on her Panoramic X-Ray, you can see
that UL2 is missing, and she has a peg-lateral tooth UR2.

Instructions to the technician for case no. 2: My instructions are going to direct the technician to add over-engineering. I
am going to tell the technician, “Please over-treat the distal root tip of the UL3 by 30 degrees.
Just like in the previous case, where I programmed 30 degrees of additional root movement in the ClinCheck plan that did not
express clinically — the additional root movement is placed as a force system to keep the tooth from tipping. Force systems, not
teeth. We are going to do the same thing in this case. I am not expecting to actually have 30 degrees of additional root movement,
but as the UL3 moves distally, I am concerned about the crown tipping distally and root moving mesially via uncontrolled tipping.
This would be undesirable, as there would be insufficient space for implant placement. Therefore, I am over-engineering the
ClinCheck plan to set up the proper force system to achieve bodily movement.
In the final X-ray, notice we now have the UR3 in proper position and the implant space prepared (20 months total treatment
time). In this situation, I over-engineered the ClinCheck plan to establish the proper force system to achieve bodily movement.
Root movement is one of the areas where I routinely over-engineer.
Please note: For details on how to manage the closure of extraction spaces, please see Chapter 3.
TOOTH-SIZE DISCREPANCIES
Tooth-size discrepancies or TSD on the ClinCheck list (also known as a Bolton discrepancy) are an area sometimes overlooked
by doctors when viewing their ClinCheck treatment plans. The Bolton ratio (named for Dr. Wayne A. Bolton) is a measure of the
relative mesio-distal widths of the upper and lower teeth. In an ideal ratio, the widths of the mandibular teeth will be 77 percent of
the maxillary teeth. This makes sense, since the mandibular teeth have to fit inside of the maxillary teeth. A Bolton discrepancy
exists when the ratio falls outside of 77 percent. Most frequently, a Bolton discrepancy is the result of narrow maxillary lateral
incisors. If we do not make up the difference and manage a Bolton discrepancy with either lower IPR or leaving space somewhere
in the maxillary arch, there is going to be a problem. The problem frequently manifests itself as a posterior open bite.
Think about it like this: If a patient who presents with maxillary spacing does not have enough tooth structure in the maxillary
arch (and they have a Bolton discrepancy where there is relative excess tooth structure in the mandibular arch) and we don’t manage
that problem, in our efforts to close the upper space the upper incisors are retracted into the lower incisors. This will in turn cause

“heavy” anterior contact on the incisors and posterior open bites. In my teaching travels, I have more than once encountered a doctor
who had difficulty understanding why their “easy” CL I upper spacing case developed a large posterior open bite. If this has
happened to one of your patients, look at the Bolton analysis available for all cases in ClinCheck Pro and consider managing the
problem with either:
Lower IPR and lower incisor retraction, possibly supported with CL III elastics
Leaving space for cosmetic buildup of narrow maxillary lateral incisors
Leaving space distal to the upper canines or in-between the premolars
CL III elastics alone, or
A combination of the above
CLINCHECK PRO
Now let’s go into ClinCheck Pro.
Step 1: Open your case in ClinCheck Pro.
Step 2: On your ClinCheck Pro. menu, select Bolton (image 4-20)
A screen will appear with the Bolton analysis for your patient.
In this case (image 4-21), the patient has a 2.77mm Mandibular Excess that needs to be managed.
Step 4: Go back into your Invisalign Doctor Site homepage

Step 5: Find Clinical Preferences and click on it (image 4-22)

Step 6: Under ClinCheck no. 9 you’ll see Tooth size discrepancy (image 4-23)
Step 7: You have three options (click on radial button of choice):

1. Leave space distal to the laterals
2. Leave space equally around the laterals
3. IPR opposing arch*
Note: You can override these preferences for any particular case. *NO. 3 is my preference: IPR opposing arch
Question: When wouldn’t I IPR the opposing arch?
Answer: When a patient presents with small or peg-lateral incisors, which are going to be set up for cosmetic tooth build-up
later on when Invisalign treatment has been completed.
SUMMARY
This chapter will help guide you through the treatment decisions and ClinCheck moves to achieve predictably excellent results in
your Invisalign spacing cases. Use the SPACING section of the ClinCheck list, along with the principles discussed in this chapter
when analyzing your ClinCheck set-ups. Learn to recognize tipping movements versus bodily movements and you will be on your
way to great results!

CHAPTER 5
Vertical Dimension
This chapter deals with managing problems that involve the vertical dimension. When we deal with Invisalign patients who have
problems in the vertical dimension, we’re looking at either deep-bite or open-bite problems. In addition, we will look at single
tooth vertical movements as well.
Deep Bite — like the parameters we have already explored, there are only a limited number of ways to correct deep bites. We
can correct deep bites with the following:
Anterior intrusion
Posterior extrusion
A combination thereof
There are considerations for each of these moves. How does one make the decision in any given case to intrude the anterior teeth,
extrude the posterior teeth, or both? In deep-bite cases requiring anterior intrusion, what criteria does the doctor consider in
deciding to intrude the lower anterior teeth, upper anterior teeth, or both? Let’s look at the ClinCheck list for guidance:
Let’s examine each of these separately:

Incisal display — intrusion of the upper anterior teeth would be indicated in deep-bite cases with super-eruption of the upper
incisors, but would be contra-indicated in deep-bite cases with insufficient incisal display.
Gingival display — similar to incisal display, upper anterior intrusion may be beneficial in patients with vertical maxillary
excess (VME) to reduce gummy smiles (image 5-1, 5-2).

Gingival margins — intrusion or extrusion of key teeth may help to improve the symmetry of gingival margins. In patients with
incisal wear and super-eruption of the worn tooth, anterior intrusion would be indicated to level the gingival margins prior to
restoration of the tooth (image 5-3).

Smile arc — when working up Invisalign treatment plans, we endeavor to create pleasing smile arcs where the curvature of the
upper anterior incisal edges follows the curvature of the lower lip. Anterior intrusion or extrusion is a primary consideration in
these cases (images 5-1, 5-2).
Lower Curve of Spee — lower incisor intrusion and/or posterior extrusion are key components to correcting deep over bites.
Some deep-bite cases requiring bite opening via posterior extrusion. For example, in patients with:
Short lower facial heights
Restorative cases with loss of vertical dimension
Hypodivergent, skeletal deep bites
CL II div.2 malocclusion
Open Bite — there are limited options here, too. We can do the following:
Extrude the anterior teeth
Intrude the posterior teeth, or
A combination of the two.
Not surprisingly, the same considerations apply:

Incisal display — anterior open-bite cases with insufficient incisal display may benefit esthetically from anterior extrusion,
whereas those patients with normal incisal display would be more likely to benefit from closure of the open bite via posterior
intrusion.
Gingival display — anterior open-bite cases with excessive gingival display would not benefit esthetically from upper anterior
extrusion, whereas those with insufficient gingival display would.
Gingival margins — leveling gingival margins may in some cases require extrusion.
Smile arc — when an anterior open bite is related to a habit, the resul- tant reverse smile arc may be remedied with anterior
extrusion.
RELATIVE VS. ABSOLUTE EXTRUSION/INTRUSION

Relative vs. Absolute Extrusion/Intrusion is another subheading in the vertical section of the ClinCheck list. Let’s examine these
movements more closely:
Relative Extrusion or Intrusion — these are predictable movements, another “Invisalign free ride,” and you don’t need any
specific attachments or major ClinCheck plan modifications to achieve relative extrusion or intrusion.
In cases that require relative extrusion, we achieve it by simply tipping teeth lingually. When teeth tip lingually, the incisal edges
of the anterior teeth travel along an arc and the bite naturally tends to deepen, as do Gilbert’s (from Chapter 3) UR2 and UL2
(images 5-4, 5-5). Again, this is a predictable movement, and no special ClinCheck plan modifications are required in open-bite
cases where we desire closure of the bite. On the other hand, in deep-bite cases that present with flaring and spacing of the
anterior teeth, retraction of the anterior teeth will also lead to relative extrusion, which would worsen the deep bite. In these cases,
compensatory incisor intrusion should be built into the ClinCheck plan to counteract the bite-deepening effects of relative
extrusion.

The same goes for relative intrusion. In deep-bite cases where the anterior teeth are lingually inclined, labial proclination will
tip the crowns forward, resulting in the incisal edges traveling in an arc away from each other (images 5-6, 5-7). It’s important to
recognize cases requiring relative intrusion or extrusion, as these movements are more predictable. Similarly, in open-bite cases
that require proclination of the anterior teeth — to resolve crowding for example — the proclination will result in relative intrusion,
which would make the open bite worse. In these cases, compensatory absolute incisor extrusion must be built into the ClinCheck
plan.

Absolute Extrusion/Intrusion — are more challenging movements with Invisalign treatment — this doesn’t mean we can’t
achieve it — however it is important to “read” your ClinCheck plan and recognize teeth that are absolutely extruding or intruding.
The superimposition tool can be helpful to determine absolute vs. relative movements. In certain cases, absolute extrusion requires
specific:
Attachment substitutions
Over treatment moves, and/or
Auxiliaries
In cases of absolute extrusion, we are physically extruding a tooth or group of teeth relative to the alveolus. This requires “grip”
— a lot of grip — most commonly on central and lateral incisors that have very smooth surfaces and minimal undercuts. In some
cases that require absolute extrusion, optimized extrusion attachments will be placed automatically by the software. The presence
of optimized extrusion attachments on the anterior teeth is a tip-off that absolute extrusion is occurring.
Let’s take a closer look at the orientation of the optimized extrusion attachment. (image 5-8). These attachments, like all

optimized attachments, are placed automatically by the software to place the specific force systems on the teeth to achieve the
desired tooth movement. It is important to understand that the forces will be perpendicular to the active surface of the attachment,
and that the aligner surface interacting with the active surface will be pre-activated to create the proper forces. Furthermore, I
strongly recommended that these attachments NOT be removed, despite the esthetic concerns of some patients. They are on the teeth
for a reason — to achieve the desired movement — and if they are removed the likeli- hood of encountering a non-tracking situation
increases.
There are clinical situations, most often on non-tracking maxillary lateral incisors, where I will reengineer the attachments to
provide additional aligner grip to help keep the teeth extruding. In my experience, I have found that a modified 4mm-long,
gingivally-beveled, rectangular attachment can be quite useful (image 5-9). I will use 3D controls to move the attachment close to
the incisal edge, where the aligner plastic is stiffer. In my experience this allows for better “grip” and more predictable absolute
extrusion. Furthermore, I will use 3D controls to “roll” the bevel as gingivally as possible to create a bevel that blends smoothly
into the labial surface of the tooth, to gain additional surface area on the attachment, and therefore more aligner “grip.”

In cases of absolute extrusion, I have had many doctors ask me, “Which way does the bevel go?” There are two options to
answer this question: we can place the bevel incisally or gingivally.
Incisal — when we use this approach we can potentially get more “grip” where there will be a 90° ledge at the gingival aspect
(image 5-10) that will engage the aligner. This makes sense because we’re going to get more aligner grip. However, there is a higher
chance for failure mode. Failure mode occurs when the aligner loses tracking and becomes totally disengaged from the attachment.
If this occurs, the aligner has the potential to place undesired lingual forces on the tooth, which can lead to inadvertent intrusion,
just the opposite of what we want.
Gingival — if we bevel our attachments gingivally (image 5-9) we get somewhat less grip, but also we have less chance to
encounter failure mode. This is my personal preference when I am looking to achieve absolute extrusion, and I find this attachment
quite useful.
DEEP-BITE OPTIONS
Invisalign G5 innovations were designed to specifically address the challenges of correcting deep overbites with Invisalign. G5

features include:
Pressure areas to intrude upper and lower incisors — these pressure areas direct the forces of intrusion along the long axis of
the tooth for more predictable intrusion.
Optimized premolar anchorage attachments — provide additional posterior anchorage to support lower incisor intrusion and
leveling of the lower Curve of Spee.
Precision bite ramps on upper incisors — disocclude the posterior teeth to remove posterior bite forces that may work against
deep-bite correction.
Conventional bite ramps on upper canines — when the overjet is greater than 3mm, the lower incisors will occlude behind
precision bite ramps. Conventional bite ramps on the upper canines in this situation may be a better option.
When patients present with deep-bite problems, the doctor has choices to make toward correction. These choices include:
Anterior Intrusion — in cases requiring anterior intrusion, the G5 pressure areas are placed on any incisor requiring intrusion
incisors automatically. You do not have to request them.
Optimized anchorage attachments on pre-molars are also placed automatically. These attachments provide anchorage to support
lower incisors intrusion. You may be asking, “Why do I need posterior anchorage to support lower incisor intrusion?” Think
Newton’s third law. For every action, there is an equal and opposite reaction. In cases requiring lower incisor intrusion, for
example, the “action” force is placed by the lower aligner against the lower incisors to intrude them. The “reaction” is for the
aligner to lift off the posterior teeth. Clearly, we don’t want this to occur. “Posterior lift off” will result in decreased intrusion force
to the anterior teeth, and the deep bite may not correct. Optimized anchorage attachments help keep the aligners engaged on the
premolars, resulting in more predictable deep-bite correction.
NOTE: A situation may arise where the optimized premolar anchorage attachments don’t appear on your ClinCheck plan. If the
software detects greater than 5° rotations on the lower premolars the patient will not get the optimized G5 anchorage attachment.
Instead, an optimized rotation attachment will be placed. In my experience, the optimized rotation attachment does not provide
sufficient anchorage to support intrusion of the lower anterior teeth. At this point, it would be time for substitution of attachments.
Let’s take a look at the Clin Checklist.
The Attachment section of the ClinCheck list helps guide you through this decision. In cases where you deem deep overbite
correction to have priority over premolar rotation, substitute 4mm-wide, occlusally- beveled rectangular attachments on the lower
first and second premolars (image 5-15). These attachments provide additional “grip” to prevent the aligners from lifting off
posteriorly, and are very effective at supporting the intrusion of the lower incisors.
For the reader: We will look at attachments in more detail in chapter 8.

Posterior Extrusion — in deep-bite cases requiring posterior extrusion, you may request precision bite ramps on the U1’s and
and/or 2’s. Precision bite ramps act like mini “bite plates” to disocclude the posterior teeth when wearing the aligners. If there is
over-jet greater than 3mm bite ramps are not effective — the lower incisors will bite behind them. In these cases, we request
conventional bite ramps on the U3’s. The conventional bite ramps or the precision bite ramps will disocclude posterior teeth and
will remove posterior bite forces that work against deep-bite correction.
WHEN TO PRESCRIBE PRECISION BITE RAMPS

How do you determine when to prescribe precision bite ramps? Following are the times when I prescribe them:
Deep-Bite Cases Requiring Posterior Extrusion — we want the precision bite ramps to disocclude the posterior teeth, which

will facilitate posterior extrusion by removing occlusal forces.
Levelling the lower Curve of Spee — I also prescribe precision bite ramps when I want to lower the Curve of Spee (COS)
when premolar eruption is needed, for the same reason. I want to remove the forces of occlusion that would interfere with the
eruption of the premolars.
Class II, Division 2 Cases — I consider using precision bite ramps in skeletal low angle (hypodivergent) cases (i.e. CL II div. 2)
where we’re looking to open the vertical dimension and lengthen the lower facial height.
Bite Plate Effect — another place to use precision bite ramps is as a bite plate to facilitate correction of dental cross-bites. It
may help to reduce the trauma to the tooth in cross-bite as it’s moving through the zone of heavy contact with the opposing dentition.
DO NOT USE PRECISION BITE RAMPS

Deep-Bite Cases Requiring Anterior Intrusion — if deep-bite correction is via anterior intrusion only, precision bite ramps
are not needed.
High Angle (hyperdivergent) Cases — for example, a patient who has a long facial height and an excessive gingival display
upon smiling is not a candidate for precision bite ramps. In those cases, we are looking to not open the vertical dimension or rotate
the mandible in a clockwise direction — I don’t recommend using precision bite ramps.

CASE STUDY NO. 1 — HALEY
Haley is a 14-year-old girl who presents with a Class 1 Malocclusion with a deep overbite and upper and lower crowding
(images 5-11 through 5-13). The VERTICAL section of the ClinCheck list is significant for Haley’s case:

We need to devise a biomechanical system in our Invisalign treatment to correct her deep overbite.

TREATMENT PLAN
Step 1: Go to Vertical section of ClinCheck list
Step 2: Go to Incisal Display
Step 3: Gingival Display is circled because Haley has excess gingival display upon smiling that speaks toward improving her
Smile Arc via intrusion of the upper anterior teeth. If we can intrude her upper anterior teeth we will help to correct her deep
overbite and it will also improve her smile esthetics.
Step 4: Leveling the deep Curve of Spee in the lower arch via lower incisor intrusion will also contribute to correction of the
deep over bite.

Haley has a deep COS, and the idea here is to level it (image 5-14). Since the lower incisors are retroclined, proclination will
lead to predictable relative intrusion. Further examination of the ClinCheck superimposition reveals a combination of relative
and absolute lower incisor intrusion, therefore 4mm-long, occlusally-beveled rectangular attachments are added to the lower 4’s
and 5’s to support the lower incisor intrusion (image 5-15).

RESULTS
Look at her after images (image 5-16) and we’ve achieved leveling of the COS through appropriate attachment design and
appropriate anchorage. The upper incisors were intruded to achieve a pleasing smile arc. In her initial and final facial images
(images 5-17, 5-18) notice the reduction in the amount of gingiva seen upon smiling and a pleasing smile arc. Her final panoramic
X-ray (image 5-19) is normal and her superimposition (image 5-20) shows proclination of the lower incisors, which was desirable
in this case both to alleviate the crowding as well as to achieve relative intrusion of the lower arch.

Summary: Halley’s treatment took 24 months with one refinement.

CASE STUDY NO. 2 — ERIN
Erin presents as a 14-year-old female with Class I Malocclusion with moderate to severely deep overbite; moderate upper and
lower crowding; the upper R3 is in cross-bite; she has a palatal supernumerary tooth; and she has a normal profile (images 5-21
through 5-23). In this case, we are going to discuss how we corrected both her deep overbite as well as how we corrected the
cross-bite of the UR3.

TREATMENT PLAN
Step 1: We want to resolve her deep overbite with a combination of intrusion of the upper and lower anterior teeth. The UR1
and UL1 require absolute intrusion.
Note: This is a case where I prescribed precision bite ramps. The reason was to give the patient a bite-plate effect to help ease
the correction of the cross-bite of the UR3 by removing the forces of occlusion that would work against jumping of the cross-bite.

Note intrusion of the UL central incisors on the ClinCheck plan (image 5-24). The precision bite ramps, which disclude the
posterior teeth and help with the cross-bite correction (image 5-25). The labial tipping of the UR3 is a predictable movement.

RESULTS
Erin’s final results can be seen in images 5-26 and 5-27. The deep over bite was corrected and the cross-bite of the UR3 was
successfully corrected.
Summary: Total treatment time was 16 months.

CASE STUDY NO. 3 — OSCAR
Oscar presents with a Class II Division 2 deep overbite malocclusion and a hypodivergent facial pattern (images 5-28 through 5-
30).

TREATMENT PLAN
The ClinCheck list reveals that the retroclined upper incisors require relative intrusion via proclination, while the lower incisors
require absolute intrusion to help level the deep COS. In addition, posterior extrusion is desired to increase the vertical
dimension in this hypodivergent facial pattern. Precision bite ramps are indicated in this case to eliminate posterior occlusal
forces that can work against posterior eruption and deep bite correction in general.

The ClinCheck plan shows a typical over treatment of the deep overbite via the moves outlined in Oscar’s ClinCheck list
(image 5-31). The instructions to the technician to achieve this are, “Please set the final overbite at 0mm.” Why? Remember, the
ClinCheck plan is a graphic representation of the forces being applied to the teeth by the aligners rather than a prediction of the
final tooth positions. Force systems, not teeth. As if we were placing reverse curved arch wires, we want sufficient forces to open
the bite. In addition, there is 30 degrees additional palatal root torque (PRT) U 2112 since the upper anterior teeth begin with severe
lingual inclination. Please see chapter 10 for more details about over treatment.

RESULTS
The final result reveals excellent resolution of the deep overbite as well as the CL II malocclusion, achieved in 40 months of
treatment using light CL II elastics (images 5-32 trough 5-34). Please see chapter 6 for a detailed discussion of sagittal correction.

ANTERIOR OPEN BITE TREATMENT
Orthodontic treatment for anterior open-bite problems with Invisalign has inherent advantages. Compared with fixed appliances,
the inter-occlusal plastic between the posterior teeth does an excellent job of controlling the vertical dimension, eliminating the
possibility of inadvertent posterior extrusion. In addition, the ClinCheck treatment plan can be set up with selective posterior
intrusion to allow for mandibular auto-rotation and subsequent bite closure. Combined with either relative and/or absolute anterior
extrusion, depending on the requirements of the case, the orthodontist has a powerful tool at his or her disposal to manage anterior
open-bite malocclusions.
As described by my friend and colleague Willy Dayan, D.D.S., Dip. Ortho, the key to successful anterior open-bite treatment is
the development of “gentle, positive Curves of Spee in both arches” via selective intrusion of posterior teeth. The development of
a “purposeful posterior open bite” in the ClinCheck treatment plan allows for mandibular auto-rotation and subsequent bite
closure. Most frequently, the upper molars are intruded along with the “middle teeth,” the lower premolars and lower first molars,
in the lower arch.
The teeth being intruded do not require attachments, since the occlusal tables provide sufficient push surface to gain intrusion.
Horizontal rectangular attachments are placed on the teeth adjacent to the teeth being intruded to provide sufficient aligner “grip”
to support the intrusion.
To illustrate these concepts, let’s examine an adult patient who presented with an anterior open bite.

CASE STUDY NO. 4 — MICHELLE
Michelle presents as a 41-year-old female patient with a Class I Malocclusion, mild upper and lower crowding, and an anterior
open bite (image 5-35 through 5-37). Anterior open bites in particular are areas that aligners handle beautifully. Her ClinCheck list
is as follows:

TREATMENT PLAN
We can take advantage of Invisalign’s ability to intrude posterior teeth to achieve closure of the anterior open bite. In this case,
the treatment plan was to intrude the upper molars along with the lower premolars and first molar to create gentle Curves of Spee in
both arches. In addition, upper and lower anterior extrusion will be programmed into the ClinCheck as well.

CLINCHECK TREATMENT PLAN NO. 1
The first ClinCheck treatment plan that came back from my technician (image 5-38) shows what at first appears to be an ideal
result. However, acceptance of this ClinCheck plan would most likely lead to insufficient bite closure. This is another illustration of
the concept that the final ClinCheck plan is not a prediction of the final occlusion. Instead, it is a graphic representation of the forces
being applied to the teeth by the aligners. Force systems, not teeth. Therefore, the ClinCheck plan was modified as follows.

MODIFIED CLINCHECK TREATMENT PLAN#2 (image 5-39)
One of the areas where I routinely over-engineer aligners is in the case of absolute intrusion. I do not expect the aligners to fully
express in a movement as challenging as intrusion, so in a case like Michelle’s the ClinCheck plan is modified a second time. I ask
for an additional 2mm of intrusion on the upper 6’s and 7’s, as well as the lower 4’s, 5’s and 6’s to the extent that at the final stage
the patient displays a 2mm posterior open-bite on these teeth.
I have placed 4mm-long, conventional, occlusally-beveled rectangular attachments on the upper first pre-molar and the upper-
second molar. Similar supportive attachments are placed on the lower second molars and lower canines. These attachments provide
anchorage to support intrusion of the upper first and second molars. Let’s revisit Newton’s Third Law: in the upper arch, the
“action” force is intrusion of the UR6 and UR7 and the “reaction” force will tend to make the aligner dislodge in the premolar
region. Anchorage attachments on the upper premolars prevent the dislodgment of the aligner, and support the absolute intrusion of
the upper molars. Similarly in the lower arch, supportive attachments are placed on the lower 7’s and lower 3’s to support the
intrusion of the lower 4’s, 5’s and 6’s. This setup, where there are supportive attachments on the teeth adjacent to those being
intruded, is a common one for absolute intrusion.
Note: I do not expect the aligners to fully express, but I want to over-engineer the ClinCheck plan. Michelle’s ClinCheck plan is
not an image of her final occlusion. It is a graphic representation of the force systems required to close the open bite. Force systems,
not teeth. I want enough force of intrusion to get the bite closed. With this last modification, the ClinCheck treatment plan is ready
to be accepted.

RESULTS
Michelle’s treatment took only eight months and her arches are well- aligned. Image 5-40 depicts successful closure of the open-
bite, and in fact, illustrates the patient did not finish with a posterior open-bite. This example shows that over-engineering gave us
the appropriate movement without excessive movement. Michelle finishes with both an esthetic and functional result.
SUMMARY
Correction of problems in the vertical dimension with Invisalign treatment, whether deep bite or open bite, require the same
basic concepts. Establishment of proper aligner anchorage in your ClinCheck setups to support either anterior or posterior
intrusion along with over treatment of intrusion and extrusion will help you achieve predictably excellent results. For more specifics
on over treatment, please turn to chapter 10, where we look at the scenarios where over treatment can be beneficial.

CHAPTER 6
Sagittal Dimension
This chapter deals with correcting problems in the Sagittal Dimension. When managing problems in this dimension we are han-
dling Class II or Class III Malocclusions. I am going to take each of these clinical problems separately and guide you through them.
CLASS II MALOCCLUSIONS
The ClinCheck list indicates four potential non-surgical ways to correct Class II Malocclusions:
Distalization of the upper posterior teeth.

Class II Elastic Jump — we can prescribe Class II elastic jumps in our ClinCheck plan to simulate the effects of our elastics
on a growing teen patient.
Extraction of teeth, typically upper first premolars, to correct Class II Malocclusion.
IPR — this would be IPR performed in the upper buccal segments to create space for canine retraction into Class I coupling of
the incisors when the patient presents with overjet.
These four areas are the non-surgical choices doctors have at their disposal. The next objective is to decide which of these to use
to treat a patient’s condition. Here are some resources that doctors might find helpful:
“Correction of Class II Malocclusion with Class II Elastics: A Systematic Review by Janson et.al, March 2013, American
Journal of Orthodontics and Dental Facial Orthopedics (AJODO.) — the authors started by examining over 400 papers devoted
to the topic of correction of Class II Malocclusions. Out of those 400 articles they selected 11 papers that fit their criteria. Four of
the papers looked at the effects of Class II elastics alone in correcting malocclusion. The other seven papers compared the effects
between Class II elastics and another method to correct Class II Malocclusion — for example, fixed-functional appliances.
Now to examine the four papers on “elastics alone”:
Nelson Associates, 1999
Meistrell Associates, 1986
Tovstein, 1955
Combrink Associates, 2006
The authors concluded: Class II elastics are effective in correcting Class II Malocclusion through a combination of dento-
alveolar and skeletal effects. The effects of Class II elastics in patients are:
Restraint of maxillary growth — the studies showed that in patients treated with Class II elastics the maxillary first molar
tended to maintain its antero-posterior position at the same time that the SNA angle was reduced. In a sense, Class II elastics
achieve a headgear effect.
Small amount of additional mandibular growth — the authors also found that when compared to untreated patients one could
expect 1.2mm additional mandibular growth. Dentoalveolar effects — as far as the dental effects were concerned the studies found
an average of 5.8mm overjet reduction. In summary, the authors concluded that Class II elastics work through 63 percent dental
change in position of the teeth, and 37 percent were attributed to skeletal changes (e.g., headgear effect and a small additional
contribution to mandibular growth).
Note: Because 37 percent of the sagittal correction can be attributed to skeletal change, I do not recommend using Class II
elastic-jumps in non-growing adult patients. I don’t expect skeletal change, and that is why I feel it’s much less predictable in adults
using Class II elastics than a growing teen patient.
The authors didn’t find any significant deleterious side effects with the use of CL II elastics. When they looked at vertical changes

in both the maxilla and the mandible were within normal ranges. No significant change in occlusal or mandibular plane was
observed.
Summary: My interpretation of this paper is that Class II elastics are safe and effective in correction of Class II malocclusion in
growing teen patients.
CLASS II ELASTICS VS. FIXED-FUNCTIONAL APPLIANCES

The other seven articles compared the effects of CL II elastics to fixed-functional appliances. The seven articles are:
Serbesis-Tsarudis and Pacherz, 2008
Jones et al, 2008
Nelson et al, 2007
Uzel et al, 2007
Nelson et al, 2000
Ellen et al, 1998
Gianelly et al, 1984
Here is a summary of what those seven articles collectively described: Class II elastics are similar to the effects of fixed-
functional appliances in the long term, placing two methods close to each other when evaluating treatment effectiveness. In
other words, both functional appliances and Class II elastics are safe and effective at correcting Class II malocclusion.
Class II Elastics Protocol Specifics:

Based on this research, I use the following elastic protocol for routine correction of Class II malocclusion for growing teen pa-
tients (image 6-1). Notice precision cut elastic hooks on the upper 3’s and the lower 6’s (for attaching Class II elastics) in addition
to a 3mm-long, occlusally-beveled, rectangular attachment placed on the lower 6’s act as retention to prevent the aligner from
dislodging from the vertical component of force from the Class II elastics.
Note: If you prefer a button bonded to the lower molars, prescribe a cutout on the lower 6’s instead of an elastic hook.
Step 1: Place attachments at the first visit.
Note: If you choose not to place the attachments at the first visit, don’t start Class II elastics until you’ve placed the attachments.
The aligners are not retentive enough to withstand the pull of the Class II elastics without attachments.
Step 2: Start with light elastics (1/2” 2 oz.)
Step 3: I’ll increase up to heavy (1/2” 4 oz.) — if necessary. I’ll do this in cases where the Class II discrepancy is greater than
3mm or if the teeth or the malocclusion doesn’t seem to be progressing toward Class I within a reasonable amount of time, which
would be four to six months.
On the Invisalign prescription form, see no. 4 on your prescription: Anterior-Poster (A-P) Relationship.
See Correction to Class I. Click on the two radial buttons directly across on that row — click radial buttons R and L.
Next, click on radial button: Tooth Movement Options. Click on square button: Class II/III Correction Simulation (Elastics

Required).
See “Precision Cuts — may compromise aligner strength and dura- bility” and below it reads Yes or No, click on Yes (image
6-2).

CASE STUDY NO. 1 — ABBY
Abby presented as a 16-year-old female with a Class II, Division I Malocclusion in the permanent dentition. She has a normal
overbite and a large overjet, mild upper and lower crowding, a V-shaped maxillary arch, and a normal profile (images 6-3 through
6-5). Her case will be an example of a case where we prescribe a Class II elastic-jump. Her skeletal pattern is normal. Her
cephalometric radiograph reveals protrusive maxillary anterior teeth and a normal skeletal pattern. Her panoramic radiograph is
normal. The SAGITTAL section of the ClinCheck list for Abby looks like this:

TREATMENT PLAN
A Class II elastic-jump was prescribed to address the sagittal discrepancy. A CL II elastic-jump is a ClinCheck simulation that
occurs at the last stage to simulate the correction of the malocclusion Class I in order to determine if the final occlusion is
acceptable. Four oz. elastics were selected in this case due to the large amount of sagittal correction required to achieve CL I.

As you can see in Abby’s ClinCheck plan, there are precision-cut hooks on the U3’s and L6’s, along with retentive 3mm-long,
occlusally-beveled, rectangular attachment on the lower 6’s. Also note the CL II elastic jump (image 6-6).
Here are pictures (image 6-7) of Abby in treatment wearing her aligners and using 4oz. 1/2” elastics. As is typical for my
Invisalign Teen patients, her hygiene is excellent, her tracking looks good, and she is progressing normally.
Note: Abby was going into her senior year of high school and she was a dancer and performer. She told her parents that if she
couldn’t be treated with Invisalign clear aligners she would rather keep her overbite and malocclusion the way it was previous to
treatment. Therefore, for Abby’s case Invisalign treatment was the only option. When she came to my office, I told her parents she
would be an excellent Invisalign candidate provided that she was compliant. She had to wear her aligners and elastics the required
22 hours per day — and I was confident we could get her case corrected. Most teens are compliant because they are motivated. If
you treat enough teens with Invisalign you start to realize that in the teenage population, it is just as much about psychology as it is
biology. If they are motivated, as in Abby’s case where she didn’t want to go into senior pictures or the prom wearing braces, this
motivation keeps her wearing her aligners and elastics and makes her a terrific patient.
Progress
One year into treatment you can appreciate Abby’s progress (image 6-8) with her Class II Malocclusion. She’s not quite Class I
yet, but she is progressing well. Continuing on through 16 months of treatment the progress (image 6-9), you can see her sagittal
correction continues to improve.

RESULTS
At the end of treatment (images 6-10 through 6-12) her malocclusion has been corrected from Class II to Class I. She has
excellent arch alignment and normal overbite and over-jet with excellent esthetics. Her final panoramic radiograph is normal.
Comparing her initial cephalometric radiograph to her final you can see significant change to the position of the upper incisors, and
significant retraction and resolution of her overjet. She has excellent smile esthetics.

Summary: Total treatment time is 22 months, 25 aligners, 20 refinement aligners, and 4 oz. Class II elastics.

CASE STUDY NO. 2 — EMMA
Emma (images 6-13 through 6-15) presented as a 12-year-old female in the late mixed dentition. She has a Class II, Division I
Malocclusion; she has a deep overbite; upper and lower crowding and severe lingual inclination of the upper and lower anterior
teeth. If you look at image 6-13, you can appreciate the significant amount of lower incisor crowding. Her right and left lower
incisors are blocked out to the lingual. We can also observe her deep overbite as well as the lingual inclination of the upper and
lower anterior teeth. Her panoramic radiograph is within normal limits and her cephalometric radiograph reveals a mild hypodi-
vergent skeletal pattern and upright upper and lower incisors.

TREATMENT PLAN
Emma is a growing teen, and her Class II, Division I malocclusion will be corrected with CLII elastics. Her crowding will be
resolved through a combination of posterior expansion and anterior proclination. The deep overbite correction was achieved via
predictable relative intrusion.

The ClinCheck setup features precision-cut elastic hooks on her lower 6’s, and 3m wide rectangular occlusally beveled
attachments on the lower 6’s for retention (image 6-16). The deep overbite was managed with predictable relative anterior intrusion
achieved with proclination of the upper and lower anterior teeth. The crowding was resolved through a combination of anterior
proclination and posterior expansion.
Note: One variation compared to Abby’s case, Emma has her precision-cut elastic hooks running off her upper 4’s because her
upper 3’s were insufficiently erupted to place a precision cut. It would have weak- ened the aligner so we placed them on the 4’s.
We simply run our Class II elastics from upper 4 to lower 6 instead of upper 3 to lower 6 — it works just the same. The crowding
was resolved through a combination of proclination and posterior expansion, and the deep bite was corrected via relative
extrusion gained during upper and lower proclination. Please refer to chapter 3 for more information on the options for resolution of
crowding, and chapter 5 for the details of vertical dimension correction.

RESULTS
At the end of treatment, she has well-aligned arches and her malocclusion has been corrected to Class I (images 6-17 through 6-
19). The final panoramic radiograph is within normal limits and her cephalometric superimposition shows the planned
proclination of the upper and lower incisors.

Note: As was pointed out in the Janson et.al. systematic review referenced earlier in this chapter, the maxillary first molar
tends to stay relatively the same antero-posteriorly as does A point. The superimposition shows the “headgear effect” which may
be achieved with Class II elastics. You can also see there was growth of the mandible showing forward positioning of pogonion and
reduction of facial convexity.
Summary: Treatment time was 28 months, with two refinements and the use of 2 oz. CL II elastics.

CASE STUDY NO. 3 — AVA
Ava presented as a 12-year-old female in the early permanent dentition with a Class II, Division I Malocclusion, deep overbite,
upper spacing and lower crowding. Her panoramic X-ray is in normal limits. Her cephalometric radiograph shows a Class II
skeletal pattern with a moderate amount of mandibular retrognatithism and a hyper-divergent facial growth pattern (images 6-20
through 6-22). Note the excessive gingival display on smiling. Ava’s ClinCheck list is as follows:

TREATMENT PLAN
A Class II elastic-jump was prescribed for this growing teen patient. Absolute intrusion of UR1 and UL1 was planned to reduce
the gummy smile, and intrusion of the lower incisors and flattening of the lower Curve of Spee was planned to correct the deep over
bite. Deep bite correction via posteri- or extrusion is contraindicated in this case. Posterior extrusion would lead to unwanted
clockwise mandibular rotation, which would result in a more retrusive chin as well as a larger CL II discrepancy. An in-depth
discussion of the do’s and don’ts of deep-bite correction may be found in Chapter 5.

The ClinCheck setup (image 6-23) shows Class II elastic hooks on her lower 6’s and upper 3’s, retentive attachments on the
lower 6’s as normal. The final ClinCheck stage depicts the Class II elastic-jump that we expect with the use of Class II elastics. The
deep overbite is corrected through a combination of upper and lower anterior absolute intrusion, without extrusion of the posterior
teeth. The aligner plastic between the upper and lower posterior teeth does an excellent job of preventing unwanted posterior
extrusion. This excellent vertical control is helpful in a hyperdivergent skeletal pattern. Note the overtreatment of the deep bite to
0mm, as well as 4mm-long, occlusally-beveled rectangular attachments on the lower 4’s and 5’s to support the intrusion of the lower
incisors.

RESULTS
See Ava’s final result (images 6-24 through 6-26): excellent correction from Class II to Class I, normal overbite, normal over-jet,
and well-aligned arches. Before and after comparison (images 6-27, 6-28) shows that when she presented initially she had
excessive gingival display upon smiling. We can see the improvement in the amount of gingiva that is exposed pre- to post-treatment,
which is indicative of the absolute intrusion achieved on the upper incisors. See chapter 8 for details on the attachment setup used in
Ava’s refinement ClinCheck plan to achieve this result. Her final panoramic radiograph is normal and her cephalometric
superimposition shows her maxillary molar tended to maintain its antero-posterior position as well as good control of the
mandibular plane angle.

Summary: Treatment lasted 28 months, with two refinements, and 2 oz. CL II elastics.

CASE STUDY NO. 4 — CANDACE
Candace (images 6-29, 6-30, 6-31) presented as an 11-year-old female patient with a CL II div. 1 Malocclusion, deep over bite,
upper and lower crowding, and UR2 blocked out to the labial. Let’s take a look at the SAGITTAL section of Candace’s ClinCheck
list:

TREATMENT PLAN
Distalization of the upper posterior teeth, supported with 4 oz. CL II elastics was selected in Candace’s case to both address the
CL II molar and canine relationship as well as creating space to align the UR2. You will see Candace again in Chapter 8 to learn the
ClinCheck moves used to manage the absolute intrusion of UR1 and UL1, as well as the relative extrusion of UR2.

The ClinCheck plan reveals that the posterior teeth were distalized using sequential distalization. Images 6-32-6-34 depict the
ClinCheck as the distalization progresses. Precision-cut elastic hooks are present so that the patient can wear 4 oz. CL II elastics to
both support the distalization and also block unwanted upper incisor proclination. The use of CL II elastics is critical to block
reciprocal forces which would tend to flare the upper anterior teeth and increase the over jet. Image 6-35 shows the typical staging
of sequential distalization — when each tooth achieves 50 percent of the desired distal movement, the next tooth in line begins to
distalize.

RESULTS
Candace’s final records demonstrate the correction achieved (images 6-36-6-38). Note on the superimposition that the maxillary
first molar re- mains in the same relative antero-posterior position while there is both growth of the mandible as well as dento-
alveolar changes. Sequential distalization can be a useful treatment modality in teen cases such as Candace’s.

Summary: Treatment lasted 40 months, with three refinements, and 4 oz. CL II elastics.
CL III CORRECTION
The non-surgical methods for CL III correction are elucidated on the SAGITTAL section of the ClinCheck list:
Let’s look at several CL III cases treated with different treatment methodologies.

CASE STUDY NO. 5— GABRIELLA
Gabriella presented as a 12-year-old female with Class III Malocclusion, moderate upper and lower crowding and traumatic
occlusion to her lower anterior teeth. Gabriella’s initial presentation (images 6-39-6-41) demonstrates her significant under-bite. I
felt compelled to commence Gabriella’s treatment as soon as possible to prevent additional trauma to her lower incisors and reduce
the chances of periodontal damage as well. Her panoramic X-ray is within normal limits. Her cephalometric X-ray reveals a Class
III skeletal pattern.

TREATMENT PLAN
Gabriella’s treatment plan revolves around treating her upper and lowers incisors to Steiner’s Acceptable Compromise, to
compensate for the Class III skeletal pattern. This means I added additional proclination to the upper incisors and allowed for
additional lingual tipping of the lower incisors to compensate for the Class III skeletal pattern, supported with CL III elastics.

One of the beauties of ClinCheck treatment planning is that it allows for virtual diagnosis and treatment planning. It gives us a
virtual simulation on a patient’s case before we even start. If you compare Gabriella’s mandibular and maxillary arch forms,
(image 6-42) you will note she has a square arch form in the maxilla and a V-shaped arch form in the mandible. This is a result of
the lower incisors are being forced labially and the upper incisors being forced palatally. The occlusal view of the final ClinCheck
stage (image 6-43) shows the coordination of the upper and lower arch forms. Image 6-44 shows the anticipated improvement in the
occlusion via arch form change only, without the need for a bite jump. Seeing this change in the virtual setup gave me confidence that
Gabriella’s malocclusion could be corrected. Also note the virtual bite turbos on LR1 and LL1. Virtual bite turbos are
conventional bite ramps built into the aligners that helped disocclude the anterior teeth to ease the jumping of the anterior cross bite.

PROGRESS
After eight months of treatment, note all of the benefits of Invisalign Teen (image 6-45). Her occlusion has greatly improved, and
there is significant improvement to her anterior relationship. However, at eight months, her upper incisors are still too upright and
she is displaying a posterior open-bite because of heavy occlusal contact in the anterior. In this type of case, we do not want to close
the posterior open bite by running posterior vertical elastics — that is not the problem. The reason Gabriella is manifesting a
posterior open bite is because of heavy anterior contact.
In refinement I ask for an additional 30-degrees of palatal root torque on U2112 to relieve the heavy occlusal contact, in addition
to precision-cut elastic hooks for CL III elastics (image 6-46). These two ClinCheck moves eliminate the heavy anterior contact and
eliminate the posterior open bite.

RESULTS
Study her final records (images 6-47-6-49). Note that her occlusal change comes from retraction of her lower incisors into the
leeway space and proclination of her upper incisors. These movements are enhanced by light 2 oz. CL III elastics. The final
occlusion is a solid Class I. She also has nice tissue response on the lower incisors by removing the traumatic inclusion. Her final
panoramic radiograph is within normal limits. Her cephalometric superimposition shows proclination of the upper incisors and
lingual tipping of the lower incisors, which is consistent with her CL III skeletal pattern and my treatment objectives. Three years
into retention, there has been a small degree of asymmetrical mandibular growth to the left, nevertheless her occlusion is still
holding up well (image 6-50).

Summary: Total treatment time was 19 months, 1 refinement, and 2 oz. elastics.

CASE STUDY NO. 6 — ALFONSO
Alfonso is a young adult patient who presented with Class III Malocclusion with moderate upper and lower crowding (images 6-
51- 6-53). My original treatment plan for Alfonso was orthodontics in con- junction with orthognathic surgery. However, Alfonso
refused surgery so we began to explore nonsurgical options. Based on the magnitude of his sagittal discrepancy, the treatment plan
was to use Invisalign clear aligners along with the extraction of the lower right and the lower left first premolars.

TREATMENT PLAN
The treatment plan involves treating the upper arch non-extraction, utilizing posterior expansion and IPR to align the arch. In the
lower arch, the lower right and left first premolars were extracted to create space for lower incisor retraction and ultimate coupling
of the canines and incisors.

Alfonso’s initial ClinCheck stage displays the magnitude of his Class III Malocclusion in addition to his extraction spaces where
the lower right and lower left premolars were removed. At the final ClinCheck stage, movement of the lower teeth into the
extraction spaces mirrors our discussion of bodily movement of closing spaces from the section on spacing in chapter 4. When we
move teeth to close extraction spaces the aligners are placing forces on the crowns of the teeth, tending to tip them into the extraction
spaces. Generally, that is not a desired movement. We want bodily movement so the roots finish parallel to each other at the end
of treatment.
Just like in a case where we are closing a diastema, we want to place virtual gable bends in addition to vertical rectangular
attachments on the teeth being moved into those spaces as anti-tip and over-engineering to control the position of the roots. At the
final stage you can appreciate there is a vertical attachment on the lower right and left premolar and first molars. You’ll also
appreciate that there is an optimized root control attachment on the lower canines. The software places the optimized root-control
attachments automatically with the appropriate force systems on the canines to maintain root position. In my experience, optimized
root-control attachments work very well. The software didn’t recognize that type of movement on the lower second pre-molars, and
I placed a lower conventional attachment to give the aligners grip to control positions of the roots (image 6-55).
PROGRESS
See the progress image 6-56 in treatment showing significant space closure. At this point, the lower second molars are being
protracted forward.
Note: The height discrepancy of UR1 and UL1. We will discuss how we achieved absolute extrusion of UL1 using a bootstrap
elastic in troubleshooting, chapter 11.

RESULTS
At the end of treatment (image 6-57) all spaces have been closed in the lower arch. We have achieved good coupling of the
lower incisors and Class I canines. The molar relationship is Class III by design. Alfonso achieved an excellent result for a
nonsurgical treatment plan. His final panoramic radiograph (image 6-58) reveals good parallelism of the lower roots
demonstrating that over-engineering using virtual gable bends and appropriate attachments led to good control of the teeth.

CASE STUDY NO. 7 — LUCAS
Lucas presented with a skeletal Class III Malocclusion, prognathic mandible, deficient maxilla, and moderate upper and lower
crowding. His cephalometric X-ray reveals a significant sagittal discrepancy and a significant Class III relationship (images 6-59-
6-61).

TREATMENT PLAN
The treatment plan involved leveling and aligning both arches to de- compensate, followed by maxillary advancement and
mandibular set- back surgery. Proclination of the lower incisors allowed for alignment of the lower arch as well as appropriate pre-
surgical decompensation.

The CL III elastic-jump is a useful pre-surgical planning tool to ensure good upper and lower arch coordination prior to surgery.
Images 6-62 and 6-63 show before and after CL III elastic-jump ClinCheck images.

RESULTS
Image 6-64 shows Lucas 62 one week after surgery. In this case the surgeon, Dr. David A Behrman, Chief of the Division of
Dentistry, Oral and Maxillofacial Surgery, Weill Cornell Medical College, placed TADs in the upper and lower arches for post-
surgical stabilization. The placement of TADs meant there were no fixed appliances that needed to be placed on the teeth before or
after surgery.
Once Lucas was released by the surgeon, he required one additional refinement series to refine the final occlusion. His final
result is depicted in images 6-64-6-66.

CHAPTER SUMMARY
When I began treating patients with Invisalign aligners in 2006, I would never have dreamed that sagittal correction would be a
routine part of my Invisalign treatment planning 10 years later. While each and every case is unique, I hope this chapter has outlined
some of the most common treatment planning options for Class II and Class III cases. Using the ClinCheck list to help guide you
through your Invisalign treatment decisions will lead to good treatment plans and great results!

CHAPTER 7
Transverse Dimension
In the previous two chapters, we have examined how to address orthodontic problems with Invisalign treatment in two planes
of space: vertical and sagittal. The third plane of space is the transverse dimension. When we are correcting transverse conditions
with Invisalign clear aligners, there are several considerations:
Expansion to resolve crowding — do we want to prescribe posteri- or expansion to resolve crowding? A very common
scenario would be a case like Gilbert (see also in chapter 3 his original case study) who presented with a Class I Malocclusion and
constricted dental arches. In this case, expansion of the transverse dimension using Invisalign to gain arch length helped to create
space to resolve his crowding (images 7-1 and 7-2).

A case like Gilbert’s would benefit from dental expansion. However, when you prescribe dental expansion you have to think
about how the teeth are expanding. With Invisalign treatment, the default movement when prescribing posterior expansion is buccal
tipping. In a case like Gilbert’s, tipping works out well because his teeth begin palatally inclined. The palatally inclined teeth are
being uprighted — and that is perfectly fine.
In Gilbert’s case we don’t need any posterior buccal root torque (BRT) because the teeth started out palatally inclined, but you
have to watch for that condition. In other patients with upright posterior teeth with expansion using Invisalign, there can be a
tendency to tip the teeth out toward the buccal, relatively extruding the palatal cusps and intruding the buccal cusps. Most of the time
that is not something that we want. In cases where you see unwanted tipping of the posterior teeth, ask your technician to give you
posterior buccal root torque to maintain bodily movement.
Similarly, a patient like Emma (from chapter 6) who presents with constriction of the arches and palatal inclination may also
benefit from transverse expansion to help resolve her crowding (images 7-3 and 7-4). She sets up well for expansion in the
transverse dimension to gain arch length to resolve her crowding, without the need to program any posterior buccal root torque.

These movements are predictable tipping movements with Invisalign clear aligners. Tipping movements are predictable and
typically don’t require any ClinCheck modifications.
Posterior cross bite — what about patients who require posterior expansion to resolve a posterior cross bite? With patients who
present with posterior cross bite, it is critically important to consider whether the patient presents with a dental cross bite or
skeletal cross bite. For example, the patient in image 7-5, and his ClinCheck in image 7-6 presented with a dental cross bite on the
upper-right side. His arch is constricted so we can set him up for dental expansion using Invisalign.

In cases where you have anchor teeth on either side of the cross bite that are not in cross bite for example, the UR7 and the UR3,
those teeth provide anchorage to move the collapsed portion of the arch. Image 7-7 depicted his ClinCheck setup. The final result
(image 7-8) shows very predictable movement and nice correction of the dental cross bite on the upper-right side.

Note: Something to think about — one has to think through whether it’s wise to treat a skeletal problem with a dental appliance
— whether it be fixed appliances or aligners. It’s also important when we’re dealing with a patient who is a child vs. adult — and
in particular, a prepubescent child vs. an adult patient.
RED FLAGS
Skeletal cross bites are a big red flag, particularly in adults — they are unpredictable to treat orthodontically non-surgically,
regardless of the appliance used. I do not recommend attempting to correct a skeletal cross bite on an adult patient with Invisalign.
However, in a prepubescent child pre-Invisalign rapid palatal expansion (RPE) is quite predictable. If we can capture the patient
before the onset of the pubertal growth spurt, conventional phase I treatment with rapid palatal expansion can set the patient up for a
more predictable Invisalign experience later on. My good friend and colleague Gary Brigham DDS MSD refers to this as
“developing an Invisalign Teen farm system.” In essence, the transverse discrepancy is corrected before the patient enters into
Invisalign treatment.
Note: As I travel the world consulting with doctors on their Invisalign cases, it’s not uncommon to see ClinCheck plans for adult
patients with skeletally constricted maxillae that show a tremendous amount of transverse expansion in the maxillary arch. In my

opinion, one has to question whether or not this type of correction is attainable on a routine basis. This raises the question of
whether it’s wise to treat a skeletal cross bite with a dental appliance.
What are my considerations for a patient like the one in image 7-9? I would treatment plan this patient for surgically assisted
rapid palatal expansion (sRPE) prior to beginning Invisalign treatment. If the patient was not amenable to surgery, I would consider
maintaining the posteri- or cross bite and treating the patient with Invisalign without cross-bite correction.
Other red flags are unilateral cross bites — they can be a challenge. In many cases where the patient is in braces or aligners, I
will use cross elastics to help with that movement. The ClinCheck plan depicted in images 7-10 and 7-11 might be a typical setup;
here is a patient who has a posterior cross bite on the right side, and I’ve set them up with button cutouts on the lower surfaces of the
LR6 and LR7, as well as on the palatal surfaces of the UR6 and UR7. I will bond buttons on those surfaces (see image) as well as
the lower arch and have the patient run a 1/4-inch H6 elastic to help to correct the cross bite (image 7-12).

One final consideration for transverse dimension problems being treated with Invisalign clear aligners is over-treatment. For
example, in the same patient we looked at in the last set of images, this is what the final ClinCheck stage looks like (image 7-13).
Notice over-treatment of the expansion from mandibular constriction in the arch and additional expansion in the maxillary arch. A
good rule of thumb in a case like this with a unilateral cross bite would be 3mm of additional expansion past ideal.
This patient is now set up for success for two reasons:
1. We use cross elastics to aid in the movement.
2. We have over-treated the ClinCheck plan to place additional forces on the teeth to achieve the desired result.

CHAPTER SUMMARY
When it comes to treating transverse problems with Invisalign clear aligners, it is important to remember that correction of dental
cross bites is more predictable than skeletal cross bites. Carefully consider- ing whether your ClinCheck treatment plan follows
sound orthodontic principles that will help you achieve predictable cross-bite correction in the right cases, and avoid frustration in
those patients where correction is less predictable. The use of cross elastics and 2mm of expansion over treatment will increase the
predictability of correction of transverse dimension problems, reduce the number of case refinements, and help achieve excellent
results on a consistent basis.

CHAPTER 8
Attachments
Attachments are integral to successful Invisalign treatment, and a good understanding of the different types and their applications
will help to improve the outcomes of your cases. There are fundamentally two types of attachments. These can be categorized as
either optimized or conventional.
OPTIMIZED ATTACHMENTS
Optimized attachments are automatically placed by the software and are one of many Smartforce® features that are engineered to
place the required force systems on the teeth to get the desired movement. They are customized individually for each tooth using the
concept of biomechanics. If we can develop the appropriate force systems to be placed on a tooth or group of teeth, we can then
achieve the desired tooth movement.
Optimized attachments are engineered for a variety of tooth movements, and they are placed automatically by the software. It is
important to note that they cannot be requested. You cannot write on your prescription, “Please give me an optimized rotation
attachment.” The technician will write back and inform you that this is not possible.
TYPES OF OPTIMIZED ATTACHMENTS

Let’s look more closely at the various types of optimized attachments:
Rotation — there are optimized attachments for rotation of canines and premolars. For example, in the patient (image 8-1) who
has a rotated maxillary canine, there is an optimized rotation attachment placed on the canine with the active surface of the
attachment oriented to allow the aligner to place the correct force system to achieve correction of the rotation. The active surface is
what I call the “business end” of the attachment. The active surface is oriented in the proper direction so the aligner can place the
appropriate forces on this tooth to achieve the desired movement, which in this case is distal-in rotation along with distal root tip.
The aligner shape is activated, which means it changes at each stage to maintain the force system at the appropriate levels — and
they work quite well. This is the same patient, Jessica from chapter 3, clinically before treatment (image 8-2) and after one year of
treatment with no refinements required (image 8-3). As you can see we achieved effective rotation with the use of optimized rotation
attachments.

Extrusion — these are the second kind of optimized attachments. For example, with this patient, Michelle from chapter 5, (image
8-4) with an anterior open bite, we are looking for absolute extrusion of the upper incisors. The active surface of this attachment is
oriented in such a way as to allow the force system of that aligner to be perpendicular to the active surface of the attachment. We use
this kind of force system to achieve extrusion of these teeth and closure of the open bite. Here is the same patient clinically (image
8-5) before treatment and after eight months of Invisalign treatment (image 8-6). Optimized extrusion attachments may be on single
teeth or groups of teeth when multiple extrusions are required.

Root control — these attachments are the third type of optimized attachment. Let’s take a look at the panoramic radiograph of a
patient (image 8-7) who is congenitally missing the UL2. The treatment plan revolves around distalizing the upper canine to prepare
a space for an implant. This movement is challenging, and we need to have crown and root movement at the same time. An
optimized root control attachment (image 8-8) will help put the appropriate force system on the UL3 to achieve bodily movement to
prepare a space for a future implant.

Note: The force systems being applied to the UL3 are not a couple, meaning that the aligner is not placing equal and opposite
forces on this attachment. The forces are modulated to give you the desired tooth movement. In this case, the larger distal force is
acting on the gingival attachment and a smaller mesial counter force is acting on the incisal attachment (image 8-9). These forces are
adjusted automatically to achieve bodily movement or root movement depending on the case.
Here is the panoramic radiograph of the same patient (image 8-10) after 20 months of treatment where appropriate root

movement for implant-space preparation was achieved.
Multiplane — these attachments appear on maxillary lateral incisors when root movement and extrusion are simultaneously
required (image 8-11).
Support — Invisalign G5 introduced optimized deep-bite attachments for premolar teeth to support leveling of the lower Curve
of Spee, and Invisalign G7 introduced optimized maxillary lateral support attachments when absolute intrusion of either the
maxillary central incisors or maxillary canines is required.
CONVENTIONAL ATTACHMENTS
Conventional attachments are the second type of attachments. Conventional attachments can be ovoid, rectangular, beveled or
non-beveled, and oriented horizontally or vertically. They are used for the following: aligner retention and anchorage, to support
intrusion, extrusion or root control. Conventional attachments can be requested or you can place them yourself using 3D Controls in
ClinCheck Pro.
Examples include:
Gingivally beveled rectangular attachments — (image 8-12) the direction of the bevel is how we use nomenclature. The
bevel is sloping toward the gingival aspect of the tooth. Gingivally beveled attachments come in handy for many situations that we
will explore in this chapter.
Occlusally beveled attachment — (image 8-13) the bevel is slanting toward the occlusal surface. This type of attachment is
used for aligner retention to support leveling of the Curve of Spee, and to support absolute extrusion on posterior teeth.
Vertical attachments — (image 8-14) this kind of attachment is used for root control. Vertical attachments may be beveled
either mesially or distally.

Ellipsoid attachments — (image 8-14) these attachments are not in my typical armamentarium
OPTIONS FOR ATTACHMENT PLACEMENT USING CLINCHECK PRO

ClinCheck Pro gives you options for the design and placement of conventional attachments under 3D Controls. Under
“Attachments and Cuts,” (image 8-15) you can drag and drop a variety of conventional attachments into your ClinCheck
treatment plan.
Conventional attachments may be customized. Options include (image 8-16):

Resizing the attachments by clicking on the attachment already placed on the tooth and selecting either 3, 4 or 5mm in length.
Changing the orientation of the attachment either by rotating the attachment in any direction you want. Push the attachment into
the tooth by clicking on it and grabbing the black line to push the attachment in or out of the tooth to change the orientation of
the attachment through rotation.
Finally, I want to encourage you to do some of these moves yourself using 3D Controls in ClinCheck Pro. It’s easy and quick.
You can put the attachments exactly where you want them. It’s a time-saver once you get the hang of it and learn how to get the
attachments exactly right.
Give 3D Controls in ClinCheck Pro a try. Simply drag and drop the desired attachment where you want it. If you make a mistake,
you can click on the “Undo” button one move at a time. If you feel like you really messed up your ClinCheck do not panic! Go back
to your “Reset” button and reset everything back to the way it was when you started.
Note: 3D Controls are not available in ClinCheck Web.
RULES OF THUMB
Here are two important rules of thumb when placing conventional attachments on teeth:
Horizontal attachments for vertical movements — use these attachments when placing attachments for vertical tooth
movements. In this case (image 8-17) I am looking for vertical movement to erupt the meisial aspect of the LL6. Since it is a
vertical movement, I have placed a horizontal rectangular attachment on that meisial aspect of the LL6 to give additional grip and
push surface to get that movement. In this case, I used a horizontal attachment to achieve vertical movement.

Vertical attachments for horizontal movements — in this ClinCheck plan (image 8-18) a vertical attachment will effect
horizontal movement of the LR5 and the LR6. These attachments will support the horizontal translation of the teeth. When horizontal
movement is desired, think vertical attachments.
HOW TO DECIDE WHAT ATTACHMENTS TO USE?

In deciding on what attachments to use on a particular case, this is where the ClinCheck list comes in handy. You have choices:
optimized, retentive and substitutions. You will have cases where you want to accept optimized attachments just the way they come
from your technician.
Optimized attachments — these work well for cases that don’t have significant vertical, sagittal or transverse problems. For
example, simple Class I Crowded cases where the optimized attachments work great just the way they are without any major
modification.
Retentive attachments come in handy in situations where you are looking for additional aligner retention, for example, when
you are running Class II elastics off precision-cut elastic hooks on the lower first molars as described in chapter 6. Placement of
an occlusally beveled rectangular attachment on the mesial surface of the molar provides additional retention to prevent the aligner
from dislodging as a result of the vertical vector of force from the CL II elastic.
Substitutions — there are times when I will substitute one attachment for another. An example would be in cases where I am
looking for additional aligner retention in a case with a teen patient with short clinical crowns. It may be a case where there is a
conflict with a precision cut, where I will take the optimized attachment off and place a conventional attachment so I can have an
attachment and a precision cut on the same tooth.
Additional anchorage attachments — there are times when I will substitute additional anchorage attachments to support either
absolute intrusion or absolute extrusion. An example would be in cases where I want to close an anterior open bite through the use

of absolute intrusion of the upper molars (images 8-19, 8-20). We do not need attachments on molars since there are plenty of push
surfaces. I do need anchorage, however, on the adjacent premolars to support the intrusion. Think again of Newton’s third law. The
“action” is intrusion of the molars, while the “reaction” will tend to make the aligners slip off from the adjacent premolars, which I
do not want to have happen. This case is where I will go into 3D Controls in ClinCheck Pro and select attachments and cuts. I am
going to increase the size of the retentive attachment on upper 4’s and 5’s to give me additional aligner grip to support absolute
intrusion of the molars.
Another example of attachment substitution would be in Ava’s case (from chapter 6). Toward the end of her treatment, the UR1
and UL1 required absolute intrusion to complete her case. Today, Invisalign G7 optimized support attachments would be placed by
the software, but these attachments were not available when Ava was treated. I therefore substituted 4mm-long, gingivally beveled
rectangular attachments on the UR2 and UL2 to provide additional aligner grip to support the intrusion of UR1 UL1 (images 8-21-
8-23).

Note the size and placement of these attachments in image 8-21. For cases like Ava’s requiring absolute intrusion of the upper
central incisors or for cases requiring absolute extrusion of the upper laterals, I make two modifications that help make these
attachments perform very well. First, I use 3D Controls in ClinCheck Pro to rotate the bevel completely to the gingival. This
provides for a long, forgiving gingival bevel that has a broad, flat surface for additional aligner grip. The second move is to move
the attachment 2mm from the incisal edge of the tooth, where the aligner plastic is stiffer and grip is at its greatest. I use these
modified attachments frequently and find them to work very well.
The third common attachment substitution occurs when a deep overbite requires correction, as in Haley’s case from chapter 5
(images 8-24- 8-26). To support the leveling of the lower Curve of Spee, 4mm-long, occlusally beveled rectangular attachments are
added to the lower 4’s and 5’s to support the lower incisor intrusion.

Note to the reader: It may seem contradictory to bevel the retentive attachments on the lower 4’s and 5’s occlusally, while the

retentive attachments on the upper 2’s are beveled gingivally. Here is why it works — in the buccal segments, the forces of
occlusion work to keep the aligners engaged, and the 90-degree gingivally oriented “ledge” provides maximum aligner grip to
support the lower incisor intrusion. On the upper lateral incisors, however, there are weaker occlusal forces and “failure mode” is a
greater possibility. The long gingival bevel on the upper 2’s, while somewhat less retentive, are more forgiving if there is a small
degree of non-tracking.
CHAPTER SUMMARY
Understanding the different types of attachments and how to handle them are critical to achieving excellent treatment results. This
chapter deals with the most common situations that arise during Invisalign treatment. If you do not find the information you need in
this chapter, go to your Invisalign Doctor Site (IDS), click on the “Education” tab, and in the “Search” box type “attachments”.
You’ll find pages of videos and papers written to help guide you through any specific clinical problem that is not covered in this
chapter.

CHAPTER 9
IPR and Staging
Inter-Proximal Reduction (IPR), removal of enamel in-between the teeth, is indicated for specific issues. The number one reason
is to alleviate crowding. From chapter 1, a basic Invisalign principle is that teeth need space to move. In a patient that presents
like Jessica, from chapter 3 (image 9-1) IPR can be a useful to gain arch length to resolve the patient’s crowding. The ClinCheck
list will help guide you through the important IPR decisions:
To explain:
Round Trip to Stage — round tripping, temporary proclination of the upper or lower incisors is a useful technique to improve
access for IPR. In many cases, it is not necessary to procline the anterior teeth so far forward to perfectly align the interproximal
contacts before performing IPR. I will “read” my ClinCheck plan and determine the stage at which the contacts are sufficiently
aligned to gain safe access to perform IPR. “Round trip to Stage” indicates at which ClinCheck stage the proclination ends and the
IPR begins. This can both significantly shorten treatment time by reducing the number of stages, as well as prevent excessive
proclination, which may lead to gingival recession and/or bone loss.
Amount: U Ant/L Ant/U Post/L Post — fill in the amount and location of the IPR you would like to perform in these fields.
JESSICA’S CLINCHECK LIST

To explain, in Jessica’s lower arch, 0.3mm of IPR will be performed after the lower anterior teeth have been round tripped to
stage 13. The lower incisors are not perfectly aligned at stage 13, however the contacts are comfortably accessible.

The patient’s ClinCheck plan (see Image 9-2) indicates the use of 0.3mm of IPR from lower canine to lower canine to create
room to resolve the lower incisor crowding. At the end of treatment, the lower arch is well aligned (see Image 9-3).
Instructions to the technician: Round-trip to improve access for IPR.
THE SECOND USE OF IPR — BOLTON DISCREPANCY

The second indication for IPR is to adjust for a Bolton Discrepancy, also known as a tooth-size discrepancy. When a patient has a
tooth-size discrepancy as a result of narrow maxillary lateral incisors, the choices for managing a Bolton Discrepancy are:
IPR in the lower arch
Leave space for esthetic build-ups of the narrow maxillary laterals
Leave space somewhere else in the maxillary arch
In cases where the maxillary lateral incisors are not esthetically too narrow, lower arch IPR is an effective way to normalize the
Bolton ratio and help finish with a normal occlusion.
THE THIRD USE OF IPR — REDUCTION OF OVERJET (OR UNDER BITE)

The third use of IPR is to reduce overjet in Class II cases or under bite if the patient is Class III. For example, in a case like the
one depicted in image 9-4, the patient presents with a Class III malocclusion. In this case, IPR has been added in the lower arch to

create additional space to aid in the retraction of the lower canines and couple them into Class I. This case in particular also has the
use of Class III elastics to enhance the correction of the Class III malocclusion. Posterior IPR is being applied to both sides to help
couple the canines.
This ClinCheck view (see Image 9-5) is of the patient set up for Class III elastics and lower posterior IPR to retract the lower
interior teeth to improve the coupling of the incisors and canines. The final result can be seen in image 9-6.
FOURTH USE OF IPR — REDUCE HEAVY ANTERIOR OCCLUSAL CONTACT

The fourth use of IPR is to reduce the heavy anterior occlusal contact. If you have treated enough patients with Invisalign clear
aligners this image (see image 9-7) probably doesn’t look all that unfamiliar. There are cases where we have to manage posterior
open bites. In my experience the vast majority of post-anterior open bites are due to heavy anterior contact. In this case IPR was
added to the lower arch in order to retract the lower incisors to relieve the heavy anterior occlusal contacts and settle the posterior
open bite (image 9-8).

This ClinCheck set-up (see Image 9-9) is how the posterior open bite was resolved. You can see the IPR is creating space to
retract the lower anterior teeth supported with Class III elastics to allow for auto-rotation of the mandible and closure of the
posterior open bite. The final ClinCheck stage depicts the expected resolution of the problem (image 9-10).
FIFTH USE OF IPR — MANAGEMENT OF DARK TRIANGLES

IPR to reduce the appearance of dark interproximal triangles is common in some adult patients who have lost some papilla.
This patient (see image 9-11) was unhappy with the dark triangle between the UR1 and UL1.

The ClinCheck plan (image 9-12) was set up with IPR in the maxillary arch in order to create space for the retraction of the
upper incisors and improvement of the dark triangle. The final results show improvement of the dark triangles through the use of IPR
(see image 9-13).
IPR TECHNIQUE
There are several techniques for IPR including the use of manual diamond/polishing strips. If you prefer this technique you
would start off with the thinnest strip possible to open interproximal contact. Use a gentle back-and-forth motion until the strip is
passive. Then migrate to a thicker strip to widen the contact. Work to the thickest strip needed.
The second option is the use of slow-speed diamond. Start on the facial using slow RPMs and engage the disk against the tooth
surface. Start on the facial and then gradually work through the contact. Starting on the facial will greatly reduce the chances of
ledging.
The third technique is the use of a high-speed bur where you break interproximal contact with light, even, brush-like movements.
Water spray is used to help reduce clogging and overheating of the bur.
PROCEDURE
As far as the procedure goes you will get a treatment overview sheet in every box that indicates the amount of IPR that needs to
be done and what stage by which it needs to be performed. Review the IPR amounts on the form included in the aligner box and
determine the appropriate IPR method. Confirm the amount of interproximal enamel removed with thickness gauges. Feel for tactile

resistance when the proper amount has been removed and the reason you do it that way is that you would then want to go in and
polish the interpoximal surface with polishing strips, until adjacent surface is rounded and smooth. Then verify the final gap
dimension with thickness gauges and record the date and amount of IPR in the patient record.
INSIDER TIPS FOR IPR

Tip 1: When working with teen patients makes sure you discuss IPR with the parents three different times. A nice
brochure is available from the AAO that you can review IPR in detail — and we give that to the patients and their parents on the
first visit. The second time we discuss IPR is at the scan or impression appointment. The third time to discuss the IPR procedure is
right before we begin — and to discuss it in particular with the child. Sometimes the kids come back to the treatment area and the
parents stay in the waiting room. The last thing I want to have happen is for the kid to walk out into the waiting room with possibly
bloody aligners. With the papilla high up in teen patients it is possible to cause gingival bleeding. I don’t want the parents to be
upset. Parents often forget the first two discussions about IPR. We discuss it one more time right before we’re going to do it and that
way everyone is on the same page and understands.
Tip 2: Slightly under do it. For example, in the previous case that called for 0.3mm of IPR, I’ll start off and perform 0.2mm and
then monitor contacts. If contacts are not tight we’ll continue on the aligners and monitor any areas where we might go back with a
strip and lighten the contacts. I have found by slightly under doing the IPR initially it helps to reduce the chances of open contacts at
the end of treatment.
STAGING
In discussing staging, we look at two areas of importance: attachment placement and timing of IPR. What is the big deal about
staging? Staging your procedures will increase the efficiency of your practice. We want to be profitable with our Invisalign patients
and we don’t want to have unnecessary appointments. Staging helps reduce office visits and patients appreciate not having to come
to your office more than necessary. Let’s look at the ClinCheck list:
For example, with our patient Jessica (see image 9-14), we gave her six sets of aligners at the beginning of treatment (note that
this protocol was used for two week aligner changes). At the start of her treatment we insert aligner number one and then give her
aligners two through six, and each set is worn for two weeks. This approach means Jessica is going to return in twelve weeks to
have aligner number seven inserted, which means I want to stage important events at the time she will be returning for her regular
appointments. Specifically, the events are performance of IPR and placement of new attachments. In my office, since we dispense
six sets of aligners per visit that would be for stages seven, 13 and 19.
It may seem trivial, but if Jessica comes back to the office for her regular appointment and she’s ready to insert stage seven and

my staff says, “Dr. Glaser, she has to come back in at stage 8 to have an attachment put on,” that is a visit we really didn’t need to
have. Whatever your normal interval of seeing patients, for example, at every eight weeks then you would adjust your procedures
accordingly. On your ClinCheck you want to plan for IPR and new attachments at regular intervals, which will help to reduce maybe
two, three or maybe four visits per treatment — and that time adds up.
Why in the middle of treatment would a new attachment appear? Sometimes there are incompatible features such as the example
where you can’t have a power ridge on a tooth at the same time you have an attachment. So for patients that need root torque first,
then extrusion you may have multiple stages where a power ridge exists on a tooth and at some point on your ClinCheck you may
need extrusion and that is when you’ll see an attachment appear.
Staging allows you to:
Reduce the total number of appointments
Increase office efficiency
Reduce chair time
Please your patients at the same time
Note: A new development in Invisalign aligner treatment is seven day aligner changes. For those patients that I deem acceptable
to chang their aligners every seven days,, at the start of treatment the patient inserts the initial aligner on day number one, and we
give the patient aligners numbered two through eleven. This corresponds perfectly with the new, smaller aligner boxes. The patient
leaves with the entire box, which both keeps the aligners organized for the patient and greatly reduces our box-storage needs!
CHAPTER SUMMARY
IPR and staging are important items to manage on each and every patient. Proper IPR technique and staging of events such as new
attachment placement can help ensure treatment proceeds smoothly and appropriately.

CHAPTER 10
Over Treatment and Over correction
Why do we consider over treatment in our Invisalign ClinCheck plans? In Chapter 1, we explored the similarities between pre-
adjusted “straightwire” appliances and Invisalign clear aligners.
Let’s look again at pre-adjusted edgewise appliances. In straightwire appliances the braces are pre-adjusted, meaning the tip,
torque, ins and outs, and rotation are pre-built into the brackets, the concept being that a straight wire placed into this system should
align all of the teeth. As we know “straightwire” really isn’t straightwire. What I mean by that is as orthodontists we don’t routinely
“throw in a wire” and the case somehow magically treats itself.
A short list of reasons why braces are not “self-treating” are:
Anatomical differences between patients
Variations in tooth size, shape and anatomy
Skeletal variations
Differences in bone density
Play between wire and slot
Genetic differences between patients
Because of those differences we’re not “doing” straightwire; we’re practicing orthodontics. It’s the same approach with
Invisalign treatment. We are not “doing Invisalign”. Instead we are performing orthodontics with the Invisalign appliance.
Despite there being a tremendous amount of science and engineering built into every aligner, these genetic and anatomical
differences from one patient to another means we are the doctor, adjusting along the way for the individual needs of each patient.
Adjustments we do make up for these differences.
Based on that premise, these are the four areas to consider over treatment in the ClinCheck list:
Deep/Open Bites
Tip
Torque
Expansion
DEEP BITES
In chapter 5 we discussed the treatment of problems in the vertical dimension. In this chapter, we explored over-engineering
moves to successfully manage deep bites. Just like with the patient (see Images 10-1, 10-2) who presents with a deep bite, if this
patient were being treated with fixed appliances it would be quite reasonable to place a reverse-curve arch wire to help level the
lower Curve of Spee (see Image 10-3).

The question is: If the patient were wearing straight-wire appliances, why would we need to over-engineer the arch wire? We
all learn as orthodontists that this arch-wire shape produces a force system, which will help to level the lower arch and flatten the
Curve of Spee. We place extra into our arch wire knowing that it will produce force systems to give us a flat arch.
The same ideas apply with Invisalign treatment. How would we ask for a reverse Curve of Spee arch wire with Invisalign?

Simply write in your prescription: “Please set the final over bite at 0mm.”
Those instructions will over-engineer the ClinCheck plan so that the final stage for a patient like the one depicted in image 10-2,
the final over bite is set at 0mm. As we have discussed many times throughout this book when we’re looking at a ClinCheck plan
we’re not looking at a prediction of the final occlusion. We are looking at a graphic representation of the force systems made by
the aligners to the teeth. Force systems, not teeth. Just like the Reverse Curve of Spee arch wire, we add Reverse Curve of Spee to
our lower arch in the ClinCheck treatment plan. As you can see in this patient (see Image 10-4), he didn’t end up with a Reverse
Curve of Spee, but rather he ended up with a flat arch and appropriate bite opening. This ClinCheck plan was over-engineered to
produce a normal final result.
Here again is Haley from chapter 5 (see Image 10-5). Similar to the previous patient, Haley presents with a deep over bite. Look
at the final ClinCheck stage (see Image 10-6) where an additional 2mm of intrusion was added to the upper and lower incisors so
her final over bite is 0mm. The ClinCheck plan is over-engineered but in reality she doesn’t not wind up with the over engineered
results (see Image 10-7). She has upper and lower arches that are flat and coordinated and an excellent functional and esthetic final
result.

To the reader: This concept of deep bite over treatment is one that I have built right into my clinical preferences: “For all deep-
bite cases, please finish with the final overbite at 0mm.” My technician builds in over treatment — my prescription — for all my
deep-bite cases.
OPEN BITES
The over-engineering principle also applies to open bites. Let’s revisit Michelle’s case, from chapter 5 (see image 10-8). If you
recall from this chapter dealing with problems in the vertical dimension, Michelle presented with an anterior open bite. Her
treatment plan is to over-engineer her ClinCheck plan with 2mm of additional intrusion on the upper molars to create a 2mm
posterior open bite. Why do we do it this way? The ClinCheck plan is not a prediction of the final occlusion, but rather a prediction
of the force systems acting on the teeth. Force systems, not teeth. I want to place an additional intrusion force on the upper molars.
Intrusion is a difficult movement. I am not expecting the full expression of the aligners. I am not expecting the patient to develop a
posterior open bite, but I want to place additional forces on the upper molars to ensure we gain additional intrusion to allow for
auto-rotation of the mandible and closure of the bite. Here in this image (see image 10-9) is the area of over treatment on the upper
molars.

If you compare this posterior open bite we created on the ClinCheck plan and Michelle’s final result (see image 10-10) you will
note that she does not clinically have a posterior open bite at the end of treatment. This is the best illustration regarding the
difference between the graphic representation of the force systems acting on the teeth in the ClinCheck plan and why it’s not a
prediction of the final occlusion. We asked for additional intrusion that we know is not going to fully express to get the desired
amount of intrusion that we need for an excellent final occlusion. A good rule of thumb that we need for a case like Michelle’s
would be 2mm of additional intrusion of the posterior teeth.

Another possible move (not performed in Michelle’s case) is to ask the technician to extrude the upper and lower anterior teeth
into a hard contact, which is also an over-engineering move. We don’t expect the teeth to come into hard contact, but knowing there
may be a slight under-performing of the aligners we ask for over treatment to gain our desired results.
TIP AND EXPANSION

The third over-treatment movement is tip. A good rule of thumb for tip of individual teeth is 10 degrees of over treatment of tip
when there’s no space present in the arch; and 30 degrees of over treatment of tip to close space. For example, this patient (see
Image 10-11) with missing tooth number 10, our treatment plan is to distalize the UL3 back into Class I to create space for an
implant. Look at the ClinCheck plan (see image 10-12) and the instructions to the technician: Please over treat the distal root tip of
the UL3 by 30 degrees. Since orthodontic treatment is applied at the crown, which is some distance away from the center of rotation
of the teeth, orthodontic treatment has a tendency to make some teeth tip. In this case, if we move the UL3 distal crown tips distal
even more and will result in an un-esthetic situation. In addition it won’t position the root of the UL3 in a place where the implant
will be able to be placed between the UL3 and UL1.

We ask for additional 30 degrees of distal root tip of the UL3 not expecting it to express. We want to place the appropriate force
systems on the UL3 to obtain movement of the root. Image 10-13 shows the patient one year into treatment. As you can see from the
panoramic X-ray we did achieve bodily movement of the UL canine; in fact, at this point one year into treatment, there is still a
slight mesial root inclination. At case refinement, we asked for an additional 30 degrees of distal root tip. Twenty months into
treatment the appropriate implant space has been created (see image 10-14).
TORQUE
The rule of thumb for torque is 10-30 degrees depending upon the case. For example, in this patient (see Image 10-15) the
clinical challenge was moving the UL and UR lateral incisors labial out of cross-bite. Orthodontic treatment is applied at the
crowns with Invisalign clear aligners or fixed appliances, the upper lateral incisors have a tendency to tip out labially, and we don’t

want that to happen. We want these teeth to move bodily. This patient’s ClinCheck plan was set up with 30 degrees of additional
labial root torque of the UR2 and UL2 as anti-tip (see image 10-16).
After 22 months of treatment time, see the patient’s results (see image 10-17), and as you can see the UL laterals are positioned
well and the root position looks appropriate. The teeth are not over-torqued even though we asked for 30 degrees of additional root
torque, but we didn’t get expression of it in the final results. The 30 degrees of labial root torque prevented the crowns from
tipping labially to control the positions of the roots appropriately.

EXPANSION
Turn back to chapter 7, where we examined the over treatment moves for patients with posterior cross bites. The rule of thumb to
follow is an additional 3mm of expansion past ideal.
OVER CORRECTION
Let’s explore the difference between over correction and over treatment.
OVER TREATMENT
Up until this point in the chapter, we have explored the four areas where over treatment should be considered: deep/open bite,
tip, torque and expansion. Over treatment occurs gradually throughout the ClinCheck plan from the first stage to the last, and can be
thought of as over-engineering the ClinCheck plan to place additional forces on the teeth to achieve the desired result.
OVER CORRECTION
Over correction, on the other hand, is designed to build in “extra” correction in two specific areas: rotations and ins/outs.
Always represented by three final aligner stages designated with a “+”, over correction is the tenth parameter on the ClinCheck list.
The over treatment and over correction techniques I employ in my practice were taught to me by my friend and colleague William
Kottemann, DDS, MS. Dr. Kottemann cites the August 1986 Journal of Clinical Orthodontics interview with Dr. Bjorn Zachrisson.
In this interview, Dr. Zachrisson discusses his concept of “11/10” orthodontics for rotations and ins and outs. Dr. Zachrisson
stated, “To me, 11/10 orthodontics means slight overcorrection of those most important sites of relapse. I want relapse to work
in my favor and not against me. Therefore, it makes more sense to have slight overcorrection. Then if there is any relapse, it will
relapse toward an ideal position rather than away from an ideal position.”
Based on Dr. Kottemann’s interpretation, anterior rotations are routinely over corrected five degrees, and anterior in/outs are
over corrected by 0.2mm.
Do I always use all three over correction aligners? No! I make the decision to use over correction aligners on a cases-by-case
basis. In those cases where gaining final alignment has been a challenge, I am more inclined to use all three stages. If, however, the
final alignment at the last non-over-corrected stage looks ideal, I may choose to stop at that point.
Building over correction of anterior rotations as well as ins/outs is a great way to reduce the number of refinements on your
patients. In Dr. Kottemann’s practice his refinement rate is a low 10 percent. If it’s good for Bill, it will be good for you too!
Here’s a tip: In any case where you choose not to use your three over-correction aligners, don’t throw them away. Why? They’re

great emergency retainers! Give them to the patient in case their final retainers are lost.
CHAPTER SUMMARY
Over-engineering your ClinCheck treatment plans is an important concept to master. If you follow the guidelines in this chapter,
you will be well on your way to achieving excellence with Invisalign!

CHAPTER 11
Troubleshooting
I was blessed to study under the legendary Dr. Anthony A. Gianelly at the Boston University Goldman School of Graduate
Dentistry. As I was winding down my final year of orthodontic residency, I asked “Dr. G,” as his students fondly called him, why he
didn’t talk about using elastics and other auxiliaries to “sock in” cases at the end of treatment.
“Barry,” he said, “If you control your mechanics from the beginning of treatment, you won’t have to worry about socking in your
occlusion at the end.”
Indeed, Dr. G instilled into his students the importance of thoughtful and meticulous treatment mechanics from beginning to end,
carefully anticipating and adjusting for side effects at every patient visit. By doing so, treatment progressed in a controlled fashion,
leaving little to no “clean-up” necessary at the end of treatment.
It’s the same with Invisalign treatment. By using the ClinCheck list to guide you in employing the concepts we have explored in
this book, your Invisalign cases will track better, with fewer refinements and less side effects. Non-tracking will be greatly
diminished, and dealing with problems such as posterior open bites will become a rarity in your practice.
Nevertheless, despite the most thoughtful ClinCheck setups, there are at times issues that can arise during treatment. Let’s take a
look at the most common troubleshooting issues and their remedies in the following descriptions.
LOSS OF ANTERIOR TOOTH TRACKING DURING ROTATION

The most common problem encountered when an anterior tooth loses tracking is lack of space. At the first sign of non-tracking
during anterior rotation, interproximal contacts should be checked with floss, and any tight contacts should be “eased” with an
interproximal strip. A common error is to ignore minor non-tracking issues, hoping they will go away on their own. Unfortunately,
this approach rarely works and the problem gets progressively worse over time. Monitoring and adjusting tight contacts at each
visit will help to improve tracking, reduce the number of case refinements, and reduce overall treatment time.
STUBBORN ROTATIONS 1 — DIMPLE PLIERS

Have you ever had a case where you just can’t get the last few degrees of rotation on an upper or lower anterior tooth? Here’s a
time-saver — instead of refining the entire case, use a dimpling plier to place a small “divot” into the aligner, thus increasing the
force to the desired tooth. I used this technique all the time in my pre-Invisalign days when treating patients with Essix® appliances,
and it can be equally effective for minor rotational correction with aligners.
STUBBORN ROTATIONS 2 — BOND BUMPS

There are some anterior teeth rotations that won’t respond to dimpling of the aligners. If you are certain that tight interproximal
contacts are not to blame, it may be that the dimple created in the aligner does not create sufficient force to achieve the desired
rotation. In these cases, instead of doing a case refinement, try bonding a “bump”. A bump is a small 1/2mm- thick dome of
attachment material on the surface of the tooth requiring additional force. For example, if the UR2 requires additional mesial-in
rotation, bond a small composite bump on the mesial aspect of the labial surface of the tooth. Have the patient seat the aligner, and
adjust the height of the bump so the patient feels pressure on the tooth. Have the patient return in 1-2 weeks and check for progress.
This technique is very effective to achieve the last few degrees of rotation and helps reduce the number of case refinements and
overall treatment time.
STUBBORN ROTATIONS 3 — VIVERA® RETAINERS

In cases where there is just the slightest suggestion of a rotation on an anterior tooth, the thicker, stiffer plastic of Vivera®
retainers can be just what the doctor ordered. Here’s the trick — check for tight contacts, ease as necessary and have your patient
wear their Vivera® retainers full time for a month. Very often, the stiffer, thicker plastic will help achieve the last few degrees of
rotation. If, after a month of full-time wear, the tooth in question is not fully corrected, consider bonding a small bump as noted in the
previous section of this chapter.
NON-TRACKING IN ABSOLUTE EXTRUSION 1 — IPR

We discussed the differences between absolute and relative extrusion in chapter 5. Absolute extrusion of anterior teeth is by far

the more challenging movement with aligners. The software is very good at recogniz- ing absolute extrusion and placing the
appropriate optimized extrusion attachments to help gain the desired tooth movement. If an anterior tooth extrusion is not tracking,
the first things to look at are the adjacent contacts. To reiterate, one of the basic aligner concepts outlined at the beginning of this
book is that teeth need space to move. Check for tight interproximal contacts with floss and employ IPR to ease the tight contacts
to allow the tooth in question to extrude.
NON-TRACKING IN ABSOLUTE EXTRUSION 2 — LARGER ATTACHMENTS

If the adjacent contacts are not tight, you may consider placing larger attachments on the tooth requiring extrusion to gain
additional “aligner grip”. For non-tracking maxillary lateral incisors, I will place a modified 4mm-long, gingivally beveled
rectangular attachment. I orient the bevel of this attachment similarly to that of an optimized extrusion attachment. While not
“optimized,” the long gingival bevel provides greater surface area and is quite effective in those “stubborn” cases where the
maxillary lateral incisor is not extruding properly. For more specific details on how to design and place this and other conventional
attachments, please refer to chapter 5, where we review the considerations such as “failure mode” when placing conventional
attachments.
NON-TRACKING IN ABSOLUTE EXTRUSION 3 — BOOTSTRAP ELASTICS

Have a case where everything is tracking well except for one anterior tooth? A bootstrap elastic is a handy tool to use in those
cases where you don’t want to stop and order additional aligners, since the remaining teeth are tracking well. A window is cut into
the labio-gingival aspect of the aligner, and a V-shaped cut is made on the linguo-gingival aspect of the same tooth to form a small
elastic hook. Bond a clear ceramic button on the labio-gingval aspect of the non-tracking tooth and have the patient attach a 3/8”
elastic from the button — over the incisal edge — to the V-shaped hook. The elastic places a force to the tooth, which extrudes it
back into the aligner. If it sounds complicated, it’s not. Please refer images 11-1 through 11-3. Bootstrap elastics can be very
effective in getting the tooth back on track!

NON-TRACKING IN ABSOLUTE EXTRUSION 4 — TRIANGLE ELASTICS
Extruding high canines with aligners can be unpredictable. A technique I frequently use is elastic-assisted extrusion. A button
cutout is placed on the canine requiring extrusion, and two precision-cut elastic hooks are placed on the lower canine and first
premolar. A ceramic button is bonded to the labial surface of the canine requiring extrusion, and the patient is instructed to wear a
1/4” heavy elastic from the button to the elastic hooks in a triangle configuration (see images 11-4, 11-5). The elastic provides an
additional eruptive force to keep the canine extrusion on track.

PREMOLAR ROTATIONS — BUTTONS/ELASTICS
Premolars, being more rounded, present fewer “push surfaces” than anterior teeth. As a result, rotating them with aligners can be
a challenge. There are several ways to deal with this, pre-Invisalign buttons and elastics being one method. In this scenario,
buttons or brackets are bonded and elastic chain used to rotate the teeth prior to beginning Invisalign treatment. Generally, I prefer to
employ buttons and elastics during Invisalign treatment. In your ClinCheck setup, place cut outs on the tooth requiring rotation as
well as the adjacent tooth, since buttons bonded in these areas will not affect aligner fit. Light elastic chain can then be placed on the
buttons to aid in rotation (see images 11-6, 11-7).

POSTERIOR OPEN BITE
A common assertion with Invisalign treatment is that the interoc- clusal plastic can lead to inadvertent posterior intrusion, with a
resul- tant posterior open bite (POB). In my experience, this is often NOT the case. In my estimation, the leading cause of a vast
majority of the POB’s during Invisalign treatment are heavy anterior occlusal contacts. It is my contention that if these conditions
are recognized and managed during the initial ClinCheck setup, it greatly reduces the chances that a POB will develop later on. I
direct you back to Dr. Gianelly’s wise words: “If you control your mechanics from the beginning of treatment, you won’t have to
worry about socking in your occlusion at the end.” Control the ClinCheck plan, control the case.

HEAVY ANTERIOR OCCLUSAL CONTACTS
Heavy, premature anterior occlusal contacts will prevent the posterior teeth from occluding, and is the leading cause of POB
during Invisalign treatment. Heavy anterior occlusal contact may result from the following circumstances:
UNMANAGED BOLTON DISCREPANCIES

In chapter 4, we explored the relationship of tooth size (Bolton) discrepancies to posterior open bite. In cases where there is a
relative defi- ciency of tooth structure in the maxillary arch, the upper anterior teeth may wind up in heavy occlusal contact with the
lower anterior teeth. It is important to recognize Bolton discrepancies on the initial ClinCheck plan and decide on the appropriate
remedy, such as lower IPR and or leaving spaces in the upper arch before beginning treatment. Please refer to chapter 4 for detailed
information on the options to manage Bolton discrepancies to prevent the development of POB.
LOSS OF UPPER ANTERIOR TORQUE
Orthodontics, whether with fixed appliances or aligners, tends to tip teeth. In cases where palatal tipping of the upper anterior
teeth is not desired, during upper incisor retraction for example, make sure to build palatal root torque overtreatment into the
ClinCheck plan. Overtreatment of palatal root torque by 10-20 degrees provides anti-tip forces, similar to the use of high-
torque brackets in fixed appliance cases.
CL III GROWTH
In teen patients with a mild CL III growth pattern, it is important to manage the growing face with the use of CL III elastics
and/or lower IPR to prevent heavy anterior occlusal contact. It’s a good idea to add CL III hooks to the initial ClinCheck plan
in case they are needed as treatment progresses.
POSTERIOR OPEN BIT 2 — SECTIONING ALIGNERS

There are some cases, in patients who are heavy bruxers for example, where a small posterior open bite of 1mm or less may be
induced from slight inadvertent posterior intrusion. Some patients may report that they don’t feel their back teeth touch, or you may
detect lack of posterior contact using articulating paper. These cases respond very well to aligner sectioning. In the final three
aligner stages, snip the aligners distal to either the canines or first premolars and have the patient wear the sectioned aligners full
time as usual. In most cases, the posterior occlusion will settle in over the final six weeks of full-time aligner wear.
POSTERIOR OPEN BITE 3 — BUTTONS/ELASTICS

If the aforementioned aligner sectioning procedure fails to gain solid posterior contact, bonding small buttons on the posterior
teeth along with the use of vertical elastics worn full time can be effective in estab- lishing the final posterior occlusion (see images
11-8, 11-9).

I want to reemphasize that thoughtful ClinCheck treatment planning using the principles in this book greatly reduces the incidence
of POB. In my practice, I find myself using buttons and elastics in very rare cases. Managing heavy anterior occlusal contacts from
the first ClinCheck plan and throughout treatment is the key!

Conclusion
I hope this book has been educational and maybe even enlightening when it comes to your Invisalign treatment plans and
techniques. In writing this guide, I wanted to discuss and demonstrate effective ways to set up your ClinCheck treatment plans and
give you fresh ideas to accomplish more than you might have ever considered Invisalign treatment could do. I also intended to
share my own lessons learned and best practices as I had discovered the most effective ways to help patients achieve a healthy
occlusion and esthetic smile.
As I demonstrated in the various case studies and successes, Invisalign treatment offers orthodontists a tool to attract new
patients. These patients may be the people who might not otherwise have sought orthodontic treatment because they wanted to
avoid the appearance of metal in their mouths. In the past, this opportunity to help these patients achieve a functional, esthetic
occlusion might have seemed impossible without the use of traditional braces. Yet as my book has revealed, Invisalign treatment can
correct a wide variety of complex malocclusions — certainly much more than many of you might have thought possible.
In addition, I hope I opened your mind to the possibilities of successfully treating teens with Invisalign clear aligners. This
widely untapped market — only 6 percent of teenage orthodontic patients in the United States are being treated with Invisalign — is
another potential growth center for your practice. I treat 75 percent of my teenage patients with Invisalign clear aligners and so can
you!
I also wanted to show you through the principles of sound ClinCheck design ways to maximize efficiency with Invisalign
treatment by reducing tracking problems, posterior open bites, and excessive refinements. These efficiencies are truly a win-win
proposition. The patient benefits from all of the esthetic and lifestyle conveniences of Invisalign clear aligners, while the
orthodontist benefits by treating their Invisalign patients with fewer appointments, less chair time, less stress, and almost no
disruptive emergency appointments. These efficiencies can help keep a practice competitive in times like these where the dental
landscape is rapidly evolving.
Maybe in the past you did a break-even analysis with your Invisalign costs and realized things like mistakes in the correction
process were often not getting the desired results and requiring longer and more costly treatments. Unexpected costs due to
mistakes and miscalculations could extend the need for longer treatment time and more unanticipated appointments. Maybe you
even tried basic Invisalign treatment and soon discovered that you were less profitable and not gaining real market value. You
might have thought to abandon the practice because it made no economic sense to your practice.
Now that you’ve read about my best practices and principles I hope you are inspired and feel confident that offering Invisalign as
a treatment option for a wider variety of malocclusions and dental issues can open the door to greater opportunities. You don’t
necessarily have to worry that you will face costly treatment overruns. You feel greater confidence in the aligner technology and
ClinCheck Pro software. Maybe you’ve avoided Invisalign treatment completely out of fear that you can’t make it work. Yet now
you’ve read all of my techniques and tricks to ensure reliable results. Now you do feel like you want to expand your Invisalign
clientele and know it will be a success if you follow my suggestions and ideas.
If nothing else, I hope this book has opened the door either wider in your practice to use Invisalign treatment in more patients or
has opened a completely new revenue opportunity. You now have an entirely new perspective on what is Invisalign, how you can
use it, and how you can even improve upon it with your own skills. Maybe you didn’t use Invisalign clear aligners at all in your
practice and this book enabled you to see effective ways to apply it to almost any malocclusion. You feel certain you will be able to
leverage this technology to expand your market opportunities and successfully capitalize on these potential revenue streams.
Ultimately, you might see a great (and as demonstrated) reliable opportunity to grow your practice.
Moreover, you can feel confident that you can achieve the very best clinical results treating a wide variety of patients with
Invisalign clear aligners. The principles outlined in this book are sound orthodontic principles that will help open your mind to
looking at your ClinCheck setups in an entirely new way — as “force systems, not teeth”. Through a comprehensive understanding
of how an aligner interacts with the dentition as well as a common-sense approach to biomechanics, you will be able to “read”
your ClinCheck setups more accurately and customize them to achieve the results you want. You will feel completely in control of
the process and will be able to translate a virtual treatment plan you view on your computer to a successful clinical outcome for the
patient.
In my experience, I know Invisalign clear aligner treatment is the future of this industry. I honestly feel that today’s orthodontists

who don’t capitalize on its value and benefits will be left behind. More and more patients are going to be expecting the Invisalign
option. As market de- mand increases, you cannot afford to be the one practice on the block that doesn’t offer it. Rest assured, the
office up the street — the competi- tors going for your same market share will be using it. The real question, will they use it in the
innovative ways I’ve just explained? If you’re using my tips and tricks chances are competitor’s practices are not. So not only do
you offer Invisalign treatment like the next orthodontist, but also you’ve figured out how to get the most opportunity out of the
technology. Looking at it from this perspective might turn on a light bulb. A-ha! I can be competitive and stay up with the latest
technology — and even better, I can leverage that technology to get better results.
In my opinion, this approach is a win-win. You are more competitive because you offer the most up-to-date techniques and best
practices, and the patient benefits from an excellent clinical outcome, a pleasant orthodontic experience, as well as the confidence
that comes with a fantastic smile. If this argument doesn’t convince you to try out the ideas I’ve shared with you in the book than I
don’t know what else will.
In short, Invisalign treatment is the future of this industry. If you want to stay ahead of the curve and be profitable in the interim,
then don’t hesitate to try my tried-and-true techniques. I wish you much success in your endeavors.

Resources
Please download a free copy of the ClinCheck list at Dr. Glaser’s
innovative educational site:
AlignerInsider.com
Need more help? Dr. Glaser is available for personalized,

one-on- one Invisalign® coaching at
yourorthocoach.com

About Dr. Glaser
Dr. Barry J. Glaser received his BA in Psychology from Binghamton University, was awarded his DMD degree from The
University of Pennsylvania School of Dental Medicine and earned his Certificate of Advanced Graduate Studies in Orthodontics
from Boston University. He served as Associate Director of Orthodontics at Montefiore Medical Center in New York City from
1992 to 1995. He has been in private practice in Cortlandt Manor, NY, USA since 1994.
Dr Glaser’s feature article “From Skeptic to Elite” can be found in the June 2014 edition of Orthodontic Products magazine,
and he has con- tributed several additional articles published in Orthodontic Products. Dr Glaser is featured in the book, “Your
Smile, Your Health, Your Success” published by 3L Publishing in 2015.
Dr. Glaser is an Align faculty member, an Invisalign Elite Preferred Provider and has given hundreds of Invisalign lectures
throughout the world. He has spoken at numerous Invisalign Summits, and has an active schedule travelling around the world
teaching doctors about excellence in orthodontics using Invisalign. He is the founder of the innovative educational website
AlignerInsider.com, and is available for one-on- one virtual Invisalign coaching at yourorthocoach.com.
Dr. Glaser resides in Cortlandt Manor, NY with his wife Tracy and sons Scott and Jake, along with boxers Roxy and Dempsey.


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To Tracy, Scott and Jake,

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PRINCIPLE NO. 2: MULTIPLE MOVEMENTS AT THE SAME TIME

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PRINCIPLE NO. 4: OVER-ENGINEERING CLINCHECK PLAN IS A MUST

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PRINCIPLE NO. 5: TEETH NEED SPACE TO MOVE

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BASIC ALIGNER PRINCIPLES

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ClinCheck list can be pared down to these concepts:

The 10 Critical Parameters are:

CROWDING AND SPACING

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VERTICAL, SAGITTAL AND TRANSVERSE

ATTACHMENTS, IPR AND STAGING

OVER TREATMENT AND OVER CORRECTION

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Jessica’s Upper Arch

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Summary: Total treatment time was 22 months.

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