Orthodontics

Ovais H Malik

Ailbhe McMullin and David T Waring

Invisible Orthodontics Part 1:

Invisalign
Abstract: This paper discusses the invisible orthodontic treatment modalities of Invisalign aligners, lingual appliances and aesthetic
brackets. The first part of this three-part series will discuss Invisalign aligner treatment. The second part will discuss lingual appliance
treatment and the third part will focus on aesthetic brackets. The benefits and drawbacks of Invisalign treatment are considered in detail,
including examples of treated cases and a review of the literature to date.
Clinical Relevance: Patients are increasingly requesting more aesthetic forms of orthodontic treatment. Clinicians need to be aware of the
indications and limitations of such invisible therapies so that they can fully inform their patients.
Dent Update 2013; 40: 203–215

A recent YouGov Survey estimated that 45% of adults deem aesthetic appliances
of adults are unhappy with the appearance (Invisalign, lingual and ceramic) as attractive
of their teeth and 20% would consider and acceptable, whilst only 55% viewed
having some form of orthodontics to stainless steel bracket systems in a similar
improve the alignment and appearance of light.3 Indeed, perceived intellectual ability
their teeth.1 The British Lingual Orthodontic can be linked to appliance appearance,
Society found in a 2009 survey that 72% with those with no visible appliance or a
of people were unaware of the option of clear aligner rated above those with steel or
invisible braces.2 When questioned, 90% ceramic appliances.4
Figure 1. Patient wearing an Invisalign aligner.

Invisalign
Ovais H Malik, BDS, MSc(Orth), MFDS Align Technology first takes approximately 25 aligners but varies
RCS(Ed), MOrth RCS(Eng), MOrth RCS(Ed), introduced Invisalign in 1999. To date according to the amount and complexity
FDS(Orth) RCS(Eng), Consultant in over 58,000 dentists and orthodontists of required tooth movement.6 Concern has
Orthodontics, University of Manchester worldwide are Invisalign certified, with been raised about the potential release
Dental Hospital, Higher Cambridge an estimated one million patients treated of bisphenol A from these plastic aligners
Street, Manchester, M15 6FH, Salford so far.5 It involves wearing a series of but laboratory in vitro ageing studies have
Royal NHS Foundation Trust, Stott customized clear plastic aligners (Figure 1) ruled out any potential cytotoxicity or
Lane, Manchester and Northenden for a minimum of 20 hours per day. They oestrogenicity.7
House Orthodontics, Sale Road, are changed on a two-weekly basis. It is Together with the indications
Manchester, M23 0DF, Ailbhe McMullin, estimated that each aligner moves a tooth listed in Table 1, Boyd has suggested
BDentSc(Hons), MFDS RCS(Ire), Specialist or group of teeth by 0.25 to 0.33 mm. CAD- that aligners can help to close a mild
Registrar in Orthodontics, University of CAM technology is combined with virtual anterior open bite and correct cross-bites.8
Manchester Dental Hospital and David 3D model correction software (ClinCheck) Case reports also demonstrate that the
T Waring, BChD, MDentSci, MFDS to stage tooth movements and correction Invisalign system can be an alternative to
RCS(Eng), MOrth RCS(Ed), FDS(Orth) of the malocclusion (Figure 2). The fixed appliances for the surgical set-up of
RCS(Ed), Consultant in Orthodontics, ClinCheck can be used for visualization of orthognathic cases with skeletal Class III
University of Manchester Dental Hospital treatment results and sharing information patients successfully prepared for surgery.8,9
and Northenden House Orthodontics, with patients throughout the duration of It is suggested that cases with minimal need
Sale Road, Manchester, M23 0DF, UK. treatment. A typical course of treatment for significant dental movements are best
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 Orthodontics

Figure 3. Invisalign aligner with optimized

attachments and power ridges.

can be used to upright retroclined upper

incisors, such as in Class 2 Division II
cases. Invisalign Teen has also been
introduced for adolescents, with the
Figure 2. Invisalign ClinCheck Software. design compensating for incomplete
eruption of the canines, second premolars
Indications for Invisalign More Difficult Cases for Invisalign and second molars. It also has a built-in
blue wear indicator to gauge the amount
 Mild to moderate crowding with IPR or  Crowding or spacing more than 5 mm
of wear achieved. The advantages and
expansion planned (1−5 mm)  Dental expansion for blocked out teeth
disadvantages of Invisalign are listed in
 Mild to moderate spacing  Alignment of high canines
Table 2, with a classification system in
 Severe crowding where a lower incisor  Molar uprighting
Table 3. Initially, case series did suggest
extraction is planned  Skeletal anterior-posterior discrepancies
there was no measurable orthodontically
 Deep overbite problems where overbite can over 2 mm
induced inflammatory root resorption
be reduced by intrusion and incisor  Severely rotated teeth over 20 degrees
(OIIRR) associated with Invisalign, but a
advancement  Open bites
recent case report presented extreme
 Narrow arches that can be expanded  Cases requiring extrusion of teeth
OIIRR associated with the upper incisors.10
 Closure of premolar extraction spaces
Clinical studies with Invisalign
Table 1. Indications and limitations of Invisalign. therapy have begun to quantify treatment
efficacy, but to date no randomized
Advantages for Invisalign Disadvantages for Invisalign controlled trials have been undertaken.
The mean accuracy of Invisalign for all
 Aesthetic  Expensive laboratory costs tooth movements was estimated at 41%
 Comfortable to wear  Lack of operator control in a recent prospective clinical study,
 Decreased chairside time  Limited control of root movement but only anterior teeth were examined.
 Improved oral hygiene  Limited intermaxillary correction The most accurate movements were
 Eliminates bonding issues to heavily-filled teeth lingual constriction of the mandibular
 Adaptable − can combine with fixed appliances canines and rotation of the maxillary
 Prevents occlusal wear in bruxists central incisors, whilst extrusion of the
central incisors and mesiodistal tip
Table 2. Advantages and disadvantages of Invisalign.
of the mandibular canine were least
accurate.11 Clements et al, in their 2003
study, did comment that aligners were
most successful in improving anterior
suited to Invisalign therapy.9 Recently, the placement has been lowered with more
alignment and least effective for buccal
Invisalign protocol has been modified to appropriate attachment designs. Optimized
occlusion.12 Djeu et al’s retrospective
help address issues with managing more attachments (Figure 3) are now designed
comparison of outcomes of non-
difficult cases. The effects of interarch to improve extrusions of anterior teeth
extraction Invisalign and fixed appliance
elastics used to correct anterior-posterior and canine rotations with aligner forces.
treatments, using the American Board of
discrepancies have been built into the These next-generation attachments are
Orthodontics objective grading system,
software; interproximal reduction is customized to a patient’s unique tooth
found a significant difference in the pass
timed to the stage when there is best anatomy. Power ridges (Figure 3) now
rate of Invisalign compared to Tip-Edge
access to the interproximal contacts help to deliver lingual root torque by
treatment (20.8%, 47.9%, respectively).
and the threshold to trigger attachment optimizing forces on upper incisors. They
Treatment time was significantly less
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 Orthodontics

a Type Description of System

Invisalign Full Maximum flexibility in treatment of a wide

range of malocclusions

Invisalign Anterior Treatment limited to moving upper and lower

anterior teeth (canine to canine) with crowding
or spacing of 4 mm or less per arch

Invisalign Lite Treatment for minor crowding or spacing

(including orthodontic relapse). Only allows use
of 14 aligners or less

Invisalign Teen Treatment for teenage patients. The device has

unique innovative features that address patient
compliance, natural eruption of permanent
teeth and control of root movement

Vivera Retainers Retainers made by Invisalign at the end of

treatment

b Table 3. Classification of the Invisalign system.

a d

e
b

Figure 5. (a−e) Intra-oral views of Case 1.

to fixed appliances so that patients can

be fully informed of potential treatment
outcomes.
The following two cases
demonstrate the successful use of the
for Invisalign at 1.4 years compared to 1.7 Invisalign system for the treatment of Class II
years for Tip-Edge treatment.13 It has been and Class III malocclusions, respectively.
suggested that the highest incompletion
rates are seen in premolar extraction cases.14
More research needs to be Case 1
undertaken to quantify the effects of A 24-year-old female presented
Figure 4. (a–c) Extra-oral views of Case 1. Invisalign further, particularly in comparison with the chief concern of crowding of her

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 Orthodontics

mesio-labially rotated canines (Figures 4

and 5).
The pre-treatment OPT
(Figure 6) shows the presence of all the
permanent teeth with overall good alveolar
bone density and good root morphology.
The cephalometric radiograph (Figure 7)
confirmed the mild II skeletal base with
proclined upper incisors.
The treatment objectives were
to align the arches and reduce the overjet
by retroclining and retracting the upper
incisors, intrude the lower incisors to level
the curve of Spee and thus decrease the
overbite. Upper and lower crowding was
to be resolved by interproximal reduction.
The buccal segment occlusion and Class I
Figure 6. Pre-treatment OPT of Case 1. molar relationship was to be maintained
with both fixed and removable retainers
c
to maintain the treatment outcomes.
Polyvinylsiloxane (PVS) impressions,
occlusal bite, photographs, radiographs
and the treatment planning form were sent
to Align Technology for the creation of a
ClinCheck (Figure 8). The ClinCheck allows
the doctor to accept or revise the projected
d
staging, tooth movements and finished
treatment results prior to the manufacture
of the Invisalign aligners (Figure 9). In this
case, treatment involved 11 aligners for the
upper arch and 24 aligners for the lower
Figure 7. Pre-treatment cephalometric radiograph
arch. Three attachments were bonded in
of Case 1.
the lower arch to permit three-dimensional
a control of tooth movement (Figure 10). The
patient was asked to change the aligners at
two-week intervals. Interproximal reduction
of 1.5 mm was carried out in the upper
e labial segment from canine to canine and
2.5 mm in the lower labial segment from
canine to canine. The patient did require
refinement aligners, which involved three
b
aligners in the upper arch and four in the
lower arch. In addition, a further 0.4 mm
of IPR was required between the upper
incisors to reduce the small black triangular
gaps. The total treatment time, including
the refinement aligners, was 14 months.
At the end of treatment a
Figure 8. (a–e) Pre-treatment still photos of Invisalign ClinCheck (Case 1). successful outcome was achieved with a
happy and satisfied patient (Figure 11).
Both upper and lower arches were well
aligned with complete reduction of overjet
upper and lower teeth. She did not want 7mm and an overbite that was increased and overbite (Figure 12). Upper and lower
to wear conventional fixed appliances. and complete. In addition, the upper fixed bonded retainers were fitted from
On examination, she presented with a arch presented with mild crowding with canine to canine. In addition, the patient
Class II division 1 incisor relationship on proclined upper incisors. The lower arch was given vacuum-formed retainers to be
a mild skeletal II base with an overjet of presented with moderate crowding with worn on a night-time basis.
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 Orthodontics

a Case 2 Treatment progressed well with the aligners.

However, towards the end, the patient was
A 42-year-old male presented
still Class III incisally.
with Class III incisors on a mild III skeletal
In this case, Class III elastics
base with average lower face height and
(Figure 20) were used with the aligners to
Frankfort mandibular plane angle (Figure
help with correction of the Class III incisor
13). Intra-orally the incisor relationship
relationship and achieve positive overjet and
was Class III with an overjet of -2 mm to
b overbite. The patient had to wear the elastics
the UR1. The overbite was decreased and
on a night-time basis for a short period to
incomplete with moderate crowding of
achieve the desired result.
his upper arch. The lower arch presented
Treatment involved 15 aligners
with mild crowding (Figure 14). The UR1
for the upper arch and 11 aligners for the
was of poor prognosis and had a long-
lower arch and interproximal reduction of
standing post crown. The post crown had
2.5 mm between lower canine to canine.
been loose a few times and the patient
c No refinement aligners were required in this
was told by his dentist that he required
case. Total treatment time was 8 months.
implant/bridge replacement of this tooth.
The extra-oral view (Figure 21)
The patient and his dentist both wanted
of the patient at the end of treatment shows
to align his teeth fully before implant
improved incisal by proclining the upper
replacement of the UR1.
incisors. Intra-oral pictures show a positive
The OPT confirmed the poor
overjet and overbite has been achieved and
prognosis of the UR1 (Figure 15). The
d the patient has Class I incisors with good
cephalometric radiograph also confirmed
buccal segment interdigitation. The positive
his mild Class III incisor relationship and
overbite is going to contribute to the stability
skeletal profile. The upper incisors were
of the Class III incisor correction (Figure 22).
slightly retroclined and the lower incisors
The patient is now in the process
were proclined. This would help with the
of having implant replacement of UR1. They
Class III incisor correction (Figure 16).
were fitted with an upper vacuum-formed
Treatment for this patient
retainer and a lower fixed bonded retainer.
was carried out with Invisalign aligners.
The aims of treatment were to relieve the
crowding in both upper and lower arches
and correct the Class III incisor relationship. Discussion
e Space in the upper arch was created by A systematic treatment plan
proclination of the upper incisors and in is crucial with the Invisalign system. The
the lower arch by interproximal reduction. ClinCheck software can be used for diagnosis
PVS impressions and full records were and treatment planning. It acts as a valuable
taken for development of ClinCheck tool to assess the need for expansion,
(Figure 17 and 18). The treatment began extraction, interproximal reduction,
with aligners. These were changed at two- distalization or proclination. This mode of
week intervals. Attachments were bonded treatment requires the clinician to plan out a
on all the canines, upper left lateral incisor reasonable sequential tooth movement for
and lower right first premolar to provide every tooth from start to finish.
retention for the aligners (Figure 19). Aligners are recommended over
Figure 9. (a–e) Projected post-treatment still
photos of Invisalign ClinCheck (Case 1).

a b c

Figure 10. (a–c) Patient with Invisalign aligner and attachments in situ (Case 1).

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 Orthodontics

a a b

c d

Figure 11. (a–d) Post treatment extra-oral views of Case 1.

a b
d

c d
e

Figure 12. (a–e) Post treatment intra-oral views

of Case 1. Figure 13. (a–d) Pre-treatment extra-oral views of Case 2.

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 Orthodontics

Figure 15. Pre-treatment OPT showing poor prognosis post-crown UR1 of Case 2.

Figure 16. Pre-treatment cephalometric

d radiograph of Case 2.
c
b

e e
d

Figure 14. (a–e) Pre-treatment intra-oral

views of Case 2. Figure 17. (a–e) Pre-treatment ClinCheck of Case 2.

conventional fixed appliances for several better oral hygiene; approach unsuitable for treating certain
reasons:  Aligners are generally more comfortable advanced cases. Simple malocclusions have
 They are clear and therefore more to wear. been treated successfully with Invisalign,
aesthetically acceptable, especially for adults; However, there are some but more complex cases do require fixed
 They can be easily removed, thus ensuring limitations, which make the Invisalign appliances or other treatment options
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 Orthodontics

a a

Figure 20. Use of Class III elastics with the aligners.

b b

an important part of Invisalign treatment

− as with fixed appliances, extra time is
occasionally needed to finish a case. The
same principle applies with Invisalign. In
c c order to achieve the best results, refinement
aligners are sometimes required, as
described for Case 1.
One of the other drawbacks of
the Invisalign technique is that, although
the ClinCheck shows correction of the
malocclusion with aligners, in some cases
this may not occur and clinicians may have
d d to use auxiliary techniques to achieve the
best result. As in Case 2, Class III elastics
were used with aligners for the complete
correction of the incisor relationship.

Conclusion
The Invisalign system has
opened up a contemporary area of adult
orthodontics, helping patients who may
not want traditional fixed appliances or
where removable appliances may be
ineffective. The treated cases demonstrate
e e that the Invisalign system can be a valuable
substitute for fixed appliances in mild to
moderate malocclusions.
We still have a great deal to learn
regarding the biomechanical feasibility and
effectiveness of the Invisalign system. High
quality randomized clinical trials are required
to support the claims about Invisalign
treatment. However, the key to success is
appropriate case selection. Orthodontists
will have to rely on the inadequate available
Figure 19. (a–e) Case 2 with aligners in place evidence, expert opinions and their
Figure 18. (a–e) Projected post-treatment showing the aligner engaging the attachments. Invisalign clinical experience when using the
ClinCheck of Case 2. system.

the teeth in an upright position during space

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214 DentalUpdate April 2013
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 Orthodontics

a b a

c d

Figure 21. (a–d) Extra-oral views of Case 2 at end of treatment.

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