Principles and Biomechanics of Aligner

Treatment

Ravindra Nanda BDS, MDS, PhD

Professor Emeritus, Department of Orthodontics, University of Connecticut Health Center,
Farmington, Connecticut, USAProfessor Emeritus, Department of Orthodontics, University of
Connecticut Health Center, Farmington, Connecticut, USA

Tommaso Castroflorio DDS, PhD, Ortho. Spec.

Department of Surgical Sciences, Postgraduate School of Orthodontics, Dental School,
University of Torino, Torino, ItalyDepartment of Surgical Sciences, Postgraduate School of
Orthodontics, Dental School, University of Torino, Torino, Italy

Francesco Garino MD, Ortho. Spec.

Private Practice, Torino, ItalyPrivate Practice, Torino, Italy

Kenji Ojima DDS, MDSc

Private Practice, Tokyo, JapanPrivate Practice, Tokyo, Japan
Table of Contents

Cover image

Title page

Copyright

Dedication

Contributors

Foreword

1. Diagnosis and treatment planning in the three-dimensional era

Introduction

Intraoral scans and digital models

3D imaging

References

2. Current biomechanical rationale concerning composite attachments in aligner

orthodontics

Introduction

Geometry (active surface orientation)

Location

Size
 Functions

Basic attachment configurations in current aligner orthodontics

References

3. Clear aligners: Material structures and properties

Introduction

Polymer molecular structure and thermal properties

Physical and chemical aging of aligner polymers

Conclusions and outlook

References

4. Influence of intraoral factors on optical and mechanical aligner material properties

Introduction

Water absorption

Optical changes

Short-term mechanical loading of aligner materials

Long-term loading

Clinical loading patterns of aligner materials

References

5. Theoretical and practical considerations in planning an orthodontic treatment with

clear aligners

Introduction

Theoretical and practical considerations in CAT

Biologic considerations in aligner orthodontics

Patient compliance

CAT fundamentals recap

 References

6. Class I malocclusion

Introduction

Diagnostic reference

Treatment plan

Class I conditions

References

7. Aligner treatment in class II malocclusion patients

Introduction

The clinical protocol

Maxillary distalization case reports

References

8. Aligners in extraction cases

Introduction

Diagnosis and treatment plan

Treatment progress

Treatment results

Discussion

Conclusion

References

9. Open-bite treatment with aligners

Diagnosis of anterior open bite

Biomechanics for anterior open-bite correction

 Aligner protocols for open-bite treatment

Case report 1

Case report 2

References

10. Deep bite

Introduction

Leveling of the curve of spee

Leveling the upper incisors

Case report 1

Case report 2

References

11. Interceptive orthodontics with aligners

Introduction

Maxillary expansion

Expansion case reports

Class II malocclusion

Mandibular advancement case reports

Conclusions

References

12. The hybrid approach in class II malocclusions treatment

Introduction

Tooth-borne hybrid approach with distalizing device

Case report 1
 Case report 2

References

13. Aligners and impacted canines

Introduction

Early diagnosis and treatment

Late diagnosis

Treatment planning and orthodontic management

Labial impactions

Palatal impactions

Clinical case

References

14. Aligner orthodontics in prerestorative patients

Introduction

Space management in the anterior region

Case study

Space management in the posterior region

Management of posterior overerupted molars

Management of patients with a history of temporomandibular disorders

Case study

References

15. Noncompliance upper molar distalization and aligner treatment for correction of
class II malocclusions

Upper molar distalization in aligner treatment

Clinical procedure and rational of the Beneslider

 Clinical case

Clinical considerations

Conclusions

References

16. Clear aligner orthodontic treatment of patients with periodontitis

Malocclusions related to periodontal disease

Orthodontic treatment in patients with periodontal disease

Diagnosis and treatment planning

Orthodontic movements

Retention

Conclusions

Clinical case

References

17. Surgery first with aligner therapy

Historic background

Splint-aided maxillary and mandibular fixation without labial fixed appliances

Transitioning into and out of surgery with clear aligners

Surgery first and cat

Case study

Conclusions

References

18. Pain during orthodontic treatment: Biologic mechanisms and clinical management

The importance of orthodontic pain

 Biologic mechanisms of orthodontic pain and clinical correlates

Orthodontic tooth pain in clear aligner therapy

Modulators of pain: Psychological factors

Clinical considerations for the management of orthodontic pain

References

19. Retention and stability following aligner therapy

Retention and stability in orthodontic treatment

Retention protocols and the choice of retention appliance

References

20. Overcoming the limitations of aligner orthodontics: A hybrid approach

Introduction

Transverse expansion of the posterior teeth

Canine and premolar rotation

Extrusion, intrusion, and overbite control

Molar distalization

Conclusions

References

Index
Copyright
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043

PRINCIPLES AND BIOMECHANICS OF ALIGNER TREATMENT, FIRST

EDITION ISBN: 978-0-323-68382-1
Copyright © 2022 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any

means, electronic or mechanical, including photocopying, recording, or any information
storage and retrieval system, without permission in writing from the publisher. Details
on how to seek permission, further information about the Publisher’s permissions
policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).

Notices
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds or
experiments described herein. Because of rapid advances in the medical sciences, in
particular, independent verification of diagnoses and drug dosages should be made.
To the fullest extent of the law, no responsibility is assumed by Elsevier, authors,
editors or contributors for any injury and/or damage to persons or property as a
matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

ISBN: 978-0-323-68382-1
Content Strategist: Joslyn Dumas
Content Development Manager: Ellen Wurm-Cutter
Content Development Specialist: Rebecca Corradetti
Publishing Services Manager: Shereen Jameel
Project Manager: Nadhiya Sekar
Design Direction: Patrick Ferguson

Printed in India

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Dedication

To Catherine, for her love, support, inspiration, and encouragement.

RN

To Katia, for showing me what love is and for keeping my feet on the ground. To Alessandro,
Matilda, and Sveva, because you made the world a brighter place. To my friends, Francesco and
Kenji, for your passion, enthusiasm, commitment, and support: you are always an example to
follow. To Ravi, for your trust and friendship, for your guidance and leadership: you have
translated a vision into reality. It was a wonderful journey with you; thanks for your time and
for sharing your experience.

TC

I would like to dedicate this book to all my family with a special thought to my dad, mentor and a
visionary, who shared with me a passion in aligner orthodontics for 20 years.

FG

My thanks to Francesco and Tommaso for sharing their friendship with me over so many years.
The time I spent writing this book with Ravi was amazing, like a dream for me. I am truly
grateful to my family for all of their support.

KO
Contributors
Masoud Amirkhani, PhD, Institute for Experimental Physics, Ulm University, Ulm,
Germany
Sean K. Carlson, DMD, MS, Associate Professor, Department of Orthodontics,
School of Dentistry, University of the Pacific, San Francisco, California, USA
Tommaso Castroflorio, DDS, PhD, Ortho. Spec.
Researcher and Aggregate Professor, Department of Surgical Sciences, Postgraduate
School of Orthodontics, Dental School, University of Torino, Torino, Italy
Orthodontics Unit, San Giovanni Battista Hospital, Torino, Italy
Chisato Dan, DDS, Private Practice, Smile Innovation Orthodontics, Tokyo, Japan
Iacopo Cioffi, DDS, PhD, Associate Professor, Division of Graduate Orthodontics
and Centre for Multimodal Sensorimotor and Pain Research, Faculty of Dentistry,
University of Toronto, Toronto, Ontario, Canada
David Couchat, DDS, Ortho. Spec., Private Practice, Cabinet d’Orthodontie du dr.
Couchat, Marseille, France
Fayez Elkholy, DDS, Senior Physician, Department of Orthodontics, Ulm
University, Ulm, Germany
Francesco Garino, MD Ortho. Spec., Private Practice, Studio Associato dott.ri
Garino, Torino, Italy
Aldo Giancotti, DDS MS, Researcher and Aggregate Professor, Department of
Clinical Sciences and Translational Medicine, University of Rome “Tor Vergata”, Rome,
Italy
Juan Pablo Gomez Arango, DDS, MSc, Associate Professor, Orthodontics Program,
Universidad Autonoma de Manziales, Manziales, Colombia
Mario Greco, DDS, PhD
Visiting Professor, University of L’Aquila, L’Aquila, Italy
Visiting Professor, University of Ferrara, Ferrara, Italy
Luis Huanca, DDS, MS, PhD, Research Associate, Department of Orthodontics,
University of Geneva, Geneva, Switzerland
Josef Kučera, MUDr., PhD
Assistant Professor, Department of Orthodontics, Clinic of Dental Medicine, First
Medical Faculty, Charles University, Prague, Czech Republic
Lecturer, Department of Orthodontics, Clinic of Dental Medicine, Palacký University,
Olomouc, Czech Republic
Bernd G. Lapatki, DDS, PhD, Department Head and Chair, Department of
Orthodontics, Ulm University, Ulm, Germany
Luca Lombardo, DDS, Ortho. Spec., Chairman and Professor, Postgraduate School
of Orthodontics, University of Ferrara, Ferrara, Italy
Tiantong Lou, DMD, MSc, Division of Gradual Orthodontics and Centre for
Multimodal Sensorimotor and Pain Research, Faculty of Dentistry, University of
Toronto, Toronto, Ontario, Canada
Kamy Malekian, DDS, MSc, Private Practice, Clinica Bio, Madrid, Spain
Gianluca Mampieri, DDS, MS, PhD, Researcher and Aggregate Professor,
Department of Clinical Sciences and Translational Medicine, University of Rome “Tor
Vergata”, Rome, Italy
Edoardo Mantovani, DDS, Ortho. Spec., Research Associate, Department of Surgical
Sciences, Postgraduate School in Orthodontics, Dental School, University of Torino,
Torino, Italy
Ivo Marek, MUDr., PhD
Assistant Professor, Department of Orthodontics, Clinic of Dental Medicine, Palacký
University, Oloumouc, Czech Republic
Consultant, Department of Orthodontics, Clinic of Dental Medicine, First Medical
Faculty, Charles University, Prague, Czech Republic
Ravindra Nanda, BDS, MDS, PhD, Professor Emeritus, Division of Orthodontics,
Department of Craniofacial Sciences, University of Connecticut School of Dental
Medicine, Farmington, Connecticut, USA
Kenji Ojima, DDS, MDSc, Private Practice, Smile Innovation Orthodontics, Tokyo,
Japan
Simone Parrini, DDS, Ortho. Spec., Research Associate, Department of Surgical
Sciences, Postgraduate School in Orthodontics, Dental School, University of Torino,
Torino, Italy
Serena Ravera, DDS, PhD, Ortho. Spec., Research Associate, Department of Surgical
Sciences, Postgraduate School in Orthodontics, Dental School, University of Torino,
Torino, Italy
Gabriele Rossini, DDS, PhD, Ortho. Spec., Research Associate, Department of
Surgical Sciences, Postgraduate School in Orthodontics, Dental School, University of
Torino, Torino, Italy
Waddah Sabouni, DDS, Ortho. Spec., Private Practice, Cabinet d’Orthodontie du dr.
Sabouni, Bandol Rivage, Sanary-sur-Mer, France
Silva Schmidt, DDS, Department of Orthodontics, Ulm University, Ulm, Germany
Jörg Schwarze, DDS, PhD, Ortho. Spec., Private Practice, Kieferorthopädische
Praxis Dr. Jörg Schwarze, Cologne, Germany
Giuseppe Siciliani, MD, DDS, Chairman and Professor, School of Dentistry,
University of Ferrara, Ferrara, Italy
Ali Tassi, BSc, DDS, MClD (Ortho), Assistant Dean and Chair, Division of
Graduate Orthodontics, Schulich School of Medicine and Dentistry, The University of
Western Ontario, London, Ontario, Canada
Johnny Tran, DMD, MClD, Division of Graduate Orthodontics, Schulich School of
Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
Flavio Uribe, DDS, MDentSc, UConn Orthodontics Alumni/Nanda Orthodontics
Endowed Chair, Program Director and Chair, Division of Orthodontics, Department of
Craniofacial Sciences, University of Connecticut, School of Dental Medicine,
Farmington, Connecticut, USA
Benedict Wilmes, DDS, MSc, PhD, Professor, Department of Orthodontics,
University of Düsseldorf, Düsseldorf, Germany
Foreword
Ravindra Nanda, Tommaso Castroflorio, Francesco Garino, Kenji Ojima

Aligners represent the new frontier in the art and science of orthodontics. This new
frontier offers new opportunities and challenges, but also requires the need for
additional knowledge. A rethinking of biomechanics and force delivery concepts is
needed along with the role of materials used for aligners. There is a need for combining
established concepts with new tools and technologies which aligner treatment requires.
When considering new methodologies, orthodontists should always remember that
technology is a tool and not the goal. Diagnosis, treatment plan, and biomechanics are
always the key elements of successful treatment, regardless of the treatment
methodology. Aligner orthodontics is quite different than traditional methods with
brackets and wires. Force delivery with aligners is through plastic materials. Thus, the
knowledge of the aligner materials, physical properties, attachment design, and the
sequentialization protocol is crucial for treatment of malocclusions. It is also imperative
to understand limitations of aligner treatment and how to overcome them with the use
of miniscrews and auxiliaries.
Aligner treatment requires new knowledge; the number of clinical and scientific
reports about all the different aspects of aligner orthodontics is increasing year by year.
This book represents an up-to-date summary of the available research in the field as
well as a clinical atlas of treated patients based on the current evidence. We have made
an attempt to provide benchmark for clinicians, researchers, and residents who want to
improve their skills in aligner orthodontics.
We would like to express our great appreciation to all the friends and colleagues who
have contributed to this book. It was a pleasure to work with all these talented
orthodontists.
We would like to say thank you to the Elsevier team for their support, patience, and
guidance during the challenging Covid pandemic.
List of Tables
Table 5.1 Suggested Amount of Movement per Aligner
Table 9.1 Case Study 1: Problem List
Table 9.2 Case Study 1: Treatment Objectives
Table 9.3 Case Study 1: Summary of Cephalometric Changes
Table 9.4 Case Study 2: Problem List
Table 9.5 Case Study 2: Treatment Objectives
Table 9.6 Case Study 2: Summary of Cephalometric Changes
Table 11.1 Pre- and post-treatment volumetric and linear measurements obtained in the
reported cases.
Table 13.1 Factors Affecting Prognosis
Table 15.1 Cephalometric Summary
Table 16.1 Framework for Staging and Grading of Periodontitis
Table 16.2 Periodontitis Stage
Table 16.3 Orthodontic Movements And Malocclusion Features
Table 16.4 Stages of Periodontitis
Table 16.5 Grades of Periodontitis
Table 18.1 Strategies to Reduce Pain During Orthodontic Treatment
List of Illustrations
Fig. 1.1 Steps in diagnosis and treatment planning in the digital orthodontics era.
Fig. 1.2 Integration of cone-beam computed tomography data, facial three-dimensional
scan, digital models from intraoral scans, and virtual orthodontic setup.
Fig. 1.3 (A) Digital models and measurements obtained from cone-beam computed
tomography data. (B) Digital models and measurements obtained from intraoral scans.
Fig. 1.4 New generation of intraoral scanners with integrated near infrared (NIR)
technology. (A) Itero Element 5D (Align Technology, San José, CA, USA) decays
detection scheme. (B) 3Shape Trios 4 (3Shape A/S, Copenhagen, Denmark) fluorescent
technology for surface decay detection (left) and NIR technology for interproximal
decay detection (right).
Fig. 1.5 Cone-beam computed tomography data elaboration for enhancing diagnosis
and treatment planning.
Fig. 1.6 Case of impacted lower canine in which the cone-beam computed tomography
data are helpful in defining the right mechanics.
Fig. 1.7 Occasional report of misunderstood right condyle neck fracture results in a 9-
year-old child being prescribed cone-beam computed tomography for orthodontic
reasons.
Fig. 1.8 Airway measurements from cone-beam computed tomography data.
Fig. 1.9 Example of cone-beam computed tomography data integration in a surgery
three-dimensional planning software.
Fig. 1.10 Cone-beam computed tomography data used to plan an orthodontic expansion
in a subject with poor periodontal support (upper). Orthodontic expansion,
corticotomies, and bone grafts were planned to obtain an excellent final result without
bone dehiscence (lower).
Fig. 1.11 Stereophotogrammetry (A) and laser scan (B) three-dimensional
reconstructions of the face of the same patient.
Fig. 1.12 Superimposition of the virtual setup on the smile picture of a patient with
unilateral agenesis, visualizing from left to right the initial situation, the
postorthodontic situation, and the final smile with restorative simulation.
Fig. 1.13 The virtual patient in which cone-beam computed tomography data, facial
three-dimensional reconstruction, and virtual setup obtained after teeth segmentation
are superimposed.
Fig. 2.1 (A) Mesial tipping moments (red curved arrows) produced by aligner forces (red
arrows) occurring during space closure. Antitipping moments (blue curved arrows)
produced by forces (blue arrows) acting at rectangular vertical attachments (B).
Opposing moments are canceled out, promoting bodily movement.
Fig. 2.2 The typical force couple generated during bracket-based alignment of rotated
tooth with a fully engaged 0.014 NiTi archwire consists of two force vectors: one that
pushes against the posterior wall of the slot (red arrow) and a second that pulls away
from the same wall (blue arrow).
Fig. 2.3 (A) Aligner-tooth mismatch. (B) Elastic aligner deformation and activation of
forces upon aligner insertion. (C) Tooth alignment after aligner sequence.
Fig. 2.4 (A) Active surfaces of attachments. (B) Direction of forces acting at active
surfaces. (C) Resultant force affecting the first premolar will produce extrusion and
clockwise, second-order rotation.
Fig. 2.5 (A) Due to the distance between the center of resistance (blue dot) and the line of
action (red dotted line), large mesial tipping and negligible mesiolingual rotational
moments should be expected. (B) A more mesial and apical attachment location will
result in reduced mesial tipping and increased mesiolingual rotational moments,
increasing clinical efficacy.
Fig. 2.6 During expansion, labial attachment location (A) produced smaller net buccal
molar tipping moments than lingually bonded attachments (B).
Fig. 2.7 (A) Attachments located on teeth adjacent to force application increase aligner
retention when using intermaxillary elastics. (B) Attachment position close to the
gingival margin and occlusally beveled geometry is ideal for aligner retention.
Fig. 2.8 (A) Multiple tangential forces (red arrows) acting during aligner-based, bicuspid
rotation. (B) Due to slipping effect, incomplete expression of expected rotation with
space between tooth and aligner (in yellow) will be observed.
Fig. 2.9 (A) Properly designed attachments produce complementary force vectors
required for predictable tooth movement. (B) Polymer stress relaxation and creep, along
with incomplete rotation and unintended force (blue arrow), may occur during sequence
of aligner-based, tooth rotation stages.
Fig. 2.10 (A) Image from ClinCheck treatment plan. (B) Loss of tracking with incomplete
expression of rotation and extrusion of left upper bicuspid. Lack of coincidence between
attachment (green shaded area) and its corresponding recess in the aligner (green outline)
is observed.
Fig. 2.11 (A) Converging buccal and lingual crown surfaces. (B) Undesired aligner
dislodgment during extrusive movement.
Fig. 2.12 (A) Optimized Extrusion Attachments (Align Technology, Santa Clara, CA) on
central incisors. (B) Gingivallyoriented inclined plane with optimal active surface
angulation.
Fig. 2.13 (A) Forces transmitted by the aligner (red arrows) and resultant forces (purple
arrows) acting on the tooth. (B) A reduction of the angle between active attachment
surface and buccal tooth surface produces stronger resultant extrusive forces.
Fig. 2.14 Intrusion in the posterior segment (red arrows) produces reactive forces that
will tend to dislodge the aligner anteriorly (blue arrows). Adequate attachment selection
on anterior teeth will counteract this undesired occurrence.
Fig. 2.15 (A) Rotational forces produced by the aligner (purple arrows) are transmitted to
the tooth as normal force components (red arrows), which are perpendicular to tooth
surface tangents (purple dotted lines). (B) Incorporation of bonded attachment increases
the magnitude and efficacy of rotational moment by increasing the perpendicular
distance (green dotted line) between the line of action (red dotted line) and the center of
resistance (CRes).
Fig. 2.16 (A) Without attachment, the tooth lagged behind the aligner almost by 30%.
With attachment incorporation, this lag dropped to 5%. (B) Intrusive forces observed at
the periodontal ligament without attachments was 0.078 N for every degree of rotation,
while with attachments the load was reduced to 0.021 N for every degree. ATT,
Attachment.
Fig. 2.17 (A) Digital image of occlusal view of right upper canine. Occlusal view of finite
element method simulation of upper right canine during mesiolingual rotation. (B)
Distinctly intrusive pressure areas (red) on mesiolabial and distolingual aspects of the
tooth crown appear upon aligner insertion. The dotted line represents the aligner’s
profile.
Fig. 2.18 Optimized Rotation Attachment (Align Technology, Santa Clara, CA) with
active surface oriented to provide a compensatory extrusive force.
Fig. 2.19 (A) Force couple produced during bracket-based correction of excessive mesial
tip. (B) Equivalent force couple produced at Optimized Root Control Attachments
(Align Technology, Santa Clara, CA) during aligner-based tipping.
Fig. 2.20 Tooth displacement patterns during aligner-based distalization of upper right
canine. (A) Without attachments, distinct uncontrolled distal tipping was observed,
with center of rotation between apical and middle thirds of the root (red arrow). (B) With
attachments, the canine expressed distal bodily movement.
Fig. 2.21 Periodontal ligament strain patterns during aligner-based distalization of
upper right canine. (A) Without attachments, distocervical pressure (in blue) and
distoapical tension (in red) areas were observed, typical of uncontrolled distal tipping.
(B) With attachments, uniform pressure along the distal root surface (in blue) and
uniform tension (in red) along the medial surface, typical of distal bodily movement,
were observed.
Fig. 2.22 (A) Uprighting moment produced at single rectangular horizontal attachment.
(B) Alternative twin attachment configuration.
Fig. 2.23 Producing equivalent moments (curved arrows), an increase in intervector
distance proportionately reduces force magnitude (blue arrows) acting at attachment
surface. Two degrees of distal tipping with a 4-mm rectangular attachment (A) will
produce higher forces on the aligner than with a two-attachment configuration that
significantly separates the force vectors (B) of the acting couple.
Fig. 2.24 Class II case in which reciprocal moments between anterior and posterior
segments during extraction space closure (A) will result in 50% anchorage loss and class
II occlusion (B).
Fig. 2.25 Clockwise moments (blue curved arrows) produced by attachments bonded to
posterior teeth (A) will counteract posterior anchorage loss, reducing it to 25%, resulting
in class I occlusion (B).
Fig. 2.26 (A) By preactivating (red shaded) and subsequently inserting (red) the
archwire, a force couple (blue arrows) and its corresponding counterclockwise moment
(blue curved arrow) will be produced. (B) The same positive torque can be achieved with
aligners by producing an equivalent couple, with lower forces and increased intervector
distance.
Fig. 2.27 (A) Aligner-based expansive force (red arrow) applied at a distance from the
center of resistance (CRes) will produce counterclockwise moment (red curved arrow). (B)
Without preventive measures, buccal tipping with center of rotation (CRot) above the
furcation will occur, followed by aligner deformation and loss of control.
Fig. 2.28 (A) Opposing forces (blue arrows) acting at the occlusal surface and gingival
aspect of a rectangular horizontal buccal attachment will provide a clockwise moment
(blue curved arrow) that reduces buccal tipping, with apical migration of the center of
rotation (CRot) (B).
Fig. 2.29 (A) Programmed expansive mismatch between aligner and dental arch. (B)
Once inserted, the resultant expansive forces will have a distally decreasing magnitude
gradient.
Fig. 2.30 Low angle patient (A), with bilateral posterior crossbite (B, D) and midline
discrepancy (C).
Fig. 2.31 (A) Initial ClinCheck stage. (B) Aligners inserted, prior to bonding of upper
palatal and lower buccal buttons. (C) Crossbite elastic.
Fig. 2.32 A 100-gmf intermaxillary elastic force will produce a 90-gmf effective
transverse force, expanding the upper arch and compressing the lower arch.
Additionally, 42 gmf of extrusive force will equally influence upper and lower arches.
Fig. 2.33 In the upper arch, the moments provided by upper buccal attachments (blue
curved arrows) will counteract moments (red curved arrows) produced by elastic
expansive forces (red arrows), reducing undesired upper tipping. In the lower arch,
unopposed lingual elastic forces (dotted red arrows) will result in expected lingual
tipping (dotted red curved arrows).
Fig. 2.34 (A, B) Initial bilateral crossbite and midline discrepancy. (C, D) Aligner-based
correction with complementary use of intermaxillary elastics.
Fig. 3.1 Chemical structure of polyethylene terephthalate glycol material (PET-G).
Fig. 3.2 Chemical structure of polyurethane material (PU).
Fig. 3.3 Specific volume versus temperature. Tm represents the melting temperature and
Tg the glass transition temperature.
Fig. 3.4 Differential scanning calorimetry of polyethylene terephthalate glycol (PET-G).
Fig. 4.1 Bending forces depending on the (dry or wet) storage conditions and the
unloaded or loaded condition. Note 0.75-mm polyethylene terephthalate glycol (PET-G)
specimens were investigated in a three-point bending setting with a span length of 8
mm at a deflection of 0.1 mm. The specimens were either only thermoformed and then
underwent only one short deflection with simultaneous force, stored for 24 hours in
water without loading, loaded continuously for 24 hours without water immersion, or
loaded continuously for 24 hours with water immersion. The error bars represent the
standard deviation for the different measurements.
Fig. 4.2 Invisalign aligners. (A) Prior to first intraoral application. (B) After a 1-week
wearing period.
Fig. 4.3 Forces measured for 0.75-mm polyethylene terephthalate glycol (PET-G)
specimens in a three-point bending setup with a span length of 8 mm. The central
support was deflected by 0.1 mm. Two short loading-measuring cycles with 0.1-second
duration, separated by a 2-minute recovery break, were performed.
Fig. 4.4 (A) Forces measured during multiple 5-minute loading and 5-minute loading
cycles for a 0.5-mm polyethylene terephthalate glycol (PET-G) specimen in a three-point
bending setup with a span length of 8 mm and a deflection of 0.2 mm. (B) Enlargement
of a data segment (see top of A) showing the gradual force decrease during the 5-minute
loading time. (C) Enlargement of a data segment (see bottom of A) showing the slight
force increase during the 10-minute minimal load time at the corresponding deflections.
Fig. 4.5 Average force reduction reported for polyethylene terephthalate glycol (PET-G)
aligners in the course of 50 aligner seating-removal procedures based on the data
published by Skaik et al.20 The error bars indicate the standard deviation.
Fig. 4.6 Schematic modeling of viscoelastic material behavior using a standard linear
solid model. (A) Maxwell representation of a standard linear solid model. (B) Kelvin
representation of a standard linear solid model. Such models combine springs and
dashpots in a certain arrangement to describe the overall behavior of a system under
different loading conditions. Springs represent the elastic component of a viscoelastic
material, whereas dashpots represent the viscous component.30 Due to combination of
such elements, an applied stress varies with the time-dependent change of the strain.
Fig. 4.7 Two fundamentally different experiments and parameters, respectively,
describing the time-dependent behavior of a viscoelastic aligner material. (A) The creep
phenomenon is observed if the load (and stress level, respectively) is kept constant over
time. (B) The stress relaxation behavior is characterized by loading the material under
constant strain and deflection, respectively.
Fig. 4.8 Normalized stress relaxation for polyethylene terephthalate glycol (PET-G)
materials loaded for 1 week in a three-point bending setup with a constant deflection of
the specimen leading to a constant strain.
Fig. 4.9 Decay of the forces measured after the loading and unloading periods during
the 1-week observation time.
Fig. 5.1 Thresholds of acceptance of smile esthetics from laypeople point of view.
Fig. 5.2 Rectangular attachments on posterior teeth in CA Digital software.
Fig. 5.3 Rectangular attachments on anterior teeth in CA Digital software.
Fig. 5.4 Rectangular attachments on posterior teeth in Align Technology ClinCheck
software.
Fig. 5.5 Optimized and conventional attachments in Align Technology ClinCheck
software.
Fig. 5.6 Initial tooth displacement of second molar distalization with class II elastics
applied directly on upper canine (sagittal view).
Fig. 5.7 Initial tooth displacement of second molar distalization with class II elastics
applied directly on upper canine (occlusal view).
Fig. 5.8 Initial tooth displacement of second molar distalization with class II elastics
applied on aligner at upper canine level (sagittal view).
Fig. 5.9 Initial tooth displacement of second molar distalization with class II elastics
applied on aligner at upper canine level (occlusal view).
Fig. 5.10 Initial aligner displacement of second molar distalization with class II elastics
applied directly on upper canine.
Fig. 5.11 Initial aligner displacement of second molar distalization with class II elastics
applied on aligner at upper canine level.
Fig. 5.12 Initial tooth displacement of second molar distalization with class II elastics
applied on aligner at first premolar level. Initial displacement amount is shown in the
attached legend.
Fig. 5.13 Initial tooth displacement of first molar and second premolar distalization
without class II elastics. The mesial shift of posterior teeth is clinically relevant.
Fig. 6.1 Biomechanical design of conventional attachments for extrusion (A) and distal
rotation (B)
Fig. 6.2 ClinCheck tools to check incisor inclination.
Fig. 6.3 Pretreatment records young adult patient with severe crowding and negative
premolar torque. (A-E intraoral pictures)
Fig. 6.4 Posttreatment records young adult patient with severe crowding and negative
premolar torque treated with torque correction and interproximal reduction. (A-E
intraoral pictures)
Fig. 6.5 (A) Pretreatment records young adult patient with narrow upper arch and smile
black corridors. (B) Posttreatment records young adult patient with narrow upper arch
and smile black corridors treated with upper expansion and lower torque correction.
Fig. 6.6 Double conventional attachment in case of severe rotation.
Fig. 6.7 Pretreatment records tooth size discrepancy A-D intraoral pictures.
Fig. 6.8 Posttreatment records toothsize discrepancy treated by space opening and
interproximal reduction A Digital project B-E intraoral pictures.
Fig. 6.9 Cross (A-B intraoral pictures) elastics to support posterior expansion.
Fig. 6.10 Anterior contact during buccal movement for crossbite resolution.
Fig. 6.11 Pretreatment records of lateral incisor in anterior crossbite. A-D intraoral
pictures
Fig. 6.12 Posttreatment records with complete correction of crossbite in reduced number
of aligners. A-B intraoral pictures
Fig. 6.13 Pretreatment records of severe posterior crossbite with maxillary contraction.
A-E intraoral pictures
Fig. 6.14 Posttreatment records after expansion + torque correction + interproximal
reduction + bite ramps. A-E intraoral pictures F Digital setup showing bite ramps for
posterior disocclusion.
Fig. 6.15 Class III elastics. A- intraoral pictures B Digital Setup
Fig. 6.16 Space opening for Peg shaped restoration. A pre-treatment B digital plan C
post treatment
Fig. 6.17 Pretreatment records of lateral incisor agenesis with apical distance less than 5
mm. A-D intraoral pictures E panoramic x-ray
Fig. 6.18 Posttreatment records of monolateral, lateral incisor agenesis with Invisalign
and fixed sectional for root control. A-E intraoral pictures
Fig. 6.19 Pretreatment records of bilateral, lateral incisors agenesis. A-D intraoral
pictures
Fig. 6.20 Posttreatment records of bilateral, lateral incisors agenesis treated by space
closure and teeth reshaping. A-D intraoral pictures
Fig. 6.21 Space opening by distal tipping of molars. A pre-treatment intraoral picture B
post-treatment intraoral picture with implant inserted
Fig. 6.22 Pretreatment records of overerupted upper second molar. A-B intraoral
pictures C panoramic x-ray
Fig. 6.23 Posttreatment records of overerupted upper second molar treated by aligners
only. A-B intraoral picture C panoramic x-ray
Fig. 7.1 Case 1 initial clinical and radiographic records.
Fig. 7.2 Case 1 frontal and sagittal views of initial ClinCheck.
Fig. 7.3 Case 1 final clinical and radiographic records.
Fig. 7.4 Case 1 frontal and sagittal views of final ClinCheck.
Fig. 7.5 Case 1 lateral x-ray comparison and cephalometric maxillary superimposition
before and after therapy.
Fig. 7.6 Case 2 initial clinical and radiographic records.
Fig. 7.7 Case 2 frontal and sagittal views of initial ClinCheck.
Fig. 7.8 Case 2 upper occlusal views at the beginning, after molar distalization, and at
the end of therapy.
Fig. 7.9 Case 2 end of distalization; intraoral frontal, occlusal, and sagittal views.
Fig. 7.10 Case 2 final clinical and radiographic records.
Fig. 7.11 Case 2 frontal and sagittal views of final ClinCheck.
Fig. 7.12 Case 2 lateral x-ray comparison and cephalometric maxillary superimposition
before and after therapy.
Fig. 7.13 Case 3 initial clinical and radiographic records.
Fig. 7.14 Case 3 sagittal views of initial, intermediate, final pre- and postjump
ClinCheck.
Fig. 7.15 Case 3 final clinical and radiographic records.
Fig. 8.1 (A) Smile appearance of the patient. (B) Frontal picture at rest. (C) Three-quarter
picture at rest. (D) Three-quarter smile appearance. (E) Profile smiling. (F) Profile at rest.
Fig. 8.2 Initial intraoral pictures.
Fig. 8.3 (A) Initial orthopantomography. (B) Initial lateral x-ray.
Fig. 8.4 ClinCheck initial stage. (A) Frontal view. (B) Right view. (C) Left view. (D)
Upper arch view. (E) Lower arch view.
Fig. 8.5 Schematic representation of vertical orthodontic tooth movement design in the
frontal plane (A). Amount of vertical movements for upper canines and central incisors
(B).
Fig. 8.6 Schematic representation of attachments and auxiliaries required in extraction
cases.
Fig. 8.7 (A) Initial smile esthetic analysis. (B) ClinCheck simulation into the smile frame
of the Digital Smile Design software.
Fig. 8.8 Treatment progresses in the frontal view.
Fig. 8.9 Treatment progresses in the right view.
Fig. 8.10 Treatment progresses in the occlusal views.
Fig. 8.11 Posttreatment pictures.
Fig. 8.12 Final smile esthetic analysis.
Fig. 8.13 (A) Final orthopantomography. (B) Final lateral x-ray.
Fig. 8.14 Posttreatment extraoral pictures.
Fig. 8.15 Final stage of the ClinCheck refinement.
Fig. 9.1 Optimized extrusive attachments of the Invisalign system.
Fig. 9.2 The anterior extrusive forces and reciprocal posterior intrusive forces work in
synergy to correct the anterior open bite.
Fig. 9.3 Rectangular shape attachments with beveled edge toward gingiva.
Fig. 9.4 Palatal attachments and occlusal attachments on upper molars.
Fig. 9.5 Case Study 1: Initial clinical records.
Fig. 9.6 Case Study 1: Pretreatment x-ray records.
Fig. 9.7 Case Study 1: Pre- and post-ClinCheck superimposition.
Fig. 9.8 Case Study 1: Final clinical records.
Fig. 9.9 Case Study 1: Posttreatment x-ray records.
Fig. 9.10 Case Study 2: Initial clinical records.
Fig. 9.11 Case Study 2: Pretreatment x-ray records.
Fig. 9.12 Case Study 2: Pre- and post-ClinCheck superimposition.
Fig. 9.13 Case Study 2: Invisalign with temporary anchorage devices for posterior
intrusion.
Fig. 9.14 Case Study 2: End of posterior intrusion.
Fig. 9.15 Case Study 2: Final clinical records.
Fig. 9.16 Case Study 2: Radiographic control and cephalometric superimposition.
Fig. 10.1 Schematic representation of the optimized bite ramps designed by Align
Technology (San José, CA, USA) and embedded into aligners. They change shape and
positioning along the treatment to provide optimal support to lower incisors at every
stage of treatment.
Fig. 10.2 Schematic representation of pressure areas designed by Align Technology (San
José, CA, USA) and incorporated into the aligner to redirect the intrusive force along the
long axis of the incisor.
Fig. 10.3 Initial extraoral photos.
Fig. 10.4 Initial intraoral photos.
Fig. 10.5 (A) Initial orthopantomography. (B) Initial lateral x-ray. (C) Initial tracing.
Fig. 10.6 Treatment stages scheme illustrating the frog protocol in which alternate
intrusion movements of canines and incisors are planned. On the Y axis teeth are
displayed, while on the X axis treatment stages are displayed: every stage corresponds
to five aligners. The blue lines indicate active movements, brown lines indicate
overcorrection stages. Red arrows down indicate when attachments should be placed,
while red arrows up indicate when attachments should be removed.
Fig. 10.7 (A) Initial curve of Spee. (B) Final curve of Spee.
Fig. 10.8 Final extraoral photos.
Fig. 10.9 Final intraoral photos.
Fig. 10.10 (A) Final orthopantomography. (B) Final lateral x-ray. (C) Final tracing.
Fig. 10.11 Tracing superimposition.
Fig. 10.12 Initial extraoral photos.
Fig. 10.13 Initial intraoral photos.
Fig. 10.14 (A) Initial orthopantomography. (B) Initial lateral x-ray.
Fig. 10.15 In progress intraoral photos. Molar tubes were used on lower first molars for
class II elastic anchorage.
Fig. 10.16 Final extraoral photos.
Fig. 10.17 Final intraoral photos.
Fig. 10.18 (A) Final orthopantomography. (B) Final lateral x-ray.
Fig. 11.1 Invisalign First optimized attachments for maxillary expansion.
Fig. 11.2 Invisalign First maxillary expansion protocol staging.
Fig. 11.3 CG intercanine widths assessed at gingival level, CC intercanine widths
assessed at cusp level, cG inter-E widths assessed at gingival level, cC inter-E widths
assessed at cusp level, MG intermolar widths assessed at gingival level, MC intermolar
widths assessed at cusp level.
Fig. 11.4 The anterior and posterior depth of the palatal vault is defined as the vertical
distance from the contact line between the cusp of the right and left canine and
mesiopalatal cusp tips of the right and left first molars to the palatal vault, respectively.
The palatal volume was defined by the median sagittal, distal, and gingival planes as
boundaries of the palate. The distal plane (DP) passed through two points at the distal
of the first upper permanent molars. The gingival plane (GP) was created by
intersecting the distal and median sagittal planes (MSP) through the center of incisive
papilla, which is considered a stable point structure.31 All planes were perpendicular to
each other.
Fig. 11.5 The palatal surface area was defined by the median sagittal (MSP), distal (DP),
and gingival (GP) planes as boundaries of the palate. The distal plane (DP) passed
through two points at the distal of the first upper permanent molars.
Fig. 11.6 Case 1 pre- (A) and post (B) therapy scans of the maxillary arch.
Fig. 11.7 Case 2 pre- (A) and post (B) therapy scans of the maxillary arch.
Fig. 11.8 Runner appliance. Upper arch aligner (A) and lower arch aligner (B).
Fig. 11.9 Intraoral Invisalign First with mandibular advancement feature.
Fig. 11.10 Invisalign First with mandibular advancement feature. Upper arch aligner (A)
and lower arch aligner (B)
Fig. 11.11 Case 3 Initial extraoral pictures.
Fig. 11.12 Case 3 initial intraoral pictures.
Fig. 11.13 Case 3 initial radiographic records.
Fig. 11.14 Case 3 sagittal view of ClinCheck.
Fig. 11.15 Case 3 final clinical records.
Fig. 11.16
Fig. 11.17 Case 3 changes of mandibular profile and cephalometric values before and
after therapy.
Fig. 11.18 Case 4 initial clinical and radiographic records.
Fig. 11.19
Fig. 11.20
Fig. 11.21 Case 4 sagittal view of ClinCheck and superimposition of initial ClinCheck
with final ClinCheck (occlusal view).
Fig. 11.22 Case 4 final clinical records and changes of mandibular profile.
Fig. 11.23
Fig. 11.24 Case 4 cephalometric values before and after therapy.
Fig. 12.1 Case 1. Extraoral pictures before treatment.
Fig. 12.2 Case 1. Intraoral pictures before treatment.
Fig. 12.3 Case 1. (A) Panoramic x-ray before treatment. (B) Lateral x-ray before
treatment.
Fig. 12.4 Case 1. Intraoral pictures at end of sagittal first phase.
Fig. 12.5 Case 1. Intraoral pictures before additional aligner stage.
Fig. 12.6 Case 1. Extraoral pictures at end of treatment.
Fig. 12.7 Case 1. Intraoral pictures at end of treatment.
Fig. 12.8 Case 1, (A) Panoramic x-ray at end of treatment. (B) Lateral x-ray at end of
treatment.
Fig. 12.9 Case 2. Extraoral pictures before treatment.
Fig. 12.10 Case 2. Intraoral pictures before treatment.
Fig. 12.11 Case 2. (A) Panoramic x-ray before treatment. (B) Lateral x-ray before
treatment.
Fig. 12.12 Case 2. Intraoral pictures before sagittal first phase.
Fig. 12.13 Case 2. Intraoral pictures before additional aligner stage.
Fig. 12.14 Case 2. Extraoral pictures at end of treatment.
Fig. 12.15 Case 2. Intraoral pictures at end of treatment.
Fig. 12.16 Case 2. (A) Panoramic x-ray at end of treatment. (B) Lateral x-ray at end of
treatment.
Fig. 13.1 (A–E) Early deciduous teeth extraction leads to loss of space and canine
impaction.
Fig. 13.2 (A–C) Small size lateral incisors and impacted cuspids.
Fig. 13.3 (A) Missing lateral incisors and (B) bilateral cuspid impaction.
Fig. 13.4 (A–C) Back of right canine prominence in late mixed-dentition patient.
Fig. 13.5 (A, B) The orthopantomography refers to the patient in Fig. 13.4, Ericson and
Kurol canine impaction analysis.
Fig. 13.6 Success rate of early deciduous canine extraction (from Ericson and Kurol).
Fig. 13.7 (A–C) Inclination of the canine on lateral cephalometric analysis; parents of
this patient refused phase 1 treatment, and upper left canine impaction occurred 3 years
later.
Fig. 13.8 (A, B) Canine eruption in alveolar mucosa.
Fig. 13.9 (A, B) Canine erupted labially with lack of keratinized gingiva and higher risk
of recession.
Fig. 13.10 (A–E) Deep horizontal impaction may undermine the eruption with a good
periodontal support.
Fig. 13.11 (A, B) Lateral incisor on the eruption path of the impacted canine.
Fig. 13.12 (A–C) Clinical case study baseline extraoral.
Fig. 13.13 (A–E) Clinical case study baseline intraoral.
Fig. 13.14 (A–G) Clinical case study baseline x-rays.
Fig. 13.15 (A–E) Clinical case study progression.
Fig. 13.16 (A–F) Clinical case study progression.
Fig. 13.17 (A–C) Clinical case study extraoral final.
Fig. 13.18 (A–E) Clinical case study intraoral final.
Fig. 13.19 (A, B) Clinical case study final x-rays.
Fig. 14.1 Initial intraoral pictures showing multiple restorations.
Fig. 14.2 Initial orthopantomograms.
Fig. 14.3 Clear aligner treatment with attachments and buttons was started. The upper
front fixed restoration was sectioned prior the orthodontic treatment start. Class II
elastics anchored on upper canines and lower first molars were used to reinforce canine
class I relationship.
Fig. 14.4 An implant was placed in 1.2 area.
Fig. 14.5 Frontal view of 1.2 implant with (A) and without (B) aligner.
Fig. 14.6 Frontal view of the final upper anterior restoration.
Fig. 14.7 Final intraoral pictures.
Fig. 14.8 Final extraoral pictures and x-rays.
Fig. 14.9 Initial orthopantomogram of a patient for which a prerestorative orthodontic
treatment was required. 12.2 and 2.2 were congenitally missing. The interdisciplinary
treatment plan was designed to recover a proper interarch relationship and preparing
the case for future restorations on upper front teeth and in the lower arch after the
uprighting of 3.7 and intrusion of overerupted 1.7.
Fig. 14.10 Initial intraoral and ClinCheck lateral views in relation to the mesial tipping
of 3.7, caused by the premature loss of 3.6.
Fig. 14.11 Initial intraoral and ClinCheck occlusal views in relation to the mesial tipping
of 3.7.
Fig. 14.12 Attachment configuration used to recover a proper alignment and leveling of
the arches and the uprighting of 3.7. Pontic was not prescribed in 3.6 area to increase the
stiffness of the aligner.
Fig. 14.13 Final intraoral and ClinCheck lateral views with successful uprighting of 3.7.
Fig. 14.14 Final intraoral and ClinCheck occlusal views with successful uprighting of
3.7.
Fig. 14.15 Initial intraoral and ClinCheck lateral views in relation to the overeruption of
1.7, caused by the premature loss of 4.6.
Fig. 14.16 Initial intraoral and ClinCheck occlusal views of the upper arch.
Fig. 14.17 Attachment configuration used to recover a proper alignment and leveling of
the arches.
Fig. 14.18 Final lateral intraoral and ClinCheck views of the right side showing
intrusion and leveling of 1.7 obtained with the aid of a buccal miniscrew and a
segmented auxiliary arch bonded on 1.8 and 1.6 after proper modification of the
aligners.30 Intrusion of 1.4 was planned to level gingival edge to the 2.4 one. An implant
was placed in 4.6 area during the final stages of the orthodontic treatment.
Fig. 14.19 Final intraoral and ClinCheck occlusal views of the upper arch.
Fig. 14.20 Final orthopantomogram.
Fig. 14.21 Initial intraoral pictures.
Fig. 14.22 Initial extraoral pictures and orthopantomogram.
Fig. 14.23 Initial cone-beam computed tomography scans highlighting the asymmetric
condyles position.
Fig. 14.24 Lower occlusal splint.
Fig. 14.25 Cone-beam computed tomography scans showing condyle repositioning due
to the splint effect.
Fig. 14.26 Acrylic provisionals used to keep the new mandible position during the
orthodontic treatment.
Fig. 14.27 Initial stage of the ClinCheck.
Fig. 14.28 Final stage of the first ClinCheck.
Fig. 14.29 Intraoral pictures at the end of the first set of aligners.
Fig. 14.30 (A) Lateral and (B) posteroanterior x-rays at the end of the first set of aligners.
Fig. 14.31 Intraoral pictures at the end of the second set of aligners.
Fig. 14.32 Final stage of the second ClinCheck.
Fig. 14.33 (A) Final orthopantomogram and (B) lateral x-ray.
Fig. 14.34 Intraoral pictures showing the lower implants and the final prosthodontic
restorations.
Fig. 14.35 Final extraoral pictures.
Fig. 15.1 The Beneslider appliance is based on one or two mini-implants with
exchangeable abutments.
Fig. 15.2 The aligners can cover the bonded connection like a big attachment. After
distalization, steel ligatures are to modify the active Beneslider into a passive anchorage
device.
Fig. 15.3 The aligners can be cut out in this connection area (“button cutout”). Springs
are removed in this case to modify the active Beneslider into a passive anchorage
device.
Fig. 15.4 A 37-year-old female patient with an angle class II malocclusion characterized
by anterior crowding and a deep bite.
Fig. 15.5 After insertion of two Benefit mini-implants in the anterior palate (A) and
installation of the Beneslider mechanics (B). Superimposition of an intraoral picture of
the maxillary arch and the ClinCheck to demonstrate desired tooth movement
directions (C).
Fig. 15.6 Beneslider was activated by pushing open springs distally after delivery of the
aligners. Connection areas of the Beneslider with the molars are covered by the aligner
(“big attachment”).
Fig. 15.7 Radiographs after 5 months of treatment. Ortopantomography and lateral x-
ray after 5 months of treatment.
Fig. 15.8 Intraoral pictures after 8 months.
Fig. 15.9 Intraoral pictures after 10 months showing many small spaces due to the
semisequential distalization.
Fig. 15.10 Intraoral pictures after 12 months. Molars are distalized in a Class I occlusion
The Beneslider is modified into a molar anchorage device by two steel ligatures, which
are deactivating the Beneslider. From this moment, bicuspid, canine, and incisor
retractions are following.
Fig. 15.11 Intraoral pictures after 14 months.
Fig. 15.12 Upper arch after 15 months. All spaces were to be closed to the distal.
Subsequently, the Beneslider was removed for refinement.
Fig. 15.13 Treatment result after 19 months.
Fig. 15.14 Superimposition of before and after cephalograms (S-N). Upper incisor
retraction is significant.
Fig. 16.1 Pathologic tooth migration in an old man.
Fig. 16.2 Pathologic tooth migration in a young woman. (A) Intraoral picture
highlighting the tissue breakdown. (B) Extraoral picture (please note the position of
element 2.1). (C) Scheme representing tissue breakdown.
Fig. 16.3 Transseptal fibers balance loss and pathologic tooth migration.
Fig. 16.4 Preliminary evaluation of an ortho-perio patient.
Fig. 16.5 In this class II adult patient, incisors are crowded, extruded, and proclined.
Soft and hard tissue grafting can be helpful before orthodontic treatment to prevent the
development of recessions.
Fig. 16.6 In this adult patient, a previous excessive orthodontic expansion promoted a
gingival recession on teeth 13 and 23. The occlusal instability has led to orthodontic
relapse.
Fig. 16.7 Orthodontic relapse in a young patient; teeth 33, 32, and 43 are located outside
the buccal bone. The twisted retainer, probably not passive, allowed a radicular torque
movement48 on tooth 32 that promoted a gingival recession with lack of adherent
gingiva.
Fig. 16.8 Different tooth shapes.
Fig. 16.9 Center of resistance variation in case of bone loss.
Fig. 16.10 In this patient, a stainless steel power-arm has been bonded to tooth 12, and
retraction has been performed using maximum anchorage.
Fig. 16.11 Mesialization of lower third molars.
Fig. 16.12 Selective intrusion of worn teeth.
Fig. 16.13 Baseline intraoral view.
Fig. 16.14 Baseline smile.
Fig. 16.15 Working contacts.
Fig. 16.16 Baseline status.
Fig. 16.17 Baseline periodontal chart.
Fig. 16.18 Reevaluation chart.
Fig. 16.19 (A) Tooth-by-tooth diagnosis. (B) Tooth-by-tooth prognosis.
Fig. 16.20 Periodontal status and chart at reevaluation.
Fig. 16.21 Regenerative therapy on tooth 14. (A) Bone sounding, (B) incisional photos,
(C) flap photos.
Fig. 16.22 Regenerative therapy on tooth 14: biomaterial photos. (A) Defect cleaning. (B)
Emdogain (EMDs). (C) Pref Gel (EDTA). (D) BioOss.
Fig. 16.23 Regenerative therapy on tooth: suture photos.
Fig. 16.24 Regenerative therapy on incisors. (A) Incision pfotos and, (B) flap photos.
Fig. 16.25 Regenerative therapy on incisors: biomaterial photos. (A) Defect cleaning. (B)
Emdogain (EMDs). (C) Pref Gel (EDTA). (D) BioOss.
Fig. 16.26 Osseous resective surgery 6-degree sextant.94-96 Alternative therapies:
periodontal supportive therapy,85,91,97 conservative surgery,98-101 resective bone
surgery.94-96
Fig. 16.27 Resective surgery: bone remodeling.
Fig. 16.28 Orthodontic records.
Fig. 16.29 ClinCheck beginning (A) and end (B): frontal view.
Fig. 16.30 ClinCheck beginning (A) and end (B): upper arch.
Fig. 16.31 ClinCheck beginning (A) and end (B): lower arch.
Fig. 16.32 ClinCheck beginning (A) and end (B): right side.
Fig. 16.33 ClinCheck beginning (A) and end (B): left side.
Fig. 16.34 End of preprosthetic orthodontics.
Fig. 16.35 Implant 1.5, 1.7.
Fig. 16.36 Implant placement.
Fig. 16.37 Implant placement photos.
Fig. 16.38 Implant placement: biomaterials. (A) Bony window. (B) Sinus membrane
elevation. (C) BioOss. (D) BioOss and membrane positioning.
Fig. 16.39 Final orthodontic x-rays.
Fig. 17.1 Surgical splint with holes to be used in a patient undergoing orthognathic
surgery using Invisalign as the only appliance for orthodontic treatment. Note that no
labial orthodontic appliances are present.
Fig. 17.2 Surgical final splint without occlusal coverage to be left for 4 to 5 weeks
postsurgically due to a three-piece-maxilla osteotomy.
Fig. 17.3 Three-dimensional virtual surgical plan. (A) Presurgery. (B) Planned
osteotomies consisting of three-piece-maxilla with impaction of the posterior segments
and mandibular advancement with genioplasty.
Fig. 17.4 Postsurgical occlusion deviating slightly from the planned occlusion. A) Right
buccal, B) Left buccal, C) frontal occlusal views.
Fig. 17.5 Occlusion seated with intermaxillary elastics and clear aligners to the planned
outcome after 3 months. A) Right buccal, B) Left buccal, C) frontal occlusal views.
Fig. 17.6 Pretreatment extraoral photos. A) Frontal lips relaxed, B) smile, C) profile, D)
Oblique, E) Oblique smiling views.
Fig. 17.7 Pretreatment intraoral photos. A) Right buccal , B) Frontal, C) Left buccal
occlusion. D) Maxillary and E) Mandibular occlusal views.
Fig. 17.8 Pretreatment digitized lateral cephalogram.
Fig. 17.9 Pretreatment panoramic radiograph.
Fig. 17.10 (A) Three-dimensional (3D) virtual surgical plan presurgery. (B) Landmark
changes with the planned surgery in 3D. (C) Counterclockwise rotation of the
maxillomandibular complex.
Fig. 17.11 Planned postsurgical occlusion with overcorrection. A) Right buccal, B)
Frontal, C) Left Buccal views of the planned occlusion
Fig. 17.12 Extraoral photos 2 weeks postsurgery. A) Frontal, B) Profile, and C) Smiling
views.
Fig. 17.13 Intraoral photos 2 weeks postsurgery. A) Right buccal, B) Frontal and C) Left
buccal views of patient in occlusion.
Fig. 17.14 Reduction of facial swelling 2 months postsurgery. A) Frontal, B) Profile, and
C) Smiling views.
Fig. 17.15 Intraoral photos 2 months postsurgery. A) Right buccal, B) Frontal, and C)
Left buccal views.
Fig. 17.16 Lateral open bite on the right is still present 5 months after surgery. A) Right
buccal, B) Frontal, and C) Left buccal views of patient in occlusion.
Fig. 17.17 Cantilever arm extended from bonded lower right molar tube to upright this
tooth using an elastic from the maxillary miniscrews; aligner cut distal to the lower
right canine to allow eruption of the buccal segment.
Fig. 17.18 Extraoral photos 12 months postsurgery.
Fig. 17.19 Intraoral photos 12 months postsurgery. A) Right buccal, B) Frontal, and C)
Left buccal views of patient in occlusion.
Fig. 17.20 Posttreatment extraoral photos. A) Frontal, B) Smiling and C) Profile views.
Fig. 17.21 Posttreatment intraoral photos. A) Right buccal, B) Frontal, and C) Left buccal
views of patient in occlusion. D) Maxillary and E) Mandibular occlusal views.
Fig. 17.22 Posttreatment lateral cephalogram.
Fig. 17.23 Posttreatment panoramic radiograph.
Fig. 17.24 Superimposition of the skeletal and soft tissue changes.
Fig. 18.1 Trajectory of dental pain after orthodontic procedures.
Fig. 19.1 Examples of relapse after orthodontic treatment, where either the patient failed
to wear the retention appliances after rapid maxillary expansion (A-C) or the retention
regime selected was insufficient for a noncompliant patient; the rotational relapse of
lateral incisors (D-F) and palatal movement of upper left canine (G-I) shown could have
been prevented by bonding a fixed retainer and including problematic teeth.
Fig. 19.2 Calculus accumulation and gingival inflammation around the lower bonded
retainer (A and B).
Fig. 19.3 Examples of failures of bonded retainers. (A) The detachment of a composite
resin layer is usually a consequence of bonding errors. (B) The loss of the adhesive layer
due to mastication or premature contact on the bonded retainer. (C) Premature contact
on the retainer wire, wire fatigue, or selection of a wire with insufficient mechanical
properties (small diameter dead-soft wire) resulting in fracture of the wire. (D)
Extending the upper retainer to the canines increases the risk of fracture, with
consequent wire activation and unwanted tooth movement.
Fig. 19.4 Two distinct types of unexpected complication of lower bonded retainers:
opposite torque on two adjacent incisors (X effect; A, B) and opposite inclination of
contralateral canines (Twist effect; C, D). Both X effect and Twist effect may be
accompanied by severe gingival recession (A, C).
Fig. 19.5 Unexpected complication of lower bonded retainer (Twist effect): lower left
canine moving out of the bony envelope (A-C). Significant bony dehiscence can be
identified on dental cone-beam computed tomography (B, C).
Fig. 19.6 Treatment of a complication associated with a lower bonded retainer. (A-C)
Lower left central and lateral incisors severely proclined by a fractured bonded retainer
and lingual gingival recessions occurring on both incisors. (D-F) Retreatment with a full
lower fixed appliance corrected the torque of the incisors and was followed by a
periodontal reconstructive surgery. (G-I) Final reconstruction with full porcelain crowns
and bonding of a new lower fixed retainer.
Fig. 19.7 When long-term retention is indicated, regular recalls are necessary to check
retainers; however, attendance of patients decreases in the retention period, as seen on
this graph.
Fig. 19.8 Hawley retainer with frontal bite plane in occlusal (A), front (B), and lateral (C)
views.
Fig. 19.9 Vacuum-formed thermoplastic retainer in the upper jaw in frontal view (A)
and smile (B).
Fig. 19.10 Retention activator after class II treatment in lateral right (A), frontal (B), and
lateral left (C) views.
Fig. 19.11 Different types of commonly used fixed retainers. Upper retainers can include
incisors only (A), or even both canines, either continuous (B) or segmented (C); the
segmented version is more suitable because premature contact on the retainer can be
avoided, thereby decreasing both the incidence of fracture and the adhesive layer. (D)
Lower fixed retainer usually includes canines and incisors. Vestibular retainers can be
used after difficult extraction space closure (E) or as a space maintainer prior to implant
placement (F).
Fig. 19.12 Examples of typical indication in which use of fixed retainers is
recommended. (A, B) Difficult extraction space closure. (C, D) Large midline diastema
closure in a periodontally compromised patient. (E, F) Space closure in a patient with
generalized spacing. (G, H) Severe crowding and tooth rotations.
Fig. 19.13 (A, B) Lateral open bite often occurs after aligner treatment. (C, D) The clinical
picture at the end of treatment may thus differ when compared to the final situation
depicted in the treatment planning software. (E, F) However, the clinical situation after
2 years in recall shows that the teeth will eventually settle into the desired position.
Fig. 19.14 Natural settling of teeth after orthodontic treatment in recall after 6 months,
as visualized on T scans of a patient wearing a Hawley retainer at nighttime (A, B) and
a thermoplastic retainer (C, D).
Fig. 19.15 Treatment of an open bite with aligners that was facilitated by intrusive force
in the lateral segments.
Fig. 19.16 Relapse of anterior open bite due to short retention thermoplastic retainers
and consequent extrusion of second molars. Situation after treatment (A-C) and 1.5
years in recall (D-F).
Fig. 19.17 Treatment planning software can be used to plan the position of lower
incisors exactly, avoiding unwanted proclination of the lower incisors and thus
preventing the risk of relapse.
Fig. 20.1 Initial intraoral photographs of adult patient with class I malocclusion
dentoalveolar contraction in both arches.
Fig. 20.2 Intraoral photographs during aligner therapy with composite buttons.
Fig. 20.3 Final intraoral photographs after 20-step aligner treatment.
Fig. 20.4 Initial intraoral photographs of a young patient with skeletal and dental class
III and narrow upper jaw.
Fig. 20.5 Rapid palatal expansion with arms for Delaire mask on deciduous second
molars.
Fig. 20.6 Hybrid expander with dental and skeletal anchorage in upper jaw and arms
for Delaire mask.
Fig. 20.7 Intraoral photograph during aligner therapy.
Fig. 20.8 Final intraoral photographs after 11-step aligner treatment.
Fig. 20.9 Initial intraoral photographs of adult patient with skeletal contraction of upper
jaw, class III tendency and gingival recession in both arches.
Fig. 20.10 Rapid palatal expansion with skeletal anchorage (MAPA method).
Fig. 20.11 Intraoral photograph during aligner therapy.
Fig. 20.12 Final intraoral photographs after aligner therapy.
Fig. 20.13 Initial occlusal intraoral photographs of an adult patient with severe rotation
of the upper incisors (A) and right lower canine (B).
Fig. 20.14 Occlusal intraoral photographs during treatment with composite buttons on
the lingual surfaces of teeth 1.3, 2.1, 2.2, and 4.3.
Fig. 20.15 Intraoral photograph during aligner therapy.
Fig. 20.16 Final intraoral photographs after 20-step aligner treatment.
Fig. 20.17 Initial photographs of a young patient with rotation greater than 20 degrees of
left upper canine and left second premolar.
Fig. 20.18 Application of microtubes on rotated, mesial, and distal teeth.
Fig. 20.19 Occlusal photographs. (A) Upper arch with thermal NiTi 0.013 sectional. (B)
Upper arch with aligner covering thermal NiTi 0.013 sectional. (C) Lower arch with
thermal NiTi 0.013 sectional. (D) Occlusal photograph of lower arch with aligner
covering thermal NiTi 0.013 sectional.
Fig. 20.20 Final intraoral photographs after seven-step aligner treatment.
Fig. 20.21 Initial intraoral photographs of young patient with anterior open bite and
maxillary contraction.
Fig. 20.22 Bite-block expander with anterior grille.
Fig. 20.23 Frontal intraoral photograph after the first stage of treatment with palatal
expander and grille.
Fig. 20.24 Intraoral photograph during aligner therapy.
Fig. 20.25 Final intraoral photographs after 10-step aligner treatment.
Fig. 20.26 Initial intraoral photographs of a young patient with deep bite and class II.
Fig. 20.27 Lateral intraoral photograph during aligner therapy combined with class II
elastics.
Fig. 20.28 Final intraoral photographs after 14-step aligner treatment.
Fig. 20.29 Right initial intraoral photograph of a patient with class II subdivision and
contraction of the upper jaw.
Fig. 20.30 Lateral intraoral photograph during aligner therapy combined with class II
elastics.
Fig. 20.31 Right lateral intraoral photograph lateral after aligner treatment.
Fig. 20.32 Left initial intraoral photograph of a patient with class II subdivision and
contraction of the upper jaw.
Fig. 20.33 Rapid palatal expansion and pendulum with skeletal anchorage (MAPA
method).
Fig. 20.34 Lateral intraoral photographs during aligner therapy (A) and combined with
class II elastics (B).
Fig. 20.35 Left lateral intraoral photograph after aligner therapy.