Ortho Summit 2012 - Amazon S3 · 16x9 PPT Template_9-29-12_v1 12 Ortho Summit 2012 67 Sagittal...

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Ortho Summit 2012

Dr. Willy [email protected]

www.orthoclined.com

Engineering Your Invisalign Treatment PlanTo

Conquer a Wide Variety of Cases

2

• DDS ( 1986) and Diploma of Orthodontics from the University of Toronto (1991)

• Orthodontic practice in Toronto, Canada, focused on Cosmetic and Rehabilitative Orthodontics.

• Invisalign Super Elite Provider and member of the Aligntech Institute Faculty

• Lecturer at the University of Toronto, and Guest Lecturer at Tel Aviv University and Hadassah University in Jerusalem

• Featured speaker at the Pankey Institute, Invisalign Forum and Invisalign Summits, and numerous Align events worldwide.

• Member of the AAO and CAO, and other dental organizations

• Married to Ellen Dayan ( Restorative Dentist ), and 4 great children, Laurel, Ariel, Jamie, and Jory

Dr. Willy Dayan

1) Diagnosis and Treatment Plan.....It Still Matters

2) Understanding Bio-mechanics of Invisalign

3) They are All Invisalign Cases!

Engineering Your Invisalign Treatment Plan To Conquer a Wide Variety of Cases

Outline

4

Orthodontics is not just Straight Teeth

Comprehensive Orthodontic Diagnosis

•Skeletal Foundation•Posterior Interdigitation•Anterior Guidance•Transverse Relations•Vertical Dimension of Occlusion•Lip Support•Lip Competency•Neutral Zone•Straight Teeth•Smile Lines

Align upper and lower arches is not a treatment plan!

Should these people get the same treatment plan and same retainers?Customize our retention the way we customize our treatment plan!

AfterBeforeIntra-orally Extra-orally

BiologicalVariation!

6

Orthodontics is not just Straight Teeth

Comprehensive Orthodontic Diagnosis

•Skeletal Foundation•Posterior Interdigitation•Anterior Guidance•Transverse Relations•Vertical Dimension of Occlusion•Lip Support•Lip Competency•Neutral Zone•Straight Teeth•Smile Lines

Align upper and lower arches is not a treatment plan!

•Who is the clinician and who is the technician.

•Doctor your ClinCheck!


Ortho Summit 2012





Outline

A Review of Bio-Mechanics of Invisalign!

Willy’s Golden Rules of ClinCheck Analysis

1) Think Like Plastic and Feel Like a Tooth.

2) Stop watching the video as teeth moving, but think of it as aligners surfaces changing.

Some Clinical Examples

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Levelling Deep Curve of Spee

What if the bicuspids have optimized rotation attachments ?!?!

10

Upper Lateral Incisor Bodily Movement

Need 2 points of contact to create a rotational moment.

11

Translating Roots Mesially or Distally

Controlling Root Tipping.

Focus on the correction of LL2 and LR2

12


What the tooth needs to feel, and what we need to see!


Ortho Summit 2012

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Do you see arrows in your Clincheck Video?

Before Start CC1 End CC1

After CC1 Start CC2 End CC2

Tracking atEnd of CC2

Do you see arrows in your Clincheck Video?

Before Start CC1 End CC1

After CC1 Start CC2 End CC2

Tracking atEnd of CC2

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Opening Space for a Missing Maxillary Lateral Incisor

A ClinCheck Treatment Plan after the first plan did not work!

Go To ClinCheck 1

Go To ClinCheck 2( instructed by orthoclined.com )

Before After cc1

Progress Xrays cc2

I tried that and it did not work, so my conclusion could be......Invisalign can’t do that!!! But is that true?

Conclusion:Ask not what Invisalign can do….but ask yourself what you can do with Invisalign!!!

Not finishedyet

Enhanced Restorative / Prosthetic / Periodontal Dentistry Using Orthodontics

Go to Clincheck


Go to Clincheck


Ortho Summit 2012


Before

Refnmnt

Go to RefinementGo to Clincheck


Before

Refnmnt

Go to Clincheck Go to Refinement

Go to ClinCheck

Anterior Torque Control

Plan is to leave some maxillary anterior spacesfor restorative finish on maxillary incisors

Anterior Deepbite and Torque Control

Before

End of1st Order

The ForceSystem!





Outline

They are All Invisalign Cases!

1) Vertical Challenges

2) Sagittal Challenges

3) Crowding, Spacing and Alignment Challenges

4) Cuspid Impactions


Ortho Summit 2012

Vertical Challenges

Deep-bite and Openbite

Assessing The Vertical Dimension of Occlusion

What does it tell you about the forces on the teeth that havecreated this equilibrium?

Bite Turbos: Incisors or Cuspids?

The idea is to have the ledges act as a removable anterior bite plane to avoid excessive posterior contact of upper and lower aligners .



The reality of too much overjetallows mandible to close distal to ledges .

Go to Cuspid “Turbos” Clincheck



The reality of too much overjetallows mandible to close distal to ledges .

Go to Cuspid “Turbos” Clincheck

30

Vertical Challenges: Deep Anterior Overbite

Before

ClinCheck is not teeth moving, but the force system to get them there.


Ortho Summit 2012

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Stage 36Before


Before

After

Stage 36

4 weeks ofanterior bite plane


Before

After

Aligner NumbersMx: 38+0=38Md: 38+0=38

Treatment Appointments: 11(Including Impressions and debond and retention)

+1: Impression+2: Insert Aligners and attachments+6: Invisalign progress at 9,15,21,27,33,38+2: Debond Attachments and Retention

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Go to Clincheck


First ClinCheck Final ClinCheck

36




+1: Impression+2: Insert Aligners and attachments+4: Invisalign progress at 9,15,21,25+1: Debond Attachments and Retention


Ortho Summit 2012

Vertical Challenges: Deep Anterior OverbiteAre they all the same?

Vertical Challenges: Deep Anterior OverbiteAre they all the same?


Before

Deep-bite, with desire to open vertical dimension of occlusion with mandibular posterior eruption.


Go to ClinCheck

Before After


Go to Clincheck

Deepbite, with desire to open vertical dimension of occlusion with mandibularposterior eruption.

Prognosis of UL2 and UL3 guarded.


Ortho Summit 2012


Before

During

Post-orthoPre-Resto

Post-Resto

A pleasure for the Patient....A pleasure for the Dentist!


Before

Final

Naturally You!

Not …….. Extreme Makeover

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Vertical Challenges: Posterior Intrusion

Go to ClinCheck


Before

Post-Orthodontic


Treatment Appointments: 9

+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress and refinement impressions at

9,15,20,2,9+1: Debond Attachments and Retention

Treatment Efficiency

Before Post-Orthodontic Post-Prosthetic Final


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Vertical Challenges: Anterior Openbite

InitialRecords

Go to Final ClinCheck

Go to Clincheck 1


Ortho Summit 2012


Selected Posterior IntrusionMild Anterior IPRAuto-rotation of MandibleNo Incisor Extrusion

BeforeProgress 1Stage 9

Progress 2Stage 15

Progress 3Stage 21

With Aligners…..and ONLY ALIGNERS

Openbite closure42 weeks

Before Progress

Initial Ceph Tracing Progress Ceph Tracing

Before and After (First Order) Cephs

Before and After Superimpositions

Summary of Progress Analysis

•It appears that from initial to progress the upper and lower molars were intruded, and that the mandible has auto-rotated forward into a more closed position.

•In addition it appears that the lower incisors were extruded

Go to Clincheck Refinement


Ortho Summit 2012


Selected Posterior IntrusionMild Anterior IPRAuto-rotation of MandibleNo Incisor Extrusion

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Before AfterTreatment Time: 18 months

Mx: 28 + 8 =36Md: 28 + 8 =36

Aligner Numbers

Treatment Appointments: 9(Including Impressions and debond and retention)+1: Impression+2: Insert Aligners and attachments+6: Invisalign progress and refinemnt at 9,15,21,28,1,8+1: Debond Attachments and Retention

Before End TreatmentPrior to Refinement

Posterior Intrusion to Establish Anterior Coupling


Before

After

3 yrs Post-ortho

( no fixed retainers)

3 Years Later Time for New Vivera Retainers

Still Coupling…..Still Smiling!

Before During Aligners Ready for Refinement Final

Posterior Intrusion to Establish Anterior Coupling



Treatment Appointments: 9(Including Impressions and debond and retention

+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress at 9,11,15,21, 6+1: Debond Attachments and Retention

Go to ClinCheck

Working Smarter …. Not Harder!!

Avoiding the Openbite!!


Ortho Summit 2012

Go to ClinCheck


Avoiding the Openbite!

Before Final



+1: Impression+2: Insert Aligners and attachments+2: Invisalign progress at 9,15,+2: Debond Attachments and Retention


Sagittal Challenges

Class II and Class III Malocclusions

Sagittal Challenges: Class II and Class III Treatment

•Aligner tooth movements depend on intra-arch anchorage.

•They do not replace the need for inter-arch anchorage.

•They do not replace the need or auxiliary treatment appliances such as:

•Rapid Palatal Expanders•Headgear•Functional Appliances•Herbst Appliance•Orthognathic Surgery•Inter-arch elastics•Etc…..

•Comprehensive Diagnosis and Treatment Planning 1st……ClinCheck Later!

65

If it is too good to be true......it probably is to good to be true!!!!

It is still orthodontics….Not magic!

Sagital correction......................OR NOT!!ClinCheck Coaching Request at Time of Refinement.

Lets do the math together!

66

If it is too good to be true......it probably is to good to be true!!!!

It is still orthodontics….Not magic!

Sagital correction......................OR NOT!!ClinCheck Coaching Request at Time of Refinement.

Lets do the math together!


Ortho Summit 2012

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Sagittal Challenges: Class II Correction

What do you like to use for Growth Modificationand Molar Distalization?

Sagital Challenges: Class II Correction

Power Ridges forAnterior Torque

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Beginning of First Order

End ofFirst Order

New Scan for2nd Order

Power Ridges are Effective at Anterior Torque

Go to Clincheck Refinement

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Before Final

Mx: 25 + 11 =36Md: 25 + 11 =36

Aligner Numbers

( oops....aligners still on!)

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Sagittal Challenges: Class II Correction: Functional Appliance

Functional Appliance

Initial Records

Treatment Plan

•Stage 1: Procline max incisors followedby functional appliance

•Stage 2: Invisalign with Class IIelastics if required

Initial Records

Treatment Plan•Stage 1: : Procline max incisors followed

by functional appliance•Stage 2: Invisalign with Class II

elastics if required


Pre-Invisalign RecordsTreatment Plan•Invisalign

Go to ClinCheck


Ortho Summit 2012

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Final RecordsInitial Records

Aligner NumbersMx: 15 + 0 = 15Md: 15 + 0 = 15

Stage 2: Invisalign Only


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Sagital Challenges: Class II Correction: Elastics

Class II Elastics

Go to Clincheck

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Class II Correction During Invisalign

•Continuous Staging•IPR delayed until stage 21•Bite Jump at end of Clincheck

Sagittal Challenges: Class II Correction: Elastics

Before

Class II Elastics: Stage 9

Progress: Stage 9

Before After

Treatment Efficiency ( stopped refinement at #5)


Treatment Appointments: 9+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress and refinemnt at 9,15,21,2,5+1: Debond Attachments and Retention


78

Initial

Final

1 year Retn.Mx:Vivera NightsMd: Fixed Wire

Note posterior inter-occlusalspace closing slowly.



Ortho Summit 2012

79Go to ClinCheckVP: mxd 44; RF 18

Root Control in Extraction Sites.


At stage 29 and until stage 44, the extraction sites are closed and remain closed.

Before

Progress: Pictures at stage15

Progress: Pictures at Stage 25

Ready forRefinement


Go to RefinementVP: mxd 44; RF 18

VP: mxd 44; RF 18


Go to ClinCheck

Surgical Class II Case

Transfer of records with request for surgical treatment with Invisalign.

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•Last aligners trimmed around selected braces.

•Aligners removed for fabrication of surgical splint, and during surgery.

•Full time aligner wear, immediately after surgery and with post surgical elastics.

•Once patient healed and ready for post surgical orthodontics, will decide on detailing

with refinement as required.


Ortho Summit 2012

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Post Surgicalwith aligners.

Post Surgicalwithout aligners.


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No RefinementNo Repairs


Work Smarter….Not Harder!


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Sagittal Challenges: Class III Correction: IPR in Lower Arch

Go to ClinCheck

Go to Clincheck Go to Refinement

Before Refinement


Before Refinement

After


Before After




+1: Impression+2: Insert Aligners and attachments+9: Invisalign progress at 9,15,21,27,33,37,1,10,17+1: Debond Attachments and Retention

After 6 monthsretention



Ortho Summit 2012

Before

Treatment Plan: Achieve Maxillary Expansion First…..Then Invisalign and Elastics

Sagittal Challenges: Class III Correction: Pre-Invisalign Expansion and Elastics

92

Before



The Expander ( not same patient)

93

Before


Go to ClinCheck

After Removable Expander


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•Cut-outs

•Elastic hooks

•Posterior intrusion

•Bite jump.


Not same patient....Fastest Elastics in the West!!

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Before After Removable Expander

After

96

After

Before


Aligner NumbersMx: 25 + 0=25Md: 25 + 0=25

Treatment Appointments: 12+4: Removable Expander+1: Impression+2: Insert Aligners and attachments+4: Invisalign progress at 9,15,21,25+1: Debond Attachments and Retention

Maxillary Removable Expander and then



Ortho Summit 2012

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Sagittal Challenges: Class III Correction: Lower Incisor Extraction

Go to ClinCheck Final


Maxillary IPRLower Incisor Extraction

Progress Pictures


100

Refinement In Mandible Only

6 Aligners with 0.2mm IPR from 3 to 3 increase overjet.

Time for Refinement Aligners for Finishing Details


Aligner NumbersMx: 36 + 0=36Md: 36 + 6=42


+1: Impression+2: Insert Aligners and attachments+7: Invisalign progress at 9,15,21,27,33, 36,6+1: Debond Attachments and Retention

Before

After


Crowding, Spacing&

Alignment Challenges


Ortho Summit 2012

Go to Clincheck

Spacing

Spacing

Go to Clincheck

Before After 1st Order

Go to Refinement•Pictures only.•To Close remaining spaces

Spacing

Go to Clincheck

Before

After1st Order

Go to Refinement

After

Before




+1: Impression+2: Insert Aligners and attachments+6: Invisalign progress at 9,15,21,25, 1, 6+1: Debond Attachments and Retention

SpacingAfter

Go to Clincheck

Spacing

Go to Retainer Refinement

Go to Clincheck

Spacing

Go to Retainer Refinement


Ortho Summit 2012

SpacingBefore




+1: Impression+2: Insert Aligners and attachments+6: Invisalign progress at 9,15,21,25, 1, 6+1: Debond Attachments and Retention

After

Go to ClinCheck

110 NM:MXD28 No RF!

111

What the tooth needs to feel, and what we need to see!

Staging treatment to expose useful surfaces.

Before

After

112 NM:MXD28 No RF!

What is yourfirst choice?

Go to ClinCheck

Go to ClinCheck Go to RefinementShe is already too happy!

Before Refinement


Ortho Summit 2012

Before Final



+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress at 9,15,21,27,32,4+2: Debond Attachments and Retention

116

Chief Complaint: •I don’t like my smile and •Fronts spaces and twisted teeth.Significant Clinical Findings: •Severe rotation of UR2 and UL2•Minimal vertical maxillary incisor display on smileRecords: •Panoramic Xray: 38 missing. •Lateral Cephalometric Xray: WNL

Orthodontic Treatment Plan: •Align both arches•Possibility of inter-arch elastics•Erupt/ Extrude maxillary anterior teeth•Possibility of bonding of

maxillary anteriors post-orthodontics.

Go to Clincheck FinalGo to Clincheck 1

Go to Clincheck Final

118

Before Progress 1 Progress 2 ( finish md)

With Aligners and maxillary extrusion and rotation of lateral incisors.

Advantage of New Smart Track and Optimized Attachments

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Before Final

Go to ClinCheck120 VT:MXD27/45, MCC30/30 RFMXD10


Ortho Summit 2012

StartRFNMT

121

Before

StartMCC.

VT:MXD27/45, MCC30/30 RFMXD10

After

Go to MCC Go to RFMNTGo to ClinCheck

StartRFNMT

122

Before

StartMCC.

VT:MXD27/45, MCC30/30 RFMXD10

After


Go to Clincheck


Before

Final

Go to RefinementGo to Clincheck


Before Final


Treatment Appointments: 11 (Including Impressions and debond and retention)

+1: Impression+2: Insert Aligners and attachments+5: Invisalign progress at 9,15,20, 1,9+2: Debond Attachments and Retention

Go to Clincheck



Ortho Summit 2012


Before

Later

Atts off forWedding

Refinement


Before Refinement

Go to Clincheck Go to Refinement 51 Aligners

Go to ClinCheck

Go toClinCheck

40 Aligners

Go to ClinCheck Go to RetainerRefinement

Before Time for Retainer Refinement

Cuspid Impactions


Ortho Summit 2012

133

Cuspid Impaction

•2 consultations have suggestedthat cannot erupt tooth andto remove the tooth.

Our plan......3D Scan

The Challenges

•Horizontally impacted UR3•Roots of UR4 in the path

of eruption

Even Radiologist missed on first try due to

panorex distortions

135

Creative Thinking 90/10

•Custom Maxillary TPA with extra arm from TPA and leaning on lateral.

•Lingual button to rotate UR4 distal to the lingual•Buccal Brace on UR4 to tip root distally•Expose UR3 and Erupt into space.•Later Invisalign to finish.

136

Periapicalprogress xray6weeks into treatment

At 12 weeks into total treatment time, removed palatal activation wire and usedbuccal wire from UR6 to UR3.

7 months after exposure.

Begin treatment with customized TPA, and exposure with activation each 3 weeks

137

After 7 months of activation, all hardware removed, new button on UR3and fabrication of maxillary holding aligner with boot strap elastic.

138

Cuspid Impaction: 90/10....10 First!


Ortho Summit 2012

RF

Cuspid Impaction

Class II elasticsRight Side

140

Progress

Progress 2

Start Invisalign

Progress 1

Before

90/10 Before Invisalign

Class II ElasticCustom Hook on UR2

Before

RF

Back to the Question….

Can Invisalign treat a cuspid impaction case?.........

Before

RF



It’s not the right question....Braces or Invisalign do not treat patients!!!!

Before

RF




I am not an Invisalignist .... I am an Orthodontist who uses Invisalign.

Before

RF





So what is the right question.........

Is a cuspid impaction case an Invisalign candidate?


Ortho Summit 2012

Before

RF



Cuspid Impaction Case…Is an Invisalign Candidate!



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Viewing all Patients as Invisalign Candidates

• Diagnosis and Treatment Plan.....It Still Matters

• Understanding Bio-mechanics of Invisalign

• They are All Invisalign Cases!

Dr. Willy Dayan

•[email protected]

•www.orthoclined.com

147

Dr. Willy Dayan

•[email protected]

•www.orthoclined.com

Ortho Summit 2012 - Amazon S3 · 16x9 PPT Template_9-29-12_v1 12 Ortho Summit 2012 67 Sagittal...

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Transcript of Ortho Summit 2012 - Amazon S3 · 16x9 PPT Template_9-29-12_v1 12 Ortho Summit 2012 67 Sagittal...