Getting Started with Invisalign
If you’re interested in getting on your way to a new smile without the use of metal, ceramic, or lingual braces, you will have to visit a certified Invisalign dentist or orthodontist for a consultation. Many consultations are complimentary, but the scope of the examination will vary by location and office. Typically, the doctor will take a look in your mouth and discuss some of the problems and solutions to your malocclusion. The cost and duration and treatment may be discussed as well. Proper diagnosis and treatment planning requires photos, a cephalometric x-ray, and full mouth series or panoramic x-ray, but may not be included in the complimentary assessment. Be wary of doctors providing a treatment plan or cost without all of this information.
When you are ready to go ahead with your treatment, it is time to fabricate a 3-D model of your teeth. Depending on the ofﬁce, this may be an option the same day as your consultation to help get you started with your treatment as soon as possible. The goal is to create an exact representation of your teeth to allow the doctor to formulate your treatment plan. There are two ways of doing this:
1. iOC Digital Invisalign Tooth Scanner
In the past, PVS impressions were the only way to send 3-D information to Align Technologies. In the spring of 2011, Align bought the technology of the iOC scanner, allowing for an instant 3-D capture of the teeth. It is a non x-ray scan, and has several advantages, including increased accuracy, and comfort. Now there is no need to worry about gagging, messy materials, or inaccurate impressions.
At the start of 2013, Align launched the Invisalign Outcome Simulator to help patients view a still shot of what their teeth may look like after treatment, a few minutes after an iOC scan is taken (not available with PVS impressions). It is a very rough representation and can sometimes be misleading depending on the treatment plan your doctor selects for you. Note that there is no way to save this image or rotate it into other views, and that it is not a guarantee of a final result, so many patients may opt to take a picture of the monitor. It is also not a ClinCheck video, but the scan is what is used to develop your treatment. Many doctors do not find showing this outcome useful, as it is a computer generated result, whereas the final Invisalign result requires the doctor’s direction.
It is truly an amazing technology, but currently, the cost of a single scanner is well into five figures. While there are many digital scanners out there, currently, only the iTero scanner is accepted for Invisalign treatment (3Shape Trios no longer accepted). Due to its advantages, potential patients should prefer to seek treatment from doctors who are using the scanner as it is the gold standard in achieving an accurate record of your teeth.
2. Polyvinyl siloxane impressions (PVS)
This used to be the only method of getting a record of your teeth. However, it is much less accurate than having a digital scan. This process involves a series of polyvinyl siloxane impressions (PVS) and bite registration. These impressions create an imprint of your teeth to help formulate your treatment.
Note that most offices that are using PVS likely do not perform many Invisalign treatments.
All records are sent overnight to Align Technology in California, where they are sent to Juarez, Mexico for scanning a 3-D model of your teeth. The digital record is then emailed to Costa Rica where technicians (not dentists or orthodontists) create a simulation of the way your teeth will move (ClinCheck ). It is your doctor’s responsibility to ensure that the movements provided by Align technicians are biologically and physically possible in your mouth.
Often, several modifications and edits of tooth movement are required and you are paying your doctor to properly provide instructions to the technician. Proper instructions must be detailed to the technician, while there are other movements that can be adjusted by the doctor using the “3-D Controls” in the ClinCheck software. When satisfied, your doctor will accept the simulation and begin the process of aligner fabrication in Mexico. Unfortunately, many inexperienced doctors do not recognize improper or impossible movements, and accept treatment because the video simulation produces a good result. This is one of the most common reasons for failed Invisalign treatment.
Remember that the ability of your doctor to show you a ClinCheck that produces a nice end result does little to ensure that you will achieve the desired results. In fact, it is often the case that the ClinCheck does not look like your final result, since it is the way the doctor needs trays fabricated to move your teeth to produce the correct force system, rather than it being a video of the exact progression of your teeth. Said a different way, the ClinCheck may overdo certain movements to get you to your final result. Consider a situation where you want to bend a paper clip to make it straight. You will often have to bend it past the point of being straight in order for it to end that way.
Due to the importance of communication with the technicians, Align has a study club several times a year to allow doctors to visit the Align Treat Facility and visit their technicians. From the perspective of Invisalign experience, this is something you should be looking for when selecting your doctor.
Approximately 4-6 weeks after your Invisalign scan or impression, you can expect your first treatment visit beginning with your first aligner, attachments/IPR if needed, and instructions on their wear and care. Some doctors delay attachment placement until a later stage, but our experience is that it is best to place them from the start.
Please note that you may experience the following when first beginning treatment:
- Transient lisp until used to the aligners
- Teeth may develop some soreness associated with tooth movement
- Bite may feel weird or different
- Some adjustment period to the aligner, but most of our patients get used to the aligners so well that they eventually feel awkward when they are not wearing them
- Adaptation of teeth to the aligner may not be ideal to start
- Clenchers or grinders may experience a temporary increase in these activities
On the positive side, patients often receive compliments that their teeth look shinier and straighter even when just starting treatment, due to the smooth contours of the aligner. Aligners are generally changed every five days to a few weeks. There is some variation to that depending on the rate of movement. This can be modified by the doctor by producing fewer movements per aligner, allowing you to change the tray more often, use of AcceleDent or Propel Vpro5, or due to patient biological factors that would vary by individual. For example, younger patients might be able to change trays more rapidly due to their physiological life cycle.
Keep in mind that changing 50 trays weekly is the same final treatment time as 25 trays every two weeks if the rate of movement is maintained.
Aligners are generally changed every five days to a few weeks. There is some variation to that depending on the rate of movement. This can be modified by the doctor by producing fewer movements per aligner, allowing you to change the tray more often, use of AcceleDent or Propel Vpro5, or due to patient biological factors that would vary by individual. For example, younger patients might be able to change trays more rapidly due to their physiological life cycle. Keep in mind that changing 50 trays weekly is the same final treatment time as 25 trays every two weeks if the rate of movement is maintained.
The following are several aspects of Invisalign that are not mentioned on the Invisalign website or by many doctors. However, they are extremely important components of proper Invisalign care.
IPR (Interproximal reduction)
IPR (Interproximal reduction), is also known as filing, grinding, slenderization, and enameloplasty. Whatever the name is, it refers to the reduction of tooth enamel from the interproximal surfaces of the teeth to create sufficient space for tooth movement and/or to aid in the removal of “black triangles” at the gumline. Patients are often concerned about this part of treatment increasing sensitivity, cavities, being painful, or leaving gaps. It is completely safe method to reduce anywhere from 0.2mm-0.6mm without concern when performed properly as shown by decades upon decades of study.
IPR is often achieved using a diamond-plated wheel, bur, or strip. The method used will be determined by the doctor based upon amount, and location desired. Sometimes IPR is done prior to a scan, while other times it is done as treatment progresses. IPR is sometimes required when unplanned, and sometimes not required when planned. An experienced doctor will be able to guide your treatment in this regard. Don’t be concerned if you feel the bur, disc, or strip at the gum level, or if you see a bit of blood. Proper IPR requires reduction all the way to the gum level to avoid ledges that may create traps for plaque and make it difficult to floss. Improper reduction may not allow proper tooth movement and delay the progress of treatment.
Attachments are virtually invisible bumps that help move the teeth and grab the aligners. They are bonded temporarily on the selected teeth using a white filling material. Note that decision for which teeth need attachments and the type of attachment placed are influenced by the experience of the doctor performing Invisalign movements. An attachment template that is made of a more flexible material than the aligner, with wells for placement of the resin, aids the doctor, hygienist or assistant in their placement.
Some patients may experience the loss of Invisalign attachments. This is an uncommon occurrence in experienced offices, but can occur because of:
- Improper bonding technique and isolation
- Inadequate movement of the teeth during the first two aligners due to poor compliance or improper treatment planning
- Improper removal of the aligner
Should an attachment come off, you should notify your doctor. At times, the attachment must be replaced, and other times, it is not as urgent. Only your doctor will know what the best course of action is based upon your treatment plan and current stage of care.
If you’re concerned with how attachments look, consider that they are much less visible than braces. Without them, your treatment will be compromised. Currently, there are attachments in various shapes and sizes to aid in rotations, extrusions, intrusions, bodily movement, and to anchor units of teeth against another. The judicious use and placement of these attachments is critical to more advanced treatment.
Most people, other than you, won’t even notice that you have attachments, especially when the aligners are in (which they should be... 22 hours per day!) Note that the addition of attachments to the teeth may make aligners more difficult to remove. Don’t worry, it will get easier with practice and as the teeth settle into the aligner as you get more practice. Many patients find that easing the aligner off from the inside at the back on one side, then the other side, followed by the front, facilitates aligner removal. Various types of instruments are available to help you remove your aligners as well.
The words buttons and attachments are often incorrectly used interchangeably. Buttons are physical auxiliary appliances that can be clear or silver in colour. They are used to aid challenging tooth movements, just as they would be used with fixed braces. Some elastics. They are considered an advanced part of Invisalign treatment and are currently being used by highly experienced Invisalign doctors.
There are also times when sections of fixed braces may be suggested before, during, or after your Invisalign treatment. Again, remember that you are purchasing orthodontic services rather than Invisalign.
With more advance treatments, there may be a desire to move the upper and lower jaws relative to each other. This movement is done in a similar fashion to that with regular braces with the use of elastics. Elastics can be used to buttons on the teeth, or small hooks or “precision cuts” placed in the aligners. There are different reasons for the use of each, and your doctor should be able to explain when hooks are needed and when buttons should be used.
Aligner seaters- AcceleDent and Proper VPro5
Two of the largest barriers to treatment are the duration of treatment, and the potential for pain or discomfort. Recently, the field of orthodontics has adapted long known principles of bone remodelling from orthopedics now with Propel VPro5 and AcceleDent to help address these two issues.
Before Propel VPro5 and AcceleDent, there have been a few techniques that have been used to accelerate orthodontics such as Wilckodontics and Propel. The principle of tooth movement is that there is a need for bone remodelling via osteoclasts (removing bone from surfaces of the teeth where they need to move) and osteoblasts (cells that build bone behind the tooth where it has moved from.) Wilckodontics is a periodontial procedure whereby the the gums are retracted and the holes are made in the bone around the teeth, whereby causing bleeding. This promotes the blood factors required for healing, and thus tooth movement. Teeth do move faster with this procedure, but the comfort aspect takes a backwards step, since it is quite painful.
This product helps improve tracking of Invisalign aligners and comfort through use of its device for 5 minutes per day.
Results in maximum seating
Shorter process time to achieve maximum seating
More comfortable process than other means of seating (chewies)
Better compliance to the seating process
Improves comfort in retention
Improves aligner comfort with aligners and braces
AcceleDent is a product that has been used in Australia since 2009, in the USA since 2012, and was cleared for use in Canada in the spring of 2013. MCO Invisalign Orthodontics was happy to have some of the first units available in Toronto. Many of our patients who were already in Invisalign treatment and started AcceleDent mid-treatment commented on how much more comfortable changing the trays became, not to mention being happy with changing trays more quickly.
It is FDA approved as a Class 2 medical device with clinical trials at two universities in Texas showing a 38-50% increase in tooth movement. It works by providing a pulsating vibration at a key frequency (30Hz) which has been shown to stimulate the bone remodelling process. This is very different from the vibrations of sonic tooth brushes and other devices. Patients use it for just 20 minutes per day and can do so while doing many daily tasks.
There is a possibility for faster treatment with braces and Invisalign aligners to be changed every 4-7 days, significantly decreasing the amount of treatment time required. Best of all, over the study of 1000s of patients, there have been no adverse effects, including no significant root resorption.
Additional Aligners (formerly Mid-Course Correction/Refinement)
Sometimes the teeth don’t move exactly as prescribed in the ClinCheck or treatment was planned to move teeth to a certain point, and then recapture the teeth as they move more into place. If this occurs in the middle of the course of aligners, a new impression or scan may be taken to “reboot” your treatment. This is known as mid-course correction. This may happen several times during the course of the duration of your treatment. Whether your treatment includes this will depend on the agreement with your doctor.
Refinement would be the equivalent of detailed finishing with braces treatment. It should not be viewed as a failure of treatment, but rather as a part of the process, if required. After the first course of trays, there may be slight movements that need to be achieved. At this point, new impressions can be taken, and a new course of trays can be used to help with the remaining movements. Note that in North America, there are up to 3 refinements included in the lab for providers, but what is included in your treatment fee is going to vary from office to office.
Be careful about getting complacent with your aligners because you feel they fit. Generally, they will fit from one aligner to the next without issue, even if you have not been using them for the correct amount of time. However, missing just 5 to 10 percent of the wear time across several aligners may result in aligners that suddenly no longer fit, several aligners down the road.
In many treatments, patients may notice that their last few aligners have a “+” sign associated with them. These aligners generally serve the purpose of overemphasizing certain movements, which generally would be tightening up any loose spaces around the front teeth.
It is important to note that these aligners do not always need to be used, they can be extremely tight compared to regular aligners, and if not used properly, can actually make the teeth become overcrowded as the space is tightened. Again, proper instruction from your Invisalign doctor is required.
This is a relatively simple procedure that is may be performed at the end of treatment or when different types of attachments are required. It simply involves the removal of resin that was bonded to the teeth using a dental handpiece and teeth scalers. No anaesthesia is required, and there is no pain involved in this procedure. Some patients may experience some sensitivity if there is gingival recession or root exposure present.
Retention including Vivera Retainers
Invisalign offers a product known as Vivera Retainers or Invisalign retainers. They can be made any stage of treatment, or from a new impression or scan. The material is a stiffer and more durable than Invisalign’s aligner, and they can be incorporated with fixed lingual retainers (which may or may not be recommended for your particular case with the majority of Invisalign patients not requiring fixed retainers). They come in sets of four and it is a way to ensure that you maintain your new smile by making sure you always have a retainer available in case you break or lose your current one. It is suggested that patients order a new set of Vivera retainers when they are wearing their fourth one in their subscription.
Please note that Vivera subscriptions are generally not included in your treatment fee and many offices or dental labs can offer a more economical and superior product. The range in North America can go from about $400-$1200 depending on whether a new impression/scan is needed. On a positive note, with proper care, our patients have reported that each retainer lasts, on a conservative estimate, at least a couple of years, and often much longer. Note that Essix-style retainers, can confer the same stability and durability more cost-effectively if using a similar material and made by a lab professional.