Digital technology in Aligner therapy

Dr Ayman R. Khalifa
Associated Professor of
Orthodontics , COD,GMU
 What is aligner ?
The term ‘orthodontic aligner’ most commonly refers to
clear, removable, plastic appliances that can produce small
tooth movements . The name aligner reflects the origin of
the appliances in correction of mild irregularity, often in
cases where post-orthodontic
❑ Clear aligners have become a
common treatment option for many
adults and teens, seeking to improve
their smiles and occlusion while
avoiding traditional braces therapy.
History
Of
Aligners
In 1945, Kissling created a rubber-
based tooth positioner and proposed
the concept of using them in
successive series for incremental
tooth movements

In 1997 the Invisalign evolution

was introduced by Chishti and
Kelsey from stanford university
(Align technology.)
 3. Initially aligners were used in cases where one or two
teeth required a small amount of movement. These aligners
were referred to as ‘positioners’. The aligners were
constructed by laboratory technicians, who sectioned and
repositioned any teeth, usually with a maximum tooth
movement of approximately 0.2 mm. The teeth were secured
in the new position and the subsequent cast was used to
construct the aligner using thermoplastic vacuum-formed
sheets .
Clear aligners can be categorized into four basic categories:
1. Thermoformed appliances:
Two types of plastic thermoforming machines dominate the
market: a)Pressure types
b) Vacuum types
 Pressure machines force heat-softened plastic over a cast
with positive pressure within a chamber.
 A vacuum machine adapts heat-softened plastic to a cast by
negative pressure.
 3 Contemporary aligners
 Contemporary orthodontic aligner treatment has been driven by the research and development arising from the
Invisalign® system, which was introduced by Align Technology in 1998. Invisalign® is a proprietary orthodontic
technique that uses sequential computer-generated plastic aligners to deliver a course of treatment.

 The popularity of contemporary aligner treatment may be attributed to several factors

FABRICATION OF
ALIGNERS
1. • Select a Case and Treatment Goal

2. • Submit Case

3. • Align Technology procedure

4. • Treatment finalization with the ClinCheck® software

5. • Making aligners

40
Case Selection Criteria
-Esthetic concern - is a significant factor for adult patients who prefe
-Patients with short dental roots may be better candidates for clear
than for
fixed appliances.
Digital aligner construction
2.1. Impressions
Impressions must always be taken using PVS (polyvinylsiloxane)
impression material.
COMMON ERRORS IN IMPRESSION MAKING : failure to capture sufficient detail of the
distal of the second molars

2.2. Bite Registration

Material is directly injected onto the patient’s occlusal surfaces. A layer
of about 5 mm of bite material is usually sufficient
2.3 Photographs. All the extraoral & intraoral photographs are taken.

2.4. Radiographs. One full-mouth series x-ray and/or panoramic x- ray is

required.

2.5. Prescription Form To specify the specific goals of the treatment and
to suggest the specific path of tooth movements required to achieve the
desired corrections.
 Digital design and
treatment plan

Intraoral Scanning Digital Study

February 25, 2025
Cast

[Link]
3 Align Technology Procedure

 Attachments
Small, tooth colored dots made of
composite, placed in certain locations on the teeth to
provide extra grip for the aligner, also
they create the anchor point that is
needed to help apply the force
of the aligner.

February 25, 2025

[Link]
 Trimming

Tooth
Alignment February 25, 2025

[Link]
Tooth
Segmentation

Adding February 25, 2025

Attachments
[Link]
 Adding a
Base

Numbered
Aligners

February 25, 2025

[Link]
 Manufacturing
Process

3d Printer (for printing the casts) Plastic

sheet

February 25, 2025

Aligners
[Link]
Thermoformer
Manufacturi
ng

February 25, 2025

[Link]
Trimmin
g

February 25, 2025

[Link]
February 25, 2025

[Link]
 Types of Attachments

1-Conventional:
Conventional attachments are passive attachments that increase the
engagement of
the aligner onto the tooth.

2-Optimized: February 25, 2025

They are designed to control the point of application of force, the
direction of the force, and the amount of force applied, which is
customized for each individual tooth
[Link]
 23
The configuration of attachments should be chosen based on the type
of tooth movement and retention requirements
How do attachments use force to
move teeth?
Couple and moment

February 25, 2025

[Link]
 Clinical steps for applying
attachments

1. Etch
2. Rinse and dry
3. bonding
4. Air dry
5. Light cure
6. Load the button wells with composite
material.
7. Place the aligner tray into the mouth.
8. Light cure the composite material
February 25, 2025
through the tray. Remove the aligner
tray from the mouth.

[Link]
 Supplementary Aids in
Aligner Treatment
1) Elastics
Rubber bands recommended
when more force is needed to move the tooth into
proper alignment Especially used to improve upper
and lower jaw fit together

2) Miniscrews
As anchorage in cases of an open
bite, a hybrid technique is used, a combination of
miniscrews and clear aligners (partial fixed appliance)

February 25, 2025

[Link]
 3) Buttons
Buttons are tiny tooth-
colored brackets for
attaching rubber bands.

February 25, 2025

[Link]
HYBRID TECHNIQUE

February 25, 2025

[Link]
 Hybrid technique

Orthodontic therapy that primarily uses

clear aligners but during short periods, clear
cosmetic braces will be used to help speed the
treatment of malocclusions that don’t readily respond
to clear aligners alone.

February 25, 2025

[Link]
The question is:

Does the Aligner Treatment is effective

as the Fixed appliance Treatment?
202
0
202
2
Removable… provides better oral
hygiene

Predictable outcomes to software

Inflammatory root resorption

lower than fixed

Reduced problems with eating

Lower impact on
patient’s quality of life
Di
s
Difficult to treat No Skeletal Requires at least
complex issues effect 22 hours wear a
day

Dental correction
related to the Possible non Needs clinical
anatomy of the tracking
teeth experience

Interaction
High Cost between teeth High tendency
saliva, and of relapse
aligners

Removable- needs patient’s

cooperation
Fixed Appliance vs Aligners

FIXED APPLIANCE CLEAR

ALIGNER
Pull on teeth Push on
teeth
Archwire engages Plastic engages
in around
bracket teeth
Reciprocal Anchorage No reciprocal
Anchorage February 25, 2025

[Link]
In/out/rotations

Action of Fixed
Appliance

Action of February 25, 2025

Alligners

[Link]
 Torque

In Fixed appliances Aligners have the power

February
torque is built into the bracket 25, ridge feature for lingual
2025
slot and arch wire bends. root torque

[Link]
 Anchorag
e
Fixed appliance Clear aligners
Reciprocal and based on Digitally predetermined
Newton’s 3rd law. One and may be
segment of teeth will changed at different stages
act as anchorage for of
another treatment offering extremely
segment of teeth good
control of anchorage because
the
anchorage teeth may be
immovable
at some stages of
treatment.

February 25, 2025

[Link]
NO side effects for tooth movements?(Anchorage)

Ex: With fixed appliances, extrusive force on the canine

produces intrusive forces on the adjacent teeth. (side effect)

February 25, 2025

Ex: In aligners ,extrusion of maxillary incisors with multi-
tooth extrusive attachments to close an anterior open
bite.
[Link]
February 25, 2025

[Link]
KEY TO SUCCESS

Adequate
patient Adequat
Patient
selection e Patient
monitori
records motivatio
ng and
with full n
tracking
data
Thank you!
21
Orthodontic aligners
S. K. Barber

Chapter contents
21.1 Definition of orthodontic aligners 276
21.2 History of aligners 276
21.2.1 Thermoplastic aligners 276
21.2.2 Spring aligners 277
21.2.3 Contemporary aligners 278
21.3 Tooth movement with aligners 278
21.3.1 Understanding tooth movement with aligners 278
21.3.2 Scope of tooth movement with aligners 278
21.4 Clinical stages in aligner treatment 278
21.4.1 Case selection 279
21.4.2 Treatment planning 279
21.4.3 Consent 280
21.4.4 Starting treatment 280
21.4.5 Adjunctive treatments 280
21.4.6 Monitoring progress 280
21.4.7 Retention 282
21.5 Digital aligner construction 282
21.6 Uses for aligners 283
21.6.1 Types of cases 283
21.6.2 Who should provide aligner treatment? 283

February 25, 2025

21.7 Advantages and limitations of orthodontic aligners 283

Principal sources and further reading 286

[Link]
276 Orthodontic aligners

Learning objectives for this chapter

• Gain an understanding of the types of orthodontic aligners.

• Gain an understanding of the advantages, limitations, and potential uses for aligners.
• Gain an overview of the clinical and laboratory stages in aligner treatment.
• Appreciate that an understanding of diagnosis, treatment planning, and biomechanics is as important for aligners as for conventional
fixed appliances.

Orthodontic aligners are growing in popularity. This chapter provides an in more detailed information are guided to the ‘Principal sources and
overview of the key features of orthodontic aligners but those interested further reading’ section.

21.1 Definition of orthodontic aligners

The term ‘orthodontic aligner’ most commonly refers to clear, remov- relapse had occurred. Contemporary aligner treatment usually refers
able, plastic appliances that can produce small tooth movements to the process of providing a series of aligners to deliver comprehensive
(Fig. 21.1). The name aligner reflects the origin of the appliances in treatment for a range of malocclusions.
correction of mild irregularity, often in cases where post-orthodontic

21.2 History of aligners

Removable appliances were first used in orthodontics in Europe in the The aligners were constructed by laboratory technicians, who sectioned
nine- teenth century as a method for straightening teeth. Later advances in and repositioned any teeth, usually with a maximum tooth movement of
enamel bonding technology and recognition of better results with fixed approximately 0.2 mm. The teeth were secured in the new position and
appliances resulted in greater use of fixed appliances with removable the subsequent cast was used to construct the aligner using thermoplastic
appliances becoming a largely adjunctive treatment. The discovery of vacuum-formed sheets (Fig. 21.2).
vacuum-formable thermoplastic sheets in the 1980s led to a resurgence in The Hilliard thermoforming pliers were later developed to enable
the popularity of removable appliances as a stand-alone treatment in the tooth-moving forces to be added to the aligner by the clinician at the
form of aligners. chair-side. The pliers were used to create a projection in the appliance
which then applied force to the tooth as the plastic returned to its origi-
21.2.1 Thermoplastic aligners nal state. Various pliers were designed to apply different forces to the
teeth and to modify the projections as the teeth moved.
Initially aligners were used in cases where one or two teeth required a
small amount of movement. These aligners were referred to as
‘positioners’.

February 25, 2025

Fig. 21.1 The term orthodontic aligner most
commonly refers to clear, removable, plastic
appliances.

[Link]
 History of aligners 277

Even with the introduction of pliers to create projections, individual

thermoplastic aligners had limited ability to move teeth due to the stiff-
ness of the material. To overcome this, sequential aligners were used to
incrementally move the teeth and achieve greater overall tooth move-
ment. Using the method previously described, laboratory technicians
would perform multiple incremental tooth movements, producing an
aligner at each stage. The considerable time requirements and technical
difficulties associated with modifying multiple casts to produce a series
of aligners by hand limited the scope of this method.

21.2.2 Spring aligners

The spring aligner was developed as an alternative method for
align- ing anterior teeth. These appliances employ two opposing
(a) nickel- titanium sprung bows, which straighten teeth by applying
reciprocal force labially and palatally (Fig. 21.3). The appliances
are designed

(b) (a)

(c)
February 25, 2025
Fig. 21.2 The laboratory stages in construction of a simple orthodontic (b)
aligner to procline the mandibular right lateral incisor. (a) A dental cast
is produced from the impression; (b) the tooth that requires movement Fig. 21.3 Alignment with a spring aligner appliance. (a) The maxil-
is sectioned from the cast, repositioned, and secured; (c) a working cast lary central incisors are retroclined and the lateral incisors are rotated.
is produced to make the aligner using vacuum-formed thermoplastic (b) The opposing palatal and labial bows simultaneously apply force to
sheets. the palatal surface of the central incisors to procline the teeth and to the
mesial corner of the lateral incisors to de-rotate the teeth.

[Link]
278 Orthodontic aligners

to provide a short course of treatment (usually less than 4 months) and

are limited to mild crowding of rotated or labiolingually displaced inci-
Box 21.1 Factors that may have contributed to the
sors. The most common commercially manufactured spring aligner is
popularity of contemporary orthodontic aligners
the Inman Aligner™, but most laboratory technicians can produce a • Advances in technology providing greater tooth movement
spring aligner from a standard appliance prescription. and versatility.
• Advances in technology leading to improved treatment outcome.
21.2.3 Contemporary aligners • Increased treatment demand by adults.
Contemporary orthodontic aligner treatment has been driven by the • Increased demand for aesthetic orthodontic treatment.
research and development arising from the Invisalign® system, which • Extensive marketing by manufacturers to clinicians and
was introduced by Align Technology (San Jose, California, USA) in 1998. patients leading to increasing awareness.
Invisalign® is a proprietary orthodontic technique that uses sequential
computer-generated plastic aligners to deliver a course of treatment.
Other manufacturers have emerged to offer complete aligner treatment
that follow similar principles, but Invisalign® remains the most popular treatment for teenage patients. This younger age group presents
system worldwide. The combined benefits of three-dimensional (3D) partic- ular challenges for aligner treatment, such as changes to the
planning technology, improved materials, mechanics arising from under- dentition with continued tooth eruption, difficulties in gaining
standing of aligner tooth movement, and computer-aided manufacture sufficient purchase on partially erupted teeth to fully control tooth
of multiple aligners have led to a much broader scope for orthodontic movements and retain the aligners, and potential compliance issues.
aligner treatment. This is discussed more in the following sections. Manufacturers are rapidly developing solutions to address these
The popularity of contemporary aligner treatment may be attributed potential difficulties and it is likely that through continued research
to a number of factors (Box 21.1). Although designed for adults with fully and development, aligner treatment will evolve further and become
erupted permanent dentitions, there is a growing demand for aligner established as an adjunct or alternative to other orthodontic treatment
modalities in many countries.

21.3 Tooth movement with

aligners
21.3.2 Scope of tooth movement with
21.3.1 Understanding tooth movement
aligners
with aligners
Much like other removable appliances, early aligners were
Application of force to achieve tooth movement with aligners is differ- largely restricted to tipping movements of the crown due to
ent to other orthodontic appliances. For aligners, the plastic enclosing limitations in the force vectors that could be transmitted to the teeth.
the tooth has two functions: application of force for tooth movement The ability to apply adequate forces to correct buccolingual tip and
and retention of the appliance. Tooth movement is achieved by elastic rotational movement of flat teeth, such as incisors, allowed aligners
deformation of the aligner and the composition of the plastic is therefore to manage rotated, pro- clined, or retroclined anterior teeth; however,
important. The material needs to be stiff enough to deliver the correct there was little scope for mesiodistal or vertical tooth movement, or
level of force, but also highly elastic so it will return to its original shape root torque.
when stretched, moving the tooth with it. Retention for the appliance is Advances in understanding of tooth movement mechanics have ena-
usually provided by the natural undercuts of the tooth, however, in some bled the development of a range of different shaped attachments that
cases the functions of retention and elastic deformation can compete, for are placed on teeth to increase engagement between the aligner and
example, displacement of the aligner when trying to extrude teeth. This tooth. These attachments have been carefully designed using biome-
has been addressed to some extent by adding composite attachments to chanical knowledge to allow the aligner to exert a range of force vectors.
the teeth. Attachments provide a surface for the retainer to grip on to and Attachments, in conjunction with advanced plastic aligner materials,
prevent unwanted displacement of the aligner in addition to providing enable more difficult tooth movements to be achieved, such as de-
a point of force application to achieve more difficult tooth movements.

February 25, 2025

rotation of round teeth (canines and premolars), relative intrusion/
An understanding of the biomechanics of tooth movement with extrusion of one or multiple teeth, and root torque. With appropriate
aligners will help clinicians to achieve more predictable results. For fur- understanding, planning, and use of modern aligner technologies it is
ther information, readers are directed to the sources given in ‘Principal possible to achieve a scope of tooth movement with aligners that is
sources and further reading’. comparable to fixed appliances.

21.4 Clinical stages in aligner treatment

It is a common misconception that the brand of aligner is important to with all orthodontic treatment, success depends on accurate diagno-
the eventual success of aligner treatment. The type and brand of aligner sis of malocclusion, establishing patients’ expectations from treatment,
may determine the scope of potential tooth movements, however, as careful treatment planning, and understanding of mechanics.

[Link]
 Clinical stages in aligner treatment 279

21.4.1 Case selection radiographs, and detailed impressions in a stable material. Bite registra-
tion is usually taken in maximum intercuspation and should be checked
When deciding whether alignment treatment is a viable option, it is carefully, as errors in bite registration increase the risk of unattainable
impor- tant to elicit the patient’s key concerns and establish treatment treatment plans.
goals. If significant tooth movement is required or there is an A prescription is sent by the clinician with the records to the manu-
underlying skeletal discrepancy that requires correction, other forms facturer to allow the technician to deliver a preliminary sequence of
of treatment may be preferable. It is essential that treatment objectives tooth movements. In the prescription, the clinician specifies the aims
are measured against the scope of the appliance to deliver the necessary of treatment, including which aspects of malocclusion are to be cor-
tooth movements and any biological limitations posed by the rected or accepted. The manufacturer will usually produce a virtual set-
malocclusion. Advances in aligner technology have broadened the up that reflects the desired outcome described in the prescription. The
scope of treatment with aligners but this will not compensate for poor virtual set-up can often be viewed in a software program, such as the
case selection by inexperienced clinicians. Invisalign® ClinCheck (Fig. 21.4).
The virtual set-up is not the treatment plan but simply the technician’s
21.4.2 Treatment planning 3D interpretation of the prescription provided by the clinician. It should
Regardless of the aligner system, full diagnostic records are required be noted that the technician is usually not orthodontically trained and
for treatment planning. This includes clinical information, photographs, is

(a)

(b)

(c)

February 25, 2025

Fig. 21.4 Treatment planning check using
the Invisalign® ClinCheck programme. Only
select stages using front and right buccal
views are included in this example, but the full
programme provides a detailed 3D plan with
an extensive range of views. (a) Pre-treatment
intra-oral photographs; (b) pre-treatment digi-
tization for treatment planning, created from
impressions and wax bite; (c) mid-treatment
stage with evidence of attachments and inter-
proximal enamel reduction; (d) prediction for
end of treatment.
(d)

[Link]
280 Orthodontic aligners

not responsible for the treatment plan. The technician will follow the into the aligner, and teeth must be fully seated in the current aligner
instructions on the prescription and ensure the tooth movements are before moving to the next one.
within the software limits for that particular brand of aligner, but it is
the clinician’s responsibility to approve the virtual set-up. The prelimi-
21.4.5 Adjunctive treatments
nary set-up details the sequence of steps, the amount of movement per
aligner, the use of adjunctive treatments such as attachments, elastics, Adjunctive treatments m a y be required to facilitate the required
and interproximal reduction. The clinician can view the virtual set-up tooth mo v emen t. T h e most c o m m o n adjunctive treatments are
and make adjustments to the treatment plan to ensure the treatment placement of attachments, interproximal reduction and use of inter-
objectives are met. arch elastics.
Attachments are selected and located during the treatment plan-
ning stage to allow force application in the desired vector or to pro-
21.4.3 Consent
vide additional retention. The attachments are placed using a stent
Treatment planning and consent are covered in detail in Chapter 7; to allow composite to be bonded to the tooth in the correct shape
however, it is worthwhile highlighting the issues that are most perti- and position (Fig. 21.5). There is anecdotal evidence that during
nent to aligners. The effectiveness of aligners is not yet established and treatment the attachments may be prone to some staining. Patients
clinicians are wise to avoid overselling the alleged benefits of aligners should be warned about this but reassured that at the end of treat-
compared to other types of treatment. Much like fixed appliance treat- ment attachments will be removed without any permanent effect on
ment, the outcome of treatment is influenced by the experience of the the enamel if diet control and oral hygiene are satisfactory through-
clinician and careful treatment planning and delivery. out treatment.
Patients should be aware of any potential limitations posed by Interproximal reduction is often incorporated into treatment plans to
the biological constraints of the malocclusion and limited treatment provide space for alignment of teeth. The timing, location, and extent
objectives should be clearly stated. Aligners are not able to overcome of interproximal reduction is specified in the prescription (Fig. 21.6).
the aspects of treatment that are biologically determined, such as any Usually a maximum of 0.3 mm and 0.5 mm of enamel removal is
limitations in the final tooth position, the rate of tooth movement, advised per interproximal surface for anterior and posterior teeth
and the need for long-term retention. Treatment time depends on respectively, although the extent of reduction possible should be
the extent of tooth movement needed and compliance with aligner judged individu- ally for each tooth based on enamel thickness and
wear and conservative estimates are advised to allow time for detail- crown morphology. Current evidence suggests that interproximal
ing the occlusion with additional aligners if needed. Adjunctive enamel reduction used in appropriate cases and within recognized
treat- ments should be described and agreed during treatment limits causes no long-term detriment to dental health.
planning and consent. Inter-arch elastics c a n b e applied to notches o r h o o ks incor-
Aligners have similar potential side effects as other removable appli- porated during the aligner construction (Fig. 21.7) or by bonding
ances, namely effects on speech, increased salivation, discomfort, and metal or clear buttons directly to the tooth surface. Much like fixed
gagging, and these may be more marked in adults than children. The orthodontics, inter-arch elastics allow correction of the anteropos-
patient should be warned that in most cases aligners must be removed terior relationship. If the application points for elastic traction are
for eating and drinking, as this can impact eating habits and the num- cut into the aligner, these need to be designed to prevent displace-
ber of hours of wear that are achievable. The benefit of being able ment of the aligner by the elastic force.
to remove aligners for cleaning may be countered by the risk of non- More advanced adaptations to aligners are also possible. Aligners
compliance with wear and patients should be assessed on an indi- have been designed to incorporate interlocking blocks to apply a Class
vidual basis. II correction, working in the same way as other types of functional appli-
ances. Aligners have reportedly been used in conjunction with other
orthodontic auxiliaries, for example, temporary anchorage devices
21.4.4 Starting treatment
(mini-screws) to correct vertical discrepancies. This type of treatment is
Following confirmation of the treatment plan and consent, highly complex and should only be undertaken by experienced
align- ers are manufactured and dispatched to the clinician to ortho- dontists who are competent in this approach
commence treatment. The first aligner is fitted, and instructions
are provided including the hours of wear needed per day, usually a
21.4.6 Monitoring progress

February 25, 2025

minimum of
22 hours, alongside dietary and oral hygiene advice. Advocates One potential benefit of aligner treatment is reduced chair-side
of aligner treatment claim patients report lower pain experience time arising from patients being able to change their own
than with fixed appliances, however, there is no good evidence to aligners. The patient can be instructed how to monitor progress to
support this claim. Pain depends on the individual and analgesia determine when the next aligner can be started. However, it is
advice is recommended, as aligners often feel tight initially. still important that patients are seen regularly to allow the clinician to
Where a series of aligners are to be used, patients should be instructed monitor progress and provide support. Progress is assessed by
how and when to progress to the next aligner. Teeth should be ‘tracking’ comparing actual tooth move- ment to expected tooth movement and
with the series of aligners, meaning the teeth move as expected to fit this allows any problems to be

[Link]
 Clinical stages in aligner treatment 281

(a)

(b)

Fig. 21.5 Application of attachments. (a) Attachments are added to the teeth dur-
ing the treatment planning stage. (b) A plastic flexible stent is produced from the
treatment plan. The stent is used to place the composite attachments in the correct
position and shape. (c) Composite attachments in place. Note there is some staining
around the attachments and patients should be warned of this during the consent
process.
(c)

February 25, 2025

Fig. 21.6 A prescription for interproximal reduction is included in the treatment plan. In this case, 0.3 mm of enamel reduction is required between the
mandibular incisors to allow alignment of the teeth.

[Link]
282 Orthodontic aligners

Fig. 21.7 Use of Class III inter-arch elastics with aligners. The elastic attaches to notches on the gingival margin of the aligner.

identified and managed swiftly. The most common reasons for lack of
progress are loss of tracking (Fig. 21.8) arising from insufficient wear,
insufficient interproximal reduction, inadequate application of force on
teeth, for example, from incorrect attachment placement, or as a result
of an unfeasible plan where too much movement is planned from one
aligner.

21.4.7 Retention
A
s with all forms of orthodontic treatment, retention is a key component
of aligner treatment and the patient must be aware of the commitment
to long-term retention from the outset of treatment. Removable, fixed,
or combined retainers may be used depending on patient preference.
Retention is discussed in detail in Chapter 16.
Fig. 21.8 The upper aligner is not seating fully on the lower right lateral
incisor, indicating a problem with tracking.

21.5 Digital aligner construction

Most manufacturers use their own proprietary software and process- this should correspond to the treatment objectives. At this stage, it is
ing equipment for computer-aided aligner construction, however, the usual for the preliminary plan to be reviewed by the prescribing cli-
systems tend to follow a common sequence. The key stages are sum- nician. Ideally, software that enables 3D visualization of each aligner
marized here but for further information about a specific system it is stage is used to allow real-time adjustments by the clinician to the
advisable to contact the manufacturer. tooth movements to finalize the treatment plan. Modifications can be
Firstly, a digital study model is creating using a direct scan of the made and rechecked until the clinician is satisfied that the treatment
impression or scan of a dental cast. The teeth are articulated using the is feasible and will achieve the desired outcome. It is also possible to
bite registration and any obvious artefacts are removed at this stage. show the patient the proposed plan and expected tooth movements
Some systems allow the teeth and bite to be scanned directly and trans- at this stage.

February 25, 2025

ferred to the manufacturer without the need for an impression and this Following finalization of the treatment plan by the clinician, the digi-
can reduce the time required for the digitization stage. tal study models are transferred to cast production. Previously a series
Tooth movements are executed by the technician using instructions of stereolithographic models were produced and each model was used
from the prescribing dentist. The teeth are moved incrementally to to fabricate an aligner. However, developments in 3D printing technol-
ensure the forces applied are within physiologically acceptable ogy now mean aligners can be produced directly from the computer
limits, usually around 0.25 mm and 0.33 mm per aligner for anterior software by the manufacturer. It is likely that with the reducing price of
and poste- rior teeth respectively. Adjunctive treatments are added as 3D printers and the increasing use of aligners, in the future, in-house 3D
required to achieve the range of desired tooth movements. Once the printers will enable the manufacturer to transfer the aligner details to
full sequence of movements has been executed, the final occlusion is the clinician for printing on site.
provided and

[Link]
 Advantages and limitations of orthodontic aligners 283

21.6 Uses for aligners

21.6.1 Types of cases Table 21.1 Uses for aligners
The type of case that can be successfully managed with orthodontic
Simple Alignment of anterior teeth by tipping
aligners depends on the tooth movements required to correct the maloc- Alignment of rotated incisors
clusion and the ability of the aligner system to achieve this movement. Mild–moderate anterior crowding (may require
Different aligner systems are able to deliver different types of tooth interproximal reduction or expansion)
move- ments and this, alongside clinician competence, will determine Posterior expansion
Distal molar tip
whether aligners are a suitable treatment method. More complex cases
require a more sophisticated system that incorporates adjunctive Moderate Closure of mild–moderate spacing
treatments (Table Intrusion or extrusion of teeth
Severe rotations on round teeth
21.1). There is little evidence beyond the level of case reports to evaluate
the efficacy of orthodontic aligners for correction of specific types of Complex Expansion to allow alignment of a totally
mal- occlusion and the rapid advances in technology combined with blocked out tooth
Severely ectopic teeth
individual patient variation present challenges for generalization across Molar uprighting or any teeth with significant
cases. undercuts
Most aligner systems are suitable for simple cases where mostly Closure of extraction spaces
tipping movements are required. Where there is moderate crowding, Bodily distalization of molars
Management of anterior open bite
space for alignment is gained through interproximal reduction,
expan- sion, or a combination of both. Alignment in the anterior
region com-
expansion monly
is not results in
desirable, proclinationreduction
interproximal of the incisors and
will be the effect
necessary.
of For
this more
shouldcomplex
be considered in relation other countries. Therefore, specialists and general dentists who have
cases, where toothtomovement
the overjetbeyond
and overbite.
tippingIfis
proclination or sought the appropriate training and are competent to perform the treat-
required, attachments are necessary to enable appropriate force appli-
ment to a satisfactory standard are generally allowed to offer ortho-
cation. Attempts to close spaces without attachments to drive root
dontic treatment. Competency will depend on the aligner system used,
movement will result in tipped crowns. For intrusive or extrusive move-
the complexity of the case, and clinician experience, so clinicians must
ment of one or two teeth, attachments enable differential force applica-
decide on a case-by-case basis whether they feel able to offer treatment.
tion on adjacent teeth. On round teeth, such as premolars and canines,
One area of concern has arisen around manufacturer training courses
attachments provide a point of force application. Inter-arch elastic trac-
which only include information about the one specific system. In these
tion may also be necessary to correct the buccal segment relationship.
cases, clinicians may not have sufficiently broad knowledge to be able
Complex cases are those judged to require significant tooth move-
to provide all treatment options in a balanced way to allow informed
ment, such as bodily movement of teeth over a distance after extraction
decision-making. It is important that patients are informed of the quali-
(Fig. 21.9) or distalization of molars. For complex cases, the selection of
fications and experience of clinicians offering treatment, including any
an appropriately advanced aligner system and execution of treatment
limitations in what they are able to offer, and if the patient requests addi-
by an experienced clinician is essential for success.
tional information or a second opinion, a referral should be offered.
Evidence shows treatment outcomes are improved by accurate diag-
21.6.2 Who should provide aligner treatment?
nosis, careful treatment planning, and operator experience. Those at
In the UK, the General Dental Council states dental treatment can the start of their aligner journey are encouraged to select cases carefully
be performed by any dentist who has the necessary skills and is and seek mentoring from more experienced colleagues where possible
appropri- ately trained, competent, and indemnified. Similar to ensure patient care is optimized.
guidance exists in

21.7 Advantages and limitations of orthodontic aligners

Many claims have been made by supporters and manufacturers of ortho- It is generally acknowledged that aligners are more aesthetic than

February 25, 2025

dontic aligners and while the body of evidence to support these claims is
growing, there are few high-quality trials to determine the effectiveness
of aligners compared to other treatment methods. The most commonly
metal buccal fixed appliances but not as inconspicuous as lingual fixed
appliances. The appearance of aligners compared to ceramic fixed
appliances is more difficult to judge and depends on the particular sys-
proposed advantages of aligners include more aesthetic appliance, tems in use and personal preference. The ability to remove aligners for
improved dental health in terms of periodontal health and reduced risk cleaning and eating might be expected to reduce the risk of periodontal
of decalcification, and a reduction in chair-side time, overall treatment problems and decalcification; however, this has not yet been substanti-
time, pain experience, and root resorption. The current body of evidence ated and it is likely that the risk of treatment is related more to individual
for orthodontic aligners is insufficient to conclusively support or refute motivation than the appliance.
these claims although future high-quality randomized trials are planned.

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284 Orthodontic aligners

Fig. 21.9 A female adult patient who under-

went comprehensive treatment with ortho-
dontic aligners (treatment was provided by
Catherine McCanny). The patient presented
with a Class II division 1 incisor on a Class I
skeletal base with moderate upper and mild
lower arch crowding. The malocclusion was
complicated by a Class II buccal segment rela-
tionship on the right side and a 2 mm centreline
discrepancy. Treatment involved extraction of
the maxillary right first premolar and treatment
with the Invisalign® system. The malocclusion
was successfully corrected in 30 months and
bonded retainers were provided.

Key points

February 25, 2025

• Aligners have gained popularity over the last decade due to advances in the understanding of tooth movement with aligners and
increased demand for aesthetic orthodontic appliances, particularly for adults.
• Aligners may provide an alternative to fixed appliances for amenable malocclusions in the hands of trained and competent
clinicians.
• Diagnosis, treatment planning, and use of appropriate biomechanics is the responsibility of the treating clinician, not the aligner
manu-
facturer.
• More complex cases may require aligners to be used in combination with fixed appliances or other adjunctive treatments.
• It is essential a full orthodontic assessment is undertaken and the full range of treatment options are discussed with the patient.

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 Advantages and limitations of orthodontic aligners 285

Fig. 21.9 (Continued)

February 25, 2025

Relevant Cochrane review
Yu, Y., Sun, J., Lai, W., Wu, T., Koshy, S., and Shi, Z. (2013). Interventions for managing relapse of the lower front teeth after orthodontic treatment.
Cochrane
Database of Systematic Reviews, Issue 9, Art. No.: CD008734. DOI: 10.1002/14651858.CD008734.pub2
This review included aligner treatment but no studies that fulfilled the inclusion criteria were identified.

[Link]
286 Orthodontic aligners

Principal sources and further reading

An interesting discussion of the purpose and ethics of adult orthodon-
Azaripour, A., Weusmann, J., Mahmoodi, B., Peppas, D., Gerhold-Ay, A.,
tics, including the scope and limitations of aligner treatment.
Van Noorden, C. J., et al. (2015). Braces versus Invisalign®: gingival
param- eters and patients’ satisfaction during treatment: a cross-sectional Paquette, D. E., Colville, C., and Wheeler, T. (2016). Clear aligner treatment.
study. BMC Oral Health, 15, 69. [DOI: 10.1186/s12903-015-0060-4] In: Graber, L. W. and Vanarsdall, R. L. (eds) Orthodontics: Current Princi-
[PubMed: 26104387] ples and Techniques (6th edn), pp. 778–811. St. Louis, MO: Elsevier.
Evidence that Invisalign® treatment is associated with better gingival This chapter provides a detailed overview of the history and current
health and patient satisfaction, but caution is advised due to limitations approach to the use of clear aligners, focusing principally on Invisalign®.
in the methodology. Tuncay, O. C. (2006). The Invisalign® System. New Malden: Quintessence
Best, A. D., Shroff, B., Carrico, C. K., and Lindauer, S. J. (2017). Treatment Books.
The original Invisalign® textbook, which although slightly
management between orthodontists and general practitioners per-
outdated now, does provide a historical perspective to the system.
forming clear aligner therapy. Angle Orthodontist, 87, 432–9. [DOI:
10.2319/062616-500.1] [PubMed: 27874282] Weihong, L., Wang, S., and Zhang, Y. (2015). The effectiveness of the Invis-
An interesting comparison of treatment perspectives between align appliance in extraction cases using the ABO model grading system:
different types of clinicians from the USA. a multicenter randomized controlled clinical trial. International Journal
Bowman, S. J. (2017). Improving the predictability of clear aligners. Seminars of Clinical and Experimental Medicine, 8, 8276–82. [PubMed: 26221410]
in Orthodontics, 23, 65–75. [DOI: 10.1053/[Link].2016.10.005] A trial to compare fixed appliances and aligners for extraction treat-
Discussion of some of the common aligner problems and possible solu- ment in adults. Limitations were noted in the methodology.
tions. Wheeler, T. T. (2017). Orthodontic clear aligner treatment. Seminars in
Gay, G., Ravera, S., Castrflorio, T., Garino, F., Rossini, G., Parrini, S., et al. Orthodontics, 23, 83–6. [DOI: 10.1053/[Link].2016.10.009]
(2017). Root resorption during orthodontic treatment with Invisalign®: A paper describing the types of malocclusion that can be
treatment with aligners.
a radiometric study. Progress in Orthodontics. 18, 12. [DOI: 10.1186/
s40510-017-0166-0] [PubMed: 28503724] White, D. W., Julien, K. C., Jacob, H., Campbell, P. M., and Buschang, P. H.
A prospective cohort study that suggests root resorption with aligners is (2017). Discomfort associated with Invisalign and traditional brackets:
similar to other systems using light forces.
a randomized prospective trial. Angle Orthodontist, 87, 801–8. [DOI:
Qureshi, A. (2008). The Inman Aligner for anterior tooth alignment. Dental 10.2319/091416-687.1] [PubMed: 28753032]
Update, 35, 569–71, 574–6. [DOI: 10.12968/denu.2008.35.8.569] [Pub- This trial suggests aligner treatment may slightly reduce pain
experi- ence and analgesic use.
Med: 19055094]
A summary of the design and uses of the most commonly used commer- Zheng, M., Lui, R., Ni, Z., and Yu, Z. (2017). Efficiency, effectiveness and
cial spring aligner appliance.
treatment stability of clear aligners: a systematic review and meta-analy-
Noah, J. H., Sharma, S., Roberts-Harry, D., and Qureshi, T. (2015). A discern- sis. Orthodontics and Craniofacial Research, 20, 127–33. [DOI: 10.1111/
ing approach to simple aesthetic orthodontics. British Dental Journal, ocr.12177] [PubMed: 28547915]
This review found a lack of evidence to support claims about the effec-
218, 157–66. [DOI: 10.1038/[Link].2015.55] [PubMed: 25686433]
tiveness of orthodontic aligners.

References for this chapter can also be found at: [Link]/uk/orthodontics5e. Where possible, these are presented as active links
which direct you to the electronic version of the work, to help facilitate onward study. If you are a subscriber to that work (either individually
or through an institution), and depending on your level of access, you may be able to peruse an abstract or the full article if available.

February 25, 2025

[Link]