Expert

secrets: The
5 key steps
to get the
perfect
ClinCheck
*Also works with Spark Approver

Dr. Luis González Barbero

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place

ALIGNER
SUN&FUN in Alicante

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¡Welcome to this e-book about
digital planning in invisible
orthodontics!
In this e-book you will find a simple method useful
to review your treatment planning as a true expert. Said
method is compatible with any software you use.

Note that biomechanical principles used here are

applicable to any aligner system. They are based on
building force systems that have proved to work
properly through thousands of cases treated with clear
aligners, mostly using ClinCheck®/ApproverTM for
planning them.

Whether you are an expert or a beginner planning your

first cases with aligners, using a clear and consistent
method is the key to achieve successful treatments and
avoiding mistakes or deviations in planning that
ultimately take to effectiveness reduction. Similarly to
fixed appliances treatments in which you have to re-
cement a bracket due to an inadequate initial
positioning, errors in planning will mean more
refinements and increased overall treatment time,
reducing aligners effectiveness.
 Treatment planning softwares are thoroughly useful
tools for the orthodontist. Once discovered there full
potential, you will be able to solve all sort of cases, even in
less time than with traditional braces. The accuracy of the
aligners can overcome that of conventional orthodontics.

The so called five-step method proposed here will teach

you how to afford planning in an expert orderly way:
starting off with a global approach, reviewing the basics of
diagnosis, and continuing with the sequence of
movements and the design of proper attachments for each
teeth.

When using ClinCheck®/ApproverTM for planning, more

important than the final outcome are the stages teeth
follow to achieve it.

Extraoral and intraoral references

First step, before starting to "play" with the program's

controls, is to determine the extraoral and intraoral
references based on which the treatment is going to be
planned, a matter that should be explained to the
technician for a clear understanding.

Taking these references into account, teeth movements

will take place within the biological limits of each patient.
These references are taken with the help of photos.

Most relevant ones are explained below:

Extraoral references:
Midlines: Dental midlines position with regard to facial
midline is the first reference to be assessed, given its
aesthetic importance.

A midline deviation, particularly in the case of the upper

midline, caused by poor planning, will significantly worsen
the esthetics of the smile, no matter how good the
occlusion works.

Orthodontic treatments are planned based on the

patient's face; the mouth is a pillar of facial aesthetics and
as such should be considered.

For example, the correction of an asymmetric Class II can

be done by superior distalization, inferior mesialization or a
combination of both, depending on midlines configuration
and on how many millimeters the teeth can be displaced.
Fig.1. Patient with deviation of both midlines with respect to the facial midline. Sequential
distalization of the first quadrant is planned to center the upper midline and create space to align
the canine and mesialization of the fourth quadrant to center the lower midline.

Exposure of the upper incisors: Another aspect to highlight about

the aesthetics of the smile is teeth and gum exposure while at rest
and smile positions. One of the treatment goals will be to improve
(or at least not worsen) that exposure.

When a patient shows a problem in the vertical plane, whether it is

an open bite or an increased overbite, the therapeutic strategy will
depend on the degree of the anterior teeth exposure.

For example, if a case with an augmented overbite shows a correct

exposure of upper incisors, it can be corrected by posterior
extrusion and/or lower anterior intrusion, but upper incisors
cannot be intruded.

If they are intruded, upper incisors exposure will be reduced,

worsening the aesthetics of the smile even if the patient's
orthodontic problem is corrected.

Fig.2. Patient with 100% overbite and adequate upper incisors exposure when smiling. The overbite is
corrected by lower intrusion for not reduce upper incisors exposure.

It may also happen that a patient shows an open bite in which

upper incisors are not exposed (Fig.3). In this case, bite closure will
be achieved almost entirely by upper extrusion.

If lower incisors were extruded, even if the bite was closed, the
smile arc would worsen.

For this reason, in this case the use of an additional anchorage was
needed in order to achieve bite closure only by extruding upper
incisors and canines.
 Fig.3. Patient with open bite without exposure of upper incisors when
smiling. Bite closure is panned by 85% upper teeth extrusion and 15% lower
teeth extrusion.

Intraoral references:
WALA ridge: At transverse level, the expansion that can be
performed will depend on the bone width of each patient.

The WALA ridge or WALA line, which clinically corresponds to the

mucogingival junction (equivalent to the junction between the
basal bone and the alveolar bone), is a reference that can be seen
in the photos and is used to determine the arch shape of each
patient and the amount of expansion that can be planned.

An indiscriminate expansion could lead to periodontal problems,

such as recessions or dehiscences, and compromise the treatment
stability and aesthetics results.

Fig.4. Case with a severe dental compression in which the WALA ridge (dashed line)
and the negative torque of the posterior teeth allow a large expansion (about 2-3
mm per side) to be performed safely.
With this reference, it is possible to calculate approximately the
millimeters of expansion needed and request them to the
technician.

Incisor inclination: To assess the inclination of the incisors with

respect to upper and lower jaws, measurements of the IMPA angle
(angulation of the lower incisors with respect to the mandibular
plane) and of the Burstone angle (angulation of the upper incisors
relative to the palatal plane) will be taken from the cephalometry.

As we know that for the IMPA the norm is 90º and for the
Brustone, 110º, it is possible to determine the amount of
proclination or retroclination necessary in each patient.

Fig.5. Patient with gingival recessions and excessive proclination of the upper and lower incisors.
Increased overjet cannot be corrected using Class II elastics, as it would worsen the lower incisor
inclination. In this case, overjet reduction was done by extracting the upper premolars to retrude the
anterior teeth. In the lower arch, IPR and radiculolingual torque were planned in the lower central
incisors to improve the roots position.

With regard to these angles, it should be noted that they are not
assessed isolated, but together with the gingival biotype and the
level and thickness of the alveolar bone.

Proclining the lower incisors in a patient with a wide symphysis

and a thick biotype is not the same as performing such movement
in a periodontal patient with a narrow symphysis.

In the image bellow, in the third case, if it is necessary to tilt lower

incisors beyond the norm, it may have no consequences at the
periodontal level, while in the first case, the most likely result of the
same movement is that part of the cortical bone will be lost and
gingival recessions will appear.

Fig.6. Examples of lateral cephalometric radiographs showing different widths of symphysis and
cortical bone. These characteristics are usually related to the facial pattern.
 On ClinCheck®/ApproverTM, there are two ways to observe the
amount of expansion/proclination being performed.

On one hand, we have the Movement Chart, where the

vestibular/lingual displacement of all the teeth appear in
millimeters.

These numerical values ​s erve as a "guide": the angulations and

measurements made by the software are of the clinical crown, not
of the entire tooth. For example, when 5º of coronobuccal
inclination are planned, these 5º correspond to crown inclination,
they are not exactly equivalent to 5º inclination of the complete
tooth.

Below we have two examples where the row in which these

movements appear is highlighted with a blue box, making a
difference between coronal and root movement.

Fig.7. Invisalign ClinCheck® Movement Chart.

Fig.8. Spark ApproverTM Movement Chart.

On the other hand, we can use the superimposition
tool, which allows us to compare the initial and final
teeth position.

This option is more visual and comfortable to use

than the Movement Chart, but it requires more
practice to learn how to detect unwanted root
movements.

Fig.9. Superimposition of the initial (blue) and final (white) position of the teeth in
two different plans.

Movement sequence
As discussed previously, the teeth movement
process is more important than the final
ClinCheck®/ApproverTM result.

If the sequence is not well established, the teeth

will not move as planned. The reason why some
movements are sequenced is no other than
achieving better predictability and avoid aligner
misalignments during treatment, even if this means
a greater number of aligners.

If the complex movements are performed

simultaneously, the number of aligners will be less,
but the chances of achieving the expected result
decrease drastically.

Some of the most common moves are explained

below:

Alignment and extrusion: Alignment and extrusion

of teeth with aligners is a complex movement.
Unlike brackets, which are attached to the teeth
and can do this movement without any problem,
aligners extrude the teeth by applying a force to the
surface of the corresponding attachment.

When one or more teeth are extruded with aligners,

the plastic tries to “catch” the tooth and pull it
down. If, at the same time as this movement, the
rotation or inclination of the tooth is corrected, it is
very likely that the aligner gets misadjusted.
If movements are sequenced, starting with the alignment and
ending with the extrusion, the chances of misalignment are
reduced as well as the risk of interference appearing between the
teeth of both arches.

Fig.10. Movement sequencing in a case with anterior open bite and posterior crossbite. First, the
teeth are aligned and the upper arch is expanded, and then the anterior teeth are extruded.

Distalization/mesialization: Distalization and mesialization

movements are planned in cases where it is necessary to correct
the sagittal aspect. Depending on the available anchorage,
distalization/mesialization will be done sequentially or
simultaneously.

Thus, a Class II can be corrected with a combination of upper

distalization and lower mesialization, but these movements will be
planned differently.

Fig.11. Sequential distalization and expansion of the first quadrant.

In the upper arch, sequential distalization of 1/2 pattern is planned.

This sequence begins by gradually distalizing the posterior teeth,
moving no more than two teeth at a time.

When the molars have finished their movement, the anterior teeth
begins to retract.

For achieve a predictable distalization, Class II elastics use is

recommended. Elastics use may vary for night time or 24 hours
depending on the number of teeth that are being distalized. The
greater the number of teeth distalizing, the longer the elastics will
be used, since there is a greater demand for anchorage.
 Fig.12. Patrón de
distalización en W. A la
vez que se hace la
distalización
secuencial, se alinean y
proinclinan los dientes
anteriores (inicio
estético). Cuando los
primeros molares
finalizan su
movimiento, se retruye
todo el frente anterior.

In the lower arch, as the midline is deviated from

the facial midline, the teeth in the fourth quadrant
will be mesialized. This mesialization can be done
sequentially or simultaneously.
Usually, lower mesialization will be planned
simultaneously, which is known as a "virtual jump".
This virtual jump represents the mesializing effect of
the force applied by Class II elastics on the lower
arch.

Instead of asking the technician to create a

sequential mesialization pattern of the teeth in the
fourth quadrant, he or she will be asked to plan a
virtual jump of the lower arch to achieve bilateral
Class I.

This virtual jump is an estimation, and it depends of

many factors, as the patient´s age or compliance.
For this reason, it is necessary to assess in the
check-ups throughout the treatment whether the
time and/or the strength of the elastics is reduced
or increased according to the similarity between the
"real" and "virtual" jump progression.

Fig.13. Graphic representation of the virtual jump of the fourth quadrant. The
superimposition between the initial (yellow) and final (white) positions shows
the mesialization of the fourth quadrant teeth. Planned expansion and IPR
allow this mesialization to be achieved without proclining the lower incisors.
Torque: The torque or tilt movement can be one of the most difficult
to achieve if not sequenced correctly. Sometimes, this movement is
planned by displacing the root palatally instead of making a buccal
movement of the crown.

The greater the root movement, the less predictable the movement
will be, since the force system generated is less efficient and the
aligners will loosen after a few weeks of starting treatment.

Fig.14. P.I.R Protocol: coronal Proinclination, Intrusion and en masse Retrusion.

The optimal sequence to achieve the correct teeth inclination

begins by tilting the crowns towards buccal. As the center of
resistance is located in the coronal third of the root in single-rooth
teeth and in the furcation of multirradicular teeth, vestibulizing the
crowns will produce a slight lingualization of the roots.

Once adequate torque has been achieved and with the roots inside
the cancellous bone, retrusion and/or intrusion movements can be
performed easily.

Movements coordination

When moving teeth, keep in mind that the mouth is an organ

where the upper and lower arches work together. When the
patient chews, swallows saliva, clenches the teeth... occlusal
contacts appear and they can affect the movement of the teeth.

Occlusion is one more aspect to consider in aligner treatments. For

this reason, the movements of both arches will be carried out in a
coordinated way, so that the forces of occlusion hinder or block the
movements as little as possible.
To achieve this coordination, following instructions will be asked to
the technician:

Match the number of active aligners in both arches.

If, for example, the movements of the lower arch are performed in
20 stages and those of the upper arch in 60 stages, interference
will likely appear between the teeth of both arches.

If there are 60 active aligners in the lower and in the upper arch,
even if the movement speed of lower teeth is reduced, the
technician will be able to adequately coordinate the movements
without increasing treatment time.

Fig.15. Class III patient in whom, due to inadequate planning (central image), interferences appear in
the anterior teeth. In the following planning (right image), it is requested to carry out the anterior
alignment without heavy contacts between the teeth of both arches.

Avoid interferences or heavy contacts of the lower teeth with

the upper teeth during their alignment.

If the mouth were a box, the upper arch would be the "lid" that
covers the lower arch. If this lid is not larger enough, if there is no
room created either by expanding or proclining the teeth, the
movements of the lower arch will be limited, since the upper teeth
will block these movements.

Fig.16. Case of lower second molar uprighting by distal crown tilting to open a space for placing an
implant after orthodontic treatment. The software shows the heavy contacts that will appear during
the movement of the piece and that can make uprighting difficult.
In certain cases, such as crossbites or Class II and Class III, it can
not be avoided that, due to the type of teeth movement,
interferences or punctual hypercontacts appear.

The need to make occlusal adjustments to resolve these

hypercontacts and facilitate the movement of the teeth will be
assessed during the periodic check-ups.

Fig.17. Case of upper sequential distalization in which heavy contacts appear between the molars of
the upper and lower arches. Occlusal adjustments to eliminate these contacts during revisions will
help improve the predictability of distalization.

Arch shape and expansion

With few exceptions, most patients have compression or

some type of abnormality in the shape of their arches.

Making a comparison with fixed orthodontics, where the arches are

selected according to the size of the patient's mouth, in the
ClinCheck®/ApproverTM it is possible to individualize the shape
and size of the ideal arch for each case.

Based on the fact that a parabolic arch shape is intended, which

allows us to achieve proper aesthetic and functional results, all that
is left is to indicate the technician how large the arches should be,
that is, how much expansion we want for the case.
en ser las arcadas, es decir, cuánta expansión necesita el caso.

Fig.18. Before and after a case with severe compression and asymmetric lower arch. The expansion
planned using a parabolic arch shape as a reference (right image) creates enough space to solve
crowding and retrude the lower incisors.
 To quantify the expansion, we go back to the first point,
where the transverse width of the basal bone was discussed. By
looking at the WALA ridge and the torque of the posterior teeth, it
is possible to roughly estimate the number of millimeters of
expansion needed on each side of the mouth.

In this transverse plane, the goal is to achieve 0º torque. The more

negative the posterior torque, the greater the possibilities of arch
expansion.

Expansion, even if it is a characteristic that is valued in the

transverse aspect, has consequences in the three planes of space:
sagittal, vertical and transverse. Therein lies the reason for its
importance.

By performing a correct expansion with the appropriate torque in

the posterior sectors, the occlusal contacts will improve and the
chewing forces will be correctly transmitted to each of the teeth.

We need to point out that, when speaking of torque 0, reference is

made to upper teeth. Lower teeth will have a slightly negative
torque (especially the molars) so that the buccal cusps of the lower
molars and premolars can properly engage in the pits of the upper
teeth.
Using this information, the orthodontist has to be able to clearly
explain to the technician the following aspects:

How to do the expansion: Depending on the posterior torque, it

may be requested to perform the expansion “en masse”, making the
same displacement towards buccal of the crowns and roots, or by
coronobuccal tilting until reaching a 0º torque, in which the
displacement of the crown will be greater than the one of the root.

In periodontal patients and/or those with a thin biotype, excessive

expansion can worsen the periodontal condition of the teeth. By
means of planning an additional radiculolingual torque movement
during expansion, the risk of increased recessions or buccal cortical
loss will be reduced.

Fig.19. Expansion performed by coronobuccal tilting of the posterior sectors until 0º torque is
achieved.
Amount of expansion: Based on the intend of
achieving a parabolic arch shape, there are several
ways to request the technician the desired expansion.

If the second and/or third molars are present in

the mouth and well positioned, they will be used as a
reference to expand both arches.

In this way, by not vestibulizing these teeth, they will

serve as anchorage to expand the arches. If desired,
they can be slightly compressed while expanding the
rest of the teeth to increase anchorage and make
expansion movement more predictable.

If, on the other hand, the position of the second

and/or third molars is not adequate (for example, if
they are in crossbite), they cannot be used as a
reference. In these cases, the number of millimeters
of expansion to be carried out in each half-arch will
be provided to the technician. This expansion can be
symmetric or asymmetric, depending on the needs of
the case.

Fig.20. Superimpositions of the upper (left) and lower (right) arches showing the
anchorage provided by the second and third molars in the expansion of the teeth
anterior to them.

It is possible that these instructions may not take to

the desired result.

If a more precise control is desired, the shape of the

patient's arches could be modified using the “Arch
Shape” tool available in the ClinCheck®/ApproverTM.
 Attachments, bite ramps and IPR

Starting off with the diagnosis, all the relevant factors have been
analyzed to achieve a logical planning that is compatible with the
biological limits of the patient. In this last section, the accessory
elements that facilitate the achievement of all the aforementioned
movements, will be addressed.

Attachments: Attachments are small composite reliefs that allow

the aligner to generate more effective force systems to perform
certain movements or, simply, they can be used "passively" to
increase the retention of the aligner.

Their shape and size will depend on the function they fulfill. If
attachments were not placed, the smooth surface of the teeth
would make some movements impossible to achieve, such as
extrusion or root tipping.

Their retentive function is no less important, especially in patients

with short clinical crowns, such as children. In these cases, the
expulsive anatomy of the primary teeth makes it necessary to place
attachments on practically all of the teeth to prevent the aligner
from being easily dislodged.

Fig.21. Patient with mixed dentition who had horizontal attachments placed on all primary teeth to
increase aligner retention.

Attachments are placed by ClinCheck®/ApproverTM in accordance

to the desired movement for each tooth.

By default, ClinCheck® will apply the so-called optimized

attachments, based on SmartForce® technology.
On the ApproverTM software, however, only conventional
attachments will be placed. At first glance, it may seem that since
the program places the attachments automatically, there is
nothing to check. But that is not the case.

Sometimes the software can make a “mistake” placing

attachments, there is not enough space to place them, or an
attachment is placed in a position or has a shape different that the
one desired. In these cases, it will be necessary to modify the
attachments or place new ones to achieve the desired movement.

Next, several examples will serve to explain the basic concepts of

attachment design:

Rotation: Depending on the anatomy of the tooth, rotation can

be corrected with or without attachment.

Flat teeth, such as incisors, will not require attachments for

this movement, while smaller, rounder teeth such as
premolars, will require attachments to rotate them. Rotation is
a movement that takes place in the horizontal plane. The
attachment to be placed will be vertical, so that the plastic has
an adequate contact surface on which to apply force and move
the tooth.

To make the movement more effective and avoid mismatches,

the vertical attachment will be beveled in the opposite
direction to the rotation movement.

Fig.22. Diagram of the forces applied by the aligner in the rotation of the incisors.

Fig.23. Diagram of a premolar rotation. The bevel is in the opposite direction to the force, which
increases the contact surface between the attachment and the aligner.
 Extrusion: All pure extrusion moves need attachments to
occur. As it is a movement carried out in the vertical plane, the
necessary attachment will be horizontal. The direction of the
bevel will change depending on whether the extrusion is on
anterior or posterior teeth.

In canines and incisors, the bevel is placed gingivally

oriented, in the opposite direction of the force. However, on
premolars and molars, the bevel will go incisally.

This change in orientation in the posterior teeth is done

because they have shorter clinical crowns and are less
retentive against vertical movement than the incisors and
canines.

Therefore, by placing the bevel of the attachment towards the

incisal edge, the upper part of the attachment provides
greater retention of the aligner and, as a consequence, less
misalignment.

Fig.24. Diagram of the extrusion of the upper incisors. Horizontal gingival beveled attachments allow
the aligner to apply an effective extrusion force.

Distalization/mesialization: In this type of movement, the aim

is to carry out a en masse movement of the teeth, either
towards the mesial or the distal aspect. Sometimes this en
masse movement will not be pure, but will have a small
component of inclination if the tip of the teeth is not
adequate.

When the aligner “pushes” a tooth, the generated force vector

causes a greater displacement of the crown than of the root,
giving rise to a tilting movement. In order to achieve an en
masse displacement, an attachment is placed aiming to
create a pair of forces whose resultant passes through the
center of resistance of the tooth.

For example, in an upper sequential distalization, the aligner

exerts the force on the mesial aspect of the molars to be
distalized.

This force alone would cause distal tipping of the crowns.

 Placing a vertical attachment with the bevel in the opposite
direction to the movement, that is, oriented mesially, a new
force vector appears, opposite to the force exerted by the
aligner on the mesial face of the tooth. In premolars, canines,
and upper central incisors, the tooth surface is large enough to
accommodate two attachments for root control.

The molar crowns, however, are usually lower in height, giving

room just for a single attachment.

Fig.25. Diagram of the forces applied by the aligner in molar distalization.

Intrusion: The aligner by itself is not capable of intruding one

or several teeth. To achieve this movement, you need to "grip"
or hold on to the teeth adjacent to the teeth to be intruded.

This anchorage is achieved by placing horizontal incisal

beveled attachments on adjacent teeth. The attachments
provide the necessary retention so that the aligner does not
disengage when the intrusion force is applied.

Fig.26. Diagram of the intrusion of a maxillary first molar assisted by the attachments placed on the
adjacent teeth.
 Expansion: Depending on the posterior teeth torque, the
expansion can be performed whether by a coronobuccal
tilting movement, by an en masse movement (if there is a 0º
torque at the beginning), or by a combination of both.

In case the movement is only by coronal inclination, no

attachments will be necessary to perform it. When part of the
movement entails a displacement of the root to the buccal,
attachments will be placed to control the root movement and
prevent the crowns from tipping due to an uncontrolled
inclination.

Fig.27. Scheme of the force system applied to prevent the molars from “flaring” during the buccal
movement.

This can be explained as similar to the distalization and

mesialization movements, but in this case on the transverse
plane.

If the aligner pushes the crowns from the palatal/lingual side,

some horizontal incisal beveled attachments are needed so
that the plastic has a point of support on the buccal surface of
the teeth, from where it can apply a vertical force for
controlling root movement during the expansion.
Bite ramps: Bite ramps are accessories that
are placed to achieve disocclusion of the
posterior sectors, just like the turbo-bites
used with fixed appliances.

The ClinCheck® has two different types of

bite ramps: the optimized bite ramps, which
change position at each stage adapting to
the new positions of the teeth, and the
conventional ramps.

Optimized bite ramps can be placed on

maxillary incisors, while conventional ramps
can be placed on maxillary incisors and
canines.

In the ApproverTM, on the other hand, bite

ramps can be placed on the incisors, canines
and premolars of both arches, not just the
upper arch, offering greater versatility.

Once we know the options available in each

software, the next question is: for which
cases are bite ramps useful?

Increased overbite
Class II
Crossbite (anterior or posterior)
Posterior open bite
Bruxism

In these clinical conditions, bite ramps

placed on the anterior teeth "release" or
reduce the contacts of the teeth that are
going to move, facilitating the aligner work.

For example, in a Class II case where upper

sequential distalization is planned, the bite
ramps placed in the upper incisors and
canines generate posterior disocclusion,
reducing the interferences that may appear
between the upper and lower molars.
In an anterior crossbite, the upper teeth have to "jump" the lower
teeth to solve the malocclusion. Bite ramps placed on the lingual
surface of lower incisors will help make this jump more effective.

In cases where there is a vertical problem, such as increased

overbites or posterior open bites, ramps help improve the
predictability of lower incisor intrusion and posterior extrusion.

Fig.28. In the first picture (left) we can see how the increased overjet makes the bite ramps
functionless. In the image on the right, on the contrary, the lower teeth contact the bite ramps of the
upper incisors.

In some situations, bite ramps are not necessary, either because

they are useless or because they can negatively affect the teeth or
the biomechanics of the treatment:

Anterior open bite

Increased overjet
Negative anterior torque
Extrusion
Compromised periodontal status

If a patient has an anterior open bite or increased overjet, the

teeth will not contact the bite ramps, so they will have no function.

If bite ramps are placed on teeth that are being extruded, at a

certain moment the contact of the ramps with the teeth of the
opposite arch could stop or hinder the extrusion movement.
In cases where the anterior teeth have negative torque, the ramps
will be placed, if needed, once the appropriate torque has been
reached.
Placing them at the beginning, the force vector that appears due
to the contact of the lower teeth with the bite ramps is contrary to
the proclination movement, which favors the misalignment of the
aligner and reduces its effectiveness.

In periodontal patients, the teeth that usually show worst

condition are the upper and lower incisors. When placing bite
ramps on teeth with mobility and periodontal compromise, the
contact between the ramp and the tooth can harm their support
structure, worsening their condition. Therefore, in these cases, it is
better not to place bite ramps.

IPR (InterProximal Reduction): IPR or stripping is a procedure

applied to practically all patients treated with aligners.

ClinCheck®/ApproverTM allows us to accurately plan the exact

amount of IPR needed for each case.

The main situations in which IPR is performed are:

Crowding:

In many cases, expansion and/or proclination are not enough

to create the space needed to align the teeth. As explained in the
first section of the book, each mouth has biological limits.

When these two therapeutic strategies are not enough to align the
teeth, IPR will be also planned. IPR, as a general rule, is performed
on the anterior teeth, where the crowding is usually found. This
provides a number of advantages:

Better access to the work area.

Working in the anterior area is easier than in the molar or

premolar area, where the handling of rotary instruments is limited
by the opening of the patient and the lower visibility of the area.
 Create space in the area with crowding, facilitating the
movement of crowded teeth and reducing the number of
aligners.

If, for example, in a case of anterior crowding, IPR is planned

on premolars, the premolars should be moved distally to make
room for the canines and incisors to align.

If IPR is done between incisors, the alignment starts from the

beginning, getting the problem addressed in shorter time.

Reduce black triangles.

By doing IPR, the anatomy of the teeth improves, changing

from a triangular shape to a more rectangular shape. This change
allows for a better contact point between the teeth and minimizes
the appearance of black triangles after aligning the teeth.

In patients with periodontal disease, these black triangles cannot

be completely eliminated with IPR, so a multidisciplinary
treatment will have to be assessed to achieve optimal aesthetics.

Fig.29. Planned IPR in the lower anterior area to correct crowding without proclining the lower
incisors.
Bolton discrepancy:

ClinCheck®/ApproverTM displays a tool that calculates the

mesiodistal width of all the teeth and shows if there is an excess or
defect of dental material in any of the arches. The Bolton
discrepancy can be solved in two ways:

Performing IPR in the arch that presents dental material

excess.

Opening spaces in the arch that presents dental material defect

for the subsequent placement of veneers or restorations.

There may also be cases in which both ways are necessary.

The discrepancy correction is relevant, not only from an aesthetic

point of view, but also in order to finish the orthodontic treatment
with proper outcomes with regard to overjet and also molar and
canine relationship.

Fig.30. Case in which asymmetric IPR is planned to correct the Bolton discrepancy between the
upper and lower arches and between the left and right sides of the lower arch.
 In short, the success of planning lies in an orderly review of
the different treatment aspects, carrying out this review "from
outside to inside", starting off with an adequate diagnosis and
avoiding the temptation to start moving the teeth on the
ClinCheck®/ApproverTM without clear references.

We hope that this book serve as a basis for you to start planning
treatments with invisible orthodontics. At least, an overview on
how to review a ClinCheck®/ApproverTM is provided.

After gaining experience, your approach will be improved and

you will add new elements to it according to the protocols or
sequences that work best for you. The good and rewarding thing
about orthodontics is that there is not only one way to do things.

Each professional has his/her own work style that ends up

reflecting in each treatment and in every patient who passes
through his/her hands.

We can only provide some ingredients for you to get the recipe
for success. The rest is up to you!