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 PRINCIPLES and
BIOMECHANICS of
ALIGNER TREATMENT
This page intentionally left blank
 PRINCIPLES and
BIOMECHANICS of
ALIGNER TREATMENT
Ravindra Nanda, BDS, MDS, PhD
Professor Emeritus
Department of Orthodontics
University of Connecticut Health Center
Farmington, Connecticut, USA

Tommaso Castroorio, DDS, PhD, Ortho. Spec.

Department of Surgical Sciences, Postgraduate School of Orthodontics
Dental School, University of orino
orino, taly

Francesco Garino, MD, Ortho. Spec.

Private Practice
orino, taly

Kenji Ojima, DDS, MDSc

Private Practice
oyo, apan
Elsevier
3251 Riverport Lane
St. Louis, Missouri 63043

PRINCIPLES AND BIOMECHANICS OF ALIGNER TREATMENT, ISBN: 978-0-323-68382-1

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

To Katia, for showing me what love is and for keeping

my feet on the ground. To Alessandro, Matilda, and
Sveva, because you made the world a brighter place.
To my friends, rancesco and Keni, for your passion,
enthusiasm, commitment, and support you are always
an eample to follow. To avi, for your trust and friend
ship, for your guidance and leadership you have trans
lated a vision into reality. t was a wonderful ourney
with you thanks for your time and for sharing your
eperience.
TC

 would like to dedicate this book to all my family with a

special thought to my dad, mentor and a visionary, who
shared with me a passion in aligner orthodontics for
 years.
FG

My thanks to rancesco and Tommaso for sharing their

friendship with me over so many years. The time  spent
writing this book with avi was amaing, like a dream
for me.  am truly grateful to my family for all of their
support.
KO
Contributors

Masoud Amirkhani, PhD Aldo iancotti, DDS MS

Institute for Experimental Physics Researcher and Aggregate Professor
Ulm University Department of Clinical Sciences and ranslational
Ulm, Germany edicine
University of ome “or ergata”
Sean K. Carlson, DMD, MS ome, taly
Associate Professor
Department of Orthodontics uan Palo ome Arano, DDS, MSc
School of Dentistry, University of the Pacic Associate Professor
San Francisco, California, USA Orthodontics Program
Universidad Autonoma de aniales
Tommaso Castroorio, DDS, PhD, Ortho. Spec. aniales, Colomia
Researcher and Aggregate Professor
Department of Surgical Sciences, Postgraduate School of Mario reco, DDS, PhD
Orthodontics Visiting Professor
Dental School, University of orino University of ’Auila
orino, taly ’Auila, taly
Orthodontics Unit Visiting Professor
San Giovanni attista ospital University of Ferrara
orino, taly Ferrara, taly

Chisato Dan, DDS uis uanca, DDS, MS, PhD

Private Practice Research Associate
Smile nnovation Orthodontics Department of Orthodontics
oyo, apan University of Geneva
Geneva, Siterland
Iacopo Ciof, DDS, PhD
Associate Professor osef Kučera, MDr., PhD
Division of Graduate Orthodontics and Centre for ultimodal Assistant Professor
Sensorimotor and Pain esearch Department of Orthodontics
Faculty of Dentistry Clinic of Dental edicine
University of oronto First edical Faculty
oronto, Ontario, Canada Charles University
Prague, Cech epulic
Daid Couchat, DDS, Ortho. Spec. Lecturer
Private Practice Department of Orthodontics
Cainet d’Orthodontie du dr Couchat Clinic of Dental edicine
arseille, France Palacý University
Olomouc, Cech epulic
ae lkhol, DDS
Senior Physician ernd . apatki, DDS, PhD
Department of Orthodontics Department Head and hair
Ulm University Department of Orthodontics
Ulm, Germany Ulm University
Ulm, Germany
rancesco arino, MD Ortho. Spec.
Private Practice
Studio Associato dottri Garino
orino, taly

vi
 Contributors vii

uca omardo, DDS, Ortho. Spec. Simone Parrini, DDS, Ortho. Spec.
hairman and Professor Research Associate
Postgraduate School of Orthodontics Department of Surgical Sciences, Postgraduate School in
University of Ferrara Orthodontics
Ferrara, taly Dental School, University of orino
orino, taly
Tianton ou, DMD, MSc
Division of Gradual Orthodontics and Centre for ultimodal Serena aera, DDS, PhD, Ortho. Spec.
Sensorimotor and Pain esearch Research Associate
Faculty of Dentistry Department of Surgical Sciences, Postgraduate School in
University of oronto Orthodontics
oronto, Ontario, Canada Dental School, University of orino
orino, taly
Kam Malekian, DDS, MSc
Private Practice ariele ossini, DDS, PhD, Ortho. Spec.
Clinica io Research Associate
adrid, Spain Department of Surgical Sciences, Postgraduate School in
Orthodontics
ianluca Mampieri, DDS, MS, PhD Dental School, University of orino
Researcher and Aggregate Professor orino, taly
Department of Clinical Sciences and ranslational edicine
University of ome “or ergata” addah Saouni, DDS, Ortho. Spec.
ome, taly Private Practice
Cainet d’Orthodontie du dr Saouni
doardo Mantoani, DDS, Ortho. Spec. andol ivage
Research Associate Sanarysurer, France
Department of Surgical Sciences, Postgraduate School in
Orthodontics Sila Schmidt, DDS
Dental School, University of orino Department of Orthodontics
orino, taly Ulm University
Ulm, Germany
Io Marek, MDr., PhD
Assistant Professor ör Schare, DDS, PhD, Ortho. Spec.
Department of Orthodontics Private Practice
Clinic of Dental edicine ieferorthopädische Prais Dr örg Schare
Palacý University Cologne, Germany
Oloumouc, Cech epulic
onsultant iuseppe Siciliani, MD, DDS
Department of Orthodontics hairman and Professor
Clinic of Dental edicine School of Dentistry
First edical Faculty University of Ferrara
Charles University Ferrara, taly
Prague, Cech epulic
Ali Tassi, Sc, DDS, MClD Ortho
aindra anda, DS, MDS, PhD Assistant Dean and hair
Professor Emeritus Division of Graduate Orthodontics
Division of Orthodontics Schulich School of edicine and Dentistry
Department of Craniofacial Sciences he University of estern Ontario
University of Connecticut School of Dental edicine ondon, Ontario, Canada
Farmington, Connecticut, USA
ohnn Tran, DMD, MClD
Keni Oima, DDS, MDSc Division of Graduate Orthodontics
Private Practice Schulich School of edicine and Dentistry
Smile nnovation Orthodontics he University of estern Ontario
oyo, apan ondon, Ontario, Canada
viii Contributors

laio rie, DDS, MDentSc enedict ilmes, DDS, MSc, PhD

onn rthodontics Alumnianda rthodontics Professor
Endoed hair Department of Orthodontics
Program Director and Chair University of Düsseldorf
Division of Orthodontics Düsseldorf, Germany
Department of Craniofacial Sciences
University of Connecticut
School of Dental edicine
Farmington, Connecticut, USA

Aligners represent the new frontier in the art and science of
orthodontics. This new frontier offers new opportunities
and challenges, but also requires the need for additional
knowledge. A rethinking of biomechanics and force deliv-
ery concepts is needed along with the role of materials used
for aligners. There is a need for combining established con-
cepts with new tools and technologies which aligner treat-
ment requires.
When considering new methodologies, orthodontists
should always remember that technology is a tool and not
the goal. Diagnosis, treatment plan, and biomechanics are
always the key elements of successful treatment, regardless
of the treatment methodology. Aligner orthodontics is quite
different than traditional methods with brackets and wires.
orce delivery with aligners is through plastic materials.
Thus, the knowledge of the aligner materials, physical
properties, attachment design, and the sequentialiation
protocol is crucial for treatment of malocclusions. t is also
imperative to understand limitations of aligner treatment
and how to overcome them with the use of miniscrews and
auiliaries.
Foreword
Aligner treatment requires new knowledge the number
of clinical and scientic reports about all the different as-
pects of aligner orthodontics is increasing year by year. This
book represents an up-to-date summary of the available
research in the eld as well as a clinical atlas of treated pa-
tients based on the current evidence. We have made an
attempt to provide benchmark for clinicians, researchers,
and residents who want to improve their skills in aligner
orthodontics.
We would like to epress our great appreciation to all the
friends and colleagues who have contributed to this book. t
was a pleasure to work with all these talented orthodon-
tists.
We would like to say thank you to the lsevier team for
their support, patience, and guidance during the challeng-
ing ovid pandemic.
avindra anda
Tommaso astroorio
rancesco arino
eni ima
ix
Contents

1 Diagnosis and Treatment Planning in the 12 The rid Approach in Class  Malocclusions
Three-Dimensional Era 1 Treatment 13
TOMMASO CASTROFLORIO, SEAN K. CARLSON, and FRANCESCO GARINO, TOMMASO CASTROFLORIO, and
FRANCESCO GARINO SIMONE PARRINI

2 Current Biomechanical Rationale Concerning 13 Aligners and mpacted Canines 1

Composite Attachments in Aligner
Orthodontics 13
JUAN PABLO GOMEZ ARANGO
3 Clear Aligners: Material tructures and
Properties 3
MASOUD AMIRKHANI, FAYEZ ELKHOLY, and BERND G. LAPATKI
4 nuence o ntraoral actors on Optical and
Mechanical Aligner Material Properties 3
FAYEZ ELKHOLY, SILVA SCHMIDT, MASOUD AMIRKHANI, and
BERND G. LAPATKI
5 Theoretical and Practical Considerations in
Planning an Orthodontic Treatment ith Clear
Aligners 
TOMMASO CASTROFLORIO, GABRIELE ROSSINI, SIMONE PARRINI
6 Class  Malocclusion 1
MARIO GRECO
7 Aligner Treatment in Class  Malocclusion
Patients 
TOMMASO CASTROFLORIO, WADDAH SABOUNI, SERENA RAVERA,
and FRANCESCO GARINO
8 Aligners in Etraction Cases 3
KENJI OJIMA, CHISATO DAN, and RAVINDRA NANDA
9 Open-Bite Treatment ith Aligners 
ALDO GIANCOTTI and GIANLUCA MAMPIERI
EDOARDO MANTOVANI, DAVID COUCHAT,
TOMMASO CASTROFLORIO
14 Aligner Orthodontics in Prerestoratie
Patients 1
KENJI OJIMA, CHISATO DAN, and TOMMASO CASTROFLORIO
15 oncompliance pper Molar Distaliation
and Aligner Treatment or Correction o Class 
Malocclusions 1
BENEDICT WILMES and JÖRG SCHWARZE
16 Clear Aligner Orthodontic Treatment o Patients
ith Periodontitis 
TOMMASO CASTROFLORIO, EDOARDO MANTOVANI, and
KAMY MALEKIAN
17 urger irst ith Aligner Therap 3
FLAVIO URIBE and RAVINDRA NANDA
18 Pain During Orthodontic Treatment: Biologic
Mechanisms and Clinical Management 
TIANTONG LOU, JOHNNY TRAN, ALI TASSI, and IACOPO CIOFFI
19 Retention and tailit olloing Aligner
Therap 
JOSEF KUČERA and IVO MAREK
20 Oercoming the imitations o Aligner
Orthodontics: A rid Approach 
LUCA LOMBARDO and GIUSEPPE SICILIANI

10 Deep Bite 1 nde 

LUIS HUANCA, SIMONE PARRINI, FRANCESCO GARINO, and
TOMMASO CASTROFLORIO

11 nterceptie Orthodontics ith Aligners 11

TOMMASO CASTROFLORIO, SERENA RAVERA, and
FRANCESCO GARINO

x
 1 Diagnosis and Treatment
Planning in the
Three-Dimensional Era
TOMMASO CASTROFLORIO, SEAN K. CARLSON,
and FRANCESCO GARINO
Introduction
rthodontics and dentofacial orthopedics is a specialty area
of dentistry concerned with the supervision, guidance, and
correction of the growing or mature dentofacial structures,
including those conditions that reuire movement of teeth
or correction of malrelationships and malformations of
their related structures and the adustment of relationships
between and among teeth and facial bones by the applica-
tion of forces andor the stimulation and redirection of
functional forces within the craniofacial comple.
To accurately diagnose a malocclusion, orthodontics has
adopted the problem-based approach originally developed
in medicine. very factor that potentially contributes to the
etiology and that may contribute to the abnormality or in-
uence treatment should be evaluated. nformation is gath-
ered through a medical and dental history, clinical eami-
nation, and records that include models, photographs, and
radiographic imaging.  problem list is generated from the
analysis of the database that contains a network of inter-
related factors. The diagnosis is established after a continu-
ous feedback between the problem recognition and the da-
tabase Fig. .. ltimately, the diagnosis should provide
some insight into the etiology of the malocclusion.
rthodontics diagnosis and treatment planning are deeply
changing in the last decades, moving from two-dimensional
 hard tissue analysis and plaster cast review toward soft
tissue harmony and proportions analyses with the support
of three-dimensional  technology.  detailed clinical e-
amination remains the key of a good diagnosis, where many
aspects of the treatment plan reveal themselves as a function
of the systematic evaluation of the functional and aesthetic
presentation of the patient.
The introduction of a whole range of digital data acuisi-
tion devices cone-beam computed tomography T,
intraoral and desktop scanner  and , and face scan-
ner F, planning software computer-assisted design and
computer-assisted manufacturing  software,
new aesthetic materials, and powerful fabrication machines
milling machines,  printers is changing the orthodon-
tic profession Fig. ..
s a result, clinical practice is shifting to virtual-based
workows. Today it is common to perform virtual treat-
ment planning and to translate the plans into treatment
eecution with digitally driven appliance manufacture and
placement using various  techniues from
printed models, indirect bonding trays, and custom-made
brackets to robotically bend wires or aligners. Furthermore,
it is becoming possible to remotely monitor treatment and
to control it.5
The introduction of aligners in the orthodontics eld
led the digital evolution in orthodontics. The two nouns
evolution and revolution both refer to a change; however,
there is a distinctive difference between the change im-
plied by these two words. volution refers to a slow and
gradual change, whereas revolution refers to a sudden,
dramatic, and complete change. hat has been claimed
as the “digital revolution” in orthodontics should be
claimed as the “digital evolution” in orthodontics. rtho-
dontics and biomechanics have always had the same
denitions, and we as clinicians should remember that
technology is an instrument, not the goal. This differenti-
ates orthodontists from marketing people.
The diagnosis and problem list is the framework that dic-
tates the treatment obectives for the patient. nce formu-
lated, the treatment plan is designed to address those obec-
tives. n aligner orthodontics,  software displays
treatment animations, helping the clinician to visualie the
appearance of teeth and face that is desired as treatment
outcome; however, those animations should be decon-
structed by the orthodontist frame by frame or stage by
stage, to dene how to address the treatment goal from me-
chanics to seuence. nly an accurate control of every sin-
gle stage of the virtual treatment plan can produce reliable
results. s usual, it is the orthodontist rather than the tech-
niue itself that is responsible for the treatment outcome.
ontemporary records should facilitate functional and
aesthetic  evaluation of the patient.
Intraoral Scans and Digital
Models
s are uickly replacing traditional impressions and plas-
ter models. These scanners generally contain a source of
risk for inaccuracy because multiple single  images are
assembled to complete a model. ecent studies, however,
have shown that the trueness and precision of s of com-
mercially available scanning systems are ecellent for orth-
odontic applications. igital models are as reliable as tradi-
tional plaster models, with high accuracy, reliability, and
reproducibility Fig. ..
1
2 Principles and Biomechanics of Aligner Treatment

Database

Clinical examination
Chief complaint
Medical history
Models Photographs Radiographic imaging
Dental history
Intraoral scan 3-D facial scan CBCT
Extraoral exam
Intraoral exam
Functional exam

Problems

Problem List

Mechanics
plan:
Synthesis Treatment which movements Staging Treatment Virtual setup Treatment
and diagnosis objectives with which definition prescription Virtual patient re-evaluation
auxiliaries
Fig. 1.1 Steps in diagnosis and treatment planning in the digital orthodontics era. (Modied from Uribe FA, Chandhoe
TK, Nanda R. Indiidaied orhodoni dianoi. In Nanda R, ed. Esthetics and Biomechanics in Orthodontics. nd ed.
S Loi, MO Eeier Sander .

Fig. 1.2 Integration of cone-beam computed tomography data, facial three-dimensional scan, digital models from
intraoral scans, and virtual orthodontic setup. Courtesy of dr. Alain Souchet, ulhouse, rance.
 1 • iagnosis and Treatment Planning in the Three-imensional ra
B
Fig. 1.3 A igital models and measurements obtained from cone-beam computed tomography data. B igital
models and measurements obtained from intraoral scans.
Furthermore, the models can also be used in various
orthodontic software platforms to allow the orthodontist
to perform virtual treatment plans and eplore various
treatment plans within minutes as opposed to epensive
and time-consuming diagnostic setups and waups. er-
forming digital setups not only allows the clinician to e-
plore a number of treatment options in a simple manner
but also facilitates better communication with other den-
tal professionals, especially in cases that reuire combined
orthodontic and restorative treatments. The virtual treat-
ment planning also allows for better communication with
patients and allows them to visualie the treatment out-
come and understand the treatment process.5
Further advantages of virtual models of the dental
arches are related to study model analysis, which is an es-
sential step in orthodontic diagnostics and treatment plan-
ning. ompared to measurements on physical casts using a
3
measuring loop andor caliper, digital measurements on
virtual models usually result in the same therapeutic deci-
sions as evaluations performed the traditional way. Fur-
thermore, with their advantages in terms of cost, time, and
space reuired, digital models could be considered the new
gold standard in current practice.
igital impressions have proven to reduce remakes and
returns, as well as increase overall efciency. The patient
also benets by being provided a far more positive eperi-
ence. urrent development of novel scanner technologies
e.g., based on multipoint chromatic confocal imaging and
dual wavelength digital holography will further improve
the accuracy and clinical practicability of .
ecently near infrared  technology has been inte-
grated in . The  is the region of the electromagnetic
spectrum between . and  mm Fig. .. The interaction
of specic light wavelengths with the hard tissue of the
4 Principles and Biomechanics of Aligner Treatment

NIRI - A reflective concept of light and its mechanism of action

The iTero Element 5D intraoral NIRI image of a healthy tooth

scanner uses light of 850nm that
penetrates into the tooth structure to
produce a NIRI image

Image interpretation - Healthy tooth

Enamel is mostly
transparent to
NIRI and appears
dark

Dentin is mostly
scattering
to NIRI and
appears bright

Image interpretation - Tooth with caries

ealthy enamel
appears dark

roimal carious
lesions of the
enamel appears
bright

A
Fig. 1.4 e generation of intraoral scanners ith integrated near infrared I technology. A Itero lement 
Align Technology, San osé, CA, SA decays detection scheme.
 1 • iagnosis and Treatment Planning in the Three-imensional ra
B
Fig. 1.4, cont’ B Shape Trios  Shape AS, Copenhagen, enmar uorescent technology for surface decay
detection (left) and I technology for interproimal decay detection (right).
tooth provides additional data of its structure. namel is
transparent to  due to the reduced scattering coefcient
of light, allowing it to pass through its entire thickness and
present as a dark area, whereas the dentin appears bright
due to the scattering effect of light caused by the orienta-
tion of the dentinal tubules. ny interferencespathologic
lesionsareas of demineraliation appear as bright areas in
a  image due to the increased scattering within the re-
gion. Therefore  provides information regarding possible
decays without any -ray eposure.
Through the use of digital impression making, it has
been determined that laboratory products also become
more consistent and reuire less chair time at insertion.
3D Imaging
CONE-BEAM COMPUTED TOMOGRAPHY
 imaging has evolved greatly in the last two decades and
has found applications in orthodontics as well as in oral and
maillofacial surgery. n  medical imaging, a set of ana-
tomic data is collected using diagnostic imaging euip-
ment, processed by a computer and then displayed on a 
monitor to give the illusion of depth. epth perception
causes the image to appear in . ver the last 5 years,
T imaging has emerged as an important supplemental
radiographic techniue for orthodontic diagnosis and treat-
ment planning, especially in situations that reuire an un-
derstanding of the comple anatomic relationships and
surrounding structures of the maillofacial skeleton. From
the introduction of the cephalostat, roadbent stressed the
need for a perfect matching of the lateral and posteroante-
rior -rays to obtain a perfect  reproduction of the
skull. T imaging provides uniue features and advan-
tages to enhance orthodontic practice over conventional
etraoral radiographic imaging. ateral cephalometrics
provides information on the sagittal and vertical aspects of
the malocclusion with little contribution about unilateral
or transversal discrepancies. The latter seem to be related to
5
urbaniation and industrialiation becoming more freuent
in the last decades.-5 Therefore, the need for a diagnostic
tool providing information on the  aspects of the dento-
skeletal malocclusion is increasing. hile the clinical ap-
plications span from evaluation of anatomy to pathology of
most structures in the maillofacial area, the key advantage
of T is its high-resolution images at a relatively lower
radiation dose.
posing patients to -rays implies the eistence of a
clinical ustication and that all the principles and proce-
dures reuired to minimie patient eposure are consid-
ered. The  concept should always be kept in mind
 is an acronym used in radiation safety for as low as
reasonably achievable. This concept is supported by profes-
sional organiations as well as by government institu-
tions.  ecogniing that diagnostic imaging is the single
greatest source of eposure to ioniing radiation for the 
population that is controllable, the ational ommission
on adiation rotection and easurements has introduced
a modication of the  concept.  represents
as low as diagnostically acceptable. mplementation of this
concept will reuire evidence-based udgments of the level
of image uality reuired for specic diagnostic tasks as
well as eposures and doses associated with this level of
uality. ittle research is currently available in this area.
For  imaging modalities used in orthodontics, the ra-
diation dose for panoramic imaging varies between  and
 µv, while a cephalometric eam range is between  and
5 µv.  full mouth series ranges from  to 5 µv based
on the type of collimation used. hile  and  radia-
tion doses are often compared for reference, they cannot
truly be compared because the acuisition physics and the
associated risks are completely different and cannot be
euated. The actual risk for low-dose radiographic proce-
dures such as maillofacial radiography, including T, is
difcult to assess and is based on conservative assumptions
as there are no data to establish the occurrence of cancer
following eposure at these levels. owever, it is generally
accepted that any increase in dose, no matter how small,
 Principles and Biomechanics of Aligner Treatment
results in an incremental increase in risk. Therefore there
is no safe limit or safety one for radiation eposure in orth-
odontic diagnostic imaging.  recent meta-analysis about
the effective dose of dental T stated that the mean adult
effective doses grouped by eld of view F sie were
 µv large,  µv medium, and  µv small.
ean child doses were 5 µv combined large and me-
dium and  µv small. arge differences were seen
between different T units.
The merican ental ssociation ouncil on cientic
ffairs  proposed a set of principles for consideration
in the selection of T imaging for individual patient care.
ccording to the guidelines, clinicians should perform radio-
graphic imaging, including T, only after professional
ustication that the potential clinical benets will out-
weigh the risks associated with eposure to ioniing radia-
tion. owever, T may supplement or replace conven-
tional dental -rays when the conventional images will not
adeuately capture the needed information.
ecently, a number of manufacturers have introduced
T units capable of providing medium or even full F
T acuisition using low-dose protocols. y adustments
to rotation arc, m, kp, or the number of basis images or
a combination thereof, T imaging can be performed at
effective doses comparable with conventional panoramic
eaminations range, – µv. This is accompanied by
signicant reductions in image uality; however, viewer
software can be helpful in improving the clinical eperience
with low-uality images. ven at this level, child doses have
been reported to be, on average,  greater than adult
doses. The use of low-dose protocols may be adeuate for
low-level diagnostic tasks such as root angulations.
BENEFT OF CBCT FOR ORTHODONTC
AEMENT
The benets of T for orthodontic assessment include
accuracy of image geometry. T offers the distinct ad-
vantage of  geometry, which allows accurate measure-
ments of obects and dimensions. The accuracy and reli-
ability of measurements from T images have been
Fig. 1.5 Cone-beam computed tomography data elaboration for enhancing diagnosis and treatment planning.
demonstrated, allowing precise assessment of unerupted
tooth sies, bony dimensions in all three planes of space,
and even soft tissue anthropometric measurements—
things that are all important in orthodontic diagnosis and
treatment planning.-
The accurate localiation of ectopic, impacted, and su-
pernumerary teeth is vital to the development of a patient-
specic treatment plan with the best chance of success.
T has been demonstrated to be superior for localiation
and space estimation of unerupted maillary canines com-
pared with conventional imaging methods.5  ne study
indicated that the increased precision in the localiation of
the canines and the improved estimation of the space con-
ditions in the arch obtained with T resulted in a differ-
ence in diagnosis and treatment planning toward a more
clinically orientated approach.5 T imaging was proven
to be signicantly better than the panoramic radiograph in
determining root resorption associated with canine impac-
tion.  ne study supported improved root resorption
detection rates of  with the use of T when com-
pared with  imaging. hen used for diagnosis, T
has been shown to alter and improve the treatment recom-
mendations for orthodontic patients with impacted or
supernumerary teeth. 
ased on the ndings of a recent review and in accor-
dance with the T entomaillofacial aediatric
maging n nvestigation Towards ow ose adiation
nduced isks proect, T can be considered also in
children for diagnosis and treatment planning of impacted
teeth and root resorption Fig. .5.
aillary transverse deficiency may be one of the
most pervasive skeletal problems in the craniofacial re-
gion. ts many manifestations are encountered daily by
the orthodontist.
lthough many analyses of the lateral cephalometric
headlm have been developed for use in orthodontic and
orthognathic treatment planning, the posteroanterior
cephalogram has been largely ignored. The diagnosis of
transverse discrepancy is uite challenging in the daily
practice because of several methodologic limitations of the
proposed methods.
 1 • iagnosis and Treatment Planning in the Three-imensional ra
Fig. 1. Case of impacted loer canine in hich the cone-beam computed tomography data are helpful in dening
the right mechanics.
The maillary and mandibular skeletal widths at differ-
ent tooth level, buccolingual inclination of each tooth, and
root positions in the alveolar bone can be determined and
evaluated from the T Fig. .. ith this information,
the clinician can make a proper diagnosis and treatment
plan for the patient.
The temporomandibular oint T can be assessed for
pathology more accurately with T images than with
conventional radiographs. The T volume for orthodon-
tic assessment will generally include the T and therefore
is available for routine review. everal retrospective analy-
ses of T volumes indicate 5 to  of incidental
ndings are related to T Fig. ., which is signicant
enough for further follow-up or referral.
T data can also be used to obtain the volumetric ren-
dering of the upper airways. tudies of the upper airway
based on T scans are considered to be reliable in dening
the border between soft tissues and void spaces i.e., air,
thus providing important information about the morphol-
ogy i.e., cross-sectional area and volume of the pharyngeal
airway5 Fig. .. owever, despite the potentials offered
by the techniue in this eld and the potential role of ortho-
dontists as sentinel physicians for sleep breathing disorders,
limited, poor uality, and low evidence level literature is
available on the effect of head posture and tongue position
on upper airway dimensions and morphology in  imag-
ing. atural head position at T acuisition is the sug-
gested standardied posture. owever, for repeatable mea-
sures of upper airway volumes it may clinically be difcult to
obtain. ndications and methods related to tongue position
and breathing during data acuisition are still lacking. Fur-
thermore, a recent study focusing on the reliability of air-
way measurements stated that the oropharyngeal airway
volume was the only parameter found to have generalied
ecellent intra-eaminer and inter-eaminer reliability.
n orthognathic surgery, igital maging and ommuni-
cations in edicine  data from T can be used to
fabricate physical stereolithographic models or to generate
virtual  models. The  reconstructions are etremely
useful in the diagnosing and treatment planning of facial

asymmetry cases. They can also be used to generate substi-
tute grafts when warranted. T can be useful as a valu-
able planning tool from initial evaluation to the surgical
procedure and then the correction of the dental component
in the surgery-rst orthognathic approach.
n addition, databases may be interfaced with the ana-
tomic models to provide characteristics of the displayed tis-
sues to reproduce tissue reactions to development, treat-
ment, and function. The systematic summariation of the
results presented in the literature suggests that computer-
aided planning is accurate for orthognathic surgery of the
mailla and mandible, and with respect to the benets to
the patient and surgical procedure it is estimated that
computer-aided planning facilitates the analysis of surgical
outcomes and provides greater accuracy Fig. ..
 recent systematic review was conducted to evaluate
whether T imaging can be used to assess dentoalveolar
relationships critical to determining risk assessment and
help determine and improve periodontal treatment needs in
patients undergoing orthodontic therapy. The conclusion
was that pretreatment orthodontic T imaging can as-
sist clinicians in selecting preventive or interceptive peri-
odontal corticotomy and augmentation surgical reuire-
ments, especially for treatment approaches involving buccal
tooth movement at the anterior mandible or maillary pre-
molars to prevent deleterious alveolar bone changes. This
assumption seems more suitable for skeletally mature pa-
tients presenting with a thin periodontal phenotype prior to
orthodontic treatment Fig. ..
3D FACA RECONTRUCTON TECHNUE
The accurate acuisition of  face appearance character-
istics is important to plan orthognathic surgery, and ecel-
lent work is based on an eact  face modeling.  precise
approach to  digital face prole acuiring, which is ap-
plied to simulate and design an optimal plan for face sur-
gery by modern technologies such as , is reuired.
Three types of  face modeling methods are currently
used to etract human face proles T technology, 
 Principles and Biomechanics of Aligner Treatment

Fig. 1. ccasional report of misunderstood right condyle nec fracture results in a -year-old child being pre-
scribed cone-beam computed tomography for orthodontic reasons.

Fig. 1. Airay measurements from cone-beam computed tomography data.

 1 • iagnosis and Treatment Planning in the Three-imensional ra
Fig. 1. ample of cone-beam computed tomography data integration in a surgery three-dimensional planning
softare. (ohin Imain, Chaorh, CA, USA.
the passive optical  sensing techniue, and the active
optical  sensing techniue. The  reconstruction
method based on T technology is sensitive to the skeleton
and can be conveniently utilied for craniofacial plastics,
as well as the oral and maillofacial correction of abnor-
malities. oft tissue data etraction, or segmentation,
can be created using a dedicated software. For orthodontic
purposes, the image should be recorded with eyes open
and with the patient smiling. The smiling image will per-
mit the use of dental landmarks to superimpose the digital
models on the  face reconstruction for treatment plan-
ning purposes. ovel technologies aiming at acuiring
facial surface are available. tereophotogrammetry and
laser scanning allow operators to uickly record facial
anatomy and to perform a wider set of measurements5
not eposing patients to radiation Fig. .. tereopho-
togrammetry still represents the gold standard with
respect to laser scanning at least for orthodontic applica-
tions since it is characteried by good precision and repro-
ducibility, with random errors generally less than
 mm.5 ith this method,  images are acuired by
combining photographs captured from various angles
with synchronous digital cameras, with the main advan-
tage of reducing possible motion artifacts. The main limi-
tation at this stage is represented by the high cost of the
instrumentation.
ccording to arver and acobson and arver and ck-
erman, it may be inappropriate to place everyone in the
same esthetic framework and even more problematic to at-
tempt this based solely on hard tissue relationships since the
soft tissues often fail to respond predictably to hard tissue
changes. ntegrating T data, facial  reconstruction,

and digital models with specic simulation software will
provide useful indications in relation to orthodontic treat-
ment results and the eventual need of interdisciplinary in-
tervention.
RTUA ETUP
everal software programs are available on the market to
create virtual setups able to produce the seuence of physi-
cal models on which thermoforming plastic foils are used to
create aligners.
etup accuracy is improved when virtual teeth segmen-
tation is applied on digital models obtained by  or digiti-
ation of plaster casts, reducing the loss of tooth structure
observed during the cutting process of the plaster in con-
ventional plaster and wa setups.
The segmentation process starts with marking mesial
and distal points on each tooth or simply indicating the
center of the crown on the occlusal view of the arches, de-
pending on the software used. Then the software generally
identies the gingival margin. Teeth segmentation and the
tooth-tooth-gingiva segmentation are eecuted semiauto-
matically, but the operator can always correct the auto-
matic process. nce teeth are segmented they are separated
from the gingiva, and a mean virtual root shape and
length are derived from proprietary databases is applied.
ecently, virtual setup software programs are starting to
use real root morphologies derived from patient T data
when available. Tooth segmentation from T images
in those cases is a fundamental step. ecent engineering
innovations made the process simple and timesaving with
respect to the past.
1 Principles and Biomechanics of Aligner Treatment

Fig. 1.1 Cone-beam computed tomography data used to plan an orthodontic epansion in a subect ith poor
periodontal support (upper). rthodontic epansion, corticotomies, and bone grafts ere planned to obtain an e-
cellent nal result ithout bone dehiscence (lower)

A B
Fig. 1.11 Stereophotogrammetry A and laser scan B three-dimensional reconstructions of the face of the same
patient. (From Gibei , iarei , oa , e a. Threedimeniona faia anaom eaaion reiabii of aer
anner oneie an roedre in omarion ih ereohoorammer. J Craniomaxillofac Surg. 
.
 1 • iagnosis and Treatment Planning in the Three-imensional ra 11

Fig. 1.12 Superimposition of the virtual setup on the smile picture of a patient ith unilateral agenesis, visualiing
from left to right the initial situation, the postorthodontic situation, and the nal smile ith restorative simulation.

nce the teeth have been segmented and the interproi-
mal contacts dened, the arch form is adusted using soft-
ware tools that can create an individual arch form. igital
arch templates are also available, while several software pro-
grams consider the  an acronym for ill ndrews
and arry ndrews ridge.
The occlusal plane as well as the original vertical plane
are used as reference. ach tooth can be moved in the
space since the reuired nal position has been achieved. t
is important to mention that tooth movements on comput-
ers are unlimited. Tooth alignment and leveling can be
planned on the computer screen, but this result may not be
realistic for that specic patient. bviously, tooth movement
has its biologic limitations. n the basis of the used system
the virtual setup could be prepared by a trained dental tech-
nician or by a software epert; however, every setup should
be based on biologic principles and on a biomechanics
background making the orthodontist the initial designer
and the nal reviewer of every setup.
s progress in digital imaging techniues accelerates and
tools to plan medical treatments improve, the use of virtual
setups in orthodontics before and during treatment will
become the mainstream in orthodontics Fig. ..
novel  superimposition techniues, clinicians are able to
simulate the outcome of both the osseous structures and
the soft tissue posttreatment.
The  data integration makes the diagnostic process
and the treatment planning more accurate and complete,
provides an effective communication tool and a method for
patients to visualie the simulated outcomes, instills moti-
vation, and encourages compliance to achieve the desired
treatment outcome Fig. ..
hat technology is providing to orthodontists is ama-
ing; however, what is still missing is the fourth dimension
i.e., the dynamic movements of the mandible and the sur-
rounding tissues integrated in the virtual model. dealisti-
cally, the capture of digital data for virtual modeling should
happen in a one-step, single-device approach to improve
accuracy. Future research will ll this gap and will realie
the dream of the real virtual patient.

3D DATA NTEGRATON
The creation of a virtual copy of each patient is dependent
upon the integration of  media les and the possibility
of their fusion into a uniue and replicable model. T
data can be used as a platform onto which other inputs can
be fused with acceptable clinical accuracy. These data
sources include light-based surface data such as photo-
graphic facial images and high-resolution surface models
of the dentition produced by direct scans intraorally or in-
directly by scanning impressions or study models. The inte-
gration of hard and soft tissues can provide a greater un-
derstanding of the interrelationship of the dentition and
Fig. 1.13 The virtual patient in hich cone-beam computed tomogra-
soft tissues to the underlying osseous frame. ndividual phy data, facial three-dimensional reconstruction, and virtual setup
 models of tooth are needed for the computer-aided obtained after teeth segmentation are superimposed. Courtesy of dr.
orthodontic treatment planning and simulation. ith the Alain Souchet, ulhouse, rance.
12 Principles and Biomechanics of Aligner Treatment
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 2 Current Biomechanical
Rationale Concerning
Composite Attachments
in Aligner Orthodontics
JUAN PABLO GOMEZ ARANGO
Introduction
he orthodontic techniue that we now call “aligner or-
thodontics” has evolved considerably over the last 
years. mprovements in behavior of aligner plastics, treat-
ment planning software, and three-dimensional 3
printing have served one basic but fundamental inten-
tion to mitigate the biomechanical limitations inherent
to aligner-based tooth movement. nother signicant
development designed to overcome the aforementioned
biomechanical shortcomings of aligner systems has been
the continuous improvement of biomechanically comple-
mentary composite attachments. ttachments were con-
ceived to produce supplementary force vectors that, when
applied to teeth by the aligner material, transform the
resultant system, allowing complex tooth movements.
he application of one of the initial geometric congura-
tions was initially presented by the clinical team from
lign echnology nc., as basic  x 3 mm rectangular
structures, bonded to the lower incisor buccal surface, in
an attempt at controlling undesired tipping during space
closure after incisor extraction ig. .. s the
incisors adacent to the extraction space begin to incline
mesially, the rigid, xed structure of the attachment
collides with aligner plastic, producing force couples that
counteract the initial moment, reducing undesired tip-
ping see ig. ..
rthodontic tooth movement with conventional bracket
techniues can deliver sophisticated force systems due to
the manner in which the rigid ligature-archwire-bracket
scheme “grasps” the malaligned tooth. his particular
arrangement allows broad control of magnitude and direc-
tion of applied force vectors, and, conseuentially, of tooth
movement ig. ..
t is important to keep in mind that attachments work,
not as active agents that produce forces, but by passively
“getting in the way” of plastic as it elastically deforms due
to lack of coincidence between tooth position and aligner
material “mismatch”, establishing the force vector that
subseuently affects the tooth ig. .3.
iomaterials used for attachment fabrication must as-
sure that reuirements in adhesion, wear resistance, and
esthetics are fullled.  recent study suggests that con-
temporary microlled resin composites provide sufcient
wear resistance to deliver a stable attachment shape
during treatment, assuring its functionality. Mantovani
et al.3 also concluded that the use of bulk-lled resins for
attachment fabrication improved dimensional stability
when compared to low-viscosity resins, which experience
higher polymerization shrinkage. he use of translucent
composites generally provides sufcient esthetic accep-
tance and stain resistance as long as an adeuate bonding
techniue is executed, in which voids bubbles in attach-
ment surface and excessive residue ash left on tooth
surface are avoided.
everal considerations come into play when determining
the optimal attachment design for a specic clinical obec-
tive geometry, location, and size.
Geometry (Active Surface
Orientation)
t the time of aligner insertion, orthodontic forces will be
produced in response to the particular complex pattern of
mismatches between plastic and tooth structure. his pat-
tern of mismatch–plastic deformation–orthodontic force is
critical for attachment design during digital simulation to
produce specic areas active surfaces that will contact
aligner plastic with predetermined force magnitudes,
producing the desired force vectors and conseuent tooth
movements. ot all the surface area of attachments will be
in direct contact with the aligner. he active or functional
surfaces can and should be determined with thoughtful
biomechanical intentionality, in accordance with clinical
obectives ig. .. hile the magnitude of the force
produced is determined by the amount of mismatch along
with the characteristics of aligner material, the direction
of the force will depend on the orientation of the active
surface. he principles of mechanics state that the direction
of the normal component of the contact force the vector
that in this case acts upon the active surface of the attach-
ment will always be perpendicular to that surface see
ig. .. dentifying the direction of these complemen-
tary force vectors is essential for treatment planning, espe-
cially when more than one force acts simultaneously. n
these cases, the resultant forces must be properly recog-
nized to deliver predictable tooth movements see ig. ..
13
14 Principles and Biomechanics of Aligner Treatment
B Fig. 2.3 (A) Alignertooth mismatch. (B) lastic aligner deformation
Fig. 2.1 (A) Mesial tipping moments (red curved arrows) produced by
aligner forces (red arrows) occurring during space closure. Antitipping
moments (blue curved arrows) produced by forces (blue arrows) acting
at rectangular vertical attachments (B). Opposing moments are
canceled out, promoting bodily movement.
Fig. 2.2 The typical force couple generated during bracetbased
alignment of rotated tooth ith a fully engaged . iTi archire
consists of to force vectors one that pushes against the posterior
all of the slot (red arrow) and a second that pulls aay from the same
all (blue arrow)
C
and activation of forces upon aligner insertion. () Tooth alignment
after aligner seuence.
Location
ased on the premise that the magnitude of a moment is
proportional to the perpendicular distance between the line
of action and the center of resistance, to fully understand
the effect of aligner-based orthodontic forces being applied
in any particular moment, it is essential to establish this
distance in the three planes of space. nce this correlation
has been clearly established and uantied, there will be a
much clearer picture of the effectiveness of expected
rotational moments as well as the possibility of anticipating
undesired occurrences such as buccolingual and mesiodis-
tal tipping and intrusion. n a case in which mesiolingual
rotation of the tooth is reuired, localization of attachment
 will produce a strong mesial tipping moment and a weak
mesiolingual rotational moment ig. .. n this specic
clinical situation, a better alternative would be with attach-
ment location , in which modication in distance from
line of action to center of resistance would reduce tipping
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 15

A B C
Fig. 2.4 (A) Active surfaces of attachments. (B) irection of forces acting at active surfaces. () esultant force
affecting the rst premolar ill produce etrusion and clocise, secondorder rotation.

A Distal Mesial B Distal Mesial

Fig. 2.5 (A) ue to the distance beteen the center of resistance (blue dot) and the line of action (red dotted line),
large mesial tipping and negligible mesiolingual rotational moments should be epected. (B) A more mesial and
apical attachment location ill result in reduced mesial tipping and increased mesiolingual rotational moments,
increasing clinical efcacy.

tendency as well as increase mesiolingual rotational capac- Size

ity see ig. ..
nother example of the inuence of attachment local-
ization is observed during transverse arch expansion,
when buccal tipping of posterior segments is detrimental
to treatment obectives.  recent unpublished nite
element analysis  study of the mechanical effects
of the bonding position of rectangular horizontal attach-
ments found that the resultant tipping moment acting
on the molars was greater when located on the lingual
surface of the rst upper molars versus the labial surface
ig. ..
ttachment size is important because of its mechanical
and esthetic implications. mall congurations are desir-
able because they are less noticeable however, as size di-
minishes, so does the ability to produce predictable forces
due to reduced active surface area. n the other hand,
larger attachment designs are desirable because of their
increased biomechanical capabilities, but they result in in-
creased aligner retention with subseuent patient discom-
fort and negative esthetic perception, especially with high-
prole congurations in anterior teeth.
16 Principles and Biomechanics of Aligner Treatment

A B
Fig. 2.6 uring epansion, labial attachment location (A) produced smaller net buccal molar tipping moments than
lingually bonded attachments (B).

Functions nongingivally beveled such as a horizontal rectangular or

PROVIDING ALIGNER RETENTION
or aligner-based orthodontic forces to affect teeth as con-
ceived in digital simulation, the aligner must be stably
seated after insertion and remain so for the duration of
treatment. ccasionally, decient adaptation of the aligner
may occur, usually resulting from faulty fabrication, but
may also occur due to the many reactive forces produced
once properly tted. or example, as a freuent response to
intrusive forces acting on the posterior teeth, the aligner
will tend to be dislodged in the anterior segment, and vice
versa. he use of intermaxillary elastics, especially when
they are engaged directly to the aligner, will also tend to
vertically dislodge it in the direction of the elastic
force. onding retentive attachments on teeth adacent to
those receptors of the elastic force is recommended to
maintain proper aligner engagement ig. ..  study
by ones et al. suggests that the optimal attachment con-
guration, when high aligner retention is imperative, is a
occlusally beveled design, as close to the gingival margin
as possible see ig. .. s a general rule of attachment
design, occlusal beveling will facilitate aligner insertion
due to the inclined plane conguration as well as increase
force and discomfort reuired for aligner removal.
AVOIDING ALIGNER “SLIPPING”
specially when rotating rounded teeth, the sum of a se-
ries of tangential forces is responsible for tooth movement
ig. ., causing inconvenient displacement slipping
of the aligner in relation to the tooth surface, reducing the
system’s efcacy and predictability, and resulting in lack
of full expression of digitally planned rotation with the
tooth lagging behind the corresponding aligner stage.
linically, incomplete rotation and loss of tracking will be
observed, manifesting as a space between tooth and plas-
tic see ig. .. ppropriately designed attachments
can help the aligner lock in to the tooth crown, greatly
reducing this undesired slipping effect.

A B
Fig. 2.7 (A) Attachments located on teeth adacent to force application increase aligner retention hen using inter
maillary elastics. (B) Attachment position close to the gingival margin and occlusally beveled geometry is ideal for
aligner retention.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics
A tion of the aligner material is evident. his time-dependent
B
Fig. 2.8 (A) Multiple tangential forces (red arrows) acting during
alignerbased, bicuspid rotation. (B) ue to slipping effect, incomplete
epression of epected rotation ith space beteen tooth and aligner
(in yellow) ill be observed.
DELIVERING PREDETERMINED FORCE VECTORS
he fundamental purpose of composite attachments in
aligner orthodontics is to produce specic, complementary
force vectors reuired for predictable tooth movement,
which are not possible with the sole use of aligners thermo-
formed with existing materials ig. ..
A B
Fig. 2.9 (A) Properly designed attachments produce complementary
force vectors reuired for predictable tooth movement. (B) Polymer
stress relaation and creep, along ith incomplete rotation and unin
tended force (blue arrow), may occur during seuence of aligner
based, tooth rotation stages.
17
nfortunately, to harness the full clinical potential of
bonded attachments, current polymers have yet to resolve
limitations associated with their viscoelastic and hygro-
scopic nature. nce inserted, the initial force produced by
the aligner after it is elastically deformed is not constant
and will decline with time. his time-dependent reduction
of force under constant deformation is called stress relax-
ation.  ot infreuently, due to unwarranted localized
stress caused by excessive mismatch, lack of compliance,
or shortcomings inherent to the polymer, the aligner is not
able to accommodate the attachment. hen forces exerted
upon the aligner exceed its capability to adust to the new
position, unintended forces will appear, the tooth will lag
behind, and control will be lost see ig. .. ig. .
illustrates how this phenomenon is responsible for the
incomplete expression of the expected tooth movement,
where only 3 of the  degrees of predicted rotation were
achieved after completion of the entire seuence of stages.
n this case, after the aligner is removed, plastic deforma-
plastic deformation under constant force is called creep and
is attributed to reorganization of polymer chains. t is
important to underline that this permanent deformation,
so detrimental to clinical performance of plastic aligners, is
not caused by a violation of the materials’ elastic limit but
is due to a time-dependent, mechanochemical phenome-
non of a different nature.
his inherent aw of aligner plastics is the maor cause
behind the inconsistent force levels and plastic deformation
that result in one of the most dreaded occurrences for
orthodontists practicing aligner orthodontics, now com-
monly referred to as loss of tracking. ig. . illustrates an
example of the clinical manifestations of this complex
reality in which mesiolingual rotation and extrusion of a
rst upper left bicuspid were incorporated in the digital
treatment plan but did not fully occur. he lack of coinci-
dence between the attachment and its corresponding recess
in the aligner is unambiguous evidence of loss of tracking,
a contingency that in many cases must be resolved by
obtaining updated digital dental models from which a new
treatment seuence must be designed.
Basic Attachment Conurations
in Current Ainer Orthodontics
he evolution of attachments, derived from a better under-
standing of the effect of geometry, location, and size of the
composite structure, has resulted in a diverse array of con-
gurations with well-dened biomechanical obectives.
VERTICAL CONTROL
he tendency of conventional xed orthodontics to in-
crease vertical dimension, especially in open-bite patients
with increased anterior facial height, has been studied.
ligner-based treatment has proven to be an effective
alternative for open-bite correction-3 with encouraging
results.3 uccessful treatment often includes the sum of
complementary clinical strategies such as the combined
effect of counterclockwise mandibular rotation, posterior
intrusion, and anterior extrusion.
18 Principles and Biomechanics of Aligner Treatment

A B
Fig. 2.1 (A) mage from linhec treatment plan. (B) oss of tracing ith incomplete epression of rotation and
etrusion of left upper bicuspid. ac of coincidence beteen attachment (green shaded area) and its corresponding
recess in the aligner (green outline) is observed.

ANTERIOR ETRSION
orrection of open bite based solely on anterior extrusion is
to be viewed with caution because of possible negative ef-
fects such as root resorption, periodontal deterioration, in-
stability, and unfavorable esthetics.  long with these
clinical restrictions, aligner extrusion poses mechanical lim-
itations in anterior teeth in which buccal and lingual crown
surfaces converge towards the incisal edge ig. ., fa-
cilitating aligner dislodgement and rendering this type of
tooth movement virtually impossible see ig. . with-
out the use of supplementary composite attachments. 
gingivally oriented, inclined plane conguration ig. .
provides a force system that improves predictability of this A
type of movement. he importance of attachment design
can be illustrated with a graphic simplication of a complex
interaction of vectors. he resultant force acting on the

A B
Fig. 2.11 (A) onverging buccal and lingual cron surfaces. (B) nde
sired aligner dislodgment during etrusive movement.
B
Fig. 2.12 (A) Optimied trusion Attachments (Align Technology,
anta lara, A) on central incisors. (B) ingivallyoriented inclined
plane ith optimal active surface angulation.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 19

150°
110°

A B
Fig. 2.13 (A) orces transmitted by the aligner (red arrows) and resultant forces (purple arrows) acting on the tooth.
(B) A reduction of the angle beteen active attachment surface and buccal tooth surface produces stronger resul
tant etrusive forces.

incisor is derived from the two red arrows that represent

buccal and lingual forces present during aligner-based
extrusion ig. .3. educing the angle formed by
the active surface of the attachment and the buccal surface
of the tooth will result in a stronger resultant force see
ig. .3. linicians must be wary of excessive reduction
of this angle, which along with excessive force may produce
difculty of aligner-attachment engagement with the ensu-
ing localized plastic deformation.

POSTERIOR INTRSION
ecent studies suggest that the presence of interocclusal plas-
tic during aligner treatment  may produce a bite-block ef-
fect that potentiates bite closure and posterior intrusion capa-
bilities. his improves treatment outlook, especially in cases in
which anterior extrusion is not desirable and intrusion of
posterior teeth, with the conseuent mandibular rotation, are
to be considered as part of the strategy for bite closure. s
mentioned previously, intrusive forces acting in the posterior
region will tend to dislodge the aligner in the occlusal direc- Fig. 2.14 ntrusion in the posterior segment (red arrows) produces
tion. ven with light posterior intrusive forces, an opposite, reactive forces that ill tend to dislodge the aligner anteriorly (blue
reactive force should be expected in the anterior arch that will arrows). Adeuate attachment selection on anterior teeth ill counter
tend to vertically dislodge the aligner ig. .. ingivally act this undesired occurrence.
positioned rectangular horizontal or occlusally attachments
beveled towards the incisal edge should provide the necessary
of specialized attachments, which improve biomechanical
aligner stability for optimal treatment progress.
capabilities.
he limitations associated with rounded crown
FIRSTORDER CONTROL
morphologies are due to some extent to three particular
Ri realities
otation of teeth with rounded anatomies such as bicus- n s mentioned previously, in rounded crown congura-
pids and molars is another movement particularly dif- tions, the tangential nature of the forces produced
cult to accomplish with plastic aligners without the help during aligner-based tooth rotation, along with very
2 Principles and Biomechanics of Aligner Treatment

low coefcient of friction between the two surfaces,
facilitates a slipping effect between the aligner and
tooth.
n he line of action of the normal force vectors resultant
from tangential forces delivered during rotation of
rounded crowns crosses at a short distance from the
center of resistance, resulting in weaker rotational
moments ig. .. hese difculties are overcome by
means of specically designed composite attachments,
with properly oriented active surfaces, reconguring re-
sultant force vectors with increased intervector distance
see ig. . and resulting in stronger, more effective
rotational moments. dditionally, the attachment struc-
ture blocks the slipping effect between aligner and tooth
surface, allowing a fuller expression of desired tooth
movement.
n nother effect observed in laboratory experimentation
as well as in clinical practice is unintended intrusion
during rotational tooth movement. n another study
using nite element analysis, researchers demon-
strated that during aligner-based rotation of an upper
canine without attachment, not only did the tooth lag
behind the corresponding aligner stage almost by 3,
but it also displayed clinically signicant intrusive forces
that were found to be 3. times greater without than
with attachments ig. .. he same numeric model,
from an incisal perspective, revealed distinct pressure
areas on the mesial and distal slopes of the incisal ridge
ig. ., to which this undesirable effect can be attrib-
uted and corresponds to the normal components of the
forces imparted by the aligner. ue to the orientation of
With ATT
Without ATT
30

25

Canine rotational lag (%)

20

15

10

0
0.25 1.25 2.25 3.25
A Aligner rotation (°)
With ATT
Without ATT
A
0.50
0.45
0.40
0.35
0.30
Fy (N)

0.25
0.20
0.15
0.10
0.05
0
0 0.5 1.0 1.5 2.0 2.5 3 3.5 4
B Rotation (°)
B Fig. 2.16 (A) ithout attachment, the tooth lagged behind the aligner
almost by . ith attachment incorporation, this lag dropped to
Fig. 2.15 (A) otational forces produced by the aligner (purple arrows) . (B) ntrusive forces observed at the periodontal ligament ithout
are transmitted to the tooth as normal force components (red arrows), attachments as .  for every degree of rotation, hile ith
hich are perpendicular to tooth surface tangents (purple dotted lines). attachments the load as reduced to .  for every degree. ATT,
(B) ncorporation of bonded attachment increases the magnitude and Attachment. (Adapted from óme P, Peña M, alencia , et al.
efcacy of rotational moment by increasing the perpendicular distance ffect of composite attachment on initial force system generated
(green dotted line) beteen the line of action (red dotted line) and the during canine rotation ith plastic aligners a three dimensional nite
center of resistance (es) elements analysis. J Align Orthod. .)
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 21

Buccal

Distal Mesial

Mesial
Distal

A Lingual
Fig. 2.18 Optimied otation Attachment (Align Technology, anta
lara, A) ith active surface oriented to provide a compensatory
etrusive force.

B
Fig. 2.17 (A) igital image of occlusal vie of right upper canine.
Occlusal vie of nite element method simulation of upper right ca
nine during mesiolingual rotation. (B) istinctly intrusive pressure ar
eas (red) on mesiolabial and distolingual aspects of the tooth cron
appear upon aligner insertion. The dotted line represents the aligner’s A
prole. (Adapted from óme P, Peña M, alencia , et al. ffect of
composite attachment on initial force system generated during canine
rotation ith plastic aligners a three dimensional nite elements
analysis. J Align Orthod. .)

the surface area, these forces are clearly intrusive. his

undesirable intrusive effect can be reduced with appro-
priate attachment design, orienting the active surface at
an angle in which the normal component of the force
transmitted by the aligner will express an extrusive
tendency ig. ..

SECONDORDER CONTROL
ipping movements are easily achieved with bracket-based
biomechanics ig. .. n the other hand, aligners
lack control of mesiodistal root position due to the system’s
B
inability to produce the reuired force couples, explaining
why modication of anterior teeth angulation is so chal- Fig. 2.19 (A) orce couple produced during bracetbased correction
lenging. o improve second-order capabilities, aligner-based of ecessive mesial tip. (B) uivalent force couple produced at Opti
systems rely on specialized attachments that generate mied oot ontrol Attachments (Align Technology, anta lara, A)
during alignerbased tipping.
euivalent force couples see ig. ..
22 Principles and Biomechanics of Aligner Treatment

Ai T
uccessful closure of extraction spaces with aligners is
also particularly difcult without excessive tipping in the
direction of tooth movement. umeric models describ-
ing tooth displacement ig. . and periodontal liga-
ment  strain ig. . patterns during distal tooth
movement have shown that ptimized oot ontrol t-
tachments lign echnology, anta lara, , when
bonded to upper cuspids, produce force systems capable of
controlling undesired inclination during extraction space
closure.
Pi T
n the posterior segment, tipping movements are not easily
obtained with aligner-based mechanics without combining
xed auxiliaries such as buccal tubes, power arms, etc.,
and these tooth movements, although possible, reuire
sophisticated treatment planning, clinical expertise, and
patient cooperation. dditionally, as with most complex
force systems, specialized attachments must be designed to
A B
enhance the biomechanical capabilities of the aligner. he
goal of this conguration of composite attachments is to Fig. 2.21 Periodontal ligament strain patterns during alignerbased
produce a force couple and its corresponding moment distaliation of upper right canine. (A) ithout attachments, distocervi
cal pressure (in blue) and distoapical tension (in red) areas ere
that will incline the tooth in the desired direction observed, typical of uncontrolled distal tipping. (B) ith attachments,
ig. .. lternatively, the rectangular, horizontal uniform pressure along the distal root surface (in blue) and uniform
attachment can be replaced with two shorter attachments, tension (in red) along the medial surface, typical of distal bodily move
with variable distance separating them according to the ment, ere observed. (Adapted from ome P, Peña M, Martíne ,
clinician’s plan see ig. .. t is important to remem- et al. nitial force systems during bodily tooth movement ith plastic
aligners and composite attachments a threedimensional nite
ber that the magnitude of the moment will depend on the element analysis. Angle Orthod. .)
amount of activation and corresponding mismatch
prescribed in the digital treatment plan. n the other hand,
the magnitude of the individual force vectors acting at the

A B
Fig. 2.2 Tooth displacement patterns during alignerbased distalia
tion of upper right canine. (A) ithout attachments, distinct uncon
trolled distal tipping as observed, ith center of rotation beteen
apical and middle thirds of the root (red arrow). (B) ith attachments,
the canine epressed distal bodily movement. (Adapted from ome B
P, Peña M, Mart√≠ne , et al. nitial force systems during bodily tooth
movement ith plastic aligners and composite attachments a three Fig. 2.22 (A) prighting moment produced at single rectangular hori
dimensional nite element analysis. Angle Orthod. .) ontal attachment. (B) Alternative tin attachment conguration.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 23

A B
Fig. 2.23 Producing euivalent moments (curved arrows), an increase in intervector distance proportionately
reduces force magnitude (blue arrows) acting at attachment surface. To degrees of distal tipping ith a mm
rectangular attachment (A) ill produce higher forces on the aligner than ith a toattachment conguration that
signicantly separates the force vectors (B) of the acting couple.

aligner-attachment contact will depend on the distance
between these two vectors. s the distance between the vec-
tors decreases, the forces produced at the active surfaces of
the attachments to produce an eual uprighting moment
will increase ig. .3. his is an extremely important
detail, considering aligner polymers’ high susceptibility to
creep-related plastic deformation, which reuires the use of
the lowest forces possible.
Dii M
n effective strategy for controlling anchorage during ex-
traction space closure is anterior and posterior moment to
force ratio manipulation in favor of the segment that
reuires anchorage.3 s shown in ig. ., a reciprocal
moment to force ratio between anterior alpha and poste-
rior beta segments will result in group  space closure, in
which both segments will meet at the middle of the extrac-
tion space resulting in class  malocclusion see ig. ..
o obtain class  occlusion, posterior anchorage must be
reinforced. onding rectangular horizontal attachments on
the buccal surface of posterior teeth ig. . will result
in clockwise moments that will resist mesialization of
posterior teeth, resulting in group  space closure and the
desired class  occlusal outcome see ig. ..

A B
Fig. 2.24 lass  case in hich reciprocal moments beteen anterior and posterior segments during etraction
space closure (A) ill result in  anchorage loss and class  occlusion (B).
24 Principles and Biomechanics of Aligner Treatment

A B
Fig. 2.25 locise moments (blue curved arrows) produced by attachments bonded to posterior teeth (A) ill
counteract posterior anchorage loss, reducing it to , resulting in class  occlusion (B).

TIRDORDER CONTROL magnitudes reuired for third-order control are signi-

Ai T
orue modication of anterior teeth with conventional
brackets is easily achieved by means of preactivation of
the rectangular archwire, producing a complex, high-
force couple when fully engaged in the rectangular slot
ig. .. ccomplishing the same type of movement
with plastic aligners demands an euivalent couple, derived
from horizontal, parallel, and opposing forces applied on
buccal and lingual surfaces see ig. .. ecause of the
relatively ample distance between the couple vectors, force
cantly lower than those reuired in euivalent bracket-
based force systems.
Pi T
orrection of transverse deciencies by expansion of the
dental arch continues to be a challenging clinical obective
with current aligner-based techniues. his has led to a
widespread tendency of clinicians to overcorrect expansive
movements in 3 treatment planning. he main reasons
for lack of efcacy and predictability in the transverse plane
are excess buccal tipping and insufcient force levels.

A B
Fig. 2.26 (A) By preactivating (red shaded) and subseuently inserting (red) the archire, a force couple (blue ar-
rows) and its corresponding counterclocise moment (blue curved arrow) ill be produced. (B) The same positive
torue can be achieved ith aligners by producing an euivalent couple, ith loer forces and increased intervec
tor distance.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 25

Excess Buccal Tipping Insufcient Force Levels

ecause forces act at a distance from the molar’s center of
resistance ig. ., buccal tipping must always be ex-
pected when expansive forces are applied, especially when
aligner-based forces are used. ith negligible friction
and conseuent pervasive sliding effect between plastic
and tooth crown, and relatively low stiffness as uncon-
trolled tipping occurs during expansion, the aligner will
tend to are, losing control as dissociation between tooth
and plastic occurs see ig. ..
he use of attachments horizontal rectangular or oc-
clusally beveled bonded to the buccal surface of posterior
teeth helps improve third-order control by counteracting
the undesired tipping moment as a result of a couple with
opposite forces acting at the occlusal surface and at the
gingival aspect of the attachment ig. ..
ue to their horseshoe-shaped geometry, orthodontic
aligners deliver expansive forces in a particular manner in
which an anteroposterior decreasing force gradient will
be observed ig. .. ecause of this distinct mode of
force transmission, researchers have found that efcacy
planned vs. nal increase in arch width of upper arch
expansion dropped from  at rst premolars to  at
the second molar.  ncreasing force levels during arch
expansion by using thicker or lower elastic modulus poly-
mers for aligner fabrication would improve this shortcom-
ing, but not without the inconvenient increase in force
levels of all other tooth movements programmed during
the expansive stages. n alternative solution is the use of
intermaxillary elastics, especially in cases with reduced
anterior facial height, in which buccolingual tipping and

Lingual Buccal
Lingual Buccal

A B
Fig. 2.27 (A) Alignerbased epansive force (red arrow) applied at a distance from the center of resistance (CRes) ill
produce counterclocise moment (red curved arrow). (B) ithout preventive measures, buccal tipping ith center
of rotation (CRot) above the furcation ill occur, folloed by aligner deformation and loss of control.

Lingual Buccal Lingual Buccal

A B
Fig. 2.28 (A) Opposing forces (blue arrows) acting at the occlusal surface and gingival aspect of a rectangular hori
ontal buccal attachment ill provide a clocise moment (blue curved arrow) that reduces buccal tipping, ith
apical migration of the center of rotation (CRot) (B).
26 Principles and Biomechanics of Aligner Treatment

A B
Fig. 2.29 (A) Programmed epansive mismatch beteen aligner and dental arch. (B) Once inserted, the resultant
epansive forces ill have a distally decreasing magnitude gradient.

A B

C D
Fig. 2.3 o angle patient (A), ith bilateral posterior crossbite (B, ) and midline discrepancy ().

extrusion of posterior segments are acceptable ig. .3.
lastic forces originated from buttons bonded to palatal
upper and buccal lower aspects of molars ig. .3 will
produce a force vector with vertical and horizontal com-
ponents of clinically relevant magnitudes that must be
considered during treatment planning. n the example in
ig. .3, a -gmf vector produced by a crossed inter-
maxillary elastic will be transmitted to the system as
 gmf of horizontal and  gmf of vertical force. s
mentioned previously, horizontal rectangular attach-
ments are effective in mitigating undesired tipping by
counteracting excessive rotational moments ig. .33.
y controlling vertical and transverse force levels, as well
as desired and undesired tipping moments, predictable
aligner-based treatment of different types of transverse
discrepancies is possible ig. .3.
 2 • urrent Biomechanical ationale oncerning omposite Attachments in Aligner Orthodontics 27

A B C

Fig. 2.31 (A) nitial linhec stage. (B) Aligners inserted, prior to bonding of upper palatal and loer buccal
buttons. () rossbite elastic.

90 gmf

42 gmf
100 gmf

Fig. 2.32 A gmf intermaillary elastic force ill produce a gmf

effective transverse force, epanding the upper arch and compressing
the loer arch. Additionally,  gmf of etrusive force ill eually in§u
ence upper and loer arches.

Fig. 2.33 n the upper arch, the moments provided by upper buccal
attachments (blue curved arrows) ill counteract moments (red curved
arrows) produced by elastic epansive forces (red arrows), reducing
undesired upper tipping. n the loer arch, unopposed lingual elastic
forces (dotted red arrows) ill result in epected lingual tipping (dotted
red curved arrows)
28 Principles and Biomechanics of Aligner Treatment
A B
C
Fig. 2.34 (A, B) nitial bilateral crossbite and midline discrepancy. (, ) Alignerbased correction ith complemen
tary use of intermaillary elastics.
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 3 Clear Aligners: Material
Structures and Properties
MASOUD AMIRKHANI, FAYEZ ELKHOLY, and BERND G. LAPATKI
Introduction
The continued improement of medical treatment de-
mands easy to use, cheaper, and more durable products
without compromising the treatment outcome itself. ue
to inherent properties and aailability, polymeric materi-
als show high potential for medical applications. oly-
meric materials are lightweight, easy to manufacture,
cheap, and ersatile. These properties allow them to be
used in dierse medical applications such as implants,
prostheses, and orthodontic appliances. s of any mate-
rial used for medical applications and intraoral applica-
tions in particular, the polymer must be biocompatible
and must not induce aderse reactions., The restrictions
and the standard in choosing a polymer depend on the
type of application.
In orthodontic applications, polymers are exposed to the
intraoral enironment, which comprises seeral different
substances including water, electrolytes, enymes, bacteria,
among other components. dditionally, consuming differ-
ent food and drin changes the acidity and ion concentra-
tion and may temporarily introduce organic solent e.g.,
alcohol to the polymer enironment. This means that the
polymer must be resistant to chemical corrosion. rinci-
pally, corrosion causes a particle release, which—depending
on the sie and form of particles—might inuence the
mechanical properties of the polymer as well.
nother important aspect is the thermal properties of
the polymer. lthough the intraoral temperature remains
relatiely constant near °, a polymer could be sub-
ected to arying temperature during intraoral application.
This means that the intraoral temperature might change
from a subero range e.g. while eating ice cream to alues
as high as 6° e.g., while drining tea. uch temperature
ariations lead to expansion or contraction of the material,
which might hae an inuence on the interaction between
the polymer and the teeth. Thus, a polymer must be able to
tolerate temperature alteration without a pronounced
olume and mechanical performance change.
The mechanical stability of the polymer also plays an
important role in orthodontic applications. or instance, a
polymer used for aligners must withstand high occlusal
forces otherwise, fractures or deformation might occur. 
change in the mechanical properties of the polymer during
the intraoral application period could also lead to un-
wanted changes of the mechanical loads applied to the
teeth. en for a chemically stable material i.e., a material
showing no corrosion, the mechanical properties of the
polymer can still ary oer time due to aging and creep.5-
30
There are two types of aging: physical and chemical
aging.5 6 Both chemical and physical aging render the
polymer brittle and stiffer, thus a lower strain may be gen-
erated during the application.
This chapter will focus on the basic properties of poly-
mers typically used for aligners. It will also include an
explanation of the chemical structure and thermal prop-
erties of these polymers. s the effectieness of a polymer
for dental use depends on thermal, chemical, and me-
chanical stability, these issues also will be discussed
briey. inally, future perspecties of polymers used for
aligners are described.
Polymer Molecular Structure
and Thermal Properties
olymers are ery long and entangled molecules with non-
conentional thermal and mechanical behaior. In this
section, the structure of a polymer and its thermal behaior
will be described. This comprises the specication of glass
transition, aspects of aging, and the stability of the polymer
in the intraoral milieu.
WHAT IS A POLYMER?
The word polymer is deried originally from the ree
words poly “many” and méros “units”. This indicates
that polymers consist of many repeating units connected
to each another through chemical bonding. ormally, if a
substance contains ust a few molecules, an addition or
remoal of only a few atoms would change the material
properties signicantly. or example, if one would add ust
 to heptane 6, then the boiling point of the
resulting molecule  increases by °. ith poly-
mers, in contrast, the number of repeating units could be
changed by one or more units without any noticeable
change in the polymer properties.
Typically, a polymer chain is made of seeral thousand
repeating units with a length of seeral micrometers and a
diameter ust around  nm. The polymer chain is usually
exible, twisted, and intertwined. The molecular weight
and chemical structure of the polymer determine most of
its properties. In contrast to small molecules haing a
specic sie and molecular weight expressed in gmol or
gmol, a polymer bul contains polymer chains with
many different sies and molecular weights. ence the
molecular weight of the polymer reects an aerage of
many different polymer chains.
 3 • Clear Aligners: Material Structures and Properties 31

C C O CH2 CH2 O

O n
Fig. 3.1 Chemical structure of polyethylene terephthalate glycol material (PET).

O H O H H

C N C N C O C C O

H H HH H
n
Fig. 3.2 Chemical structure of polyurethane material (PU).

Based on their thermal behaior, the three different
classes of polymers are thermoplastic, elastomer, and
thermoset. lear aligners belong to the thermoplastic
group. Thermoplastic polymers melt and flow upon heat-
ing aboe a certain temperature. Two widely used poly-
mers for aligners are polyethylene terephthalate glycol
T- and thermoplastic polyurethane T.- The
latter is a special thermoplastic form of polyurethane
which melts by heating, facilitating the thermoforming
process. Both of these thermoplastic materials are trans-
parent in the isible light spectrum, are impact-resistant,
and highly ductile. ust these properties in particular
mae them ery suitable for use as aligner material.
T- is a copolymer that constitutes two repeating units
ig. .: polyethylene terephthalate and glycol. The addition
of glycol preents the crystalliation of the T upon heating.
This maes T- less brittle and more resistant to mechani-
cal stress. T- is a ersatile polymer used in many other
applications such as protectie coer e.g., smart card, elec-
tronic deices, food containers, and medical instruments. ne
can thermoform, print, drill, bend, polish, and cut T- easily
without noticeable impact on its stability and physical proper-
ties. s T- can be easily thermoformed and also recycled, it
is also the material of choice for three-dimensional printing.
The building bloc of polyurethane is urethane ig. ..
 is aailable in both soft and rigid form, maing it ideal for
automotie interiors, pacaging, coating, exible foam, and
construction.  is impact resistant, is a good electrical iso-
lator, bonds well with other material, and is chemically sta-
ble in the presence of water and oil. The ersatility of  is
due to the fact that one can lin urethane molecules using
ore specically, if a polymer is obsered in a short time
scale, it behaes lie a solid material. If the experiment,
howeer, is performed during a longer time period, poly-
mers may ow and show a liuidlie behaior.
This phenomenon is to be exemplied on the basis of the
behaior of a simple liuid ethanol, which normally crys-
tallies. et us assume that the liuid is cooled below its
melting point. ig. . illustrates the change of the specic
olume of the material ersus its temperature. The specic
olume, dened as olume diided by mass, is the reerse of
the density. uring cooling, the specic olume of the liuid
decreases continually as long as it is still in the liuid phase.
There exists, howeer, a point the freeing point at which
the specic olume will decrease drastically and form a
crystalline solid. uch olume discontinuity is related to the
reduction of specic olume due to the crystalliation. Be-
low the freeing point, the specic olume remains almost
constant een though the cooling process is continued. The
freeing or melting point is a material property and does not
depend on the cooling rate or method of the measurement.
It also has a clear thermodynamic denition without any
room for interpretation.
nder certain conditions, small molecules and many
types of polymers, howeer, do not follow the mentioned
uid
Liq
id
-l iqu
led
Specific volume

different chemicals in ery different structures. This allows oo

p erc
tailoring the hardness of  to the specic application. In Su
general,  is biocompatible, but to mae it applicable as
Amorphous
aligners,  is usually combined with other material.

Crystalline
GLASS TRANSITION-THE MACROMOLECULAR
BASIS OF VISCOELASTICITY
epending on the temperature, most materials exist in a
solid, liuid, or gas state. ach of these states could be pre-
cisely described by thermodynamics laws. oweer, the Temperature Tg Tm
inestigation of polymers reealed that most of them do not
follow these basic material states. Instead, they show uid Fig. 3.3 Specic olume ersus temperature. Tm represents the
melting temperature and Tg the glass transition temperature.
or solidlie, time-dependent characteristics.
32 Principles and iomechanics of Aligner Treatment
0.34
0.33
0.32
0.31
Heat flow/mass (m/m)
0.30
0.29
0.28
0.27
0.26
0.25
0.24
0.23
0.22
45 50
Fig. 3.4 ifferential scanning calorimetry of polyethylene terephthalate glycol (PET).
scenario but demonstrate another behaior. This is een
applicable to simple liuids such as ethanol small mole-
cules. If a ery pure ethanol is stored in a bowl with no
corner and in a refrigerator without ibration, it can be
cooled to below freeing temperature without freeing.
ence there exists a temperature range below the melting
point called the supercooled region in which the sub-
stance remains liuid. If the cooling process is continued,
a temperature range will be reached at which the super-
cooled liuid transforms into a glassy state called the glass
transition temperature Tg. In this solidlie form, the sub-
stance has ery different properties than the crystalline
state. lassy material is an amorphous material, which
does not hae a long-range order. The structure of material
in the glassy form is therefore more similar to a liuid than
to a crystalline structure. xcept for only a few examples,
solid polymeric materials mainly exist in such an amor-
phous state. This is primarily related to the fact that the
polymer’s long chain is entangled with other chains. ence
it is usually difcult for the polymer chains to orientate and
build an ordered crystalline structure.
It has to be noted that simple polymers may actually
show crystalliation if the cooling rate is low enough so
that the polymer chains are allowed to nd their minimum
state of energy i.e., their euilibrium. oweer, for many
polymers with entangled chains, moements of polymer
chains are hindered too much, maing it physically impos-
sible to reach the crystalline state. The usual state of
polymers is, conseuently, solidlie with an amorphous
structure. eertheless, the polymer chains retain their
tendency to orient and to achiee an euilibrium state. This
tendency is the source of the specic behaior of amor-
phous polymers, which is plastic and elastic-lie, and
might alter between these characteristics throughout time.
55 60 65 70 75 80 85 90 95 100 105 110
Temperature (°C)
These aspects explain why the glass transition tempera-
ture plays an important role in dening a polymer’s proper-
ties, though it must be mentioned that the glass transition
temperature is an ill-dened transition. The latter means
that different measurement techniues may lead to differ-
ent Tg alues. ifferential scanning calorimetry  is a
widely accepted techniue for determination of the Tg
alue. ig. . shows results of  measurements for
T-. sually the middle of this range i.e., 5° for
T- is taen as the determined Tg alue.
rom an application-oriented iew, any thermoforming
must occur aboe the Tg temperature. The exemplied
 cure further indicates that, if T- is heated aboe
6°, its mechanical properties will change drastically.
ore specically, around a temperature of 6°, T-
will start to get softer and deform easier. Intraorally, this
temperature is usually not exceeded for a sufciently long
time, so T- stays mechanically stable during dental
applications.
Physical and Chemical Aging
of Aligner Polymers
In the fabrication process, aligners go through thermo-
forming. uring subseuent clinical application, they are in
contact with salia, food, drins, among other chemicals.
onseuently, as the orthodontist reuires a reliable appli-
ance, sufcient material stability is needed under arying
conditions. The stability of the aligner is measured by its
aging i.e., the change of its properties oer time. olymer
aging has seeral sources. ith respect to intraoral applica-
tion of polymers, two aspects of aging should be considered
in particular: physical and chemical aging.5 6

PHYSICAL AGING OF POLYMERS
hysical aging of polymers principally occurs, as men-
tioned earlier, in an amorphous i.e., noneuilibrium
form. ery system with the noneuilibrium state tends to
decrease its energy to thus approach its euilibrium state.
If enough mobility is obtained, the chains may rearrange
themseles to their lowest energy state, which might be
compared to crystalliation. This in turn will lead to a
decrease of the specic olume, a decrease of the enthalpy,
an increase of the hardness and brittleness, and changes
to other properties.5 This effect particularly changes the
mechanical properties of the polymer. ccordingly, physi-
cal aging can be dened as the relaxation of a polymer
toward a more stable energy state. If the usage of a poly-
mer occurs far below its Tg temperature, the polymer
chains will not hae enough inetic energy to moe and
rearrange. ence, by choosing an aligner with a Tg alue
much higher than the intraoral temperature, physical
aging might be largely aoided. It is important to note in
this context that a polymer’s Tg alue may also change
due to enironmental inuences.
hysical aging of polymers can be inuenced by expo-
sure to water and many other inds of molecules in the
intraoral medium. s mentioned, the specic olume of
an amorphous polymer is high in comparison to a crystal-
line polymer. This means there exists a lot of free olume
in the amorphous polymer below the Tg temperature.
onseuently, for prolonged exposure of such a polymer
to water, water molecules could diffuse into the material
alongside other molecules. The latter is one of the reasons
for discoloration of aligners. It is important to note that
the absorption of these molecules may also change the
properties of the polymer.  typical change is called the
plasticiing effect.6 To explain further, consider using
spaghetti as an example. roided that a bowl contains
spaghetti without sauce, the noodles cannot moe as eas-
ily because they stic together. oweer, by adding a sauce
to the bowl, the spaghetti noodles separate, which enables
them to slip along each other. In polymers, the plasticiing
effect follows almost the same logic: the small, embedded
molecules are placed between the polymer chains to in-
crease the mobility of the chains. The plasticiing effect
will reduce the glass transition, and therefore the polymer
will be more affected by physical aging.
rom a clinical perspectie, physical aging can affect an
aligner in two ways. Initially, the polymer will become softer
due to the plasticiing effect. s a result, force magnitudes
applied to the indiidual teeth are reduced. In the long run,
howeer, due to the effect of classical physical aging, aligner
polymers become harder which will increase the applied
forces and more brittle increasing the ris of breaage.
CHEMICAL AGING OF POLYMERS
s introduced, aligners may also suffer from chemical ag-
ing, which is the result of a chemical interaction between a
polymer and its medium. t present, none of the aailable
aligner materials is inert, which means that these materials
do react with certain chemicals included in salia, drin, or
food. hemical aging can affect a polymer ia different
mechanisms. or example, water molecules can brea the
3 • Clear Aligners: Material Structures and Properties 33
polymer chains and shorten them hydrolysis, or a similar
reaction can occur due to the interaction between the oxy-
gen and polymer oxidation.  polymer suffering from
chemical aging is more liely to deelop cracs and induce
notch effects.
ote, too, the time dependency of the mechanical prop-
erties of an aligner might be related to creep which will be
explained in the next chapter. reep is different from aging
phenomenon. It occurs due to application of mechanical
stress to the material, whereas aging is the result of a
polymer’s noneuilibrium state or medium, which occurs
without any external stress application. Both phenomena
are similar to each other, but they are related to uite differ-
ent mechanisms and should therefore not be confused.
Conclusions and Outlook
The two aligner materials mainly used i.e., T and
T- hae a distinct chemical structure leading to differ-
ent responses to thermoforming, exposure to the intraoral
milieu, and mechanical stress. ence it is of great impor-
tance not to generalie the characteristics determined for
one aligner material een one brand. ethodologic con-
ditions for material tests must be as realistic as possible.
or example, the mechanical properties of aligner materi-
als differ greatly before and after thermoforming. Thus a
realistic test should include the thermoformed material
specimen or aligners. urthermore, stress measurements
should be performed in a simulated intraoral medium.
lso, the production process the method of molding,
cooling, etc. affects polymer structure, which in turn
might alter the performance of aligner materials. To
obtain alid comparisons between tested materials and to
achiee reliable treatment results, test procedures and
clinical application protocols should be standardied. nly
then will the full potential of clear aligners be reealed.
ligner manufacturers or dental suppliers should inform
users i.e., orthodontists about any changes in the chem-
ical composition and production process. eertheless, it
is often rather difcult to obtain such information.
References
. illiams . n the mechanisms of biocompatibility. Biomaterials.
:-5.
. ires , erreira , odrigues , et al. eural stem cell differentia-
tion by electrical stimulation using a cross-lined T substrate:
expanding the use of biocompatible conugated conductie polymers
for neural tissue engineering. Biochim Biophys Acta.
55:5–6.
. umphrey , illiamson T.  reiew of salia: normal composi-
tion, ow, and function. J Prosthet Dent. 5:6–6.
. idaa , Iwasai , aito , et al. Inuence of clenching intensity
on bite force balance, occlusal contact area, and aerage bite
pressure. J Dent Res. :6-.
5. odge I. hysical aging in polymer glasses. Science. 56:
5–.
6. rissman , cenna B. hysical and chemical aging in 
and their effects on creep and creep rupture behaior. J Polym Sci B
Polym Phys. :6-.
. iggleman , chweier , ablo d. onlinear creep in a
polymer glass. Macromolecules. :6-6.
. Bower I. An Introduction to Polymer Physics. ambridge: ambridge
niersity ress .
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strider; quite a useful man over timber he might be; but he is a little lacking
in—what shall I say, Adagio con molto expressione ma non troppo, if you
know what I mean.

PETS

Walter, the white mouse, perished in May. The doctor said it was too
much exercise on an empty—well, he put it rather crudely. You know what
doctors are. And you know how white mice will exercise. The tailor said
Walter was too small to make up into a white waistcoat, even an evening
one, and that he would be hopeless as a tie. I advertised for a white mole,
but they seem to be rare. Altogether it was a sad year for pets.

THOUGHT

Perhaps the past year was, above all, a year for thought. To the pursuit
of thought we devoted many days in many positions. Some people would
find it impossible to think properly immediately after breakfast but we
proved that, given a sufficiently comfortable chair, the impossible could be
achieved, that one could be as thoughtfully busy in the morning as in the
afternoon.

XYLONITE

We did not do any of this.

YCLEPT
 We were yclept every morning punctually at eight (and arose punctually
at nine thirty) throughout the year.

ZEUGMA

I suppose you thought I couldn't do X. Y. Z. Well, this is just to show

you. In the ordinary way, of course, I should have referred to the zeugma
under music. We ordered a low-strung one last month, but it has not yet
been delivered.

* * * * * * *

So much for my record of the past year. Reading it over now I feel that I
have not spent the last twelve months in vain. At the end of them I can say
truthfully that I am, if not a year wiser, at least a year older, a year fatter.
And still a happy bachelor.

LETTERS TO CHARLES

DEAR CHARLES,—Can you lend me a penny? I have just been

making up my accounts for the day (the idea occurred to me suddenly; it's a
thing I have never done before) and I am seven shillings and a penny out.
The seven shillings I don't mind, but the penny worries me dreadfully. I
think that if you lent me another one I should gradually be able to settle
down again.
 I lie when I say I have never made up accounts before—I did it on one
memorable occasion years and years ago. When John and I were at school
we had certain expenses, such as subscriptions to the mission and to various
house competitions, train fares, masters' wedding presents, haircutting and
so on, which did not come out of our pocket money or tips, but which were
specially sent to us from home. To save the trouble of this we were given, at
the beginning of one term, five pounds to see us through all these expenses,
with the understanding that we were to account for it afterwards.

"Afterwards" meant the holidays, which (to begin with) were a long
way off. As they came nearer we consoled ourselves with the thought that
the required "account" was a mere formality which would probably not be
insisted upon; the actual money had been spent—which after all was the
main thing, the idea of the whole proceeding, so to say. To wish to linger
over the details of its gradual dissolution would be morbid. However to our
horror a day did come in the holidays when we were peremptorily ordered
to provide our account and to hand over the balance.

There is, as you know, Charles, never any difficulty about providing an
account—the trouble is to hand over the balance. In our case the balance
was exactly nothing, we had not a penny in our pockets. The money had
been spent all right, an unusual number of masters having been married that
term (some of them for the third or fourth time in the year), but we could
not possibly make up our accounts so that to a farthing the two sides
balanced. It would look so unnatural. How could we march solemnly into
the library and say "By a perfectly amazing coincidence the money you
gave us was just precisely the amount which the circumstances demanded.
There is no balance."

It was a very hot afternoon, and we were unhappy. The matter of the
accounts was not the only shadow which hung over us. John had a fox
terrier—so had I; but whereas my dog was a Little Englander, and stayed at
home, John's was an Imperialist, who roamed the country. He had
disappeared again the night before, and had been observed in the morning
in a village three miles away. Thither toiled John in search of him that hot
afternoon, his heart torn between his love for his dog and his duty to his
parents. And Rags and I remained at home to see what we could make of
finance.

We made but little of it. The more I thought of it, the more impossible it
seemed to say that every penny (no more, no less) of the five pounds had
been spent properly. One idea I had which touched genius—namely, to
furnish an account for five pounds ten (say) and point out that the balance
was owing to us. Ours was always a great family for ideas. But you see the
weak spot, Charles—that we hadn't demanded the ten shillings long ago.

And then John returned. No, he had not found his dog, but he had found
a shilling in the road. He had spent (he simply had to spend, he said) a
penny ha'penny on refreshment, but the tenpence ha'penny he had brought
back joyfully. And in the evening a beautiful account (on the double-entry
system) and tenpence ha'penny balance were handed over with ceremony.

So much for finance, Charles. Now I've got some news for you. I've just
had a nephew! (Uncle doing well.) Did you know? Look here, we'll arrange
a sporting match between him and your son over hurdles for 1922. Your
boy will still be a year older, but, bless you, I don't mind that. My nephew is
so ugly at present that I feel he must be intended for the highest honours at
something. Probably hurdles. Of course if either of us perishes in the
meantime the nominations become void. ("The nominations become
void"—did you notice that? Quite the sportsman.)

What sort of weather are you having? I ask because the weather differs
according to the locality, and down at Castle Bumpbrook it may be quite
fine, while it is raining here, and vice versa. Why is this? Why shouldn't the
weather be the same everywhere? Something to do with the solstices, I
believe. What is a solstice? (I have asked you no end of questions in this
letter, and I don't suppose you will answer one of them.)

Do you grow oranges at Castle? (Forgive the familiarity.) Exhausted by

my divings into the remote and wicked past, I have just eaten about six. I
get through quite a dozen a day. The fact is I heard a doctor say the other
night that they were extremely good for the complexion—or else extremely
bad, I couldn't quite catch which. He spoke very indistinctly. It was a pity
that I missed what seems to have been the important word; it wouldn't have
mattered so much about the "extremely." However, I go on eating them, and
if one day you turn up in town and find me a full-blown mulatto, you will
know that the word was "bad." I shall become a sort of test case, like
"Wreford v. Partington (1883)." Eminent people will refer to me. How nice
to be referred to—not that it would be the first time. "Refer to drawer," I
remember on my cheques at Cambridge. That, sir, was me.

Do you know, I made up the names Wreford and Partington on the spur
of the moment. The names are simple enough, but I think the combination
is wonderful. There must have been such a case in 1883. Who do you think
Wreford was? I fancy he was a small chandler, and he fell down the coal
shoot of Partington's in Cannon Street. James Partington, the senior partner,
said (fairly enough) that a great firm like his, which had branches all over
England (including Norwich), must have coal some time, if they were to
cope successfully with increasing foreign competition, which, owing to the
present Gov—— Oh no, this was 1883; I forgot. Well, anyhow, he said they
must have coal. Wreford retorted that he didn't mind their putting coal down
their shoot, but when it came to including respectable citizens of London
——

You remember the excitement when the case came on? We were only
babies then, but I have a recollection that my nurse was a pro-Partington.
Wreford won, but as he was heavily fined for having knowingly caused a
crowd to collect it did him little good, poor man.

Good-bye. Write to me soon and tell me all about Castle Bumpbrook.

What a glorious name. I often say it to myself. It is the only strong language
I ever use now.

II

DEAR CHARLES,—Many thanks for your definition of a solstice. Is it

really? Fancy! By answering one of my questions you become a unique
correspondent. Nobody else answers questions in a letter. Sometimes, of
course, one is asked, "What train are you coming down by on Saturday? Let
me know at once." But the proper thing to do in such a case is to wait till
Saturday afternoon, and then wire "Just missed the two twenty-two. Hope
to catch the next." Questions in letters are mostly rhetorical; which is why I
ask you, How, oh, how could you have the nerve to head your paper "Castle
Bumpbrook," and fill it with arguments against the Budget? It is hardly
decent. You know, I doubt if you ought even to have heard of the Budget at
Castle Bumpbrook.

What I expect from you is pleasant gossip about the miller's daughter. Is
she engaged yet to the postman? Has the choir begun to practise the
Christmas anthem? When does Mrs Bates' husband come out? These are the
things you should tell me. Tell me, too, of your simple recreations. Has
whist reached Castle Bumpbrook yet? It is a jolly game for four. One
person deals and you turn up the last card, and then the—— But I must
send you a book about it.

I have been having a correspondence with my landlord as to what I

should do in case of fire. Of course, if your little cottage got alight, you
would simply hop out of the window on to the geranium bed; but it is
different in London. Particularly when you are on the top floor. Well, he
tells me that I can easily get out on to Mr Podby's roof next door ... and so
home. This is certainly comforting, but—Podby! I don't like it, Charles.
Supposing anything happened, just think how it would look in the papers.
"The unfortunate gentleman was last seen upon Mr Podby's roof...." No, I
shall have to go for the drain-pipe at the back.

Look here, I have two stories to tell you. One is quite true, the other
isn't. Which will you have first? All right, the truth.

When I first came to town I was very—I mean I believed everything I

was told. One Sunday I met a small but elderly gentleman on the
Embankment, who asked me the way to the German Embassy. He had the
river to his south, so obviously all the embassies were in the other direction.
I pointed vaguely towards the north. He thanked me and said that—— (By
the way, do you prefer oratio recta? I forgot to ask you.) Well, then, he said:

"The embassies would be shut on a Sunday, hein?"

 I said: "Doubtless."

He said: "I am a Professor at Heidelberg. I have just arrived in London,

and I have no money. To-morrow I go to my Embassy and get some.
Meanwhile, could you lend me five shillings?"

Charles, in those days I was very—— Well, I gave him half-a-crown.

He said: "I should like to pay this back to you."

I said: "Quite so. That is the idea."

"Then would you give me your card, so that I can send you the money
to-morrow?"

Charles, I—— You see, I had just had some cards printed. They had
"Mr" on for the first time. I was very—— Well, I gave him one.

That ends the first scene. An interval of nearly five years elapses, and
we come to last Saturday. I was walking through the Green Park, when a
small but elderly gentleman came up to me.

He said: "Is this the way to the School of Music?"

I said: "Which one do you want? There is the Guildhall School, and the
Royal College, and the Royal Academy, and——"

He thought for a moment, and then he said in German the German for
"Do you speak German?" (My dear Charles, I can't spell it). I said "Nein."

He considered a little, and said, "Parlez-vous français?" I said—(What's

the French for "Not very well"? Well, that's what I said).

At this his face brightened. He drew a long breath, and began:

"I am a Professor of Music at Heidelberg——"

Charles, I had to interrupt him. I simply couldn't help it. I said; "Then
you owe me half-a-crown." He stopped, and looked at me with a sort of sad
dignity. Then he turned round with a sigh and plodded wearily across the
park. And, oh, I do hope he had better luck with somebody else, because he
has been at it for five years now, and it must be a heart-breaking life. His
hair had gone quite grey since I saw him last.

Charles, you do see that that is a true story, don't you? If I had been
making it up, I should have said that he gave me back my own card as a
reference. I wonder why he didn't. I suppose it had got rather dirty after five
years.

Do you want the other one now? It is the merest anecdote, and Hilda
told it me, and I know it's not true.

She has a cat called "Didums poor little kitty wee, then"; you put the
accent on the "then," and spread it out as long as you can. Well, Didums,
etc., goes about eating moths; a curious diet for a cat, but I believe it keeps
them thin. He swallowed them whole, you know, and Hilda told him how
cruel it was. She seems to have spoken of the sufferings of the imprisoned
ones in the most moving terms. Anyhow she found Didums next day up in
her bedroom remorsefully eating a sealskin coat.

I am surprised at Hilda. If she is not careful her baby will grow up a

journalist. I have seen him since he came back from you. This time I
approached from the west, and I noticed a great difference. He is certainly a
fine child, and as he let me put him to sleep I love him. After all, looks don't
matter tuppence to a man. The great thing is wisdom. Knowledge comes,
but wisdom lingers. I remember a General Knowledge Paper in my Mays.
One of the questions was "Give a list of the chief coaling-stations you
would pass on your way to New Zealand." The only two I could think of
were Cyprus and Rickett Smith. I never heard whether I got full marks:
probably not. But since that day knowledge has come for I have a friend in
the Admiralty. He was a very high wrangler the year I wasn't, and just as
Fisher is the man behind the First Lord, so he is the man behind Fisher; at
least, he tells me so. And he buys his tobacco by the knot—or is it the quid?
—and plays the Hague Convention at bridge, and (as I say) knows all the
coaling-stations from Cambridge to New Zealand.
 Wisdom Lingers. What a splendid title for a novel. You would expect a
fine moral tale, and it would turn out to be the story of the Lingers family.
Wisdom K. Lingers. There you have the essence of successful book-
naming. I hand the idea to you, Charles, in the certainty that you would
steal it anyhow.

Do you know anything about gas? I buy a lot every week for my geyser.
You get about 1000 for half-a-crown. A thousand what? I don't know; but I
like to take part in these great business transactions, and I am now writing
to ask if they could make it 1200 seeing that I am a regular customer. No
harm in asking.

III

DEAR CHARLES,—Do you truly want me to recommend you

something to read? Well, why not try the serial story in some ha'penny
paper? There you get a glimpse of the real thing. I turned idly to "Lepers in
Israel" (or whatever it is called) last night, and found myself suddenly up to
the neck in tragedy. Lord Billingham ...

Charles, you're a married man, tell me if it really is so. The gentle

Pamela is urged by a cruel mother to espouse Lord Billingham for his
money's sake. Lord B. is a vulgar brute, I'm afraid; in any case Pamela is all
for young Prendergast; but one must be sensible, you know, and money
does make a difference, doesn't it? So she becomes Lady Billingham; and a
year or two later Prendergast comes back from South Africa to find that it is
he who is the real Lord Billingham after all. (I got most of this from the
"synopsis," which enables you to start the story now, so I can't say how it
was they overlooked him in the first place.) It would be extremely cruel
(you see that, Charles?) to talk about it, because Pamela would then become
plain Mrs Stubbs, and no money at all; so Prendergast decides to say
nothing to anybody. But he was reckoning without Mrs Trevelyan, no less.
Mrs Trevelyan finds out the secret, and threatens Prendergast that she will
tell everybody that he is the real Lord Billingham unless he marries her. So
of course he has to.
 It is at this moment that we meet Captain Pontifax. Captain Pontifax is
in love with Mrs Trevelyan, at least he thinks he is, and he says that if she
doesn't marry him he will let on about what happened to Mr Trevelyan, who
was supposed to have died of old age. At the same time the news gets out
that Prendergast is really Lord Billingham, and so Pamela does become Mrs
Stubbs; and, as Prendergast cannot honourably withdraw from the alliance
he is about to contract with Mrs Trevelyan, it looks as though she is going
to be Lady Billingham. But on the eve of the wedding a body is found at the
bottom of the old chalk quarry.... Whose? ...

What I want to hear from you, Charles, is, Do people always get
married for this sort of reason? Are you really the Duke of Norfolk, and did
Kitty discover your secret and threaten to disclose it? Oh, you coward! I
don't mind anybody knowing that I am the true Earl Billingham.

About the body. We shall know to-morrow. I think it's Captain Pontifax
myself, but I will send you a telegram.

Are you an authority on dress? A man got into my carriage on the

District to-day wearing a top-hat, a frock-coat, and brown boots. Is that
right? I ask it seriously, because the point I want to discover is this:
Supposing you suddenly found that you had nothing in the house but brown
boots and a frock-coat, would a bowler or a topper be the better way out of
it?

You see the idea, Charles. If you add a bowler then the thing you have
to explain away is the coat. I don't quite see how that is to be managed; you
could only put it down to absent-mindedness. But if you add a topper then
you have only the brown boots to account for. This could be done in a
variety of ways—a foggy morning, a sudden attack of colour-blindness, or
that your mother asked you to wear the thickest ones, dear, and never mind
about the silly fashion. It is an interesting point which has never been dealt
with properly in the etiquette-books. You and I are agreed upon the topper,
it seems.

I went to a play last Tuesday. It was not bad, but the funniest scene
happened right at the beginning, when I watched an American buy a seat at
the box-office. They gave him J13., and he only discovered it after he had
paid for it, and had put his change carefully away. Do you know, Charles,
he nearly cried. The manager assured him there was nothing in it; people sat
there every night, and were heard of again. It was no good. He got his
money back, and went away looking quite miserable. Isn't it childish? I am
going to be married on Friday, 13th May, just to show. When is that?
Sickening if it's not for years and years. I have a patent calendar somewhere
which tells you the date for any year up to 1928. I never know why it
should stop there; something to do with the golden number getting too big.
It won't go backwards either, which is a pity, because I have always wanted
to know on what day of the week I was born. Nobody will tell me. It was
one of the lucky days I am sure. How can I find out?

(To-morrow.)—I have just sent you a telegram to say that it was Sir
Richard Tressider's body. Strange that you hadn't thought of him. Charles, I
felt very shy in the post office. Yes, about Castle Bumpbrook. She didn't
believe there was such a place; I offered to bet. We went through the
Telegraph Directory together. Do you know, you come in the Castles, not in
the Bumps at all. (Put me among the Bumps.) Something ought to be done
about it. I always thought Castle was your Christian name, kind of.

Yes, it was Sir Richard's corpse. It occurs to me now that you will get
this letter a day after the telegram. How did I put it?

"Body believed to be that of Sir Richard Tressider. Death certified as by

drowning. Inspector Stockley suspects foul play."

An elevenpenny touch, Charles, and I never signed it, and you'll wonder
what on earth it's all about. Probably you will dismiss it as a joke, and that
would be elevenpence thrown away. That cannot be allowed. You can get a
telegram repeated at half-price, can't you? I think I shall go and have a
fivepenny-ha'penny repeat.

I say, what are you doing about the weather? Are you taking it lying
down? I want to sign a petition, or write to my M.P. (haven't got one, then I
shall write to yours), humbly showing that it's the rottenest do there's ever
been. Do you remember the story (it comes in Gesta Romanorum, or
should) of the man who built a model of another man and threw things at it,
and the other man sat in a bath with a mirror in his hand and whenever the
first man threw he ducked under the water. If he got under in time his
enemy missed, and it was all right. Otherwise he was killed. Well, I am
going to rig up a Negretti in my room, and throw boots at it, and if the
original has to spend all his time in a cold bath ducking, I think, Charles, we
shall get some warmer weather soon.

"Oh, how this spring of love resembleth

The uncertain glory of an April day."

Charles, in your courting days was she ever as cold to you as this?

IV

DEAR CHARLES,—Don't talk to me about politics, or the weather, or

anything; I have lost my tobacco-pouch. Oh, Charles, what is to be done? It
is too sad.

I bought it in a little shop at Ambleside, my first, my only friend, on the

left-hand side as you go down the hill. It was descended from a brown
crocodile in the male line, and a piece of indiarubber in the female; at least,
I suppose so, but the man wouldn't say for certain. He called it a trade term.
I smoked my first pipe from it—on the top of Scafell Pike, with all England
at my feet. The ups and downs it has seen since then—the sweet-smelling
briars it has met! In sickness and in sorrow it comforted me; in happiness it
kept me calm. Old age came upon it slowly, beautifully. In these later years
how many men have looked at it with awe; how many women have insulted
it and—stitched its dear sides together!

It passed away on a Saturday, Charles; this scion of the larger Reptilia,

which sprang into being among the mountain-tops, passed away in a third-
class carriage at Dulwich! The irony of it! Even Denmark Hill—— But it
matters not now I have lost it. Nor can I bear that another should take its
place. Perhaps in a year or two ... I cannot say ... but for the present I make
shift with an envelope.

Two thoughts sustain me. First, that no strange eye will recognise it as a
tobacco-pouch, no strange hand (therefore) dip into it. Secondly, that the
Fates, which have taken from me my dearest possession, must needs have
some great happiness in store for me.

Charles, I perceive you are crying; let us turn to more cheerful things.
Do you play croquet? I have just joined a croquet club (don't know why),
and one of the rules is that you have to supply your own mallet. How do
you do this? Of course, I know that ultimately I hand a certain sum of
money to a shopman, and he gives me a very awkward parcel in exchange;
but what comes before that? I have often bought a bat, and though I have
not yet selected one which could make runs, I can generally find something
which is pretty comfortable to carry back into the pavilion. But I have never
chosen a mallet. What sort of weight should it be, and is it a good thing to
say it "doesn't come up very well"? I have, they tell me, a tendency to
bowness in the legs and am about a million round the biceps; I suppose all
that is rather important? Perhaps they have their mallets classified for
different customers, and you have only to describe yourself to them. I shall
ask for a Serviceable mallet for a blond. "Serviceable" means that if you hit
the ground very hard by accident it doesn't break; some of these highly
strung mallets splinter up at once, you know. As a matter of fact, you can't
miss the ball at croquet, can you? I am thinking of golf. What about having
a splice with mine; is that done much? I don't want to go on to the ground
looking a perfect ass with no splice, when everybody else has two or three.
Croquet is a jolly game, because you don't have to worry about what sort of
collar you'll wear; you just play in your ordinary things. All the same, I
shall have some spikes put in my boots so as not to slip. I once took in to
dinner the sister of the All England Croquet Champion. I did really.
Unfortunately I didn't happen to strike her subject, and she didn't strike
mine—Butterflies. How bitterly we shall regret that evening—which was a
very jolly one all the same. Here am I, not knowing a bit how to select a
mallet, and there possibly is she, having just found the egg of the Purple
Emperor, labelling it in her collection as that of the Camberwell Beauty. Let
this be a lesson to all of us.
 Charles, I feel very silly to-night; I must be what they call "fey," which
is why I ask you—How would you like to be a pedigree goat? I have just
seen in an evening paper a picture of Mr Brown "with his pedigree goat."
Somehow it had never occurred to me that a goat could have a pedigree; but
I see now that it might be so. I think if I had to be a goat at all I should like
to be a pedigree one. In a way, I suppose, every goat has a pedigree of some
kind; but you would need to have a pretty distinguished one to be spoken of
as a P.G. Your father, Charles, would need to have had some renown among
the bearded ones; your great-uncle must have been of the blood. And if this
were so, I should, in your place, insist upon being photographed as a
pedigree goat "with Mr Brown." Don't stand any nonsense about that.

If I ever have a goat, and you won't let me call it Charles, I shall call it
David. My eldest brother, you, know, was christened David, and called so
for a year; but at the end of that time we had a boot-and-knife-boy who was
unfortunately named David too. (I say "we," but I was still in the
Herebefore myself.) This led to great confusion. When the nurse called for
David to come and take his bottle, it was very vexing to find the other
David turning up with a brown shoe in one hand and a fish-knife in the
other. Something had to be done. The baby was just beginning to take
notice; the leather polisher had just refused to. In the circumstances the only
thing was to call the baby by his second name.

Two or three years passed rapidly, and I arrived. Just as this happened,
the boot-boy took the last knife and went. Now was our chance. My second
name had already been fixed; it was immediately decided that my first
should be David. The new boot-boy didn't mind a bit; everybody else
seemed delighted ... and then someone remembered that in ten years' time I
should be going to school.

Yes, Charles, the initials D.A.M.... You know what boys are; it would
have been very awkward.

And so now you see why I am going to call my pedigree goat David.
 V

DEAR CHARLES,—I am learning to dance the minuet. I say "the"

instead of "a" because I am sure mine is a very particular kind of one. You
start off with three slides to the left, then three to the right, and then you
stop and waggle the left leg. After that you bow to your partner in
acknowledgement of the interest she has taken in it all, and that ends the
first figure. There are lots more, but one figure at a time is my motto. At
present I slide well, but I am a moderate waggler.

Why am I doing this, you ask. My dear Charles, you never know when a
little thing like a minuet will turn out useful. The time may well come when
you will say to yourself, "Ah, if only I had seized the opportunity of
learning that when I was young, how ... etc." There were once two men who
were cast ashore on a desert island. One of them had an axe, and a bag of
nails, and a goat, and a box of matches, and a barrel of gunpowder, and a
keg of biscuits, and a tarpaulin and some fish-hooks. The other could only
dance the minuet. Years rolled by; and one day a ship put in at that island
for water. As a matter of fact, there was no water there, but they found two
skeletons. Which shows that in certain circumstances proficiency in the
minuet is as valuable as an axe, and a bag of nails, and a goat and a box of
matches, and all the other things that I mentioned just now. So I am learning
in case.

My niece, aged twenty months (do I bore you?), has made her first joke:
let it be put on record and handed down to those that come after. She
walked into the study, where her father was reading and her mother writing.
They agreed not to take any notice of her, in order to see what would
happen. She marched up to her father, stroked his face, and said, "Hallo,
daddy!" No answer. She gazed round; and then went over to the writing-
desk. "Hallo, mummy!" Dead silence. She stood for a moment looking
rather puzzled. At last she went back to her father, bent down and patted his
slippers and said, "Hallo, boots!" Then she walked quite happily out of the
room.

However, we won't bother about her, because I have something much

more exciting to tell you. M'Gubbin has signed on for the something Rovers
for next season! I saw it in the paper; it had a little paragraph all to itself.
This is splendid news—I haven't been so happy about anything for a long
time. Whaur's your Wully Gaukrodger now? Let us arrange a Pentathlon for
them. I'll back M'G., and you can hold the towel for Gauk. My man would
win at football of course, and yours at cricket, but the other three events
would be exciting. Chess, golf and the minuet, I think. I can see M'Gubbin
sliding—one, two, three, one, two three—there, now he's waggling his left
leg. Charles, you're a goner—hand over the stakes.

Look here, I smoke too much, at least I have been lately. Let's give it up,
Charles. I'll give it up altogether for a week if you will. Did you know that
you can allay the craving for tobacco by the judicious use of bull's-eyes?
("Allay" is the word.) You carry a bag of bull's-eyes with you—I swear this
is true, I saw it in the press—and whenever you feel a desire to smoke you
just pop a bull's-eye in your mouth. In a little while, they say, your taste for
tobacco—and I imagine for everything else—is quite gone. This ought to be
more widely known, and then your host would say, "Try one of these bull's-
eyes, won't you? I import them direct," and you would reply, "Thanks very
much, but I would rather have one of my own, if I may." "Have a bull's-eye,
if you like," your partner would say at a dance. Of course, too, they would
have special bull's-eye compartments in trains; that would be jolly. But it
would ruin the stage. The hero who always lights a cigarette before giving
off his best epigram—I don't know what he'd do. You see he couldn't ...
well, he'd have to wait such a time.

Why are they called bull's-eyes? I don't believe I've ever seen a bull's-
eye really close. If you look a bull in the eye he doesn't go for you. Which
eye? He might be a left-handed bull; you'd look at the wrong eye; then
where would you be?

The world is too much with me, Charles, but all the same I've just
ordered a flannel suit which will make Castle Bumpbrook stare. Sort of
purplish; and it makes up very smart, and they can do me two pairs of
trousers in it, whatever that means. I should have thought they could have
done me as many pairs as I liked to ask for, but it seems not. They only
print a limited edition, and then destroy the original plates, so that nobody
else can walk about looking like me. I asked the man if he thought it would
play croquet well, and he said, yes. By the way, I have learnt some more
about croquet since I wrote last. First, then, you can go round in one, if
you're frightfully good. I should like to go round in one; I suppose that
would be the record? Secondly, if you're wired from all the balls, "so that
you can't get a clear shot at every part of any one of them," you go into
baulk, and have another turn. This must happen pretty often, because you
could never have a clear shot at the back of a ball, unless you went right
round the world the other way, and that would be too risky, besides wasting
so much time. No, I can see there's a lot to learn in the game, but patience,
Charles, patience. I shall go round in one yet.

VI

DEAR CHARLES,—Are you coming up to town this month? If you do

we will make a journey into Shepherd's Bush together, and see the
Exhibition.

I am afraid I have been doing Shepherd's Bush an injustice all these

years. John and I once arranged a system of seven hells, in which we put all
the men we hated. Nobody known personally to either of us was eligible (so
your name never came up, dear Charles), which meant that they had to be
filled with people in the public eye. The seventh division contained two
only: one a socialist, who is thought a good deal of—by himself, I mean;
the other a novelist who only writes about superior people who drop their
"g's." The punishment for this class was simple; perpetual life in an open
boat on a choppy sea, smoking Virginian cigarettes—John's idea chiefly, he
being a bad sailor. The doom decreed for the unfortunates in the fifth class
—now I am coming to the point of this reminiscence—was more subtle:
they had to live at Shepherd's Bush, and go to a musical comedy every
afternoon.

There were four men in the fifth class. Three of them we need not
bother about, but the latest arrival was a certain cleric who advertised a
good deal. One day we met somebody who knew him well. We broke the
sad news to him gently, and he was much distressed about it. He asked if
there was any hope. We replied that if his friend turned over a new leaf, and
kept his name out of the papers for a bit, he might in time be promoted into
the fourth division—where, every day, you watched Sussex play Essex at
Leyton and had mutton sandwiches for lunch. He was so glad to hear this
that he made us promise to let him know when any such step was
meditated. Accordingly, after a month of perfect quiet on the part of the
reverend gentleman we sent his friend a telegram: "Bernard left Shepherd's
Bush by the nine o'clock steamer this morning."

And now it looks as if the Bush were much more of a place than we
thought.

Every week or so I have an inspiration; and I had one yesterday, when

the thought struck me suddenly that it would be a good idea to buy some
postcards. You get them at the post office—six stout ones for ninepence. Oh
no, that can't be right—nine stout ones for sixpence. I shouldn't think a
postcard would ever get too stout—not unpleasantly so, I mean; you hardly
ever see an obese postcard. I don't believe I have used one of any
dimensions for ten years; yet they are such handy things when you want to
say "Right O" or don't quite know whether you are "very truly" or
"sincerely." The postcard touch is hereditary. Some families have it, ours
hasn't. But now it is going to begin. Tomorrow I buy as many stout ones for
sixpence as they will give me.

Talking of buying croquet mallets and things—I went into a little

tobacconist's a little while ago (What for? Guess), and while I was there a
man came in and ordered a pipe, two ounces of bird's-eye, and a box of
matches. I wanted to tell him that you really required a rubber pouch as
well, and a little silver thing for pressing down the tobacco. It must want
some nerve to start straight off like that, especially at his age—forty or so. I
am about to play golf seriously, and I shall certainly get my clubs at
different shops—a driver at the Stores, a putter in Piccadilly, a niblick
(what's a niblick? Anyhow, I shall have several of them, because of the
name)—and several niblicks in Fleet Street. It would be too absurd to buy a
dozen assorted clubs, one ball, a jersey and a little red flag all at the same
place.

Yes, I should love to come down and play cricket for Castle
Bumpbrook, and many thanks for asking me. I don't make runs nowadays,
Charles, but if you feel that the mere presence of a gentleman from Lunnon
would inspire and, as it were, give tone to the side, then I am at your
service. You do say "Lunnon" in the country, don't you, when you mean
London? And you say "bain't" too. How jolly! "I bain't a bowler, zur"—and
you pronounce the "b-o-w" as if it were a curtsey and not a cravat. "Put Oi
——" It's no good. I can't keep it up. Put me in last and I'll make 3 not out,
and that will bring me top of the averages. (If you divide 3 by 0 you get an
awful lot, you know.) You have an average bat, I suppose? I like them rather
light—or I would take the money, whichever would be more convenient.

I have just written myself a letter, pleasantly standoffish, but not

haughty. The reason is that I have my doubts about the post office, so I am
giving them a test. My address, as you have discovered, is an awkward one.
There are nine distinct ways of getting it wrong, and most people try two or
three of them. But the letters do get here eventually, after (I expect) a good
deal of sickness on the part of the postman. What I am beginning to wonder
now is whether a letter with the right address would arrive; I fancy that the
chief of the detective department would suspect a trap, and send it
somewhere else; and, as I am certain that I have never received one or two
letters which I ought to have had, I am writing to myself to see.

It is a great art, that of writing nicely to yourself; to say enough, yet not
too much. When John was getting engaged, he wrote to himself every day.
Before he started doing this he used to spend hours sitting and wondering
whether the postman had been. The few letters he had had from her came
by the eight-thirty post. At eight-fifteen he began to look out; nothing
happened. An awful quarter of an hour followed. Eight-thirty—no
postman's knock; never mind, perhaps he's late. Eight-thirty-five—well, it is
rather a busy time; besides he may have fallen down. Eight-forty—one ray
of light left; he did come once, you remember, at eight-forty-two. Eight-
forty-five—despair. A half-an-hour's agony, you observe, Charles. Then he
thought of writing to himself in time for that delivery. The result was that he
remained quite calm, knowing that the postman was bound to come. "Ah,
there he is. Will there be a letter from her? Yes—no." You see? Your heart
in your mouth for five seconds only.
 I never saw any of these letters. But I should say that at the beginning
they were sympathetic—"Buck up, it's all right"—or hopeful—"Never
mind, she'll write to-morrow"; later on they would become cynical—"Done
in the eye again. What on earth do you expect?"; and, finally, I expect,
insulting—"You silly ass; chuck it." ... Then, of course, she wrote.

Good-bye. Don't forget I am going to play for you. Would it be side to

wear flannels? White boots would be a bit lofty, anyhow. Then I shall wear
one brown pad on the right leg.

VII

DEAR CHARLES,—Many thanks for your letter. Don't side just

because you get up at six o'clock, and feed the cow, or shave the goat, or
whatever it is. Other people get up early too. For the last few weeks I have
sprung out of bed at seven-thirty. (I always "spring" out—it is so much
more classy.) But I doubt if I can keep it up.