Most leading Invisalign providers have developed some tendencies and techniques that can increase predictability and efficiency of treatment. Using ClinReview Consulting will increase your knowledge base, and improve you clinical effectiveness. Here, Dr. Goodman and Dr. Glick list several definitions, techniques, and clear up a few confusing Invisalign policies.

Mid-Course Correction
If a patient requires restorative work in the midst of a course of Invisalign, either due to trauma or caries, a new impression may be required. Since this is not Invisalign’s fault, a charge is incurred. However, if a patient’s aligners simply begin to fit poorly, several options exist, including submitting a new impression for a new set of aligners. This form of Mid- Course Correction is often not charged. Please ask your TM for confirmation since Invisalign’s policies change from time to time.

Invisalign Express
According to Align, Invisalign Express comes in two different varieties:

• Invisalign Express
• Invisalign Express Partial Treatment

It is important to understand the distinction between the two options. For a case to be accepted as Invisalign Express, it must be 10 aligners or less, AND also consist of predictable movements. Specifically, Align lists the following parameters (as of 4/2/07) for a case to qualify for Express:

• Spacing or crowding of less than 2 mm per arch
• Rotation of cuspids/bicuspids less than 10 degrees
• Rotation of incisors less than 15 degrees
• Less than 1.5 mm dental expansion per arch
• Less than 2 mm midline correction
• No pure extrusions

With each Express case, doctors have the option to purchase one set of up to 10 refinement aligners for an additional cost of $125.

Cases that are 10 aligners or less, BUT whose movements exceed the criteria listed above are considered Invisalign Express Partial Treatment cases. An example of such a case would be a clincheck that might show 9 aligners of pure extrusion or improvement of a severe rotation of more than 45 degrees. While Align will allow you to order a case like this for a cost of $750, it does not permit the purchase of any case refinements.

The take home message is that Align concedes that many Invisalign Express cases do not treat out perfectly. We suggest that you use the product with this information in mind, and make the patient aware of the limitations. Also, consider viewing the full Invisalign treatment not as double the cost of Invisalign Express, but rather a product with advantages such as three sets of unlimited refinement aligners.

Extrusion of anterior teeth
Extrusive movements of anterior teeth are unpredictable with Invisalign. Certain attachments make slight extrusion feasible, but any type of open bite correction or extrusion of more than 1mm is not reliable.

Attachment placement
Many practitioners find it helpful to wait to place attachments until after the 1st or 2nd aligner in order to allow the patient to get used to Invisalign before the attachments.

IPR
We recommend delaying the completion of any IPR until the alignment between a given contact point is such that your access to each contacting surface is ideal. You will know that your access is ideal when you are able to replicate the contours of those contacting surfaces. This can be seen in any clincheck. If teeth are significantly overlapped, you will find it impossible to properly contour those teeth until the crowding is unraveled. By waiting until you have straight-line access for your IPR, you will have a better chance of doing it more accurately. Also, no matter how much IPR is required for a given contact point, try to stage it so that you do not do more than 0.2 mm of IPR on that contact point at a given appointment. This allows you to be quite accurate with your IPR and it also prevents patients from going home with large gaps between their teeth.

Case refinement
Educate your patient from day 1 that case refinement is a part of the Invisalign process. It is no coincidence that Align allows for 3 case refinements to be included in their fee, as cases do not always treat out to perfection as seen on the clincheck. As orthodontists, we often reposition brackets or place bends in our wires to compensate for something that didn’t go 100% according to our initial plan. We look at case refinements in the same way and consider them to be an invaluable part of detailing and finishing cases.