Sequential Removal Orthodontics: An Alternative Approach

Abstract

Orthodontic treatment is one of the most essential and effective way to make individual smile in to radiant and
more attractive smile. Sometimes patients are hesitant about the pain and discomfort related to brace, as well as
as metallic smile is a deterrent for style conscious young adults who want straighter teeth but refuses traditional
metal orthodontics. Invisalign aligners are utilized to fix crooked or mal aligned teeth, and also close spaces and alter
overbites. The treatment includes wearing clear, plastic plate that is custom made for the mouth, making Invisalign a
less-recognizable option. This review article has been prepared by doing a literature review from world-wide web and
pubmed/medline.

Full text

32
International Journal of Contemporary Medical Research
International Journal of Contemporary Medicine Surgery and Radiolog y Volume 2 | Issue 1 | January-March 2017
Sequenal Removal Orthodoncs: An Alternave Approach
Rahul Srivastava1, Bhuvan Jyo2, Sachin Kushwaha3, Anu Shastri4
1Reader, 3Senior Lecturer, Department of Oral Medicine & Radiology, Rama Dental College, Hospital & Research
Centre, 4BDS, Consultant Dental Surgeon, Kanpur, UP, 2Dental Surgeon, Department of Dental Surgery, Ranchi Instute
of Neuro-Psychiatry and Allied Sciences, Ranchi, Jharkhand, India
Corresponding author: Dr. Rahul Srivastava, Reader, Department of Oral Medicine & Radiology, Rama Dental College,
Hospital & Research Centre, Kanpur, (U.P), India
How to cite this arcle: Rahul Srivastava, Bhuvan Jyo, Sachin Kushwaha, Anu Shastri. Sequenal removal
orthodoncs: an alternave approach. Internaonal Journal of Contemporary Medicine Surgery and
Radiology. 2017;2(1):32-36.
INTRODUCTION
e word orthodontics came from two Greek words
orthos’ means normal, correct, or straight and ‘dontos’
means teeth. Correction of malocclusion by correcting
and improving the position of teeth is main concern
of orthodontist.1 Orthodontic treatment has a vast
horizon ranging from straighter teeth through enhanced
occlusion. It is also a great way to improve a person’s
overall self-image. During orthodontic treatment braces
are used to move the teeth by applying the pressure. Fixed
orthodontic treatment requires placement of multiple
types of small brackets to the teeth, which are connected
by wire and rubber bands. A wire is regularly tightened by
the dentist or orthodontist to gradually shift the teeth and
jaw. With all the advancements in the field of orthodontia
still wearing braces has never been easier. e brackets
appear ugly on the patient’s smile, looking even dark on
the teeth. It is very unattractive for any typical individual
and it is even a more concerning issue for the individuals
who are more established, who can't bear resembling a
metal-mouth just to have straighter teeth. Having metal
free mouth is what any person in personal relation job
always dreams of- flashing metal isn’t consider being a
fashion. Investigators brought forward a few solutions like
ceramic or composite braces, lingual orthodontics, and
clear aligners to address the increasing aesthetic demand
as an alternative to conventional braces.2-4
As stated earlier metal braces are not complied well due
to them being unaesthetic. Invisalign and its revolutionary
multiple clear aligners has become an aesthetic alternative
to metallic smiles, which are not that noticeable.5
Invisalign is a virtual orthodontic appliance that is utilized
to straighten the teeth without support of an undetectable
way.
Invisalign makes utilization of the series of transparent,
removable teeth aligners that will gradually straighten
the teeth, which is the best alternative for patients who
consider dental braces that require no consideration of
metal wires or brackets.
ese clear aligners have come as a boon for those who
want a treatment without compromising on their smiles.6
Invisalign is perceived as a viable orthodontic procedure
that corrects a wide assortment of bite, spacing and
crowding issues utilizing a series of uniquely custom made,
almost invisible, comfortable and removable aligners.
While Invisalign is regularly asked for its aesthetic
advantages, numerous patients don't understand that it
additionally has various oral health advantages.7
With the advent of CAD/CAM its uses for Invisalign
treatment plan gives a projection of post treatment
objectives beforehand so that the patient knows what
all to expect after completion of the treatment protocol.
Worldwide 300,000 patients have been treated by using
Invisalign.8
e clear aligners from Invisalign have been patented.
With progressive repositioning of teeth and frequent
change of aligners gives the promised results. Being
removable and the ease of using it makes cleaning of teeth
Review ARticl e
ABSTRACT
Orthodonc treatment is one of the most essenal and eecve way to make individual smile in to radiant and
more aracve smile. Somemes paents are hesitant about the pain and discomfort related to brace, as well as
as metallic smile is a deterrent for style conscious young adults who want straighter teeth but refuses tradional
metal orthodoncs. Invisalign aligners are ulized to x crooked or mal aligned teeth, and also close spaces and alter
overbites. The treatment includes wearing clear, plasc plate that is custom made for the mouth, making Invisalign a
less-recognizable opon. This review arcle has been prepared by doing a literature review from world-wide web and
pubmed/medline.
Key word: Sequenal Removal Orthodoncs

Srivastava, et al. Sequential Removal Orthodontics
33
International Journal of Contemporary Medical Research
International Journal of Contemporary Medicine Surgery and Radiolog y Volume 2 | Issue 1 | January-March 2017
as well as the aligners easier after meals. e aligners are
smooth and comfortable and they don’t irritate your gums,
cheeks and tongue. e invisalign system also eliminates
any allergic reaction with metal.9
INVISALIGN-WHAT EXACTLY
THIS IS ??
e patented clear aligner technology of Invisalign
is a clear choice and alternative for image conscious
population who would never opt for the visible wires and
braces. Invisalign was presented in the late 1990s by Align
Technology Inc, and because of cutting edge innovation
permitted a much less complex way to deal with this
kind of treatment. In 1998, Align Technology (Santa
Clara, Calif) presented Invisalign, a series of removable
polyurethane aligners, as a stylish contrasting option to
fixed labial braces.8,10
ese aligners are made of medical grade plastics, are
biocompatible and approved for human use in the oral
cavity. Using the latest CAD CAM technology the trays
are molded and carved with laser precision (Figure:1).11
Invisalign is a different way of aligning teeth. e
technology uses computer assisted 3D virtual models to
correct dento alveolar malocclusions. A series of aligners
is necessary to achieve the desired result. ese aligners
move the patient’s teeth gradually into their desired new
position. Each aligner is programmed to move a tooth
or a small group of teeth 0.25 to 0.33 mm every 14
days.
is revolutionary tooth movement technique has attracted
all the more patients towards teeth straightening.12,13
PROCEDURE
A series of simple steps including radiographs,
photographs, impression making alongwith prescription
from the dentist is sent to the laboratory. e ClinCheck®
software model creates the treatment protocol.
is 3D interactive software allows the technician to move
each tooth in three dimension, predict the “collisions (2
teeth occupying the same space) and build the sequence
of movements precisely to obtain the optimal tooth
movement and the resolution of the malocclusion.
(Figure:2)
After the treatment protocol is approved by the treating
dentist, a series of aligners are sent to the treating dentist.
Number of the aligners are determined by the complexity
of the condition. e number of aligners delivered is
based on the complexity of the case and can range from
as few as ten for minor corrections, up to 25 for moderate
corrections and whopping 40 for severe conditions.
e aligners are numbered and are accompanied with
date chart and specific instructions and are to be worn for
maximum period of time in a day,only to be removed while
eating and maintenance of oral hygiene. ese aligners are
generally replaced every two or three weeks and 6-8 weeks
of follow up with the consultant. To facilitate specific
orthodontic movements some patients requires
bonded aesthetic attachments and/ or elastics. 12,14
ALIGNER INSERTION
1. Ensure you have the correct aligner— upper for
maxillary teeth and lower for mandibular teeth.
2. To help maintain a strategic distance from disarray
each aligner is engraved with unique case #, a-UII
for upper and -LII for lower, followed by the stage
number.
3. Aligners can be worn in any of the arch first, they
need to be placed in the incisors area and then slowly
adjusted over the molars till it snaps into the desired
position. One should not bite the aligners in to the
desired position as this will cause irreparable damage.
4. One should expect minor fitting issues when
the aligners are changed but they are resolved
subsequently. Whatever the issues it is not advisable
to jump the sequence of the aligners in any case.
5. e force have been incorporated into the aligners in
such a way that it gradually reduces from 200 grams
to 40 grams within 48 hours. It is advisable to start
the use of the aligners in late evening so that by the
morning the force is reduced by 100 grams and that
would facilitate easy removal.
Figure-1: Invisalign teeth aligner
Figure-2: 3D interactive Clincheck® software

Srivastava, et al. Sequential Removal Orthodontics
34
International Journal of Contemporary Medical Research
International Journal of Contemporary Medicine Surgery and Radiolog y Volume 2 | Issue 1 | January-March 2017
ALIGNER REMOVAL
1. e aligner is removed by tugging the fingers at molar
area and slowly dislodging it while moving on the
other side.
2. Avoid removal of the aligner frequently.
3. No sharp object should be applied on the aligners
4. Aligner needs to be stored after rinsing and shaking
off the excess water.
5. e old stage aligners are replaced by new ones
and they need to stored in a zip lock pouch till the
treatment is completed.15
MECHANISM OF ACTION
After the impressions are made, a complete treatment
course is planned taking into consideration the pre-
treatment occlusion and the predictive orthodontic final
outcome. is is achieved using 3D computer imaging
technology and is used for fabricating custom made series
of individualized aligners. As these aligners are replaced
sequentially at the stipulated time (two weeks at least) the
teeth move incrementally at the rate of 0.25mm per tooth
until a desired position is attained.16
TREATMENT DURATION
As the aligners are changed the movement of the teeth
become slow as the replacement time approaches and
even slower when the treatment tends to finish. It is
recommended that aligner should be worn till teeth are
aligned to the desired position and also till your consultant
suggests to discontinue. e consultants reviews the
progress every six weeks and treatment takes approximately
7 to 15 months depending upon the number of aligners
which can range from 10-30.6
TRADITIONAL BRACES V/S
INVISALIGN
Traditional braces causes discomfort, pain, mouth ulcers,
tooth disclorations, plaque deposits, poor gingival health,
dental caries, inability to chew and diet restrictions.17
Comparison between traditional braces and invisalign is
listed in Table:1
INDICATIONS
1. Somewhat crowded and mal aligned issues (1–5 mm).
Treatment that should be possible with slight lateral
and/or antero-posterior expansion, with some minor
inter proximal tooth diminishment, or by extraction
of a lower incisor.
2. Spacing problems (1–5 mm).
3. Profound overbite issues (Class II division 2
malocclusions) where the overbite can be lessened by
intrusion and advancement of incisors.
4. Narrow arches that can be expanded without tipping
the teeth excessively.
Parameters Tradional Braces Invisalign
Color Metal braces have typically silver colour, for tooth
color braces paent has to pay extra.
Clear/invisible
Treatment me 24x7 for a normal of 2 years, conngent upon
paent needs.
22-24 hrs/day for 6 months to year and a half, con-
ngent upon paent needs.
Cost $1,800-$5,500 Average of $5,000
Maintenance Brush brackets and wires consistently while
brushing teeth; Waterpik might be useful.
Invisalign Cleaning system, or brushing and rinsing
trays in luke warm water
Follow up visits About every month Change aligner trays every 2 weeks; visits every 4 to
6 weeks
Follow up to treatment Posioner or retainer likely needed ongoing,
maybe only at night
Posioner or retainer likely needed ongoing, maybe
only at night
Pros More eecve for more complex issues.
No temptaon to leave them out, so less self
discipline is needed for success.
No extra cleaning steps required besides regular
brushing and ossing
Invisible
Removable
No issues with food geng caught.
No diculty eang.
No discomfort from wires.
Cons May have some pain, sores or discomfort from
wires, brackets or tooth movement
May have some tooth discoloraon or breakage
May have diculty eang scky, hard foods
May have discomfort from tooth movement.
Must remove before eang or drinking anything but
water.
Must brush aer each meal to avoid staining.
NOT ideal for Paents playing rough contact sports regularly Paents with:
bridgework
back tooth bite issues
The need to rotate canines or premolars
The need to move teeth vercally
Lack of discipline to keep trays in for at least 22
hours daily
Table-1: Dierence between tradional braces and Invisalign

Srivastava, et al. Sequential Removal Orthodontics
35
International Journal of Contemporary Medical Research
International Journal of Contemporary Medicine Surgery and Radiolog y Volume 2 | Issue 1 | January-March 2017
5. Relapse after using appliance therapy.
6. Minor rotations.18,19
CONTRA-INDICATIONS
1. Teeth with crowding and spacing more than 5 mm.
2. Anterior-posterior skeletal discrepancies of more
than 2 mm (as measured by discrepancies in cuspid
relationships).
3. Centric-relation and centric-occlusion discrepancies
4. Severely rotated teeth (more than 20 degrees).
5. Open bites (anterior and posterior) that need to be
closed.
6. Extrusion of teeth.20
DISADVANTAGES
1. It is a fact that the aligners are removable means they
are not persistently adjusting the teeth; consequently
they were to a great extent reliant on a patient's
propensities and their consistency in wearing the
aligners. e accomplishment of the Invisalign
aligners depends on a patient's dedication to wear
the aligners for at least 20–22 hours for each day, just
evacuating them when they are eating, drinking, or
brushing their teeth.
2. Invisalign® aligners are unable to rotate certain teeth.
For eg. few round shape lower premolars are difficult
for aligners to hold and rotate.
3. Various tooth movement capabilities of the wires and
braces is not yet incorporated in these aligners but as
advancements come in the near future we may attain
greater tooth movements leading to better treatment
results but of course will garner increased cost.
4. Likewise, these aligners have limited control over
various root movements -paralleling, revolution
rectification and tooth uprighting and extrusion.
5. Skeletal discrepancy is another area where the usages
of the aligners will have no effects, it would require a
surgery or prior orthodontic functional phase.
6. Some dentoalveolar movements of maxillary incisor
protrusion has been reported by these aligners.
Elastics to button bonded to the buccal aspects of
the aligners were also used but dislodging of the
aligners prevented the protocol. Having said that,
2mm sagittal A-P corrections of the buccal segment
have been reported through meticulous treatment
planning.
7. As the aligners are removable the operator doesn’t
have control over the treatment, if the patient for some
reasons discontinue its usage the whole treatment
plan has to be re-done which is called 'reboot' this
causes increase in the cost of the treatment though
one can buy a plan to cover the 'reboot'.
8. Align Technology admits that these aligners are bit
costly than the traditional wire and brackets systems.
9. As the aligners are removed while eating their chances
of being lost is high.
10. Severely tipped teeth (more than 45 degrees)
11. Teeth with short clinical crowns
12. Arches with multiple missing teeth.
ADVANTAGES
Being inconspicuous is the essence of these aligners, they
do the treatment without hampering the appearance
of the subjects and hence, has gain popularity amongst
young adults.
To add, aligners being removable in nature do not
interfere during chewing of food where as metallic braces
comes with strict diet plan and hygiene protocol from the
specialist.18,21
FDA APRROVAL
FDA in 1998 has permitted Align Technology, Inc.
to market its Invisalign aligners and these have been
classified under Class II medical devices with mandatory
510k clearance.
INVISALIGN COST?
e cost of orthodontic treatment using braces or the
aligners are almost equal and ranges from $3000- $8000
in USA. e treatment cost of using invisalign aligners
are determined by various factors like specific needs
of the particular patient and the plan designed for the
same. Various other determinants which have effect
on the overall cost of the treatment are duration of the
treatment, your location, doctor's experience and dental
plan/insurance. In some cases, complex treatment needs
may result in costs that exceed the range above.21
CONCLUSION
If anybody has a desire for a delightful smile, metallic
braces cannot be an option? Now, Invisalign® could
provide for you that smile you generally needed without
utilizing brackets also wires. Invisalign® is arrangements
of customized, clear, retainer-like appliances that can be
utilize to straighten the teeth. Basically unobservable and
removable, patient might at last smile with confidence.
e Invisalign framework has opened another territory
for grown-ups orthodontics, serving patients who might
not have any desire of routine appliances or for whom
conventional removable appliances might be unsuccessful.
REFERENCES
1. Roberts-Harry D, Sandy J. Orthodontics. Part 1: Who
needs orthodontics? Br Dent J. 2003;195:433-7.
2. White WD. Orthodontics. [cited 2016 Oct 9]. Available
from: http:// www.drwhiteortho.com/braces-101/
orthodontic/orthodontic-treatment-braces/
3. Metal braces advantages and disadvantages. c 2014
[updated 2013 July 30; cited 2016 Oct 9]. Available
from: http://bracesorinvisalign.com/metal-braces-

Srivastava, et al. Sequential Removal Orthodontics
36
International Journal of Contemporary Medical Research
International Journal of Contemporary Medicine Surgery and Radiolog y Volume 2 | Issue 1 | January-March 2017
advantages-and-disadvantages/
4. Acar YB, Kovan AI, Atesx M, Biren S. How Efficient
Are Clear Aligners? Clear Aligners vs Traditional
Orthodontic Treatment: A Systematic Review. Turkish
J Orthod. 2015;27:106-10.
5. Calcagno JC. Why do adults need orthodontic
treatment or braces? c 2003-2016 [cited 2016 Oct 9].
Available from: http: // www. drcalcagno.com/why-do-
adults-need-orthodontic-treatment-or-braces
6. Esfandiari AN. Invisalign treatment Irvine [homepage
on the internet. c 2015 [cited 2016 Oct 9]. Available
from: http://www.dramirdds.com/Invisalign-
Treatment-Irvine.php
7. Are these your teeth? Invisalign the clear alternatives
to braces. c 2011 [cited 2016 Oct 9]. Available from:
https://s0.yellowpages.com.au / 71b22e27-7df1-4912-
93ef-6d06eb876dab/hervey-bay-dental-torquay-4655-
document.pdf
8. Kuo E, Miller RJ. Automated custom-manufacturing
technology in orthodontics. Am J Orthod Dentofacial
Orthop. 2003;123:578-81.
9. Invisalign- For your dental health. c 2004 [cited
on 2016 Oct 10]. Available from: http://www.
cosmeticdentistfortlauderdale. net/ Davie/ articles/
ort_inv.pdf
10. Aesthetic Orthodontic appliances. In:An Introduction
to Orthodontics. Mitchell L, Carter NE, Bridget
Doubleday B, editors. Oxford University Press. 2007;
223-7.
11. Details about Invisalign- Treatment time frames. c
2000-2016 [cited 2016 Oct 9]. Available from: http://
www.animated-teeth.com/dental-braces/a3-invisalign-
dental-braces.htm
12. Invisalign Instruction manual. [cited 2016 Oct 9].
Available from:https://wikisites.mcgill.ca/Dentalpedia/
images/f/f6/Invisalign_mcgill.pdf
13. Align Technology Inc. e Invisalign reference guide.
Santa Clara: Invisalign; 2002.
14. Informed consent and agreement for the invisalign
patient. c 2010 [cited 2016 Oct 9].Available from:
http://www.newhopesoleburydental.com/wp-content/
uploads/2015/06/Invisialign-Consent.pdf
15. Newhart S. Invisalign manual. [cited 2016 Oct 9].
Available from: http:// www.drnewhart.com/docs/
NP%20Handout%20-%20Invisalign.pdf
16. Lozzi M. How invisalign works. c 2009 [cited 2016 Oct
9]. Available from: http://www.ortodonziaverona.it/
comeinvisaru.html
17. Braces vs Invisalign > From an orthodontist that
uses both [homepage on intenet]. [cited 2016 Oct 9].
Available from: http:// happytoothnc.com / braces-vs-
invisalign/
18. Joffe L. Invisalign: early experiences. J Orthod.
2003;30:348-52.
19. Naik VR, Chavan P. Invisalign: e invisible braces. Int
J Contemp. Dent. 2010;1:54-7.
20. Phan X, Ling PH. Clinical limitations of Invisalign. J
Can Dent Assoc. 2007;73:263-6.
21. Questions for your doctor [homepage on the internet].
c 2016 [cited 2016 Oct 9]. Available from: http://www.
invisalign.com/how-do-i-get-it/questions-for-your-do
ctor#sm.000tlj7vf13d2es3yon13o9jncc4q
Source of Support: Nil; Conict of Interest: None
Submitted: 04-01-2017; Published online: 09-02-2017