A New Helping-Hand Concept for Invisalign Users

Many general dentists have said that they need assistance in 3 key areas when doing Invisalign (Align Technology) cases, especially in their initial learning stages: case selection to improve treatment predictability, reducing doctor time and effort when doing their cases, and minimizing the amount and depth of specialized training required to use the system. In response to these requests Align Technology has developed a new treatment planning and monitoring system to address these areas (Table). This provides the general dentist with assistance in getting optimal results when utilizing Invisalign techniques for the orthodontic treatment of their patients.
The product, Invisalign Assist, was designed to assist general dentists who are in the early phases of their Invisalign training, typically doctors who are in their initial learning curve, and may not yet have much experience with the systemís techniques and outcomes. Despite their lack of experience, they want to be confident that they can successfully deliver excellent orthodontic treatment to their patients. By using this system, and through performing the scheduled activities in the Appointment Planning feature, the doctor becomes more familiar with the finer points of the process. This in turn helps to ensure that an orthodontic case done with this system has a successful clinical outcome. Furthermore, instead of avoiding the use of Invisalign, which is a common response to the uncertainty that many recently trained dentists report, they can go through the treatment process with more confidence using this additional procedural and technical support.

INVISALIGN ASSIST TREATMENT

Treatment delivery with Invisalign Assist occurs in the following stages: (1) assessment and prescription for Invisalign Assist treatment, (2) virtual set-up and aligner delivery, (3) progress monitoring, and (4) treatment finishing and retention. Letís look at each of these stages in more detail.

STAGE 1:
Assessment and Prescription

Figure 1. Simplified ClinCheck interface for Invisalign Assist showing appointment map (on left).
Figure 2. Records needed for initial Invisalign Assist submission include PVS impressions, PVS bite registration, and patient photos.

After choosing Invisalign as his or her treatment method, the doctor writes a diagnosis and treatment plan evaluating the patientís chief concerns and needs and submits a prescription form to Align Technology. This prescription includes appropriate instructions so the technician can create a ClinCheck virtual set-up that is then posted online for the doctor to review (Figures 1 and 2).
When using the standard Invisalign product, this prescription is fairly detailed. The doctor can also add precise instructions so the Invisalign technician can understand what the doctorís treatment goals are and what is necessary to achieve them. Invisalign Assist, however, requires a much a simpler prescription form and treatment plan. The Invisalign technician then follows these instructions to create the ClinCheck set-up.
When the doctor chooses Invisalign Assist rather than standard Invisalign, the doctor is, in effect, informing Align Technology that he or she agrees to the Invisalign Assist set-up protocols, and that the treatment goal is primarily to address the patientís aesthetic needs as the chief concern. The doctor is also stating that he or she wants the ability to deliver this treatment by relying primarily on the use of the aligners only, rather than utilizing more complex orthodontic techniques and auxiliaries.

STAGE 2
Delivery and Virtual Set-up

Because Invisalign Assist is meant primarily for simpler cases that require less movement, fewer elements are required for the doctor to fill out on the Invisalign Assist prescription form when submitting a case. This is partly due to the less complex nature of the cases for which the service is designed, and partly because of the improved software capabilities developed to facilitate the online submission of forms and records.

In this spirit, the Invisalign Assist treatment submission process in all treatment phases has been simplified. This reduces the amount of input the doctor needs to provide yet still captures the information Align Technology needs to fulfill the doctorís prescription and successfully achieve his or her treatment goals.
During creation of the virtual set-up, if the case doesnít meet with the clinical rules of Invisalign Assist, the doctor will be informed that his or her treatment goals cannot be achieved using this product. Three treatment choices are then presented:

  1. Switch to the standard Invisalign product. This gives the doctor a more involved and detailed level of interaction to guide the technician in the design of the virtual treatment set-up. It also places more control in the doctorís hands for treatment planning decisions that may require the use of more advanced orthodontic skills and auxiliary techniques.
  2. Refer the patient to a more experienced Invisalign provider, such as an orthodontist. If the doctor feels that achieving the desired clinical result in this particular case goes beyond his or her level of comfort or experience with Invisalign, this may be the preferred choice.
  3. Finally, the doctor may also cancel the treatment, and Align Technology will not attach a financial penalty.

ClinCheck and Appointment Mapping

If the case qualifies to be treated with Invisalign Assist, the virtual set-up is delivered online for the doctor to review using Invisalignís proprietary ClinCheck software. This enables the doctor to review and ìplayî the virtual treatment on the computer in the form of a 3-D movie that shows how the teeth are expected to move from their initial position to their final desired position (Figure 1).
Also included in this virtual treatment set-up is a full summary of the clinical actions that the doctor should perform in order to deliver Invisalign treatment to the patient, as well as a detailed plan for the tasks and actions that should be performed during each patient appointment that will take place through treatment delivery. In this task list, the doctor will find specific information on what should happen during each office visit, enabling the doctor to plan accordingly.
When the doctor accepts the Invisalign Assist virtual treatment plan, instead of fabricating and delivering all of the aligners re-quired to attain the desired treatment outcome to the doctorís office (as is the practice with standard Invisalign), an initial set of 10 upper and lower aligner stages (roughly 20 weeks) are fabricated and shipped to the doctorís office. This initial set of aligners includes detailed information on all of the clinical tasks that should take place during the use of the first set of 9 upper and lower stages, which will be given to the patient in 3 office visits, each 6 weeks apart.

STAGE 3
Progress Monitoring

Figure 3. Progress display of teeth: off-track (blue) and on-track (green). Treatment staging will be modified accordingly, and then the next set of aligners will be manufactured incorporating the needed corrections. Figure 4. Illustration of actions required and who performs them, within Invisalign Assist.

After the patient has worn the ninth set of aligners and visits the doctorís office for the fourth appointment, the doctor then takes a new set of upper and lower impressions. These impressions are sent to Align Technology so treatment progress can be assessed by comparing it to the virtual treatment plan. (During this time, the patient will be wearing a 10th set of aligners to hold teeth in place while Align Technology performs the assessment.) If the treatment is tracking well, the next set of aligners is promptly fabricated and shipped to the doctorís office. If, however, the progress assessment determines that some corrective action is needed to achieve the prescribed final outcome, the next part of the treatment will be restaged from the position of the teeth at that time. The next set of aligners, with the new staging, are then fabricated and shipped to the doctor. In either case, the new aligners will now be sent to the doctor with a list of tasks that should be performed during the remaining appointments (Figure 3).
Depending on the length of treatment, additional progress impressions may be needed periodically so the treatmentís progress can be monitored and appropriate adjustments can be made. At any point in the treatment delivery, if teeth do not track as expected the doctor can take a set of impressions and send them at no additional cost to have the progress assessed and the treatment restaged (if needed). This is an important safeguard to help ensure that the originally approved treatment goal is successfully achieved (Figure 4).

STAGE 4
Treatment Finishing and Retention

After the patient has worn all of the aligners, the doctor can review the clinical outcome and decide if additional detailing or finishing is desired. This could happen, simply due to the fact that tooth movement is not completely predictable. It may also occur due to patient compliance issues or because of a desire to address a patientís aesthetic concerns that may still be present at the end of treatment.
If the doctor and the patient agree that additional refinement is necessary, as many as 3 refinement cycles are included in the product price. This helps ensure that both the patient and doctor finish the case satisfied that the initially agreed upon treatment goal has been achieved. These refinements must be performed within 180 days after treatment is completed.
By superimposing the progress impressions with the original virtual treatment file at the patientís current stage (using the Progress Tracking software), Invisalign Assist allows the technician to restage any teeth that are not tracking with the aligners as planned. This technology, coupled with regular progress impressions, is designed to help ensure that any potential prob-lems in the treatment delivery are caught before they fully manifest clinically in the patientís mouth.

CONCLUSION

Doctors should gain greater clinical confidence knowing that when they treat a case using Invisalign Assist, the virtual treatment outcome goals established before treatment begins are much more likely to be achieved clinically, and that they will be aided during treatment by new clinical technologies designed to keep the case on course. It provides the assistance doctors need to succeed clinically, while at the same time helps them gain the clinical experience and confidence necessary to successfully integrate Invisalign into their practices. This helps ensure more doctorsí success, and, most importantly, more patientsí satisfaction.


Dr. Sterental is the clinical director of new product development at Align Technology, where he has worked since February 2003. He is also a member of the companyís Speakers Bureau, and was a contributing author of the textbook, The Invisalign System, edited by Dr. Orhan C. Tuncay. He is also an adjunct clinical assistant professor in the Invisalign Undergraduate Clinic at the University of the Pacific, San Francisco. He is an international member of the American Association of Orthodontics, and a member of the World Federation of Orthodontics and the Venezuelan Society of Orthodontics. Prior to joining Align Technology, he worked in private practice as an orthodontist in Caracas, Venezuela, from 1989 to 2002. Before that, he worked in private practice in general dentistry from 1985 to 1989. He earned his dental and orthodontic degrees from Universidad Central de Venezuela, Caracas. He can be reached at terental@aligntech.com.