Invisalign versus implant therapy

Case presentation: Invisalign versus implant therapy

Every day we are faced with challenging cases. Should we extract, file down or build up?

But with experience one begins to understand which treatments work, which are too outlandish and which should never have been started.

However when a tooth is destined for removal then the resultant space presents a dilemma.

Should we restore the space or should we prepare adjacent teeth for a bridge and thereby reduce the life expectancy of these teeth as well.

Restoring a space has evolved from dentures to the use of dental implants, mini or maxi. Even if a mini implant can be used, does the patient want implants and will there be adequate space for a reasonably life like crown?

It seems logical that if the space is too small to restore then we should try to close the space instead of opening it up for an implant. This option is gentler, quicker and less expensive.

A delightful lady was referred to me for an opinion on how to restore a failing UR2 post crown.

She came with her husband and I have to say that we got on right from the start.

The lady was 60 years of age and in good health. Her dentition was relatively unrestored and she had good oral hygiene.

Her brother in law was a dentist and had read one of my articles on Invisalign and hence referred the patient to me for a solution.

She presented as follows:

  • Class 2 skeletal base
  • Class 2 div 2 dental crowding
  • RHS canine was full class 2 and rotated
  • LHS canine was half class 2
  • Overbite was slightly deep
  • Centrelines incoincident
  • Arch collapse laterally especially RHS with slight open bite
  • Upper central incisors were retroclined and the laterals were crowded

Initial presentation:


UR2 had been prepared to bring it into the arch 35 years ago with a metal porcelain post crown.

It was very long and had a tapered crown. The length signified that the tooth must have sat very high labially but would have been short at the incisal edge.

It had a vertical root fracture and was beyond saving. The problem was that the root was still outside the dental arch and the interproximal space was about 3mm.

There was no room for a dental implant so the options discussed were:

  • Orthodontic distalisation of RHS segment to create space for an implant
  • Cantilever bridge from UR3 with a similar pontic
  • Fixed UR13 bridge
  • Denture
  • Close space orthodontically

As the patient had class 2 div 2 dental crowding I advised the patient that we could use Invisalgn to:

  • Upright the centrals
  • reduce the overbite
  • correct lateral arch collapse
  • correct lower crowding
  • close UR2 space
  • preserve her natural teeth

The problems that I had were as follows:

  • Would the gap close?
  • Would the gum line be uneven?
  • Should I have waited for soft tissue maturation?
  • Will uprighting her arch create more space when we are trying to close a space?
  • Would the patient accept the attachments?
  • UR3 class 1 was not going to be the goal here
  • Correcting centre line would have created more space RHS to then have to close

Patient agreed on Invisalign treatment as she wanted to preserve her natural teeth. She was happy not to correct the centre line because her UR2 space closure was her priority.

Her brother in law removed the UR2 and she came in for impressions.

Invisalign scans were produced and the images are shown as below:


There were 28 upper and 11 lower aligners. The treatment included :

  • Arch expansion by derotating 654/456
  • There was some IPR required LHS to improve the canine position
  • Uprighting central incisors
  • Intruding upper incisors to reduce overbite and bringing the UR1 closer to UR3
  • Intruding lower incisors to flatten occlusal plane
  • Derotating UR3 mesially towards UR2 space

The aligners were custom made for each individual stage and there was no pontic allowed UR2 due to lack of space.

The patient changed each aligner every 2 weeks and came on Saturdays every 8 weeks for a review.

Her oral hygiene was impeccable and she had only 1 problem and that was a slightly dry mouth with the aligners.

The space was less noticeable with the aligners in due to the natural reflection of the material.

The patient had no problems in removing the aligners and she started to notice how her smile widened with throughout the treatment.

Once the lower treatment aligners were finished we carried out some minor refinement.

After approximately 15 months the treatment was finished.


You will notice that the UR2 space closed completely and moving the canine mesially created an incisive papilla. Lower gum line is even as well. The occlusal photo shows a nicely rounded arch.


“The teeth are still looking good, I am really pleased that I had them done, money worth spending ( one less holiday!)”


If a patient has had healthy teeth for over 55 years then why would she want them filed down for a bridge? It is never too late to do Invisalign.

Using Invisalign to treat a dental phobic who wants braces

A dental phobic is a person afraid of anything to do with dentists. These phobics are happy to brush and floss but fail to attend for dental treatment for fear of needles and also the drilling procedure.

Case presentation

The following is a case of a young 19 year old female who as a needle phobic had avoided vaccinations, dental injections and had even bit her last dentist on the finger.
She presented with her mom in desperate need of orthodontic treatment.

Naturally she had not accepted dental extractions and fixed orthodontics as a teenager but was now keen to be able to smile.


She was an attractive young girl who did not like to smile.
After careful consideration of her dislike of dentistry and for not losing a finger I examined her and found her suitable for Invisalign treatment.

The patient was a mild class 2 dental and on a class 1 skeletal base

UR3 was half class 2/ UL3 was class 1 leading to a proclined UR1

Centrelines were acceptable

Oral hygiene needed improving

I wanted to reduce the amount of dental procedures for her so I decided:

  • No extractions
  • No interproximal reduction
  • Attachments were delayed for 6 months
  • Upper arch space was created by distalising the molars
  • Lower arch space was created by arch expansion
  • The distalisation of the molars is only possible if the third molars are missing or oven unerupted
  • There were 35 upper and 17 lower aligners


I saw the patient every 6-8 weeks with no problems or tantrums.

At aligner 11 after molar distalisation, the premolars are then distalised allowing the anteriors to start correction.
At the end of the treatment of 18 months I was so happy that we agreed to remove the attachments and then take impressions for retainers.


Unfortunately the dental phobic had spent the last year on Google and had become obsessed with her teeth. She wanted them even straighter and had asked for a second opinion.
Another dentist not knowing how nervous she had been recommended further anterior correction, which would have involved IPR.

She came back to the surgery and started shaking and crying in front of me. I was annoyed as I had already ordered the retainers and this precluded further refinement.

So I was surprised by her change of heart as I had thought that she would be happy just having them straighter. But I was wrong as she wanted the straightest.

I agreed to pay for Invisalign Lite (14 aligners) and she agreed to pay for new retainers.
The upside was that she did refer her mother for Invisalign as well.

The refinements were 7 aligners in total and again no IPR.
She then did not attend for over 15 months and decided to treat herself with the aligners.

After that period the patient attended wanting even more retraction of the UR1, but I refused to bend to her wishes. I commented that she was non- compliant and that if she wanted more work then she should see that other dentist.

After 45 minutes of deliberation and mediation with her mother she agreed to retainers and only after I had contoured the incisal edges of at least 8 anterior teeth.


The patient did have a soft tissue triangular space between 1/1 but that could only be reduced with
aggressive IPR.

The final alignment actually looked worse than the refinement but this was because the patient never attended for reviews.

Invisalign when used to its full potential allows the dentist and patient to benefit from full spacecreation and minimal IPR.

When treatment planning involves the patient then Invisalign can convert the dental phobic into a fully committed dental patient.

Orthodontic referrals can be forwarded to
Dr R Kumar is conducting national seminars on removable orthodontics and Invisalign certification and enquiries can be forwarded to


Correcting overjets

“Orthodontics is a speciality that is taught very little at the undergraduate level. Students get a few lectures and learn how to make a removable acrylic appliance, and perhaps they may even get to treat a few simple cases. The majority of teaching is done at post graduate level.

I studied at Guys Hospital, we were taught comprehensively the structure of the tooth, crown and veneer preparation and dental materials. I qualified in 1989 at the time of no prior approval. One of my first patients had severely proclined but healthy teeth. I prescribed orthodontics or crowns but the patient opted for a quick fix. I still remember how I decoronated 6 upper anterior teeth, root filled them and post prepped them all in one sitting (this was certainly not minimally invasive dentistry). Tapered metal cast posts and porcelain bonded crowns were prescribed and fitted. Twenty-three years later the teeth are stable and nothing has failed…”

This is an excerpt from an article I wrote for the July 2013 issue of The Dentist Magazine.

Click here to view a PDF with the full article.

Change With A Smile


Invisalign for extreme crowding….will it work?

In 2004 I had maintained a private practice in the West End for over 9 years and I was doing a lot of cosmetic smile makeovers.

So I naturally wanted to progress and learn more about the art of smile makeovers from the US.

I knew of an eminent clinician in New York who ran a veneer course. So I Googled him, but I came across some very bad reviews. On one website I found an image of one of his failed veneers:

I naturally did not want to fall into the trap of promising excellent cosmetics on shaky ground such as the prepped tooth above.

Now we all know veneers can be very thin or even non prep but how many patients do you see that have straight teeth and want veneers?

In 2004 at an orthodontist’s open evening I stumbled upon Invisalign. I went on the course and certified as an Invisalign provider.

On the Monday morning after the first patient that I saw had come in with multiple spaces and protruding teeth. He had come asking for veneers, but then I thought if I do veneers, he will end up looking like Jim Carrey in the Mask.

I convinced him that he would look silly and he needed orthodontics. I showed him how Invisalign works; he was my first case.

After 9 years and 760 cases of Invisalign I have never looked back. In fact I have done only 3 smile makeovers in that time; 2 were replacing old veneers .


Invisalign as many of you know is a clear aligner system. The parent company is Align Technology and is based in California. They have scanning facilities in Costa Rica, research facilities in USA, UK, Israel, Holland etc. At a recent conference I was informed that Align spent $45,000,000 last year in R&D.

Invisalign is a series of aligners that are planned with computer aided design and scanning (CAD), and created with 3D printing (CAM). Each aligner exerts a small force and the teeth usually move according to plan.

Impressions are taken as 2-stage silicone impressions or you can take digital impressions with the new Itero scanner.

I would like to describe an interesting case of moderate to severe crowding in a class 1.

Invisalign case

Dr KN had just recently qualified as a medical doctor and came in from a recommendation.

He was very quiet, did not smile and wanted his teeth straightened. He did not want to have fixed braces.

Start images

My findings were:

Class 1: collapsed posterior segments: moderate upper, severe lower crowding: centrelines were not coincidental: mild class2 canine RHS.

I agreed that we could try Invisalign as the lower arch was very crowded and that the scans would show if lower extractions were necessary.

The planning was done by me and I wanted to avoid extracting upper premolars because the patient was very conscious of his smile and he did not want prolonged treatment if possible.

Treatment schedule:

The aligners came back as 39 uppers and 29 lowers. The upper arch was expanded and interproximal reduction was carried out at the 2/3rd stages in order to help shift the upper centre line and to

reduce interproximal triangular spaces. Lower first premolars were extracted at the beginning.

I saw the patient every 6-8 weeks for reviews. I checked the aligner fit, attachment activation, contacts and collisions.

Over time his crowding was alleviated and he started to chat and smile more often.

After a period of 18 months we took refinement impressions for minor corrections and closing the extraction spaces. There were 7 refinement aligners in total.

Refinement images

Final images

Things that I did not do

I did not consider class 1 canine positions important because that would have involved removing 2 upper premolars or unnecessary stripping. The lower incisors were not in the midline as that would have involved either LHS molar distalisation and longer treatment, or aggressive stripping LHS and shifting all the lower RHS teeth to the LHS.

Patient was not concerned and was happy with the treatment time.


Orthodontics for a general dentist is always a steep learning curve. It takes about 1 year to see results and you do not really know whether they will be as expected.

Invisalign is a system that is easy to use for the patient, but difficult for the dentist to implement. If you have a non-compliant patient then the results will be less than satisfactory.

But a well planned and well explained treatment using Invisalign with a compliant patient is a new way to do orthodontic treatment.

When can I use Invisalign for a patient living in another country?

Orthodontics is the art of moving teeth to a place of patient satisfaction. We do not cut, trim, mask or cover teeth to get this desired position. We have to use our skills as dentists to propose a series of tooth movements and the teeth must follow.
Tooth movement does not always go to plan and that is why it is imperative that the patient attends regularly for review of treatment.
About 18 months ago a couple turned up and the groom wanted his teeth straightened. The problem was that he was leaving in the next weeks for India and would not be back for 12-16 months.
He had:
upper centre line was off to the right
upper and lower crowding
upper lateral incisor was in a crossbite and not visible on smiling
So I examined the patient and assessed his condition and with some trepidation, agreed to provide Invisalign.
Invisalign is a series of clear aligners that are changed in a series every 2 weeks creating orthodontic movements.
Invisalign also needs some interproximal spaces and composite attachments
that are usually done after the scanning and planning process.
But the patient was leaving soon and could not come back when the aligners were here.
So I had to give him attachments and make spaces.
Attachments are usually put on after the aligners arrive as the box contains a template for the attachment process.
So at day 1 I improvised.
I had a patient case unused with an attachment template and used it to place attachments where I deemed them necessary.
I also carried out some interproximal spacing where I thought necessary.
I then took the impressions.
It is very unusual to start a case with attachments already on, but Invisalign did not notice.
I viewed the scans and agreed with the movements.
I stipulated that there should be no more spacing/dentist intervention until the end.
The braces arrived and the patient paid for them to be delivered to India.
BUT customs got hold of them and wanted money.
They were held up in customs for 2 months before the patient got hold of them.
During the treatment he sent me some pictures of the aligners in the mouth.
18 months he came back and WOW
the teeth were exactly as the scan and I had predicted.
He had some cleaning to do and very little else. But to get his moneys worth he wanted a little more pushing out of the aligner…cheeky bugger.
Anyway enjoy the picture of Invisalign 18 months in 1 visit

My teeth are so good that I forgot how bad they were

My teeth are so good that I forgot how bad they were

This lady had complained of anterior crowding and had already had orthodontic treatment. Her main complaint were the 2 severely overlapped upper incisors.

We assessed her scans and decided against extractions. The arches were expanded, the lower teeth pushed down and out into a wider arc.

The biggest problem we had was the overlap of her central and lateral incisor. Due to this overcrowding, the gum tissue had never developed or was deficient. So when we straightened the teeth, we had a soft tissue triangular space.

We had to reshape the sides of the 2 teeth to be less triangular and to allow Invisalign to bring the teeth together.

It took over 2 years to finish, because the patient became obsessed with these 2 teeth and had actually forgotten how crowded she was initially.

We spent about 9 months just refining the 2 upper incisors.

I was happy with the result but the patient had forgotten the beginning until I showed her the original photos. She then agreed with me, but she never wrote a testimonial.

See for your self.


Invisalign to widen the arch and instil confidence

How to widen the arch and instil confidence without metal braces


Miss SM was a very shy person and could not really afford Invisalign. But she hated her smile and had absolutely no confidence.  She hated that her front tooth was sticking out so much.

She had moderate crowding with a narrow high upper arch, which compressed her dental arch leading to overcrowding.

She wanted to know if I could treat her with Invisalign, and I said yes.

My aim was to use the Invisalign aligners in a sequence to gently push out the dental arch and create spaces for her front teeth.

We took did not take any upper teeth out and we started Invisalign.

Even though she did not come as regular as I had hoped, I could start to see a change in her confidence. She was more talkative and open.

We are at the end of the initial set of Invisalign aligners and she is getting married soon. We will continue with refinements afterwards.

You can see a nearly perfect rounded arch form that needs some slight refinement.


Invisalign; when to take a tooth out

Dental crowding is an issue of too many teeth and not enough space.

Why is that?

Are we normally born with too many teeth? The answer is No! What has happened is that the size of our dental arch is either developing into a smaller arc, or our dental arch is being constricted.

The latter is usually the case. As we stress over our studies, partners, work and health, we tend to clench and grind our teeth.

The action of our chewing muscles on the teeth causes movement inwards and constriction, leading to dental crowding.

So with Invisalign I usually expand the dental arch to create space, but not always.

Sometimes it is easier to take out the offending tooth and then straighten the teeth

See below, a severely crowded lower arch, corrected by Forma with Invisalign in just over 10 months. The outer tooth was removed first and Invisalign worn night and day.


Do you treat yourself to a television or a better smile?

Dental crowding is a major factor in low self esteem, low confidence, bullying, hiding behind your peers, lack of social contacts and even a better spouse!
So if teeth are such trouble then why don’t we do something about it?
Let’s imagine the 46″ Sony Plasma is looking a little jaded and the picture looks so fuzzy that you thought that England had just scored 5 goals?
Well you thought wrong, that was Germany.
So now it’s time for High Definition TV.
So you drag your wife ( as it’s usually men who buy big TVs ) to the local Comet and convince her that you need a HD LED 50″ Sony.
So that evening the TV is placed on a wall bracket and they both watch Top Gun in HD.
As a thank you he has an early night and they have some fun.
Problem was that he has bad breath and his teeth are very crowded, she can taste his meal on his teeth.
So the moral of this little story is you cant take your high tech HD TV with you to bed.
If you have a dental problem and your spouse is kind enough to point it out, then at least look into sorting it out before your adorn your house with the latest gadgets.
Here is an example of how Forma Dental can make a difference.