If you are a frequent reader of my blog (www.straightsmilesolutions.com/blog) or a subscriber of my YouTube channel (https://www.youtube.com/c/Straightsmilesolutionsortho), you’ve become accustomed to my tricks and tips on attachment and auxiliary design and placement. And you probably know that I think “optimized” attachments are mostly an over-hyped, proprietary feature of Align Technology. Below, I have compiled some tips and tricks for attachment placement and design. These aren’t from any book or class, they are just tricks that I’ve learned over 18 years as an Invisalign provider.
- You CAN put attachments on both the lingual and palatal of teeth, if there’s space and clearance.
For rotated teeth, just ask! We do this all the time in braces with moments and counter- moments with buttons and chain, why not in aligners? Fun fact: many white-label aligner companies also let you do this. Make sure you remove the palatal ones towards the end of treatment before they affect the bite, though. Treatment timing is critical.
- Invisalign needs more attachments than other systems because of retention. If you don’t use Invis, you’ll need FEWER attachments.
Invisalign’s very scalloped and low-profile trim and elastomeric, thermoplastic material necessitates the use of copious attachments. That’s just how it is. Often, they are only there to hold the aligner in. This is why some direct-to-consumer companies have higher trim and still get good outcomes.
- Always put attachments on for extrusions of incisors, even if the software doesn’t recommend IT.
Anytime I see incisor or canine extrusion, I ask for attachments. If it’s a lot of extrusion (more than 1mm- aka a blue or black dot), ask for a “full-sized horizontal, rectangular attachment”.
- Always put attachments on for rotations of incisors or premolars more than 15 degrees.
Anytime I see big rotations on premolars or incisors or canines, I ask for attachments. If it’s more than 20-25 degrees, I ask for “full-sized vertical, rectangular attachment,” or you can ask for a counter-moment with an opposite attachment on the lingual or palatal (see #1).
- Power ridges are uncomfortable and cause the plastic to jet-out. There are other ways to get torque but they involve either hybrid treatment (with braces) or attachments.
I’m not a huge fan of power ridges, but they can work for single tooth torque in a patient who can tolerate the irritation of the plastic. Orthodots are great aligner band-aids.
- Chewies are necessary to FULLY engage your attachments.
All your patients should be using aligner chewies regularly. They are a $1 key to success that you should give to every patient, and you can buy all shapes and flavors on Amazon. Sometimes gaps or tracking issues aren’t related to the actual tooth where you see them but are related to an adjacent tooth that is intruding and not tracking. For example, if you are intruding #8 and the intrusion isn’t tracking, you might see a gap/tracking issue incisal to #7. Doctors can get puzzled because there was no extrusive mechanics in the treatment plan, but this is just relative to the movement on the adjacent tooth. Using chewies everywhere around a tooth that isn’t tracking, not just on the tracking gap, will help to fix the case without a refinement. Usually, it is best to “backtrack” one or two aligners and start the movement over.
- If you are using precision cuts and elastics, it is best to bond to the TOoth and not use slots, because this causes retention and tracking issues and requires way more attachments to anchor the aligner on the mouth.
I stopped using slots and only started to use buttons on class 2 and class 3 movements. Yes, it’s a few more minutes to bond, but ultimately, you’ll need fewer attachments for retention and will have less tracking issues.
- Open bite cases will need large attachments on the premolars to support the extrusion.
I actually think it is EASIER to treat open bite cases with plastic than with braces, but don’t forget to put full-sized horizontal attachments on the premolars AND eliminate any myofunctional habit prior to starting aligner treatment (tongue thrust, mouth breathing, finger sucking). Believe it or not, some adults still do these things and it will unravel your outcome. The tongue is one of the strongest muscles in the body. I always say that open bites come from somewhere, so you must be a detective to find the source and treat it as well.