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hello lie donation thank you for watching the laws of attachments this is a presentation I gave in Las Vegas at the AAC a convention in June and I dive deep into my theory of attachments give you some rules and principles to follow when thinking about when to use what attachment and it references some great invisalign forefathers john morton scott for a few others and one of my mentors randy Kunak and if you like what we're talking about you can dive a little deeper with those guys I also want to emphasize something that is very important to me and that is access to align our education and it's just my theory that the more we contribute and collaborate the more we all grow and there's just not enough out there and if you feel like there should be more free invisalign education available on platforms like YouTube and Facebook please like comment share and this is the you know equity I get is when you guys share and enjoy this stuff it makes me want to do more so please enjoy the laws of attachments thank you much you so how many of you guys get Clint checks from Invisalign that look like this attachments basically on every tooth in the mouth why does it look like this why are we getting Clint checks back like this and is this a good Clint check but it's kind of a quick trick question because we don't have a picture of the patient we don't have images we don't have x-rays we have no idea what this patients concerns are or their diagnosis is and that is the key Invisalign Clint check algorithm is constantly advancing and it is an amazing sophisticated piece of software but it doesn't take the patient's face and concerns into consideration and when people are doing directed consumer products like you know many of the ones advertised out there they aren't either they're using the scans or models of teeth to try to move teeth without attachments in IPR without understanding a person's diagnosis and concerns so yeah maybe this is the right Clint check for a patient but we know that if we have attachments like this on a patient that are placed by the Invisalign algorithm and that is trying to torque these roots to the distal which means they're trying to get these mid lines to match up but you know if you study Bill Robbins and and if you looked at facially driven diagnosis or global diagnosis we know that the position of the central incisors is more about where they fit in the face and less about how they relate to the lower arch so this could be a great clinch check it we don't know but if it is not if the end result does not put the teeth in relationship to face in the right place and we know we don't need these double spike attachments because it's much easier to tip the crowns to the left if we're torquing the roots to the patient's left and not tipping the crowns to the assuming they're or just the patient's right and the crowns to the patient's left then we don't need these double spikes at all Randy Kunak who's been a amazing mentor to me and orthodontist that's willing to train and teach dentists and I hope has benefited greatly from it has said this and his lecture called the reference tooth he says that when you begin an Invisalign case you start with a facially driven diagnose you look at all the information you look at the x-rays you look at the periodontium and you determine the teeth that don't need to move first and then you right-click on a clinic and you make them unmovable and you reverse-engineer the case from there you determine the easiest ways to move the teeth that have to move now this concept if you understand this and grasp this you will save yourself so many refinements I call them revisions if you have to change the outcome but a refinement you can prevent if you get the diagnosis right and only move the teeth that have to move so important so let's get into attachments real basic overview what is an attachment it is a projection of plastic off a tooth that's bonded onto the tooth at the beginning of a Invisalign case to help affect the force systems on a tooth some movements cannot be accomplished without attachments and those movements for example are extrusion of a tooth plastic cannot extrude a tooth without an undercut for the plastic to grab onto it be equivalent to a picking up a wet watermelon seed with your fingers patients don't understand that sometimes it's a hard thing to grasp and when you are looking at a direct-to-consumer product that doesn't have attachments there's no way they could extrude tooth to bring it down and there's really no way that they could get certain route torques accomplished and things like that you need attachments to get the specific forces on teeth there are different sizes and shapes and VIS lines been doing a lot of research for the last 22 years to determine what the best shape is to get the right forces on a teeth on a tooth it's a very sophisticated science and it looked like this on the clench ekhan our planning motive protocol and in the mouth it looked like this very hard to see slightly translucent this tooth has a little excess on that you can see there's a little staining around there patients can feel them especially these spiky ones that project off the tooth there's a teardrop attachments so we need to know why they're there whether or not they're needed and we need to be able to educate patients what to expect you know there are pros and cons to attachments certainly it's also important that every Invisalign provider and professional knows what the attachments are therefore why did the algorithm put them there you need to memorize this it's very easy to find just google smart force attachments and features by Invisalign that's the title opinio you will find it and it has a list of every single attachment what it's there for why they're put on what the different generational movements are the g6 g7 g8 with the conventional attachments look like it why they are the shapes that they are this is simple and it has to be memorized it's only three pages they are also updates to this constantly and so we have to be abreast of the newest and best attachments out there so please memorize that and understand those things if you want to understand a little bit more about why different attachments are shaped different ways and why certain attachments are better than others john morton published a video and it's called the innovations of Invisalign and it is hard to find I recommend going to align our nation it's a Facebook page that a few of us aligned with professionals host and Jeff Skinner posted this video john morton video i think it is the single best resource to understand why attachments are used and understood john morton is brilliant and has done more a line of research for Invisalign and other companies and about anybody else i've ever read please check that out the newest addition to attachments are the large optimized attachments i do want to make everyone aware of this that was not put on the smart feature slide this just came out about two months ago let's go back to this and this is what it looked like there larger the idea is that the active surface where the dimple is where the plastic engages is bigger and is a bigger relief for the tooth to move into bigger is better as we say in Texas and hopefully this will allow more force on teeth and more predictable movements with these attachments I've been reading and studying the last 12 years since I graduated different techniques in a liner science I was trained in 2006 a lot of updates have come out a lot has been written a lot of it is hidden behind barriers either have to be a dentist or orthodontist or spend a ridiculous amount of money to understand it and I feel that it is ever-growing skill and science and we are still writing these text books and they quickly become outdated and I think it's important that everyone have access to these things if they want it some of the more influential pieces of literature and my experience have come from dr. berry glaciers book the Invisalign treatment he's an orthodontist has been open to training professionals sandir ties was helpful and dr. David Galler has been a tremendous influence on me with his reengaged course and his tip Tuesday's Lawless that's hardly good it's kind of hidden is there a best way to do it there's a lot of different theories out here every one of these books propose new ways to do clinch checks and I've applied these theories to different cases and sometimes bury glaciers techniques are better than dr. gallo sometimes dr. galas are the best and Werner ships had some great advanced techniques in his book it just depends and it depends on your practice and things on your patient and what they can tolerate those books in that literature has influenced my theory and has also influenced these laws these are five laws of attachments and I kind of reference where I learned them and and I'll give praise where praise is due number one law of attachment is you place Anchorage attachments on bicuspids this is dr. gallery dr. Glazer they talked a lot about this and dr. Glaser's 10 commandments of and business line and you do that unless you have natural Anchorage from teeth I'll go into that more law to you use smart attachments when you need them for specific tooth movements and that's John Morton and he's got lots of science to back this and I say that you use munch used to amplify those specific movements number three use out to my support attachments when you are extruding upper laterals and number four you use power ridges the lingual to torque on non continuous teeth dr. Glasser talked about this in his ten commandments and I'll go into that a little bit more and last you use the template aligner to put on smart attachments only guys first law Anchorage this is a common presentation in my office you notice very few attachments on this case and one of the full clincher is a slide but you see that the lower arch were intruding the anterior teeth loops and we have deep bite protocol attachments optimized extrusion attachment on a first bicuspid and the aligning has these thermoplastic features with dimples on it to get actual intrusion of the teeth and these are the magic trick here the secret sauce the sexy rectangular beveled attachment horizontal rectangular beveled attachment on the bicuspids for anchorage that's the key here and in my opinion anchorage is make-or-break feature it is the ability of the plastic to be anchored locked onto the teeth so that you have maximum aligner touching intimacy to the teeth to get the right force systems all right so rule one is Anchorage the horizontal rectangular bevel this is what it looks like they are standard on almost all my cases I put them on there to get aligners to lock on a teeth you'll notice patients they can eat with them even sticky food because the plastic is locked under those undercuts of those beveled attachments and I've been debated many times on what the position of those attachments should be if you look at this case here the bevel is facing the incisal edge and some people say well it's better to put the incisal or the bevel towards the gingival margin and have the the undercut and the other vector and to them I say cool whatever it doesn't really matter for Anchorage we're not trying to get a specific vector for some the teeth we're really there to get that plastic anchor on the teeth so that we can get the processor to do what it does best on the other teeth so for bicuspid attachments it doesn't matter if you're trying to be nice to the patient and they have natural undercuts in the teeth and other teeth and you have a good adaptation of the terminal molar and you get a undercut on that molar the plastic kind of anchors on there by itself and I tell you to put the bevel towards the gingival so when the patient is taking the aligners out it slides off this is kind of an abstract concept but if you have the the undercut right here it locks on and patients can even like break their nails sometimes trying to pull them off they're really anchored on powerfully so if you have undercuts the terminal molars or natural other cuts in the teeth you do not need to put the bevels towards the incisor like this so the debate about which direction to put them is the wrong debate the bevel can be towards the gingival edge or computers incisal edge depending on if there is natural undercuts elsewhere what are the exceptions to putting a CH Bev on teeth well number one if you have a lower incisor inter intrusion like this case you want to put an optimized attachment not an H bit and that is written in the g6 protocols from Invisalign check that out another exception is when there is natural undercuts in teeth and where do you get natural undercuts teeth that are pareo involved with a seed exposed there's natural undercuts there or if there is a missing tooth on the patient's arch that arch gets a ton of Anchorage from the plastic wrapping and the undercuts from the missing tooth and if you put h Bev's on all the bicuspids and have those undercuts the patient will have a miserable time removing their aligners and that decreases the patient's experience and our goal is to provide the optimum patient experience get my little picture out of the way here other exceptions not to place Anchorage attachments so rule one is about the Anchorage from natural to shape rule to the other reason not to place HMF attachments is the moment of force needed to achieve a specific movement let's say a rotation movement on a bicuspid is a reason to use an optimized attachment and not an H bib a smart attachment for a specific movement outranks a smart attachment so for example let's go back to that picture if I were trying to rotate this first bicuspid I would allow the algorithm to place an optimized rotation attachment instead of a H Bev attachment hope everyone understands that it's an important concept all right rule to respect the smart attachments use smart attachments for specific vectors of force in only specific vectors now the algorithm will automatically kick on and tell you when a optimized attachment is needed for number seven if you look at the tooth movement table there is a there is a twenty six point one degree mesial rotation and so they put an optimized rotation attachment on that tooth and my advice if that tooth does need to rotate 26.1 degrees you follow the advice of the algorithm these teardrop attachments that means that number six is extruding it also means that is rotating because the teardrop attachment does it extrusion and rotation now invisaligns algorithm wants to put perfect canine guidance on every case and look like perfect denture teeth but sometimes that's not in the page to the patient's best interest I look at this case and I think that the incisal edges of eight and nine they need to be even with number six but it looks like it's a little thingy a little long I will go in double-click eliminate that vetro movement verify that I do and in fact need a Museo rotation and often I will eliminate the optimize or the teardrop attachment if I still need the extrusion then I'll put an extrusion optimized extrusion attachment but oftentimes I'm eliminating these attachments and the rotation attachments depending on the patient's diagnosis that's the key the double spike has to do with route twerking and if you look at this tooth number nine has a five point one degree mesial tip torquing and you needed to see if that is actually what you need if I'm tipping the crown medially that means the I'm torquing the route distally in this case I don't really think I need to do that and actually this is set up to them sorry to do a mesial root torque torque the root medially it is completely necessary based on my initial assessment here I would double click that zero it out see that is a better treatment plant and then it removed the devil spike these are some abstract concepts and I know take some practice basically I determine what teeth need to move and how I'm going to move them based off the holy scripture here from dr. Geller and Ostreicher the go acceleration chart this was built on the backs of a lot of aligner science a lot of other research by people like Morton and I Stryker and dr. Geller certainly consolidated into this amazing single page reference and I go into this on crushing clench X a little bit try to look at this and understand if you have questions comment she but any tier one movement you don't need attachments for period tier two attachments certainly help and you want to make sure you change aligners at least seven days to ten days if you're using a munch you can tier two movements can go back to tier one in Tier three movements you certainly need to help with and sometimes attachments will help sometimes you need more than that it's unless you need to use propel or an accelerator to accomplish those kinds of movements and then sometimes you know route torque is simple if you have grid Anchorage and it's a young patient you don't need to pray so every case requires understanding of the patient's diagnosis this is a great framework to apply to every case but it doesn't mean that you have to adhere to it like a blackjack cheat sheet and that's the example I like to use to go into more about smart attachments I want to reference something Scott Frei and orthodontist in the owner of the ortho cosmos published on his blog and Scott Frey has a lot of great information unfortunately it's not available to many people unless you're an orthodontist and I got to give him credit for these slides I do have access to these and these are excellent he showed heat maps basically showing where the force moment of force is coming from with plastics and I will go into this slide in the more detail but I want everyone to understand this why smarten why we use certain smart attachments and only use them for certain movements well smart attachments were well tested John Morton Tessa does and he showed that they increase the biomechanical force systems and the predictability of certain movements he also helped design each shape of every smart attachment and he tested them tested them on over 10,000 cases and using big data from Invisalign scans and invisaligns impressions he was able to see which ones worked better and it's a constantly growing group and I don't believe that any other aligner system out there has that kind of data and as usually a decade or so behind every other clear aligner systems behind what Invisalign is doing because of the information that they have in data the description of these movements is available online they are not customizable manually you have to they have to be put on by Invisalign as Clint check algorithm and the algorithm automatically puts them on based on the tooth movements prescribed to teeth and munchies improve the effectiveness of certain attachments and munchies can be found at OCA america.com let's look at this scott fries slide so what this showed is that there are certain attachment designs here you have a horizontal a bevel up bevel down and you're trying to do a mesial root tip and what that means is the tip of the root imagine this tooth is long you're trying to torque them easily and all of these attachment designs we see that the moment of force is on the gingival distal third of this canine and with very little engagement on this attachment and what this diagram showed is that of all these different attachments design designs maybe this double spike design here you gained a little bit on the attachment but all in all the moment of force was unaffected and another thing we found that these regular attachments is these regular attachments may actually interfere with certain moments of force now you imagine them you get a root torquing moment on this gingival third you also get a little moment on the attachment in the opposite direction and additionally if that tooth does not track and then the attachment is bulging out of the tooth pushing the plastic away from the teeth you will get a reduced moment of force so what this slide basically tells us is it doesn't really matter what the regular attachment design looks like and that they all the same moment of force just from the plastic alone unrelated to the attachment I find that very interesting and intriguing John Morton published this slide actually this is guff Reagan but John Morton did the study and he showed as well that optimized rotation attachments outperform no attachment and conventional attachments consistently the extrusion of different molar features are the same and again this is Scott Frei from North of Cosmos blog it's pretty resounding that the studies from a John Warren and Beach Scott Frey that the optimized attachments outperform every others moving on optimized support attachments for extrusions some of you have heard the saying luck the federals pardon my french but lateral incisors can be difficult to move based on their size and shape and they are literally look they look like watermelon seeds and aligners have a difficult time engaging these the optimized g7 support attachment looks like a little smiley face in my opinion has been the best solution to extruding lateral incisors they're also very good at intruding central incisors and they provide a downward vector of force adjacent to this big tooth that is getting an upward vector of force and you get an optimized intrusion vector so if you are intruding a central incisor or extruding a lateral incisor I like this optimized support attachment dr. gehler and his tip Tuesday's has a hierarchy of optimized extrusion attachments and he said that the optimized extrusion after my support is the greatest followed by optimized extrusion which looks like a little skateboard ramp followed by an H Bev are the order of magnitude and greatness these can only be triggered by the algorithm you cannot place these yourself you get a tell Invisalign to put them on by extruding the tooth here's a little key tip when deciding whether or not to put an optimized extrusion attachment on a lateral you need to first look at whether or not that movement needs to occur at all and what I'm finding in my practice is that many times the gingival height gingival height zenith here is more important than the incisal edge some patients want the incisal edges to be flush but i encourage is get the general zenus flush right place and use bonding to make that tooth look proportional I think you'll have more success with that than trying to extrude and the outcome cosmetic outcome will look much better I have several cases that can share where I've done this and used a optimized flow I have a presentation published and a lamination I'd like to put that on youtube as well the next rule the next law is power ridges for root torque now barely glaciers noted that power ridges a they work but they work less effectively when they're placed on contiguous teeth meaning teeth next to each other and for many cases let's say for a class two div two case where both the central incisors are tipped lingually we need to route torque lingually in order to correct that they'll put to power edges adjacent and what we found is that the powerage is when they're on continuous teeth the plastic lifts off the two teeth and is less effective so it is better sometimes to alternate them and to say put the power Ridge on number eight on a liner one through nine and on ten through twenty for example put it on number nine and you might get more effective use of the power ridges that said power ridges help and they're a tremendous thermal plastic feature two lingual eyes the roots no other aligner system I have seen has that feature besides Invisalign now you need to know that when this is prescribed on your clinic the patient can experience discomfort because the aligner plastic sits off the teeth just a little bit and their upper lip does rub on that plastic they are also a little bit uncomfortable and they you can see them slightly on the teeth John Morton published this slide and he looked at you know 12,000 upper incisors and 14,000 about lower incisors and with cases with lingual root are prescribed an average of seven point four degrees route torque power ridges increased success or were better in five hundred percent of the cases this is pretty substantial this is a large group study and using scans and and revisions he was able to really dive deep and figure that this was a very important feature I mean to acquire seven point four degrees of lingual rhetoric is not easy that's a difficult movement for braces for Invisalign whatever another cool thing if you have let's say for example you have a scissor bite where the incisors are tipped in the staties of the lower teeth and the tip back and you have two Pro Klein the incisors forward pro kleh nation you don't need power wages but if you're trying to tip the roots back on all four teeth it's difficult you can get some benefit from placing an H Bev rectangular gingival attachment on the facial instead of a powerage that does provide a little bit of a root torquing feature to the plastic and now john morton did not test that versus power ridges but i found in my practice that is an alternative to a power Ridge in the last law is to use the template aligner when putting on attachments this is kind of a no-brainer for some Invisalign since an aligner it has a t on it and that T printed online means template the aligners have either a t au or an L I'm sorry a T n or an O there is the patient ID number u meaning upper L meaning lower then it will say in for a normal aligner it means an active aligner t4 template liner or Oh for overcorrection aligner the only aligner used to put smart attachments on is the template aligner and that is because the active aligners that the normal and overcorrection have a dimple in them and that dimple is used to engage the smart surface and if you use that aligner to place the template on that attachment will no longer have an active surface it's very important now that said for non smart attachments the regular attachments you can use a normal liner you can also when refining leave on your normal attachments because they're there for Anchorage and not for specific force vectors based on what we learned with Scott phrase slide the regular attachments provide little to no help with specific vectors of movement and that regular attachments help with Anchorage and Anchorage only so if you are using attachments in your case let's say you're using another aligner system let's say ClearCorrect and they don't have smart attachments the only benefit you're getting from the attachments is Anchorage you're not getting smart features and then for refinements again you can leave on your attachments if they are non smart but you need to take off the smart attachments because you have to reboot them back on with your template aligner and when you deliver your refinement I hope that's clear the laws again one through five I won't read them you have them right here guys if you want a copy of this presentation of PDF happy to send it to you leave comments email me Robin Bethel at gmail.com or on Facebook happy to send them I got to give a shout out to the people who influenced my theory and these people have all been so open and generous with their information obviously dr. Geller and dr. Ostreicher a lot of my colleagues have been American Academy clear lining doctors and gala rides he's given a lot of information that go chart specifically dr. Randy Kunak for being a pioneer orthodontist just like dr. Ostreicher for training and being patient with dentists dr. Barry Glaser wrote the first book about a vis align Theory rid of pioneer fantastic human being if you have an opportunity to find him on facebook or give him a shout out he's got a lot of information he also has a podcast called the aligner podcast look it up John Morton's video phenomenal it's kind of in the depths of the internet but you can find it on our Facebook page and then my peers and mentors and my practice learned a lot and continue to learn there and I hope that we all continue in the spirit of giving and collaboration share with each other to get our 10,000 hours of experience so that we can provide the best outcome for our patients a little soapbox people complain about dread to consumer we created direct-to-consumer by not performing optimally for our patients and allowing general dentists and dental professionals to learn this stuff because most of our patients come to us you know thinking about aligners and we aren't able to offer solutions because we don't know what we're doing and we're not practiced at this so I want to change that anyway guys I really appreciate what everyone's done and what you guys for watching this video please share it with your friends and colleagues I do have a case here I like to show and you guys can watch if you like exit this presentation here I have a clinic this one was shared with me through a line our nation this case came in pretty much attachments on every upper tooth besides the molars we have Anchorage attachments we have double spiked root torquing attachments and we have optimized extrusion attachments on every incisor we see this patients class three and we see molar distal ization on the left side and then on the right and flowering of the incisors ideally for a restorative final outcome what's wrong with these attachments well a extrusion attachments with no extrusions prescribed they do nothing so they can be completely removed so in this case I would first look at the forces prescribed in the outcome and I could tell you all these need to be taken off from 7 through 11 the lower arch number 25 has an extrusion attachments will I can remove that 22 with four degrees I'd remove the rotation attachments on 4 and 27 then I would analyze whether or not we want to distal eyes and a class-3 case distal eyes the upper molars there are a very few cases I would distal eyes molars on I love the philosophy that the maxilla belongs forward for airway and that is my theory and if I can avoid distal izing molars I do this doctor was awesome submitted photos and let me see if I have a copy here is the patient photos you can see class three small laterals and the patient's face the profile I would not say that this person is they're not cognatic their chin is not too far forward I would not say this is a skeletal need for a you know orthognathic surgery to bring the chin back I would say that the maxilla could come forward now when you Pro Klein the incisors you will give a little lip lift but I would definitely eliminate the distal ization of molars in this case and by doing that all we need to do is Pro Klein and expand the maxilla a little bit leave spaces and then there's a debate over the mandible we could do IPR to bring some of these lower teeth back to provide some space between the teeth to sue me to provide some overjet to protect our final veneers we could even extract number-25 tip these teeth to close that space and get some overjet there's a lot of ways to look at it there's not really a wrong answer but this clinch it can certainly be made easier this was a good example here another thing you want to be careful about with these cases is you don't want to translate the roots of the incisors buccal e too much I mean they are showing 1.3 1.4 there is a maxillary plate there it's not going to want to find a budge we can't grow maxillary bone and adults easily there's debate to whether that's possible at all but you can't expand the arch you can't expand in the bicuspids and you can get space museum distal and extract a lower incisor to make room for those beautiful veneers anyway guys it's a great case thank you so much for following more to come more you share the more you comment the more we can grow and share with one another and get momentum behind us so that more are willing to share information thank you guys have a great night see you later