CLINICAL TIPS & TECHNIQUES

Class II Correction with Invisalign — ®

Leveraging Molar Rotation

Dr. Mazyar Moshiri

“Invisalign is an excellent appliance for use in treating Class II malocclusions with success. special attention to
correcting poor rotations of upper molars is very beneficial in treatment outcomes and progress, and their
correction achieves many important goals towards Class I progression.”
DR. MAZYAR MOSHIRI

Orthodontic correction of mild to moderate Class II malocclusions Here are Dr. Moshiri’s techniques for addressing Class II
with the Invisalign® system may be handled both predictably with Invisalign:
and efficiently. Dr. Mazyar Moshiri generally considers the
following variables below, in priority. Correction of any mesial Tip 1: Correct Any Mesial Rotation of Upper 1st and
2nd Molars
rotation of the maxillary molars tops this list. It has been shown
that up to 85% Class II patients have mesial rotation of their Request that the buccal surfaces of the upper molars are near
maxillary 1st molars.1 parallel to each other on the ClinCheck® treatment plan. The
majority of Class II malocclusions have a relative maxillary
When correcting a unilateral or bilateral Class II dental
transverse discrepancy, and considering the mechanics needed
malocclusion, it is important to carefully evaluate the etiology
for Class II correction involve the maxillary molars being directed
of the Class II relationships. One cause for displacement of the
towards a wider part of the arch, the doctor should request
molars is mesial movement into the leeway space left during
adequate expansion during the rotational corrections.
the transition from mixed to permanent dentition. This creates a
loss of arch length and resultant mesial version of the remaining Due to the rhomboidal shape of the upper first molars,
dentition anteriorly, creating a Class II cuspid relationship and correction of mesial rotations alone may open up to 2-3 mm
increased overjet. Any further mesial drift from anterior crowding of space per side for subsequent distalization of bicuspids and
and/or arch constriction further exacerbates this problem. cuspids. The decision to use a beveled vertical attachment
Correction of molar rotation not only helps to classify the molars (beveled distal towards the direction of the force), will depend
into a Class I relationship, but concomitantly opens room for on whether additional distalization of the molars is required in
subsequent distalization and Class I correction of the remaining combination with rotational corrections, as this decision may your
buccal dentition. change the attachment protocol. It is important to note even
without attachments rotational correction of molars with aligners
DR. MOSHIRI’S PRIORITY LIST FOR CLASS II alone is a predictable movement.
MALOCCLUSION CORRECTION WITH INVISALIGN

1. Ask for mesial-out buccal rotation of upper first molars

2. Once molars are rotated, distalize as needed to achieve ideal

Class I molar occlusion

3. Look for tooth size discrepancy (TSD) data to detail and

finish occlusion

1
Liu D, Melsen B. Reappraisal of Class II molar relationships diagnosed from the lingual side. Clin Orthod Res. 2001;4(2):97-104.
 Tip 2: Use Elastics Early and Often
One of the great benefits of Invisalign is the ability to initiate
Class II elastics early in treatment. Elastics are critical for
anchorage control and a predictable finish, especially considering
that simultaneous movements are known to be the most efficient
means of treatment. This means that as space is gained from
correction of molar rotations, space closure mesial to the molars
for distalization of the remaining buccal segment is also occurring.
This space closure needs to be controlled and directed distally.

Start patients on Class II elastic as early as aligner 3, depending

on what movements require anchorage control. If distalization
is seen on the ClinCheck treatment plan, elastics should be in
the mouth for those stages and until a superclass I relationship
is observed. Dr. Moshiri prefers to run elastic from buttons
on the lower molars to Precision Cut hooks milled into the
upper aligner with 3/16 or 1/4, 4 oz elastics. Circumstances
where a button may be placed on upper 3’s or 4’s are if
anchoring directly to the teeth will aid in distally facilitating
distal rotations of the teeth, or in a Class II division 2 patient
If correction of molar rotations is not adequate to achieve full
where you do not want to pull the aligner off the maxillary arch
Class I correction, sequential distalization with Class II elastics
due to the retroclination of the anterior teeth.
may be used in order to seat distal cusp of the maxillary first
molar with the embrasure of the mandibular first and second
molars. Practitioners should aim to see simultaneous distal
rotation, expansion, and distalization of the molars. I do
not routinely attempt more than 2 mm of total sequential
distalization with aligners.

For this type of distalization, it is important to have an attachment

on the maxillary second molar to initiate the movement. Ask
for distalization to be delayed until attachments have been Tip 3: For Class II Malocclusions with Minimal Overjet,
bonded on the teeth if your clinical protocols place attachments a Class II Correction Simulation (Bite Jump) is Useful to
at later stages. Additional attachments may then be placed on Demonstrate the Projected Class II Correction. This is
every other tooth up to the cuspids, in order to make appliance Represented as an Instantaneous Reduction of Overjet.
removal amenable to the patient. The bite jump may be used to represent total gradual en masse
movement of maxillomandibular arches from continuous Class II
If a patient has maxillary 3rd molars present, ask for their extraction
elastic wear during treatment. If movements are controlled
after the patient has their impressions/scan to take advantage of
in terms of anchorage, the bite jump tool can be useful in
inflammation and space created. Once the buccal occlusion is
demonstrating what to expect for patient’s treatment outcomes.
nearly seated into full Class I on the ClinCheck treatment plan,
This tool is primarily used to simulate, in one instance, the
I ask for retraction of the 2-2 segment with additional lingual root
sequential movements that are occurring over a period of time.
torque to achieve proper overbite and overjet.
 CLINICAL TIPS & TECHNIQUES

The bite jump is used primarily to represent dental AP correction of expansion indicated on the ClinCheck treatment plan
of Class II / Class III malocclusion and autorotation closure may not express clinically, especially when using a lot of
of open bite patients, unless the treatment plan calls for Class II elastic wear which has a constrictive force on the
orthognathic surgery, or if mandibular growth is expected for maxillary arch. Dr. Moshiri believes expansion needs to be
teen patients. “over-engineered” in the ClinCheck treatment plan for
proper treatment of Class II patients as the software cannot
If segmental mechanics are being used, as in tooth-by-tooth
predict the constrictive force Class II elastic wear. Otherwise,
distalization mechanics, then a bite jump is not indicated. In
interocclusal interferences may prevent proper occlusion.
this case, the practitioner would find it useful to evaluate the
particular stage of movement indicated on the ClinCheck 2. Anticipate Enough Anterior Torque for Proper Anterior
treatment plan against the actual clinical outcome occurring with Centric Contacts: Anterior lingual root torque is another
the patient’s dentition to properly track treatment success. movement that should be over-prescribed (by about 20%)
for the movement to occur clinically. First, diagnose how
Tip 4: Use a Tooth Size Discrepancy (TSD) Analysis for much torque is required off cephalometric measurements,
First Molar to First Molar (6-6)
and then instruct your technician to add this amount into
Undiagnosed tooth size discrepancies (TSD) may be a significant the ClinCheck treatment plan. For example, if the upper
cause of occlusal instability and poor treatment outcomes. This incisors require 10 degrees of lingual root torque, ask the
information may be attained via the Bolton analysis for tooth size technician to add 12 degrees of lingual root torque. This is
discrepancies. Any known TSD is important knowledge to have very important as lack of anterior root torque will distalize the
for detailing the occlusion and increasing the opportunity for mandible from heavy centric contacts, creating a Class II bite
treatment success. Given your patients’ anterior esthetics and a mild posterior open bite.
(i.e. small upper laterals), buccal occlusion, depth of bite, etc., Bite ramps (bite turbos) lingual to the upper incisors further
any existing tooth size discrepancy may be used to the clinicians’ increase the predictability of this movement. The lingual
advantage to further treat a Class II malocclusion predictably. force from the lower incisors against the bite ramp, facilitated
by the propulsive movement of the mandible forward from
For example, if at the end of the ClinCheck treatment plan the
Class II elastics, helps to seat the aligner anteriorly while
patient is still Class II in the premolar and canine areas and a
providing a counter moment to the Power Ridge on the
maxillary excess is indicated on the TSD analysis, then this may
buccal of the aligner. If the patient is Class II division 2, ask for
be used to create any further space needed for distalization or
the technician to push the teeth out first before placing bite
reduction of overjet. In another scenario, if a mandibular excess
ramps to allow for better for application of force relative to
is noted, IPR may be used for mesialization of the lower dentition
the center of resistance for the maxillary teeth.
with Class II elastics to further aid in Class I molar correction.
3. Use Aligner Chewies Daily: Instruct patients to use Aligner
Tips for Predictable Finishes Chewies on a daily basis to promote settling of the dentition
The above methodology has proven very valuable in Dr. Moshiri’s into the aligner. Ask patients to bite straight down (not side-
practice in evaluating and treating Class II patients with Invisalign. to-side like chewing gum) and to apply average pressure for
Here are some additional suggestions to further enhance 5 seconds at a time, walking the Chewie around the mouth,
treatment outcomes for Class II patients: focusing on areas where the majority of their movements are
occurring. Have patients use Chewies 2-3 times a day for
1. Request Adequate Expansion for Class II Correction: Ask for
10-15 minutes per exercise.
2 mm of buccal overjet on all teeth and avoid a “socked-in”
occlusion at the end of the ClinCheck treatment plan.
The reasoning behind this preference is that the amount
CLINICAL TIPS & TECHNIQUES

DR. MAZYAR MOSHIRI

Dr. Moshiri obtained his Doctorate, Masters in Oral Biology,

and Certificate of Advanced Training in Orthodontics from the
University of Louisville. Upon graduation from dental school,
Dr. Moshiri was honored with the American Association of
Orthodontists student award, two International College of
Dentists awards for both Leadership and Professionalism, the
Oral Biology Research award, the Omicron Kappa Delta award
for Outstanding Graduating Senior, and honorary induction into
the prestigious academic society of Omicron Kappa Upsilon. He
currently practices orthodontics as part of Moshiri Orthodontics
with three locations in the St Louis and Springfield, MO areas.

Disclosure: Dr. Mazyar Moshiri was provided an honorarium from Align for his presentation. The statements, views and opinions expressed in this presentation are those of the author, and do not
necessarily reflect the views and opinions of Align Technology, Inc.

Align Technology, Inc. © 2013 Align Technology, Inc. All rights reserved. Invisalign and ClinCheck,
2560 Orchard Pkwy among others, are registered trademarks of Align Technology, Inc.
San Jose, CA 95131 M20225 Rev B June 2013

WWW.INVISALIGN.COM