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ORTODONCIE Odborna praÂce cÏ. 4. 2013

Ortodonticke foÂliove aparaÂty. Souborny referaÂt

Orthodontic clear plastic appliances. Systematic review

*MUDr. KlaÂra BeÏlõÂkovaÂ, **MUDr. Ivo Marek, Ph.D, *MUDr. Hana TycovaÂ
* Ortodonticke oddeÏlenõ UÂstavu klinicke a experimentaÂlnõ stomatologie 1. LF UK a VFN Praha,
*Department of Orthodontics of the Institute of Clinical and Experimental Stomatology, 1st Medical Faculty of
Charles University and University Hospital, Prague
** Ortodonticke oddeÏlenõ Kliniky zubnõÂho leÂkarÏstvõÂ, LF UP Olomouc
**Department of Orthodontics, Institute of Dental Medicine, Medical Faculty of Palacky University, Olomouc

Souhrn
Jsou popsaÂny soucÏasne typy foliovyÂch aparaÂtuÊ, jejich indikace a zpuÊsob praÂce s nimi. VyÂhody a nevyÂhody
teÏchto aparaÂtuÊ jsou podrobneÏ rozebraÂny. AparaÂty typu Essix jsou pouzÏÂõvaÂny jako retencÏnõÂ aparaÂty, k aktivnõÂmu
puÊsobenõÂ na zuby jsou tvarovaÂny HilliardovyÂmi termoklesÏteÏmi. PodrobneÏ je popsaÂn zpuÊsob praÂce se systeÂmem
Invisalign, jako zaÂstupcem techniky zalozÏene na tovaÂrneÏ vyraÂbeÏne sekvenci foÂliõ dle pocÏÂõtacÏove simulace leÂcÏeb-
neÂho postupu. Jsou uvedeny take systeÂm OrthoCaps a Simply5 (Ortodoncie 2013, 22, cÏ. 4, s. 225-235).

Abstract
A survey of currently used clear plastic appliances is given; their indications and their effectiveness are descri-
bed. We discuss in detail pros and cons of the appliances. Essix appliances are preferred as retainers; to actively
affect dentition they are treated with Hilliard thermopliers. The Invisalign system is described in details, a represen-
tative technique based on sequence of factory-made aligners by computer simulation of the treatment procedure.
Another systems as OrthoCaps and Simply5 systems are described as well (Ortodoncie 2013, 22, No. 4, p. 225-235).

KlõÂcÏova slova: foliove aparaÂty, Essix, Invisalign

Key words: plastic appliances, Essix, Invisalign

UÂvod
CõÂlem kazÏde ortodonticke terapie je dosaÂhnout co
nejlepsÏõÂho mozÏneÂho vyÂsledku jak po estetickeÂ, tak
i funkcÏnõÂ straÂnce. Nelze vsÏak opominout vlastnõÂ pruÊbeÏh
leÂcÏby, ktery by meÏl byÂt pro pacienta co nejmeÂneÏ zateÏ-
zÏujõÂcõÂ. Modernõ ortodonticke materiaÂly naÂm v soucÏasneÂ
dobeÏ nabõÂzejõÂ jizÏ sÏirsÏõÂ spektrum prostrÏedkuÊ, se kteryÂmi
lze tohoto cõÂle dosaÂhnout.
V dnesÏnõÂ spolecÏnosti je prÏi hodnocenõÂ osob kladen
velky duÊraz na jejich vzhled, jehozÏ nedõÂlnou soucÏaÂstõÂ
je i uÂsmeÏv. NeÏkterÏõÂ, hlavneÏ dospeÏlõÂ pacienti vsÏak pova-
zÏujõÂ za veÏtsÏõÂ handicap nosÏenõÂ viditelneÂho ortodontic-
keÂho aparaÂtu, ktery slouzÏõ ke korekci estetickeÂho pro-
bleÂmu, oproti vlastnõ ortodonticke anomaÂlii, mnohdy
i vyÂrazneÏ rusÏive [1]. Z toho duÊvodu mohou ortodontic-
kou terapii odmõÂtat. VylepsÏenõÂ estetickyÂch vlastnostõÂ
Introduction
Orthodontics aims to achieve the best esthetic as
well as functional results. Treatment should avoid
unnecessary discomfort for a patient. Nowadays,
there is a wide range of orthodontic materials making
this aim achievable.
In evaluating people, today the great emphasis is
put on their appearance the integral part of which is
smile. Some, especially adult patients, see a visible
orthodontic appliance correcting an esthetic problem
as a more significant handicap than the problem itself
[1]. Therefore, they frequently refuse orthodontic treat-
ment. The first step to change this attitude was the use
of ceramic orthodontic brackets. Lingual fixed applian-
ces and orthodontic plastic appliances represent ano-
ther step, and they meet demands for discreetness.

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cÏ. 4. 2013 Odborna praÂce
ortodontickyÂch aparaÂtuÊ prÏisÏlo s pouzÏõÂvaÂnõÂm keramic-
kyÂch ortodontickyÂch zaÂmkuÊ. ZvyÂsÏenyÂm naÂrokuÊm na
nenaÂpadnost vyhovujõÂ jesÏteÏ võÂce lingvaÂlnõÂ fixnõÂ aparaÂty
a ortodonticke foÂlie.
Historie
Prvnõ foÂliovy ortodonticky aparaÂt pokryÂvajõÂcõ celyÂ
povrch zubuÊ prÏedstavil v roce 1926 Remensnyder [2].
Byl to ¹Flex-O-Tite gum-massagingª aparaÂt, se kteryÂm
bylo uÂdajneÏ mozÏne proveÂst mensÏõ posuny zubuÊ. Od teÂ
doby se pouzÏõÂvaly ruÊzne druhy foÂliovyÂch aparaÂtuÊ, ktereÂ
vsÏak slouzÏily spõÂsÏe k zajisÏteÏnõÂ funkce retence. Posun
zubuÊ pomocõ aparaÂtuÊ pokryÂvajõÂcõÂch cely povrch zubuÊ
popularizoval Kesling [3], ktery v roce 1945 prezento-
val pouzÏitõÂ pruzÏneÂho gumoveÂho aparaÂtu upravujõÂcõÂho
detailneÏ polohu zubuÊ po sejmutõÂ fixnõÂho aparaÂtu. Ke-
slinguÊv aparaÂt byl zhotoven na zaÂkladeÏ prÏestavby zubuÊ
do ideaÂlnõÂho postavenõÂ na saÂdroveÂm modelu. Autor
popisuje i realizaci veÏtsÏõÂch pohybuÊ zubuÊ pomocõÂ po-
stupneÂho setupu a seÂrie aparaÂtuÊ. Ponitz [4] svuÊj te-
pelneÏ tvarovany aktivnõ plastovy aparaÂt ¹invisible retai-
nerª prÏedstavil v roce 1971. NaÂsledneÏ Sheridan [5]
spojil pouzÏitõÂ aktivnõÂch foÂliovyÂch aparaÂtuÊ tvarovanyÂch
na modelech se zaÂbrusem aproximaÂlnõÂch zubnõÂch
ploch a v roce 1993 prÏedstavil techniku Essix. K dal-
sÏõÂmu rozsÏõÂrÏenõÂ mozÏnostõÂ terapie pomocõÂ plastovyÂch
ortodontickyÂch aparaÂtuÊ dosÏlo poteÂ, co Sheridan a Hil-
liard pouzÏili termoklesÏteÏ, ktere umozÏnÏovaly specific-
kou aktivaci foÂliõÂ (Obr. 1).
Mezi nejnoveÏjsÏõ technologicke postupy v ortodoncii
patrÏõ systeÂm Invisalign, ktery v roce 1997 vyvinuli Ke-
sley Wirth a Zia Chishti [6]. VytvorÏili tak novou generaci
estetickyÂch ortodontickyÂch aparaÂtuÊ. Tento prÏõÂstup
kombinuje ortodonticke principy s trojrozmeÏrnyÂmi po-
cÏõÂtacÏovyÂmi technologiemi (CAD/CAM). S dalsÏõÂm roz-
vojem teÏchto 3D technologiõÂ a ovlaÂdacõÂch software
programuÊ se posunula i uÂrovenÏ systeÂmu Invisalign.
Vlastnosti plastoveÂho materiaÂlu foÂliõÂ
V dnesÏnõ dobeÏ je k dispozici neprÏeberne mnozÏstvõÂ
plastuÊ, ktere se velice lisÏõ svyÂmi parametry. VyÂbeÏr ma-
teriaÂlu pro vyÂrobu foÂliovyÂch zubnõÂch aparaÂtuÊ zaÂlezÏõÂ na
takovyÂch faktorech, jako je naprÏõÂklad doba, po kterou
bude aparaÂt pouzÏõÂvaÂn, jeho uÂcÏel a potrÏebna tlousÏt'ka
materiaÂlu. V kazÏdeÂm prÏõÂpadeÏ musõ byÂt pouzÏity materiaÂl
inertnõÂ, netoxickyÂ, bez chuti a bez zaÂpachu a musõÂ byÂt
chemicky staÂlyÂ. Pro ortodonticke pouzÏitõ jsou vyÂhodneÂ
termoplasticke hmoty s vysokou pevnostõ v lomu a li-
neaÂrnõÂm pruÊbeÏhem elasticke faÂze. Modul pruzÏnosti
v tahu neboli YounguÊv modul plastoveÂho materiaÂlu
k vyÂrobeÏ ortodontickyÂch foÂliõÂ by nemeÏl byÂt prÏõÂlisÏ vy-
sokyÂ, aby bylo mozÏne foÂlie snadno nasadit a sejmout
a ani prÏõÂlisÏ nõÂzkyÂ, aby byla foÂlie schopna vyvinout tlak
na zuby vedoucõÂ k jejich pohybu. BeÏhem nosÏenõÂ jsou
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ORTODONCIE
Historical background
The first plastic orthodontic appliance covering the
entire surface of teeth was introduced by Remensny-
der [2] in 1926. It was Flex-O-Lite gum-massaging ap-
pliance through which minor tooth movements were
possible. Since that different types of plastic applian-
ces were used, preferably as retainers. In 1945 Kesling
[3] presented the use of an elastic vulcanite appliance
to adjust precisely the position of teeth after a fixed ap-
pliance is removed. Kesling's appliance was based on
the ideal teeth position made in a cast model. Kesling
reported major tooth movements with a consecutive
set-up and a series of appliances. In 1971 Ponitz [4] in-
troduced his thermoformed active plastic appliance,
the so called invisible retainer. Sheridan [5] connected
the use of active plastic appliances formed in models
with grinding of approximal tooth surfaces, and pres-
ented his Essix retainer in 1993. Therapeutic methods
using plastic orthodontic appliances became more wi-
despread after Sheridan and Hilliard used thermopliers
that made specific activation of thermoplastic trays
possible (Fig.1).
Invisalign system [6] represents a state-of-the-art
approach. The system was developed by Kesley Wirth
and Zia Chishti in 1997. The new generation of esthetic
orthodontic appliances was thus created. The ap-
proach combines orthodontic principles with 3D com-
puter technologies (CAD/CAM). The advancement of
the 3D technologies and related software resulted in
the progress of Invisalign system.
Characteristic features of plastic material used
A wide range of plastic materials are at disposal to-
day, however, they have very different parameters.
When deciding about the appropriate material for pla-
stic appliances, the important role is played by factors
like e.g. the period and aims for which the appliance is
used, as well as the material thickness. The material
must be inert, non-toxic, without taste and odor, che-
mically stable. In orthodontics, thermoplasts resistant
to rupture and linear form of elastic phase are prefer-
red. Modulus of elasticity, or Young module, of plastic
Obr. 1. Hilliardovy termoklesÏteÏ
Fig. 1. Hilliard Thermopliers
www.orthodont-cz.cz e-mail: redakce@orthodont-cz.cz
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ORTODONCIE Odborna praÂce
foÂlie vystaveny puÊsobenõÂ tekutin dutiny uÂstnõÂ, tedy slin
a sulkulaÂrnõ tekutiny o teÏlesne teploteÏ (prÏiblizÏneÏ 37 °C).
Plasty pouzÏite k vyÂrobeÏ tedy nesmõ podleÂhat hydroly-
tickyÂm zmeÏnaÂm vedoucõÂm k jejich znehodnocenõÂ [7].
FoÂliove aparaÂty systeÂmu Invisalign jsou zhotovovaÂny
z polyurethanovyÂch foÂliõÂ o sÏõÂrÏce 0,75 a 1 mm (0,03ª
a 0,04ª). AparaÂty typu Essix se vyraÂbeÏjõÂ z foÂliõÂ na baÂzi
polypropylenu o sÏõÂrÏce 0,75 mm, 1 mm a 2 mm. SõÂla foÂlie
se volõÂ podle vyuzÏitõÂ.
Indikace foÂliovyÂch aparaÂtuÊ
RozhodnutõÂ, zda je u pacienta indikovaÂna aktivnõÂ te-
rapie ortodonticke vady pomocõ foÂliovyÂch aparaÂtuÊ, je
v rukou osÏetrÏujõÂcõÂho leÂkarÏe a zaÂvisõ do urcÏite mõÂry i na
jeho zkusÏenostech s tõÂmto systeÂmem. Studie, kteraÂ
zkoumala rozhodnutõ leÂkarÏuÊ o indikaci ortodonticke te-
rapie pomocõÂ foÂliovyÂch aparaÂtuÊ, potvrdila zaÂvislost
rozhodnutõÂ o terapii slozÏiteÏjsÏõÂch prÏõÂpaduÊ touto techni-
kou na zkusÏenostech osÏetrÏujõÂcõÂho leÂkarÏe. SpecialisteÂ
v oboru ortodoncie dle pruÊzkumu leÂcÏõÂ pomocõÂ foÂliovyÂch
aparaÂtuÊ slozÏiteÏjsÏõÂ vady, nezÏ prakticÏtõÂ zubnõÂ leÂkarÏi, kterÏõÂ
v neÏkteryÂch staÂtech mohou tuto techniku pouzÏõÂvat [8].
PouzÏitõÂ aparaÂtuÊ typu Essix s aktivacõÂ pomocõÂ Hilliar-
dovyÂch termoklesÏtõÂ se doporucÏuje ke korekci mõÂrnyÂch
vad. Jde hlavneÏ o uÂpravu polohy jednotlivyÂch zubuÊ
nebo maleÂho steÏsnaÂnõÂ, ktere cÏasto vznikajõ jako reci-
diva po sejmutõÂ fixnõÂch aparaÂtuÊ [9]. Naproti tomu sy-
steÂm pocÏõÂtacÏem rÏõÂzeneÂho plaÂnovaÂnõÂ ortodontickyÂch
posunuÊ pomocõÂ foÂliovyÂch aparaÂtuÊ spolu s vyÂvojem
kompozitnõÂch attachmentuÊ rozsÏõÂrÏil mozÏnosti pouzÏitõÂ to-
hoto systeÂmu i na vady slozÏiteÏjsÏõÂ.
Jsou ale urcÏite podmõÂnky, ktere musõ pacient vhodnyÂ
pro leÂcÏbu foÂliovyÂmi aparaÂty splnit. AbsolutnõÂ kontraindi-
kacõÂ terapie je stejneÏ, jako prÏi praÂci s fixnõÂmi aparaÂty, prÏõÂ-
tomnost akutnõÂho zaÂneÏtu parodontu [10]. ZahaÂjenõÂ leÂcÏby
se doporucÏuje u pacientuÊ s ukoncÏenou vyÂmeÏnou
chrupu, tedy s plneÏ prorÏezanyÂmi druhyÂmi molaÂry, i kdyzÏ
i toto omezenõ se staÂva dnes minulostõÂ. PrÏõÂkladem muÊzÏe
byÂt produkt firmy Align Technology - ¹Invisalign Teenª
[10], ktery je urcÏen pro pacienty se smõÂsÏenou denticõÂ.
LeÂcÏba vaÂzÏnyÂch skeletaÂlnõÂch vad obecneÏ nenõÂ rÏesÏitelnaÂ
zÏaÂdnyÂm ortodontickyÂm aparaÂtem a v teÏchto prÏõÂpadech
je trÏeba zvolit kombinovany ortodonticko-chirurgicky leÂ-
cÏebny plaÂn. Pomocõ foÂliovyÂch aparaÂtuÊ nenõ mozÏne v je-
jich soucÏasne podobeÏ proveÂst neÏktere ortodonticke po-
hyby (viz nevyÂhody foÂliovyÂch aparaÂtuÊ).
FoÂliove ortodonticke aparaÂty pokud jsou nasazeny
soucÏasneÏ na hornõÂ a dolnõÂ zubnõÂ oblouk, lze vyuzÏõÂt i k uÂ-
praveÏ sagitaÂlnõÂho vztahu cÏelistõÂ za pomocõÂ elastickyÂch
tahuÊ II. cÏi III. trÏõÂdy.
VyÂhody praÂce s foÂliovyÂmi aparaÂty
Ortodonticke foÂliove aparaÂty splnÏujõ vysoke este-
ticke naÂroky. Vzhledem k jejich pruÊhlednosti jsou na
www.orthodont-cz.cz e-mail: redakce@orthodont-cz.cz
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material used for orthodontic plastic appliances
should not be too high (they are easy to adjust and re-
move) or too low (they can exert the pressure on teeth
to move them). The trays are exposed to mouth cavity
fluids, i.e. saliva and sulcus fluid, of body temperature
(approx. 37 °C). Therefore, the plastic materials should
not be affected by hydrolytic changes which would re-
sult in their impairment [7]. Invisalign system applian-
ces are made of polyurethane sheets, the width of
0.75 and 1.0 mm (0.03ª and 0.04ª). Essix appliances
are made of polypropylene sheets, the width of 0.75,
1.0 and 2.0 mm. The thickness of a sheet is chosen ac-
cording to the use.
Indications of plastic appliances
Orthodontic professional is responsible for the indi-
cation of the active treatment for a malocclusion with
plastic aligners. The decision depends to some extent
on his experience with the system as was proved by
the study [8]. The study revealed that orthodontists
use the system to solve more complex anomalies,
unlike general dentists (who can use this technique in
some countries).
Essix system appliances activated with Hilliard's
thermopliers are recommended for minor malocclu-
sions, e.g. alignment of the position of individual teeth
or moderate crowding, which often occur as relapse
after fixed appliance removal [9]. The system of com-
puter aided planning of orthodontic movements with
plastic appliances and the development of composite
attachments made it possible to use this system for
more severe anomalies.
Nevertheless, a patient has to meet several condi-
tions for the treatment with plastic appliances. Acute
periodontitis is the absolute contraindication (the
same holds true for the treatment with fixed appliance)
[10]. The approach is recommended in patients with fi-
nished change of dentition, i.e. with fully erupted se-
cond molars, though even this restriction is gradually
abandoned. The product of Align Technology com-
pany - Invisalign Teen [10] is intended for patients with
mixed dentition. In general, severe skeletal deformities
are not solved with orthodontic appliance but through
a combined orthodontic-surgical therapy. Plastic ap-
pliances cannot be used for some orthodontic move-
ments (see Disadvantages).
Plastic orthodontic appliances, when adjusted to
both upper and lower dental arch, may be used to ad-
just sagittal relationship of jaws with Class II or III ela-
stics.
Advantages
Plastic orthodontic appliances meet high esthetic
demands. Due to their transparency they are virtually
227
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vzdaÂlenost veÏtsÏõÂ nezÏ puÊl metru prakticky neviditelneÂ

[11]. KritickyÂm bodem v tomto ohledu mohou byÂt neÏ-
ktere meÂneÏ zaoblene attachmenty, ktere nenaÂpadnost
aparaÂtuÊ mõÂrneÏ zhorsÏujõÂ (Obr. 2). I prÏesto jsou foÂlioveÂ
aparaÂty nejmeÂneÏ viditelnou variantou ortodontickyÂch
aparaÂtuÊ. Vlaskalic a Boyd [12] ve sve studii popisujõÂ,
zÏe prÏi vyÂbeÏru ortodontickyÂch aparaÂtuÊ by celyÂch
100 % taÂzanyÂch ortodontickyÂch pacientuÊ volilo, kdyby
to bylo v jejich prÏõÂpadeÏ mozÏneÂ, pruÊhledne foÂliove apa-
raÂty. V podobne studii Rosvalla [13] byli taÂzaÂni jen do-
speÏlõÂ jedinci, u kteryÂch nebyla plaÂnovaÂna ortodontickaÂ
terapie. 90 % z nich by bylo ochotno podstoupit orto-
dontickou terapii pomocõÂ foÂliovyÂch aparaÂtuÊ v porovnaÂnõÂ
Obr. 2. FoÂlie Invisalign nasazena na zubech s attachementy
s 58 % teÏch, kterÏõÂ by prÏistoupili na leÂcÏbu pomocõÂ klasic- Fig. 2. Invisalign tray adjusted on teeth with attachments
kyÂch fixnõÂch aparaÂtuÊ.
Jednou z nejveÏtsÏõÂch vyÂhod, ale v urcÏiteÂm smeÏru zaÂro- invisible from the distance over 50 cm [11]. The only
venÏ nevyÂhodou ortodontickyÂch foÂliõÂ je jejich snõÂmatel- exceptions may be some less rounded attachments
nost, zejmeÂna prÏi konzumaci jõÂdla, nebo zubnõÂ hygieneÏ. (Fig.2). In spite of that, plastic aligners are the least vi-
NevyÂhodou je, zÏe uÂspeÏsÏnost leÂcÏby je v zaÂsadeÏ urcÏena sible type of orthodontic appliances. In their study, Vla-
prÏõÂstupem pacienta k leÂcÏbeÏ, jeho sveÏdomitostõÂ a disciplõÂ- skalic and Boyd [12] report that 100% of orthodontic
nou. NicmeÂneÏ faktem je, zÏe foÂliove aparaÂty umozÏnÏujõ patients that were addressed would opt for transpa-
provaÂdeÏnõ dentaÂlnõ hygieny bez omezenõÂ, ktera souvisõ rent aligners. Rosvall [13] questioned adults in whom
s pevnyÂmi ortodontickyÂmi aparaÂty. PrÏi dobryÂch hygie- no orthodontic therapy was planned: 90% would be
nickyÂch naÂvycõÂch pacienta se vyÂrazneÏ snizÏuje riziko willing to undergo orthodontic treatment with plastic
vzniku dekalcifikacõÂ zubnõÂ skloviny a zaÂneÏtuÊ daÂsnõÂ [11]. aligners, while only 58% would accept the treatment
VyÂskyt teÏchto komplikacõÂ je nizÏsÏõÂ v porovnaÂnõÂ s terapiõÂ with traditional fixed appliance.
pomocõÂ fixnõÂ vestibulaÂrnõÂ [14], ale i lingvaÂlnõÂ techniky
[15]. Neplatõ vsÏak, zÏe foÂliove aparaÂty jsou rÏesÏenõÂm pro One of the greatest advantages (and at the same
leÂcÏbu pacientuÊ s malhygienou. Ta je vzhledem k zaÂneÏtli- time disadvantages) of plastic orthodontic aligners is
veÂmu prostrÏedõÂ v okolõÂ zubuÊ, se kteryÂmi chceme pohy- the possibility to remove them, especially when eating
bovat, kontraindikacõ ortodonticke terapie obecneÏ. or performing dental hygiene. Treatment results de-
pend on patients' attitude, conscientiousness, and
FoÂliove aparaÂty mohou rÏesÏit komplikovanou situaci
self-discipline. Plastic aligners make oral hygiene
ortodonticke terapie, ktera nastaÂva u pacientuÊ s vroze-
easier to maintain than during the treatment with fixed
nou poruchou mineralizace zubnõÂch tkaÂnõÂ jakou je na-
orthodontic appliances. Good hygiene habits reduce
prÏõÂklad amelogenesis imperfecta. U teÂto skupiny je ob-
significantly the risk of enamel decalcification and gin-
tõÂzÏne nasadit fixnõ ortodonticky aparaÂt a bez posÏkozenõÂ
givitis [11]. The incidence of these complications is lo-
zubuÊ ho i sejmout [11].
wer than in the treatment with fixed vestibular [14] as
DõÂky hladkeÂmu povrchu jsou foÂlie na rozdõÂl od fix-
well as lingual [15] approach. However, plastic aligners
nõÂch aparaÂtuÊ pacienty velmi dobrÏe prÏijõÂmaÂny. NezpuÊso-
are not the solution for the patient with bad dental hy-
bujõÂ draÂzÏdeÏnõÂ a otlaky sliznice dutiny uÂstnõÂ. NavõÂc pa-
giene. With regard to a potential inflammatory re-
cienti popisujõÂ v prvnõÂch dnech po zahaÂjenõÂ leÂcÏby vyÂra-
sponse in the area adjacent to the teeth to be moved,
zneÏ mensÏõÂ a kratsÏõÂ dobu trvajõÂcõÂ bolestivost zubuÊ ve
bad hygiene habits are the contraindication of ortho-
srovnaÂnõÂ se stavem po nasazenõÂ fixnõÂho aparaÂtu [16].
dontic treatment in general.
OrdinacÏnõÂ doba ve faÂzi plaÂnovaÂnõÂ leÂcÏebneÂho po-
stupu a hodnocenõÂ Clinchecku je delsÏõÂ, to je ale vyvaÂ- Plastic aligners may represent the solution in com-
zÏeno kratsÏõÂm cÏasem, ktery pacient straÂvõ na krÏesle prÏi plex situation of orthodontic therapy that occurs in pa-
kontrolaÂch. PrÏi nich je rovneÏzÏ potrÏebny mensÏõ rozsah tients with congenital defect of dental tissues minera-
instrumentaÂria, nezÏ prÏi kontrolaÂch fixnõÂho aparaÂtu. lization, e.g. amelogenesis imperfecta. In these pa-
Frekvence naÂvsÏteÏv je take snõÂzÏena, meÂneÏ cÏaste jsou tients it is difficult to adjust fixed appliance and
i nutne prvnõ pomoci [11]. remove it without harm done to the teeth [11].
Unlike fixed appliances, thanks to their smooth sur-
NevyÂhody praÂce s foÂliovyÂmi aparaÂty face, plastic aligners are well accepted by patients.
FoÂliove aparaÂty a praÂce s nimi ma vsÏak i neÏktere ne- They do not cause irritation and pressure sores of oral
vyÂhody. Tou nejzaÂsadneÏjsÏõ je nutnost vyÂborne spolu- cavity mucosa. Patients also report less pain for much

228 www.orthodont-cz.cz e-mail: redakce@orthodont-cz.cz

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ORTODONCIE Odborna praÂce
praÂce pacienta, bez ktere nelze dosaÂhnout dobreÂho
vyÂsledku. I kdyzÏ pacient spolupracuje, muÊzÏe vzhledem
k nenaÂpadnosti a krÏehkosti aparaÂtuÊ snadno dojõÂt k je-
jich ztraÂteÏ nebo posÏkozenõÂ ve chvõÂli, kdy je pacient kvuÊli
jõÂdlu nebo cÏisÏteÏnõÂ zubuÊ docÏasneÏ sejmul [17].
DuÊlezÏityÂm nedostatkem foÂliovyÂch aparaÂtuÊ je ome-
zenõÂ jejich indikace ve vztahu k pozÏadovanyÂm uÂpravaÂm
zubnõÂch obloukuÊ. Nelze s nimi pracovat u veÏtsÏiny
extrakcÏnõÂch prÏõÂpaduÊ ani prÏi zarÏazovaÂnõÂ retinovanyÂch
zubuÊ. I prÏes znacÏny vyÂvoj teÏchto technologiõ a novyÂch
attachmentuÊ je staÂle obtõÂzÏne dosaÂhnout uzavrÏenõÂ
extrakcÏnõÂch mezer bodily posunem bez nekontrolova-
telneÂho sklonu zubuÊ [18]. UzaÂveÏr mezer po extrakci
premolaÂruÊ foÂliovyÂm aparaÂtem se tak neobejde bez
sklonu okolnõÂch zubuÊ a mozÏne perzistence tremat.
Pro naprÏõÂmenõÂ skloneÏnyÂch zubuÊ je trÏeba pouzÏõÂt fixnõÂ
aparaÂt. Mezi obtõÂzÏneÏ proveditelne pohyby zubuÊ po-
mocõÂ foÂliovyÂch aparaÂtuÊ patrÏõÂ daÂle uÂprava vyÂraznyÂch ro-
tacõÂ nad 45 °, a to hlavneÏ zubuÊ s cylindrickyÂm tvarem
korunky, a sklonuÊ zubuÊ veÏtsÏõÂch nezÏ 45 °. Velmi proble-
matickyÂm pohybem je extruze jednotlivyÂch zubuÊ nebo
jejich skupin, zvlaÂsÏteÏ pokud majõ kraÂtke klinicke ko-
runky [19]. ProvedenõÂ uÂspeÏsÏnyÂch derotacõÂ a extruzõÂ na-
pomohlo zavedenõ a postupne vylepsÏovaÂnõ ruÊznyÂch
typuÊ attachmentuÊ. PrÏi porovnaÂnõÂ vyÂsledkuÊ terapie foÂ-
liovyÂmi ortodontickyÂmi aparaÂty s klasickyÂmi fixnõÂmi
aparaÂty pomocõÂ ABO systeÂmu [20, 21] byly zjisÏteÏny
u foÂliovyÂch aparaÂtuÊ horsÏõÂ vyÂsledky prÏi hodnocenõÂ oklu-
znõÂho kontaktu v lateraÂlnõÂm uÂseku chrupu. PrÏõÂcÏinou to-
hoto nezÏaÂdoucõÂho vedlejsÏõÂho efektu foÂliõÂ je prÏekrytõÂ
okluznõÂch ploch zubuÊ beÏhem terapie. Jako dalsÏõÂ nedo-
statek foÂliovyÂch aparaÂtuÊ vychaÂzõÂ z obdobneÂho meÏrÏenõÂ
uÂprava torze zubuÊ lateraÂlnõÂho uÂseku chrupu [21], nic-
meÂneÏ z klinicke praxe võÂme, zÏe toteÂzÏ platõ pro zuby fron-
taÂlnõÂho segmentu, prÏedevsÏõÂm rÏezaÂky.
Posun molaÂruÊ je vzhledem k pomeÏru velikosti po-
vrchu korÏenuÊ a puÊsobõÂcõÂ sõÂly nejobtõÂzÏneÏjsÏõÂ. PrÏi jejich po-
sunu dochaÂzõÂ vzÏdy k vyÂrazneÂmu meziaÂlnõÂmu sklonu
s cÏastou cÏaÂstecÏnou perzistencõÂ extrakcÏnõÂ mezery [22].
Typy foÂliovyÂch aparaÂtuÊ
Ortodonticke foÂliove aparaÂty deÏlõÂme podle jejich puÊ-
sobenõÂ do dvou skupin:
- Zuby se rovnajõÂ dle aktivace jednotlivyÂch foÂliõÂ vyÂ-
stupky, ktere tvorÏõ leÂkarÏ prÏõÂmo v ordinaci. Do teÂto kate-
gorie patrÏõÂ naprÏõÂklad Smile-Aligner system.
- SysteÂm tovaÂrneÏ vyraÂbeÏnyÂch seÂriõÂ foÂliõÂ s aktivacõÂ
pohybuÊ do jednotlivyÂch aparaÂtuÊ dle prÏedem stanove-
neÂho leÂcÏebneÂho plaÂnu. PrÏõÂkladem teÂto skupiny je Invi-
salign.
SysteÂm Smile-Aligner
SysteÂm Smile-Aligner byl vytvorÏen Keithem Hilliar-
dem [23]. Je to ekonomicÏteÏjsÏõÂ varianta pocÏõÂtacÏem rÏõÂ-
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cÏ. 4. 2013
shorter time at the beginning of the treatment in com-
parison with fixed appliance [16].
The treatment planning and evaluation of Clincheck
takes more time, however, patient then spends less
time on check-ups in a practice. The number of instru-
ments needed is lower than in case of fixed appliance.
The need for urgent aid is also less frequent [11].
Disadvantages
Plastic appliances and working with them bring
about also some disadvantages. For good results the
extraordinary cooperation of a patient is a must. Due
to the discreet and fragile character of the appliance, it
may be easily damaged or even lost when it is removed
by a patient before eating or during dental hygiene [17].
The indication of plastic appliances is limited when
it comes to correction of dental arches. They cannot be
used in cases involving extraction or treatment of im-
pacted teeth. In spite of the fast development of these
technologies and new attachments, it is still difficult to
close spaces after extractions with bodily movement
without uncontrolled inclination of teeth [18]. The use
of plastic appliance in closing the spaces is accompa-
nied with the adjacent teeth inclination, and the spaces
may persist. To upright the inclined teeth a fixed ap-
pliance is required.
Another difficult tooth movement is represented by
the adjustment of profound rotations over 45°, espe-
cially in teeth with cylindrical crown, and teeth inclina-
tions over 45°. Extrusion of individual teeth or se-
gments of teeth, especially in case of short clinical
crowns, is also very difficult [19]. Introduction and gra-
dual improvement of various types of attachments
have helped in performance of successful derotations
and extrusions. Comparison of the results of the treat-
ment with plastic orthodontic appliance and with tradi-
tional fixed appliance with ABO system [20, 21] revea-
led worse condition of occlusion in the lateral segment
of dentition in case of plastic appliances. The adverse
effect is probably the result of imposition of occlusal
teeth surfaces during the treatment. Another problem
was indicated for tooth torque in the lateral segment
of dentition [21], however, from clinical practice we
know that the same holds true also for anterior se-
gment of dentition, incisors in particular.
With regard to the proportion of root surface area
and the active force, the movement of molars is the
most difficult. We always witness profound mesial in-
clination and frequent partially persisting spaces after
the extraction [22].
Types of plastic appliances
Orthodontic plastic appliances may be subdivided
into two groups according to their function:
229
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cÏ. 4. 2013 Odborna praÂce
zene vyÂroby ortodontickyÂch foÂliõÂ, pomocõ ktere je mo-
zÏne rÏesÏit urcÏite ortodonticke vady od pocÏaÂtku nebo
proveÂst korekce recidivy prÏedesÏle ortodonticke tera-
pie. Na rozdõÂl od systeÂmuÊ sekvence foÂliõÂ se beÏhem celeÂ
terapie pouzÏõÂva jen jeden aparaÂt typu Essix na zubnõÂ
oblouk, prÏõÂpadneÏ i võÂce, ale vzÏdy po nove diagnostickeÂ
prÏestavbeÏ na saÂdroveÂm modelu.
AparaÂty typu Essix se nejcÏasteÏji pouzÏõÂvajõÂ v retencÏnõÂ
faÂzi. V tu dobu je jejich uÂkolem pasivneÏ udrzÏet zuby
v zubnõÂch obloucõÂch ve shodneÂm postavenõÂ, jako prÏi
ukoncÏenõÂ terapie pomocõÂ fixnõÂho aparaÂtu. Pro retencÏnõÂ
uÂcÏely postacÏõÂ nocÏnõÂ nosÏenõÂ aparaÂtuÊ.
JestlizÏe je Essix foÂlie pouzÏita jako aktivnõÂ aparaÂt, pak
je opakovaneÏ tvarovaÂna pomocõÂ termoklesÏtõÂ. Aktivaci
aparaÂtuÊ HilliardovyÂmi termoklesÏteÏmi lze teÂzÏ pouzÏõÂt ve
faÂzi finishingu leÂcÏby pomocõÂ jinyÂch ortodontickyÂch foÂliõÂ
(Invisalign). Na tento typ foÂliõ lze umõÂstit i ruÊzna po-
mocna zarÏõÂzenõ (Obr. 3).
TvarovaÂnõ foÂliõ se provaÂdõ beÏhem kazÏde kontroly.
Aby bylo mozÏne pomocõ klesÏtõ ve foÂlii vytvorÏit ohyby,
je trÏeba je nejprve zahrÏaÂt na teplotu 83-94 °C v zaÂvi-
slosti na typu pouzÏite foÂlie [9]. Po nahrÏaÂtõ se klesÏteÏ prÏi-
lozÏõ na pozÏadovane mõÂsto aparaÂtu a jemnyÂm stiskem
rukojetõ se do plastu vytvorÏõ pozÏadovany vyÂstupek
[23, 24]. SysteÂm HilliardovyÂch termoklesÏtõÂ obsahuje
dohromady cÏtyrÏicet ruÊznyÂch druhuÊ klesÏtõÂ k provedenõÂ
odlisÏne aktivace aparaÂtu, nicmeÂneÏ sada zaÂkladnõÂch sÏe-
sti typuÊ klesÏtõÂ je dostacÏujõÂcõÂ.
SysteÂm Invisalign
Metoda praÂce se systeÂmem Invisalign je rozdeÏlena
do neÏkolika faÂzõÂ. PrvnõÂ krokem je zõÂskaÂnõÂ kompletnõÂ pa-
cientovy dokumentace osÏetrÏujõÂcõÂm leÂkarÏem. Ta obsa-
huje vyplneÏny anamnesticky formulaÂrÏ s detailnõÂm popi-
sem leÂcÏebneÂho plaÂnu, silikonove zubnõ otisky nebo zaÂ-
znam z inraoraÂlnõÂho skeneru, rentgenovou
a fotografickou dokumentaci. ZhotovenõÂ naprosto
prÏesnyÂch otiskuÊ zubuÊ je nezbytnou soucÏaÂstõÂ metody
Obr. 3. Plastove zaÂmky na Essix foÂlii k intruzi molaÂru pomocõ elastic-
keÂho tahu
Fig. 3. Plastic brackets on Essix aligner for molar intrusion with ela-
stic traction
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Cyan Magenta Yellow -
ORTODONCIE
- Teeth are aligned according to the activation of in-
dividual trays with the help of protrusions created by
professionals in their practice. An example is Smile-
Aligner system.
- System of fabricated trays with activation of mo-
vements into individual appliances according to the
treatment plan prepared before. An example is Invisa-
lign.
Smile-Aligner system
Smile-Aligner system was developed by Keith Hil-
liard [23]. It is a more economic version of computer ai-
ded manufacturing of orthodontic trays, and may be
used to solve a malocclusion from the beginning, or
correct the relapse. Unlike the sequence of aligners,
during the whole treatment only one Essix appliance
is used for a dental arch, sometimes more, however,
always after a new diagnostic set-up on the cast mo-
del.
Essix appliances are most frequently used for reten-
tion to passively hold teeth in dental arches in the de-
sirable position that was achieved during the treatment
with fixed appliance. For retention it is enough to wear
the aligner at night.
In case Essix plastic aligner is used as an active ap-
pliance, it is repeatedly treated with thermopliers. Acti-
vation with Hilliard thermopliers may be also used in
the finishing phase of the treatment with other ortho-
dontic appliances (Invisalign). Auxilliary equipment
may be adjusted to this type of plastic trays (Fig.3).
Trays are reshaped during every visit. To fold the pla-
stic tray, thermopliers must be heated at 83-94 °C,
depending on the type of the material used [9]. Heated
thermopliers are then applied to the chosen place of
the appliance, and the required overhang is then crea-
ted in the material [23, 24]. Hilliard thermoplier system
comprises forty different types of pliers for different ty-
pes of appliance activation; however, the basic set of
six pliers is sufficient.
Invisalign system
Work with Invisalign system includes several steps.
Complete patient's documentation is always required.
The written materials include anamnesis with a detailed
treatment plan, silicon dental impression or intraoral
scans, radiological and photographic records. Precise
dentition impression is a necessary part of treatment
with Invisalign. Impressions made of polyvinyl siloxane
are considered the most precise and stable. A good
quality impression is essential for subsequent treat-
ment. Centric occlusion and maximum intercuspation
are required. The next step involves CT scanning of the
impression. In principle, scanning is translation of solid
objects to 3D electronic data. The most frequently
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 Cyan Magenta Yellow Black
ORTODONCIE Odborna praÂce
Invisalign. Za nejprÏesneÏjsÏõÂ a dlouhodobeÏ stabilnõÂ jsou
povazÏovaÂny otisky z polyvinylsiloxanu. Kvalita otisku
je pro dalsÏõÂ pracovnõÂ postup naprosto zaÂsadnõÂ. Skus
se zachycuje v centraÂlnõÂ okluzi a maximaÂlnõÂ interkuspi-
daci. NaÂsledujõÂcõÂm krokem je CT skenovaÂnõÂ otiskuÊ.
SkenovaÂnõÂ je proces prÏevedenõÂ fyzickeÂho prÏedmeÏtu
na trojrozmeÏrna elektronicka data. V soucÏasne dobeÏ
je nejpouzÏõÂvaneÏjsÏõ metodou skenovaÂnõ pocÏõÂtacÏova to-
mografie, kde se pouzÏõÂvajõÂ ke skenovaÂnõÂ objektuÊ rent-
genove paprsky. Ty prochaÂzejõÂcõ skrz otisky a jsou za-
chyceny detektorem umõÂsteÏnyÂm za nimi. VyÂhodou CT
skenovaÂnõÂ je eliminace faÂze odleÂvaÂnõÂ saÂdroveÂho mo-
delu [25]. FaÂze CT skenovaÂnõÂ otiskuÊ zcela odpadaÂ, po-
kud leÂkarÏ na mõÂsto otiskovaÂnõÂ zubuÊ pracuje s intraoraÂl-
nõÂm skenerem. Cely proces zaÂznamu s pomocõ moder-
nõÂch intraoraÂlnõÂch skeneruÊ trva u jednoho pacienta
meÂneÏ nezÏ 15 minut [26] a neÏkterÏõÂ autorÏi udaÂvajõÂ u nejno-
veÏjsÏõÂch prÏõÂstrojuÊ pracovnõÂ dobu uzÏ do dvou minut [27].
VirtuaÂlnõÂ modely jsou sestavovaÂny do centraÂlnõÂ
okluze na zaÂkladeÏ tvaru kousacõÂch plosÏek zubuÊ. Po-
mocõÂ softwaru dochaÂzõÂ automaticky algoritmickyÂm
spojovaÂnõÂm odpovõÂdajõÂcõÂch ploch na antagonistickyÂch
zubech zubnõÂch obloukuÊ ke vzniku maximaÂlnõÂ inter-
kuspidace [28]. TõÂmto procesem jsou puÊvodneÏ na sobeÏ
nezaÂvisle 3D virtuaÂlnõ modely obou zubnõÂch obloukuÊ
sestaveny v centraÂlnõ okluzi. PrÏesne sestavenõ zubnõÂch
obloukuÊ je klõÂcÏem k dobreÂmu vyÂsledku leÂcÏby pomocõÂ
Invisalign. NaÂsleduje prÏõÂprava a vizualizace detailnõÂho
leÂcÏebneÂho postupu a ten je pak odeslaÂn zpeÏt leÂkarÏi,
ktery provede jeho posouzenõ prostrÏednictvõÂm apli-
kace ClinCheck (Clinical Checking). ClinCheck je 3D
virtuaÂlnõÂ zobrazenõÂ pruÊbeÏhu terapie pomocõÂ systeÂmu
Invisalign, zhotovene na zaÂkladeÏ leÂcÏebneÂho plaÂnu
osÏetrÏujõÂcõÂho leÂkarÏe. Popisuje zmeÏny v zubnõÂch oblou-
cõÂch v zaÂvislosti na sekvenci pouzÏityÂch foÂliõÂ [10].
Proces virtuaÂlnõÂho plaÂnovaÂnõÂ pohybuÊ zubuÊ je do-
koncÏen ve chvõÂli, kdy leÂkarÏ schvaÂlõÂ v ClinChecku naÂvrh
terapie (Obr. 4, 5). ZasõÂlaÂnõÂ, schvalovaÂnõÂ nebo uÂpravy
Obr. 4. ClinCheck s vyobrazenõÂm zubnõÂch obloukuÊ na pocÏaÂtku orto-
donticke leÂcÏby
Fig. 4. ClinCheck - visualization of dental arches at the beginning of
orthodontic treatment
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Cyan Magenta Yellow -
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cÏ. 4. 2013
used method is computer tomography in which the ob-
jects are scanned with x-rays. The x-rays pass through
the impression and are recorded by the detector be-
hind the impression. The advantage of CT is seen in
the elimination of the need to pour plaster model [25].
In case a dentist can work with an intraoral scanner,
CT scanning is not required. The recording with a mo-
dern intraoral scanner takes up to 15 minutes [26];
some authors report 2 minutes or less in case of the la-
test scanners [27].
Virtual models are constructed in centric occlusion
according to the shape of occlusal surface of teeth.
Automatic algorithmic assembling of corresponding
surfaces of antagonist teeth in both dental arches re-
sults in maximum intercuspation [28]. The originally in-
dependent 3D virtual models of dental arches are thus
assembled in centric occlusion. Precise configuration
of dental arches is the key to successful results of
treatment with Invisalign. Then the visualization of de-
tailed treatment plan is prepared and sent to the den-
tist who will evaluate the plan with the help of Clin-
Check application (Clinical Checking). ClinCheck is
a 3D virtual visualization of the treatment process with
Invisalign system according to the treatment plan
made by the dentist. The changes in dental arches re-
lated to sequence of trays are described [10].
The process of virtual planning of teeth movements
is finished by dentist's approval to the ClinCheck pro-
posal (Fig. 4, 5). Transfer, approval or modificatons of
ClinCheck are made with VIP programme (Virtual Invi-
salign Practice) providing the communication between
the dentist and Align Technology Company [28].
Align company technicians precisely plan and
describe individual stages of tooth movement, from
the initial to final position. It is necessary to consider
biology and biomechanics of tooth movement with
plastic appliance, and remember that this part of the
process is performed by software engineers, not den-
Obr. 5. ClinCheck s vyobrazenõÂm zubnõÂch obloukuÊ na konci orto-
donticke leÂcÏby
Fig. 5. ClinCheck - visualization of dental arches at the end of ortho-
dontic treatment
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cÏ. 4. 2013 Odborna praÂce
ClinChecku probõÂhajõÂ prostrÏednictvõÂm VIP programu
(Virtual Invisalign Practice), ktery zajisÏt'uje komunikaci
mezi leÂkarÏem a spolecÏnostõÂ Align Technology [28].
Technici spolecÏnosti Align sice prÏesneÏ plaÂnujõÂ a po-
pisujõ jednotlive faÂze posunu zubuÊ od vyÂchozõ polohy
k finaÂlnõÂ, ale je trÏeba braÂt v uÂvahu biologicke a biome-
chanicke zaÂkonitosti pohybu zubuÊ pomocõ foÂlioveÂho
aparaÂtu, stejneÏ jako fakt, zÏe se jedna o pocÏõÂtacÏove pro-
gramaÂtory, nikoliv o leÂkarÏe. VyÂsledkem tohoto procesu
je vyhodnocenõÂ, kolik faÂzõÂ a tedy i foÂliõÂ bude v jednotli-
vyÂch zubnõÂch obloucõÂch trÏeba k dosazÏenõÂ vyÂsledku, po-
pis rychlosti a velikosti posunuÊ, jakozÏto i nacÏasovaÂnõÂ
pohybu jednotlivyÂch zubuÊ a model kotvenõÂ, ktereÂho
bude vyuzÏito. VsÏechny tyto informace jsou zapsaÂny
v tabulkoveÂm Stage Editoru [29]. Je zde znaÂzorneÏno,
ve ktere faÂzi bude probõÂhat pohyb kazÏdeÂho jednotli-
veÂho zubu v daneÂm zubnõÂm oblouku. MaximaÂlnõÂ povo-
lena rychlost pohybu beÏhem jedne faÂze je 0,25 mm.
ClinCheck take slouzÏõ jako dobra pomuÊcka pro pa-
cienta, ktery si muÊzÏe po jejõÂm zhleÂdnutõ naÂzorneÏ prÏed-
stavit cely pruÊbeÏh leÂcÏby a snaÂze jõ tak porozumõÂ.
Velmi duÊlezÏityÂm prvkem v technice Invisalign jsou
attachmenty, cozÏ jsou male uÂtvary z kompozitnõ pry-
skyrÏice zhotovene na povrchu zubuÊ podle speciaÂlnõ foÂ-
lie. Jsou pouzÏõÂvaÂny k zajisÏteÏnõÂ lepsÏõÂ retence foÂlie na zu-
bech potrÏebne k jejich pohybu, ale take jako pomocnyÂ
prvek vedoucõÂ k veÏtsÏõÂ efektiviteÏ ortodontickyÂch po-
hybuÊ, kde jen tlak foÂlie na zub nestacÏõÂ (platõÂ to prÏede-
vsÏõÂm o rotaci premolaÂruÊ a sÏpicÏaÂkuÊ, extruzi ktereÂhokoliv
ze zubuÊ). S vyÂvojem novyÂch typuÊ attachmentuÊ se
vylepsÏujõÂ mozÏnosti prÏesneÂho provedenõÂ slozÏiteÏjsÏõÂch
pohybuÊ zubuÊ a rozsÏirÏujõÂ se tak indikace ortodontickeÂ
terapie pomocõÂ foÂliovyÂch aparaÂtuÊ [30].
NejvhodneÏjsÏõÂm materiaÂlem ke zhotovenõÂ attachmentuÊ
jsou sveÏtlem tuhnoucõÂ kompozitnõÂ pryskyrÏice [31].
Esteticke vnõÂmaÂnõ attachmentuÊ zaÂvisõ na jejich veli-
kosti a tvaru. Barva kompozitnõÂ pryskyrÏice, ze ktereÂ
jsou zhotovovaÂny, je velmi podobna barveÏ zubuÊ. Nasa-
zenõÂm foÂlie se naÂpadnost attachmentuÊ zmõÂrnõÂ.
SysteÂm Invisalign take vyÂznamneÏ pouzÏõÂva techniku
zõÂskaÂvaÂnõÂ mõÂsta pomocõÂ interproximaÂlnõÂho zaÂbrusu.
NejmensÏõ mozÏny rozsah strippingu je 0,2 mm, nejveÏtsÏõÂ
dle nastavenõÂ programu 0,5 mm a veÏtsÏõÂ muÊzÏe byÂt na-
plaÂnovaÂn pouze na prÏaÂnõÂ osÏetrÏujõÂcõÂho leÂkarÏe. [29] Roz-
sah zaÂbrusu, jeho nacÏasovaÂnõÂ a vyÂbeÏr nejvyÂhodneÏjsÏõÂch
zubuÊ byÂva plaÂnovaÂn ve faÂzi prÏõÂpravy ClinChecku a je
rozepsaÂn spolu s umõÂsteÏnõÂm attachmentuÊ na scheÂ-
matu prÏilozÏeneÂm u sady foÂliovyÂch aparaÂtuÊ. VzÏdy je
trÏeba redukci skloviny proveÂst prÏed nasazenõÂm daneÂ
foÂlie, ktera je na naÂkresu oznacÏena.
V ClinChecku je take mozÏne sledovat zmeÏny polohy
zubuÊ prÏekrytõÂm digitaÂlnõÂch modeluÊ prÏed leÂcÏbou a po je-
jõÂm ukoncÏenõÂ (superimpozice). Modely jsou barevneÏ
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ORTODONCIE
tists. The result of this process is establishing how
many stages (and thus also how many trays) are ne-
cessary in individual dental arches to achieve the
aim, description of speed and extent of movements, ti-
ming of individual teeth movement, and anchorage to
be used. This information is recorded in Stage Editor
[29]. The maximum permissible speed of the move-
ment during one stage is 0.25 mm.
ClinCheck is a good tool for patients allowing them
to see the whole treatment process and understand it.
A very important role in Invisalign treatment is
played by attachments, small formations made of
composite resin on tooth surface according to a speci-
fic tray. They secure better retention of the tray on teeth
needed for their movement, they also help to achieve
more effective orthodontic movement in case when
the tray pressure on a tooth is not sufficient (e.g. in ro-
tation of premolars and canines, extrusion of any
tooth). New attachments allow for precise perfor-
mance of more complex tooth movements, and thus
extend the range of indications of orthodontic therapy
with plastic appliance [30].
Light cured composite resin is considered the best
material for attachments [31].
Esthetic perception of attachments depends on
their size and shape. The color of composite resin is
very close to the color of dentition. When the plastic
appliance is adjusted, the attachments become vir-
tually invisible.
To secure sufficient space, Invisalign uses interpro-
ximal stripping. The extent of stripping is usually bet-
ween 0.2 and 0.5 mm; more extensive stripping is po-
ssible only when required by the dentist [29]. Stripping,
its timing and the choice of the most suitable teeth, is
planned during ClinCheck stage, and it is described
along with the positions of attachments in a chart
enclosed to the set of plastic aligners. Enamel reduc-
tion must always precede the adjustment of the given
tray specified in the chart.
The changes in teeth positions may be tracked also
with help of superimposition of the models of dentition
made prior the treatment and after the treatment is fi-
nished. Models have different colors, the initial one is
blue, and the final teeth position is in white (Fig.6).
After the doctor's approval of ClinCheck, 3D com-
puter models are converted into solid models made
of resin by the process of stereolithography (SLA).
3D object is manufactured through gradual stratifica-
tion and curing of layers. Manufacturing of plastic alig-
ners is the end of the whole process. Plastic aligner is
shaped according to SLA form, cut, removed from
a mold, polished, packed and sent to the client [25].
Align Technology company holds the patent for In-
visalign technology as well as about 350 patents for
www.orthodont-cz.cz e-mail: redakce@orthodont-cz.cz
 Cyan Magenta Yellow Black
ORTODONCIE Odborna praÂce
odlisÏeny, vyÂchozõÂ situace modrou barvou, finaÂlnõÂ po-
loha zubuÊ bõÂlou (Obr. 6).
Jakmile leÂkarÏ schvaÂlõÂ ClinCheck, prÏevedou se trojro-
zmeÏrne pocÏõÂtacÏove modely na fyzicke pryskyrÏicÏne mo-
dely prÏi procesu stereolitografie (SLA), cozÏ je proces
rychle vyÂroby forem. PrÏi SLA metodeÏ se trojrozmeÏrnyÂ
prÏedmeÏt vyrobõÂ postupnyÂm vrstvenõÂm a tvrzenõÂm. VyÂ-
roba foÂliovyÂch aparaÂtuÊ prÏedstavuje uÂplny zaÂveÏr celeÂho
procesu, kdy se plastove foÂlie vytvarujõ podle SLA
formy, zastrÏihnou, odstranõÂ z formy, vylesÏtõÂ, zabalõÂ
a odesÏlou [25].
SpolecÏnost Align Technology si nechala patentovat
technologii Invisalign a vlastnõÂ prÏiblizÏneÏ 350 patentuÊ
zahrnujõÂcõÂch sÏiroke spektrum technik pro skenovaÂnõÂ
zubuÊ a navrhovaÂnõÂ a vyraÂbeÏnõÂ snõÂmacõÂch foÂliovyÂch se-
kvencÏnõÂch systeÂmuÊ. Patenty se take tyÂkajõ pocÏõÂtacÏoveÂ
techniky 3D modelace zubnõÂch obloukuÊ a prÏenosu dat
do praxe osÏetrÏujõÂcõÂho leÂkarÏe skrze ClinCheck. Po vy-
prsÏenõÂ platnosti patentuÊ Align Technology lze ocÏekaÂvat
rychly naÂstup konkurencÏnõÂch systeÂmuÊ foÂliovyÂch apa-
raÂtuÊ se snõÂzÏenõÂm jejich porÏizovacõÂ ceny [32].
NosÏenõÂ foÂliõÂ, retence
K docõÂlenõÂ plaÂnovaneÂho vyÂsledku terapie je ne-
zbytna dobra spolupraÂce pacienta. UÂspeÏsÏneÂho po-
sunu zubuÊ dosaÂhneme prÏi nosÏenõÂ foÂliovyÂch aparaÂtuÊ mi-
nimaÂlneÏ 16-20 hodin denneÏ. K dosazÏenõÂ maximaÂlnõÂ
efektivity je ideaÂlnõÂ pouzÏõÂvaÂnõÂ 22 hodin denneÏ. [19] VyÂ-
meÏna foÂliõ se provaÂdõ zpravidla kazÏde dva tyÂdny. Jedna
foÂlie by tak meÏla byÂt nosÏena 300 azÏ 400 hodin [19].
Reakce zubuÊ na puÊsobenõÂ sõÂly jsou individuaÂlnõÂ. U neÏ-
kteryÂch pacientuÊ je mozÏne aparaÂt vymeÏnit drÏõÂve a na-
opak u jinyÂch muÊzÏe byÂt i po dvou tyÂdnech foÂlie staÂle ak-
tivnõÂ [33]. Pacient by se meÏl prÏi urcÏovaÂnõÂ doby vyÂmeÏny
rÏõÂdit postupnou volnostõÂ foÂlie, kterou lze v dobeÏ vyÂmeÏny
na zuby lehce nasadit a sejmout.
Je-li po ukoncÏenõ poslednõ faÂze jesÏteÏ nutna uÂprava
postavenõ neÏkteryÂch zubuÊ, je mozÏne tvar poslednõ foÂlie
upravit a tõÂm ji aktivovat k posunu zubuÊ pomocõÂ termo-
klesÏtõÂ. Pokud je pozÏadovana korekce veÏtsÏõÂho rozsahu
je nezbytne zhotovit nove otisky a odeslat je ke zpraco-
vaÂnõ a zhotovenõ naÂslednyÂch foÂliõÂ. Jedna se o tzv. refi-
nement [33].
Pro zhotovovaÂnõ retencÏnõÂch aparaÂtuÊ platõ stejna pra-
vidla jako prÏi praÂci s fixnõÂmi aparaÂty. Podle vyÂchozõÂ a vyÂ-
sledne situace zhotovõÂme deskove retencÏnõ aparaÂty,
fixnõ retainery nebo foÂliove aparaÂty ze silneÏjsÏõÂho mate-
riaÂlu odolneÂho vuÊcÏi abrazi.
DalsÏõ foÂliove systeÂmy
OrthoCaps (The TwinAligner)
JednõÂm z dalsÏõÂch zaÂstupcuÊ systeÂmu pocÏõÂtacÏem rÏõÂ-
zene vyÂroby foÂliovyÂch aparaÂtuÊ je neÏmecky systeÂm
OrthoCaps [34]. V principu se vyÂrazneÏ shoduje se sy-
www.orthodont-cz.cz e-mail: redakce@orthodont-cz.cz
Cyan Magenta Yellow -
rocÏnõÂk 22
cÏ. 4. 2013
Obr. 6. Superimpozice posunu zubuÊ v ClinChecku
Fig. 6. Superimposition of teeth movement
a wide variety of methods of dentition scanning, plan-
ning and manufacturing of removable plastic sequen-
tial systems, 3D modelling of dental arches, and trans-
fer of data via ClinCheck. After Align Technology pa-
tents expire, we can expect the launch of competing
systems of plastic aligners with lower costs and price
[32].
Wearing aligners, retention
To achieve the desired result of the treatment, the
cooperation of a patient is essential. Plastic aligners
should be worn for at least 16 to 20 hours a day, ideally
for 22 hours a day [19]. The trays are exchanged
usually once in a fortnight, i.e. one appliance should
be worn for 300 - 400 hours [19]. Response of teeth
to the force applied is individual. In some patients it
is possible to adjust a new appliance sooner; in other
patients the appliance may be still active even after
two weeks [33].
In case the last stage is finished and there are still
some teeth requiring adjustment of their position, the
shape of the last appliance may be altered and thus ac-
tivated with thermopliers. In case of a more extensive
correction, it is necessary to make new impressions
and manufacture new set of trays. This is the so called
refinement [33].
For manufacturing of retainers the same rules apply
as for the work with fixed appliances. Based on the ini-
tial and final condition we produce retention plates, fi-
xed retainers, or plastic aligners made of thicker mate-
rial resistant to abrasion.
Other systems
OrthoCaps (The TwinAligner)
Another representative of the system of computer
aided manufacture of plastic aligners is German sy-
stem OrthoCaps [34]. In principle, it is very similar to In-
233
 Cyan Magenta Yellow Black
rocÏnõÂk 22
cÏ. 4. 2013 Odborna praÂce
steÂmem Invisalign. I zde ma leÂkarÏ mozÏnost ovlivnÏovat
pruÊbeÏh terapie. PlaÂnovaÂnõ terapie vsÏak probõÂha vzÏdy
jen na dobu seÂrie osmi foÂliovyÂch aparaÂtuÊ. Po jejich
ukoncÏenõ je trÏeba zhotovit nove otisky, ktere se ode-
sÏlou k naplaÂnovaÂnõÂ naÂsledneÂho postupu a zhotovenõÂ
dalsÏõÂch osmi seÂriõÂ foÂliõÂ. Druhou odlisÏnostõÂ od systeÂmu
Invisalign je rezÏim nosÏenõÂ foÂliovyÂch aparaÂtuÊ. V seÂrii jsou
dodaÂny vzÏdy dveÏ foÂlie pro jeden zubnõÂ oblouk. TencÏõÂ
a meÂneÏ pruzÏna na dennõ nosÏenõÂ, silneÏjsÏõ a võÂce elastickaÂ
na nocÏnõ pouzÏitõÂ. VyÂmeÏna seÂrie probõÂha vzÏdy po trÏech
tyÂdnech nosÏenõÂ.
Simply5
Simply5 [35] od spolecÏnosti Ormco, je dalsÏõÂm sy-
steÂmem shodujõÂcõÂm se v principu v indikaci, vyÂrobnõÂch
postupech i vlastnostech se systeÂmem Invisalign. LeÂ-
cÏebny plaÂn je zhotoven na zaÂkladeÏ odeslanyÂch PVS
otiskuÊ zubuÊ nebo saÂdrovyÂch modeluÊ a vyplneÏneÂho for-
mulaÂrÏe s prÏedpisem leÂkarÏe [35].
ZaÂveÏr
FoÂliove aparaÂty jsou jen jednou variantou ortodontic-
kyÂch aparaÂtuÊ. Je trÏeba zduÊraznit, zÏe ve sve soucÏasneÂ
podobeÏ nemohou plneÏ nahradit fixnõÂ aparaÂty ve vsÏech
indikacõÂch. I jejich struÊjci prÏiznaÂvajõÂ, zÏe se sami ve svyÂch
praxõÂch neomezujõÂ na pouzÏõÂvaÂnõÂ pouze jednoho typu
aparaÂtuÊ, ale kombinujõÂ jejich pouzÏitõÂ tak, aby leÂcÏba byla
co nejefektivneÏjsÏõÂ, zaÂrovenÏ vsÏak preciznõÂ a pro pacienty
prÏõÂjemna [9]. NicmeÂneÏ prÏi korekci lehcÏõÂch a hlavneÏ neex-
trakcÏnõÂch prÏõÂpaduÊ se staÂvajõ foÂliove aparaÂty vyÂznamnou
estetickou variantou ortodonticke terapie.
AutorÏi nemajõ komercÏnõÂ, vlastnicke nebo financÏnõ zaÂjmy na pro-
duktech nebo spolecÏnostech popsanyÂch v tomto cÏlaÂnku.
Literatura/References
1. Cooper-Kazaz, M.; Ivgi, I.; Canetti, L.; Bachar, E.; Tsur,
B.; Schaushu, S.; Shalish, M.: The impact of personality
on adult patient's adjustability to orthodontic appliance.
Angle Orthodont. 2012, 82, cÏ. 3, s. 1-7.
2. Remensnyder, O.: A gum-massing appliance in the treat-
ment of pyorrhea. Dent Cosmos. 1926, 28, s. 381-384.
[Cit. In: Tuncay, O. C.: The Invisalign System, New Mal-
den: Quintessence Publishing, 2006.
3. Kesling, H. D.: The philosophy of tooth positioning ap-
pliace. Amer. J. Orthodont. 1945, 31, s. 297-304. [Cit.
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4. Ponitz, R. J.: Invisible retainers. . Amer. J. Orthodont.
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234
Cyan Magenta Yellow -
ORTODONCIE
visalign system. The doctor is directly involved in mo-
difications of treatment. However, the treatment is al-
ways planned only for the sequence of eight plastic ap-
pliances. After the therapy is finished, it is necessary to
make new impressions, plan the following phase of the
treatment, and manufacture another set of eight ap-
pliances. There are two trays for one dental arch: a thin-
ner and less flexible to be worn during a day, and thic-
ker and more flexible to be worn at night. The set is
exchanged after three weeks.
Simply5
Simply5 [35] by Ormco is another system with indi-
cation, manufacturing process and characteristic fea-
tures similar to Invisalign. The treatment plan is prepa-
red, after impressions or cast models of teeth are sent
to the company, together with the filled-in form and re-
commendation by the doctor [35].
Conclusion
Plastic aligners are only one among the many types
of orthodontic appliances. We have to emphasize the
fact that today they still cannot fully substitute fixed ap-
pliances in all the indications. Even the inventors of
plastic aligners combine and use several types of ap-
pliances to achieve the most effective and precise re-
sults by the treatment that is as comfortable for a pa-
tient as possible [9]. In cases of minor corrections
and treatment without teeth extraction, plastic ap-
pliances have already become a significant esthetic al-
ternative of traditional orthodontic therapy.
Authors have no commercial, proprietary or financial interest in
products or companies mentioned in the article.
6. Trang, D.: History and overview of the Invisalign system.
In: Tuncay, O. C.: The Invisalign System, New Malden:
Quintessence Publishing, 2006.
7. Tricca, R.; Li, C.: Properties of aligner material EX30, In:
Tuncay, O. C.: The Invisalign System, New Malden:
Quintessence Publishing, 2006.
8. Russo, A.; ViceÂns, J.: Comparative use of Invisalign by
orthodontists and general practitioners. Angle Ortho-
dont. 2010, 80, cÏ. 3, s. 425-434.
9. Hilliard, K.: The Hilliard Smile Aligner Manual, 2002.
10. Garini, F.: Invisalign Certification Course, Amsterdam,
2012 (12.10.).
11. Duong, T.; Derakhshan, M.: Advantages of the Invisalign
System. In: Tuncay, O. C.: The Invisalign System, New
Malden: Quintessence Publishing, 2006.
12. Vlaskalic, V.; Boyd, R. L.: Clinical evolution of the Invisa-
lign appliance. J. California dent. Assoc. 2002, 30, cÏ. 10,
s. 769-776.
13. Rosvall, M. D.; Fields, H. W.; Ziuchkovski, J.; Rosenstiel,
S. F.; Johnston, W. M.: Attractiveness, acceptability, and
www.orthodont-cz.cz e-mail: redakce@orthodont-cz.cz
 Cyan Magenta Yellow Black

rocÏnõÂk 22
ORTODONCIE Odborna praÂce cÏ. 4. 2013

value of orthodontic appliances. Amer. J. Orthodont.
dentofacial Orthop. 2009, 5, cÏ. 3, s. 276.e1- 276.e12.
14. Miethke, R. R.; Vogt, S.: A comparison of the periodontal
health of patients during treatment with the Invisalign sy-
stem and with fixed orthodontic appliances. Fortschr.
Kieferorthop. 2005, 66, cÏ. 3, s. 219-229.
15. Miethke, R. R.; Brauner, K.: Periodontal status in Invisa-
lign and lingual technique. Fortschr. Kieferorthop. 2007,
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16. Miller, K. B.; McGorray, S. P.; Womack, R.; Quintero, J.
C.; Perelmuter, M.; Gibson, J.; Dolan, T. A.; Wheeler, T.
T.: A comparison of treatment impacts between Invisa-
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Orthop. 2007, 131, cÏ. 3, s. 302.e1-9.
17. Lindauer, S. J.; Shoff, R.C.: Comparison of Essix and Haw-
ley retainers. J. clin. Orthodont. 1998, 32, cÏ. 2, s. 95-97.
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California dent. Assoc. 2007, 73, cÏ. 3, s. 263-266.
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American Board of Orthodontics Objective Grading Sy-
stem for dental cast. Amer. J. Orthodont. dentofacial
Orthop. 2005, 127, cÏ. 2, s. 268-269.
21. Djeu, G.; Shelton, C.; Maganzini, A.: Outcome assess-
ment of Invisalign and traditional orthodontic treatment
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23. Hilliard, K.: How to Use the Hilliard Thermopliers, 2004.
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27. 3. Trios.: Brochure, Copenhagen , 2011.
http://www.krbec.cz/uws_files/3shape_trios_brochure_
2011_uk_complete_lowres.pdf
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29. Sterental, R.: Staging. In: Tuncay, O. C.: The Invisalign
System, New Malden: Quintessence Publishing, 2006.
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Publishing, 2006.
31. Kuo, E.; Duong, T.: Invisalign attachments: Materials. In:
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Quintessence Publishing, 2006.
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orthodontics. 4th ed., St. Louis: Mosby, 2007.
33. Duong, T.; Tricca, R.: Force application with Invisalign:
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34. Orthocaps: 3D iSetup User Guide, Hamm, 2002.
35. http://www.ormco.com/products/simpli5

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www.orthodont-cz.cz e-mail: redakce@orthodont-cz.cz 235

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