MCO Orthodontics

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Getting Started with Invisalign


If you’re interested in getting on your way to a new smile without the use of metal, ceramic, or lingual braces, you will have to visit a certified Invisalign® dentist or orthodontist for a consultation. Many consultations are complimentary, but the scope of the examination will vary by location and office. Typically, the doctor will take a look in your mouth and discuss some of the problems and solutions to your malocclusion. The cost and duration and treatment may be discussed as well. Proper diagnosis and treatment planning requires photos, a cephalometric X-ray, and full mouth series or panoramic X-ray, but these may not be included in the complimentary assessment.


PVS Impressions


If you’re ready to go ahead with treatment, a series of polyvinyl siloxane impressions (PVS) and bite registration will be taken. These impressions create an exact imprint of your teeth to help formulate your treatment. The future impressions are likely to be replaced by digital scanning or 3-D x-ray imaging.

All records are sent overnight to Align Technology in California, where they are then sent to Juarez, Mexico, for scanning a 3-D model of your teeth. The digital record is then emailed to Costa Rica where technicians (not dentists or orthodontists) create a simulation of the way your teeth will move (ClinCheck). It is your doctor’s responsibility to ensure that the movements provided by Align technicians are biologically and physically possible in your mouth.


Often, several modifications and edits of tooth movement are required. When satisfied, your doctor will accept the simulation and begin the process of aligner fabrication in Mexico. Unfortunately, many inexperienced doctors do not recognize improper or impossible movements and accept treatment because the video simulation produces a good result. This is one of the most common reasons for failed Invisalign treatment. Remember that the ability of your doctor to show you a ClinCheck that produces a nice end result does little to ensure that you will achieve the desired results.

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*NEW* iOC Digital Invisalign Tooth Scanner


In the past, PVS impressions were the only way to send 3-D information to Align Technologies. In the spring of 2011, Align bought the technology of the iOC scanner, allowing for an instant 3-D capture of the teeth. It is a non X-ray scan and has several advantages, including increased accuracy and comfort. Now there is no need to worry about gagging, messy materials, or inaccurate impressions. It is truly an amazing technology, but currently, the cost of a single scanner is about the cost of a nice car. Therefore, this service may not be available, except from some of the top Invisalign doctors in North America.

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Initial insert


Treatment generally begins with your first two sets of aligners and instructions on their wear and care. You’ll come back to see your doctor in four weeks for attachments and IPR, if required. It is critical that the aligners be worn judiciously, since the attachment template used is for how your teeth should be one month from now. If the proper movement hasn’t been achieved, the remainder of treatment will be thrown off-course.

Please note that you may experience the following when first beginning treatment:

  • Transient lisp until used to the aligners
  • Teeth may develop some soreness associated with tooth movement
  • Bite may feel weird or different
  • Some adjustment period to the aligner
  • Adaptation of teeth to the aligner may not be ideal to start

On the positive side, patients often receive compliments that their teeth look shinier and straighter even when just starting treatment, due to the smooth contours of the aligner.


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Attachments and IPR

These are two aspects of Invisalign that are not mentioned on the Invisalign website or by many doctors. However, they are extremely important components of proper Invisalign care.

IPR (Interproximal reduction) is also known as filing, grinding, slenderization, and enameloplasty. Whatever the name is, it refers to the reduction of tooth enamel from the interproximal surfaces of the teeth to create sufficient space for tooth movement and/or to aid in the removal of "black triangles" at the gumline. Patients are often concerned about this part of treatment increasing sensitivity, cavities, being painful, or leaving gaps. It is completely safe method to reduce anywhere from 0.2mm-0.6mm without concern when performed properly as shown by decades upon decades of study.


IPR is often achieved using a diamond-plated wheel, bur, or strip. The method used will be determined by the doctor and based upon amount and location desired. Sometimes IPR is done prior to impressions, while other times it is done as treatment progresses.

Don’t be concerned if you feel the bur, disc, or strip at the gum level, or if you see a bit of blood. Proper IPR requires reduction all the way to the gum level to avoid ledges that may create traps for plaque and make it difficult to floss. Improper reduction may not allow proper tooth movement and delay the progress of treatment.

Attachments are virtually invisible bumps that help move the teeth and grab the aligners. They are bonded temporarily on the selected teeth by using a white filling material. An attachment template that is made of a more flexible material than the aligner, with wells for placement of the resin, aids the doctor, hygienist, or assistant in their placement. Note that some doctors may place attachments at the initial insert visit.


Some patients may experience the loss of Invisalign attachments. This is an uncommon occurrence in experienced offices, but it can occur because of:

  • Improper bonding technique and isolation
  • Inadequate movement of the teeth during the first two aligners, due to poor compliance or improper treatment planning
  • Improper removal of the aligner

If you’re concerned with how attachments look, consider that they are much less visible than braces. Currently, there are attachments in various shapes and sizes to aid in rotations, extrusions, intrusions, bodily movement, and to anchor units of teeth against another. The judicious use and placement of these attachments is critical to more advanced treatment. Most people, other than you, won’t even notice that you have attachments, especially when the aligners are in (which they should be... 22 hours per day!)

Note that the addition of attachments to the teeth may make aligners more difficult to remove. Don’t worry, it will get easier with practice and as the teeth settle into the aligner. Various types of instruments are available to help you remove your aligners as well.

After attachments are placed, we'll usually give you 4 aligners at each visit and see you in 8 weeks.  We always ask you to keep your previous aligner in case you lose your current one.  Sometimes it is ok to switch into the next aligner with some extended wear time.  We ask that you call the office to determine what is best.

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Additional Aligners (formerly Mid-Course Correction/Refinement)

Sometimes the teeth don’t move exactly as prescribed in the ClinCheck. If this occurs in the middle of the course of aligners, a new impression may be taken to "reboot" your treatment. This is known as mid-course correction. In North America, one mid-course correction is included in the lab fee for providers, given that it is not due to a change in treatment plan or dental work, such as fillings, crowns, etc. However, whether or not your treatment includes this will depend on the agreement with your doctor.

Refinement would be the equivalent of detailed finishing with braces treatment. It should not be viewed as a failure of treatment, but rather as a part of the process, if required. After the first course of trays, there may be slight movements that need to be achieved. At this point, new impressions can be taken, and a new course of trays can be used to help with the remaining movements. Note that in North America, there are up to three refinements included in the lab for providers, but what is included in your treatment fee is going to vary from office to office.

In mid 2015, Align changed refinement and mid-course correction to "additional aligners", allowing providers up to 5 years of aligners to help complete a patient's treatment.  Again, the number of revisions or aligners you are provided will depend on your contract with your office.

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Removing Attachments

This is a relatively simple procedure that is usually performed before impressions are taken for refinement/mid-course correction or at the end of treatment. It simply involves the removal of resin that was bonded to the teeth. No anaesthesia is required, and there is no pain involved in this procedure. Some patients may experience some sensitivity if there is gingival recession or root exposure present.

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Two of the largest barriers to treatment are the duration of treatment, and the potential for pain or discomfort.  Recently, the field of orthodontics has adapted long known principles of bone remodelling from orthopedics now with Acceledent to help address these two issues.

Before Acceledent, there have been a few techniques that have been used to accelerate orthodontics such as Wilckodontics and Propel.  The principle of tooth movement is that there is a need for bone remodelling via osteoclasts (removing bone from surfaces of the teeth where they need to move) and osteoblasts (cells that build bone behind the tooth where it has moved from.)  Wilckodontics is a periodontial procedure whereby the the gums are retracted and the holes are made in the bone around the teeth, whereby causing bleeding.  This promotes the blood factors required for healing, and thus tooth movement.  Teeth do move faster with this procedure, but the comfort aspect takes a backwards step, since it is quite painful.  Propel works on a similar principle.

1st generation of Acceledent

Acceledent is a product that has been used in Australia for about 4 years, in the USA for a bit over a year, and was just cleared for use in Canada in the spring of 2013.  MCO Orthodontics happy have some of the first units available in Toronto.  It is FDA approved as a Class 2 medical device with clinical trials at two universities in Texas showing a 38-50% increase in tooth movement.   It works by providing a pulsating vibration at a key frequency (30Hz) which has been shown to stimulate the bone remodelling process.  This is very different from the vibrations of sonic tooth brushes and other devices.  Patients use it for just 20 minutes per day and can do so while doing many daily tasks.

There is a possibility for faster treatment with braces and Invisalign aligners to be changed every 4-7 days, significantly decreasing the amount of treatment time required.  Best of all, over the study of 1000s of patients, there have been no adverse effects, including no significant root resorption.

This is a very exciting product that is available for patients at MCO Orthodontics who would like to have straight teeth with less discomfort and for a shorter amount of time.  Look to MCO Orthodontics as your leader for fast Invisalign and quicker braces treatment in Toronto.

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Just like any other orthodontic treatment, the use of retainers is required to maintain the tooth movement with Invisalign. There are many types of retainers, including fixed wires on the inside of the teeth, removable acrylic and wired retainers, as well as Invisalign-type retainers. Generally, you will be asked to wear the removable retainers full-time for a certain duration followed by indefinite periodic nightly wear. Patients commonly ask how long they should wear retainers for... the best answer is "as long as you want your teeth to stay straight!"

Invisalign offers a product known as Vivera Retainers. They can be made from your last stage of treatment or from a new impression. The material is slightly harder and more durable than Invisalign’s aligner, and they can be incorporated with fixed lingual retainers. Subscriptions are available where the first aligner is fitted in the office, with 3 more delivered to your address after about a month.  This ensures that your retainer fits before the rest are made.  Please note that Vivera subscriptions may not be included in your treatment fee. On a positive note, with proper care, our patients find that these retainers last well over a year.

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