The first reported three dimensional diagnosis and orthodontic treatment planning of complex malocclusion with the Invisalign appliance was reported by Boyd and Vlaskalic in 2001 [1]. Although this publication laid out the foundation for Invisalign or clear aligners’ diagnosis and treatment planning, continuous development of diagnostic tools like con-beam-computed-tomography (CBCT) for example has enhanced and provided tremendous insights into case diagnosis and treatment planning [2]. Also, the recent introduction of intraoral cameras and scanners that can provide the clinician with immediate digital model, compared to the traditional plaster study casts, can help the clinicians to make immediate informed decision rather than taking long time to work up the cases.

Contemporary orthodontic diagnosis and treatment planning include obtaining of the following records:

1. Patient’s history (Medical and dental)
2. Patient’s chief complaint
3. Clinical examination
4. Models (plaster or digital)
5. Radiographic evaluation

Patient’s History (Medical and Dental)

Obtaining patient’s history (medical and dental) is of utmost importance. I would like to stress on the following questions to the new or transferred patient:

1. Do you take any medication? If so what medication(s) are you currently taking now? The importance of this question is that, it can discover any underlying systemic illnesses that might affect your decision in terms of treatment planning for the patient. For example, if the patient is under corticosteroid for allergies or asthma, the orthodontist should be aware that corticosteroid affects bone remodeling and consequently orthodontic movement which is tightly linked to duration of treatment. Most new patients will ask the following question (how much time I will be in treatment) and the orthodontist should provide a reasonable answer, without commitment to specific duration. For example, it might be advisable based on the clinician’s experience to provide the new patient with a range of treatment time instead of locking himself/herself in specific time by saying (your treatment will take 18 months) it is better to say (cases like your case usually take in my hands 18 months on average depending on how compliant the patient is with my given instructions and also it depends on patients’ teeth and bone response to treatment).
2. Dental history is very important to know if the patient had severe dental trauma, root canal treatment, maintaining regular checkup visits with his/her dentist or not. The importance of this information in orthodontic treatment planning includes that in patients that have had trauma to their teeth, tooth mobility and root resorption might be expected. If the patient is maintaining his/her checkup visits to the dentist, this may reflect expected good oral hygiene. Towards the end of this book, I will present a case of bad oral hygiene that led to severe decalcification under the aligners and will discuss this at the end of this book.

PATIENT’S CHEIF COMPLAINT: Although the orthodontist might see different dental or orthodontic problems in the patient’s mouth upon clinical examination or after analyzing the patient’s records, it is very important to investigate patients’ main concerns and address them during the consultation or during the treatment. Patients with unaddressed concerns might not be happy or the clinician may lose the patients’ compliance which can affect the patient’s results. In order to explore this chief complaint or concern for the patient, the following question is a traditional one: Why you are here today? Or what brought you up here today?

CLINICAL EXAMINATION: This includes extra oral (profile to check if it is straight, convex or concave), this provides information about whether the patient might have skeletal class I, II or III. Also facial form (brachyfacial, mesofacial or dolichofacial type) to put into consideration the followings: If the patient is brachyfacial type, tooth movement might be difficult due to the fact that brachyfacial type patients usually have strong musculature that normally interferes with changing the occlusal pattern by orthodontic treatment. However, it may be interesting here to say that even with brachyfacial type patients, the use of clear aligners disengage the occlusion by the occlusal coverage of the teeth by plastic that can facilitate tooth movement due to minimized teeth inter-digitation.

On the other hand, dolichocephalic patients might have other problems like open bite. Also, if there is moderate to severe crowding in dolichofacial type cases, it is difficult to expand or distalize molars in these cases as these types of tooth movement can lead to exaggeration of the patient’s increased vertical dimension which might result in unacceptable results. It may also be worth mentioning here that in cases of open bite, occlusal coverage of teeth by clear aligners may serve as posterior bite plate that can help with controlling the vertical dimension of the patient.

Clinical examination of the patient’s facial symmetry is very important to differentiate between the patients that might require surgical intervention to improve patient’s asymmetric face/chin and consequently coordinated orthodontic-orthognathic treatment planning or patient that might have lateral mandibular shift due to dental interference or bilateral constricted upper arch.

Also, extra-oral clinical examination includes type of breathing as mouth breathers are usually have constricted upper arch and wide lower arch due to the unsupported upper posterior teeth from the lingual side against the inward forces of the cheek muscles. Mouth breathing should be handled first or during orthodontic treatment to minimize the possibility of relapse after treatment due to sustained inward pressure of cheek muscles on the upper posterior teeth with no or minimum tongue support for the palatal side to the upper posterior teeth.

Intraoral examination includes centric relation-centric occlusion relationship and if there is any functional shift of the mandible upon closure (anterior, posterior or lateral shift). Identification of these shifts upon clinical examination is important in predicting difficulty or simplicity of the presented case. More details about the incorporation of these possible shifts in treatment planning and results will be presented in the section of facial asymmetry as well as in class II division 2 cases. Also, intraoral examination includes gingival health, oral hygiene, molar and canine relationships, crowding/spacing, arch width and dental midlines (upper and lower) relations as well as cross bites.

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