Nonextraction Treatment Research Articles

Self-reported pain during different phases of orthodontic treatment with fixed appliance: A multi-centre randomized controlled trial in adolescents with crowding.

To compare self-reported pain levels across various treatment phases using passive self-ligating (Damon) and conventional (Victory) standardized fixed appliance systems. Adolescents (12-17 years old) with crowding and displaced teeth, planned for non-extraction treatment, were recruited from four orthodontic clinics. They were randomized into stratified blocks (1:1 ratio) using concealed allocation to receive Damon Q™ (34 boys, 28 girls) or Victory™ (39 boys, 31 girls). Pain and analgesic intake were assessed on seven different occasions with validated self-report questionnaires using a 10-grade scale. Of the 132 patients included, six were lost to follow up. Clinically relevant mean pain scores (≥4) were registered in both groups after bonding upper and lower arches and after insertion of 0.019 × 0.025 stainless steel archwire. The highest mean scores were reported on day two after bonding the upper arch (Damon 5.96, Victory 7.18, P = .011). In both groups, at least 40% reported taking analgesics during various treatment phases. The Damon group reported a lower intake of analgesics on days one and two (P = .042 and .037) after treatment initiation. In the entire sample, boys reported significantly higher mean pain scores than girls on the second and third days after bonding (P = .008 and .026, respectively). Lower pain levels were reported from the Damon group after bonding. In general, boys reported higher pain than girls did. Clinicians and adolescents need to be aware that clinically relevant pain levels can be expected not only after bonding but also in later phases.

Correction of class II malocclusion with modified pendulum appliance – A case report

Treatment of Class II malocclusion with significant crowding might be achieved without extraction if an appropriate diagnosis is made. The current study presents the orthodontic treatment for a 12-year-old female patient who was diagnosed with end-on molar relation bilaterally on class I skeletal base with proclined upper anteriors and crowding in lower anteriors. Both in terms of appearance and occlusal function, the post-treatment results met the patients' expectations. This case report details the non-extraction treatment of a class II molar relation by distalization into a class I molar relation utilizing a modified pendulum appliance.

Orthodontic considerations in hypodivergent craniofacial patterns

This article examines the characteristics of hypodivergent craniofacial patterns and explores treatment modalities in response to these features. It discusses the impact of robust masticatory muscles, which produce heavy occlusal forces. In addition, it examines the use of Botox or splints to reduce gonial angles in individuals with a square face. A nonextraction treatment approach supported by temporary skeletal anchorage devices is recommended; however, if anatomical limitations persist, extraction may be necessary when arch expansion, molar distalization, incisor proclination, or interproximal reduction cannot create the necessary space. In hypodivergent cases where a nonextraction approach is impractical, a single-arch extraction strategy may be considered to prevent a reduction in the vertical dimension. Emphasizing esthetics, particularly maxillary incisor display, a protocol of total arch extrusion of the maxillary dentition assisted with temporary skeletal anchorage device, bite raisers, and interarch elastics is suggested.

Effectiveness of laser-engineered copper-nickel titanium versus superelastic nickel-titanium aligning archwires: A randomized clinical trial.

: To compare the effectiveness of laser-engineered copper-nickel titanium (SmartArch) and superelastic nickel-titanium (SENT) archwires in aligning teeth and inducing root resorption and pain experienced by patients. : Two-arm parallel groups with a 1:1 allocation ratio were used. The participants were patients aged 11.5 years and older with 5-9 mm of mandibular anterior crowding who were indicated for non-extraction treatment. The primary outcome was alignment effectiveness, assessed using Little's irregularity index (LII) over 16 weeks with a single wire (0.016-inch) in the SmartArch group and 2 wires (0.014- and 0.018-inch) in the SENT group (8 weeks each). Secondary outcomes included root resorption evaluated by pre- and post-intervention periapical radiographs and pain levels recorded by the participants during the first week. : A total of 40 participants were randomly allocated into 2 groups; 33 completed the study and were analyzed (16 in the SmartArch group and 17 in the SENT group, aged 16.97 ± 4.05 years). The total LII decrease for the SmartArch and SENT groups was 5.63 mm and 5.29 mm, respectively, which was neither statistically nor clinically significant. Root resorption was not significantly different between the groups. The difference in pain levels was not statistically significant for the first 5 days following wire placement; however, there was a significant difference favoring the SENT group in the final 2 days. : SmartArch and SENT archwires were similarly effective during the alignment phase of orthodontic treatment. Root resorption should be observed throughout the treatment with either wire. SmartArch wires demonstrated higher pain perception than SENT wires.

Extraction vs nonextraction orthodontic treatment: a systematic review and meta-analysis.

To compare four first premolar extraction and nonextraction treatment effects on intra-arch width, profile, treatment duration, occlusal outcomes, smile aesthetics and stability. An electronic search of the literature to June 2, 2023 was conducted using health science databases, with additional search of gray literature, unpublished material, and hand searching, for studies reporting nonsurgical patients with fixed appliances regarding sixteen sub-outcomes. Data extraction used customized forms, quality assessed with ROBINS-I (Risk Of Bias In Non-randomized Studies-of Interventions) and Cochrane RoB 2 (risk-of-bias) tool. GRADE (Grading of Recommendations Assessment, Development and Evaluation) assessed certainty of evidence. Thirty (29 retrospective studies, 1 randomized controlled trial) studies were included. Random-effect meta-analysis (95% CI) demonstrated maxillary (MD: -2.03 mm; [-2.97, -1.09]; P < .0001) and mandibular inter-first molar width decrease (MD: -2.00 mm; [-2.71, -1.30]; P < .00001) with four first premolar extraction; mandibular intercanine width increase (MD: 0.68 mm; [0.36, 0.99]; P < .0001) and shorter treatment duration (MD: 0.36 years; [0.10, 0.62]; P = .007) in the nonextraction group. Narrative synthesis included three and five studies for upper and lower lip-E plane, respectively. For American Board of Orthodontics Objective Grading System and maxillary/mandibular anterior alignment (Little's irregularity index), each included two studies with inconclusive evidence. There were no eligible studies for UK Peer Assessment Rating (PAR) score. Class I subgroup/sensitivity analyses favored the same results. Prediction interval indicated no significant difference for all outcomes. Four first premolar extraction results in maxillary and mandibular inter-first molar width decrease and retraction of upper/lower lips. Nonextraction treatment results in mandibular intercanine width increase and shorter treatment duration. There was no significant difference between the two groups regarding maxillary intercanine width, US PAR score, and posttreatment smile esthetics. Further high-quality focused research is recommended.

Adult patient expectations and satisfaction: Can they be influenced by viewing the three-dimensional predicted outcome before fixed orthodontic treatment of dental crowding?

Investigating the possible changes in patients' expectations of and satisfaction with the orthodontic treatment outcomes when they were given the three-dimensional digital prediction of their teeth alignment before the beginning of treatment. A prospective non-controlled single-group clinical trial was conducted on 28 (18 females, 10 males, mean age: 20.68 ± 1.91 years) patients with Class I malocclusion and moderate dental crowding who required a nonextraction orthodontic treatment. Patients were given the expectations questionnaire on their first visit (T0). Then, patients were shown a three-dimensional digital setup-created by Orthoanalyzer software (3Shape, Copenhagen, Denmark)-of the proposed treatment results before orthodontic treatment (T1) and received two questionnaires, the second expectations questionnaire and the satisfaction with the proposed changes questionnaire. Treatment was then initiated using the fixed appliances and completed. After debonding, a question about patients' satisfaction with the achieved changes was completed (T2). Patients' expectations level significantly increased after watching the predicted alignment of teeth compared with the initial levels in terms of chewing (x¯=5.54 and x¯= 6.71), speech (x‾ =5.93 and x¯= 6.93), and oral hygiene improvement (x‾= 7.93 and x¯=8.61 ± 1.06; at T0 and T1, respectively). The remaining items showed no significant differences between the two assessment times. Patients had a higher level of satisfaction at the end of treatment than after watching the proposed outcome. There were significant statistical differences in the items related to teeth appearance (x¯= 9.12 and x¯= 9.60 at T1 and T2, respectively), and teeth engagement (x¯= 8.92 and x¯= 9.40 at T1 and T2, respectively) CONCLUSIONS: Watching the predicted alignment outcome increased patients' expectations of chewing, speech, and oral hygiene improvement compared with the initially recorded levels. Patients were more satisfied with the final result than what was recorded after viewing the predicted plan. However, these results were not clinically significant.

Three-dimensional evaluation of a virtual setup considering the roots and alveolar bone in molar distalization cases

We aimed to evaluate root parallelism and the dehiscence or fenestrations of virtual teeth setup using roots isolated from cone beam computed tomography (CBCT) images. Sixteen patients undergoing non-extraction orthodontic treatment with molar distalization were selected. Composite teeth were created by merging CBCT-isolated roots with intraoral scan-derived crowns. Three setups were performed sequentially: crown setup considering only the crowns, root setup-1 considering root alignment, and root setup-2 considering the roots and surrounding alveolar bone. We evaluated the parallelism and exposure of the roots and compared the American Board of Orthodontics Objective Grading System (ABO-OGS) scores using three-dimensionally printed models among the setups. The mean angulation differences between adjacent teeth in root setups-1 and -2 were significantly smaller than in the crown setup, except for some posterior teeth (p < 0.05). The amount of root exposure was significantly smaller in root setup-2 compared to crown setup and root setup-1 except when the mean exposure was less than 0.6 mm (p < 0.05). There was no significant difference in ABO-OGS scores among the setups. Thus, virtual setup considering the roots and alveolar bone can improve root parallelism and reduce the risk of root exposure without compromising occlusion quality.

Oral health in an urban slum, Nigeria: residents’ perceptions, practices and care-seeking experiences

Background/introductionOne of the key recommendations for the new WHO global strategy for oral health is inclusion of disadvantaged populations and their engagement in policy dialogues such that their needs and views are addressed in policy decisions.ObjectivesThis study explored oral health perceptions, practices and care-seeking experiences of slum residents in Ibadan, Nigeria.MethodFocus group discussions (FGD) were conducted with family health-decision makers in an urban slum site. Oral health perceptions, practices, and care-seeking experiences were discussed. FGDs were recorded, transcribed, and translated. ATLAS.ti qualitative research software was deployed for analysis using thematic analysis.ResultsSix FGD sessions, divided by gender and age, were conducted between September–October 2019, (N = total 58 participants, aged 25 to 59 years). Common dental ailments mentioned were dental pain, tooth sensitivity, bleeding gums, tooth decay, mouth odor, gum disease, and tooth fracture. Perceived causes of dental conditions included poor dental hygiene and habits, sugary diets, ignorance, and supernatural forces. Mouth cleaning was mostly done once daily using toothbrush and paste. Other cleaning tools were ground glass, wood ash, charcoal, “epa Ijebu” (a dentrifice), and “orin ata” (a type of chewing stick). Remedies for relieving dental pain included over-the-counter medicines, warm salted water, gin, tobacco (snuff/powdered), cow urine/dung, battery fluid, and various mixtures/ concoctions. Visits to the dentists were mentioned by a few but this was usually as last resort. Main barriers to accessing care from dental care facilities were unaffordability of service charges and fear of extreme treatment measures (extraction). Suggested measures to improve timely access to dental health care included reducing/subsidizing costs of treatments and medications, offering non-extraction treatment options, and oral health education programmes.ConclusionThe slum residents experience various forms of dental ailments mostly pain-related. The residents perceived formal dental clinics as unaffordable, thereby engaging in self‐care remedies and harmful oral health practices before seeking professional help. Policymakers and decision-makers may leverage this empirical evidence for the people’s education on early dental care and address challenges to affordable, available, and acceptable oral healthcare services among slum residents to improve access to care facilities.

Predicted overbite and overjet changes with the Invisalign appliance: a validation study.

To investigate whether the predicted changes in overbite (OB) and overjet (OJ) in Align Technology's (Santa Jose, Calif) digital treatment plan for the prescribed course of treatment with the Invisalign appliance were consistent with those same changes in OB and OJ measured with the Geomagic Control X (Geomagic US, Research, Triangle Park, NC) metrology software system. Geomagic Control X software was used to determine OB and OJ differences between the pretreatment and predicted outcome. STL files for patients satisfying inclusion criteria and undergoing nonextraction orthodontic treatment with the Invisalign appliance. The differences were compared, using the Bland-Altman analysis, to the corresponding data provided by Align Technology's digital treatment-planning interface, ClinCheck. Data regarding 76 adult patients who satisfied strict inclusion criteria were assessed. The Shapiro-Wilks test indicated normality (P > .05). The Bland-Altman analysis showed high levels of agreement between the two measurements, with a bias range of -0.131 to 0.111 for OB and -0.393 to 0.03 for OJ recorded. Clinicians and researchers can be confident that measurement data provided by Invisalign's ClinCheck digital treatment-planning facility concerning OB and OJ changes from the initial to the predicted treatment outcome are valid.

Full single arch distalization in Class II malocclusion using subzygomatic temporary anchorage devices: A case report

Abstract Distalization of the maxillary molars is among the most commonly employed nonextraction treatment strategies for angle Class II malocclusion. This approach is primarily recommended for subjects with dentoalveolar maxillary protrusion or minor skeletal abnormalities. A case of a 17-year-old Hispanic male patient with Class II skeletal base with Class II end on canines and molars, upper anterior crowding, severe overjet, and moderate overbite is hereby reported. He refused extraction; therefore, he was offered full single upper arch distalization using subzygomatic temporary anchorage devices (TADs). After 11 months of retraction, the TADs were removed and it was observed that the overjet and overbite were now within normal values and midline shift was also corrected. Satisfactory leveling and alignment, alleviation of crowding, and Class I molar and canine relationship were achieved. The aim of this case report was to describe full single arch distalization using subzygomatic TADs in a patient with Class II skeletal, molar, and canine relationships.

Skeletal Anchorage Augmentation in Extraction/Nonextraction Orthodontic Treatment: A Randomized Clinical Study.

To evaluate and compare skeletal, dental, and soft tissue parameters by therapeutic extraction of first premolar and nonextraction distalization of maxillary and mandibular arches in bimaxillary proclination using the skeletal anchorage system. About 40 orthodontic patients undergoing extraction or nonextraction treatment are enrolled in a randomized clinical trial. Participants are randomly assigned to either the extraction or nonextraction group and receive treatment augmented with skeletal anchorage. Mini implants were placed in the extraction group for retraction and infra-zygomatic crest (IZC) and buccal shelf screws were placed in the nonextraction group for distalization. Comparison between the ages of the patients among both Groups showed no significant difference. A significant difference is observed in dental and soft tissue parameters before and after the treatment in group A, whereas skeletal parameters also showed significant changes along with dental and soft tissue parameters in group B. There is a significant change in the position of incisors by retraction and facial profile improves gradually in group A while for group B, a marked change in lower facial height was even seen. On comparing both the groups, a highly significant difference can be seen with respect to the amount of incisor retraction and change in molar inclination. The time taken for retraction of incisors is less in comparison to distalization. With this, we can easily avoid premolar extraction, and in cases of impacted third molars distalization as when indicated can be helpful as a part of the nonextraction treatment plan.

Short-term stability of anterior open bite treatment with clear aligners in adults

This study aimed to examine the stability of anterior open bite (AOB) treatment with clear aligners. This retrospective cohort study included 52 adult AOB patients (aged>18 years; 15 males, 37 females) who underwent nonextraction clear aligner treatment and were at least 1 year posttreatment. Eleven cephalometric measurements were evaluated at pretreatment, end of active treatment, and at least 1-year posttreatment. Overbite change, the primary outcome variable, and other cephalometric changes during treatment and retention were calculated, and repeated measures analysis of variance were performed. Stepwise multiple regression was used to make a prediction equation for open bite relapse. The mean retention period was 2.1 ± 1.1 years. The mean change in overbite during treatment was 3.3 ± 1.5 mm; 6% of patients presented relapse at least 1 year after treatment completion. The mean change of overbite (0.2 ± 0.5 mm) during the retention period was not statistically significant (P= 0.59). None of the 11 cephalometric measurements showed significant change during the retention period. The prediction model showed that only the coefficient for a tongue posture issue at the initial examination was statistically significant. AOB was successfully corrected in all 52 patients using only clear aligners with no additional adjunctive aids such as microimplants. When retained with maxillary and mandibular fixed retainers and maxillary and mandibular vacuum-formed retainers, there was no significant change in cephalometric measurements during the short-term retention period.

Impact of molar teeth distalization by clear aligners on temporomandibular joint: a three-dimensional study

BackgroundMaxillary molar distalization is a common technique used in the non-extraction treatment of Angle Class II malocclusion that can effectively correct the molar relationship and create spaces for anterior teeth alignment. However, this approach may also impact the temporomandibular joint (TMJ) due to predictable changes in the posterior vertical dimension. Despite its widespread use, Class II malocclusions correction by molar distalization with clear aligners has not been investigated for their effects on the TMJ. Therefore, this study aimed to analyze the impact of sequential molar distalization using clear aligners on the TMJ.MethodsThree-dimensional CBCT scans of 23 non-growing patients (7 males, 16 females; mean age 29.8 ± 4.6 years) with skeletal class I or II malocclusion and a bilateral molar class II relationship treated by sequential upper molars distalization with orthodontic clear aligners (Invisalign, Align Technology, San Josè, Ca, USA). A total of 46 joints were examined before and after molar distalization using Anatomage InvivoDental 6.0.3. Linear and angular measurements of the mandibular joint were measured, including joint parameters, inclination, position, and the dimension of the condyle and articular fossa. In addition, 3D volumetric spaces of the joint were analyzed. All data were statistically analyzed by paired T test to determine the differences between the pre-and post-orthodontic procedures.ResultsNo statistically significant differences were found in all primary effects resulting from maxillary molars distalization by clear aligners on TMJ components measurements and joint spaces between T0 and T1. Meanwhile, statistically significant differences were observed in the linear position of the upper molars and the molar relationship parameter with at least P ≤ 0.05.ConclusionTreatment by sequential upper molars distalization with clear aligners does not lead to significant TMJ parameters changes in condyle and fossa spaces, dimensions, and positions.

Correction of anterior and lingual single tooth cross bite in an adult patient - A case report

Malocclusion is known to be multifactorial affecting a wide range of populations in many ways. It can have pernicious effects on the quality of life of an individual since it is associated with both aesthetic and functional matters. Crossbites, having been considered one of the most common malocclusions, also serves as a route for future problems. The objective was to treat a 22-year-old male patient who presented with a single tooth anterior and lingual crossbite. A non-extraction treatment followed by settling of occlusion which met the treatment plan was performed, delivering a corrected smile both functionally and aesthetically.

Predictability of anterior open bite treatment with Invisalign

Anterior open bite correction with Invisalign has been claimed to have relatively good predictability because of the proposed function of clear aligners to function as occlusal bite-blocks, limiting extrusion of the posterior teeth or possibly even intruding posterior teeth. This proposal, however, remains relatively unsubstantiated. The objective of this study was to investigate and determine the accuracy of Invisalign treatment in correcting anterior open bite by comparing the predicted outcome from ClinCheck to the achieved outcome for the initial aligner sequence. A retrospective study used pretreatment and posttreatment intraoral scans and predicted outcomes (ClinCheck) stereolithography files of 76 adult patients from private specialist orthodontic practices. Inclusion criteria comprised nonextraction treatment, with a minimum of 14 dual arch Invisalign aligners. Geomagic Control X software was used to measure overbite and overjet in the pretreatment, posttreatment, and predicted outcomes stereolithography files for each patient. Approximately 66.2% of the programmed open bite closure was expressed compared with the prescribed ClinCheck outcome. The use of posterior occlusal bite-blocks and prescribed movement of teeth via anterior extrusion, posterior intrusion, or a combination of the 2 made no difference to the efficacy of open bite closure. Two-week aligner changes resulted in 0.49 mm more bite closure on average. The prescribed bite closure in ClinCheck software overestimates the bite closure that is clinically achieved.

Maxilomandibular changes in patients with Class I maloclusion – A cephalometric study

Maxillomandibular analysis relates the upper and lower jaw. The anteroposterior relationship of the maxilla and mandible through both angular and linear measurements is used to assess the sagittal jaw relationship. To evaluate skeletal maxillomandibular changes in patients with class I malocclusion after extraction and non-extraction orthodontic treatment in the Solan population. Cephalometric radiographs before and after treatment of 50 orthodontic patients were used in the study. The sample was divided into 2 groups, Group I (Class I, N=25, extraction cases) and Group II (Class I, N=25, non-extraction cases). Maxillomandibular parameters (ANB, Wits Appraisal, Harvold unit length difference, plane angle AB, convexity angle and MKG angle) were measured in both groups. When comparing the two groups, significant changes were observed in the ANB angle (p=0.05), AO-BO (p=0.00), MKG angle (p=0.03) and convexity angle (p=0, 00). Conversely, Harvold (p=0.70) and AB plane angle (p=0.75) were found to be insignificant. The result of the above study indicated that bone maxillomandibular changes in ANB angle, AO-BO, MKG angle and convexity angle can be observed in patients after extraction and non-extraction orthodontic treatment.

Keep it simple: correction of anterior cross bite – an ortho-perio interdisciplinary approach

This case report explores the treatment of a 13-year-old male patient with severe dental crowding and periodontal issues using non-extraction orthodontic treatment combined with a root coverage procedure. The patient presented with a skeletal class 1 base malocclusion, and multiple anterior crossbites, along with a compromised lower central incisor and gingival recession. Despite the option of extraction, the patient declined this approach, and the final goal was to achieve stable class 1 occlusion and an improved smile.The treatment plan utilized pre-adjusted edgewise appliance (MBT 0.022 inch slot), distalization of the canine, inversion of the maxillary right lateral bracket, and the cautious use of open coil spring in the upper and lower anterior segments. After alignment was completed, a root coverage procedure was performed on the lower right central incisor. The treatment lasted for 20 months, and the results showed successful alignment of both arches, canine protected occlusion, and improved periodontal health.Overall, this case report highlights the complex relationship between orthodontic treatment and periodontal health and the importance of careful treatment planning and patient communication to achieve successful and stable results. The non-extraction approach combined with root coverage procedure proved to be an effective treatment option for this patient, leading to an improved occlusion, smile, and periodontal health.

Driving the maxillary molar distally with infra-zygomatic crest implant: A case report

There has been increase in the treatment modalities for non-surgical Class II malocclusion. This has resulted in orthodontists becoming more vigilant with extraction treatment plans and exploring possible non-extraction treatment approaches. Maxillary molar distalization is one such method. The maxillary molar is distalized to create space and helps in solving the malocclusionMany appliance were used for the distalization of molars over the period of time. Both intra-oral and extra-oral methods are present. The extra oral appliance includes headgear and heavy elastics; whereas intra oral appliance include distal jet, jones jigs, pendulum appliance, k-loop, fixed functional appliances, magnets, ACCO appliance and use of TAD’s. Thus the use of IZC implants has been effective in distalization of molars.

Alveolar bone loss and root resorption in mesialized second molars in mandibular first molar extraction cases as compared to contralateral non-extraction side in young adults: A retrospective cross-sectional study

The alveolar bone loss (ABL) and external apical root resorption (EARR) depict the safety of mesialization of mandibular second molars into the extraction space of mandibular first molars. The aim of this study was to evaluate the ABL and EARR after closure of mandibular first molar extraction space by mesialization of second molar on extraction side (ES) as compared to the contralateral non-extraction side (NES). A retrospective cross-sectional study was carried out using the pre and posttreatment orthodontic records of young adults with complete set of permanent dentitions treated with extraction of unilateral mandibular first molar and non-extraction treatment on the contralateral side. All patients underwent mini-implant supported mesialization of second molar on ES. The ABL and EARR of second molar on ES and contralateral NES were measured on digital orthopantomograms. The ABL and EARR of second molars on ES and contralateral NES were compared using independent sample t-test. A total of 36 subjects (14 males and 22 females) were included in the study. The mean treatment duration for molar mesialization was 28.75±8.05months. The mean crown and root movements of mandibular second molar on ES were 10.94±1.25mm and 9.04mm±1.14mm, as compared to 0.91±1.01mm and 0.77±0.83mm on contralateral NES, respectively. The mean ABL and EARR at mandibular second molar were found to be significantly greater on the ES than the contralateral NES (P<0.001 and<0.05, respectively). A total of seven patients (19.4%) experienced ABL≥1mm on ES as compared to none in the contralateral NES. EARR of>2mm of at least one root was found in seven patients (19.4%) in ES as compared to four (11%) in contralateral NES. There was small but statistically significant difference in the ABL and EARR of mesialized mandibular second molar at first molar ES as compared to the contralateral NES. For majority of patients this difference was small but few isolated cases experienced severe ABL and EARR.

Treatment planning protocols with the Invisalign appliance: an exploratory survey.

To investigate the changes made by orthodontists to the initial digital treatment plan (DTP) regarding the Invisalign appliance provided by Align Technology until acceptance of the plan by the orthodontist. The DTPs of subjects who underwent treatment with the Invisalign appliance and satisfied inclusion criteria were assessed to determine the number of DTPs and changes regarding prescription of aligners, composite resin (CR) attachments, and interproximal reduction (IPR) between the initial DTP and the accepted plan. Statistical analyses were calculated via GraphPad Prism 9.0 (GraphPad Software Inc., La Jolla, Calif). Most of the 431 subjects who satisfied inclusion/exclusion criteria were female (72.85%). More DTPs were required for subjects who had orthodontic extractions (median [interquartile range; IQR]: 4 [3, 5]) compared with those who did not (median [IQR]: 3 [2, 4], P < .0001). The median (IQR) overall number of aligners prescribed in the accepted DTP (30 [20, 39]) was greater than the initial DTP (30 [22,41], P < .001). The number of teeth used for CR attachments increased from the initial to the accepted DTP (P < .001). More CR attachments were observed in extraction treatment DTPs with a prescribed 2-week aligner change protocol compared with nonextraction treatment (P < .0001). The number of contact points with prescribed IPR increased between initial and accepted DTPs (P < .0001). Significant changes regarding DTP protocols were observed between the initial and accepted DTPs and between nonextraction and extraction-based CAT.