Clearly Comfortable Smiles

Operators Manual for Invisalign

Updated August 2018

(425) 765-1949

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Invisalign Operators Manual

One of the great things about having your orthodontic treatment with the Invisalign appliances here with Dr. Knudson and Clearly Comfortable Smiles is that we offer the service at a price that is hard to beat. 

Part of the reason for this is because Dr. Knudson treats so many folks that Align Technology, the dental laboratory that manufactures the appliances according to his treatment plan and prescription, does not charge him nearly as much per case as they charge most other dentists—sort of like Dr. Bob gets the “Costco price”, passing that savings on to you.  He also performs most of the work himself, avoiding the cost of a large staff.  He did not have to buy all the offices and the equipment at his Seattle area offices, but simply rents most of the space from the owner dentists on an “as needed” basis.

This manual is another reason we can give you such a good price on your treatment.  So that Dr. Knudson can devote his time to provide the best care, answer your questions about your specific case needs, and deal with any concerns you have, and see more folks per day without adding to his overhead with more days spent renting treatment space or paying staff, we have created this Operators Manual to show you what to expect at the various appointments—things that are the same for every patient.  That way he can focus on the personal part of your treatment when you are here, and see more folks without rushing you at your appointment.

We certainly welcome questions at any time, especially if you are unclear about anything you see in this publication.  So that we are always prepared to handle whatever you are concerned about at any appointment, if you notice a problem with your appliances or how your treatment is progressing, please call and let us know BEFORE your appointment. 

Please keep this handy for the duration of your care with us.  We want you to be comfortably informed about what to expect as we progress towards your new smile.

Again, please feel free to call us anytime for clarification or concerns.


Clearly Comfortable Smiles

Robert L. Knudson DDS


How do you picture your smile when treatment is completed?  It is important that we know about that prior to starting treatment.  There are, however, some things that simply moving teeth around cannot change.  There are also limitations to what Invisalign alone can treat such as making your jaws change size, closing spaces where teeth were lost, and moving the midline of your smile left or right more than a millimeter or so.  Braces, headgear, functional appliances, surgery, implant anchorage, and inter- arch orthodontic appliances and often years of treatment are needed for that sort of stuff, along with a whole lot larger fee from the provider.  We will be working towards giving you the nicest smile and best bite we can without using these things.  The vast majority of cases we see do not require that sort of treatment to achieve a nice result so long as the patient is compliant with our instructions.  We can promise “a lot better than it was” in any event, and leave you some money left over to hit Nordstrom for some new outfits to go with your new smile.   Here are some important points to be aware of:

  1. A great smile is formed from many components – tooth color, tooth shape, left side mirrors right, individual teeth are mirror images left to right, amount of tooth display when smiling and talking, amount of gums showing when smile, level of gums from tooth to tooth, smile is level with the horizon, gums filling areas between adjacent teeth, no gaps……………and so on.

  2. Crooked front teeth in adults, especially those that vertically overlap a lot (deep bite), usually have wear patterns that are uneven such that when they are properly lined up, the edges are irregularly shaped. Minor chipping and such can often be corrected with some light sanding and reshaping, but badly worn or chipped teeth may require cosmetic restoration by your dentist to look as good as you want.

  3. Fillings and crowns done when the teeth were crooked may not look normal when properly positioned. Old fillings that didn’t display much before may be in plain view now and the coloration may be wanting.

  4. Heavy wear in folks with deep bites often results in teeth being different lengths. Getting the edges as well as the gum lines even may not be possible without lengthening teeth or shortening gums.

  5. If the cusps of upper and lower teeth are meshed one notch off with your lowers set back relative to the uppers (think of two saw blades meshing and then imagine moving the lower blade back one notch) you are likely going to have some of what patients usually call “overbite” if all we do is align the teeth and nothing else. (Technically, overbite to a dentist is the amount the teeth overlap vertically. Overjet is when the upper front teeth arrive home slightly before the lowers. “Buck teeth” are when they are tipped out relative to vertical.) We will be looking to get the front upper and lower teeth to be positioned such that to the person viewing the smile, the teeth are as close to perfectly positioned in every dimension with as little “buckyness” as possible without the use of all those other orthodontic things mentioned in the first paragraph above. We usually can lessen the overjet of the teeth and make them look much nicer with minor reshaping (discussed later), but often the upper front ones still arrive first.

  6. A tooth or dentistry that just does not look good before will likely not look good in the end without some help other than moving things around.

  7. Lastly, and most importantly, braces are under the control of the dentist. You wear them 24/7/365. The wearing of Invisalign aligners is a voluntary action. The patient chooses how much to wear them. YOUR BODY, HOWEVER, DOES NOT CARE WHAT YOUR CHOICE IS. The osteoclasts and osteoblasts that cause the removal and replacement of bone allowing the permanent movement of your teeth need a continuous signal to do what they do with predictability. If you choose not to wear your appliances for a day, that process will shut down and require 10-14 hours wear the next day BEFORE THE PROCESS EVEN STARTS UP AGAIN. So, that 14 hours of wear actually accomplishes absolutely nothing in terms of permanent movement. It is a little bit of “pay me now or pay me later”. There is no getting out of wear time. Part-time wear will give part-time results. If you want to get done quickly and correctly, it is 20-22 hours a day, every day.

Starting your Invisalign treatment

Congratulations!   You are about to begin one of the most modern dental treatments available.  Let’s get started.

As you progress in your treatment, DO NOT THROW AWAY YOUR USED ALIGNERS.  There are times when they may be needed.  

Aligners can be difficult to place and remove at times.  It is usually best to position the front teeth in the aligner first and then the back teeth.  Removing them is usually best done in reverse.  Tease them off from one side to the other.  Rapid removal may result in tearing of the plastic, reducing the effectiveness, or even making the appliance unusable.  If you accidently crush and distort part of the aligner, do not attempt to fix it.  If you have your next aligner, skip to it if possible.  If not, simply trim off the distorted part with nail clippers.  If the aligner is too badly distorted, call us immediately to let us know and go back to your last aligner.

Please remember to take your aligners out every time you eat or drink anything other than still water.  The aligners will capture some of whatever you drink, and most everything we drink has sugar, color, or acids in it that will stain or damage your teeth with prolonged contact.

KEEP THE ALIGNERS CLEAN!!!  Use lukewarm water and dish soap and a toothbrush.  Hot water will distort them.  If possible, brush and floss before putting your aligners back on after eating.  At minimum, rinse your mouth thoroughly.  Aligners provide additional area for plaque to grow in your mouth, so you will need to keep them clean “lest you offend with your breath.”  Take it from the guy on the smelling end – dirty aligners stink.  Get in the habit of carrying a toothbrush with you, both to clean your own teeth and your aligners several times a day.

You are receiving two cases for your aligners.    Do not leave your aligners out of the case where pets or small children can reach them.  They are very expensive “chew toys”.  There is a substantial fee to replace an aligner that would not be covered by dental insurance if you have it.

Should you lose your current aligner, you may try to go to the next one in the series.  If it fails to seat fully after wearing for two days, please go back to the last aligner that fits and call us so we can order replacements for the lost ones.

Change your aligners every two weeks unless Dr. Bob says to do differently.  Generally, aligners must be worn about 300 hours at 20-22 hours per day to complete the programmed movement for that individual appliance.  NON-COMPLIANCE MAY RESULT IN AN ADDITIONAL MONITORING FEE.  Occasionally bite into your aligners to further activate the tooth movement.  If you try in a new aligner and it does not sit all the way down, wear it for two days.  It should settle in.  However, if it doesn’t, put the previous one back in and call the office.  We are always happy to help with questions or problems that may come up. DO NOT WEAR ALIGNERS OUT OF ORDER!

DO NOT USE IBUPROPHEN (ADVIL), ASPIRIN, ALEVE, OR ANY OTHER NON-STERIODAL  ANTI-INFLAMMATORY PAIN RELIEVER DURING TREATMENT.  Tooth movement through bone depends on an inflammatory process and these medications will slow or stop the progress when in use.  If you need a pain reliever, use Tylenol or  the generic.

When you change to a new aligner, you should expect some discomfort to follow.  The inflammation that is causing the discomfort is a necessary part of the process of getting the boney change that allows teeth to move.  Some folks minimize the discomfort by taking Tylenol about a half hour before bedtime, inserting the new appliances, and sleeping during the peak of the “pressure”.

PLEASE WEAR YOUR ALIGNERS TO YOUR APPOINTMENTS.  Bring any unused ones with you should you be behind in your progress.  At each monitoring appointment Dr. Knudson may use a diamond coated sandpaper strip to smooth or reshape teeth slightly.  In addition to the “slenderizing” of teeth necessary to create enough space for proper alignment, often teeth will get stuck due to rough fillings, tartar deposits, or other things that prevent the sliding of one tooth past another.

Once you are done with your two weeks wear and have advanced to the next set of aligners, we suggest you save these used aligners.  There are circumstances where they are valuable.  We have had cases where folks had recently started and then had a medical crisis where they could not wear aligners and they relapsed back and we were able to use the old aligners to re-start treatment without having to charge for new aligners.  Sometimes we find it necessary to back up a few steps due to an uncooperative tooth or perhaps aligners worn a less than the recommended time per day. 

The habit of saving the aligners is most appreciated by the patient when they do not wear their retainers enough after treatment or lose them and neglect to call us right away for new ones.  When your teeth relapse, you can probably go back through your old aligners and find ones that fit and treat yourself back to straight free of charge so you can get back into your new retainers.  Simply getting your retainer to re-straighten your teeth may be a painful experience if they have slipped too much.  Aligners are much softer and more comfortable to use.

So, when you are done with an aligner set, clean them as you normally do and then place them for ten minutes in a solution of 1 tablespoon of bleach in a cup of water.  Rinse them well and let them dry.  Put them in a plastic bag somewhere they will not be crushed (maybe in a shoebox).

We can replace aligners easily if they are lost and you need them.  All we need is the aligner number and the account number on your MasterCard…………….best to keep them safe.

Application of attachments

There are two functioning parts to the invisalign orthodontic system – the clear, plastic trays, and the small tooth-colored “attachments” that are applied to some teeth to allow the clear aligner to perform orthodontic movements that it could not do without a better grip on the tooth.  Your second treatment appointment will involve the placement of these attachments. The material used is referred to as “composite resin” – the same material used in tooth-colored fillings. 

ATTACHMENTS ARE NOT OPTIONAL.  They will remain on the teeth until the completion of treatment.  They will be gently removed before you receive your retainers.  If you wish to have them removed for a special event or photo shoot, you will need to stop advancing in your aligners until they are reapplied.  There is a fee for that service which involves additional templates from invisalign and additional clinic time.  This is not covered by dental insurance even if you have orthodontics included in your coverage.

You must be done with the highest number aligner given you at your last treatment appointment prior to having the attachments placed, as the templates used assume that your teeth have been corrected to that point.    If you are not currently in that last aligner at the time of your attachment appointment, please call so we can synchronize the placement of the attachments with your actual progress.

Should one or more of your attachments be lost during treatment, please contact us and let us know the following before you advance to the next aligner:

  1. Which tooth is it on (How many teeth back from the middle on that arch)?

  2. If it is all or only partially gone.

  3. What aligner number you are currently on.

Dr. Knudson will advise after he reviews the movement sequence of your treatment whether or not you should continue as planned or see us for replacement of the attachment before progressing. 

Progress Appointments

At these visits we will be monitoring your progress through the series of aligners.  If all is well and you are wearing the appliances as directed it will probably be a very short appointment. 

You should arrive for these appointments wearing your current aligners so that we can see that the aligners and your teeth match up.  If you still have unused aligners in your possession, it would be best to have them with you.  Sometimes Dr. Knudson may need to modify the action of an aligner to get you back on track if things are not progressing as planned. 

He may also insure the contacts between teeth are smooth using some very fine grit sandpaper strips so that teeth can slide past each other without binding.  This is different that the “slenderizing” to be discussed later in this manual. 

You will receive additional aligners at this appointment, and we will schedule your next visit.  Sometimes the day you will either be done with those aligners and the day we are in your favorite location will not be in sync.  If such is the case, after wearing your last set of aligners for the prescribed two weeks, simply wear them only at night like a retainer to hold the teeth in place until you are seen again. 

You are welcome to appoint at any of our offices, and some are quite convenient and quick to get to outside of rush hour traffic times.  You do, however, need to be in contact a minimum of a week before you wish to see us if you need aligners, as all are stored at our home office in Bellingham and we may not be returning there for several days.  

The sandpaper thing.

It is one thing to align the teeth within each dental arch.  It is quite another to make sure when you bite together that the uppers and lowers fit properly for function, comfort, and minimal wear over time.  There are certain “must do” things when we align the teeth orthodontically.   Some are complicated things that you go to dental school to learn, but some are easily understood:

  1. It is an eating machine first and foremost. You have to be able to properly masticate your food as the first step of digestion.

  2. Your upper front teeth must overlap your lower front teeth – nobody wants to look like a bulldog.

  3. Having no remaining gaps between teeth is a desirable goal both for looks, and so the chicken doesn’t get stuck between your teeth.

  4. If we do not make the teeth properly mesh upper to lower, your chewing muscles will do that as soon as we let go of the teeth, making retention after treatment a constant battle.

  5. If your upper cuspid teeth (canines, fangs, Dracula teeth…) do not touch the lower cuspids when you close normally, over time you will likely end up with excessive wear on your back teeth. The canine overlap basically keeps you from being able to chew like a cow, and unless you are planning to become an extremist wild organic vegan, that is not a good quality to have in your bite.

  6. Because the size and shape of your teeth are genetically determined and you might have Mom’s teeth on top and Dad’s on the bottom, or because you may have had fillings or crowns done that are “atypical” in size, when the once crooked teeth are lined up, they may not fit properly when you bite down. Indeed, that may be the very reason they are crowded in the first place (see #4 above).

Roughly half of the patients we see have a need to alter the total arch length of their teeth (reduce the distance from the last tooth on the right around the front teeth to the last tooth on the left) in order for a proper upper to lower fit.  The best way to do this in most cases is to do what is called “interproximal  reduction” or what we refer to as “IPR” or the “sandpaper treatment”.  This is not something unique to invisalign.  It has to do with the size and shape of your teeth, not how they got moved around. 

By “slenderizing” some teeth and gently removing fractions of a millimeter of enamel from the surfaces where teeth touch their neighbors (where the floss goes through and the enamel is the thickest) using diamond coated strips or discs, we can achieve proper bite and a better, more stable smile without extraction of teeth in most cases.  It requires no anesthetic and actually is often simply removing a little of the filling or porcelain on a crown that you may have and not tooth structure.  We always do the minimum amount necessary to achieve the necessary result.  Not doing this will likely result in the need to leave a gap in the arch of teeth opposing the one needing IPR in order to fit properly upper to lower.

This technique may also be used to allow the roots of teeth to be brought closer together and reduce a dark triangle or spit space where the gums do not entirely fill up the area between neighbor teeth even though each tooth is actually touching its neighbor.

Nearly done.

With your attachments removed we will ask you to start wearing your last aligners only at night.  Why?

When you are wearing upper and lower aligners for nearly 24/7 your teeth are being straightened with two layers of plastic between them. The plastic is just as thick in the back as it is in the front, so when you take the aligners out and bite down, you probably only hit firmly on teeth towards the front.  The reason for this is that your jaw is a hinge and when you open and close, your front teeth travel further than your back teeth do. 

Now, when you were a kid and lost your baby teeth, the adult teeth erupted into place.  That tendency to erupt is still present though not as speedy as when you were 10 years old, and wearing aligners for only a few hours at night is not enough to prevent that natural eruptive force from bringing the teeth down the fraction of a millimeter to even out the bite forces.  Before we fit you for retainers we want to make sure that bite in fact is going to be good, so we usually have you wear your last aligners just at night for at least a month and sometimes longer.

We are also looking for teeth that seem to relapse or pop out of place within a few hours of removing your appliances.  These teeth likely do not have enough room to be in place and are under pressure from the other teeth -- the aligner is enough to hold it in place but the neighbor teeth win when you remove the tray.  This usually means we need to do a little of the sandpaper thing in that area.

We also want you to have the opportunity to get any dental work such as fillings or crowns that will change the shape of your teeth done prior to getting your retainer.  We want your retainer to fit the teeth as they are going to be for the next few years.  If you decide to get your teeth worked on, be sure to take your appliances with you to the dentist so they can be evaluated for fit after the work.  If they do not sit into place without the sensation of pushing on your teeth, have the dentist make you a temporary retainer until you can see us.  Better yet, coordinate your visit to the dentist with an appointment with us to get molds for retainers the same day you get your new dentistry.

What if I move away from the area before treatment is complete?

Sometimes folks have to move before treatment is complete.  We always try to have treatment be as expedient as possible, but if you do find yourself in a situation where you must leave the area, here are some options:

  1. If you are satisfied with the results as they are, we can simply move you into retention

  2. If you wish to complete treatment in your new location we can arrange to transfer your case to another invisalign dentist in that area. If you have paid for retainers as part of your fee we will contact the dentist and arrange to pay for those when yours are ordered by the new office. The new dentist will likely have a fee to complete the case. Because 90% of the work and 100% of the cost to us to produce your aligners occurs up front, there is no refund from Clearly Comfortable Smiles if you transfer.

  3. You may complete your aligner wear without progress visits with us and then have a local dentist remove your attachments when you are done. In cases like this we recommend you wear each set of aligners as close to 24/7 as possible and wear them for THREE weeks before changing just to make sure all movements have been completed. If you are satisfied and do not wish a case transfer to a new dentist and you are owed retainers, call us and advise the aligner numbers that you finished with and we will get retainers to you.

  4. The fee from a new dentist may be substantial and you may find it cheaper to come back here from time to time and let us complete things. You can always stop wearing aligners 24/7, switch to nighttime only wear to retain things, and see us when it works in your schedule.

Using invisalign certainly gives you more options than braces, and our lower fees likely mean that even though you may have additional fees from a new dentist, you likely saved money using our services compared to the “average” invisalign provider. 

Round two?

Nine out of ten folks will be pretty well finished with the completion of their first series of treatment aligners if they actually follow instructions on wear and come to their scheduled appointments.  Nine out of ten will NOT be if they try to fudge on wearing aligners.  Most all folks need some refinement after the first round, especially those cases with lots of major movement involved.  Folks that fudge should expect a long refinement, perhaps as long as the first run through.  We do not charge extra for refinements unless folks are very uncooperative in their wear, if they miss too many appointments, or if they try to modify their treatment from what we recommend.  Some folks want to skip having attachments.  They are an essential part of predictable movement of the teeth and attainment of the nice final result.  If you do make that request for non-placement or early removal, we will allow only a single refinement without charge.  If you wish to continue beyond that end point, there will be very substantial additional cost.  (There is a much smaller fee to remove and replace attachments for things like a wedding, and because that is simply a pause in treatment, it does not decrease your eligibility for future refinements.)

You are done!

Well, that is only sorta’ true.  You may be done with active orthodontic movement, but you will never be done with the next phase – retention. 

Retention is for either the rest of your life, or until you no longer want straight teeth.  You get to choose. Probably half of my adult patients are folks that had braces before, some even twice, and then did not wear retainers properly. 

Orthodontic relapse occurs primarily because when you move a tooth, the gums stay attached and may be stretched or compressed in some fashion.  The gums contain fibrous tissues that act like a rubber band, putting force on the tooth to return towards its former position.  Until all the gum cells have died and new ones have been born, there is a tendency to relapse.

When you first get done, the tendency to relapse is most pronounced, but even twenty years after completion, there is still some tendency for the teeth to “go back home”.

For virtually all our patients we recommend the retainers made for us by invisalign because they are comfortable to wear – they are basically industrial strength aligners without the attachment stuff.  These retainers can readily correct small relapses that may occur because you forgot your retainers for a couple of nights.  They are also the least expensive retainers we see on the market and can be replaced with identical ones with the click of a mouse. 

We do not recommend, except in rare cases, that you rely solely on a bonded wire retainer.  You often see these on kids that just finished braces because they often cannot be trusted to wear or to not lose their retainers.  Paying the dental bill has a magical effect on retainer wear, however, so we are pretty sure you won’t need that.  We do provide these for patients who want them but NEVER RECOMMEND THEM AS THE ONLY RETAINER.  Besides the fact that dental hygienists hate them because they are so hard to clean around, they often pop loose.  Unless you get a new one in place within a day or two, the teeth relapse and you have to back up and retreat your teeth to straight.  They also only retain the teeth they are attached to (usually the lower front six incisors) and do nothing for the back teeth.    A combination of removable invisalign retainers with a bonded wire is the better solution in the situations where the wire is actually needed.

What if I mess up and let my teeth relapse too far for the retainer?

Sometimes life doesn’t work out as planned (Duh!).  Dr. Knudson offers options for retreating patients he treated before at a reduced rate.  This is usually around $1000.00 less than similar treatment would cost a person seeking treatment from us for the first time. 

Appliance Fatigue

Wearing aligners 24/7 certainly gets tiresome after a few months.  Treatment can sometimes stretch to years when things don’t progress as rapidly as planned for whatever reason.  Sometimes our patients express a desire to be done before Dr. Knudson is satisfied with the result.  We encourage you to listen to his explanation as to why he is concerned.  Patients usually see straight teeth and a nice smile and want the attachments off and the retainers in.  Dr. Knudson is looking in his crystal ball 20 years into the future and wanting you to be just as happy then with the result.  Remember, he does not get paid more for being picky with your case.  He gets paid more when happy patients refer their friends and family, even 20 years from now (but let’s hope he doesn’t have to be here at age 83 redoing your case).

I heard about Express treatments

Invisalign does offer other products to Dr. Knudson called Invisalign Express 5 and Express 10.  The number represents the number of aligner sets that they will manufacture to correct the patient’s  orthodontic problem.  It does not mean it will move your teeth more or faster than normal treatment.  The limitation is that should more be needed, you have to buy another product to finish the case, or you have to accept the partial correction provided by 5 or 10 aligners.  We can offer those at a slightly cheaper fee than our normal full treatment cost, but we are talking only  $300 to $500 less because Invisalign’s bill to Dr. Knudson is really not much less.  Because of his status and one of the top 1% of invisalign providers in North America, he gets a substantially better price on the laboratory fee for full treatment from them, but no such discount on these Express treatments.  With the limits they place, if you insisted on one of these Express treatment options, we will ask you to sign off on a statement that you are willing to accept the final result they produce, or you will need to pay an additional  $1000 - $1200 to upgrade to full treatment . 

On top of that, full treatment allows us to take whatever time you need and however many appliances necessary to achieve a great result.  Our price for full treatment is so much less than any other office we know of, so you are already saving a ton of money by coming here in the first place.

Thank you

Please remember that we always welcome questions about how your treatment is going and are open to suggestions on how to improve it.  Consultations for your friends or family are always free, and if they go ahead with treatment we will give them special pricing for their treatment package.