Personalised Learning

Combining clear aligners with fixed

Key questions this course answers:

  • What treatment modalities work best for certain movements?
  • What is the ideal sequence of fixed appliances in combination with aligners?
  • What are cases that I should consider a full fixed arch?

It may seem a little unwieldy, but sometimes a combination of tools can lead to the most efficient treatment journey. Fortunately in orthodontics there are often many ways to skin a cat. Understandably patients normally want the treatment journey to be as aesthetic as possible, but often their greatest priority is that it is as efficient or speedy as possible!


Each malocclusion is different and presents its own challenges. What we really want to look out for is the necessary tooth movements to get from the presenting occlusion to the end result. Movements such as tipping of crowns and intrusion can be nicely achieved with aligners, whereas root torquing movements, significant expansion and rotations (especially of molar, premolars and lateral teeth) can prove more difficult. Naturally it follows that we will all encounter cases where we need the strengths of both aligners and traditional braces.

Sequencing and Tips

Rotations can be particularly difficult with aligners as we are solely reliant on attachments to grip and move the tooth. Additionally, when a rotation is severe we may need to "reposition" attachments on the same tooth part way through treatment as it slowly turns around. In such instances, a short course of fixed appliances can be more efficient to address any severe rotations first and then move on to aligner treatment. The same could be said of cases requiring significant expansion.

You can see that the lower left second premolar is severely rotated, and an attachment used for derotation would eventually block it from completing that movement.

Root torquing movements, however, will often be a finishing touch. In severe Class 2/3 cases aligners may do a wonderful job of positioning the crowns where we want them but to get the roots into the optimal position sometimes a short course of fixed appliances at the end of treatment can finish the job more efficiently.


When you assess the difficulty of tooth movements you may well find that the upper arch is suitable for aligners and the lower to fixed - if so, go for it! There is no inherent problem with this and if it's the most efficient treatment for your patient you'll be doing them a great favour with the combination.

We hope this helps provide a high level view of considerations for fixed appliances in combination with aligner therapy. Stay tuned for more- such as; other ways to manage tricky rotations!

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