Dr Tif Qureshi
Orthodontic treatment relies upon effective decision-making by the clinician in order to deliver a functional and aesthetic outcome.
To ensure predictable results, treatment planning must be comprehensive and detailed. In orthodontic care, clinicians may be familiar with the term ‘staging’, broken down further in some of the literature to ‘macro-staging’ and ‘micro-staging’. It refers to the breakdown of the intended movement of teeth in a sequential manner.i Understanding how to effectively stage care is imperative, especially when taking on more complex cases.
Understanding staging
In the context of orthodontics, staging refers to intended movements over time.[i] For example, it details how many steps are needed for a rotated incisor to be ideal positioned within the arch, with each increment envisioned and planned for. This is essential for every kind of orthodontic treatment, but especially so in complex cases where multiple movements may be occurring simultaneously (known as a simultaneous pattern), or one tooth may need to be adjusted first to allow for further amends across the dentition (a structured pattern).[ii]
The tooth that is moved the most throughout the staged treatment is referred to as the leading tooth. By breaking down the progressive movements of this tooth in particular, clinicians can judge the total number of aligner trays needed throughout care,i and give an estimated time for completion.
The literature notes that slowing down tooth movement can lead to better tracking and predictability of results, especially with the use of clear aligners.i By first staging the movements of the leading tooth, clinicians can slow down movements in other areas of the dentition alongside the same timeframe for the greatest success.
Little and large
Macro- and micro-staging is discussed in the literature to further breakdown the clinical understanding of staging orthodontic tooth movement. Macro-staging is the general biomechanical movement that must be achieved throughout the entire dentition for success; it is a comprehensive view of treatment within each arch.ii
When determining the predictability of success for macro-staging, clinicians must consider whether they wish to progress with a simultaneous pattern or structured approach (the latter being more favourable in many complex cases). The use of attachments, and the anticipated sources of anchorage should be considered also. ii The latter will change the course of treatment dramatically; whether patients require differential intra-arch anchorage, inter-arch anchorage with elastics, or skeletal anchorage, each will affect the treatment needs and timeframe.ii Identifying the impact each has is made possible with clinical experience and high-quality professional training.
The term micro-staging refers more closely to the movements of each individual tooth. An orthodontist must determine the types of movement needed for each element, differentiating between bucco-lingual crown inclination or bucco-lingual root inclination changes, rotations, and more. This then allows clinicians to judge if and how they should create space for further movement, before carrying out compressions or extrusions that will typically block movement from other teeth.ii
Whilst breaking down conventional approaches to staging into macro- and micro-staging can extend the time taken to formulate a treatment plan, the benefits are felt throughout the workflow. Focusing on each tooth’s needs with a micro-staging approach can help to minimise difficulties in the long-term by increasing predictability and safely accelerating the speed of completion.
Developing knowledge
Staging, whilst it simplifies the orthodontic treatment process, is a complex task. It requires ample knowledge of tooth movements, and the possibilities afforded by modern clear aligner solutions. Implementing staging in complex cases can be especially difficult, but it is imperative to a successful treatment outcome.
As seen in the General Dental Council’s ‘Standards for the Dental Team’, clinicians must only carry out treatment that they are trained, competent and confident in completing with success.[iii] This includes orthodontic treatment that utilises staging for optimal outcomes.
The Clear Aligners (Level 2) course from IAS Academy helps clinicians develop their staging skills for predictable tooth movements, alongside insights into treatment planning for complex cases, staging interproximal reduction, and more. The one-day course is ideal for clinicians who have completed a handful of aligner treatments, but want to develop their understanding and capabilities with any system that they choose. Plus, delegates have access to a mentor after the course is completed, who can aid with guidance and insights throughout treatments.
Correctly planning and carrying out staging for orthodontic tooth movement is imperative for success. Developing knowledge about what it means on a macro and micro level can increase predictability and reduce errors, leading to happier patients and dental teams.
For more information on upcoming IAS Academy training courses, please visit www.iasortho.com or call 01932 336470 (Press 1)
[i] Mehta, S., Patel, D., & Yadav, S. (2021). Staging orthodontic aligners for complex orthodontic tooth movement. Turkish Journal of Orthodontics, 34(3), 202.
[ii] Martínez-Lozano, D., Castellanos-Andrés, D., & López-Jiménez, A. J. (2024). Staging of Orthodontic Tooth Movement in Clear Aligner Treatment: Macro-Staging and Micro-Staging—A Narrative Review. Applied Sciences, 14(15), 6690.
[iii] General Dental Council, (2019). Standards for the dental team. (Online) Available at: https://www.gdc-uk.org/standards-guidance/standards-and-guidance/standards-for-the-dental-team [Accessed April 2025]
