Tech tip: anterior open bite with clear aligners

The following information is for reference when specifically dealing with dentoalveolar tooth movements with clear aligners and excludes all medical, functional, developmental and skeletal causes for open bites.

An anterior open bite is generally defined as a condition where the upper & lower posterior teeth are touching when the patient bites down, but the anterior teeth are not in occlusion.

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An open bite can occur during transition from primary to permanent dentition, and is considered to be a temporary stage of normal dentoalveolar growth and development.

Causes

Anterior open bite, like most other malocclusions, can either be hereditary or have environmental causes and are usually a combination of both.

Some of the more common environmental causes are:

  • Thumb, finger or pacifier sucking
  • Abnormal tongue function (such as tongue thrusting) or large tongue that occupies the space between the teeth
  • Trauma or pathology to one or both condyles
  • Neurologic disturbances, iatrogenic factors, e.g. extruding molars during treatment
  • Airway pathology

Some conditions, such as TMJ degeneration, can manifest as an open bite. Factors like onset and disease progression can also come into play. Along with this, other factors such as habits, mode of respiration, tongue size, smile display are all considerations—each of these a complex topic in itself.

Open bite & clear aligners

If an anterior open bite is present before, during, or after treatment with clear aligners, a comprehensive evaluation must be completed in order to properly determine the reason for the openbite, whether it is due to a dental, skeletal, muscular, or other etiology; only then can the appropriate course of treatment be applied.

Some dental open bites can be corrected with clear aligner treatment, pending examination and diagnosis to determine eitology of the open bite. When you submit your case, be sure you provide your technician with your treatment details for how you plan to correct the anterior open bite in the "Additional instructions" section. 

We hope you found this information helpful. Find more information like this in our Help Center.

Until next time…

Tech Tip: Basic principles for difficult movements

Rotations, extrusions and intrusions are some of the more difficult movements to achieve with clear aligners. Here are some basic principles to observe when attempting to rotate, extrude or intrude a tooth during clear aligner treatment.

Intrusions & extrusions

1. A tooth that’s not upright will not extrude or intrude easily.

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2. Place a horizontal engager and tilt it upright first.

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3. Make sure there is adequate interproximal space; use IPR where appropriate to make space and prevent collisions.

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4. Then extrude or intrude slowly.

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Extrusion

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Intrusion

5. If an extrusion doesn't work, try button & elastic auxiliaries.

Rotations

1. A tooth without space won't rotate.

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2. Give it adequate space to move/rotate without restriction by adjacent teeth.

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3. Then place an engageron the tooth to be rotated and rotate it.

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4. If you're having trouble with rotations, see our article on troubleshooting rotations.

We hope you found this information helpful. Want more information like this on the topic of clear aligner treatment? Check out our Help Center which is filled with useful information.

Until next time...

Your auxiliaries questions answered

We sent out a survey recently asking doctors for their questions about the use of auxiliaries in clear aligner therapy. Our Clinical Advisor, Dr. Ken Fischer, has the answers.

(Note: Nothing here is absolute, we're simply offering some advice and suggestions and it should be taken as such. It's up to you to use your professional judgement on what is best for you and your patients.)

What are the main indications for auxiliaries, what are their limitations and side effects?

Auxiliaries enhance the force applied by aligners. When a tooth is not tracking with the aligner, the auxiliaries can direct pressure in the desired direction. Limitations and side effects will vary depending on the type of auxiliary and how it is applied.

How can I predict when I may need to use these systems? I would like to be able to tell a patient that these items may be used in their treatment.

Predicting the need for auxiliaries gets easier with experience. You can tell your patient that auxiliaries may be necessary when you see difficult movements such as extreme rotations, extrusions, and inter-arch corrections.

I would like to learn how to incorporate the use of auxiliaries into my cases to provide the best treatment outcomes. Do you have any recommendations?

The first step is to learn to identify difficult movements in the treatment plan. For details on how to use auxiliaries to enhance these movements, check out our article in the Help Center on this topic.

How do you best use pliers in a situation where a tooth is not moving as predicted?

Pliers create dimples in the aligners to nudge the teeth with a little extra pressure. They can be surprisingly effective. Before applying dimples, make sure there is adequate space on the opposing side of the aligner for the tooth to move into.

Are elastics used when the clear aligner fails to move the tooth or is it sometimes incorporated into the original treatment setup?

One must remember one of the basic tenets of clear aligner treatment: when a tooth is properly/fully encased in the plastic aligner material, it cannot be moved except by the forces built into the aligner.

Elastics are effectively used in conjunction with aligners in two scenarios:

  1. Class II elastics, Class III elastics, and vertical elastics can be used with aligners to effect dental arch (skeletal) movement, not individual tooth movement. This type of elastic application should be incorporated into the initial treatment plan designed by the doctor and can be included in "Additional instructions" when submitting a case.
  2. Elastics can be used to extrude individual teeth into occlusal gaps in the aligner caused by the teeth not moving as expected.
I have difficulty adhering buttons to crowns, any suggestions?

Assure PLUS All Surface Bonding Resin from Reliance Orthodontics is great for bonding to crowns. You may also want to consider using micro-abrasion to roughen the porcelain surface.

I have trouble with not being able to have elastic hooks or button cutouts in aligners. What do you recommend?

Since cutouts are not offered at this time, an alternate option is to create your own cutouts with a hole punch or coarse football diamond bur. If the patient declines this option, then you may want to explain the potential consequences of reducing the efficacy of the aligner treatment.

I have trouble getting the button to stay on the aligner.

Due to the flexibility of the aligner material, it can be difficult to keep buttons bonded to the aligner material. You can try micro-abrasion to roughen the aligner surface before bonding.

Can you develop a way to use elastics?

If the doctor desires to use Class II or Class III elastics as treatment auxiliaries, ClearCorrect recommends aligner treatment where the treating doctor uses elastics and buttons bonded to the teeth, since cutouts or notches in the aligner material are not offered at this time. This technique is more efficient, effective, and practical for the doctor.

Could you use ramps on upper anteriors to help open closed bites?

ClearCorrect does not build ramps into its aligners. There is no credible research validating the clinical effectiveness of built-in ramps. Incisor intrusion is a more effective and predictable technique for improving deep bites.

With ClearCorrect aligners, how extreme can you go in the overall treatment plan?

ClearCorrect is an advanced system of clear aligner therapy that uses the latest digital technology, design and clinical approaches. ClearCorrect aligners have been used to treat a wide range of types of malocclusion, ranging from simple cases to advanced extraction and surgical cases, alone and in conjunction with other techniques. Success will depend on the expertise of the doctor, the compliance of the patient, and biological factors.

A big thank you to all the providers who answered our survey!

Check out our Help Center for more helpful information on clear aligner treatment.

Until next time...

Another victory for ClearCorrect: No appeal for Align at the Supreme Court

ROUND ROCK, TX--(Marketwired - August 31, 2016) Last November, the United States Court of Appeals for the Federal Circuit cleared ClearCorrect, LLC of any liability in the International Trade Commission (ITC)’s investigation relating to Align Technology’s claims of patent infringement. In March, the Court of Appeals denied the ITC and Align’s petitions for rehearing en banc. Now ClearCorrect is happy to announce that the ITC and Align have elected not to appeal that decision, solidifying the third victory in a row for ClearCorrect after several years of litigation.

Several of Align’s patents remain at risk of cancellation, as the United States Patent and Trademark Office continue its inter partes review and ex parte reexaminations initiated by ClearCorrect.

Now that the ITC decision is finalized, Align’s sole remaining lawsuit against ClearCorrect is expected to resume in Texas federal court. ClearCorrect anticipates that this final case will follow in the footsteps of the previous three and demonstrate that ClearCorrect does not violate any valid patents held by Align.

Tech Tip: Pontics

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It is not unusual for a patient undergoing orthodontic treatment with clear aligners to have one or more missing teeth. One of the unique features of treating with aligners is the opportunity for the doctor to provide a virtual pontic to fill in the missing space.

Definition

pontic is defined as an artificial tooth on a fixed dental prosthesis that replaces a missing natural tooth, restoring its function and esthetics. It usually fills the space previously occupied by the clinical crown of the missing tooth.

virtual pontic is a tooth-shaped placeholder in an aligner created in the space left by missing teeth. Since the aligner does not cover a tooth in this location, there is a resulting void in the aligner. Fortunately, this void can be painted or filled to create the appearance of a tooth in that space.

For larger spaces in the posterior areas, a bar is often added to improve structural integrity, instead of a tooth-shaped void.

You can request a virtual pontic at the time of case submission, in the "Additional Instructions" section. The technician will need to know whether you want the space filled by the pontic to close as the teeth move, or be maintained for future restoration.

Pontics are represented on treatment setups as translucent teeth.

Pontic Techniques

A virtual pontic can be left as an empty void in the aligner, but if you want it to look more like a tooth, there are two main techniques to choose from:

Pontic aligner paint

The inside of the void can be coated with pontic aligner paint (such as Perfect-A-Smile,available in the ClearCorrect Store). This light cure paste comes in varying colors which can be mixed to approximate the shade of adjacent teeth and applied by the doctor or staff prior to delivery of the aligners. This technique is only necessary while the space resembles the shape of a tooth.

Instructions for applying Perfect-A-Smile are available in PDF and video formats.

PVS adhesive material

Instead of painting the inside of the plastic aligner, the pontic void can be filled with a tooth-shaded, vinyl polysiloxane (PVS) adhesive material. While this technique can look good, the material is prone to falling out of the aligners.

We hope you found this information helpful! You can find more like this in our Help Center.

Until next time…

ClearCorrect Dream Team at Siroworld

Drs. Barsoum, Fischer, and Gardell talk about CEREC scanners and clear aligners.

“We’d all like to extend the message to the patients that dentistry has changed. It’s the not the same old stuff they used to be afraid of in the past. The future holds a lot more positive restorations, smiles, teeth straightening – come and get it!” - Dr. Ken Fischer

 

New treatment setups & treatment planning

Reviewing and approving the treatment setup for your patient is one of the key factors in planning treatment. This is where you get to map out the treatment outcomes desired by you and your patient.

ClearCorrect's role is to help you create the treatment setup you want for your patient. We can offer recommendations for the course of treatment, but those recommendations are not absolute. It's up to you to make any necessary changes to customize an ideal treatment plan for each individual patient.

Browser-based treatment setups are here

From now on, treatment setups for new cases will be displayed as a web page, instead of as a file in Adobe Reader. This reduces crashes, works on mobile devices, and lays the groundwork for future improvements. Tooth charts are missing right now, but we expect to add them soon. You’ll still need Adobe Reader to view setups that were created before this release.

If you have any trouble, first make sure your browser is up to date and then let us know at support@clearcorrect.com.

Viewing and approving the treatment setup

A treatment setup contains 3D models for each step of the treatment, representing the tooth movements that you prescribe. If you approve the setup, these models will be printed and used to manufacture the aligners.

Treatment setups appear in the case list on dr.clearcorrect.com when they're ready for your review.

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Click a case in the list to visit its case page. You'll find the treatment setup near the top. Click the treatment setup icon and your setup will open in a web browser window. New web-based setups should work in current versions of Internet Explorer, Chrome, Safari, and Firefox for Mac, Windows, iOS, and Android.

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A link to a shareable version, which hides the patient's first name and evaluation button is also available for new setups. Click "Share link" and copy the URL that is displayed. This can be pasted into an email or text message for sharing with patients or colleagues.

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Evaluating the treatment setup

You’ll want to start by confirming the accuracy of the model and bite articulation. Put the timeline in the starting position and tilt the model up to check for gaps between the upper and lower incisors—this often indicates an improper bite.

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From the front, check the midline relationship. Use the right and left views to verify the overjet, overbite, canine, and molar relationships. Use the occlusal views to confirm that the impressions or intraoral scans accurately captured the shape of the teeth.

If you’re satisfied with the starting model, carefully review the subsequent steps to verify that the planned tooth movements are safe and effective.Verify that any recommended IPR and engagers are sufficient to achieve your goals.

Bear in mind that these models really represent the shape of the aligners that you will be given—no one can guarantee what the teeth will do in real life. ClearCorrect’s technicians will attempt to follow your instructions as closely as possible. As the prescribing doctor, you are ultimately responsible for your patient’s orthodontic care.

When you’re done reviewing the setup, click EVALUATE to return to the case page.

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If you're happy with the treatment as shown, click APPROVE to accept it and pay for the case, then click SUBMIT. When we get your approval, we'll start manufacturing the sequence of aligners represented in the treatment setup.

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Declining the treatment setup

If the model looks inaccurate, you want to move the teeth differently, or you want to cancel the case, click DISAPPROVE and let us know what you want to do. Our technicians will do their best to make any changes you request and upload a new version for your approval within a few days.

This also is where we can adjust any of your preferences related to IPR (which teeth, when and how, no IPR, expansion, limited IPR, limited expansion, etc.) or engagers based on your specifications.

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You will receive an email notification once your revised treatment setup is ready to be viewed, either right away, at the end of the day, or at the end of the week, depending on often how you've asked to receive notifications.

Consider the treatment plan when submitting your case

The ideal time to look at your treatment goals is when you're submitting your case. Beginning with the end in mind is the best way to get the treatment plan you want for your patient.

Submitting more information leads to receiving better treatment setups. Our technicians are good, but they're even better with your input. We will work with you to get the treatment plan you desire.

Anticipating potential problems pre-treatment setup and deciding what approach you want to take, is also something to consider when submitting your case. Here are some common problems to consider when reviewing your setup:

Specific instructions to address any of the above problems can be given in the Additional Instructions sections when submitting a case.

We hope this information helps you submit & evaluate your future cases!

Until next time...

Coming soon: treatment setups in your browser

We’re rolling out a change next week—instead of downloading a treatment setup and viewing it in Adobe Reader, you’ll be able to view setups directly in your web browser, without any plugins or additional software. Changes you might notice include:

  • Support for mobile devices—approve your setups any time, anywhere.
  • A link to a shareable version, which hides the patient's first name and evaluation button.
  • Crisper, more responsive 3D graphics.
  • No more crashes caused by Adobe Reader updates.

You won’t need to do anything different—you’ll still click the same icon to view setups on the case pages, and approve or decline them like you do today. The setup should work in the current version of Internet Explorer, Chrome, Safari, and Firefox. If you're not sure whether your browser is up to date, you can verify that here.

Tech Tip: Extruding with auxiliaries

To create an aesthetically aligned smile, sometimes teeth need to be pulled in line with the other teeth.

Extruding teeth with auxiliaries (elastics, buttons, etc.) is a technique used to extrude a tooth that has not erupted as desired.  As always, the patient must wear the aligner (and elastic) for a minimum of 22 hours each day, or the process will not work. Watch for extrusions not occuring with your cases, as this can be one of the reasons a patient's treatment has gone off track.

How to...

Below are step by step instructions on how to extrude teeth with auxiliaries.

Download a printable guide here.

Parts needed:

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Instructions:

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Using a coarse sandpaper disc, roughen enough area on the tray to place an orthodontic bracket on the facial gingival 1/3 of the tooth to be extruded.

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You can see the relative size of the roughened area circled here in green.

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Prepare a 50/50 mixture of resin cement base and catalyst and place a small amount onto the ceramic bracket.

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Place the ceramic bracket on the roughed-out area of the aligner tray. Adjust as needed, then wait 2-3 minutes for the resin cement to set.

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Using a coarse football diamond bur, start at the top of the tray on the lingual side and cut a space to clear the bracket, leaving room for the tooth to extrude.

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Once the tray is cut, it should look something like this.

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Remove the engager from the tooth to be extruded.

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Etch the tooth to be extruded on the lingual side.

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Rinse the acid and dry with the air/water syringe.

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Bond the metal bracket with a composite resin recommended for bonding orthodontic brackets.

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Break contact on the mesial side of the tooth being extruded using a metal diamond strip, then break contact on the distal side the same way.

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Insert tray and place the elastic over the facial bracket (on the tray) and the lingual bracket (on the tooth).

Check out our Troubleshooting section in the Help Center for more helpful troubleshooting techniques to use in clear aligner treatment.

Until next time...

Tech Tip: All about checkups & revisions

We sent out a survey recently asking doctors for their questions about monitoring treatment, checkups & revisions.

In this week's tip, we've consulted with our new Clinical Advisor, Dr. Ken Fischer, to get answers to some of your questions. Dr. Fischer has over 40 years of orthodontic experience with 16 years of experience with clear aligners.

Monitoring treatment

What would you present as a "checklist" of what to look for at each checkup appointment with and without aligners in the patient's mouth? For example (but not limited to), Compliance Checkpoints.
  1. Visually confirm that the aligners are fitting completely, i.e. no incisal gaps or space between the tooth and the aligner.
  2. Confirm that patient is wearing the correct aligners.
  3. Watch patient remove the aligners; removal should be easily done without difficulty.
  4. Examine the condition of the aligners; "pristine" condition may suggest lack of wear.
  5. Use floss to confirm loose interproximal contacts between all teeth, especially at any Compliance Checkpoints. Address any tight contacts found.
  6. Evaluate the presence and condition of previously placed engagers.
  7. Confirm good fit of next aligners and patient’s ease in placing them.
  8. Refer to treatment plan paper work or treatment setups and perform any scheduled procedures, i.e. IPR, place or remove engagers, compliance checkpoints, etc.
  9. Confirm proper wear schedule and document dates to change aligners.
  10. If desired, verify that tooth movements have occurred by referring to the treatment setup.
  11. Look for blanching of the gingiva at the trim line. Blanching is occasionally seen around gingival frenum and may also be due to distortions in the impression. Often these are very minor and can be trimmed back with scissors.
  12. Some clinicians may find it helpful to run a finger along the aligner trim line to feel for sharp edges or areas where it has lifted away from the gingiva.
What are some of the key indicators that a patient is ready to move to the next aligner?
  • Full and complete fit of current aligners
  • Patient able to easily remove and place current set of aligners
  • Loose contacts and spaces closed at compliance checkpoints
  • Planned tooth movements have occurred
When I check in with the patient and if something is off or a gap is not closed, I have been told to just continue the trays. Why should I check if there isn't anything to do about it?

In most cases, minor gaps or incomplete movements can be resolved by extending the wear of the current aligners, but it is important to determine why the teeth are not tracking completely. If the clinician determines non-tracking is due to patient non-compliance, there may be a need for alternative measures such as backtracking. With backtracking, it is recommended you have the original steps remade by the lab.

In some cases, where IPR has previously been done, I don't see space closure. I continue with the trays and eventually things seem to iron themselves out. Should I be holding the patient in a current tray until that spacing closes? In general, should I be referring back to the treatment setup to compare where the patient's teeth are for each step?

Yes, holding the patient in the current aligner until a compliance checkpoint is satisfied, is good protocol. Referring to the treatment plan or setup is appropriate to confirm the need for a compliance checkpoint and to determine if the planned tooth movements have occurred. However, it is not a requirement to evaluate the position of the teeth at each step.

What is the best way to determine if the set of aligners has accomplished its goal? Sometimes when the next set of aligners is inserted, the insertion is difficult and the fit seems very, very tight and almost painful for the patient. How do you determine if the appliance has done its job, or if the arch is ready for the next appliance?

A sign that the aligner has "...done it's job..." can be if there is unquestionable good fit of the current aligner. However, even if aligners appear to fit properly and comfortably, that doesn't guarantee that the teeth are actually moving as intended. For suggestions on how to identify unseen tracking issues before treatment goes off track, see our article on Tracking Issues. A tight fit of the next aligner may very well be due to a considerable amount of tooth movement programmed for the next stage.

I have difficulty with knowing for sure on claims from patients that they are wearing their aligners the proper amount of time are true or not, do you have any suggestions?

Do not be too eager to sternly criticize or debate the patient’s claims that they are wearing their aligners as directed, but remind them that if the aligners do not fit as expected the most likely reason is lack of wear. If you continue to see signs from appointment to appointment that the aligners are not fitting well, motivation tactics should be applied. Also, check out our article on non-compliant patients which has some common signs for determining if your patient has been wearing their aligner properly.

Does the position of the engagers need to be adjusted as the teeth move?

Only if the aligners are not tracking or if a revision is requested.

Do some patients have more of an open bite with aligners than others?

Some patients exercising heavy masseter muscle activity may experience a slight post-treatment open bite due to the intrusion of the posterior teeth by the strong clenching of those teeth. This phenomenon resolves itself by removing the posterior sections of the last aligners for a few weeks to allow the intruded teeth to return to occlusion.

Please explain the "C chain", when it's indicated and what it does. Does it help when contacts of anterior teeth are not tight at the end of treatment?

The term "virtual C chain" (aka digital power chain) was originally used with brackets meaning a piece of elastic that wraps around metal braces and pulls the teeth closer together. In clear aligners, a digital power chain is not an actual, physical entity. It is a concept attained by the technician setting the teeth in tight, or even slightlyovercorrected, contact intended to close all spaces between the teeth.

Tracking and fitting

Does treatment need to track exactly as laid out in the treatment setup that I approved?

Yes, precise tracking is very important for a successful treatment result, otherwise, a revision will likely be required.

I have difficulty judging when a tooth is not tracking and when to intervene. How do you know if you case is not tracking?

The accepted definition for "not tracking" is when the teeth do not fit well in the aligners.

Example; in molar uprighting, when the aligner is not tracking, what I have done is allowed the other steps to continue to move the anterior and biscuspids, and have the patient try to "seat" the aligners around the uncooperating molars. THEN, I eventually take NEW impressions, and revise the prescription (and prolong the case) to go back and "capture" and engage the molars. So, 1) should I just request engagers on all molars that require bodily movement, and 2) what may be the reason for the original aligners not engaging the molars? (i.e., the attempted movements are TOO BIG, in micros for the aligner to fully engage the molar, or is it something else?)

A horizontal rectangular engager should always be placed on the mesiobuccal cusp for molar uprighting in order to improve the aligner’s ability to control this difficult movement. Once one recognizes that the molar is not tracking and fitting properly, do not continue with subsequent aligners; the poor fit around the molars may cause the aligners to not fit other teeth well, diminishing their effectiveness to complete staged movements.

I have difficulty with knowing when to change the course of treatment if you feel things are not tracking as they are supposed to. Is there a time or point in treatment that is "better" or "ideal" to change the course of treatment?

When the clinician observes poor tracking on two consecutive appointments, it is time to think about a revision; and begin to implement corrective measures.

Revisions

Please clarify what is considered a revision vs. mid-course correction.

ClearCorrect refers to any change to a treatment plan defined by a subsequent setup as a "revision"; this change can occur during treatment or at the end of it. The competitor in the past offered a "mid-course correction" for any change to a treatment plan defined by a subsequent setup if that change was made during treatment. Effectively, there is no actual difference in the two procedures.

Do I have to remove engagers and start over or can the engagers be left in place?

It is a best practice to remove existing engagers prior to taking a new impression or scan for a revision, and ClearCorrect requires it.

Do we always get all the trays at once when we do a revision?

Revision trays will be sent in groups of up to 12, just like they were delivered originally.

Is it considered a revision if the patient simply did not achieve the original treatment goals?

It is considered a revision if additional aligners are ordered to complete unfinished treatment goals.

Would it be better to back up a couple of steps and try to "recapture" the planned treatment before doing a revision?

If the aligners have not been tracking, backtracking may work, but if the aligners have been fitting properly, a revision would likely be necessary to finish treatment.

Is a new impression always necessary for a revision?

A revision can be based on existing models that fit well, on new impressions, or on new intraoral scans. See our article on revisions for more information on this topic.

Usually on a revision the patient wants some fine tuning. Rotations of a few degrees for example. Should I continue with a revision or place brackets on the patient to finish? It seems to me minor rotations are infrequently accomplished with revisions. Should I be placing engagers on those teeth?

While placement of brackets is an additional cost to the doctor and unpleasant for the patient, they can be used. However, complete rotation can be accomplished by:

Tips & tricks

Some of our providers offered a few tips & tricks for monitoring treatment, checkups & revisions. Nothing here should be taken as official advice or recommendation from ClearCorrect or its employees. It's up to you to use your professional judgment on what is best for you and your patients.

  • To monitor treatment, when performing checkups, I most often open the patient’s online case and just look at where the computer says the tooth position and bite are designed to be at that stage and then compare.
  • I constantly compare the patient’s progress with the treatment setup.
  • Watch the velocity of movements. If movements are too quick for extrusion, rotation, then it most likely might not happen clinically.
  • I have learned for the most part to not give multiple aligners to patients. I think it’s extremely important to be able to monitor on a regular basis.
  • If just 1 or 2 teeth, I try to dimple and window first. Need hand stripping to assure space to move.
  • I have learned to ask for overcorrection in my original prescriptions.

A big thank you to all the providers who answered our survey!

Check out our Help Center for more helpful information on clear aligner treatment.

Until next time...