Tech Tip: Ankylosed teeth

When attempting to move teeth around, you may find yourself dealing with an "ankylosed tooth".

An ankylosed tooth means the root of a tooth is permanently connected to the jaw. It cannot move because the tooth no longer has the protective periodontal ligament around it. The root of the tooth will then become permanently attached to the jaw bone.

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An ankylosed tooth looks exactly like a regular tooth, except that sometimes it may be higher or lower in the gum line. A tooth can become ankylosed while it is still growing out of the gums. When that happens, the tooth is usually shorter due to its growth having been halted mid process.

Medically, it is not known exactly what causes a periodontal ligament to dissolve from around a tooth’s root and cause ankylosis—but something happens that damages the ligament. One of the suspected causes is dental trauma, particularly occlusal trauma.

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There are usually no symptoms or pain with a tooth becoming ankylosed and it is often discovered when examining a patient’s mouth, taking x-rays or when trying to use braces. The only way to handle an ankylosed tooth is to leave it where it is or remove it surgically.

A patient can still get clear aligners if they have an ankylosed tooth. Just keep in mind that clear aligners will only move teeth that are not ankylosed. If a doctor suspects an ankylosed tooth, they can tap on the teeth with a dental mirror. The ankylosed tooth will have more of a solid sound when tapped compared to the dull, cushioned sound of other teeth. It can then be confirmed with X-rays.

Tech Tip: Evaluating a treatment setup

Making sure that the treatment setup reflects the treatment goals for you and your patient is probably the most important part of the case submission and approval process. It’s essential that you know what to look for and the best way to communicate these needs to your technician. Here are our suggestions or “how to” for evaluating a treatment setup.

Evaluating a treatment setup

  • Begin with the end in mind – make sure you’re focused on the treatment goals for your patient when evaluating the treatment setup.
  • As you go through the treatment setup, make notes of any items to adjust (if necessary)
  • Confirm the software has accurately related the models and bite registration:New Treatment Setup 5-1.png
    • Put the timeline of the treatment setup in the starting position and tilt the model up to check for gaps between the upper and lower incisors—comparing this view to the patient’s photographs and records can reveal any improper bite registration for the model.
  • From the front view, check the midline relationship.
  • Using the right and left views, check the accuracy of the:
    • Overjet
    • Overbite
    • Canine relationship
    • Molar relationship
  • 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.
  • If you requested overcorrection or a digitial power chain, verify that you are satisfied with these. 
  • Note the number of required aligners and wear schedule.
  • New Treatment Setup 8.pngWhen you’re finished reviewing the setup, click EVALUATE. There are 4 options to choose from:
    • Approve the setup and select a price option for the case, which will kick off production
    • Decline the setup and ask for adjustments
    • Decline the setup and submit new impressions or scans
    • Decline the setup and cancel the case 

We hope this information proves helpful when reviewing your patient's treatment setups. 

 

ClearCorrect e-courses

                       
                       

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Getting Started: 
Clear Aligner Basics

New to clear aligners? Start here. This course will provide you with the skills and confidence you'll need to begin treating patients with ClearCorrect.

Topics include:

  • Clear Aligner/Orthodontics basics
  • How to select & submit cases for treatment
  • How to manage a case
    • Engagers – best practices
    • IPR – best practices
    • Checkups & revisions
  • How to finish a case
    • Identifying problem issues prior to the last aligner
    • Retainers & retention

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Practice Enhancement 
With Clear Aligners

Learn how you can take your practice to the next level with a ton of useful marketing and managing insights accrued over decades of first-hand experience.

Topics include:

  • How to use clear aligners to enhance your practice success
  • How to set up your team for success
  • External and internal marketing
  • How to establish the clear aligner experience in your practice

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Beyond Aligner Basics: 
For the Experienced Provider

If you've got a good amount of experience with clear aligners, but you're looking to do more complex cases, we highly recommend this course.

Topics include:

  • Mastering troubleshooting techniques
  • How and when to use auxiliaries for clear aligners

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Questions? Call your sales rep at 
(888) 331-3323.

About the presenter

Dr. Ken Fischer has been practicing as an orthodontic specialist in Southern California since 1975. He is a former president of the California Association of Orthodontists and a former council chair for the AAO. Dr. Fischer embraced clear aligner treatment in 2000 and has treated a broad spectrum of malocclusions in over 1200 patients. He served on the Invisalign Clinical Advisory Board for 13 years, but now serves ClearCorrect as its Clinical Advisor. He is the author of a number of published articles, a mentor, domestic and international lecturer, and consultant for clear aligner orthodontic corrections.

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ClearCorrect is designated as an Approved PACE Program Provider by the Academy of General Dentistry. The formal continuing dental education programs of this program provider are accepted by AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from 4/1/2015 to 3/31/2019. Provider ID 304173.

 

Tech Tip: More on non-compliant patients

This week we have some additional education and tips on non-compliant patients.

If you break down the subject of non-compliant patients a bit further, you can see there are two main types:

  • The deliberately non-compliant patient
  • The inadvertant non-compliant patient

With clear aligners the deliberately non-complaint patient may be less common. But differentiating the two may help you to understand them better. Here are some tips on this which don't promise to resolve the issue, but may help us to better motivate the non-compliant patients.

Is there an underlying reason for the non-compliance?

  • Lack of education on the basics, importance of and reasons behind the specific instructions
  • The aligners are uncomfortable, embarrasing, interfering with work or life conditions 
  • Patient is forgetful

Understanding the specific issue for that patient can help you both to come up with workable solutions. 

Education

Education is KEY to compliance and the importance of it should not be underestimated. A thorough education from the start should help to deter non-compliance. A fair percentage of your patients are non-compliant whether you are aware of this or not. We covered some tools and resources for this in our tip last week, specifically:

Having the patient repeat your instructions back to you can help to ensure that they have been accurately understood. 

Involve the patient in every step

  • Involving the patient from the initial consult, to records, to appointments and retention with details of the procedures and a timeline can help to enlist cooperation. 
  • Set goals that patients understand (the setup is a good visualization of the final goals) and establish mini-goals along the way (for example, we have finished closing spaces, we are now half done, we are in the finishing steps, etc)

Communicate and support

  • Be honest when non-compliance is suspected and remind patients without scolding them. For example "I'd like to see you finished by ___ date, can we work together to make this happen?"
  • Encourage patients and share your enthusiasm with their treatment—e.g., "Your teeth are moving like that of a teenager. Keep up the good work!” 
  • Let them know you care. Listen to patients. Sometimes they have life events or situations where aligner wear may not be the highest priority. Let them know you are there for them no matter what and you will bend over backwards to help them achieve their goal of a beautiful smile. 

Documentation

All documentation is important as is true in most industries. For non-compliant patients it is especially good practice to document throughout treatment, as you may need this later.

Key notes for documentation:

  • Missed appointments
  • Patient comes to appointment without their aligners on or with them
  • Mysteriously "clean" aligners (2 or 3 weeks of wear on an aligner will show)
  • Aligners are still tight after 2-3 weeks of wear (should be loose, easy to insert and remove)

For further information on non-compliant patients, visit our help center here

Until next time...

Flex & Unlimited now available

As previously announced, we are releasing our new Flex & Unlimited pricing options today to all US providers (with the exception of certain dental groups).

Here's what to expect.

When you submit a case, you won't be asked to choose a "case type." Instead, there's a new option to recommend or limit the number of steps:

Duration: Recommend or Limited to 12 steps

  • If you leave this on Recommend, we'll show you how many steps we need to try to reach your prescribed goals on the treatment setup. (This is kind of like the old "Recommend a case type" option.)
  • If you choose Limit, you can restrict the duration of the treatment. (This is kind of like the old "Limited 6" and "Limited 12" options, except you can choose any number you want.) This is just an upper limit—we won't be moving teeth slower or faster to hit a particular number. If it takes fewer steps than your limit to reach your prescribed goals, we'll use fewer. If it takes more, you might not reach all of your prescribed goals.

Submitting a case is still free.

When you get your treatment setup, you'll see how many steps are planned. If everything looks good, click Approve. That's when you'll be presented with a choice between Flex or Unlimited pricing options:

Approving treatment setup

Any case can be treated as Flex or Unlimited, regardless of duration. You'll see the exact duration and cost of both options. If you're not sure which one to choose, here are some points to consider:

  • If you want the safest, most predictable option, you can't go wrong with Unlimited. Your costs will be covered for the next five years, no matter what happens. Remember, this now includes up to two sets of retainers every six months.
  • If you want the most affordable upfront cost, that's going to be Flex for all but the longest dual-arch cases. Flex is also a good option if you and your patient are prepared to deal with any additional costs that may come up during treatment.
  • If you want to optimize your overall cost over the entire treatment period, it's a little less clear-cut. With Flex, additional aligners (such as revisions, replacements, and retainers) are priced at the same rate as aligners for new cases. You'll also need a new treatment setup for any revisions. This can vary a lot from doctor to doctor and from patient to patient. Some people don't need anything but what's shown in the initial setup; others start over almost from scratch multiple times. Once these additional costs are factored in, Unlimited can end up being the more affordable option over time for many cases.

There are no strict guidelines, but here are some rules of thumb for the types of treatment that might be best suited for each treatment option:

Flex

  • Minor anterior movements
  • Minor crowding or spacing
  • Relapses from previous orthodontic treatment
  • Minor movements in a single arch
  • Combination treatment (transitioning between traditional orthodontics and clear aligners)

Unlimited

  • Moderate to severe crowding or spacing
  • Midline misalignment
  • Overjet and overbite
  • Open bites
  • Class II and Class III bite relationships
  • Non-compliant patients
  • Patients with potential interruptions, such as military service, pregnancy, weddings, and frequent travel
  • Patients desiring retention with clear aligners after treatment

If you still have questions, we've got answers:

Tech Tip: Education and other resources for patients

Once you have a clear aligner candidate in front of you, educating them is the key to obtaining positive results in clear aligner therapy. Setting realistic expectations at the outset of treatment can help make the patient's experience smoother.

We have several resources for educating your patients on clear aligners. 

For patients wanting more information on clear aligners, we recommend the 3-minute video How Clear Aligners Work, which covers:

  • Clear aligners and their relation to traditional orthodontics
  • How the aligners are made
  • How the aligners straighten teeth
  • How the teeth move and change in relation to pressure
  • Importance of wearing the aligners 22 hours a day

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We also offer a short Before and After video showing clear aligner results with various types of issues:

  • Crowded upper and lower arches
  • Overbites
  • Shifted midlines
  • Crossbites
  • Upper and lower arch spacing 

Patient reviews are also available here

Your patient may also find our aligner wear and care guide useful, covering:

  • Expected daily wear schedule
  • How to care for the aligners
  • Do's and donts on food, drink, storage, etc.

It's essential for each patient to read and sign the informed consent form before committing to treatment, which covers:

  • What clear aligners are and how they workInformed Consent.png
  • Potential risks of clear aligners in relation to
    • expected results
    • adverse reactions
    • potential dentition issues (black triangles, irritation of soft tissue, IPR, tooth sensitivity, etc)
    • potential relapse
    • additional costs.
  • What they are agreeing to in relation to treatment and results

For patients that need help with financing, we partner with beWell patient financing, providing:

  • higher approval percentages
  • a dedicated account manger
  • an easy application process
  • no "gotcha" interest rates or pre-payment penalties

Our ClearCorrect online store provides a few patient items for those interested, including:

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  • OAP aligner cleaner
  • Outies (aligner removal tool)
  • Aligner cases 

If you have further suggestions or any feedback on the above, you can send us an email or provide feedback in the box below.

Until next time…

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Flex & Unlimited Q&A webinars

We've received a lot of great feedback and questions about the new Flex & Unlimited price options that we announced last week. 

We're offering two free live webinars on May 15 and May 19 to discuss the details of Flex & Unlimited and answer any questions you may have. If that interests you, you can register here.

These new options are currently in testing with select providers—we'll be making them available to all U.S. providers on June 1, 2017, and the rest of the world later this year.

You can find more details and FAQs at support.clearcorrect.com.

Or, if you still have questions, just email us at support@clearcorrect.com or give us a call at (888) 331-3323.

Tech Tip: Is your patient a good candidate?

One of the best ways to determine if your patient is a candidate for clear aligners is by determining if they will be compliant or not. If you suspect they will not be compliant, meaning if your patient cannot agree to wearing aligners for 22-hours a day, they are not likely a good candidate for clear aligner treatment and it’s more than likely that you and your patient will not get the desired results. 

As a new provider, some examples of good initial candidates for clear aligner treatment, in addition to committing to full compliance and wear: 

  • Minor anterior spaces or crowding
  • Ortho relapses
  • Single arch treatment with minor goals

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With some experience and success under your belt, here are some sample moderate cases:

  • Moderate anterior spaces or crowding
  • Minor to moderate overjet and overbite correction
  • Class II and Class III cases 

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The following conditions could reduce the expectations of successful treatment with clear aligners and we do not recommend doctors treating them without a considerable degree of education and experience with clear aligner treatment:  

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The presence of any of these conditions does not prohibit treatment with clear aligners, but the doctor must consider how their presence affects the patient’s candidacy as a good aligner patient.

Check out our Help Center which is filled with useful information on the topic of clear aligner treatment.

Until next time…

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Announcing new Flex & Unlimited pricing

We just introduced some awesome new options at the AAO Annual Session, and we can't wait to tell you about them: starting June 1, you'll be able to choose between Flex (simple, per-aligner pricing) or the new and improved Unlimited (one flat fee for five full years of aligners—and retainers).

With Flex, you get exactly what you need—no more, no less. We’re making it super easy and ridiculously affordable (up to 70% less than the other guys). Single-arch treatment just got a whole lot cheaper. Whether you need just a couple of aligners or dozens of steps, you can customize your treatment to meet your patients' needs without squeezing into pre-set pricing tiers.

If you're the type who prefers to "set it and forget it," you're going to love the changes we've made to Unlimited treatment. For one flat rate, you'll get five full years worry-free—including retention. Unlimited covers all aligners, revisions, and replacements for five years. Your case won't close before the five years are up, even if you order retainers or treatment goes slower than expected. Best of all, the new Unlimited treatment also includes multiple sets of retainers—up to two pairs every six months—at no extra cost during the five-year period.

You can choose to treat any case as Flex or Unlimited, regardless of length, when you approve the treatment setup. It's entirely your choice whether you want to prioritize lower upfront costs with Flex, or cover your bases for future revisions and retainers with Unlimited.

These new options are currently in testing with select providers—we'll be making them available to all U.S. providers on June 1, 2017, and the rest of the world later this year.

You can find more details and FAQs at support.clearcorrect.com.

We're also offering two free live webinars and Q&A sessions discussing the details of Flex & Unlimited on May 10 and May 15. If that interests you, you can register here.

If you still have questions, email us at support@clearcorrect.com or give us a call at (888) 331-3323.

Tech Tip: 2 basic principles for clear aligner treatment

Clear aligners have a lot of advantages over metal braces—most obviously, they're clear and they're removable. There is a tradeoff, though. Because they aren't attached to the teeth, some movements can be more difficult to acheive than they are with traditional braces.

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For this reason, it’s important for you to know the limitations of clear aligners so that you can properly assess whether they can achieve the treatment outcomes that you and your patient desire. There are two key principles to keep in mind.

Principle 1: Teeth need space to move.

When you prescribe your case, you can plan to create space with extraction, arch expansion, or IPR, depending on how much space is required. However, despite prediction and planning, there may be some instances where insufficient space will still be an issue.

For example, when teeth crowd each other there may be tight contacts between them. Tight contacts between teeth are common and exist naturally due to the patient's dentition. The teeth are so crowded, they press up against each other, and literally put each other under pressure. You can try to relieve this pressure by creating space (for instance, by performing IPR).

If there's enough pressure, the surrounding teeth may just move in to fill the space you’ve created. If this happens, you may need to create more space than originally intended. If this is not caught and addressed, it can prevent treatment from going forward as planned because the rest of the movements no longer have sufficient space to straighten out. This can result in treatment going off track and the aligners no longer fitting.

Checking Compliance-1.pngYou can check for tight contacts by running floss between the teeth. If the floss has a hard time popping in and out, then you know that you have a tight contact. (If the floss pops in and out easily, then you have light to moderate contact.)

Conversely, you don't want too much space left between the teeth. Compliance Checkpoints can also help you to tell if the space you made is closing as planned.

Solutions for creating more space

TIP: Always track the amount of IPR being done. We offer an IPR tracking chart for this purpose.

Principle 2: Teeth need pressure to move.

Most teeth will move with a little bit of consistent pressure on them. However, some types of teeth, some movement, and some other factors are more prone to issues than others. These include:

Solutions for increasing pressure

Each of these solutions can increase pressure. The key is knowing when to apply each one.

engager illustration.png Engagers may be included in the treatment plan based on your prescription and/or the technician’s recommendation. Engager preferences and timing can be adjusted according to the needs of the patient—just let us know when submitting the case or in a revision.
Dimples can be created in office with dimple pliers. These are used to increase pressure to assist with difficult movements. They can also be used to increase the retention of an aligner when needed, such as with short clinical crowns.   dimple.jpg
extruding with aux.jpg   Buttons and elastics can be used to help with extrusions. See our technique for extruding with auxiliaries.
Buttons and elastics can also be used to help with rotations. See our technique for rotating with auxiliaries.   elastic in place.jpg

Overcorrection is when the technician stages the last few aligners with a little more pressure in the desired direction to ensure the teeth move into their final position. Overcorrection can be requested in your case submission form at the start of treatment, or in a revision.

Digital power chains can be used to close residual spacing, which can occur if too much IPR was done. Or some cases start with spacing, and you just want to ensure all spaces have closed.

General solutions

Here are some techniques that can assist with both insufficient space and insufficient pressure:

Backtracking is used to get the teeth back on track by having the patient wear an earlier aligner longer before advancing to the next step. You can get best results by requesting a fresh replacement. You can combine this with other solutions, like adding dimples, extruding with auxiliaries, IPR or hand stripping, all designed to get the teeth back on track without requiring a revision.

Longer wear schedules may help with patients that you suspect are non-compliant or need more time to achieve planned tooth movements.

Increasing patient compliance can be achieved with incentives according to what you want to offer. Here are some incentives used by doctors:

  • Educating the patient that by wearing their aligners 22 hours a day, they can avoid delays and added costs, and will be more likely to complete treatment within the expected time frame.
  • Explaining the alternative (traditional braces) if aligners are not worn 22 hours a day.
  • Using the treatment setup as an incentive to be compliant – reminding them of what their teeth could look like if they keep to their wear schedule.

Consequences

The consequences for not monitoring or addressing insufficient space and/or insufficient pressure can include:

We hope this article helps you to achieve your desired treatment outcomes. For further education on our techniques and solutions, visit our Help Center.

If you missed any of our previous tech tips, we post them regularly to our blog, which you can find here.

Until next time…