Tech Tip: Posterior open bite with clear aligners

A posterior open bite is when the upper & lower anterior teeth are touching when the patient bites down, but the posterior teeth are not in occlusion.

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Causes

There are many possible causes for a posterior open bite and it is fairly common with clear aligners. Usually it's temporary. It can be caused by the “hinging” action of the jaw.

Imagine placing a 1 mm sheet of flat plastic over the occlusal & incisal surfaces of the lower teeth. As the jaw closes, the posterior teeth will contact first. The patient would have to bite down firmly to get the anterior teeth to touch completely.

The same thing can happen when the teeth are covered by clear aligners. When the patient first starts wearing them, the posterior teeth are the first to contact. After wearing the aligners for a while, the teeth adjust to compensate, and before long, the patient can bite evenly with the aligners on.

The posterior teeth will intrude slightly to accommodate for the thickness of the aligners as occlusal forces are applied. Once the teeth have adjusted to the aligners, if the patient removes the aligners and bites down, the anterior teeth will make contact first and the posterior teeth probably won't quite touch.

Solutions

Here are some common approaches for a posterior open bite.

For posterior open bites present during clear aligner treatment:

  • Remember to check the occlusion during treatment visits and look for signs of posterior open-bite. Request a revision to slightly intrude the anterior teeth by ~0.5mm - 1.0mm on both arches, depending on the amount of open-bite. This relative intrusion will allow the posterior teeth to extrude, thereby closing the posterior open-bite.
  • To assist with re-establishing posterior contact, an open tray approach can be taken. Cutting off the aligner at the terminal molar to establish contact and gradually working your way forward until a canine to canine tooth aligner is left and posterior contact is established.

For posterior open bites present after clear aligner treatment:

  • After the patient has worn the final retainer for 3-6 months and the teeth are stable, the patient can switch to wearing the retainer on alternate days to give the posterior teeth freedom to move back into their normal position.
  • Or you can have the patient try the combination of wearing the upper retainer one night and lower the next and so on.
  • A Hawley retainer could be prescribed, which won't interfere with occlusion, allowing the posterior teeth to super-erupt freely.
  • A fixed retainer is also another option.

If you liked this article, check out our Help Center which is abundant with helpful information on clear aligner treatment.

Until next time...

Now offering dimple pliers

We’re happy to announce a new addition to our online store! Five Star Orthodontic's 1mm Retention Dimple Plier.

This plier is recommended for use when making dimples. You can pre-order these new pliers and save 10% by entering the promo code: PLIERS when ordering. The pre-order sale expires on August 4th.

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1mm Retention Pliers

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Dimpling is used as a chairside measure to increase pressure on the tooth for difficult movements or to add retention.

Use them to place small 1mm x 1mm deep dimples into your aligner. Unlike similar pliers from other companies, these pliers do not require heating of the aligner or plier.

We’ll be offering these pliers for $90.00, but for a limited time, you can save 10% by using the promo code.Take advantage of the pre-order price as it will only be available until August 4th.

  Click to pre-order!

Estimated shipment - August 4th

Tech Tip: Where to place dimples

A dimple is a small depression made in the plastic of the clear aligner. The dimple  increases pressure on a tooth to help make desired tooth movements or to increase retention of the aligner. 

Uses

Dimples can be used for:  

The force made by dimples will only be as strong as the aligner’s strength, so it's best to place dimples in a fresh aligner that has not been worn yet or request a remake of the aligner if retention is inadequate.

Overcorrection & Dimpling:

If overcorrection is requested in the treatment setup, it reduces and often negates the need for dimpling. Whenever possible, planned overcorrection in the treatment setup is more advantageous than making dimples (since dimples need to be made for each aligner and are generally limited to one or two teeth).

Dimpling is used as a chairside measure to increase pressure on the tooth for difficult movements. However, the amount of tooth movement is limited as there must be adequate space on the opposing side of the dimple within the aligner to allow the tooth to move. Often this is limited to the size of the air gap between the aligner and the tooth.

There are different approaches to overcorrection and dimpling. Some clinicians prefer to utilize overcorrection as much as possible and dimple only for difficult movements. Others do not plan overcorrection and dimple the aligners as needed, however as described above, dimpling only works for select movements.

How to... 

Dimples are made using a dimpling plier. Be aware that different manufacturers make dimpling pliers that produce slightly different sized dimples and some pliers require heating while others do not. Refer to the plier manufacturer for specific instructions.

Where to place dimples:

For added retention:

  • To add additional retention to aligners - place a dimple between two teeth on the lingual and facial sides of the aligner.

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For rotations:

  • For distal rotations - place dimples on the lingual mesial and facial distal side of the tooth.

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  • For mesial rotations - place dimples on the lingual distal and facial mesial side of the tooth

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For tipping:

  • For facial tipping place dimples on the lingual mesial and distal sides of the tooth.

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  • For lingual tipping place dimples on the facial mesial and distal sides of the tooth.

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  • For mesial tipping place dimples on the lingual and facial of the distal surface of the tooth on the occlusal 1/3.

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Dimples_-_mesial_tipping_FD-3.jpg 

  • For distal tipping place dimples on the lingual and facial of the mesial surface of the tooth on the occlusal 1/3.

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For torquing:

(Engagers are recommended for torquing but not for small movements. Fresh aligners are the best option to get a tooth to torque. You may end up needing more than one replacement for stubborn teeth.)

  • To torque lingually place one dimple on the facial gingival. 
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  •  To torque facially place one dimple on the lingual gingival.

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  • To torque mesially place dimples on the lingual and facial of the distal surface of the tooth on the gingival.

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  • To torque distally place dimples on the lingual and facial of the mesial surface of the tooth on the gingival.

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For translation:

(Engagers are necessary for large mesial and distal movements. IPR may be needed if there is contact preventing movement.)

  • To translate lingually place dimples on the facial occlusal 1/3 at the center and on the facial gingival.

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  • To translate facially place dimples on the lingual occlusal 1/3 at the center and on the lingual gingival.

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  • To translate mesially place dimples on the lingual distal surface of the tooth on the occlusal 1/3 and gingival. And place dimples on the facial distal surface of the tooth on the occlusal 1/3 and gingival.

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  • To translate distally place dimples on the lingual mesial surface of the tooth on the occlusal 1/3 and gingival. And place dimples on the facial mesial surface of the tooth on the occlusal 1/3 and gingival.

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The information provided above on where to place dimples can be found in our Help Center and referred to at your convenience. We hope you find it useful!

Keep an eye out for our upcoming pre-sale announcement for dimple pliers!

Until next time...

Interview: Dr. Ken Fischer shares his thoughts on ClearCorrect

Last time we interviewed Dr. Fischer, we asked if we could film him at his practice in Orange County, CA. This time, he tracked us down at this year’s AAO Annual Session to answer some frequently asked questions about ClearCorrect. Here’s what he had to say:

Thanks Dr. Fischer!

Early voting for the 2016 Townie Choice Awards is open!

Voting’s pretty neat. It takes Americans’ most treasured right—shouting opinions at strangers—and makes it both civilized and offi­cial.

But sometimes voting is hard—you‘ll have some tough decisions to make in November.

Fortunately, this summer, the correct choice is clear. In the Townie Choice Awards, there’s only one affordable, friendly, and fast candidate who makes quality aligners right here in the USA.

If you complete your 2016 Townie Choice Awards ballot by July 17th, Dentaltown will enter you to win:

•              Bose Soundlink Bluetooth Speaker

•              FitBit Blaze Watch

•              $500 Amazon Gift Card

•              Tuition to the 15th annual Townie Meeting

PLUS! You would be featured on the cover of December 2016 issue of Dentaltown Magazine and you'll win $1000!

Choosing candidates in other 2016 elections might be hard….but for the Townies, the choice is clear.

Vote Today!

ClearCorrect Announces Dr. Ken Fischer as New Clinical Advisor

ROUND ROCK, TX--(Marketwired – June 29, 2016) - ClearCorrect, LLC announced today the addition of orthodontist Dr. Ken Fischer, DDS as its new Clinical Advisor. Dr. Fischer brings with him over 40 years of orthodontic experience.

“As a seasoned clinician with years of experience in treating patients, Dr. Fischer complements and brings a wealth of knowledge and experience to our team,” said Dr. James Mah, ClearCorrect CTO. “He is a great presenter and provides step-by-step approaches to aligner therapy. Dr. Fischer’s emphasis on treatment efficiency and practicality will be appreciated by all ClearCorrect providers.”

Dr. Fischer currently owns an orthodontic practice in Villa Park, California. He has been an active and well-respected member of several dental organizations, including the American Association of Orthodontists, Pacific Coast Society of Orthodontists, California Association of Orthodontists, American Dental Association, California Dental Association, Orange County Dental Society, and American Academy of Forensic Sciences.

In addition to over 16 years of clear aligner experience, Dr. Fischer has authored numerous articles, guest-lectured at UCLA, and assisted the Orange County Sheriff – Coroner Department as a forensic odontologist and expert witness.

Dr. Fischer became a ClearCorrect provider in 2013. Since then, he has spoken at various dental meetings and presented numerous webinars for ClearCorrect. Regarding his new position, Dr. Fischer said, “After 41 years of continuous clinical practice I am anxious to share my experience and knowledge with a growing company that is already making significant contributions to our orthodontic profession.”

“We’re thrilled to have such an accomplished and experienced advisor on hand,” said ClearCorrect CEO Jarrett Pumphrey. “We’ve always thrived on feedback from our providers, so having Dr. Fischer’s perspective and expertise will be a tremendous benefit to the betterment and development of our products and services.”

Tech Tip: Providers offer impression tips & tricks

We recently asked some of our providers to share their tips & tricks for taking impressions.

Nothing here should be taken as official advice or recommendation from ClearCorrect or it's employees. It's up to you to use your professional judgement on what is best for you and your patients.

Here are some pearls of wisdom a few of our providers wanted to share.

Tips & tricks on impression technique

  • "Put putty in a good fitting tray, put plastic (like saran wrap) on putty, put in mouth and then when set, remove plastic and use light body syringe around teeth and put back in mouth until set. The putty is like a custom tray."
  • "Dry off the teeth with gauze first, and make sure the tray fits passively over the entire dentition."
  • "Don’t overseat the tray to the point where it contacts the teeth. It will cause a perforation in the impression material."
  • "I have the assistant dry the teeth completely with a 2x2 piece of gauze, prior to placing tray in mouth. I load most of the tray with a layer of putty or heavy body, and a thin layer of light body PVS, then quickly put a thin layer of light body directly on the teeth, especially on the facial of the anteriors. I make sure that the lip is retracted to avoid trapping air."
  • "Dry the mouth and begin from the distal of the most posterior tooth, and concentrate more on lingual of lower and buccal of upper."
  • "I use a universal body straight out of the cartridge intra-orally and in the tray. I place material via the cartridge over all teeth and add extra around and in the buccal space of the most posterior tooth bilaterally."
  • "Be sure to use adequate materials."
  • "Place light body on all surfaces of teeth to be included in the treatment, then place the heavy body over it."
  • "I prefer to let the putty set a little before I put the PVS wash in. This prevents my pushing through to the putty and/or the trays."
  • "I do a putty/wash technique. The trick though is to pop in the putty impression first, pop it out in 12 seconds or so, fill the wash into the putty, and reseat while both are soft and let them solidify in tandem…no distortion of trim needed."
  • "Put a thin layer of wash on top of heavy body at the occlusal and incisal position prior to seating. Have patient rinse mouth with mouthwash prior to impression to cut surface tension. May need to prophy first to remove heavy plaque or food from between teeth."
  • "Place a strip of red rope wax across the posterior border of the upper impression tray to limit the flow of the impression material posteriorly."
  • "I have a lot of success with 3M Position & trays. You can use a border molding/wash technique by systematically adding material and the design of the tray helps prevent overflow which reduces the gag reflex."
  • "Having the patient bite slightly helps if they can."

Tips on tools for taking impressions

  • "Use OptraGate retractors."
  • "Use cheek retractors."
  • "Use a very stiff, fast set, VBS material in small amount at end of the tray as a separate first step to stabilize tray for final impression and to prevent material from running past tray and gagging the patient."
  • "I now use different viscosity material for my orthodontic impressions than I use for crown & bridge impressions. My assistant fills the tray with a syringeable monophase PVS while I dry the teeth and syringe a light body PVS on the occlusal surface. I then place a thin layer of the light body PVS over the monophase in the tray, and seat. Works every time!"
  • "I use wax in the posterior of the trays to build a “dam” on the upper to prevent pulls or running of material. Both putty/wash and heavy body wash works well."
  • "I typically do a light body wash over a medium body. That usually helps pick up the sulci accurately."
  • "I use a fast set (90 second) from Parkell to minimize patient gagging and discomfort."
  • I use Panasil Tray Fast Heavy and Panasil Initial Contact X-Light."

General tips on taking impressions

  • "Practice – technique is more important than materials."
  • "Prepare patient that it is not the most comfortable experience but it will be over quickly and cooperation is needed to ensure you only have to do each arch once."
  • "Take your time."
  • "Patient compliance is very important."

Tips about scanners

  • "The CEREC Omnicam is very intuitive."
  • "Intraoral scanner is the way to go!!"
  • "Getting dental impressions is easy with my OmiCam!"

We hope you found some of the information helpful!

Until next time...

Tech Tip: Information on impressions

In case you missed it, in our last tech tip, we walked you through how to locate an occlusal view of your original PVS impression scans in the doctor's portal.

On that same topic, we recently did a survey to find out what questions you had about impressions and the most common question was:

I have difficulty getting the distal of the last molars. Do you have any suggestions on an easy way to capture these?

Posterior distortion of the most distal teeth in the arch is 3rd on the list of most common impression issues. It can be difficult to get a good impression since it's hard to see back there. There are a couple of ways to avoid this problem:

1. Make sure that you're using a correctly-sized tray. It should extend past the last tooth in the arch without touching the gums.

2. Before inserting the tray containing light body, add some light body directly to the occlusal and distal portion of the last tooth in the arch, ensuring that the last tooth is completely covered with impression material.

And in case you haven't seen these, we have an array of articles in our Help Center, covering various impression topics. Whatever your questions are, these articles likely have the answers:

We hope you found this information helpful! Keep an eye out for our upcoming article on some provider offered tips & tricks on taking impressions.

Until next time...

USPTO determines Align’s claims probably invalid

We got some great news from the USPTO!

But first, let me explain. No, there is too much. Let me sum up:

Last year, ClearCorrect petitioned for ex parte reexaminations , asking the United States Patent and Trademark Office (USPTO) to review several of Align’s patents.* These ex parte reexaminations are currently underway. So far, the USPTO has indicated agreement with ClearCorrect's position that all 75 claims of the patents in question are invalid.

Meanwhile, our legal team has also petitioned for an inter partes review of Align Technology’s patent #6,699,037 (’037) with the USPTO Patent Trial & Appeal Board. (Align has not accused ClearCorrect of infringing this patent, but it contains claims similar to those in other patents that Align has asserted against us.)

An inter partes review occurs between two parties, with the USPTO judges acting as examiners. This approach allowed ClearCorrect’s legal team to directly present key examples of “prior art” that predate Align’s in an effort to question ‘037’s patentability.

Phew! Here’s the “great news” part:

On May 23rd, 2016, the Patent Trial & Appeal Board accepted ClearCorrect’s petition and decided to institute a trial to reexamine key claims of the ’037 patent. The board determined that there is a “reasonable likelihood that ClearCorrect would prevail in showing that claims 1, 2, 9, and 10 of the ’037 patent are unpatentable.” (Over 70% of challenges accepted by the board result in cancellation of patent claims.)

Scott A. McKeown (a partner with the Washington, DC law firm Oblon, McClelland, Maier & Neustadt), who is leading our effort at the patent office, explains:

“We now have the board's feedback on our key ground of invalidity, which is presented in the inter partes review. We now know there is strong likelihood for a positive outcome for our pending reexamination proceedings. This is exactly what we hoped to accomplish when we filed the ’037 review.”

Cool! So what’s going on now?

We are still awaiting final decisions in the ex parte reexaminations. Ex parte reexaminations tend to take one to two years to resolve. Inter parte reviews can be faster—we expect a final decision in this case within a year. Align’s one remaining lawsuit against us is still stayed as the ITC deliberates whether they want to try their appeal again with the Supreme Court.

The board’s decision to review this patent is the latest in a series of legal victories for ClearCorrect. It is also indicative of reasoning that should also apply to the remaining lawsuit with Align. There is little reason to think that Align’s claims will fare better outside of the USPTO, since the same or similar patents will be cited. Align’s chances for success are rapidly diminishing as their claims are repudiated at every turn.

High-five, Legal. You rock.

*U.S. patents 5,975,893; 6,217,325; 6,398,548; 6,626,666; 6,722,880; 7,125,248; 7,578,674; and 8,070,487.

Tech Tip: Notes from your Technician

You may have noticed notes from your technician regarding your treatment setup. These notes can be about the case type, your prescription or the quality of your impressions. These notes or comments do not always require a response.

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If you have a question or would like to respond to the note, you can click DISAPPROVE and there will be a field for you to enter your response.

When disapproving a treatment setup, providing your technician with the following information will give them a clear picture of the problem and what you want changed, resulting in a quick turnaround on your setup.

  1. Tell your technician what you don't like about the setup.
  2. Tell your technician what angle you are viewing the setup from.
  3. Give your technician simple instructions on how you would like any issues to be corrected.

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The other type of note you might receive from your technician is usually a question on your prescription or materials before they can provide your treatment setup. In this situation, you will see the action item below, with the technician's notes and a field for you to reply.

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You may also receive emails (daily summary emails) notifying you that there is a note from your technician. You can click on the case in the email and it will ask you to log in to the doctor's portal where you will see the case and notes from the technician to reply.

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Viewing your original impression scans

The note from your technician may sometimes be about your impressions. If you would like to review your original impression scans, you can scroll down from the notification box and in the History section of the case, where you will see a title "Upper impression, lower impression received" along with the date it was receieved and an icon of the impression.

Each of the icons in the history can be clicked on, opened and viewed. (This is also how you can access your invoice, photos and the treatment prescription for the case.)

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We hope this information is useful to you when you're reviewing and approving your treatment setups!

Until next time...