ClearCorrect editorial: Dr. James Vogler

Introducing the Starter Kit

ClearCorrect Starter Kit

The first day of orthodontic treatment can come as a shock—it takes a while for most people to get used to pressure being applied to their teeth. That’s why ClearCorrect begins with starter aligners, designed to apply gentle pressure before ramping up movement in later steps.

We introduced starter aligners a few years ago as part of "Phase Zero." Now we’re expanding that concept into the new Starter Kit, shipping today at the start of every case.

Along with starter aligners, you’ll get:

  • a welcome letter for your patient with wear & care tips
  • a storage case
  • an OUTIE aligner removal tool
  • a sample of OAP Cleaner
  • and two Chewies to help seat the aligners.

Just pass everything on to your patient. If you want more of anything, it'll be available in our online store.

Starter Kit paperwork

We won’t ask you to approve the fit of the starter aligners on ClearComm anymore—we’ll just send the treatment setup as soon as it’s ready, and you'll be free to approve it right away.

Your patient should wear the starter aligners just like any other step, and (assuming you approve a treatment setup) Phase 1 will be scheduled to arrive when they're done.

If you do find a problem with the fit of the starter aligners, you can handle it like any other phase—request a revision on ClearComm and send in new impressions or scans. We'll now accept revisions right up until the ship date of each phase, so you can request a revision even if Phase 1 has already entered production.

The Starter Kit is now included with all new cases at no additional charge.

Tech Tip: Loose or mobile teeth

Here's a question we've gotten from a few doctors new to orthodontics:

I have a patient that is in the middle of treatment and I noticed that some of the teeth are mobile or feel loose. The patient did not have any periodontal problems before treatment and keeps their teeth clean. Should I stop treatment until the mobility goes away or should I not be concerned about this and continue with aligner treatment?

Dr. Mah responds:

Dr. James Mah

Tooth mobility of ~1mm is relatively common during active tooth movement. The tooth socket is being remodeled to allow for the tooth's movement. During remodeling, it is slightly enlarged.

In addition, the periodontal ligament is undergoing tremendous remodeling in phases of resorption and reformation. During this time, it is not as taut and does not function as well, resulting in slight mobility.

Also, the supporting bone has a dense cortical border with trabecular bone in between. The significance of the trabecular bone is that it is not homogenous. Rather, its appearance is like "Swiss Cheese" with spaces between the supporting bone scaffolding. As a tooth is moved through bone, it will pass through the bone scaffolding and the spaces. In the latter, there may be more mobility.

Having said this, clinicians should be on the lookout for occlusal interferences, periodontal disease, endodontic problems, excessive root shortening and pathology during orthodontic tooth movement. Mobility of greater than 1mm should be further evaluated for any possibility of these other problems. Most commonly, excess mobility is due to occlusal interferences.

Tech Tip: How to pick a treatment option

One of the most common questions we get from doctors is "How do I know which case type to choose?"

As you may know, we offer three treatment options:

  • Limited 6 (up to 6 steps)
  • Limited 12 (up to 12 steps)
  • Unlimited (as many steps as needed, with up to 3 years of revisions)

Working with Dr. Mah, we've prepared this simple chart to help you predict which treatment option might be best for your case:

 

If you're still not sure where your case falls, it's always safest to err on the side of caution and give yourself a little wiggle room. You can't go wrong choosing Unlimited.

You can also consult our case parameters to determine how well-suited your patient is for treatment with clear aligners.

Please let us know if you have any feedback or questions. Have a great weekend!

Tech Tip: All about retainers

Traditional orthodontic treatment isn't over when the braces come off, and clear aligner therapy is no different. After straightening their teeth, patients need to wear a retainer to prevent them from relapsing.

Doctors can request one free set of retainers whenever they close a ClearCorrect case. When that set wears out, doctors can order another from ClearCorrect by submitting a new "Retainer" case and choosing their existing patient's name.

But are those removeable retainers the best option for everyone? How often should a patient wear retainers, and for how long? We decided to ask our new Chief Technology Officer, James Mah, what his recommended retainer protocol is.

Dr. James Mah

Dr. Mah on retainers

In the broadest sense, my recommended protocol for retention is the method which best suits the patient.

First, it is important to have a discussion with the patient about retention before treatment is accepted and initiated. I can't tell you how many times I've heard from patients that have had aligner therapy that they were not told that retention was necessary. These patients had relapse and were seeking retreatment.

Secondly, I consider the patient's malocclusion and look specifically for factors that are associated with significant relapse tendency. Such factors include: generalized spacing, severe rotations, tongue thrusting, anterior open bite, deep bites and retreatments.

Next, I have a frank discussion with the patient regarding fixed vs. removable retention and learn from them which type they will most likely comply with. I ask questions about their occupation and whether it involves doing a lot of public speaking and ask whether they have recently lost items such as keys or a cell phone. In this discussion, I also explain the pros and cons of fixed vs. removable retention.

I've found a diversity of patient responses. Some patients request Hawley–type retainers as they have had previous experience with them and like their durability. Other patients have become accustomed to the aligners, like the comfort and esthetics and simply want to continue with thermoformed retainers. Yet others wish to be "done with" appliances and don't want to give the effort to continue to remember to insert and remove appliances. In these situations, fixed retention is the best option. I inform these patients that they will need to use floss threaders and take a little more time cleaning around the fixed retainer but this is rarely a significant set back for them. I also recommend fixed retention for patients with the aforementioned significant relapse factors. In the most severe situations, I consider using both fixed retention AND a thermoformed retainer or a Hawley on top.

In summary, if the patient has a mild or moderate malocclusion without significant relapse factors, a variety of retention options are available, in part depending on their preference. If there are significant relapse factors, I recommend fixed retention and occasionally both for severe situations. Most commonly, the fixed retention I use is a braided wire bonded to each tooth, extending from canine to canine.

As far as how long to wear them, this is not an easy question to address. A variety of retention options and wear schedules are available. One common recommendation is full–time wear for about 12 months and night–time wear in the following years. Every patient is different, however, and the clinician must recognize the risk factors for significant relapse, as mentioned above. Clinicians must use their judgement to treat and retain as appropriate.

Most patients (and in fact, many dentists) don't know that humans lose approximately 1mm of dental arch length per decade of life with the longest arch lengths occurring in the late teenage years. While 1mm of arch length loss may not be significant in the twenties and thirties, by the time one reaches the age of 50, 3–4mm of arch length has been lost and dental misalignment has now appeared or worsened. For this reason, ideal tooth alignment is almost never seen in individuals over the age of 60. Anatomists theorize that the lack of a coarse diet and lack of interproximal tooth wear is to blame, but this is only a theory. Not surprisingly, arch length loss follows the general pattern of bone loss of all bones in the human body. Peak bone mass is achieved in the late teenage years or early twenties. Sadly, it's all downhill from then.

Understanding that the normal process of aging is working against good dental alignment, I recommend long–term retention. When patients ask how long they need to wear retainers, I explain this phenomenon to patients and most understand. I use an analogy that relapse is like wrinkles. Wrinkles will happen, one just doesn't know exactly when and where. Further, there are three things that are certain in life—death, taxes and orthodontic relapse. Fortunately, one can ward off the latter by wearing retainers long–term. The removable types often do not need to be worn all the time but only at night or even less to maintain dental alignment while we enter our golden years.

Meet our new Chief Technology Officer

In related news, we're thrilled to welcome one of the authors of the previously-referenced trimming study, Dr. James Mah, as our new Chief Technology Officer. He’ll be helping us develop improved treatment protocols, training resources, and all-new products.

Dr. James MahDr. James Mah is a practicing orthodontist as well as a clinical professor and the program director in Orthodontics at the University of Nevada, Las Vegas. He has pioneered research and developments in 3-D imaging and modeling in orthodontics for the purposes of diagnosis, treatment planning and therapeutics as well as anthropology and forensics. He is involved in the research and development of 3-D facial imaging devices, intra-oral scanners, CAD/CAM applications in dentistry and cone-beam CT scanners.

He obtained his Bachelor of Science, Doctorate of Dental Surgery, Master of Science degrees and his Certificate of Specialization in Orthodontics from the University of Alberta, Canada. He then graduated from Harvard Medical School with a Doctorate of Medical Science degree and completed a Post-Doctoral Fellowship in the Department of Orthopaedics at Children’s Hospital, Boston. He was a full-time faculty member in the Department of Orthodontics at Harvard School of Dental Medicine prior to his current positions. Dr. Mah has authored over 100 publications, four textbooks, many book chapters, several patents and has made numerous presentations nationally and internationally.

As a recognized expert in 3-D imaging, visualization and modeling, his work has been featured in the Los Angeles Times, The National Post, Tech TV, and other magazines and journals. His research laboratory is funded by grants from the National Institutes of Dental and Craniofacial Research National Science Foundation McAlister Foundation, California Wellness Foundation, the American Association of Orthodontists Foundation, Sun Microsystems, and a number of industry partners. He is also a founder of the Conferences on Orthodontic Advances in Science and Technology and an organizer of the Biological Mechanisms of Tooth Movement conference series. He serves as an editor for the Journal of Clinical Orthodontics and is a reviewer for the American Journal of Orthodontics & Dentofacial Orthopedics, Journal of Clinical Orthodontics, Korean Orthodontic Journal, the International Journal of Oral & Maxillofacial Surgery and Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics and Dentomaxillofacial Radiology.

Tech Tip: We’re trimming differently to make retention 2x - 4x stronger

As you know, strong retention of aligners on the teeth is key to producing desired tooth movements and tracking of aligners.

In a recent study*, doctors from the University of Nevada compared the retentive strength of three trimming techniques:

Examples of aligner trimming techniques

  • A) a scalloped margin,
  • B) a straight cut at the gingival zenith, and
  • C) a straight cut at 2 mm above the gingival zenith.

The difference between the techniques was remarkable.

For clear aligners without attachments, the straight cut 2 mm from the margins was about twice as retentive as the scalloped cut. For clear aligners with attachments, the straight cut 2 mm from the margins was over four times as retentive as the scalloped cut!

Trimming the aligners differently had more of an impact than adding or removing engagers. Scalloping the aligners right at the margin is the technique employed by “the other guys.” Traditionally, we’ve loosely scalloped our aligners slightly over the gumline.

Based on these findings, we’ve decided to start trimming our aligners with a smoother contour and a larger overlap with the margins. This technique should improve the efficiency of the aligners and may reduce the need for engagers in some cases. We expect the new aligners to move teeth more effectively, especially when performing difficult movements like torquing.

Ideal trim area shown between alveolar crest and marginal gingiva

We also expect our aligners to be more comfortable than before, because there will be less risk of them impinging on the unattached marginal gingiva. The edge of the aligner will be concealed further under patients’ lips during everyday use, so this should also slightly improve the discreetness of the aligners.

You won’t see a difference right away, but we expect to start rolling out the change over the next few weeks. As always, we welcome your feedback.

*"The effect of gingival-margin design on the retention of thermoformed aligners" by Daniel P. Cowley, James Mah, and Brendan O'Toole in the Journal of Clinical Orthodontics: JCO 11/2012; 46(11):697-702. Illustration used with permission.

ClearCorrect is moving

WE'RE MOVING TO ROUND ROCK

Office will be closed August 30 - September 2

As we mentioned earlier, we’ll be relocating this weekend from Houston to a shiny new lab facility in Round Rock, Texas (just north of Austin).

Our new address is:

21 Cypress Blvd
Suite 1010
Round Rock, TX 78665

Our phone number remains the same: (888) 331-3323.

Any shipping labels generated by ClearComm will use the new address from now on. If you have any old unused labels sitting around, now's a good time to toss them. We'll still get shipments sent to the old address for a little while, but it'll take longer for us to receive them.

Our office will be closed from Friday, August 30 through Monday, September 2. We will be unavailable by phone or email during this time. ClearComm and our public website will also be down temporarily. While we're offline, you can check our Facebook page and Twitter feed for updates.

We plan to be back up and running as usual at 9 AM Central Time on Tuesday, September 3. Once the dust settles, we look forward to showing you around the new building.

Talk to you again after the move!

Van driving between Houston and Austin

More on CEREC

We announced last week that we now accept intraoral scans from CEREC scanners. As you know, the CEREC software wasn't designed with full-arch orthodontic treatment in mind, so this process hasn't been validated by Sirona yet. The scans we're receiving are working great, but we do want to clarify that Sirona and Patterson Dental cannot provide official support for any issues you encounter specifically related to submitting ClearCorrect cases. The good news is that we are currently in talks with Sirona about adding official support for ClearCorrect submissions in future software updates. If you do run into trouble, please let us know, and we'll be happy to share your feedback. Thanks!

We’ve excised the excise tax

A couple of weeks ago, we announced that we were going to start adding a separate line item to invoices to cover our cost for the 2.3% medical device excise tax.

A few doctors responded with questions, so we decided to take one more look to make sure we we hadn't missed anything. Our attorneys and accountants dug deep into the murky depths of the federal tax code and returned with some excellent news. Based on the latest guidance from the IRS, as a dental lab manufacturing a Class II medical device, it looks like ClearCorrect is not required to pay the excise tax.

We'll refund the line-item fees that we've collected over the last two weeks, and you won't be seeing them on your invoices any more. We're just as happy about this as you are, and we apologize for the mixed messages. This is a brand-new law, and there is a lot of disagreement even between experts over exactly how to apply it.