Tech Tip: Auxiliaries and tooth movements

In the majority of cases the aligner itself will do most (if not all) of the work to accomplish the patients treatment goals. However, sometimes auxiliaries are needed.

The term “auxiliaries” as used in orthodontic treatment with clear aligners refers to an entity or item that may be used in conjunction with clear aligners to enhance the movement of, or effect a change in, the teeth or skeletal components.

Some of the more common auxiliaries used in clear aligner treatment are:

1. Bonded brackets or buttons with elastics for:buttons, brackets, elastics.jpg

2. Limited braces

  • Closing anterior and posterior open bites
  • Pre-aligner treatment in the late mixed dentition

3. Expanders for:

  • Skeletal expansion
  • Dental expansion greater than 3-4mms

4. Dimples made with pliers for:

  • Improving retention of the aligner
  • “Nudging” a tooth (rotations, tipping, torqueing)

5. Pontics when teeth are missing for:

  • Esthetics
  • To maintain space pre-restoration

6. Class II correctors and Molar distalizers

7. Temporary anchorage device (TADs)

Where a movement is not being achieved as desired or planned with the aligner alone, auxiliaries can help to effect the desired movement.

Auxiliaries can assist with the following movements:

  • Tipping

  • Torqueing

  • Rotations

  • Extrusions

Until next time...

Tech Tip: Editing your prescription instructions

Occasionally a doctor will call in and ask for a change to be made to a prescription form, a treatment setup or a revision request. 

While support is happy to answer any questions you have about this, there are legal liabilities to us verbally receiving these instructions and forwarding them to the technician. Meaning that we will be required to ask you to log into the doctor's portal and request these instructions directly. 

If you have a treatment setup pending approval, you can update your prescription by declining the treatment setup and communicating the new information to the technician in your notes. If you’ve already approved the treatment setup, you may need to request a revision and make your changes there.

If your treatment setup is not available yet, (it was recently submitted or declined), feel free to contact support for assistance. 

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You will receive an email notification once your new 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 how often you've asked to receive notifications.

Tech Tip: Finishing a case

Doctors often request a revision for some final touch-ups to hone in on the treatment goals. For instance, you might want to request some additional aligners to close a gap or complete a rotation, moving the teeth into their final position.

Determining if treatment is finished to your standards and your patient’s satisfaction once the last aligner has been worn gives you both the opportunity to take advantage of all options for correcting any undesirable issues.

Sometimes, your perception of a nicely finished case is different from the patient’s. When you give the patient an opportunity to express their satisfaction of the treatment result before announcing that treatment is finished, your patient will feel like you care about how they feel about their result.

Identifying potential issues prior to the last aligner

Here are some potential issues and the steps you can take to address them:

1. Residual spaces

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What to do:

  • Review the treatment setup to confirm that there should be no spaces remaining
  • Order a case revision to close the spaces
  • Request a ‘digital power chain’ in a case revision to ensure the remaining spaces are closed (ClearCorrect can adjust the 3D model to lingualize all the spaced teeth by about 0.2 mm, pulling the teeth closer together the same way a power chain does)

2. Incomplete rotations

Patients are most aware of “imperfections” with the upper and lower incisors.

What to do:

  • Continue with the last aligner for an additional couple of weeks – you may want to consider using the ‘dimples’ technique to complete the rotation
  • You can fabricate an in-office reset aligner to complete the rotation or request a remake of this last step
  • Order a revision to complete the rotation

Remember – there must be adequate space to rotate into (see image below) 

3. Teeth are not aligning as expected

In the example below, there’s not enough space to align the upper left central incisor.

 incomplete rotations 2.jpg

A situation like the above requires a revision to provide more expansion or proclination to open sufficient space to optimize the alignment of those incisors; there is too much crowding for IPR.

What to do:

  • Order a case revision to get the remaining alignment needed

4. Irregular or uneven incisal edges and marginal ridges

uneven incisal edges.jpg

What to do:

  • In many cases of mild incisor edge irregularities, conservative enamoplasty to smooth the incisal edges slightly will significantly improve the appearance of the whole smile line and impress the patient with how much better their teeth look.
  • In situations of moderate to severe incisal edge or occlusal wear, restorative dentistry could be of great benefit to provide a better esthetic result

5. Occlusion not fully interdigitated or idealized

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Not every case will end up with an idealized, fully interdigitated Class I occlusion like the example above, and not every case needs to. It's up to you and your patient to decide what goals you're happy with. If you are aiming for absolute perfection, it's probably going to take some fine-tuning to get there.

What to do:

  • Order a case revision to achieve the full interdigitation desired

6. Posterior openbite due to intruded posterior teeth.

This is thought to be caused by extreme masseter activity when wearing aligners and is the most commonly proposed etiology, which is an intuitive explanation, but not proven by clinical research.

posterior open bite.jpgposterior open bite after.jpg

What to do:

7. Black triangles

Black triangles can happen with any method of alignment, including traditional braces. This is a natural consequence of alignment correction, so it can't always be avoided.

Black Triangle.jpg

What to do:

  • Alert the patient pre-treatment of the potential if it exists
  • Re-contour (IPR) wide incisal edges
  • Emphasize with patient the importance of an optimum oral hygiene regimen

And thats it for now. Until next time...

Tech Tip: Adjusting a Treatment Setup

treatmant setup.pngWhen you evaluate a treatment setup, sometimes you might want to make some adjustments before you click approve and order your aligners.

For example, if you forgot to mention something on the case submission form, this is your chance to let the technician know.

Or, maybe your prescription was complete, but you want to adjust the position or movements of the teeth once you see them in the setup.

Here are a few examples of adjustments you might want to make:

difficult movement.jpgYou can slow down difficult movements.

Moving less per step can help roots stay upright and translate, rather than lagging behind and tipping. (Of course, the tradeoff is more steps and longer treatment time, so this is where Unlimited pricing really shines.) Our default movement protocol is 0.3 mm per step.

You can adjust the wear schedule to 1, 2, or 3 weeks.

You can choose your wear schedule when you submit the case, but you may want to change this once you see how the teeth are staged. Our technicians can adjust this in the treatment setup, or you can ask our support team to make this change once treatment has started. (This is less important for Flex treatment, but it can affect when Unlimited phases ship, and when legacy cases close.)

You can let us know that you'll be extracting a tooth if you find that you need to create more space than IPR and expansion can handle.

(Remember to translate the teeth slowly to avoid tipping.) You can also request vertical engagers on either side of the extraction site to help keep the roots parallel.

You can tell us about Class II correction techniques that you intend to use, such as:

  • Molar distal rotationclass II.jpg
  • Molar distalization
  • Using elastics with buttons bonded to the aligners (not preferred, but can be done)
  • Using elastics with buttons bonded to the cuspids and molars by manually modifying the aligners

The technician does not need to know exactly when or how you're modifying the aligners, but you should tell the tech that you plan to use elastics so we can properly adjust the angulation of the upper and lower incisors. We don't simulate the effect of elastics, so the setup may not accurately represent all of the Class II correction that you hope to acheive.

You can tell us about any other auxiliaries that you intend to use, such as:

You can adjust your engager preferences.

For example, you can:

  • Remove or reduce engagers (current research indicates that we may not need as many engagers as traditionally thought).
  • Request vertical or horizontal engagers.
  • Specify when to place or remove engagers.
  • Add engagers as anchorage for intrusion and extrusion.
  • Add engagers to increase aligner retention with short clinical crowns.

You can also adjust your IPR preferences.

For example, you can:

  • Schedule IPR for specific stages.
  • Adjust the scheduled amount per appointment between 0.1 to 0.3 mm. Consider the full arch when deciding how much IPR is needed.

If you want to make an adjustment to a treatment setup,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.

You will receive an email notification after your new 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 how often you've elected to receive notifications).

We hope this helps you tailor each prescription to your patient's needs.

Until next time…

Online marketing services for ClearCorrect providers

We've recently partnered with S3SB, a prestigious Los Angeles web design and marketing agency, to provide online marketing and practice-building services customized for ClearCorrect providers.

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S3SB offers a full suite of services, including:

  • 20% off a full website design for ClearCorrect providers
  • Updates to existing pages
  • Search engine optimization
  • Paid search ads
  • Reputation management
  • Lead tracking
  • Monthly metrics

You can call (855) 674-S3SB or click below to receive a free marketing evaluation.

Request a free marketing evaluation

P.S. You know what goes great with a redesigned website? Our Practice Success workshops! You can learn more marketing tools and tips for building your practice from orthodontic specialist, Dr. Duane Grummons. Check out our upcoming sessions in New York, Las Vegas, and Orlando or check out our Practice Enhancement e-course, coming soon!

Tech Tip: Impression Materials

When submitting a case with physical impressions, we only accept PVS impressions on disposable trays. For more information on best practices with taking impressions, see the full article here

Per our terms and conditions, alginate impressions, stone models, and metal impression trays will be rejected. These and all other submitted materials become the property of ClearCorrect and will not be returned.

To clarify the reasons for this:

  • Alginate dries out and the material itself can shrink or expand depending on environmental factors. This can make the aligner too big or too small, depending on any changes.
  • Stone models don’t always survive the shipping process. We usually see some sort of chipping, especially along the cusps/incisal edges. Sometimes this can be a whole tooth, but most of the time it will be something minor that’s hard to detect but can still cause fitting issues.
  • Additionally, with stone models, we can’t control the quality of the stone model. The impression can be perfect, but if the pour-up is bad the scan will be compromised. Things like air bubbles can be filled in, but it leaves us guessing at what the shape of the tooth is actually like.
  • Metal trays cannot be run through our scanner, requiring a pour up process which, as mentioned above, is prone to error. 

We hope this helps to clarify why these materials will be rejected. If you have any further questions, feel free to check out the articles relating to this in our help center.

You may also contact our support team at support@clearcorrect.com or at 888-331-3323. 

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.

Image result for ankylosed teeth

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.

ankylosed tooth.jpg

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

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...