Tech Tip: Why do my patient’s teeth still need movement at the end of treatment?

Question:

My patient has finished wearing their final aligner, but some of the teeth still aren't where we want them to be. What gives?

Answer:

First, make sure that your patient has been wearing their aligners for at least 22 hours a day. You can ask your patient, of course, and you can also verify wear by checking for occlusal scuffing and slight yellowing of the aligner material. Patient non-compliance is a common reason for teeth not tracking.

Even if the patient has been wearing the aligners regularly, it's very common for cases to require overcorrection to acheive ideal results.The final aligner should match the shape shown on the treatment setup—however, this doesn't always actually move the teeth into that position. It may be necessary to apply additional force by creating aligners with the teeth moved farther than you actually desire.

This is not unique to ClearCorrect. Age, sex, root length, bone levels, bone density, medications, and some systemic conditions can all affect the effectiveness of treatment. Studies show that orthodontists often fall short of their goals, especially for certain types of tooth movement. 

Overcorrection is especially likely to be needed for these types of movement:

  • Rotations (particularly single-rooted teeth whose roots have a circular cross-section)
  • Labial-lingual alignment (particularly of incisors)
  • Expansion
  • Extrusion (because the PDL tends to pull the tooth back into the socket)

If you know you're going to need overcorrection, you can request it upfront in your initial prescription. Just be sure to keep an eye on those teeth so they don't move too far. 

It's always safest to err on the side of caution—if you submit your case as Unlimited, additional phases won't add to your lab fee. When you submit a Limited 6 or Limited 12 case, you should be prepared for the possibility of purchasing an additional phase.

Make sure your patient is aware that there is no guarantee of acheiving results within a certain timeframe. Make sure they're aware that additional treatment may be required after the final step. (Some of this is covered in the required informed consent & agreement, but you'll probably also want to attach your own conditions regarding fees and outcomes.) It's better for everyone when you set realistic expectations at the beginning of the case.

Until next time…

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: Three time saving impression tips

A high-quality impression is the foundation of a successful case. Whether for a submission or a revision, accurate impressions are vital to ensuring that treatment is effective and time-wasting delays are avoided. We recently determined that 3 basic issues are accounting for over 75% of all the bad impressions that we receive. Here are the issues, and how to correct them.

Most frequent impression problems: 1) Double impression, 2) Material not fully set, 3) Posterior distortion, 4) Relining/reinserting, 5) Tray too small, 6) No light body, 7) Not enough material, 8) Missing opposing impression, 9) Material lifter off of tray

Issue #1: Double impression in 2-step material

The most common problem that we find is a double impression, which usually happens during a 2-step impression.

The easiest solution is to switch to a simpler, more reliable 1-step impression material, such as Sultan Genie VPS. We've prepared a video and a printed guide for this type of material.

If you prefer the 2-step impression process, that's okay too. Just keep an eye out for double impressions. Remember to cover the putty with a plastic sheet when you take the first impression, and to take your second impression before the first one has fully set. We have a video and printed guide for this type of impression as well.

Issue #2: Material not fully set

Our second-most common issue is material that hasn't fully set before being removed. There are two simple things you can do to prevent this problem:

  1. Set a timer and make sure to follow the directions for your material exactly.
  2. Discard the first 1 inch of material that comes out of every new mixing tip.

Issue #3: Posterior distortion

The final big issue is distortion of the most distal teeth in the impression. It can be hard to see back there, and sometimes the posterior teeth get shortchanged. 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 material.

We hope this helps. Look for these issues before you send your impressions in, and you could save yourself & your patient the hassle of taking new impressions.

More Helpful Tips:

  • Make sure the tray is not too small and fits your patient well. If the teeth are touching the edges of the tray, the tray is too small.
  • Use plenty of PVS material. It's better to have too much than too little.
  • Remove all engagers prior to taking the impression. We need impressions free of engagers to make accurate molds.
  • Fill in deep undercuts with wax. This will allow you to remove the impression material cleanly without creating tears or distortions.

We hope this helps. Looks for these issues before you send your impressions in, and you could save yourself and your patient the hassle of taking new impressions.

Sirona announces CEREC® ortho software

Going digital has never looked better

ClearCorrect is proud to annouce that it's working with Sirona, a giant in the dental industry, to develop a new generation of software that allows dentists to use their CEREC® scanner for orthodontic applications.

Sirona has over 50 years of experience in orthodontics, and was the first to introduce digital imaging to dental practices everywhere with the OPG and CEPH X-Ray units.

What this means for you: you'll be able to quickly capture a full 3D image of your patient's dentition with Sirona's patent pending guided scanning process, review the images with the patient and diagnose their needs with a seamless 3D interface, and deliver all this information to us directly so we can get started on manufacturing your patient's aligners.

Check out the full press release here.

The new treatment setup is here!

Treatment-Setup-Banner-v1

Good news, everyone!

We've finished beta-testing the new treatment setup, and we're starting to roll it out to all of our doctors. It's going to be a gradual transition, so don't be surprised if you receive the older style of setup during the next few weeks.

If you want to play around with the setup early, you can download this sample.

We've prepared a brief video demonstrating some of the new features, including:

  • Color gums & teeth
  • Models for every step of treatment
  • 3D representations of IPR & engagers
  • Tooth charts & instructions for every step
  • Missing teeth & placed engagers on chart
  • Treatment animation
  • Embedded link to ClearComm
  • Better Mac support
  • Improved interface

Check it out:

Pro Tip: If the models occasionally flicker, you can fix it by adjusting your settings. In Adobe Reader, go to Preferences > 3D & Multimedia and change Optimization Scheme for Low Framerate to None.

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Tech Tip: Why does my patient still have a gap after treatment?

Occasionally, you may notice a small gap between the central incisors even after the patient has completed aligner treatment. This includes the so called "black triangles" that occur when the interdental gingiva doesn't fully fill the void between teeth at the gingival margin. If your patient read their informed consent & agreement form, they'll be aware of possible outcomes like this ahead of time. Although it doesn't happen often, it can be a disappointment for a patient who just went through months of treatment.

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. If a gap remains after the aligners come off, additional orthodontic treatment may be required to close it. Here are a few solutions that might work for your patient:

  • In the case of black triangles, perform IPR at the point of contact to allow the affected teeth to come together.
  • Restorative therapy might be in order to fill smaller gaps caused by insufficient interdental gingiva.
  • Reconstructive periodontal therapy, also known as "periodontal plastic surgery", may also be considered to increase interdental papilla height and volume to fill the black triangle void.
  • The digital power chain is a valuable technique that eliminates gaps by bringing the teeth closer together. If you have diastemata, you don't have to rely on traditional metal braces to do this! ClearCorrect has its own power chain that doesn't require elastics.

Before we go...

Just a friendly reminder - we don't accept stone models in your case submission materials; we only need the PVS impressions and some high quality photographs. If you'd like, you can even send us X-Rays, although it's not required.

Actually, one more thing...

A few doctors have told us they're having trouble viewing our treatment setups while using Google Chrome instead of Internet Explorer. Here's an easy troubleshooting solution that's been helpful to many of you.

  • Make sure you the have newest version of Adobe Reader (currently 11.0.06).
  • Type "chrome://plugins" into the search bar (without the quotes).
  • You'll see a list of plugins. Find the one labelled "Chrome PDF viewer" and deactivate it.
  • Close Chrome and bring it back up.

And that should do it! If you were having difficulty reading Treatment Setups in Google Chrome and this helped, let us know. As always, we love to hear from our providers, so if you have a question or a suggestion you'd like featured in one of our tech tips, drop us a line.

Tech Tip: Common questions and concerns

We often survey our customer service representatives to get an idea of what our providers are interested in knowing. Below is a short list of some of the most commonly raised concerns and questions.

What can I do to prevent my patient's engagers from popping off?

From the wiki:

There are several possible causes for why an engager might fall off - usually while removing the aligner - although the most common cause is that the composite is not fully adhering to the tooth.

Read more...

My patient's front teeth occlude properly, but the posteriors don't.

From the wiki:

There are many possible causes of this situation. This phenomenon is fairly common with clear aligners, and it’s usually temporary. It can be caused by the “hinging” action of the jaw.

Read more...

Can I hand strip during treatment if it's not recommended by ClearCorrect?

From the wiki:

Take IPR into your own hands! The recommended amounts of IPR in the treatment setup and treatment plan are for guidance only. You are the doctor, and are the one ultimately treating the patient. Small amounts of unscheduled IPR can get treatment back on track much quicker than submitting a lengthy case revision.

Read more...

Why is it so critical for me to submit good photos if you have the impressions?

From the wiki:

When submitting a case to us, you'll need to take photos of your patient from eight very specific angles. We use these photos both to identify the patient, as well as to make some decisions regarding the fullness of the lips in profile.

Read more...

Will ClearCorrect return my impression trays?

No, we don't return impression trays or other records. As our terms & conditions state:

“Records submitted to ClearCorrect become the property of ClearCorrect and will not be returned to Doctor.”

If you're especially fond of your impression trays, don't forget that we accept intraoral scans from most major scanners on the market! If you don't have an intraoral scanner, send us disposable impression trays instead. If there are any questions you'd like addressed in one of our future tech tips, we'd love to hear from you!

Guess who's back?

Just in case you didn't catch our recently released tour video, here it is again! Take a two minute tour of our facility and see what goes on behind the scenes. Click the player to be taken to the video.

 

IntroVideo-screen-v1

ClearCorrect offers free retainers

Just a friendly reminder - one of the unique perks ClearCorrect offers is a pair of free retainers at the end of any case.

After a patient is finished with their clear aligner treatment, it's important they get (and wear) their retainers to prevent relapse. Make sure to order your free retainers within a year of receiving your final phase so you don't miss out! If your patient needs a new set of retainers after they've used up the free ones, you can submit a new "Retainer" case on ClearComm. Just remember that when you order your free retainers, it automatically closes your case, so make sure your patient is happy with their teeth. If you decide later on that more tooth movement is necessary, you can just submit a new case.

A few months ago, we released a tech tip discussing the importance of proper retainer use.We regularly get questions about how long patients should wear their retainers. Let's take a look at what Dr. Mah has to say:

Screen_Shot_2014-02-20_at_1.50.59_PM

 

How do you talk to your patients about wearing their retainers? Drop us a line and give us your ideas, and we will use them in a future tech tip.

Tech Tip: avoiding case revisions

 

As we've mentioned in previous tech tips, you can avoid unproductive case revisions by checking for tight contacts on a regular basis. Teeth can't move when they're jammed up against other teeth. By reducing the enamel a bit at the point of contact, you can free up space for the teeth to move.

If you're looking to avoid a lengthy case revision, consider the following steps:

  • Use a diamond strip to handstrip between areas of tight contact. Our IPR tutorial video shows you exactly how to do this. 
  • Confirm your patient has been compliant in wearing their aligners. It's critical they wear them at least 22 hours a day to maintain osteoclastic activity. Compliance checkpoints can be found on the treatment plan on treatments with IPR.
  • If rotations are not occurring as planned and you have verified there are no tight contacts, use an orthodontic retention dimple plier to add pressure on that tooth, pushing it in the direction it needs to rotate.
  • If you encounter a stubborn tooth that won't extrude, see our simple guide to extruding with auxiliaries.
  • Request a replacement aligner from us and keep your patient in the same step for another three weeks to complete the movement, then continue on with the next scheduled step of treatment.
If these solutions don't work, then it might be time to request a revision. Make sure to call us first and reference our Wiki to ensure you've exhausted all possible troubleshooting options. Don't forget: there is no fee to request a revision, but if the result of the revision requires upgrading your treatment option, you'll need to pay the difference.

Reference Links:

Do you have your own ideas for avoiding a case revision, or have experience troubleshooting? Drop us a line in the comment section below, and we'll share your experience in a future tech tip!

Tech tip: non-compliance - part 2

Two weeks ago, we gave you a few tips on how to spot non-compliant patients. Today, our Chief Technology Officer, Dr. James Mah, offers up his three keys for ensuring compliance:

  1. Education
  2. Motivation
  3. Verification
Dr. James Mah"As far as education, clinicians should discuss the basics of tooth movement and the importance of wear time. Relatively continuous pressure to teeth is required for effective tooth movement. Many patients don't know this and fail to achieve the required hours. Compare a patient that wears aligners 20 hours per day to another that wears them 8 hours per day: the first patient will have 2.5 times the continuous forces as the other, and that will be reflected in the resultant tooth movement rates.

Motivation for aligner patients is most often verbal praise for a job well done. In my office, we provide 'wooden nickel tokens' as rewards for cooperation. Patients can trade the tokens for gift certificates and other rewards. Additionally, we remind them that orthodontics is serious business and continually remind them that the result will be well worth the effort.

In situations where compliance is lacking, we often need to have a frank discussion with the patient. Even before treatment begins, I let patients know that treatment success is a team effort between them and my office. I simply state that 50% of their success is up to me and the other 50% is up to them. If they don't live up to their end, we have to accept more compromises. In addition, decreased wear often results in no net tooth movement. When the aligner is worn, teeth begin to move toward the correction but when it is removed the tooth moves back to its original position. I ask patients "Why pay me to rock your teeth back and forth?"

On the topic of verification, first I warn them from the first aligner on that we'll be checking wear "under the microscope" and if I find it lacking, I'll be brutally honest with them. This makes it easier when I come down hard on a patient for non-compliance. I can then say 'I told you from the beginning that I'll be checking.'"

Finally, if you're looking for a few more tips on how to discreetly verify whether a patient is wearing their aligner, keep the following things in mind:

  • Well worn aligners fit loosely and will almost fall out on their own. If there are any tight spots or binding, you can be clear the aligner has not been worn enough.
  • Ask patients to bring in their current aligners. A lot of non-compliant patients will "forget" their aligners at home and encourage their clinician to dispense the next set.
  • Well worn aligners will feature discoloration and the occlusal surfaces will show signs of wear.
  • The next aligner will fit tightly, but won't be too difficult to get in.

And that's it! If you have any tips of your own you'd like to share, we'd love to hear from you!

Until next time...