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…

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.  

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...

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

How clear aligners work.png

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:

OAP_New_1024x1024.jpg
  • 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…

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

mild treatment.jpg

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 

moderate treatment.jpg

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:  

missing teeth.png

severe crowding.jpg

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…

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.

properly fitting aligners.jpg

braces.png

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…

Tech tip: Methods for inserting aligners

When a patient tries on an active aligner for the first time, it's not going to exactly match the position of their teeth. (Obviously—that's how aligners work.)

Ideally, aligners should fit snugly at first, then loosen up over a couple of days as the teeth move into position. Sometimes, however, variables in patients' dentition or other factors such as flaring, inclining, or proclining teeth can cause discomfort for the patient or make the aligners difficult to insert.

If you have trouble inserting aligners, here are some techniques that you can try:

1. Front to back

Use this technique when the anterior teeth are excessively proclined (tipped forward) or excessively crowded.

  • Insert the aligner on the anterior teeth.
  • Then push the tray down over the posterior teeth.

2. Back to front

Use this technique when all of the teeth are relatively upright.

  • Insert the aligner on the posterior teeth first.
  • Then push the tray down over the anterior teeth.

3. Side to side

Use this technique when the posterior teeth are excessively inclined lingually.

  • Insert one side first, coming forward to insert the anterior teeth.
  • Then press down on the other side.
  • Cautiously, press the aligner on using the fingers; do not bite the aligners on with teeth.

4. Sectioning the aligners prior to insertion

Use this technique when there is excessive anterior proclination or excessive posterior inclination.

  • Cut the aligner in half along the midline.
  • Insert one side of the aligner fully into place, then insert the opposite side.
  • After a couple of stages, it probably will no longer be necessary to section the aligners prior to insertion.

5. Anterior then lingual or buccal

Use this technique when the teeth are flared either lingually or bucally.

  • Insert the aligner on the anterior teeth.
  • Then push the tray down on the side that is flared, for example, if the teeth are flared lingually, push the tray down on the lingual side. If flared bucally, push down on the buccal side. (If the aligners are inserted in the most difficult area first, the rest of the area should be easy to insert.)

When you get the aligners on, they should snap into place. If they don't, or if there is a small incisal gap, you can give the patient a couple of Chewies to bite on for a few days. These should help the aligners to fully seat.

For additional help with aligners not seating, we have a few articles that may be helpful to you:

We hope this information is helpful! Check out our Help Center which is filled with useful information on the topic of clear aligner treatment.

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

Until next time…

Tech Tip: Troubleshooting engagers

While most of the time placing and removing engagers is a fairly simple process, it can sometimes be troublesome. We thought we’d offer up some of our “tricks of the trade” when it comes to troubleshooting the more common issues with engagers.

When engagers are not fitting in the aligner, aka “engagers are not tracking”

When an engager does not line up with the space created for it, it can cause discomfort or pain when inserting and removing the aligners. It can also delay the movements of the affected teeth.

In this situation you don’t want to force the aligner into place over the misaligned engager – this can do more harm than good by moving the tooth in unwanted ways.

Try the following options:

  • Remove the engager that's not fitting in the aligner, and use the previous aligner as a template to place a new engager on that same tooth.
  • Check for tight contacts that may be preventing movement and if you find any, follow instructions given for breaking tight contacts.
  • Inspect the engager for excessive bulk and/or flash. The excess material can cause the aligner to lift away from the tooth making the aligner less effective and may lead to tracking issues.
  • Try backtracking with the previous aligner, the teeth may just need more time to make the needed movement.
  • Though the engager will still apply pressure to the tooth and work towards completing that difficult movement, there may be a slight gap in the aligner because that tooth will be moving a little behind schedule. (In the meantime, Chewies may help close those gaps and help your patient feel more comfortable.)
  • If the aligner fits everywhere else, remove the engager that isn't fitting into the aligner and continue with treatment. That particular tooth probably will not move as scheduled on the treatment plan, but the movement can be completed later with a refinement at the end of treatment using auxiliaries or dimples.
  • If all else fails, remove the engagers from all of the teeth, take new upper and lower impressions, and request a case revision. This may delay treatment, but it will allow us to tweak the treatment plan for that particular tooth.

When engagers fall off

The most common cause for why an engager might fall off when removing the aligner, is that the composite is not fully adhering to the tooth. Bond failures are usually technique related and by doing each step well, the cumulative error in the chain of failure is reduced.

Common conditions related to engagers falling off (it could also be a combination of these issues):

  • Plaque might prevent the etch from working
  • The tooth could be a restoration (Try to avoid bonding engagers on restored teeth whenever possible. Advances in tooth-colored restorative materials have brought forward materials that do not etch, even with fluoric acid and are tremendously resistant to sand-blasting.)
  • Lubricant used on the engager template could have accidentally smeared on the tooth
  • Compressed air that is used to dry the tooth is contaminated with oil or water
  • Using too much primer
  • Excess moisture or saliva
  • Inadequate light curing (All light cure units wear down with time resulting in reduced curing intensity. Refer to your manufacturer's guidelines for proper care and maintenance to maintain performance.)

Try the following:

  • When plaque prevents the etch from working, using a pumice will remove the plaque properly.
  • If the tooth is a restoration, use a special etch for porcelain from your dental supplier. (Note: This does not always work.) Here is an article on bonding systems that may help you in choosing a bonding agent.
  • If lubricant from the template is accidentally smearing on the tooth, lift the template off of the tooth during insertion. Or, if possible, use the previous aligner to install the engager without using lubricant. The composite won't adhere to used aligners as much as it will to new templates.
  • Compressed air used to dry the tooth is contaminated with oil. This is the most common problem with compressed air and is hard to correct in the system.  Make sure to service and maintain your compressors to ensure clean, dry air. Try drying the tooth with a low-heat blow dryer that can be bought at a dental suppler. 
  • Using too much primer will weaken the bond between the engager and the tooth. Primers are meant to work in thin layers. A blast of compressed air for 3-5 seconds can help thin out the layer of primer. Refer to the manufacturer's guidelines before attempting this for the first time.
  • Intraoral retractors and saliva evacuation systems can help reduce excess moisture or saliva and will increase the integrity of your bonds.

Broken engager templates

Engager template can sometimes break due to a lack of lubricant in the engager void and surrounding area.

What to do?

If the engager template breaks, we’ll be happy to replace it. You may call and place the order with us, or fortunately, there is a quick and easy alternative that keeps your patient in active treatment.

Instead of waiting for a replacement template, you can use the current step as the engager template. Since it has been worn, the composite should easily release from the engager void.

Or, if you don’t have the current step, you can have your patient wear the new set of aligners without the engagers. Schedule your patient to come back for another appointment two weeks later, then use the worn-out aligners as an engager template for the next step.

We hope this tip helps you with any potential issues you might have with placing engagers. Check out our Help Center which is filled with useful information on the topic of clear aligner treatment.

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

Until next time…