Tech Tip: Extruding with auxiliaries

To create an aesthetically aligned smile, sometimes teeth need to be pulled in line with the other teeth.

Extruding teeth with auxiliaries (elastics, buttons, etc.) is a technique used to extrude a tooth that has not erupted as desired.  As always, the patient must wear the aligner (and elastic) for a minimum of 22 hours each day, or the process will not work. Watch for extrusions not occuring with your cases, as this can be one of the reasons a patient's treatment has gone off track.

How to...

Below are step by step instructions on how to extrude teeth with auxiliaries.

Download a printable guide here.

Parts needed:

parts_needed_auxiliaries.png

Instructions:

aux1.png

Using a coarse sandpaper disc, roughen enough area on the tray to place an orthodontic bracket on the facial gingival 1/3 of the tooth to be extruded.

aux2.png

You can see the relative size of the roughened area circled here in green.

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Prepare a 50/50 mixture of resin cement base and catalyst and place a small amount onto the ceramic bracket.

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Place the ceramic bracket on the roughed-out area of the aligner tray. Adjust as needed, then wait 2-3 minutes for the resin cement to set.

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Using a coarse football diamond bur, start at the top of the tray on the lingual side and cut a space to clear the bracket, leaving room for the tooth to extrude.

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Once the tray is cut, it should look something like this.

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Remove the engager from the tooth to be extruded.

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Etch the tooth to be extruded on the lingual side.

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Rinse the acid and dry with the air/water syringe.

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Bond the metal bracket with a composite resin recommended for bonding orthodontic brackets.

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Break contact on the mesial side of the tooth being extruded using a metal diamond strip, then break contact on the distal side the same way.

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Insert tray and place the elastic over the facial bracket (on the tray) and the lingual bracket (on the tooth).

Check out our Troubleshooting section in the Help Center for more helpful troubleshooting techniques to use in clear aligner treatment.

Until next time...

Tech Tip: All about checkups & revisions

We sent out a survey recently asking doctors for their questions about monitoring treatment, checkups & revisions.

In this week's tip, we've consulted with our new Clinical Advisor, Dr. Ken Fischer, to get answers to some of your questions. Dr. Fischer has over 40 years of orthodontic experience with 16 years of experience with clear aligners.

Monitoring treatment

What would you present as a "checklist" of what to look for at each checkup appointment with and without aligners in the patient's mouth? For example (but not limited to), Compliance Checkpoints.
  1. Visually confirm that the aligners are fitting completely, i.e. no incisal gaps or space between the tooth and the aligner.
  2. Confirm that patient is wearing the correct aligners.
  3. Watch patient remove the aligners; removal should be easily done without difficulty.
  4. Examine the condition of the aligners; "pristine" condition may suggest lack of wear.
  5. Use floss to confirm loose interproximal contacts between all teeth, especially at any Compliance Checkpoints. Address any tight contacts found.
  6. Evaluate the presence and condition of previously placed engagers.
  7. Confirm good fit of next aligners and patient’s ease in placing them.
  8. Refer to treatment plan paper work or treatment setups and perform any scheduled procedures, i.e. IPR, place or remove engagers, compliance checkpoints, etc.
  9. Confirm proper wear schedule and document dates to change aligners.
  10. If desired, verify that tooth movements have occurred by referring to the treatment setup.
  11. Look for blanching of the gingiva at the trim line. Blanching is occasionally seen around gingival frenum and may also be due to distortions in the impression. Often these are very minor and can be trimmed back with scissors.
  12. Some clinicians may find it helpful to run a finger along the aligner trim line to feel for sharp edges or areas where it has lifted away from the gingiva.
What are some of the key indicators that a patient is ready to move to the next aligner?
  • Full and complete fit of current aligners
  • Patient able to easily remove and place current set of aligners
  • Loose contacts and spaces closed at compliance checkpoints
  • Planned tooth movements have occurred
When I check in with the patient and if something is off or a gap is not closed, I have been told to just continue the trays. Why should I check if there isn't anything to do about it?

In most cases, minor gaps or incomplete movements can be resolved by extending the wear of the current aligners, but it is important to determine why the teeth are not tracking completely. If the clinician determines non-tracking is due to patient non-compliance, there may be a need for alternative measures such as backtracking. With backtracking, it is recommended you have the original steps remade by the lab.

In some cases, where IPR has previously been done, I don't see space closure. I continue with the trays and eventually things seem to iron themselves out. Should I be holding the patient in a current tray until that spacing closes? In general, should I be referring back to the treatment setup to compare where the patient's teeth are for each step?

Yes, holding the patient in the current aligner until a compliance checkpoint is satisfied, is good protocol. Referring to the treatment plan or setup is appropriate to confirm the need for a compliance checkpoint and to determine if the planned tooth movements have occurred. However, it is not a requirement to evaluate the position of the teeth at each step.

What is the best way to determine if the set of aligners has accomplished its goal? Sometimes when the next set of aligners is inserted, the insertion is difficult and the fit seems very, very tight and almost painful for the patient. How do you determine if the appliance has done its job, or if the arch is ready for the next appliance?

A sign that the aligner has "...done it's job..." can be if there is unquestionable good fit of the current aligner. However, even if aligners appear to fit properly and comfortably, that doesn't guarantee that the teeth are actually moving as intended. For suggestions on how to identify unseen tracking issues before treatment goes off track, see our article on Tracking Issues. A tight fit of the next aligner may very well be due to a considerable amount of tooth movement programmed for the next stage.

I have difficulty with knowing for sure on claims from patients that they are wearing their aligners the proper amount of time are true or not, do you have any suggestions?

Do not be too eager to sternly criticize or debate the patient’s claims that they are wearing their aligners as directed, but remind them that if the aligners do not fit as expected the most likely reason is lack of wear. If you continue to see signs from appointment to appointment that the aligners are not fitting well, motivation tactics should be applied. Also, check out our article on non-compliant patients which has some common signs for determining if your patient has been wearing their aligner properly.

Does the position of the engagers need to be adjusted as the teeth move?

Only if the aligners are not tracking or if a revision is requested.

Do some patients have more of an open bite with aligners than others?

Some patients exercising heavy masseter muscle activity may experience a slight post-treatment open bite due to the intrusion of the posterior teeth by the strong clenching of those teeth. This phenomenon resolves itself by removing the posterior sections of the last aligners for a few weeks to allow the intruded teeth to return to occlusion.

Please explain the "C chain", when it's indicated and what it does. Does it help when contacts of anterior teeth are not tight at the end of treatment?

The term "virtual C chain" (aka digital power chain) was originally used with brackets meaning a piece of elastic that wraps around metal braces and pulls the teeth closer together. In clear aligners, a digital power chain is not an actual, physical entity. It is a concept attained by the technician setting the teeth in tight, or even slightlyovercorrected, contact intended to close all spaces between the teeth.

Tracking and fitting

Does treatment need to track exactly as laid out in the treatment setup that I approved?

Yes, precise tracking is very important for a successful treatment result, otherwise, a revision will likely be required.

I have difficulty judging when a tooth is not tracking and when to intervene. How do you know if you case is not tracking?

The accepted definition for "not tracking" is when the teeth do not fit well in the aligners.

Example; in molar uprighting, when the aligner is not tracking, what I have done is allowed the other steps to continue to move the anterior and biscuspids, and have the patient try to "seat" the aligners around the uncooperating molars. THEN, I eventually take NEW impressions, and revise the prescription (and prolong the case) to go back and "capture" and engage the molars. So, 1) should I just request engagers on all molars that require bodily movement, and 2) what may be the reason for the original aligners not engaging the molars? (i.e., the attempted movements are TOO BIG, in micros for the aligner to fully engage the molar, or is it something else?)

A horizontal rectangular engager should always be placed on the mesiobuccal cusp for molar uprighting in order to improve the aligner’s ability to control this difficult movement. Once one recognizes that the molar is not tracking and fitting properly, do not continue with subsequent aligners; the poor fit around the molars may cause the aligners to not fit other teeth well, diminishing their effectiveness to complete staged movements.

I have difficulty with knowing when to change the course of treatment if you feel things are not tracking as they are supposed to. Is there a time or point in treatment that is "better" or "ideal" to change the course of treatment?

When the clinician observes poor tracking on two consecutive appointments, it is time to think about a revision; and begin to implement corrective measures.

Revisions

Please clarify what is considered a revision vs. mid-course correction.

ClearCorrect refers to any change to a treatment plan defined by a subsequent setup as a "revision"; this change can occur during treatment or at the end of it. The competitor in the past offered a "mid-course correction" for any change to a treatment plan defined by a subsequent setup if that change was made during treatment. Effectively, there is no actual difference in the two procedures.

Do I have to remove engagers and start over or can the engagers be left in place?

It is a best practice to remove existing engagers prior to taking a new impression or scan for a revision, and ClearCorrect requires it.

Do we always get all the trays at once when we do a revision?

Revision trays will be sent in groups of up to 12, just like they were delivered originally.

Is it considered a revision if the patient simply did not achieve the original treatment goals?

It is considered a revision if additional aligners are ordered to complete unfinished treatment goals.

Would it be better to back up a couple of steps and try to "recapture" the planned treatment before doing a revision?

If the aligners have not been tracking, backtracking may work, but if the aligners have been fitting properly, a revision would likely be necessary to finish treatment.

Is a new impression always necessary for a revision?

A revision can be based on existing models that fit well, on new impressions, or on new intraoral scans. See our article on revisions for more information on this topic.

Usually on a revision the patient wants some fine tuning. Rotations of a few degrees for example. Should I continue with a revision or place brackets on the patient to finish? It seems to me minor rotations are infrequently accomplished with revisions. Should I be placing engagers on those teeth?

While placement of brackets is an additional cost to the doctor and unpleasant for the patient, they can be used. However, complete rotation can be accomplished by:

Tips & tricks

Some of our providers offered a few tips & tricks for monitoring treatment, checkups & revisions. Nothing here should be taken as official advice or recommendation from ClearCorrect or its employees. It's up to you to use your professional judgment on what is best for you and your patients.

  • To monitor treatment, when performing checkups, I most often open the patient’s online case and just look at where the computer says the tooth position and bite are designed to be at that stage and then compare.
  • I constantly compare the patient’s progress with the treatment setup.
  • Watch the velocity of movements. If movements are too quick for extrusion, rotation, then it most likely might not happen clinically.
  • I have learned for the most part to not give multiple aligners to patients. I think it’s extremely important to be able to monitor on a regular basis.
  • If just 1 or 2 teeth, I try to dimple and window first. Need hand stripping to assure space to move.
  • I have learned to ask for overcorrection in my original prescriptions.

A big thank you to all the providers who answered our survey!

Check out our Help Center for more helpful information on clear aligner treatment.

Until next time...

Tech Tip: Patient compliance & wear schedules

It's been a while since we've talked about patient compliance and since it's on the top of the list for causing trouble in clear aligner treatment, we thought we'd offer a refresh and an expert opinion on the topic.

We consulted our Clinical Advisor, Dr. Ken Fischer, and here's what he had to say:

What is your experience with patient compliance and how has it affected your success or lack of success with clear aligner treatment?

Patient compliance, or wearing the removable aligners as instructed by the doctor, is absolutely critical in successful outcomes. Not every patient is going to be 100% compliant and wear their aligners 22 hours per day, every day, as we would like them to do. The Doctor's challenge is to learn and understand how each individual can best be motivated to maximize their compliance. Some patients can be "directed", others will need to be "pushed", but either way, full compliance is necessary to accomplish the treatment goal.

What is your percent of compliant vs. non-compliant patients?

Without considering the variance in the degrees of compliance, I think anywhere from 60%-75% of aligner patients are reasonably compliant and are willing to do what it takes to get the desired results. The other 25%-40% do not have the self-discipline necessary to be good, compliant aligner patients. Patient compliance is an issue that must be dealt with commonly in the practice on a daily basis, but that does not mean that we have to struggle with most patients at each appointment.

How do you manage patient compliance? What are your tips and recommendations for gaining patient compliance?

The key is to learn what is the best "motivator" or "incentive" for each patient; younger, adolescent patients will be motivated by techniques or stimulators different than those appealing to adult patients. The common denominator is for the patient to understand that they cannot complete their treatment unless they wear the aligners as directed. This means understanding the variables, that they will either have to stop treatment with an incomplete result, wasting the fee they paid, or finish with an outcome we can all be proud of. When we present the alternative treatment with braces, the patient will usually appreciate the importance of compliance.

See our article on non-compliant patients and compliance checkpoints for more information, tips and tricks on the topic of patient compliance.

Patient wear schedules

The wear schedule you give to your patient is entirely up to you. When you submit your case, you're able to request a 3-week, 2-week or even 1-week wear schedule, and dispense as many aligners as you see fit at each appointment. We recommend that your patient wear each set for at least two weeks for optimum results.

We also consulted with Dr. Fischer on this topic:

What should a doctor consider when deciding what wear schedule to choose for a patient?

95% of cases will be best suited for the 2 week wear schedule. That is the appropriate time it takes the skeletal and periodontal changes to occur with adequate tooth movement. 1 week intervals may be used when using accelerators such as; Acceladent (vibration), Propel (microperforations), Biolux/OrthoPulse (selected wavelengths of light) and Wilcodontics (surgically assisted orthodontics). (When using any of these the dentist will need to closely monitor for root resorption or other complications of moving teeth too fast.) 1 week intervals can also be OK when there is a minor amount of overall movement necessary for correction. 3-4 week intervals are good when there is questionable compliance or particularly difficult movements to accomplish.

Also, one may suggest that "young" teeth move more quickly and "older" teeth move more slowly due to the biological skeletal remodeling process, therefore the wear schedule for younger teeth can be shortened (1 week) and lengthened (3-4 weeks) for older teeth. However, clinical circumstances exert more influcence on the optimum wear schedule than the age of the teeth.

The health of the tooth is not as important as the health of the supporting bone and periodontal tissues when determining the aligner wear schedule. Even devitalized teeth can be moved if the periodontium is healthy.

Wear schedules can be changed by contacting one of our support representatives either by phone, email or by sending us a chat.

Thanks Dr. Fischer for sharing your experience and wisdom! 

Until next time... 

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.

Posterior_Open_Bite.jpg

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...

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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 Dimples_-_distal_rotations_FD-4.jpg

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

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Dimples_-_mesial_rotations_FM-4.jpg

For tipping:

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

dimples_-_facial_tipping_L.jpg

  • 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.

Dimples_-_mesial_tipping_LD-3.jpg

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.

Dimples_-_distal_tipping_LM-3.jpg

Dimples_-_distal_tipping_FM-3.jpg

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. 
Dimples_-_torque_lingual-4.jpg
  •  To torque facially place one dimple on the lingual gingival.

Dimples_-_torque_facial-3.jpg

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

Dimples_-_torque_mesial_LD-5.jpg

Dimples_-_torque_mesial_FD-4.jpg

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

Dimples_-_torque_distal_LM.jpg

Dimples_-_torque_distal_FM.jpg

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.

Dimples_-_translate_lingual_F-3.jpg

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

Dimples_-_translate_facial_L-4.jpg

  • 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.

Dimples_-_translate_mesial_LD-3.jpg

Dimples_-_translate_mesial_FD-4.jpg

  • 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.

Dimples_-_translate_distal_L-4.jpg

Dimples_-_translate_distal_F-3.jpg

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...

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...

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.

Screen_Shot_2016-05-27_at_3.49.48_PM.png

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.

Screen_Shot_2016-05-27_at_4.09.38_PM.png

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.

Screen_Shot_2016-05-27_at_4.12.50_PM.png

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...

Tech Tip: All about scanners

Making accurate dental impressions is easily the most essential part of submitting a case. There are many different options out there for capturing dental impressions, from traditional impressions to the wide variety of intraoral scanners available on the market today.

3-D technology has had a significant impact on dentistry in the last 20 years, and it is only expected to increase in the coming years. More and more doctors are moving over to intraoral scanners.

We thought that a tip covering intraoral scanning with ClearCorrect might be helpful, whether you already use an intraoral scanner or if you're considering one.

Intraoral scanners

A study from 2014 found that the use of intraoral scanners could significantly accelerate the work flow of making impressions.

Some benefits of using an intraoral scanner include:

  • More comfortable for patients than conventional impressions
  • Save costs on impression materials
  • No shipping hassles
  • Higher accuracy than traditional impressions
  • Fewer errors resulting in having to re-impress
  • Facilitates sending scans to ClearCorrect electronically, resulting in a faster turnaround

ClearCorrect accepts records from most intraoral scanners currently on the market.

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With the wide variety of intraoral scanners available, selecting the best intraoral scanner for you really comes down to your preferences. Some things you might want to consider when choosing a scanner:

  • Is the scanner portable?
  • Is the scanner light and easy to use?
  • Will the scanning experience be comfortable for patients?
  • Is there a cost for image export and storage?
  • Is the software for the scanner compatible with your practice management software?

Submitting a case to ClearCorrect with scanners

You can upload scan files from any intraoral scanner to ClearComm as long as the file is in STL format. (STL is an open, industry-standard file format that can be exported by most popular scanners.) Export your STL files from your scanner to your computer, and then upload those files just like your photos when you submit a case online, or on the case page after submitting.

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STL files are not necessary if your scanner has the option to select ClearCorrect as your dental lab and upload scans directly from the scanner. CEREC Connect and TRIOS currenty offer this option.

We provide instructions for some of the common scanners:

Model or impression scanners

We also accept scans from model or impression scanners like Motion View's Ortho Insight 3D Scanner. Whether you're using an intraoral scanner or a model or impression scanner, ClearCorrect works with your team to accept digital files enhancing productivity and quality.

Scanning tips

Here are a few tips for using scanners:

  • We strongly recommend that you visually inspect your STL files before you submit them to us. We recommend netfabb Studio Basic, which is available free for Windows, Mac, and Linux. Other STL viewing options include viewstl.com, MiniMagics and FreeCAD.
  • Some scanners output several files, but the only files we want are the upper and lower arches. The arches should be saved in separate files, with the arches oriented in occlusion.
  • Scan both arches, even if you're only treating or revising one of them. Recreating the occlusion based on one arch is prone to error. (This advice applies to PVS impressions as well.)
  • We prefer "closed shell" models, but "open shell" models are acceptable too.
  • To prevent aligners from flaring at the edges, always capture at least 3-5 millimeters of gum in the scan.
  • While bite registrations are no longer a requirement for submitting PVS impresions to ClearCorrect, this is still part of the workflow with some scanners. You can capture more accurate bite scans by including as much of the occlusion as your scanner allows.
  • We can't provide support for your scanner software, but if you have any other questions, as always, our knowledgeable support reps are here to help.

We hope you found this information useful!

Until next time…

Tech Tip: Case submission FAQs & tips from providers

In a recent survey, we asked some of our providers about any questions they might have on the topic of case submission, prescription and treatment setups. Below are some of the questions and answers. We hope you find this information helpful!

FAQ about case submission, prescription & treatment setups

Is ClearCorrect now 2 weeks for each aligner? I’m still using the 3 week method.

We did change our default wear schedule from 3 weeks to 2 weeks in 2015. At the same time, we also added the ability for you to choose your patient's wear schedule when you submit your case. With this change, you're able to request a 3-week, 2-week, or even 1-week wear schedule and you can dispense as many aligners as you see fit at each appointment. (This only applies to new cases--any cases that started on a 3-week schedule should still be on that schedule.) We recommend that most patients wear each set of aligners for at least two weeks. See our full article on aligner wear schedules.

Wear schedules can be viewed in the treatment setup and in the fine print on the treatment plan.

If a bite is no longer needed, how do we bypass this in CEREC Connect?

At this time, a bite scan is a requirement and part of the workflow when scanning with CEREC Connect. While we've made bite registrations optional, most doctors still like to take a bite scan to have as a record to compare to the bite that we provide in our treatment setup.

I understand that this system is only for anterior teeth. Is that correct?

No, ClearCorrect is an advanced system of clear aligner therapy that uses the latest digital technologies, design and clinical approaches to treat various types of malocclusion, ranging from simple to advanced extraction and surgical cases depending on the knowledge and expertise of the doctor.

What are the most common issues that cause a Limited 12 aligner case to be elevated to an Unlimited case?

When the ClearCorrect technician reads the case submission form, they try to follow all of the doctor's instructions taking into account the requested case type. However, if they can't follow both the treatment plan and case type instructions, they will prioritize the treatment plan instructions over the case type which can lead to upgrading the case to an Unlimited. If it's noted on the case submission form that the case type is a higher priority over the treatment plan, along with a note of which correction is allowed to be compromised for the case type, then our technician will follow those instructions instead of their normal protocol.

I’m not sure about the amount of trays to plan for. Maybe a guideline to selecting the right case type?

In 2015 we made a change where by default and at no charge to you, our technicians recommend a case type appropriate for the treatment you prescribe, which eliminates the need for you to choose the case type for your patient. However, if you have a preference, you can indicate it when you submit the case.

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Either way, the case type won’t be final until you approve a treatment setup and pay for the case.

If you want to choose your case type, we've prepared a simple chart to help you predict which treatment option might be best for your case:

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Can I ask for specific sizes or shapes of attachments for the setup?

Not at this time. Engagers are an active area of research and development at ClearCorrect and elsewhere. Many variations of engager shapes have been proposed and discussed in literature and professional forums, but in practice, once the shape is thermoformed in the engager template, problems of adaptation and air gaps reduce the capability of many of these designs.

Without conclusive information and until the mentioned adaptation problems are resolved, ClearCorrect is happy to stick to the simple horizontal and vertical engagers that we've been using for the last ten years, which have proven sufficient to help with movements requiring an engager.

Fortunately, because of the way we trim our trays, our aligners are 2-4 times stronger than our competitors. This can reduce the need for engagers in many cases.

It looks like some overcorrection was built into the treatment setup. Is this correct?

Overcorrection is only added to the case per the doctor's instructions. Overcorrection can be requested at the beginning of a case when filling out the submission form, when submitting a revision or when reviewing/approving the treatment setup.

No bite turbo or bite ramps were offered, is this something that will be coming or is it even necessary with the greater gingival coverage that ClearCorrect has in their aligners?

Doctors can request lingual engagers to prevent full closure of the teeth. This is an advanced treatment technique, and should be monitored carefully. Whether a bite turbo and/or bite ramp is necessary would be determined on a case by case basis.

In cases with anterior interproximal reduction, how can I have a virtual power chain added to the end of the treatment sequence so that I have all the required aligners, including for the power chain, without having to request a revision?

When submitting the case, just ask for overcorrection with a digital power chain on the last two steps in order to get a virtual power chain without having to request a revision.

How do you determine which teeth will start the movement? (Or, phrased differently); How do you stage treatment?

We use protocols that have been developed by our Chief Technology Officer, orthodontist Dr. James Mah; ClearCorrect founder Dr. Willis J. Pumphrey; and our VP Products, Paul Dinh, CDT. These protocols are applied on a case-by-case basis by our technicians to help get the outcomes you prescribe for your patients.

Is there a process that I can tweak the final treatment setup myself?

Not at this time, though we are aware that doctors are interested in this functionality. The current process for adjusting your treatment setup is described below.

How do I make adjustments to a treatment setup?

If the model looks inaccurate, you want to move the teeth differently, or you want to cancel the case, click DISAPPROVE when viewing the treatment setup 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 of the treatment setup for your approval within a few days.

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I have difficulty with viewing the setup. It isn’t real clear to see the final result. I kind of just go on faith that it is going to look good.

At the bottom left of the setup, you'll see a timeline representing every step of the case. The starting position of the teeth is shown at the left. Steps with checkup appointments are numbered on the timeline, and the final position of the teeth is represented on the right as a retainer.

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To navigate between steps, you can drag the slider, click on a step, click the Previous and Next arrows, or click Play to animate the treatment from beginning to end. You can click Previous at the beginning or Next at the end of treatment to quickly toggle between views before and after treatment.

Shortcuts are available for the most common views: Upper occlusal, Lower occlusal, Right, Front, and Left. You can also rotate the model to view the teeth from any angle by clicking and dragging.

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I sometimes need help in deciding on the treatment setup.

When approving a treatment setup, it's best to begin with the end in mind - consider the whole treatment and what are the goals for that particular patient. Also, when filling out the case submission form, the more information you give the better treatment setups you'll receive.

For more information, see our recommendations for how to evaluate the treatment setup in our Help Center article on this topic.

As a “bracket man” for years, I feel that the torque movements are hard to envision. Can some support evidence or outcomes be made available to give me more confidence?

We understand that being able to see some successful outcomes is helpful. We offer a number of different case studies covering a variety of scenarios from treatment of a Class II with crowding and a deep bite, to treating an anterior open bite with clear aligners. You can check out all of our case studies in our Help Center.

Provider tips & tricks

Some of our providers offered a few tips & tricks for submitting cases. Nothing here should be taken as official advice or recommendation from ClearCorrect or its employees. It’s up to you to use your professional judgement on what is best for you and your patients.

  • "I usually let ClearCorrect dictate the course of action. I have had an extraction case that I had never done before and the ClearCorrect technician walked me through it and said that she had seen my other work and was sure that I could do this as well. It made me feel good."
  • "I look at my comprehensive diagnosis and go through in my head step-by-step what I need to correct the deficiencies."
  • "I like to avoid placing attachments at the initial stages, so that the patient can become accustomed to the appliances before making it tougher to remove them."
  • "I would recommend that all doctors finish with a digital power chain."
  • "I would overcorrect all rotations and ask for power chain to close any original spacing. My experience tells me that less engagers allow better fitting and tracking of aligners."
  • "I always leave 1mm of overjet between anteriors at completion to prevent a slight posterior open bite."

Thanks to all the providers who answered our survey!

Check out our Help Center for more helpful information on treating your patients with clear aligners.

Until next time...