Clear Aligners Doctor's Guide

Introduction and Process

Part 1 – equipment

1.1 – Scanners

Part 2 – Indications and placing an order

2.1 – Clinical indications

2.2 – Diagnostic records

2.3 – Impression taking

2.4 – 3D model quality requirements

2.5 – Treatment plan

2.6 – Review/approve aligners plan

2.7 – Case info

2.8 – Product types

2.9 – IPR

2.10 – Attachments

2.11 – Power Ridges

Part 3 – Chair-side

3.1 – Performing IPR

3.2 – Placing attachments

Part 4 – Refinements

4.1 – Submitting refinements

Introduction

Clear Aligners are a sequence of transparent, removable trays to treat the malocclusion. We use state-of-the art software to simulate the outcome of the treatment. The software allow us to calculate the estimated number of aligners necessary to treat the patient. The doctors will have access to an online portal to upload and communicate with the CAD designers. This will facilitate an effective and efficient discussion concerning treatment planning and approve the treatment.

Clear Aligners must be worn for 20-22 hours/day and removed only for eating and brushing. The aligners have a minimal impact on speech and diction. This method can be used in combination with or as part of other orthodontic therapies, including removable and/or fixed appliances (brackets).

1. Equipment and consumables

1.1 Intra-oral and model scanners

We accept high-quality occluded models in STL format acquired directly, through intra-oral scanner. The list of compatible scanners is shown below. Furthermore, some scanners offer direct connectivity or bridge with our systems, which means that scan files can be sent through directly, instead of being manually uploaded.

This list is not conclusive, and many additional scanners are also compatible with the process.

Name	Type	Maker	Clear bridge
iTero	Intra-oral	Align Technologies	Yes, My iTero
Trios	Intra-oral	3Shape	Yes, Trios Connect
CEREC	Intra-oral	Sirona Dentsply	No, in discussion
Tru-definition	Intra-oral	3M	No
CS3600/3700	Intra-oral	Carestream	Yes, CS Connect
AoralScan 3	Intra-oral	Shining 3D	Yes Shining 3D Portal
Medit	Intra-oral	Medit	Yes, Medit Lab

2. Indications and Placing An Order

2.1 Indications

Clear Aligners are recommended for treating the following indications:

A diastema of 6.0 mm or below
Closing gaps
Overcrowding ● Teeth rotation
Expansion
Anterior teeth and premolars in a crossbite
Space retention in mixed/permanent dentition
Correction prior to an orthopedic treatment
Passive/active/double retention device
Relapse
Deep bite

Indications not recommended for Clear Aligners

A diastema larger than 6.0 mm
Crowding larger than 6.0 mm
Expansion or distalization of more than 1.5 mm
Class III
Monitoring torque or the distal inclination of the teeth
Deciduous or not fully erupted dentition
Active periodontal disease
Repeating diseases (depends on the severity of each case).
Patients with bruxism, craniomandibular dysfunction or hypersensitivity to materials used for Clear Aligners

Diastema

Cases of diastema with positive dentoalveolar discrepancy of up to 6.0 mm. Best results can be achieved when the diastema is present in the anterior region, especially when teeth are angled forward (positive torque) and a correction is made using loss of torque. Another category involves cases with a small diastema in the molar region, for example, when there are spaces left after orthodontic treatment with fixed appliances.

This type can become more complex if the diastema is present due to the displacement of teeth “in mass” in the middle line. Closing a diastema larger than 4.0 mm requires additional forces to the locking mechanism, for example, maxillary elastics, etc.

Closing horizontal and/or vertical gaps:

Please consider overjet and overbite (vertical overlap or deep bite). Closing anterior upper region diastema, where there is an increased horizontal overlap and decreased vertical overlap, contributes to the efficacy of the treatment, since the increased horizontal overlap provides some more room for movement. Upper posterior teeth and the vertical overlap will increase during the drift.

Closing a diastema in the anterior upper teeth in cases with normal horizontal overlap and increased vertical overlap allows the intrusion of the front anterior teeth, thus providing a gap to push back the front side of the upper teeth.

Treating a diastema in anterior upper teeth in cases with normal horizontal and vertical relationships can be more challenging. It is recommended to first perform compensation of the intrusion/extrusion, depending on each case.

Closing a diastema in the anterior lower teeth can work well if the boundaries of the horizontal and vertical overlap are close, since the drift of the lower posterior teeth increases the horizontal and vertical overlap. Other conditions are less favorable for treatment.

ATTENTION!

It is necessary to warn the patient that midline control represents a considerable challenge. In addition, treatment may require some occlusal adjustment, accomplished by limited IPR (interproximal reduction) and other orthodontic techniques

Overcrowding:

Cases of misaligned teeth having a negative dentoalveolar discrepancy of up to 6.0 mm. Crowding must occur in the anterior region. Clear Aligners may be used only in cases requiring first order adjustments or correction of inclination. If correction of crowding is required prior to proceeding with tooth movement, one must ensure a sufficient time frame to bring about the necessary changes. Correcting crowding and rotations can be obtained by expansion and/or IPR.

ATTENTION!

Teeth Rotation:

Prior to proceeding with correction of rotations, sufficient space must be established by expansion or IPR. Shape cutters with vestibular and the lingual surfaces of the strips contributes to the correction of rotations. In contrast, the rounded shape of the lower canines and premolars makes rotation correction more challenging. In such cases, additional accessories are needed – attachments and power ridges that allow for correction of tooth position. Such tools are automatically included in the 3D Clear Aligners plan.

Intrusion:

Intrusion is particularly effective in cases of deep frontal occlusion. It can be performed with Clear Aligners in two ways: a) individual intrusion: the intrusion is performed on 1-2 teeth and the movements are pre-programmed into the aligners. A retainer must be fitted on the rear teeth; and b) group intrusion: obtained by programming a gap between the aligners and the occlusal surface of the premolars and molars, which, in combination with the patient’s bite in the anterior segment, brings about the desired Intrusive movement.

The impact of Clear Aligners is always enhanced by chewing. In the treatment of intrusion chewing greatly increases the effectiveness of the treatment so it is recommended to advise the patient to gently chew whilst wearing the aligners.

When the prescribed extrusion covers only one tooth, this can be achieved by installing attachments, included in the Clear Aligners plan.

Expansion:

The purpose of expansion is to secure space, which will be used to deal with a certain malocclusion problem. In crowding cases, expansion must first be performed to provide the necessary space. In the image below, the space between the upper and lower central incisors was formed by an Clear Aligners expansion treatment.

Another example of using Clear Aligners for oblique-lateral expansion. The result is a gap between the central incisors.

In this case, no gap existed between the central incisors during the procedure, IPR for expansion is performed after alignment of the teeth to maintain the proximal contour as much as possible.

The IPR must be performed in advance prior to the alignment stage.

Types of expansion:

A. Bilateral extension

B. Oblique lateral extension

C. Expansion of A-R (front – rear section)

2.2 Diagnostic records.

Prior to submitting the first Clear Aligners case, it is necessary to create a clinical account. You can create an account on our website at www.klearmoves.com

To be able to provide a high-quality and realistic aligner plan, all necessary records must be uploaded as part of the aligner order submission. Such records include at least the following:

2.3 – Impression Taking

2.3.1 – The 3D model in an STL format, acquired through and intra-oral scanner

Prior to obtaining impressions or 3D models, it is critical to perform the following; 1) prevention and removal of plaque; 2) verification of proper brushing and dental hygiene habits; 3) elimination of caries; 4) prosthetics; 5) elimination of gingivitis; 6) removal of wisdom teeth.

2.3.2 –Minimum Pictures needed

Face, Smile, Profile

2.3.3 Intra oral images. Left and right bite. Upper and lower arch. Teeth in occlusion.

2.3.4 – 1 X panoramic X-ray image.

2.3.5 CBCT if one available

If you own a CBCT export the files in a DICOM formant and send the files via WeTransfer. Visit www.wetransfer.com and send the files to order@klearmoves.com. Use the free option. The file transfer will be encrypted and only authorized users will receive the files

If possible, it is highly recommended (but not obligatory) to upload additional facial/intra-oral images and a cephalometric X-ray image. Below is an example of a full records set after uploading to the Clear order:

2.4 Impression-taking.

Scans must be in STL file format only.
Both arches, upper and lower, to be saved as a separate file
Both arches must be scanned and positioned in occlusion.
Both arches should be submitted, even if service requested is for one arch only. Visible border between soft and hard tissues.
No scratches on tooth vestibular surface.

Avoid any scan errors (see examples below)

All teeth must have complete surfaces

Avoid large voids on model surface

2.6 Treatment Plan

Together with the diagnostic records, a detailed treatment plan is necessary to provide the setup technicians with instructions on case objectives. The information provided will be combined with the clinical preferences prescribed in the “Profile” section to create a clinically viable plan that conforms with your orthodontic preferences.

2.7 Review and approve an Aligners plan

Once ready, you will be prompted to review via the web portal

2.8 Case information

An attachment and IPR report will also be provided

Product types

Clear Aligners fall into two categories – Light, Mild, and Comprehensive. After reviewing and approving the case. You will have the option to buy a package that will address the patient particular situation

A. Light – up to 10 aligners per arch total. Treatment typically lasts about 2-6 months. Treatments can range from minor displacements of individual teeth to relapses, small size diastemas, minor rotations or crowding.

B. Mild – up to 20 aligners per arch total. Treatment lasts about 10 -12 months including pronounced crowding, larger diastemas and other dental anomalies.

B. Comprehensive– up to 30 aligners per arch total. Treatment lasts more than 10 -12 months including for more complicated pronounced crowding, larger diastemas and other dental anomalies.

2.10 IPR (interproximal reduction)

PR is a clinical method whereby the mesiodistal diameter of one or a few teeth is reduced in a controlled fashion by removing precise amounts of tooth enamel. IPR represents an alternative to extraction or expansion in cases where creating additional space is necessary for treating the malocclusion.

When needed, the Clear Aligners plan indicates the amount of IPR required for each tooth, as well as the step when the IPR has to be performed.

1. IPR must be performed after teeth alignment, to prevent damage to the vestibular tooth surface.

2. It is recommended to use progressive IPR (0.2 mm in each area of contact at a follow-up visit).

3. The IPR in each diameter is limited to 0.75 mm in the upper arch and 0.5 mm on the lower.

4. Total IPR is limited to 1.0 mm every 3 weeks.

5. After each procedure, use soothing materials to reduce sensitivity.

6. For effective IPR, it is recommended to assess the shape and size of the tooth in question. Basic tooth shape can be divided into three types: S – square, O – oval and T-triangular.

Tooth categorization depends on the form: square teeth have a square shape and a relatively large contact surface, closer to the gingival edge. Triangular teeth are triangular in shape and characterized by a smaller contact area near the cutting edge. Oval teeth are oval in shape and possess intermediate characteristics.

All these characteristics allow us to conclude that for approximating IPR, the most favorable form is “triangular”, allowing surface contouring without excessive proximity to the dental roots and preventing compression of interdental surfaces.

The table below provides average anatomical dimensions in the context of IPR:

Tooth	Mesio-distal crown diameter	Anterior wall thickness	Mesio-distal width	Distal wall thickness
Upper arch
Central incisor	9.0 mm	2.0 mm	5.0 mm	2.0 mm
Lateral incisor	6.4 mm	1.4 mm	3.6 mm	1.4 mm
Canine	9.5 mm	3.0 mm	4.0 mm	2.5 mm
1st pre-molar	7.0 mm	2.0 mm	3.0 mm	2.0 mm
2nd pre-molar	6.8 mm	1.8 mm	3.2 mm	1.8 mm
1st molar	10.3 mm	2.5 mm	5.3 mm	2.5 mm
2nd molar	9.2 mm`	2.2 mm	5.0 mm	2.0 mm
Lower arch
Central incisor	5.4 mm	1.2 mm	3.0 mm	1.2 mm
Lateral incisor	5.9 mm	1.3 mm	3.4 mm	1.2 mm
Canine	6.9 mm	1.5 mm	3.9 mm	1.5 mm
1st pre-molar	7.0 mm	1.5 mm	3.9 mm	1.5 mm
2nd pre-molar	7.3 mm	1.8 mm	3.7 mm	1.8 mm
1st molar	11.2 mm	3.0 mm	5.5 mm	2.7 mm
2nd molar	10.7 mm	2.8 mm	5.3 mm	2.6 mm

2.11 Attachment types

2.12 – Power Ridges

Power ridges are added to the anterior teeth as another way to improve inclination or “in and out” tipping. On the aligner, they appear at the gum line on the outside. Power ridges are used on an “as needed” basis in the aligners plan and do not require any special instructions provided by the treating clinician

3. Chair-Side

3.1 Performing IPR.

There are various methods to perform IPR. Some methods use abrasive strips (manual or mechanical) with different grain thicknesses from medium to ultra. Note that abrasive strips of high caliber are used for grinding and of smaller caliber for cleaning so that you can keep the original contour of the teeth crowns and surface smoothness.

IPR with abrasive strips

When using manual IPR with abrasive strips, it is recommended to first perform insulation job, absolute or relative (usually the latter).

It is important that the site is isolated and dry, because saliva can make the strips get wet and lose their effectiveness. This method uses steel abrasive strips and rubber strips for processing. It can be applied manually or with the help of special devices that clamp the strips, giving them the same effect as a hacksaw. The advantage in this case is a greater degree of control over the amount of enamel removed and high quality processing.

Special gauges can be obtained from Clear, please contact our partners.

For IPR the Ormco SKU 800-8102 Interproximal Stripper Kit is recommended

4.2 Placing attachments

As indicated previously, some treatment stages may require the use of attachments on the aligners, fabricated from any light-curing adhesive. Use the matrix (aligner # 0) as a guide for placing the attachments

Apply a generous amount of composite material to the attachment.

The amount applied should be slightly above what’s necessary to fill the attachment void, to exclude incomplete contact with the tooth. The tooth surface should be prepared according to instructions for the filling material.

Recommended materials for attachments:

1. Adhesive system Adper Single Bond 2 (3M)..

2. Dental composite Filtek 250 or z550

5. Case Refinement

5.1 Submitting refinements

If the treatment is not progressing in line with the approved plan, a refinement order may be submitted.
Upload a new set of images (4 photos minimum) prior to removing the attachments; A new panoramic X-ray at this point is not mandatory:
After removing the attachments upload new STL files for both arches
Submit a “Refinement” order and describe the objective of the refinement.
If the order which requires the refinement prescribes a significantly different number of upper and lower aligners (for example 5 lower and 15 upper aligners) we recommend wearing the last upper aligner until the treatment for the lower is refined and only after the clinician submitted the refinement order.

ATTENTION!!! Relapses are not covered by the refinement protocol..