Digital workflow for clear aligner therapy

A female patient presented for an initial comprehensive exam, including routine cleaning and dental care. At the time of the appointment, she mentioned that she did not like how her front teeth “turned in” and said they keep getting worse (figure 1). She had been to an orthodontist for a consult but didn’t want to be in brackets for two years, so she asked what other alternative treatment methods there were. This patient had no prior restorations on her front teeth. She wanted to know the difference between bonding and veneers and whether she was a candidate. I explained that both options would be a little tricky in this situation due to the nature of her bite, and I was fearful that they would continue to break. The patient was very concerned about “cutting down her teeth,” and therefore crowns were not an option.

In our office, comprehensive exams start with the hygienist. Our team takes a CBCT (figure 2), extraoral photo series (figure 3), intraoral photos, periodontal charting, and an initial interview to find out any concerns prior to a doctor entering the room. If the hygienist believes there is a need for a digital impression, she will ask an assistant with a scanner to take a quick scan. The best part of the evolution of scanners is that these impressions can be done in less than five minutes. In this case, we used a CEREC Primescan to scan the upper and lower arch as well as the bite (figure 4), and the hygienist let me know the patient’s wishes prior to my exam.

I discussed the option of clear aligners to concentrate on aligning the patient’s anterior teeth to create a more ideal overjet and overbite. We talked about the possible need for interproximal reduction (IPR) and either leveling the anterior teeth or adding composite to adjust for the wear. The patient preferred the method of adding composite and keeping treatment as conservative as possible. She then had her teeth cleaned, and I submitted the case to SureSmile.

What I love about SureSmile is the responsiveness to both the initial treatment plan and any modifications that may be needed. It is not uncommon to get patients in treatment within two weeks after impressions. With the delivery of trays, you also receive a recipe guide as to where to place attachments, when the attachments should be placed and removed, and where IPR is needed (figure 5). The other plan I love to see is the initial and final occlusion (figure 6). This is a great tool to show the patient how the bite will change. You can also use it as a guide if you need to do any post-op occlusal adjustments.

The software is quite intuitive and similar to other clear aligner systems. This plan called for 19 upper aligners and 14 lower aligners (figure 7). The patient wears the aligners for one week at a time unless the movement doesn’t track, in which case it would be for two weeks. I have been so impressed with how well the SureSmile aligners track, and patients are complimentary about the comfort of the trays. The majority of my patients are wearing their aligners for one week.

The T1 shows where the attachments are located. There is an attachment template included in the kit. We start by using pumice on the teeth that need attachments, etch the teeth with Blue Etch, rinse, bond the necessary teeth, fill the template with flowable composite, and light-cure. When it is time to remove the attachments, we polish off the attachments with a red stripe diamond until it is close to the teeth, and then we use an Enhance cup to remove the remainder of the composite without damaging the teeth.

When I look at smile design cases, I like to see where the lips fall in conjunction with the teeth when the patient smiles. As seen in Figure 8, I love the feature of this software that lets me overlay where the lip line is going to be so I can plan future restorations. After 19 weeks of wearing trays, the final result with attachments is still in place (figure 9). The plan was very close to the proposed treatment, and the next step is to remove the attachments and place composite on nos. 8 and 9 to restore the teeth to a more ideal height and width ratio (figure 10). You can see in Figure 11 that the teeth are aligned as we wanted them, and the next step is to replace tooth structure (figure 12).

Editor's note: This article appeared in the July 2021 print edition of Dental Economics.

Kristine Aadland, DMD, graduated from Oregon Health & Science University School of Dentistry in 2006 with clinical honors. In her dream practice, she is constantly pushing the limits of CEREC technology with bridges, implants, orthodontics, and her same-day smile makeovers. Dr. Aadland is visiting faculty for CDOCS in the forum and at their Scottsdale facility, and she travels for CEREC trainings, ACCEPT courses, and other speaking engagements.