Essentially, every dentist has the right to offer orthodontic treatment that is covered by the statutory health insurances. So for any dentist with a basic interest in orthodontic treatment, there is little to stand in the way of practical implementation, as it only requires minimal prior investment. In our practice, we opted for the ClearCorrect® aligner system because the treatment is very clearly structured, which makes it much easier to integrate into practice routine. There is a wide range of support available to practitioners for practical implementation with entry level and user courses: there are now 1-day courses available online or in-person, with explanations on how to select patients, and what needs to be considered when starting up (information: www.clear-correct.de/veranstaltungen). Experts in the Treatment Planning Service offer support in specific case setup in the initial phase or in complex cases by creating an exact 3D case plan. A clinical advisor from the Straumann Group can also be consulted for advice when discussing the treatment plans. What is important is that both the case diagnosis and the treatment decisions are the responsibility of the practitioner during the entire therapy and that the consulted technicians adhere to these specifications. The ClearPilot® planning software allows the practitioner to check and approve the proposal.

Today, two years after the introduction of the additional aligner offer, we primarily correct moderate crowding in Class I dentition and covered bites. We continue to refer patients with rotated teeth, tilted molars or who require crossbite correction or those who require orthodontic treatment or orthodontic measures during the growth phase to specialist orthodontic practices. Practitioners and patients alike benefit from the addition of aligner therapy to the treatment offer. This means that dental care, as well as minor tooth corrections as a pre-prosthetic measure and the therapy of slight to moderate misalignment, can be carried out in the familiar surroundings of the practice. Patients appreciate this very much as it is convenient, saves time, and gives them a sense of security. It is also helpful for practitioners if they can continue to keep an eye on their patients. It can be difficult to calculate schedules for outsourced treatment steps, such as shaping of the anterior mandible by the orthodontist, while the veneers for the maxilla are being planned in the practice. Experience has shown that patient consultation is especially important to ensure compliance – after all, the patient has to wear the aligners for 22 hours a day. It is also important to provide detailed descriptions of the “engagers”, special attachments to support aligner therapy, and also to inform the patient about the need for approximal enamel reduction to achieve the best possible treatment success. In cases where there is crowding, up to 0.3 mm of enamel is removed from the teeth specified in the treatment plan. Especially in the initial phase, it is recommended to use the calipers provided in the system which can check if there is any substance erosion. ClearCorrect® is hardly noticeable and is therefore discrete to wear (Fig.1). The aligners consist of the new three-layer ClearQuartz® material that has high retention properties and does not discolor. As, unlike other aligners, the smooth, straight trimline extends over the gingival margins, they are more comfortable for the patient to wear. This results in higher retention forces which generally reduces the number of attachments required compared to similar therapies.4 The tongue also quickly gets used to the aligner, so it does not take long for speech to sound normal. As the aligners are removable, patients do not need to adjust their eating habits or dental hygiene. The individual aligners are generally changed after 14 days, which means that changes are quickly evident - an added motivation for many patients. In the meantime, tech-savvy patients can also have an additional remote check-up with the Dental Monitoring App. Based on current photos of the dental status, which patients take themselves, the artificial intelligence-based (AI) system can detect when the aligner should next be changed.

The following treatment case describes the correction of the dentition of a 22-year-old patient who presented to the practice with this request. Secondary findings were muscular CMD problems and migraines that occurred at short intervals - and had done so for many years. Fig. 2 to 4 show the baseline of the dentition from different perspectives. After the treatment goals had been established with the patient, the treatment procedure with subsequent shaping of both jaws was explained to her to create the digital planning model. It should be noted that the aligner system offers both the option to be used conventionally by taking impressions of the upper and lower jaw or using an intraoral scanner. In this case, digitalized data were uploaded to the web-based Doctor Portal in our own laboratory.

The 3D case planning was based on the transmission of data to the ClearCorrect® Doctor Portal by the planning team and could be clearly followed step-by-step in the ClearPilot planning software. For the entire six-month treatment period, the experts used twelve individual aligners with the support of eight attachments to achieve the required correction. After carefully checking the planned treatment steps, the therapy was ultimately authorized by the attending dentist. The order for the aligners was placed and they were individually manufactured and handed over to the patient in the practice with instructions on how to wear them. The patient switched to the next aligner every 14 days. In her check-up in week 4 (corresponds to the use of aligner 3), eight supporting engagers were applied to teeth 13, 31, 32, 33, 35 and to 41, 42 and 43. These are usually applied when patients start wearing aligner 3, so they have time to get used to the aligners. In this case there was no need for an enamel reduction.

Treatment could be continued as planned after half a year and the patient received a retainer for mandible and maxilla to secure the result in the long-term. In cases where the attending physician needs to refine the result, the unlimited price options of ClearCorrect® offer the greatest possible security as this also ensures that unexpected costs are kept to a minimum. The option covers a fixed fee for the aligner and retainer for five years and is not only recommended for comprehensive treatments and long-term retention, but also for practitioners who are still inexperienced in aligner therapy and who are finding their way. The two other tariffs - One and Flex - are alternative price options offered by the manufacturer.

Figures 5 to 8 record the final result of the therapy from various perspectives with a before and after comparison. Fortunately, the patient was not only very pleased with the esthetic correction, but the treatment actually had further benefits: The CMD-associated symptoms receded and the regular migraine attacks disappeared.
Figures 9a to 9c show the baseline situation and the final result of the therapy in the planning software ClearPilot from various perspectives for direct comparison. Fig. 9b: Screenshots of the ClearPilot software visualizing the 3D planning (planning with 12 aligners, each worn for 14 days). The dental baseline of the 22-year-old patient is shown above in each. The screenshots below show the treatment result six months later in direct comparison (frontal view, occlusal view of maxilla, occlusal view of mandible.)

Conclusions for clinical practice

There are many benefits to including the ClearCorrect® aligner system in the treatment options available at general dental practices; it is an uncomplicated process, as there are hardly any investment costs for the practice and structured training provides the necessary professional background. Experts can also provide support with planning initial or more complicated cases on request. No special software needs to be installed, as the Doctor Portal and planning software are web-based and are accessed on standard browsers. Impressions can be taken conventionally or with an intraoral scanner and are uploaded as .stl files. This flexibility makes it even easier to introduce aligner therapy with ClearCorrect®. This is why it is clearly also ideal and highly recommended for younger colleagues even when they are setting up a practice.
Patients also benefit from the extra offer in the practice: They tend to greatly appreciate being able to be treated for minor and moderate dental corrections such as crowding or pretreatment for prosthetic treatment in the familiar practice setting. The resulting satisfaction also reinforces the relationship between the practitioner and the patient going forward. It is not uncommon for the patient to request further esthetic treatments after the correction, such as bleaching to follow on from the aligner therapy.

Tips on documenting the patient consultation

• Personalize information and ensure documents are signed.
• Set out the planned treatment time, pointing out that treatment may take longer than the estimated time and that new impressions may need to be taken (i.e. refinement).
• Also cover composite attachments (also known as engagers) for difficult tooth movements (number & teeth) in the consultation sheet. 
• Point out that enamel reduction (interproximal enamel reduction) may be required to make space for tooth movements (number and interdental spaces) and that the teeth may become hypersensitive and that the mouth may be pain-sensitive, especially when the aligners are changed.
• Point out the wearing time (22 hours/day).
• Include a declaration that the above-mentioned special features have been explained and that the patient has read and understood the actual consent form and cost agreement.

ClearCorrect® : a history

Dentist Dr. Willis Pumphrey (USA) founded ClearCorrect in 2006 to correct misaligned teeth with transparent aligners. In 2017 the Swiss Straumann Group took over the company. Today the transparent ClearCorrect® aligners are produced in Germany. They are made of a tough, innovative multilayer ClearQuartz® material which is also very stain resistant. As they are transparent, the aligners are discrete, an attribute valued by patients. And since they are removable, there are no eating or dental hygiene restrictions.