Don’t click “approve” until you follow this guide for efficient evaluation of clear aligner cases
An extremely important part of building your clear aligner practice is to have a consistent and effective way to evaluate, modify and ultimately approve your case setups.
If you’re in a startup mode to building your clear aligner practice, the volume of cases you will be evaluating will be mostly manageable. However, it won’t be long until the number of new cases as well as additional orders of aligners will be overwhelming. It’s never too early to start getting your system in place for evaluating your setups in a systematic and consistent way, so let’s get started.
Here is my eight-step checklist for evaluating your setups. I use ClinCheck software for Invisalign, so some references will be specific to that brand, but the overall principles apply no matter which company your practice contracts with.
1. Check the initial photos and make sure they match the digital images provided.
This may sound like a simple step, but if there is a discrepancy, such as the bite set too far forward or a midline shift that does not really exist, you’ll end up treatment-planning your case for failure right from the start.
Sometimes the problem can be the photos improperly taken by a team member, or the bite registration was inaccurate on the scan that was submitted. Either way, you need to figure out the correct occlusion and start to treatment-plan from an accurate bite.
Once you confirm the bite and digital image are both the same, you can proceed.
2. Check the final results on all dimensions.
I know what you’re thinking: “But what about the video?!” It’s tempting to watch the video right away, but please hold back this temptation! The video is very distracting, and often you will miss certain key movements that could end up being a problem later in treatment. Instead, click the final results and check the occlusion and alignment on the right and left sides; check the arch forms; evaluate the leveling of the curve of spee; and evaluate overjet, overbite and finally the midline to make sure it is centered, if that is the goal.
When I’m going through this process, I have a pad of scratch paper nearby and write down the parts of the setup I don’t like and will ultimately modify.
3. Review the “comments” provided by the technician who set up your case.
The comments section will often outline potential issues with the ClinCheck and may require you to take new PVS impressions or provide a new scan.
4. Review the treatment card.
This card will outline clearly where and when the attachments will be placed; precision or button cuts placement; when and where IPR is planned; and, most importantly, what types of movements are considered “moderate” or “advanced.”
Another way to evaluate the “blue” or “black” movements is the use of the tooth movement assessment tool (TMA). This tool, when activated, will place blue or black dots on teeth on your ClinCheck and help you clearly see what movements you may need to add attachments or use other auxiliaries to help achieve your treatment outcomes.
5. (The step you’ve been waiting for!) Watch the animation/video of your setup.
While you’re watching the video, open the staging tab to evaluate how the movements are staged and to make sure you agree with what you see. This tab will show you, in a similar fashion to the treatment card, when and where attachments are placed, IPR is programmed, and passive and overcorrection aligners are indicated. You may notice delay in starting some tooth movements and other staging, where some teeth stop moving and others continue to be aligned.
Knowing these details as you’re watching the video tremendously helps to prevent surprises later in treatment, when you realize that maybe you needed to place the IPR later in treatment or to be more efficient, all at the same time.
6. Back to the tools and the use of the Bolton analysis tab.
A quick look at this tab will help you determine if you need IPR that was not previously planned, or possibly plan on cosmetic bonding or veneers on upper lateral incisors.
I use it to help evaluate space requirements when there is a missing tooth and I need to create space for an implant.
You’re getting close here to the end of this process, and I know you’re thinking that this is taking a lot longer that you normally spend on your cases! Once you get the system in place, you will find that you can get through this process in 5–10 minutes.
Following this systematic approach and writing down changes you want to make along the way will help you build a modification plan that will ultimately save you time and effort in future modifications, and even minimize future additional aligner orders.
7. Check the occlusal contacts using the “occlusal” tool.
Your occlusal plan will vary depending on the type of case you’re working on. I’ve found this tool to be helpful in preventing posterior open bites in correction of deep bites, and a key tool when planning open bite correction with clear aligners.
8. Make your modifications, then submit the case back to the technicians.
The key to expediting this final process is to use the 3D tools as part of the software. These tools allow you to add or remove attachments, extrude or intrude teeth, rotate and torque teeth, program IPR or spacing, expand or contract arches, and add or remove precision or button cuts. You can also modify your case by typing in notes to your technician and providing those details. This feature becomes less useful as you get better at the 3D tools, but as a beginner, typing in instructions is often the first way to communicate those changes.
If you decide to communicate with your technician, be specific in what you want. Saying things such as “expand the posterior teeth” is not very specific and you may get too much or not enough of what you want. Communicating that you want “2mm of buccal movement on the lower right posterior teeth” will essentially guarantee you will get this accomplished in your case.
In summary, here are the eight steps to evaluating your clear aligner cases successfully:
- Check the photos and make sure they correlate to the digital image.
Check the final occlusion, including the arch forms, overjet, overbite and midlines.
Check the comments tab.
Check the treatment card and the tooth movement assessment tool.
Watch the animation with the staging tab open.
Check the Bolton analysis for restorative needs or potential IPR.
Check occlusal contacts and make sure they’re synchronized with your treatment plan.
Make your modifications using the 3D tools and communicate specific details to the technician. Then submit your changes.
The who, when and where of evaluations
The next area that needs to be systematized is when and where you’ll take the time needed to evaluate and modify your cases.
Let’s start with the possible option to delegate a part of this process. While I’ve been talking about the steps you need to take to evaluate a ClinCheck in a systematic way, this system that I have presented here is something that can be easily delegated to a coordinator or other clinical team member. A checklist can be developed from this list as a guideline to your clinical assistant, so in situations where you’ve trained an employee to do the initial modifications for your cases, you can be sure they’re not missing any key steps to a successful outcome for your case.
I always recommend that the doctor ultimately be the one who hits “approve” on their own cases. However, training team members to handle some of the initial modifications of your cases can be effective and minimize your computer time.
As your practice continues to grow with clear aligners, you will find that you may exchange some of your “doctor chair time” to “doctor computer time.” Scheduling time to do your cases is important and a system needs to be put into place.
If you’re in a startup phase with your clear aligner practice, carving out time can easily be placed into your daily schedule. Often 11 a.m. to noon is a slower time of the day, and blocking out this hour in your practice is a great way to get the cases completed while at the office. Many doctors find themselves doing their cases during their lunch hours with their turkey sandwich! If you cannot find an hour during the day to do your cases, then you may need to plan time—either early morning, before patients, or at the end of your day before you leave the office for home.
If you’re an established practice, you will find that as your practice switches to more clear aligners, your schedule will change dramatically because patients need different types of appointments, and those intervals will be further apart. Because most of our patients want to be seen after work and school, the busiest times of the day are midafternoon and evening. Starting your patient schedule later in the day—or even in the afternoon—a few days a week may give you an opportunity to get your cases completed and avoid the after-dinner computer time.
Ultimately, scheduling specific time to manage your cases is an important part of a successful and growing clear aligner practice. Having systems in place to evaluate and modify your cases systematically, as well as specific time in your business day to work on your cases, will ultimately allow you to provide extraordinary patient outcomes and provide you with the practice culture and lifestyle you desire.