Clear Aligner treatments are a valuable and commonplace item in our modern clinical armoury. We might encounter barriers to fulfilling our patients expectations from treatment.

This article proposes some solutions to potential problems associated with clear aligner therapy.

Prior to initiating clear aligners the dentition should be in a “good” condition and the patient free of primary dental disease.  It is imperative that a full examination as well as clinically appropriate X-rays are taken to assess anything untoward including caries, periodontal disease, areas of pathology (eg. failing root canal treatments, root resorption or restorations). Manage any outstanding clinical issues accordingly and record your baseline findings.

Understanding case selection is important when providing clear aligners. Every case is unique and should be reviewed prior to treatment initiation. Selecting the right case is experience-dependent and will vary from dentist to dentist. Inappropriate case selection can contribute to issues further down the line. Anterior 5 to 5 cases are often a good place to start. Knowledge on which cases to select will build over time, enabling more complex cases to be considered.  

If you need support, ask an experienced colleague or visit our free accreditation course and case selection blog. 

To avoid disappointment, meet or exceed your patient’s expectations. All disappointment could be due to unmet expectations.

Understand your patients’ personality. Discuss their aims, objectives and the emotions underlying their reason for seeking treatment. Are their expectations realistic? Will you be able to meet them? If not, think about referring. 

• Clear aligners are just one tool in the orthodontic armoury

• Not all tooth movements are predictable so anticipate results that may be hard to attain

• Fully explain all stages of treatment including impact of attachments and IPR 

• Gain approval of the treatment plan and explain it is not a guaranteed outcome

• Patient agrees to wear aligners 22 hours per day and to remove them when eating/drinking

Tooth movements are unpredictable and perfection is subjective. No clear aligner system can guarantee teeth will move as planned and the potential for refinement should be discussed at the outset.  Refinement is the option to correct slight discrepancies at the end of treatment and can be due to a variety of reasons including:

• Teeth do not move as predicted

• More complex cases have a higher rate of refinement

• IPR may need to be reviewed or enhanced

• Patient may not maintain good compliance

Regular monitoring will help identify if teeth are moving as planned.  Prior to all treatments, either build in the additional cost of refinement or have clear discussions on additional fees. 

Effective attachment placement is critical to success and must match the treatment plan. I find that a soft template and flowable composite give the most predictable results. Check for flash and running in the interproximal areas. At the end of treatment,  Polishing the enamel surface and re-fluoridation is advisable after removal of attachments.

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When prescribed, IPR must be managed correctly. The treatment plan provides a guide. Using the right tools and applying clinical judgement are critical.

In my experience, practitioner’s tend to underdo IPR. This might compromise tooth movements. It is always possible to revisit IPR requirements as the treatment progresses. Practitioners can choose to use additional IPR as and when necessary according to space requirements.  It is important to use a gauge to determine the correct amount of IPR provided. Consider which tools and materials you prefer to use. Discs and burs can be quite aggressive, whilst strips can offer a greater degree of control. If IPR is inadequate then repeated cracking or breaking of aligners might be observed. Measure that sufficient IPR is present using gauges. This will avoid the need for reparative refinements at the end of the treatment. 

See IPR blog for more details

Clinician monitoring is critical. If an aligner is not seating fully,  this will highlight an issue early on. The earlier this is identified the easier the reparative solution. If tooth movement is not tracking according to the plan, check patient compliance and use your clinical judgement to consider providing additional IPR, when required to necessitate further tooth movements. 

If a replacement aligner is needed and cannot be provided within a short period of time, consider placing the preceding aligner until a replacement can be fitted to avoid further relapse.

Aligner hygiene should also be regularly reviewed. Only use cold water and an approved aligner cleaning tablet otherwise aligner damage/deformation might occur. A common error people make is using denture cleaning tablets (eg. Steradent) with hot water. This is sure to deform the aligners.

Without retention, teeth will most probably relapse.  It is imperative that retention is discussed with the patient before starting treatment.  Retainers must fit correctly in the mouth to be effective. If not, take a new 3D scan or PVS impression.

The retainers will not fit until after the attachments have been removed. Consider fixed retainers as an alternative to removable retainers.