After the clinician sends the patient’s records, diagnoses the malocclusion, formulates a treatment plan and fills in the prescription form, this is communicated to the technician.
Using this data, the software generates a simulation of the tooth movements into the final occlusion that will have to be reviewed by the practitioner to ensure the best orthodontic goals and sequences.
14.1 The Perfect ClinCheck Review in 10 Steps
- Check initial occlusion
- Review comments tab
- Review the final position
- Check the number of stages in treatment
- Dynamic evaluation of the ClinCheck
- Simultaneous movements
- Sequential movements
- Reciprocal movements
- Check the superimposition tool
- Review the Tooth Movement Assessment (TMA)
- Review attachments
- Review IPR
- Review precision cuts
14.1.1 Check Initial Occlusion
Review the initial occlusion with the photographs sent to make sure the occlusion is set correctly. Note that you can send the bite registration if taking impressions, although it is not mandatory.
- If there is a discrepancy between centric occlusion (CR) and centric relation (CR), we must send every record in CR and check the technician sets up the initial occlusion in CR. In this case it is suggested that occlusal photographs be taken with articulating paper marks to assist the technician in setting up the initial occlusion.
- If the initial position in the ChinCheck is not the same as the initial position for the patient, ask the technician to set up the occlusion to the point of initial contact; sometimes new photographs may be required.
- Check the initial occlusion from all points of view: anterior view, right and left buccal views and the anterior overjet view. Check also if there is canting of the occlusal plane, as the initial position of the malocclusion must be set up with the same canting (for this purpose, the smiling photograph and the intraoral frontal are mandatory).
- Review the initial occlusion for incisors with gingival recession at the beginning (ask the technician not to procline and do the IPR in earlier stages to avoid round‐tripping). In addition, check that the technician does not cover the enamel–cement line or maximum contour of the tooth with the gum recession.
- Look for implants in the initial occlusion, and check that those teeth do not move in the ClinCheck. In these cases, also ask the technician to cut the gingival margin 3 mm towards the occlusal in order to prevent over‐retention of the aligner.
14.1.2 Review Comments Tab
This is the tab where the technician communicates with the practitioner. This tab may include:
- Problems with the impressions or the scan: for example if, due to soft tissue, the most distal teeth have not being included in the appliance. In this case, the clinician will have to decide whether to take new impressions/scan or surgically remove the soft tissue to enable a better registration of the distal teeth.
- A request for further instructions in order to solve the malocclusion. For example, if the clinician asked to correct the class II, but did not indicate how (e.g. by upper distalization, lower mesialization, mandibular advancement or posterior IPR) the technician might ask for further instructions to achieve the final goal. It is therefore really important to provide these, as practitioner’s treatment plan is the key to a positive treatment outcome.
- Comments on attachment and precision cuts placement.
14.1.3 Review the Final Position
The final occlusion setup should be checked to see if the occlusion meets the treatment goals. The panoramic X‐ray should also be checked at this time to ensure that all pretreatment root inclinations have been corrected in the final occlusion.
Views that have to be evaluated:
- Anterior view: check midlines, crown tipping of the incisors, aesthetic alignment, overbite, arch form and buccal corridors
- Overjet view: anterior overjet and anterior occlusal contacts. Check the overjet in both canines is the same
- Buccal right and left view: review the incisor torque, the interincisal angle, canine and molar relationships right and left, buccal interdigitation
- Occlusal views (maxillary and mandibular): symmetry of the arches, arch form, alignment, marginal ridges and central fossae
- Posterior view: cup‐to‐fossa relationships, buccolingual torque of posterior teeth
14.1.4 Check the Number of Stages in Treatment
The number of stages of active and passive treatment is indicated on a bar at the bottom of the screen (Fig. 14.11). Colours define characteristics of the aligners:
- Active aligners are represented in blue
- Passive aligners are light blue
- Overcorrection aligners are brown
If the correction of the malocclusion depends on the use of elastics, we must ensure that there are enough aligners to achieve the correction of the malocclusion (this topic will be covered in Chapter 20).
If the correction of the malocclusion depends on mandibular advancement (MA), we must ensure that we have at least 25–30 stages of the advancement phase so the malocclusion can be resolved.
14.1.5 Dynamic Evaluation of the ClinCheck
This phase is essential: hit the play button and check each tooth movement carefully from the initial position to its final one. This is crucial to obtaining a predictable treatment result.
The staging tab will show which teeth are moving in each stage, and it is also possible to evaluate which teeth are responsible for the lengthening of the treatment.
In order to shorten the treatment time further once the teeth that are taking longer to correct have been addressed, we can elect to perform the IPR in an earlier stage, limit certain movements or request to move certain teeth in the later stages of treatment, and accompany these with auxiliary techniques.
The animation of tooth movement should be viewed from the anterior view, right and left buccal views, and maxillary and mandibular occlusal views.
As practitioners, we must assess the individual tooth movements as well as the sequence of tooth movements showed in the staging tab.
14.1.6 Reviewing Occlusal Views
When starting to review occlusal views:
- Decide whether a symmetric or an asymmetric expansion is going to be performed.
- Proclination: establish anteroposterior limit of the proclination depending on the periodontal tissue and the initial position of the incisors.
- Do not move teeth which have no space to be moved. Take special care with lateral incisors and second premolars in lingual positions: first, create enough mesio‐distal space, then move them to their ideal position. Teeth require space to move, if there is not enough space, then teeth will collide with adjacent teeth and tooth movement may not be fully expressed. Delay the movement of a lingually displaced tooth until after space has been provided.
- Anchorage attachments, consider what attachment is needed to solve the malocclusion. For example, to level the curve of Spee, anchorage attachments distal to the incisors are needed in order to intrude them.
- Differential anchorage: analysis of the force vectors.