Submitting Your Aligner Prescription: How to Optimize Your First Plan
Submitting an aligner prescription is a pivotal step in delivering effective and efficient orthodontic treatment. By providing clear, detailed, and precise instructions, you can reduce time spent revising simulation plans and streamline the treatment planning process. Early in my aligner journey, I wasted countless hours reviewing suboptimal plans due to miscommunication with the lab. Over time, I learned that a carefully crafted prescription can save time and lead to better outcomes. Read below or watch the video here.
Here’s my guide to submitting aligner prescriptions with confidence, ensuring your first plan is as close as possible to your treatment goals.
1. Identify Teeth You Don’t Want to Move
When planning aligner treatment, it’s important to recognize that not all teeth need—or should—be moved. Communicating this to the lab is critical.
Why Some Teeth Should Remain Stationary - some teeth may already be in an ideal position or pose practical challenges for movement. For example:
The last molar: These are notoriously difficult to move with aligners and often aren’t included in fixed appliance treatments either. This is because there is nothing behind the last molar to provide anchorage for force delivery.
Posterior teeth with a Class I occlusion: If the first and second molars are well-intercuspated, avoid moving them unnecessarily to preserve the occlusal relationship.
How to Prevent Unwanted Tooth Movement - clearly identify these teeth by either selecting them on the relevant chart or by writing appropriate note in the prescription. Ensure the lab understands that these teeth should remain covered by the aligner, even if they aren’t being moved. This helps prevent undesirable eruption, which could lead to open bites or occlusal imbalances.
By clearly defining stationary teeth in your prescription, you set a stable foundation for the rest of the treatment plan.
2. Be Specific About Attachment Placement
Attachments are crucial for achieving certain tooth movements, but they need to be strategically placed. It’s equally important to identify teeth where attachments should be avoided.
Crowned Teeth - Composite attachments don’t bond well to crowns and can debond frequently, causing frustration for both the patient and clinician. Avoid placing attachments on these surfaces unless absolutely necessary.
Amalgam Restorations - Similar to crowns, teeth with large amalgam restorations may have compromised bonding strength. It’s worth assessing whether attachments are needed on such teeth or if alternative strategies can be used.
Communicate Clearly with the Lab - Review clinical photographs and note any teeth with restorations or crowns i.e. don't just rely on looking at your scanned teeth during the planning. This ensures your prescription considers the practicalities of bonding and avoids unnecessary complications during treatment.
3. Define Your Desired Incisor Relationships
Aligner treatment often involves aligning teeth, resolving crowding, and but not always correcting incisor relationships. Technicians rely on your instructions to know exactly what you’re aiming to achieve. Vague or incomplete directions can lead to ineffective plans and wasted time.
Cases where you are trying to create a class I occlusion - If you plan to comprehensively treat the malocclusion, specify the mechanics required to achieve your goal. Without these details, the technician cannot plan the tooth movements needed to achieve a corrected overjet or incisor position. For example:
"Extract upper first premolars and retract upper incisors to correct the overjet."
Alignment-Only Cases - Not every patient wants or needs a fully corrected occlusion, and your plan should reflect their preferences and limitations. For cases where alignment is the primary goal, be explicit about any compromises you’re willing to accept. For example:
"Align teeth and resolve crowding with IPR while accepting an increased overjet at the end of treatment."
Clear instructions on incisor relationships help the technician create a plan tailored to your patient’s goals and clinical needs.
4. Overbite Correction with Aligners
Vertical relationships, particularly overbite correction, are a common focus of aligner treatment. However, true incisor intrusion is often difficult to achieve with aligners. Most overbite corrections rely on relative changes in tooth position.
How Overbite is Corrected with Aligners Aligners primarily achieve overbite correction through:
Incisor inclination changes - in other words, proclining the incisors produces a relative change in their height along with an associate reduction in overbite.
Posterior extrusion - extruding the premolars and molars will produce earlier posterior contacts. This means the mandible will not rotate (or hinge) as far forwards during closing, having the effect of reducing the overbite.
Provide Clear Instructions - Define the method of correction in your prescription. For example:
"Correct the overbite by allowing lower incisors to procline and intrude by 2mm while avoiding posterior extrusion."
By articulating your approach, you minimize ambiguity and guide the technician toward a predictable plan.
5. Focus on Final Tooth Positions First
When submitting your first plan, prioritize the final tooth positions over the finer details of staging and mechanics. This initial step is about ensuring the overall treatment goals are achievable.
What to Focus On in the First Plan
Arch form: Ensure the simulated arch form aligns with your treatment goals.
Alignment: Verify that teeth are positioned correctly in the final outcome.
What to Address in Subsequent Reviews - Details like attachment design, staging, overcorrections, and buttons can be adjusted in later reviews. At this stage, the priority is to confirm that the teeth are positioned appropriately for the desired result.
By separating the planning process into phases, you avoid becoming overwhelmed by details too early and create a clear roadmap for the technician.
Orthodontic Learning Points
Teeth to Avoid Moving: Clearly identify stationary teeth and ensure aligners cover them to prevent eruption.
Attachments: Avoid attachments on challenging surfaces like crowns or amalgam restorations to minimize patient inconvenience.
Incisor Relationships: Provide specific instructions for alignment and overjet corrections to meet patient goals.
Overbite Adjustments: Define vertical correction strategies, focusing on relative movements rather than true intrusion.
Stepwise Review Process: Prioritize final tooth positions in the first plan and refine staging and mechanics in subsequent reviews.
Conclusion
Submitting a detailed and specific aligner prescription is the foundation of efficient and effective treatment planning. By clearly outlining your goals, identifying teeth to avoid moving, and providing precise instructions for relationships and mechanics, you can reduce revisions, save time, and achieve more predictable results.
Approach each prescription with care and precision—it’s a small investment of effort that pays off in better treatment outcomes and happier patients.
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