CA Clear Aligner Clinical Protocol, and Why it is as it is.
MartE[degrees]n Pedernera, DDS
In this article, biological basis of CAA CLEAR- ALIGNER clinical protocol is explained.
CAA CLEAR-ALIGNER, clinical protocol.
Removable or fixed orthodontic treatments are based on the insertion of the appliances and their periodical activation. It should be always started with a very mild activation and then the appliance should be progressively reactivated so the movement can be effective. In this way, removable appliances should be activated through their screws, arches, springs, etc., and fixed appliances require replacement of the arches, elastic chains, etc. so the treatment progresses adequately.
In all cases, failure in the use of removable appliances and debonding of fixed appliances (treatment interruption), or failure in periodical activation of them, means the increase of the treatment time.
Biological bases of CAA CLEAR-ALIGNER Protocol
CAA CLEAR-ALIGNER protocol is based on sequential aligners carried out over the impressions, and plaster casts carried out each 4 weeks. One "step" of treatment includes a plaster cast set-up, 3 aligners (CAA-soft, CAA- medium, CAA-hard) pressure moulded over this plaster cast set-up, and a report on movements carried out in the set-up. It corresponds to one month of treatment.
The treatment starts when the diagnosis is finished. The impressions are taken, and a 0.5 mm dental movement is carried out in the plaster cast set-up. Over this plaster cast, 3 CAA CLEAR-ALIGNERS of 3 different thicknesses are pressure moulded.
The patient should use CAA-soft during the first week; CAA-medium, during the second week, and CAA-hard, during the third week. After the third week, the patient should go to the clinic so the new impressions can be taken. He will use a CAA-hard during the fourth week while the new step is prepared in the laboratory.
In the first step of treatment, a 0.5 mm movement of the tooth is carried out. An inclination of the tooth is searched for inside the periodontal space. A vasodilation is carried out, as well as the increase of osteoblasts and osteoclasts, which enables the treatment with these aligners. Clinically, dental movement will not be observed.
In the following steps, a 1 mm movement is carried out in the set-up. This activation produces pressure zones and traction zones in periodontal ligament. In pressure zones, bony resorption is produced, and the tooth moves in this direction. In traction zones of ligament, bony apposition is started, and it is much slower.
If the patient doesn't use enough the CAA CLEAR-ALIGNER (17 hours per day) the tooth returns to the initial position and it also might present the mobility because the bony resorption has been produced, but not bony apposition in the opposite zone.
If a patient doesn't come to the clinic so the new impressions can be taken and the new step carried out, and he continues using the same CAA CLEAR-ALIGNER, the tooth will remain in that position, but the density of osteoblasts and osteoclasts is reduced. In this way, when the treatment is re-activated, it won't be possible to continue with 1 mm movements in the set-up, but it will be necessary to start again with the 0.5 mm movement, which means the delay of the treatment.
Therefore, it is very important to motivate the patient to use the CAA CLEAR-ALIGNER 17 hours per day, and to make sure they come regularly to the activation appointments, so the treatment time or number of CAA CLEAR-ALIGNERS is not increased.
When treatment objectives are achieved, the patient should use a 1 mm thick aligner, CAA RETENTION (Fig. 6). CAA RETENTION is formed over the final plaster cast, without any dental movement.
This appliance keeps the tooth in the final po- sition and periodontal ligament traction in the zones in which the bony apposition is needed.
The patient should use CAA RETENTION at least 6 months, but fixed permanent retention is rec- ommended to avoid the relapse. The stability is achieved when the alveolar bone remodelling is finished. If the use of CAA RETENTION is not sufficient, the relapse will take place.
During the active phase of the treatment, other types of CAA CLEAR-ALIGNER which increase the treatment effectiveness can be used.
When a plaster cast set-up is carried out in the laboratory, the aligners CAA-soft, CAA-medium and CAA-hard are carried out, but CAA Bubbles can also be made so when the patient can use it during the fourth week and achieve greater movement.
CAA Bubbles Activable
When a plaster cast set-up is carried out in the laboratory, the aligners CAA-soft, CAA-medium and CAA-hard are carried out, but before the CAA-hard is pressure moulded, a space can be created in the direction of the movement of the tooth, so the clinician can create an ac- tivation bubble in the clinic using the CAA-Tip 1 Pliers when impressions are taken for the next step.
CAA Forced extrusion
To achieve an effective extrusion movement, CAA POWER GRIP will be used, bonded on the tooth, 2 buttons in CAA CLEAR-ALIGNER and extrusion elastics, as it is shown on the scheme of the figure 12. It is activated by changing the elastics 3 to 4 times per day. The CAA CLEAR- ALIGNER is carried out in a such a way that when the necessary extrusion is finished, the tooth stops to extrude.
CAA Forced intrusion
CA Forced intrusion has buttons for anchorage of the intrusion elastics and it is ac- tivated by changing the elastics 3 to 4 times a day. The CAA CLEAR-ALIGNER is carried out in a such a way that when the necessary intrusion is finished, the tooth stops to intrude.
To adjust midline or overjet, upper and lower CAA CLEAR-ALIGNER can be used with in- termaxillary elastics (Fig. 14). It is activated by changing the elastics 3 to 4 times a day.
CAA Expansion Screw
During the expansion phase, CAA-hard can be used with the expansion screw Vector 40 (Fig.15). These appliances are activated by a screw turn each 3-4 days.
It is very important to maintain the rhythm of activations to complete the treatment within the planned time. It is important to make sure patients come to control appointments by orga- nizing a "reminder system", as well as a system to motivate the patient in using, cleaning and taking care of the CAA CLEAR-ALIGNER, so the treatment can be completely effective.
Echarri P. Clear Aligner. 1st Ed. Madrid (Spain):Ripano Medica; 2012
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