Dentist’s Ultimate Guide to Clear Aligner Attachments

Dentist’s Ultimate Guide to Clear Aligner Attachments image

Specialist Orthodontist Dr Katie Xu reveals her critical tips for designing, making and bonding clear aligner attachments.

It’s no secret that the clear aligner market has been growing rapidly in recent years – and patient demand for clear aligner treatments is showing no signs of slowing down. In Australia, the clear aligner market is forecast to be worth around AUD$705 million by 2028, with an annual compound growth rate of 28.7%.

This is largely being driven by increasing demand for aesthetic orthodontic treatments. As clear aligners are virtually invisible when worn, they have become a popular choice for adult patients who may not want to wear traditional braces.

At the same time, the development of advanced digital technologies has made clear aligner treatments more efficient and effective. Digital intraoral scanning and increasingly sophisticated clear aligner planning software have greatly improved the precision of clear aligner treatments. This is helping dentists achieve more predictable outcomes and shorter treatment timelines.

However, with many competing clear aligner brands now available, entering the clear aligner market can be confusing for dentists. That’s why Avant has simplified clear aligner treatments with our new seven-step Refine Aligner solution that is making clear aligner treatment easier – and more accessible – than ever. 

And the financial barriers to entry are low for dentists. Refine Aligner is compatible with all intraoral digital scanning systems – and we also accept physical impressions – so there’s no need to invest in new equipment or processes. 

However, there are some important things dentists should know about clear aligners in order to achieve the best treatment outcomes. Mastering clear aligner attachments is critical to the overall performance of the aligners.

Dr Katie Xu, a Specialist Orthodontist in Melbourne, says there are very few cases where clear aligner attachments are not required. 

“I would typically use attachments for all clear aligner treatments other than very minor post-orthodontic relapse cases,” she explains. “Without clear aligner attachments, you’re going to limit the treatment to very minimal movements over three, four or even five months.”  

How do clear aligner attachments work? 

Clear aligner attachments are small tooth-coloured buttons that are placed on the tooth surface to help clear aligner trays grip the teeth more securely. They are typically made from composite material, and essentially act as anchors to help the aligner trays apply the necessary force to move the teeth.

Attachments can be useful in cases where there are teeth that need to be rotated, tilted, or moved in a specific direction. In such cases, attachments can help the aligner trays apply the necessary force to move the teeth in the desired direction.

Attachments can also be helpful for patients who have a more complex orthodontic case, where there are multiple teeth that need to be moved in different directions. They can provide additional support and control during the treatment process.

But, to be most effective, the placement of attachments must be carefully planned and positioned to ensure that they are in the optimal location to apply the right amount of force to move the teeth in the desired direction. 

“When we’re dealing with difficult movements, clear aligner trays will typically slip off,” says Dr Xu. “Attachments improve aligner tray retention by keeping the plastic aligners seated firmly on the teeth. This ensures the aligner is able to exert the forces needed to support precise and difficult movements and rotations.

Do all clear aligner brands use attachments? 

Some clear aligner brands use attachments as a standard part of their treatment process, while others may use them only in certain cases where additional force or control is needed. In some cases, a brand may offer different types of attachments or no attachments at all, depending on the specific needs of the patient.

It’s important to note that the decision to use attachments is typically made by the treating dentist or orthodontist, not the aligner brand itself. Your dentist or orthodontist will evaluate your specific case and determine whether attachments are necessary to achieve the desired results with clear aligners.

However, Dr Xu warns that clear aligner brands that don’t use attachments may not be the best choice for anything more complex than minor post-orthodontic relapse cases. 

“There are a few brands out there that advertise that their aligners don’t need attachments, but I haven’t used any of those personally,” she says. “I’ve seen some clear aligner brands that say their plastic covers more of the gingival surface to grip the tooth without attachments, but I have my doubts that they would work very well. Some DIY aligner brands also don’t use attachments, but DIY aligners have a lot of limitations.”

What are the different types of clear aligner attachments?

Clear aligner attachments typically come in different shapes to achieve specific roles. 

1. Rectangular: Rectangular attachments provide a large surface area for the aligner to grip the tooth and apply force to shift it into the correct position. The rectangular shape is ideal for teeth that need to be moved into a straight line.

2. Square: Square attachments are similar to the rectangular shape but have a smaller surface area. They may be used when a smaller attachment is needed, such as for teeth that are closer together.

3. Circular: Circular attachments are typically used for teeth that need to be rotated. The shape allows for the aligner to apply force evenly around the tooth to rotate it into the desired position.

4. Triangular: Triangular attachments are often used for teeth that need to be tilted or tipped. The shape provides a point of contact to apply force to the tooth to shift it into the correct position.

In addition to the shape of the attachment, the size and placement of the attachment are also important considerations. The size of the attachment will depend on the size of the tooth and the amount of force needed to move it. The placement of the attachment is also crucial to ensure that the aligner is applying force in the correct direction.

How do dentists ensure proper attachment placement? 

Clear aligner attachments are typically placed on specific teeth that require additional force to achieve the desired movement during treatment. But placing an attachment in the wrong location on a tooth can cause a number of problems. 

For example, if an attachment is placed in the wrong location, it may not provide the necessary force to move the tooth in the desired direction, which can result in slower or less effective treatment outcomes. Attachments can also feel sharp to the patient when new, and can cause discomfort or irritation if positioned too close to the gum line or other sensitive areas of the mouth.

Dr Xu says this is why attachment placement is an important part of the clear aligner treatment planning process. 

“The treatment plan will establish the most effective staging process – or which tooth moves where and when. With that pattern set, we can then start looking at what attachments we need to facilitate all of those various movements. The clinician needs to verify that the placement of each attachment is not going to interfere with any of the other movements.

“For example, a lot of patients have a canine tooth that needs to come down for alignment. Often they will have a lower clear alignment treatment going on as well, so if the attachment is placed very high on the opposing canine tooth, you might find that the top canine can’t fully extrude because it will start to hit the lower attachment.” 

That’s why Avant gives dentists easy access to our expert Australia-based lab technicians as part of our Refine Aligner solution. They are here to help you throughout the clear aligner design process, including setting when each movement occurs in the staging process.

How are clear aligner attachments made?

Clear aligner attachments are typically made in the dental practice by a trained dental assistant or technician. Dr Xu says aligner brands typically provide attachment moulds based on the approved treatment planning design composed in the company’s clear aligner software.

“The moulds come as plastic trays that we fill with a composite material to make the attachments,” she explains. “The type of plastic differs between clear aligner companies. Some provide a stiff plastic tray, while others use a soft plastic tray.  

“Dentists generally use a composite to fill the moulds, but there’s a bit of an art to it. It’s important to make sure there are no air bubbles, and you need to just slightly overfill it – but it’s easy to overdo it so it can take some practice.” 

Dr Xu says she prefers to use a flowable composite, which tends to better fill the mould voids. However, she says using a non-flowable composite might improve the durability of the attachment. 

“I find using a flowable composite makes it easier to replicate the sharp edges of the attachments and stop air bubbles, but they do dent to wear down a lot faster than attachments made with non-flowable composites. However, non-flowable composites are more difficult to pack into the really small mould voids. It becomes more technique sensitive. If the composite is not packed down properly you will get more air bubbles, and you also need to shade match the composite to the patient’s teeth.”

Dr Xu adds that the translucent nature of the flowable composite means attachments better mimic the natural colour of the patient’s with no shade matching required. 

As flowable composite attachments may need to be replaced as they wear, Dr Xu says she would choose to use a non-flowable composite in certain cases. 

“I’d probably use a non-flowable composite if the patient lives a long way from the practice and I can’t see them often to check for wear. Heating the composite can help to get a better result. But regardless of which material you use, it’s critical not to underfill or overfill the attachment moulds. If it’s underfilled, your attachment is not going to stick. And if it’s overfilled the aligner tray won’t seat properly and treatment will be very inaccurate.”

What is the bonding process for clear aligner attachments?

Before bonding the clear aligner attachments to the patient’s teeth, Dr Xu says its vital to ensure the clear aligner trays fit accurately.

“Once the fit is confirmed, I’ll use retractors and an etch in a syringe form to etch just where the attachments are going. This makes clean-up a bit easier.”

A bonding agent is applied to the tooth surface after the acid etching process. This bonding agent acts as an intermediary layer between the tooth surface and the adhesive that is typically applied to the underside of the attachment.

“I then fit the pre-loaded attachment template in the patient’s mouth and make sure it is firmly seated. Some dentists prefer to section the template, but I like to keep the template in one piece.” 

Once the attachment is in place, a curing light is used to activate the adhesive and bond the attachment to the tooth surface. Then any excess material is removed, and the attachment is polished to ensure a smooth surface.

All up, Dr Xu says the appointment takes around 30 minutes. Although this varies depending on the complexity of the aligner treatment and the number of attachments required. 

“It’s also important to keep a close eye on the aligner attachments in follow-up appointments – particularly if you used a flowable composite to make the attachments,” Dr Xu concludes. “If they lose their shape, make sure they are replaced.”  

The final word

The clear aligner market in Australia is expected to be worth AUD$705 million by 2028 due to increased demand for aesthetic orthodontic treatments. 

Clear aligner planning software has made treatments more effective and efficient, and barriers to entry are low with Avant’s Refine Aligner solution that simplifies clear aligner treatments and makes them more accessible to dentists without the need for new equipment. 

However, clear aligner attachments are critical to the overall performance of clear aligners and must be carefully planned and positioned to apply the right amount of force to move the teeth in the desired direction. 

The decision to use attachments is typically made by the treating dentist or orthodontist, and clear aligner brands that do not use attachments may not be the best choice for more complex cases.

Want to find out more about Avant’s Refine Aligner clear aligner solution? Please email contact@avantdental.com.au or phone 1800 287 336.

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