SureSmile Case Submission

SureSmile Case Submission Form
Case Submission Guidelines and Acknowledgement
- All records submitted must be fully de-identified to protect patient privacy. This includes removing or redacting any personally identifiable information, such as names, birth dates, addresses, and any other details that could link the case back to the individual.
- Ensure all images and scans are free from identifiable features. For extraoral photographs, please ensure the eyes are covered, and masking is applied to remove any identifying features.
- Include a signed consent form from the patient (or legal guardian) authorizing use of records for educational purposes.
- Attach authorization from the treating doctor, confirming that consent was obtained, and the submission complies with privacy laws.
- Submit clear high-resolution images (jpeg/png for photos and radiographs) and a any document detailing the case, diagnosis, treatment plan, progress, and outcomes.
- Cases will be reviewed, and additional information may be requested to ensure compliance.
Acknowledgement: Agreement to abide by the case submission guidelines and the right to publish the case in the global case library.*

Yes, I agree.
Consent & Release of Information and Patient's Images
Doctor Consent

To review and sign the Consent and Release form, kindly click on the link below to access the Adobe Sign website. The site will open in a new window or tab, please return back to this form to continue the submission process.

Dentsply Sirona Doctor Consent & Release Doctor information and signature is required.
I acknowledge that I have reviewed and signed the Doctor Consent.*

Yes, I agree.
Patient Consent or Authorization

This is to be submitted only if extraoral photographs of the patient are submitted.
If you already have a Patient Consent & Release or Authorization form, you can upload a copy here.*

Please upload signed consent form of the patient.
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If you do not have a Patient Consent & Release form, you can:
1. Click on the following link to download and print a copy. Dentsply Sirona Patient Consent & Release
2. Obtain the patient's required information and signature
3. Upload a signed copy in the designated area above.
Doctor Information
Full Name*

First NameLast Name
Active E-mail*
example@example.com
Practice Name*
Practice or Clinic Website
City*
Country*
Years of Experience*
SureSmile User Since*
Year
Doctor Headshot*

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Case Summary
Patient ID*
Example: A3B5 For internal use only.
Which platform did you treat this case in*

SureSmile AlignerSureSmile OrthoSureSmile Advanced
Treatment Start Date

MonthDayYear
Date
Treatment End Date

MonthDayYear
Date
Patient Age at Start of Treatment
Treatment Duration*
(in months)
Patient Gender

MaleFemaleOther
Initial Diagnosis*
(Detailed description of the patient's condition)
Case Type (select all that apply)*

Class IClass IIClass IIISubdivisionCrowdingSpacingImpactionsMissing ToothIncreased OverjetDeep BiteOpen BiteAnterior CrossbitePosterior CrossbiteNarrow ArchesMidline shiftDiastemaAsymmetry
Treatment Objective

Aesthetic ImprovementFunctionalityBite CorrectionOrthopedic correctionOther
Treatment
Which SureSmile services and products were used? (Select all that apply)*

Diagnostic ToolsTreatment PlanningAlignersDo-It-Yourself AlignersIndirect Bonding TraysLabial Robotically Bent WiresLingual Robotically Bent WiresInterdisciplinaryHybridRetainersVPro
What additional auxiliaries and appliances were used? (Select all that apply)*

NoneElasticsTADsExpandersClass II correctorsClass III correctorsDistalizersIPRExtractionsOther
Clinical Outcomes
Final Result
(Brief description of the outcome)
Retention*
(e.g., Fixed Retainers, Removable Retainers, etc.)
Case Records

Please make sure all records are de-identified.
Initial Records

Please submit individual images.
Intraoral Photographs*

Frontal, Right Buccal, Left Buccal, Upper Occlusal, Lower Occlusal Note: All of these records are mandatory
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Extraoral Photographs

Frontal, Frontal Smile, Profile, and any other
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Radiographs

Upload option for OPG, Lateral ceph., etc.
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Supplementary Photographs

Add any or all additional photos here.
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Final Records

Please submit individual images.
Intraoral Photographs*

Frontal, Right Buccal, Left Buccal, Upper Occlusal, Lower Occlusal Note: All of these records are mandatory
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Extraoral Photographs

Frontal, Frontal Smile, Profile, and any other
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Radiographs

Upload option for OPG, Lateral ceph., etc.
Cancelof
Supplementary Photographs

Add any or all additional photos here.
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NOTE: Submission of additional information and records will be required should this case be selected for the SureSmile Case Library. Dentsply Sirona, SureSmile reserves the right to use submissions for education, learning, marketing purposes.

Dentsply Sirona Orthodontics Inc., DBA SureSmile®
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SureSmile Case Submission Form

Case Submission Guidelines and Acknowledgement

Consent & Release of Information and Patient's Images

Patient Consent or Authorization

Doctor Information

Case Summary

Treatment

Clinical Outcomes

Case Records

Initial Records

Final Records