StraightSmile Solutions®

What if a Crooked Tooth WON’T MOVE!! What’s Next? TADS?

Occasionally, as orthodontists, we get a stubborn tooth. We try and try but the tooth won’t move. Here are some of the solutions and resolutions for this issue:

1. Reassess your mechanics. Is what you are doing even biomechanically POSSIBLE? Check articulation. Check contacts. Call a friend who is an orthodontist for a second opinion.
2. If it’s aligners, maybe the patient isn’t compliant?
2. There is a bony defect (can’t do it)
3. It’s ankylosed (can’t do it)


if it hasn’t budged at all after 2 refinements or 12 months in braces (it looks EXACTLY the same!)- it’s not going to move – first go back to step 1 and make sure it’s even biomechanically possible.
It might be ankylosed. Try taking a good PA or CBCT and try to follow the pdl.


This is a hard one but after this many aligners it should be mostly there if it wasn’t ankylosed so either he’s non compliant at les than 22-23 hours a day or it’s ankylosed
Put the patient on on weekly Invisalign virtual check ins or try In-Hand-Dental to rule out the non-compliance issue
Maybe he switches to 24/7 wear with and eats with the upper one in. that often works.


I recently had an issue like this with a patient – it was a bone defect (we caught it on a CBCT that was professionally read by a dental radiologist) the bone was too ossified and we couldn’t upright the tooth. It wasn’t ankylosed per-say but the bone wouldn’t remodel.

So rule all of this out before jumping to conclusions and placing TADS and wasting the patient’s time and money.

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What is STOPPING General Dentists from doing MORE Invisalign and Clear Aligners?

I married a general dentist. We met at UCSF Dental School and we were in the same anatomy lab group. I always knew I was going to specialize. I was “gunner” (that’s what we called the high academic students back at UCSF in the 90’s). I was there for one reason only: to become an orthodontist.
Once we both started practicing, my husband wanted to start doing orthodontics, but that door didn’t open until both ClearCorrect and Invisalign launched to general dentists around 2006.
Ever since then, I’ve been helping general dentists launch and scale orthodontics in their practices. I see 4 major roadblocks/push-points that prevent a general dentist from really scaling aligners in their practice:

1. Inaccurate and Ineffective education:

Unfortunately, Invisalign and ClearCorrect don’t teach aligners the right way. They do it backwards. You need to understand basic orthodontics FIRST and then extrapolate that into aligners. The most successful doctors are the ones who did braces and Phase 1 interceptive FIRST. They don’t just take a course, they actively do this kind of orthodontics in their practice. To account for the lack of quality orthodontic education for these doctors, I created my own FREE educational system for aligners on Youtube and it’s available for every doctor all over the world.

2. Lack of a Proper Accountability Loop for Compliance:

Compliance and removable appliances go hand-in-hand. General Dentists have zero experience with compliance. Orthodontists are masters at it. We know when patients are lying (which is often) and when they aren’t. That comes with experience. For those who want a short-cut, I recommend one of the new AI based virtual monitoring systems like: In-Hand Dental or Dental Monitoring System. Yes, Invisalign does have one that is free, called “invisalign Virtual and although it’s very limited and clunky to use for both doctors and patients, it’s better than nothing. You want your patients checking in EVERy Aligner with their aligners off AND on and trying in both their old aligners and new ones to check bite and tracking and compliance.

3. Manufacturing  and Technology Issues:

This is very rare with Invisalign but I see it all the time with ClearCorrect, Sure Smile, Reveal and In-House Aligners. That’s adding another variable into the equation. I always recommend that doctors OUTSOURCE their first 50-100 in-house aligners so that they can remove that variable and just focus on compliance and treatment planning.

I don’t recommend that any dentists get started with any clear aligners  (or Invisalign) without an Intra Oral Scanner. Unfortunately, the USA, Align Technology only permits use of the iTero® scanner. Analog impressions are outdated and do cause additional manufacturing issues to present more frequently and lead to poor outcomes too often. 

4. Interdisciplinary Care: 

Lastly, it is CRITICAL that terminal molars be 100% captured for best outcomes and additional impacted molars, supernumerary teeth, active periodontal disease and oral habits be remove and resolved before treatment begins. This may mean that treatment has to be delayed so that a patient can collaborate with an OMT (Oral Myofunctional Therapist) or an Oral Surgeon or Periodontist. This additional and often unanticipated interdisciplinary care can also add to the expense of the treatment plan to the patient. The good news is that often in a general dental office, these procedures can be kept in-house and add to the overall production of the case and improve outcomes.  

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Advanced Aligner Tricks and Tips for Ideal Outcomes

In 2002, when I was an orthodontic resident at the University of Connecticut, I snuck out of my residency program for a long weekend with the defense that I was “visiting family” for a so-called “family emergency” in San Francisco. Although I do indeed have family in the Bay Area, this was no crisis! Our program director had DECREED that “no residents would become Invisalign® certified under his dead body”—and believe it or not, it was grounds for expulsion!

Keep in mind that 2002 was a generation before the “#MeToo” movement. Although the true stories of the atrocities that occurred in that residency is something for a Lifetime movie series, this blog is not a rant about power inequities that still exist in our residencies but, instead, about how to successfully move teeth with plastic.

Contrary to his evil successor, my true mentor, Dr. Charlie Burstone, was benevolent and brilliant. Although he passed on before being able to see how his principles and techniques could be extrapolated into removable aligner orthodontics, I know he would be proud and fascinated.

I have discovered over the years that like many orthodontists, I have a superpower; I can see a case and predict precisely how the teeth should move within the complex puzzle of orthodontics. Because I’ve focused so much on plastic vs metal over the past 18 years, I just quite possibly might be the most talented, self-proclaimed “aligner orthodontist”, certainly in the US, if not in the world. I can quite definitively say that aligners, especially Invisalign®, can do EVERYTHING braces and do, especially when married with interceptive, functional, habit and airway removable appliances. Not only CAN aligners do it ideally, they also can do it healthier and more quickly than braces.

Tip #1:
Understand the five primary ways to move crowded teeth with plastic:
● Proclination
● Expansion
● Sequential Distalization
● Extractions
Not all aligner companies can move teeth all five ways, nor is it healthy or predictable to move teeth in all these ways for every patient. Orthodontics is a puzzle, and every patient I see is an algorithm that must be solved.
Direct-to-consumer aligners don’t move teeth using the last three methods because you’d need an x-ray or an in-office visit to predictably move teeth with these methods.
Younger patients with healthy teeth, gums, and bone can handle more expansion and proclination. Older patients may need to rely on the latter three.

Tip #2:

Understand attachments but don’t get caught up in the hype about OPTIMIZED attachments. Remember, the attachment is just a handle for the aligner to grip the tooth. The teeth don’t know or care if it’s optimized. It’s my personal belief that most of these attachments are just proprietary and often unnecessary features that help to validate a high lab fee.

Depending on the trimline and rigidity of the plastic and the size and the morphology of the teeth, you may need more attachments for a particular case. It’s not UNUSUAL for an Invisalign case to have over 20-25 attachments! That’s because their material has a healthy, gingival-trimline and is very light and elastomeric in nature.

Truth be told, I haven’t had much success with attachment-less Invisalign aligners. I also don’t normally change around the recommended attachments too much. Instead, I like to put FULL-SIZED attachments on max laterals that are displaced and need rotation, root correction, or extrusions.

I also check the treatment plan for those dreaded blue or black dots and scrutinize every case to make sure they have nice, chunky attachments if it involves those more complicated movements referenced above.

Tip #3:

Don’t venture into Lite, Express, Moderate, In-House, or Flex unless you’ve implemented successful virtual tracking on all your cases AND if your refinement rate is less than 10%. You’ll end up losing money in the long run, either through additional lab fees, extended treatment, and chair-time overhead, and of course, through the frustration of unhappy patients. Patients who are unhappy don’t send internal referrals. A good ortho patient will often refer 2-10 friends and family members. Ortho is a walking advertisement. When you do a good job and are EFFICIENT in your treatment, friends and family notice your expertise both through social media and personal interactions and will seek you out as an ortho expert.

Tip #4:

Never, ever do single arch treatment.
It rarely works out, and patients expect it to be quick, easy, and cheap. It isn’t.

Tip #5:

Buy an accurate IPR system. Don’t use burs or disks. Learn to do it right. Good IPR takes time. If you are sloppy with your IPR, you’ll have an unhappy patient, and the case will take longer.

Tip #6:

Understand the concept of round-tripping and avoid it when possible. Unless you tell the lab “no”, you’ll likely get this on your IPR cases. I’ve seen countless cases with devitalized or lost teeth due to excessive round-tripping. Orthodontists use round tripping all the time, especially with IPR cases and straightwire cases where OCS (open coil springs) are needed, but we also know how to pick these cases and take cephalometric x-rays. We also know when not to round-trip on inappropriate cases. Now, I know Invisalign has announced they are now allowing CBCT submission to factor into treatment plans, but would I really TRUST a technician to make that decision for MY patient? No. I am the doctor, and I make that decision. Not a lab tech.

Tip #7:
Double check your articulation on EVERY. SINGLE. CASE. I can’t tell you how many times I’ve seen cases get royally screwed up, even if they were scanned by iTero because the doctor didn’t double check. The issue happens more with refinements than with initial cases, but now, with the “occlus” (green-dot) button, you can easily check both initial and final articulation. Finally, ClearCorrect has implemented this feature as well. It’s the very first thing I check before reviewing a case.

Tip #8:

Habits are the bane of an orthodontist’s existence. You MUST eliminate habits before starting any treatment OR work with an OMT (Oral Myofunctional Therapist) to eliminate them concurrently, but that is an additional third-party fee and step for the patients. It’s very easy to train your RDH in a four-day course to be an OMT, and a dentist can do it as well. I highly recommend it, and it’s an additional revenue-builder for your practice.

Remember, habits aren’t just fingers, thumbs, and pacis. They are also tongue thrusts and mouth breathing which often goes undetected in adults. From my experience, a severe habit will undo and unravel an amazing ortho outcome, even WITH permanent retention.

Tip #9:
Be wary of big masseter or low-angle cases. They can cause havoc on your aligner cases if left undiagnosed or improperly treatment-planned. Have you ever had a posterior open bite in an aligner cases? What a pain! Based on my experience, most could have been prevented by using bite turbos. The issue is that many aligner companies don’t offer this feature. I would never use an aligner company that didn’t have anterior bite turbos. Masseter Botox is also a great solution for these cases.

Tip #10:
Less is more with movements and staging per aligner. Did you know that slower and lower forces actually makes the treatment go FASTER and more predictably, causes less discomfort, and is healthier for the patient? I’ve never had an issue with Invisalign and Clear Correct in slowing down the plans. I take every Invisalign plan and double the number of aligners. For ClearCorrect, I triple. Unfortunately, SureSmile often refuses to let you slow down their plans, so for that reason, I refuse to use their product. (Also their dashboard is horrific and non-functional and looks like it was coded by a 2nd grader).

In conclusion, my orthodontist as a teen was the president of the AAO, the American Association of Orthodontics. He was also a member of our church and a friend of the family. I won’t name him by name because, although he had so many accolades and awards and was a very kind man, he damaged my teeth so severely that I can’t even bite into an apple now. Braces are dangerous, and as a result, I’ve dedicated my career to finding healthier, more esthetic, and more humane ways to create smiles.

I’ve poured myself into aligners and removable appliances, and now, with this blog, I am going to give YOU access to my carefully curated list of tricks and tips to idealize aligner outcomes! If you follow my guide, you’ll also be able to enjoy and efficiently and successfully build your own removable appliance practice. If you want help with a case, we offer 1:1 support. Visit book a session today!

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How to Hire and Pay for an In-House Orthodontist at Your Group Dental Practice

Are you looking to add orthodontic services to your group dental practice? No matter whether you are a general dentist, pediatric dentist, or a DSO, adding these services can seem like a great opportunity to expand your business and increase your revenue.

However, while they can be beneficial, there are also a host of challenges and complexities that you will face. At least once a week, practices will ask me, “can you help me to find an orthodontist for my practice?” and having been both an ortho looking for opportunities and the owner of a practice looking to hire people, I know what works and what doesn’t.

That is why I thought I would take a closer look at the many hurdles you will face…

Why should you hire an orthodontist?
While there are a considerable number of issues and challenges with adding orthodontic services to your practice, if done correctly, it can be very beneficial. If you are tired of referring patients out, then it can help you to offer patients a far more comprehensive range of treatment options in-house, helping to increase revenue and elevate your practice.

What are the challenges of adding orthodontic services?
While there is certainly a host of opportunities by adding these services, many practices underestimate just how complex of a process it is. In fact, more often than not, most corporations will not follow through with the expansion due to the challenges that arise.

Some of the most common issues you will face include:
1) Large investment
One of the first challenges that come with adding orthodontic services is the large amount of investment that is required. In order to offer high-quality orthodontics, you will need to pay for significant tools and equipment, including an internal scanner, which requires clear budgeting.

Of course, you will then face additional costs throughout each quarter, too, from lab fees to replacement equipment, so it is essential you understand the costs involved before starting.

2) High turnover
Another major challenge is that orthodontics faces extremely high turnover rates. It is very unlikely that your new doctor will stay for a long time, with many either not being up to standard, leaving to find better remuneration, or to start their own practice.

This creates significant challenges, as you will need to either be able to complete the services yourself or pay for an experienced orthodontist to join your team temporarily.

3) Payment
You will also need to establish how you will pay your doctor. You should not be paying your orthodontist in full until the entire project has been completed and the patient has signed a statement of satisfaction.

That means you should break the fee down into clear segments for work completed, and this needs to be clearly outlined in their contract.

4) Availability
It is also very likely that your doctor will only be able to do one certain day a week. While to begin with that will likely work well and patients will understand, eventually, life will dictate that patients need to swap days or that your doctor might no longer be able to make that day.

It is also very likely that at some point in time, you will also face a patient who needs emergency treatment. In both of these instances, you will need to either be able to step up or face having to refer them to another practice. As the owner, it is your responsibility to pick up the pieces.

Need help?
If you are in need of support with expanding your business or orthodontics, then StraightSmile Solutions® is here to help you. We are a web-based orthodontic consulting service designed to support general and pediatric dentists, new graduates, dental laboratories, and those in the dental industry.

Want to find out more? Get in touch with our team today!


A Guide to Submitting Invisalign Refinements / Additional Aligners

I help doctors submit for refinements/ additional aligners every day. Here’s what I need to know first:

1. What aligner is the patient currently holding on?
2. Did you take new scan/impression?
3. Did you remove the old attachments before the impression?


Here’s a guide to doing it yourself:


If you need help with a case, please go to and we’d be glad to help you.


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This article will bring to you relevant questions and answers that will reveal the pearls required for achieving efficient and profitable orthodontic practice in a GP Practice.

Q. 1 What are the steps to take when incorporating orthodontics into a GP practice?

There is no “one size fits all approach” to launching or scaling orthodontics in a GP Practice. Our team takes time to get to know our GP Clients and helps them select the best systems that will fit the needs of their practice. An initial phone call is totally free to learn more. You can schedule it at


2. What are the Major Classifications of GP Orthodontics?

  • Branded and Unbranded Aligners
  • IDB/ Straight-wire Braces
  • Functional appliances / Phase 1 Interceptive/ Pedo Airway and Habits

Q. 3. Which of the GP Orthodontics should be undertaken first?

It all depends on the demographics of the patients. Our pediatric dentists consider the functional appliances for Phase 1 as the first category. General dentists treat older patients. Aligners are the initial category of our GP. On the other hand, the IDB straight wire is the initial category of dentists specialized in handling teenagers and young adults. You should also consider your competition and your location. More affluent demographics tend to prefer Invisalign over braces. In some populations, metal braces are considered fashionable and a sign of wealth. Know trends and your demographics before you make this decision.

Q 4. What are the armamentarium to have before starting Orthodontics?

Before commencing Orthodontics, all categories of doctors must make provisions for panoramic x-ray and intra-oral scanners. Although an IOS isn’t required, it will be very difficult to profit and scale without one. iTero is probably the best choice if you are considering Invisalign. There’s no reason you must get the most current iTero and break the bank. I recommend the iTero 2 which works just as well and still has access to the IOS (Invisalign Outcome Simulator Software) but is about half the price of the iTero 5. The bulky wand can be switched out for a newer one for a small, additional fee. It is a tiny bit slower than the 5, but you’re talking about 20-30 seconds.  $20000 is about the going price for a refurbished iTero 2 which isn’t much more than a Medit and is a lot more functional for ortho. Talk to your rep for more information.


Q. 5. Is it profitable to launch Orthodontics?

Of course, it is very profitable! You are expected to make an initial provision for supplies worth about $2000 before you can undertake the straight-wire category. Don’t be too concerned about this because it is possible to earn six figures in a year without investing in any additional supplies, equipment, marketing, or staff.

Our team can assist you with a long list of all the pertinent supplies you must have before starting Orthodontics. Follow the link below to have access to our courses and tutorials. Reach out to us if you’re interested in having a copy.

Q. 6. What are the categories of GP Orthodontics case selection?

All general dentists are expected to select cases that fall under the following categories: Green, yellow, and red categories. New dentists to orthodontics should stick with green cases. For more information, see this blog:


  1. 7. What is the future of orthodontics in the US?

Currently it is estimated that about 52% of Orthodontic cases in the US are handled by the GPs. On the other hand, an estimated 82% of GPS and Pediatric Dentists are delivering Orthodontic services. Why be part of the minority and allow DTC aligner companies to take your patients? Take back control of your patients’ oral health care by offering in-house orthodontics.

Q 9. Why is it important for general Dentists to offer both aligners and IDB and/or Phase 1 Functional Appliances?

More so, the preferences of the patient should be put into consideration. Availability of options gives room for the patients to practice the use of the appliances. Patient compliance is another major reason. For instance, not all the patients will comply with a removable appliance. It is not possible to optimize all bio-medical dynamics with a single solution. With diversification, you’re sure of achieving better outcomes and supporting patient preference. Regardless, you should have compliance contracts and paperwork in place. We have many of these documents in our store:

Q 10. Which oral habits negatively affect successful Orthodontic outcomes?

This is very dicey because of the numerous habits that can deter the success of Orthodontic procedures. Some of these habits are: Digit-sucking, thumb-sucking, lip-sucking, mouth-breathing, abnormal-tongue resting position, tongue-thrust, reverse tongue-thrust, and backward-swallow, to name a few. The importance of incorporating habit solutions into Orthodontic cases cannot be overemphasized. Of course, they bring about excellent results. It becomes more complicated when you’re dealing with kids, but you should always keep it in mind in adults too.



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TMD, TMJ, and Orthodontics

What do TMD and TMJ mean?

These are both acronyms that refer to the same condition, though one is more specific than the other. The first one, temporomandibular joint disorder (TMD) is the correct term that is used in the industry of orthodontics. It means that you have a disorder in this joint, which connects the temporal bone to your jaw.
The other term, temporary mandibular joint (TMJ) is referring to the same thing but is incorrect since it’s just referring to the join itself and not the condition impacting it! While some experts will use TMJ, most use TMD because it’s more professional.

What does it mean to have a TMD?

It basically means that you are having a problem moving your jaw up and down and it should be treated. This could be caused from arthritis in the joint itself over time. It could also be caused by stress which causes many to grind their teeth together.
TMD can also be caused by something more traumatic, such as a direct injury to your jaw, or even something like whiplash.

How is a TMD diagnosed?

Firstly, it’s ruled out from other conditions that can be causing a problem. To do this, experts may do an MRI or CT to see if the TMJ disc is in its proper position while your jaw is moving. This will help either note it as the problem or rule it out! This usually involves a referral to an oral surgeon for diagnostics. Usually, I start with my patients by having them keep a diet journal and eliminating all chewy or crunchy foods and chewing gum from their diets for a few weeks first. If the discomfort is still severe, we may refer them to a specialist. Otherwise, masseter Botox can also be helpful.

What are symptoms of a TMD?
The cause of the TMD often can note how weak or severe the symptoms are. Common symptoms include:

● Pain in the jaw, neck, shoulders, or ear (when moving your jaw)
● Your jaw gets locked open or shut sometimes
● Clicking or popping when moving jaw
● Earaches, dizziness, ringing in the ears

What treatment is available for living with a TMD?

Most of treatment is going to be about adapting your habits to help you prevent further damage to this joint. However, many will blend this with orthodontic treatment as well. The most popular options include:

● A splint: This is a clear guard that fits over your teeth. It will help align your bite properly and can reduce the pressure that is put on when you grind your teeth. This is worn all the time except for brushing your teeth and eating.

● A nightguard: This has extra thickness in it that will give your jaw more comfort when worn and can help ease pain and other symptoms. This is worn only at night, or during particularly bad flare-ups.

● Repositioning treatment: Through either dental work, or more advanced orthodontic work, you may need to receive help and treatment for a bite problem that is causing or exacerbating the problem.

In a nutshell, I don’t recommend treating patients with TMD orthodontically unless the pain has been eliminated first.

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Why Doesn’t StraightSmile Solutions Do Lecture Courses on Aligners?

I do sometimes offer courses. I post them on my website here:
The reason I don’t do actual “courses” is because these are always sponsored (because they are expensive to put on) and  in doing so you give your heart and sole away legally and you can’t speak freely.  I’ve had that happen to me in the past and I don’t wish to do that again.
If you want a destination course, I recommend my friend, Dr. Rishi Popat- here’s his courses:
Mostly, we do 1:1 coaching with doctors because that’s the best way to learn.
Also- we have over 3000 videos which are FREE and everything you need to know is there!
Check out our YouTube channel and just search by any keyword. I am sure you’ll find what you are looking for.
Here’s the link:
Of course, please do subscribe because we add new videos almost every day and we take requests!!
Also, check out
That’s where we post our archived webinars.

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How Do StraightSmile Solutions Invisalign Protocols Differ from Molis and GLR?

I often get asked this question and I really don’t have an answer for it, outside of “we do things differently”:

1. We don’t have some blurb that you cut and paste in your comments section of your Invisalign Clinical Preferences.

* This never works! All it does it slow down your treatment-planning and confuse the technicians.

2. We don’t move only anterior teeth:

* How can you expect predictable outcomes if you are only moving “some teeth”?

3. We correct habits BEFORE Invisalign Starts

* This is self-explanatory. All oral habits (mouth breathing, tongue-thrusting, thumb-sucking) MUST be corrected fully before treatment starts.

4. We don’t do compromised/ orthognathic cases.

* These need jaw surgery and we don’t try heroics. Refer them to ortho.

5. We stage our treatment 2-3x longer

* Why over-promise and under-deliver?! Our way just works better and patients LOVE it!!

6. We LOVE bite turbos!

* Love, Love, Love! BUT- take them off a few aligners before the end or you’ll have overjet.

7. We believe in weekly changes but also weekly virtual tracking for an accountability loop.

* Why do refinements, when they aren’t often necessary? Do things right the FIRST time!

8. We Believe in Phase 1 Tx and Growth Modification and Expansion should be done Early in Phase 1 Treatment

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Class 3 Space Closure Mechanics

It is so important to manage space well with anchorage for Class III cases. Below are my “Class III Spacing Beads on a String Mechanics”.

At the heart of this is ANCHORAGE! The LLHA is my anchorage of choice for class 3 cases with lower spacing. If the class III case has only upper spacing, the LLHA isn’t helpful. As long as the LLHA is in you can just chain 6-6 on the lower (molar to molar)

The best way to manage this maxillary space is to close the space in units. Start with upper 3-3 (canine to canine). Once that is closed, you’ll
long-tie/undertie max 3-3. If not, please do that for anchorage. So undertie max 3-3 and chain 4-4 or 3-4 on both sides. Either way. Have the patient come back every 3 weeks for chain change.

Once the 4’s have fully protracted and uprighted, remove the lace/undertie and redo it to 4-4 and repeat, but this time to the 5’s (and so on, to the 6’s, to the 7’s, all the time wearing class 3 elastics.

If the patient is an elastic-wearing champ, this will all work out just perfect. Let him know that. If he’s not, he’ll be getting a lower incisor extracted. This is up to him. You will do everything you can to avoid this but he must wear 3/16 heavy class 3 elastics BILATERAL until the spaces are closed.

IF you get to edge to edge occlusion at ANY TIME and there’s still space left, the deal is off and a lower incisor comes out.
If you get to edge to edge and all the spaces are fully closed (including molar spaces), just add lower IPR.

This will realistically take 6-9 months. The more he wears elastics, the faster it goes. Also make sure you power chain is NEW!