Straight Smile Solutions

Do you NEED a Ceph Xray for your Invisalign Patient?

Ultimately, you’ll need to consult your dental practice act in your state or country for the answer on this question.

For me, I only take cephs if there’s a benefit from the cephs. I take cephs on growing kids who need AP or vertical changes and on adults where we are contemplating making drastic AP or vertical changes.

If you are just starting orthodontics in your practice and you don’t want to invest in a ceph arm or module, you can always refer out for the ceph. There are many oral and maxillofacial radiologists in urban areas who often have free-standing xray only practices.

If you don’t have a center near you, you can also consider a dental school.

Lastly, find a friend nearby who you can outsource the xray too, who will be professional and not poach your patient.


Allergies to Invisalign or Braces Tricks and Tips to Manage Allergies During Orthodontic Treatment

Allergies are real in orthodontics. The first step is a comprehensive medical and dental history.

The most common allergies are:

1. Latex (Gloves, Braces Elastomerics)
2. Nickel (Metal braces and Wires)

I find most real allergies are usually only in adults. Whenever a patient declares that they have a latex allergy, the first question I ask is, “tell me what happens”. True allergies can manifest just as mild itching all the way to anaphylaxis. If a patient mentions anaphylaxis or swelling of the mouth or tongue or throat, I’ll often request a medical clearance from the patient’s allergist or PCP in order to proceed with treatment with braces.

Although it’s possible to reduce latex or nickel exposure with self-ligating, ceramic braces or aligners vs traditional metal braces with elastomeric ties, it often can add to the patient expense. These products are often more expensive. Treatment is often slower with non-latex elastics vs latex elastics.

I’ve never seen an allergy to clear aligners, but reportedly in the literature it does happen albeit, very rare.


Management of Discomfort with Orthodontics Patients

Discomfort is real in orthodontics. I’ve had both braces and aligners as a patient several times and I’ve also treated tens of thousands of orthodontic patients. I can tell you that the pain IS real and management of discomfort is critical to patient trust and compliance.

I always address the elephant in the room at the “start” appointment. Usually, the younger patients have very little discomfort but teens and adults often do. There are two kind of discomfort in orthodontics:

1. Related to rubbing of the new appliances

2. Related to the moving of teeth

All patients should be given wax and orabase at delivery appointment. I usually instruct the patients to use the wax liberally on any area that is bothering them. Take a small piece of wax the size of a pea and press it on any area that is causing irritation. Always use wax before bed as well. Some patients may go through many packages of wax just the first week alone so remind patients they can always buy more at their local drug store or stop by the office for more. Wax should be removed for brushing and flossing but can be worn while eating.
Usually after a few weeks, the lips and cheeks will become more resilient (like wearing new shoes) and the wax will no longer be needed.

Teeth movement is another kind of discomfort. This can express just as a dull aching or a very real, sharp pain that throbs. Usually this will kick in about 24-48 hours after a change of aligner trays or after an orthodontic “tightening” and will last several days. It’s important to get ahead of the pain with OTC painkillers like Motrin and Tylenol. Follow the direction from your MD if you have any questions.

Aligners usually have much lower discomfort than braces but that all depends on the type of thermoplastic material that is used and how the treatment is staged. Aligners that are changed every 3-5 days have much lower discomfort than ones that are changed every 2 weeks because the forces are lower and more gradual.

Occasionally, you’ll have a patient who is having severe discomfort and having trouble managing the pain. I recommend the “pulse” method for short-term, severe, acute discomfort. Have the patient contact their MD with dosages and questions. This involves taking BOTH NSAIDS (like motrin) AND Tylenol but not at the same time. Normally Motrin is taken every 6-8 hours and tylenol is taken every 4-6 hours. Never exceed the recommended maximum dose of either medication. I have the patient start with Motrin at breakfast and make sure they are eating it with a meal. 2-3 hours later they take the first dose of Tylenol just to “stay ahead” of the pain. You don’t wait until you feel discomfort to take the next dose. Stay on a schedule. Every 3 hours or so during the day you are taking a dose of the pain relievers, alternating NSAIDs and Tylenol. The last dose before bed should be the NSAID because it’s longest acting.

I wouldn’t do pulse for more then 24-48 hours and then stop. They may no longer need it after that. Some patients will start pulse BEFORE their aligner change or orthodontic adjustment.

Make sure your patient contacts their PCP or MD with questions about dosages and medications.


How to Launch Virtual Consults for Invisalign and ClearCorrect and Braces

You should offer both virtual consults and in-person consults in your practice. Block a variety of times in your schedule every week for virtual consults on an admin day.

Be sure you are still sending out all your medical and dental Hx and office paperwork in advance through DocuSign as well as a “Smile Questionnaire.” For a sample of one, please email me at [email protected] To prepare for a virtual consult, it is really helpful to have some initial images. I love SmileSnap® and for this. Don’t worry too much about the quality of images. They’re to give an “idea” of whether the patient is even a candidate and if an in-person consult might be necessary to finalize the consult. Be sure to have samples of what ideal photos look like on your website and encourage patients to bite on their back teeth in the biting photos and use retractors like chopsticks or spoons. You can also mail the patient a retractor along with a welcome letter.

Once the paperwork and selfies are returned, you can offer the patient a virtual consult or an in-person consult. Preference should be to a virtual one based on the patient’s availability and simplicity of treatment.

Have a variety of convenient appointments available. Calendly is a good option for scheduling if you don’t want to invest in an expensive system. Premium Calendly is only $144 per year and you can embed the widget in your website, which draws more traffic. A team member can run the virtual consults and “pull in” the doctor when needed. If you want to “test drive” Calendly, you can see it in action at my own website at
So to recap here are the steps:

1. Embed a widget like SmileSnap or on your website to capture the initial “selfie” photos in a HIPAA-compliant manner. This will give you an idea of what is going on and if you should schedule an in-person consult or a virtual consult. It’s also helpful to do some kind of smile screening questionnaire. I have a copy of this kind of questionnaire in my archives to feel free to request if you’d like a template.

2. Have all your forms available through DocuSign as well as a Smile Questionnaire.

3. If the case looks simple and/or if the patient is looking for anterior improvement only, a virtual consult should work and you may not need a subsequent in-person consult. You can use Calendly to have the patient schedule it and send a private zoom link once they do. The OM or TC can run the show and pull the doctor in as needed if the patient is ready to sign paperwork. It is helpful to have the patient’s selfie photos ready to share and refer to. It’s a good idea to review them ahead of time with the doctor as the patient’s smile questionnaire. It is still okay to do a virtual consult for more comprehensive needs, but the doctor will likely need to confirm the consult with more records and an in-office clinical exam.

4. Having transparent fees on your website is very helpful. I like to have one fee for “branded” aligners like Invisalign and one fee for “limited,” “anterior” or white label/in-house aligners. Just two fees only. No up-sell.

5. If the patient is engaged an interested and it looks like a good match, bring the doctor into the virtual consult. Patient should have their retractors, spoons or chopsticks ready for the doctor. A treatment plan is created, and contracts and financials can be sent by Docusign/Stripe or Paypal. Regardless, Patient gets emailed Tentative Treatment Letter


Should you pick Braces, ClearCorrect or Invisalign?

I am asked this question quite often by my consumer followers.

First of all, it’s a personal decision. In the right hands with an EXPERIENCED doctor, almost everything that can be done with braces CAN be done just as well with aligners. There’s a few one offs for me: jaw surgery cases. mixed dentition and impacted canines. Now, that being said, I said CAN do, I didn’t say it is faster. Sometimes aligners are faster for some things, sometimes braces are faster. So ultimately it comes down to what you want.

Aligners are healthier for your teeth and gums as well because you can brush and floss easier and they often (but not always) distribute lower forces and cause less side effects and discomfort. That being said, not all doctors are trained to do good aligner work. Just because they rank high on the Invisalign doctor locator, doesn’t mean they are good.

Here’s a few more facts:

  1. Most orthodontists are indeed very good at braces.

2. Most dentists doing aligners ARE NOT orthodontists.

3. Most dentists doing braces ARE orthodontists.

4. Many general dentists do excellent orthodontic work, some of them better than orthodontists because they take more time and often do the work themselves with the patient instead of outsourcing to a team member.

You need to pick your doctor carefully. For aligners here’s a few good litmus tests to ask the doctor:

1. What percentage of your Invisalign/ClearCorrect cases do you submit as comprehensive or moderate vs Express, Assist, Go or Lite or Flex?

* If the doctor says mostly Go, Assist, Express or Lite or Flex, I would not pick that doctor. They are clearly doing anterior only or just “improved” work and not comprehensive work (ideal). That means they aren’t making things perfect. That’s totally okay if that is what a patients wants as long as the risks, benefits and alternatives are explained…. but for me it’s always the exception in the practice, not the majority of patients.

2. What percentage of your aligner cases need attachments, elastics, bite ramps or IPR (the answer should be 99%+ of one or another).

* If the doctor doesn’t have at least one of these on all their cases, they don’t know how to “idealize” the case and make cases perfect. They are just an “improved” doctor, which again, is “fine” as long as that is what the patient wants (see above). This is NOT fine for children, IMPO.

3. What percentage of your aligner cases need revisions or refinements or mid-course corrections?

*If the answer is over 50%, I would run. They don’t understand aligners and/or they don’t know how to handle compliance or optimize a treatment plan.

4. Can I see my ClinCheck/Clear Pilot before signing a treatment contract or financially to the treatment?

*If the answer is “no”, I would run.

Here’s the real truth. Keep in mind that doctors are charged a hefty lab fee from Align Technology or Straumann (the owners of Invisalign and ClearCorrect) up front. In the US, the fee is between $1500-$1900 for a Comprehensive/Moderate/Unlimited case. We have to pay that fee upfront even though we likely haven’t collected that much from the patient in the form of a down payment or insurance. Insurance pays the doctor over the lifetime of the case. We don’t get a lump sum up front. Therefore we are in the hole/aka negative cash flow when we start your case. When I worked for several large orthodontic practices, we were pressured to tell patients that they should pick braces instead of aligners all the time unless the payment was paying in cash up front. That’s the truth. We make more money off braces cases in theory BUT it does take more chair time/office time which also has a value so I think it’s really about the same but many people don’t think like I do.

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Tricks and Tips for In-House Retention

To get started, we only recommend that you make in-house “lifetime” retainers if you have the proper armamentarium, including a pressure-vacuum former like a Durfomat or Biostar. A standard vacuum-former doesn’t give enough detail/fit for long-term retention. If you don’t have the proper equipment, it is best to refer your retention out for fabrication to a local lab or Align Technology Vivara. Remember, “essix-type” retainers last on average 6 months to 2 years so throughout a lifetime the patient will need to replace them often. Be sure you are transparent about how the re-ordering process will work and what the cost is. Also, if the patient gets new dental work, a new retainer may need to be made.
Not all plastic is alike. Material for retention is stiffer and often thicker than aligner or bleaching material. Here’s some of our favorites:
• Essix ACE® Plastic (Clear material with a green Essix® protective film on both sides)
• Essix C+® Plastic (Cloudy material- NOT perfectly clear) – good for bruxers
• Essix Plus
• Zendura Classic

1. If you are taking impressions, PVS is better than alginate for long-term retention. We don’t recommend using alginate except for temporary retention. A scan is always better, and scans can be stored in the cloud for easy re-ordering.
2. If you are making it in-house, pour your impression up in stone, not plaster.
3. The case should be trimmed to a 3/4-inch base. Any thicker, and the plastic won’t adapt ideally. Bubbles should also be removed.
4. Make sure you get the right size and shape thermoforming plastic to fit your machine. Some are circles, some are squares.
5. Wheel saws and electric heat knives are helpful for removing the cast from the plastic.
6. Iris or Mayo scissors can be used to trim further, and wheels can be used to polish

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How to Solve the Broken Bracket Mystery

Broken brackets are a pain for both parents, patients, doctors and teams. It is critical that the doctor solve the broken bracket mystery so that the case can get back on-track. Every broken bracket is often at least another month in braces. I normally don’t count brackets that break within 24 hours of bonding and I give 3-5 free broken brackets throughout treatment. Any breakage beyond that is “$X” if reported
and scheduled for repair immediately and “$y” if not reported. I also charge for extra treatment time if the breakage is chronic.

In my offices, I had a few questions I would always ask:

1. When did it happen?

* If it happened within 24 hours of the bonding appointment, it is likely the fault of the doctor or team. If it happened more than 24 hours later, it is likely the fault of the patient. Be sure that parents and patients are aware of this policy and that parents call immediately to report broken brackets. I’ve always bent over backwards to accommodate patients who had a broken bracket that was just placed within the 24 hour window because I know it’s likely an error on my end. Patients and parents should be checking their brackets daily. If they are flossing it will be quite evident if one is broken.

2. Where is the adhesive? Check to see where the adhesive is. The residual adhesive location gives more information on the source of the breakage.

Glue on Tooth:

1. Light Cure Unit needs Calibration
2. Too Heavy of a Wire
3. Too Much Force at Tie-in (heavy-handed)
4. Patient Diet Compliance
5. Bite Interference

Glue on Bracket
1. Improper Etching
2. Improper Isolation
3. Plaque on Tooth at Bonding
4. Using Fluoride Pumice or Toothpaste before Bonding
5. Using Listerine Before Bonding
6. Whitening too Close to Bonding Appointment
7. Improper Priming
8. Light Curing Improperly
9. Improper Calibration of Light Cure

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How is Invisalign Treatment Staging

This is an analogy I like to use about aligner staging:

Picture a big river with lots of stones to use to walk across. (This is a hypothetical analogy).

We only have “so much” asphalt to manufacture the stones.
We could have 10 big stones, each 2 feet from one another…


We could have 20 little stones, each 12 inches from one another.
Are you more likely to successfully cross without falling in with the 10 big stones spaced far apart or the 20 little stones each very close together?

Probably the little ones, right?

With Invisalign Comprehensive and ClearCorrect Unlimited, you can slow the movements down as much as you want and have tons of little stones and change it more frequently. 7 days, 5 days, 4 days.

It doesn’t cost more.

It is basically impossible to get off track if you do this as long as you use your team’s “second skin” scripting. The 7 days (or 2 weeks) doesn’t even START until it is fully on, seated and tracking like a 2nd skin.

A Guide to Fixing Anterior Openbites in Growing and Adult Patients

Anterior openbites are frustrating in every patient. Too often, I see doctors just jumping-in and trusting the treatment planners into a plan that isn’t predictable or retainable long-term.

I always say, doctors should never take an openbite case until they’ve been a detective first. They need to find all the etiologies and treat those FIRST and then do the ortho.

Here are the tools I recommend using in order to learn more:

1. Adult or kids sleep and habits / OSA questionnaire
2. Mallampati Scoring
3. Look for adenoids in the ceph xray
4. Look for mouth breathing clinically
5. Look for tongue thrust clinically
6. Check patency of the nasal airway

Treatment may mean putting in a fixed or removable tongue or habit appliance first for 6-9 months before braces or aligner begins or working with a myofunctional therapist.

If Malimpotti, adenoids or nasal patency is an issue or if the sleep questionnaire gave red flags, I would refer out to the ENT before starting treatment.

Although this delay may be frustrating for patients, this would be standard of care and you’ll be likely increasing the health of the patient and the quality of their life long-term. You’ll also be likely to have a better orthodontic outcome.

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Handling Non-Compliance in Orthodontic Patients

Non-Compliance can be very frustrating in orthodontics. As you scale up, it is unfortunately inevitable that you’ll experience non-compliance on a regular basis. The key to overcoming it is to have a plan of action.

Establish Expectations Upfront with Parents and Patients

Before I even get started, I always discuss expectations in the contract with parents and patients. You might even want to have a separate written compliance contract that outlines this and have both patient and parents sign it. I explain “the why” behind why I prefer compliance-based mechanics for orthodontics (discomfort, patient experience, oral hygiene) and what the expectations are for both parents and teens. I also explain my “3 Strikes” rule with compliance: patients and parents get 3 warnings about non-compliance; after those 3 warnings, further action will be required.

Example #1- Overjet Patient with Elastics

1. Discontinue treatment and leave overjet –this compromised outcome will remain. The patient will then sign a discontinuance form.

2. Some kind of compromised “improvement” option:
– IPR to improve overjet (IPR can be done at no cost but risks include removing protective enamel – N.B. I wouldn’t charge extra for this);
– distalization appliance (If I was going to do the fixed, distalization appliance, I would charge the patient for impression, insertion, lab fee and additional appointments since there is no logical reason for this outside the patient being non-compliant, so maybe a $500-$800 upgrade fee);
– or, extractions (I would charge extra for the actual procedure and also for additional Tx time.)

Example #2- Cross patient with a Schwartz expander

For RPE, I would charge the patient an upgrade fee for converting from removable to fixed; an impression/lab fee; and, for an insertion. If they still aren’t turning, have the patient come in weekly and you can turn for them – I would charge a small fee for this too.

Demonstrate good patient management, by thinking about the “why” behind the non-compliance. Of course, if it is an issue like the mom is blind or has a disability and can’t turn that’s a different story: just have them stop by weekly for someone in your office to turn for them.

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