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.
Understand the five primary ways to move crowded teeth with plastic:
● Sequential Distalization
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.
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.
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.
Never, ever do single arch treatment.
It rarely works out, and patients expect it to be quick, easy, and cheap. It isn’t.
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.
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.
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.
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.
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.
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
https://www.straightsmilesolutions.com/services/to book a session today!