Straight Smile Solutions

Oral habits like thumb-sucking and using a pacifier use can be normal, soothing reflexes from birth to one year of age. The majority of children naturally outgrow their habit easily on their own. However, habits that persist after the age of three or four risk oral complications:

• Crooked teeth
• Narrow arches
• Proclined teeth (AKA buck teeth)
• Longer and more complicated orthodontic treatment, possibly including surgery or extractions
• Posterior crossbites (the upper arch fits inside the lower arch)
• Anterior open bite
• Smaller airways
• Impacted teeth
• Long facial height by changing the growth pattern

Eliminating Habits

The first step to eliminating habits is to examine the patient and take limited, orthodontic records. Panos, cephs, and uncomfortable intraoral photos aren’t needed at age 3-5 but may be needed in older children. For children ages 3 and 4, I recommend making the exam fun by having the child use his own fingers to retract his teeth and make a “funny” face while biting his teeth together like an alligator. I used to save a few of these photos to show the child how other kids did it and offer a copy of the photo home as a souvenir.

I also recommend getting a baseline SDB/Habit Questionnaire for documentation. Many pediatric oral trainer companies have their own version of this form, or you can purchase one from our store.

For kids under age 5, often all you need to do to correct the malocclusion is to eliminate the habit. Positive reinforcement is the best step to start:

• Children may suck their thumbs when they feel insecure. Work on correcting the cause of anxiety, instead of the thumb-sucking habit. Stress in the home often needs to be corrected before you can address the habit.
• Reward children when they refrain from sucking. Use a Sticker Chart on a calendar.
• Give verbal praise to the child. Encouragement from siblings also helps. Success with habit cessation is a win for the whole family, and the siblings should also get a reward or a family celebration, like a trip to the ice cream parlor!
• If these methods fail, remind the children of their habit by bandaging the thumb or putting a sock on the hand at night. One of my favorite tricks is to take a large, men’s, long-sleeve T-Shirt and tie knots in the ends of the arms. You can let the child decorate it with fabric pens or tie-die it so that it’s less like a punishment and more like a fun adventure!

If that method isn’t successful, I recommend a soft, removable habit correction appliance which I call a “Tooth Pillow”. These are stock (not custom), so taking an impression isn’t necessary. Fees start at $50 and go up depending on what company you use. Some companies do require you to take a certification course to order these appliances.

For more information, check out our top-selling eBook or watch our YouTube video where I discuss U Concept® U Kiddy, Pacifiers, and Binky help for ages 2-4 years old.

For kids, older than age 5, often more aggressive treatment might be necessary beyond the removable appliances, including fixed or removable palatal cribs and/or palatal expanders. These will require full orthodontic records and an impression or scan.

These custom appliances usually stop thumb sucking immediately. They are used for 6-12 months, at least.

“please fabricate u/l schwartz with no occlusal acrylic, lab please pick best clasps”

This is pretty standard for fixed if you want to archive the script for future patients.

Only variation would be one of the following:

1. Please add anterior bite plate
2. Please add sagittal to distalize tooth _____

3. Please add sagittal screw to advance tooth ____

4. Please add tongue/thumb crib

Ultimately this is pretty easy. Not too many variations.

“please fabricate u/l fixed expander with buccal tubes”

or 

“please fabricate u/l fixed expander”


This is pretty standard for fixed if you want to archive the script for future patients.

Only variation would be one of the following:

1. Please solder anterior bite plate
2. Please solder facemask hooks

3. Please solder tongue/thumb crib

1. Educate Yourself
From my 20 years in the orthodontic industry, I’ve compiled my top tips for selling that ortho case. For more detailed clinical tips and tricks, I recommend my book: https://www.straightsmilesolutions.com/store/ebook/
2. Non-Surgical and Non-Extraction
Advertise yourself as a 99% non-extraction and non-surgical orthodontist in kids under age 10. This can be a very lucrative statement. No one wants to have teeth taken out and nobody likes jaw surgery, so give your customers what they truly want for the parents who are willing to accept Phase 1 treatment! Of course, there are occasional pathology and one-offs who have skeletal asymmetries, hence 99% rather than 100%,
3. Complimentary Panoramic Xray for Screening
Panoramic Xrays are the gold standard for screening kids aged 7 and up for orthodontics. Don’t charge and don’t be stingy – it will pay off in the long run. When parents can visualize potential impactions, the argument for early treatment is all the more powerful.
4. AirwayDontics
Screen every. Single. Patient for airway issues. Use a SDB screening form. Good airways are directly correlated with Phase 1 orthodontics and also better behavior and grades in school, and most parents are unaware of the connection. Educate them with YouTube videos and blogs. For more information, check out our YouTube page, which has hundreds of videos on the subject: https://www.youtube.com/c/Straightsmilesolutionsortho
5. Get Social!
Now that you are loaded with invaluable new knowledge, we have come to the last and the most important step – go and put the knowledge into practice! Start with social media: regularly post some of the claims above to your social media accounts: use Facebook, YouTube, Instagram, and TikTok. Thousands of practitioners are doing this already!

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. https://www.aaomr.org/find-an-omr2#/

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 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.

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.

VIRTUAL CONSULTS
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 www.GPOrthoTracking.com 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 www.straightsmilesolutons.com/contact
So to recap here are the steps:

1. Embed a widget like SmileSnap or www.GPOrthoTracking.com 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

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.

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 are 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

Essix comes in 030, 035, 040.