Straight Smile Solutions

Doctors often ask me about wire sequence for patients. It can be impossible to create a cookbook/cookie-cutter wire sequence but in general this is how I do it:

1. 14 niti (but sometimes you go go straight to 16 if not that crooked)
Very rarely do I need to start with 12 niti. It is only if it is crazy crooked or with very high canines.

2. 16 niti (but sometimes you can skip this if it “cooked” good in 14)

3. 18 niti ( you can do front teeth power chain only in this wire but go mesial to mesial only from lateral to lateral and put a single tie on the distal)

*** stop here*** wait until 18 niti is 100% passive and then re-eval bracket position and rebracket to ideal prn.

Once all the bracketing is perfect and both you and the patient are 100% happy with the alignment and leveling of the teeth you can move on.

4. 17×25 niti
(in this wire you work on bite and close spaces so elastics and power chain if needed)

5. 18×25 niti

Usually done after this unless there are transverse issues still and then you can go into SS wire like 18×25 Stainless

OR

If you still have deep bite or open bite issues you can go into RCS/ACS wires

https://www.youtube.com/watch?v=dGTteuhjjrI&t=98s
https://www.youtube.com/watch?v=6XxBmenWd2g&t=50s

Contact us at https://www.straightsmilesolutions.com  or https://theorthoswhisperer.com for support on any ortho case.

There can be numerous reasons why Invisalign, ClearCorrect or clear aligners aligners crack but this blog will discuss the most common reasons. In order to diagnose the issue you need the following records:

1. The Treatment Plan
We are looking to see if the treatment plan was indeed “good” and even viable. If it is too rapid or unpredictable, this may be a cause of the breakage.

 

2. Compliance
I always recommend creating an in-house aligner tracking system but there are turn-key resources out there like www.GPorthotracking.com. You must have tracking pictures to measure the patient’s compliance.

3. New dental work or new teeth
If new molars are popping up like 12-year old molars or 3rd molars, this can act as a lever or pivot and cause flexing of the tray. Consider rescanning and be sure you capture the full distal aspect of the terminal molar.

If you have a patient who is breaking aligners, be sure to connect with us for a complimentary consultation at www.straightsmilesolutions.com or https://theorthowhisperer.com

PURPOSE: The purpose of this appliance is to widen the arch(es) usually to aid in the correction of a crossbite (usually due to a functional shift), resolve crowding, and/or expand overly constricted arches, particularly in the posterior region. When designing your appliance, make sure you communicate your goal to the lab so that the design is optimal.

DELIVERY: Seat the appliance with your fingers. If teeth have been lost or new teeth have erupted since the impression, you may need to adjust with an acrylic bur. The appliance should seat evenly with no rocking and adhere securely to the teeth. The patient should be able to remove and reinsert the appliance properly.

INSTRUCTIONS
Week 1: The first week is an adjustment period for the patient. The patient should wear the appliance 24/7, except for eating and sports.

Subsequent Weeks: The patient should activate the appliance 1x-2x per week and continue to wear the appliance 24/7 except for eating and sports. The frequency will vary with the skeletal maturation of the patient. Do this on the same day consistently and chart the number of turns completed. It’s best to activate the appliance at night after brushing teeth to minimize discomfort.
Turn the appliance in the direction of the arrow. Make sure you are always turning the same direction and completing the turn fully before removing the key. You should see the next hole before you remove the key. If you can’t see the next hole, the turn isn’t fully completed. If they key doesn’t have a safety handle, tie floss on the key before sending it home with the patient. Tell the patient to bring the expander and the key to every appointment.
APPLIANCE CHECKS: It’s best to check the appliance every 4-6 weeks to ensure that the turns are being done properly. At each appointment check the jackscrew length with a periodontal probe and document. Also check the fit of the appliance to ensure it still fits properly. Adjust as needed to accommodate new teeth or loose teeth. Check the teeth that are being activated with floss to see if contacts are opening. Usually after 2-3 months, you will see the crossbite correct and/or the crowding begin to resolve. The arch form will become U-Shaped. Once you have acquired the optimal amount of space, retain for 3 months full time. This stabilizes the outcome. Palpate the roots around the buccal plate for any fenestration or pathology. You will have some relapse, so it’s best to expand a little bit more than needed.

Precision cuts with Invisalign can be a bit scary for a general or pediatric dentist.

Here’s a few of my favorite videos. My suggestion is to make your home care and demonstration videos eventually with your own patients and post them on your website.

https://www.youtube.com/watch?v=RGP1aofolXg&t=15s

(note- she’s using slot to slot which is different than is slot to button)

Contact us at StraightSmile Solutions for sample home care and tracking instructions.

You can buy the 3/16 medium elastics and buttons from the Invisalign store.

3/16 medium is for slot to button (1/4 medium if they have big teeth)
3/16 light is for slot to slot
3/16 heavy for button to button

 

Elastics need to be changed at least 4 times a day.

Check the bite as well as the tracking at every appointment or consider using a system like www.GPorthotracking.com

To schedule a complimentary ortho coaching session, please visit www.straightsmilesolutions.com or https://theorthowhisperer.com

In this blog post, we’ll be talking about removable retainer options. Your dentist can discuss the best retainer for your smile as there are pros and cons to each type. This is something that you may want to discuss with your dentist even before you start braces or aligners.

A retainer keeps your teeth from moving after they’ve been straightened with braces. Several decades ago, dentists recommended retainers for only 3-6 months, but we’ve found now that retainers should be worn for life to ensure the best long-term outcome.

Hawley Retainers

Lab Fee: $80-150

Biomaterials: plastic or acrylic with metal wire

Longevity: 1–50 years

Characteristics:

• adjustable

• can choose plastic color to personalize

• doesn’t stain easily

• easily removed for eating and oral hygiene and won’t likely need replacement unless major dental work is done.

• metal wire visible in front of teeth

• can be lost or damaged

Also called wire retainers, these are removable retainers made of thin metal wire and plastic or acrylic and are shaped to fit the roof of your mouth or along the inside of your lower teeth. The attached metal wire runs across the outside of your teeth to maintain alignment. A local lab usually makes these unless the dentist has an orthodontic technician in-house.

The retainer is adjustable if you need a better fit when you first get it or if your teeth need slight realignment later.
It’s more durable than a clear plastic retainer.
It can last for years if used and cared for properly (note: the author has had hers for 25 years and it has never needed an adjustment!)
It allows the bite to settle fully and balance because the teeth can touch, which may be better for the TMJ.
Its disadvantages:

It affects your speech more than other retainers.
It’s more noticeable than the other types of retainers.
It initially costs more than a clear retainer, but it is more economical over a lifetime.
Clear Retainers

These are removable retainers that are molded to fit perfectly within the new position of your teeth. To make this type of retainer, a mold or scan of the teeth is created, and that image is 3D printed. Then, very thin plastic or polyurethane is heated and sucked down around the mold. It is not advisable to use your last aligner as a retainer because it isn’t thick enough to hold the teeth straight long term.

Essix®, Vivera®, Zendura®- Lab Fees:

• $275 for four upper/four lower for Vivera

• Essix $30-$70 per retainer from an orthodontic lab. Or, make your own Essix or Zendura A in-house if you have a Biostar and 3D printer at $3 a retainer.

Biomaterials:

* plastic or polyurethane

Longevity:

6–12+ months

Characteristics:

• fitted so that teeth stay in place better

• thin and easy to talk

• clear/invisible

• convenient to have multiple back-up pairs made

• easily removed for eating and oral hygiene

• may need yearly replacement so this can get expensive over a lifetime

•may need new impressions and retainers if any dental work that changes shape or size (filling)

•easier to lose or damage

A clear plastic retainer has the following advantages:

It’s invisible.
It’s less bulky and may be more comfortable than a Hawley.
It’s less likely to affect your speech than a Hawley retainer.
Disadvantages of a clear retainer:

It’s not adjustable if you need realignment or if you get new fillings or dental work. It would need to be replaced every time. Often the doctor will charge not only for the new retainer but also the new scan/impression. This will get expensive over a lifetime.
If it cracks or breaks, it can’t be repaired.
It can warp if exposed to heat (e.g. left in a car.)
You may need five, ten, or more retainers PER arch in a lifetime. Each one lasts an average of 6 months.
It tends to become discolored (and more visible) over time.
Top and bottom teeth don’t touch naturally with this type of retainer.
It can trap liquids and bacteria against your teeth, which can cause cavities and periodontal disease.
The main difference in the three common brands of clear retainers is the type of plastic material they are made of. The brands are Vivera®, Essix®, and Zendura®. Vivera is sometimes incorrectly called Invisalign®. The same company makes the two products, but Invisalign is an aligner used to straighten teeth instead of metal braces. It is not a retainer.

There are pros and cons to each retainer type. Your orthodontist will recommend the best type for you based on your teeth and why you need braces. But don’t forget to consider your preferences on the look and amount of time and effort you are willing to spend on it. You will most likely be using and maintaining your retainer for a lifetime, so it’s important that you have the retainer that works best for you. Dentists: If you have questions about setting up your retainer options, please visit us at www.straightsmilesolutions.com

I’ve written quite a few blogs on retention.

There is no one size fits all protocol.

The Orthodontic Aftercare Opportunity

Esthetic Bonded Fixed Retainers

Bonded Retainers

Choosing the Best Type of Retainer after Orthodontic Treatment

There is also a lot on our youtube page.

https://www.youtube.com/channel/UCZQDILf1sP5qR4p78673bzA?view_as=subscriber

Basically, you need to pick the right retainer to fit the case clinically.

I love positioners and hawleys the most and essix and bonded retainers the least. The pros and cons are listed above in the blogs and YouTube.

Hawleys and Essix need to be worn full time for at least 6 months and can be tapered after that but the exact tapering schedule needs to be customized for each patient or relapse occurs.

Here is my scripting, let’s say I am talking to my hypothetical patient, Sarah, who is 13.

“Sarah, you’ve been doing a great job with your retainers. Let’s talk about phasing your retainers down. I know you’ve been wearing them 24/7 but you do take them out for eating and sports. Tell me a little bit about how that is for you. What is the longest you’ve left them out? Did they feel tight or achy when you put them back in? If so, that was too long. Your teeth have already moved and if we do that too often, they won’t move back. Try to find how many hours you can leave them out without feeling any discomfort. That is your sweet spot. Each month try to add one more hour. Some patients can safely go to nights after 6 months of full time wear and some may take years to taper back. Listen to your body. It is a marathon, not a sprint.”

It blows my mind how many of my www.straightsmilesolutions.com doctors don’t take the time to idealize and optimize their Invisalign Doctor Profile. If you want help, please visit www.straightsmilesolutions.com and click on “contact-us” to schedule a free call.

This is a free, no-brainer, five-minute exercise that can get you referrals.

Here are the steps to rise the ranks and hopefully be displayed on the first page of the doctor locator in your city:

Go to this page: https://www.invisalign.com/get-started/find-a-doctor
Put in your zip code. Search and see where you are. If you aren’t on the first page, you have work to do! Be sure to look at teens and adults.
Make sure you are treating at least 5 teen patients per year to stay on the teen locator.
Now log in to you Invisalign portal. Did you accept the advantage TOS this year? If not, accept it. Go to the top, right corner under your name and click the tab to the profile section.
Take a professional picture and upload it. Also take some time to fill in all the blanks to update the hours, insurance and other important sections of the profile.
That’s it! As you rise in the ranks (bronze, silver, gold..etc) you’ll also rise within the doctor locator. If you get an iTero you’ll also rise.

Note- the following is the interpretation of codes and billing by Dr. Amanda Wilson and StraightSmile Solutions. Please consult your own dental practice act in your own state or country and the insurance company you are partnering with. For a 1:1 coaching session by Dr. Wilson to optimize orthodontics in your practice, please visit www.straightsmilesolutions.com and click on “contact us” to schedule a complimentary coaching session.

Limited: (D8010-D8040)

Not all orthodontic treatment is equal. In its simplest form, limited treatment would focus a single tooth or a few teeth or on all the teeth in just one arch. It may be directed at the only existing problem, or at only one aspect of a larger problem in which a decision is made to decline comprehensive therapy. In other words, let’s say a patient comes in with a 9mm overjet and 100% overbite but she doesn’t want bite correction. She just wants a diastema between her top teeth corrected and no lower braces. That would be limited. Most DTC (direct-to-consumer) care like Candid® and SmileDirectClub® is limited, but not all. Six Month Smiles® is also limited because they only use round wires and they don’t correct bites or torque teeth. Most Invisalign® Express and Lite would be considered limited.

Comprehensive: (D8070-D8090)

Comprehensive treatment would involve idealizing the bite, smile, alignment of all teeth, and soft tissue esthetics. It may or may not involve taking and interpreting a cephalometric x-ray. Most Invisalign Moderate and Comprehensive treatment would be comprehensive because you can correct transverse issues, vertical issues and AP (anterior-posterior) issues. Straightwire braces would also be comprehensive as long as you are taking the patient up to rectangular wires and expressing torque and improving the bite.

Interceptive: (D8050- D8060)

Phase I is performed during the early mixed dentition (when a lot of baby teeth are present) to address a functional or skeletal issue. This procedure lasts for about 6 – 18 months. After this Phase 1, a child may or may not need further orthodontic treatment (Phase 2). If a child does need further treatment with Phase 2, a new contract will have to be signed and new payments will have to be made. Phase I Treatment can often simplify or eliminate the need for full comprehensive orthodontic treatment because it is designed to encourage jaw growth and correct problems on its early development, reduce crowding and likelihood of impactions. Phase 1 may just be removable or fixed appliances to fix a bite and may or may not include some braces or aligners on the front teeth. It is designed to fix functional issues. Cosmetic issues may be addressed in Phase 2.

Other Codes:

That being said, there are some codes that fall under the orthodontic section that are procedure-specific. There are codes for fixed and removable habit appliances (D8210, D8220) such as those used to break a thumb-sucking habit. It is important to know that codes for these appliances include their removal. There are also codes for exams (if you charge a fee for those), diagnostic records, and even new codes for CBCT images. These codes for procedures such as gingivectomies, or surgical exposure of an impacted tooth. These should only be submitted once the procedure is performed, not at the beginning of orthodontic treatment.

Please join our webinar on January 9th to learn more!

www.straightsmilesolutions.com/media

Step #1- Send your impression to a lab to get your PVS impression digitized to a STL file.

There are 2 labs that I use here:

1- The Orthodontic Lab

2. Specialty

TOL is half the price of Specialty so let’s start there.

Step #2- TOL sends the STL to the Aligner Design Company.

There are 4 aligner design companies I work with. Email me for a personal introduction for a StraightSmile Solutions discount. Prices are $90 to $299 per case for design.

Step #3- Manufacturing

Once you approve the case, the design company sends the case to the lab you choose for manufacturing. Cost starts at $15 per aligner.

We offer anyone currently in the dental industry a 20 minute complimentary consultation. Visit www.straightsmilesolutions.com to schedule your phone call by clicking in the top, right corner.

Have you ever had a negative review from a patient? I admit – I’ve had a few in my career. All seasoned dentists get them, even if, in your mind, you didn’t deserve it. I had a doozy on Yelp that shook me to the core and haunted me for a good 10 years! It had nothing to do with my skill as an orthodontist but was simply a misunderstanding about retention. This is something that was so avoidable if my whole team had a better orthodontic aftercare program. I was hoping to post it for you, but Yelp has FINALLY archived it! Hooray!
Orthodontic retention is the most underestimated phase of treatment; practices typically have a protocol for retention that involves a single set of retainers and a finite number of retention visits. In residency, we were taught to see the patient at 1, 3 and 6-month intervals and then discontinue treatment. All additional visits were at cost. When things go wrong with the retention phase after all that investment, they go really wrong and feelings can be hurt if they aren’t addressed properly. If you take a few moments to read negative YELP and Google reviews about orthodontists, most do have to do with retention! What an easily preventable problem!
Orthodontists expect that patients will do their part to wear the retainers as directed to allow the teeth to stabilize, but teeth aren’t static; the periodontal fibers are dynamic and things can settle and shift. Patients expect that their teeth will stay in the final positions forever, but that is unlikely.
Retention patients deserve attention and transparency from the practice in terms of fees and replacement options. I think it is important to start addressing this at the beginning of treatment, not at the end. Start the conversation about expectations. Some patients come in with a preference for a certain type of retention, but this doesn’t always coincide with the orthodontist’s practice philosophy.
Let’s talk about the bonded retainer. There is a time and a place for them, but for me, a bonded retainer is a marriage, and unless I feel it is the best retainer for the patient. I’ll usually recommend an upgrade fee and/or require the patient to invest in an in-house insurance policy for breakage and/or relapse.
Retention is also a great opportunity for revenue, through insurance and subscription programs. The lowest cost retainer, the clear essix, isn’t meant to last a lifetime. A child may run through 6-10 essix retainers PER ARCH in a lifetime, so you should clearly set-up a replacement program so that they can be replaced before they warp, crack or break. Be direct about what is included in the cost of orthodontic treatment and what is additional.
Retention Options
It’s important for offices to consider each of these plans in terms of what makes the most sense for each office. Give the patient a copy of the retention menu at the start of orthodontic treatment, and, if possible, build the additional cost into the whole treatment on the front end so that fees aren’t accessed at the end of treatment when they should be celebrating the outcome and posting their praise about you and your team on social media!
Here are a few retention options that I recommend:
1. Replace if needed: This is the cheapest option for the patient but not the best option. If a retainer is lost or broken, they are replaced, as needed, by the office. This is the traditional plan and the most basic. I don’t recommend this for new patients, only for trusted patients who understand retention. Give your fee on the front end and honor the fee. It can be a sliding scale that increases over time. Initially, it shouldn’t be a revenue opportunity. It is an opportunity to service the patient. If it is within the first year, you may want to include one freebie. I remember my mom being so angry with my brother’s orthodontist because he lost his retainer at college out of state. She had to fly him back home AND pay $500 for new retainers. Granted, this was back in the 90’s. That is crazy expensive!
2. Retainer insurance: This program is uniquely designed by each office with the goal of lessening the cost of lost or broken retainers. I like the idea of a small monthly or annual fee for this insurance. Think Amazon Prime. $5 a month or $50 a year to lock the retainers in at an affordable rate of $50-$100. This is best if you can store the STL of the finished outcome in the cloud so it can easily be duplicated and mailed without an impression or scan.
3. Lifetime retainers: Programs like this acknowledge that retainers are a lifetime commitment and that they should be replaced periodically over time. In general, this program is presented as an additional service at the initial treatment consultation. Fees range between $500 and $1000 added to the treatment fee, but they are often spread out over the financing term for the treatment fee as a whole. I don’t like this option because I think it devalues your practice if you ever need to sell because there only risk for the new buyer and no production.

A clear, convenient and easily understood long-term retention plan is an important part of a professional orthodontic practice. It is only a matter of time before venture capitalists see the opportunity in retention for DIY, so it is critical that you get a jump on the opportunity to launch it in your office.

Orthodontic sleep, airway, tele-medicine and aligner companies are the hottest tech startups and StraightSmile Solutions® has the experience to to help you scale! We offer anyone currently in the dental industry a 20 minute complimentary consultation. Visit www.straightsmilesolutions.com to schedule your phone call by clicking in the top, right corner.