Straight Smile Solutions

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

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…

Or


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.

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.

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.

There is no one size fits all approach to this. I often talk to new doctors about how to take that initial step of introducing orthodontics into a GP practice. Each doctor and office will need to consider several aspects in making the decision and each will need to create their unique pathway. These aspects include:

• Patient demographics
• Competition from neighboring practices
• Patient requests. What are patients asking you to offer?


1. There are three key categories for GP Orthodontics and although I think it is wise for doctors to ultimately offer all three, it is often better to concentrate on just one through an initial launch. The categories are:
o Aligners (branded and unbranded)
o IDB Straight wire
o Phase 1 Functional Appliances

A pediatric dentist should start with Phase 1 Appliances. A general dentist with a mostly older patient population should start with aligners. A younger doctor with a mostly teenage demographic might want to start with straight wire.

2. Supplies and Armamentarium

Every doctor should at least have an intra-oral scanner and a panoramic x-ray before they start ortho. Beyond that, there is no real additional cost to starting Aligners or Phase 1, unless you are doing Invisalign. The start-up investment for consumables for straight wire will be around $2000. I have a start-up list of supplies needed. If anyone would like a copy, please contact me. We also have a hands-on course here: https://www.straightsmilesolutions.com/services/digital-courses/

3. Case selection. Please refer to this blog https://www.straightsmilesolutions.com/blog/case-selection-for-gp-orthodontics-cases/ for case selection suggestions.

I like to think about orthodontic case selection for general dentists as falling in to either green, yellow or red light categories:

1. Green Light:
These criteria apply to all general dentists, regardless of experience level.
• Class 1 molar AND canine.
• No missing or impacted teeth except 3rd molars.
• No history of present or past periodontal disease.
• Mild to Moderate (less than 6mm) Crowding or Spacing.
• Overbite (deep bite) between 10%-70%.
• No open bite.
• No crossbite.

2. Yellow Light
These criteria apply to dentists who may have conducted more than 50 aligner and braces cases and who regard themselves as ready to tackle more complex cases:
• Slight Class 2 cases (molar or canine up to 4mm).
• Edge to Edge cases (anterior crossbite only, not  
  posterior crossbite).
• Deep bite/Overbite cases- any severity.
• Open bite, up to 2mm, if the etiology of the open bite (tongue thrust, habits, airway) has already been diagnosed and treated.
• Mild periodontal disease with attachment loss, that has been treated, and is under control (less than 3mm of attachment loss). A 1-month       evaluation has been completed and charted. All pockets are not less than or equal to 3mm.
• Posterior Crossbite cases in children under 13 years old.
• Mixed Dentition Cases.

3. Red Light
Do not take these cases. Refer out unless you have an orthodontist to help you.
• Impacted canine cases – buccal only.
• Full Step Class 2 Cases.
• Negative overjet up to 2mm.
• Open bite up to 4mm
• Moderate Perio Cases

Anything else outside these criteria, should always be referred out to ortho

StraightSmile Solutions believes that all doctors should invest in an intraoral scanner. It is a “no brainer” to us.
By now we are aware of the benefits of intraoral scanners and what we should be looking for when purchasing one: speed, improved carbon footprint, accuracy, an open system, and flexible workflows. There are so many scanner options, this investment is often an overwhelming decision. I would strongly recommend you attend a dental show with your staff and physically try the scanner out.

Here are a few variables you might want to consider when selecting the right scanner for you and your practice:

1. Tidy and Realistic Graphics

A clean and pretty scan is an incredibly powerful tool to educate patients, especially in the co-discovery consultation process. Patients have a very positive reaction to seeing their mouths in the virtual world almost instantly, and the feedback is incredible: attrition, abfractions, alignment… and that’s just the A’s!

2. Easy Exporting and Integration, Open Platforms, and Monthly Fees

Some scanner companies make you jump through hoops to export the images to labs and other design companies. I would be wary of any scanning company directly owned by an aligner company unless you are solely and 100% dedicated to that brand of aligners.
With open systems, you can send files to almost any service that can receive them. But even today, not all systems are totally open, so it’s important to research all of the systems you consider.

3. Ease of Use, Comfort, and Portability

When investing in new technology, it’s always good practice to take your staff’s feedback into consideration. After all, they’ll most likely have their hands on it the most. Will the scanner stay in one room or will it need to travel from op to op or from office to office? How heavy and bulky is the wand? Do any of your team members currently have wrist or shoulder issues? Are your patients mostly children or adults? Some of the wand sizes are too big to be comfortable for young patients.

4. Training, Repairs, Warranties, Service, and Support

Do you have a team member who is already a whiz with this scanner or will you need training and support? The first few months can be frustrating. Make sure you get training and support if and when you need it. How long is the wait period once you purchase before you can schedule your training and onboarding session? Ask this before you buy. Get referrals and references from 5-10 other doctors who are using this system to find out more. What happens if the system breaks? How long does it take to get repairs or a replacement?

5. Cost
Scanners can range from 15k -50K plus monthly or export fees. Find out the total fees and if there is any financing or leasing options. Does the scanner include the monitor or do you need to buy a computer? How much are extra tips if they break?

If you are a frequent reader of my blog (www.straightsmilesolutions.com/blog) or a subscriber of my YouTube channel (https://www.youtube.com/c/Straightsmilesolutionsortho), you’ve become accustomed to my tricks and tips on attachment and auxiliary design and placement. And you probably know that I think “optimized” attachments are mostly an over-hyped, proprietary feature of Align Technology. Below, I have compiled some tips and tricks for attachment placement and design. These aren’t from any book or class, they are just tricks that I’ve learned over 18 years as an Invisalign provider.

1. You CAN put attachments on both the lingual and palatal of teeth, if there’s space and clearance.

For rotated teeth, just ask! We do this all the time in braces with moments and counter- moments with buttons and chain, why not in aligners? Fun fact: many white-label aligner companies also let you do this. Make sure you remove the palatal ones towards the end of treatment before they affect the bite, though. Treatment timing is critical.

2. Invisalign needs more attachments than other systems because of retention. If you don’t use Invis, you’ll need FEWER attachments.

Invisalign’s very scalloped and low-profile trim and elastomeric, thermoplastic material necessitates the use of copious attachments. That’s just how it is. Often, they are only there to hold the aligner in. This is why some direct-to-consumer companies have higher trim and still get good outcomes.

3. Always put attachments on for extrusions of incisors, even if the software doesn’t recommend IT.

Anytime I see incisor or canine extrusion, I ask for attachments. If it’s a lot of extrusion (more than 1mm- aka a blue or black dot), ask for a “full-sized horizontal, rectangular attachment”.

4. Always put attachments on for rotations of incisors or premolars more than 15 degrees.

Anytime I see big rotations on premolars or incisors or canines, I ask for attachments. If it’s more than 20-25 degrees, I ask for “full-sized vertical, rectangular attachment,” or you can ask for a counter-moment with an opposite attachment on the lingual or palatal (see #1).

5. Power ridges are uncomfortable and cause the plastic to jet-out. There are other ways to get torque but they involve either hybrid treatment (with braces) or attachments.

I’m not a huge fan of power ridges, but they can work for single tooth torque in a patient who can tolerate the irritation of the plastic. Orthodots are great aligner band-aids.

6. Chewies are necessary to FULLY engage your attachments.

All your patients should be using aligner chewies regularly. They are a $1 key to success that you should give to every patient, and you can buy all shapes and flavors on Amazon.  Sometimes gaps or tracking issues aren’t related to the actual tooth where you see them but are related to an adjacent tooth that is intruding and not tracking. For example, if you are intruding #8 and the intrusion isn’t tracking, you might see a gap/tracking issue incisal to #7. Doctors can get puzzled because there was no extrusive mechanics in the treatment plan, but this is just relative to the movement on the adjacent tooth. Using chewies everywhere around a tooth that isn’t tracking, not just on the tracking gap, will help to fix the case without a refinement. Usually, it is best to “backtrack” one or two aligners and start the movement over.

7. If you are using precision cuts and elastics, it is best to bond to the TOoth and not use slots, because this causes retention and tracking issues and requires way more attachments to anchor the aligner on the mouth.

I stopped using slots and only started to use buttons on class 2 and class 3 movements. Yes, it’s a few more minutes to bond, but ultimately, you’ll need fewer attachments for retention and will have less tracking issues.

 

8. Open bite cases will need large attachments on the premolars to support the extrusion.

I actually think it is EASIER to treat open bite cases with plastic than with braces, but don’t forget to put full-sized horizontal attachments on the premolars AND eliminate any myofunctional habit prior to starting aligner treatment (tongue thrust, mouth breathing, finger sucking). Believe it or not, some adults still do these things and it will unravel your outcome. The tongue is one of the strongest muscles in the body. I always say that open bites come from somewhere, so you must be a detective to find the source and treat it as well.

I am a huge fan of FitStrip for IPR but here’s a non strip option for those of you who have STRAIGHT TEETH and need IPR. (I don’t recommend this on rotated teeth).
https://www.strauss-co.com/index.php/en/dental-homepage/dental-kits/282-ipr-kit

Here’s what you need to do to start facemask therapy in a growing patient with a retrognathic maxilla:
(note links are just suggested- you can buy from any vendor):

Buy it from ebay (or any ortho company) https://www.ebay.com/itm/J-J-Ortho-Orthodontic-Protraction-Facemask-Reverse-Headgear-for-Underbite/221863787243?hash=item33a81cbaeb:g:soQAAOSwoRFdFsW3
Also need extra oral elastics: https://www.pearsondental.com/catalog/product.asp?majcatid=744&catid=6538&subcatid=26057&pid=79161 or https://www.henryschein.com/us-en/Search.aspx?searchkeyWord=extra+oral+elastic
I usually do 8oz 1/2 inch but some people do 16 oz but you can always work up to that if you aren’t seeing results.
So around $50 ish  and the elastics can last for many patients.