Missing Tooth Cases; Invisalign and Clear Aligners or Braces?

When we think about typical clear aligner cases, we tend to think about patients who have a full set of teeth – however, occasionally, you may have a patient who has recently lost a tooth asking for clear aligners or braces. Knowing how to approach these cases might not always be clear, which is why we’ve outlined some key things to consider today.
Which is Better for Missing Teeth: Clear Aligners (Invisalign) or Braces?
There’s no simple way to say whether you should use clear aligners such as Invisalign or braces with a missing tooth patient. This will generally depend on two things, in particular:
1) Where is the missing tooth located? First, you should consider where the missing tooth is located. If the missing tooth is in the back of the mouth and the patient doesn’t need a pontic, both braces and clear aligners could work.
2) How big is the span? In addition to considering where the missing tooth is located, you should also consider how big the span is (i.e., is the empty space large or small). If the missing tooth has a small span, braces may work, but this could still have complications compared to using clear aligners.
While you can potentially use braces on a missing tooth patient, this may represent a choking hazard, meaning this can have a lot of liability involved. Moreover, when working up to heavier wires, there may be a greater risk of the wires snapping, so a very soft diet will be crucial.
Fortunately, products such as Invisalign can work with missing tooth cases with a pontic, so be sure to keep this option in mind.

Success with Eruptive Guidance Biotrainers- Can they Replace RPE? Active vs Passive Wear
Introduction
Dr. Amanda from StraightSmile Solutions discusses pre-orthodontic treatment with biotrainers and eruptive guidance appliances. Eruptive guidance biotrainers are showing promise for accurately guiding and regulating exercise intensity. By providing direct muscle feedback, these devices may reduce reliance on the subjective RPE scale. However, more research is needed to evaluate biotrainer effectiveness and user acceptance for both active and passive wear applications across various exercise modalities.
I. Overview
A. Pre-treatment orthodontic appliances like biotrainers can work to straighten teeth if used correctly

B. Success depends on several factors:
1. Starting age – earlier is better (ages 2-6 ideal)

2. Severity – works better for milder cases

3. Wear time
a. Must be worn actively 4-6 hrs/day plus overnight
b. Passive overnight wear alone has limited effect
C. Not a standalone treatment for all orthodontic issues
1. Won’t expand palate or split midline suture
2. May need supplemental treatment (e.g. myofunctional therapy)
II. Using Biotrainers for Early Intervention
A. Goal is to guide eruption of incoming teeth
B. Appliance features eruption guidance slots
C. Progressive series of appliances as child grows
D. Can help avoid future orthodontic treatment
E. Success factors
1. Compliance with wear time
2. Starting very early around age 2-5
III. Limitations
● Extremely time-consuming and difficult compliance, especially for older kids
● Most patients unwilling or unable to wear appliances actively during day
● Not a standalone treatment for more significant orthodontic issues
● Will not expand palate sutures or correct breathing/airway problems
IV. Appropriate use and billing
A. Can work for the right patient if worn properly
B. Should be affordable, not $4000-6000
C. Doctors should not bill insurance for these
D. Set patient expectations – no promises or guarantees
V. Considerations in Clinical Practice
A. Set realistic expectations about effectiveness
B. Bill cash not insurance for these appliances
C. No guarantees of results given variability in compliance
D. Consider supplemental therapies as needed
Summary
Biotrainers and early orthodontic guidance appliances can be an affordable option for mild alignment issues in some pediatric patients but have limitations in more severe clinical situations. Starting very early and maintaining patient compliance with wear time is critical to success. Supplemental treatments may still be needed depending on the clinical factors present in each unique case. While early treatment can work for the right patient who is extremely compliant, it is not a miracle cure-all. Most cases still require traditional orthodontics or adjunctive care from other specialists.

Have you ever wondered about whether you could use Invisalign or clear aligners as an alternative to doing RPE expanders or palatal expansion on your patients? Palatal expansion can be a useful tool, but if you are doing an Invisalign or clear aligner case, you may want to consider: is palatal expansion really necessary?

Using Invisalign for Palatal Expansion Cases

If you have a patient who needs palatal expansion, an alternative option may now be available. Indeed, Invisalign is releasing its range of expanders designed to clip into your patient’s clear aligners.

As such, if this Invisalign product is rolled out and available for you to try, it may be possible to go straight into your Class II cases that need palatal expansion without having to do the expansion first. This could be incredibly useful for streamlining palatal expansion cases.

However, in some cases, it’s worth noting that more minor expansion cases may not necessarily need expanders at all. In E&T, vaulted palate, and airway issue cases, for example (among others), you’ll definitely want to still use an expander. However, in cases where the palate is only slightly constricted, and there are no significant complications (such as airway difficulties), it may be possible potentially to see improvements with Invisalign alone.

Orthodontic Relapse Due to Airway Issues and Mouth breathing
I. Introduction
Orthodontic relapse is a persistent issue, often caused by underlying issues like mouth breathing and airway problems. Dr. Amanda from StraightSmile Solutions emphasizes comprehensive screenings and enlisting OMT and ENT experts when necessary. She provides proactive solutions, such as patient release forms and webinars, to address root causes and ensure optimal, lasting orthodontic outcomes. Her insights help practitioners respond appropriately and prevent complications.

A. Orthodontic relapse is a common issue often caused by poor habits like mouth breathing and airway problems

B. These problems can be addressed with treatments like Orthodontic Movement Therapy (OMT) to prevent relapse
II. Recommendations from Dr. Amanda
A. Get a written release from ENT stating surgery is not needed to proceed with orthodontics
● Template available for free
B. Attend Dr. Amanda’s webinar to get free documents
● Can request free ENT document
● Also offers document templates for free
C. Emphasizes screening patients for sleep disorders and airway issues
● Parents often don’t put in the effort to properly screen
● This can lead to patients not getting proper treatment
III. Preventing Complications and Relapse

A. Record patients’ sleep during procedures to identify potential problems

B. If airway issues are not addressed, further treatment may be needed
● The jaw may still grow down and back
● This can lead to open bite
● May require jaw surgery later, depending on age and severity

C. Need extensive documentation to protect patient
● Free redo of treatment
● Insurance coverage
● Potential refund

D. More unpredictable growth with standard braces vs. clear aligners

E. Have patients sign informed consent documents to set expectations
IV. Role of OMT and ENT
A. Can identify issues like adenoids/lingual tonsils with imaging

B. If red flags are found, refer to OMT and ENT

C. More virtual OMT options and training orthodontic teams on it is helpful
V. Importance of patient screening and documentation
A. Get a written release that surgery is not needed

B. Provide extensive documentation to protect patient
● Free touch-ups, insurance coverage, refunds
C. Screen for sleep disorders and airway issues
● Parents often don’t screen well enough

D. Record sleep during procedures to identify issues
VI. Additional treatments sometimes needed
A. If the airway is not addressed, further problems likely
● Jaw grows down and back
● Anterior open bite
B. May need ortho plus jaw surgery
● Depends on age and severity
C. Informed consent doesn’t explain enough
● Need to protect patients better
VII. Managing unpredictable growth
A. Growth unpredictable with standard braces
B. Improve informed consent forms
C. Check adenoids on x-ray and lingual tonsils
VIII. Conclusion
Dr. Amanda stresses the importance of screening for airway and sleep issues to prevent orthodontic relapse. She provides free documents and templates to improve informed consent and protect patients. More virtual OMT options and staff training on implementation could further enhance outcomes.

Understanding SN/GoGN (Mandibular Plane Angle) in CEPHs

CEPHs are an incredibly useful tool when working out the right treatment plan for an orthodontics patient. However, there’s a lot you’ll need to know as part of this – and understanding the different values is integral. Luckily, we’ve outlined some key things you should know about SN/GoGN values in your CEPH results to help inform your ortho treatment plans.
What is the SN/GoGN?
First, we need to define what the SN/GoGN measures. The SN/GoGN value in CEPHs measures the angle of the lower jaw relative to the cranial base. This can then indicate whether the growth is going flat or vertical (steep) in the patient.
As you complete more CEPHs during your orthodontic career, you’ll likely begin to recognize when a patient is growing flat or steep without even needing to reference the numbers first.
What is the Normal Value?
The normal value should be around 30. However, a patient who is growing flat will likely have a lower number than this; meanwhile, a patient growing steeply will have a higher number.
What Does a Flat or Steep Jaw Mean?
If your patient is flat, this will often be a genetic trait and accompanied by a very square-shaped jaw, or this may be the result of Class II cases. It’s rare for a flat bite to be Class III.
Contrastingly, a steep patient will often be a Class III case. It can also be due to a downwards and backward growth openbite. These steep jaw patients may commonly also experience difficulties with their airways, which may need addressing.

Dr. Amanda from Straight Smile Solutions discusses the CCO Shift Triad, a concept crucial for recognizing CR-CO shifts in mixed dentition patients. This knowledge is essential for general, pediatric, and aligner dentists to achieve optimal outcomes. Visit Straight Smile Solutions for more insights.
I. The CCO Shift Triad
A. CCO shifts are very common in mixed dentition patients
B. Orthodontists are trained to spot CCO shifts easily, but general and pediatric dentists may not notice them as readily
C. It’s important to identify CCO shifts before planning treatment, as treating the apparent issues without unraveling the shift first can lead to poor outcomes
D. Screen every kid patient for signs of a CCO shift
II. 3 Signs of a CCO Shift
A. Facial asymmetry
1. Jaw off to one side (usually lower jaw)
2. Likely due to a shift rather than true asymmetry B. Unilateral class 2 or 3
3. Very rare to have a true unilateral class 2 or 3 in kids – it’s usually bilateral with a shift C. Lower midline off
4. Upper midline is on, lower midline shifted
5. Seen with the other 2 signs
III. Implications for Treatment Planning
A. Don’t take apparent issues at face value without considering an underlying shift
1. Apparent midline discrepancies
2. Apparent unilateral class 2 or 3 B. Put “re-evaluate for shift” in the treatment plan
3. Reassess in 6-12 months to see if asymmetry or discrepancies persist after unraveling any shift C. Be especially vigilant with aligner cases, as a shift can’t be fully unwound like with braces
IV. Learn More
A. Other videos on the YouTube channel about CCO shifts

Assessing and managing this triad is crucial for proper orthodontic treatment planning and helping guide eruption of permanent teeth into optimal positions. Proper diagnosis and early treatment can prevent more complex issues.

I. Introduction
A. Opening statement about Straight Smile Solution
B. Mention the upcoming webinar on January 18, 2024, sponsored by DSN DSi
C. Encouragement to watch previous videos on Bolton for foundational knowledge

II. Understanding Bolton Discrepancies
A. Brief recap of Bolton and its basics
B. Differentiating between Class One, Class Two, and Class Three malocclusions
1. Focus on mild cases (1-1.5mm) for Class Two and Three

III. Mild Class Two Cases
A. Maxillary Bolton in Class Two
1. Increased overjet due to Bolton discrepancy
2. Solution: Finish the case as Class One, possibly using elastics or posterior IPR
B. Mandibular Bolton in Class Two
1. Balanced situation; typically, no intervention needed
2. Mention of potential minimal IPR or overjet adjustments

IV. Mild Class Three Cases
A. Maxillary Bolton in Class Three
1. Positive scenario: Bolton discrepancy complements the Class Three malocclusion
2. Minor adjustments, possibly IPR, to achieve optimal outcome
B. Mandibular Bolton in Class Three
1. Challenge: Overlapping issues with both Bolton discrepancy and Class Three malocclusion
2. Possible solutions involving extraction, distalization, and strategic tooth build-up
3. Emphasis on early detection for effective treatment planning

V. Using Clear Pilot for Bolton Calculation
A. Reference to a future video on accessing Clear Correct Bolton from Clear Pilot
B. Positive feedback on Clear Pilot’s accuracy and ease of understanding
C. Encouragement to use aligner technology for treatment visualization, even in potential braces cases

VI. Conclusion
Dr. Amanda from Straight Smile Solutions provides valuable insights into the complexities of Bolton discrepancies, particularly in aligners or braces for mild class two or class three malocclusions. Her advanced lecture sheds light on the nuanced options for addressing these cases. Dr. Amanda emphasizes the importance of understanding how Bolton discrepancies impact treatment outcomes and highlights practical solutions for achieving optimal results. Dentists and orthodontic professionals can benefit from her expertise, making informed decisions in their practice.

Avoiding Overcorrection with Deprogramming Aligners

Have you completed the deprogramming section of your Invisalign case, only to find yourself wondering: what next? Well, once you’ve achieved good contacts on the back teeth, knowing how to progress is important, and luckily, we’ve outlined some key points in today’s guide to help.

Things to Consider

There are a few things to consider when looking at how to avoid overcorrection with deprogramming aligners. These include how quickly you can get the patient into the clinic and whether you have an itero scanner on site. Ideally, you’ll want to get the patient into the clinic within two weeks to begin finishing the case and fitting the final refinement aligners .

Once Solid Contacts Are Achieved

Once all of a patient’s permanent teeth have solid contacts following the Invisalign MA deprogramming section, you can let the patient know that they only need to wear the trays at night. By limiting the time that the patient wears their aligner trays, rather than having them on 24/7, this helps avoid overcorrection.

Naturally, the more your patient wears the aligners, the more their teeth will extrude. However, if the patient doesn’t wear them at all, the front teeth may still shift, which can impact the final results. Thus, finding a balance by limiting the time that the tray is used can provide a good balance between fixing the bite and overcorrection, allowing for more successful finishing with the final refinement aligners.

What If I Can’t Get the Patient In Quickly?

If you can’t get the patient into the clinic quickly, or if you can’t get the finishing refinement delivered quickly, you may need to get a set of Essex retainers made up. These allow you to avoid overcorrection, thus ensuring that the final refinement trays fit the patient comfortably.

Why You Should Get An OMT’s Support Before Taking Lateral Openbite Due to Lateral Tongue Thrust Patients

As a general dentist, getting into the world of orthodontics can offer a wealth of opportunities. However, orthodontics for general dentists isn’t always straightforward, and being aware of tricky cases – and when you should get support from a professional orthodontist or OMT – is vital. This is the case with lateral openbite patients due to lateral tongue thrust, and we’ve outlined why in today’s guide.
Why You Should Not Take Patients with a Lateral Openbite Due to Lateral Tongue Thrust
If you come across a patient with a lateral openbite due to lateral tongue thrust, we strongly recommend that you avoid taking these cases on. Indeed, these cases should instead be referred immediately to an OMT, as these cases will often be incredibly difficult to finish – and, even if they do work initially, retainment is usually very poor.
Many patients will be reluctant to go to an OMT, naturally, since this can be incredibly expensive. Often, it’s not just the cost of an OMT consultation either; there are often additional costs for the patient to pay, such as surgeries, tongue releases, cervical chiropractic care, and the like.
The Risk of Taking On These Cases Before Getting an OMT’s Support
The poor success of lateral openbite cases due to lateral tongue thrust can lead to many issues down the line. When the patient notices that their orthodontics treatment plan isn’t working in the long term or is not progressing normally, you’ll likely experience a lot of complaints, and you may even need to refund the treatment plan entirely.
Get the OMT to Sign The Patient Off First
While these cases are tricky, it is potentially possible to treat these patients. However, you should never attempt to do so until an OMT has signed off the patient as having corrected the issues.
Still feeling unsure? Make sure you get professional support from an orthodontics consultancy team – such as us here at Straight Smile Solutions – to help you avoid taking on risky cases.

2023 Invisalign and Clear Aligner Refinement Instructions
I. Introduction

Dr. Amanda from StraightSmile Solutions discusses the five key things needed when submitting an Invisalign or clear aligner refinement case. Emphasizing the importance of knowing the current aligner number, attachment status, previous IPR done, updated photos with bite registration, and tracking photos of the aligners in the patient’s mouth. Having this information ensures a proper refinement ClinCheck for a successful case outcome.
II. 5 Things to Submit for a Refinement

1. What aligner number is the patient currently on?

– You need to know exactly what aligner the patient has been wearing so the new ClinCheck is accurate.

2. Were attachments removed or left on for the refinement scan?

– Decide whether to keep or remove attachments based on how the initial treatment went.

3. Was all the prescribed IPR done on the previous ClinCheck?

– Check records to ensure IPR isn’t repeated on the same sites.

4. Provide a full set of intraoral photos with articulating paper.

– This ensures the bite is accurate in the ClinCheck refinement.

5. Provide tracking photos with aligners in.

– Shows how aligners are fitting and tracking.
III. Best Practices for Better Outcomes

– Use a virtual monitoring system to oversee patient compliance.

– Ensure aligners fit like a glove with no gaps before advancing.

– Have the patient seat aligners fully before starting new tray.

– Follow clear aligner delivery protocol.
IV. Conclusion
To complete clear aligner treatment, whether Invisalign or another system, clinicians must follow proper protocols. For refinements, provide the aligner number, attachment status, IPR done, photos with bite marks, and tracking photos. Ensure proper ClinCheck staging, aligner delivery with seating instructions, and virtual monitoring. When steps are skipped, treatment predictability suffers, leading to suboptimal results, unhappy patients, and unnecessary refinements. Attention to detail and consistency in process is imperative for clear aligner success.