StraightSmile Solutions®

Having a child with an overjet (colloquially overbite) malocclusion can a be stressful and confusing experience. It doesn’t help that many doctors disagree about the best treatment practices to correct this bite discrepancy.

1. Early Skeletal Correction- Phase 1 Functional Appliance Correction before skeletal maturity (usually ages 6-9)
2. Late Dentoalveolar Correction- Use rubber bands at the same time as braces (ages 11-14)

Research actually supports both philosophies, but the aesthetic outcome may differ.

Early Skeletal Correction:

Pros:
Early correction and actual skeletal change through the growth of the lower jaw can be obtained easily with removable, functional appliances. Two of the most popular appliances are the Twin Block™ and the Bionator.™ Headgear is another common way to correct overjet, but StraightSmile Solutions® doesn’t support traditional headgear for bite correction because it moves the upper teeth backward instead of forward, which may affect the tongue space or airway volume. More research is still needed to understand all of the possible effects. My professional experience does indicate that children who have early, successful Class II correction are less likely to need premolar extractions and orthognathic surgery as an adult.
The Twin Block™ is a comfortable appliance that can be customized and “blinged-out” to make wearing it more fun for a young child. It looks very much like two retainers. The Bionator™ is a one-piece appliance that may be more challenging to wear at school, but it does have the favorable side effect of helping to correct mouth breathing and oral habits, which may also improve facial aesthetics in the long term.

Cons:
Early treatment often comes with an additional price tag. Many orthodontists charge twice for this set of orthodontic treatments, which pushes the fees to around $6000-$10000 for the whole correction. Timing and compliance (full-time wear) are the key. For the best outcome, these need to be worn up until the peak growth spurt. This can be as early as age 8 in a female and as late as age 15 in a male. Parents often don’t understand the importance of timing with these appliances.

Late Dentoalveolar Correction:

Pros:
The advantage of Class II elastic treatment to correct an overjet is that it usually costs less overall. It can be accomplished with either clear aligners or traditional braces. With clear aligners, intraoral elastics may be worn from the very start, with the first align¬er, which may be a quicker correction. In contrast, with braces you have to wait until about halfway through the braces treatment to initiate the elastics so that the wire is heavy enough to support the forces.

Cons:
Class II elastics are a common treatment modality to correct a Class II dental malocclusion, and their effects are primarily dentoalveolar. That means that bone isn’t growing; the teeth are just tipping to fix the bite. This could be considered a less stable outcome in the long term, and it won’t provide the patient with the accompanying improvement in profile aesthetics.

For support with your orthodontic cases, please visit www.straightsmilesolutions.com.

Tax refund season is here, and orthodontists are getting ready for one of their most profitable times of the year. As the CEO of StraightSmile Solutions®, I am often contacted by consumers looking for honest advice about selecting the best doctor. The Invisalign® Advantage® tiered doctor program can often be confusing for prospective patients, so I am writing this blog piece to set the story straight.

1. Your doctor gets points for every Comprehensive® case he/she submits. He does not get points for “limited”/ “express” cases.

2. The more points your doctor accrues, the more discounts he/she receives on lab fees. Last I checked, private practice doctors can get up to a 38% discount on lab fees if they are diamond providers. This brings the lab fee for a Comprehensive case to about $1150.

3. That discount may or may not affect the fee paid by the patient, but it’s certainly something you may want to bring to the table when negotiating fees.

4. Orthodontists’ offices work like car dealerships. Everything is negotiable, and cash is king. If you are using insurance, you don’t have as much leverage to negotiate.

5. If your doctor is in a group practice or has multiple locations, he or she may be more likely to be a Diamond provider. This doesn’t necessarily mean they have the most experience; it just means they’re better at “playing the game”. It also doesn’t necessarily mean they will give you the best treatment.

6. The best way to get the best treatment from your Invisalign® provider is to ask to see your ClinCheck® before you contract to start treatment or start to pay for it. Ask to have a copy of it sent to you for your records, and ask the doctor to explain your treatment plan. Shop around for the best treatment plan.

7. A doctor who has an intra-oral scanner (not necessarily an iTero® brand) is a good indication of experience, as is a doctor who will sit down to explain your ClinCheck.

8. If your Clincheck® is between 14-25 aligners, ask if there is an option to get generic aligners. Now that many Invisalign® patents are expired, it’s often possible to use a generic brand of aligners, which might lessen the lab fee by $1000 for the doctor. The doctor may be willing to pass some of that savings on to you.

If you are interested in scaling orthodontics in your practice, please visit www.straightsmilesolutions.com.

Team StraightSmile Solutions https://www.straightsmilesolutions.com/believes strongly that all patients should have routine dental photography completed at each new patient and recall examination. This process not only increase treatment acceptance but also mitigates risk management. We have partnered with  https://www.dentalphotographymadeeasy.com/to bring you this blog piece.

Below are 23 dental conditions that can routinely be monitored with dental photography and videography:

1. Crowding

Crowding can make it difficult to access all of a tooth’s surfaces for adequate brushing.

2. Spacing

Spacing is a double-edged sword. Not only is it not aesthetically pleasing, it also can cause a periodontal food trap, which causes food to lodge under the gums and can lead to painful infections if left untreated.

3. Attachment Loss

Over time, malocclusion and poor oral hygiene can lead to further periodontal breakdown or attachment loss.

4. Poor Oral Hygiene

5. Gingival Inflammation

6. Attrition

Improper function of teeth can lead to chipping and premature wear, which eventually necessitates costly dental procedures, such as root canals and crowns.

7. Abfractions

Imbalanced malocclusion can lead to bruxism and parafunction, which can cause gingival abfractions and permanent damage to teeth.

8. Trauma

9. Impingement

Severe overjet will continue to progress and eventually cause gingival impingement, which can lead to fremitus and tooth loss.

10. Overjet

Not only is overjet unattractive, but it can also lead to trauma and other speech and mastication complications.

11. Overbite

Overbites always become more severe over time.

12. Crossbite

Crossbites can create abnormal CR/CO shifts and cause abfraction, attrition and mobility.

13. Rotations

14. Midline Asymmetry

15. Soft Tissue Anomalies

16. Pathology

17. Extrusions

Extrusions can also cause gingival asymmetries.

18. Caries

19. Open bite

Most open bites have a fundamental etiology that needs to be addressed before the malocclusion can be corrected. A myofunctional therapist can be very helpful when treating these conditions, which include tongue thrust and mouth breathing.

20. Tongue Thrust

Tongue Thrusts can start as an infant and become innately programmed as muscle memory. These are easiest to eliminate in infants and young children. Over time, tongue thrusts can cause open bites and an unfavorable vertical growth of the face.

21. Fremitus

Over time, overbites can become more severe, leading to periodontal breakdown, root resorption and fremitus of the incisors.

22. Mouth Breathing

Mouth breathing is closely related to open bites and vertical growth of the face. These are best eliminated in infants and young children. The underlying etiology of the mouth breathing must be diagnosed and corrected.

23. Mobility

To schedule a complimentary consulting session or to become a StraightSmile Solutions® client, please visit https://www.straightsmilesolutions.com

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In preparation for the 2019 Chicago Mid-Winter convention, StraightSmile Solutions® has partnered with Yankee Tech Digital® to develop this list of suggested features to consider when selecting an Intra-Oral Scanner. Please feel free to contact our teams for more information or for support. To schedule a complimentary consultation, please visit www.straightsmilesolutions.com.

1. Price

This can vary from $10000-$40000. The difference could cover a college tuition or a new automobile, so choose wisely. Don’t be sucked into something you don’t need. Also, some labs are willing to subsidize the payment in exchange for work, or you might be able to lease a scanner.

2. Maneuverability

Are you setting up a designated “scan spot” in a single op, or do you need flexibility to seamlessly move the unit from op to op or from office to office? Based on your needs, a decision must be made regarding the correct form factor of the computer system to be used for scanning.

3. Monthly User Fees

Are you prepared for monthly user fees? Some scanners do not include a data fee with purchase, but others include it for a year.

4. Tech Support

If something goes wrong (which it will!), how quickly will the problem be resolved? Is this guaranteed in writing? How quickly do they guarantee you a replacement unit?

5. Weight

This is really important to your staff. How would you feel all day holding a heavy unit? Back and shoulder issues could become a liability for your office’s bottom line. A lot of assistants have small hands, and increased weight can make it harder to steer the wand and difficult to scan posterior distal areas and other sharp angles.

6. Tip Size/Comfort

Are you scanning pedo or geriatric patients? Consider the smallest possible tip for patient comfort.

7. Cross-Arch Accuracy (in microns)

If you are scanning for aligners, be aware that the recommended cross-arch accuracy should be no more than 200 microns. Getting a reliable full-mouth scan has always been an issue for intraoral scanners. Unlike desktop scanners, intraoral scanners have much smaller fields of view, which means a drastic increase in both the number and complexity of image-stitching operations. As you move the scanner head across a surface, individual images are stitched together rapidly to form the final model. With longer scanning areas, the errors ultimately add up, resulting in more and more deformations. This is where cross-arch accuracy comes into play.

8. Replacement Tip Cost

No brainer. You’ll need a lot.

9 Tip Lifespan

Is this guaranteed? How the tips are handled when sanitizing them will impact their lifespan; that’s why it’s critical to make sure that there are no wet spots left behind the tip mirror.

10 Touchscreen Capability

It’s just so cool to have this feature to sell a case. Consider good OSHA practices.

11. File Type

Is STL all you need? Another popular file format is PLY. A PLY file contains more information that an STL file, and it is becoming more popular with CAD/CAM software packages.

12. Mode of Image Capture

Do you want continuous or stable image capture? Continuous image capture systems are video-based. Video-based intraoral scanners are generally faster and easier to upgrade.

13. Use of Powder

More intraoral scanners are coming on the market that do not require powder in order to take impressions. However, there may be instances when powdering may be necessary due to the complexity and situation of the procedure. Too many shiny surfaces can make it difficult for the scanner to define the geometry of the teeth. The good news is that taking an impression for orthodontic treatment is not generally necessary.

14. Open Solution

A no brainer unless you want to be beholden to others: An “open connection” means the laboratory can work with any CAD/CAM system that accepts STL, the standard format. The laboratory can then use its own equipment for 3D printing. Open connections provide the benefits of an integrated system without the drawbacks of a proprietary format.

15. Disposable Tips

Do the math. Does this make sense? At least you don’t have to worry about your staff melting your tips. However, this is not an environmentally friendly option.

16. Manufacturer’s Warranty. Does the manufacture offer an extended warranty? If so, what is covered under the warranty?

17. Multidisciplinary Functionality

What applications do you plan to use the IOS for? Just aligners? Surgical guides? To scan implant abutments? For crowns and bridges? Accuracy is very important with multi-disciplinary functionality.

18. Automatic Bite Alignment Registration

Tools and utilities to edit, enhance, and analyze the captured impressions are very helpful!

Return on Investment

Many dentists struggle to decide whether intraoral scanning technology is worth the price. Although digital scanners currently range from $10,000 to $40,000, this cost can quickly be recovered in reduced overhead and increased practice efficiency. For example, an internal survey by Align Technology® indicated that 36% of dentists had to reappoint at least one patient per month to retake PVS impressions. The cost effectiveness of intraoral digital scanners is demonstrated by a conservative practice model. A busy orthodontic practice with a large volume of clear aligner patients spends $800 per month, or $9,600 per year, on impression materials. Assuming $300 of hourly production, an average 15 minutes of chair time savings computes to $75 of savings per production hour. Further, assuming a conservative estimate of 200 scans per year, the practice can realize $15,000 in production savings. These inventory and chair-time savings total $24,600 in one year—roughly the price of an intraoral scanner. Factoring in the costs for warranty coverage, scanner tips and supplies, and model fees, an intraoral scanner can pay for itself within two years. Clearly, the value of this technology exceeds the initial investment.

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As an orthodontic consultant and the CEO of StraightSmile Solutions®, I am frequently asked to report on the pulse of the orthodontic industry. A year ago, I was one of the first bloggers to report on the Invisalign Store® experience and franchise developments. As an initial team member of the SmileDirectClub®, a Bay Area native, and a citizen concerned about corporate cannibalization, I openly welcomed the opportunity to visit both the Candid Co® and Uniform Teeth® stores in San Francisco, learning more about the future of DTC orthodontics.

Appointment Scheduling:

Candid Co®:

Setting up the appointment online was simple, and the appointments were convenient and plentiful. Their brick-and-mortar store is in the swanky, financial district of San Francisco and, interestingly enough, is on the same block where I had my first summer job in retail at high school! Like Invisalign Stores®, Candid Co® has certainly invested in prime real estate.

I was prompted to sign a TOS online in advance to “save time.” It consisted of a medical/dental history and an informed consent form, which was more robust than that of the Invisalign Store® and other comparable direct-to-consumer (DTC) aligner companies. However, I did find parts of it confusing and redundant.

Uniform Teeth®:

At first glance, the process seemed like any other DTC aligner company. As a matter of fact, this company has just recently been infused with 4 million dollars of funding from venture capitalists looking to invest in the DTC aligner industry. That being said, I was disappointed; the appointments were neither convenient nor plentiful. As a matter of fact, they only book appointments in the morning and the early afternoon, and the next available scanning appointment wasn’t for 3 weeks! After some due diligence, I realized that this is indeed not at all a DTC aligner company, but an orthodontic office cleverly disguised as one. This is just one of the locations of the orthodontic practice of Dr. Kjeld Aamodt, who is a fellow UCSF grad. I can hardly believe that my alma mater supports the use of UCSF in all his marketing materials. Hats off to Dr. Aamodt for rebranding his office as a DTC aligner scan shop during non-prime hours. It’s a clever use of chair time and staff utilization, but I don’t think there is anything proprietary about this process. In reality, any dentist could do the same with an in-house aligner lab and Dental Monitoring® System.

Once I scheduled the appointment, I received several texts and emails about the process and was informed that I would indeed be scanned and examined directly by a licensed, UCSF-trained orthodontist. He even named the doctors who may be doing my scan. I would also receive, as needed: a complimentary panoramic x-ray, a CBCT and oral exam for periodontal disease and pathology.

Those who were selected for Uniform Teeth® would have minimal to no additional appointments and would be using teledentistry for check-ins. Once I found out the true story, I canceled my appointment. I do not consider Uniform Teeth® to be part of the DTC revolution.

Candid® Appointment Day:

Candid was running behind on their appointments. They did text me in advance to let me know, which I appreciated. I was given a bamboo toothbrush and some sparkling water while I waited. They did check my ID to verify my identity. I waited for almost an hour to be seen, but I wasn’t bored because there was quite a lot of drama in the packed waiting room. One father was furious because although he was able to schedule a scanning appointment, the scan techs declined the patient, who was underage (13) and had no ID. Candid® only accepts patients aged 16 and older – but to the father’s credit, this policy wasn’t clearly indicated when he made the appointment. The father was given a handful of Starbucks gift cards and a profuse apology. I do respect this decision from the corporation because patients who are still growing shouldn’t be treated with DTC aligners and there’s no way to access growth in a remote setting without a hand-wrist x-ray. It’s only a matter of time before the DTC companies like Invisalign Stores® start to venture into this arena, though!

Finally, it was my turn to be seen and although the tech was very kind and professional, she was untrained. She was not a licensed RDA, DA or RDH in the state of California, either. I have to give credit to both SmileDirectClub® and Invisalign Stores® for a much better scanning experience. The Candid® Tech routinely violated numerous HIPPA and OSHA regulations; she also wore very little PPE. Her scripting was quite erroneous. The scan with a Carestream 3600 and photos was a tortuous 39.5 minutes of pure discomfort. The chairs didn’t recline, and I was forced to contort my head, face, tongue, and neck into all kinds of awkward positions for her to get her images. The quality of her records was abysmal.  In reality, I’ve personally done this with the same equipment in less than 6 minutes. After the scanning session, there were some hard sells and bargaining, during which it became evident that this tech was compensated on commission. She created all kinds of BS to try to sell the aligners to me up front. I could almost say that she was practicing dentistry without a license because she was clearly diagnosing and treatment planning. Although I don’t feel that DTC Aligner companies are violating any dental board regulations, I do know that many California Dental Board regulations were inherently breached in that 39-minute appointment. Here was her diagnosis and treatment plan:

1. She told me that the black triangle between my lower incisors would eventually cause decay if not corrected with aligners immediately.
2. I was also told that my (at most) 3 degrees rotated LR7 would cause “severe TMJ” if not treated by aligners.

She tried to get me to buy the set-up sight unseen for an initial discount of $100. The hard sell continued, reminiscent of buying from a used car dealership. She upped her ante to $200 off if I purchased in full today.  I declined and eventually, she set me up with an appointment with her treatment coordinator, Jared, who would consult with me at a later date once my treatment plan was ready for review. Since she didn’t land the sale, I didn’t get a swag bag like the others, and I was escorted out without barely a “thank you”. All in all, I would give the Candid® store experience a 1 out of 10. Since it’s supposedly a company run by orthodontists, I was very disappointed in the experience.

Visiting the scan shops is a wake-up experience for this seasoned orthodontist. The industry is changing, and you need to reinvent yourself or get lost in the shuffle. If you have questions about scaling orthodontics outside the DTC arena, please visit www.straightsmilesolutions.com for more information. Since growth modification and airway are a huge part of my consulting practice, I am absolutely excited to witness the DTC pivot into using teledentistry to help correct bites with elastics and removable functional appliances. It would be a very easy value-add to the DTC dental industry.

Post note: Team Candid® did contact me after this article was published and ensured me that any compliance concerns addressed in this letter have been addressed and corrected.