If you would’ve told me 18 years ago that I’d be treating several new clear-aligner patients a month in my orthodontic practice, I would’ve thought you were out of your mind. But I have an ever-increasing percentage of patients in clear aligners—and that’s the case across the market, as well. I’ve been board-certified since 1994, and while I might not get “board-quality results” with Invisalign every time, I do get several every month.
There was a learning curve, of course. I remember when I first started, whenever I saw a clear-aligner patient on my schedule I felt a little queasy: What was I going to see? How would I treat it? Fast-forward one decade, and now I eagerly look forward to the clear-aligner cases, while the fixed cases are usually responsible for more of my unease.
How could this change have happened? Here are the top nine things that affected my experience as an orthodontist who’s embraced clear-aligner treatment.
1. Digital scanning
The thought of taking PVS impressions inspires that queasy feeling again. Just not having the gagging sound in the office is worth it! Not to mention all the other benefits: scans that take three minutes or less; no retakes or models. Which leads me to …
2. Additional aligners
Thanks to the scanner, it’s easier for me to create additional aligners than to reset a single bracket. I don’t know about you, but it’s rare for me to not have to reset at least one bracket in fixed, which in my office requires a half-hour appointment. (Seating the patient, removing the archwire and adhesive, preparing the bracket and tooth, setting the new bracket—praying it stays this time!—and replacing the archwire takes at least 20 minutes. I’m not one who likes stress, so I add extra time just in case.) The scans take five minutes.
Invisalign now offers unlimited aligners for five years, which takes the stress off the entire process. You don’t have to design the ClinCheck with the goal of eliminating additional aligners, as in the past, which for me means no overcorrection, etc. In fact, I love doing additional aligners; the patients get your very best and appreciate your thoroughness.
Now, I know this never happens to you, but a patient’s tooth has been known to rotate after a few months of retainer wear. Sometimes he or she is so upset that you end up putting brackets on again. If you’re using aligners, you can scan and fix these issues, and the only cost is a new retainer and a five-minute scan.
3. Much of the process isn’t dependent upon doctor time
Scans and all records can be performed by assistants. And when creating additional aligners, it’s not necessary to remove attachments; optimized attachments should have worked, so they now become “conventional.” Once you get the ClinCheck back, you can always digitally remove and replace as necessary.
4. The big one (to me): Modifying your ClinCheck.
ClinChecks are derived from a program called Treat, which Align Technology trained my techs to use. But they’re not orthodontists, of course, and the Treat program is like so many other computer programs and goes by default values. Cut-offs need to be made and hierarchies developed.
Let me explain: Suppose UR1 needs to be extruded 0.51 millimeters. Because the cutoff is 0.5mm, the extrusion would be classified as a “moderately difficult” movement and there would be an attachment placed. But if UL1 needed extrusion of 0.49mm, that would be below the 0.5mm cutoff—no attachment would be placed and the tooth would be assigned as an “expected” movement. However, we know that the difference between the two is not clinically distinguishable.
This goes for optimized attachments, also: If a tooth needs rotation and extrusion, which attachment should be assigned to it? You must determine which is more important, and can place an attachment that you believe will work best. IPR, tooth positions, order of movement, timing of movement, arch form, arch width, unwanted movements, size and shape of attachments—all these require doctor input. I’ve found that most orthodontists are comfortable changing final tooth positions and add a few degrees of torque or rotation. That is simply not enough and doesn’t make you much better than a GP using the appliance. So how are you going to get better?
5. These are not braces!
Just because you’ve been trained in orthodontics doesn’t mean you can easily shift into clear aligners. Although biomechanics is biomechanics, they don’t work the same and each has its own strengths and weaknesses. Having a driver’s license doesn’t mean I can drive an 18-wheeler, even if it’s a “transportation mode” just like an automobile. Change your thinking to adapt to clear aligners! I have fun with these now, and the appointments are usually five minutes or less spread sometimes over three months. (That’s why I have time to post cases on Orthotown and write this article.)
6. Spend the time to learn this system.
Expect the unexpected. I’ve found that when unusual things happen in fixed, most times docs don’t even notice because such things occur all the time and they’re used to it. But the first time you have a posterior open bite or a tooth intrudes in a clear-aligner case, this becomes a big deal.
Even assessing wear and compliance requires a new way of thinking. After doing orthodontics forever, you just know if a patient is wearing his elastics or headgear. The same eventually goes with aligners—at first you may not know if the problem is the patient or the appliance’s capabilities, but as you get more comfortable it’s easy to distinguish.
(Also, I know this sounds unusual, but with fixed you can sometimes move a root 20 degrees off by bracket placement error. There is no such issue with clear aligners.)
7. Don’t use braces as a crutch.
I rarely use any fixed whatsoever with aligners. I don’t use Class 2 or Class 3 correctors before aligner therapy; I do it all with aligners because I consider them to be wonderful appliances for such issues.
If I would have said that 10 years ago, I would’ve thought I was on drugs. But if you’re persistent, you will really learn how to use the appliance.
8. Get acquainted with the continuing education
section on the aligner’s website for doctors.
I’ve listened to almost every lecture that’s been posted since I started, and I’ve taken every CE course. I even listen to the GP lectures to see what they’re being taught. I want to know everything about everything.
You’re going to need to go to some of the live CE courses that are available. Although not widely available, there are meetings besides the biannual big summit.
9. Start taking advantage of when clear
aligners are the treatment of choice.
Open bites because of posterior coverage are no-brainer aligner cases. I particularly like doing lower incisor extraction cases with clear aligners; I can preplan the occlusion, pinpoint any IPR necessary on the upper, and there’s no need for brackets to parallel the roots.
Adjusting to a clear-aligner practice takes time and effort, but I’ve discovered that clear aligners have been the main force in growing my practice. Whether you like it or not, they’re the wave of the future.
Peer inside
Dr. Harnick’s
practice
Dr. David Harnick’s Albuquerque practice was featured in an Office Visit in the July/August issue of Orthotown. It’s not too late to check it out! Visit
orthotown.com/harnick-office to read the Q&A and check out the pictures.