Clinical Companion Guide Table of Contents Step 1: Select a Case and Treatment Goal . . . . . . . . . . . . . . . . . . . . 4 Getting Starting - Your First Patient . . . . . . . . . . . . . . . . . . . . . 4 Introducing Invisalign to Your Patients . . . . . . . . . . . . . . . . . . . 4 Patient Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Typical Photographic Series . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Invisalign Treatment: Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . 6 The Consultation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Discussing Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Step 2: Submit Case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Taking Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Case Submission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Step 3: Finalize Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 ClinCheck Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Step 4: Start Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Aligners are Delivered . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Starting the Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Attachments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Interproximal Reduction of Enamel (IPR) . . . . . . . . . . . . . . . . 12 IPR: Goals, Strategies and Techniques . . . . . . . . . . . . . . . . . . 12 FAQs for IPR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Dispensing the Aligners to Your Patient . . . . . . . . . . . . . . . . . 14 Step 5: Monitor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Are Teeth Tracking? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Monitoring Extrusions: Buttons and Elastics . . . . . . . . . . . . . 16 Monitoring Rotations: Detail and Eraser Pliers . . . . . . . . . . . .16 FAQs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Step 6: Finish . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Retention: 3 Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 The information provided herein is intended as a tool only. Whether and what orthodontic treatment to prescribe for a patient is the responsibility of the treating dental professional in the exercise of his/her independent medical judgment. Step 1 Select a Case and Treatment Goal Getting Started - Your First Patients Now that you are certified to provide Invisalign to your patients, a question commonly asked is “How do I begin?” The best way to begin sharing Invisalign with your patients is to ask the question “How do you feel about your smile?” This simple question opens the doorway of communication between doctor and patients. Most people know how they feel about their smile, but have never been asked about it. After asking how your patient feels about their smile, ask the next question “Is there anything you would like to change?” Allow your patient some time to explain how they feel about their smile and some of the frustration they may feel. Have them point out to you what bothers them. As your patient explains, ask yourself, “What is this patient’s chief concern?” Introducing Invisalign to Your Patients 1. Tell all your patients that you now offer Invisalign. 2. Hand them an actual Invisalign aligner. Encourage the patient to look at it closely and then demonstrate to your patient how the aligner works. 3. Hand your patient an Invisalign brochure. Patient Interest When a patient shows interest in the product, let them know that you will need to set up a consultation appointment. 1. Explain to your patient what you will do at the consultation appointment: look at photos, consult the ClinAdvisor and discuss the best treatment plan. 2. Inform your patient that before he or she leaves today, a staff member will be taking photos of their mouth and face. 3. Before the patient leaves, ensure them that you have their best interest in mind, and will decide with them, the best plan of action to improve their smile. 04 Taking photos of patient Materials needed: 1) Digital Camera 2) Files in .jpg format are recommended Typical Photographic Series Right Buccal Anterior Upper Occlusal Smile Left Buccal Lower Occlusal Repose Profile . 05 Invisalign Treatments : Diagnosis NOTE: To treat cases exceeding parameters identified, auxiliaries and/ or advanced Ortho techniques may be needed. Recommended product application for doctors who have completed initial training with limited case experience1 FULL HOW MUCH CROWDING CAN I CORRECT? approx. 2 mm/arch approx. 5 mm/arch HOW MUCH SPACING CAN I CORRECT? approx. 2 mm/arch approx. 5 mm/arch LOWER INCISORS up to 20 degrees approx. 40 degrees UPPER CENTRAL INCISORS up to 20 degrees approx. 35 degrees UPPER LATERAL INCISORS, CANINES, BICUSPIDS up to 20 degrees approx. 25 degrees MOLARS up to 20 degrees approx. 20 degrees approx. 1 mm/arch approx. 1 mm/arch (with IPR) (with IPR) WHAT A/P CORRECTIONS CAN I MAKE? None Allowed None Recommended HOW MUCH OVERJET CAN I CORRECT (NOT INCLUDING IMPROVEMENT ATTAINED THROUGH A/P CORRECTION)? approx. 2 mm approx. 4 mm approx. 2 mm/arch approx. 2 mm/arch WHAT ROTATIONS CAN I CORRECT? HOW MUCH MID-LINE CORRECTION CAN I MAKE? HOW MUCH OVERBITE CAN I CORRECT? 1 The corrections identified are recommendations only and are dependent on factors outside the control of Align Technology, Inc., and Align Technology, Inc. does not guarentee the achievability of any particular treatment outcome. The doctor is responsible for determination of which cases to treat with which product, if any. Except for product protocol limitations for Express, techniques are subject to doctor determination of patient and product suitability and treatment decisions. Please refer to Pricing, Terms and Conditions for more information. Product Criteria - Less than 10 stages of movement Maximum Extrusion of 0.5 mm* Maximum Posterior Intrusion of 1 mm* Maximum IPR of 2 mm* No Sagittal (A/P) Correction * May be exceeded if requesting Partial Treament FULL PRICE $750 (whether single or dual arch treatment) PRODUCT CRITERIA 1 1 1 1 1 REFINEMENTS 10 or fewer stages of treatment Maximum Extrusion of 0.5 mm Maximum Posterior Intrusion of 1mm Maximum IPR of 2 mm per arch No Sagittal (A/P) Correction 06 General Applicability Subject to Customer Determination of Patient Suitability Limited to one for purchase at $125. Includes ClinCheck Review and modification opportunity. Not available if Partial Treatment was Approved. 2 Up to 3 included at no additional charge. Includes ClinCheck Review and modification opportunity. 1 Not Available Available 1 One set of 3 stages for purchase at $99 to achieve previously approved final position. No ClinCheck is provided Not Available MID-COURSE CORRECTION DETAILING $1,495 1 Some restrictions apply - see Pricing Terms and Conditions 2 Partial Treatments may be purchased at the Invisalign Express price for cases with partial malocclusion correction, or for treatment plans that exceed the extrusion, IPR, or posterior intrusion criteria. Other Invisalign Express restrictions and criteria apply. Partial Treatments are not eligible for refinement. The Consultation The consultation appointment can be just as important as the patient’s very first introduction to Invisalign. At the consultation appointment: 1) Leave enough time to explain the process of Invisalign, answer any questions, and discuss the financing. 2) Show patient a sample ClinCheck to get them excited about the Invisalign system. 3) Answer any questions your patient may have, and if you need product support, don’t hesitate to call Invisalign customer support 1-888-82-ALIGN or email at [email protected]. Discussing Financing When looking at patient financing, consider Dr. Charles Blair’s advice in the Invisalign “Practice Development – Quick-Start Guide”, “Dental treatment is an excellent investment in your medical and psychological well-being. We believe that financing should not be a barrier to obtaining this important health service. We recognize that our patients have different needs and provide the following payment options: No Interest Payment Plans (3, 6, 12 or 18 months) • No down payment • Monthly payments as low as ___________ • Outstanding balance due before payment plan period is over to qualify for 0% interest • Good credit status required Extended Payment Plans (24, 36 or 48 months) • No down payment • Monthly payments as low as ___________ • Outstanding balance due before payment plan period is over to qualify for 0% interest • Good credit status required Cash or Credit Card Payments • Payment in Full - A bookkeeping courtesy of ___% or $_______ is given for direct payment in full by cash or check at the start of records, resulting in a one-time payment of $________ Or • Dr. SmileMore’s Payment Plan o $__________ at records (Date: _________________) o $__________ at Aligner Delivery (Date: _________________) o $__________ per month for _____ months (Dates: _________________) * If for any reason the estimated amount is not paid by your insurance company, it becomes your obligation.” Your invoice is issued when Invisalign ships the aligners, therefore you have about 90 days from the time you submit your records, until the time the full payment is due to Invisalign. 07 Step 2 Submit Your Case Taking Records There are four required records that need to taken from your patients before the end of the consultation visit: impressions, bite registration, photographs, and x-rays. Impressions Materials needed: 1. Impressions must be taken using PVS impression material, both upper and lower, even if treating only one arch. 2. It is recommended to use PVS impression materials that comply with ISO specification 4283 and/or ADA specification 19. 3. Brands that conform to these standards: • Dentsply Aquasil® and Aquasil Ultra® • 3M/ESPE Imprint™ 3 Heavy Body 3M/ESPE Imprint™ 3 Light Body Wash • Discus Splash!® • Heraeus-Kulzer Flexitime® • GC Examix® 4. Correct Invisalign tray size which should fully cover the terminal molar. Commonly Used Impression Techniques 1. One Step: • Full Putty Arch with Light Body • Heavy Body with Light Body 2. Two Step: • Putty Dam with Medium Body • Heavy Body with Light Body Bite Registration Materials Needed (PVS only, No Wax bite): 1. Brands: • Regisil® (Caulk) • Blu-Mousse® (Parkell) • Presidente Jet Bite (Coltene/Whaledent) • Occlufast Rock (Zhermack) Recommended Technique: 1. Use a full-arch registration 2. Layer a thick line of PVS bite registration material across the mandibular arch (more material is better) 3. Have patient “bite on their back teeth” 08 X-rays 1. One Full Mouth Series X-ray or Panoramic X-ray (these records should be current) 2. Files in .jpg format are recommended Case Submission When submitting your patient’s case, the best option for submission is online. Online submissions are much clearer to Invisalign technicians, since they do not have to interpret doctor’s handwriting. Online submission steps 1. Select “Start New Case” from the top box on the left hand corner of the screen - under “Tools and Forms”. 2. Enter patient information and order type. 3. Complete online "Prescription and Diagnosis" form. 4. Upload photos using the Kodak Template (Recommended) or attach low resolution images individually. 5. Upload radiographs (PANO, FMX). After successful upload, please be sure to click “Submit Form”. Wait for Submission Confirmation and print two copies of the treatment form. Keep one for your files and submit one with your records. 6. Send upper & lower PVS impressions, bite registration and a copy of the treatment form in the submission box provided. 09 Step 3 Finalize Treatment Plan ClinCheck Review Once you have submitted all of your records for Invisalign: 1. Wait until you are notified by VIP to review your patient’s case for final approval. The ClinCheck Review will allow you to look over, modify and finalize your patient’s treatment plan. 2. Evaluate the ClinCheck Review. At this point you will have two choices: • Accept the case because it is exactly what your patient needs. • Modify the case if there is anything you want to change. If you elect to modify, there will be two ways for you to make the changes: o Use the Wizard, which will take you through a series of steps within the ClinCheck Review. o Click on the Modify button and type comments in directly. 3. Once you decide that your case is ready for submission, click Accept. Align Technology will not manufacture your patient’s aligners until you have approved the ClinCheck file. 10 Step 4 Start Treatment Aligners are Delivered The aligners will be delivered within 7-10 business days after your final online approval. Within the box will be all the following: 1. Aligners 2. IPR form 3. Attachment template (if applicable) 4. Patient Starter Kit Starting the Treatment After receiving the aligners, make sure that the aligners fit. Once the aligner fits, depending on the case, begin the process of putting on the attachments. Attachments The attachments are composite forms bonded to the tooth’s surface. The attachments are placed to assist in aligner retention (short clinical crowns and non-retentive tooth shape) and to aid in tooth movement (rotations of teeth, intrusion, extrusion, and space closure). Posterior dental composite for the attachments is recommended. Placing Attachments 1. Place Template to Test Fit 2. Isolate Teeth 3. Dry Teeth 4. Etch Enamel 5. Rinse and Dry 6. Apply Bonding Agent 7. Place Posterior Composite into Template 8. Place Template over Teeth 9. Cure Composite 10. Remove Template and Composite Flash 11 Interproximal Reduction of Enamel (IPR) There are 3 ways to perform IPR on your patient: the manual method, slow speed disc, and high speed bur. Hand Strips Advantages- less aggressive and easy to position Disadvantages- less comfortable for patient, lip/tongue control to avoid injury, and takes more time Slow Speed Method Advantages - fast and efficient, clean vertical cuts, and little patient objection compared to hand strips Disadvantages - technique and control are important (avoid making a ledge, avoid soft tissue injury). Access is typically limited to anterior teeth only and alignment of teeth is needed for proper access. High Speed Method (Better suited for posterior IPR) Advantages - fast Disadvantages - minimum thickness is 0.3mm and alignment of teeth is needed for proper access. IPR: Goals and Techniques IPR Goals Occlusal View Before Before Goal After Goal After Note: Amount of IPR shown is not drawn to scale. Actual amount of IPR will vary and is the responsibility of the treating clinician. 12 IPR Techniques IPR Strips Slow Speed Disc Single sided and double sided available in a variety of widths. Single sided and double sided available in a variety of widths IPR- How much and when? Before accepting a ClinCheck, determine if the amount, location and timing of the proposed IPR meets your needs. Perform IPR when interproximal contacts are touching; this enables easier measurement of the amount of IPR done and ensures the proper amount is measured. Some doctors will leave 0.1mm of IPR in reserve for “finessing”. IPR: Tips Tip #1- Contour and polish the proximal faces immediately after IPR with composite polishing instruments to ensure smooth surfaces. Tip #2- Consider digital calipers to measure the thickness of discs. Tip #3- Write down how much IPR was done for each contact point. FAQs for IPR: 1. Why might I want to alter the proposed IPR values during my ClinCheck Review? - The treating clinician needs to determine if the amount, location, and timing of IPR proposed is appropriate for their patient. The clinician may want the IPR to be spread out or relocated. The clinician may also check the x-rays and find the enamel to be too thin for the prescribed IPR. 2. Can creating space all at once pose concerns? - By creating space all at once, the patient may object to sudden gaps appearing between their teeth. Typically, 0.5mm per contact is the maximum proposed IPR. The aligner should mask the appearance of most gaps that are less than 0.5 mm. 3. What are the contraindications of IPR? - Some contraindications of IPR are sensitive teeth, thin enamel, enamel damage/imperfections, and poor oral hygiene. Be sure to note that food impaction may occur while the spaces are being closed. Also poor access to contacts, flat contacts or subgingival contacts may be contraindicated. 13 Dispensing the Aligners to your Patient When your patient comes in to receive their aligners, make certain you spend some time describing what the patient needs to do in order to be successful. Each box of aligners comes with a Starter Kit (Instructions for Use). 1. 2. 3. 4. Review instructions for use. Review aligner placement and removal. Check aligner fit for tissue impingement. Emphasize the importance of patient compliance. Patients are to wear the aligners in two-week intervals until the treatment is complete. The patient should wear the aligners for at least 22 hours a day or 300 hours biweekly. 5. Show your patient how to remove, clean and store the aligners. Consider telling your patients not to throw any aligners away. 6. Patients should not be given all of their aligners at one time; rather you should give them 2-3 sets of aligners at each visit in order for you to monitor the treatment. 14 Step 5 Monitor Are Teeth Tracking? As your patient comes in every 4-6 weeks for monitoring, make sure the patient is wearing their aligners and that the teeth are tracking. If your patient is not wearing their aligners at least 22 hours a day, their teeth will not move at the pace of the proposed treatment. Does the aligner fit? Check to see if the current aligner fits well and that the attachments are in place. Attachments can be “marked” to see if they are engaged in the “bubbles.” Track carefully the rectangular attachments, because lack of engagement introduces the possibility of unwanted force. A ttachm ent not engaged Attachment engaged Are contacts too tight? Next, you want to see if the contacts between crowded teeth are too tight by using unwaxed dental floss. It is important to check all contacts. If they are too tight, you may need to open them. If you are implementing IPR, it is best to do the next IPR portion, as soon as the teeth touch. Remember to polish IPR surfaces to ensure smooth contacts. Help patient monitor “good fit” Educate your patient on how to make sure aligners are engaged. Tell your patient that they must get an ideal fit before moving to the next aligner. Make sure they are aware that flossing should get easier. If they detect that flossing is becoming more difficult, they should come in for an appointment. 15 Monitoring Extrusions- Buttons and Elastics If you find that an extrusion is not occurring, utilizing Buttons and Elastics may be helpful: 1. Check for tight contacts. 2. Cut window in the aligner to place button, leaving space for extrusion; you can use scissors or a hole puncher. 3. Polish aligner, especially if you used scissors. 4. Bond button 5. Create tab on the lingual 6. Run small elastic in kit Monitoring Rotations- Detail and Eraser Pliers The detail and eraser pliers are meant to help correct minor alignment issues at the end of the treatment. There may be a tooth lagging behind or a light interproximal contact. Detail Pliers The detail pliers available from Invisalign can assist in the rotation of a tooth. The detail pliers are specifically designed to address rotation problems by adding pressure points to the aligners. Remember that the detail pliers are to be used when the movement has been programmed into the aligners, but the teeth have not fully expressed it. Reinforce dimples with ClearLoc so that proper pressure is maintained. Eraser Pliers The eraser pliers can help you erase a dimple if you need to reposition the dimple and can bend the aligner to create room for the movement of a tooth. 1. Before using the detail plier, adjust the screw stop to regulate the depth of the dimple on the aligner. Be careful not to adjust the setting too low or you may punch a hole in the aligner. 2. Use the pliers to create a dimple on the aligner where the tooth needs to be pushed. 16 FAQs 1. What happens if a patient loses an aligner? - Put your patient in their previous aligner and order a replacement from Customer Care. Replacement charges will apply 2. What happens if the next aligner does not fit? - Wait until the previous aligner fits correctly. You may go back one stage or use a refinement. 3. What happens if a patient breaks a tooth during their treatment? - Restore a temporary tooth that will fit in the aligner. Consider using the aligner as a template for your temporary restoration. You will complete the final restoration at the end of the Invisalign treatment. If the temporary tooth does not fit in the aligner, you may consider a midcourse correction. 4. What if an aligner breaks? - Put your patient in their previous aligner and order a replacement from VIP or Customer Care. 17 Step 6 Finish Retention- 3 Types Retention is extremely important as you conclude your patient’s treatment. Anything that is moved, must be retained, otherwise it will move again. There are several options for retention: Removable 1. Vivera Retainers: Patients enrolled in the Vivera retainer program receive a full year of retention coverage, with fresh, clean retainers automatically delivered to you or to your patient every three months. Vivera retainers are made with the same state-of-the-art technology as Invisalign® aligners, and use 3-D digital imaging, proprietary clear thermoplastic material and advanced fabrication technology. For more information go to www.viveraretainers.com. 2. Hawley Retainer: Patients may complain about the wire though. 3. Vacuform Retainer: made in-house. Fixed 1. Bonded lingual wire: You can make the fixed retainer yourself. You can buy the lingual wire at an ortho supply house in many different thicknesses. It is recommended to use the braided (coaxial) .0155" lingual wire attached with flowable composite. The bonded lingual wire is optimal for the lower teeth where relapse is more critical. Combination Fixed and Removable 1. Combination: Take an impression after bonding the lingual wire and make a vacuum retainer. This option is used for maximum stability of anterior teeth in addition to posterior coverage at night. 18 Contact Information Key Phone Number Customer Support 1-888-822-5446 [email protected] Key Websites www.Invisalign.com Patient website for clinicians and consumers alike. www.Invisalign.com/VIP Your Virtual Invisalign Practice to access patient ClinChecks, case forms, submit cases online, and view current promotions. www.AligntechInstitute.com Your resource for clinical education for the Invisalign system. Access live and online ce training opportunities 24/7/365. www.InvisalignRebate.com Sign up for and view your Invisalign Loyalty Rebate amount. www.PracticeMarketer.com Take advantage of all the Invisalign marketing ads. You can customize these ads and posters to fit your specific needs. www.DrCharlesBlair.com Program for revenue enhancement and filing Invisalign on insurance tips www.CareCredit.com Financing options for your patients at special rates for Invisalign Certified offices. 19 For more educational resources: www.aligntechinstitute.com 881 Martin Avenue Santa Clara, CA 95050 www.invisalign.com
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