Clinical Companion Guide

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.
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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
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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.
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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