StraightTalk

May 2014 | Vol.16 Straight Talkrom the other side”NTEMPORARY PRODUCT SOLUTIONSSimplifying Dental Photography One-Step VPS Impressions Ensurefor Invisalign Treatment Accuracy for Invisalign TreatmentDigital Master Impressions: Placing Invisalign Attachments UsingA Clinical Reality! Proper Technique and Materials© Contemporary Product Solutions • 2014

EyeSpecial C-II Built in dental grid lines and spot focusing capabilities.SMART DIGITAL CAMERA,DESIGNED EXCLUSIVELY FOR DENTISTRY 8 Dental shooting modes – Easier, faster and more reproducible images SNESCII-0314 Auto focus, zoom and isolate Auto flash adjustment for true color Visit www.shofu.com or call 800.827.4638 3.5 inch LED/LCD touchscreen – Works with exam gloves Water/chemical resistant – Essential for infection control in the office SureFile – Proprietary photo management softwareShofu Dental Corporation • San Marcos, CA

WelcomeW e would like to dedicate this issue of CPS Magazine to our partners Erik Brinker at Invisalign. Our trainers of 81 consisting of patient coordinators, President hygienist, and dental assistants have to this date, taught over Shannon 55 classes and over 3000 team members. Our classes teach Pace Brinkerorthodontic records that consist of digital photography, impression taking, CDA, CDDplacement of attachment, patient communication, marketing and financial Vice President solutions. We have been very pleased with all the venues and all the friends we have made along the way. In this issue you will see various step by step techniques, articles and videos of procedures. We hope you enjoy this issues and we hope to see you at one of our classes. Thank you!Erik Brinker Shannon Pace Brinker, CDA, CDD President Vice President May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 3

Contemporary Product Solutions Table of Contents309 A 26th StreetVirginia Beach, VA 23451 Simplifying Dental Photography757-226-9498 for Invisalign Treatmentwww.cpsmagazine.com 6by Shannon Pace Brinker, CDA , CDD...................................................Magazine Advertising Shannon Pace Brinker CDA, CDD Digital Master Impressions: [email protected] A Clinical Reality! 757-226-9498 14by Robert A. Lowe, DDS......................................................................Web Advertising Erik Brinkcer One-Step VPS Impressions [email protected] Ensure Accuracy for 757 652-2688 Invisalign TreatmentDesign and Production 25by Janice Turner.................................................................................... René Jack [email protected] in Chiefs Erik Brinker Shannon Pace Brinker CDA, CDDCo-Editor Dentistry Team Dr. Ray M. Becker, D.D.S., F.A.G.D. Dr. Phillip Kemp Dr. Allan MohrCo-Editor Dental Assistants Dawn Wiedow Juliano CDS, EFDA, RDA Niki HensonHygiene Editors Stacy Mccauley RDH Rachel Wall RDHCo-Editor Patient Coordinator Linda Zdanowicz, CDALaboratory Editor Lars Hanson, CDT4 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

Table of ContentsINVISALIGN:Insurance and FinancingCheck -ListTreatment 32....................................Scheduling for Invisalign 34...........................Dental Hygienists’Role in IdentifyingInvisalign Cases 38by Rachel Smith, RDH.........................................................................Placing InvisalignAttachments Using ProperTechnique and Materials 44by Megan Cotturone, CDA.................................................................. May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 5

Simplifying DentalPhotography forInvisalign Treatmentby Shannon Pace Brinker, CDA , CDDIntroduction agnostic records, these photographs document and provide essential information for aligner fab-When taking digital photographs for orthodon- rication. Therefore, inaccurate, incomplete, ortic treatments, dental assistants may encoun- poorly framed or focused photographs can resultter a variety of challenges during this important in poor fitting aligners, unsuccessful treatment,treatment planning and progress documenta- frustrated patients, and decreased profitability totion process. Dental photography for orthodontic the practice. Using the most dental-appropriatetreatment—including Invisalign—spans a range equipment available, simplifying the photo-tak-of images and necessitates equipment flexibil- ing process, and ensuring proper technique en-ity for capturing patient conditions at all angles. able dental assistants to produce accurate andHeavy cameras with various lighting equipment, essential photographs for Invisalign treatment.settings, and lenses—in addition to overly simple Photography Equipment & Materialssystems—contribute to confusion and challeng- Necessary equipment and materials for producinges in dental photography. clear and specific dental photography for treatmentFor example, typical point-and-shoot cameras planning includes a background, lip , an occlus-do not provide sufficient specialization to prop- al mirror, and a dental camera. A non-distractingerly capture and document the specific patient background that is either white or lightly coloredcharacteristics required in dental photographs. creates a visual contrast between the backgroundMeanwhile, advanced digital single reflex lens and the patient when extraoral photographs are(DSLR) cameras demand extensive training and taken. Lip retractors are necessary for intraoralare very heavy to operate. photographs to move a patient’s lip away from theInvisalign orthodontic treatment is planned in area of interest and isolate the teeth. Two types ofpart based on eight intraoral and extraoral pho- lip retractors (e.g., double plastic lip retractors andtographs. These contribute to creating the ideal small metal retractors) are used in Invisalign treat-customized clear aligners for each individual ment planning. (Figures A and B) Dental assistantspatient to correct their malalignment issues. can utilize the “c” end of the double plastic retrac-Although just one component of Invisalign di- tors when capturing anterior frontal photograph,6 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

ABCwhile the “v” ends are used when More advanced than a point-and- Dtaking side buccal photographs. shoot camera and easier to useThe metal lip retractors stretch than a DSLR camera, this digital are not forgotten and also pre-the patient’s lip out more than dental camera includes a high- vents the appearance of any red-the plastic retractors and, along performance 49 mm macro lens, ness that might be caused by thewith occlusal mirrors, facilitate and the built-in flash provides the retractors during intraoral pho-capturing the full maxillary or proper lighting for all photograph- tography. When taking full facemandibular occlusion. (Figure C) ic requirements, including Invis- photographs, keep the patientRecent advancements in digital align orthodontic treatment plan- slightly away from the backdropcameras have resulted in the de- ning records. Eight modes enable to avoid shadows, and stand farvelopment of dental specific cam- appropriate settings for a variety enough back to include the pa-eras that provide dental assistants of situations, including surgery, tient’s shoulders and top of theirand dental practices with the ideal mirror, face, low-glare, whiten- head. If the patient has long hair,camera for capturing the variety ing, tele macro, isolate shade, and ask them to pull it back. For re-of images necessary in every day standard. Ideal for dental treat- pose photographs, instruct thepractice. The EyeSpecial C-II Digital ment planning, the gridlines es- patient to lick their lips and thenDental Camera (Shofu Dental Cor- tablish a visual point of reference take a deep breath; this helps en-poration [www.shofu.com] Figure for creating centered and straight sure that they are in a natural andD) is a simplified, dental-specific images. The excellent depth of neutral position.digital camera system. It features a field and infrared, ultraviolet, and Intraoral photographs require closelight-weight camera body that can anti-reflection filters also improve patient interaction and specific pa-easily be held with one hand, and it the camera’s ability to capture tient instruction. Avoid using a bibincludes a strap for extra comfort. high quality images. on the patient during the photog-Compatible with Wi-Fi memory Specific Recommendations raphy portion of the records ap-cards (Eye-Fi X2, Shofu Dental Cor- for Invisalign Photography pointment to prevent implying aporation), the camera immediately Beginning the diagnostic photo- clinical procedure will take place.transfers images to the monitor graphic records with the full face Instead, use this time to connectand supports patient transfer soft- photographs ensures that they with the patient and continue dis-ware for improved record keep- cussing their Invisalign treatment.ing. With eight camera modes, fast Capturing the entire mandibular orauto-focusing, and anti-shake ca- maxillary occlusion can be difficult,pabilities, the EyeSpecial camerarequires no photography skills. Thelarge LCD touch-screen increasesits usability, and the durable wa-ter- and chemical-proof coatingensures maintenance of infectioncontrol procedures and ease indisinfection. May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 7

Photographs by Shannon Pace Brinker 2 3 1so keeping the patient at ease—as the side and chin parallel to 4well as using small metal retrac- the floor. Use the gridlines ontors at an angle—will help enable the camera’s screen to ensure 7. For the intraoral photographs,the patient to stretch out their lips straight and centered photo- switch the camera modefarther. Asking a patient to lift their graphs. The camera should back to “standard” and keepchin as far back as possible can be at the same level as the the camera in the horizontalreduce tongue interference and patient’s nose. Stand the ap- position.improve accuracy. Eliminating propriate distance away to in-saliva, lipstick, plaque, etc. when clude the patient’s shoulders 8. Instruct the patient to sit intaking intraoral photographs to the top of the head. Instruct the operatory chair and swinghelps avoid obscuring necessary the patient to smile naturally, their legs around so that thedetails of a patient’s teeth, im- and press the button halfway patient is knee-to-knee withproving image quality. down to focus, and then take the photographer. Ensure that the photograph. (Figure 2) both chairs are both at thePhotographic Technique 5. Frontal Repose: Using the same height to avoid any an- same frame, ensure that the gulations.1. After the patient is determined image is straight and the pa- to be a suitable candidate for tient is maintaining maximum 9. Full Smile: No retractors pres- Invisalign treatment during intercuspation. Instruct the ent; Make sure the patients lip the consultation appointment, patient to breath in and out. to chin and lip to nose are lined schedule the patient for a nec- Focus the image and then take up and the teeth are straight essary diagnostic records ap- the photograph. (Figure 3) across. (Figure 5) pointment. 6. Right Profile: Instruct the pa- tient to turn their entire body 10. Anterior, Frontal Retracted:2. At the diagnostic records ap- to the left, keeping their hands Using double ended plastic re- pointment, take the required at their sides. Use the interpu- tractors, place the “c” ends of nine photographs for Invis- pillary line and long axis of the the retractors in the patient’s align treatment and VPS im- face to align the camera. The mouth and instruct the patient pressions. camera should be level with to pull the retractors forward the patient’s nose. Stand the and laterally, biting all the way3. Turn on the Eye Special C-II appropriate distance away to together on the back teeth. (Shofu) camera and place it in include the patient’s shoulders Assist the patient in keeping “Face” mode. Turn the cam- to the top of the head. Focus the retractors parallel. (Figure era so that the arrow is point- on the center of the patient’s 6) Using the gridlines, center ing up. Capture the three ex- face, and ensure that the pa- traoral Invisalign photographs tient’s teeth are in maximum with the patient standing in intercuspation. Instruct the front of a neutral background, patient to breath in and out, hands at their sides, and hair focus the image, and then take pulled away from their face. the photograph. (Figure 4)4. Frontal Smiling: Instruct the patient to keep their hands to8 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

5678 9 10 the midline and ensure that bite down all the way, and incisors. Center the midline the buccal surfaces of the mo- avoid including the lip in the and take the photograph of lars are visible. Eliminate all image. Take the photograph. the mirrored image at a 60 de- distractions in the field of view (Figure 8) gree angle to the mirror sur- (i.e., saliva, lipstick, blood, etc.) 13. Occlusal, Upper: Change the face. (Figure 10) and take the photograph. camera mode to the “mirror” 15. Review the images to ensure11. Buccal, Right: Using the oth- setting. Recline the chair and that the proper frame, focus, er end of the plastic retrac- patient’s head to just below the and patient positioning are tors, place the “v” end in the photographer’s waist. Tilt the appropriate for the eight re- patient’s mouth. Instruct the patient’s chin up as far as pos- quired Invisalign photographs, patient to pull on the left re- sible. Place the smaller ends of and then proceed with taking tractor slightly, while maxi- the metal retractors in the pa- the VPS impressions. mizing exposure of the molar tient’s mouth, and instruct the region by pulling the right re- patient to pull up at an angle Conclusion tractor towards the ear. Using (maxillary image). Position the the gridlines on the camera occlusal mirrors at the rear of Capturing dental photographs screen, center the image and the terminal molar and oppo- for Invisalign treatment using a focus on the canine. Instruct site arch incisors. Center the dental-specific digital camera the patient to bite down all midline and take the photo- (EyeSpecial C-II Digital Dental the way, and avoid including graph of the mirrored image at Camera, Shofu Dental Corpo- the lip in the image. Take the a 60 degree angle to the mirror ration) eliminates the need for photograph. (Figure 7) surface. (Figure 9) extensive training, as well as12. Buccal, Left: Instruct the pa- 14. Occlusal, Lower: Bring the troublesome complications and tient to pull on the right re- retractors down (mandibular challenges. For Invisalign treat- tractor slightly while pulling image), instruct the patient ment planning, understanding the left retractor towards the to continue lifting their chin, the required images, having the ear. Center the image using and move to the front of the ideal equipment and materials, the gridlines on the camera patient. Position the occlusal and following proper photo-tak- screen, focusing on the ca- mirrors at the rear of the ter- ing technique enable dental as- nine. Instruct the patient to minal molar and opposite arch sistants to achieve high-quality photographs.  May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 9

Recommended PhotoMed Products for Invisalign RecordsShown below are the dental cameras and photographic accessories that Shannon Pace Brinker recommends during her Invisalign dentalphotography courses.If you would like to place an order for any of these items, please visit: www.photomed.net/invisalign_recommended.htm or just click theInvisalign Recommended link on the front page of the website.Please contact us at: [email protected], at 800-998-7765 (U.S. and Canada) or 818-908-5369 if you have any questionsCanon Rebel T3 / Tokina 100mm Canon Rebel T3i / Canon 100mm Nikon D7100 / Nikon 85mmMacro / Sigma EM-140 Macro Flash Macro / Metz MS-1 Macro Flash Macro / Metz MS-1 Macro Flash$1699 $2099 $2499• 12.2 megapixel resolution • 18 megapixel resolution • 24.1 megapixel resolution• 2.7” LCD screen (230,000 pixels) • built-in wireless flash transmitter • Two Custom User Modes• SD memory card • 3.0” Vari-Angle LCD (1,040,000 pixels) • 3.2”LCD screen (1,228,800 pixels)• 720p HD video 25/30 fps • SD memory card • twin SD card slots• 3.0 fps continuous • 1080p HD video 24/25/30 fps • 1080p HD video 24 fps • 3.7 fps continuous • 6.0 fps continuous PhotoMed G15 Digital Dental Camera System - $1499 The PhotoMed G15 Digital Dental Camera is specifically designed to allow you take all of the standard clinical views with \"frame and focus\" simplicity.The built-in color monitor allows you to precisely frame your subject. Focus and shoot. It's that easy. Proper exposure and balanced even lighting are assured. By using the camera's built-in flash, the amount of light necessary for a proper exposure is guaranteed and PhotoMed's custom closeup lighting attachment redirects the light from the camera's flash to create a balanced, even lighting across the field. For your convenience, we pre-program the two custom settings: C1 for portraits and C2 for the closeup views. You can, or course, reset them to any settings that you like. Our custom instructions walk you through the necessary steps to do this. Canon CP-900 Digital Photo Printer - $129 The Canon CP-900 is a dye-sublimation printer. Dye-Sublimation is a technology that uses a matched color ribbon (donor) and photo paper (receiver). As the paper passes through the printer, the ribbon is heated to a gas state. The gas permeates the photo paper before returning to a solid state. The result is an image that looks just like a 35mm print and is typically as archival as 35mm prints. The CP-800 prints a 4x6 inch image in about 60 seconds. Prints cost only .38 cents each. The CP-900 has a built-in 2.7\" LCD screen (for previewing images), a memory card slot (SD) and you can attach a USB cord for printing directly from a camera. The Canon CP-900 can also print from a computer via USB. The CP-900 is also the first of the CP-Series printers to feature Wi-Fi printing capability.Print through your Wi-Fi network from your computer or iPhone (Canon has a free app for wireless printing from the iPhone). Canon KC-36IP Print Pack - $14 (ribbon and paper for 36 prints)

Universal Wire Stainless Retractors - $24 per pairSquare 40mm and 50mm squared ends.Adult and Pedo sizes in a single retractor.Autoclavable. Sold in pairs.Buccal Retractors - $24 per pairWide end for anterior views. Narrow, longer end used for buccal views without a mirror.37mm and 52mm ends.Autoclavable. Sold in pairs.Adult Occlusal Handle Mirror - $76Chromium front surface glass2 5/8\" x 3 7/8\" - straight handleAdult Occlusal XL Mirror - $58Chromium front surface double-sided glass2 5/8\" x 5 1/4\"Adult Occlusal “Anterior Contacts” Mirror - $42Chromium front surface double-sided glass2 5/8\" x 5 1/4\"PhotoMed Black & White Portrait Background - $149Duvetyn, reversable, non-reflective black/white, 34\"x48\"includes hanging chain and grommets on other end.SD Memory Cards for Digital Cameras2GB SD memory card - $74GB SD memory card - $1016GB SD Class 10 memory card - $20 (high speed SD memory card for HD video recording) www.photomed.net • 818-908-5369 14141 Covello Street #7C, Van Nuys, CA 91405 USA • FAX 818-908-5370

Contemporary Products | Orthodontic Photo Guide

Contemporary Products | Orthodontic Photo GuideFULL FACE - RESPOSE FULL FACE - SMILE FULL FACE - PROFILESUGGESTED STOP )RU)‡LENS SETTING 1:10 AutomaticUse a non-distracting background: blue, grey, black, and brown all work well. Have the patient stand with hands at their sides.HINT: Use the interpupillary line and long axis of the face to align the camera. Camera angle should be at the same level as the patient’s nose.ANTERIOR - SMILE ANTERIOR - RETRACTEDSUGGESTED STOP )RU)‡LENS SETTING 1:3 ManualPatient is seated knee to knee facing the assistant. Both patient’s and photographer’s chair are the same level allowing the photo lens to be parallel.HINT: Use buccal retractors without a mirror for retracted shot; focus is on the central teeth.RIGHT BUCCAL LEFT BUCCALSUGGESTED STOP )RU)‡LENS SETTING 1:3 ManualSame seating position - knee to knee with patient. Have the patient place retractors, pulling further back the retractor side you are capturing.HINT: Upper and lower teeth should be together; focus are on the cuspids (right and left) and should be in the center of the frame.UPPER OCCLUSAL LOWER OCCLUSALSUGGESTED STOP )RU)‡LENS SETTING 1:3 Manual Follow us on…Try not to leave any teeth out of the photo – the wider the patient opens, the more teeth will bein the frame. Keep nose out of the picture. Keep mirror warm to avoid fogging.HINT: Place retractors and mirror then stand behind the patient and lower the chair to waistlevel. Ask patient to lift their head as high as they can, again encourage them to open wide. TheIXOODUFKPLUURUVKRXOGUHVWÁDWDJDLQVWWKHRSSRVLQJDUFKWHHWK

Digital Master Impressions:A Clinical Reality!by Robert A. Lowe, DDSIntroduction: Masterful Final by an intraoral device, similar to an intraoralImpressions camera, and sent to the laboratory by email, giv- ing a CAD/CAM machine all the necessary digitalThe excellence and marginal fit of the definitive information to create precise master models andlaboratory restorations can only be as good as dies without the use of “rubber like” impressionthe master dies from which they are created. materials. This can be a tremendous advantageThe precision of the master impression is some- clinically, in the accuracy of the master model,thing that cannot be compromised. Marginal de- and also for those patients whom it may be dif-tail and tooth structure apical to the restorative ficult to make a conventional master impressionmargin are both necessary elements of an ac- because of gagging reflex, or anatomic variations,ceptable final impression. It is important for the such as mandibular tori. There are also some pa-dentist to have a critical eye and reject all but tients who just don’t do well with a “mouth fullthe “perfect” master impression. The traditional of goop” in their mouth that takes several min-approach to making a master impression has al- utes to set before it can be removed without theways been to use a “rubber like” material that is possibility of distortion. This article will discussinjected around the preparations and loaded into the use of Itero, by Cadent. Itero is an instrumentan impression tray, then placed in the oral cavity that allows the dentist to accurately “impress”where it sets up to a rigid consistency. The set im- the oral cavity without the use of conventionalpression is removed from the oral cavity minutes impression materials. The optical information ac-later, disinfected, and sent to the laboratory with quired by Itero is then converted by Cadent toan opposing arch impression and interocclusal a master working model that is sent within 48records. The laboratory then has a “duplicate” of hours of receiving the digital information fromthe patient on which to fabricate the restoration the dentist, to the laboratory of the dentist’sthat the dentist prescribes. choice, who immediately begins the restorationThe age of CAD/CAM dentistry has lead to a tech- fabrication process. One distinct advantage ofnology by which a preparation can be scanned the Cadent produced master model over con- ventional plaster die model work is that the Ca-14 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

A BC DEdent master model is made out F Gof polyurethane. This processcreates a master die and model more esthetic with intracrev- Tissue Managementthat is extremely resistant to icular margin placement. All ce- Prior To Opticalabrasion during the restoration ramic restorations can often be Scanningfabrication process, resulting in placed at the free gingival mar-marginal integrity, interproxi- gin, or in the case of “contact Using Itero, it is convenient tomal contacts, and occlusion of lens” porcelain veneers, slightly scan the opposing arch while thethe restoration that is very ac- supragingival. This is the ideal patient is getting numb from thecurate. The Cadent model also location for dentin and enamel placement of local anesthetic. De-preserves the soft tissue archi- bonding procedures. It is impor- pending upon the number of teeth,tecture around the preparations tant to remember that a “digital or types of restorations that areby creating master dies that impression” taken by a scanning planned, a quadrant scan, or full“emerge” from the gingival tis- device cannot “see” through the arch scan can be done. Once thesues. This permits the ceramist gingival tissues or through fluid necessary preparation informa-to accurately follow the “gingi- (hemorrhage, or crevicular fluid) tion is entered into the patient’sval silhouette” in the creation in the sulcus. The optical scanner record in Itero, the software willof the emergence profile of the must clearly see the restorative instruct the operator as to whichrestoration. margin and the tooth or root views are required for that par- surface just apical to the mar- ticular case. After tooth prepara-Restorative Margin gin to create an accurate master tion is completed, the soft tissuesPlacement Is Dictated die. Digital impression making surrounding the preparation, ifby the Restorative therefore must still include the restorative margin is locatedMaterial Chosen proper tissue management equicrevicular or intracrevicular, and retraction technique to must be retracted, or deflectedWith today’s esthetic materials insure accuracy! away from the margin in such aoptions, the restorative margincan be located supracrevicu-lar (above the gingival tissues),equicrevicular (at the free gin-gival margin), or intracrevicular(in the gingival sulcus). Porcelainfused to metal crowns are often May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 15

123456789Figure 1. A preoperative view of tooth Figure 3. Retraction cord (Ultrapak: the opposing arch of the patient with numbers 3 to 5 prior to preparation Ultradent) is “laid” into the trough Itero while the local anesthesia in for indirect ceramic replacements created by the laser to deflect any the prepared arch is taking effect. due to marginal breakdown and tissue tags that may remain after the recurrent decay. troughing procedure. Figure 6. O n the top of the Figure is the model and master dies created fromFigure 2. A diode laser (EZLase: Biolase Figure 4. An occlusal view of the retraction a polyvinyl siloxane impression Technologies) is used to trough around the preparations prior to whereas the model and master dies around the preparation in capturing the optical impression. on the bottom of the Figure where preparation for taking the optical created from the Itero scan. impression. Figure 5. A dental assistant is shown scanningway that controls fluid contami- and facial veneer restorations both lingual ends is trimmed,nation in the sulcus prior to com- with both intracrevicular and and the ends of the cord arepleting the scanning process of equicrevicular margins (at the tucked into the lingual gingivalthe prepared arch. There are sev- free gingival margin). First, a sulcus so that the ends butteral ways to accomplish this task. #00 cord (UltraPak: Ultradent) against one another. If desired, is packed around each prepa- the cords may be soaked in a1) Two Cord Tissue Retraction ration margin starting from the hemostatic solution then driedA two-cord impression tech- lingual proximal to the facial with a 2X2 prior to placement.nique can be utilized to cap- aspect, then back through the Next, a #1 cord (UltraPak: Ul-ture master impressions for remaining proximal area to the tradent) is placed on top offull coverage (circumcoronal) lingual aspect. The excess at the #00 in the same fashion16 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

10 11 12 13 14Figure 7. An occlusal view of the ceramic Figure 11. A fter cementation, the margins 15 restorations are shown. (Restorations of the ceramic inlay in tooth fabricated by DSG/Americus number 5 are being polished with Laboratory, Jamaica, New York) a porcelain polishing point (Komet USA). The operative area is isolatedFigure 8. A n occlusal view of the ceramic during the delivery procedure with restorations on the Itero master Isolite. model is shown. Figure 12. An occlusal view of the completedFigure 9. After a total etch of the preparations porcelain restorations. Note the with 37% phosphoric acid for 15 precision of the marginal fit. seconds, a small amount of blood in the retracted tissue was noted after Figure 13. T his is a lingual view of an Itero rinsing and drying the area. Expasyl master model. Note the accuracy of (Kerr Corporation) is an excellent the occlusal contacts, hemostatic agent and tissue deflector during delivery of ceramic Figure 14. A close up view of the master die restorations to ensure a “blood free” as it emerges from the soft tissue sulcular environment. from the lingual aspect. Note the amount of occlusal clearanceFigure 10. T he resin cement (NX3: Kerr between the preparation and the Corporation) is syringed directly opposing arch. into the preparation using an automix tip. Figure 15. A close up proximal view that demonstrates the marginal fit of this full coverage zirconium restoration.as previously described. The should capture not only the ute, and then removed prior topreparation is cleansed with entire restorative margin, but scanning. This added retrac-AcQuaSeal Dentin Desensitizer also about .5 millimeters of tion should be sufficient to cre-(AcQuaMed Technologies) on the tooth/root surface apical ate a space between the tootha cotton pledget. When ready, to the margin. If the marginal surface and the inner lining ofthe #1 cord is teased out of the gingiva adjacent to any restor- the gingival sulcus. The goal ofsulcus using the tyne of an ex- ative margin rebounds to con- retraction is to “create a moatplorer, from the facial aspect tact the tooth/margin, a small (space for the optical scannerof each preparation and the piece of a larger diameter cord to clearly “see” the margin andamount of retraction is evalu- (#2) is placed into the affect- tooth surface) around the cas-ated. The optical impression ed area for an additional min- tle (tooth preparation) May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 17

16 17 18Figure 16. The occlusal contacts are demonstrated Figure 18. A n occlusal view of the 19using Accufilm II (Parkell) after restorations shown in Figure 17cementation with a modified resin after cementation,ionomer cement (FujiCem: GC America). Figure 19. A facial view of the completedThis restoration was delivered without any restorations shown in figure 17 inproximal or occlusal adjustment. maximum intercuspation (centricFigure 17. This is a view of a full coverage pressed occlusion). An excellent clinicalceramic crown (tooth number 3)and inlay result is shown that was built on a(tooth number 4)on the Itero master master model created by a digitaldies prior to cementation. (Restorations impression.fabricated by DSG/Americus Laboratory,Jamaica, New York)2) Troughing the Gingival of tissue that troughing around to use mechanical tissue re-Sulcus with a Dental Laser the preparation does not result traction when indicated, par-Troughing is a procedure by in loss of vertical tissue height. ticularly in the aesthetic zonewhich a laser is used to create Beware of thin periotypes and (facial aspect), and use gingivala space between the prepara- low crest bone positions relat- troughing when localized gin-tion margin and the tissue to ing to biologic width as these gival excess, or chronic inflam-aid in the proper registration of types of patients are prone to mation is present, and in areasmaster impressions. The use gingival recession. That being outside the esthetic zone Anof both diode and Er, Cr, YSGG said, when gingival troughing alternative to retraction cordwavelengths (EZ Lase and Wa- is indicated to aid in gingival in troughing procedures to canterlase MD; Biolase Technolo- displacement, use of either the a bit more hemostasis and tis-gies) can be natural adjunct to diode laser or the Er,Cr: YSGG sue deflection would be to usesoft tissue management for op- laser is much more predictable Expasyl (Kerr Corporation) aftertical impressions. In many cas- than using an electrosurgery troughing, prior to scanning thees, troughing alone will allow instrument. When troughing preparation, In the case illus-visualization of the restorative with an electrosurgery instru- trated in Figure , troughing wasmargin and emergence profile ment, the unpredictable zone performed interproximally, andso that an accurate scan can of necrosis, particularly in a thin retraction cord was placed fol-be achieved. Also, lasers are sulcular environment, can lead lowing troughing to create 360helpful in hemostasis, therefore to excessive recession and gin- degrees of totally patent sulcusthe ideal scanning environment gival sloughing following heal- for scanning to take place. Thiscan be accomplished very eas- ing. Since it is reported that the will virtually assure a perfect im-ily and quickly using laser tech- necrosis resulting from a laser pression every time. Remember,nology. It is recommended to wound is only a few cell layers the goal is not only to capturetrough a case only when there thick, this is much less likely to the margins, but also .5mm ofis enough horizontal thickness happen when troughing with a root surface apical to the mar- laser. It is still a good practice gin so that the laboratory can18 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

create the proper emergence rections can be made on the tions are shown in this case be-angle for the restoration. spot! The entire process for ing cemented using a total etch scanning an average case takes technique with resin cementOptical Scanning of about 2 minutes from start to (NX3: Kerr Corporation) (Figurethe Prepared Tooth finish. The average fast set im- 10). The margins are polished pression material takes about 1 using porcelain polishing pointsThe software present in Itero to 2 minutes to inject, load and (Porcelain Polishing Points: Ko-will tell the dentist or dental as- place the tray and an additional met USA). The completed resto-sistant which views are required 3 to 4 minutes to complete the rations are shown in an occlusalfor the optical impression. An intraoral set. A provisional res- view in Figure 12. The authorocclusal view of each prepara- toration is then fabricated and has found through the overalltion is taken and can then be placed prior to dismissal of the experience of many cases usingreviewed on the monitor for ac- patient. Itero that the marginal fit andcuracy prior to taking additional For the first case demonstrated occlusal contacts appears to bescans. For each preparation, a in this article (Figure 1), tooth better overall on the Itero cre-facial, lingual, mesio-proximal numbers 3 through 5 were to ated dies and attributes that toand disto-proximal view is re- be prepared for indirect ceram- the accuracy of the scan, com-corded. This takes the operator ic restorations. A combination bined with the precision andapproximately 15 to 20 seconds of tissue troughing with a diode durability of the model createdper prepared tooth. The adja- laser (EZLase: Biolase Technolo- by Cadent (Figures 13-19). Ofcent teeth are scanned from the gies) and retraction cord was course, ultimately the precisionfacial and lingual aspect, and used to displace the gingival of the restoration itself is de-finally two interocclusal views tissues around the margins of pended upon excellence by theare taken to capture the jaw the preparations (Figures 2-4). laboratory support (ceramist) asrelationship. Another important A conventional elastomeric im- well. However keeping in mindfeature of the Itero software is pression was taken as well as that it has been stated thatthat it allows the dentist to view an Itero optical scan (Figure only 20 to 30 % of impressionsthe entire case in three dimen- 5). Also, occlusal relationships made and received by dentalsions prior to sending the infor- for both Itero master models laboratories can be classifiedmation to the lab. In fact, the (interocclusal scan) and an op- as “clinically excellent”, we assoftware will indicate occlusal posing model created from an a profession have a way to goclearance in critical areas of the elastomeric impression and in- in ensuring the quality of ourprepared tooth, so if there is terocclusal bite records were clinical work is kept to as highnot enough space for the cera- taken. The definitive ceramic a standard as possible. It is themist to create an optimal resto- restorations are shown in both author’s belief that optical im-ration, the dentist can make an sets of master dies that were pressions taken by systems likeimmediate correction, take an created (Figure 6-8). Both sets of Itero, can help raise the overalladditional scan or scans of the dies fit very well from the mar- quality of the service we pro-corrected preparation, and the ginal perspective and are basi- vide to our patients. Technologysoftware will correct the virtual cally interchangeable on the two does not come without a price,model. This can eliminate the sets of models. This confirms to but remember, our most pre-need for reduction copings and/ the operator the accuracy of cious commodity as dentists isor additional patient visits since the scanning technology is ex- our chair time. If a technologythe lack of space required is not cellent as are the models that helps us work better, smatter,usually found out until the tech- are generated by Cadent for the more efficient, and allows us tonician pours up and mounts a laboratory. Once the marginal fit, produce better results…..it is acase. Itero provides immediate proximal contact, and occlusal small price to pay and the pa-feedback to the dentist so cor- contact is verified, the restora- tient ultimately benefits!  May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 19

Treatment Coordinator Break-out ExerciseI don’t feel I have a lot of money to take care of my mouth but I hate my cockedsmile. My teeth are crooked and my smile is lopsided. Of course I would never tellanyone this because I am too shy. I wish there was a way to change?How could you help this a man?While you were sitting in my chair, I found out that you love to sing and act, but youreally do not like the space between your front teeth. You’ve thought about trying toclose it, but you’re worried that it would affect your career.How would you approach this gentleman?You have before you a young 30 some year old lady who all her life has lived with a hugediastema. What can you do for her and her smile?How would you approach her about orthodontic aligners?This man loves to smile but wishes his teeth looked better. He works with a group ofvery distinguished gentlemen.What can you do for him and how would you go about talking to him aboutorthodontic aligners in a way that he will be likely to accept treatment.I’m ashamed to smile with my teeth. I only smile with my closed lips. And oh, by the way,look at the next picture…..that’s me, …YIKES!Why do you think this 60 year old man feels this way?How you would talk to him about his treatment with aligners. Follow us on…

Treatment Coordinator Break-out ExerciseThis guy hates to smile! Why is that?He is from the BIG city near you. If you sat across from him and talked to himabout the health of his mouth and the importance of having teeth all in theirproper position, what would you say?My teeth are not perfect. I would love to have beautiful teeth. My co-workers are a groupof lovely young girls with super white and straight teeth.What can you do for me?I am a little league baseball coach. Just your average guy. My priorities are not focusedon my mouth at this stage in my life. I came in for my routine visit and you started talk-ing to me about my crooked teeth.How would you approach this man so he would be receptive to orthodontic aligners?I am so embarrassed to smile around my friends. I have a couple of classmates who aremade fun of and called metal mouth, railroad tracks, tin man, you name it… pleasehelp me!”+RZZRXOG\RXWDONWRKHUDERXWRUWKRGRQWLFDOLJQHUVDQGWKHLUEHQHÀWV\"Can you tell I’m an angry teen! What do I need to do to my mouth to make me happy?I wear glasses too and can’t keep up with them so I squint a lot.How do you talk treatment to an irresponsible teen? Follow us on…

Scheduling for Invisalign 1 1. Complimentary Invisalign Consultation (8660) Follow us on…  ‡,4&  ‡'HPR$OLJQHU  ‡,QYLVDOLJQ3DPSKOHW 2 2. Diagnostic Records (470.20)  ‡3KRWRUHOHDVH  ‡,QIRUPHGFRQVHQW  ‡3DQR)0;  ‡,QYLVDOLJQLPSUHVVLRQV² upper & lower  ‡3XWW\  ‡$TXDVLOZDVK  ‡%LWHUHJLVWUDWLRQ  ‡3UH,QYLVDOLJQSKRWRJUDSKV   VKRWV 3 3. Clincheck  !$SSUR[LPDWHO\ZHHNV after records appointment > Approval appointment may be necessary 4 4. Initial Delivery Appointment  !ZHHNVDIWHU'LDJQRVWLF 5HFRUGV Fee $  ‡3ODFHDWWDFKPHQWVDVQHHGHG  ‡,35DVQHHGHG  ‡VHWVRIDOLJQHUVJLYHQ   SODFHGDWEHGWLPH  ‡&DUHSDFNDJHLQFOXGHV tooth EUXVKÁRVVFDVHV cleaning crystals, aligner removal tool 5 5. 24 hour follow up phone call 6 6. Schedule Aligner Delivery Appointment ‡VHWVHYHU\ZHHNV until complete 7 7. Bleach Surprise 8 8. Vivera Retainer Impressions  ‡7DNHDWWDFKPHQWVRII  ‡7DNHSKRWRVÀQDOSKRWRV 9 9. Deliver Vivera & Celebrate Package

Invisalign Quick Consultation Sheet Team Initials ____________1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB$JHBBBBBBBBBB'DWHBBBBBBBBBBBBBBBBBCC _______________________________________________________________________________________________Other Concerns ___________________________________________________________________________________'LDJQRVLV Upper LowerOcclusion Midline Class __________________ Crowding CR ________ CO ________ Spacing Shift ___________________ &URVV%LWH Fremitus _______________ Rotations Whitening3(5,2BBBBBBBBBBBBBBBBBBBB RestorativeOS ______________________(1'2BBBBBBBBBBBBBBBBBBBBTreatment 3UH2UWKRBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB )XOOBBBBBBBB$VVLVWBBBBBBBB7HHQBBBBBBBB([SBBBBBBBB([SBBBBBBBB2WKHUBBBBBBBBBBBBBBBBBBBB 3RVW2UWKRBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 5(9,(:(' ,35 $WWDFKPHQWV 2$ 5HWDLQHUV 5HÀQHPHQW KUV %LJ$SSWV 7LPH(VWLPDWHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB )HH(VWPDWHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB 1H[W6WHS 13&RPS([DP ,QYLVDOLJQ5HFRUGV 5HIHUUDO1RWHV____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Invisalign TrackingName__________________________________________________________________________________________Procedure Date Initials NotesRecords Taken  9LYHUD(VVL[+DZOH\)L[HGModels Articulated%R[Rx Completed&OLQFKHFN$SSW(PDLOClincheck Approved,QLWLDO'HOLYHU\+RXU)ROORZXSRecall%OHDFK6XUSULVH6SHFLDOLVW6SHFLDOLVW7HP(VVL[Restorative(TXLOLEUDWLRQFinal Retainer3KRWRVCelebration Letter*UDGXDWLRQ'DWH

One-Step VPSImpressions EnsureAccuracy forInvisalign Treatmentby Janice TurnerIntroduction rubs in the set impressions compromise their ac- curacy, can also lead to rejection, and may causeAmong the most important records for planning imprecise aligner fabrication.and executing Invisalign treatments are VPS (vi- It is therefore imperative that the ideal PVS im-nylpoly siloxane) impressions. These essential pression material, Invisalign impression trays,replications of the patient’s teeth positions and and proper technique be incorporated into thearch forms document their pre-treatment condi- impression taking process. Doing so helps to en-tion and help to determine treatment goals and sure that detailed impressions are created as aproposed tooth movements. Unfortunately, using foundation for fabricating predictable Invisalignan inferior impression material or improper tech- treatment aligners.nique can compromise the integrity and accura-cy of the impression, costing the dental practice Material Selectionadditional staff time, materials, and patient con- Invisalign impression trays are available in vari-fidence, as well as possibly negatively affecting ous sizes to accommodate all patients and canInvisalign treatment outcomes. be ordered online for free from Invisalign. Spe-An improper impression technique can lead to cifically designed for Invisalign treatment plan-“lift off,” failure to capture complete anatomical ning, the Invisalign trays fit uniquely in the digitaldetails, and/or omission of the last molar, which scanners that “read” the impressions. Invisalignis the most common reason that impressions are scanners read only vinylpoly siloxane (VPS) mate-rejected by Invisalign. When improper materials rial, so it is imperative that other materials (e.g.,are used, including non-Invisalign impression alginate alternatives, polyether materials) nottrays, alginate alternative materials, or polyether be used. Ideal impression material systems (e.g.materials, the impressions also may be rejected Flexitime, Heraeus Kulzer) include putty and lightbecause they cannot be read by the Invisalign wash materials, a combination that captures thescanners. Additionally, scrapes, bubbles, and May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 25

123456Figure 1. For maxillary arch: Scoop out even Figure 3 Starting in the molar area, load Figure 5. With finger make indentations amounts of Heraeus’ Flexitime putty Flexitime putty in the maxillary tray. where the teeth should be before tray catalyst and base. Knead & fold placement. Pinch the putty around together Figure 4. Load the putty around the tray the tray to extend the material into making sure you have a good even the vestibule area.Figure 2. Knead until the color is even and amount of material. without any swirls. Figure 6. Reline the impression with Heraeus’ Correct Flow Wash. Extrude wash into clinical crown area making sure to not lift the tip.details necessary for creating their lap. The patient should be quick and efficient movements,Invisalign aligners. Such details appropriately prepared prior to then placed in the tray, with theinclude all margins and ana- seating the impression tray, with light wash added on top.tomical landmarks. Additionally, the advanced nature of the im- The tray should be firmly seat-these materials set easier and pression materials and technique ed immediately, since the puttyavoid running and slumping. explained and any anxieties is thick and heavy. The putty calmed. They also should be in- should be massaged using fin-Preparing & Handling formed to be ready, since the im- gers into high detail areas toInvisalign Impressions pression material will set quickly, avoid compromise and patientThe type of gloves worn when calm anxieties, and instruct them retakes.handling impressions can al- to be ready as the impression These materials typically set inter the putty setting times. For material sets quickly. two and a half minutes. They canInvisalign impressions, dental Prior to mixing the material to- be checked by easily tearing aassistants are advised to wear gether, the Invisalign impres- piece of the light wash materialnitrile gloves, as well as to avoid sion trays should be tried in so that it breaks easily.mixing the putty’s base and cat- the patient’s mouth to ensurealyst spoons to ensure that the that they do not cut off the last Clinical Techniqueputty doesn’t set prematurely. molars. A new tip is placed onEnsure that the patient is sit- the wash body, which should be 1. After capturing the eightting up, with feet uncrossed, legs bled to remove any air bubbles. dental photographs requiredstraight out, and hands folded in The putty is mixed together with for Invisalign treatment plan-26 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

78 910 11Figure 7. Reline the impression with Heraeus’ Figure 9. Positioned behind the patient, hold Correct Flow Wash. Extrude wash the tray in the pre-molar position. into clinical crown area making sure The impression will set in 2 1/2 to not lift the tip. minutes.Figure 8. Seat the tray into the mouth. Lift the Figure 10.Final maxillary impression with upper lip while seating the tray. Heraeus’ Flexitime putty with Correct Flow Wash. ning, the patient is ready for 6. Roll the material into a “hot ty and release the material the diagnostic impressions dog” shape, and load it onto into the tray, firmly pressing records component. the tray, starting in the molar the tip into the light wash2. Put on nitrile gloves. area and pressing the putty material as it is extruded to3. Try-in the maxillary Invis- against the maxillary tray and prevent bubbles. align impression tray to en- locking it into the perfora- 9. Insert the tray straight and sure proper fit. tions. evenly into the patient’s mouth,4. Place a new tip on the light centering the tab with the pa- wash impression material 7. Before placing the tray in the tient’s nose. While seating the and bleed the tip. mouth, use a finger to create a tray, lift the patient’s upper lip.5. Scoop out even amounts of trough in the putty by making 10. Walk around the patient and the putty catalyst and base indentations where the teeth firmly hold the tray in the (e.g., Flexitime, Heraeus should be. Pinch the putty pre-molar position. Wait 2.5 Kulzer) and roll into equal around the tray to extend the minutes for the impression to balls. Combine equal parts material into the vestibular set, then remove the impres- of putty (Figure 2). Knead area, and build up the putty sion tray from the mouth. and fold together until the at the distal end of the tray 11. Try-in the mandibular Invis- putty is a uniform color and to contain the light wash and align impression tray to en- without swirls (Figure 3). capture the terminal molars. sure proper fit. 8. Place the tip of the light- body wash against the put- May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 27

12. Place a new tip on the wash the putty around the tray to 19. Disinfect the impressions, body material and bleed extend the material into the then package for shipment for the tip. vestibular area, and build up Invisalign aligner fabrication. the putty at the distal end of13. Scoop out even amounts of the tray to contain the light Conclusion the putty catalyst and base wash material and capture (e.g., Flexitime, Heraeus Kulz- the terminal molars. Dental assistants who take ac- er) and roll into equal balls. 16. Place the tip of the light- curate impressions as part of Combine equal parts of putty body wash against the putty the Invisalign treatment planning and knead and fold together and release the material into process provide an invaluable until the putty is a uniform the tray, firmly pressing the service to their team members color and without swirls. tip into the light wash mate- and their patients. They facilitate rial as it is extruded to pre- delivery and completion of suc-14. Roll the material into a “hot vent bubbles. cessful Invisalign treatments, as dog” shape and load it onto 17. Insert the tray straight and well as saving the practice staff the tray, starting in the mo- evenly into the patient’s time and money. VPS impressions lar area and pressing the mouth, centering the tab are the foundation for determin- putty against the mandibu- with the patient’s nose. ing a patient’s orthodontic needs lar tray, locking it into the 18. Walk around the patient. Place and subsequent Invisalign aligner perforations. thumbs on the premolar area fabrication. The one-step impres- and hands under the patient’s sion technique and VPS impres-15. Before placing the tray in chin to firmly seat the impres- sion materials described in this the mouth, use a finger to sion tray. Wait 2.5 minutes for article allow dental assistants to create a trough in the put- the impression to set, then achieve predictability when tak- ty by making indentations remove the impression tray ing necessary impression records, where the teeth should be. from the mouth. all while demonstrating reduced Create a deeper trough in setting time, improved viscosity, the anterior area because and detailed accuracy.  these teeth are longer. Pinch28 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

IMPRESSIONS | For Perfect Orthodontic RecordsBEGIN WITH: Nitrile glovesHeraeus’ Flexitime putty with Correct Flow Wash, Disposable Impression Trays and…For maxillary arch: Scoop out even Knead until the color is even and without Starting in the molar area, loadamounts of Heraeus’ Flexitime putty any swirls. Flexitime putty in the maxillary tray.catalyst and base. Knead & fold together.Load the putty around the tray making :LWKÀQJHUPDNHLQGHQWDWLRQVZKHUHWKHWHHWK Reline the impression with Heraeus’ Correctsure you have a good even amount of should be before tray placement. Pinch the Flow Wash. Extrude wash into clinical crownmaterial. putty around the tray to extend the material area making sure to not lift the tip. into the vestibule area.Seat the tray into the mouth. Lift the Positioned behind the patient, hold Final maxillary impression with Heraeus’upper lip while seating the tray. the tray in the pre-molar position. The Flexitime putty with Correct Flow Wash. impression will set in 2 1/2 minutes.

IMPRESSIONS | For Perfect Orthodontic RecordsFor mandibular arch: Scoop out even Knead until the color is even and without Starting in the molar area, load theamounts of Heraeus’ Flexitime putty any swirls. Flexitime putty in the mandibular tray.catalyst and base. Knead & fold together.Load the putty around the tray making :LWKÀQJHUPDNHLQGHQWDWLRQVZKHUHWKHWHHWK Reline the impression with Heraeus’ Correctsure you have a good even amount of should be before tray placement. Pinch the Flow Wash. Extrude wash into clinical crownmaterial. putty around the tray to extend the material area making sure to not lift the tip. into the vestibule area.Firmly seat the tray over teeth, making Final mandibular impression withsure the tray is all the way down. The Heraeus’ Flexitime putty with Correctimpression will set in 2 1/2 minutes. Flow Wash. Shannon Pace Brinker, CDA, CDD http://cpsmagazine.com (757) 285-9477

BITE INFORMATION | For Perfect Orthodontic RecordsTrollFoil articulating paper has enough You may use one or two articulating Dry the teeth well with an air syringe.thickness to make marks on the teeth. paper forceps.With two sets of articulating forceps and paper, hold the paper against the maxillary archand ask the patient to bite together. This will allow the articulation paper to register markson both arches.To document the marks, you will need to take full arch mirror photos of both the maxillaryand mandibular registration marks. Place documentation in the patient’s chart, as well asthe Invisalign laboratory prescription. Shannon Pace Brinker, CDA, CDD http://cpsmagazine.com (757) 285-9477

INVISALIGN Insurance and Financing Check -ListInsurance: • Get insurance verification for all special services that your office provides. • Verification to include all orthodontic benefits and previous history. • It is important to have this information readily available so that you will be able to present an orthodontic treatment plan at any appointment without having to pause to verify that they are eligible for orthodontic coverage. • Orthodontic Benefits Insurance Checklist • Age range of eligibility • Orthodontic limitations and exclusions • How are benefits’ paid out (is it a one-time payment or spread out over length of treatment) • Orthodontic allowable • Orthodontic codes and fees • Invisalign Routing SlipConsult 90021 Invisalign Consult No ChargeRecords 90029 Records $300Clincheck 09450 Case Presentation No ChargeDelivery 08080 Adolescent /Teen $4,800(Tx start Date) 08090 Adult Dentition $4,800IPR 90025 Interproximal Reduction No ChargeRetention 08680 Retainer Delivery(Hawley) No Charge $300 08692 Replacement Retainer(Per Year) 90022 Vivera Retainers No ChargeTx Visit $450 08670 Periodic Treatment• Tip- Do not “save” the orthodontic lifetime benefit. Bill what you do. Many times the insured benefits change if the insured’s employment changes. The change in employment and coverage could possibly reset the lifetime maximum with new benefits. That new maximum (if available) can be applied to subsequent orthodontic treatment.• A Template should be dated, set up and placed in patient’s insurance note field and updated as patient’s plans change.32 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

Care Credit’s RatesPromotion Description Cardholder Merchant Minimum Tran Code Interest Rate Fee PurchaseSTANDARD ACCOUNT TERMS - 1.90% $0.00 2026 MONTH NO INTEREST WITH PAY 0.00% 4.40% $200.00 206DEFERRED INTEREST12 MONTH NO INTEREST WITH PAY 0.00% 8.40% $200.00 212DEFERRED INTEREST18 MONTH NO INTEREST WITH PAY 0.00% 10.50% $200.00 218DEFERRED INTEREST24 MONTH NO INTEREST WITH PAY 0.00% 11.90% $200.00 224DEFERRED INTEREST24 MONTH EXTENDED PAYMENT PLAN 14.90% 3.50% $1000.00 62436 MONTH EXTENDED PAYMENT PLAN 14.90% 3.50% $1000.00 63648 MONTH EXTENDED PAYMENT PLAN 14.90% 3.50% $1000.00 64860 MONTH EXTENDED PAYMENT PLAN 14.90% 3.50% $2500.00 660Financing: Once a treatment plan has been presented and the patient’s co-payments determined you will then be able to offer your financing options to your patient. • Give your patient several options for payment. • Do Not offer in-house financing. It can be a risky financial risk and administrative collection nightmare. Let the experts do the financing, it is worth the investment. • Offer a payment in-full option of 3% for credit card or 5% for cash or check. (if no insurance or 3rd party financing is involved) • Have your discounted amounts pre-figured prior to speaking with patient • “If you choose to pay in full at the start of treatment, we can offer you a $xxx discount for cash or a $xxx discount for credit cards. • CareCredit is an excellent 3rd party financing option and hands down our offices favorite. • CareCredit has a special rate for Invisalign Treatment Financing • No interest options if paid in full within 6, 12, 18 or 24 months • If financed amount is $1,000 or more they can choose a 24, 36, or 48 month offer at 14.9% • Online applications are quick and simple and you receive a response within seconds . • There are other options for third party financing that you can offer or suggest to your patients. • Springstone financing, personal bank loans etc. May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 33

Scheduling for Invisalign 1. C omplimentary Invisalign Consultation (8660) • IQC • Demo Aligner • Invisalign Pamphlet 2. Diagnostic Records (470.20) • Photo release • Informed consent • Pano/FMX • 2 Invisalign impressions / upper & lower • Putty • Aquasil (wash) • Bite registration • Pre Invisalign Photographs (9 shots) 3. Clincheck (approximately 2 weeks after records appointment) • Approval appointment may be necessary 4. Initial Delivery Appointment (5-6 weeks after Dx Records) (8090) Fee $ • Place attachments as needed • IPR as needed • 1-3 sets of aligners given (put in at bed time) • Care package inc, tooth brush, floss, cases, cleaning crystals, aligner removal Tool 5. 24 hour follow up phone call 6. S chedule aligner delivery appointment (3 sets) every 6 weeks until complete 7. B LEACH SURPRISE 8. Vivera Retainer impressions • Take attachments off • Take photos (final photos) 9. D eliver Vivera & Celebrate Package34 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

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Questions for Hygienists:KDWGR,VHHLQP\SDWLHQW·VPRXWK\" Identify the Condition:KDWDUHWKHFRQVHTXHQFHVLIOHIWXQWUHDWHG\":KDWVROXWLRQVFDQ,GLVFXVVWRKHOSWKLVSDWLHQW\" $IWHUFRQGXFWLQJDQH[DPLGHQWLI\WKHSUREOHPIRU WKHSDWLHQW 0DORFFOXVLRQVKRXOGEHGLDJQRVHGMXVWOLNHSHULRRU GHFD\DQGWKHSDWLHQWVKRXOGEHPDGHDZDUHRIWKH LVVXHMXVWOLNHDEURNHQFXVSRUODUJHSRFNHWPROBLEM… CAN LEAD TO OR SHOW SIGNS OF…CROWDING ‡'LIÀFXOW\LQEHLQJDEOHWRSURSHUO\FOHDQDOOWRRWKVXUIDFHV ZKLFKFDQOHDGWRLQFUHDVHVFKDQFHRIGHQWDOGHFD\DQG JXPGLVHDVHSPACING ‡5HVXOWLQJXPSUREOHPVGXHWRWKHODFNRISURWHFWLRQ E\WHHWKCROSSBITE ‡$EQRUPDOZHDURIWHHWK ‡'\VIXQFWLRQDOFKHZLQJDQGRFFOXVDOWUDXPDOVERBITE/ ‡,PSURSHUIXQFWLRQRIDQWHULRUWHHWKDEEP BITE ‡/RZHUDQWHULRUWHHWKELWLQJLQWRJXPWLVVXHRIWKHSDODWHOPEN BITE OHDGLQJWRSHULRGRQWDOSUREOHPV ‡$EQRUPDOZHDURIWKHORZHUDQWHULRUWHHWK ‡:HDURQWKHSRVWHULRUWHHWK ‡'\VIXQFWLRQDOFKHZLQJDQGRFFOXVDOWUDXPD ‡0D\EHUHODWHGWRMDZG\VIXQFWLRQEXCESSIVE ‡,PSURSHUIXQFWLRQRIDQWHULRUWHHWKOVERJET ‡/RZHUDQWHULRUWHHWKELWLQJLQWRWKHJXPWLVVXHRIWKH SDODWHOHDGLQJWRSHULRGRQWDOSUREOHPV ‡$EQRUPDOZHDURIWKHORZHUWHHWKINSUFFICIENT ‡,PSURSHUIXQFWLRQRIWKHDQWHULRUDQGRUSRVWHULRUWHHWKOVERJET ‡$EQRUPDOZHDURIWKHXSSHUDQWHULRUWHHWK )ROORZXVRQ«

SMILES 9I@>?K<E<; CONFIDENCE 9FFJK<; RESULTS ;<C@M<I<; BEFORE AFTER 10 days of treatment For whitening in custom trays, nothing works like Opalescence PF. Its patented sticky, viscous gel won’t migrate from the tray onto soft tissues, and its variety of concentrations and flavors provide options to suit the preferences of any patient. No wonder that after more than 20 years, it’s still considered the “gold standard” in whitening.800.552.5512 | ultradent.com© 2014 Ultradent Products, Inc. All Rights Reserved.

Dental Hygienists’ Role inIdentifying Invisalign Casesby Rachel Smith, RDHIntroduction vasive treatment for straightening teeth that also can facilitate better periodontal and overall oralDental hygienists typically see patients more fre- health.quently, regularly, and for longer periods of time Invisalign treatment is used to correct severalthan any other dental team member in the prac- conditions, including gapped teeth, overbite, un-tice. Because they see patients on a routine ba- derbite, open bite, crowded teeth, and crossbite.sis, they have an intimate knowledge of a patient’s Popular for its esthetics and convenient function-mouth, condition of their teeth, and esthetics of ality during treatment, Invisalign utilizes custom-their smile. They also observe any changes that ized clear aligner trays to improve occlusion andhave taken place over time. correct tooth alignment.But something else occurs during these interac-tions. Dental hygienists build unique and trusting Hygiene & Functional Implicationsrelationships with their patients, the type in which of Misalignments patients are more likely While many patients may recognize the manner in to share their person- which crooked teeth affect the esthetics of their al feelings, goals, and smiles, they may not be aware of the other prob- concerns about their lems this may cause. Teeth crowding and rotations health and appearance. can limit their ability to properly clean all tooth sur- This type of relation- faces, contributing to an increased risk of dental ship, combined with decay and periodontal disease. Gaps and spacing the dental hygienist’s between teeth can result in additional periodontal first-hand knowledge of problems, since gingival areas aren’t protected by the patient’s oral health tooth structure. Dental hygienists have a great op- and what can be ac- portunity during routine appointments to ask pa- complished with today’s tients if they’ve encountered any problems while dental treatments, ide- flossing, which can lead easily into a casual and ally positions them to comfortable conversation about the oral health identify candidates for benefits of a straighter smile and the convenience Invisalign orthodontic of Invisalign treatment. treatment—a non-in-38 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

Patients with crossbite can cessive overjet, overbite mal- But recognizing signs of theseexhibit abnormal wear of the occlusion) include improper conditions is also an opportu-teeth, dysfunctional chewing, function of anterior teeth, nity for dental hygienists to in-and occlusal trauma. When den- lower anterior teeth biting quire about any new or wors-tal hygienists encounter signs into palatal gum tissue and ening symptoms patients mayof abnormal wear, it’s a signal leading to periodontal prob- be experiencing, whether pain,to ask the patient if he or she lems, abnormal wear of the stress, bruxing/grinding, orhas experiences any problems lower anterior teeth, poste- changes in lifestyle. When con-when eating or chewing certain rior tooth wear, dysfunctional sidered in their totality, theyfoods, or if there have been any chewing, and occlusal trauma. may lead to an open and hon-changes in their life since their It can also be associated with est conversation about ways tolast appointment. Then, the con- jaw dysfunction and pain. As ensure the patient’s long-termversation can proceed to a dis- a patient’s first regular point oral health and, if appropriate,cussion about the wear that has of contact for oral examina- how Invisalign treatment canbeen observed, and how Invis- tions, the dental hygienist can help achieve those goals.align treatment can help. observe changes in the condi- Other alignment issues are likelyComplications associated with tion of these areas and assess commonly observed during rou-overbite or deep bite (e.g., ex- whether records and examina- tine hygiene appointments, such tion are warranted. May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 39

as extrusions, midline discrepan- ment—is greatly enhanced occlusal problems, explain thecies, and insufficient overjet, the using digital dental photogra- esthetic features and benefitslatter of which can contribute to phy. Clear photographs of the of the bracketless and wirelessimproper anterior tooth function, patient—preferably the eight system, and arrange for a con-complications with posterior tooth images required for Invisalign sultation with the dentist.function, and abnormal maxillary treatment planning—enableanterior tooth wear. What’s impor- better visualization and under- Conclusiontant to remember when broach- standing of their condition anding the subject of what a patient what can be corrected. Dental hygienists have a re-may deem as unnecessary treat- Likewise, it’s equally impor- sponsibility to ensure patientment, is that dentistry that is sold tant for the patient to under- oral health and identify risk fac-often times turns into noncom- stand what the alternatives are, tors for periodontal disease andpliance, no shows, cancellations, as well as the consequences other oral health complications,and/or failed financial agree- of on-going malocclusion. In including malocclusion. Fortu-ments. However, dentistry that is a non-threatening and non- nately, Invisalign is indicatedplanned with the patient based on condescending way, patients for treating a variety of occlus-what they value and want results should be completely informed al and misalignment problemsin long-term happy, grateful, and of the biologic, functional, and in a comfortable, convenient,compliant patients. esthetic problems that could and esthetic way. When dental continue or develop if they hygienists maintain open andMoving Forward choose to forego recommend- trusting relationships with their ed treatment. And, if patients patients—and are fully awareIdentifying stable and posi- have any questions about Invis- of the many type of conditionstive attributes of the patient’s align treatment, dental hygien- that Invisalign can correct—aoral health—as well as those ists can reinforce Invisalign as foundation is established foraspects of their occlusion and an appropriate treatment for a discussing areas of concernmisalignment that can be cor- variety of misalignments and that may require further consid-rected with Invisalign treat- eration and treatment. 40 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

Pre-Clinical Conversations and Co-Discovery7KHPRVWLPSRUWDQWSDUWRIDK\JLHQHDSSRLQWPHQWLVWKHÀUVWIHZPLQXWHVLQWKHFKDLUIRUZKDW,FDOOWKH´3UHClinical Conversation” No patient bib, no gloves, no mask. Eye to eye, knee to knee in an effort to both conQHFWZLWKWKHSDWLHQWDQGDOVRVHH´ZKHUHWKHSDWLHQWLVWRGD\µ,LQYLWHPDQ\RSHQHQGHGTXHVWLRQVVXFKDV Tell me what has changed for you since the last time we got together? What, if anything, would you like me to pay special attention to today? What is most important that I know about you in order for us to best work together today? Before I bring your chair back, please tell me what you know about your oral health and what I may see when I look. (It’s amazing how much patients know and how much we think we think they don’t know.)3ULRUWREULQJLQJEDFNWKHFKDLU,DOVROLNHWRDVNWKHSDWLHQWKRZWKH\PD\ZDQWLQIRUPDWLRQLI,KDYHDQ\QHZÀQGLQJV,WHOOWKHPWKDW,ZDQWWRKHOSWKHPOHDUQDVPXFKDVWKH\ZDQWDERXWWKHLUPRXWKDQGUHPLQGWKHPthat all choices about if/how to proceed is always up to them. I value a relationship based on the patient being in control at all times and my role being one of their advocate to help them achieve their goals. In collaboration with Sheri Kay, COO & Lead Practice Coach $&7'HQWDO'HQWDO3UDFWLFH&RDFKLQJ www.actdental.com Follow us on…

Hygiene Hand-OffWhen the doctor enters the room for the exam… T Use the patient’s name in a sentence T Share something positive about the patient T Review medical history highlights T&OLQLFDOÀQGLQJV X oral cancer screening X soft tissue / perio X hard tissue / teeth / occlusion T Hygiene conversation review - Focus on “Patient wants” and “Patient outcomes” X where have we been? X where are we now? X where are we going? (possibilities) T Anything else to add?Tips to RememberX +\JLHQLVWVSHDNVÀUVWX Each person sees 4 eyes at all timesX Patient is always included in the conversationX Tentative next step is proposed to or with the doctorX Follow-up is documentedX Keep in mind - this type of experience is not about making recommendations, but rather about exploring possibilities and helping our patients make healthy choices. Shannon Pace Brinker, CDA, CDD http://cpsmagazine.com (757) 285-9477

NEXT GENERATIONMultilink® AutomixAdhesive Cementation System “ I rely on Multilink Automix for its proven strength panedrfolormnga-ntecrem” – Lee Ann Brady, DDSTrusted by leading dentists for its proven reliability proven forand ease of use, Multilink Automix provides patients ®with the security they expect. Now featuring: e.maxClinicallys

Placing InvisalignAttachments UsingProper Techniqueand Materialsby Megan Cotturone, CDAIntroduction tient’s teeth by providing greater surface area retention. Attachments for Invisalign alignersIndicated for a variety of conditions, including also serve as anchors for specific segments ofgapped teeth, overbite, underbite, open bite, teeth, so that some can move while others re-crowded teeth, and crossbite, Invisalign orthodon- main stationary. Easily removed at the end oftic treatments utilize customized clear aligners therapy using a polishing tool, Invisalign attach-to improve occlusion and straighten teeth. Popu- ments do not cause any permanent alteration tolar for many reasons, Invisalign provides a more the tooth surface(s).esthetic and functional option for patients of all During initial treatment planning, dentists can de-ages, without using brackets, wires, or bands. Al- termine whether or not attachments are necessarythough indicated to correct several conditions, and where they will need to be located. Dentistssome cases require additional features to help or dental assistants can then affix small amountsachieve the patient’s anticipated treatment re- of enamel-colored composite to the teeth requir-sults. For those cases, some tooth movements ing an attachment using a bonding agent and In-necessary for orthodontic correction require at- visalign designed template aligners. Although atachments in combination with the aligner for simple procedure that requires no aesthesia, den-proper tooth positioning. tal attachments for Invisalign treatments do re-Designed to help the Invisalign aligner trays grip quire precise placement to ensure they properlythe teeth, attachments are placed in strategic facilitate ideal tooth movement. Complicationspositions to help move the teeth in the specific can occur, especially when improper adhesion de-directions planned by the dentist. Attachments lays treatment and/or affects the esthetics of anenhance the aligner trays’ ability to move a pa- overall successful orthodontic treatment.44 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

Material and com) that matches the patient’s 1Equipment Selection enamel should be selected. This prevents the attachment from On occasion, attachments mayInvisalign provides aligner tem- interfering with case esthetics fall off throughout the Invisalignplates for creating ideal attach- throughout the treatment and treatment for a variety of rea-ments, reducing the possibility reduces patient anxiety regard- sons, most commonly improperfor variations in attachment ing the appearance of the at- placement technique. A slightlyshapes and locations. After tachments. Grandio composite wet aligner template decreasessubmitting the diagnostic re- also demonstrates enhanced the bonding agent’s ability tocords, the aligners are fabricat- wear resistance, color stabil- bond the tooth with the com-ed and, if necessary, fabrica- ity, and great sculptability to posite and reduces the bondtion of aligner templates is also achieve the ideal attachment strength. If an attachment fallscompleted. When the patient shape. off, two options are available forreturns for their first aligner reattachment. Since the originalappointment, it can include at- Other armamentarium provides aligner template most likely notachment placement and/or in- dental assistants with tools to longer fits the patient’s teeth,terproximal reduction. successfully place attachments. the dental assistant can simplyAttachments require a bond A retractor (OptraGate, Ivoclar cut out the individual tooth fromstrong enough to anchor align- Vivadent, www.ivoclarvivadent. the attachment template anders, but weak enough to avoid us) that comfortably isolates repeat the placement proce-altering the healthy tooth struc- teeth and reduces saliva and dure. An alternative option is toture during removal. Although excess fluid in the oral cavity contact Invisalign and request amany options in bonding mate- that could potentially interfere template aligner fabricated us-rials are available, Futurabond with bonding should be placed ing the patient’s current aligner.U from Voco (www.voco.com) or utilizing a very special device In two to three days, Invisalignprovides enhanced adhesion, called the Mr. Thirsty by Zirc. will ship the new template align-quick working time, and mois- Additionally, it is essential to er and the attachments can beture tolerance. use composite placement tools placed.Additionally, because main- (OptraSculpt Pad, OptraSculpt,taining high esthetics remains Ivoclar Vivadent, www.ivoclarvi-an important characteristic of vadent.com Figure 1) that al-Invisalign treatments, and be- low dental assistants to presscause placement of the attach- the composite into the tem-ments frequently occurs on an- plate well, ensure that the idealterior teeth, a shaded composite amount of material is present,(e.g., Grandio, Voco, www.voco. and stabilize the template align- er during light curing.Designed to help the Invisalign aligner traysgrip the teeth, attachments are placed instrategic positions to help move the teeth inthe specific directions planned by the dentist. May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 45

23456789Clinical Technique snaps in place and fits prop- the specific shape and loca- erly. Remove the template tion of where the composite1. Prior to treatment, explain and try-in the first aligner to attachment will be placed, the attachment process to ensure it also fits properly. with little excess on the rest the patient and prepare the (Figure 4) of the tooth. (Figure 5) patient for what to expect. 4. Use an air-water syringe 7. Rinse the etched tooth/teeth to completely air dry the for 15 seconds and dry until2. Isolate the teeth prior to treat- template. the tooth surfaces have a ment using a retractor (Optra- 5. Review the Invisalign attach- frosted appearance. (Figure Gate) or Isolation device such ment instructions regarding 6) If you do not see this then as the Mr. Thirsty by Zirc. In- shape and location. start over again re-etching sert into the patient’s mouth 6. Acid etch the enamel of the the tooth. to isolate the teeth and re- teeth to receive an attach- 8. Mix the bonding agent (Fu- duce salivary contamination. ment according to the man- turabond U) and apply it to (Figures 2 and 3) ufacturer’s instructions in the etched surface (Figure 7). Scrub the area for 20 sec-3. Try-in the attachment tem- plate and ensure that it46 | Contemporary product solutions | Staight Talk | VOL. 16 • May 2014

10a 10b 11 12 13 onds to enhance the bond aptation, and squeeze ex- 16. Keep the template in the pa- strength and dry with light cess composite away from tient’s Invisalign Box never air. (Figure 8) the etched area. (Figure 12) to give this to the patient,9. Light-cure (Bluephase, Ivo- 12. Firmly hold down the com- and seat the patient’s first clar Vivadent) the bonding posite using the instrument aligner, demonstrating how agent for 10 seconds, plac- and light cure according to put the aligners in and ing the curing light right on to composite instructions. take them out. the tooth/teeth. (Figure 9) (Figure 13)10. Load the shade-matched 13. Remove the attachment Conclusion composite (GrandioSo) into template, and then remove the window of the attach- all flash and bonding resin Invisalign treatments may some- ment template. (Figure 10). between teeth. Floss in- times require attachments as a Use the padded end of the terproximal areas and re- fundamental tool to correct teeth instrument OptraSculpt by move any excess resin or alignment and manage occlusion. Ivoclar Vivadent to press the composite. Accurate and secure placement of composite into the well, en- 14. Ask the patient to ensure attachments ensures that the ide- suring the correct amount is that the attachment isn’t al movement of teeth occurs and placed. Do not to overfill or too sharp. Polish the attach- avoids wasted time in fixing failed under-fill (Figure 11). ment as necessary using a attachments. Essential to many11. Fully seat the loaded tem- rubber tip and low-speed Invisalign cases, dental assistants plate onto the teeth. Use the polisher. can easily place attachments by instrument to apply gentle 15. Repeat the procedure for practicing the ideal placement pressure around each at- any additional attachments. technique and using the proper tachment to ensure full ad- tools and materials. This helps to achieve esthetic and functional Invisalign treatment results.  May 2014 • VOL. 16 | Straight Talk | Contemporary product solutions | 47

Placing Attachments | For AlignersBEGIN WITH: TEST FIT ATTACHMENT TEMPLATE PREPARE TEETH FOR BONDINGRAttachment TemplateRComposite material Rinse attachment template in cold Prepare surfaces to be etched byRBonding agent ZDWHUDQGWHVWÀW,VRODWHWHHWK FOHDQLQJZLWKSXPLFHREnamel etching gel EHIRUHWUHDWPHQWR)LQLVKLQJEXUVWRUHPRYHDQ\ÁDVKRComposite DispenserRDental Composite Spatula InstrumentPREPARE TEETH FOR BONDING PREPARE TEETH FOR BONDING PREPARE TEETH FOR BONDING5LQVHVXUIDFHVWKRURXJKO\ 'U\SUHSDUHGVXUIDFHVWKRURXJKO\ Apply etchant over the entire toothPREPARE TEETH FOR BONDING VXUIDFH:DLWVHFRQGV PREPARE TEETH FOR BONDING PREPARE TEETH FOR BONDINGRinse each etched tooth for Dry until tooth surfaces have a Apply bonding agent on the etchedVHFRQGV IURVWHGDSSHDUHQFH VXUIDFHDQGGU\ZLWKOLJKWDLU

Placing Attachments | For AlignersPREPARE TEETH FOR BONDING DISPENSE ATTACHMENT MATERIAL PLACE LOADED TEMPLATELight cure each tooth where bond- Thoroughly dry template and load Fully seat loaded template ontoLQJZDVSODFHG a small amount of composite into WKHWHHWK8VHDGHQWDOVSDWXODWR attachment well until slightly over- apply gentle pressure around ÀOOHG8VHDGHQWDOVSDWXODWRSDFN each attachment to ensure full WKHFRPSRVLWHLQWRHDFKZHOO DGDSWDWLRQDQGVTXHH]HH[FHVV FRPSRVLWHDZD\IURPHWFKHGDUHDCURE ATTACHMENT REMOVE TEMPLATE AND POLISHFirmly hold down composite with 5HPRYHDWWDFKPHQWWHPSODWHan instrument and cure according 5HPRYHDOOÁDVKDQGERQGLQJUHVLQWRFRPSRVLWHLQVWUXFWLRQV EHWZHHQWHHWK)ORVVLQWHUSUR[LPDO DUHDV3ROLVKDOODWWDFKPHQWVDQG SODFHWKHÀUVWDOLJQHUTIPS AND TRICKS:,ILVRODWLRQLVFKDOOHQJLQJXVHFKHHNUHWUDFWRUVDQGWU\SODFLQJDWWDFKPHQWVLQRQHTXDGUDQWDWDWLPHTo bond an attachment to porcelain, use dental products designed to condition porcelain so attachmentPDWHULDOFDQDGKHUHWRLW,IDQDWWDFKPHQWIDOOVRIIGXULQJWUHDWPHQWXVHWKHRULJLQDODWWDFKPHQWWHPSODWHDQGFXWRXWWKHVSHFLÀFWRRWKWRUHERQGWKHORVWDWWDFKPHQW,IWKHRULJLQDOWHPSODWHLVQRWDYDLODEOHRUWKLVRSWLRQLVQRWHIIHFWLYHRUGHUDQHZDWWDFKPHQWWHPSODWHEDVHGRQWKHDOLJQHUQXPEHUWKHSDWLHQWLVSUHVHQWO\ZHDULQJ Shannon Pace Brinker, CDA, CDD http://cpsmagazine.com (757) 285-9477

“When I’m doing orthodontic procedures using clear, removable teeth aligners, I find that Flexitime is the ideal impression material. For me, it delivers highly accurate impressions with every submission, which is critical because the last thing you want to deal with is a costly re-take.” -Shannon Pace Brinker FLEXITIME PUTTY AND CORRECT FLOW — THE GOLD STANDARD FOR ORTHODONTIC RECORD TAKING If you are among the growing number of dentists prescribing clear aligners to straighten teeth, Flexitime Impression Material has been a proven VPS material for the best results. Visit MyDental360.com to take advantage of this exclusive offer: Flexitime PURCHASE 1, RECEIVE 1 FREE! Enter promotional code “Align14” to redeem. Giving a hand to oral health.© 2014 Heraeus Kulzer, LLC Flexitime® is a registered trademark of Heraeus Kulzer GmbH.