with straight smile solutions straightsmiles solutions.com and today we're going to talk about
fixing posterior crossbites in adults specifically in adults with invisalign can you do it should you
do it should you even try it what happens if you try it what can you expect what should you tell
the patients what are some some scenarios where it might work what are some scenarios where it might
not work and what are some scenarios that you shouldn't even attempt so this is a really really
tough question and unfortunately so keep in mind with invisalign the default is going to be don't
fix posterior crossbites that is in your clinical preferences now some people have undefaulted that
but that should be your default unless you've changed that so your posterior crossbite shouldn't
come fixed however if you've overrided the preferences or you have things in the
comments section you might find that indeed they try to fix it or you might tell them to fix it now
even if it's not technically possible if you tell them to try to fix it they will try to fix it that
doesn't mean it's possible healthy probable um it doesn't mean that it's even going to happen
so i see this so often and i kind of wish that invisalign would sometimes they'll put like the
dots over it like the blue dots or the black dots sometimes i'll leave a little note in there saying
hey this may not be possible most of the time they don't do any of the above so you don't really know
i wish they'd almost give it a score like probability of this happening successfully
um that's one of my pet peeves with invisalign and i love that they listen to my videos because
it is a big problem you know like if you all know that your algorithm says this is
probably not going to happen let the doctors know especially the less experienced doctors
because they really get themselves in a lot of trouble with telling a patient well hey the
clinchex is possible so it must be possible well they don't realize what other side effects can
happen when you attempt something that really isn't possible so let's let's talk about the
side effects first of all and that doesn't mean you're always going to get the side effects and
to be really honest as an orthodontist i don't always even know if the side effects are going to
happen i'm going to tell the patient and these are lightly covered in your informed consent
but if you know you're doing something a bit edgy and a bit fringy you know that may or may not
be possible you really as orthodontists we tell the patients if they really want something done
and we think it's less than likely we're going to say hey look we'll do this for you or maybe we
won't i have to think about the risk benefits and alternatives i have to explain the risk benefits
and alternatives to the patient all the risks if you don't know what they are you have no business
doing this you know so i'm going to write them down specifically the patient is going to get
them explained they're going to be written down the patient's going to sign that they understand
the risk and if the patient really wants to try and they understand the risk in my mind
the benefits have to outweigh the risk now for me fixing a posterior crossbite almost
never do the benefits outweigh the risks it just doesn't why why what's the risk lots of things
you can kill the tooth you can push the tooth through the buccal plate you can kill the nerve
um you could put the tooth in a position that's unhealthy so that the forces are
not loaded properly in the future and then you're going to kill the tooth later you're
going to get parallel problems later um you have fractions later so many things can happen
so just because the clincheck this is what i'm trying to narrow hit home just because the clinch
exits as possible doesn't mean it's possible it doesn't mean it's healthy you need to know what
you're doing so my suggestion for general dennis is don't do it don't do it but let's talk about
some situations where it might be possible and ways that you can maybe do some workarounds to
make it improved but maybe not perfect and things you can look for so i have a couple scenarios here
and these aren't the perfect scenarios because i didn't really have i had patient images that
i didn't have permissions to share so i'm using stock images and what i can get so first thing
to keep in mind is crco shifts and i have a really great video on crco shifts if you want to go into
my channel i have over 3000 videos in my channel alone you go to the little magnifying glass put
in cr co or just even put in the letter cr and it should pop up if you can't find it you can email
me info straightsmilesolutions.com or contact me at streetsmilesolutions.com say hey i want the
crco ship video i will send it to you no problem it's free of charge i know where all my stuff
is and i'm happy to give it to you so anytime i see a unilateral crossbite say like in scenario
one where the midlines are off first thing i'm thinking is crco shift okay and sometimes it's
a shift from right to left sometimes it's a transverse shift sometimes it's an anterior
posterior shift sometimes it's transverse and anterior posterior so it can be in many different
planes of space so for example in this situation i saw this patient walk in my office first thing i'm
thinking is oh this patient has a major crco shift i'm going to try i think we're missing a lateral
too which makes sense but i'm going to try to line this up get the midlines lined up just even if
it's an unstable bike just to kind of see how the bite looks after i do that because that's probably
what the bite is and they're probably just shifting into a more comfortable position maybe
they're not maybe i can't guide the lower jaw back but probably i can so again first thing i looked
at anytime i see a unilateral crossbite is to see if the midlines are on okay so keep that in mind
it may not be as bad as you think once you line up the mid flat midlines and you put it where it
was supposed to be before the shift if it's just a tiny bit of expansion and the things i'm looking
at is the bone so if i draw a line here see here's where the buccal bone is and here's where the
buccal bone is down here the buccal bone on top is supposed to be wider than the buccal bone on the
bottom well here it's more in right it's more palatable so that's not what we want but then
again i don't think this is the bite anyways so it's probably so see how the buccal bone is here
it's out here and the the bone down here on the mandible is more in that's what i want to see
so if your bone is like you can only put the you got to put the teeth over the bone right maybe i
can angle it a little bit out but we don't want to blow it out the bone because then there's no
bone to put it in the roots are going to be outside the bone your tooth is going to die
you're going to get perio you're going to get endo you're going to all kind of problems and guess
who's going to be responsible it's going to be you and if you as the dentist didn't explain the
risk to the patient and you killed the tooth you could potentially be liable and i don't care if
you have an informed consent done okay you would have to and so again do the risks are the risks
less than the benefits more than the benefits you have to you are the dentist you should know these
things okay okay let's talk about scenario two scenario two we definitely have a crossbite here
you can't really see the bone sorry my number two is but definitely the bone is more in midlines are
on here okay so in this situation i believe this bite okay um bone's about the same here
but again the upper bone should be more should be wider than the lower bone so i don't think i would
fix this crossbar here in this case midlines are on bone is wider down here i might fix it maybe
canine first premolar maybe canine first premolar second premolar i'm gonna leave the molars okay
i'm gonna leave what i can that means i would have what i have to do we have some spaces down here
but i might have to extract a lower incisor or i might have to do a ton of ipr on the bottom to
tuck these in tuck these in and again you're like you're lining the teeth up in an unfavorable way
so again this is a gamble is is this there's a small risk you have to let the patient know but
at least it's looking better in this zone and i'll leave the molars in crossbar um what else
number three this is a kid i believe yes it is a kid so i believe we oh maybe we're not a kid
no i don't think we are i think these are permanent teeth so this is not my patient so
um in this case i'm not really looking at it from straight on i like to see this straight
on look to see again to see where the bone is if it's a kid or a teenager of course i'm gonna
do an expander right of course i'm gonna do an expander that makes life way easier that you
know don't even stress about it but if it's an adult again we might leave the crossbite
on the molar we might fix the crossbite on the premolars well we don't really have one here
so you'd have to really look at the bone and see if it's possible usually it's possible to fix
it on the premolars but again you're putting the tooth in a slightly unfavorable position
um ah this is a kid yes so in this case of course you do an rpe here first or shorts expand them out
and then you're going to go ahead and finish up in your braces or invisalign never never when you
see a kid and by kids of course you have to know something about the skeletal maturity age of the
patient member and girls they could go through maturity at eight nine ten you get some wiggle
room on expansion but you don't get indefinite wiggle room on expansion boys of course you have
a lot more wiggle room usually i'm thinking 14 15 maybe even 16 maybe even 17 if i'm doing slow
expansion i can do a little bit more and get away with it keep a close eye on it i'm going to expand
them first why would i want to tip teeth when i can bodily expand opening up the palate improving
the airway and getting a more stable outcome and healthier position for the teeth for time to come
right so a lot of times and that's another little bone i have to pick with invisalign
they will never tell you that they won't say hey maybe you should expand first because they can't
they can't dictate treatment they're not the doctors they have doctors on their team
and they're more than glad sometimes they're more than glad to meet with you you know if you do the
invisalign pro but rarely do they i feel like the invisalign pro i feel like it's very leaning on
towards selling the cases you know i mean that's their business right they're not gonna tell you
oh you should do an expander first they're just not so because then they're not going to get that
case right you might forget you might not do it later they're not going to sell the case so
i've done some cases and i've heard of some cases people have done with invisalign pro where it's
like come on obviously i mean your orthodontist from visiting pro and you're not saying something
that's just right and totally obvious i know you know this but that's their job right i
can't tell them not to do their job so again this goes into a whole nother discussion about
taking a liner courses from an aligner company bad move always a bad move and i don't even do a
liner courses because i don't think you should be taking an aligner course until you understand the
basics of braces and phase one you should do some cases if you want to learn a lot about aligners
you should do it the way orthodontists do do we sit and take a bunch of classes no we do not we
start seeing cases from day one we're already dentist we're gonna see that case we have some
faculty members that are gonna help us out they're gonna help us work it up we're probably not going
to take super hard cases but actually that's not true because you take whatever walks in
the first your ortho residents get all the cases and there might be surgical cases they might be
exposure cases it might be crazy easy class one cases you get what you get of course in residency
we try to balance things out just like you do in dental school where you try and different
residencies do things differently at least at mine there was no quota or anything like that you know
like some people had tons of surgery places some people had tons of exposure cases some people had
tons of class three cases it was whatever walked in and who was accepting patients that day and
you know some days we took new patients and they tried to balance it out but you know the front
desk never knew who was what you know because you hadn't examined them yet and sometimes we try to
trade around you know if we knew somebody needed more experience with something um hey so-and-so
is going to do because it's going to work on you but ultimately it was just a matter of luck of the
draw and we ended up you know maybe starting i don't know 100 200 cases i mean a lot um
definitely we took cases our first year and maybe the first half of our second year and we didn't
our third year third year was all about finishing up the cases but um yeah i'm i'm going off in
a tangent but i'm letting you know no sense in taking an aligner class you're learning absolutely
everyone i know that's taken on the liner class has not i'm not impressed with what they know
my fact i feel like their brains are ruined in terms of what they know because they're so like
they're filled with junk their brains are filled with junk not understanding exactly how teeth move
they just understand that aligner system it's very biased so oh goodness what happened there
so anyways i'm just gonna give my story and again i don't offer an aligner class so i'm not saying
this because i think there's no point to an aligner class i offer all my content for free
i make it for free it costs me money to make it i post it i eat the cost i don't sell it it's free
it's on youtube it's on my webinar page which is gpwebinar.com if you want to know something
i've got playlists you can learn everything you need to know just from my youtube channel that's
it that's all you need to know and if you want to start working on cases you will learn so much and
i'm not the only ortho consultant that's out there there's a lot of orthodontists that do consulting
find the right person for you there's tons of us that are doing it some of us do it full time
some of us do it on the side you know in addition to their practice obviously you're gonna want to
find somebody whose personality matches with you you find that they're ultra responsive they're
very responsible that they're giving you good outcomes that they're attending to your needs
and the needs of your team of course anyone that works from a liner company i think you shouldn't
work you shouldn't hire but that's just my opinion because they're going to be super biased
you know if you work with me if i think it's a case that shouldn't be with invisalign i'm gonna
tell you that i'm gonna say do braces or i think you need to do an rpe first i'm gonna tell you
don't do the invisalign start with an rpe because that's how we do things in an ortho clinic
we do what is right and that's ultimately what's in the best interest of the patient you want to
be unbiased when you look at these cases you don't want to come in and think in my head i only offer
invisalign that's all i offer because that's a mistake because it's not always the best thing for
the patient um you know so if you if you're going to offer ortho as a gp you need to be willing to
offer all kinds of work though now of course if you really only want to offer invisalign then
if it's not a good case for invisalign then refer them to somebody who does braces that's the main
thing or you know refer them to somebody that does interceptive or expanders but anyways hopefully
this was helpful again be careful committing to fixing a posterior crossbite in invisalign
think about the box think you know open the box up think about outside the box and think of the best
way to save the patient's teeth nobody died from posterior crossbite a matter of fact most times
nobody even notices so especially if you just leave it on the molars alright thanks so much