this is an excerpt of a webinar about ipr or inter-proximity reduction by garrison dental
thank you to garrison dental for allowing us to post this excerpt to see the full length
version please contact www.garrisondental.com all opinions are those of straight smile solutions
we are an orthodontic consultancy company that helps general and pediatric dentists with their
ortho cases and education for help with a case please visit www.straightsmilesolutions.com
now enjoy the show so we talked about all the good parts about ipr now let's talk about the
pain points or the bad parts or the part you are all stressed about and trust me i've been in your
shoes and i like to encourage i know most of you who are on this video are probably general dennis
there are some orthodontists i saw but for most of you general dennis out there i'm
gonna pump you up and tell you you've got this if you can do crown preps and bridge preps and
all that stuff that i am scared to do you know in dentistry i've done it but it's been 20 years plus
um then you can definitely do ipr it's not that hard especially if you have the right system so
the first thing you need to keep in mind is timing and staging and that is a personal decision so for
me i we're going to talk about round tripping in a little while but i'm much more of a fan
of let's just get the ipr done let's do all the big stuff at the first appointment when i deliver
aligners and i'm i think most of you are probably thinking about ipr in terms of aligners we do
use ipr in braces but for me i do the ipr more towards the end only if i need it in braces but
with aligners things move a little bit differently and sometimes we need to get the space up front
so i prefer to do all my big stuff at delivery again personal choice so you know putting on
attachments doing ipr bonding buttons as needed for elastics and giving take-home instructions
i also am a big um proponent of doing aligners if possible in just three appointments so that's kind
of a challenge and people some people think that's nuts but plenty of orthodontists are doing it and
they're doing it well so the three appointments would be of course records which is when you're
taking the records and the scan delivery which is when you're delivering the appliance putting on
the attachments doing the ipr delivering the buttons as needed and take home instructions
and lastly the bond everything in between can be totally virtual i'm not saying you know hand
your your patient a box of 50 liners or 40 liners i'm saying you're going to hand them maybe 10 20
and then check in with them every a liner or two virtually there are tons of great virtual
apps i actually just did a webinar last week on that topic um and if you're doing invisalign it
comes with it it's included they have their own invisalign virtual and their app so it's really
easy and if you think that your patients really love coming to see you every four weeks they don't
so you know you might as well help them out there's really no reason that you need to be
seeing them in person if you can use virtual now there's a few states where virtual check-ins are
not legal i don't keep up on all this but i hear things so of course only follow your own dental
practice act but that's just my tip and another reason to learn to do ipr well and learn to do it
at the beginning and the other reason why i like this kit that garrison sells because it allows
you to do ipr at the beginning you don't have to but at least the choice is there if you want it
another ipr pain point is tooth morphology and ideal case selection and we're not going to go
too much into that but of course like we showed you that picture before let me go back i mean
this is so easy to do ipr right but if these if we didn't have that big embrasure right there it
would be more difficult especially if the contact was sub-gingival so just things to keep in mind
sometimes we can't do ipr on a certain two so you need to put your thinking hat on and decide if ipr
is indicated for that tooth you know we're just picking well good cases and that's a whole other
story we're going to go more over armamentarium later i know a lot of people get kind of caught
up in the weeds with what they need so we'll go over that we're also going to go over the
ipr map which shows you where and when to do the ipr and of course last but not least ipr
charting you definitely want to chart your ipr because you will not remember if you did it or
you didn't do it and where you did it and also as just basic documentation it is standard of care
for you to chart that you removed enamel on so and so tooth so and so surface when you did it
how you did it what tools you used to do it did you finish polish did you deliver fluoride
so you need to chart that as well okay so what are some contraindications and risks for ipr
well lots of things right um obviously unhealthy enamel or enamel with pathology or decay
probably not a great idea a patient who's already sensitive um you can develop ledging if you do ipr
improperly you won't with this kit but i've seen a heck of a lot of legend and i've definitely ledged
in my day so we've all done it so if you use the right armamentarium you will not ledge so
let's talk about the topic of round tripping so round tripping is kind of a dirty word in ortho
and it's not wrong it's just a thing so round tripping basically means going round trip so
for example if i take a patient oh let me see if i have a i thought i had a typo not flying
around over here okay whenever i want one there it is hang on gonna grab one over here i always had
typo dots but of course this one is not crowded but if you have a tooth that's crowded okay and
we need to add ipr there's two different ways we can do it one way is to round trip which is where
we straighten the teeth by moving them forward then we do the ipr then we bring them back okay
nothing wrong with that especially if the teeth are stable and healthy and they're not having
attachment loss you know no mobility that's okay and if you feel more comfortable doing your ipr
on straight teeth that is totally fine to do but pick your case wisely because on some cases
that maybe are a little more compromised if you do that you might put them in a kind of precarious
situation with the occlusion you're maybe pushing the tooth um outside the buckle or labial plate
you're putting making the tooth a little more loose and that extra distance the tooth has to
go you know all the way forward then all the way back can really sometimes compromise the tooth
and um i have an auntie who always likes to say this is kind of like a i have one off stories but
she had braces like 20 years ago she was like in her 50s or 60s and they did round tripping
on her it was braces not aligners and try to make space and she ended up losing her front teeth so
she's like super anti-round tripping so for that reason i just want you always to be cognizant
about picking the right case for round tripping so we kind of talked about the alternatives already
but i always like to you know when you treat a plan for a patient you always need to give
what risks benefits and alternatives so we kind of talked about the risks already
right we talked about the benefits you should be able to recite this stuff in your sleep
and all the alternatives so ibr is never the only choice it is a choice there's always
other choices and you're gonna get some patience and i really actually believe that you shouldn't
finalize a treatment plan until the patient has seen it and that's something that a lot of people
disagree with me about but the patient has a right to understand the risk benefits and alternatives
i can show them the treatment plan either bring them in or you can even export an invisalign
treatment plan i'm pretty sure there's a way to export clear correct treatment plans
where it's a hipaa compliant way i know how to do it invisalign it's kind of
kind of difficult but you know it's definitely doable so they could look at it from home
i think even easier is if you had a secure zoom session and you could even do a virtual
consult after you've done the records and exam and everything but just to present the treatment plan
and show them what you recommend then you want to have them actually sign off on the treatment
plan so i recommend typing it out writing it out saying this is the treatment plan you know
invisalign comprehensive approximately 8 to 14 months you know you can give a range
because sometimes things go slower and quicker with ipr for crowding alternatives would be
you know you could say distalization proclination you can explain what some of the other options are
and the nice thing to do also is to come up with a variety of different treatment plans you could
even do one that didn't have ipr or you could do one that perhaps left the bolton discrepancy
and they are getting veneers on seven and ten or something like that and you wanna
visually show the patients the options and explain why you prefer one over the other
but giving the patient choice as to what you can offer i also want to mention and this is something
i like to hammer home a lot if you are a general or pediatric dentist if you're not an orthodontist
you know what is what i consider below standard of care is to only push your
version on the patient so i do work with doctors a lot on optimizing their ortho
and those of you who work with me you know i can i can get a little stubborn about this so
a lot of doctors will come to me and they're like i only want to do ipr i don't want to do
elastics um that's not something i want to do i'm not comfortable with it well okay you know that's
totally fine that that's what you feel comfortable with but you still have a right to give your
patient the risk benefits and alternatives you need to mention that elastics are an option
or distillation or whatever and you can let them know that's not something that you feel
comfortable doing in your office you can say i'm not an orthodontist you can offer for them to go
to an orthodontist to get that version explained to them if you don't feel comfortable explaining
it but you can't just omit that alternative to the patient that would be considered below
standard of care you have to give them all the options same thing if it's a job surgery case
potentially as an option you have to mention jaw surgery you can say that you don't offer that
practice but you have to offer to refer them out it may not be the same price if you go
someplace else but you need to inform your patient and if you don't feel comfortable
explaining risk benefits and alternatives you probably shouldn't be offering that treatment
i wrote big letters property of a line technology because sometimes they get a little squirrely when
you show their their clinch checks but it's mine so i can show it so but in any case there's no
name but you all kind of know how aligned technology works when you play the clinch
right the sites that need ipr are going to line up yellow they're going to light up yellow when it's
due so for example when i played this at a liner 17 these sites lined up yellow lit up yellow um
then later some of the other sites lit up yellow so for invisalign you have a lot of control the
nice thing about there and i don't work for any aligner company i have no particular affiliation
with any of them you know but one thing i do like about invisalign or align technology
is that it's really easy to understand it's really clear when it's due and you don't have to do that
now at 17. you just have to do it before 17. so i like to say it's like a library book you need
to do that ipr before it's due so for me i try to do it all at delivery now for example if i have a
patient who's kind of like like kind of fidgety and just can't sit for long periods of time
then i might not do it all at that appointment but i know i have to get it done before a line of 17.
so you know really just talking to your patients sometimes people can't sit there for two hours i
get that okay so we talked about tips and tricks i always recommend going 0.1 millimeters less than
what they're asking for that's just my little thing that i've learned over time another great
tip is vpc vpc is virtual power chain and that's a branded term that invisalign uses you can ask
anytime i have a lot of ipr if it's an invisalign case i'm going to ask for virtual power chain
which is three millimeters of over correction alignment of aligners they only do that three to
three which means anterior teeth only so if you've had um ipr on posterior teeth the ppc isn't going
to work remember if you've got using vpc you want to when the strip comes i should have had a strip
i had one flying around here but you want to rip the over correction aligners off and put a big vpc
on them or x them out do not leave them on the big giant strip because what's going to happen
inadvertently is you're going to think they're actual active aligners and you're going to give
the patient the whole thing and they're going to end up with crowding you only give one vpc packet
if needed at the end so once you finish let's say it was a moderate pace moderate in the us goes up
to 20 aligners so that means you'd have 17 active aligners and three vpcs which would be optional
you finish you get to a line or 17 you do not give them 18 19 and 20 because those are bpcs
you go and have the patient come in you check all the contacts you know with your floss and
if there's open contacts in the area where you did the ipr in the area that would be affected by
vpc you give them one vpc packet they wear it they come back in a week or two later and you check it
and if you as long as they're still contacts open you can always give them the next one
but the consequence of using vpc if it's not needed is that you actually get crowding
so just be a little careful we've all done that another cool refinement tip that i've used is
something called virtual ipr and now we're getting like super complicated remember how i told you to
always under do it and not overdo it so another tip if i have a refinement and i have extra space
especially if they're posterior spaces but you could do this instead of vpc if you wanted on
anterior is we'll check contacts at the refinement if there's open contacts um or light contacts i
will ask the technician for .1 millimeters of ipr on those sites unless the scan picked
it up if the scan picks it up and put 0.1 as a space then i'm fine but i wouldn't actually do
the actual ipr so i'm going to ask them for ipr but i'm not actually going to do the ipr i'm going
to virtually do it i'm going to say that i did it but i didn't actually do it so that acts almost
like a vpc and if that doesn't make sense i have a ton of videos that go into this a little bit more