hey it's dr amanda with street smile solutions straightsmilesolutions.com and sorry about my
voice today it's a little raspy lost my voice earlier this week but hopefully you can hear
me okay i'm going to start making some videos again so the topic today is about mobile teeth
so obviously we don't want to be starting treatment on cases with mobile teeth
so you need to be careful about your case selection but occasionally during treatment
you start to get mobile teeth and what should you do about that you know lots of different things so
this is actually going to be a really long video because there's so much to say so hang in there
so first thing i like to do whenever a doctor tells me hey my patient's starting to get
mobile teeth is i say well okay we need a little more information but i say well what is mobile
like what does that mean talking about light mobility like a one one plus two two plus and of
course three is depressible right that's a big no no so i'm okay with that you know the 0.5 to one
that's totally normal teeth often get a little bit mobile as they start to move because you
have to loosen it up in the socket in order to translate it right normal normal normal thought
okay but when we start going to one plus to two that's starting to get abnormal um so of course
we start there um and that's something you really should be checking every time the patient comes in
you know checking for mobility for sure so there's four major things in my mind that have to do with
mobile teeth some of them normal some of them not normal so let's kind of take you through it so
first thing i do whenever a doctor tells me this is of course i ask him
how mobile is it and did it start this way or is this something new okay
once we get that information if like i said if it's less if it's one or less eh fine you know
if it's more than one okay we gotta dig into it a little bit so that that's the first question
second question is going to be let's go ahead and pull up the x-ray and let's let's check
out the crown to root grocery ratio and if you heard my analogies before about trees
you know if you've got a tree planted in the backyard there's a lot of wind and
you don't have a very good root structure and you have a lot of you know leaves um if you don't have
a good crown to root ratio it's probably going to blow over the storm right well same thing
with teeth so you got to look at the crown to root ratio how's the bone how much root do we
have how stable is it if it's a bad crown to root ratio well yeah it's probably gonna get mobile you
know and it might get worse so we're gonna look at that um we're also gonna go ahead and we're going
to look at the treatment plan and see exactly how aggressive the treatment plan is so teeth
i mean for a stable treatment plan especially for a perio patient i wanted to be moving 0.15
to 0.2 millimeters per liner per month now the default invisalign is 0.25 so that's even faster
the default clear correct last i heard was 0.3 to 0.35 so you've heard me before say on invisibleing
treatment plans i always slow it down by two clear correct sleep treatment plans i slow it down by
three sure smile is somewhere about two and a half to three as well i slip slow them way down
on perio patients i might slow down the invisalign by three and slow down the clear crack by
four now so far with invisalign clear quick i've had no issues slowing things down they don't give
me any attitude sure smile does give attitude they actually say no so um you know these are
things to take into account this is part of the reason i always do perio patients with invisalign
is because a they're very gracious about slowing things down and b their trim and their movements
are a little bit slower a little more gentle and a little more healthy the more aggressive and the
more you're torquing those teeth if you have high trim line trying to take it off the more likely
you're going to get mobility and that's just a fact jacked you know well i don't know if there's
research to back that up but that's that's a fact check so you know just things to keep into account
so take a look at the treatment plan and you guys aren't gonna know i mean you can look at the tmts
and figure it out but i mean you're probably not gonna know it really takes a trained orthodontist
eye to tell you if this is an aggressive treatment plan or not so the first thing i'm going to do is
slow the treatment plan like way the heck down now if you're paying for an express case or a
like case or a go case or a modern case this may not work so you probably picked the wrong plan
always always always do unlimited or comprehensive on these type of cases
always because you're gonna have to slow it way down okay so that's the first thing we're checking
next thing we're checking is um are you round tripping or are you proclining the teeth and did
you get a ceph well that's the next thing i check i say well did you get us f you know did you get
staff numbers and 99.9 the doctors say no i didn't get a set well self could be standard of care on
these type of cases and i'm not going to go into the hole when to get sephon not to get stuff
most orthodontists get steps on every case that tells you something do we use it on every case
and no well we just get it on every case because it's better to have than not want than want to
not have right so um but even if you didn't get the ceph we can look at the profile and we can
we can look at the treatment plan and we can pull up that tnt or that tooth movement table which
is now available in invisalign in clearcorrect and in my white label company global that i use
those are the three companies i use i can get a tmt and i can see scroll down look at every
single tooth and i'm going to look at buccal lingual movements and i'm going to see did the
front teeth move buckly because usually the the fenders are somewhere the front teeth right
that are mobile did they move buckley during treatment it'll say like point to b you know
as opposed to 0.2 l lingual i want them to either stay where they are or i want them to move lingual
if they are perio teeth they are not allowed to move buckle now here's the caveat what if they
round tripped if they round tripped it's not going to say that it moved buckle because it actually
ended up at the same location eventually but they moved it forward in order to make space to you
could do the ipr to move it back that's called round tripping and if you don't understand what
round tripping is you need to read my other videos on round tripping to listen to my other videos on
round tripping you can go to your youtube site put in the search bar straight smile solutions
once you're there that takes you to my home page which will have a variety of different playlists
there's also a magnifying glass towards the top right hand area it's a tiny little magnifying
glass you can type the word in round trip you type that in you can see all my round tripping videos
all my videos about ipr and everything like that you're not going to know if this case round-trip
unless you know what that is and you know how to look for it if they round trip you're still
moving the tooth forward in order to make space to do the ipr to move it back that still messes
up the tooth okay round draping is totally fine in a younger patient i don't have a problem with it
but in an older patient it's a problem especially one that has period or has a chance of mobility so
in my treatment plans for period patients i put in big bald letters no round tripping no proclimation
no expansion what does that mean well that means we're doing a heck ton of ipr or we're taking on
a lower incisor so that's just how it is but that will help to prevent you know issues from
happening next thing we have to keep in mind is we have to check the occlusion we're going to use
articulating paper we're going to see if there's any premature contacts on those teeth that are
mobile i'm going to take those teeth temporarily out of occlusion so if we're getting to the point
we're starting to get mobile teeth first thing i'm going to do is check the bite i'm going to
take those teeth out of occlusion yes i'm going to have to get out my handpiece for that but you
know what better to quickly get it out of out of occlusion than to have problems you know with
mobility and that's a really good quick fix so i'm taking all these things into account in order to
hopefully save my mobile teeth i'm gonna change the treatment plan i'm going to eliminate
proclamation round tripping i'm going to eliminate premature contacts or any contacts on those teeth
i want to make sure i end the treatment plans with no contacts on those teeth and most likely
if this is happening as a refinement i'm going to go ahead and put the patient in a temporary
retainer and you could order invisalign retainers um right off their website or
you can scan and make an in-house retainer order from your local ortho lab if you'd prefer and i'm
just going to hold the patient in a retainer which is thicker than a liner and more stable
for maybe four to eight weeks with no occlusion on those teeth i'm going to take obama occlusion
to allow them to stabilize and we're going to pause the treatment for a little while
or at least pause the treatment in that arch for a little while you know depending on what's going on
and then we're going to circle back in about four to eight weeks and see if they if they tightened
up a little bit take a progress x-ray of course i didn't mention initially always take an x-ray
right because what if there's an infection or pathology or something else that's going on
the x-ray tells a lot of things i'm looking at the pdl are we getting bone lost we just have a
widening pdl that needs to tighten up because we were too aggressive so i'm gonna take a progress
pa make sure things are tightening up make sure we're still out of occlusion and then maybe i'll
go ahead and refine with those things in mind slowing down the treatment plan by three times
making sure those teeth are not in occlusion and making sure we're not proclaiming or round
tripping and usually it works out okay but if you talk to any periodontist that's out there
they're gonna say you know sometimes you have to stop treatment and that's just how it is or stop
treatment in that arch so i think anytime you have a patient that even starts with any type of period
or mobility um this does cover you a little bit in the invisalign conform consent but i recommend
having an addendum to the informed consent and basically writing out of course any
patient that has perio even if you're doing some periodontal treatment in your office it's standard
care to refer your patient out to the periodontal specialist why because you know what if this ever
gets escalated to the dental board or to insurance company and the patient makes a complaint at the
end that you made the patient lose their teeth first they're gonna do is they're gonna say hey
the patient had periodontal disease did the doctor refer to a periodontist for an opinion and if you
did not you might be in trouble okay i know you know how to treat periodontal disease simple stuff
but you know what they are the specialist and that's standard of care you send your patient
to the specialist and you have them examine your patient they will mark which teeth are hopeless
which teeth are guarded things like that then you can go to the patient and say look periodonta
says that these teeth aren't doing great so we're going to have to monitor the treatment
and if needed we might have to pause or stop the treatment and then that's another thing you need
to talk to your patient about is what does that look like what happens if we stop the treatment
there was 50 aligners and we stopped at 35 we never finished okay um just couldn't you know
without losing things so if that honestly happens you need to explain to the patient
are they getting a refund because in their mind they're probably thinking hey i was two-thirds the
way through treatment i'm getting a one-third refund well that doesn't quite work that way
because the way the billing goes for invisalign cases is generally it's front loaded because we've
got to pay obviously us the doctors have to pay that clean check fee up front which is two grand
records and diagnostics have a value bonding appointment has a value ipr session has a value
so for me you need to really be even if you think this is the case you need to kind of
explain how that would work if we had to stop mid treatment the refund would be prorated depending
on what services are done it would be a very minimum refund at most of probably three or
four hundred dollars you know if anything it may not be anything so what really i've found before
in patients and talking to a lot of patients have been through this is that that's what upsets them
the most is that you were not transparent on what that would look like they're expecting a 30 refund
you're giving them a 10 refund they're not because you didn't explain how it's how the billing works
so a lot of orthodontists actually chart this out at the beginning and they say if you have to stop
say in august 2022 the refund is only going to be 500 if you stop in july 2022 the refund is
you know 600 etc etc you know but it's a minimal refund if any and of course they're going to have
to sign a discontinuance form so i recommend also having that conversation and if you want
to create a document you can if not just have a verbal conversation or the patient sign something
just saying basically that they understand that the refund will be minimal if not at all if they
choose to stop so anyways that's pretty much it wow that was a lot of information but now you
know more on how i handle mobile teeth during orthodontic treatment all right thanks so much