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our patients into retention, and we monitor the patient’s dentition into the arch. A two-to-three year interim period is a nice break from
virtually every 3 months and in-office at 6 months, alternating with active orthodontic treatment, because it gives the patient enough time
virtual and in-office visits for the family’s convenience until all the to renew their enthusiasm about finishing their orthodontic treatment
permanent teeth have erupted, at which point we will re-scan them with Phase 2. We call the transitional phase where the patient is
for initiation of Phase 2 treatment to finish alignment of the dentition wearing appliances only at night “taking a daycation”.
and detailing of the bite. To ensure a clear break between orthodontic phases, we aim to
complete Phase 1 treatment in 9 to 12 months, and Phase 2 treatments
How do you avoid treatment fatigue during Phase 1, and when in 12-18 months. We initiate Phase 2 treatment when the permanent
is the patient’s first phase of orthodontic treatment considered 2nd molars and permanent canines begin to erupt, which is usually
“done”? around 12-14 years of age, with girls typically starting treatment
Knowing when to stop Phase 1 treatment and effectively earlier than boys. After Phase 2 treatment, we maintain the results
communicating this to parents is definitely a crucial skill to develop with Vivera® retainers and if the patient had an upper diastema, we will
because our goals of the first phase and the patient’s expectations bond a fixed lingual retainer from upper lateral to lateral (U 2-2). The
might not align. final clear retainer is a natural transition for our Invisalign patients,
If the patient isn’t enthusiastic about the Phase 1 treatment results, since they get used to the lightweight removable appliance design
they may have less confidence about starting Phase 2 later. Therefore, from the beginning, especially if they are treated with Invisalign First
its essential for the patient to feel satisfied well before the initiation of aligners for Phase 1.
Phase 2. Parents need a clear understanding of the Phase 1 objectives,
recognizing that some orthodontic problems will be addressed How have the digital treatment tools helped you to monitor
later on. They also need assurance that the issues deferred for later progress including compliance during Phase 1 treatment, to set up
treatment are not harmful if left untreated for now. Communicating for a successful multi-phase (Phase 1 and Phase 2) treatment?
which aspects can wait for later treatment without causing long-term We approach treatment with the perspective of offering a multiphase
problems is critical for providing parents with peace of mind. treatment, each phase having specific goals, and we also monitor the
For us, a successful Phase 1 treatment means that the upper and patient’s maturity at each phase no matter which appliance is being
lower central and lateral incisors have erupted in the correct location used. If a patient does not start off well with their aligners, we do not
and are generally well-aligned. We want the arches widened and let them continue to the point where their results are compromised.
symmetrically ovoid so that the remaining permanent teeth can erupt Instead, we monitor the patient’s progress early and from the very
unimpeded. Any anterior crossbites should be corrected earlier rather beginning, and we use an online platform to accomplish this in an
than later because of this reason. We will often leave or create space efficient manner. If we find out that the patient is struggling with
mesial and distal to the primary canines, and we prefer a slight excess their aligners at the very beginning (or at any point later on), we don’t
of space in the arch over lacking enough room for the permanent let the problem drag on until they become exasperated with their
canines to fully erupt. We also want the upper permanent first molars experience. Sometimes we need to try a different treatment approach,
to be fully de-rotated (mesial out), to establish a bite with solid Class but sometimes the problem is that we just need better explanations or
1 interdigitation. more frequent monitoring.
The concerns that can wait to be corrected in the second phase Remote monitoring, along with virtual consultations and intraoral
of orthodontic treatment include: permanent second molar and scanning, are all part of an efficient digital experience we have
canine eruption and alignment, rotations of permanent bicuspids, implemented across all our offices. From the intraoral scan with
and esthetic touch-ups of the anterior teeth (including any permanent the iTero® scanner, to video appointments using Invisalign Virtual
lateral incisors tilted mesially to provide a clear eruption path for the Appointments and the Invisalign Virtual Care platform, allowing
permanent canines). Instead of prolonging Phase 1 treatment and patients to upload weekly photos, these tools have proven highly
risking treatment burn-out, we continue growth modification in the beneficial for efficiency and patient motivation during treatment. For
second phase to complete any antero-posterior corrections needed to example, we usually know right away if there is any cooperation issue,
achieve Class 1. If we can get the patient to less than a half cusp Class knowing that we are monitoring their treatment progress weekly
2, we will consider it successful. encourages our patients to be compliant, and the best part is that we
are able to do all of this very efficiently without adding extra in-person
What is your protocol for the interim transition period between visits to the office.
Phase 1 and Phase 2 treatment, and when do you typically start Of course, the possibility exists that no matter how hard we try,
Phase 2 treatment? we can’t get the patient to wear their aligners properly, and we can
During the 2 to 3 year interim period between phases, we will hold always switch these patients to a “non-compliance” device for their
the patient in an upper Theroux retainer (made of Essix® material) orthopedic phase, but these devices also come with their drawbacks,
and a lower Essix clear retainer, both worn exclusively at night. The in terms of hygiene and comfort. However, we have found that with
“open” Theroux design conveniently allows the canines and premolars proper education and monitoring of kids, the problematic cases are
to follow their normal eruption path while maintaining the alignment the minor exception and not the rule.
of the anterior teeth. We will typically trim the lower Essix retainer
from time to time, to make room for any erupting teeth as they come What initial learnings can you share about your experience with

Dental Practice i November-December 2023 i Vol 19 No 6 37