4 Rules of Planning Aesthetic Dentistry (Ortho-Resto) – PDP129

Jaz’s Introduction:
The first rule of planning Aesthetic Dentistry is so key that everything about the smile just falls into place from this very first rule. I’ve got Dr. Josh Rowley today to share the four rules of planning Aesthetic Dentistry.

Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. It’s been a crazy few weeks for Team protrusive. Just few weeks ago, we hosted Lincoln Harris live in London for his famous destress dental lecture. And let me tell you, this was a MASTERCLASS in theatrics, comedy, dental comedy, and public speaking. It was just a PHENOMENAL lecture. And I’ve actually got his slides on my desktop, and for eight hours that we spoke for seven hours, right. And he only had like 38 slides. This is a sign of a phenomenal speaker. He barely looked at slides, yes, so much conviction in his message. And the lessons he shared was so real, well, a lot of big, bigger picture communication type stuff to reduce our stress in dentistry and a few slides here and there and then delving deeper into it. It was just, such an engaging lecture. There’s very few people I think, can hold and captivate an audience for six hours during the day and you learn so much at the same time. It’s just absolutely brilliant. So, hats off to you Linc for that. And I met so many of you for the first time it was great to connect with the Protruserati. Safina came all the way from Northern Ireland. She’s a dental student, it was great that you made that trip. She’s part of our telegram group. So Safina, a personal thank you for, for coming out that way on a day where there were so many train strikes from around the UK. So, thank you so much. And a shout out I mean, I can’t shout out all of you. There’s like so many I met for the first time.

It was to privilege but a shout out Sagar Patel. Sagar is someone who told me a story. When he met me, he said that the influence that protrusive had on him was so big. And the protrusive dental community Facebook group helped him to connect with his now principal. And he’s in a good place and happy environment. And that just made me feel so warm and fuzzy and happy. And in fact, we’ve been connecting and exchanging messages on Facebook. And then we had this photo that we took together, and he said, ‘May I owe my whole inspiration of dentistry back to you, became very demotivated during COVID and DST, but your passion kept me going to where I am now.’ So, this was just an amazing thing to hear from a Protruserati like him. And these messages really keep me going. And so many of you came with love and kindness. So, thank you to all the people who came to my event. And it was just lovely to see you.

Main Episode:

Now let’s join the four rules of planning Aesthetic Dentistry with Dr. Josh Rowley. Josh Rowley, welcome to the purchase of dental podcast, my friend, how are you?

[Josh]
Very well. Thank you, Jaz. Thanks for having me on.

[Jaz]
It’s an absolute privilege and a pleasure to have you on Josh. I’ve seen you grow and grow as a clinician, the stuff you’re doing an ortho restorative is amazing. I don’t know if you remember a few years ago, I asked him some help with the case and you helped me nail it. Do you remember that? Yeah.

[Josh]
Yeah. Try my best.

[Jaz]
Josh, when I asked you for help on that case, on Facebook all those years ago. So thank you again, I feel like you’ve switched aligner companies, you’re batting for the other team now. So what, what led you to change a liner sort of modality from one company to another company? Because I see you doing a lot of work with Suresmile now

[Josh]
Yeah, absolutely. Yeah, I teach and mentor anyone who needs help with any aligner brands are out there. But the main reason for me why I made the switch a few years ago now to suresmile was because of patient preference. You know, patients want a discrete nature treatment, one that maybe their friends, even relatives may not even know that they’re even doing and yeah, it really comes down to the material that they’re made from actually. And I had a friend actually who I’m doing his treatment for who just finished his braces treatment. And there’s a couple of little tweaks to do. And we’ve now just made him a couple of suresmile aligners just to finish his case, as opposed to the fine tuning. And he was like, ‘Wow, why didn’t, why didn’t I start with these aligners in the first place?’ And he’s and he’s a dentist, as well, as a dentist and a colleague of mine, and he’s honestly converted, and I’m gradually getting one by one people turning over thinking, ‘Why are people not using these?’ But yeah, the clarity is one, the ability to be able to give the patients what they’ve asked for, which is a discrete nature treatment. Something that fits in with their lifestyle, something that they can eat and chew what they want, you know, it maintains its clarity throughout the treatment as well. You know, one of the things which was a bit of a bugbear for me was after some aligners have been worn for a few days or a week or so. And they do tend to tarnish and then it makes it a bit difficult if you have to go back a couple of aligners to kind of pick teeth up and then go forward again. And so it’s again opened up a whole new arm of aligner treatment for me where I can ask the patients to go back in time, as well as go forward. So and because they’re happy to go back and wear them because they maintain their integrity.

[Jaz]
Well, I think we’re going to talk about I mean, I’d like to know a bit more about that system, because there’s something about trim heights and stuff, which seems really like voodoo science, but it seems really clever. But I want to, I want to say that towards the end. Let’s talk more about the four principles that make the four rules of aesthetic planning, which obviously with your background in ortho restorative, I think you’d be perfect for.Just to set the scene and context, the first time we met was a part of the dental Chivas trip to love and to see it to see the GC group we learnt about Junior composites. And from then I knew, ‘Okay, this guy’s really switched on guy he knows what he wants.’ And to see the dent you’ve made in the ortho restorative world has been absolutely amazing. So it’s great to have you on Josh. For those that don’t know you, Josh, please tell us a little bit about you, your journey, how you fell into orthodontics, and I actually want to know for myself, are you limited to orthodontics? I just feel like that’s that’d be a real shame if you’re not doing restorative dentistry as well.

[Josh]
How long have we got?

[Jaz]
You got 60 seconds for this intro.

[Josh]
60 seconds, well, my name is Dr. Josh Rowley, I’m a specialist orthodontist in Edinburgh in Scotland. I work in two dental practices, one which is purely focused at the orthodontics. I do a combination of NHS and private orthodontics. And the other practice is very much a general practice. I see patients for checkups, I do restorative work, limited restorative work. I tend to not do that many endodontic treatments or nothing with too much blood and guts, no surgery kind of thing.

[Jaz]
Typical orthodontist?

[Josh]
Yeah, absolutely. I mean doing a lot of teaching as well just pretty much since lockdown actually. Quite enjoying that. Just kind of sharing the past experiences, sharing the knowledge that I can. Train to help younger dentists and dentists that want to get into orthodontics later on in their career. Just to try not make the mistakes that I made as such trying to get them the quicker path. But ya know, I’m thoroughly enjoying what I do. Can I imagine myself doing anything else?

[Jaz]
Well, I would have thought when I saw you all those years ago that you were going to be fully down the restorative path. What made you pivot into specializing in orthodontics, right?

[Josh]
Yeah, absolutely. So I kind of went a little bit of a niche way into orthodontics, whereby I was working in a quite a high end practice in Edinburgh at the time, I had very good mentors around me. And as a general practitioner, I was doing a lot of aligner treatments. And I really enjoyed doing it. But I definitely found that there was that little black box of knowledge that I just didn’t know. And I thought about doing postgraduate courses privately funded, and then looked into maybe going back and doing specialty training. And it was because I then went into the hospital, and I just inquired about it. That actually, it was just a complete chance that at the time, the consultant in charge actually offered me a position the following year, in fact, starting in about two months.

[Jaz]
Wow.

[Josh]
And so yeah, it was really quite a curveball. And it wasn’t a specialist training, I have to say it was a privately funded doctorate, whereby I entered into the world of orthodontics, just wanting to know more. I didn’t have any interest really becoming a specialist. I just knew that if I want to know what’s inside this box, I’ve got to go in and do this gotta treat the patients, but of over the shoulder mentoring. And yeah, and it kind of went on from there, really. And like I said, it’s, I’ve got an engineering kind of brain. And orthodontic is all about the kind of the engineering and the planning and the cases, which I’m sure we’ll talk a lot about today.

[Jaz]
Well, you know, the education that you do, and I watch your stuff, so I know that you’re involved in planning smiles and you don’t work with DSD. And you do all that kind of stuff, which is great. So do you still do like composite bonding, veneers as an adjunct to your ortho or what? Give me a percentage breakdown. I would like to know what Josh Rowley is doing today. So in terms of your percentage of aligners, your percentage or fixed appliances for ortho. So tell me about that. And then also tell me ortho in general versus your restorative, I would just just I mean nosey,

[Josh]
That’s obviously fine. And so I would say in both practices, now, I’m 50/50 with braces and aligners. And the reason why that number might be higher than you might think, is because I do NHS orthodontics, and an NHS orthodontics is really the bread and butter of an orthodontist work. It’s the growing individuals, it’s where you can really you know, do your, see, the see, the biggest changes sometimes I suppose with functional appliances, even surgery as well. But yes, NHS leads into the private side, in the sense that you’ll get a lot of kids whose parents might ask, ‘Ah, you know, I see, you know, the results I’ve seen with my son or daughter, fantastic, you know, what do you think?. You could do with me, and they’re sitting in the chair, you know, just like the dental chair, and they just go like this, ‘You know, what can you do with this?’ You know? I’m sure you get the same. I know and only to the other. I’m doing more and more treatments with aligners now because I’m becoming more confident in what they can do. But I’m very aware of the limitations that aligners have as well. And so, as I’ll probably talk a little bit about later, aligners are really a tool for the job, just like braces are a tool. And really it’s about knowing that limitations and knowing what was best for the job, really. But in terms of ortho restorative, you’re absolutely right. I tend to focus my restorative work on the post orthodontic kind of treatments like incisal edge bonding, could even be veneers. I’m putting together a lecture for a course I’m doing next week where you know, I’m, you know, just like when you’re writing lectures, you’re traveling through your cases, and I’m thinking, ‘I better do a lot more porcelain that made me think, actually.’ It is just the tweaking at the end and reshaping the teeth and sizably to turn a good case into a great one really.

[Jaz]
So this episode what I want to extract for your mind onto Protruserati is, where do you even begin? So the rules of aesthetic planning and who better than you someone who is, you know, done all your training in ortho formal training ortho, but I know your heart is as a restorative dentist so I think someone like you is perfectly suited now. Before we cover the main thing., you know what I’m like when it comes to occlusion. I can’t I can’t possibly continue without asking you a very interesting curveball question. This is completely unscripted for everyone. I was at a lecture yesterday by Korey Feran and Moira Wong and they were talking about the orthodontic restorative interface in terms of the joint position. And what I mean by that is, the starting point for most rehabs in traditional sort of school thinking not neuromuscular but centric relation. But then it got Koray asked the audience. Okay, now orthodontist. Where do they start? Which joint position did they started? And everyone sort of said, ‘Well, they just kind of work around MIP usually, because that’s what you’re taught.’ Now for you as someone who is trained in restorative dentist, I would I’m just being nosy again, do you screen for the first point of contact in your young kids or your adults and then plan from that joint position for your orthodontics?

[Josh]
Yeah, absolutely. You know, at leaf gauges, one of the most useful tools in the armory of a dentist in my opinion. So you want to make sure that the patient is comfortable in reaching a CR position. And really, you know that leaf gauge should be a diagnostic tool. It’s a way of us deciding, is this joint healthy enough to be able to kind of like Humpty Dumpty versus patient off the wall to then put them back together again, with orthodontics? Or you know, is the joint maybe in a position that’s going to cause problems or cause potential pain when you’re doing this as well? So, for a lot of adult patients, certainly, if there are symptoms of TMD, whether that’d be muscular or intracapsular problems, so it was good to diagnose first. And they can be as simple as making a B splint or a little Lucia jig, just to get them to wear for the interim time before they get their braces on or aligners started and is a general rule of thumb for me. If that pain or problems had been having go away with that anterior or deprogrammer, then you’re good to go. Whereas if they sometimes make the problem worse, or they really can’t wear it, it might be an indication for further diagnostic records that could even be you would refer them to oral medicine clinic just to see for a second opinion as well. It has to see it’s not an area that I’m you know, a specialist in not like yourself, but certainly I know the boxes to tick to know when I’m being safe or not.

[Jaz]
Good man. Good man. It’s good to hear about orthodontist as yourself looking at the joint position in terms of their final orthodontic outcome. But anyway, that’s digressing into occlusion. Where do you start to, Okay? You got a patient in the chair, and they want a lovely smile and with your eyes, how do you begin planning aesthetic? So if you were to boil it down to four rules, as I kindly ask you to do, what are the first rule of making this, helping this patient to achieve a beautiful smile?

[Josh]
Well, we’re off. The four rules of planning Aesthetic Dentistry, and I’ve been the first really. It all starts with the face, because you got to know you know, where, what’s going to look good for the patient? Or where, what is the face asking of the teeth is what, is what we normally see. So first, it all starts with a facial photograph. And then we start what we would do as a smile design. And so the real starting position of a smile is really the incisal edge of the upper central incisors. So we’re taking our photograph, the first bit that you do when you’re doing a smile design as you oriented a photograph to the horizontal. So you’re making sure that patients face is perfectly in line. And then we-

[Jaz]
Do you use any tools for this? Like don’t like you know, sometimes people do like go a bit lopsided. So do you use like blinds behind you? Exactly. So, how do you gauge that as, as a young dentist, try and take photos, portrait photographs, how can you be sure to help you?

[Josh]
So usually natural head position, just asking the patient just to relax, shrug their shoulders, usually just before they take the photographs. Try and get the patient to look directly into the camera and just being aware and the patient might kind of just move their head left to right. So we’re getting a really nice parallel picture with the patient’s face. The software that I would use is just keynote, you can use Keynote, you can use PowerPoint, you can use paint, you know any, any software that allows you to draw lines on a page. It’s really not that simple. You could even print off a picture of the patient’s face for a smiling picture, for example, and literally draw with pen and paper. And really, you’re looking to draw that midline wires, the facial midline. And then we’re looking at two photographs that I take for every single patient walks in the door. And that is an M position photograph and an E position photograph. E position being the maximum smile that that patient can give you, you know, really exaggerating the lip movements. You want to see how high that lip moves up, or the tablet moves up, I should say. And position a bit more difficult actually. But there’s generally a relaxed position where there is no muscle activity and the upper lip. And what we’re really looking for with between these two photographs is where does the incisal edge sit. So the end position, you’re looking at maybe two to three millimeters of incisal display and maybe a slightly older patient, whereas that number will do and usually increase to maybe six or even seven millimeters for someone who’s very young. And so really, that’s our starting point. So the end position photograph-

[Jaz]
Just, so I can make it, yeah, I think we’re gonna come to it now exactly what the dentist should say to the patient to get them to make those smiles that we want.

[Josh]
Well to be honest, I just get the patient to lick their lips. So for the end position, I say, ‘Let your lips and just let your lips at rest.’ And a lot of the time for adult patients, you know, they might not show any insight or display arrest. And don’t worry if that’s the case, because that means you’ve probably got an additive case where you want to move the teeth down or maybe add length to teeth. So they then have display of incisal display at rest. And then with the E position, it is literally, just imagine I’ve told you the funniest joke and you’ve got this belly laugh. How high can you get your upper lip to go up when you’re smiling at your maximum? And that’s really what I say. And it’s important to get the diagnosis right because I do get you know, shy individuals that come in and they’re guarded, you know, you want to try and get this e&m position out of them. You got to try and make them laugh, anything you can because you can get your diagnosis wrong if you get these photographs wrong. And it’s important that you kind of are aware that is as much as the look and move.

[Jaz]
When I used to Josh, get my patients do the Emma and say Emma, but I found out that people for some reason found it funny to say Emma, and then and then I take it they start smiling. So I got I kind of got a little bit of a rest one but then I got a smile. And then and then my usual question is, ‘Did you have an Emma and your life?’ And then they really smile, okay? And they they stop getting really awkward if their partner is also in the room. So I stopped doing that one. I like your one licking lips. Exactly, exactly.

[Josh]
Yeah. And then from there, you know, you’ve got your vertical reference point, you’ve also got your horizontal reference point. And do you know where the facial midline is, and that is where you build your smile from that kind of mid dot all the way around in the back. And I suppose going back a little bit to the main title, which was the four rules of planning, you know, the next one for me is really getting the diagnosis right. You know, without the diagnosis being correct, you’re off to a bad start. And, you know, you might not be able to deliver the best for that patient. And so really just understanding where the patient has come from, when I teach certainly, you know, younger dentists, you know, what questions they should be asking of the patient. I always start with the five W’s and an H. So it’s kind of like the what, where, when, why, and how or who sometimes as well. And it’s really asking, you know, where’s the patient come from? Why’s that wear seen here? Asking yourself all these questions like if you’re in like a job interview, or something like that, you know. And it’s kind of really just getting a detailed background of why the patient is presenting in this way, but it’s only once you understand why their teeth and dentition or malocclusion is like this you can then start to treat it. So really important that we get the diagnosis right. And that just covers all dentistry, not necessarily just aesthetic dentistry, because Aesthetic Dentistry really is an umbrella term for all the specialties. Really.

[Jaz]
I guess the best example of that Josh, I’m sure you agree, is when deciding whether to lengthen the teeth downwards or push the gum go upwards or a crown lengthening. And that’s as a young dentist, I struggle in this case, but it’s all it comes down to diagnosis. And then again, your photos, just like the ones you described become so powerful, and helping you decide should you lengthen or actually this is one for the periodontist or yourself with some experience to actually make the gums go higher up a gum lift.

[Josh]
That’s it. Yeah, you can. I mean, what a smile design is, is basically a blueprint. It’s like if you’re building a house, you don’t just start laying bricks, and that’s where dentists go wrong sometimes. You got to know where you’re going. And so therefore, what do you do? Well, you bring in an architect, you work out what shape, what room size, where’s the Garrett’s going, and then you know, after that, then you ask the engineer, you know, is this actually going to work? And what I mean by the engineer and dentistry is you do trial smiles you, you might simulate the orthodontic tooth movement with orthodontic simulations. And only once you’ve actually got that you’ve got your blueprint, you’ve asked the engineer, they’re pretty happy with it, then you start building the bricks. And I always say that smile design should really be part of every special diagnosis, just like taking your X rays or taking photographs. You know, it should form part of your special investigation. Sorry, is what I meant to say. And then I suppose going on to the third kind of-

[Jaz]
Before we get to the third one, Josh, so you know, you made me think of this question now is, you know, you’re someone who I respect as a restorative dentist and then you went this formal orthodontic training, which is awesome. But when you did that orthodontic training, compared to perhaps some of the other trainees or orthodontics you’re probably a bit more experienced in the restorative side? Did you find that the orthodontic program covered these aspects of smile design in a same or different or better or worse way than what the restorative dentists teach restorative dentists?

[Josh]
That’s a very good question. Actually, it’s not one I’ve actually thought of before, but I have to say that a lot of the postgraduate orthodontic programs out there, as opposed they’re maybe more traditional in the way that they would approach the planning of cases where it’s very much study models on a bench, if I’m perfectly honest. And it’s not difficult, it might be difficult for some, but for some cases, it can be quite difficult to get the smile to the good within the face, you can get the models lovely in class one that’s not a problem, you’re taking teeth, moving teeth around, it’s just a big boy’s mechano. Really, you know, it’s just, it’s just pulling teeth here, there and everywhere. But it’s actually getting it to look good within the face. And that can depend on the canting, the sagittal cant take if there’s a transverse count how much inside of display they have, you know, things like that you’re looking at all the planes of space to fit those models in that nice class when occlusion ideally.

[Jaz]
So it’s safe to say that while whilst people were doing their study models planning, you were keeping that further to pass the exams, but you were looking at the photos more than-

[Josh]
Always having that facial picture there. And always really just having references, you don’t always have to do a full smile design. But as long as you know, your references, your starting points, you can work from there. But I like to work in a way that I’m trying, I’m gathering all the diagnostic information I can, and then kind of using that when I’m formulating a plan. And I suppose that then it’s very well I was gonna say into the thirds rule, which is-

[Jaz]
But I just want to summarize, so far. So just want to summarize rule one was begin with the upper incisal edges and plan from there.

[Josh]
Yeah.

[Jaz]
And then rule two was nail your diagnosis.

[Josh]
Absolutely.

[Jaz]
The all the W’s and H is to figure out the story and then to help you forward so that’s where we’re up to so far. So here’s what the rule three my friend.

[Josh]
So rule three, really and it’s one that I kind of follow every single day and it’s going to talk to me about dentists called Dr. Miguel Stanley. So you’ve heard before we’re in a mass-

[Jaz]
Dentist.

[Josh]
I think so yeah, you’re right. And he really kind of hit home to me it was about giving ideal a chance. And what that means is that every patient that comes in the front door, you know, they have come to you for a diagnosis. They’ve come to you, for a way presented to them, what is the best thing for them? They might come in saying, ‘Josh, my operate central incisors rotated, that’s all I want to treat.’ But I don’t ignore that. Don’t get me wrong, but I kind of put that to one side. Because I would still take the same records, photographs, scans, X rays, maybe even a cone beam CT if I needed it. And I would treat that patient, you know, as if they’ve asked me, ‘Josh, what can I do here?’ Time and money were no object, what would you love to do? Because just because they’ve come in asking for an upper central incisor rotated, doesn’t excuse the fact that might have quite bad wear in their teeth, their canines have worn down their gums are in the best condition, you know, we’ve got a duty of care for the patients and in the way I do treatment very much is that we give ideal a chance and we work back from there. So it might involve a lot of work, it might involve doing orthodontics may involve some porcelain work or composite work, it might involve very heavy work with the periodontal specialists if there’s any problems. And it might even involve orthognathic surgery because they have an underlying skeletal problem. But it’s important that the patient is aware of all that could be and then working back from there. You know, it’s there’s absolutely no harm in doing compromising for your treatment, as long as the patient is aware that, you know, that is the gold standard of what we could have in ideal world. And we can work back from there. So for me, rule three is giving ideal a chance.

[Jaz]
I love that rule, Josh, I mean, rule one is so fundamental. And when I started to actually look at smiles. Rule two is great in terms of making sure we get the bigger picture. But rule three in terms of a real communication skill to have with your patients. Because put it this way, if you never present the ideal, you never get to do the ideal if you never present comprehensive guess what you’d never get to do comprehensive. So that’s such a key one. And then recently, I was at a lecture by Lincoln Harris, who came over to London and did an amazing like performance. It was an actual performance. He was one of the best performances of his because I’ve seen him live before but he was just on fire. And it reminded me of a great thing he taught that day is that he’ll says to patients, and I’m definitely going to use this my patients is I’m going to present you the ideal plan. If it’s too expensive, and you can he says you can use what expensive, it’s okay, don’t be shy. If it’s too expensive. Let me know, we can make some compromises and find a solution that best suits you overall, but I’m gonna still plan ideally, because everyone deserves ideal. So I’m gonna plan ideally, but if it’s too expensive, let me know I have other options. And that gives you the license.

[Josh]
Yeah, it really does. And I suppose compromises can be in materials, it can be in accepting certain things of a malocclusion, for instance, and overjet-

[Jaz]
Like a slightly increased, I was just gonna say overjet. Yeah.

[Josh]
Or a crossbite, that you might not want to train a treat. And there might be limitations. And it might be that surgery is the only option. I’m sure we’ve seen. I think I saw on your stories recently that I think it was your it was your oldest son had his adenoids taken out recently, is that right?

[Jaz]
Right.

[Josh]
Yeah, we get patients that unfortunately, don’t get that done. And then they have, you know, skeletal problems that manifests throughout their adult life, and narrowing of the upper jaw, for example. And they want, they come in asking for a wider smile. And it’s something that’s orthodontics alone, it’s something that we can give them because we’d be moving those teeth out the bone. And so really their options are, you know, accepting that fact that orthodontically that’s whether you’d have to be or restoratively it can be a bit wider, you know, it can have veneers composite to widen the teeth artificially as such, or they’re moving the bones, you know, they’re moving the surgical expansion, I wouldn’t, I wouldn’t dream anyone or wish anyone to have it. But certainly it is an option. And these are the things that it’s important that anyone who’s providing orthodontics really, in my opinion knows about, you know, always plan towards the ideal. And you can always compromise from there. As long as the patient is aware of what these compromises mean long term.

[Jaz]
And medically, legally, that it just makes sense to write your note in that way as well so that they know exactly what the ideal was. And sometimes, you know, as I say, treat children idealistically treat adults, realistically, that’s a mantra drilled into me, but it doesn’t mean that we can’t present the ideal plan to adults.

[Josh]
Absolutely. Yeah. The good thing is, you know, in a lot of the patients I treat are kind of younger teenagers. And I guess they come with a bit less baggage in the sense that they normally have really nice shapes of teeth on worn, you know, good oral hygiene, ideally. And really, it’s a case of really just moving the teeth, you know, to where their face is asking. But I’d also as you know, they come with some more problems, gum problems, wear, missing teeth, things like that. So there’s a lot more to plan. And I have to say that I have no problems with saying to my patients, I don’t know. Because in reality, you know, you were thrown with so much information, first consultation situation that you can certainly let the patients know, you know what a rough idea could be. I think your teeth are at a position maybe we can think about some orthodontics here. I think the shape of your teeth could be adjusted, maybe even the color adjusted here. So you’ve got a couple of ideas. You’re planting the seed, but I’m not always telling the patient at day one that we need to do this, this and this. You know, I say, I don’t know yet. The honest answer is I’m gonna invite you back when I’m going to gather some more information. And I’m going to get you back in. And we’re going to present a couple of options for you, you know, and if one of those options fits your your budget and fits what you’re wanting, then great, we can go ahead. And I suppose the fourth kind of rule, bring me right into that really nicely, there is simulations. Because during a second consultation appointment, simulating the treatment plan for the patient and really allowing them to visualize it before they begin, it is crucial, in my opinion. And that can be as simple as doing an orthodontic setup, such as an aligner setup to show the patient the beginning and end result of what orthodontist.

[Jaz]
Different aligner companies have got different software’s and stuff. So that’s what you mean by the simulation? Right?

[Josh]
Absolutely. Yes, so the suresmile aligners, which is the company that I have been working with for a very long time, and I really, you know, enjoying using the software and really enjoying using the aligners, as I’m sure we’ll talk about it later on as well. I can even share my screen and show you, you know what the software looks like. So we’ve got an example here.

[Jaz]
And just described for those listening in the car driving on the train, chopping onions, etc. Just also describe what we’re seeing here as well.

[Josh]
So what we’re seeing here is an orthodontic simulation, it’s showing us the plan, from the start to the finish of where the teeth need to move to. Start and then the finish. And what we’re also getting here is the staging here. So the stage models of going from day one, or aligner one, all the way up to, in this case, aligner number 28. It’s showing us where the attachments need to go to provide that extra grip to the teeth that need it, as well as any space creation by the form of any IPR or interproximal reduction that’s between the teeth that allows us to get the room to align the teeth, and showing us when that’s being performed, and at what stage is being performed. And so this is something which I use a lot to just demonstrate to patients just how their treatment will play out from start to finish. And so they get that kind of a crystal ball moment of what their treatment will look like, once they’re done

[Jaz]
That when this is brilliant, but the Josh, there’s a another aligner company that I use at the moment. And they are very well known. And they have their own version of software. And I want to I want to know from you, someone who’s used both systems, is there anything different or interesting about the short smile software, because I heard yesterday at the Congress, that something about the envelope of function outlines is that they will show you the cross section of the envelope function?

[Josh]
It does indeed. So this software is really the most powerful software I’ve ever seen. It’s got so much in it. And the one of the biggest things for me are the quality control tools. So these are the tools that allow you to see the contact points tooth, the marginal ridges, tooth access and things as well.

[Jaz]
Wow.

[Josh]
As well as being able to actually kind of see and measure, you know, between the teeth, let me get the kind of measuring tool here, you can kind of clip the frame as well. So you can see the envelope of function right there, you can then move between the to see where the contact points are. It is really quite, sometimes daunting, I’m not gonna lie, the amount of buttons, but to be honest with you, you know, it’s you can use it for as much or as little as you want, really.

[Jaz]
You get out what you want what you put in. So if you want to see all that extra detail, you can reveal it if you want to. But if you want to do the usual stuff, you can do that as well I can see that. I mean,

[Josh]
The software really came from traditional orthodontic planning with brackets and wires. And it’s really kind of developed from there. And so there’s so much diagnostic information that can be you know, at your fingertips here, as well as really looking really closely into your cases to look at where they come from and where you want to get to. And that’s, you know, that’s just the software that’s not even talking about the actual aligners themselves. So yeah, you can see I’m passionate about it, because I honestly don’t know why more people aren’t using it. Because it’s like, wow.

[Jaz]
Okay well, let’s talk about that Josh. Rule one was incisal edge. Rule two was ask the questions to get the diagnosis, or the W’s and H. Rule three, which I love was give ideal a chance. And rule four was the rule of aesthetic planning is use simulation, which just makes so much sense to your patient. And also to you as you’re planning the case, oh, my God, you just overlaid the face over it. This is awesome. So, so this is cool. So that makes complete sense. And I’ll let you just tell me any other things you want to tell me about Rule Four. Before we then talk about suresmile and Why perhaps we’re using suresmile, not some of the other competitor aligners out there.

[Josh]
Yeah, I mean, for me, really, as I told you in Rule one, you know, it starts with the face, it starts with the smell design. And really with the software, you can overlay the exact teeth, both the starting model and the end model into the patient’s face. So you can see kind of what it’s going to look like in the end like a try before you buy, you wouldn’t buy a car or that taken it for a test drive first, and that’s exactly the same. So this is really the simplest version of the simulation where you can just show the patient what it would look like, you know, it’s a little bit of a cartoon here because obviously the teeth are your scans that you’ve taken in the mouth, but it really does give the patient a really nice idea of what-

[Jaz]
I’m sorry to stop you there, Josh. You said scans are, I have to ask you this right? So with certain aligner companies, you have to get a certain scanner to send. So would I need to densify? So I would have, I would have to have a prime scan to send to get suresmile aligners?

[Josh]
No, you don’t actually the suresmile aligner system is very much an open access platform, accepts scans from any brand of scanner that’s out there.

[Jaz]
Okay.

[Josh]
That’s part of the reason why I really like working with densify is that they have always been and always will be an open access software where you’re not limited by a brand as well as that you can also export things. So without jumping too far ahead here, you know, it really does give you know, the freedom and the versatility to ask for all of your aligners to be made. And that’s by suresmile itself, which comes in a very nice kind of branded packaging, just like you would with other aligner brands as well, the patients will recognize. But it does also allow you to export. So if you have a local dental lab or you have a lab in house, you can ask for them to print the models for you. For you to make your aligners or even if you want to do everything, you know, yourself, you could export each STL file, or each scan file of every stage or every aligner in that treatment. And you can make them yourself. So it’s a bit like strangers in the past about going into a restaurant, you know, you can go in and you can order from the set menu, which is like what you would do with other aligner brands where you’re limited to maybe 12, or for your 24 liners, you know, or you can have as many layers as you want, you can eat as much as you want in the buffet. Or, you know, you can choose from the ala carte menu, you can decide you don’t want to start today, but you will want to remain in the desert, and that’s fine. So you can export the STL files and make dierct yourself. Or if you really want to go to town, you can even go walk into the kitchen, and you can make your own food, you know, you can actually go in there, you’re not relying on a technician if you really want to. And I would say I’m stressed that I keep this myself for more milder cases where I can take control and be my own technician, where I can actually move the teeth myself, plan the movements, which the software allows and then actually explore or ask suresmile to make my aligners for me. So there is a-

[Jaz]
What would be the benefit to you, Josh, why would you do that step of making it in house? Is it ultimately a financial benefit of you cooking in house compared to eating out?

[Josh]
It is really the financial benefit, but also for the patient. Yeah, I mean, at the end of the day, I’m not having to pay for the chef. So yeah.

[Jaz]
Yeah. But that’s really good that dentists buy insurance might allow you to that I’m kind of surprised in a way and shocked and it’s pretty impressive that they’re pretty open with that. That’s pretty to be admired.

[Josh]
I guess you can use it for as much or as little as you wish, just like the quality control tools and the diagnostic tools in the sense that if you do have a more mild case, perhaps just a relapse, that patient has lost the retainer for a few weeks, and they said, ‘Oh, my tooth has moved a little bit.’ You know, you could literally take a scan of the mouth, upload it, move that tooth back, it will tell you just how many stages you might need. And then you know you make those aligners and it saves the cost for you since the cost for the patient, everyone wins.

[Jaz]
Is that something that you get taught by suresmile? Because I guess there are lots of courses teaching you how to do your aligners orthodontic base. So just suresmile actually teach you the methods involved. Or hey, if you want to come to the kitchen cook itself? Well, you know, here’s utensils like how’s it work?

[Josh]
The main focus for suresmile you know, as a mentor, and as a teacher myself, really, it is using the software and it is about kind of using the technicians communicating with technicians for more complex cases or cases that you want the help, basically. But it did allows you to open the doors to do that yourself. And that is something that over the years I have, I have learned myself, you know, I haven’t had much guidance other than some of my peers. But and in a sense, there is an element of trial and error here as well. You know, you are moving the tooth, mild movements, I would say I wouldn’t tackle anything above say, eight or 10 aligners and myself, but certainly the-

[Jaz]
But with that with their full package. You can do elastic tabs like the full whack?

[Josh]
Absolutely, yeah, there is no limitation. Again, you can add elastics if you need to. In fact, I’ve just listened to your one of the podcasts from Straightpril actually about elastics. And I was a bit kind of like, oh, wow, don’t use that. I don’t have to say I’m glad I listened to that lecture because it kind of are their podcasts because it really did kind of confirm that I’m doing things okay. You know, I’m not doing it for the sake of I’m doing because I’m moving individual teeth and yeah, you know, if you want, it allows you to be creative. You can add bite ramps, if you want to yourself, you can actually ask for a variable trim height. And this is one of the most underrated things and aligners at the moment is asking for a variable trim height.

[Jaz]
So first explain what that actually? What you were just about to do. I’m sorry, but also like why were no when you would ask for a lower trim height? Because I seem to have talked about this. And I’m like, firstly, okay, it’s pretty cool how you can customize something but at the moment with my lack of knowledge, I wouldn’t know when to prescribe which one and what benefits would you get? So tell us teach us enlighten us.

[Josh]
So yeah, as you said, I actually again, just listen to a podcast that Tif did I think it was the teeth and tails podcast. There’s just going on recently, actually, and he described this perfectly actually. So I’m probably going to repeat a little bit what he said if I’m honest and that is the with scalloped trim line like you might be more accustomed to using some other brands of aligners that has a degree of flexibility, okay for correcting rotated teeth for example where you want the plastic to be able to bend and almost stretch into an embrasure or into an area where that’s the plastic is quite difficult to reach. Because with aligners, you’re gonna think like the plastic how does that tooth or aligner grip that tooth, you know. I think I also liked the analogy on one of the podcasts I listened to recently where it’s like a slippery watermelon seed. I love that. For lateral incisors like slippery watermelon seeds.

[Jaz]
That’s it.

[Josh]
And, and yeah, you know, more flexible aligner trim height, like the skeleton might for rotations. But also being aware that the higher up or the more rigid the tree is. So if you’re asking for a straight trim line more associated with something like a retainer, for example, that becomes a lot more rigid. And so if the patient is needing a lot of attachments, because of control, you want to keep more control over certain tooth movements. Then again, you might choose a scalloped trim line, because you want that flexibility, so the patient can comfortably get in and out. And I haven’t cut out in the past where I thought yeah, all the attachments really high trim line, and the patient goes. And you’re like, oh, wow, that incoming out easy. So yeah, is there a degree that you know, is a bit of a learning curve as well, when you start with this other option, essentially, Maybe haven’t been had the chance to use before.

[Jaz]
So if you go for a higher trendline, ie, straights or not scallop straight, that means that you need to use less attachments that I get that right?

[Josh]
Yeah, you’re spot on, so with a more rigid, because this, the aligner is trimmed a bit higher, you can apply I suppose slightly heavier forces to the teeth just ever so slightly, and it does mean you get more control, you know. So it will mean less attachments, which is amazing, because patients generally request aligner treatment for the discrete nature of the treatment. And so when you can offer the patient a higher trim line, which keeps the plastic above the smile line, so they don’t actually see any of the plastic at all, or the edge of the plastic, I should say, which is something very visible, and you’re having less attachments, because attachments are they reflect the light at different angles, and they can be very visible. And one of the things which was one of the main reasons why I moved away from other aligner brands and, you know, years and years ago, was because actually during that fitting appointment, where you hand the patient the mirror and say here is your first aligner you know, I used to dread that because the honest truth was it didn’t like it, you know that the aligners weren’t maybe as clear as they were hoping for. And also there was a lot of attachments which just drew away from that discrete nature. And so now it is a complete cheat reversal whereby, you know, I am looking forward to given the patient the mirror and say, ‘Look how clear these are.’ The actual aligner material themselves, and look how, you know, discrete this can be free. So, you know, there’s this is a topic I speak a lot on and it’s fantastic. I’m hoping I’m bringing forward my enthusiasm for it.

[Jaz]
Absolutely, no it shines through and I do want you to spend best part of 4000 pounds to learn how to give these aligners.

[Josh]
No, no, it’s maybe not my area to say. But certainly if you’re a keen to get involved with another aligner brand is such you know, I’d always say don’t say put all your eggs in one basket, you know, look around, see what other options are available. And suresmile being one of the major competitors in the aligner market at the moment. And if you wanted to start using sure smile is a case of reaching out to one of the representatives and going out on the website and expressing your interest. There isn’t so much a course that you would pay to go on as such that you’re almost paying to have access to the software because it is such a powerful software. And with that access, then comes the case for you to do for your first case for free. So really, there’s an investment to make to start using suresmile, but if you do your first case, it balances out. So that’s really the best way I can describe it.

[Jaz]
Brilliant, brilliant. So you obviously teach for suresmile. Are you also like a mentor like on the end of a phone? If someone needs advice in planning case? Oh, how does it I guess my next question is how does support lend itself to the system.

[Josh]
So at the moment, I’m sure smile and IS Academy, myself and Tiff and Ross Hobson and many other mentors that are out there, can’t name them all. And we actually have a kind of a handshake agreement I suppose with Dentsply and suresmile to provide a lot of the teaching and also the mentoring. So if there are cases that you would like to ask questions that would photographs or get any help with then there are many mentors all over the world to help with that. There is also the communication kind of customer support line as well for simple more software related things as well. So there will be an answer to your question somewhere.

[Jaz]
Is this on like the IAS or website where you got like the room and stuff? Oh, that’s brilliant. I mean, I haven’t used on the past. I can definitely vouch for that. You know, I have so much faith in IAS, Tif, Prav Prof. So some some great people there. So IAS is very trustworthy. So that’s a really good thing to have. So that’s amazing.

[Josh]
You know, and you can again use as much or a little of the support network that’s there as you wish, you know, even things like Whatsapp group chats, if you just want a quick answer to a question as well, you know, we’re trying to keep it in the 21st century and keep everyone kind of in contact with one another.

[Jaz]
Very cool. Well, Josh, you’ve answered my main thing about the four key rules in planning, aesthetic dentistry, and it’s great coming from you so passionate about ortho restorative, and I’m sure you’ll agree that the best orthodontics might be done with from someone who’s got a restorative eye as you do. And I truly believe that. So it’s great to learn these polls from you. And thanks for sharing some extra bits about why other aligner companies might do things differently and what benefits that may present. So, you know, shout out to suresmile for that. And so it’s great to learn about that. And I trust people like you, and Tif. Tif is a huge inspiration in my carrer and I know that yours as well. So, hat tip to Tif as well. Josh, tell us how we can follow you and find out more from you on social media and also any courses that you run that kind of stuff.

[Josh]
I wish I was better at social media, if I’m honest with you, I just it’s a matter of time. It really is. I am a busy man, what can I say you know, treating, treating patients doing what I enjoy doing the most, which is actually achieving the smiles that we do. But yeah, happy for anyone to contact me via social media, things like that, if you want to, I’m on Instagram and Facebook, I would strongly encourage, you know, anyone who’s listening today to if you have any questions just to reach out to me. And yeah, you know, see what’s out there. I would say to any young dentists or dentists really wanting to get into this kind of work, whether it’s with orthodontics or smile design, do your research, you know, see what courses might be out there. I don’t particularly run any courses myself, I do a lot of the teaching through suresmile and through IS Academy. So again, you know, seek these courses out if you want to learn more. There is so much with aligners, you know, it’s not something that can be taught in a day, you know, like when you go on our course, you know, in our hotel room for one day, yes, they can teach you how to do the fundamentals, which is your IPR, your polishing your teeth, you can teach how to put attachments on but there is that black box I was talking about before that really separates the you know how to do it. But how to really can understand it really is a passionate driving test. You don’t really know how to drive and your flash drive and test.

[Jaz]
Absolutely no, you’re always done afterwards, I said the same thing about BDS. And it’s great to have mentorship, which is a recurring theme of the podcast, hence why I was able to lean on your knowledge as a mentor, a few years back on a case. So thank you, again, Josh for helping me out that time and again, helping me out this time to help these dentists better plan their aesthetics. And just you know that rule one is just so key in knowing where to begin. And I really, really, really love that rule three, that communication one. So those my two of them my favorite of the four, but I think you gave great value there. So Josh, thank you so much for for spending time with us today.

[Josh]
Thanks so much Jaz. Thanks for everyone who was listening. And yeah, everyone enjoy the rest of your weekend.

Jaz’s Outro:
So there we have it, guys, as a summary rule number one that I said right at the beginning, is to start with the upper incisal edges. Once you plan where the upper incisal edge will go into face, and your or the proposed future position of that central incisor. Everything else falls into place. That rule two was to find out what the diagnosis is diagnose, diagnose, diagnose the why the what the how, where do you want the different teeth to be. So the example I gave was whether you should lengthen the teeth or in that specific patient, would you get a better result in the face by crown lengthening. Another example would be if someone’s with the proportions of their teeth that got very small, lateral incisors, that’s really important as part of the diagnosis. So diagnose in every way possible. So you can get a better treat and plan because the diagnosis always informs your treatment plan. Rule number three was my personal favorite, give ideal a chance give the ideal treatment plan a chance, communicate it with your patient. Yes, you can make compromises. It is not a sin, it is not dirty to compromise. But if you are compromising the patient should know there’s a compromise being made. It really helps with your consent, and number four simulations. So if you aren’t using aligner therapy, then you can use the software of your line and company. Yeah, sure. Smile look like very snazzy. So thanks to Josh for sharing the screen share. But those who are listening, were able to follow along in terms of what makes this software unique. And if you’ve watched or if you’ve listened on the Protrusive premium app, you can now answer the simple questions to claim your CPD for this episode, which is really quick and easy. within 72 hours, we send you a certificate with your reflective log inside as well. One of the example questions for this episode is ‘What are the two main photos used for deciding the central incisor position?’ Is it a the D and N smile? Is it B the E and M smile? Is it C? The E and M smile? Or is it D? The D and M smiles? So if you know the answer to that one and the other ones, why don’t you join protrusive premium? Answer a few questions and get rewarded for your CPD hour for listening to the entire way and also validate your learning and reflect on it. This will be really good at the end of the year to have all your reflections and the lessons you learned from protrusive in one place. So if you’ve got a few minutes, get on the app and just answer those questions and you’re well on your way to getting CPD. Anyway, I’ll catch you in the next episode. Same time, same place. Thank you for listening all the way to the end.