Do’s and Don’ts of Aligners [STRAIGHTPRIL] – PDP071

Jaz’s Introduction: 
Like with all things in dentistry, case selection is so, so, important and we all know that orthodontics, including aligners has a very steep learning curve. That’s why in this episode, I brought Dr. Farooq Ahmed to talk all about the do’s and don’ts of aligner treatment. I mean, I wish I had something like this when I was starting align treatment because it helps you to get more efficient treatment. I mean, I made a few mistakes, nothing serious, but it gives you that magic word which is PREDICTABILITY. That’s what we want in all our treatments. And in particular with aligners.

Hello, Protruserati, I’m Jaz Gulati and welcome to this final episode of STRAIGHTPRIL. I hope you found this month interesting and stimulating and it’s going to help you with your future orthodontic cases. I want to also take this opportunity to apologize to you for not emailing you guys like usually I did my newsletter full of the episode, I started off by doing a per episode. So now I do like a roundup of some of the bigger episodes. So maybe I’ll do one for straightpril, all the orthodontic series in one email.

But emailing has been very difficult for me because I’ve moved house, it’s officially happened. It’s been a roller coaster, I’m sure any of you who have moved before will be able to relate with me. It’s been funny, I moved back from Singapore, back to the UK in 2017. I lived with my parents, it was nice living in a very traditional Indian household.

During the pandemic, it was brilliant to have six of us including my son living in the same household. I think as a bubble during the pandemic that was really special. I think I’ll cherish those memories for the rest of my life. But I think it’s time to now flee the nest. So we have our own space now. And it comes with its own challenges of childcare before I just give a shout out to my parents and have some more free time to do this kind of stuff, but I don’t have as much time anymore. But that’s fine. That’s the beauty of being a father beauty of having a family and everything just has to fit around that right?

So before we join the main episode, we’re going to look at the main things that make aligner treatment predictable, which kind of movements are favorable, which ones are unpredictable, and how to program your clinchecks to overcome that.

Protrusive Dental Pearl
Now before we get to that with Farooq Ahmed, I’m going to share the Protrusive Dental Pearl which is a retention one following on for that awesome episode with Dr. Angela Auluck episode 069 do check it out if you haven’t listened that already, is regarding fixed retainers. Now, Angela talked about placing an indirect labmade fixed retainer. But sometimes I like to place a direct one. And what I didn’t like and I didn’t enjoy the outcomes was using the sort of braided wire that you have to sort of bend yourself and apply to teeth. I could never get that perfect adaptation. So maybe it’s my hand skills or whatever.

But I felt as though there should be something better out there for GDPs or orthodontists who want to do direct fix retention and do it really well and more predictably. So what I found I learned through Mohammed Al Muzian is using the ortho flextech chain retainer. Now this is a chain retainer. So it just has this wonderful contour to the lingual surfaces of the teeth. And what I do is I get my nurse to what I put the floss between the lateral and the canine let’s talk lower, and we make a little loop through the loop goes through retainer on each side. So left and right. And so the nurse pulls it not too tight just gently so that the wire retainer adapts nicely.

So if you’re watching this on YouTube or Dentinal Tubules or wherever you can actually see the video of me actually doing this. But if you’re listening just imagine the loop floss, the retainer going through it the nurse just gently pulls it so now you have this lovely chain retainer adapted very nicely on the lingual. That retainer has just made things really easier for me when it comes to doing direct fixed retention and placement is better nicer. I overall really enjoy it. So do check out the flextech, ortho flextech chain retainer. I’ll put some links on the protrusive.co.uk website so you can check it out. Also on the Protrusive Dental community Facebook group if you’re not on there, why aren’t you on there? Anyway, hope you will enjoy this episode with Farooq. I’ll catch you in the outro.

Main Episode:
Farooq Ahmed, welcome to the Protrusive Dental Podcast, my friend. Final episode of a straightpril, horrible name, I know. I keep reminding what a crap name it is but I needed something. Welcome my friend. How are you?

[Farooq]
I’m really good. And I’m glad to be here guys. This is going to be a takeover podcast because I have my own podcast. And Jaz has finally got around to inviting me to be here. So I’m going to try and make this entertaining. I’m going to give you the content. I’m also going to try and make it awkward for Jaz because I know what he has to do to make this podcast work. And I know their exact thing to say they’ll make it awkward for him. So guys, we’re going to have a great episode.

[Jaz]
Oh my goodness, I’m scared. I’m actually really scared. But let’s see where this takes us. Well, usually if I’m allowed to for it, usually the way I do it is I would give my sort of crappy introduction of the guests to me, we spoke over lockdown, you were thinking of starting a podcast and it’s just been wonderful to see your orthodontics and summary, podcast grow and grow and grow. I think you’ve got some great people around the world orthodontist feature, you do shorter episodes, you do longer episodes. So do tell us about that for anyone who wants to get their geek on an ortho. And of course, you’re a consultant orthodontist, and you do some lecturing, mostly around aligner therapy, take it away Farooq.

[Farooq]
So that’s my thing. So I mean, I qualified as a recent consultant 2018. And I have been really engaged. I’m really lucky to be an orthodontist, guys. The academic side, the clinical side. Like it’s all come together for me, and I really enjoy what I do. And it’s led me on a journey of education, not just for the specialist train that we can park that to one side, especially aligners, it’s all been a post qualification journey.

And for me, it started on the clinical side. And then I’ve started looking at the academic side and starting a little bit of research, because I’m trying to answer the questions. And part of my role as a teacher at Guys hospital, so I lead on teaching aligners to post graduates people want to be orthodontist and kind of for me, the journey has come about through me doing treating patients in practice, yes, but also teaching people want to learn and you know yourself, Jaz with your resin bonded bridge course with the splint course, which is just amazing.

By the way, guys, you’ve got to check this out. I mean, this courses are just immense, well organized, planned, nothing like my podcasts. And the idea when you’re teaching is that you are as we spoke about on the [parapet], right, so you’ll get questions thrown at you that you do know, you don’t know, and unhinge what your theories are. So it leads you to have to reflect and really be honest with yourself and say, what is the truth? And that’s led me to where I am now, where I have a regular source in dentinal tubules, where we talk about aligners with a really expert panel of dentists and orthodontists. And it’s led me to kind of now starting more research to type questions with my role of a Guys hospital.

The podcast itself, though, that came about through lockdown, and I was really bored. And when I’m bored, bad things happen, right? So I had to do something to prevent some evil coming into the world. So this podcast filled that void of time for me. And guys, what happened is I started really following Jaz then. So it’s like, no one’s done this in orthodontics. I want some more I want to follow someone. So then I remember Jaz. Guys, if you don’t know Jaz’s fame. Yes, he’s got this podcast and the courses. But Jaz’s fame started with all of [D]. So this is like a boy band of parody videos for dental students. Right? So guys, Google it, it is his biggest hits. By the way on YouTube, I noticed. And I’ve told us this before we interview I know more about him than he knows about me. So he can seem a bit awkward.

[Jaz]
I can’t believe he already got that mentioned. That’s crazy.

[Farooq]
And it was actually the guy who made Jaz has a great video of him in a [later hosen] doing the Harlem Shake. And like it was great. Like this guy just made it. So I knew Jaz. So I started following him and he’s got a great podcast, it’s got a great website. So wants to replicate really the structure but also mean that’s a super positive. And it is all about learning and accepting ideas and thoughts and they may conflict but actually it’s all good because we’re professionals and we’re friends at the end of the day in dentistry as a brotherhood, as a sisterhood. It’s just a community right?

And that’s what I like to try to replicate that to a degree in orthodontics where we don’t have this. And that’s kind of where things are today. But this is to be honest, this is really just at the end of straightpril, scraping the barrel he can’t find another orthodontist. So he had to you have to reach out to me and I will take it with both hands.

[Jaz]
Not at all that way that we know we say we save the best for last Farooq and this is going to be such a hot topic like people want to know more and more about aligners, especially the Protruserati because the Protruserati is mostly listened to by gdps and GDP is a lot of us are doing orthodontics. I know at the end, I’m going to slip it in there just your take on gdps and orthodontics. Where’s the limit? How do you feel as an orthodontist? Where do you draw the line kind of thing.

So we’re going to touch on that. But I think the main theme we’re going to tackle today is aligners. How to be more predictable, and how to identify and dodge risks. So it’s great to have your expertise on this. So if you don’t mind, I’m going to shoot the first question. Which movements are predictable with aligners and which ones are not?

[Farooq]
Okay, it’s a big question. And so that was the premise of the question. We have to know what is predictable in orthodontics, right? So if we can put aligners to the side for a couple of minutes, it’s the fact what can we do predict to be with fixed appliances with other types of appliances? And the truth is, there’s nothing which is a 100% predictable. So we’ve got to start off with the golden truth that is not 100% predictable as a science and as a clinical specialty, and we have to acknowledge that when it comes to aligners.

So when we come to looking at the types of movements possible, we know the most predictable one with aligners are tipping, or what we tend to use in the form of alignment, which is great, because most of the cases we’re doing tend to be alignment cases, if I was to give you the numbers from the literature, we’re looking at around about 75%. So that’s where we are. So it’s good. It’s not perfect, but it’s there. And then we kind of start to scale things down as to other types of movements. So next, I tend to look at what allow us to want to clinically tend to do. So expansion tends to feature quite highly, an expansion is an interesting one, we tend to have some literature that says about 80% is good. Others that tend to say around about 40% to 50%. And I’ll come on to that kind of got topic a little bit later.

[Jaz]
Farooq, just to use percentages, just to make it tangible, these percentages, right? Is that like, let’s take the alignment one you said 75%? Is that like you treat 100 patients, 75 of them will reach the desired movement or you reach 75% in the way most of the time? Or can you just make that tangible? That figure, what does it actually represent?

[Farooq]
So that represents anterior alignment of the predicted tooth movement versus what’s achieved. So that is, if we wanted to rotate it to say 45 degrees, we’re going to get to around about 37 degrees. That’s what that information is telling us if we add it all together. So the 100% mark isn’t really there. And we see that in clinical practice, because we tend to go to refinements to some degree or another to then get the rest of those bits done. And that sounds quite bad when it isn’t, it’s kind of well if you can’t do the job, and what’s the point of doing it?

Well, it’s the same with fixed appliances, right. So if we translate it, it’s nearly impossible to finish the fixed appliance case without doing some customization at the end. Whether it’s through wire bands or changing the bracket positions. It is how orthodontics works. And it’s because not the appliance is bad. It’s because of the natural variation. These things are planned through a computer an algorithm. And the reality is biology doesn’t necessarily follow that. So we have to have an awareness in orthodontic journey. Although we’ll plan it quite a lot at the beginning specifically with aligners. It is still a continuous process. And we have to allow for that changes with refinement at the end and so forth.

And then that’s there, we’ve got expansion and then kind of towards the other side, we’ve got extrusion and intrusion movements, with extrusion being the least predictable. So again, if you were to look at some of the numbers, there was a paper by [a senior] in 2015. The idea is it’s the least predictable movement about 30%. So if you’re going to plan to extrude, a tooth five millimeters, we’re only going to get about a millimeter and a half of that predictably.

Now, these movements that I’ve just described to you, the tipping, the expansion, extrusion, intrusion, that’s looking at true movements. So if you took a model, and you just looked at the movement taking place in that one plane of space, but hopefully what was a divert this conversation today, we’ll see actually, there’s ways around that process. And we can talk about overcorrection, and other things that can then make your treatments predictable. So the way I kind of break this down is that aligners themselves will do most of the job, but the rest of the job is done in our planning. And that’s what I would like to get across the Protruserati, is that we can get predictable results with our aligners like we can get with our fixed appliances. But it comes down to our planning and our understanding of aligners. And that’s why I’d kind of want to end that question on.

[Jaz]
Brilliant. And I think one thing to bring it home is the whole thing about the clincheck. Let’s go with the aligners, you know Invisalign as a very commonly used system out there. So what I learned in my journey was that I used to look at the clincheck. And I think that’s not going to happen, that’s not going to happen. That’s not going to happen. But then I sort of started to realize why dentists were programming it in. Because exactly what you said in the first answer is because if you’re only going to get two millimeters of the five millimeters of extrusion, you over exaggerate it on the clincheck, to be able to get a little bit closer to where you expect it to be. Is that a good way of I guess, setting up the clincheck to sort of with the knowledge of which movements are predictable and which aren’t. So you all almost it’s that cartoon orthodontics, right? You’re just seeing the animation, but you’re playing it to your advantage. Is that a good way to summarize it?

[Farooq]
Absolutely, it is. The clincheck is not a visual outcome objective. Clincheck is a representation of which teeth you’re going to push with the aligner. And there’s some pushing movements with aligners that are great like [alignment as we described some of the answer are great, so we have to push a little bit harder. And extrusion and intrusion movements are those classic movements. So at the end of it and I when I do show patients, my online setups, whether it’s clincheck, or the system is that I will usually stop it before the last couple of hyenas because by the time you get to the end, it doesn’t look right. But actually that’s what I need to deliver that prediction of aligning those teeth and correcting the malocclusion.

So you’re absolutely right. It’s about interpretation. And I’m working with some really clever [bots]. And we’re trying to create an envelope of aligners. So we can hopefully publish this information where you can see what movements are predictable to do with aligners. So you know what, what will work usually, and then what to do if it goes beyond that envelope. And then you start to use auxiliaries like elastics, and so on to then make that process more predictable.

And you know aligners, they general perception amongst the orthodontic community and it is changing was that it’s not proper orthodontics. And that process is starting to change now with the use of auxiliaries and getting predictable outcomes to treatment. So we are going through this kind of change from the [old guard] where we are starting to look at aligner proper braces, but when we’re engaged with that concept is about predictability because that’s the fundamentals of orthodontics.

[Jaz]
On that point, one of the movements I shy away from or one of the cases I shy away from with aligners is deep bites. So I want to ask you Farooq, am I right to be concerned with deep bite patients? Or has something changed in the generations such that deep bites are becoming more predictable to treat with aligners? What’s your stance because classically, I know that aligners are favorable for anterior open bite, for the molar intrusion and correct me if I’m wrong. You’re the expert here. Tell me about deep bites, are my concerns correct?

[Farooq]
I shall do this two things got to mention here, guys. So one is that Jaz has done deployment orthodontics, right? So Jaz is well equipped with some of this information. So he will correct me if I’m wrong. Two, the thing that the hard thing about podcast guys is making a link between the first question the second question, and Jaz has got a quick so Jaz will use the word brilliant, quite a lot in his podcast. And I don’t be wrong. I’m all for doing this. Like I am really bad at linking one question to another question. But it’s good to hear Jaz, and he does it so much better than I do. So it’s great to hear it for me.

So yeah, I mean, the intrusion cases coming back to the question is that and I know Jaz is most likely to cut out my bits. Just stick to like a 10 minute podcast of content. Is that your right? So intrusion in deep bite cases are a challenge. And again, like my approach to orthodontics integration was don’t dispute that I need to fundamentally understand what’s going on, I can learn about having my crown prep, so it is parallel sided, or six degree taper, whatever it might be. But I need to understand why before I can almost believe it. So let’s just go back a stage.

Deep bite cases with aligners. The challenge with them is the comparison to fixed braces. So naturally, an aligner has an intrusive effect, it’s going to push all the teeth downward. And if you take into account the back teeth are going to be intruded as well. A bit if we talk about the third, they’re kind of the class three lever, like a stapler, for example, right? If we’re going to intrude all the way across, then actually we’re going to get an increase in the bite at the front. So that’s the nature of an aligner.

Now that is the opposite for fixed appliances, where their nature is to extrude teeth. So they are much better and perhaps more naturally equipped as a better phrase to use for deep bite cases. So with aligners, they don’t have the natural tendency to it. However we can correct for that. So there was a recent study by [Al Bahar], and he showed that around about 50% of deep bite cases delivered the intrusion. Okay, does that sound great? But actually, there’s a way around this process. And it’s about having overcorrection, as we spoke about kind of in the last question.

So when it comes to deep bite cases, I’ll aim to finish with an anterior open bite from the clean checking on the online setup, it doesn’t look great. But actually, I’ve now over corrected for that knowing that the aligners is not very good at delivering that force all the way. And at that stage, the patients do have a correction to their deep bite. But let’s be clear, if a patient’s got a complete bite, and there’s no lower incisors show at all, where the doing with aligners or even fixed appliances is going to be a struggle to crept in the adult patient. So it does come down for the average patient, we can do it and it’s fine. But actually for the extremes in any dimension, whether it’s vertical or horizontal and large overjet actually, appliances have their limitations to the orthodontic envelope of tooth movement.

So we’ve got to bear that in mind. I think it is possible to do. But it requires some planning to overcorrect. You mentioned that different generations. And I think that’s really interesting, because Invisalign have got the G5, they’ve recently introduced the G8. And these are just the generations of Invisalign and new features to their product. From the back, you can see that if Invisalign have tried two different types of features to correct this. It’s a difficult one to do. And I think we have to understand that. And one of the key things that they’ve changed is trying to work with Anchorage.

So I want to try and make this straightforward. When we tried to push the lower incisors down. There’s a natural tendency for the aligner to push up at the back. And that’s how the process of intrusion works. One of the problems with aligners is that they don’t retain that too well. So if the aligners has been pushed out to the front, it’s going to get pushed up at the back, the aligner simply lifts off and doesn’t pull on the teeth, or push on them. So the way that aligners and are not getting around that is by using large horizontal attachments on the back teeth, right, so it’s stopping the aligner lifting up at the back. And it helps to deliver that force in the anterior region to intrude the lower incisors. So as we know, the nature is great for it, we are finding ways to work around it. And those are the two key ways to get a predictable deep bite case.

[Jaz]
That was so elegantly put forward. Honestly, that was so elegant.

[Farooq]
I’m waiting for the brilliant.

[Jaz]
I have to change that to make it elegant now, and it was more than brilliant, it was very elegantly put. And I think the real pearl we shared there is those early in their career, playing with Invisalign, the clincheck I think the take home point is which I learned a few years ago, and I wish I’d learned earlier in my journey with aligners is don’t be afraid to get the end of the clincheck. And it look weird, or it look like, you’ve gone completely the other direction because that’s the whole point of overcorrection. And we need to be willing building that in so none more so than a deep bite case.

So a great gem he shared that was, be prepared to overcorrect but also manage expectations. And also just realize that not just like you said that case we got 100% overbite. That’s not going to be a case that should be doing or will be even easy with fixed appliances, let alone aligners. I think you’ve covered that really well.

Also, if you move on from the intrusion, extrusion and deep bite case to expansion as the next point. You mentioned already that I think you mentioned 80% to 45%, depending on the literature in terms of how much expansion is expressed. Expansion is a tricky one, because when I’ve seen people’s clinchecks, I get really concerned when I see overcorrection and expansion. A stability comes to mind about afterwards, be about recession, because I’ve done it before and I’ve got little bit recession. So it’s never nice to see recession, I guess. A guide that I use is to do not expand beyond the second molars. But where does that fit in to the whole overcorrection and expansion? And what guides or helpful tips can you give dentists who are looking to expand?

[Farooq]
Yeah, so I mean, this is a topic which, if I was to translate it into dentistry, I would say that this is a topic like veneers, right? So we have some areas where we’re going to use veneers where it’s very clear cut, right, we’ve got a hypoplastic upper incisor. WE all appreciate that veneers are going to be the best one for that one, but health wise, stability wise. But actually then there’s a large area where it’s really quite great. Where there’s questions about aesthetics questions about lots of dental substances, question about well, is that the right thing to do for the patient long term wise and people sit on different sides of the fence?

So for me expansion fits into that topic, the answer to your question is that we can expand and aligners can deliver a degree of expansion, I want to try and get to that literature because a bit nerdy, as you understand that, from my general appearance and demeanor, but to make it useful is that that number of 80% is to do with the intercanine distance. So it’s essentially anterior expansion, right. And the further back we go, that’s when it drops down to about the 45% mark around the first molars.

So we’ve got this kind of weird kind of, if you do parallel expansion on the aligner, across the arch, you’re going to get most of it in the anterior and far less posterior [John Morton], he’s one of the clinical, I think he’s a second in charge of the clinical development with Invisalign with align technology. And he was recently given the lecture and I do follow him, I do troll him a little bit as well. And he said that we don’t, we can’t, we know we can’t achieve expansion on the second molar, or we do with aligner, if we do rotate them. So from the top, this information is clear that posterior expansion is not that predictable. But actually anterior expansion is one which can be delivered reasonably well.

Now, if you go back to that analogy, I gave off the veneer for the anterior tooth is that there are some cases we know we’re going to get expansion, and it will be stable, predictable, healthy for the patient. And the classic is a posterior crossbite. So there’s a functional issue potentially there. And we can correct that through expansion and it will retain itself it won’t be unstable. And it will meet that criteria of what we want when it comes to the other cases.

So let’s talk about why do we do expansion with aligner of cases really, we’re trying to create space within the arch for our alignment or correction of malocclusion. So way to create space, which is less complex and destabilizing far less complicated extractions. So it’s kind of a neat way around that as a process. Or we may be looking to widen the patient’s smile. Okay, cool. The argument to support that is that well, it’s made your orthodontic alignment easier. The arguments against it are several fold. So the biggest one, as you’ve already mentioned, is a relapse. The question why is it going to relapse? If you’ve moved the teeth, surely the teeth can retain themselves.

And the argument always goes back to this is the neutral zones, this is our prosthodontic days, right that the teeth, we should try and position them in the neutral area between the cheek and the tongue is the same when it comes to dental positioning. So if you push the teeth towards the cheeks, the cheeks now have a greater force trying to push them back. And that’s a continuous process, which will remain until they get back to that neutral zone. So there’s always that risk of that occurring.

Now, when I gave you those numbers about the literature, what we know is that those numbers are working within the predictable parameters of about two to three millimeters. And there’s a great paper by Weir, who was in 2017 in the Australian journal, and it was quite a nice breakdown of two to three millimeters predictable, three millimeters, okay, you have to work a bit harder, four millimeters with aligners is not a predictable movement in any sense. So if we were to stick to do you want to do some alignment, expansion or cases, when we go back next weekend, the idea of two millimeters, you’re pretty comfortable delivering that, it’s going to be tipping movements that aren’t going to be bodily movements with it. And that’s also been shown by a paper by [Sue] not too long ago.

And that’s exactly our fixed appliances work by the way, guys. So again, this isn’t aligners is not doing the job properly, which I feel sometimes the reputation takes them in that direction. It’s this exact same with fixed appliances, if we’re going to do expansion, we will tip those teeth in our adult patients. And the only way to get a bony changes is to doing surgical intervention, or for a younger patients doing it before the sutures fuse. So it’s the same. And we know from fixed appliances, again, we’re delivering up to three to potentially four millimeters of expansion.

But then after that, we know it’s not going to really take place. So we need to kind of put our orthodontic type hats of limitations on that we would do with fixed braces and apply that to aligners as well. And I would say two millimeters is know what we can deliver. But actually going beyond that we shouldn’t. And I know, Jaz, we’ve had a conversation about the [wala align].

[Jaz]
I was just going to come to that actually.

[Farooq]
Yeah, so the [wala align], it’s an interesting one. So this was kind of by the one of the founding fathers, if I could call him Larry Andrews. And the idea that at the mucogingival junction, there’s a relationship between that kind of horizontal point, relative to the midpoint of the crown of the tooth and the labial face

[Jaz]
Best observed from like an occlusal photo, right? It’s the best way to word the way I was taught, right?

[Farooq]
Absolutely. And the idea that there’s a distance, which is essentially safe for expansion, if you were to maintain that. And if you want to increase the expansion, if as long as you stay within those limits, it should be relatively sound, I think that’s a great starting point to get used to visually assessing cases using the [wala align]. And the idea with aligner is I feel it’s got an advantage over fixed appliances, because the basis of this line is that you have a custom arch form. So it’s not replicated the same, it’s not the same, you shape it just getting wider, it follows a patient’s initial U shaped arch, if that’s what they have, and it kind of grows in that same shape to maintain it on all the teeth. And I think it’s a good reference point to use, combined with knowing that two millimeters unless you’ve got a functional reason should be your predictable amount. Anything beyond that, you’ve got to be asking yourself, is there a more predictable way to gain the space for this particular case?

[Jaz]
Well, would that two millimeters though, because you know that two millimeters are predictable? And maybe that also aligns well with your objective and what you’re hoping to achieve? Then, even with the expansion, would you then program in three to four millimeters expecting to see that two millimeters? To what extent do you overcorrect when it comes to expansion as well?

[Farooq]
That’s a great question. And looking at the way the process of expansion works, essentially, you’re going to get that two millimeters delivered predictively with the aligner. So this isn’t the deep bite type case where we need to start overcorrecting from the outset in our plan. It’s not that realm is the fact that two millimeters will happen, right. And actually, when it gets to the third millimeter, it’s not going to happen that well. And the fourth millimeters is going to happen less predictably.

So actually, overcorrection is probably not going to do you any favors. More so it’s going to do detriment, because in your space plan, you’re going to predict you’re going to get more space to be able to align the teeth. And if you haven’t managed to create that which you most likely won’t actually then you’re not going to align your teeth fully anteriorly. So actually, it’s really good idea to actually say no more expansion than two millimeters.

And I’m a great one for actually with my aligners now is isn’t the preset features is switching off expansion as a method of correcting the occlusion, see what the setup comes back with and then add a small amount to it of two millimeters when it comes back. Rather [nose working] with the other way around. Because I feel as though we get lured into this self-false sense that actually I’ve expanded or not needed to do much IPR really, really simple. But actually we’ve gone down a relatively unpredictable road at that stage. So that’s kind of my tip at the moment is to try and remove expansion from the cases, see what it looks like and then add some into afterwards.

[Jaz]
If anyone was multitasking, while Farooq just said that you need to rewind 60 seconds, and listen to that, again, that was a real, real gem right there. I think that’s really, really cool. I think that’s going to help a lot of people. And I just wanted to ask one more question on the realms of expansion, because it’s three or four more areas I want to hit. But before I actually even get to this next one is I want to say that you are officially the geekiest guest to ever come on Protrusive. Dental Podcast. Yes, officially over overtaken Nik Sethi in a number of references, you’ve actually said and we’re just about halfway or something like that. So the references are flowing in nicely. So you are officially the geekiest guests, which is amazing Farooq, I expected no less from the host of the Orthodontics In Summary, guys, you should check that one out, what’s the website for the for the podcast?

[Farooq]
www.orthoinsummary.com. And you guys will go there. And actually the most popular podcast topic that I have is aligners. If it’s into this, we’ve got 19 of them. And I’ve kind of gone across the spectrum with it. So I’ve tried to go to I’ve looked at Invisalign, of course produce a lot of content. And I think education content is good guys, I’m not trying to dismiss them. But I’ve gone to some independent aligner or authorities and we’ve listened to them speak and we’ve captured their key points, and only five minutes long. So I think you can gain hopefully, a rounded understanding. And a lot of I’ve expressed to you guys today about how aligners work. And you know what the reality is that we’re still at the learning stages of this science. And I don’t think we should be ashamed of that. I think some orthodontist, because it’s not you will have the evidence we’ve got for the fix.

But we also growing and developing. And I think actually I feel that gdps have very much helped that process to accelerate. And I’ll be honest with you, Jaz, like I qualify as a specialist, I just got my MOrth exam, which is the bar exam for orthodontics in the UK. And my first aligner case, I contacted my cousin who’s a general dentist and said, ‘Look, man, I’ve got this clincheck what is happening on this cartoon?’ So I don’t think it’s restricted to a speciality or what have you. I think we can all understand things together. And some of my general dental practitioner claims as fundamentally phenomenal questions, which do question how the science works. And we then have, I feel responsibility, at least in my setting, as an educator, to then find that information out and share it like we’re doing today

[Jaz]
That’s a really wonderful perspective. Now I’m going to come on to a final question on expansion I was an asked, which is, I can’t, just to critique my practice, which is that I commonly do like to lock and make the second and third molars unmovable, because I feel you know that you can predictably expand it and also to impart a degree of Anchorage? Is that something that you do is that a good protocol to follow?

[Farooq]
I think it’s a great idea to have in place. Now, it comes down to it. And again, I always like to draw analogies to dentistry is that if we looked at the free-end saddle situation, right, so we’re going to make ourselves a partial denture, we’re going to free-end saddle, we know that actually, the compression of the tissues is quite difficult to get retention because it’s better posterior, and we don’t have that in a free-end saddle situation. So it’s the same when it comes to aligners, we just don’t have enough to be able to move those back teeth predictively. So therefore not moving those is a very good way of stopping unwanted tooth movements and having less predictability.

So for example, if we were to program in a rotation to second permanent molar of 15 degrees, okay, it doesn’t sound too horrific. But as it’s starting to push on that tooth, it’s struggling to do it, that has implications and how well that aligner fits further forwards. And actually, we may not be able to align up our anterior upper canine because the aligner is struggling to sit in that posterior quadrant. So actually, and again, it’s one of my things that I’m going through at the moment is expansion is one but twos I go through the teeth and get in a bit of a nerd or look at the tooth movements of each tooth in all six planes. I’d love it. I love it. I’m not going to lie to you. It’s like what it’s like reading code or read in the matrix. Let’s try make a cool, Jaz. Let’s try it. I look at the numbers.

This best when I’m doing it with my postgraduate trainees at the Guys hospital I say put the two staple I look at it like I’m just the architect. But actually, yeah, anyway, I will give you all my secret. So the idea of it is that I will then remove movements I feel as well it’s automated this process I don’t need torque in my upper right seven like it’s not needed for this case. I wouldn’t do it for fixed it’s an unwanted movement. I’ll just remove movements from my posterior segment in all dimensions and not let the computer dictate that and it’s going to give you more predictability on where do you want it. So I think not locking six and sevens are good and seven and eights are good.

The only time I probably do something different is if I’ve got a crossbite posteriorly and just the sixes in crossbite, which isn’t the most uncommon situation. And actually sometimes I want to have the aligner think of having some reciprocal movements taking place. And that just gives me a bit more push on the six which is buccally and crossbite to allow it to align. Even though I know the seven and eight are unlikely to move because it’s two teeth versus one tooth. That’s the only exception for me. But I think it’s a great starting point until you’re going to get start looking at more advanced movements.

[Jaz]
Excellent. So you see, I’m changing my words that I’m using now so that you don’t catch you with brilliant again. But you did remind me with the mention of torque there that I read somewhere, or listen somewhere, probably this listen, that when you are doing expansion, that is good practice to also check that as the molars are expanding, you’re adding in some palatal root torque, so that it somehow imparts more of a bodily movement rather than just tipping. Right? No, sorry, buccal root torque my mistake. I meant buccal root torque. So that it comes to it comes like a bodily movement, rather than just tipping like that. You want to be the roots with it. So it almost makes it familiar, like a bodily movement. Is that something that you follow?

[Farooq]
Yeah. So I mean, I do. And it’s now a feature within the G8 as well. So they’ve introduced this, I think aligner users were already implementing this as a process. But it hinges on having a buccal attachment, just on the square attachment horizontal on those buccal teeth, to allow that movement, that expression of force to take place in the tooth. Again, it’s great conceptually, and it does deliver, but it doesn’t deliver 100%. And that’s what we’re finding. And to be honest, again, it’s quite true with fixed appliances, is that we can deliver buccal root torque to posterior segments, but it takes a long time to actually deliver it. And how predictable it is, is always a question mark, I think the aligners are the same.

If you kept a case in of aligners in a line of say, for an extra six to nine months at the end, just to put in this buccal root torque, I think the likelihood is you will deliver it. And again, when we look at fixed appliances, and what cases do take a very long time. So actually, we’ll add in some buccal root torque because we’re going to be streaming for another nine months. So we then see it happen. I think it’s we’re comparing the scenarios in two different realms. And actually, if you do want to deliver expansion, you want to make it predictable, you’ve got to make the treatment much longer to account for that to ensure that you are going through the refinements process as well to get these roots upright.

Whereas I think if we then looking at just creating expansion for the purpose of creating space within the arch, so we can do alignment, I think there are other ways to achieve that in a more predictable way. Let’s do what we can predict to be with expansion. Okay. But let’s look at some of the other ways so we can live with this case, perhaps in a relatively shorter timeframe. Not trying to cheat the system here. But let’s just work with that envelope of movement with the aligners.

[Jaz]
Speaking of timeframes, you just reminded me of another useful question for dentists is that sometimes I’ve started to play around with my clincheck requests in terms of velocity, velocity of tooth movements. And sometimes if I find that my lower alignment is taking 26 aligners and upper is taking 16 then I will sometimes say well, why don’t you slow the upper ones down, so that they’re both taking a more equal amount of time overall, in terms of how many aligners are going to be active? What’s your take on that? And do you ever make this request of either speeding up the velocity to the max or slowing it down? And when? And when not? Is that a good idea to do?

[Farooq]
So I think this is such a great point. And again, guys, I’m going to be humbled here and say that I picked up this tip from a general dental practitioner colleague, and we were looking at a case together and I was trying to show off and he said, Well, you know, why don’t you just increase the number of aligners in the upper arch to match the lower. And it’s something that I’ll do all the time.

Now, the idea of slowing down tooth move is about increasing predictability with that movement. We have compliance potential issues that are there, we’ve got some move teeth that may well be stubborn for whatever reason. And actually, the slower we do anything, when it comes to orthodontics, the more predictable it is. And again, guys, I’m going to relate this back to the fixed appliances exactly the same. We know if we go through a slowest space, changing our wires, and slow amount of space closure taking place, we’re taking teeth out, it’s far more predictable, less side effects, more predictable position. So I absolutely do that. And I think it’s a great way forward.

I think actually, if we really wanted to live it every case put it to be would slow down the movement in every tooth, but then there’s a timeframe and so forth to it. And for me that feature is that if we’re doing the average, if I’m treating the average case, actually, that’s something I’ll bear in mind when it comes to refinement. So if I’ve had an issue with several teeth not moving particularly well, in my refinement, I will say can you actually give me twice the aligners for this particular case.

Now the case I’m treating recently, which is a an older lady, she’s in her late 60s, and we’ve had some periodontal issues historically, she just finished with a periodontist. And she’s come to see me we need to do quite a lot of work. She’s had a tooth taken out, we’re going to move all the teeth into that space, and we’re going to use aligners to deliver it. And we have now gone from having only 18 aligners, I couldn’t see how that would happen in that timeframe, double that up to 36 and I was looking at something which will work more predictably take into account the fact that she’s had history of perio, I want to keep the forces really light and also the amount of tooth movements she needs. It looks like a lot to me on the on the clincheck.

Now in both respects, we’re now making them to a safe one. And like a colleague of mine from from Kuwait, he got caught out with a perio case where he didn’t change the velocity of it. And actually the case then developed in such a way that there was mobility at the end, that was a real worry in the state for a period of time, we just not respect to the biological boundaries. And in some respects, fixed appliances may have an advantage, because there are really light wise that we generally start off with, which usually deliver a really low force, and we increase the force as we’re going along with aligners, it’s like a one set force, it’s kind of going to do that for each type of movement. So we’re perhaps a little bit more likely. So we’ve got to be more tuned into that. But yeah, when in doubt, try and increase the aligners and I know some of my colleagues will try and reduce the aligners trying to get to certain price brackets and packages.

And guys, I mean, that works out great from the financial perspective, right. But on the other side of it, guys is that that’s when you then start referring your cases onto somebody else there for the job. So it’s one of those and I don’t mean that in a negative perspective to general dental practitioners, please that’s not what I’m saying. I’ve had a consultant colleague do the same thing. To reduce the number of aligners price point, it gets to the end, the teeth aren’t straight. So I think we have the ounce of duty to deliver the case. And then the rest of it will follow and you’ll get a bigger discount by having more patients. How about that?

[Jaz]
Well said and it’d be amazing to see the stats from Invisalign in terms of how many aligners are needed for each patient, I’m sure when it gets to seven and 14, there’s a big spike. It just happens that this malocclusion needs 14 layers. And it’s I’m sure there’s a huge spike, because they’re trying to make it financially feasible and all that kind of stuff as well.

One thing you’ve covered all the main questions really well, the rest are almost like accessory questions and the whole theme of do’s and don’ts. So recently, I had Robin Bethell on the podcast as part of straightpril. And we talked about the long and short of elastics. And he completely surprised me that we were talking about this, he rarely or seldom uses elastics, like class two and class three elastics. And I think the paper he quoted did mention about the whole skeletal changes not being possible, which we kind of know already. And we knew having a chat afterwards on Facebook. And I feel as though you have some good thoughts and some input to add in this debate because maybe for dentoalveolar reasons and certain cases elastics may have a role. Now we did say that for extruding naturals, most common time, the bootstrap techniques are go back to the episode you have listened already. So that’s a given. But tell us about into maxillary elastics. When do you use them, Farooq?

[Farooq]
This is this is a great topic. And one that I’m still learning more and more about. Now elastics, I think, again, I got to take a step back and say, why are we using elastics? And they have multiple uses. And it’s a bit like a flat plastic like you can use it for so many procedures, I don’t think any of us will say Actually, it’s just used for one procedure. So elastics, in the broadest sense, are used to help control tooth movement. So that’s the premise, it’s going to help us deliver a movement more predictably. So we can use it to stop unwanted tooth movements. So say we want to prevent teeth proclining, for example. We can use it to create active movements. So we can have an increased overjet. And we can use it to reduce the overjet.

And as you mentioned individual tooth movements through things like bootstrapping, we take one tooth, elastic goes over it and extrudes one tooth into the aligner. So there are those kind of three components to it. Now I think we have and it has been mentioned by Robin’s podcast you did with him and I was listening to it is that yet skeletal moves aren’t possible with them. And when they are shown there is no strong science to support issues yet isolated cases and social media cases where we have questions about it.

So for me intermaxillary elastic, so what are we describing here, so the class two elastics, essentially the pulling from the front of the upper teeth to the bottom back teeth, and that’s where the direction of forces taking place. We’re pulling the top teeth back, we’re pulling the bottom teeth forwards. Now this is where we’re going to start now talking about well, what’s the purpose of it? Are we doing it to stop unwanted movements, or we’re going to use the word anchorage and I appreciate that terminology goes into be of orthodontic wizardry.

And I don’t wish to use a [smoke and mirrors] but essentially, I’m going to say we want to align want to align our upper incisors, and we don’t want to procline. So we’ll use some class two elastics to stop that unwanted tooth movement. And then we’ll talk about correcting and overjet. So we’re going to use heavier elastics to do use an active force to bring back the upper incisors, maybe procline the lower incisors if we feel it’s appropriate. So those are kind of how it works. And the way that you make the difference between ‘Am I doing it for anchorage or to stop unwanted movement versus active movements’ is the amount of force and how long the force is therefore, so the most common type of elastic to use and again, I’m going to go into some numbers here is a medium force which is three and a half ounces and usually a quarter of an inch.

Now that information kind of is relatively in the background. But the idea that’s the most common used elastic in orthodontics, I’ve got a reference [Mansour] 2017. And so it’s essentially just show that can be it’s a very versatile elastic can be used in most situations for class two and class three. But the idea is that I’ll get patients to register at nighttime if I want to stop the unwanted movement. If I want to get active movement, I get into wear it more often.

Now we spoke that might not be a skeletal so these are dental alveolar changes again, just translating the orthodontic kind of terminology, we’re just going to retrocline the upper incisors and procline the lower incisors. So if a case warrants that and can have those changes, class two elastics are fantastic at achieving it. And I found myself more and more using elastics with my aligner cases from the anchorage perspective.

So to control which way the teeth are going to straighten essentially, either going to straighten by coming forward, kind of stopped them from coming forwards by using the elastics. And again, it’s just a nighttime usage, the same elastic. Nature is helping me to control I want the teeth to straighten, how’s it now going to happen, and I feel so that’s a lot of what orthodontics is, the mechanics themselves will do the job. But then we kind of tweak it here, tweak it there to move it left to move it right, and so on and so forth.

So that’s my take on elastics I think the great tools, there’s a guy who I covered in one of my podcasts, [Calver] is a professor in in Brazil. And he just uses elastics all the time. And his cases are phenomenal. But he still respects the biological boundaries. And where it’s not where proclination to the lower incisors is a bad thing. They’ve got recession, that he won’t use them. So they aren’t the tool that solves all problems. And by no means are they tool to work. To stay away from I feel as though actually having a go with him is a great idea. And next time you guys are treating an aligner case. And you feel is actually incisors may procline, I don’t want that to happen. I would say build in some class two elastics. Get the precision cuts on the upper canines, [top tick] precision cuts upper canines, cutouts for the lower sixes and then just put some buttons on them. Or you can buy the ones from AutoCAD, there’s loads of buttons, you can buy metal or clear and get the patients to wear them evening and nighttime patients are really cool with them.

Especially when you’re using a nighttime they’re really up for what they like the idea of using something at nighttime to help the case progress and get a better predictable result. And they commit to them quite nicely. You’ve got if you haven’t had the typodont I think Invisalign a [greatly] because they actually have the cutouts on the typodont. So again, guys, if you have got that from the aligner, and I think most people get that when they go on the course is that you’ll see the cutouts, get some elastics just have a play, I would play putting them on. And I do think it’s something to try and incorporate into regular practice.

[Jaz]
One of the advantages I think clear aligners has compared to fix appliances that what I’ve done fixed planes, I was trained in fixed appliances. And the whole thing that for example, you place a wire and it expresses a force. And then if that force gets expressed for too long, perhaps you lose control of the case, or you get too much of a movement that you perhaps didn’t want. Whereas with aligners, it can’t go beyond the realms of the aligner itself. So this whole concept of preventing too much proclination, I almost don’t understand it with aligners, because surely the tooth cannot procline beyond the actual position of the aligner itself. So really, how is elastics helping in that case? Do you see what I mean?

[Farooq]
I hear what you’re saying. And you’re right isn’t advantage of aligners. They’re a closed system, essentially, nothing can move without everything moving. That’s how the premise of it works. Well, it’s fixed appliances, each tooth has individual force, as you read correctly described, and you can get on what a tooth movements, so fixed appliances, like spinning a plate, you kind of have to keep it spinning, you have to keep engaged with it. And if you don’t, then things are gonna start to fall off. Whereas aligners, they will stop at that certain stage and not fall. So there is that advantage when it comes to the planning stage.

We’re coming to answer your question as to Well, why would that happen if it’s a closed system is that unfortunately, the prediction of aligners from the software isn’t 100% accurate. So when they’re talking about aligning the upper anterior teeth, is that you may think they don’t align posteriorly. But actually, if you’ve not created enough space to do that, or if the software hasn’t managed to do that, what’s actually going to happen is that the teeth are going to straighten, but the upper incisors going to procline, they’ll still stay within that same system, but actually things have moved spatially forward in the patient’s face. And that’s part of the challenges when we try to interpret our online setups is that although they put the arches together, these forces acting independently on these open their arches, and actually, you can move a whole arch forwards and not be aware of that den taking place in your plan.

So the idea of having the class two elastics and I’ll probably [typify] it and say we’ve got a slightly increased overjet right, we’ve got a five millimeter overjet and mild crowding upper and lower. This is a classic case of me and want to align the upper teeth and lower teeth and we’ll do some IPR and actually if I weren’t to, I know use some nighttime class two elastics. Now that will hopefully maintain a five move to overjet may improve it ever so slightly, but it’s not going to make it worse.

Now, if I didn’t use class two elastics, the chances are the overjet will increase by about a millimeter, as is the nature of teeth as you start to procline, lowers to procline upper teeth are bigger as they procline, it will make a bigger overjet. So the idea of having that elastic in place is the insurance policy to not deliver that detrimental effect. And as I say, the closed system is great as a concept, but it doesn’t mean it’s all anchored at the back, or the teeth experiencing a force and it can push things forward as a result.

[Jaz]
Thank you Farooq for clarifying that confusion. I think you answered really comprehensively. That’s brilliant. Farooq on IPR do’s and don’ts of IPR please tell us.

[Farooq]
So guys, IPR is such a topic where fields deserves session in itself.

[Jaz]
Dr. Devaki, orthodontist. She came on, actually to talk about a whole episode on ipr actually recently, which was awesome. That was some episodes ago now probably locked down one, and she covered it wonderfully. I’ve got lots of messages from GDP saying, Wow, they really need that I think I called the episode IPR for Dummies. So we covered that, but I want the Farooq special. I want your masala on IPR because everyone’s got their sort of way of doing it and their philosophies.

[Farooq]
Yeah. So the one message I would give about IPR is that you have to be perpendicular to the surface that you want to cut. So you got to be 90 degrees to the surface that you want to reduce. Now that then translating it into how does that clinically practice if we have a rotated tooth, for example, lower central incisor, it’s 45 degrees rotated for argument’s sake, is that I will go in typically with a hand strip, because a hand strip is flexible, I can contour it, single surface cutting to make sure it’s perpendicular to that interproximal contact point, right.

Now, with IPR with when it comes to hand strips, we can deliver 0.1 millimeter pretty predictively with the different thickness. And if you double it up, then you get 0.2 millimeters. So that’s kind of my thought process when it’s quite a malalign tooth. Then we’ve got the discs and the reciprocating strips and the burs, I do use all of them, they’re all kind of there in my armamentarium. But they don’t get used as often.

So if I wanted to use a disc or reciprocating strip, actually is quite difficult to get 45 degree angle at rotated incisor and to get that instrument in because it’s a stiff instrument, actually, when we put it interproximally, it’s going to go 90 degrees to the adjacent teeth, not to that rotated tooth. And that means when I’m using it, I’m going to go and I’m not powered up perpendicular to that surface I want to reduce, it’s always going to make it an oblique cut, which means I take some proximally, I’m going to take some labially as well.

And that is the issue with using these heavier instruments for IPR. I will then wait until the teeth are aligned, and then I’ll go in with my heavy IPR. Now again, I’ve tried to make my life a bit simpler, because it’s simple because you know, who wants to have a complicated life. So I generally tend not to do beyond 0.3 millimeters of IPR in the labial segment 0.4 in the posterior segment, and I won’t go any further back than the six five contact point. So for me, those are my limitations, one because I want to ease my life, two, because actually, now, I can do most of the IPR with hand strips. And if I’m going to do 0.4 millimeters, lower right three quadrant for example, I will then ask the aligner company to stage it. So one 0.2 from the beginning, the next visit, I do the other 0.2. And I can easily deliver that.

Now there are some more complex cases where I’ve needed to do 0.5 millimeters are really quite involved digitalization cases, and so on and so forth. And that’s when I take out the bur. And the bur for me is that is the get out of jail for the complex case. But I don’t use it for my average case, because I don’t feel as though I need to be delivering it. predictively managing it, I would say the next thing to take home from the perpendicular positioning of your IPR strip or disc or whatever you’re using is then to use an IPR gauge. Because no matter how good you think you are eyeballing it, and how predictable you think your instrument is of being a measurement tool is not going to be as accurate as using an IPR gauge, and then make a record of what you’ve done.

And my third tip would be is if you do stage your IPR, you get everything for me this is like this is like this, I was going to do this as a course now I can’t do because I’ve given all to you, Jaz. So the third one is to measure the contact point if you’ve staged it before you do the IPR because you may already have some space there. So you need to be predictable to what you’re delivering now when I’ve worked with some of the companies and I’ve done some teaching for different companies, is that the biggest bugbear the laboratories have is practitioners under doing the IPR, they’ve just not done enough.

They’ve essentially taken a hand strip, they’ve run through the contact points. And they’ve kind of given it a day. So I’ve done IPR, it’s not the case, it does take a while to deliver 0.1 millimeters, IPR, you got to go with the light strip, you go going heavy strip, you got to check it sometimes to double up to make sure it’s there. So be honest with yourself that you’re doing it.

And I can’t stress enough how important it is to be perpendicular to that surface, because you may do the right amount, but you’ve done it the wrong surface. So even when the tooth straightens, you haven’t aligned it because the space isn’t where the company has planned it to be. So on those accounts, those are my top tips, making sure you’re perpendicular. If you can’t do it, use a strip, you will be able to do it, making sure that using a gauge when it comes to it. And when you’re staging your ipr, if you’re doing a lot of it, then make sure you’re measuring it before you do that the second time. And for me that is something which has worked really well.

[Jaz]
The interesting thing that happened when we released that episode with the Devaki on IPR was that a lot of dentists messaged me saying, ‘Thank you, Jaz for making something simple and easy to understand, because and this is what they say they said, because I thought when they were asking for 0.5 like, and you’ve got like a rotated tooth, they were actually a lot of time. So what people told me is they’re making 0.5 at that place, whereas actually, you want 0.5 from the contact point area, which sounds very simple. And obviously, it sounds very obvious. But when you got rotative, people were taking off, you know, a bit of labial as well. And just because they they’ve achieved that 0.5 space, it’s not in the right area.

[Farooq]
We had actually planned kind of conceptually to deliver an IPR hands-on day kind of this is unfortunate, just lockdown. So never really materialized any further than the concept. But it’s something which I feel really strongly about. I think it’s something and again, guys, I’m not going to say it’s because of all the bells and whistles in the titles. It’s To be honest, a lot of it’s for my own experience, I have made a mess of IPR so many times with all instruments that I’ve described, even hand files, where I’ve taken off the wrong surface, because I was using the wrong side of it as simple as that. And all these things have kind of made me quite humble in the process of delivering IPR. And to be frank with patients and with myself, if I haven’t done the right amount. I’ll do it the next time. And I think all of those things are how you deliver predictable results. And for me, aligners are about respecting the boundaries of the biological limits, and also the delivering the correct amount of forces to the teeth and creating the space the right way. So I think if we get those two together, we are all really producing predictable results with aligners

[Jaz]
Farooq, we’re coming up to that Magic Hour point. And I just want to say, Wow, you’ve added so much value, I think a lot of people are gonna go away, feeling a lot more confident, feeling like they’re gonna make better choices when it comes to clinchecks and, and case suitability. So I think you’ve got given so much value and so many references that who knows how many people will to keep up but you got if you guys want more, please do check out Farooq ortho in summary podcast, if you like his style, which you should, because he’s such a, I love those analogies. You know, you gave so many good tangible analogies, which I love. So thank you for sharing those. But I just wanted to finish on one thing, which we did discuss beforehand, which is where do you think the role of gdps is in terms of orthodontics? Where is the limit? How do you feel about us dabbling? How do you feel about us doing comprehensive cases?

[Farooq]
Okay, so I mean, this is a question where I’ve had different opinions of times going on. And to give you the longest short of it, I started off saying it has to be theoretical knowledge based, and then say, no, it has to be experience based, you have to have a certain number of cases. And I’ve settled on, if you know how aligners work, then you should do it. And that for me branches, so many different equations that can take place, and it still comes back to the same answer and this a friend of mine, [Mandy Gosl], he’s a specialist orthodontist. And he’s got his own course, on diploma. So he’s a great guy. And he posted on Facebook recently about how diamond providers, I won’t use the expensive but essentially they there’s no guarantee that they’re giving any reasonable quality because a penny drops at different stages for different people, you can make the same mistake 100 times, you can make mistake once and learn from it.

So I think it’s incumbent upon us to learn about how they work, be honest with ourselves. And I can’t say that enough for somebody who has made mistakes and has to come to terms with having to ask for help for cases, and then not allow those unknown unknowns to exist. And that’s my stress. And I was really fortunate to be involved with [C fast] and delivering some of their teaching with the aligners. And what I loved about those guys, is that they said at the end of the course, this is your beginning of your journey in aligners. Next, go on this other company’s aligner course, go in this company’s aligner course, make sure from this course once you’re certified to use all clients and blah, blah, blah.

You now go and learn some more information about it. So you don’t have these unknown unknowns. And I think that’s a really powerful company who encouraged you to use other products, especially educational ones. So you’re not tied into them. One, you may not be loyal to them two. But three is that they know for you to do that job predictive, but you need to know about it. So I would suggest for people to go and learn more about the process, when it comes to what can gdps do, I don’t think there should be limits imposed on that. We are honest as orthodontists as practitioners as to what we understand, and we should stick to that as our process. But having listened to conversations like ours today, for example, hopefully some people have gone away with some pearls from it. But listen to the people’s conversations as well, like we did like Robin’s talk, we may have had a different opinion when it came to use of elastics.

But I mean, it was really cool to see how what he thought and how bootstrapping was working for him. And having these conversations is how we will grow. And again, we may be talking about experts and so on, but we are community of people. And as we grow, we will grow as a field as well. So the more we know, the more questions we’ll ask them what answers we’ll find, and we’ll all get better at doing our jobs. And I do feel as though we are summations of the people around it. So I hope we can share this information. And general dental practitioner colleagues can carry out orthodontic treatment within their sphere of understanding and I tried to keep it to that I don’t think there should be limitations on products. I don’t think there’s limitations on tooth movements.

And I like when I was applying for the dentist as a general practitioner colleague, Nadeem Younis, who’s involved with the [Bard], the aesthetic Academy, there’s a lot of composite course and so on. He’s not a specialist. He was my mentor when I was going through training applications for training for orthodontics, he delivers an orthodontic contract. But there are people out there who are very good may not have the bells and whistles associated with their name, but the definitely people out have my family members treated by so I don’t think you should be restricted.

But what I would say is that the discrepancy I feel between specialists and general practitioners who are carrying out this treatment is comes down to the online setup. And the clincheck if you want to talk about Invisalign, is that I feel as though the orthodontist is is more kind of in tune to question to know what movements are biologically predictable, and which ones aren’t. And I think that’s where I do hold the companies to account at the automation process. I really feel in be doing it now with the trainees is that we give them just an online set up with the teeth not straight and see where it goes. You straighten the teeth using the software. So they know what they know what movements they’ve put into the process. It looked at each individual tooth movement, and they’ve put it in themselves. So and then also well, was that predictable? Is it not predictable is a biological sample. Whereas a company’s through automating it have negated that process of understanding about which tooth movements are taking place. So that I feel as though is an educational issue, a convenience issue from a corporation perspective, but actually I think the Dentists have lost out in that process. Was orthodontists have got that from the other training.

[Jaz]
The most eye opening moment for me, Farooq, was when I went to I’m not going to mention any names or anything, I went to a lab. And they were doing these orthodontic setups for clear aligners. And I just sat and I observed what these technicians were doing, right. And they just highlighted the circles around each individual tooth. So digitally, the tooth is cut out, and they just made them look pretty. And that was it.

There was these guys aren’t dentists, they’re just putting them roughly where they think they should go, and then they send a dentist to approve. So I completely echo everything you said in terms of understanding what is possible, what is predictable, taking into account biology as well. And I really look forward to your envelope of aligners, you could be the next prophet. So when you do get that out, please do share it with us all.

We’d love to have that and do join the Protrusive Dental community. It’d be great to have you on there as well as our sort of aligner expert or one of our aligner experts now. And I think you really wrapped up very nicely with so much humility, so much geekiness. And so many knowledge bombs, Farooq thank you so much for all your input today. It was absolutely brilliant. And thank you for embarrassing me as well.

[Farooq]
It’s an absolute pleasure to be here. Really, I’ve been waiting for the call up is taken far longer than I’ve been messaging before. But either way, I appreciate it, my friend. It’s been an absolute honor. And I and again, guys, I just want to say I am really indebted to Jaz. He really helped me direct me as to how to set up my own stuff when it came to orthodontics. I do see him as really as somebody to aspire to when it comes to positivity when it comes to education. And really, I think you’re leading the way, Jaz. So look forward to seeing what you’re going to do next.

Jaz’s Outro: 
I appreciate you so much, man. Thanks so much for coming on today. Hope you enjoyed that episode. Thank you for listening all the way to the end. I think Farooq is such a humble specialist, I mean, I love people like him who you know, he’s practicing a really high level like he’s a consultant. He does so much for the profession and education. He’s so down to earth and he’s so with it with a GDP so Farooq man, keep doing what you’re doing. We love it. Thank you so much for helping us gdps and also helping the profession of orthodontics. I think you’re really you’re advancing orthodontics, man, you’re spreading knowledge, you’re helping them run out. So I respect that massively. So from the next episode, we’re no longer in straightpril mode and the next episode I have for you is productivity with a prosthodontist with my good friend Ricky Bhopal. I hope you enjoy it and I’ll catch you then.