Deep Bites and Aligners – How to Improve Predictability – PDP170

[Jaz]
I always thought that deep bite, if it’s super deep bite you’re better off going for fixed appliances because aligners will struggle with deep bite correction.

But speaking to the Taheri brothers showed me that actually, you can do a lot when it comes to deep bite with aligners. Which attachments should you use and when? How should you stage your deep bite correction? And what about bite ramps? What are they? Why are they so effective in deep bite correction? And why you should use them with care?

Hello Protruserati, I’m Jaz Gulati and you’re listening to your favorite dental podcast. Thank you for joining me again. If you’re new, welcome to the podcast. You picked an interesting one, a very orthodontics based one. I cover all sorts of dentistry over the last four years or so. So do check out our backlog of episodes.

Protrusive Dental Pearl
Now, every main episode, I give you a Protrusive Dental Pearl. Today’s dental pearl is all about how I record my clinical videos. Now, recently on YouTube, I published a video about how to record awesome clinical videos using a loop mounted camera. So I’ll put the show links for that one below. But also if you search how to record awesome clinical dental videos, it will come up.

Essentially It’s using something called an OXO 4K. I think it’s a spanish company but they have made the best camera that I have seen. I’ve tried a few and I’ve also spoken to a few very experienced colleagues. And they have suggested that OXO was the best and i’ve been using it for over 18 months now And you can see from the content that I post some of the videos are really crisp and the point of view footage that you get especially on some of the videos I have on the Protrusive app. That’s all powered by the OXO.

So if you’re looking about how you can use videography in dentistry, that’s why it’s shining a light on the review I did recently. Now let’s join the Taheri brothers and I’ll catch you in the outro.

Main Episode:
So Damon and Ramtin Taheri, welcome to the Protrusive Dental Podcast. Great to have you both on. How are you both?

[Damon]
Good, Jaz. Thank you so much. Thank you so much for having us. First of all, we’re big fans of the podcast. So, yeah, we’re honored to be featured on here now and hopefully have a nice chat and hopefully have something that people can learn from.

[Jaz]
Oh, absolutely. I’ve been looking forward to this because the topic we’re covering today, which is a deep bites and aligners, it’s a big one for general dentists, a big one even for orthodontists, especially there are still some orthodontists, which we’ll talk about later that are very much fixed in their mindset that actually aligners are not suitable for any form of a deep bite.

But when I look at your guys cases online, like, I’m just amazed about how much you two are achieving with aligners. So today I really want to extract all this goodness out of your brain and share it with our colleagues so we can all learn together, but before we dive into all that good stuff, tell us a little bit about yourselves, like your brothers and you both went into ortho. Like what’s that about?

[Ramtin]
Yeah. So, Jaz again, just to sort of come back to being with us. Thank you so much for having us. It’s a absolute pleasure. We’re a big fan of the podcast and we’re both orthodontists. We both specialized in Sweden. And it was really a case for us of like, for me, especially, and I went into the specialty slightly earlier in the day because I’m older, but it was really a case of, I didn’t, in terms of the dentistry that I was doing, it was very like NHS and based on just volume.

Wasn’t a big fan. We were doing, and I was doing, I think this is the sort of nice thing from us is that we have been doing Invisalign for a long time. So I was doing it as a GDP. I decided to specialize because I felt like I wanted to do something different. I really enjoyed the orthodontic side of things.

I went to university where one of the at that time one of the few universities in the world that was had aligner of therapy as one of the sort of modalities of treatment along with like, lingual braces and things like that. So we really got into it at that point. Really started understanding how it works.

[Jaz]
Is that why you picked it? Is that why you went to Sweden? I mean, that’s something to unpack right there. Like, is that because you want to study in that country? Do you have some sort of connection to Sweden? How did you end up going to Sweden to study?

[Ramtin]
So we’re just, I know we don’t look it, but we’re both Iranians originally, but Damon was born in Sweden. I was a year old when we moved to Sweden from Iran and we lived in Sweden for the first 13 years of our lives. So we only came to the UK in 99. And then, we have that connection to Sweden always. So we had back and forth all the time. One of our friends who’s an orthodontist said that, they have this opening or it’s like a new year admissions time for applicants.

So I just tried my luck. I might as well try and see what happens, I was successful and decided to make it happen. I think Damon just decided to follow in that path as well. And it’s such a good place to study. We had a lot of big names teaching there. It’s the founding father of implants comes from Gothenburg University.

He was working. We had a whole Bruno in my clinic there. We have a lot of important people in orthodontics. So it seemed like a good place to go and go study.

[Jaz]
And but to actually practice orthodontics, you decided to come back to the UK. Why is that? Do you not fancy practicing in Sweden? Just asking in terms of lifestyle choice, life and career choices, you know?

[Ramtin]
I mean, Sweden is amazing. Sweden is a really nice country to live in. We felt that, we feel British at this point. We feel English. And although the accent doesn’t agree, but we do feel English.

And this is where our family, so it was never a case of moving back there because our parents are here. So it was really just a case of going there, specializing, coming back, I did, I’ve been more so me than Damon did consider maybe staying for a year or two, but at the end, sort of everything sort of lined up. I’ve got a job here, everything lined up to come back to England. Yeah.

[Jaz]
And the interesting thing about being an orthodontist, something I’ve said to orthodontists before, and I hope you don’t get offended by this, but I say it to all the orthodontists that come on the podcast, is if you don’t like clinical dentistry, be an orthodontist.

If you don’t like the whole matrix thing, if you don’t like too much blood, if you don’t like scaling, awake, calculus and prepping margins and be an orthodontist, was that something that you can resonate with?

[Damon]
Yeah. I mean, personally, I think, yeah, 50% of that is exactly what you said. I want to come to work. If you’ve had like a tough weekend where you’ve just been out and about, you just want to start a Monday. You don’t have to worry about like damaging a nerve. You don’t have to think about missing the canal. What I like about orthodontics, it’s very hard to mess up. Like if you do mess up, you can normally pick up on it like six weeks down the line.

So yeah, I wanted an easy life. I enjoyed dentistry. I did a lot of, when I graduated, I lived, it was like 50 percent NHS, 50 percent private. I think for me personally, I found it. I find it quite stressful. I’m a little bit OCD. I always want things to be perfect and I want to be in control of it. And I feel with general dentistry, you have to be good at fillings.

You have to be good at crown preps, root canal treatments, dentures. It will take, I felt it would take a lot, really long time before I get to the level where I feel very at peace with be able to give that really high quality day in day out. And it just felt like a really long pathway to get to somewhere where I didn’t have, I enjoyed it. I did have a passion for it.

So that’s when I thought, Ramtin’s gone and specialized. He loves it. We have very similar tastes. So I already knew I would like it. And yeah, when we got into it, it was exactly kind of what I’d hoped, I have full control now, pretty much like 99. 9 percent of things you can control in orthodontics.

And that’s what I like. I don’t like being out of control and you can excel at something to a very high level. So that gives me pleasure. That was my personal side. I don’t know about you.

[Jaz]
It’s a beauty in finding a beautiful thing about finding a niche. And then the second thing I was gonna mention actually is as an orthodontist, like you were considering perhaps staying in Sweden, but as an orthodontist, like when you work somewhere, you can’t just like, I’ll hand in my notice and see you later, I’m going in three months. You’ve got this responsibility to be there for your patients.

So I guess it kind of removes that element of an orthodontist being able to just move practices and fly around because you kind of have to commit to see off the treatment. So I noticed that even with GDPs to do orthodontics, they still have to come back to finish the cases. Do you find that a bit annoying?

[Ramtin]
In terms of the case, that’s a very good point. It’s not a case of as soon as you’re done somewhere, you like, you give your three month notice and you go off for three months. You have to finish your cases where at least you have to wait for a replacement that’s able to come in, feel comfortable with your cases, take those over.

So of course, it’s one of those things where I think as orthodontists, we don’t quite move around practices as much as perhaps GPs might do. But, we don’t take on jobs very easily, if I could like that, and it’s like with all orthodontists, like we have our practices in Leeds, we have a couple of practices in Leeds that are NHS ortho practices.

And it’s not a case of you just take on anyone and, they come and go. It’s a very careful process of finding the right people. And then those people will be won’t be an easy, okay, interview today, they start tomorrow. It’s a case of you create a relationship. Because they know that once they’re in and they’re treating patients, they’re going to be there for the long haul.

So, yeah, that’s a bit of a difficult side of things, but at least you’re much more careful when choosing somewhere to work and luckily since 2019 or 18, when we opened up our own practice, we’ve sort of been in the one place. So it’s been pretty straightforward.

[Jaz]
Amazing. Well, let’s unpack the main theme of today, which is deep bites, right? So I have this belief and I’m really happy for you to shatter this belief, right? But it might be true to some extent. So the belief is that the deeper the bite, I’m going to refer out for fixed appliances. So basically as the bite gets deeper, both in terms of dentally and skeletally, that kind of stuff that I think, okay, maybe this is not for aligners, how much truth is there in that, but also, really how predictable can deep bite correction be with aligners? So it’s like a two prong question.

[Damon]
Yeah. Jaz, it’s a question we hear all the time. Even my own earliest experiences with aligners was a deep bite case that just didn’t go well. And I was like, Invisalign is rubbish. Clear aligners are rubbish. Let’s go back to old school. And I think I want, this is what we’re trying to teach our delegates on our course as well, is I want them to get away from the kind of mentality that, oh, aligners will only take you this far and then you need to use fixed braces.

We pretty much use Invisalign in 99 percent of our cases, unless the patient prefers fixed braces. Sometimes we use a hybrid if we feel we want more control, for example, of like really complicated extraction cases. But 99 percent of our cases would do with aligners. And I think the first thing you need to understand is like every brace has its own limitation.

Fixed braces have their own weaknesses. Everything has its own weakness. And once you understand what that weakness is, then it’s easy to find a way around it and to navigate around that to get to the same results. So yes, obviously the deeper the bite, the harder it becomes to fix it. But then you have to strengthen your clinch check.

You have to strengthen your plan and find what things going to add into this to make it more predictable. Yeah, I can’t remember the last time we had to, well, I don’t think we’ve ever had to change from aligners to fix braces, to fix a deep bite case. Obviously there’s cases where it’s so deep that even with braces, sometimes you need to use like a bite plate to open the case in those cases.

Yes. Then probably you can consider doing maybe like a really early, like a removal appliance, but those cases are rare. I mean, in the last four years, I’ve probably seen one or two cases where it’s been that deep and that’s in adults. In kids, if I see those deep bite cases, I’ll be absolutely fine.

Kids are 10 times easier to treat. Results wise, as in it just behaves so well compared to adults, but yeah, I think there’s probably been one or two cases in the last three years where we had to use, for example, TADs to help level that lower jaw. But as long as you plan your clincheck well, you understand what anchorage demands in these.

You need to understand overcorrection. You need to understand accessories that you need, like bite ramps. Then you can pretty much, in our opinion, you can treat any case predictably with aligners.

[Jaz]
Well, we’re going to unpack all those things that you said about I want to clarify for the younger colleagues about TADs and overcorrection, what that means and how important it is for when you’re designing the clincheck.

So we’re going to unpack all that. So really, how far can you go? I think you wanted it, Damon, is that actually in your specialist clinic, you don’t necessarily shy away from liners just because it’s a deep bite. You just know that you’re going to compensate for that deep bite correction in other ways, which is great to hear.

And I’ve even seen some patients on fixed appliances and the orthodontist has really struggled to get the deep bite correction in fixed appliances. And then maybe at that point, yes, TADs might come into the equation. So let’s focus on adults, right? And let’s focus on this episode is mostly done by GDPs.

And we want to help our GDPs who are, let’s say, using aligners, whichever brand they’re using, right, to get better outcomes. So let’s imagine a patient with a 75 percent overbite. Okay, so 75 percent overbite. And obviously that’s the only information I’m giving you. So there’s all the other parameters that you’re fixing.

But because we’re homing in on the deep bite correction, how predictable can it be in terms of how certain movements have a percentage of predictability amount to it? So, firstly, if you can unpack what are the actual mechanisms that you’re doing, for example, is it purely intrusion of the anteriors or is it also overruption if you’d like, it’s a poor term there.

Extrusion, there we are, that’s a better term, of the molars. How much of that is happening and what predictability, how they get that little dots and the blue dots and the black dots and what do you tend to see with these deep bite corrections?

[Ramtin]
So Jaz, I think the first thing to realize is that, aligners as other types of appliances have their inherent weaknesses when it comes to deep bite correction. And I think the number one thing that everyone alludes to is the fact that you have this plastic between the teeth posteriorly. So there is this intrusive, inherent intrusive force on these posterior teeth. So in effect, what we’re doing is in a deep bite, when we’re trying to open the bite up, we’re doing the opposite with the tray.

And if the patient keeps clenching on these bits of plastic that keep pushing teeth away from each other. As a result, the mandible sort of shifts, swivels up and forward to form a boat to rotation to make the bite even deeper. So in terms of how we try to treat these cases, I think you have to realize that what you’re looking at, the actual setup for the treatment, let’s say for this line, the clincheck, I think the thing that people have to differentiate is the fact that this, what you see on the clincheck is not actually where the teeth are going to end up, what you’ll see is the tray that’s for the trays, tray one to 30, tray number two, three, four.

And that’s how the tray changes to apply a force to the teeth to get that desired tooth movement. Now in terms of deep bites, the things that we have to deal with to like on a very simple basis. The curve of speed is the big one, that’s the curvature that runs from the posterior teeth up to the incisors.

Generally in the UK, patients tend to be very class two-ish. There is that lack of inter incisal contact as a result of super eruption of the lower incisors and canines. And as a result, you get this curve where the molars and premolars are sort of lowered down and things move up anteriorly, resulting in a deep bite.

So the first thing we need to do is solve or correct that curve of speed. So that’s the first one. The second factor we look at is the curve of Wilson. So this is the curve, the transversal curve that runs on the cusp of the molars and premolars in the lower jaw up to the premolars and molars on the other side.

And it basically indicates that the posterior teeth, lower jaw, if you look in transversal, they’re sort of tipped in like this usually. We like to upright, and we like to flatten out that curve of Wilson. We then have to look at the inclination of the incisors, like Damon said, if you’re intruding incisors, there’s a difference between absolute intrusion, where you’re intruding the tooth down like this along this long axis, versus if you’re proclining, if I’m proclining my incisors forward.

But for climbing forward, I get relative intrusion, which helps towards a deep bite correction. So we’re looking at curve of Spee, curve of Wilson, the incisor inclination. We then look at how we can support the movements that we’re doing. For example, anterior bite ramps. Anterior bite ramps helps us intrude the lower incisors in order to level the curve of Spee.

It also allows us to get some posterior extrusion takes away that intrusive effect of the trade. So we’re looking at various factors to get the help from the deep bite correction, as opposed to just, let’s overcorrect the, for example, open bite of deep bite. Yes, overcorrect, but there are factors that you look at that lead to the overcorrection.

[Jaz]
So just talk about, everything is brilliant, but just talk about overcorrection. So some people are new to aligners, right? And they might be new to clinchecks. Like even I had a colleague last week David, Ramtin, who messaged me on Instagram. He had a tough case and then he spoke to the Invisalign case cafe on the phone, whatever the guy who the guys who help you and he’s relatively new in the aligner world.

And he was shocked because and to you guys, this is like, well, this is obvious, right? But a young practitioner starting aligners, okay. They still believe. And that’s just like I did, that what you see in the clincheck, what you see is what you get. Whereas you’ve put it beautifully that no, that’s not the movement, that’s the tray.

And if you think of it as this is a tray, and it’s like a representation of the forces that are going to be happening, which is the best explanation I’ve heard. And if you’ve got anything else about it, I’d be happy to hear it. But a lot of our colleagues still need to remember that just because you see the clincheck doesn’t mean it’s going to happen.

So that’s really, really important to emphasize. But for those of you who are starting out really beginners, What is overcorrection? How does that look on a clincheck? And why is it important?

[Damon]
Yeah, I can take it. So yeah, Jaz, I think that’s a very good point where you said we call it it’s a forced system. It’s not a true representation of where the teeth are going to be at the end. So, when we first started out exactly the same as everyone else, you take it for, it’s gospel. Whatever you see on the ClinCheck, you think you can’t change it. That’s exactly what AI or technology says. That’s the best way to get from A to Z.

And I think as soon as you realize that’s actually probably the worst possible way to get to A to Z, then you start, you need to be the pilot. You can’t have a technician telling you what the best way is. You always, of course, they do a great job. They give you a good baseline, but that baseline needs to be improved quite a lot if you want predictable results.

And I think overcorrection, it, again, it comes down to understanding that what you see on the clincheck, it’s not what’s going to happen in real life. So certain things, for example, from our point of view. We don’t over correct everything. So we’re very confident in the way we move the teeth. Again, you can change attachments on the clincheck.

You can change the thickness, the shape, the orientation, which way they’re beveled. You can change when you do your IPR, you can change how much IPR you do. So everything should be adjustable and you should be looking at these things. I know it sounds stressful, but one of the things we talk about on our course is protocols to say these are the steps you can follow to make it more easy to follow.

But from our side, the things we overcorrect, we never overcorrect like rotations because we feel confident in the way we can move the teeth. And by that, I mean, the staging, staging is the sequence of the movements that makes a huge difference. Probably the most important factor in Invisalign planning is your staging and round tripping, which we can discuss a little bit about, but yeah, we don’t overcorrect rotations.

The things we do overcorrect are expansion and vertical changes. So overbite correction. And how much we expand, because it’s exactly the same thing we do with fixed braces. I don’t know if you have any experience with fixed braces, Jaz, have you ever?

[Jaz]
I do.

[Damon]
So if you expand an upper arch with fixed braces, you bend the wire out. It’s a lot wider than it looks, and then you slot it in and you want the wire to ideally, expand for you a little bit. You’re not going to get all of that. You might get like 20 percent of it. Now you have to think about aligners exactly the same. I don’t see why we should do it differently with fixed braces than compared to aligners.

Aligners are probably the same strength compared to like a 1925 hat, for example. So if we overcorrect with fixed braces, we should definitely overcorrect with aligners. And that’s especially with expansion and especially with the vertical correction as well. If you’re finishing your clinchecks with a perfect overbite. I can guarantee it’s going to look very imperfect in real life. So yes, we do overcorrect. Obviously that depends.

[Jaz]
So just to make it really tangible. So overcorrection is basically example is a deep bite patient. And if you overcorrect them, you’re going to on the ClinCheck, they’ll finish with an AOB.

[Damon]
Well, it depends on the case. And these are the things you need to understand. Not every deep bite case is the same. So if you have a, for example, you have a deep bite case. Where it’s very crowded, the incisors are retroclined, then that’s a lot easier. Why? It comes back to what Ramtin was saying about the relative extrusion and intrusion.

When you procline teeth, they almost fall over, right? They lean forwards. So it looks like you get some intrusion, but it’s relative intrusion. So that’s your best friend when it comes to deep bite case. If you see crowding, retrocline incisors, amazing. Just by aligning the teeth and proclining the teeth.

Obviously in the correct way, then you could see the debug will open up really well. So in those cases, yes, you still need to overcorrect. So for example. If it’s like crowding and you’ve got like a comprehensive package, we tend to finish it kind of edge to edge. But if you’ve got a case where, for example, you have spacing, the spacing is your worst, is like the worst enemy with a deep bite case, because it’s the opposite.

If you close spaces, the teeth retrocline and you get relative extrusion, and when you get relative extrusion, deepen the bites, so then you have to over correct more because you’re working against yourself, so yes, you can still fix it and we do all the time, but you have to make sure you control how much you open the bites in the front, basically. I’d overcorrect a bit more.

[Jaz]
Hey guys, it’s just Jaz interfering here with an important message. Remember how we’re raising money for Nafisa? Nafisa has A type 1 and we are so close to getting genetic therapy for her. Remember, she’s a daughter of Sakina, who’s a dentist, just like you. She’s one of the Protruserati and her daughter needs our help.

So far they’ve raised, and also with a little bit of our help, 778,000 which is amazing, but we need about 1. 8 million to get this very expensive genetic therapy for Nafisa before she turns age two. Now, the latest update is that if they can reach a million, the company has agreed to start her genetic therapy and they can pay the rest in installments.

So we’re actually really close to getting Nafisa the care that she needs. So we can keep her alive and well. There’s a video I recorded all about this on my Instagram page @protrusivedental, and if you’d like to support Nafisa, head over to protrusive.co.uk/nafisa. That’s N-A-F-I-S-A. Thanks so much and back to the main episode.

[Ramtin]
I can just add something to that concept. So exactly what Damon says, we have to be careful with the overcorrection too. We can’t overcorrect in a generalized manner for everyone. It has to be depending on what other factors are there. But again, it comes down to the fact that we know that there are inherent issues with the aligners, similar to what fixed braces are, like Damon said, fixed braces have this degree and as you all know from doing fixed braces, there’s a slot inside the bracket and it’s playing with a wire that doesn’t quite fully fit the bracket, which means that some of those forces are lost in translation. With aligners we can imagine Jaz, they’re super flexible, you can take a tray is sort of bended like this, super flexible, so you have more play, you have more flexibility, you have more force losses.

So that’s the discrepancy, that overcorrection comes from just overcoming those weaknesses within the plastic where the forces are lost. And to try to make up for that so we can go away from those studies where excellent studies the studies that shows that there’s a I don’t know 30 percent predictability in incisor intrusion there’s a 50 percent predictability of canine intrusion. You need to compensate for that and add in the overcorrection to overcome those shortcomings.

[Jaz]
Just because we haven’t covered it, you explained it, for those who are well versed in Invisalign, which most people listening, yeah, they’ll get that straight away, but for those who’s really beginning, an overcorrection is if the tooth needs one millimetre intrusion, you might put in two millimetre intrusion you’re doing it too much, basically, just a primitive there. Now, on a 75 percent deep bite case, that example that we made up, basically, would you ever need to use a things like TADs, how often do you guys use TADs to assist you with a deep bite correction? And it just more primitive than that. What are TADs?

[Ramtin]
TADs are Temporary Anchorage Devices. They’re small mini screws, different diameters, different lengths, the common one that we use is about seven, eight millimeters long, like a mini implant, basically. We place it into the bone for various reasons.

And the theory is that by having the screw in the bone, it gives you absolute anchor. She gives you something to push against or pull against that doesn’t move at all. So in a case where you want, for example, to carry out a movement that has side effects in terms of his movement, or it can cause a worsening we’re trying to do by adding the TADs in, you can take away the reciprocal action of a force.

So you solely can, for example, putting two low TADs in the long jaw, you can intrude the incisors without any side effects, and you have a hundred percent anchorage in pulling these predictably. Okay, so there’s just an adjunct to fix or align the therapy or fix braces just to give us a bit more support when needed.

To answer your question in terms of why we use them or when we use them, in terms of deep bites, we don’t use them a lot, to be completely honest. We usually use TADs for open bites when needed for posterior intrusion. We use it sometimes when someone hasn’t increased in size of display in the upper jaw to protrude the front teeth up to reduce the gummy smile.

And we use it very rarely for deep bites as well. So generally with the deep bites, we tend to put them between the lower lateral incisor and canine, buccally on either side. The patient then puts the tray in. We’ll put a couple of buttons on the inside of the lower canine and maybe the lower lateral incisor.

I would have an elastic that runs from the screw buccally across the tray if we need to buttons lingually, and that will just give us some absolute intrusion, some proclamation too, but generally intrusion to solve a deep bite. The times we tend to use it, do you remember I said that to correct the curve of speed, where the molars and premolars are lower down, the incisors are higher up, sometimes when we correct this, we need, for example, if I’m intruding incisors, I need a lot of support from the posterior teeth.

I need anchorage from the molars to give me the sort of, if you imagine, the strength needed to push those lower incisors down. So we tend to, for example, put an attachment on the lower sixes. Having an attachment in lower six to three really locks in. It doesn’t lift off, it stays locked in, which gives the anchorage needed for the incisors to intrude.

If I, for example, don’t have those lower molars, let’s say I have missing teeth in the lower jaw posteriorly, I only have the incisors, I’m not going to be able to intrude those incisors if I don’t have the anchorage in the posterior teeth. So in cases like that, I might consider putting TADs in instead to compensate the fact for the fact that I don’t have my full mechanics available.

That I would have available otherwise. Other reasons I would place it again, like I mentioned, if someone has a very deep bite, I don’t just want to intrude the lower incisors, but actually partial reason is the upper teeth are overextruded. I want to intrude upper incisors. Often TADs is a lot more of a predictable way to do that.

[Jaz]
Well, one of the other, so it’s good to know that you don’t use it so often, but it’s there as an option. So you explained that really well in terms of why you might do it. And there’s a great description of going from the buccal to the lingual with the two elastics. That’s a nice visual that we can imagine.

Now, another technique that you mentioned already in the podcast is bite ramps, which I think is very important for correcting deep bites and liners. Can you explain what bite ramps are you kind of touched on it just explain what they are and where in the protocol because now we’re gonna get more into protocols do you use it?

Like is it from aligner one have bite ramps all the way through and they even have them in the retainers in the future or is it a certain stage? Can you talk more about what they are and and how they are used in your protocols?

[Damon]
Yeah, so bite ramps, I think they’re crucial in deep bite correction, but it’s crucial to use it in the right way. Often I see them used incorrectly and I’ll touch on that in a second, but it comes back to the same principle in that inherently aligners want to make the bite deeper because you have this, you normally only occlude in the back. It creates an intrusive force to the molars. The molars obviously bite later and you get this anterior and upwards rotation of the mandible.

So it deepens the bite just by wearing the trays. So what you’re trying to do with anterior bite ramps is twofold. One is you’re trying to transmit the force. So you’re not biting in the back as much, but you’re biting in the front. And then it’s the same as like DAHL principle. Imagine you have a DAHL appliance, you get intrusion of the upper and lower incisors.

And at the same time, you get disclusion of the molars. And then they want to obviously erupt until the contact again, exactly the same as what we do with fixed braces. Sometimes we put these two blobs of composite lingually on the central incisors, come back three, four months later, and the posterior teeth are now occluding, and then you remove the bite ramp and you’ve established a new, basically a new overbite.

So we’re trying to take the force from the back to the front, but also we’re trying to increase the intrusive force of the incisors in the front. We’re trying to, again, we know they’re weak, the aligners in intruding the incisors. So we’re trying to see how can we make it more predictable. So we’re increasing the force in the front.

So it helps to intrude the incisors a lot easier. Now, bite ramps, you have to be careful where you use them. I think sometimes people use them like, first of all, you should, if you want to fix the deep bite, you should be using a canine to canine either both the canines, either both the laterals. Or both the centrals, there’s no need to use them, for example, like two to two or three to three.

The reason I say that, and the reason that sometimes people use them incorrectly is whenever you use a bite ramp and the way a bite ramp looks on the aligner, it’s like a little extension of the plastic, but the plastic is not filled. So that bit of the plastic is not in contact with the tooth. And with aligners, the most important thing is plastic cover.

The more plastic cover you have in contact with the tooth. The more 360 control you have. So if you start sacrificing your plastic cover, then you have to make sure it’s for a good cause. So let’s say for example, and Invisalign will do this unfortunately sometimes. Let’s say there’s like a deep bite, but also a big overjet.

If you hit the right threshold, Invisalign will just put on bite ramps for you, but then you look at the bites and there’s no antagonist contact. The only way a bite ramp will work if there’s antagonist contact. So the first thing you have to check is, is there antagonist contact? Otherwise they’re completely useless.

And if anything, they’re working against what you’re trying to do. And then as I said, you don’t need to put them in all the teeth. So you put them, for example, on just the laterals or just the centrals or just the canines. A lot of the time we end up putting them on the canines. And that’s because if the tooth needs a big movement, like a big rotation or like a big extrusion or like a torque issue, then we prioritize plastic cover over the need for a bite ramp.

I can fix the deep bites in other ways. So because of that, and normally the laterals are always twisted, right? The centrals have like a torque issue in these cases. So in a lot of those cases, we put them on the canines. And then we look at the simulation. We see, okay, how long are they in contact?

Maybe after 20 weeks, I’ll tell Invisalign after 20 weeks, remove the bike ramps, because then I can see, you know what? The overjet or like a class two div two case, the overjet might increase and suddenly they’re not in contact. So you have to really dissect the clincheck can see every little bit, is it useful or is it working against me?

Now we’re using less tabs with deep bites because we’re kind of pushing the boundary of what we can do. We’re kind of moving towards, we’ve experimented in last year and it works really well. We’re trying to increase the force in the front. So this is not for everyone, by the way, I will not go straight into this, but we started experimenting with actually filling the bite ramps.

So you’ve got physical bike ramps in the back. You have to do that with patients that are very cooperative, that are going to be okay with having a very strange bite for a good few weeks. I normally do it for about three months. And younger patients, ideally, older patients will really struggle.

[Jaz]
So, this is the bite ramp, like using it, like, so actually filling it in the aligner or filling it as an attachment on the teeth?

[Damon]
No, so yeah, you’re filling it on the tooth. So imagine you have your attachment templates. You actually feel the lingual side of it as well. And then when you take off the tray, it’s still stuck on the teeth. So, exactly the same principle.

[Jaz]
So when they’re eating and stuff, basically, you’re still getting the benefit, basically, that’s the idea, right?

[Damon]
Yeah, yeah. But these cases, Jaz, again, you have to be careful because it’s very tricky for the patient. Trickier than fixed braces, I find. So you have to have that conversation with them.

And I only really reserve that for cases where they might need TADs. So I say, look, either we go down the TAD route, or we can go down this route. I really only use the cases where it’s like, there’s no crowding. The teeth are already slightly inclined forwards, so I don’t have that luxury of the relative intrusion.

Then you need almost like a level of absolute intrusion. They work a treat, but you have to be careful. You have to make sure you’ve got balanced contacts. There’s a lot of things to take into account, but this is more towards like the advanced level. There’s probably, I think-

[Jaz]
I think the Protruserati listening today, a lot of these are very restorative minded and very well versed in DAHL and actually they’re thinking, yeah, you know what? That makes a lot of sense. And it does. And certainly you’ve blown my mind. I mean, I’m guilty of treating a deep bite case or having a deep bite element and be like, yeah, bite ramps go for it. I didn’t even think about the fact that it wasn’t covering the tooth.

And so that’s opened my mind. So that’s great. I love that. I’m sure there’s others who feel the same. So guys, I’m loving this already. It’s hard to discuss now about the actual, the meaty, the juicy parts, which everyone’s been waiting for, right? It’s actually your secret sauce. Yeah, your aligner protocols, the top one you get all the time.

Like, hey, DMing you like, hey, what’s the best attachment for X movement? What’s the best attachment for that moment? I bet you guys are sick of that question. Right? So spill all of this. I know every case is unique, but what would you say to someone who says, what is the best attachment? And also what are generally the treatment protocols.

And I think you mentioned also about round tripping and what that means as well. I’m sure you’ll get into that in terms of how you explain it.

[Damon]
Yeah. That’s the protocols. It’s important. We have our own we’re calling the CAT protocols, the complete aligner program protocols. It’s just something that works really well for us.

We’re not saying this is the absolutely right way to do it. It just works very particularly for us. It’s based on like 10, 000 plus cases. So we trial and tested over the years and we’ve come up with something that works, extremely effectively and predictably. And it’s just understanding if you understand what causes the bite, like Ramtin said, you’ve got accentuated curve of speed, you’re trying to level that curve of speed.

So we break it into movement mechanics and reaction mechanics. So movement mechanics is basically the movements you have to do on the clincheck to make it look the way you want and reaction mechanics are controlling some of the reactionary forces as a result of that. So essentially what you want to do, you want to intrude the three to three, and you want to extrude posteriorly to that.

And that works great. Action reaction. So as one side goes down, one side goes up. And what we normally do is we find like a premolar. That’s like our reference point, the one that’s kind of the highest. And then we just align, we just extrude the other posterior teeth to the same level. So we’re trying to get away from that curve and we want to try and flatten it in the back.

So that’s kind of a step one and step two, find a reference premolar, extrude the other teeth. So they’re on the same level and then you want to intrude. Initially we intrude the three to three by millimeter to two, depending on the case, then we deselect the canines and we select your lateral incisor, the incisor to incisor, and we intrude those a little bit further again by about a millimeter or two, depending on the case.

The reason for that is, canines are a little bit more predictable in how much we get with the intrusion that we asked for. So we don’t need to over correct as much, whereas the incisors are much weaker. So the step one is just, that’s the moving mechanics. We’re trying to create like a fixed braces, a sweep effects.

We’re not trying to go for flat cover speed. We’re trying to go the opposite. Then once you’ve decided which way, you know how to set up those teeth, then you have to decide how to allow those movements to happen. So that’s the anchorage bit. That’s the attachments part of it. And attachments are absolutely crucial in deep bite cases.

You need attachments in the back, like Ramtin said, as you intrude the front, like a seesaw, the back wants to come up, which is good because you want the posterior teeth to extrude, but that won’t happen if the plastic is lifting off the back. So you need an attachment in the back, normally one on the molar, one on the premolar, the right type of attachment as well to lock it in and to help this extrusion take place.

Because as soon as the plastic is allowed to play, you’re losing so much force, not just in the back, but also in the front as well. So you really lock in the plastic in the back and then you allow for that intrusion to happen a lot more accurately. You also need some attachments in the front, normally on the canines and maybe one each on the incisors.

And that’s for the canines. It’s for anchorage again, to help intrude the incisors, because if you remember, they need to intrude a bit more than the canines. And then the incisors, we normally put a couple of attachments on there, not for anchorage, but to stiffen the plastic. The more attachments you have the less play, the less bouncing you have of the tray.

So that’s just to really stiffen the plastic and almost making the tray like a thicker wire. So you can exert more of your force. And then you check your overcorrection, make sure that it’s edge to edge. Do you want to open more if it’s like a spacing case?

So that’s a very quick summary. Obviously our deep bite lectures is like an hour and a half in reality, but that’s a very quick summary of what you should be looking at when you’re planning your deep bite cases, and then you look at your accessories like making sure there’s at the end of your occlusion, it should look heavy in the back and obviously open in the front or no contact in the back.

You need to check where your anterior bite ramps are. If there’s any heavy rotations, like I said, you want to put them on the canines. If the canines need big movements, then you just leave them off completely, for example. And then when it gets more advanced, like an extreme deep bite, that’s when you start looking at filling bite ramps and things like this.

I hope that gives you a very quick overview.

[Jaz]
Yeah, it certainly does. Just because you mentioned about round tripping and for the younger colleagues it’s something I’m very familiar with, but how would you describe what round tripping is and how might you notice it and what relevance does it have specifically to deep bites, if at all?

[Ramtin]
I mean, the thing with round tripping is that I think we’ve gone a little bit away from it here in the UK. For some reason, everyone seems to think that round tripping is something that should be avoided at all costs. Whereas-

[Jaz]
What is round tripping?

[Ramtin]
Yeah, so round tripping is basically the tipping out of teeth, the buccal tipping out of teeth to create space, mesial and distal to the teeth to eliminate collisions, basically.

And then once you have that space and there are no collisions, you then retract back everything to alignment. So what you do is instead of going from like A to B, you go like A to C. And then you bring it back to B because you’re trying to do it with collisions without collisions. You’re trying to, instead of just aligning teeth, for example, you tip them out first.

So there’s no collision between those teeth. And then once there’s no collisions, you then retract them back into alignment. It’s what we do with fixed braces. When you put up, when you have fixed brackets on the teeth, you put a wire in, you don’t just magically align the teeth. The wire wants to go back to its original position.

As you know, as it goes towards its original position, we often round trip. Now. We can control the amount of round tripping we do. We want to reduce it sometimes, in which case, for example, with fixed braces, you might take out the lower premolars. You don’t bond the lower two to two. You retract the canines first.

You have space around the laterals. Then you bond or engage laterals and incisors. It’s the same with aligners. You’re basically ensuring that the alignment happens without collisions. Now, very important because if you’re treating a deep bite case, the alignment that you create is what helps you as you procline to create space and get them into alignment.

That proclination is giving you that relative intrusion to help you in a deep bite correction. So in order to be able to solve a deep bite, you need to accurately, predictably solve crowding. And that crowding has to be solved using round tripping. If anyone tells you don’t round trip with aligners. It’s not orthodontics. It doesn’t work predictively.

[Jaz]
I agree. I mean, when I was a junior years of learning aligners and stuff, and orthodontics in general, I had that sort of belief in me that was passed on to me, that don’t round trip. Like it’s really bad for gingival reasons and all that kind of stuff that you don’t want to see that on the ClinCheck.

That happens and do lots of heavy IPR, do it early, do lots of stripping. So you avoid that round tripping. But then when I did a few cases of fixed appliances and I realized, oh, actually, yeah, this, this is how fixed pointers works, right? And so why are we so, so afraid of it? Yes, there might be some times that you might want to slow down or just be careful and sequence things, right?

Which you guys are masters of. But yeah, it’s a good lesson there for GDP. Don’t be so afraid as it’s made out to be. It’s not as bad of a thing. And so saying that as you guys know, I’ve got to pick up my kid, but I’d love to promote and then talk about your course. People are raving about it on Facebook from what I’ve seen, talking about the definitive course to learn aligner mechanics, the best attachment, the best protocols. So tell us about your course. So, you know, where does it run? How often you hold it?

[Damon]
Yeah. The Complete Aligner program is kind of our pride and joy. I think we found there was, there was a need for further education with aligners I think people go on this certification course and then they’ll be like, good luck, do orthodontics.

And it takes three years for us full time to fully understand orthodontics. So that’s one side of it. And then the other side is you don’t actually understand the mechanics of it. So what we’ve tried to do is get people away from the issues that we had, the journey we had to get through go through all the rubbish, all the shit to be able to get to where we are now.

So we’ve made it very, very simple. I love getting spoon fed. I don’t like fluff talk. I want direct step by step understanding of this is exactly how to get from A to Z. A lot of time you go on a course and it all makes sense during the day. And then you leave and you’re like, yeah, it was amazing. But I have no idea what to do now.

So we want to move away from that. So we give these set protocols and it’s all in this big handbook to take away of not just clinic, not just like theoretical ClinCheck, yes, we go through every malocclusion. We give them set protocols for deep bites, open bites, attachments, when to use what attachment.

But we also discuss things like how to fit your Invisalign tray, how to streamline that journey, what tools you can use to increase the efficiency for that. We talk about IPR in detail because I feel IPR is undertalked about, such an important part. We talk about how to do it. We show videos of exactly how we do it, how to stage it.

People don’t understand you can do IPR at a later date compared to what Invisalign tells you. So it’s all about doing things at the right time. We take away some of the stress that people have about aligners and IPR. To make it very simple because it doesn’t need to be complicated. Orthodontics is very simple, but you need the tools to get there.

So yeah, intense two days. If everyone really wants to kind of push their aligner to the next level or next levels, even, I think it’s a no brainer if you want to learn more about that.

[Jaz]
And who’s your ideal delegate in the sense that you want someone who’s like literally just done like the certification and they’ve not done a single case, or do you like it if they’ve done like maybe 5, 10 cases? Who’s the ideal candidate to learn from your course?

[Ramtin]
I’ll say we can’t, I think the thing with Jaz is that it’s all the protocols that we give are based on orthodontic principles. That’s what it is, it’s not like some sort of shortcut, it’s just us taking someone’s understanding and telling them, this is what you need to focus on.

It really is good for anyone, starter to advanced users. And I think something we’re introducing very soon is like an introduction part as well, which will cover all the basics, basic aspects of it as well. It’s going to be like an online thing that people do before the two day course is part of the course.

So I honestly think that it’s beneficial for everyone that wants to do. A lot of cases I want you to take one more cases and we’re doing a couple every year in London, couple of courses every year in London. And we’re also doing our first course in Los Angeles next year as well in May. So exciting times ahead. Yeah. So it’s going to be cool.

[Jaz]
How do I book that one?

[Ramtin]
Yeah, you’re in man. You’re in anytime you want Jaz. Yeah. LA is the one though. That’s why we’re doing it there, just to have fun.

[Jaz]
Amazing, well-done guys, I’m very proud so much. Well done, that’s amazing. Well, I encourage everyone, I’m putting the show notes, so just check out your cases. They speak for themselves. Your amazing Instagram page, I was checking out your stories the other day. I think you were talking about deep bites in that story actually, so if you want to see the proof, then have a look at your protocols online. I’ll put the website in the show notes, but you can just share the website so people can log in and learn about how to upgrade their aligner knowledge.

[Damon]
The website is www.aliners.co.uk, but without the G. Don’t ask why it’s the only website we could find that wasn’t taken. So it’s A-L-I-N-E-R-S. Aliners.

[Jaz]
Aliners without the G. Perfect. Amazing. Well, Damon, Ramtin, thanks so much for your time. And I look forward to meeting you one day, hopefully in the flesh. Hopefully in LA, who knows, but that’s very exciting. The American audience will have something to look forward to as well, as well as the Brits. And I think everyone has gained, for me, it’s just like little nuggets here and there. I mean, I’ve learned a lot from you guys, but that whole little thing about the byte rounds being overused, I’m definitely guilty of that.

So I’m going to change that about my protocols right away. And you covered a lot in terms of overcorrection and the mechanics. So yeah, I really appreciate that and I think everyone’s going to love it. So please do comment below guys, if you enjoy this episode today and I’ll catch you soon guys. Thank you so much.

Both:
Thank you so much. We really appreciate it.

Jaz’s Outro:
Well, there we have it guys. Now we can employ a few extra techniques to make sure we get more predictable deep bite correction. If you know any other orthodontic or aligner topics that you’d like me to cover, please let me know. Comment below. And if you’ve made it this far, at least we deserve a like if you’re watching this, if you’re listening.

Again, I really appreciate you listening all the way to the end and you deserve some CPD. You deserve some certificate to prove that you’ve learned something and you can get that on protrusive.app website, answer a few questions, you get your certificate emailed to you by Mari. And speaking of, I want to thank my team as always nowadays, Erika Allen Benitez, who is my producer, Krissel Jane Facoon, who produced the premium notes for this, and Mari Benitez, who will sort you out with CPD.

Thanks again, Protruserati, and I’ll see you same time, same place next week.