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General Dentists Doing Orthodontics [STRAIGHTPRIL] – PDP067

We don’t refer all our extractions, root canals and crowns – then surely there is a role of GDPs to carry out Orthodontics? In the last 10 years we have seen a boom in GDP Orthodontics and much of this is ‘Alignment Only Orthodontics’. Protruserati, welcome to Straightpril!

Dr Nick Simon shares his journey and advice with Jaz

Need to Read it? Check out the Full Episode Transcript below!

In this episode we discuss:

  • How GDPs can get involved in Orthodontics
  • Which, according to Dr Nick Simon, is the best Orthodontic system for GDPs?
  • His views on all the Dentists jumping on the Invisalign bandwagon
  • How significant is the loss of anterior guidance in ‘STO’ (Short Term Ortho) cases
  • The 2 most common mistakes GDPs make while carrying out Orthodontics

Sponsor: Did you check out the Mini Smile Makeover course? You can attend again in the future at no additional cost – THAT’s awesome!

Protrusive Dental Pearl: I use the Beauty and the Beast Mirror to ask patients what they hate most about their smile. It injects personality and humour – but you also find out exactly what the patient does not like about their smile!

If you enjoyed this episode, you should also check out Are Class I Molars Important? With Dr Mo Almuzian

Click below for full episode transcript:

Opening Snippet: There aren't any systems that are better than each other. There may be an educational system and i do believe that the IAS from what i have experienced because it travels from simple to complex removable to fixed...

Jaz’s Introduction: What’s the best thing about online courses like i mean i’ve done a lot of online courses and even more in-person courses and what i love about online courses is the ability to rewind and re-watch and skip forward and to go to that exact point which you need which sometimes in like an in-person course if you’re watching someone do a technique or if you’re in a lecture component you sometimes just relying on your notes thereafter and you lose that magic of revisiting that exact moment which you can with online courses. So i think the future of dentistry and dental education is very much online courses i mean i know in-person courses has its place but there is something magical about the revolution with online courses in dentistry, however and it’s a big however is because i want to tell you about the mini smile makeover course this is a sponsored episode by enlightened and mini smile makeover but i wanted to give you some context and perspective right? So online course is awesome because you get to revisit. Now what i loved about the mini smile makeover course where i went around about 18 months ago so and really enjoyed all the pearls that Dipesh Palmer shared and i relied on my notes and the little handouts they gave but the beautiful thing about the course is that they allow you once you go on the course and you become a delegate, they allow you to come again in the future and sit at the back so you’re not actually you don’t actually get to the hands-on bit again because obviously that’s for the paying delegates but because you’ve done their course you get to sit in the back and you can bring your laptop you know note making and sometimes the ability to re-watch that live presentation, the live lectures and the beauty of being able to network again with fellow dentists is just sensational. So i think that’s a wonderful model to carry out dental education i actually really wish and hope that this catches on and other course providers will also allow you to you know once you go on their course allow you to come again in the future and just sit in the back and absorb and that’s another reason why when someone asked me which composite core should i go on i’m very quick to recommend the mini smile makeover of course because of this ability to go again and i look forward to joining them this summer for my revisit. Hello Protruserati . I’m Jaz Gulati and welcome to another episode of the Protrusive Dental podcast and the very first episode of straightpril this month we’re focusing all about orthodontics but i guess i’m a general dentist you know i’m not a specialist therefore the sort of direction or the perspective of all the episodes is from the perspective of a general dentist like so many general dentists are doing or carrying out orthodontics. It’s actually amazing the the sort of growth it’s had in the last 5-10 years amongst gdps but i also have some specialists this month who will be sharing their perspectives on retention, on when to compromise and when to go comprehensive which i know you will love. That’s going to be really key up so but today I’ve actually got a GDP, Nick Simon, who’s very well known about as a GDP in the world of orthodontics. And I want to sort of pick his brain about which is the best GDP friendly system out there, which is a question so many of you ask, I just want to get some insight from him to inspire you all in terms of how he got involved with orthodontics as a GDP because back when Nick Simon got involved with GDP orthodontics, it was something that was a lot more frowned upon than it is now. I mean now, it’s so much more accepted that general dentists carry out orthodontics, and they do so at a good high level and we should champion that but to back when he was getting involved. There was still a lot of friction from the orthodontist that you know, you know, General Dentist should not be doing orthodontics kind of thing. So it’s great to have him on with his perspective. Essentially, what Nick Simon shares is that he saw many of his patients had lower incisor crowding. I mean, so many of our patients have that right. And quite often the patients would say to him, I want to get this sorted. So he refer the patient to an orthodontist. Now the patient would come back to Nick and say, Listen, I went to the orthodontist, and they want to remove my teeth and it’s gonna be two, two and a half year treatment. And this is not what I want, can’t you just straight in my lower teeth. And that’s what sort of sparked his interest in thinking Hang on a minute, should I be able to help these patients perhaps? So that was a real eye opening moment for him in terms of sparking his interest in orthodontics. Now for those of you not in the UK, and Nick does reference someone called Anoop and what he meant by Anoop Maini, who is a phenomenal dentist. Unfortunately he passed away Over a year ago, and it’s really sad because he was such a great pioneer in the UK and Europe of GDP orthodontic, so I want this episode to be almost like a tribute to him as well. He was a great guy. I spoke to him a good few times. He what he did to advance GDP orthodontics has been unrivaled by anyone I know. So that’s who you meant when he mentioned Anoop. And I think even though we should all take a moment to tribute, the wonderful platform that Anoop set up for general dentists doing orthodontics in you. The Protrusive Dental pearl I want to share with you is something I use in most of my orthodontic consultations. Here’s what I do, okay, is because what I want to find out from a patient is what is it that they want to change the most? What is their biggest hate? What is their biggest desire for their smile, because alongside all the objectives you want to achieve through orthodontics, you really need to make sure you nail the patient’s wishes and expectations. So the way I do that is I sort of inject some humor into a situation I inject some my personality into a situation, I was inspired to do this by Mohammed Al museun, who taught me orthodontics. And basically is this, you say to the patient? Do you remember the magic mirror from Beauty and the Beast? And of course, everyone remembers the magic mirror from Beauty and the Beast, right? So what I do is I have this sort of Disney versions, little handheld mirror. And I say, Well, here it is, here’s the mirror, okay, I want you to look at the mirror. And when you look at your teeth, you say to the patient, and I want you to tell me exactly every single little thing that you don’t like about your teeth, so that I can help you. And I think this is great because it gets, you know, the child or the adult laughing if they’re with a parent, they start laughing. It’s cool. It’s a quirky, fun little thing, but it also gets you that really important information you need, which is what is it that bothers them the most is the whole thought sort of, if I had a magic wand, what would you change kind of question, except just delivered in a different way. So I’ll put a link on the show notes about exact mirror that I have. I think it’s from the Disney Store. But you can use anything using imagination. I just want to share that with you two fold thing here. One is injecting some fun and personality into the question and two the importance of asking that question because you want to know exactly what they don’t like about their smile. I also want to share some cool news with you. I recently became an admin on the Facebook group for ripe global. Now, going back, I mean, you heard the Lincoln Harris episodes, which were phenomenal, as you know, and Lincoln started restorative implant practice excellence Facebook group some years ago. And the point of the group was to post full protocol photos. And I learned so much from watching these great clinicians around the world post up their full protocol cases, like who’s got time for before and afters, no one, you want to see that every single detail because inspires you, you’re gonna see a patient one day who has a similar presentation to what you saw on the forum, and you’ll get ideas and you’ll get inspiration. So I’ve been a huge fan of the group, huge fan of ripe global I’ve done videos for them, I keep adding content on their website, and was a great honor to receive the silver badge case, denoting the fact that I am now an admin for ripe global. So if you’re not already on the ripe global Facebook groups got over 80,000 of us dentists all over the world. please do join, it will be great to see you on there. I also want to give a shout out to Demetrius, who is a Cypriot dentist based in Germany. Okay, so Cypriot dentist based in Germany, Demetrius, thank you so much for reaching out. And I respect Demetrius because he reached out with positivity and with love, but also some very useful constructive feedback for me, which is this sometimes a lot of you when you’re listening to the podcast, you are driving. And sometimes I might say something like nti sci, or I’ll say something some acronym, right. And you guys, when you’re driving, you’re like, you want to know what it is, you don’t want to continue listening the episode because you want to find out what I just referred to, and you can’t because you’re driving, you can’t Google that thing. So I’m going to make it a aim to not use abbreviations so much or if I do to explain what they mean. So everyone benefits now because a lot of these episodes have been pre recorded like me my content calendar is for next three or four months. This change may not be immediately reflected, but I really really value Demetrius your feedback. Thank you so much. And then really appreciate you listening to the Protrusive Dental podcast my friend, guys enjoy this episode with Nick Simon all about GDP orthodontics, which is the best system how to get involved with orthodontics. What are the dangers pitfalls at the end, he shares with you The two biggest mistakes we make as gdps. Hope you enjoy guys.

Main Interview:

[Jaz]
Nick Simon, welcome to the Protrusive Dental podcast. How are you?

[Nick]
Great. So thank you so much for having me, as you know, quite a keen avid listener to your podcast. I’ve enjoyed a lot of the previous episodes and it’s an honor just to be here today. So thanks.

[Jaz]
I really appreciate that and you know, I first personally I’ve known about you For many years, actually, I’ve probably known about you since I was a student in Sheffield, like maybe in 2011. Nine years ago, I’d heard about you, because the good work you’ve done, yeah, the good work you’ve done in the realm of GDP, orthodontics, right, and I’m a house level and now SoFo boy. So that’s in West London. And I knew this gentleman and his dentist in Ealing, doing really high quality work. And I sort of, I’ve sort of seen your name pop up everywhere. And then I got a message from you in the summer in the middle of pandemic, it was so nice to see the message from you. And you mentioned the podcast and the resin bonded bridge course and stuff like that. So it’s been so nice, another person like yourself, who I’ve been able to connect with from the podcast. So again, thank you so much for reaching out and eventually led to this. And I’m sort of I’m twisting around forcing you to come on here, because I think you think that you don’t have much summary for some reason, but I think you’ve got so much to share. So I’m really excited for today’s chat. But for those people who don’t know, who are Nick, just tell us a little about yourself, and what is your thing? Where do you practice a little bit of your background?

[Nick]
Background? Certainly. So well, I made my first appearance in the mid 60s. I was born at the London Hospital in Barts Health. And 18 years later, I made a return as an undergraduate. So that’s why I did my dentistry. And I have two wonderful parents, I could not have chosen better parents really, my dad was a dentist, he was one of the best dental communicators I’ve ever come across his way with patients was genius. And yet he has also skills, one of the early adopters of implants. He was a past president of the AGI. My mother was the business brain. I say that in in that my dad used to tell me that in the days when before computers, they had record cards, the nurse would transport the cards from the dental area dental clinic to my mom at reception, and she would add another zero on to the bill. And I think she said that no one complains, no one ever complains. And that’s how it was really so I grew up in northwest London suburbia in a very comfortable environment really. And at the age of 18. I went off to university had a great time there. And my first touch point, I suppose with orthodontics because as you say, I’m sort of known in a way for GDP orthodontics, although we’ll come on to what sort of type of GDP is the orthodontics? I don’t know if you because I think you went to London as well. Is that correct?

[Jaz]
I went to Sheffield.

[Nick]
Oh, you say Sheffield. Yeah. But after London, I come the final year where we had the orthodontic section. I do remember going off to a clinic maybe once a week or every two weeks, where we were looking at removable appliances. And my memory from that is that I actually can’t remember that anything moved. There were no teeth that moved. And a few years after qualifying, I heard that orthodontics was one of the best paid specialties that there was no in dentistry. And I really couldn’t compute it. I wonder what is going on here. I mean, at college, I thought it was a little bit like, you know, perio and ortho, maybe not real well. So max facts. I’m not that keen. I mean, Maxfact is serious stuff. I wasn’t keen enough on that stacks, although I really could understand what was going on. transitioners where I’ve been really. So that was my first touch points with ortho. My second was listening to Tif Qureshi. I think in the early 90s, when he came over and started talking at the VA CD, there’s a little section known as members pearls. And members were able to talk for about 20 minutes on their preferred subject. Tif was talking about what was to be the Inman aligner. And he was moved. And also doing some lower incisal bonding. And at that stage, I had no real ambition to move any teeth at all. But I do remember badgering him. Artists, let me talk on how he got his incisal composites to stay on because I couldn’t actually translate that my technique was very similar to him. But being at a clinic with sort of very low budgets, we were using very low budget materials, and they were falling off. So those are my two touch points with ortho. And it really got started when a friend of mine showed me a picture of some crooked lower incisors that he made straight and I thought my gosh, loads of clients come to me asking me Can I do this? And I say, No, I can’t. I’ll send you off to the orthodontist. They go to orthodontists they come back saying they’re not going ahead. They need these taken out. It’s going to take too long. They don’t want to go through that time and expense. So I took what was to be the first six months smart course with, this was before it came here, was in America with three other buddies from the UK. So we came over and we were

[Jaz]
So you flew to the States?

[Nick]
I flew to the States.

[Jaz]
And how many years qualified were you at this?

[Nick]
20 years qualified? This was 2008 2008. Yeah. So the course, for a little while, I think Ryan Sweeney tested it out dental town was where a lot of the adverts were placed. And the threads that Ryan did on, I’m going to open up a clinic, I’m going to do short term author, I’m not going to do anything else. And people said he was crazy. But I mean, you know, history shows what a going concern it was and how well he did out of it. And there were two proponents of that there was Ron swinging six months smiles, and Richter Paul with his power procs. So I did both. So I flew out and did both. And it was changing, it was mind changing, because this was a time when so called smart design was coming out. And we were all somewhere prepping teeth to make them straight. The so called portions of Boston Deficiency Syndrome, where you just place veneers from. So I came back thinking that this is going to be really good. I was really enthusiastic about it. And I started to ask a lot of questions on the forum, how to do this and how to do that. And in the matter of time, I was answering the questions. So I was helping too many other dentists. And then after that, I worked for another team on the Cfast. And then on IAS, I’ve heard sort of experience with three different types of forums, helping dentists worldwide with simple fix ortho.

[Jaz]
So one of the reasons I had you on is because when I learned that you’d actually work alongside and educated with multiple systems. One of the overarching questions I want to help answer today, which is extremely controversial, and I appreciate that is the age old question that you see all the time when people are initially getting into orthodontics. And they say, which is the best system, right? So people will say, Oh, is it QST? quick straight teeth? Or is it IAS? Or is it Cfast? Or people will say, Hey, I’m thinking of doing Damon braces, you know, so there’s so many different systems and whatnot. So that’s one thing that I think you’ll be in a good position, potentially, your answer might be biased, but I like the fact that you’ve really been with so many different camps. So I’m really looking forward to what you think about that. But is there anything else that you want to add in the in the background, just to add a bit of a sort of context, before we really dive into those questions?

[Nick]
I’m not being paid by any of the companies at the moment. So I guess I’m in a position where I can really be completely open about it. I think it is, as you say, it’s a very common question in the UK, certainly in the Facebook forums, people are asking that especially new dentists, and it’s a fair question to ask I mean, how do you decide what courses to go on? You put up a question and you start to take advice there. We both know that there’s no tooth as I said, on their come, I’m upset you put on a quick straight teeth bracket there and not an IAS one over what because you know teeth responds to force vectors, biomechanics, and not to logo. It’s human beings that respond to logos.

[Jaz]
Absolutely. All orthodontics is a prescription of a force. Yeah. And when you think of it that way, you know, whether even you know, we’re going to eventually build up to clear aligners, no matter what the cost or price, but we’re going to build up to that as well. Because nowadays, I mean, I think four years ago, people used to be like, which is the best fixed appliance system or which is the best system and that what they meant was, which is the best bracket system. But nowadays, more and more, it’s no longer which is the best system is like should I do Invisalign go or should I do Invisalign full? Pass the new question that you’re seeing more than the old question you’d get was like, which system so we can see this evolution. If you’d like of orthodontics in terms of preference of new dentist into aligners.

[Nick]
Yeah, I can understand that. Because fixed braces, I mean, think what happens is that teeth move along the wire, and they can be a little bit unpredictable. And this is the thing. I mean, when I was doing the Six Month Smiles, for example, we were told, and I wasn’t doing Invisalign, then from still actually, but we were told, how frustrating is it to finish off your Invisalign cases? So your clear aligner cases? How many refinements do you have to do? You know, you start saying to the patient, are you wearing your aligners, and there’s a kind of trust issue going on. So how it was sold is that the wire was acting all the time, and you’re gonna finish the cases better. Yeah, it’s an interesting thing. We will touch on that but before

[Jaz]
I ask you like I’ll just point like I asked you, which is the best system, fixed braces before I do that. You did touch on the type of GDP-Orthodontics that you do so what is it you know, that makes your What is your sort of philosophy or style of orthodontics, if you know what I mean by that my question because you sort of touched on it about You’re known for a certain type of orthodontics. And I’ve touched up on that. What do you mean by that?

[Nick]
Well, I’m also it develops and it evolves because I’m reading back while I’m doing in my braces. I’m doing less cases. I think when it came to GDP-Orthodontics, and suddenly working on the forums, one of the mistakes I could see was, someone would do a weekend course. And then on the Monday think they’re an orthodontist. You know, can I do this? Can I do that? Can I make space for this implant? And you know, there’s a reason why it takes years to get your em off. And as I do more fixed ortho, the more respect I have for orthodontists, and as I did more ortho, the more cases I was referring out to orthodontists. And you know, I have a good relationship with orthodontist too. But it does make you think now there was that advert? I don’t know Jaz, if you remember that advert that they’d be put out. It was some..

[Jaz]
in the Daily Mail or something?

[Nick]
Yes, it might have. I can’t remember. I think the telegraph springs to mind that I remember exactly. But I remember that there was a double page spreads or big, big page adverts by the BLS saying that GDPs, no beware who you choose for your orthodontics. Should you even be going to a GDP? Maybe you should only be choosing your specialist ortho bearing in mind that a lot of gdps were subscribers to the BLS. It was a concern. And in a trust, the tragic loss actually is mainly because, you know, Anoop was GDP-Orthodontics, and no we actually met at a six month smile course that was taking place near Ealing, I went along to meet Ryan Swain because he was traveling to eat UK and he doesn’t travel over that often. Well, I met a newt, we just got chatting, where do you live? Where do you live? Turns out, we only live two minutes down the road, only two minutes. And that became the start of a great friendship. But once that POS advert came out, that was a springboard for Anoop, to really create the ESAO, the European Society of Aesthetic Orthodontics. And what that did, I think that was a really important era in orthodontics for gdps in this country, because it brought everyone together, regardless of the system. There aren’t any systems that are better than each other. There may be an educational system. And I do believe that the IAS from what I have experienced, because it travels from simple to complex, removable to fixed. And I’m and you’re now if I have a case where I have concerns or questions, I’ve got three specialist orthodontists who I can ask and get answers quick time. I think it’s just fantastic. And it evolves. But the ESAO was nondenominational. We did courses, talking about how to assess orthodontics, how to diagnose and how to treatment plan, because in my days, that’s not what we did. We didn’t have anything, you know, the assessment form is very much a form, and a call now, especially with an uptake of weight, especially since the GDC. And orthotics litigation. We all know that any GP providing orthodontic really has to do their assessment diagnosis, like a specialist like an orthodontist, there’s no real difference. So it did change marketly, then ones is that the company’s took notes, and the company’s raise standards so that we are now safer dentists across the board. And I think that was an important moment for the ESAO, once happens, there wasn’t really any word for the ESAO to go. So it just sort of stopped.

[Jaz]
But it achieved something quite significant for the like you said to the GDP movement and you know, Anoop Maini rest in peace really legendary person I was a student when I first saw him speak and you’re right. I mean, that activity I was seeing as a young dental student and you know, your, I think I believe you were involved and Tif. And all these great gdps in orthodontics we’re doing so much to facilitate us as GDP is to do more orthodontics. And I think you guys have revolutionized the situation and created a real boom in a way. But there are dangers of that as well, which we can we can touch on. But yeah, essentially the answer to highlight is there is no best system, but consider the fact that mentorship and guidance and a thorough assessment should be a foundation of any system that you choose. Absolutely. It’s the educational pathway, which is the key thing. So the next question I asked Nick is, I know you said you don’t do clear aligners, right. So why did you because you seem like someone who’s very passionate about orthodontics and you respect it and you know you have a good relationship especially So did you ever consider to Hey, I, you know, maybe the demand is there and patients are asking you, Hey, can I have clear aligners? Can I have Invisalign? And then perhaps you’re converting these patients into fixed appliance patients, or you are not treating them and referring them on but don’t you think that it’s time you provided clear aligners?

[Nick]
I do. So I am going to, in fact, I decided I don’t do any clear aligners. So the best way forward for me is actually taking the Diploma in clear aligners, so I’m booked on it for early next year. Brilliant. So I thought that’s gonna force me about clear aligners. Because I think there’s very, I mean, I’m not gonna say Invisalign is the best system, because I don’t know, I just think I need to try it. And to I think the market will be very interesting with other clear aligners, like 3M, and I think [brand] are coming into it. I think with more and more usage of digital scanning, I think that there’s going to be a lot of interesting clear aligners,

[Jaz]
I think I am waiting for a clear aligner company to be able to compete with Invisalign to continue, because they have such a huge market share. But to be fair, from my experience, Nick, having now used three clear line systems purely out of testing, and to see, hey, is there something better or is there something in a different approach to Invisalign and both the other alternative UK based clear alinger systems I used, one I used on my wife, and one I use on a patient, I was very disappointed converting to that, was upset, I was extremely disappointed, my wife was in agony. From from a clear aligner system, I’m not going to name because I don’t want to, you know, defame any system, but she was an agony, and none of my Invisalign patients that ever said their agony, and I know. So that’s one factor. And the other one, I use another laboratory based clear aligner system, the plan is sent me I was so upset with it, that when I actually also submitted Invisalign, there was a stark difference. So, Invisalign can achieve this in seven aligners or six aligners, or as it took this local company, 13 aligners, and it was just doing unnecessary movements. So, I do think that the amount of money that Invisalign invest into their technology, and their development is more than with all these other companies make.

[Nick]
It’s having more, and that’s the difference, isn’t it? Their real relevance is huge. So there are streets ahead. And you know, where we are. Westfields, for example, there’s a pop up shop that the public are well versed to knowing what’s out there on the market, and they asked for it by name, you know, fantastic for Invisalign. So, yeah, I’m going to start to get involved. I want to look into clear aligner systems. I didn’t really fully answer your other questions, I’m going to tell you why I’m starting to rain back on my fixed aligner. Fixed cases. And it’s to do with compromise results. Now term came up anterior aesthetic, anterior alignment orthodontics, in as, two comprehensive orthodontics. So either going to do the whole caboodle, well, we’re going to choose to do certain things. And the patient might choose only to look at their front scrounging. So a patient may be class two, have an they might have crowding at the front. And we may say, okay, we’re going to keep the premises at back as they are. But we’re going to align your front teeth only. And although Actually, I haven’t had any comeback, but at the same time, unlike CIF who has all these patients coming back for it seems like recalls, every few years at least, I don’t have that. But I do wonder about anterior guidance, because if we’re taking teeth, potentially out of anterior guidance or sharing less teeth on anterior guidance, how’s that gonna function over the course of a lifetime. And I’m just thinking that may be in a closed system where we can potentially actually predict the outcome a little bit more, I’m starting to think that maybe a class one crowding system is probably the safest system that there is, I can tell you that probably, I’m not really a dentist that goes for awards or anything like that. I don’t really give a monkey’s about that. But probably one of the things that warms my heart the most wasn’t a moment in a lecture that Professor Kevin O’Brien was giving. I just happen to be in that lecture. And he’s talking about and to a lot of GDPs, and maybe some not wonderful cases, and then he and then upflush one of my cases, and he said this is what we should be aiming for. I was really surprised that because, one I don’t know where you got this case from. But what it was it was case it was class one at the back class one canine relationship crowding other. And I think, you know, that’s why we should be Yes, I’ve done extraction cases, but I will always have that mentors. And is there a role for gdps in orthodontics? Absolutely. I mean, we’ve been doing it before, there’s a specialty. There’s been dentists attaching themselves to hospitals and doing clinics, we know about smile design and where to put teeth. But I think we do need to be careful, we shouldn’t take on too much there should be an educational pathway, because things don’t always go to plan. And I think as a GDP, it’s going to be more difficult.

[Jaz]
Well, I want to ask you, Nick, exactly some scenarios where you’ve seen because you’ve mentored gdps, in orthodontics, what kind of troubleshooting mistakes that gdps tend to make that you could just give some pearls on but before we get to that, just touching on a few points that you made, let’s discuss, for what it’s worth, if you don’t mind my opinion on these cases where you’ve got, let’s say, a class two, Division Two with very steep anterior guidance. And then you make you convert them essentially, to a class two a division one, because you’ve just done some anterior alignment orthodontics. So that is a concern, because you lost the anterior guidance. And you mentioned about the term How about their function throughout life. In my map of the world, you’ve got patients with AOBs, and you’ve got patients with incomplete overbites all over the place, right, whether they got plenty of space, and they don’t have much anterior guidance to begin with, and they’re fine. And then you convert this patient from very significant anterior guidance to no anterior guidance. So I worry not about how they all function. I worry about how they will parafunction, because I do believe I am in this camp that a lot of the issues are there, from the people who aren’t chewing for longer than 17 minutes a day, for people who are rubbing their teeth together when they shouldn’t be rubbing their teeth together. And that’s where I think the role of anterior guidance is more crucial. So when you’re doing a rehabilitation, you’re protecting, the reason why they needed a rehabilitation in the first place is because they destroyed their dentistry. So how can you create a minimal stress dentition. So that’s just my thinking of it. But certainly I do get happier. And I’m much happier as a GDP providing orthodontics, when I have a patient who’s already in class one canines a Class two molars, and I’m just relieving the crowding. I know that’s a home run case. And I totally share your sentiments that we should pick and choose our cases. And that’s really a beauty of being a GDP, right, you can do some cherry picking. So I just wanted to share that little point in there. And then the other thing that I want to talk about is you mentioned a great thing about a closed system right as you apply that aligners are closed system and what is interesting, because I agree with you in that respect. But sometimes when I have when I speak to orthodontists who perhaps only provide fixed appliances and I really admire you the fact that you know you’re such an experienced GDP with orthodontics, and I’ve seen your cases they’re phenomenal. And if Professor Kevin O’Brien in a podium will bring up your slides, and wow, kudos to you and to him as well to for highlighting and championing GDP orthodontics, I think, you know, well done to him as well for for sharing that. But the fact that you’re so experienced and already know so much about assessment and proper orthodontics, and you’re continuing to not just dabble, but you’re going for a diploma in that so amazing. You know, keep up that spirit. That’s fantastic. But when I speak to people who don’t have your mindset, and they stick to only what they know, fixed appliance, and they don’t even want to consider clear aligner therapy, what they say to me is they say Jaz, the problem is lack of control with Invisalign, they say that I as an orthodontist, don’t have the control, I like to put my you know, by wire bends my brackets in the right place to have the maximum control. But in my mind, that doesn’t make sense, because I think as soon as you put brackets and wires, everything is now moving. Yes, you can do a few things, you know, auxiliary things to reinforce anchors and whatnot. But essentially, if you don’t see the patient for a prolonged period, time is everything, the wires is taking effect, whereas with a clear aligner it can’t move beyond the parameters of that clear. aligner. So who’s right, who’s wrong? Are we? We both right? I mean, where do you stand on that?

[Nick]
In that conversation, orthodontists? Or are you talking about gdps providing fixed braces?

[Jaz]
I’m talking about anyone who provides orthodontics and who believes who stands in the camp that I have the most control with fixed appliances compared to someone with clear aligners.

[Nick]
Well, I think there’s definitely a difference between an orthodontist and the general dentist.

[Jaz]
Of course.

[Nick]
If I was a specialist orthodontist, I would go with my training. But let’s say that we’re GDP and we both talked about biomechanics briefly at the beginning, there’s different ways of doing it. And I’ve seen some amazing cases on forums that dentists do with Invisalign. So it’s down to the education and the skill set of the dental provider. That’s what it comes down to, and how much time you’re going to devote to it. But I do like the fact that teeth can’t move outside that clear aligner I also understand it could be frustrating sometimes, in delivering that care. I just haven’t done any Invisalign. So I thought the best way to go and deal with that is to take a diploma in clear aligners and force myself to do it.

[Jaz]
I mean, that’s amazing. That’s brilliant. I mean, from someone who’s done a fair cases, fair few cases in Invisalign, or clear aligners. The thing that we struggle with the most would be canines, you know, rotations of canines moving those canine, you know, similar to some degree with fixed appliances where they’re very anchorage demanding. You also class three cases where you got minimal overjet, you got crowding, and then you can just bring out those lower incisors. And what you end up with with clear aligners or any system is you get a posterior open bite because you haven’t retracted the lower incisors enough and you haven’t accounted for that. So it’s lack of planning, lack of diagnosis that you can run into trouble. So in your experience, this leads nicely to what kind of what couple of scenarios, few gems Can you share with gdps, about common errors or common mistakes that you have seen gdps make with orthodontics that you’d like to just share to avoid?

[Nick]
Okay, well, I’ll come obviously, from the fixed bracket, fixed camp. So the main one, but there’s two main ones, which are failure to assess, failure to diagnose and failure to plan. And the next big one is failure to communicate. So I know on the IAS websites, there’s now take an online course on how to do your assessment, diagnosis and treatment planning. I know Ross Hopson has done that. I think that’s invaluable. Really, I think the answer 100 quid to have that knowledge is just a fantastic. Communication, it’s part of consent, failure to tell people that theit teeth, they’re going to procline, failure to tell them that they’re going to end up with black triangles to anticipate, failures to tell them about retention, who’s responsible for the retainers? Are they going to the maintenance? Who’s going to pay for the maintenance? Problems with IPR? Not doing enough, maybe doing IPR when extraction is the best policy. Failure to refer from the very beginning is a concern over proclining, not looking at bio type, getting recession. Now, these are all big parameters that GDP got into trouble really over.

[Jaz]
Brilliant. So you get the communication one’s really big, but you also get a few clinical ones, black triangles, what is your best way to communicate to a patient a black triangle? You just show them a photo? Or have any analogies that use or any diagrams? I show other people’s cases. Obviously.

[Nick]
I do, though, I show I show patients because one of the things I do with fixed braces is I take a lot of photos. So I’m always on top of my cases, I’m taking photos from before we put the braces on, I’m taking photos of the bonds up, at the bonds up. And before the next treatment, I’m thinking what do I plan to happen? What am I planning to do at my next visit? And so it’s ongoing. So I keep tabs on it. You know, I say to myself, this morning, I put on the bracket and it was like a millimeter out in a vertical plane. You know that tooth is the intro to extrude. So I know about it, I’m measuring it, I’m looking at it, I’m looking at the shape of the wire. So I’m trying to keep tabs on what’s going on. I think that’s really important.

[Nick]
Brilliant. That’s a great job, take lots of photos and critique it. And that leads very nicely to one of my last questions is what percentage of your cases are you, once bond it up? Because I imagine are you doing freehand bonding or have your brackets or are using a template?

[Nick]
Yeah, so I’ve freehand bonded for the last, for almost all my cases, actually, it’s very rare for me to and so you know, companies would like you to use their labs because obviously it’s profitable for them. When I took the six month smile course. We were taught to do both. And so initially, to get me going, up and running, I would use a laboratory services for that. And as you become more experienced, I would then set my own brackets and using various companies, I’m not saying it could be any company. I can actually look at a bonding tray and see that the bracket is not in the right position. So I’ve missed that one out and and reinserted myself. But I’m not as fast as an orthodontist. I’m not an orthodontist. I’m a GDP. And you know, I know where I am.

[Jaz]
Having taken IAS courses, and advanced course, then we’re expected to bond up all the time. And so that’s what I do. Brilliant. And when you’ve done that, and you’d like you said, you’ve taken a photo. And by the way, that is a real pearl that we should highlight that you know, when you’re starting out to use these lab services, but eventually, but also to critique when you get back and really look at it, is that bracket really in the right place? What’s the action that will be happening? So that’s a great tip. And when you take the photos, like recently, you said, is a millimeter out in the vertical plane? In what percentage of cases will you be re bonding brackets at a later visit? to just get your bracket positioning perfect? Yeah.

[Nick]
So the two ways that I know of getting into things, the right shape is either to bend the wire, or to move the bracket, it’s a little bit tedious to keep moving the bracket. So it’s easy to bend the wire, which was our failure to bend stainless steel. So you need better brackets in order to do that. Is there a better bracket? Probably there is. Can you beat a metal bracket? I don’t know. I don’t think so. Also with a ceramic bracket, but if you’re going to use, you know, the composite brackets, or what are they poly carboxylated.

[Jaz]
Polycarbonate, I think.

[Nick]
Plastic, we’re calling a classical piece of plastic, then they can’t retake a stainless steel wire. So it all comes down to your bracket selection and your prescription as well. And your education. So do you want to chip in unless a bracket is obviously out. And that’s I’ve had, you know, really late night, which is rare on the night before, I’m not going to start and then there’s an obvious bracket out of position, I’m not going to change it until I’m into a 20-20 wire says probably on visit three or so. Because as things start to level, then I’ll start to pick and choose which ones. And yes, I will spend time placing, replacing my brackets as to what I want to achieve. Brilliant.

[Jaz]
Fantastic. And just as a last nitty gritty detail, which is your bracket system of choice, like for example, when I do do brackets, I’m using 3M’s MBT prescription brackets, I forget the exact name, but they’re by 3M. Which ones use parity. That’s the one.

[Nick]
Yeah, I think and also I like purity as well. They just come up. They’re very good as well, purity. And

[Jaz]
I do like the ones with the self adhesive bit. So you don’t even have to worry about putting the button and it’s already got the self adhesive. It just makes sense. But anyway, Nick, we’ve got we’ve had a few gems, he talks a little bit about the evolution of GDP, orthodontics, I pinned you and I asked you about which system is best. And you gave a very humble answer. And you gave us some really good gems overall and as your you know, previous history in advising other gdps and I’m so glad to hear that you will be going into the clear aligner space. And I admire the way that you’re going about it. So and I wish you all the best with that diploma. I’m sure you’re gonna Ace it and get distinction and all that sort of stuff. No pressure. Any closing comments from you, Nick, my friend for anyone listening who’s thinking about advancing themselves in orthodontics.

[Nick]
I think it’s an exciting journey to take, I wouldn’t not be scared about it. I think it’s a pathway like most things in life, start off small and start to grow. But I think it’s really enjoyable. It’s certainly something that our patients have been asking us for, you know, they’ve been growing up with teeth that they’re not proud of. And in the lockdown period, using zooms apparently is a growth in terms of people asking for orthodontic treatments because they’ve been seeing themselves on zoom and whatever. And seeking all that is aesthetic treatment. So I would say go for it. Choose a company, which has, I think a good educational pathway. And have fun.

[Jaz]
Amazing. Thanks so much, Nick once again for for coming on and sharing those pearls is really, really great having you on the podcast.

[Nick]
It’s my pleasure. Thanks very much for having me. I really enjoyed it. Just Jaz.

Jaz’s Outro: Well, there we have it. Dr. Nick Simon. Thanks so much for guys for listening all the way to the end. I always appreciate it very much. Do follow us on Instagram. It’s @protrusivedental, DM us with your ideas and where you want me to go in the direction of the podcast. I’m really enjoying getting on these varied guests and the next one is a specialist orthodontist. What are we talking about? When is it okay to do a compromise plan and when should you not do a compromise orthodontic plan and you should be doing comprehensive plan. So what I mean by compromise plan is like you have someone with an increased overjet and crowding and to sort out the overjet and the crowding you may need to remove two teeth to allow you To resolve the overjet, but the patient for example, says that you know what, I don’t want any teeth removed. And I just want the crowding result and that’s it. I don’t care about my overjet. So is it okay to just resolve the crowding and leave the patient in a class two division one, ie a compromised result. So that’s all be tackling with Mandeep Gosal aka the ‘gos’ and he’s a specialist orthodontist. I know you’ll love it very much. And I’ll catch you next week, same time, same place.

Hosted by
Jaz Gulati

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