Clear Aligner Therapy: Treating Adult Lower Anterior Crowding the Right Way

But just to move the teeth and put the teeth back to where they need to be is such a great starting point for your patient. And I also think that by the patient starting with that process, it gives them the ability to realize, oh, well, look at how conservative my dentist is. They're trying to do the best for me. All of a sudden, the patient's thinking to themselves, when I'm done with this tray, I'm really thinking about doing something with my teeth. It's the easiest way to present comprehensive treatment for your patients. Welcome to Austin, Texas and welcome to the Phil Klein Dental Podcast. In today's episode, we'll be talking with Dr. Rob Ritter about how GPs should recognize and address crowding of lower anterior teeth in their adult patients. In his view, treating those crowded teeth is more than just aligning them. It lays the groundwork for longer-lasting, minimally invasive aesthetic and restorative dentistry. We'll also dive into how the right approach to communicating with the patient using digital tools builds patient trust. supports comprehensive care, and improves clinical outcomes. We'll also address when a GP should keep the case in-house and when to refer to a specialist. Dr. Ritter is a practicing dentist in Jupiter, Florida for over 30 years and a nationally recognized speaker on cosmetic dentistry. He's the founder of The Protocol Live, a training program for dentists who want to elevate their clinical skills, fine-tune their treatment planning, and boost their case acceptance. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Ritter, pleasure to have you on the show. Great to be here as always, Phil. We're very happy to have you on, Dr. Ritter, and thank you for all your contributions to Viva Learning over the years. You have decades of experience, and we really appreciate you sharing a lot of that experience with our audience. So today we're going to be focusing on something that's pretty common, especially in adults, and that is lower anterior crowding. So as general dentists, why should we be cognizant of this condition, and why should we have that discussion with the patient regarding their crowded lower anterior teeth? That's a great question. It's a great start. I think we have to be very cognizant of the fact that things change. Nothing is static. Things are always moving. And myself included and my wife as the example. My wife went through orthodontics when she was a child. Let's use her as an example. Interesting case, they pulled out one premolar on the maxillary arch, kept the other premolar, and she had relapsed through the years. My wife is now into tray 21 of 25 of Invisalign because she noticed the crowding. She noticed the wear. And what happens is over time, we know that we can get wear of incisal edges. We can get a collapse of the bite. We get compensatorial wear as well. And what really happens through time... is if a patient collapses their bite because the teeth are not in the right position, if somebody breaks a tooth or snaps it off at the gum line, there's no room to restore the crown. And this is why what we see is for patients coming from other practices, of course, they come in with these odd-shaped crowns that are very short because there's no room. Why did that happen? Because teeth move. The easiest thing to look for, really, is the lower anterior teeth. You look at the lower anterior teeth. Now, of course, we have chair-side scanners. And every patient gets scanned whether they're a new patient in hygiene or they come in for a consultation. And by manipulating that image, they're seeing that the teeth are crowded and the patient always asks, are those my teeth? Of course, yeah. Yeah. Who else's are they? They're yours. I didn't know my teeth looked like that. They do. I said, and I asked the simple question, are you interesting in straightening your teeth? And they go, well, I don't really care what they look like. I said, it's not about the way they look. That's the benefit at the end that they'll look great. What I'm really concerned with is the teeth are not in the right position. And if you take a look at the opposite teeth, the opposite arch, you notice the wear that's happening either on the edges of the teeth on the upper or behind the teeth where the bite is collapsed and you can see the notches that are occurring or the wear facets on the posterior teeth. And then you do the hardest thing, which is to be quiet and let the patient take all the information in and realize that their teeth are not as straight as they could be. I want to always emphasize to the patients that if you're noticing that the teeth are shifting, it's only going to get worse. It is not going to get better on its own. And the problem becomes they get exponentially bigger solutions to the problem. If you can handle it sooner and you can go ahead and move forward with some sort of orthodontic treatment, and I'm talking about just simple, let's say Invisalign, because that's what we use. We have Align Scanners. We use Invisalign, even though there are other companies out there. I like to see people move into those trays because then after the teeth are straight, a lot of times patient says, you know what? Maybe the teeth are not the color I'm looking for or my teeth are a little short in the front. All of those things cosmetically can be fixed once the teeth are in the right position. We got to get you there first. Before aligners and for those patients that did not accept bracket and wire for obvious reasons as an adult, dentists were kind of. put into a corner where they had to over prep the teeth in order to kind of bring everything into alignment by removing tooth structure and then restoring it after that. I mean, is that what happened in many cases, unfortunately? Potentially, you're correct. And so there are people who still to this day that do not want to go through any orthodontic treatment, whether it be simple like... Invisalign trays, clear aligners, or going through the traditional model of orthodontics by an orthodontist. Now, to be fair, I share a wall and I've shared a wall with an orthodontist for the last 20 years. And we have the highest case acceptance of any dentist in town for adult orthodontics because number one, we believe in it. Number one, right off the bat, we believe in it. And of course, there's the immediacy and the ability for the orthodontist to come next door and us bring a patient next door. Taking that out of it, we all know as dentists that putting the teeth where they need to be orthodontically, is really the best solution for patients, right? It's the most conservative treatment. You're taking care of maybe sometimes not one tooth, but maybe 28 teeth to put them in the right position, which is so much less money than doing, let's say, complete rehabs on these patients. We'll be getting right back to our guest in a second, but first... When it comes to digital workflow equipment, it's important to partner with companies that provide premium products with unparalleled service all at an affordable price. That's why you should check out Shining 3D Dental. a company that offers a complete and integrated suite of high-quality and easy-to-use digital dental equipment. Their local offices are based in California and Florida, so you get in-time comprehensive support. In fact, Shining 3D Dental can furnish your office with an entire suite of digital equipment for under $27,000. This includes their AoralScan3 wireless intraoral scanner, Metasmile 3D facial scanner, and the Acufab 3D printer with its post-price. So whether you're taking your first step into digital dentistry or you're looking to add additional equipment, check out Shining 3D Dental's complete digital dental portfolio. To learn more, visit shining3ddental.com. Now I'm not talking about the patient. where the dentition is destroyed. The vertical dimension of occlusion is collapsed. A couple of teeth are missing. They'll need implants. They need to have the vertical open. They need a replacement of teeth. I'm not talking about them. I'm talking about the patients that could benefit from traditional orthodontic therapy. Now, was it more difficult 30 years ago to get adults to move forward with orthodontics? orthodontics? Yes. Until it wasn't. Meaning if they want a couple of teeth restored because there was just no room, I would tell them, I cannot restore this case without orthodontics first. And then you have to do the hardest thing, which is hold your ground. And I've seen a lot of dentists who are afraid, and I'm not supposed to say that word. So let me take that out. They're concerned that the patient would go to another practice and let the dentist then do a bridge and jump the occlusion or put it in where there was really no room to do it. And this goes back to the way we always felt about it. If they wanted to do that, I really can't stop a patient from doing that because you're choosing me because you either like my care, my skill, my knowledge, my team, my facility, whatever that is. But I was not about to compromise on what I knew would not last long term. And my goal was to always have restorations that outlived my career because the number one death sentence for a practice is redoing dentistry. It's a profit killer. Where does that stem from? That stems from doing dentistry that you know is not going to work, but you're trying to make the patient happy. And sometimes when the teeth are not in the right position, you've got to get them in the right position. So now we fast forward to 20 years ago when Invisalign came out. When Invisalign came out, it changed everything for us, didn't it? Because now the GP could very easily take a scan. And of course, we know that Align purchased Itero, right, from K-Dent. And we digitize the process from the chair to go ahead and have those designs made. And then aligners delivered where we could easily move the teeth relatively quickly. Now, it's evolved to the point where you can do more complex cases the more confident you get with this technology. But just to move the teeth and put the teeth back to where they need to be is such a great starting point for your patient. You'll never lose with having the teeth in the right place. And I also think that by the patient starting with that process, it gives them the ability to realize, oh, well. Look at how conservative my dentist is. They're trying to do the best for me. It's really not a big, because remember, most times with Invisalign, you can make monthly payments or graduate those payments out. All of a sudden, the patient's thinking to themselves, when I'm done with this tray, I'm really thinking about doing something with my teeth. It's the easiest way to present comprehensive treatment for your patients. So we're a big proponent of orthodontics, not just for children. for adults as well. Right. So I do want to ask you this question, Dr. Ritter, about referring out to a specialist, because I know GPs, many of them are doing some form of orthodontics in their office and clear aligners is obviously becoming a big part of that. When do you make the decision to refer out to a specialist? You know, what is that? that decision-making factor where you say, okay, this is going to the specialist? Because with all due respect, you're a great cosmetic dentist, but you don't have the training, the education, and the experience that an orthodontist has. So you have to know when to draw the line. Couldn't have said it better myself. Couldn't have said it better myself. And I think that is self-awareness, Phil. I am not an orthodontist, never pretended to be an orthodontist at all. I look at these cases and say to myself, okay. Are they completely overclosed, right? Are they bilaterally in misalignment? Are we jumping cases here? How far out of a class, is it a class three situation? Anything that looks to be beyond what I could get a good result on, that goes out to the orthodontist. It just goes out. I'm not trying to be a hero in my practice. I want to be very clear what I mean by that. I can't solve everybody's problem. There are times I need a specialist to help me out. And recognizing the fact that some of these cases are beyond my scope makes it very simple for me, quite honestly. It's very simple. And is that decision made after you scan or do you take a visual examination? Oh, no, it's after a scan. But before it gets sent to, well, there's two ways to do this, right? I think after a while, you can look at a scan yourself and say, I can do this in-house or it needs to be sent out. Invisalign, and I can only speak to Invisalign because that's what I utilize in my practice because of the iTero scanners that we have. You can send that out for a quick diagnosis where it takes about two minutes where it comes back with a proposal to show you and the patient what could potentially be the endpoint. It's not definitive, but it gives you an idea. So if you're questionable, you can send it out to the software and let them do a little bit of the work. If it's something that's simple, I'll do it. If it involves truly, if I have to jump. cases posteriorly with cross bites, massive, massive rotations, over bites that are 100% deep, that's getting referred out. Now let's talk about the AI component of this that you mentioned. This gets sent out when the patient agrees to move forward with Invisalign, a case that I think I can handle. And when this gets sent out, it gets sent out in a template from one of the many, many courses that are given by Invisalign. There's at least four or five different teaching facilities that you can either go there and take or different, you know, symposiums, things like that, that are given. And they provide you with a template. So when you submit your case with their template, it gets you about 50 to 75% of what the final case you would like to look at. However, when I open up those cases and I look at the arches, it doesn't look right to me. It really never comes back 100% perfect. You mean the AI generated? The AI generation. No, it's not. You know, I think for me right now, I don't mind doing it because I kind of know what teeth look like and I kind of know where they should be. As we progress in dentistry, there's no doubt that the AI, which is culling all of this data from the thousands and thousands and thousands of cases that are done, are extrapolating that information to get a better proposal. And it's going to get better as the years go on. But for right now, I still think you need to tweak some of those designs. So you have to open up that case. And then what I do is I just look at the arch and I say to myself, those, you know, posteriorly, the arches need to be brought out in the buckle corridor. And then I make it look more in the incisal view. I tip it and I go, well, that tooth needs to turn a little bit more and that tooth needs to be here. And I make all those tweaks to it. And does it take a little bit of knowledge to do that and understand the controls? Because it's basically you're kind of doing the orthodontics on the screen before you hit send to produce the trays in succession. You didn't have those control systems, you know, 10, 15 years ago. You just you didn't have it. And so I think for us now in dentistry, because of the advent of AI and the technology. the workflows, it is making things so much more simpler than ever before to get a quality product for your patient. Before we get back to our guest, I'd like to give a huge shout out to our sponsor, Voco, the Prevention Pros Dentist Trust for products that truly make a difference, like Pro Fluorid Varnish. This isn't your typical thick, sticky varnish. It's thin, transparent, tastes great, it has seven flavors, and delivers the ADA-recommended 5% sodium fluoride for a strong burst of protection. VOCO's unique Procolophany formulation helps the fluoride stay in the teeth longer for extended uptake. And that's exactly what you want. And then there's Admira Protect. VOCO's light-cured nanofill desensitizer that keeps patients' sensitivity free for up to two years. It's a great practice builder, and yes, CDT code 9911 makes billing simple. If prevention matters in your practice, join the thousands of dental offices that depend on VOCO. Visit voco.dental. Now, that's not to say things also won't need to be tweaked. the end of the aligner therapy. I've noticed that as well. Sometimes teeth don't move as quickly as we think they do. Every human is a little different. Their body reacts differently. So don't think that where you're starting, where you're ending is always going to be the end point. You might need to tweak along the way. Yeah. And it might not track at the same timeframe that AI is saying it should. So when they're changing trays, some trays may not fit at the time they're supposed to. Correct. That is correct. So what about interproximal reduction? versus extracting teeth how do you make that decision as a general dentist or do you or when it comes to extractions if that's needed is that something that will say hey this needs to go to an orthodontist that's my cutoff point whenever there has to be an extraction involved i don't like doing those cases and who tells you who tells you there's an extraction necessary do you rely on ai for that or do you make that decision I kind of look at it myself. I mean, I can confirm it with the AI, but the other advantage that I do have, let's face it, is the orthodontist next door. So if it's one of those questionable cases, I will ask one of the orthodontists to come next door. Can you take a look at this? I'm thinking this is a little bit beyond my scope. I think we might need an extraction here. I try to stay away from extraction cases altogether. I would rather do expansion, especially now with Marpy, we're expanding arches more than ever before rather than taking teeth out. That's another part of this I'd like to touch on if we can. Yeah, sure. What about IPR versus extracting? Okay, let's talk about that first. I have no problem with IPR. IPR is needed in a lot of cases. IPR with the systems that are set up now with the different types of materials that we have to either use strips or different finishing burrs that can get in there and do the IPR. I explained to the patient we're going to remove a couple of hair thickness of the teeth and then IPR the teeth. There's no problem with IPR. And I think the patient understands just... by looking at the scan that a lot of times those teeth, because we need to make some major changes to accommodate the space and the size of the teeth, we're going to have to go and strip some of those teeth out a little bit. And of course, I don't say stripping or cutting. I say, we're just going to remove a couple of hair thickness of the enamel. You have a million years worth of enamel. And you're looking at what? 0.2 millimeters, 0.3 millimeters? Most of the time. And that's probably... the max. Right, right. But the other cases that need to have the extractions, those are the more complex cases. I know there are people who are doing a lot of Invisalign who are comfortable doing that. I just, for me personally, it's just not something I really enjoy. So that's where I'll refer that out. And talk about the expansion. Yeah, let's talk about expansion versus what we used to do in dentistry. Let's start for where we used to come from. Back then when the archers were small, what did they do? Serial extractions of first premolar cases. We see it so much in older adults now. But, and of course, what happened when they had that done, when they were 15 years old, you took out the first premolars, they pulled everything back. And when they were 15, 16, 17, 18 years old, the teeth looked terrific. But what happened was, and we learned this later on, is we didn't change the envelope of function. All we did is we make the teeth look better. And the way that the patient chews and speaks from the outside in, what was in the way of their chewing stroke. was their teeth. So what happens is the 15-year-old girl who had the four premolar extracted comes back to you at 35, 38, 42 with incisal edge wear because the teeth were in the way. Typically, they have wear from six through 11, canine to canine, maxillary and mandibular teeth. And typically in those cases, the molars look intact. And so we say to them, the patient comes to see you. And they say, oh, I want to get porcelain veneers on my teeth. And what the dentist doesn't realize is that's now called a constricted chewing envelope, meaning we've pulled the teeth back into the envelope of function, that post-Seltz diagram that we learned about in dental school, that we knew point A, B, C, but we had no freaking clue what it really meant. It meant the way that the patient would open and close, the way that they chew or the way that they speak. And what happened was the muscles. And the way that you're chewing stroke and the muscle end grounds did not change. The teeth were in the way and you started to wear down the teeth. Now the problem becomes the patient wants to do something with their teeth. Well, if the dentist just goes ahead and does what they used to call the social six and lengthen the teeth with the porcelain, what would happen was they would get chipping of the incisal edges because they made the teeth longer, interfering with that chewing stroke, the envelope of function. And the patient would either break the veneer, chip the veneer. where the veneer would pop off. And of course, what would happen? Oh, I'm sorry, the lab missed, you know, the lab didn't make a strong enough veneer. The bonding resin wasn't strong enough. It had nothing to do with that. It had everything to do with your lengthening teeth, but you have not changed your envelope of function. So what happened? We had to tell our orthodontist to stop doing it. And I can tell you, Phil, years ago, an orthodontist who no longer practiced in my area, and of course I wouldn't say his name, I had a conversation with him. And I said, do you see this happening? And with a big Cheshire grinned smile, he goes, no, I don't see that ever happening. And the answer was, of course, no, you didn't. Because you didn't see them at 40 years old. You saw them at 15. We'll be right back with our guest in a second. But first, if you're looking for a digital dental camera, I highly recommend the iSpecial digital camera by Shofu. Hands down, it's the easiest camera to use, takes beautiful high-res photos, and it pays for itself quickly with the boost in case acceptance. Don't wait. Visit Shofu.com and use the code VIVA for a special offer. Now, it's stuck in my lap to fix the problem. And now I got to be the bad guy and tell them, I cannot veneer your upper six teeth. Why can't you do that? Well, because if I just lengthen the teeth, you're going to break the veneer versus just wear them down. Well, what do I have to do to fix this? Well, you don't have very good options here. Option one is you can go back into orthodontics first to move the upper teeth out to then I can create new porcelain veneers, but you have to go through ortho first. Or I have to open your bite with restorative material to get the teeth out of the way. And of course, I've had meltdowns in my practice. Patients get upset. Patients transfer. And that's okay, because I'm not going to do something that's not right. My saying in my practice is just because you don't want to do the right thing doesn't mean I'm going to do the wrong thing. Now, what we've evolved into is what we call expansion in morphe, where now, because we know in addition to the teeth being not in the right position because of the first permolars, we know about airway. What did that also do? It retreated the mandible. constricting the airway by pushing the tongue back. So now what we're doing is we're expanding the maxillary arch and trying to expand the mandibular arch to accommodate more room for the teeth, opening up the airway, letting the tongue come forward. So now we're not taking teeth out anymore. The orthodontists are expanding them either with functional appliances and or in conjunction with traditional ortho or even Invisalign. What a great adjunct now. And those functional appliances, What is the typical time period that a patient has to wear those? And I know it's case by case, but typically, you know, generally speaking, what are we looking at? Oh, they're anywhere from at least six months up to a year and a half. At that point in time, they're ready to have those veneers placed. Well, it depends if it can be fixed with a functional appliance. Sometimes it cannot. Sometimes a functional appliance serves as the starting point. They still need to go through orthodontics. See, that's where I refer that out to my orthodontist. That's I do not get involved in that. That's just beyond my scope. And even though I understand what's going on, I don't feel comfortable doing it. And how do you know that a functional appliance won't be the final treatment before veneers where you would need to send it to an orthodontist? How do you know that? Well, what you can do is obviously you're going to get a pan-ceph, right? You're going to do syphilometric tracing. You can also send those digital scans over to a... a company called Evident, which will go ahead and give you all the numbers associated with the position of the teeth and how much room you've got for you to determine if you can now put the veneers in place if you have enough room. Because my thing is, if we don't have the teeth in the right place, I cannot do the restorative product for you. I just I can't do that. And because I know it's going to fail. And I'm just not going to do that. I just it's not worth it to me. Yeah, it's great that you brought up the whole idea. of how we're moving away from those proverbial extraction of the bicuspids to make room for the orthodontic movement of the teeth, not knowing what would come down the pike when the patient becomes 30, 40 years old, which you described so well. And also the expansion process of the palate and the mandible. So important, not only to treat the aesthetic zone where you can get some long-term success with it, but also for the airway. So all really good stuff. So what would you say to an adult, Dr. Ritter, who's been putting off treatment for years for lower anterior crowding because they say, you know what, Dr. Ritter, it's just too late. I'm 65 years old and I just think it's too late. What's your answer to that? Oh, I've got a great answer for that based on reality. So I had a woman just in that situation and she was 75, Phil. 75. She had some anterior crowding, both maxillary and mandibular. And I said to her, you know, and she talked to me about a couple of her upper front teeth. And I said, we'll just say Mrs. Jones. Mrs. Jones, I'd love to be able to fix those teeth for you, but I don't have any room to do it. And really, I think you have to go through some orthodontics first. Now, whether it be traditional orthodontics or whether it be Invisalign. And then once the teeth are in the right place, I can go ahead and restore those upper teeth for you. Maybe not even have to touch your lower teeth. Maybe just do the upper front four teeth. How does that sound? And she said something that was shocking to me that I use as the example of moving forward. I did this probably 15 years ago. She says, okay, let's get started. I said, that's great. So of course we got started on the case. And then finally, when we were done, I said, I got to ask you a question. You very easily said, yeah, let's get started. You didn't think twice. You didn't come at me. with the majority of what everybody would say, which is I'm too old for this. She goes, listen, my father lived to be 98 and my mom lived to be 99. That means I got another 25 years ahead of me. And if I got 25 years ahead of me, I want my teeth to look good so I can bite my food and be happy. So let's get started. You know what? What a great perspective for everybody. Absolutely. Yeah. Right. So of course, that became the story. Whenever I had a patient that was over the age of, say, 50 years old. I used that story. I said, that's not an excuse. I had a 75-year-old woman do this. So don't tell me that you're too old for it. My answer is, you're never too old. You're never too old. That's a great story. I mean, there's no question about it, Dr. Ritter. Clear Aligners has been such a boon to the field of orthodontics, both on the general practice side and the specialty side. And it keeps going. I mean, the momentum is not stopping. There's new companies coming into the space. And the digital scanning is becoming more prevalent in every office, which aligns itself, no pun intended, toward doing clear aligner therapy. I mean, it's just a huge win for the profession. I think it's a great starting point. It's a great revenue builder for the practice. You gain confidence through this process. The patient gets confidence in you. And listen, even last year, Align, and I can only speak to Align, okay? And there are other good companies out there. I don't want you to think there's not. There really are. And there's some people very astute utilizing the other companies. There's some other abilities because let's face it too, Align, if you want to use Invisalign, you have to use their scanner. I'm not, you know, tone deaf to that. right however they came out with a product field called smile architect which not only shows you what the teeth are going to look like after the orthodontics it actually lets you manipulate that to show them what their teeth could look like after ortho and after restorative treatment so now you're combining both to where the patient gets excited and says wow i can start this journey get my teeth in the right position and now i kind of have an idea of what my teeth could look like Maybe I don't do it right after I finish my Invisalign, but maybe six months or a year later, I can come back and do those other sorts of restorative products on top of my teeth, whether it be direct composite, whether it be porcelain veneers, whether, you know, maybe they need crowns and it does the work for you. What a great adjunct to your practice. It's such a great way to incorporate aesthetics into your practice. that's really what it is right it's based upon aesthetics by putting the teeth to where they're going to look good but functionally stay there for a long time i think it's a great way for a practice to establish itself, to gain trust from the patient, to get some really, really nice results that the patient will visualize themselves and then come to the conclusion, I want to take it the next step further. And because of the tools that are available for you today, I just don't see why you wouldn't get started with this. Yeah, I have one last question for you. discussion with the patient about conservative dentistry, minimally invasive dentistry by treating the patient orthodontically first versus what many dentists did in the past where they restoratively straighten the teeth by aggressively preparing the teeth. They call it instant ortho, Phil. They call that instant ortho, right? Yeah, I know. Instant ortho. So that's the real term. Does that conversation with the patient alert them to the fact that, wow, this is a practice I want to be involved with? And by having that conversation with the patient, Dr. Ritter, does it make it clear to you this is the kind of patient you want to treat? And those patients that want the instant ortho, you have no problem with them going somewhere else. The answer is absolutely, Phil. Let me make this as simple as possible. I tell the patient this simple line. If you do the Invisalign first, that means I have to be less aggressive. I have to take less tooth off. If I take less tooth off, that means the restoration is going to last longer. It's that simple. You don't do this. Can I do this with just restorative material? Absolutely. I have to be more aggressive and take more tooth. And let's be clear about that. You're not magically going to grow tooth back. So if you don't want to do the orthodontics first, can I get you there with porcelain veneers and or crowns? The answer is yes. I have to be more aggressive and take more tooth. If that doesn't bother you, that's fine. If you're one of these people that says, I want you to take as little tooth as possible. because the less tooth I take, the stronger the tooth is, and the longer the restoration will last, then you've got to go through ortho first. But you will do the restorative work if they don't want to do the ortho. I mean, I was thinking you were going to say you would say, I can't do that in this practice. Well, it depends on the case. It's very case selective. There are some cases, Phil, that actually the ortho, because the teeth are so destroyed, that the ortho, it's not going to really help that much. I still need to restoratively do the teeth, so it's not going to help. Those are relatively few, though. The overwhelming majority of cases could benefit from ortho first. Now, there are other practices that don't believe in that philosophy, and that's fine. That's just not happening at our practice. We have a very high conversion rate for orthodontics because we do know, and I can tell you through the years, that the cases that went through ortho, that I can conservatively prepare them for porcelain veneers, let's say. I have cases in the mouth, Phil, that are 25, 26 years old, still in the mouth. And we know that the average porcelain manier in the United States lasts 10 years. I'm more than double that on my cases. And that's with ortho. That's with the ortho first. Sometimes with ortho, sometimes without. But that's also because I'm a meticulous nut. who takes his time, who does the procedure correctly, who follows the manufacturer's instructions, who doesn't rush the laboratory. I mean, there's so many factors that go into that. However, having said all that, if I could get every one of my patients to orthodontically move the teeth first and or see a periodontist to get the teeth and the gums and the gingival height and the osseous in the right position. while, what a boon to the patient and a boon to the practice. Yeah. And that's the right way to do it if you can. And that's the perfect world. So as we wrap this episode up, we're running out of time. I do want you to tell our audience, if you would, about your training program. Where can they get more information about it? It's called The Protocol Live, one word, theprotocollive.com. Theprotocollive.com. Theprotocollive.com. And you can either have a phone number to call or you can go ahead and just register right there. There's a link to go register for the course. The course is given four times a year, Phil, here in Jupiter. And it sells out every time. So the other thing I would tell you about the course is... Come with a friend or two. There is nothing like traveling into a place like Jupiter and coming with your friends and learning together in a small group learning. There's nothing better. Yeah, and there's like 15 doctors in a group. Maximum 15, because I want to keep it small. I want to keep it intimate. I want people to have that shared experience, camaraderie. And there's nothing like being able to interact with people, not just at the coffee breaks or the lunches, but we take them out to a great dinner over by the Jupiter Lighthouse. And just sharing as much information as possible. I want them to go back with as much information to be able to implement the change they need in their practice to have the practice of their dreams. Yeah, it sounds like an experience. I hear the food is fantastic. Yes, it is. All right, Dr. Ritter, you have a good one. Thanks so much for your time. Thank you very much for having me.