Clear Aligners in General Practice: Ortho First and Then Do Great Things

You're listening to The Dr. Phil Klein Dental Podcast Welcome to the show. I'm Dr. Phil Klein. In today's podcast, we'll delve into the benefits of having a good fundamental understanding of the science of orthodontic diagnosis and treatment planning when it comes to clear aligners. Our guest is Dr. Shalin Shah, who runs a private practice, Center for Orthodontic Excellence, in Princeton Junction, New Jersey, and lectures nationally and internationally. Shaleen, it's a pleasure to have you on Dental Talk. Dr. Klein, the privilege is all mine, and thank you for the blessing. Yeah, and we just discussed offline, the audience didn't hear that, but we are both Penn grads, alums from Penn. You went to undergrad there and dental school, so did I, and you also went to ortho school, and I did the same thing, but I went to endo school. We were talking about a mutual friend of ours, Slick Van Arsdale, who is an amazing orthodontist, and it's amazing that you got to know him as well. So we're talking about clear aligners. This is like a major trending thing going on right now in dentistry. You know, when you think that it's got to the point where we're done with all the heavy duty marketing of aligners, it goes to another level. So apparently this technology and procedural part of orthodontics is really working right successfully for those dentists that know how to utilize this tool. So let me ask you this question to start off this podcast. Why is it important to really understand? for a clinician, and mostly a GP we're talking about, the basics and even the nuances of orthodontic diagnosis and treatment planning when clear aligner companies do all the workups? It's actually perhaps one of the most important concepts to focus on when looking at clear aligners in the restorative space. Dentistry is always known and defined potentially by... It's part science and part art. The part art only comes with a strong foundation of the science component. If we don't understand the etiologic factors, come up with the subsequent diagnoses and the right treatment plan for that patient, then we can't have results that are going to be truly long-term predictable and stable. And when we look at clear aligner companies, we should be looking at them through the same lens that we do. our dental labs when we send out a crown prep we don't look at the dental lab having a series of dentists present to validate whether the crown prep was done to the ideal form and then ultimately choosing which type of crown material is appropriate in their eyes for that patient but rather what they're doing is they're supporting what we as clinicians have defined as the right solution for that individual and then delivering on that the same is really for clear aligners where we see clear aligners and the software and that development and technology advancements as something as a truly powerful tool it is still a tool a tool that we as clinicians need to utilize in the appropriate way. It's incumbent upon us to come up with that diagnostic pathway for the individual and subsequently what is the right treatment approach. Now, the software does enable us that ability to take a look at really what does the ultimate outcome look like, but it is on us to define and determine what is the right outcome for that patient. Looking at orthodontic diagnosis, we like to use the analogy of the GPS. Rarely will we ever sit inside our car. at a known point of origin and a known destination, but an unknown pathway and ever just start driving. We want to have a calculated pathway in terms of how long that distance will be, what will the journey actually entail in the way of turns as well as temporal investment. And that is no different when we look at clear aligners. And then the final thing is this, if we are looking at our relevance in the clear aligner space where there is a market now that is being addressed to via direct to consumer products our value proposition remains in the field of science that we understand as clinicians truly why the patient presents as they do and ultimately when we treat them to a healthy occlusion, why it truly will be long-term predictable and stable. And that's the reason why Ortho 101 diagnosis and treatment planning is indispensable when we are doing clear aligner treatment, but why we can still leverage the clear aligner software and the companies to help support ultimately what we decide is right for our patients. Very well said. I like the analogy of the GPS. That's a very good point that you made. So let's say I'm a GP, right? I'm hearing all about clear aligners and how important it is to get patients to get involved with clear aligner treatment because it's so important to get the teeth in the proper form and function, proper alignment. I'm speaking as an endodontist, not an orthodontist, but it's important to get these teeth aligned properly so that the long-term success of your restorative work holds up. As a GP, I don't have any real... understanding of orthodontics i may be out in practice for 10 years i haven't taken any ortho courses since dental school what are we talking about as far as a learning curve if a gp says yeah you know i want to get into clear aligner procedures in my office how do they get that basic understanding of all this One of the great things is that my dad is also a restorative dentist, and part of his upbringing in India was that he also trained as an orthodontist. And we were having this conversation for two very different but specific reasons. Number one is that when we talk about orthodontics, and as an orthodontist, I've committed my lifetime to orthodontics, and I will die as an orthodontist. So when we... talk about sharing this ideology with our brothers and sisters in the GP space. Is it something where we find that there's an opportunity for the restorative teams to ultimately take away something that we do on a daily basis. And one of the things that we had come up with is that when we look at orthodontics as it exists currently in the marketplace, one of the things we recognize is direct-to-consumer has already created a pathway as a solution for patients wanting clear aligners treatment. By spending time to share really what orthodontics is with our dear brothers and sisters in the restorative space, we will help the number one person in this entire process who are the patients. There is a segment of orthodontics that can be done and done well within the restorative space. And by sharing the joy and love we have of orthodontics, it also helps the restorative teams to understand really what is our role. And how can we help in those more interdisciplinary types of cases? So that actually is my segue into the second point that dad and I had about orthodontics. And he said, Shaleen, it's this simple yet this profound. Orthodontics is something that restorative dental teams already have a strong command on because orthodontics is in fact full mouth reconstruction of the enamel. Where? restorative dentistry looks at local anesthesia and crown preps to be able to create an ideal static and functional occlusion. What orthodontics does is we fear the needle. Instead, what we do is we actually move the teeth into that right form and function. And that information is already in our foundation as restorative dental teams, but the nuanced understandings of how teeth... move what is that safe zone in terms of what's mild to moderate crowding because that's a subjective actual statement how do we quantify that to keep us in the safe zone if we're looking at correcting mild to moderate class two and class three scenarios what does that actually constitute when we take a look at mild and moderate vertical discrepancies what does that look like there are Amazing programs through CDOX. There's a four-day sharing program there that breaks that down into the quantitative and the objective, as well as Dent Supply Sirona is coming out with some programs as well that makes that very prescriptive. And that's really what we all thrive on. If we can have a recipe-based approach of understanding. This is something that's great in my wheelhouse. And then this is something that would be beneficial in the orthodontic practice in the orthodontist's hands. It makes it really simple, not only in the way that we're able to care for our patients, but also able to deliver in the way that our patients ultimately deserve. Right. Now, C-Docs, that's Scottsdale, Arizona, right? That's an in-person training program. Exactly. Yep. You got it perfectly. Yeah. Yeah. I was recently there. It's a beautiful facility. We actually did a live webinar and a podcast from the training auditorium there at C-Ducks in front of some KOLs. Viva Learning hosted that with GC America. So that was really super good. That makes a lot of sense. So my question is regarding the setups for aligners, for clear aligner therapy, what is the prescriptive yet pragmatic way to evaluate these clear aligner setups? So there are two different pathways. One of the products that we use and we find is unparalleled is the SureSmile pathway. So I'm going to jump to the second component first. In that SureSmile setup, there is a checklist, which is a systematic approach that will not only share on the screen the virtual areas that we should be looking at, but it will actually juxtapose the clinical photography that you submitted against. that digital setup for you to begin to compare where is the patient starting and where is that patient ending up. The first part of that prescriptive pathway that we like to share is Andrew's Six Keys. And there was a blessed moment that I had with Viva Learning where we did a one-hour webinar on that ortho 101 diagnosis and treatment planning. Andrew's Six Keys is a landmark article written in 1972 that really goes through all of the salient yet critical aspects of what a static occlusion should look like. from the starting position of the molar, where the mesobuccal cusp should engage in the mesobuccal group of the lower, all the way to the tip and the torque, as well as the rotations or the absence of rotations, absence of spaces, and a level curve of speed. That would be the ideal prescriptive pathway to ensure that the case setups that we're getting back are the setups that we should be seeing clinically realized within our patients. Is there some level of understanding that you could verbalize for us today in this podcast that would give the GP a feeling of this case is too complex for me to do using clear aligners, but if it's not reached that level, yes, I should be fine using clear aligners. I know you're very familiar with the Dense Plycerona Ortho system, SureSmile, which you talked about, and there are others on the market, of course, but where is that line to be drawn? perfect question so this is the sharing assertion um that we offer is that there are three categories there is the quantity of the crowding there is the class discrepancy which would be the second one class two or class three and then the third one would be the vertical components so a class one mild to moderate crowding scenario prescriptively would mean that any arch that has a crowding of six millimeters or less crowding of six millimeters or less should be considered as a green light or as we like to call a green light scenario in the restorative space because that crowding resolution could be achieved by interproximal reduction certainly something within the wheelhouse of the restorative space part number two is the class discrepancy anything that is a class two or a class three that deviates by no more than three millimeters from a class one occlusion so in a class two scenario the mesial buckle cusp would be no more than three millimeters mesial to the lower buckle groove or in a class three scenario the mesial buckle cusp of the upper would be no more distal than three millimeters to the buckle crew for the third part for a mild vertical discrepancy. The overbite should be no more shallow than one millimeter of an overbite and no deeper than six millimeters of an overbite. That generally, those three buckets, if we stay within those, we would be in the safe zone for clear aligner therapy within the restorative dental practice hands. So let me ask you this, what advancements have clear aligners made in the last five years? It's been incredible first to just have the vision of an individual to say, hey, you know what, let's have a market disruption. We have brackets and wires. There must be a better way and a more aesthetic way to be able to deliver orthodontic movements. And that was the advent of the clear aligners. For a long time, we were essentially subservient to that clear aligner technology in the way that it was designed, thinking that scallop trays were exactly the way that we would have to go, the types of attachments, whatever the names would be proprietary to each individual systems. That design was really the only way to be able to move those teeth. Recently, what we have found within these last five years is, in fact, the aligner structure itself does not actually have to be static. There are certain scenarios that require different types of structures that would not only efficiently move those teeth, but more precisely. And if we look at just the brackets and the wires... evolution the brackets never stayed the same we never had non -prescriptive brackets thrive through the 2000s into of course 2022 we now have prescriptive brackets we have self-ligating brackets because we recognize there is a more effective way to move teeth and so what we have seen come to market is now the scalloped edges really are not the most effective way to move teeth we can change the aligner design we can make them straight trim line so that they invaginate into the embrasure spaces and that invagination into the embrasure spaces is what we like to call endogenous attachments it's able to better grip these teeth to more precisely move them subsequent to that we also recognize that attachments are not needed all over the teeth If we have the right design and understanding how clear aligners move teeth. For far too long, we were looking at clear aligners moving teeth based on brackets and wire knowledge. And they move teeth very differently. And now that we understand clear aligner tooth movement as it relates to how a clear aligner can move teeth. we have changed the algorithm by which those clear aligners actually will be designed for the tooth movement so we have a structural design and we have a software development design change and that has created a synergistic impact in these last five years and the way that clear aligners are ultimately delivering care. And again, if the audience wants more information on SureSmile, they can look that up online, of course, and they can visit Dens Plus Rona Ortho for more information on that. So to wrap up this last question, what is the orthodontic value proposition to the patient? So when a doctor is presenting this and they see the patient has, they're in the safe zone, they're looking at the crowded lower anterior teeth of a... who's 60 years old, they're seeing some chipping on the upper incisors, loss of incisal guidance, all the typical stuff that goes along with the natural crowding of the lower interiors. What's the value proposition and what's the way to get case acceptance? Absolutely, Dr. Klein. And certainly speaking to what we see exactly like you had delineated so well in terms of the lower crowding, chipping of the teeth, those are things that begin that conversation for patients. They can certainly see that at a perceptible level. But for us to get out of the narrative that's been perpetuated within our communities that orthodontics really is an aesthetic or cosmetic procedure only, which really puts us in an elective... pathway of decision-making and moving us back into a healthcare-driven value proposition, which is exactly what orthodontics is, we like to use this analogy. If we were to take a... bridge and go from point A to point B, point B to point A, point A to point B, and point B to point A. The reason that it's an unremarkable journey every single time is because, in fact, it is predictable. And the reason it's predictable is because it is based on a sound engineering infrastructure. The exact same is true for our mouths. For us to open and close, close to open, open and close, close to open it, do that repeatedly. every single time without consequence to our four functioning systems, which is our dental, our skeletal, our muscular, and our neural. The only way that we're able to do that is through a sound engineered architecture. And the byproduct of that is a healthy, beautiful smile. And that is exactly what orthodontics delivers on every single time. The whole shift here in what you're saying is that the presentation to the patient, this is more of a medical. therapeutic treatment because if the architecture of the mouth is not set up ideally you're leading to all sorts of oral health problems and of course the longevity of your restorative work is compromised and i guess that's what the value proposition is and i'm hearing that more and more by doctors that are talking about aligners i'm one of those patients who actually suffer from pretty bad mandibular crowding. You probably can see it on the video. Maybe you can't. I already checked, Dr. Klein. I'm like the case in point. I'm like the perfect candidate for that. But I'm at the point where it's almost too far down the road for interproximal reduction. I might have to have a tooth removed to make room. We won't do that consultation on this podcast. We'll save that. I see Chalene leaning forward on the video. So he's trying to see my lower. teeth crowding. But yeah, so great podcast. Thank you very much. We hope to have you on soon. If you want to get the full story from Shaleen, check out his incredible webinar on vivalearning.com. Just type in S-H-A-L-I-N, Shalin, and his last name is Shah, S-H-A-H, and you'll be able to see that right then. Thank you very much. We appreciate your time. Thank you, Dr. Klein. This moment was my blessing. I appreciate it.