“The purpose of Dental Monitoringisn’t to disconnect you from your patient, it’s to make sure you see them atthe right moment for the right reason.”
“Fix problems early andyou don’t have problems. If you intercept an issue straight away, you can oftenavoid side effects altogether.”
“If you don’t change yourprotocol, DM won’t reduce appointments, you do. The technology empowers smarterscheduling, not magic.”
“AI isn’t replacingorthodontists. It’s replicating their eyes, helping you catch what you’d wantto see, every single week.”
In this episode, I’m joined by PhilippeSalah, CEO and founder of DentalMonitoring. We explore the evolution of AI-based remote monitoring in orthodontics, how it aims to change the way we communicate with patients, provide data of our practice but also where the evidence remains mixed. Philippe addresses questions on reliability, patient compliance, and the impact on rapport when monitoring replaces in-personvisits. We discuss the real-world challenges of cost, protocol adaptation and workflow change, as well as the future role of AI, sustainability, and data-driven insight in clinical practice.
02:07 – How did youcome up with the concept of Dental Monitoring?
08:50 – How accurateis Dental Monitoring, and what happens if the AI misses something?
13:55 – Where do yousee the benefits of Dental Monitoring if studies show limited reduction invisits or treatment time?
18:56 – Is remotemonitoring less able to build patient rapport compared to in-person officevisits?
24:53 – DentalMonitoring comes at a financial cost, what is the return on investment forclinicians?
29:48 – Is DentalMonitoring for every patient, given compliance and scanning challenges?
33:02 – AI consumesglobal energy resources, how does Dental Monitoring address environmentalresponsibility?
36:52 – Tell us aboutDental Monitoring Insights and how it impacts clinical practice.
42:28 –What advicewould you give to orthodontists
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“Will AI it replace the orthodontist? No. Will it replace the bad orthodontist? Hopefully, yes.”
“With AI, you could probably get prediction accuracy down to less than 10% , because it can analyze what the human brain cannot”
“Computers are designed to crunch data. That’s all they do. The rest is up to you.”
“AI is not going away. There are billions invested in this technology. You better get on with the program.”
“Don’t drive your car inreverse… Don’t go backwards.”
In this episode of Orthodontics in Interview,I’m joined by Jean-Marc Retrouvey, researcher and innovator in AI-drivenorthodontics. We explore the concept of the “virtual patient” and how artificial intelligence is reshaping orthodontic diagnosis, biomechanics, and aligner staging. Jean-Marc shares his candid thoughts on the pace of change inacademia versus industry, the role of AI in predictions within orthodontics, and how clinicians can embrace AI without losing their judgment. With insightsfrom his work in both universities and industry projects, Jean-Marc offers a compelling vision of how orthodontics will evolve in the AI-era.
· 01:47 What isthe “virtual patient” concept?
· 03:39 Wherewill AI impact clinicians, diagnosis vs outcomes?
· 07:21 Can AIbe our biomechanics co-pilot?
· 10:34 Why arealigner companies behind in AI?
· 12:57 Whatpractical changes will AI bring to aligner staging?
· 15:20 Why didyou say academia is too cautious for AI’s pace?
· 19:24 Shouldorthodontic AI education come from industry, and is that biased?
· 22:13 DoesRicketts’ 1983 “judgment over computers” still hold?
· 25:13 Will AIreplace clinician experience and literature in EBP?
· 30:44 Are weat risk of data overload with 3D/CBCT integration?
· 35:01 How dowe use AI responsibly given its environmental costs?
· 37:59 Why movefrom academia to industry, and what are you building at LuxCreo?
· 41:11 Whitepapers vs peer-review: what’s the real difference?
· 44:35 Your one piece of advice toorthodontists?
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🕒Timestamps of Key Questions & Answers
“The biggest variable with any clear aligner treatment is the patient themselves — not the plastic.”
“We must remain the conductors of the orchestra, not the technicians of an algorithm.”
“Aligners are not inferior to fixed appliances — but neither are they magic. The truth lies somewhere in between.”
“Research often lags years behind reality, so we’re not judging today’s aligners with today’s evidence.”
In this episode of Orthodontics in Summary,I’m joined by Guy Deeming, orthodontist, business leader, and Director of Professional Development at the British Orthodontic Society We dive into the reality of clear aligner therapy, discussing the recently published Delphi Consensus Statements and if theyagree with his clinical practice. Guy discusses compliance and where the orthodontist role has changed in the era of algorithms. Guy shares candid insights into alignerlimitations, clinical pearls for complex cases, and his vision for orthodontic education.
· 01:12– Are aligners now the go-to appliance for mild to moderate crowding?
· 03:22– Delphi consensus statement:What are aligners’ limitations?
· 05:16– Why do clinical results differ so much from research findings?
· 11:08– “no-go” cases for aligners?
· 15:28– Extreme cases on social media: genuine progress or misleading?
· 17:56– Are orthodontists just technicians of aligner companies’ algorithms?
· 24:57– Profitability, corporate influence, and the in-house aligner movement.
· 28:30– Extraction cases with aligners: realistic or flawed?
· 32:52– Distalisation: predictable movement or just tipping?
· 36:31– Should orthodontic training programmes include formal aligner training?
· 44:50– Direct-to-print aligners: fad or the next revolution?
· 48:08– Guy’s one piece of advice to orthodontists on approaching aligner therapy.
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Join me for a podcast summary looking at Ai in orthodonticsand its clinical application. A growing topic in orthodontics, and one of themost featured topics at this years AAO. This summary is based on 3 lectures fromthis year’s summer meeting by Juan Francisco Gonzalez & Jean Marc Retrouvey,Tarek ElShebiny , Jonas Bianchi and Lucia Cevidanes. We will look whatAi is, the way it works and its clinical application, as well as a criticalview on this young field.
What is Ai:
1. Technology that enables computers and machinesto simulate human intelligence, perform 1 task very well, e.g. voice command, Youtuberecommendations
2. Predictive modelling, makes calculations, convert information into numbers or categoriesand recognise patterns
Levels of Ai: Machine learning, Neural Networks and Deep Learning
1. Machine learning
a. The ability for a machine to learn from data andpast experience to identify patterns and make predictions
2. Neural Networks
a. Specific model which relies on interconnectednodes, which perform a mathematical calculation of associations , patterns, andprobabilities
3. Deep learning
a. Is a complex version of neural networks
Virtual patient
· CBCT segment + STL file – segmentation of theteeth and roots, with labelling of different stuctures
o Can print model, visualise ideal vector andcalculate ideal vector
o However clinician still required to establish biomechanics
· CBCT integration for aligner cases, Unpublishedthesis Khalid Alotaibi:
o Treatment planning confidence increased 50%, leastchange was treatment planning modification
Diagnostic data:
· Ai cephalometric tracing
o 46% of 24 landmarks 2.0mm within
o 4 different programmes Iortho, Webceph, Orthodc, cephx
o All landmarks had good overall agreement butvariation in identification
· Facial Analysis
· Automated 3D facial asymmetry analysis usingmachine learning Adel 2025
o Study – 7 landmarks
o Identified manually and with deep learning
o 5 accurate, 2 significant difference but notclinically relevant
Diagnostic accuracy of photos
· Clinical photos assessment by Ai, and comparedto clinical examination
· Sensitivity 72%, specificity 54% Vaughan & Ahmed2025
Growth prediction
· Poor agreement age 9
Comparison between direct, virtual and AI bonding
· DIBs – uses Ai for bonding
· Compare Ai Vs user modified indirect bonding Vsdirect bonding (gold standard), 0.5mm significant
· Incisors accurate
· Premolars and lower laterals inaccurate
Monitoring
Previous podcast exploring the accuracy of remote monitoring
o with Ferlito 2022 80%repeatability from 2 scans 44.7% repeatability and reproducibility
Bracket removal from scan and retainer fit
Tarek Assessment of virtual bracket removal by artificialintelligence and thermoplastic retainer fit AJODO 2024
o Retainers for both – clinically acceptable
FDA approval of Ai in dentistry
· FDA - Software of Medical Diagnosis
§ 4 dental:
· Dental Monitoring
· Ray Co
· X-Nav technologies
· Densply Sirona
What’s next
· More data learning to train AI model
· Robotics customising appliances per patient
Can you really treat complex cases with aligners?
“We’ve done a study of myextraction cases... when you do one or two sets of additional aligners, thenyou will be able to get everything to ideal”
“I will never try to bring17 and 18 mesial to close space”
“The staging that eachcompany does, it does make a difference. If your technician doesn’t understandhow to move the teeth in the right stages… it’s never going to happen”
“If I have a patient whois not wearing the Class II elastics, then you cannot distalize.”
“If you learn to say no tosome of your patients, then you will be a more successful orthodontist.”
In this episode of Orthodontics in Interview,we sit down with world-renowned orthodontist Dr. Chris Laspos to explore thereal-world efficacy of aligners, hybrid treatment strategies, and the evolvingrole of auxiliaries and digital planning in modern orthodontics. With over 25years of experience and a background in craniofacial care and surgicalorthodontics, Chris shares insights into clinical decision-making, caseplanning, and the mindset needed for success. Extraction treatment, anterioropenbite and distalisation are discussed and how to improve outcomes, thisinterview is packed with clinical pearls and honest reflections of alignertreatment.
00:00 - Introduction
01:45 - How did you find your way into aligners as an orthodontist?
03:42 - How do you reconcile aligner efficacy data with your clinical results?
06:24 - Can extraction cases be effectively treated with aligners?
07:10 - Do you prefer fixed appliances or aligners for extractions?
09:10 - Do you use more auxiliaries with aligners to compensate for efficacy?
12:03 - Are aligner systems heading toward minimal differences like fixed appliances?
12:49 - Do some aligner systems truly offer better outcomes?
17:59 - How do you manage anterior open bite cases with aligners?
21:02 - How predictable and reliable is distalization with aligners?
24:27 - Can aligners be used effectively in surgical orthodontic cases?
27:54 - What are your thoughts on remote/virtual monitoring?
30:26 - What are common mistakes orthodontists make with aligners?
32:33 - Should general dentists use aligners in practice?
34:15 - Could AI or case simplicity justify aligners by non-specialists?
38:12 - Beyond clinical skill, what makes a successful orthodontist?
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Interproximal Reduction, When, Why, and How | 9 MINUTE SUMMARY
In this episode, I dive into the fundamentals of interproximal reduction(IPR) when to use it, why it matters, and how to do it effectively.
We’ll cover how much IPR can safely be carried out, compare differentclinical protocols and their pros and cons, and take a critical look at howaligner software plans IPR (and where it may fall short).
This summary is based on Dr. Flavia Artese’s insightful lecture at therecent American Association of Orthodontists Annual Session in Philadelphia,along with insights from my own clinical research and experience.
How much IPR is possible?
Recommended amount ½ to 1/3 of outer enamel
Estimate with periapical radiographs are inaccurate, under-estimateas well as over estimate Meredith 2017 Brine 2001
Quantity of the enamel each interproximal surface Kailasam2021 systematic review, with an excellent table created by Bosio in 2022 highlightingthe enamel present and hypothetical safe reduction, ranging from 0.3-0.7mm,with 5-10% greater enamel on the distal surfaces
Can all teeth have IPR?
· Triangular teeth are ideal
o Large interradicular distance, roots canapproximate with no issue
· Square shaped teeth not ideal
o Reduced interradicular distance, rootapproximation of 0.8mm = loss of crestal bone Taera 2008
Are we accurate with IPR? Johner 2013 AJODO
· Manual strips Vs rotary disc Vs oscillatingstrips = all underperformed IPR by up to 0.1mm
Protocols:
Small Vs Large
· 0.1-0.2mm manual strips
· 0.3mm+ larger reduction
· Polishing required – If not = 25 um furrows retainplaque Jack Sheridan1989
Separation posterior region
· Separator – Requires measuring of premolarbefore and after
· Bur – needle bur
o Parallel occlusal plane
o Recontour tooth surface to create contact point
· No separator - requires contact point to be broken, advantageis the measurement of the IPR site is accurate
Bolton’s analysis
· Based on excess, rather than tooth removal
Proportionality
· Width
o Canine 90% of central incisor
o Lateral 70% of central incisor
IPR planning
Bolton’s discrepancy + Tooth proportionality
= whento add or remove tooth structure
However
· “Don't do pre-emptive stripping for balancingtooth mass ratios between arches. Chances are it will work out just fine” Jack Sheradin 2007 JCO
Method of use for 4 mm of IPR:
· Posterior to anterior – Jack Sheridan
o Posterior IPR first, followed by distalisation,e.g. 4-5 first, distalise 4
o Maintain arch length with stops etc, maintainanchorage
· Anterior to posterior – Farooq
o Anchorage preserving
o Tony Weir 2021 the most common site in clinicalpractice was the lower anterior segment
IPR on overlapping teeth
· Not possible to achieve ideal anatomy withmotorised IPR instruments
· Posterior IPR first, distalise, followed byanterior alignment and IPR – Flavia
· Use of handstrips is possible on overlappingteeth - Farooq
Limits of IPR
· 4-5mm, although Sheridan described possible 8.9mm,technically challenging
· IPR is not a possibility for sagittaldiscrepancy:
Greater Bolton’s discrepancies in class 3 and class 2malocclusions, SR 53 studies Machado 2020, greater in class 2 and 3 casesalbeit a small difference of 0.3-0.8%
Retained primary 2nd molars
· Idealise occlusion
· Consider root morphology divergence, as post IPRspace may not close
o If divergence greater than crown, reconsider asspace closure unlikely
Why do we need to use IPR with aligners? Dahhas 2024
· Alogrythm reduces the number of aligners
· More IPR rather than saggital correction
· IPR staged inappropriately with large IPR whilstcontact point overlap, which is difficult to perform adequate anatomicalreduction
Join me for a summary of CBCT use inorthodontics, where I look into the current risk of cancer with CBCT use, the differenceit can make to treatment planning, and the 3 most common incidental findingsorthodontists should be aware of. This was one my highlight lectures from lastyears British Orthodontic Conference by Consultant Dental Radiologist, SimonHarvey.
How much radiation comes from dentalCBCT, medicine?
Effective dose of modern machines:
· Dose from full DPT with adigital system = 20-25µSv
· KAVO, MoritaX800 4 x 4cm =16uSv
· FDA values of CT scans acrossthe boy from Lubar 1500uSv – Heart 16000uSv
FACT 1 – effective dose in dental imagingare far below the rest of medicine
Background radiation
· Terrestrial radiation
· Cosmic radiation
o Flight London – New York 56uSv– cancer UK ‘does not effect risk of cancer, even for frequent flyers’, 4uSvper hour
o Pilots do not have an increasedrisk of cancer
UK 3000 uSv annually
FACT 2 – EFFECTIVE DOSES IN DENTAL IMAGINGARE FAR BELOW THE NATURAL BACKGROUND RADIATION
American Association of Physicist inMedicine AAPM
“evidence supporting increased cancerincidence or mortality from radiation doeses below 100mSv is inconclusive” –cancer incidence and mortality from the use of diagnostic imaging are highlyspeculative, discourage these prediction of hypothetical harm
FACT 3 EFFECTIVE DOSES IN DENTAL IMAGINGARE SO LOW, THEY DO NOT CAUSE CANCER
Clinicians improved confidence andconsistency in treatment planning decisions.
Impacted canine:
· 3 radiographs - namely occlusal view, opg , periapical = still not confident about prognosis.
· CBCT = clear follicle and impactedcanine proximity to adjacent tooth, = easily make up the decision estimatingprognosis
o 22%-44% change of plans Hodges 2013 Stoustrup 2024 change in treatment plans ofimpacted teeth. The majority related to change in planning, with approximately10-20% a change in exposure Vs extraction. Keener 2023
· Cleft – quantification of bonedefect volume for grafting and localisation of ectopic teeth
· Surgery – location of importantanatomical structures
3 Commonincidental findings for orthodontists
· Dense bone island-
o Radiopacity with no radiolucenthalo
o Mandibular premolar region
o Harmless, may resorb roots ifcontact it
· Sinus mucosal thickening
o Antrum floor intact
o Only concern if 5mm+
· Trabecular pattern
o Around inferior dento-alveolarcanal
o No corticated boarder
o normal in children, technicalreason is physiologic response as more RBC’s are developing surrounding thatarea.
Pregnant women –yes as not irridating pelvic reason, CBCT beam is horizontal so no risk
Conclusion
1. CBCT superior for resorption,material change to treatment plans and improve confidence of the orthodontists
2. No recommendation for takingfull mouth CBCT instead of DPT ahead of starting every orthodontic treatment asroutine and x rays should never go hand in hand
3. Small volume CBCT does is solow it doesn’t cause cancer
Orthodontics In Interview: Aligners, Limited or Just Misunderstood? tommaso castroflorio
“The biggest difference in overcoming the limitation (of aligners) is to understand how to control aligner deformation”
“We need to improve the available knowledge about aligners, because we need to control the companies, we do not need companies controlling us”
“I think you can treat also complex cases, in my practice I treat extraction cases”
“There are limitations in every technique, I think that the good orthodontist understands how to manage the limitation and how to overcome them”
“Large mass 3D printing will represent an important evolution in orthodontics, aligners and braces”
Tommaso explores the current understanding ofaligners, there limitations in terms of an appliance and scientific research. We explored the debate of aligners treating complex cases, why attachment designs still have limitations, and the role of aligners as functional appliances. We discuss emerging concerns of micro and nano-plastic toxicity andenvironmental concerns of aligners.
TIMELINE
00:00:00 Introduction of Dr Tomasso Castroflorio
00:00:51 Tomasso's Early Experiences with Aligners
00:08:21 What are the Limitations of Aligners?
00:11:24 How do we Overcome Limitations with Aligners?
00:17:59 Should Aligners be Restricted to Mild to Moderate Cases?
00:20:22 Research IndicatesAligners Only Tip Teeth into Extraction Sites, Do you Agree? 00:25:50 Importance of Visualization in Orthodontics?
00:29:27 Are Functional Appliance Aligners Advantageous over Conventional Functional Appliances?
00:35:08 Has There Been Over-emphasis on Attachment Design?
00:44:18 What are the Consequences of Microplastics and Aligners?
00:50:32 What is the Future of Aligners?
00:53:54 Who do you Admire the Most in Orthodontics
00:55:36 Advice from Tomasso to all Orthodontists
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Join me for a summary of recent long-term research of resorbed teeth due to impacted canines. This podcast is based on an excellent lecture by Julia Naoumova delivered at last year’s British Orthodontic Conference. Part 2 with focus on the prognosis of resorbed teeth from impacted canines, and follows on from part 1 with explored outcomes of open Vs closed exposures of impacted canines – see here for part 1.
Root resorption of incisors reported at 19-67% Erikson 2000 Walker 2005, Mitsea 2022
Anna Dahlén and Julia Naoumova 2024 retrospective CBCT study n =27 incisors
Mean Follow-up average 9 years (5.5-14.6)
Patient reported outcomes
Survival 100%
Horizontal grade 3 moderate resorption n=17 (resorption inner dentine not involve pulp moderate)
Horizontal grade 4 severe resorption n=12 (pulp exposed severe)
Vertical grade 3+ severe resorption n=7 (resorption 2mm-1/3rd moderate)o
Vertical grade 4 extreme resorption n = 1 (resorption 1/3rd +)
No significant difference in any grade of resorption long term of the following:
Symptoms
Mobility and ankylosis
Discolouration
Increase gingival pocketing but not clinically significant
RR horizontal changes with time
No change 81%
Worse 4%
Improve 15%
RR vertical changes with time
No change 43%
Worsen 57%
Expected as had orthodontic treatment as well
Previous research
1-23 years Survival 93-100% Falahat 2008 , Bjerklin 2011, Becker 2005, Jönsson 2007
Jönsson 2007 showed grade 1 mobility when root length < 10mm
Conclusion:
Extraction of asymptomatic based purely on root resorption should be routinely performed
Paper by Anna Dahlén and Julia Naoumova 2024
Longitudinal study of root resorption on incisors caused by impacted maxillary canines—a clinical and cone beam CT assessment
https://doi.org/10.1093/ejo/cjae052
Join me for a summary of the management of impacted canines, the latest evidence regarding different techniques for alignment. This podcast is based on an excellent lecture by Julia Naoumova delivered at last year’s British Orthodontic Conference.
Part 1 will focus on recent findings of a modified open exposure technique Vs closed exposure, in terms of duration but also other key outcomes, health, pain, use of analgesics, time absent from school and costs. The next episode, part 2, will look at the prognosis of resorbed incisors related to impacted canines long term.
Previous research no difference between closed Vs open exposure for alignment, aesthetics, treatment time, surgical success, treatment times. Limited to 2D views Parkin 2017, Sampaziotis 2018, Cassina 2018.
Questionnaire of current decision making of open Vs closed: n=48 orthodontists = current clinical decision making by orthodontists based on preference Naoumova 2018
Multicentre RCT Margitha Björksved 2018, 2021
Modified open exposure with Glass ionomer OPen Exposure, first described by Nordenval 1999
6/12 of spontaneous eruption
Traction with orthodontic appliances
Results
Total time: no difference 26 months (95% CI −3.2 to 2.9, P = 0.93)
Canine eruption time: Open exposure quicker by 3 months 8.5 months Vs 11.5 months (95% CI 1.1 to 4.9, P = 0.002). With no traction in open exposure group
No difference in periodontal status, root resorption, surgery time, complications,
Pain: greater in closed group
Greater pain with bilateral open exposure
Closed exposure more painful applying traction
Analgesics use (preliminary data):
Day 1 nearly all patients use
Day 5 drops to less than 50% of patients use
Day 10 most have stopped taking analgesics
Costs: – no difference
€3,400 healthcare costs
€6,300 including patient costs
Missed days of school (preliminary data)
Day 1 - 76% open Vs 65% closed exposure
Day 2 - 3% open Vs 6% closed exposure
Open exposure with GOPEX Not appropriate for:
Close to adjacent tooth, to avoid material on adjacent teeth
Very high canine position
Older patient – start traction straight away, probability of ankylosis increases Cernochova 2024
1% at age 15
4% at age 20
14% at age 25
97% at age 45
Conclusion:
Both open and closed techniques are viable, however with open exposure of GOPEX technique the canine erupts spontaneously and quicker
Less pain with open exposure unless bilateral
Most patient will miss 1-2 days from school
Pain relief common for the first 5 days, but maybe used until day 10
Papers
Join me for a summary looking at remote monitoring in orthodontic clinical practice, and if it can improve, quicken and enhance orthodontic clinical practice. This podcast is based on an excellent webinar by Jonathan Sandler and Juan Carlos Varela, as part of the Angle-net webinar series. I discuss how Dental Monitoring works, the proposed advantages and a review of the emerging research on this innovation in orthodontics.
What is Dental Monitoring?
AI software which assesses occlusal and dental changes through a series of intra-oral photographs taken by the patient using their smartphone
How does it work?
Upload STL / digital study model
Ai segmentation of teeth which maps digital study model to the photos
Aligner fit analysis:
Discrepancy between tooth surface and aligner fit
Either proceed, continue wear or see clinician
Fixed appliances
Assess rate of movement and schedule appointment
Other proposed benefits
Oral hygiene assessment
Breakages
Retention changes
What do patients think of it?
Patients attitudes to remote monitoring
81% interested in reducing number of appointments due to telemonitoring – Dalessandri 2021
25% of patients found scans difficult to perform, with duration of scan 2-17 minutes Hansa 2020
Does it reduce appointments and make treatment quicker? Sangalli 2024
Decrease the number of in-office visits by 1.68–3.5 visits
No difference in treatment duration
No statistical reduction in emergency appointments
Are treatment outcome better (aligners)?
No difference in tooth movements Hansa 2021
No difference in number of refinements Hansa 2021
PAR changes – no difference in quality of outcomes Jarad Marks 2024
Is oral health better?
DM reduced plaque scores Costi 2019
31% Improved hygiene Manzo white paper
Other innovations with remote monitoring?
Remote STL files
Scan taken without patient attending the practice
Scanbox
Formulate STL file and fit aligner in surgery
Is Dental Monitoring accurate? Ferlito 2022
80% repeatability from 2 scans
44.7% repeatability and reproducibility
Discrepancy between scanbox and intra-oral scan varied between 0.5-1.9mm, angular measurements maximum error 8.9 degrees
Conclusion
2-3 appointments less
No difference in overall duration
Some people struggle to use
Accuracy and repeatability variable
No difference in the quality of the outcome
Areas which are of concern
Unknown accuracy of occlusal assessments from a reliable retruded contact position
Patient motivation maybe better delivered in person
Ai environment cost 2-3% of energy used by data centres
Other ways to reduce time?
Diagnostic and treatment planning acumen
Identify main aspect of malocclusion and address through efficient mechanics
“We do not accept the weaknesses of out appliances as absolutes, but rather we adjust out treatment mechanics to account for them Mazyar Moshiri,
“If you are not willing you use elastics – you are not able to get finishing like braces” Mazyar Moshiri “We cannot have a reasonable discussion of efficacy and accuracy until we study the appliance as orthodontic clinicians, and not as scientists Mazyar Moshiri Join me for the first summary of 2025, exploring finishing with clear aligners. Mazyar Moshiri explores overcorrection with aligners, when they should be used and his protocol. It was a lecture from last year’s AAO winter meeting.. This episode consists of overcorrection methods of 4 malocclusions: deep bite, anterior openbite, class 3, and expansion. Maz also shares his pearls on what to watch out for when using clear aligners with overcorrection. EXTRAS: Mazyar Moshiri has kindly given permission for the summary slide of his overcorrection protocol to be included in the podcast notes, please see the podcast website https://orthoinsummary.com/ Overcorrection Deep bite - achieve AOB Over-intrusion lower incisors to achieve a 50-100% of total movement predicted Favourable if proclaining teeth, unfavourable if retroclining Use of attachments on premolars, note the hierarchy of attachment design places anchorage for anterior intrusion 5th, “Drs have to doctor the Clincheck”. Anterior openbite Posterior intrusion – overcorrect with occlusal bite blocks class 3 triangular elastics canine and premolars Force down on posterior bite blocks May require controlled relapse following overcorrection, done in refinement NOTE – aligners continuous force system, reciprocal extrusion of anterior teeth is expected Class 3 case Retract lower incisors with retromolar tads and 6 Oz 3’16th Side effect – increase in curve of spee – similar to retraction on a NiTi wire, aligner is not stiff enough to resist Correction in refinement with anterior intrusion to eliminate premature contacts, DO NOT EXTRUDE POSTERIOR TEETH, as aetilogy is anterior iatrogenic extrusion Expansion Overcorrection of 1-2 mm, greater the further posterior Attachments, plan buccal attachments +/- palatal attachments, to account for likely buccal tipping, ensuring buccal root torque and preventing palatal cusp dropping Tip: for palatal cusp dropping place occlusal attachment on the palatal cusp to prevent extrusion during expansion Caution – if already in buccal version, consider limited correction
“it's a platform for mass customization”
“I think Lightforce system has more friction than it should right now.”
“We operationalize great outcomes.”
“People that need to have a Cochrane review to prove to themselves the sky is blue, those are not the people that should be using Lightforce right now”
Alfred and I discuss his digital bonding system, Lightforce, we explore the product as well as the strength of the claims around it. Alfred replies to criticisms of the product as we explore the emerging evidence of his digital bonding system.
Alfred gives his opinion on the digital evolution within orthodontics, we have a candid discussion on the use of digital orthodontics and where there are still areas of significant improvement needed.
Join me for a look at CBCT and its use in the diagnosis of the transverse problem, and if it offers the solution to the debated topic. The podcast is based on a lecture by Chun Hsi Chung at this year’s AAO and appraises established methods of assessment, the Curve of Wilson and the WALA ridge line through the lens of a CBCT, as well as how to use a CBCT to assess the maxilla and mandible, which although revealed an ideal measurement, may not be telling the full story.
What is ideal?
inclination
Curve of Wilson – CBCT study
Vertical distance buccal and lingual cusp, 1mm vertical difference
Buccal inclination upper 5 degrees Alkhatib 2017
Lingual inclination lower 12 degrees Alkhatib 2017
Andrews WALA ridge 2000
Bucco-lingual distance from crown ( FA point) to the most prominent portion of mandibular buccal alveolar bone (coincident with mucogingival junction)
Hypothesised teeth over the basal bone , Glass 2019
1st molar = 2mm
Ideal mandibular intermolar width FA – FA = WALA-WALA distance minus 4mm
Normal width CBCT
CBCT age 13 N = 79 Miner 2012
Maxilla slightly smaller
mid point molar root on lingual bone -1.22 +/- 2.91mm
CBCT Age 22.7 years Koo 2017
Measure CoR furcation 1st molar Mx – Mn = -0.39+/- 1.87mm
CBCT 56 adults normal occlusion Lee 2022 PENN STUDY
Buccal – buccal on crestal bone, furcation, 6s
Lingual – lingual crestal furcation 6s
Reliable reading on lingual aspect – buccal shelf bone prevents reliable readings
Maxilla narrower than mandible -1 +/- 3mm
Previous literature Tamburrino 2010 describes 5mm cortical plate level of furcation buccal aspect, however Lee 2022 showed for males 1.1mm +/- 4.5mm and 1.6mm +/- 2.9mm
Without cbct can transverse diagnosis occur?
Models = lingual surface at furcation level (4mm vertical below gingival margin) maxillary width slightly narrower than mandible -2+/- 3mm
Issue with CBCT for diagnosis
Standard Deviation is large = +/- 3mm, range from -4mm-+2mm falls into SD
Issue with study model transverse analysis from 4mm at the gingiva
Not validated
Join me for a summary looking into the increasingly popular topic of paediatric obstructive sleep apnoea, a review of orthodontic treatments available, and how effective they are in this growing field of both medicine and dentistry. This episode is a summary of Alberto Capriglio’s lecture from the AAO and Carlos Flores Mir’s lecture at the IOF earlier this year.
OSA - Defined upper airway dysfunction causing complete or partial airway obstruction during sleep
Sleep = Slow wave sleep – constructive phase of sleep (recuperation of the mind)
· Growth hormones secreted
· Glial cells within brain restored
· Cortical synapses increase in number – Moberget 2019
Outcomes to paediatric patients of SDB: (AASM)
· delays in development, Poor academic performance, Aggressive behaviour, attention- deficit/hyperactivity disorder, , emotional problems in adolescence
First line medical treatment – adenotonsillectomy
· 40% residual OSA
Effect palatal expansion
1. Roof the mouth = base of the nose - Increase in nasal airway volume - Reduction in OSA, if obstruction in naso-pharynx,
2. Short term reduction in OSA (not cure AASM)
a. 20% improvement in AHI, 85% of cases Villa 2015
b. 15% got worse by 20%
c. 57.5% residual AHI greater than 1 - not resolution
3. Caprioglio 2019 long term AHI return to initial scores, from 7 to 5 long term
4. Change in metabolism when combined with Vit D3
a. Vit D3 with RME increases reduction in AHI, sustained long term, Caprioglio 2019 AHI 61.9% Vs 35.5% long term
Expansion other outcomes - school performance Bariani 2024
· AJODO – RME improves academic performance –
o BEHAVOUR 1 of 8 parameters improved only for academic performance - change small 0.68
o COGNITIVE 1 in 8 improve
Mandibular advancement
Move mandible forwards and open space behind the tongue – oropharynx
· Anatomical – increase size of oropharangeal airway
· YAnyAn 2019 mandibular advancement for pOSA systematic review: 1.75 AHI reduction (CI) −2.07, −1.44) – modest change
· However long term use required of the paediatric patient
Orofacial features in children with obstructive sleep apnea. Fagundes Flores-Mir 2022
o No craniofacial features specific to pOSA – ANB,
o However medical diagnosis through polysomnography may under-estimate incidence,
o Broader diagnosis such as snoring, may over-estimate OSA
AADSM 2024 – consensus statement
· Expansion
o Prevention: No consensus
o Management: No consensus
o Cure: Insufficient
· Mandibular advancement
o Prevention, management, cure – unclear
More about OSA?
To hear more about OSA, please check out the last interview on orthodontics in interview with Sanjivan Kandasamy, where we had a deep dive into OSA and where we are in our understanding today from the research
Interview with Sanjivan Kandasamy on OSA
Join me for a summary looking at The Posterior Bolton Discrepancy, a new take on the classic Bolton discrepancy. Wayne Bolton’s analysis has been critically appraised and the outcome from Patrick Foley and his team has been the formation of the posterior Bolton analysis, a new perspective on an established tool in orthodontics which seeks to give better insight into the location of tooth size discrepancies. He has also explored through his research the effects of premolar extractions and the likely outcomes of compromised occlusal outcomes, and where we should expect to see it within the posterior segment.
Wayne Bolton established the Bolton’s ratio:
· Mesial distal widths of teeth
· Original study 55 well treated cases
· Anterior – ideal 77.2%
· Overall 91.3% - Anterior tooth size discrepancy maybe masked by a compensatory posterior discrepancy
What is the posterior Bolton’s ratio
· Not included in original study
· Formular sum of mandibular 4s, 5s, 6s,/ maxillary 4s, 5s, 6s x 100 = 105.27% - data from original Bolton’s study
Ratio confirmed by Mongillo 2021
· N=55 patients ideal outcomes
· Digital casts (from plaster)
· Posterior ratio 105.77% +/- 1.99% Vs Bolton’s data of 105.27%
The effect of 4 premolar extractions on the posterior Bolton ratio
Study: Mongillo 2021 (extraction of all 4s) Holton 2023 (extraction of upper 4s, lower 5s)
· Posterior Bolton increases 107% +/- 2.23% (or U4s and L5s 106.52 +/- 2.52%), ideal digital removal of teeth
· Observed Bolton’s was 110.48 % = 3.18% above Bolton’s ideal
· Space of 1.1mm – 1.28mm remains in mandible when ideal arch – only 1 patient did not have space
Clinical options
i. compromise occlusion
1. slightly class 3 molar and class 1 canine
2. class 1 molar and slightly class 2 canine
ii. IPR upper arch
iii. Bonding
· Anterior and posterior Bolton may be valuable in diagnosis and prediction than an overall Bolton
Join me for a look into a recent digital innovation within orthodontics, Lightforce. I explore how the 3D printed labial bracket system works, the features and what the proposed advantages. Recent research exploring the advantages of Lightforce is discussed as well as my comparison to other digital innovations within orthodontic appliances.
What is Lightforce
· Manufacturing: 3D printed brackets Cad/Cam
· Material: ceramic polycrystalline labial
· Planning: Digital planning using Lightplan, visualisation of the outcome, alter both tooth position and bracket position, individualise prescription per bracket as a result of planned movements
· Flexibility in positioning: Brackets do not have to be in the Facial Axis of the Clinical Crown, through altering the base thickness, the resulting moment can be achieved through the center of resistance
· Torque expression is independent of the vertical position, for the same reasons
· 0.018", 0.020", and 0.022", including combinations
Stages
1. Submit records
2. Digital planning using lightplan, visualisation of the outcome,
3. Case approval
4. Indirect bonding tray – light-Tray, with brackets in situ
Other advantages
· Accuracy of 3D printed slot
· Adapted base, less adhesive
· Minitubes, biteturbos
What are the proposed advantages and claims around Lightforce with evidence
1. Shorter duration of treatment due to precision
a. JCO 2024 Wheeler 2024 Retropsectice study, 900 lightforces cases and over 300 conventional cases, 30% shorter and 30% fewer appointments. significant floors, with a lack of outcome measure and matching of controls
Proposed advantages and claims around Lightforce ithout evidence
2. Reduced complications white spot lesions, dehiscences and root resorption as relate to duration
3. Remove issue of compliance or biomechanics as limitations to treatment outcomes
4. Saving Doctors time and money, remove repositions
5. Reduce or eliminate wire bends
What are my thoughts?
· Labial fixed appliances are catching up with aligners and lingual appliances
· New possibilities of varying biomechanics, slot size, bracket position and customised prescription
· Presence of Lighforce features within other appliances:
o Customised brackets Insignia / Incognito
o Digital planning: aligners, Insignia
· No customisation of archwires with Lightforce
· Not sure how Lightforce would reduce appointment intervals, ligation is conventional ligation through elastomeric modules, with plastic deformation
Papers and videos on Lightforce
https://www.jco-online.com/media/42415/2023_09_500_waldman.pdf
JCO retrospective study
https://www.jco-online.com/media/43897/2024_05_273_wheeler.pdf
Youtube videos from Lightforce company, Alfred Griffin
https://www.youtube.com/watch?v=zSNkYVgZ69I&t=2s&ab_channel=People%2BPractice
Disclaimer
The podcast is opinion and may not be 100% accurate or representative of the lecture / speaker, the podcast is not endorsed by an institute or the speaker and is the independent work of Farooq Ahmed and the Orthodontics in Summary team. It is not intended to over-ride or replace the requirement clinicians have in being familiar with the relevant training and guidelines for the treatment they provide.
Contributions
Contents and editing
Farooq Ahmed
Join me for a podcast summary looking at the effects of aligners when expansion occurs. In this podcast we will explore if bone loss occurs with expansion and why bone loss doesn’t necessarily cause recession. The podcast is based on the lecture and research by Greg Huang presented at this year’s AAO, and includes some more recent research on the topic
PICO
Population adults, 22 maxillary arches, 20 mandibular arches
Intervention – expansion with aligners, average 3.7mm
Control – minimal expansion, average 0.6mm
Outcome – bone height and width from CBCT
What was the bone loss?
Maxilla
· Minimal bone loss
· Minimal bone height and width change
Mandibular
· Significant bone loss
· 1.5mm height mandibular centrals
· 1.4mm height premolars
What movement took place of the incisors?
Maxilla
· Little change in bucco-lingual inclination
Mandibular
· Labial and buccal tipping increased
What were the overall changes?
Dental changes
· 3-4mm of expansion
· Mainly at premolars
· Mainly buccal tipping, not bodily movement
· Lower incisors procline
Similar bone loss with aligners expansion from other studies, Zhang 2023 , Allahham 2023
Should CBCT’s debate within the literature regarding voxel size of a CBCT and false negatives. Accuracy of alveolar height CBCT 2019 Yuan Li BA systematic review showed
· CBCT Vs skulls/patients
· Bone height 0.03mm
· Bone width 0.11mm
My thoughts: no difference in cbct and gold standard, however the measurements were all of large structures, not bone height or thickness of less than the voxel size
Predict bone loss
· Upper arch no predictors as limited changes
· Lower arch, same as for fixed appliances, but the quantity was missing
o Proclination
o Expansion
o Buccal expansion and tipping
Systematic review of orthodontics 48 articles de Llano-Pérula 2023
· Proclination
· Less keratinised tissue
· Thin biotype
· Prior recession
· Crossbite
· Previous recession
· Age
Does bone loss = gingival recession?
· Not generally found from Greg’s study
· When significant bone loss of 3mm, far less than 3mm gingival recession
Significant retraction of upper incisors and intrusion Kim 2024. Loss of Palatal bone however in retention palatal bone recovered
Hypothesis
· If PDL and periosteum are maintained epithelium is maintained
· If the root moves back into the bone, the bone recovers – as PDL and periosteum osteogenic, and tension generated between PDL and periosteum
· PDL-periosteum hypothesis – proposed by Greg Huang
What I liked about Greg’s lecture was that he started with declaring his conflict of interest as an academic, both the royalties he receives for his books as well as research funding, which was great to hear and a trend I hope continues. Acknowledged the hard work of the research lead, his trainee and the time-consuming process of orientating CBCT slices of 1000s of images
“Airways are like TMD controversy on steroids”
“it amazes me we still think we can grow mandibles”
“We have an appliance (expansion) and are trying to fit it into a diagnosis”
“it is unethical to call yourself an airway orthodontist”
Sanjivan describes why there is controversy in airways and orthodontics, where the research stands on treatment with expansion and mandibular advancement, can mouth breathing cause adverse development, the effects of extractions on the airway, as well as ethics within current practice of airway orthodontics.
Click on the link below to view previous episodes, to refresh topics, pick up tricks and stay up to date.
YouTube
https://youtu.be/m2NIp1XhnxQ
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Join me for a summary exploring an innovation of the use of bone-anchored plates in class 2 correction. This was a clinically novel idea presented by Hugo De Clerck, who has been an innovator in the use of bone-anchored plates and has published seminal papers on the topic for class 3 treatment. Hugo explores the use of bone-anchored plates in the mandible, combined with a Herbst appliance. He presents his data of 90 patients treated in Brussels by his research team. PROTOCOL Customised bone anchored plates in lower anterior mandible – digitally designed per patient with surgical guide Transmucosal between lower canine and 1st premolar Herbst: modified to attach from upper 1st molar to the lower bone anchored plates Procline upper incisors prior to fitting Bone anchored-Herbst Expansion of the upper arch 2-3 modifications to Herbst piston to lengthen during treatment Duration 10 months HOW DOES IT WORK Growth of the mandibular body: mainly, bone modelling. Average growth 5-7mm, whereas conventional herbst 2-2.5mm of chin projection. New growth of bone as ramus moves backwards, resulting in lengthening of the mandible Force generation: in similar to the conventional functional appliance, with contraction of medial and lateral pterygoid and stretching of the suprahyoid and temporalis muscle Lower incisor proclination: No lower incisor proclination: There is a distal force on the mandibular dentition instead of a forward force from conventional functional appliances, due to the appliance attaching to the mandibular body, not the dentition Condylar displacement: Longer duration, of up to 10 months which results in stimulation of growth of the body of the mandible, conventionally this stops with a herbst as the lower incisors procaine, resulting in only 2 months of condylar displacement and therefore less stimulation of growth Glenoid fossa remodelling. The glenoid fossa remodelled in a forwards direction, however it was small and unpredictable, with some posterior remodelling Rotation of mandible – similar to the conventional functional appliance, a posterior rotation reduces the effects, anterior rotation enhances, for every 1 degree 1.1mm increase projection. Achieve via expansion and removable appliance Upper molar distalisation: Hugo saw this as unfafourable and advised lengthening the herbst piston to reduce upper molar distalisation, therefore maximising mandibular lengthening Age 13-15 Not possible with miniscrews, due to the quantity of force Breakages of Herbst still occur Is growth maintained long term – unable to state No control as requirement for cbct of untreated patients. Contributions Contents: Farooq Ahmed Edited and produced: Farooq Ahmed
