First, Get It Straight

Goff,Stan;

First things first: Let’s get something straight. Although this phrase is often used to clarify a point and possibly mitigate a problem, it can and should also be a rallying cry for clinicians looking to meet the restorative treatment desires of their patients.

Sure, everyone wants a shiny, beautiful smile, and some patients want it right away. What many people don’t understand, however, is that misaligned teeth not only can lead to problems with a patient’s overall health but also can prevent dental restorations from functioning and from lasting a long time.

More times than not, the best treatment for these patients is orthodontic procedures that straighten the teeth and correct the problems that may be causing difficulty chewing or shifting the jaws. The best-looking veneers may provide instant gratification with a pretty smile, but if the patient’s teeth are not positioned properly, health issues such as tooth decay, gum disease, and abnormal wearing of tooth enamel may follow, and these new pretty teeth may chip away.

“I tell them, ‘I know you want this beautiful smile and you’re frustrated. You know what, this thing keeps breaking. But the reason it’s breaking is because of your bite and the way you’re hitting these teeth. So if you want these teeth longer, we’re going to need to move them first into the proper position,’ ” says Sarah Jebreil, DDS, AAACD, an esthetic dentist and beauty expert in Newport Beach, California. Jebreil is a member of the Dental Products Report editorial advisory board.

Even for general practitioners (GPs) without a lot of orthodontic training from their dental school days, providing the basics of orthodontics for their patients has become easily and predictably possible thanks to the advances in clear aligners. With clear aligner therapy in their tool kit, clinicians can educate their patients on the importance of correcting malocclusion and then do something about it.

Sure, some patients may still ask for a quick fix—maybe they really must have veneers placed right away because a wedding or other big event is coming up. But it’s beneficial for them to understand that orthodontic corrections can lead to better long-term results, often less invasive treatments, and—in the end—a happier, healthier mouth.

“I love this subject [because] conservativeness is a passion for me,” Trent W. Smallwood, DDS, a cosmetic dentist in Tempe, Arizona, explains. “In the past, patients would come in with malocclusion, bad tooth position, and I didn’t think of orthodontics as an option because brackets and wires were unsightly. As a result, I would often just prepare the teeth and place veneers on 10 teeth to straighten the teeth as my own form of instant orthodontics. It was a widely common practice a few decades ago. If one tooth was too long or short, rotated, or crooked I would just prepare it, and the porcelain restorations would correct the issue. Sadly, that was the philosophy in those days for many of the patients.…

“Then I realized that with clear aligners I could potentially move the teeth to better positions and then, as needed, come back and selectively use veneers on some teeth instead of arbitrarily doing 10 teeth to get all the teeth in order. I enjoyed the paradigm shift because I finally possessed more options for my patients and could be more conservative in my treatment.”

For more on this topic, read these 2 sidebars:

• How Invisalign® Helps Patients and Clinicians Improve More Than Just Esthetics

• Evenley Technologies Shares More Insight on Clear Aligners

It was with this realization that Dr Smallwood developed a greater understanding of the connection between orthodontics and restorative dentistry. He also came to realize that today’s clear aligner therapy and the advanced materials and software now available should be considered for every patient looking to improve their smile and oral health.

“So that brought up myriad different things for me,” Dr Smallwood adds. He has used a variety of clear aligner systems over the years and currently works with Dentsply Sirona’s SureSmile® Clear Aligners. “I realized there was such a connection between the restorative side and the ortho side. I recognized the effectiveness of bridging the gap between the 2 treatment powerhouses.… Not every patient will take this opportunity for clear aligners first, but it just affects so many things, whether it’s large case restorative implants or even partial dentures, which can be completed so much more effectively and conservatively.

“A lot of times if we have teeth that are malaligned, or if they had braces years and years ago that relapsed and it’s not necessarily the most ideal environment, we can often separate a bridge, for example, to remove the pontic, or partial, and then come back and correct the teeth and place an implant. We’re overall able to improve the malocclusion and the overall health of the environment, which is wonderful, with clear aligner therapy.”

A huge plus to straightening teeth prior to completing additional cosmetic dentistry is the minimally invasive outcomes, Dr Smallwood says.

“Where I really saw the gap close between restorative and orthodontics was instead of doing large case restorative on every patient, with clear aligners I can be more selective and far more conservative, saving valuable tooth structure in the process,” he explains. “With veneers, for example, I get a lot of requests to enhance their smile or to enhance their function with porcelain restorations. I realized that if I actually retrocline the teeth about 3° and create a 0.1 to 0.2 mm diastema between the teeth to allow for porcelain, I could actually place prepless [minimally invasive] veneers upon the teeth. In the past, I’d have to take as much as 60% [of the tooth structure] away. [By using clear aligners] I take none, which is amazing for the patient and makes me sleep better at night.”

Jeffrey Rohde, DDS, another member of the Dental Products Report editorial advisory board who has a restorative and surgical dental practice in Santa Barbara, California, also feels better knowing he offers his patients a conservative option that preserves more of the natural teeth and boasts predictably strong results.

“If you have a tooth that’s angled in the wrong direction and you want it to look straight, do you first cut off all the parts of the tooth that are not in line with where you intended to go? Then you can prep the tooth, but essentially what you’re doing is you’re amputating whole sections of tooth versus if you move the tooth into the correct position,” Dr Rohde says.

With orthodontics, some issues can be corrected in a way that will prevent the same problems from reoccurring, which is why Dr Rohde believes GPs should offer clear aligner therapy to their patients.

“It’s not that you’re going to do clear aligners every time. But it should absolutely be in your wheelhouse or in your bag of tools that you have,” he says.

Dr Rohde believes less invasive treatment plans with clear aligners are a way for clinicians to be proactive, taking steps to provide long-term solutions.

“What it represents to me, basically, is that in general dentistry we are often reactive. Oh, that cusp broke. Let’s put a crown on. Oh, there’s decay. Let’s put a filling in,” Dr Rohde says. “But the idea is you’re moving from reactive to proactive so that you can look at a case and [really fix it]. You have someone, for example, with severe lower anterior crowding. As general dentists, you all know where it’s going. You know this person is going to lose these teeth in their lifetime because they’re so crowded. It’s going to cause bone loss. It’s going to be hard on them. So are we just waiting for that to happen so that we can react with some extractions? Or how about we recommend to this person, ‘Hey, why don’t we do some conservative orthodontics.’ ”

There are several benefits to fixing malocclusion, and they’re not just esthetic. The American Association of Orthodontists states on its website that orthodontic treatment can, among other things, ensure proper function of teeth; create a healthy, attractive smile and facial structure; assist in maintaining a good bite, which in turn makes it easier to chew and speak; help avoid tooth decay/loss by making teeth easier to clean; and prevent the need for expensive dental procedures that could result from untreated orthodontic issues.

Dr Jebreil offers patients the Invisalign clear aligner solution and she too does so for more than just improving the esthetics or patient smiles.

“You know, getting into the minimally invasive approach, my practice is focused solely on cosmetics,” Dr Jebreil explains. “When I have a patient come in and they want to improve their smile, oftentimes, I will recommend Invisalign or ortho first to get the teeth in the right position. Because then we have to do fewer veneers or final restorations when everything is in the right position. Additionally, you don’t have to prep the teeth as much. Also, sometimes a patient will come in and they’re constantly chipping their bonding. The reason why is because the bite isn’t in the right position. So I use Invisalign to increase the longevity of my restorations by getting the teeth into the proper bite.”

Educating the patient on the keys to correcting malocclusion and its role in conservative care and better, longer-lasting health is very important, she says.

“I tell them, ‘I know you want this beautiful smile and you’re frustrated. This [restoration] keeps breaking. But the reason it’s breaking is because of your bite and the way you’re hitting these teeth. So if you want to keep these teeth longer, we’re going to need to move them first into the proper position.’ ”

Dr Jebreil adds that most patients are usually OK with a treatment plan using clear aligners because they’re tired of things breaking or they’re unhappy with the way things look in their mouth. Additionally, she says, some patients who might have initially been opposed to cosmetic dentistry and just wanted Invisalign will decide to go with more cosmetic treatments once their teeth have been straightened.

“A lot of times patients who don’t want to do cosmetic dentistry but are open to Invisalign, once you get the teeth into the right position and the gingival levels aligned, the patients start to pay more attention to their teeth,” she says. “Then they become more aware and more open to cosmetic dentistry because they see how their teeth wore unevenly. A lot of times people think Invisalign is going to make them have that beautiful billboard smile. In reality, it’s still going to be your own teeth, just straighter. Once they’re in the right alignment, then it’s a great time to introduce cosmetic dentistry.”

Align Technology, which makes Invisalign, made it clear at this year’s company summit that orthodontics is about a lot more than just pretty smiles. A prominent theme at the 2023 Invisalign GP Summit in September was the opportunity to change the standard of care for patients by incorporating tooth movement into comprehensive and everyday dentistry, not only for esthetics but also for function and more conservative restorative preparation and better restorative outcomes.

“Align Technology’s products help dental professionals achieve the clinical results they want and deliver effective, leading-edge visualization and treatment options to their patients. Align’s goal is to give patients of all ages access to the smiles they want and deserve. Align’s smile-changing technology and innovations are designed to meet the demands of today’s patients with treatment options that are effective, convenient, and efficient while helping to improve overall oral health,” says Mitra Derakhshan, DDS, MS, senior vice president, global clinical, at Align Technology.

“When a person does not have enough room in their jaw for their teeth to fit normally, the teeth can bunch up, overlap, and twist, sometimes getting pushed to the front or the back,” Dr Derakhshan adds. “Crowded teeth can make it hard to brush and floss well. Then it’s easier for plaque, tartar, and harmful bacteria to build up. Down the line, this can lead to tooth decay and gum disease. Crowded teeth can also get worse over time. By addressing these orthodontic issues head-on, problems with oral health later down the road can potentially be avoided.”

Align Technology and Dentsply Sirona are just 2 of many companies making big pushes to have an impact in the clear aligner marketplace. Patient demand; increased awareness of how untreated malocclusions may impact oral, physical, and mental health; and greater predictability with today’s solutions all play key roles in the clear aligner boom. Clear Correct, Candid, 3Shape, Orthosnap, orthobrain, OraPharma, OrthoFi, Evenly, and On Demand Orthodontics, and many others also are making news in the field of clear aligner orthodontics. They all, however, need to fit into the best overall restorative plan for patients to provide the best long-term care.

Evenly, a telemedicine platform that enables dentists to provide advanced orthodontics, developed a doctor-directed orthodontic treatment plan. Barry J. Beck, CEO of Evenly Technologies, says patients who go with orthodontic treatment tend to become more invested in their overall oral health.

“Patients with crowded teeth often have poor plaque control,” Beck says. “When teeth are properly aligned, oral health naturally improves, especially because it is easier to clean the teeth. Additionally, it is widely accepted that patients having orthodontic treatment usually develop a heightened dental IQ [a patient’s understanding of their oral health and what affects the health of the oral environment] and deeper interest in their overall dental health. These patients will be more inclined to be interested in implants for missing teeth, as well as veneers, whitening, and more regular hygiene visits.”

Evenly provides a specialty orthodontic service within the GP’s office, greatly increasing the likelihood that patients will get the orthodontic treatment they need, Beck says. For example, restorative results are better if a stable foundation is part of the restorative process. Restorations are often compromised by restrictions imposed by occlusion, lack of space available, and asymmetric midlines, yet some patients are still reluctant to seek out the recommended orthodontic treatment.

“Additionally, communication between the general dentist and orthodontic offices is often missing or delayed,” Beck adds. “An in-office orthodontic service such as Evenly helps patients conveniently achieve the expert orthodontic treatment they need and streamlines the communication between the dentist and orthodontist. This ensures the teeth that are the focus of the restoration will be positioned to optimize the restorative result. The Evenly platform facilitates clear communication between the dentist and orthodontist since we work inside their office. This close communication also helps to properly align treatment goals between the general dentist and the orthodontist.”

Wayne Hickory, DMD, MDS, MS, chief medical officer of Evenly Technologies, knows the role proper tooth position plays in the success of restorations as well as the patient’s oral health.

“It is important to screen all restorative patients in advance for their orthodontic needs,” Dr Hickory says. “Firstly, restorative dentistry is best performed on a good foundation of periodontal health and healthy and esthetic tooth positions, and orthodontics position teeth with this in mind. We sometimes find that dentists jump right into implant or other restorative procedures without considering the benefits of doing orthodontics first.”

It is difficult to provide orthodontic treatment to fix a patient’s occlusal health and tooth position after restorative dentistry has been performed, he adds. For example, tooth sizes and shapes can be wrong for creating an ideal result, and some teeth are not movable after restorative dentistry.

“The worst situation an orthodontist encounters is implants placed prior to orthodontics,” Dr Hickory says. “Because implants cannot be moved, even just 1 implant placed prior to proper orthodontic treatment severely limits the ability to align the other teeth. Conversely, sometimes we strategically request implants before or during orthodontics because once their ideal position is determined, implants can be placed to provide anchorage for moving other teeth. In cases where many posterior teeth are missing, this may be a requirement.”

Dr Smallwood, who lectures on clear aligner therapy, knows it is the dentist who can often get the patient on the right path to straighter, healthier smiles.

“GPs are at the forefront of patient malocclusion and can be an instrumental part of their patient’s improvement of oral health. It often starts with straighter teeth that will improve their periodontal condition, occlusion, and function. It will also collaterally improve their appearance and the patient’s dental IQ,” Dr Smallwood says.

“Clear aligner therapy opens up the doors for opportunities for more conservative dentistry for the patient. I’m 55 years old, so I’m of the generation that didn’t have a lot of training on some of the newer technologies in clear aligner therapy.… For example, I didn’t have any clear aligner training when I went to dental school but several classes behind me did receive education on evolving orthodontics,” he adds.

Traditional wire and bracket orthodontic methods are very different than training for clear aligners, but many people don’t think that way, according to Dr Smallwood. They tend to think ortho is ortho, where one uses wires and brackets and the same mechanisms to move the teeth.

“Well, not exactly,” Dr Smallwood clarifies. “Clear aligners move teeth and at the same time, for example, you can modify bone position. We can now turn a T-shaped arch into more of a U-shaped arch. Traditional ortho moves teeth through bone. The bone modifies around the tooth but it doesn’t really move; with clear aligners, it’s far more efficient. With clear aligners, movement is more controlled and methodical. And it’s overall better for the patient; surrounding bone and structures can be modified and improved.”

Dr Smallwood loves that SureSmile Clear Aligners deliver consistent results and that refinements are reduced compared with other systems he previously used.

“For me, I work primarily with SureSmile. I love their product. My refinements have gone down considerably. Most costs have diminished by about 40%, and the product itself is just far superior. With other companies, it was an over 70% refinement rate; with SureSmile I’m having less than 20% cases going to refinement, and that makes me happy and the patients thrilled. Their cases are getting completed on time and they refer more people to us. We just love it.”

Dr Rohde says the digital workflow he uses with SureSmile along with Dentsply Sirona’s Primescan intraoral scanner makes the process of delivering clear aligners to his patients quick and easy. The material itself and the VPro high-frequency device—an at-home treatment that can improve aligner seating and accelerate tooth movement—are big selling points for using SureSmile in his practice.

“The workflow of the product is awesome. I can do a digital impression using Primescan—it’s super fast,” says Dr Rohde, who also likes that technicians help clinicians set up the SureSmile cases. “Based on your instruction you have a review process, and I would say it’s more predictable and simpler. One of the many reasons why we chose SureSmile is because there’s a huge amount of support. It’s not just your local rep. You have online resources and forums that you can go on. They’ve developed a whole new DS Academy [that covers] literally everything you could possibly ask for. This is big because classes for many GPs when they were in school just didn’t get that much into orthodontics. Now there’s a ton of online education, as well as certification classes, to go to. They also can help you identify what is a great first-year case and what is something I should still refer out.”

Dr Jebreil likes that because Invisalign has improved so much over the years she can count on strong results for her patients in a predictable amount of time.

“In a lot of these restorative cases that [need to fix] the bite, I can do it in an Invisalign treatment,” Dr Jebreil says. “It’s 14 trays and usually about 4.5 months. A lot of times if I give them a VPro vibrating device, we can do it in close to 3 months. Most [patients] are OK with that.”

Because of these timely, quality results, many of her patients will opt for Invisalign rather than rush into other treatments such as veneers, which may not last because of existing malocclusion problems.

“I used to explain to patients, ‘Yes, I can put a couple of pretty teeth on there for you, but if we straighten up things we can address the whole idea of overall health,’” she says. “I think if patients had a better understanding of that, that’s obviously something that they would want 100%. The other thing is, everybody wants to have veneers and this and that cosmetic procedure done. The reality is that most patients aren’t a candidate for that. But with Invisalign, if you make some spaces and straighten teeth a little bit, then we are in a position to do prepless veneers [or other cosmetic treatment] and they’re really happy about it.”

The increase in popularity of clear aligner therapy such as Invisalign is directly related to the technological and material advancements that they have made, says Jason T Gladwell, DDS, MSD, Gladwell Orthodontics. “The materials today compared to a decade ago provide significantly better and more predictable movements and treatment outcomes,” adds Dr Gladwell, a customer of OrthoFi. “Along with the material innovations, the software innovations and AI advancements have made it much easier to close the gap between general dentists and orthodontists in terms of providing a specialist level of care in those offices. Where years ago general dentists were much more apprehensive to providing orthodontic treatment in their own offices, these new advancements have made it much easier to provide the care that patients need and deserve. This allows for practitioners to provide better restorative care as they are putting the teeth where they need to be in order to increase long-term success of the restorations.”

Adding orthodontics to a treatment plan where appropriate, clinicians also see an increase in the acceptance of restorative dentistry such as implants, veneers, and other more esthetic procedures that patients were previously disinterested in, Dr Gladwell says. “Once patients start to put things where they belong, they realize how much they actually focus on their smile and teeth, and are more open to the procedures that we know as providers will be of benefit for them. Another advancement that is helping general dentists to provide quality orthodontic care is the advancement of treatment planning solutions and programs. Our Strategic Partners Program is designed to help a general dentist provide specialist level of care inside a GP office. We do this by having our orthodontists take over the ClinCheck set up for the general dentists, and having our educational team provide training for all aspects of the treatment. Everything from case acceptance, clinical protocols and efficiencies, and case selection, diagnosis, and treatment planning,” he states.

Because of the successful outcomes with clear aligner therapy, Dr Jebreil sees patients opting for more restorative care once the teeth have been moved into the proper positions. She also adds teeth whitening into the plans along with the orthodontics.

“Sometimes patients aren’t open to doing surgery—for example, crown lengthening,” she says. “So if you can improve the teeth with ortho, they’re much more amenable to doing it that way. That’s a benefit there. The other thing is a lot of times people will come in and they have spaces, and they want me to do veneers or do bonding to close the spaces. But in reality, if the spaces aren’t appropriately divided—like for the final restoration—you need to move the teeth. A lot of times, even though they have spaces, you don’t necessarily want to close them but you want to distribute them into the proper position so that when you do your final restorations, everything is proportional.”

Get them straight and get them bright and patients may very well get on board with other restorative and cosmetic care that can lead them down the path to a good-looking, healthy smile for years to come.

“With all of my Invisalign cases, I like to implement whitening after Invisalign; even with ortho, it tends to trap a lot of plaque,” Dr Jebreil says. “We always plan the whitening in addition to Invisalign, and it’s always a gateway to more treatments. Once the teeth are whiter, they then see how the old restorations are yellow or they notice other nuances. I really, really think Invisalign and whitening together is a great gateway to other treatments.”

Dr Rohde uses a football analogy to explain how orthodontics fits into delivering the best possible restorative to your patients.

“It’s my belief that the dentist does represent the primary care person for that patient—you’re the first line of defense. You’re the quarterback,” he says. “When someone comes in with perfect teeth, but has tartar and bleeding gums, what are you going to do? Refer that? No, you’re going to get them a cleaning.… Our patients’ health is actually our responsibility in many ways.

“Now, whether they [adhere to our suggestions], that’s a whole other discussion. If someone comes in and they have bleeding gums, we need to let them know why. If they come in for an orthodontic-related reason, then again, we need to let them know why. Don’t let the educational side of things keep you from making recommendations. When we learn this stuff well, we can look at crowded lower anterior teeth and let the patient know that periodontal disease is in their future. It’s all related.”

Dr Smallwood sums it up by stating that clear aligner therapy in his practice allows him to cover all the bases and give his patients what is best for them.

“I do feel like dentists look at things like orthodontics and restorative as black and white. They don’t really relate them,” Dr Smallwood says. “I’ve got to tell you; those circles are all perfectly aligned for me. I always think of how the 2 forms of treatment can benefit the other. Nowadays, most cases could benefit from the use of clear aligners. Not everyone will accept it, but it’s available to us and can be predictably performed. There will be an additional cost and an additional timeframe, which are 2 elements that patients are always concerned with, and rightfully so. It’s our job to explain the benefits of clear aligner treatment.”

So get this straight—getting teeth in the proper position first is the optimal way of delivering the best long-term care for your dental patients.