Your Ortho Questions Answered – Root Resorption, Retention, Interceptive and More! – PDP186

Protrusive Dental Podcast

How long should you wait after a root canal before starting Orthodontics?

Should we be scared of orthodontic movement in those taking bisphosphonates?

How do you decide if diastemas should be closed restoratively or orthodontically?

Dr Daniel Neves answers every one of the questions and several more sent in from the Protrusive Community

These questions are the tricky case-specific ones we ponder about and crave guidelines for – straight talking Dr Neves makes it all tangible.

https://youtu.be/ZufVChjEJk4

Watch PDP186 on Youtube

Protrusive Dental Pearl: Retention is not a ‘one and done’ process. It should be customised for the individual and maintained appropriately – including at every routine check up.

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

Highlights of this Episode:
04:40 Protrusive Dental Pearl
05:53 Introduction to Dr Daniel Neves
12:16 Reducing the Risk of Relapse
17:20 Anterior Diastema
21:47 Temporary Anchorage Devices (TADs)
26:20 Jaw Issues in Adults
29:20 Root Resorption
34:25 Recession Cases
38:00 Timing of Orthodontics after Root Canal Treatment
39:39 Bisphosphonates and Orthodontics
40:16 Aligners around Implants
42:22 Final Thoughts

If you liked this episode, you will also like GDP Alignment vs Specialist Orthodontics [STRAIGHTPRIL] – PDP068

Click below for full episode transcript:

Jaz's Introduction: It's May 2024. May the force be with you. That's the theme of this month. Whilst I've got episodes on all different sorts of topics like we usually do on Protrusive, we're starting off with this orthodontics podcast. And let me tell you, if there's one episode you've listened to on Protrusive around the theme of orthodontics, make it that.

Jaz’s Introduction:
This one, we cover such a great breadth of topics with my guest, Dr. Daniel Neves. We were actually recording. We actually sat on a sofa watching the sunset in Valencia, Spain, while we were recording this podcast. It’s a special one is a great energy, great wisdom from our guests. So I’m really excited to share this with you.

Look, the kind of themes that we cover is get my notebook out. The kind of themes you cover are anterior crossbites in children. This is actually what stemmed this podcast. Me and my colleague Suzy, we were feeling pretty bummed because we saw this kid, I think he was like eight or nine years old, and he had an anterior crossbite.

And we thought, wow, this is really suitable. We think this would be a great case for an orthodontist within our publicly funded system in the UK to do some interceptive treatment for this anterior crossbite. And we were bummed because the orthodontist declined it. The orthodontist said, let’s wait until age 12.

Let’s wait for all the teeth to come through and then refer this back. And I was really left scratching my head like, Hmm, hang on a minute. I’m pretty sure an anterior crossbite is an indication for early treatment. So let’s find out what Dr. Daniel Neves had to say about that.

We also at the end talk about root resorption. What if you have root resorption? How big of a problem actually is that for our patients? And then what if they experience some relapse and they want to have some aligners? Is it safe to do aligners and little minor movements on patients who have suffered with root resorption?

Another one we covered. Again, all these questions are from you guys, the Protrusive Dental Community on our app, Protrusive Guidance. It’s been so great to engage with a Protruserati. And so the question was bisphosphonates. What do you do with patients on bisphosphonates when you’re considering orthodontics? What about doing aligners with someone who already has implants?

What extra precautions or measures should we be looking at? What about fixed retention? Is it actually forever? Is there a time where we should perhaps consider removing that fixed retention or changing it up? We also discuss diastema. Is diastema always an orthodontic issue? And when is it a restorative issue? When should we be using our resin or ceramic to treat diastema instead of orthodontics? And of course, the big one. The big one I ask is, are extractions an acceptable treatment modality? Orthodontic extractions, are they acceptable in this day and age? So let me tell you guys, this episode really packs a punch. It’s really concise. It’s really packed with gems. And I hope you gain a lot from it.

Dental Pearl
Hello Protruserati, I’m Jaz Gulati and welcome back to your favorite dental podcast. Every PDP episode I give you a Protrusive Dental Pearl. Today’s pearl is very relevant to what we discussed with Dr. Daniel Nevers Maintaining Retention for our Patients.

So of course we tell our patients retentions for lifetime and the importance of wearing your Essix retainers plus or minus your fixed retainers. But really what we should also be telling them that it’s a dynamic thing that every, four to five years should be reassessed. And so it’s important that we have that kind of conversation with the patient.

And also the patients that we are seeing year by year, every six months, and they happen to have orthodontics in the past. Are these patients bringing in their essix retainer so you can check them? And are we scrutinizing or critiquing the fixed retainer? Because we’ve all seen instances where the fixed retainer has caused some sort of issues.

You know how these retainers get activated and teeth start to talk out of the retainer. I really regret about five, six years ago. I really regret seeing a case where this young lady had a lower incisor which was like completely going out of the bony envelope in the lower because this fixed retainer got activated right so the fixed chain got activated somehow and you see this one rogue lower incisor like really really like the root is like really lingual and you see like loads of recession here and you know this is a fixed retention issue.

Now, I didn’t have the cojones at the time as a GDP to say to the patient, hmm, this is not good. We need to take off this retainer ASAP. Because it’s a bit like, wait, an orthodontic specialist has done the orthodontics here. Who am I to go and remove their fixed retainer? But I realize now that actually that was a disservice to the patient.

I shouldn’t have underplayed it. In fact, I didn’t underplay it. I really educated her. I showed her the photo. I said, this is a real issue. Please could you see your orthodontist ASAP and discuss it. So I think I’m really happy I did that. And I think that should be the first port of call. Are they still in touch with their orthodontist?

Can they still get back to get an opinion and management of this scenario? But if you’re patient, you know, they’re not going to see an orthodontist because they’re hundreds of miles away and they’re looking to have some sort of care with you. Then actually we should have the confidence to detect that. Okay, this fixed retainer is now failing.

And the longer this stays on, is it going to be a bigger problem? To document that, to communicate it, and actually to manage it for the patient to remove that fixed retainer potentially, which is continually doing damage. So the lesson is re evaluate and always think about the maintenance of the retention, be it fixed, removable, or both.

Let’s now join this main episode, which is eligible for CPD or CE. All you have to do is answer the quiz on protrusive guidance. So in the all CPD section, you click on the episode, you answer the quiz, and the CPD Queen Mari will send you your certificates. Also, she’ll send you your quarterly certificates and annual certificates.

So for the price of a tax deductible Nando’s, you can only get CPD for episodes like this. You can actually get access to all my master classes from sectioning school to plonkers and the dozens of premium clinical videos, hundreds of hours of content on protrusive guidance. Check out www. protrusive. app and select the package that’s best for you.

If you just want to join for the community and for the engagement and for learning to be part of the nicest and geekiest community in the world, then you can go ahead and just join the free community plan. I catch you in the outro.

Main Episode:
Dr. Daniel Neves, thanks so much for joining the Protrusive Dental Podcast. How are you today?

[Daniel]
I’m very good. Thank you very much for the invitation.

[Jaz]
I’ve never recorded in front of the sunset before . So for those who are watching on YouTube and most of the listeners are on like, Spotify and Apple and stuff, but it’s just a beautiful sunrise in Valencia. Yes, as they affectionately call it.

We’re here delivering a IPR workshop for intensive. We were practicing all day yesterday and it was just great to speak to you and get to learn about you. And I then posted on my community. So is it, as I was telling you, there’s a home of the nicest and geekiest dentists in the world. We call it, right?

[Daniel]
That’s very cool.

[Jaz]
And I said, I have a brilliant orthodontist I want to record with. What questions do you have? Like a mishmash of ortho questions, right?

[Daniel]
Uh huh.

[Jaz]
And then when I was speaking to you on the taxi on the way back, I was like, yes, I found my guy because I’m so excited to share what you said in the taxi, but also generally answer his questions before we delve deeper into that. Daniel, tell us a little bit about yourself. When you practice, what’s your passion?

[Daniel]
All right. Very good. So dentistry is my passion is the passion of my family. Actually, my mom and my dad, they’re both dentists and they started back in 1971. So it’s more than 50 years ago. Cool thing is that the whole family, they turn out to be dentists as well.

Both my sisters, they’re dentists. And also my wife is a dentist. So I live in a dental environment and I have been seeing dental chairs since I was a little kid so that got me into it big time so I practice in Curitiba that’s a big town about for Brazil about three million people in the south part of Brazil and I’m an orthodontist practicing only orthodontics for more than 25 years now and doing I would say 90 percent of clear aligners currently and 10 percent of fixed appliances in the office.

[Jaz]
Which is what I asked you yesterday. And also having an interest in interceptive orthodontics?

[Daniel]
Oh, big time, big time. I do early intervention quite a lot because my sister is a pedodontist. And then she has a pediatric dentistry and we see a lot of kids. And she sees a Kids since they are babies. And then we do follow growth and development and doing that and making sure that they grow in a nice and good way. It allows them to have an easier way with the occlusion when they are adolescents. And then it’s easier for them. It’s easier for me. It’s better for everyone.

[Jaz]
And it helps the trend towards non extraction. It feeds that in so that you’re not cornered to have to extract for space.

[Daniel]
There you go, Jaz. If you looked like 20 years ago, the amount of extraction cases that we had in the office was huge. Now I can literally count in the palm of my right hand the number of extraction cases that I have in my office. Not that they’re not needed anymore. Some of them are because of face characteristics and all of that. But, like, they’re very, very rare now.

[Jaz]
Great. Well, let’s dive into the first question, which is very much on the theme of interceptive orthodontics. My dear friend and colleague who I work with Suzy, she sent me a photo of a patient actually shared this photo to me a few weeks ago. Now, because we’re most people are listening, I will describe it a nine year old boy, the upper left central and lateral incisor. I avoid using numbers because there’s lots of American listeners.

Upper left central and lateral incisors are slightly retroclined and then on the opposing, so on the mandible, the lower left central. And lateral, instead of being retrocline, they’re procline, because if the upper is retrocline, the lower is procline, i. e. an anterior crossbite. We have an anterior crossbite, and we can see, when she showed me the image, about how much, like, recession this boy, nine year old boy, had on this lower left central and lateral.

And so I said, Suzy, I think we should totally refer this to get a specialist opinion. And I was really sad, Daniel, because two specialists, one nationally, publicly funded, and one even private said, Hmm, it’s very difficult because there’s no premolars yet. How can we help to retain an appliance? Without premolars.

And I went away from that experience. And me and Suzy were both like, Hmm, maybe we’re not so clever as we thought. Maybe these orthodontists are right. And we are like, we were silly to even ask. I felt like, Oh my goodness, maybe my diploma in orthodontics has gone to waste. And then when I showed you those images, please, what was going through your mind?

[Daniel]
Yeah, a big time. So when we see a crossbite, that’s one of the things that triggers our brain on there. We need to do something. Like, either if it is a posterior crossbite and then you have a deviation that needs to be addressed.

But if you have an anterior crossbite, the main thing would be the gingival recession. And we saw those recessions on the lower incisors. For a nine year old boy. Yes, imagine, so ten years down the road, how those incisors would be. Like, there’s no bone in the buccal area.

[Jaz]
But the patient and the mother don’t complain of that. They were actually complaining of a chipped upper left central because of the crossbite. Now there’s a chip, and then when he smiles, there’s a chip. So it’s funny, they come in with this issue, but actually we’re seeing all the clusel issue, the recession issue.

[Daniel]
And it’s funny because a lot of patients don’t really know how the occlusion should be, right?

[Jaz]
They think it should be edge to edge.

[Daniel]
Edge to edge, that’s the big time worldwide, right, right? So, isn’t it edge to edge? No, then you have to explain.

[Jaz]
That’s a cartoon.

[Daniel]
Yeah, the upper area up there is slightly forward. And then they wrap around the lower arch. So that’s the quite interesting thing. But even if you like don’t have the traditional anchorage, we do have many different ways today to design appliances with different kinds of anchorage that would give you the enough support. Even if you have only the interior teeth, you could build something in the interior teeth to help correct that cross bite and that cross bite needs to be corrected as soon as possible.

[Jaz]
And I imagine that doesn’t take a long time to correct, right?

[Daniel]
No, exactly. As soon as you give the-

[Jaz]
Disengage

[Daniel]
For the space, you disengage, then the movement is quite easy. It’s the movement of proclination and retro proclination. A combination of both proclination and the upper retro proclination in the lower, that’s gonna be very fast and very predictable as well.

[Jaz]
And then you get the sudden like bite jump.

[Daniel]
Yeah, the end. There you go. And the retention for that. It’s kind of a natural retention because the occlusion will retain it for itself. So you don’t really need to think, oh, how do I retain this now? So that’s quite nice.

[Jaz]
Okay, great. So Suzy, we’re going to touch heads again and figure out what to do for this young boy in the UK. Because I was, me and you, Suzy are both strongly in favor of him getting early interceptive treatment.

And I’m so glad to have found Daniel who agrees. I mean, not because you’re confirming my bias or anything, but because I genuinely my values and what I truly believe it was my own son. And Suzy said the same. It was her daughter. So I’m glad you’re with that. So let’s see the next question I had. In fact, I’m going to answer, these are some questions I thought of.

Let me answer the other questions that the community came up with first. So we talked about anterior crossbite case, that specific one. I’m going to leave out the orthodontic one, even though you do a fair few interdisciplinary case, I’m going to come back to that one.

[Daniel]
Yes.

[Jaz]
I want to find something more that’s applicable to most GDPs. So here’s a relapse one, obviously.

[Daniel]
All right.

[Jaz]
This is Dr. Kostas Koleonidis from Greece. He says, sorry for the primitive question, but I’ve been wondering, is there a consensus on when or whether it’s relatively safe to remove a fixed retainer with a minimum risk of relapse?

[Daniel]
Okay.

[Jaz]
He says, I’ve heard about two years after the end of orthodontic treatment, but I’m not sure. So essentially, it happens to me as well, where when the fixed trainer fails, when, not if, but when it fails, you have that conversation of, hmm, you know what? Things are pretty good. Should we just take off this fixed retainer, clean away the calculus? And now you just rely on your essix retainer. What are your thoughts about this sort of treatment approach? We’re removing things.

[Daniel]
I really like it. This is something that we see every day. So studies would show that retention and stability with like adolescents would be around five or six years. So five or six years that you would remain, retain that fixed retainer in place, but that patient needs to be seen at least like every six months to make sure that there’s no plaque retention.

There’s nothing that actually is acting against your retention. Imagine if something happened and the patient didn’t notice and then you have a tooth moving out of place, then it’s actually because of that retention that you had the relapse. So the retention. Needs to be seen and the retention needs to be replaced.

Just let’s say that you are keeping that for six years. It doesn’t need to be the same retention for six years. After two years, you can replace that retention. To make sure that there’s no stress within the wireframe. There’s nothing that would actually alter the position of those teeth. So, not only the retention is important, but the maintenance of that retention is also very, very important.

[Jaz]
It’s not like a once and done.

[Daniel]
No, yes. Forget about it. A lot of adults come and say, yeah, do I have to use that for a lifetime? Yes. Lifetime. And then I don’t see you anymore. Like I come from an environment where we have the office in the same place for more than 50 years. So we’re used to see our patients for lifetime.

And then we see, and we keep seeing them like every four, six months. And that’s so important to make sure that you build a community with your patients. You keep seeing them and then you’re going to get referrals from those patients that come for a quick check, quick cleaning, just to make sure that everything is good.

But your question on like patient came with the broken retainer, is it better to replace it or to bond it again, or to remove it. Sometimes if you just bond one little place, sometimes you put some pressure on it and then you might alter the characteristics of that. Yes, you make it active. And then you start either proclining or retroclining a tooth. And that’s quite dangerous. So it needs to be passive and it needs to be well taken care of.

[Jaz]
So in the case of if you are in a position that the patient says, you know what, I find it annoying, can we remove it? What are your thoughts about removing fixed retention that’s been there for two, three years?

[Daniel]
Alright, so there’s a good and nice talk that I do with the patient when we decide on that. So if we decide on, yeah, let’s remove it, so let’s say that the patient is not brushing properly and then there’s plaque retention accumulation, I tell the patient, okay, we’re going to remove that and then you’re going to be able to floss better.

But I want you to floss better. It’s not because you can floss better that you’re not going to do that. Yeah, you have to do that. But please come back to me in about a month just for me to make sure that everything is in good shape. And then I’ll give you four months. And then I’ll give you four months again.

And then I keep seeing you until I’m sure that everything’s stable. And I can let you go without the retainer. If I see anything moving after a month, then I still have enough time to keep it stable without any basic orthodontic movement that I would need to. So it’s maintenance and monitoring is very, very important. Monitoring the patient.

[Jaz]
So there we are, Kostas. You can do it, but make sure you monitor closely. But in that situation, I would still feel uneasy about removing their fixed retainer and leaving them with nothing. I would still want a removable clear retainer. Is that part of your protocol?

[Daniel]
That’s the safest part, yes. Take an impression or scan the patient. Do a removable retainer. It could be like plastic retainer and it would go like from molar to molar or even from bicuspid to bicuspid. And then you might think, wow, if it’s only bicuspid to bicuspid, would the upper molars over erupt or the lower molars over erupt? If they’re using night only, leave for short period of time, it would not have that problem. So yes, I would.

[Jaz]
I think, I think as a guideline, if they can do full launch, do it.

[Daniel]
Do it.

[Jaz]
If there’s a special reason for whatever reason, maybe they need lots of posterior work in the future coming up soon, then that might be a good indication for that.

[Daniel]
Exactly that. But again, monitoring is key. Monitoring is key. Don’t just do something and then just say bye to the patient. And then whenever you see that patient again, you might be, oh, what happened here?

[Jaz]
Amazing. Thank you, Kostas, for that question. So, Shilpi asked about intrusion with aligners without TADS. I’m going to look at this one and also let’s cover Mohamed. Mohameds a dental student actually in the U. S. Mohamed Abo-Basha, shout out to him. He runs the Very Dental Student podcast, was part of the Very Dental Network. All right. So his question is, what are the contraindications, if any, for anterior diastema closure via orthodontics, how easily do they relapse?

And I think really the next part of that question is what are the alternatives? So we know that we can do it restoratively or we can do it a orthodontically. So I guess what goes through your mind when you are saying, should you send it to your wife or to your sister to have a concept or a ceramic, or actually you are the best person for this or orthodontically. And then what are the relapse considerations?

[Daniel]
Very nice question as well. So it’s all about diagnosis and treatment planning. So we need to evaluate the occlusion. So you need to evaluate the interincisal angle. How much overjet do you have? So if you are planning on closing that gap, closing that diastema, but you don’t have enough overjet, and then you are going towards an edge to edge bite. Then you’re going to have pressure against that closure of the diastema and then that diastema is going to open again.

[Jaz]
And you get fremitus and occlusal overload.

[Daniel]
There you go. So if you do have overjet and you do have the space, then yes, you can close the diastema. But you have to take a look at the frenum. So the frenum attachment, how low it is, if it needs any intervention. Now, next question. If it needs any surgical intervention in the frenum, when? Before closing the diastema or after closing the diastema?

[Jaz]
So I imagine this is a split opinion, so go ahead and say what do you do and why?

[Daniel]
Alright, so what would be my opinion and my way of doing that? I would close the diastema first, and after closing it, what I do is kind of press that frenum, and then after I press it, I let it remodel. And then we do the surgical removal of that because the tissue, the scar tissue that would form around that would help me with stability. And if I think the other way around, if I remove it before, the scar tissue could be as strong as the frenum itself, and then it would give me a hard time closing that gap.

[Jaz]
That’s a very good way to think about it. I like that. Okay, so there’s a good justification there. What about looking at teeth that perhaps are like a Bolton’s discrepancy? Maybe they’re a bit thinner, the width is not adequate, and perhaps they would benefit from restorative volume. In that case, perhaps it might be an indication for no ortho, and treat purely restoratively. Am I in the right area?

[Daniel]
Yes, you’re in the right area. So if I, it’s not because they have a freedom, that they have a gap, they have a diastema that I need to intervene. I need to be the one closing that gap.

[Jaz]
I mean, ideally, I think all those are best because if you reduce their restorative burden throughout their entire life-

[Daniel]
That’ll be my goal.

[Jaz]
But in some cases where the tooth are insufficient, like peg laterals, for example,

[Daniel]
Peg laterals, that’s a big, big example. So, and again, the peg laterals with the overjet and entering incisal position. So you distribute the teeth in such a way that you leave the ideal position for the restorative dentist to do the bonding. Then you get the best combination of all occlusal aesthetics and then the intercisal angle, which is like very vital on the stability of the treatment.

[Jaz]
So correcting and visualizing the correction of the overjet and the interincisal angle and then okay, at this point, would the dust may be fully closed or not? And then see, does this tooth need volume or not? And then it’s a combination sometimes.

[Daniel]
A combination. A lot of times we don’t close the whole way. We close like part way and then we do the bonding. Very interesting case that we’re working now in the digital era, like we’re doing all digital planning and all of that.

So we’re doing this pilot where I did exactly that. So the patient came with a huge diastema and I actually, instead of doing the full closure, we’re just doing the restorations on the central incisors. I actually distributed the space in between the central incisors, in between the central and lateral incisors, and between the lateral incisors and the canine.

[Jaz]
So it’s a multiple diastema, like just generalized spacing.

[Daniel]
Instead of only one, I had five diastemas, but really small ones. And when you do that, you have a smaller amount of resin, but distributed on those anterior teeth. And then again, it helps you with stability, and it helps you with the general overview of the occlusion.

[Jaz]
Okay, great. I love how concise and good your answer because I warned you that. Okay, there’s so many questions, right? Fine. Excellent. So let’s take Shilpi’s question now. Shilpi Kachhwaha. Thank you so much, she said intrusion with aligners without TADs. So I guess what she’s asking is TADs can help to improve the predictability of our movements for most general dentists yet.

I know you teach on TADs as well but we’re not yet embracing TADs as much as our orthodontist colleagues. But what do you think is the limit of intrusion without TADs? And then you can actually add in the flavor. Okay, then what do TADs bring to the equation when it comes to intrusion?

[Daniel]
All right, so we have to think as well in which teeth are we talking about? So if we’re talking about a molar and let’s say the patient lost a lower first permanent molar, which is quite frequent for example in Brazil, and then you have the overextrusion of the upper first molar. So you need to intrude that. What would be the limit? It all depends also on the configuration of the occlusion, but normally I would set it at one millimeter.

So up to one millimeter, you would be able to do the intrusion with the aligner itself. 0. 7 to one millimeter max. Predictable. Predictable. More than that, you would need TADs. Where? You would probably put a TAD in the buccal, one in the lingual side, and then it would run elastics either to a button on the buccal and lingual surface of that molar, or running over the occlusal surface of that molar.

Not difficult to do, but think that maybe you could place the TAD and the TAD might get loose and then the patient might get bothered by that and yes, we do avoid it when we can. But a lot of times that 0. 7, that one millimeter is very important in the prosthetic preparation on the lower teeth when you are going to place an implant and maybe a crown over that.

Those 0. 7 are very, very important for us, but I would keep it at that range, 0. 7 to 1 millimeter, the max for intrusion. If we think about a deep bite and then an anterior intrusion.

[Jaz]
That’s my next thing because as a restorative dentist treating tooth wear into lower incisors, I like virtually always want to intrude those because usually by compensatory eruption in their smile aesthetics, they’re showing too much lower incisor. And if you add restorative resin or ceramic to the lower incisor, now you’re showing even more.

[Daniel]
Even more. And then so we need that intrusion.

[Jaz]
Yes. Yes. So what is the limits of intrusion with and without TADs anteriorly?

[Daniel]
So without TADs in the anterior, then the anterior would go over the one millimeter limit because then you can distribute that intrusion. We call it the frog intrusion. I kind of stage it, and then I use the bicuspids as anchorage, and then I start intruding the canine. Then I use the canines as anchorage, intruding incisors. Then I go back to the canines, then I go back to the incisors, and then I do that staging. If I do that staging, I would multiply that number of millimeters that I could do in the anterior region.

So I could go over that one millimeter, 1. 5, even two millimeters, would be like very good. It all depends on the curve of spee and the age of the patient as well. I could do some extrusion of the posterior teeth. There are so many different techniques then to level that curve of spee. And obviously the smile line of the patient is quite important. But yes, on those cases, we could also use tats in the anterior region in the lower, and also on the anterior region in the upper for the gummy smiles patients.

[Jaz]
Gummy smile. And also maybe if you’re going beyond 1. 5 millimeters, two millimeters, I mean, the relative benefit here is if you’re doing some degree of proclination, you get that relative intrusion.

[Daniel]
The relative intrusion.

[Jaz]
When you say the 1. 5, two millimeter, like let’s say up to 1. 5, That figure, is that true intrusion? Does that include the relative intrusion?

[Daniel]
No, that was true. True, because with the relative, you would get very good intrusion. I have a lot of examples with, like, deep bites that you could barely see the lower incisors, but you could have relative intrusion with the protrusion of the upper and lower incisors, and then you have a normal overbite at the end of the treatment.

So I would keep the 1. 5 to 2 millimeters on the pure intrusion, not the relative one. And you brought a very nice concept, the relative intrusion and actually the relative extrusion the other way around as well, when you retrocline the teeth. And that’s one of the dangers of clear aligners.

When you close spaces and then going back to the diastema question, if you try to close the diastema and you just close it and you retrocline it, then you can get the relative extrusion and get deep bite and posterior open bite, which is a nightmare with the clear aligner treatment.

[Jaz]
Yes, yes. And we have covered that before. So very good. And a great point made in good links. I’ll put in the show notes, the episode we discussed about anterior interferences being a very key reason for posterior open bite with aligners. Great, so now we can come on to, not just my question just yet, because Christos, I will not let you down Christos, Christos Athanasoulis, what an international bunch, I love it.

So he says, It’s a very vague question, so let’s pick a facet of it. He says, jaw issues in adults. Now, I don’t know what he means yet, but he says, the role of orthognathic surgery, braces versus liners. Okay, so it’s like five questions in one. So, let’s give you your cake, Christos. Okay, so you’ve already answered braces versus aligners, that you do 90 percent aligner treatment. So we know that a lot of it is possible. All right. And I know the answer you’re going to say here, but let’s just have it in 20, 30 seconds are extractions an acceptable part of orthodontics in 2024?

[Daniel]
Yes, it is acceptable, but avoidable if you do the interceptive early on, and on those 90%, I would include the surgical cases, 100 percent of my surgical cases, they’re done with clear aligners.

[Jaz]
Wow, that’s cool. So we know the role of orthodontic surgery is there. And we talk about, you mentioned in a taxi essay, the geeky taxi ride, surgery first. So tell us about doing the orthodontics first, then doing the surgery, or doing the surgery first, then the orthodontics. What are the current trends and philosophies?

[Daniel]
Yeah, surgery first is a concept that is being more and more in vogue now. But you need certain characteristics in order to do the surgery first approach. You need occlusion that would be stable when you do move that. So you do like, again, you can do many different ways of digital planning and then you can pretty much do the virtual surgery on that patient before you even-

[Jaz]
It’s amazing. I was at the AES in Chicago, and what they showed, the simulation was, the planning is just fantastic.

[Daniel]
Yes, yes. And if you imagine the planning with the face, like how bad it was years ago and how good it is now that you can actually see the face of the patient after surgery. So, for patients that would benefit from the surgery first approach, let’s say a class two malocclusion where you can bring the jaw forward and then you have a pretty stable occlusion after you move that and then you can finish that occlusion. For patients with TMD, patients that would have difficulty opening their mouth.

Pain and all of that. And then you could address those cases and then you need to reposition the condyle as well. And then yes, those patients would benefit from the surgery first approach. But if you do the surgery first approach and you don’t have a stable occlusion after you do the surgery. So if it’s not the indication for the surgery first approach, you might have a lot of issues after the surgery.

So it needs to be very good indication for that. And again, diagnosis and treatment planning is key. There’s not one simple answer for everything. It’s always diagnosis and treatment planning. And then we talked about technology and everything. Everything could be done, like, automatically by AI and all of that.

But if there’s not the intervention of us, the dentists, nothing is going to work. So we are always going to be there and we are always going to be important. So don’t worry. You’re not going to disappear. You’re not going to be substituted for a computer. Right.

[Jaz]
No, we need the human touch. AI makes mistakes all the time.

[Daniel]
Oh, yeah.

[Jaz]
It’s only like with our human touch that these treatments are possible. Brilliant. Christos, thanks so much for that question. So that’s community questions done. I’m gonna ask about root resorption.

[Daniel]
All right, cool.

[Jaz]
I’ve got some patients who’ve had fixed appliance in the fast typically and take a periapical radiograph of their anteriors. The upper anteriors, for example, centrals, maybe 50 to 70 percent of resorption. Now, they may come a time. So firstly, how stable is that long term for the patient in terms of prognosis of those teeth? Let’s go with that.

[Daniel]
So you would be surprised that they are pretty stable as long as the bone around it is healthy. So even if you have like 50 percent resorption, you could expect that those teeth would last a long time.

[Jaz]
And you expect them to be mobile, but sometimes they’re still very solid.

[Daniel]
Sometimes they’re, yes, yes. And as soon as you, like, stop that orthodontic force, stop the trauma, you stop the orthodontic resorption, so they don’t keep going.

So, if it is caused by the trauma that you are causing with the orthodontic forces. And then with the fixed appliances, one of the main problems is that we were using, like, very heavy wires, and doing a lot of round tripping. I would be moving to the right, then moving to the left, then moving to the right, moving to the left.

What is the main problem there? diagnosis and treatment planning. So, the cool thing is that with the digital plan and the digital era, again, you have a nice way of planning and knowing the next steps. So, some studies are already showing that the amount of root resorption that we are seeing nowadays with clear aligner treatment, for example, is much less than we used to see with fixed appliances.

So, yes, if you do see under the microscope, you’re going to have root resorption on a lot, a lot, a lot of patients. But visible ones, you do have those root resorption, but don’t worry about them. But obviously, if you see some root resorption, take a look at the biomechanics that you were using and maybe take care on that.

[Jaz]
Change the course.

[Daniel]
Change the course of how you’re doing that. Yes, some patients would be more prone to that and you would see some of that in some patients. But that’s something that you need to be aware. How do you find out? X-rays. So very, very important to take x rays of their patients before, during and after treatment.

[Jaz]
Very good. Now, so we can reassure our patients that as long as they avoid periodontal disease, that’s actually, that doesn’t mean they’re going to lose their teeth for sure. It can keep them. And I’ve seen lots of years, decades of follow up, showing your practice coming from so many dentists in the family.

I mean, that’s a great thing because I aspire to be that dentist who’s been in one clinic for many years. And I was saying to you to learn, but the benefit you have from being a family run clinic. For so many years is that you have your father’s failures and then all these and you learn and you learn from these things.

[Daniel]
You learn from that so living that and witnessing that is quite important and those are the kind of chats that we have during lunch time during dinner like we talk about that and that’s the funny part. We enjoy that.

[Jaz]
That’s very it’s very true. I can see that energy that you have in the love for dentistry, which is why I’m so happy to be chatting to you There’s a big yellow ball in the sky shining at us. You’re used to this in Brazil. It’s summer in Brazil. For me, from the UK, this is bliss. Okay, anyway, so I’m just going to take a moment to appreciate the Sol.

Now, to finish off that question about resorption. What if they have a bit of relapse along the way and now they have that, they ask him, Jaz, can I just do some aligners to realign these teeth. Now, I get nervous, oh my God, where there’s already been root resorption, and I don’t want to traumatize these teeth further. Any guidelines, advice you can give to me or our colleagues about relapse treatment for those who’ve already suffered with root resorption?

[Daniel]
Awesome question, Jaz, and that happens quite a lot. And then you have to consider, okay, so, we are going to move the teeth again. We’re going to provoke a trauma again. If we are going to provoke a trauma again, root resorption will happen again. At what extent? We need that the extent that we are going to cause is as minimum as possible. So I would use very light forces. So yes, I would prefer to use aligners. And then I would evaluate in the diagnosis and treatment planning, what would be the benefits on placing those teeth in a better position, according to the occlusion.

If I see that there’s any trauma with the occlusion, that trauma with the occlusion will cause that tooth that has a root resorption to be in a bad position down the road. So yes, I would definitely like go on that risk and do the orthodontic treatment. But yes, you could do the orthodontic treatment and you could stay pretty stable after that treatment.

Unless you see that whatever you were going to do, the benefits of that doesn’t justify the risk of having more root resorption. But most of the cases, it would be safe to go ahead and treat a tooth that has root resorption already.

[Jaz]
I think if the benefit is purely aesthetic, and even then it’s a minor aesthetic improvement, Sometimes to have that conversation that maybe veneers or to plan it in a way where it’s additive as much as possible might be better for the patient.

[Daniel]
Yes. A lot of times we think, right, the, yeah, no, let’s move the teeth instead of putting veneers, but that’s a perfect example where placing veneers could be better than doing the orthodontic movement. So it’s all about, again, diagnosis and treatment planning.

[Jaz]
As has been the theme of this episode so far. Yeah. Brilliant. Recession cases. Let’s talk about premolar recession, for example.

[Daniel]
Okay.

[Jaz]
Upper premolar recession, just to make a very specific example. When we are suggesting orthodontic treatment of that, we are always mindful of our movements to not cause further recession. Now, assuming that the oral hygiene has been controlled, the toothbrush trauma has been controlled, how can we predict how much worse the recession could be through orthodontics?

And I’m always visualizing the way the roots are moving when you’re doing the treatment. A lot of the time, when the premolars are, let’s say, in standing a bit, and if you give it buccal torque, crown torque, if you like, so, or palatal root torque. Is there any evidence that you could be improving the recession? Like, can you get the premolars to go back in the bone, and the bone grow over it? I don’t know. This is really, genuinely interesting.

[Daniel]
Yeah, and that’s a very nice example. And I do have some cases that I show during my lectures that show exactly that. So, sometimes you have the narrow arches, but they are narrow because of the lingual inclination of those bicuspids. So when you do the slash expansion slash, you’re not actually-

[Jaz]
Relative expansion.

[Daniel]
Relative expansion. There you go. So you’re doing, actually the proclination, you’re uprighting those.

[Jaz]
Uprighting.

[Daniel]
And as you upright, yes, you do move the roots. like inside the bone. So the adaptation of the gingiva will benefit for that patient, will improve for that patient. So we see a lot of cases, yes, that we have the improvement. So it’s not a contraindication of the treatment when you do have those recessions. Unless they are already, like, buccally inclined, and then in order to do that, you are going to give the torque in the other position, like going to a buccal root torque.

[Jaz]
Yes, yes.

[Daniel]
Then you are in big, big trouble, and then you’re taking the root out of the bone. So same way you can take root out of the bone, yes, you can place the root inside the bone. So that way that you described is perfect. You do the torque, and then you improve the position of that root, and then you improve also the gingiva on that area.

[Jaz]
Good. Cause I was always worried about recession cases, but I think the highlight of the point in this short discussion now was that not all recession is equal.

[Daniel]
No.

[Jaz]
Not all orthodontic movements equal and therefore it’s case by case.

[Daniel]
Yep.

[Jaz]
And just like you said, someone’s already got a wide smile and they’re going to have orthodontics be very careful. And sometimes if I notice that the case, mostly the incisor issue in my planning, I would say do not move the premolars. Is that a fair approach to take?

[Daniel]
That’s a fair approach. Yes. Cause then you use them as landmarks and then as you program the areas that you are going to move with the orthodontic treatment.

[Jaz]
How much gingival improvement in the recession can you get? Like if you have recession, let’s say three, four millimeters beyond the CEJ and then you correct the inclination upright in the premolars and perhaps the roots now going back in the bone. Can you really get gingival grafts right to the CEJ? Is that something you’ve seen? Or maybe a couple of millimeters?

[Daniel]
Maybe a couple of millimeters, max. But you would see visually improvement, which the patient would be quite happy with, and you were going to be quite happy.

[Jaz]
And it may or may not now need a graft.

[Daniel]
Exactly. It might be the difference of needing a graft or not. And then, again, it’s all part of the conversation that you do have with your patient. But don’t give false expectations for your patient. Oh, yes, this is the perfect example. We’re going to give you the gum back here at the gingiva back on you. Now, my expectation is that it’s going to stay as it is. And then at the end, you see, wow, it got improved. Then you’re happy. Your patient is happy and everyone is fine.

[Jaz]
I think the approach I take is that I want to make sure that we don’t make a recession worse because there’s always a risk. But then if you get any improvement, that’s a bonus.

[Daniel]
That’s a big bonus. Exactly that.

[Jaz]
Excellent. Okay. Last few questions. Now, when I see curved banana shaped roots, Okay. Does that make your orthodontic movement trickier? Do we know if the teeth are less predictable to move when they’ve got funky angulations and curvatures in their roots?

[Daniel]
Yeah, remember that depending on the movement that you are applying, you are going to have an area of where you’re pressuring and the area of tension.

So, yes, when you do have those curves, it might be more difficult for you, especially on the bicuspids that you would see that. Also on the molars where you were going to see that. So it all depends on how you were going to move those teeth. They could be more prone to root resorption as well, depending on the kind of curve that they present.

[Jaz]
Okay, that’s fine. What about apical infections and then when you have the root canal treatment for the right reasons, is there a guideline in terms of how, how long you wait before you start orthodontic therapy after a root canal treatment?

[Daniel]
So if you have an infection, as long as that infection is not there anymore and you have a proper treatment being done and you don’t have any other signs, you can go ahead and use that tooth in the orthodontic treatment without any kind of issues.

[Jaz]
So you don’t need to wait for some sort of bony healing on the radiograph?

[Daniel]
If you did have a big infection and a big bone void, yes, I would wait. But if you have like minor stuff, no, I would not need to wait. But major infections and major bone loss? Yes, definitely. I with about six months, I would say.

[Jaz]
Okay, I think a good clinical guideline and therefore would be If the clinical signs of infection, for example, they had a sinus before and then the drain sinus is gone, the pain before pain is gone, and they had a specialist treatment and a microscope and you’re happy with it, you’re going to be less worried in that case, right?

[Daniel]
Yes, you have the green flags to go ahead and start. Exactly that.

[Jaz]
Brilliant. Bisphosphonates and orthodontics. At what point are you concerned about treating patients with orthodontics with the history of bisphosphonates? Should we be worried like we are in implants and extractions?

[Daniel]
I think so. Yes. And I think it’s the same kind of concern that you would have with any area and then having the care and having all the monitoring on that patient as good as you can, that would be the way to go.

[Jaz]
Okay. And so it’s the same as, like, we worry more about IV as fast as it gets. And everything has to be a conversation with the patient.

[Daniel]
Yes, conversation with the patient.

[Jaz]
Okay. Last question now. Okay. All right. And then we’re going to head to the workshop. Okay. So aligners around implants. Now we know obviously we can’t move implants, right? We can’t move titanium.

[Daniel]
Yes.

[Jaz]
Often what I would do on my planning is select the implant tooth and say, do not move. But am I missing a trick here? Perhaps, I’m thinking, should we be planning a movement on that implant to gain some sort of anchorage advantage? If there is, and I’m not utilizing that yet. So, any advice about when you already have implants and therefore you’re now working on the teeth around the implants? Any guidelines for aligners for implants?

[Daniel]
Okay, so we mentioned about the landmarks, right? So we would use that implant as a landmark, and that landmark is immovable, but a very good source of anchorage, a very good source of anchorage. So if I’m planning an arch form, I can plan the arch form around that implant.

It doesn’t matter that the arch form is going to go through that implant line, but I can create an arch form around that implant and maybe later, change the crown position to that new arch form that I am forming. But I use that implant as an anchorage source either for arch forming or for elastics when you have a class two or class three or even on intrusion you could use that as a very good helpful way of doing that.

So we think about TADs as an accessory but implants are a huge accessory. And when you go to the interdisciplinary gig, you would do that. So, and when you think, well, I have an implant, it’s immovable. But remember that you can reposition the crown so you can use that to reshape your to orthodontic treatment.

And then if you need to change the crown later, that’s fine. As long as you understand that the implant is not moving, but you can replace the crown later in a different position. For example, we can do some mesialization or distalization, and then you just cut part of the crown, and then later on you change the crown. You do whatever change you would need.

[Jaz]
So like IPR on the implant crown?

[Daniel]
IPR on the implant, yes. When you get the movement-

[Jaz]
And then you replace the crown in the future.

[Daniel]
Perfect.

[Jaz]
But you’re still selecting it as not movable, you’re not planning any orthodontic movements in it to amplify inclusion.

[Daniel]
No movement, but I am planning the movement around it. Perfect. Around it. Yes.

[Jaz]
Daniel, thank you so much. Honestly, that was like a quick blast of all the questions. I love your enthusiasm in dentistry to meet the energy that you bring. It’s great. And it’s been great to connect with you here in Valencia. We’ll definitely keep in touch, my friend. And guys, if you’ve got any more questions, send them in.

And maybe I have a feeling that I’ll be seeing you again in the future. So please tell us how can we follow you on social media? I mean, you do so much teaching, like last year you went to 33 countries. Tell us how I can learn more from you. How can follow you?

[Daniel]
Yeah. So I have lots of fun, like visiting different countries, different cultures, different people. And that’s what makes me happy. And that’s what engaged me so much. So you can follow me on Instagram. @docdanielneves. So doc Daniel Neves, you would follow me, whatever I will be traveling to and teaching, or I can meet you on a Congress worldwide, anywhere in the-

[Jaz]
Congress near you soon.

[Daniel]
Yes, yes, exactly that. So yes, let’s stay in touch. Definitely.

[Jaz]
I’ll put your Instagram handle in the show notes. Very approachable orthodontist and just so forward thinking it’s been really great to meet you. Thanks so much.

[Daniel]
Thank you. Thank you very much, Jaz.

Jaz’s Outro:
Well, there we have it, guys. Thank you so much for listening all the way to the end. What did I say? What did I say? It was good, right? It was so gem packed. This is what Protrusive is all about. So thank you to my guest, Dr. Daniel Neves. Check him out on Insta. He is absolutely fantastic. What a guy.

You can get 45 minutes of CPD. Why not? You’ve listened all the way. You watched all the way. You deserve this certificate. So just go ahead to Protrusive Guidance App or the website www. protrusive. app, answer the questions, get your certificate emailed to you. But of course, if you want opportunities to submit your questions for future episodes, just like this one from the community, these ones are always the best, because you guys ask the best questions.

It’ll be great to see you on Protrusive Guidance. I’ll be very honest with you, I’m not entirely sure if we have any more orthodontic episodes this month, which is a shame, because we start with a bang, but we want to keep it going. But I have got lots of orthodontic based episodes from the past.

In fact, a few years ago, we did Straight-pril. And we had great orthodontic episodes then. Now with the setup of protrusive things got a little bit complex and stuff. And there’s a lot on the content calendar. So maybe we will have another ortho episode this month. But if we don’t, I hope this one did this month, this theme of May the force with you some justice.

I hope you have a fantastic May, wherever you are in the world. And as ever, I’m so, so grateful for your listenership. Catch you same time, same place next week. Bye for now.