Stan Goff is a Managing Editor with MJH Life Sciences, which includes Dental Products Report, Dental Practice Management, Dental Lab Products, Modern Hygienist, and Dentist's Money Digest. He has covered the dental industry since 1999 and can be reached at sgoff@mjhlifesciences.com.  

First, Get It Straight | Image Credit: johnalexandr - stock.adobe.com

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 

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 

 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.

Dentsply Sirona’s SureSmile® Aligner solution includes expert support tailored to a specific practice’s goals.

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.

Articles

When GPs use clear aligner therapy to correct occlusion, it opens a realm of possibilities for the best long-term restorative care for their patients. 

First, Get It Straight

How Invisalign® Helps Patients and Clinicians Improve More Than Just Esthetics | Image Credit: © Align Technology

In addition to helping patients achieve a straighter smile, Invisalign clear aligner treatment also can help address dental problems, including as follows:

Align’s end-to-end digital platform is a unique combination of software, systems, and services designed to provide a seamless experience and workflow that integrates and connects all users: doctors, labs, patients, and consumers, according to Mitra Derakhshan, DDS, MS, Align Technology senior vice president, global clinical. The company strives to help its customers move their practices forward by connecting them with new patients, providing digital solutions to increase practice efficiency, and helping them deliver the best possible treatment outcomes.

Invisalign clear aligners are made of SmartTrack®, which is a patented material that moves teeth more precisely and comfortably. Other advancements such as SmartStage® technology and SmartForce® attachments enable doctors to have optimal outcomes and greater predictability across a range of situations.

Invisalign clear aligners are made of SmartTrack®, which is a patented material that moves teeth more precisely and comfortably. | Image Credit: © Align Technology

Other technologies that are helping dentists deliver successful predictable outcomes for their patients’ needs include as follows:

 combines iTero™ intraoral scans, facial photos, and ClinCheck software to help doctors create treatment plans that integrate orthodontics and restorative treatments. With the powerful ClinCheck In-Face Visualization tool, doctors receive a facial rendering 

To read the November/December cover story: 

that they can use for treatment planning and help patients visualize their smile after Invisalign treatment and restorative dental treatment. Ortho-restorative treatment represents a growing opportunity for general dentists. It provides doctors with a single ecosystem for combined visual tooth movement planning plus restorative dental care. Currently, approximately 45% of restorative cases in North America can benefit from orthodontic treatment, according to Align Technology.

 is a mobile companion to the Invisalign Doctor Site that streamlines practice workflow by putting many of the Invisalign treatment features such as photo capture, Invisalign Virtual Care, Invisalign Virtual Appointment, and Invisalign SmileView simulation into 1 convenient app. The intuitive user interface also allows them to manage and prioritize tasks such as ClinCheck treatment plans awaiting approval and prescriptions ready for submission.

 helps dentists provide the best clinical care for their patients, grow their practice, and easily integrate digital scanning and imaging as a core part of their digital workflow. The series of scanners and imaging systems builds on the success of the award-winning iTero Element family and offers all of the existing orthodontic and restorative digital capabilities doctors have come to rely on—plus faster processing time and advanced visualization capabilities for a seamless scanning experience in a new sleek, ergonomically designed package. The iTero Element 5D Imaging System is the first integrated dental imaging system that simultaneously records in 3D, intraoral color, and NIRI.

 combines iTero™ intraoral scans, facial photos, and ClinCheck software to help doctors create treatment plans that integrate orthodontics and restorative treatments. | Image Credit: © Align Technology

, available on the iTero Element Plus Series, covers a range of dental health conditions to help patients better understand their oral health. It lets doctors create and share a custom oral health report, capturing the treatment recommendations discussed during the patient consultation.

 integrates iTero intraoral camera and NIRI images within exocad DentalCAD 3.1 Rijeka software and allows dental professionals to visualize the internal and external structure of teeth. Clinics can share files with their lab, helping streamline collaboration and drive consistent outcomes.

In this sidebar, part of the November/December cover story, Invisalign explains how their clear aligners help address a number of bite issues and other dental problems. 

Evenly Technologies Shares More Insight on Clear Aligners | Image Credit: © Evenly Technologies

Information provided by Evenly Technologies

Technology has changed radically, especially over the last few years. Aligner treatment goals and design are now done remotely on a computer model. Evenly Technologies’ advanced digital modeling enables dentists to accurately render a patient’s new smile before they even begin treatment, according to Barry J. Beck, CEO of Evenly Technologies.

A draft of the treatment is provided by technicians, based on the doctor’s prescription and preferences. If needed, the doctor can then make as many modifications as necessary to provide the patient with the exact smile they wish to achieve. Although experienced practitioners can achieve great results with traditional metal braces, aligners allow doctors to target a predetermined goal where every tiny amount of movement is 100% useful, requiring no estimated movements; the movements all happen at the same time versus in stages. Braces are a series of estimated adjustments and re-evaluations where treatment is accomplished in stages. Today, many cases can be treated more accurately and faster with aligners rather than braces with no broken wire emergencies or dietary restrictions.

Wayne Hickory, DMD, MDS, MS, chief medical officer, reviewing a clear aligner treatment plan. | Image Credit: © Evenly Technologies

Evenly’s expert treatment coordinator (TC) comes to each dental office equipped with a portable scanner and provides a free consultation to every patient, including a 3D scan, and then presents a treatment projection overseen by Evenly’s expert orthodontists. The TC is in communication with an orthodontist as needed. The Evenly orthodontist creates a custom clear aligner orthodontic treatment plan and Evenly delivers the aligners to the patient at the dental office and guides interproximal reduction and attachments. Then Evenly sets the patient up on a remote management platform for convenient weekly check-ins with the Evenly team. At the end of treatment, Evenly provides treatment closeout and free retainers.

Wayne Hickory, DMD, MDS, MS, chief medical officer of Evenly Technologies, says there are pitfalls when patients and clinicians skip orthodontics when planning restorative dentistry.

“One of the most common dilemmas is a patient wanting or needing veneers for upper anterior teeth while there is an inadequate overjet,” Dr Hickory explains. “The ability to make the veneers an ideal height is greatly limited due to occlusal interferences. This increases the risk of breakage of the veneers or opposing teeth, especially if the patient forgets to wear a nightguard. Of course, it is difficult to unwind restorative work to perform orthodontics afterward.”

In the past, doing restorative work without addressing orthodontic problems was more defensible because many adult patients were not receptive to braces, he says.

Expert treatment coordinator reviewing a customized patient treatment plan. | Image Credit: © Evenly Technologies

“Today, we have the technology and experience to make clear aligner orthodontics a much easier experience, including home time and evening only options, along with the use of remote monitoring to reduce office visits to as few as 3 visits throughout the entire treatment,” Dr Hickory adds.

He suggests dentists consider 4 questions before performing a restorative procedure:

Will the restoration limit the ability to do orthodontics in the future?

Is the occlusion preventing the fabrication of an ideal restoration?

Will the occlusion reduce the longevity of the restoration?

Are tooth positions negatively affecting tooth sizes and symmetry?

In this sidebar, part of the November/December DPR cover story, Evenly Technologies explains how possible pitfalls develop when patients and clinicians skip orthodontics when planning restorative dentistry.


Evenly Technologies Shares More Insight on Clear Aligners

Micah Huish is the manager for DentiMax’s imaging team. He has more than 5 years of experience working with imaging software and sensors and helping clinicians get the best x-ray images possible. He has a bachelor’s degree from Arizona State University.

Correct These 3 Mistakes to Take Better X-Rays | Image Credit: © DentiMax

My team and I work one-on-one with dentists and their staff to ensure they get high-quality images for accurate diagnosis. This happens during a dial-in process, where practitioners capture x-rays on actual teeth. We fine-tune the imaging software filters to create diagnostic images tailored for optimal quality. After viewing thousands of x-ray images, we consistently see 3 common mistakes.

Clinicians often position the x-ray head too far from the patient. Think of an x-ray head generator like a shotgun: The farther you are from the target, the more spread out the x-rays will be. This can cause light images because of the increase in the source-to-object distance. It’s important to place the x-ray head close enough to the patient’s face during exposure.

The DentiMax Dream Sensor is known for delivering precise diagnostic x-rays at the highest resolution possible. It has received very high marks in clinical reviews, including a 96% in its Dental Advisor clinical evaluation. The sensor shows extraordinary anatomical details with reduced noise and improved tissue contrast for accurate diagnoses. It also provides a large active image area of 900 mm², allowing you to capture more teeth in the x-ray. The sensor has open compatibility and works with most imaging software and dental sensors on the market.

To do so, ensure that your cone placement is consistently the same distance from the patient’s cheek for every shot. Try to get the x-ray tube as close to the skin as possible. When you need to aim at a larger angle to capture the apices of a maxillary molar, don’t move the cone too far away from the patient. Consistency with placement distance is the key to dependable image contrast.

Another common issue is underexposed x-rays that look too light and grainy. The most noticeable symptom is increased noise, which leads to grainy images with uneven patterns or streaks, hindering the clarity of specific details. Moreover, the radiographs appear excessively white or light when they are underexposed, indicating that the x-ray beam did not penetrate the density of the patient’s anatomy.

 Cone cuts are a common positioning error. To avoid this problem, align the x-ray cone with the aiming ring of the positioner to ensure you are pointing directly at the sensor. | Image Credit: © DentiMax

Overexposure of the x-ray makes the images look too dark with blooming or cervical burnout. Burnout will be seen as black areas that creep into the teeth in the x-ray. Extreme cases can even hide entire teeth in the x-ray.

Neither under- nor overexposed images can be properly fixed within the imaging software; the data were corrupted when captured. The most common cause of both issues is from a single exposure time setting being used for all x-rays and for every patient. Refer to your sensor’s recommended settings for proper exposure settings.

 This example illustrates problems that occur with an overexposed image. When this happens images look too dark and in extreme cases entire teeth can be hidden in the x-rays. | Image Credit: © DentiMax

Rushing to complete x-rays can stem from various factors, such as a busy schedule, patient discomfort, or familiarity with the procedure. However, not allocating enough time to take x-rays properly can compromise the quality and accuracy of the images obtained. Inadequate positioning and missed angles commonly happen when rushing.

Cone cuts—which can appear as a clear zone on traditional radiographs after processing— is one of the positioning errors I consistently see. Each patient’s bite is different, and the sensor tends to move slightly once the patient closes their mouth. Be sure to watch the sensor in the patient’s mouth when they bite down on the bite block. When you align the x-ray cone with the aiming ring of the positioner, you can ensure you are pointing directly at the sensor.

X-rays that are underexposed will look too light and grainy. These images cannot be properly fixed within the imaging software so it’s key to initially capture sharp images. | Image Credit: © DentiMax

When taking a 2-dimensional image of a 3-dimensional object such as a tooth, overlap can happen. This is caused when there is incorrect horizontal placement of the x-ray tube head in relation to the teeth when aiming at the sensor. Ensuring the x-ray cone is both horizontally and vertically aligned with the aiming ring of the positioner system will help reduce overlap.

Implementing regular reviews of adherence to best practices and peer-review observation of each other’s techniques can help prevent these common mistakes, improve workflow, and reduce retakes.

To learn more about DentiMax and the company’s

x-ray sensors and imaging software, visit the website

DentiMax’s imaging manager shares tips for getting the best images.

Correct These 3 Mistakes to Take Better X-Rays

In collaboration with a team of hygienists, Parkell’s insert engineers devoted thousands of hours to create DuraTip® ultrasonic inserts and achieve what was previously considered unthinkable; continuous excellence across an entire 3 mm of wear. DuraTip inserts shatter the industry standard of progressive efficiency loss over 2 mm of tip wear, by providing optimal performance for not just 1 mm, not just 2 mm, but for an entire 3 mm of tip wear.

Widely known, but rarely considered, insert tip wear can greatly affect the efficiency and performance of an ultrasonic insert. Traditionally, when the insert tip loses 1 mm of length from wear, it results in approximately a 25% loss of scaling efficiency. When wear reaches 2 mm, efficiency is reduced by an astounding 50%.

Unfortunately, instead of replacing the insert when warranted by excessive wear, clinicians may try applying additional pressure to compensate for this loss in efficiency, incorrectly thinking this additional force will make up for the loss of effectiveness. In actuality, the exact opposite is true, the additional force lessens the vibration of the tip, thereby making the insert even less effective.

The consequences of tip wear can be severe, causing harm and discomfort to both patients and clinicians alike. For the patient, a worn insert may not only be unable to remove calculus from the root surface but may also cause more pain during the procedure. For the clinician, in their efforts to remove stubborn deposits, applying increased pressure to the insert, dampens the amplitude, lowers the energy transfer, and reduces tip movement, the result of which is diminished cleaning efficiency and effectiveness. Do you really want to put your hand and wrist at risk by scaling all day with inserts that are worn beyond usability? The time is now to just say NO to contributing factors to hand strain, wrist fatigue, and carpel tunnel syndrome.

This patented technology and unmatched ability to maintain peak performance for an entire 3 mm of tip wear, makes DuraTip inserts ideally suited for every stage of patient care, while also offering the dental professional the advantage of being able to stay on schedule, maintain their hard-earned stellar reputation, and most importantly, provide exceptional treatment.

By raising the bar on the standard of care over the entire life of the insert, Parkell’s DuraTip ultrasonic inserts are reinventing the way clinicians view insert wear. From cradle to grave, DuraTip inserts provide the ability to maintain an unprecedented level of performance over their lifecycle, which is a tremendous value for every office’s hygiene department.

Parkell is confident that it’s just a matter of time before DuraTip inserts are recognized for their incredible value, longevity, durability, and consistently excellent performance patient after patient.

DuraTip’s excellence is achieved through novel patented internal geometries at the tip and connecting body, and unsurpassed energy transfer and durability across an innovative W-stack design for optimized performance and effective deposit removal. The W-stack design also decreases the risk of damage during handling and instrument processing. While traditional stacks are prone to bending that leads to a decrease in energy and the ability to make the tip move efficiently and effectively, DuraTip’s stack design provides greater rigidity and stability over time.

DuraTip inserts are designed and manufactured in the USA. Parkell’s quality-control process assures spot-on frequency, 100% stroke testing and ideal water flow. DuraTip is currently available in 30K Universal Slim and 30K Perio Slim.

It is time to raise the bar with Parkell’s new DuraTip insert – experience the same “like new” performance for the entire life of the insert.

[SPONSORED] By raising the bar on the standard of care over the entire life of the insert, Parkell’s DuraTip ultrasonic inserts are reinventing the way clinicians view insert wear.

Unprecedented “Like New” Performance for the Entire Life of the Insert – Introducing Parkell’s New DuraTip® Inserts

John Flucke, DDS, is in private practice in Lee’s Summit, Mo. He also serves as chief clinical editor and technology editor for 

® and keeps an active blog filled with thoughts and tidbits on the world of technology at blog.denticle.com.

Abstract

I remember going to get some lumber with my grandfather in his pickup truck. I lived in Kansas City, Missouri, and the city sits on the corner where the Missouri River makes a hard turn east and heads toward St Louis. My grandfather and I were headed for a lumberyard on the north side of the river.

The night before there had been a huge rainstorm that had dumped a record-setting amount of rainfall on the area. As we were crossing the bridge over the Missouri River, I looked out the window of the truck and noted to my grandfather, “Wow! It looks like the water is almost up to the bridge!”

My grandfather always enjoyed mixing in philosophy when educating me and I will always remember him smiling at me and saying, “Sometimes you don’t raise the bridge, you lower the river.”

Bewildered, I asked, “What does that mean?”

He smiled slyly and said, “It doesn’t make much sense now, but it will later. Trust me.”

My grandfather’s education stopped when he completed the sixth grade in a 1-room schoolhouse, but in a lot of ways he was smarter than many people I know who have postgraduate degrees. Over the years, his old-school philosophy has helped me to better understand the world as well as to help me make much better decisions.

I know some of you are now wondering what the heck my grandfather’s philosophy has to do with dental composites…. But hear me out.

We follow guidelines to ensure success. Some of these guidelines are for safety or other truly critical reasons, and some are things you must do because of the limitations of tools or materials.

For example, materials used to fabricate dental crowns have minimum reduction limits to allow for adequate bulk of material. This is the minimum amount of material that can exhibit the expected physical properties. Making a lithium disilicate crown too thin will doom it to fracture. We aren’t prepping a tooth because we want to remove more tooth structure than necessary; we are preparing enough room around the tooth to allow the restorative material to have adequate strength and therefore fracture resistance.

So let’s apply this to direct composite restorations. For years we have been taught the philosophy and technique of incremental placement. The concept has 2 basic tenets. The first is that as they polymerize, composites shrink and occupy less physical space. The second is that curing lights must reach the entire increment that has been placed.

The reason that we follow these 2 rules? Simply put, it is because they were necessary at the time they were created. Now we are doing so because we were taught that way mixed with “Because we’ve always done it that way.”

Early composites would shrink quite a bit as they cured, so the idea of incremental placement had the doctor place small amounts, usually in 2- to 3-mm increments so the stress created by shrinkage during curing was applied to each individual increment, spreading out and thus minimizing its impact. Each increment—due to its size and the physical properties of the composite material—shrank when cured. Then another increment was placed over this previously cured material. The idea was sound because this spread the polymerization shrinkage over multiple layers, which decreased the overall stress on the tooth being restored.

However, as composites have evolved, their polymerization shrinkage has decreased. Current materials do not shrink as much as previous generations. This has brought about the concept of bulk fill composites that are placed in a single increment. However, the one problem with light-cured, bulk fill composites is effective photopolymerization.

In addition to early-generation dental composites exhibiting greater polymerization shrinkage, clinicians were also limited by the available curing light technology. To properly reach the material and completely pass through it from top to bottom, a curing light had to deliver a certain amount of energy. If, for any reason, the energy delivered was inadequate, the material would not cure properly, which would result in postoperative sensitivity, material breakdown, and the ultimate failure of the restoration.

The practice of incremental placement helped with the curing light power problem as well as the material shrinkage problem. Not only did small increments decrease shrinkage stresses, but they also allowed lower-powered curing lights to get photons through these increments from the top to the bottom. This helped create restorations that were cured as well as possible considering the limitations of the hardware.

Catapult Education, LLC is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

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Catapult Education designates this continuing education activity for 1/4 credit.

For more info on this activity, or to take the quiz and obtain your continuing education credit follow the link from the QR code or visit 

www.catapulteducation.com/course/laser-curing

Science never stands still and as research and development continued, smaller and, more importantly, higher-powered curing lights were brought to market. These lights provided the ability to cure increments in shorter periods.

Bulk fill materials also were brought to market. To compensate for the limitations of curing light technology, the materials were more translucent than other dental composites. This allowed photons to penetrate further into the material to allow for bulk curing, but the esthetics of the materials were lacking. It saved time, but in the give-and-take of using early bulk fill composite materials, those time savings came at the cost of a less esthetic restoration.

Many doctors appreciated the efficiency bulk fill composites brought to restorative procedures, but the translucency caused the materials to appear a bit gray.

There was also the problem brought about by curing these deeper layers of composite. Every curing light on the market has a maximum output that depends on the manufacturer’s design. That means that one light might provide greater depth of cure than another. This caused confusion in offices with different brands of curing lights, and it made troubleshooting more difficult on those occasions when sensitivity occurred. What dentistry needed was a predictable depth of cure.

However, confidence in the depth of cure must be balanced with the need for efficiency. Any time a doctor starts the process of placing a composite restoration, a game of “beat the clock” commences. Adhesive dentistry is sensitive to technique, and the longer the process takes, the greater the chance of the restoration process being derailed due to contamination from blood, saliva, or crevicular fluid. Short curing times make the process easier, faster, and more predictable. Neither the patient nor the doctor wants appointments to take longer, especially the doctor who knows that any type of contamination increases the possibility of postoperative complications.

Although the physical properties of dental materials continue to improve with reduced polymerization shrinkage and deeper depths of cure, it is also important to consider advancements in technologies for the polymerization process. Since their introduction, LED curing lights have been the standard technology for intraoral curing of dental materials because of their broad-spectrum light output, high intensity, and minimal heat generation.

However, there is now a more powerful curing option in the form of solutions such as the Monet Laser Curing Light from CAO Group.

A curing laser offers several unique advantages over traditional LED curing devices. A curing laser can produce more than 2 to 3 times the energy output of an LED curing light. A laser produces approximately 2400 to 4500 mW/cm2 of power compared with most LED units on the market that produce roughly 1300 mW/cm2 of output at regular power with some reaching approximately 3000 mW/cm2 with Boost Mode settings.

With the higher-intensity laser light, clinicians can cure material in less time than with an LED light. An LED curing light might have curing cycles of 10 or even 20 seconds, but a laser curing cycle can be as short as 1 second. A sometimes overlooked benefit of these short curing cycles is also they greatly decrease the chances of contaminating the field.

By their nature, lasers are coherent beams of light, that makes it easier to collimate the beam so the stream of photons does not diverge as it exits the head of the light. This keeps the photons concentrated on the target tooth/restoration while also providing uniform and predictable intensity. Most LED curing lights provide a divergent beam that sprays the photons in a wide area, and many do not have the full intended impact on the photopolymerization of the composite material. Instead, the beam disperses the farther it gets from the light source. As those photons spread out the power of the beam is reduced and more of the light strikes the surrounding tissue and has no effect at all.

With its beam concentrated within a narrow spectrum, a laser is capable of providing greater focus and intensity than a LED light which has a more widespread spectrum.

Collimation also means there is very little decrease in intensity drop-off due to distance.It is always advisable to get the curing device as close as possible to the target. However, this is difficult, if not impossible, to achieve when curing a proximal box or a deep area on the floor of any prep. Reaching those hard-to-reach places with a curing laser is much more reliable because of its collimation. It also provides a more reliable depth of cure.

Lasers are also monochromatic, which means the photons are all of 1 specific wavelength. This means the photoinitiator’s absorption at that wavelength is maximized (Figure 1).

The intensity of the beam and its collimation translate to an impressive depth of cure. As I mentioned earlier, one of the reasons for incremental curing was that small increments allowed the curing light photons to reach the bottom of the material increment. Laser curing technology provides greater depth of cure with significantly less time.

Curing is incredibly intrinsic to the clinical success of adhesive restorations, whether they are direct composites or indirect bonded prosthetics. High-intensity cures that provide better depth of cure in less time are now a reality. These amazing results are attainable by using a handheld curing laser.

Just like my grandfather pointed out at the bridge, sometimes to get to a new solution, you have to look at the problem from a different vantage point. If you want to up your game when it comes to bonded restorations, consider adding a curing laser to your armamentarium.

Earn 1/4 Continuing Education Credit after reading this article about dental curing technology.

Rethinking Adhesive Dentistry From the Outside In

Computers are integrated into every part of a modern dental practice. Software platforms manage almost everything: scheduling, billing, communications, charting, treatment planning, imaging, and more.

By adopting software platforms that integrate smoothly and avoid overlapping functions, practices can develop efficient workflows that drive success and steadily guide operations for everything from clinical procedures to patient communications. Unfortunately, when the opposite happens and a practice uses solutions that do not integrate, workarounds get incorporated into workflows and redundancies creep into processes.

Finding the optimal software mix is critical, but it’s not an easy task. There is a multitude of software platforms designed for dental practices, and many offer a wide array of both native features and add-on modules to expand capabilities.

It can be an intimidating arena to navigate, but with the right mindset and the right partners, any dental practice can find the best software mix to support, streamline, and enhance operations.

When seeking new dental software, there are a number of pitfalls to avoid. Among the most common is not properly assessing your needs or your options when it comes to potential software vendors and their various platforms. It’s important to know what you have, what you want, and what’s available before doing anything else.

“Before any decisions are made in switching or adding software, dental professionals should conduct a thorough audit of the practice and then ask themselves the question, ‘What opportunities for growth exist?’ ” says Alan Rencher, chief technology officer for Henry Schein One.

This audit can be undertaken by the practice, or via a service such as Henry Schein Practice Analysis, powered by Jarvis Analytics, which analyzes practice data to uncover a deeper understanding of operations, Rencher says. Regardless of who performs the analysis, it should provide a good picture of where a dental practice is today. However, Nina Gilbert, senior global product manager, general dentistry, Sensei at Carestream Dental, notes it’s also important to consider the scalability of the software. A practice does not want to buy something that works today but will not keep working tomorrow. Mike Huffaker, chief revenue officer for Planet DDS, notes that it’s important to be ready for something unanticipated in the future.

“You still want to have the ability to make your own choices as technology changes. As technology advances, you want a software platform that will allow you to take advantage of the best tools at any given time,” he says.

With cybersecurity an important consideration today, Gilbert notes that it’s important to not only know if the software is secure, but also that the company making the software is also constantly working to make sure its platform is safe.

As important as it is to gain a sense of what is needed and to evaluate the technical and security capabilities of potential vendors, it’s just as critical to get the staff on board with potential changes. Plan to dedicate time for training when onboarding a new solution.

“Implementing software is where practices will run into problems if their team members, whether office managers or operations team, haven’t bought into the change of switching software. So you need buy-in whether you’re implementing a new artificial intelligence (AI) solution, patient communications tool, or analytics platform,” Huffaker says.

Training is another key detail that is often overlooked by practices during software transitions. Khamzat Asabaev, founder and CEO of SoftSmile, notes that it’s important to not only factor in the time for training but also the cost associated with dedicating that time to training. When viewed as a cost in both time and money, software training might seem like a good area to find savings, but both Asabaev and Alvin Lin, managing director of Aspire Software’s health and dental division, agree this often proves to be more costly in the long run.

“I’ve observed numerous dental offices resist closing for training and implementation, leading to subpar training experiences and inadequate learning for their teams. This often culminates in a challenging first day with the new system, setting a precedent for ongoing struggles,” Lin says.

Once a practice is set up for a successful software search and implementation with a needs assessment and an excited staff, it’s time to start looking for an application to meet the practice’s needs. Dental software can do a lot of different things for a practice, but some capabilities truly stand out for the positive effect they have on operations and efficiency.

It’s vital that software be flexible and interoperable so platforms can easily work with each other for different tasks. The growth of cloud-based dental applications has helped increase software interoperability, making it possible for practices to provide an enhanced patient experience.

“The future of dental technology is interoperable, cloud-based, and innovative. Every dental practice has unique needs. In a world where convenience takes priority in our day-to-day lives, having a comprehensive patient experience software is a must,” Rencher notes.

Lin agrees, noting that software delivering appointment reminders, confirmations, patient greetings, and reputation management is now vital for almost every dental practice. Gilbert also says patient engagement is a key function, adding that this really connects to every part of running a practice from the claims processing to clinical documentation and treatment planning.

Although clinical images are important for dental professionals, they are not easy for patients to understand. However, some treatment planning and case presentation platforms feature high-quality 3D visualizations. This makes it easier for clinicians to communicate the value and potential outcomes of treatment proposals.

“Creating detailed and customized treatment tailored to each patient’s needs is important, but even more important is how you communicate treatment to patients—which is greatly enhanced with realistic graphics and visuals. Better graphics make it easier for doctors to handle complex cases and enhance the patient experience,” Asabaev says.

Cloud-based dental software does more than just make it easier to connect with patients. As more practices operate as groups, cloud-based software applications make it easier to cohesively manage multiple locations. Huffaker notes that the cloud isn’t just for practices with more than 1 location. Some practices can simplify complex internal systems by shifting to a cloud-based application.

“Dental practices have built software stacks that are becoming unwieldy and create significant integration challenges, particularly for legacy software solutions. To simplify your practice, [information technology], operations, and even vendor relationships, moving to cloud-based practice management software is the natural direction the industry is headed, and I think we’ll see this trend accelerate,” Huffaker says. “The whole industry is at an inflection point. It’s an exciting time as we think about investing in practice management solutions and moving to the cloud. We’re seeing an acceleration in cloud adoption that is becoming more broadly understood by a wider segment within dental.”

Software can be the foundation of an efficient dental practice, or it can become a workflow bottleneck that frustrates staff and patients. Selecting the right platforms and getting the most out of the ones you choose are critical steps to success.