aligners international magazine of aligner orthodontics No. 1, 2022

editorial | Dr Carlo Fornaini Researcher, université Nice Sophia Antipolis, Nice, France Researcher, university of Parma, Parma, Italy The COVID-19 pandemic dramatically and totally changed all medical clinical practices owing to the necessity of limiting or, when possible, eliminating, physician–patient contact and reducing hospitalisation. This goal became a major concern and pushed researchers to discover nov- el modalities for managing medical and dental care in a broad range of situations. Beyond the pandemic, such telemedicine offers convenience, such as distance con- sultation and patient management, for oncological, geri- atric and special needs patients, who may sometimes have difficulty coming to clinics, among other examples. Tele-orthodontics, a term coined by Dr Taylor Squires, may offer a low-cost way of managing orthodontic treat- ment. It may help to reduce expenses, such as transpor- tation and direct consultation with a specialist, and it may also aid general dentists in screening and appropriately referring potential candidates for orthodontic treatment. Through tele-orthodontics, it is possible to provide at- home orthodontic care and to monitor treatment progres- sion by digital technology using a smartphone. Aligner treatment offers the ideal situation: it allows the patient to independently progress through aligner trays, and this may decrease the number of in-office visits and so help orthodontists to supervise treatment progress even when the patient is at home. For this reason, we decided to dedicate this issue of aligners to the different points of view and aspects of aligner systems, to offer you a complete state-of-the-art overview of this new way of performing orthodontics, which is growing dramatically in popularity all over the world. We think that you will find all these articles interesting, and we hope that they will also stimulate your daily practice. Sincerely yours, Dr Carlo Fornaini aligners 1 2022 03

| content Cover image: Orthosnap www.orthosnap.com issn 1868-3207 • Vol. 1 • Issue 1/2022 1/22 aligners international magazine of aligner orthodontics opinion The role of the orthodontist: Healthcare provider or salesperson? trends & applications Effective application of interproximal reduction during aligner treatment opinion Aligners: More regulation or just a consumer product? 04 aligners 1 2022 editorial Dr Carlo Fornaini opinion The role of the orthodontist: Healthcare provider or salesperson? – Drs Anna Hajati & Mary Zafiropoulou case report Treatment of a patient with a congenitally missing lateral incisor using aligners: A case report – Drs Iro Eleftheriadi & Christodoulos Laspos opinion page 28 Aligners: More regulation or just a consumer product? – Dr Miguel Stanley trends & applications Effective application of interproximal reduction during aligner treatment – Dr Gina Theodoridis feature War in Ukraine: Dentists will not sit idly by – Dr Miguel Stanley & Nathalie Schüller page 38 How to make time work for you instead of against you– five time management tips for 2022 – Jerko Bozikovic business news Clear aligners: the star of 2021 – Jeremy Booth research 4D-printed clear aligners found to show promise – Jeremy Booth page 44 industry news Making aligners digitally, the K and B way using 3D printing – Kristen Benitez industry report Cast mould clear aligners: Orthosnap upends market with greater precision, lower cost – Jeremy Booth Laser cutting–the future of aligner manufacturing – Dental Manufacturing Unit Release 12: New Spark clear aligners – Ormco meetings The third European Aligner Society congress in Malta proved a great success EOS annual congress 2022–techniques may change, but the principles remain the same International events about the publisher submission guidelines international imprint 03 06 10 20 28 32 34 38 42 44 48 50 52 54 58 60 61 62

| opinion The role of the orthodontist: Healthcare provider or salesperson? Drs Anna Hajati & Mary Zafiropoulou, Sweden & Greece products. To reach out, they use influencers to create healthcare loyalty. Some practitioners, presented as key opinion leaders or another type of expert, have become a part of this ecosystem of a certain product or method. Prof. Kevin O’Brien assesses this practice on his ortho- dontic blog.1 A key opinion leader is by definition a trusted, well-respected influencer with proven experience and ex- pertise in a particular field. In healthcare, these leaders could be physicians, hospital executives, health system directors, researchers, patient advocacy group members, and more. Some key opinion leaders gain benefits from promoting specific products that have little evidence-based support, turning them into profitable salespeople instead of health- care providers. They go from serving a patient as a doctor to selling a product or method. Being part of such an eco- system in turn efficiently increases the need for con- sumption of these marketed tools. Companies also market their brand through clinics, dentists and patients. Many clinics adapt to this without even realising it. People find the messages attractive, as they desire a happier life the invisible, easy and affordable way. Are the messages we send out ethical or even true? A study recently pub- lished in The Angle Orthodontist assessed claims mainly concerning treatment duration within Instagram posts on six popular marketed orthodontic products and found that only 2% of the 472 claims assessed were true.2 This seems to imply that we need to ask ourselves whether our messages on our websites and social media posts are accurate. Doctor-driven or artificial intelligence-driven orthodontics? New integrations between medical imaging, planning, manufacturing, performance and communications have created many new opportunities for both dentists and patients. An orthodontist can capture records in one part of the world, and the patient can receive his or her appli- ances in another. A patient can start treatment in one part of the world and continue treatment in another part of the Image: iStock. Introduction The demand for gorgeous, perfect smiles has exploded in recent years. During the COVID-19 pandemic, the amount of time spent behind the screen, whether in Zoom meetings or FaceTime chatting with friends and loved ones, has given rise to a greater demand for whiter, straighter, perfect-looking teeth. Direct-to-consumer social media marketing is challenging the role of the or- thodontist as a legitimate source of healthcare-related in- formation for patients. In addition, advancements in tech- nology have given the impression that orthodontic treatment is now very discrete, easy, fast and affordable for individuals looking for the perfect smile. These are the clear promises given to consumers. But is it that easy? And most importantly, is it true? Patient or consumer? Increased social media marketing involving messages aimed at attracting potential consumers to buy tooth straightening appliances and services has turned pa- tients interested in cosmetic procedures into consumers. The most influential companies in the dental industry have been extremely successful in reaching out to their end consumers, patients, and consciously deliver mes- sages aimed at attracting more customers for their 06 aligners 1 2022

opinion | and appliances ordered. The treatment will start without anyone checking the teeth, gingiva or function or dis- cussing preferences. It is an advancement of technology and it opens the door for even greater flexibility and au- tomation. It is, however, a consumer-driven approach based on 3D renderings and does not take into consid- eration biology and other aspects, like function. In the future, could AI alone be enough to drive the orthodontic planning and treatment process, without input from an orthodontist? The challenge When a patient is turned into a consumer and a medically advanced procedure is marketed as a branded product, the information provided to the patient is skewed. We make it difficult for patients to make well-informed deci- sions when important information regarding their treat- ment is not communicated to them. When companies value a healthcare provider based on products pur- chased, he or she is turned into a salesperson, which has very little to do with his or her professional competence. Soft skills are difficult to measure and sell, so doctors stick to marketing and selling products. But if we, who have a duty to serve our society and our patients, do not provide ethical and accurate information, there is a risk that patients will suffer. Orthodontic care involves ad- vanced medical procedures, requiring medical and dental history taking and consideration of a number of biological factors, like function and dental health status, Image: ra2 studioo/Shutterstock. world more easily than before. The course of treatment can even be tracked and monitored by the orthodontist from a distance. Recently, even artificial intelligence (AI) has been imple- mented by companies for automation of treatment goals and monitoring. We should remember that AI in this sense is nothing more than algorithms implemented in a system by a human, based on calculations from refer- ence material and predictions. These new technologies enable improved precision, save time and allow more flexibility. Many tend to believe that tooth movements can be planned and performed in digitally supported environ- ments without having a dentist examine the mouth. The patient-turned-consumer can order the appliances online or go to a beauty salon or a store to have records taken Image: iStock. aligners 1 2022 07

| opinion about Dr Anna Hajati is the founder and owner of OrtodontiAkademin, an or- thodontic practice in Stockholm in Sweden, and has been employing dig- itally supported treatment processes since 2009 to improve treatment out- comes and the patient experience. She is the first orthodontist in Scandi- navia to have successfully imple- mented the SureSmile Advanced platform. She obtained her DDS and PhD from Karolinska Institutet in Stockholm and her certification in orthodontics from the Centre for Orthodontics and Paediatric Dentistry in Linköping in Sweden. Dr Hajati is a member of the World Federation of Orthodontists, Ameri- can Association of Orthodontists (AAO), European Orthodon- tic Society, Swedish Association of Orthodontists, and Dental and Craniofacial Bionetwork for Image Analysis. She is an elected ambassador for the AAO in Sweden. Dr Mary Zafiropoulou is an ortho- dontist currently practising in Athens in Greece. She has been using digitally supported treatment processes since 2014. She is the first orthodontist in Greece to have successfully imple- mented the SureSmile Advanced plat- form. She obtained her DDS from the University of Sheffield in the UK in 2005 and her orthodontic licence from the University of Go- thenburg in Sweden in 2011. Dr Zafiropoulou is a member of the World Federation of Orthodontists, American Association of Orthodontists, Hellenic Dental Association and Greek As- sociation for Orthodontic Study and Research. References: 1 O’Brien K. Who pays the piper? An influx of key opinion leaders. 2018 Oct 15 [cited 2022 Mar 09]. Available from: https://kevinobrienorthoblog.com/ pays-piper/. Alkadhimi A, al-Moghrabi D, Fleming PS. The na- ture and accuracy of Instagram posts concerning marketed orthodontic products: a cross-sectional analysis. Angle Orthod. 2022 Mar 1;92(2):247–54. doi: 10.2319/070421-530.1. 2 Image: iStock. as well as dental, functional and skeletal diagnosis. In the long run, there is the risk that communication by ortho- dontists who have the competence to provide good and safe care will be drowned out and important competence will be lost. Conclusion With the advancements of technology, a new reality of endless possibilities is upon us. If orthodontists want to keep up, time and effort need to be put into learning these new technologies, always being mindful of using them to improve patient care. The appliance and approach best suited to each patient need to be figured out, as there is no one-size-fits-all approach. A doctor spends his or her time educating patients and listening to their needs, is compassionate and honest, and builds trust and reliability. Information needs to come from the expert’s mouth in an honest, unbiased way. We should all ask ourselves: who am I and who do I want to be? And how do I stand up for the ethical values that come with my duties as a medically trained specialist? How do we make patients aware so that they can make informed decisions about their short-term and long-term dental health? We all need to think about the conse- quences of what we communicate via our various chan- nels. Although the profession may seem like it is entering a new era, the reality is that it might not be very different from the past. Its core values and belief systems are the same: patients’ best interests are and should always be at the centre. Practitioners need to see patients as people and not consumers. There is a place for technology, but technology alone does not offer much if there is no skilled human behind to drive it. 08 aligners 1 2022

| case report Treatment of a patient with a congenitally missing lateral incisor using aligners: A case report Drs Iro Eleftheriadi & Christodoulos Laspos, Greece and Cyprus Introduction The maxillary lateral incisor is the second most common congenitally missing tooth.1, 2 Owing to the aesthetically prominent region it is located in, treatment of this condi- tion requires a multidisciplinary approach aimed at excel- lent functional and aesthetic results. There are several treatment options based on orthodontic space manipu- lation: orthodontic space opening and replacement with a tooth-supported restoration3 or a dental implant4 and space closure that involves canine substitution.5 The treatment decision should be agreed between the treat- ing dentist and the patient, based on the expectations of the latter and the predictability of treatment. Multiple factors affect this decision, such as the type of malocclu- sion, the size, shape and colour of the canines,6 the oc- clusal relationship (overjet and overbite), the facial profile, the arch length and tooth size discrepancies.7 In the case reported in this article, a female adult patient presented with a congenitally missing maxillary left lateral incisor. Clear aligners were used to open the space for a single implant placement and achievement of a functional occlusion with excellent aesthetics. Figs. 1a–h: Pretreatment facial and intra-oral photographs. 10 aligners 1 2022

case report | Fig. 2: Initial panoramic radiograph. Figs. 2a–e: Pretreatment digital models. Case presentation Diagnosis The patient was 32 years old when the treatment started and presented as follows (Figs. 1–3): • missing maxillary left lateral incisor; • Class II division I malocclusion; • maxillary midline deviation to the left; • mild crowding in the mandibular arch; • Bolton discrepancy (mandibular excess of 3.06 mm in the anterior area and of 1.47 mm in total); • long face with facial asymmetry; and • convex profile with retruded mandible and prominent nose. The patient had an implant in position #46, whereas teeth #16 and 26 had been endodontically treated. These teeth showed no symptoms; thus, it was decided to re-evaluate the endodontic treatments only if necessary. Fig. 3: Pretreatment panoramic radiograph. aligners 1 2022 11

case report | The third molars were not present. The evaluation of the cephalometric radiograph (Fig. 4) showed a retrognathic mandible (SNB: 74.2°) and normal inclination of the incisors, both maxillary (Ui–FH: 111.3°) and mandibular (Li–APog: 24.2°). Treatment objectives and treatment plan The treatment objectives were the following: • levelling and aligning of both arches; • space opening for the missing lateral incisor; • correction of molar and canine relationships to Class I; and • correction of the midline deviation. The treatment plan included: • correction of the molar and canine relationships to Class I with maxillary distalisation; • opening of space in position #22 for a single implant; • midline correction; and • opening of space for enlargement of tooth #12 and interproximal reduction in the mandibular area to improve the Bolton discrepancy, allowing better occlusion and digitisation. Treatment progress This case was treated with the Invisalign system of align- ers (Align Technology). The approved initial treatment plan included 49 aligners with distalisation of maxillary posterior teeth to Class I (approximately 3.5 mm; Fig. 5). A space of 6.5 mm in the area of the missing lateral incisor was planned for the implant, and interproximal reduction was planned in the mandibular anterior region. On the right side, the button cut-out for the Class II elastics was placed on tooth #47 instead of tooth #46, to avoid damage to the implant crown. Since the patient was living abroad and close monitoring was not possible, some mid-treatment corrections were necessary (Fig. 6). During treatment, the following issues arose: poor posterior occlusion during the distalisation process and tipping of tooth #21 (Fig. 7). The latter was caused by the lack of an attachment on this tooth in the initial treatment plan. These issues were addressed in the additional aligner order with torque control and extrusion of posterior teeth to establish good posterior occlusal contacts and with the use of optimised root control at- tachments to correct the angulation of the maxillary central incisors (Fig. 8). Figs. 6a–h: Mid-treatment photographs showing the need for some corrections. aligners 1 2022 13

| case report Figs. 12a–c: Final lateral (a & c) and frontal intra-oral photographs (b). Figs. 13a & b: Final occlusal photographs. Fig. 14: Final smile close-up photograph. Fig. 15: Final smile extra-oral photograph. Treatment result The panoramic radiograph after orthodontic treatment showed the correct parallelism in the maxillary left ante- rior region for the implant placement and the conver- gence of the roots of teeth #44 and 45 (Fig. 9), but we decided not to spend extra treatment time on the latter, since the patient was really pleased with the result at that point. After completion of orthodontic treatment, perfect Class I molar and canine relationships had been achieved and the midlines were coincident. A temporary crown was placed on the single implant (Figs. 10 & 11), and prosthetic restoration of tooth #12 and final restoration of the implant were completed. An excellent final result was achieved. The soft tissue in the implant area had com- pletely healed, contributing to the high-level aesthetics achieved (Figs. 12–15). Regarding the final cephalometric analysis, the facial height (LFH: 56.5 mm) and measurements of soft tissue 16 aligners 1 2022

case report | Fig. 16: Final cephalometric radiograph and analysis. remained the same. The inclination of the maxillary incisors was well preserved (Ui–FH: 115.8°), and the mandibular incisors were slightly proclined (Li–APog: 30°; Fig. 16). malocclusion.13–15 Space opening is favoured in cases of Class I malocclusion, spaced maxillary dentition, or large size differences between canines and first premolars.16 Discussion Congenitally missing permanent maxillary lateral incisors have been reported to occur in 3.5–6.5% of Caucasians, the occurrence in females outnumbering that in males by a rate of 3:2.8–10 There are various treat- ment options, including substitution with reshaped canines and orthodontic space opening and prostho- dontic replacement or auto-transplantation. It has been found that the treatment choice of space closure versus space opening is still a debated issue among orthodon- tists and prosthodontists.11, 12 According to the literature, space closure and canine substitution is preferred in cases of unilateral missing lateral incisors, balanced profiles, canines and premolars of similar size and colour, bimaxillary protrusion or Class II A recent retrospective study concluded that decision- making for treatment of congenitally missing lateral incisors is directly dependent mainly on the following factors:17 1. patient’s age at treatment commencement; 2. individual characteristics of each clinical situation; and 3. collaboration of the specialists in the treating team. Even though there are studies supporting the superiority of space closure treatment,11, 18 each case should be indi- vidually evaluated. In the case reported in the present study, the option of space opening for prosthetic rehabil- itation was chosen, since the goal was to achieve Class I molar and canine relationships and a wider smile. To avoid compromise, Class I molar and canine relation- ships were achieved, the Bolton discrepancy was im- proved and the midlines were coordinated. Other studies have also shown excellent aesthetics and functional aligners 1 2022 17

| case report results with space opening and prosthetic rehabilitation.19 Both treatment alternatives have been found satisfactory, having similar functional and periodontal results,20 whereas in another study, laypeople rated both treat- ments as equally good.21 Our choice of space opening was also supported by the possibility of gaining an excel- lent occlusion. Recent advances in the Invisalign system allow predictable distalisation of posterior teeth to facili- tate treatment of Class II and III malocclusions.22 Aligner therapy in association with composite attachments and Class II elastics has been found to achieve sufficient dis- talisation with no changes in facial height.23 As shown in the cephalometric analysis, this was achieved in the pre- sented case, since facial height remained the same com- pared with the initial situation. Regarding the slight ten- dency for posterior open bite, it has been found that settling and improvement of occlusal contacts occur beyond three months after treatment.24 Thus, improve- ment of this situation and tight occlusal contacts are ex- pected in the post-treatment period. As far as the choice of single implant placement and restoration in the area of the missing lateral incisor is concerned, it has been found that it is the most common treatment alternative.25 It leaves adjacent teeth intact; thus, its main advantage is conservation of tooth structure. Our treatment choice was based on detailed multidisci- plinary diagnosis and planning, and this has been found to be imperative for achieving the best individual results for patients with missing lateral incisors.26 The contribu- tion of digital technology has been recognised in improv- ing and simplifying diagnosis, treatment planning and ex- ecution in orthodontics.27 The tool of digital set-up for diagnosing and treatment planning has been found reli- able for reproducing orthodontic treatment.28 ClinCheck software (Align Technology) was effectively utilised in the presented case, in order to plan the multidisciplinary treatment and communicate it between the treating team and the patient. Conclusion Missing maxillary lateral incisor cases should be manag- ed from an interdisciplinary diagnostic and treatment perspective. There are considerable benefits of using ClinCheck software as a tool for treatment planning and communication among clinicians and the patient, to finalise a treatment plan that addresses all the patient’s concerns. This case report shows how a successful team (orthodontist, restorative dentist and surgeon) when using state-of-the-art methods, can strive for ex- cellence and create aesthetic and functional smiles with no compromise. about Dr Iro Eleftheriadi received her DDS in 2011 from the National and Kapo- distrian University of Athens, and her master’s degree in medical statistics in 2014 from the Athens University of Economics and Business, both in Greece. She received her master’s degree in orthodontics and her spe- cialty certification in 2017 from Tel Aviv University in Israel. She is a doctoral candidate at the School of Dentistry, University of Athens, Greece. Dr Christodoulos Laspos received his DDS in 1995 from the National and Kapodistrian University of Athens in Greece and his MDSc in 1999 from the College of Dentistry University of Tennessee Health Science Center in Memphis in the US. He specialised in treating individuals with craniofacial malformations through a craniofacial fellowship in 2000 at the University of Texas Southwestern Medical Center in Dallas in the US and has been certified by the European Board of Orthodontics. He is a doctoral candi- date at the dental school of the University of Bern in Switzer- land. Since 2000, Dr Laspos has practised in his private orthodon- tic practice in Limassol in Cyprus. He is the founder and director of MEDICLEFT, the Cyprus Center for Clefts and Facial Deformities, and of the Chrysallida Foundation, the Cyprus Association of Individuals with Clefts and Other Craniofacial Anomalies, and the director of the Synergy Foundation, which provides continuing education courses for dental professionals. He is a scientific collaborator at the dental school of the European University Cyprus. Dr Laspos lectures internationally on craniofacial malforma- tions, orthognathic surgery, a multidisciplinary approach to care and new technologies in orthodontics. He is an active member of the Angle Society of Europe and the president of the European Orthodontic Society. 18 aligners 1 2022

case report | References: 1 Graber LW. Congenital absence of teeth: a review with emphasis on inheritance patterns. J Am Dent Assoc. 1978;96:266–75. 15 Rosa M, Zachrisson BU. Integrating esthetic dentistry and space closure in patients with missing maxillary lateral incisors. J Clin Orthod. 2001;35:221–34. 2 Dermaut LR, Goeffersc KR, DeSmit AA. Prevalence of tooth agenesis correlated with jaw relationship and dental crowding. Am J Orthod Dentofacial Orthop. 1986;90:204–9. 16 Shaf I, Phillips JM, Dawson MP, Broad RD, Hosey MT. A study of patients attending a multidisciplinary hy- podontia clinic over a five-year period. Br Dent J. 2008;205:649–52. 3 Kinzer GA, Kokich VO. Managing congenitally missing lateral incisors. Part II: Tooth-supported restorations. J Esthet Restor Dent. 2005;17(2):76–84. 4 Kinzer GA, Kokich VO. Managing congenitally missing lateral incisors. Part III: Single-tooth implants. J Esthet Restor Dent. 2005;17(4):202–10. 5 Kokich VO, Kinzer GA. Managing congenitally missing lateral incisors. Part I: Canine substitution. J Esthet Restor 2005;17(1):5–10. 6 Krassnig M, Fickl S. Congenitally missing lateral incisors–a comparison between restorative, implant, and orthodontic approaches. Dent Clin North Am. 2011 Apr;55(2):283–99, viii. doi: 10.1016/j.cden. 2011.01.004. Epub 2011 Mar 9. PMID: 21473994. 7 Paduano S, Cioffi I, Rongo R, Cupo A, Bucci R, Valletta R. Orthodontic management of congen- itally missing maxillary lateral incisors: a case re- port. Case Rep Dent. 2014;2014:731074. doi: 10.1155/2014/731074. Epub 2014 Mar 9. PMID: 24711929; PMCID: PMC3970084. 8 Goodman JR, Jones SP, Hobkirk JA, King PA. Clinical features and management of mild to moderate hy- podontia. Dent Update 1994;21:381–4. 9 Daugaard-Jensen J, Nodal M, Skovgaard LT, Kjaer I. Comparison of pattern of agenesis in the primary and permanent dentition in a population characterized by agenesis in the primary dentition. Int J Paediatr Dent. 1997;7:143–8. 10 Montagu MFA. The significance of the variability of the in man. Hum Biol. incisor teeth lateral upper 1940;12:323–58. 11 Robertsson S, Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of ortho- dontic space closure versus restorative treatment. Eur J Orthod. 2000;22:697–710. 12 Kiliaridis S, Sidira M, Kirmanidoy Y, Michalakis K. Treatment options for congenitally missing lateral inci- sors. Eur J Oral Implatology. 2016;9:5–24. 13 Fekonja A. Hypodontia in orthodontically treated chil- dren. Eur J Orthod 2005;27:457–60. 14 Zachrisson BU, Rosa M, Toreskog S. Congenitally missing maxillary lateral incisors: canine substitut- ion. Point Am J Orthod Dentofacial Orthop 2011 Apr;139(4):434, 436, 438 passim. 17 Kafantaris S et al. Factors affecting decision-making for congenitally missing permanent maxillary lateral in- cisors: a retrospective study. Eur J Prosth Rest Dent. 2020;28:1–10. 18 Gassem AB, Hashem D. Multidisciplinary manage- ment of congenitally missing lateral incisors: a min- imally invasive approach. Clin Case Rep. 2021 Jul 26;9(7):e04521. 19 Nagi A, Amita. Interdisciplinary management of con- genitally missing maxillary lateral incisors. J Oral Biol Craniofac Res. 2020;10:184–8. 20 Manzotti LDM et al. Congenitally missing maxillary lateral incisors: functional and periodontal aspects in patients treated with implants or space closure and tooth re-contouring. Open Dent J. 2012;6:248–54. 21 Hedmo C, Lindsten R and Josefsson E. Laypeople and dental professionals’ perception of the aesthetic outcome of two treatments for missing lateral inci- sors. Clin Exp Dent Res. 2022 Feb;8(1):262–9. 22 Ojima J et al. Upper molar distalization with Invisalign treatment accelerated by photobiomodulation. J Clin Orthod. 2018;12:675–83. 23 Ravera et al. Maxillary molar distalization with align- ers in adult patients: a multicenter retrospective study. Progress in Orthod. 2016;17:12–21. 24 Razdolsky BY, Sadowsky C, BeGole EA. Occlusal contacts following orthodontic treatment: a follow-up study. Angle Orthod. 1989;59(3):181–5. 25 Kokich V, Kinzer GA, Janakievski J. Congenitally miss- ing maxillary lateral incisors: restorative replacement. Am J Orthod Dentofac Orthop. 2011;139(4):435–43. 26 Pavesi NIP, Manzotti LDM, Pascotto RC. Congenitally missing maxillary lateral incisors: update on the func- tional and esthetic parameters of patients treated with implants or space closure and teeth recontouring. Open Dent J. 2014;8:289–94. 27 Cuncha TMA, Da Silva I, Kaila K. Orthodontic digi- tal workflow: devices and clinical applications. Dental Press J of Orthodontics. 2021 Dec 15;26(6):e21spe6. 28 Barreto MS et al. Reliability of digital orthodontic setups. Angle Orthod. 2016;86:255–9. aligners 1 2022 19

| opinion Aligners: More regulation or just a consumer product? Dr Miguel Stanley, Portugal Fig. 1: Unhappy 40-year-old female patient after two years of aligner treatment. (Image: White Clinic) Why do we need to straighten teeth? How do we do it? What is the best way? These are the big questions now- adays, and I think that the answers to these questions, as well as how we actually do these treatments, have changed over the past decades. After the French dentist Pierre Fauchard, who is credited with inventing modern orthodontics, first published his pioneering book in 1728 on dental treatments, in which he explained how to use a Bandeau device, a horseshoe- shaped piece of iron that helped expand the palate, people figured out that they could improve facial anatomy and the position of the teeth and consequently improve chewing, posture and ultimately facial aesthetics, by ap- plying mechanical forces to teeth. This made it something desirable and, to a certain extent, a consumer product. There are so many different ways to do this nowadays, so much has been discussed, analysed and proved to be true, and by the same token, we all have come to under- stand that many things that we were doing in the past no longer make sense. I am certain that we have all seen his- toric images of external devices applying mechanical forces that look like something out of a Tim Burton movie. It is strange to think that in the past people would be open to use of such dramatic orthodontic devices in order to achieve a better smile. We have come a long way just in the past 20 years. I gradu- ated in 1998, and I never really got into orthodontics as a practitioner, but very early on understood its importance in my clinic. I am proud to say that I have been working alongside a fantastic orthodontist since the very begin- ning, for almost 20 years now. Back in the day, we used classic brackets with elastics, and I always paid a lot of attention to how much art, planning and strategic thinking went into diagnosing each case. Early on, in 2003, we acquired a digital panoramic radiography unit that could also take cephalometric radiographs to enable proper cephalometric planning. The investments in appropriate technologies have not stopped since. As an implant surgeon and prosthodontist, I had the right team and tools to head bravely into the new century. I am very happy to say that, with solid foundations in science and clinical evidence and the right mentors, for over 20 years we have been doing interdisciplinary case management and pre-surgical orthodontic treatment, combining or- thodontics and implant treatment in complex cases, to then finally restore a case to perfect occlusion when nec- essary. Little did I know back then that this would be the right way to do things 20 years later and ubiquitously ac- cepted. Today, thanks to concepts such as digital smile design (DSD) and special software and 3D printers, we can very 20 aligners 1 2022

opinion | easily understand where we need to take the dentition with orthodontic movements prior to minimally invasive treatment with veneers, just as an example. Back then, this required quite a lot of thinking and a very hands-on approach. I feel I have acquired knowledge as the founder and clinical director of an interdisciplinary clinic to talk about orthodontics and aligners. I very clearly remember the excitement when we discov- ered the Damon system, which used self-ligating brack- ets that were gentler on teeth and soft tissue and that re- quired a lot less force to move teeth with much higher efficiency and in fewer appointments. Dr Alessandra Curto, head orthodontist at the practice, took a course on the system and we immediately implemented the system at the White Clinic. Despite the cost of the system, we quickly understood the implicit benefits of having a system that was faster, required less management and was ultimately more comfortable for our patients. Obvi- ously, we passed on that extra cost to the patient, and yes, it was a harder sell back then; Portugal was and still is, after all, the second or third poorest economy in the European Union, but our ethos has always been nothing but the best for our patients. It is important to say that we have absolutely no commercial relationship with Damon system and never have had. I just always believe good things deserve a mention. We still use this system today and have done some amazing cases over the years that we believe could still not be done with aligners, although the things we can do with aligners is increasingly improv- ing. It is important to say that my team and I have always practised Slow Dentistry (Slowdentistryglobalnetwork.org) and spend on average 2.5 hours planning each case prior to starting therapy and follow the No Half Smiles treat- ment philosophy, which I created in 2006. This philoso- phy basically means that we never treat just one arch, or perform partial dentistry, leaving untreated teeth in the oral cavity. The aim is to always restore the whole mouth to health, function and, if so desired, aesthetics. Patients with few problems have fast treatment times and little work is necessary, and those with major issues need a lot more work, time, patience and care and their treat- ment ends up costing a lot more too. No matter what, we always focus on establishing good occlusion and biology, as aesthetics can usually only be achieved after these pa- rameters have been set. It is also worth mentioning that the White Clinic has never had investors or shareholders, is not part of a dental service organisation (DSO), or had never worked with an insurance company. We also have never sold courses or distributed dental products. Why am I saying this? Well because we can focus all our time and our resources on investing in technology, training and doing the right thing always. I am not saying that these are wrong, just that we prefer to focus on the patient and on what truly matters, doing extraordinary dentistry every day and updating knowledge and tech- nology as it comes into existence, so we are always ahead of the game, offering our patients the best there is to offer in any given year. When in 2005 we were introduced to clear aligners from Align Technology, I was truly blown away. I mean 3D printing was unheard of in real life; it was a thing of sci-fi. I love exciting new technologies that offer more and are better for our patients. Remember, in 2005 there was no social media and no real way of seeing what the world was saying about anything. We started using aligners im- mediately, and I can tell you that it was not an easy sell to patients, mostly because of the cost. Notwithstanding, we pushed on, and I recall that sales represented about Fig. 2: Large gaps between the teeth caused by poor orthodontic planning. (Image: White Clinic) aligners 1 2022 21

| opinion Fig. 3: Large gaps between the teeth caused by poor orthodontic planning. (Image: White Clinic) 5% in the first year. Few dentists in Portugal were using clear aligners, and it was really difficult to gain credibility for this modality, as there were no social benchmarks. Patients had no way of knowing what they were like, asking friends and family, as no one was really using aligners back then and no big marketing was being done, so we really had to spend hours of our time explaining to patients what they were and the implicit benefits over tra- ditional fixed appliances, which include the following: • easier to floss and brush teeth; • more aesthetic; • better for people with public-facing jobs that require them to talk, model or act, for example, and for high- performance athletes; • ability to eat one’s favourite sticky foods; • more control over the planning and better visualisation of the final result; • possibility of refinement at the end; just to give a few examples. In many cases, we had patients wanting aligners, but the traditional method was better, and vice versa. We would only do what was best for the patient. I did some TV shows on prime-time TV, performing inter- disciplinary dentistry, and to the best of my knowledge, it was the very first time in the world that a TV show used dental implants as part of a smile makeover. Unfortu- nately, orthodontic treatment was not included, but it was an incredible opportunity to show the country the differ- ence between single-tooth traditional quick-fix dentistry and full-arch smile restorative treatment. As a result, the White Clinic became a household name in dentistry and a benchmark in the country for excellence in oral care. This obviously made communicating complex treatment and products such as clear aligners a lot easier, and as the years went by, aligners became more ubiquitous in our major cases, including complex ones. We performed increasingly more pre-veneer orthodontic cases, and consequently our confidence levels in the technology grew and I would say that by 2009/2010 they represented 50–60% of our orthodontic cases. As clinical director, my job has always been to implement new strategies, technologies and techniques and to ensure that we have the time to implement things into our workflow and ensure that whatever we do has the pa- tient’s best interests as the primary focus. This means that we always incorporate anything that will make the workflow and outcome faster, better and, if possible, more affordable for the patient. This last objective has not really always been possible, as employing new technolo- gies usually involves more investment, time and training and expensive materials. I was very fortunate early on in my career to start lecturing around the world, mostly on implant dentistry, but since I am also a cosmetic prostho- dontist, I spent a lot of time showing the audience and my colleagues these orthodontic cases that we were treating that were all, by default, interdisciplinary in their planning and execution, the final focus always being on occlusion. Biology is “king” at the White Clinic, and for this reason, we acquired the very first full field of view digital CBCT unit in the country in 2008. This specific one allowed us to stitch the DICOM files together, enabling our team to see the skull in all its glory in a beautiful 3D image. I have to say that the initial premise of acquiring CBCT technology was to improve our planning for dental im- plants, at the time the most complex part of the practice. However, we very quickly understood the implications this technology could have for improving treatment for or- thodontic patients who had complex biotypes or required complex movements. Being able to complement the cephalometric analysis, done with traditional 2D images from a panoramic and tele-radiographic unit, was quite groundbreaking. We were able to instantly see the tooth– 22 aligners 1 2022

opinion | bone ratio without any of the soft tissue and to use the software to rotate the skull and understand immediately the challenges that we would face in applying complex orthodontic movements—revolutionary! This is some- thing we started doing daily in our practice back in 2008, when only 1% of dental practices globally had CBCT technology, according to major manufacturers. Armed with this new imaging capability, we grew our orthodontic department exponentially. To the credit of Dr Curto, in 20 years of working together, we have never had one case of root resorption and, in the roughly 5,000 cases performed together, perhaps no more than ten in- stances of minor gingival retraction. These were primarily due to the patients’ thin biotype and the risk was ex- plained to these patients prior to initiating the treatment; therefore, we were not surprised when it occurred and we were able to restore the gingiva with minor gingival grafting by our periodontics department. I have set all this out to demonstrate that we really take treatment planning seriously. It takes time. Those of you who work with aligners know the importance of entering the right information into the software through the aligner provider’s platforms to then work with the company to ensure that the treatment is the best possible for the patient. If we did a global survey right now on the average time that dentists spend on planning with the software for their aligner cases, what do you think the answer would be? What is the ideal time that an orthodontist or general practitioner should spend interacting on the cloud soft- ware to ensure the safest biological movement possible? Obviously, the more complex the case, the more planning must be done, or so the consumer or other dentists might be led to believe! As I progress in my career, I am learning more about the dark side of dentistry and of growth strategies that clini- cians and corporations have that very rarely have the pa- tient’s best interests at heart. There seems to be many instances of corruption of care in which I would presume the patient trusted the dentist to give him or her the best care and believed that the Hippocratic oath of do no harm was being applied throughout the entire procedure. This was so much easier to control when it was the dentist di- rectly applying the brackets and arch wires and bending them to apply micro-forces throughout the orthodontic treatment with the traditional method. There was no in- terface, no outsourcing of planning and no third party, and if things went wrong, the dentist had to "face the music". He or she was the person in charge and could not shift the blame of poor outcome to anyone else. Ob- viously, we would still see some cases of simple ortho- dontic treatments taking much longer than they should have, the business plan of the dentist being to have con- stant income from a large multitude of patients. I believe that this is one of the upsides of aligners, as there is a clear end date built into the system. I have seen hun- dreds of cases over the years of patients who have had their mouths ruined by orthodontists who seemed to completely forget or overlook the inflamed gingivae and carious lesions in the four to five years in which they were straightening their teenager patients’ teeth. Obviously, Fig. 4: Before beginning the 18-month retreatment. (Image: White Clinic) aligners 1 2022 23

| opinion Figs. 5a & b: (a) After an 18-month treatment to open space, driven this time by design, and (b) after implant and final ceramic resto- rations. (Image: White Cllinic) aligners actually changed the game in more ways than one. We now have the opportunity to outsource planning and have an end date in mind at the very beginning of the procedure. This is fantastic! However, like all software and even any artificial intelligence, also used in orthodon- tic planning nowadays, it is all about who programs the software and what the ethos of that planning is. This means that the better the information given to the soft- ware is, the better the engineers or technology can design the case. Even today, most orthodontic aligner cases require the dentist to interact with the providing company to fine-tune the treatment proposed. It is obvi- ously utopia to believe that everybody does it properly. As the founder of the Slow Dentistry Global Network, which focuses on seeing fewer patients a day in order to provide a higher degree of care, safety, hygiene and treatment planning, I have never worked any other way and I am well aware that there are many dentists around the globe who do take the appropriate amount of time to put proper thought into planning cases and aligners and interact more than once with the providing companies, suggest- ing many alterations based on their intimate understand- ing of the patient’s mechanics and physiology. But let us face it, can we really believe that companies that are listed on stock exchanges and have a duty to their shareholders to generate as much profit as possible really care about dentists who take extra time in carefully planning their cases? Do they prefer practitioners who sell the largest number of cases as possible? This is a very important question. As I see it, if we look at the way things are being done currently, we have some systems that are rewarding dentists with such accolades as "plat- inum" and "diamond" provider recognition, implying that these clinicians must be better providers then those who are simply bronze or silver providers. Why would a poten- tial patient seeking aligner treatment choose a provider who appears to be less than the best? Moreover, we all know, or should know, that many of these reward systems also allow the providers to pay less per case if they sell more cases—this is a massive financial incentive to sell as many cases a year as possible. Why? Recognition as a platinum or diamond provider is not only cheaper and more profitable, but also creates the illusion in the mar- ketplace that the provider is a better dentist. This is simply not the case in general. I think we need to have an open discussion about this. Would it not make more sense to reward dentists based on quality of outcome instead of volume of sales? Do you not think that the consumer would prefer to have a dentist whose final results are almost always identical to the initial treatment plan discussed with the provider, whose final scans are very close or identical to the treatment plan, or who achieves results with no root resorption or gingival recession and within the time frame established? I think that these are the orthodontists who should receive ac- colades and global recognition for being the best of the best! What we have is pure capitalism disguised carefully as great healthcare. Is this really the best we can do in 2022? Do not get me wrong: I am all for being profitable, but it should never be at the expense of the patient’s trust. Trust is the foundation of any medical relationship. If we are selling patients the fact that we are better than our peers because we have received such accolades, then we need to be open about exactly what those accolades are and commit to improving our ecosystem. I think that dentists who take more time to plan cases, use CBCT and intra-oral scanning technology, and carefully integrate orthodontics with periodontics and restorative dentistry start any case with a DSD study, in order to un- derstand whether the tooth ratio is ideal for the patient’s face. This is also something most aligner companies overlook, focusing only on straightening the arch and bringing the occlusion ideally to a Class I occlusion, often 24 aligners 1 2022

opinion | Fig. 6: 3D-printed mock-up and index tray to test the new design. (Image: White Clinic) overlooking the fact that the teeth might be too small for the patient’s mouth. I have seen this happen so many times. Treatment seems to be going well, but at the end of such a long journey, the patient is unhappy with the results, because he or she does not really understand that the problem involved the shape and size of the teeth too and not just misalignment. This should not be hap- pening in 2022. We have the tools and resources to un- derstand all of this, before we even touch the patient’s anatomy. Would it not make more sense to let the patient know prior to initiating a long orthodontic treatment that at the end of the procedure her or she might need to undergo some crown lengthening and/or veneers? People have a right to know before they decide to proceed with alignment that they will have to incur extra costs and undergo more therapy to achieve the desired results. This is all possible with digital software and can be outsourced just like the aligners. I believe that groundbreaking technologies such as those employed by DSD, deserve all the respect and recognition, as these promote and enable the ideal of de- signing the smile prior to treatment, and this is critical to understanding what is necessary throughout the entire treatment (I have no commercial relationship with DSD–I am just a fan). We were doing it long before the technol- ogy existed; it just took a lot longer. Many dentists were doing this, but now, more can do it. It appears, however, that way too many dentists are too cheap or too lazy to invest time and money or, even worse, are scared that the extra costs will scare patients away. Success is a mindset! Having an intra-oral scanner and a CBCT unit and using the cloud and even outsourcing planning only makes life easier, but you have to have the moral compass to make certain that you are always putting your patient’s biology first and not your pocket just so that you can jump cate- gory, obtain more rewards and be recognised as the leader in your community to outshine your competition. This is not a race. You should only consider yourself a leader when all your cases are delivered with the best in- tentions possible and the best results consistently. Recently, I gave a lecture in Como in Italy for the Digital Dentistry Society, of which I am the vice president. I pre- sented only one case: the case of a 44-year-old woman with no financial limitations who went to a very good or- thodontist in my country to have aligner treatment. After two years of treatment, she could not close her mouth properly, had massive gaps between her teeth and was suffering from tension headaches and temporomandibu- lar joint issues as a direct result of her treatment. She was desperately trying to find out what was going wrong and why her aligners were not offering her the solutions that she was sold in the beginning. I am sad to report that the dentist in question extracted two healthy premolars because, I presume, the software told him to do so. I can only speculate that no CBCT scan or DSD or even thought process went into the treatment planning for this patient, who lost not only her smile but also her trust in dentists. After careful discussion with my team, looking at the CBCT scan and conducting a DSD, we quickly under- stood that the tooth ratio was too small for her face. Her premolars should not have been extracted. If anything, she needed her arch expanded to improve her airway, and at the end of her orthodontic treatment, she needed a vertical dimension augmentation via full-contour veneers. We printed a 3D mock-up for her, and she was brought to tears seeing photographs and herself in the mirror and finally understood what was possible with a proper plan. We spent a lot of time helping her understand why things went wrong and what we could do to improve the situa- tion. It took us two years to reposition the teeth, to open the gap created by this orthodontic mismanagement and aligners 1 2022 25

| opinion Figs. 7a &. b: Comparison of (a) the initial situation with (b) the final result with full-contour veneers, implants and a new vertical dimension after the aligner treatment. (Image: White Clinic) to finally place implants where her premolars had been, establishing her smile and function. She is the most grateful patient today and has had her trust and not just her smile restored. She is a very communicative patient and refers a lot of work. We are grateful. I believe that the reason this happens in the first place is that the largest clear aligner companies in the world seem to be focused on profit and take very little respon- sibility for quality control regarding the final use of their product. It is very easy for them to say that it is the den- tists’ responsibility at the end of the day to do the right thing. They are right, but not all dentists have the right training, tools or mindset. We need more quality control to benefit the patient. Rewarding dentists on volume of sales and not quality of outcome creates an environment for absolute corruption of care in my opinion. Some dentists might not like what I have to say, but I am sure that the patient, who is the real consumer at the end of the day, would prefer to know the facts. I believe soon the interface will be more public facing and patients will have access to this information. Times are changing; we must change with them. The technology that was invented back in the nineties using 3D printing and stereolithographic technology and soft- ware to straighten teeth was absolutely incredible. It is now available ubiquitously around the world, many com- panies providing what appears to be the same thing. I personally will always prefer to work with companies that can integrate CBCT data with intra-oral scan data, we are already using such systems that have a higher degree of monitoring of treatment planning. I would also love to see them offering rewards on the quality of outcome, based on the final CBCT and intra-oral scans sent back, comparing the results with the treatment plan- ning. I do not think that exists yet, but I have heard that some companies are working on this, and that is the way it should be done! Unfortunately, I have come to under- stand, after 24 years in dentistry and having lectured in more than 54 countries around the globe, that owing to global economics not every dentist can place ethics at the centre of their treatment all the time. They often lack the resources to do the right thing and are trapped in the past. It is the obligation of large companies to ensure some oversight in the technology to make sure that the patient, who is the real consumer, receives nothing but the best. Hopefully artificial intelligence will mitigate these concerns in the future, and I am certain that we are all heading in the same direction: great volume of sales and extraordinary quality of care. about Dr Miguel Stanley is the founder and clinical director of the White Clinic in Lisbon in Portugal, which has a large interdisciplinary team that uses ad- vanced technologies, materials and software to treat some of the most challenging cases. For decades now, Dr Stanley has lectured around the world on his areas of expertise, includ- ing cosmetic dentistry, prosthodontics, implant dentistry, digital dentistry, hard- and soft-tissue management, complex case management, ethics in treatment planning, Slow Den- tistry and clinical practice management. Dr Stanley is the co- founder of the Slow Dentistry Global Network, a non-profit organisation, and serves on the board of the Digital Dentistry Society, among others. He publishes regularly and is an adjunct assistant professor at Penn Dental Medicine in Philadelphia in the US. He is the only dentist in the world to have made a documentary on dentistry with National Geo- graphic and is very passionate about helping dentists of all ages and demographics around the world find congruence between what they have learned and how they practise. www.whiteclinic.pt/en miguelstanley.com digital-dentistry.org 26 aligners 1 2022

| trends & applications Effective application of interproximal reduction during aligner treatment Dr Gina Theodoridis, Greece The concept of interproximal enamel reduction (also re- ferred to as IPR or stripping) as a means of providing space to alleviate a crowded dentition was first intro- duced in orthodontics as early as the 1960s. The pioneer in the introduction of this approach was John Sheridan, a renowned clinician in orthodontics. His primary contri- butions included the introduction of the clear Essix re- tainer, a prelude to today’s aligners. He was also an ad- vocate of interproximal air rotor stripping, which he used primarily for adult patients as a method to gain dental arch space to avoid extractions. The IPR technique has also been applied in fixed appli- ance treatment, in order to address a Bolton discrepancy, correct black triangles and increase stability of the final outcome. The significance of IPR in clear aligner treat- ment is more important throughout the treatment com- pared with fixed appliances. During the levelling phase in fixed appliance treatment, the round nickel–titanium wires allow free labial movement of teeth; thus, small col- lisions on marginal ridges do not tend to block the move- ment. On the contrary, with clear aligner therapy, the plastic aligner material covers the labial surface of the teeth completely, and the teeth cannot spontaneously move to a larger arch perimeter; because of this effect, any marginal ridge collision that may occur can influence the aligner’s performance. Maintaining incisor inclination is better controlled in aligner treatment, and aligners have an advantage in this aspect. Interproximal reduction can be an attractive alternative to tooth extraction in patients with mild to moderate crowding because it allows the transverse arch dimensions and anterior tooth inclina- tions to be maintained. With the increasing popularity of aligner movement in recent years, as more adult patients are seeking aesthetic non-extraction orthodontic treat- ment, it appears that interproximal reduction has become a more common practice in the orthodontic office. Nowadays, most aligner digital set-up software shows the exact staging of the movement and the exact point where IPR must be applied, as well as the required amount of IPR. In this article, we will discuss the steps of 28 aligners 1 2022 Fig. 1: Ideal stage for IPR. Fig. 2: Non-ideal stage for IPR. an IPR approach in aligner treatment, covering proper treatment planning, clinical tips on IPR application and proper finishing techniques. ClinCheck software (Align Technology) will be used as an example of how to handle IPR in treatment planning, followed by a description of the clinical procedure using a vibratory oscillating device.

trends & applications | Fig. 3: The use of an IPR gauge is important. Fig. 4: Checking interdental contacts for collisions. Treatment planning When to apply IPR ClinCheck software can suggest the location of IPR based on the clinician’s treatment criteria, that is, the final labial position of the teeth. The software can be automat- ically adjusted to detect collisions and apply the neces- sary amount of IPR if required, an amount that the clini- cian can also manually adjust. An important principle is that with aligner treatment the clinician can specify the exact envelope of movement, setting a labial or buccal limit of the movement and avoiding any unwanted expan- sion or proclination of the teeth. Based on this principle, the software will calculate the amount of IPR for the spe- cific arch width. Using the 3D control interface with ClinCheck , the clinician can see real-time changes and view occlusal contacts continuously during modifica- tions. There is also the possibility of modification of the stage at which IPR will be performed, and this is entirely controlled by the clinician. Performing the IPR with con- tacts as occlusally parallel as possible is paramount to avoid irregularities. Rotations and misaligned teeth can result in irregular enamel reduction and non-ideal final in- terproximal contacts (Figs. 1 & 2). How much IPR is considered safe? The amount of IPR that is to be performed in a specific contact must be carefully considered and relative to the enamel thickness of the teeth. Using an IPR gauge is es- sential (Fig. 3). For example, since enamel thickness in mandibular incisors is on average 0.8 mm, IPR in the range of 0.2–0.5 mm per contact (if performed to 0.10– 0.25 mm per tooth surface) should not be harmful for the tooth. The clinician also must consider that the distal surface of the tooth has slightly thicker enamel; therefore, focusing on that surface between two contacts is ideal. I personally tend to limit IPR on a first ClinCheck treat- ment plan to a value of 0.3 mm, if possible, as usually we may need some extra tenths of a millimetre on a refine- ment set-up. As a personal rule of thumb, I do not exceed 0.5 mm per contact. ClinCheck software may be set to alert the clinician when a non-conventional IPR value is entered and to add all IPR that has been performed in previous treatments. Many clinicians who are using various aligner systems chose to perform all IPR in the beginning of the treatment despite the fact that it may be needed at different stages in the treatment. I strongly disagree with that, as it may cause unnecessary enamel reduction, irregularities on the marginal ridges when they are not parallel and reduced treatment efficiency. I follow the exact staging that I planned on the software, deviating to a maximum of one to two aligners before the stage of planned IPR and never after. Checking interproximal contacts chairside Any interproximal blockage in the neighbouring areas (not where IPR will be performed) may also cause align- ment problems. All contacts must be frequently checked with dental floss (Fig. 4), and if needed they can be cleared with a thin manual IPR strip without significantly reducing tooth substance. This is recommended after the first few weeks of aligner treatment, as contacts tend to become looser after that period. Areas of severe crowd- ing must be checked regularly for heavy interproximal contacts. Keeping the symmetry on the tooth surface Although IPR, when done within reasonable values, does not alter tooth size noticeably to the naked eye, the clini- cian has a digital tool to help him or her achieve symme- try when performing this procedure. ClinCheck software provides the Bolton analysis table with measurements for all tooth sizes (Fig. 5). Using this table, the clinician can chose to apply more of the IPR on the larger tooth surface when comparing the two same opposing teeth. I would like the future software evolution to incorporate a feature on the 3D model to guide the clinician towards the surface that needs more reduction (perhaps a highlighted tooth surface on the virtual model). As Align’s protocols are regularly enhanced with new features, I have communi- cated this wish to Align’s development team and hope to see it incorporated soon. The latest software develop- ment is the live update feature, which enables real-time aligners 1 2022 29

| trends & applications Fig. 5: Bolton’s analysis table depicting tooth size discrepancy. Fig. 6: Live update allows real-time modification and case approval. highly recommended, as this helps visualise the detail in altering tooth morphology and the detection of any irreg- ularities that may require finishing (Fig. 11). IPR on posterior teeth It is my personal preference to avoid stripping in the pre- molar and molar areas unless really necessary. I do not agree with massive posterior IPR for the sake of creating a Class I occlusion. Furthermore, in these areas, there is a tendency for food entrapment, and this creates a po- tential risk for caries if IPR is excessive. Additionally, pre- molars and molars have point interproximal contacts and flattening their proximal surfaces could result in peri- odontal problems. If the clinician needs to perform IPR in the posterior areas, he or she should avoid flat stripping files, as it is not possible to create a point contact using them. If there is need for IPR in the premolar or molar region and the desired value is 0.3 mm or more, the best way to achieve this is with a stripping bur. It is quite difficult to create a clearance of less than 0.2 mm with a stripping bur, as this is too technique-sensitive. Finishing Steps must be taken to ensure that the enamel surface remains smooth after enamel reduction; therefore, pol- ishing is important. Finishing the contacts where IPR has been performed is of paramount importance to avoid ir- regularities that can lead to periodontal problems, caries and discoloration. For finishing anterior teeth after IPR, we use a 15 μm extra-fine polisher strip in the Oscident handpiece. In order to reduce any sharp edges that may have been created by the files, we use a resin polishing bur on the edge of the contact (Figs. 12 & 13) with extreme caution, as this may further open the contact. As a final step, we apply a topical fluoride to the IPR-treated surfaces. After the agent is applied, the patient wears the aligner and is instructed not to rinse for 30 minutes (Figs. 14 & 15). Use of a fluoride-containing mouthwash at home is highly recommended. We have observed clinically that meticulous polishing of and topical fluoride application to IPR-treated surfaces are associated with Fig. 7: The Oscident handpiece. Fig. 8: IPR stripping files. viewing of the changes and staging pattern without having to send the modifications back to the technician. This saves a considerable amount of time for the clinician and allows faster approval of the modified treatment plan (Fig. 6). IPR on anterior teeth As a rule, for a contact of 0.2 mm or less, I use manual stripping files, as mechanical stripping can create more space than needed. For anything above that value, I prefer a manual vibratory handpiece, the Oscident hand- piece (Fig. 7). I have observed that oscillating diamond strips work more efficiently compared with the manual IPR system and that they result in a more refined enamel surface. We use a set of diamond strips ranging from extra fine to coarse (Fig. 8). The stripping is always per- formed with water spray, as this helps create a smoother surface on the enamel (Figs. 9 & 10). The handpiece also comes in a version with a light, which I find very helpful in performing detail work. The use of surgical loupes is 30 aligners 1 2022

trends & applications | Fig. 9: Using an oscillating handpiece with water spray for IPR in the maxillary arch. Fig. 10: Using an oscillating handpiece with water spray for IPR in the mandibular arch. Fig. 11: Performing the IPR procedure under surgical loupes helps visualise details. Fig. 12: Checking contacts for sharp edges. Fig. 13: Finishing the edge of the contact. reduced incidence of interproximal discoloration. It is un- likely the caries will develop if the interproximal reduction procedures are performed in the manner described. Summary The use of IPR is an effective means of treating cases of mild to moderate crowding with aligners. Align’s treat- ment planning software allows control of the amount and staging of IPR. The flexibility of observing the different IPR scenarios in real time via the live update new feature. ClinCheck software provides the user with an additional feature via the Bolton’s analysis table that allows more detailed and precise enamel reduction, taking into consid- eration the size of the teeth. Enamel reduction can increase available space, but the quantity of enamel that can be removed without adverse consequences should be carefully evaluated. There is clinical evidence that the use of IPR can help the clinician better meet his or her original standards in treatment. However, the clinician must devote time and attention to detail for the IPR-treated case, as this is an irreversible procedure and must be done as meticulously as possi- ble, always following the ethical practice of preserving tooth structure and finishing to perfection. The best IPR- treated cases are the ones that another clinician would not easily detect. Fig. 14: Applying varnish to IPR-treated contacts. Fig. 15: The patient wearing the aligner after fluoride application. about Dr Gina Theodoridis obtained her degree in orthodontics from New York University in the US, where she was also a member of the teaching staff. She has been employing clear aligners in orthodontic treatment for more than 20 years and is an international lec- turer and an Invisalign diamond pro- vider. She is a member of the board of directors of the European Aligner Society. She has a private practice in Athens in Greece. aligners 1 2022 31

| feature War in Ukraine: Dentists will not sit idly by Image: Serhii Ivashchuk/Shutterstock. Dr Miguel Stanley, Portugal & Nathalie Schüller, Dental Tribune International On 27 February, three days after Vladimir Putin launched his invasion of Ukraine, Dr Miguel Stanley set off from Lisbon in Portugal to Cracow in Poland with his friend Mike and father-in-law, Viktor Beznosiuk, who now lives in Portugal and even at 68 years old could not be dissuaded from going to fight for Ukraine. It is important not to stay silent; it is important to try to do your part and stand against anything that threatens a people, a country, our liberties, or our freedom. We often feel helpless; we might not know how and where to start. We might feel that whatever we do will only be a drop in the ocean, but even a drop can help. Staying silent with your words or actions in response to anything that is unjust or violent or threatens us all, often becomes a larger threat. In this article, Dr Stanley shares why he wanted to and why he had to drive 6,600 km to aid Ukrainians. Many people have asked me whether I did what I did because my wife is Ukrainian. I think that my actions were a response to the absolute chaos that has descended on a civilised, democratic European nation. With children and civilians dying, I could not just sit idly by knowing that these people were suffering, and more was surely to come. Therefore, instead of just talking about it, I decided to do something about it. Knowing that my father-in-law wanted to go to help the war effort despite his age, instead of putting him on an aeroplane and bidding him farewell, I drove with him and a friend on a three-day journey from Lisbon to Cracow in a van filled with phar- maceutical supplies from my clinic and from a nearby pharmacy, along with baby diapers and anything that I thought people might need. On the way, I made a few phone calls to several col- leagues based in Germany, and Dr Markus Tröltzsch from Ansbach and Dr Jan Kurtz-Hoffmann from Leipzig to- gether organised another truckload of pharmaceutical supplies, suture thread and everything we thought might be necessary in a war situation. We funded this trip pri- vately and drove all of our supplies in two cars to Cracow. A good friend of ours, Dr Nazariy Mykhaylyuk from Kiev, put us in touch with the director of Polish dental distribu- tor FM Dental, Wojciech Feć, who has put his life on hold and has been doing amazing work to aid Ukrainians. He helped us make sure that the supplies we had brought reached Ukraine safely and were properly distributed. Ukraine is an amazing country with a democratically elected president, and there are no reasons to justify this attack. That is the reason why the world has responded with sanctions against Russia. The Russian population will unfortunately suffer the consequences of these sanc- tions, but there is little alternative for bringing pressure to bear on the government. There are of course many good people in Russia who do not want this war. Much of the population do not know what is really going on, having 32 aligners 1 2022

feature | been fed lies by their government and not being provided with accurate information, as news outlets that do not toe the government line have been suppressed and banned from publishing. Those Russians who are factually informed are not allowed to even mention the word “war” to refer to what is happening. We were very pleased to see many organisa- tions suspending their activities in Russia. As dentists, we too did what we could. Within the first five days of the invasion, with Dr Christian Coachman, the founder of Digital Smile Design, and a group of over 200 leading dental sur- geons, we wrote an open letter to CEOs and or- ganisations within the dental community, asking them to suspend all activities in Russia pending a peaceful outcome to end this horrific war in Ukraine. As dentists what we can do is to suspend all commercial activities with Russian companies until this is over and try to give our Russian friends balanced news. Dr Miguel Stanley and some of the volunteers during the trip from Portugal to Poland. (Image: Volunteer of the trip) As dentists, we can also donate carefully packed and clearly identified supplies that are needed in a war situa- tion: gauze pads, central lines, suture thread, analgesics, antibiotics. Obviously, we can make donations of financial aid and even open our homes to help displaced Ukraini- ans stay in places of safety until they can return to and rebuild their country. We left my father-in-law at the border between Poland and Ukraine, and we brought back two displaced Ukrainian women and their three children, the youngest only 8 years old, safely to Portugal, where families were willing to welcome and support them. The outpouring of support from other nations, not just bordering nations but many other European countries, has been overwhelming, and it warms my heart to see so much humanity in the world and so many good people out there. It is difficult to see that so much pain can be inflicted by so few on so many. Editorial note: In an interview given to US television station WKYC, Ukrainian dentist Dr Nazariy Mykhaylyuk re- counted fleeing 750 km west of Kiev with his family on the first day of the attack in Kiev. It seems difficult to fully grasp the feeling of fear when we see images on the news. “It seems like it’s impossible to happen in your own country and once it happens, believe me it’s super scary and all you want to do is to save yourself and your family and to go as far as possible from the zone under attack,” he said. Dr Mykhaylyuk sees the goal of the invasion as being to scare the Ukrainian population into giving up. He believes that Ukrainians “will not give up, because this is the fight, the war, for our nation. We hope it’s going to finish as soon as possible because our army is very mo- tivated, people are very brave. It is our land; it is our country; and we don’t want anyone to come here and tell us how to live”. One can understand his anger, seeing what this invasion has done to his home. He concluded by saying that “the West, the US, Europe and NATO, need to understand that they have to protect Ukraine because right now Ukraine is protecting Europe. We are the border between Russia and the European Union”. This article was first published in French in the Dental Tribune France, Vol. 14, N° 4, April 2022. Dr Miguel Stanley lighting a candle for hope and for peace in a church in Cracow in Poland. (Image: Volunteer, trip Portugal to Poland) aligners 1 2022 33

| feature How to make time work for you instead of against you—five time management tips for 2022 Jerko Bozikovic, Belgium Time is a very interesting thing, since everybody experi- ences it differently. This might sound weird to you, and yet the following situations will probably be familiar to you. Have you ever felt that sometimes time flies while at other times it feels like it is passing very slowly? Have you had days on which you can finish a lot of things on your to-do list, yet on other days you do not even finish a few things from your to-do list? Have you sometimes felt that others have so much more time to finish their projects, do hobbies and accomplish their dreams, but you struggle through the day just to get the basics done? Welcome to time management! Even though we all have 24 hours in a day and 60 minutes in an hour, everybody experiences time differently. You might ask why. Well, because there is a difference between objective time and subjective time. Objective time is time measured according to your watch, and sub- jective time is time as it feels to you. Often, there is a dis- crepancy between the two. For example, you have a meeting starting at 10:00 a.m., so at 9:55 a.m. you are about to shut down your PC in order to pick up a coffee on the way and be in time for the meeting, but then sud- denly an email pops up. You look at it and think to your- self I’ll just answer this quickly. It’ll only take me a minute. As you are answering the mail, you realise you need to get some extra input for that mail, maybe requiring going back to some earlier mails from the sender or copy– pasting in some text etc. Instead of a quick 1-minute answer, it becomes an 8-minute task, by which time you leave too late to get a coffee on the way and arrive at the meeting late. Recognise this? That is the difference between objective time and subjective time. Guess what? Most people under-estimate time; we always think we will be able to do much more than objective time allows. That is why we make such long to-do lists we will not be able to finish or have many tasks for the weekend and then realise on Sunday evening that we have not done even half of them. Tip: you can do this by defining some tasks in your agenda, write down how much time you’d like to spend on them and then ask yourself whether this a realistic time frame based on your previous ex- perience with this same task. This can help you focus on what you can do in the allotted time rather than what you would like to do. Do you have any idea how many thoughts a human being has on average in a day, only when awake, not asleep? In his book, Eckhart Tolle tells us that we have between 40,000 and 60,000 thoughts a day, which is about one every second.1 Can you imagine you are doing some- thing, working, discussing, eating, travelling, and every second, you have a new thought popping up in your mind? No wonder sometimes people say they are going crazy because their mind is always full. He also tells us that 95% of our thoughts are related to the past or the future, meaning that we are mostly thinking of things that we did not finish, accomplish, finalise or let go of, or ev- erything we still need to do, plan, achieve, finish, etc. This means that we are only 5% in the here and now. If I asked you whether we are the most effective in the past, present or future, what would you reply? The correct answer is the present, yet we spend little mental time in the here and now. How do we manage these thoughts and manage to be more in the present? A thought is created by an internal or external trigger. For example, you are at your clinic and you see one of your staff members walking past really fast. The external trigger of seeing this creates a thought such as my colleague is walking around the clinic really fast. Your thoughts might then continue more consciously: Why is she running around so quickly? Has something happened that I need to be aware of? Has something gone wrong with a patient? Should I call her to ask? These conscious thoughts arising from associa- tions with the initial external trigger thought are the reason we have so many thoughts. To be more efficient with our time, we need to learn to observe associative thoughts arising from these internal and external trigger thoughts and then stay in the present with what we are actually doing, rather than associating and projecting thoughts into the future. Of course, sometimes it is necessary to associate and act, for example in creative brainstorming. It is not about not allowing the mind to associate, but more about being aware of when it is efficient to do so 34 aligners 1 2022

feature | “Time management requires self-discipline, self-mastery, and self-control more than anything else.” Brian Tracy Image: Cherry blossom/Shutterstock. and when not. Tip: mindfulness is a great technique, teaching us to be more in the present, and there are great online courses to help you on this journey. Prioritising appropriately is another aspect of time man- agement that can be challenging. In a coaching or train- ing session, I ask participants to identify three tasks they will commit to finishing in the next two weeks. I then ask them whether these tasks are urgent, and often they say they are. I ask them how long these tasks have been on their to-do lists. Sometimes, these tasks have been on a list for a day, a few days, a few weeks or a few months. How can something be urgent if it has been on a to-do list for days or weeks? I consider urgent tasks those re- quiring attention in the next 24 hours. When people regard something as urgent, they abandon their planning and current tasks to focus on that urgent thing. Often, important tasks are identified as urgent tasks. Impor- tance refers to the value of a task and urgency to its time frame. Eisenhower’s matrix provides a framework for dis- tinguishing between urgent tasks and important tasks and for deciding which actions to take: do now, schedule for later, delegate (this can be in all directions, not only top-down, and means that the task needs to be done now but not necessarily by you) and eliminate (some- times no is also an answer, depending on the context; Fig. 1). You can apply this model to many areas: planning your day, dealing with emails and phone calls, and treat- Fig. 1: Eisenhower’s matrix for task management. Image: AkuZone/Shutterstock. ing interruptions. Regarding the last, if something is im- portant and urgent, of course interruptions are permissi- ble; however, if the matter could be conveyed in an email or spoken about over lunch, you could communicate that preference. Tip: when someone asks you to do some- thing urgent, ask him or her by when he or she needs it done at the latest so that you understand what is meant with “urgent”, allowing you to rearrange your planning if necessary. aligners 1 2022 35

| feature another, and at the end of the day, they feel that they have been communicating with everybody and nobody, but did not get to do their real work. To address this, it is a good idea to create a clear commu- nication tools etiquette that defines the order of importance and urgency and a framework setting out what tools or apps are to be used for what kinds of commu- nication and how often these tools or apps are to be checked. For example, patients can make appointments via phone or via an online appointment tool but not via social media. Your social media channels are checked once or twice a day for a maximum of 30 minutes, to read and answer any questions, and then these apps are switched off. Emails are checked three times a day (in the morning, around lunchtime and before the end of the workday) for a maximum of 30–45 minutes per session, and then the email app is switched off, including auto- matic notifications of new emails. This way, emails will be given focused attention and be responded to within 3 hours, and when the app is closed, we will be focused on other tasks. Tip: have an open group discussion with your team and ask them to help define a commu- nication etiquette for all the different communication tools and apps and how you will respect that within your team and communicate with your patients. As you can see, time management has application to so many different areas, and of course, there are many more tips and insights to be shared. If you would like to know more about it, search online, follow an online webinar, read a book, book a training session for you and your team (I am available to do this online with you if you would like to), keep talking with your team about improving pro- cedures, collaboration, etc. Time management is an ongoing journey, and either we feel like victims of time, unable to control it or manage it, or we start mastering time, having it work for us instead of against us. Time management involves self-management. The excuse of not having time to do a certain task is never about not having time; it is about not making that task a priority. By making excuses, we are victims of time; by prioritising, we take responsibility for our choices, and that of course is always the preferred pathway. Enjoy your journey of discovering self-management in the context of time management as well. Reference: 1 Eckhart Tolle. The power of now. New World Library. 2004. 236 p. Image: Maslowski/Shutterstock. Multitasking—everybody wants to do it, but it is an illu- sion; we cannot multitask, not even women can, even though we often hear that they can. Our brain cannot do two things at the same time with the same level of atten- tion and quality. If you are talking to a colleague while checking your emails, your brain focuses on the conver- sation and then moves the focus to your emails, meaning that you cannot focus on both at the same time and you cannot be efficient in either task. We might think that we are multitasking, but we are actually task-hopping, focus- ing on one task and then on another and then another and then coming back to the first task. People who really can uni-task, meaning start and finish the task at hand before starting and finishing another, will be more efficient in what they do. Do a little experiment to see this for your- self. Ask your team to play along in a meeting by doing the following task: first ask them to write on a piece of paper the word “multitasking” and below it the numbers “1”, “2”, “3”, “4”, “5”, “6”, “7”, “8”, “9”, “10”, “11” and “12” on one line. Time them. Then have them mix both lines: “M 1”, “U 2”, “L 3”, “T 4”, “I 5”… and time this. You will see that the second task will take longer. The first exercise employs uni-tasking and the second multitasking. Tip: learn a new behavioural habit of starting and finishing something in a single stretch, rather than jumping from one to another unfinished task. The more communication tools and apps—emails, phone, social media, Zoom, Microsoft Teams, online chat apps, WhatsApp, intranet—we have available to use, the more confused and lost we get. This is contrary to what one might expect, since all these should make life easier. People can contact us in many ways, and since all com- munication can come in simultaneously and all commu- nication tools and apps can be open simultaneously for use, it has become unclear which communication to answer first. With all their communication tools and apps open at the same time, people jump from one app to 36 aligners 1 2022

feature | ADVANCED CLEAR ALIGNER SYSTEM FOR ORTHODONTISTS MORE CONTROL AND FLEXIBILITY FOR PREDICTABLE TREATMENT PLANNING With clinical experience from trusted doctors around the world, SPARK has created an advanced clear aligner system that is designed to meet the needs of the orthodontists. From Ormco, where your practice is our priority. To find out more, go to: ormcoeurope.com Approver Software featuring CBCT integration for more predictability. 19% better contact with the tooth for precise tooth movement. TruGEN™ material with higher sustained force retention.* More clear, more comfortable, stains less.* “The combination of Material and Soft- ware helped me to reduce the need for refinements by 20%.” Dr. Iván Malagón, Spain ormcoeurope.com *Data on file. aligners 1 2022 37

| business news Image: Alexandr Grant/Shutterstock. In 2021, clear aligner sales helped dental markets to recover from office closures in the previous year. Clear aligners: the star of 2021 Jeremy Booth, Dental Tribune International Last year, clear aligner therapy provided dentists around the world with an attractive income stream even as patient volumes remained sluggish. Indeed, major dental compa- nies increased investment in their clear aligner portfolios during the year and some did so while divesting other parts of their businesses. Record case shipments were recorded, and the continued development of clear aligner therapy supported the maturing and further adoption of digital workflows and spurred new innovations in treat- ment planning. It is therefore fair to say that clear aligners did more than simply straightening of teeth in dentistry in 2021. Dental markets proved their resilience in 2021, and clear aligners helped them to virtually claw themselves back to pre-pandemic levels of sales and oral care provision. If we consider the newest and most cutting-edge areas of dentistry—such as fully digital workflows and 3D print- ing—we find clear aligner therapy at centre stage. For example, a recent study led by researchers at Semmel- weis University in Budapest found that the field of ortho- dontics accounted for the second most common use of 3D printers in dental settings. Dental manufacturers churned out more software updates during the year that further integrated intra-oral scanners and clear aligner systems into orthodontic practice, and the popularity of clear aligners helped to achieve a broader acceptance of teledentistry among consumers, insurance providers, and dental boards and associations. Let us take a closer look at the performance and business activities of the major clear aligner manufacturers in order to better understand just how—in the words of Align Technology CEO Joseph Hogan—“digital orthodontics presents the fastest growing and largest market in the world of medical devices”. Envista gains new intra-oral scanning port- folio, targets high growth areas Major dental brand owner Envista Holdings announced in late 2021 that its acquisition of Carestream Dental’s intra-oral scanner business was expected to close in the first half of this year. Amir Aghdaei, CEO of Envista, told investors in February that the company’s long-term strat- egy was to support dentists as they increasingly digitise 38 aligners 1 2022

business news | their workflows. Intra-oral scanners, he said, were a “crit- ical first step to many high-value specialty dental proce- dures, including implant surgical guides, prosthetics and clear aligner treatments”. Envista grew to beyond pre-pandemic levels in 2021, helped along by a stronger focus on faster-growth and higher-margin specialty products and technologies, of which its orthodontic business is a key part. Although hedging its bets on a mixture of fixed appliance and clear aligner therapies, the company’s clinician-led clear aligner system, Spark, reached US$100 million (88.6 million) in sales in November and its 100,000th patient. Responding to a question about Envista’s focus after the Carestream acquisition, Aghdaei said that offering differ- entiated solutions to patients through an integration of its portfolio was key. “Look at the orthodontic space,” he commented. “[We] see this combination of bracket and wire as well as clear aligner offer significant opportunity for us to become a lot more digitally capable.” He ex- plained that, in 2022, Envista would continue to ramp up its Spark offering. “In order to do that, we want to create an open platform that we can integrate other capabili- ties, other software tools, other [artificial intelligence] tools [into], so we can give people choices,” he said. Align Technology ships more trays than ever before With consistently high sales volumes throughout the pan- demic, Align has shown the world that clear aligner ther- apy can stand the test of difficult times. The company shipped 2.5 million Invisalign cases in 2021, a year-over- year increase of 54.8%, and aligners earned the company a record US$3.2 billion (2.82 billion) during the year. With German software developer exocad now under its wing, the Invisalign manufacturer has evolved into one of the largest digital dentistry providers with its Align digital platform—consisting of software, hardware and services that support clear aligner therapy and restorative dentistry. The company believes that new innovations in its digi- tal platform will revolutionise orthodontics and restorative care by providing dentists with access to real-time treat- ment planning and modification capabilities, as well as with greater flexibility and more accuracy in treating mal- occlusion. Hogan said in February: “It’s through the con- vergence of advancements in digital technology, Align’s unique capabilities and know-how, and data from millions of Invisalign patients that we are able to bring these new Invisalign innovations to our customers this year.” A cornerstone of Align’s digital platform is the iTero intra- oral scanner, which, together with Invisalign, has has- tened the adoption of digital workflows among dentists around the world. In 2021, Align nearly doubled its reve- nue for imaging systems and CAD/CAM services, reach- ing US$705.5 million, and the vast majority of Invisalign case starts in the fourth quarter were submitted via an intra-oral scan: 85.4% worldwide and 89.1% in the Amer- icas, up from 84.0% in the comparable period in 2020. Straumann says nearly 90% of clear aligner case starts come from intra-oral scans Global player Straumann Group’s orthodontic portfolio features both direct-to-consumer (D2C) and business- to-business (B2B) clear aligner systems and no fixed appliances. Despite this, orthodontics was the fastest-growing business segment at Straumann in the fourth quarter, and it was helped along by the new clear aligner material ClearQuartz and the updated software ClearPilot 2.0. Responding to a question during a call with analysts in February, CEO Guillaume Daniellot said he did not see a lack of fixed orthodontic appliances in the portfolio as a disadvantage; he pointed to the example of Align, which does not sell these either and yet is the market leader in the general dentist and specialist segments. “It’s more about investing significantly in our capacity on the soft- ware capability of clinicians,” he said. Daniellot explained that Straumann had “significantly invested in new software development in 2020 where new features are now available in order to increase treatment capabilities. On top of that, our scanners now integrate with our orthodontic software, driving convenience and efficiency at the clinician side”. The adoption of intra-oral scanners into digital orthodontic workflows among Straumann customers had been rapid, and close to 90% of all clear aligner case starts are submitted digitally by clinicians, he added. Straumann’s clear aligner solutions showed high double- digit growth through last year, and Chief Financial Officer Dr Peter Hackel added that dentist-led D2C sales had been higher than those from the B2B segment. Straumann sells the DrSmile and Smile systems directly to consumers (Smile to those in Latin America) and the ClearCorrect brand directly to dentists. Dentsply Sirona says clear aligners are an essential part of its digital strategy US-based company Dentsply Sirona has been one of the most outspoken among major dental companies on the topic of digitisation in dentistry. Like Straumann, the company offers D2C and B2B clear aligner systems, and it said in February that aligner sales had boosted its fourth-quarter result, together with sales of dental aligners 1 2022 39

| business news implants and CAD/CAM tech- nologies. Organic sales from those three product seg- ments experienced double- digit growth in the quarter, and this in turn increased sales of the company’s technology and equipment. “In three years, we scaled our clear aligners from having no presence in this space to a busi- ness that generated US$274 million in 2021,” Former Chief Financial Officer Jorge Gomez said. SureSmile, the compa- ny’s B2B brand, grew by 60% during the year and eclipsed US$100 million in annual sales, and its D2C brand, Byte, strug- gled, owing to high competition and COVID-19-related changes in consumer spending. Image: Dmitry Markov152/Shutterstock. A recent study found that the field of orthodontics accounted for the second most common use of 3D printers in dental settings. Speaking about the benefits from the company’s con- siderable investment in equipment and integrated digital workflows, former CEO Donald Casey said: “These di- agnostic capabilities feed into our outstanding treatment planning offerings in four of the essential dental work- flows. Those areas include implants, clear aligners, resto- rations and endodontics.” He added that “dentists [were] looking to add more sophisticated diagnostic tools that will allow them to incorporate more complex procedures like implants and clear aligners to the practices”. Casey said: “Clear aligners are an essential part of our digital strategy and increase our exposure to one of the fastest-growing areas in dentistry.” SmileDirectClub suffers pandemic head- winds, increases focus on technology Leading provider of D2C clear aligners SmileDirectClub (SDC) struggled in 2021, but managed to finish the year with revenues that were down just 2.9% compared with 2020. The company appeared to have missed out on the economic immunity to COVID-19 that seemed to have been afforded to other clear aligner manufacturers, owing to the financial effects of the pandemic on its target demographic. “The increased cost of non-discretionary goods and ser- vices is likely limiting the ability to spend on discretionary goods and services,” CEO David Katzman said in De- cember, noting that inflation had accelerated during the second quarter of 2021 and was having a higher relative impact on those with lower incomes. The macroeconom- ic headwinds caused the company to “move upstream” to attract customers from higher income brackets. By default, this meant that SDC is now challenging mar- ket leader Invisalign in what Katzman said was a natural progression—“going from a disruptor to a challenger”— actively competing against Align and increasingly selling aligners directly to dentists. In a phone call with analysts in March, Katzman said that the company was continuing to invest in technology that supported its remote service, including its new SmileOS artificial intelligence-driven treatment planning software. He said that the software delivers better treatment out- comes, predicts tooth movement with greater accuracy and would “help our network of doctors treat a broader range of patients”. In February, SDC announced a new partnership with Carestream Dental which will see the latter’s intra-oral scanners used in SDC’s flagship SmileShops and partner network locations. When it comes to the benefits of offering clear aligner therapy in dental clinics, SDC’s chief clinical officer, Dr Jeffrey Sulitzer, says that dentists are not known to overlook a strong sales proposition. Speaking to Bloomberg about the company’s B2B offering, which it rolled out shortly before the COVID-19 pandemic, Dr Sulitzer stated that “orthodontists and dentists do what is in the best interests of their practices. When there is a good business opportunity, they will take advantage of it”. 40 aligners 1 2022

| research Image: M. Escobar/Shutterstock. 4D-printed clear aligners found to show promise Jeremy Booth, Dental Tribune International A study led by researchers at the University Hospital Bonn has found that 4D-printed orthodontic clear align- ers can apply biocompatible orthodontic forces in order to move teeth. The technology of 4D printing is based on the 3D printing of shape memory materials. The 4D aligners are clear aligner trays that are 3D-printed using shape memory polymers (SMPs), and the implica- tions of this novel material in clear aligner therapy could include reducing the cost of treatment and its burden on the environment. for both patients and manufacturers, the use of succes- sive plastic clear aligner trays also carries with it ethical concerns related to the environment. Various studies have examined applications for SMPs in medical materials, including for orthodontic applications. The researchers, however, sought to add to what they perceived was a lack of data in the literature concerning SMPs and tooth movement, by measuring the forces generated by the 4D aligners and thereby, their suitability in the treatment of malocclusion. Clear aligner trays are made of various types of polymers and are typically designed to move a tooth within the range of 0.2 to 0.3 mm—or to rotate it by 1° to 3°—before being replaced by successor trays. As the authors of the study point out, this stepwise treat- ment model requires more time and a higher cost for ma- terials than treatment using fewer trays would. Naturally, The researchers, from dental faculties in Germany, Egypt and the UAE, used a biomechanical system in order to use forces to correct the malposition of a maxillary central incisor (tooth 21), in a custom-made typodont model using 4D-printed aligners. The generated forces were measured at different temperatures, and the clear aligner trays were made of ClearX v.1.1 material in the two thick- nesses 0.8 mm and 1.0 mm. The forces delivered were 42 aligners 1 2022

quantified using an orthodontic measurement and simu- lation system (OMSS). factors such as humidity and salivation. They concluded, however, that the 4D aligner was capable of moving teeth using biocompatible orthodontic forces. They found that the 4D-printed aligners were capable of achieving significant tooth movement within the range of 2.5 ± 0.5 mm, with little variation between the two thick- nesses. In the OMSS simulations, it was found that the range of maximum forces delivered varied according to the different temperatures tested (37°C, 45°C, 55°C), but that they were all within the range of acceptable physio- logical orthodontic forces, as reported by the literature. In contrast to other studies, the researchers found that using a thicker aligner had no effect on the generated force, except at the higher temperature of 55°C. The authors highlighted a number of limitations to the study, such as its focus on the isolated movement of a single tooth and not on a complex clinical case, and the fact that it did not account for intra-oral conditions and They wrote: “Although orthodontic aligners have been studied in several aspects and great progress was done in orthodontic treatment by aligners, practitioners still report some drawbacks to aligner use.” They explained that these drawbacks included the limited movement achieved by single aligner trays, which necessitated changing regimes. They concluded: “Therefore, we believe that if a method could be applied to decrease the number of the aligners per treatment, together with a method to accelerate the biological movement of the teeth, that would be a quantum leap in the field of ortho- dontics.” The study, titled “Potential application of 4D technology in fabrication of orthodontic aligners”, was published online on 28 January 2022 in Frontiers in Materials. research | AD shop.dmu.dental Watch the Video! aligners 1 2022 43

| industry news Making aligners digitally, the K and B way using 3D printing Kristen Benitez, US K and B Orthodontics is a small orthodontic laboratory located in Norwalk in Connecticut in the US. I co-own the laboratory with my mother, Jane Hyatt, who opened it in December 1997. In December 2017, the dental field was rapidly moving towards a digital approach and the labo- ratory’s analogue techniques were starting to lose ground. Around the same time, I was looking to move into something new, so we decided to work together and transition the laboratory to digital with me as the new digital dental technician. To do that, we would need to identify and invest in software and digital equipment, specifically a 3D printer. After much research, we narrowed the selection down and saw the software and equipment up close at LMT LAB DAY Chicago in the US prior to making our final de- cision. We had a clear list of requirements for our pur- chase. There was little point in investing in equipment purely based on what was the cheapest. If the output was inaccurate, inconsistent or unstable, it would have a direct impact on our day-to-day production, which even in the analogue world is essential to maintain. If our models were not accurate, then our work would not be either, and if the printer was unstable, then we would quickly lose clients. The printer also needed to be capable of producing a certain number of models per day and be priced within our budget. With all these considerations, we chose the Asiga MAX UV (Fig. 1). Fig. 1: Asiga MAX UV 3D printer. Fig. 2: 3D-printed models in the optiprint model resin in light ivory. Only six months after purchasing our first 3D printer, work started to pick up, so a second printer was needed. There was no hesitation in selecting a second MAX UV. The demand for our digital services continued to grow, and in June 2020, we purchased our third Asiga MAX UV. Our digital growth did not end there. Once dental offices started to open again after the COVID-19 lockdowns, they no longer had time to manufacture Essix retainers in- house and turned to us for support. We needed more 3D-printing capacity and purchased two of the PRO 4K80 UV, Asiga’s larger, higher throughput 3D printer. For our laboratory, the demand for clear aligners has ex- ploded. Around 98% of our clients have scanners and the rest send us aligner cases via stone models. In order for us to be able to work on stone models, we scan them ourselves using an E1 desktop scanner (3Shape). We take the scan data, base the model and trim it to create a horseshoe model, which saves both time and material when 3D-printing. We then set the models up for tooth movement using the Ortho Analyzer software (3Shape). During the segmentation process, in which the planned tooth movement is entered into the software, it is ex- tremely important that the anatomy of the tooth is as precise as possible. This precision will give me the most accurate reading when I need to consider interproximal contact points, occlusion and the anatomy of the tooth to be moved. The last step that needs to be considered before I can even start moving teeth is each root place- ment. This will allow for the software to know how each tooth needs to move in relation to its root direction. Straightening of the patient’s teeth can then begin. 44 aligners 1 2022

industry news | Fig. 3: The MINISTAR S for vacuum forming. Much of the knowledge I have gathered over the years regarding aligners has been from hands-on training by our orthodontists. They have taught me what the con- straints are per aligner, how to take into account contact points that are too great, when it is appropriate to have spaces to allow for better movement, and when and how you should place attachments. Whenever I am aligning a patient’s teeth, I always aim to overcorrect the problem area. What I have found over the years of working with aligners is that when you think it is perfect the final result will not be that way. Therefore, an overcorrection will help ensure that ideal alignment will be achieved. The first thing I check are the contact points. There is no point in moving teeth if it will poorly affect the patient’s bite or if there is no room for the teeth to move. The interproximal contacts should be no greater than 0.5 mm. If the contacts are greater, interproximal reduc- tion (IPR) will typically be done or the mouth will be ex- panded to reduce pressure from movement, allowing re- alignment. Virtually, I will go ahead and perform IPR if needed. When performing IPR, the most that should be removed is 0.15 mm per surface, so the most reduction done between two teeth should equate to 0.3 mm in total. You do not want to remove too much, as this will impair the integrity of the tooth. The same careful consideration needs to be given to the opposing teeth as well. I check the bite using the same feature I use to check the interproximal contact points. It is important to make sure that the movements done do not impact the opposing teeth too much. Personally, when working with the inci- sors, I do not want too much contact, so the most I allow is 0.1 mm. To avoid too much contact, I retract or intrude the teeth, or talk with the dentist regarding preparation of the teeth accordingly. When working with molars, the contact points are obviously higher. As I have become more comfortable with aligners, I have started moving premolars and molars. Regarding attachments and when and where to place them, what I have been taught is that if the tooth you are trying to align reaches a value greater than 10 mm, it is best to add an attachment. In most of the cases I have worked on, many issues that I was trying to resolve in- volved de-rotation. It is important to consider where the attachment needs to be placed based on what is needed. It is important that pressure is applied by the attachment to aid movement in the desired direction. Once I have realigned the teeth, I then specify the number of aligners required. The amount of movement allowed per aligner is 0.3–0.4 mm. It is at this stage that I send my ClinCheck treatment plan (Invisalign, Align Technology) to the dentist for approval before I can start the produc- tion of aligners. Once the treatment has been approved, we set up the 3D-printing process. This starts with loading the final models into the 3D-printing software, which provides automatic placement and positioning. Once all the models are in place, we transfer this data to the PRO 4K80 UV. Our workflow benefits from printing as many models as possible, as this saves time and costs. aligners 1 2022 45

| industry news If a patient has undercuts, it is important to block out those areas. We have had many offices ask us what we use to prevent the aligner from breaking when removing it from the model. Compound 101 (Great Lakes Dental Technologies) has worked well. While there are other ma- terials to use, Compound 101 does the trick and does it fast. The putty fits into the undercuts, but comes off the models nicely, leaving them pristine for delivery. I apply the needed block-out prior to vacuum forming. The piece of equipment I use for vacuum forming is the MINISTAR S (SCHEU-DENTAL; Fig. 3). The pressurised vacuum allows for a more accurate fit. Each aligner is cut out using a saw and handpiece. In order to scallop each aligner, I use a composite bur from Komet. Lastly, I use a fine Scotch-Brite disc to polish the aligner edges (Fig. 4). Once all the aligners have been fabricated, polished, and cleaned, it is time for packaging (Fig. 5). The great thing about being local and having 3D printers that can handle the volume of our work is that we are able to provide a much quicker service than any of our com- petitor laboratories. Additionally, offices like to use us because we can provide quality work in a quick time frame without the large laboratory fees. This allows for our clients to provide more affordable treatment to their patients. In summary, the advice I would give to any laboratory trying to build its business is to take your time growing. Do not try to bite off more than you can chew. We made the decision to buy all our equipment slowly and when we could afford it. Always keep an eye on new technologies and pending developments in the dental field. The indus- try is continuously changing. It is important to know what those changes are and how to stay ahead of them. That also means that you should work with the best-quality equipment and materials. If you take shortcuts, your work will reflect that. Lastly, make sure you love what you do, because at the end of the day, it makes it all worth it. Fig. 4: Polishing the aligner edges with a fine Scotch-Brite disc. For the past two years, our laboratory has been using the optiprint model resin in light ivory (dentona) for 3D print- ing (Fig. 2). We prefer the ivory colour because the detail visibility is greater than with a white resin, for example. This colour is also closer to that of stone models, which are still part of our workflow for some clients. The 3D- printing time is reduced by printing the models at a layer thickness of 0.1 mm. This resolution provides a nice balance of detail definition, accuracy and print speed. After all the models have been printed, they are cleaned and processed. We process all parts through a pre-wash and then a post-wash of isopropanol, and once dry we polymerise them in a photopolymerising chamber for 6 minutes per batch. For all our aligner material, we use Zendura FLX, which is 0.3 gauge. This material is very flexible and truly works wonderfully for moving teeth. All of our clients are happy with the tracking of each case, and patients say that the trays are very comfortable. Zendura makes a specific at- tachment template that we use when the patient needs attachments placed. Fig. 5: Aligner ready to be sent off. 46 aligners 1 2022

| industry report Image: Orthosnap. Cast mould clear aligners: Orthosnap upends market with greater precision, lower cost Jeremy Booth, Dental Tribune international Digital is undoubtedly the current buzzword in the field of orthodontics, but what if digitally produced clear aligners were less accurate and more costly compared with those made using cast moulds? According to Orthosnap, using 3D printing to produce clear aligners, undermines the clinical performance of the treatment and even detracts from its greatest selling point, by making aligners more visible when worn. Dental Tribune International (DTI) spoke with Michael Yoon, president and CEO of Orthosnap, who says that dentists should remain critically aware of the strengths and limitations of digital technologies in the treatment of malocclusion. According to Orthosnap, the 3D-printing process intro- duces inaccuracies into clear aligner trays from the bottom up, owing to optical discrepancies and resolution limitations that are inherent in the manufacturing tech- nique. The team at Orthosnap says that these inaccura- cies undermine the predictability of clear aligner treat- ment, and that striations created through the 3D-printing process result in aligners that are less clear. Dr Yan Pogorelsky founded Orthosnap in 2010 in order to address what he saw as shortcomings in the market. The company has since challenged the clear aligner es- tablishment by favouring its own patented cast mould technology over 3D printing in the manufacturing of clear aligner trays. The New York-based company asserts that this results in a dentist-led clear aligner system that offers a tighter fit, better and faster results, and higher revenue for dentists. Yoon, who has a background in engineering and busi- ness and is a long-time friend of Dr Pogorelsky’s, told DTI that Orthosnap’s product is so different from most clear aligner solutions that it can sometimes be daunting to explain it all at once. He said that treatment begins with a polyvinylsiloxane impression that is used to produce a highly accurate mould from diepoxy resin. “If we receive an STL CAD file, we use a hybrid approach, printing only a single model at the highest resolution possible, taking much more time but only having to do it once,” Yoon added. Orthosnap then utilises a dynamic physical model (DPM), a patented process that uses a pin, dowel and sleeve system in order to produce precise tooth movements through specific pins designed for those movements. He commented: “Because we focus on the highest fidelity tooth models, our aligners are very precise and preserve our dentists’ investment of effort in obtaining the highest quality of physical or digital impressions. Our system is capable of full tooth body movement, high predictability of outcomes and fewer attachments.” 48 aligners 1 2022

industry report | Company information states that the use of DPM allows incremental movement of individual teeth in isolation from adjacent teeth and that Orthosnap aligners are accurate to within a few micrometres, whereas commercially 3D-printed aligners have resolution errors of > 100 μm. Yoon explained that Orthosnap’s solution provides advantages for dentists and patients and that the company can offer aligners at up to 40% less than the average market price. This price benefit arises from Orthosnap’s reduced production costs. Yoon explained: “Because we do not consume expensive resins to produce a base model for each step, our costs are lower. We use lean manufacturing principles and produce in batches, which delivers both the economic benefit of distributing the lab cost over time rather than upfront and building in flexibility and adjustments throughout treatment. This pairs very well with digital patient moni- toring systems that provide input into the ongoing treat- ment, in addition to the convenience of reduced visits for both the patient and the provider.” Indeed, Orthosnap is critical of the efficacy of 3D-printed clear aligners, but the company does embrace digital dentistry. Yoon told DTI that digital technology has broad application—particularly in medical fields such as den- tistry—and that dentists should think critically about when and how digital dentistry best applies to dental treatment and the operations of their dental practice. “Preserving the integrity of data for processing is one of the best-use cases for application of digital technol- ogy,” he explained. “For example, recording patient records digitally, electronic communication, online scheduling, electronic payments, digital marketing— these are all great examples of where technology preserves the integrity of data during transfer and processing. Digital manufacturing of aligners has more trade-offs, as it is an expensive process that consumes large amounts of costly resin, takes much more time, and introduces systematic resolution errors that are orders of magnitude greater than the molecular compounds used in a moulding process. So yes, it has a lot of down- sides, and it is important to be aware of these and make thoughtful decisions to balance the pros and cons.” Dentists benefit regardless of case complexity Orthosnap offers its clear aligner system to general den- tists and orthodontists in the US and is currently expand- ing to international markets. Dentists can be trained to use the company’s system in as little as an hour, have access to proprietary treatment software and are free to set their own pricing. The company has received excellent feedback on its clear aligner system from dental practitioners, who have, in turn, received positive feedback from patients on the results of their treatment. Yoon said: “We have grown rapidly in the past few years to serving over 1,400 dentists who love our unique approach, and our dentists love the results. The fit is much better, which leads to more predictable results, reduced chair time and lower costs.” He said that these benefits apply to the treatment of various classes of malocclusion. When it comes to very simple cases, the low cost of Orthosnap trays makes them highly competitive with those of direct-to-consumer clear aligner systems. “Equally, in very complex cases, the accurate fit of our aligners makes movements predictable and able to achieve that which other solutions have difficulty achiev- ing,” he added. According to the company, the benefits of opting for its aligners are clear. Image: Orthosnap. aligners 1 2022 49

| industry report Laser cutting—the future of aligner manufacturing The Laser Aligner Cutter (LAC) brings to the dental market an excellent solution for the production of align- ers with a high-quality finish. Cutting the thermoformed clear aligners with the LAC removes the need for any post-processing, such as polishing, after cutting, saving significant time and labour. The entire process is ex- tremely efficient, taking less than a minute. The LAC im- presses with excellent cutting and edging quality, as the laser cuts the aligner body cleanly and precisely and the sharp edges are rounded off. The LAC has an engraving function, which can be used to inscribe treatment steps. This allows the patient to distinguish between aligners and benefits the specialist during the treatment planning process. The LAC is compatible with all major thermoforming systems and works with any model. It has digital inter- faces to world-leading suppliers. Dental Manufacturing Unit is headquartered in Science City, Salzburg’s business, science and innovation hub. The dental automation specialist company has a team of engineers who have developed a technology platform that is now used in 32 countries. Request a quote today at shop.dmu.dental. contact The Austrian company Dental Manufacturing Unit has designed and manufactured the Laser Aligner Cutter as a three-part system: the laser cutter, the suction unit and the separator. The separator was created to help the specialist to detach the model from the aligner foil in a few seconds. It is compatible with any type of model and material. The suction unit has an important role in making the cutting process clean. Owing to the suction unit, there is no smoke or dust during the workflow. Dental Manufacturing Unit Jakob-Haringer-Straße 8 5020 Salzburg Austria Phone: +43 662 2653 5910 sales@dmu-gmbh.at www.dmu-gmbh.at shop.dmu.dental 50 aligners 1 2022

industry report | J O I N U S AT The 97th Annual Congress of the European Orthodontic Society 30 May to 3 June 2022 | Limassol, Cyprus Techniques may change, the principles remain the same Register at discounted rates by 1 April on eos2022.com Keynote speakers: Andrea Ricci Christos Katsaros Demetrios Halazonetis Dirk Wiechmann Dimitrios Mavreas Domingo Martin Gina Theodoridis Giuliano & Giovanna Maino Gregory Antonarakis Jim Vaden Juan Carlos Perez Nikolaos Pandis Rolf Behrents Ute Schneider-Moser Zoe Nicolaou Varela With thanks to our sponsors Follow us Platinum Sponsor Gold Sponsor #EOSCongress #orthodontics Enquiries: EOScongress@tfilodestar.com aligners 1 2022 51

| industry report Release 12: New Spark clear aligners Ormco Corp. has announced Release 12 of its Spark clear aligners, offering clinical enhancements, product optimisation and case planning improvements to give dentists more flexibility, efficiency and control. These in- clude: • root visualisation using submitted CBCT DICOM files for accurate treatment planning;1 • added posterior bite turbos for premolars and molars to assist with clinical conditions requiring posterior bite opening;1 • wider choice of material with the availability of both TruGEN and TruGEN XR for Spark 10 and Spark 20 to ensure greater precision in finishing;1 and • upgrades to Spark’s Approver software and dentist portal to help optimise planning, treatment and prac- tice communication.1 “The enhancements in Spark Release 12 give orthodon- tists more reasons to choose Spark clear aligners for their practice and their patients,” said Eric Conley, senior vice president and president of digital orthodontics at Envista Holdings. “Spark is proven to perform better than the leading aligner brand, while providing superior clarity and stain resistance.” Customers are excited about the steady stream of in- novations coming from Spark. “Spark aligners are con- sistently outperforming other aligners I have used in the past. Spark’s more predictable tooth movements lead to fewer refinements and shorter treatment times,” said Dr John Warford.4 “Spark is focused on the clinical needs of orthodontists, quickly implementing new innova- tions to provide doctors with an optimal aligner experience.” Root visualisation for accurate treatment planning Eighty-two per cent of Spark dentists agree that root visualisation is a key factor in ensuring predictable tooth movement.2 With Spark Release 12, dentists can now submit DICOM files to the Spark design team to ensure that the roots shown in the Spark Approver software are positioned precisely over the roots in the DICOM files. Dentists can also easily import CBCT scans directly into the Spark Approver software from the website.1 In addition, Spark Release 12 is designed to deliver more comprehensive diagnosis and treatment planning by introducing three new CBCT presets: skin, translucent skin, and bone and soft tissue.1 52 aligners 1 2022 “Spark is the only clear aligner system with the ability to truly have root and bone relationships available. To work in three dimensions for all the anatomy will allow us to deliver the healthiest orthodontic treatment that has ever been done,” said Dr Bill Dischinger.4 Additional clinical enhancements Posterior bite turbos, previously available only for molars, are now available for premolars. This feature will help mitigate molar intrusion while correcting anterior open bite, crossbite or other conditions requiring posterior bite opening. Spark’s posterior bite turbos have been rigor- ously tested and need no bonding or composite filling.1 In addition, bite ramps will now reposition automatically as treatment progresses, to enhance engagement between the bite ramps and teeth throughout treatment.1

industry report | • New support for scanned appliances: The Spark Approver software will display scanned attachments, buttons, fixed retainers and brackets. Once scanned, appliances are displayed in the treatment PDF to dis- tinguish between existing and new attachments during bonding. “I like to keep things simple, and Spark has helped me easily and efficiently correct both anterior open bites and crossbites without additional procedures beyond the aligners,” said Dr Michael DePascale.4 • Spark Approver software performance improvement: An upgraded 3D model features more responsive movements and faster rotation for a more seamless performance. Product optimisation for control and flexibility TruGEN XR, previously only available for refinement cas- es, is now available for primary cases of Spark 10 and Spark 20. TruGEN XR is slightly more rigid and thus presents an ideal solution for finishing, refinement and limited-stage cases.1 TruGEN and TruGEN XR both have more sustained force retention,1 superior stain resistance1 and clarity,1 and bet- ter contact surface area with the tooth than the leading aligner brand.1 “TruGEN XR is my finishing wire in clear aligner therapy,” Dr Dischinger remarked. “With brackets and wires, we like to use stiffer wires for the finishing stages of treat- ment. In clear aligner therapy, we have never had that ability until now. TruGEN XR, with its slightly stiffer prop- erties, gives me the control I’m looking for in finishing the small details of each case.” Spark Approver software and case portal enhance- ments for efficient workflow Seventy-five per cent of Spark dentists agree that Spark’s Approver software provides a better user experience be- cause it is easier and faster to use than the leading align- er brand’s software.3 Release 12 will make it even easier for dentists and their staff to use Spark’s software and case portal and consult with the Spark treatment planning team. The new enhancements include the following:1 • View capture and private dentist notes: Dentists can capture and send specific views of the 3D model in the Spark Approver software, along with their notes, to facilitate communication between dentist and design- er. The Spark Approver software also enables dentists to enter and save private case notes, which provide treatment reminders for improved workflow. • Redesigned auxiliaries panel: A simplified design al- lows dentists to easily add different auxiliaries and change options according to their desired treatment plan. • Detection of potential issues with attachments—new Spark Approver feature: Spark Approver software now provides detailed information when it detects any po- tential issues with attachment collisions or proximity issues with the trim line. “Since I’ve been working with Spark, the brand has shown tremendous dedication to our profession, con- stantly innovating its product based on the feedback and goals of orthodontists. This has given me complete con- trol and customisation of Spark aligners to meet all of my patients’ needs,” said Dr DePascale. Spark aligners are manufactured by Ormco, a global leader in innovative orthodontics products, with 60 years of expertise, research and development, and high man- ufacturing standards. Ormco has helped dentists treat more than 20 million patients in more than 130 countries. 1 Data on file at Ormco. 2 Based on a survey of 67 Spark dentists who have approved 100 or more Spark cases. Data on file. 3 Based on a survey of 61 Spark dentists who have approved 100 or more Spark cases. Data on file. 4 Drs Warford, Dischinger and DePascale are paid consultants for Ormco. The opinions quoted in this material are those of the respective dentist. Clinicians should use their own judgement in treating their patients. contact ormco.com sparkaligners.com media@sparkaligners.com aligners 1 2022 53

| meetings The plenary hall. (Image: Mauro Calvone) The Third European Aligner Society congress in Malta in 2021 proved a great success, as Dr Graham Gardner, past president of the EAS reports It is a pleasure to report back on the European Aligner Society’s first live face-to-face event in over a year and a half. In Malta, the European Aligner Society (EAS) hosted its third international congress, which had had to be postponed several times from the original date in March 2020. There was an air of excitement as companies unpacked their equipment to set up their incredible booths in the exhibition hall and attendees arrived. Colleagues from all over Europe and from various countries around the world were reunited. The Hilton Malta hotel was a fabu- lous backdrop to the congress, which began with a number of workshops on Thursday, 7 October, as a warm-up to the main events due to take place the follow- ing day. Attendees could choose from a variety of sessions hosted by a several of the companies supporting the event, allowing them to enjoy a hands-on experience. The main plenary session started on Friday, 8 October, and continued on Saturday, 9 October. Although the number of attendees was understandably lower than originally hoped for, there were still 221 at- tendees, and there was a palpable atmosphere of ex- 54 aligners 1 2022

meetings | citement as the first session was opened by EAS Presi- dent Dr Alain Souchet and his event organising team, Dr Tommaso Castroflorio, Dr Francesco Garino and EAS CEO Dr Leslie Joffe. The programme aimed at addressing certain aspects of aligner orthodontics, and the morning sessions were dedicated to diagnosis and treatment planning, which obviously transcends any specific aligner system, as this is probably one of the most important steps in successful orthodontic treatment. It was clear from the latest advancements presented at the congress that we now have the facility for 3D treatment planning incorporating CBCT scans and that new software advancements can use this data to generate 3D tooth movement simulations which allow for an even more realistic visualisation of the final tooth position. It is becoming evident that, as this digital ad- vancement evolves, it is allowing us not only to more ac- curately predict crown movement but also to assess root movements. The ability to move the roots to the correct place could contribute to even more successful outcomes in orthodontic treatment with aligners than we originally thought possible. As many clinicians battle with investment in CBCT and its use, it is worth mentioning that, when the lateral cepha- logram was first introduced, most rejected its signifi- cance, and it took a further 20 years before it was widely accepted in orthodontic treatment planning. People are generally resistant to change, and this may be the case with CBCT at present. Radiation exposure for patients always remains a factor to consider. However, the quality of the presentations and the evidence suggested is per- suasive that 3D treatment planning is the next evolution in orthodontics. New horizons are always exciting devel- opments in our wonderful world of orthodontics. The Friday afternoon session and the Saturday session focused on clinical tips to improve predictability in aligner therapy. Presenters discussed practical solutions to the common challenges encountered in aligner orthodontics, and the use of temporary anchor devices (TADs) to enhance predictability was a common theme. TADs not only offer improved anchorage (directly or indirectly) but can also reduce unwanted vectors of force. Of course, correct placement of the TADs is crucial in achieving the desired treatment objectives. Sound biomechanical knowledge of how to achieve the final result influences the placement of TADs, and once again, understanding 3D movement influences TAD placement. Another topic discussed in the presentations was that of correct staging. The advantage of plastic biomechanics is that it allows us to stage movements sequentially, reduce velocities when appropriate and assess anchorage requirements precisely. It was im- pressive to find the envelope being pushed to include Third European Aligner Society Congress committee (from left to right: Dr Leslie Joffe, Dr Jose Gandia, Dr Gina Theodoridis, Dr Francesco Garino, Marco Moschin, Elena Cimenti, Dr Alain Souchet, Dr Tommaso Castroflorio and Dr Graham Gardner). (Image: Mauro Calvone) aligners 1 2022 55

| meetings orthognathic surgery and refreshing to see different aligner systems coming to market and producing excel- lent results. Aligner therapy is now a mainstream approach to suc- cessful orthodontics, and EAS was delighted to an- nounce the introduction of the European Board of Aligner Orthodontics certification for excellence in aligner ortho- dontics. The accreditation process will require five cases to be submitted and presented by the candidate to the accreditation board, as well as an oral exam. Successful completion of these steps will result in prestigious EAS accreditation, confirming excellence in aligner therapy. Details of the process can be found on the EAS website. The welcome return to live events made us realise, more than ever, how much we had missed them. Online meet- ings are great for short presentations but you forget how wonderful a live event is until you are back in an audito- rium sharing the learning experience with other enthusi- astic colleagues and being educated and entertained by the different personalities and presentation styles of our esteemed presenters. Being able to ask questions face to face, interact with the presenters and share ideas with colleagues is a welcome return. To the attendees and companies who made it across to Malta, we thank you for a wonderful few days together and for getting the ball rolling for the return to live events. The European Aligner Society is looking forward to wel- coming attendees to its summer meeting in Oporto in Portugal in July and later to its fourth congress, which will take place in the wonderful city of Turin in Italy on 11–13 May 2023. Dr Graham Gardner, pictured centre, with Dr Francesco Garino (past-president, 2018–2019), left, and Dr Tommaso Castroflorio (president-elect, 2022–2023), right. (Image: Mauro Calvone) 56 aligners 1 2022

| meetings EOS annual congress 2022— techniques may change, but the principles remain the same 30 May to 3 June 2022, Limassol, Cyprus It is my pleasure and honour to invite you to Cyprus, the island of love and the crossroads of three continents, to enjoy the 97th European Orthodontic Society congress, to be held from 30 May to 3 June in the city of Limassol. The congress title is “Techniques may change, but the principles remain the same”. The topics will cover and answer questions on clinical and scientific issues that we face in our everyday practice and will present all the latest advancements in our profession. The keynote speakers are among the best in their field and have been chosen to ensure that the scientific level of the congress will be excellent. By attending the con- gress, you will be able to benefit from: • three days of exceptional scientific sessions and keynote lectures by leading experts; • an exhibition of a wide range of orthodontic and dental products, as well as new technological develop- ments in orthodontics; • a pre-congress course on 31 May: “How to select and use skeletal anchorage for your patients” by Drs Giuliano and Giovanna Maino; • a postgraduate course on 31 May: “Ninety years of cephalometrics. Ready for something new?” by Prof. Demetrios Halazonetis; • over 400 posters, showcasing the latest research on new technologies, multidisciplinary treatment, and a variety of scientific and clinical topics; • a networking programme and cultural and leisure activities to make the most of your stay in Limassol. The congress will be an excellent opportunity to share knowledge, gather new scientific information and learn all about orthodontic advancements. At the same time, you will be able to enjoy the sun, the sea, the culture and the hospitality of Cyprus, and you will have the opportu- nity establish long-lasting collaborations and friendships. It will definitely be an unforgettable experience! 58 aligners 1 2022 We invite you to be a part of it and let your smile shine in Cyprus, the island of love! To register, please visit the website at eos2022.com, and please send enquiries to EOScongress@tfilodestar.com. Dr Chris Laspos, EOS president 2022

REGISTER FOR FREE DT Study Club – e-learning community Xxxxxx | THE GLOBAL DENTAL CE COMMUNITY THE GLOBAL DENTAL CE COMMUNIT Y THE GLOBAL DENTAL CE COMMUNIT Y THE GLOBAL DENTAL CE COMMUNIT Y THE GLOBAL DENTAL CE COMMUNIT Y webinars / live operations / online CE events / CE credits www.dtstudyclub.com @DTStudyClub Tribune Group 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.This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group and Dental Tribune Int. GmbH. 59 aligners 1 2022

| meetings International events American Association of Orthodontists – AAO 21–24 May 2022 Annual Session 2022 Miami Beach, US www2.aaoinfo.org/meetings/ British Orthodontic Society 2022 – BOS 15–17 September 2022 British Orthodontic Conference Birmingham, UK www.bos.org.uk ------------------------------------------------------------- ------------------------------------------------------------- European Orthodontic Society – EOS 31 May–3 June 2022 Annual Congress 2022 Limassol, Cyprus www.eoseurope.org/annual-congress/ German Society of Orthodontists – DGKFO 21–24 September 2022 Annual Meeting Berlin, Germany www.dgkfo.de ------------------------------------------------------------- ------------------------------------------------------------- European Aligner Society – EAS 1–2 July 2022 The 2nd Summer Meeting Porto, Portugal www.eas-aligners.com Italian Society of Orthodontics – SIDO 13–16 October 2022 53rd International Congress Florence, Italy www.sido.it ------------------------------------------------------------- ------------------------------------------------------------- Spanish Society of Orthodontics – SEDO 22–25 June 2022 68th Annual Congress Madrid, Spain www.sedo.es Fédération Française d'Orthodontie – FFO 11–13 November 2022 24es Journées de l’Orthodontie Paris, France www.journees-orthodontie.org/ ------------------------------------------------------------- ------------------------------------------------------------- Canadian Association of Orthodontists – CAO 15–17 September 2022 72nd Annual Conference Saskatoon, Canada www.cao-aco.org/en/events Swiss Orthodontic Society 17–19 November 2022 Annual Congress Interlaken, Switzerland www.swissortho.ch ------------------------------------------------------------- ------------------------------------------------------------- 60 aligners 1 2022

m o c . k c o t s r e t t u h S / s l i e x p 2 3 © submission guidelines | Xxxxxx | How to send us your work Please note that all the textual compo- nents of your submission must be com- bined into one MS Word document. Please do not submit multiple files for each of these items: · · the complete article; all the image (tables, charts, photo- graphs, etc.) captions; the complete list of sources consulted and information the author or contact (biographical sketch, mailing address, e-mail address, etc.) · · images must not be In addition, embedded into the MS Word document. All images must be submitted separately, and details about such submission follow below under image requirements. Text length Article lengths can vary greatly—from 1,500 to 5,500 words—depending on the subject matter. Our approach is that if you need more or fewer words to do the topic justice, then please make the article as long or as short as necessary. We can run an unusually long article in multiple parts, but this usually entails a topic for which each part can stand alone because it contains so much information. In short, we do not want to limit you in terms of article length, so please use the word count above as a general guideline and if you have specific questions, please do not hesitate to contact us. Text formatting We also ask that you forego any special formatting beyond the use of italics and boldface. If you would like to empha- sise certain words within the text, please only use italics (do not use underlining or a larger font size). Boldface is reserved for article headers. Please do not use underlining. Please use single spacing and make sure that the text is left justified. Please do not centre text on the page. Do not indent paragraphs, rather place a blank line be- tween paragraphs. Please do not add tab stops. Should you require a special layout, please let the word processing pro- gramme you are using help you do this formatting automatically. Similarly, should you need to make a list, or add footnotes or endnotes, please let the word process- ing programme do it for you automatically. There are menus in every programme that will enable you to do so. The fact is that no matter how carefully done, errors can creep in when you try to number footnotes yourself. Any formatting contrary to stated above will require us to remove such format- ting before layout, which is very time- consuming. Please consider this when formatting your document. Larger image files are always better, and those approximately the size of 1 MB are best. Thus, do not size large image files down to meet our require- ments but send us the largest files avail- able. (The larger the starting image is in terms of bytes, the more leeway the designer has for resizing the image in order to fill up more space should there be room available.) that Also, please remember images must not be embedded into the body of the article submitted. Images must be submitted separately to the textual sub- mission. You may submit images via e-mail, via www.wetransfer.com or Dropbox directly to us. Please also send us a head shot of yourself that is in accordance with the requirements stated above so that it can be printed with your article. Image requirements Abstracts Please number images consecutively throughout the article by using a new number for each image. If it is imperative that certain images are grouped together, then use lowercase letters to designate these in a group (for example, 2a, 2b, 2c). Please place image references in your article wherever they are appropriate, whether in the middle or at the end of a sentence. If you do not directly refer to the image, place the reference at the end of the sentence to which it relates enclosed within brackets and before the period. An abstract of your article is not re- quired. Author or contact information The author’s contact information and a head shot of the author are included at the end of every article. Please note the exact information you would like to appear in this section and format it according to the requirements stated above. A short biographical sketch may precede the contact information if you provide us with the necessary informa- tion (60 words or less). In addition, please note: · We require images in TIF or JPEG for- Questions? mat. · These images must be no smaller than 6 × 6 cm in size at 300 DPI. Please contact Nathalie Schüller at n.schueller@dental-tribune.com. · These image files must be no smaller than 80 KB in size (or they will print the size of a postage stamp!). aligners 1 2022 61

| international imprint aligners international magazine of aligner orthodontics Imprint Publisher and Chief Executive Officer Torsten R. Oemus International Office Dental Tribune International GmbH Holbeinstraße 29 04229 Leipzig Germany Phone: +49 341 4847 4302 Fax: +49 341 4847 4173 General requests: info@dental-tribune.com Sales requests: mediasales@dental-tribune.com www.dental-tribune.com Sign up for the free newsletter by scanning the QR code and receive the latest news on aligners, as well as the digital version of the magazine. For print copies and subscription, please contact: info@dental-tribune.com. Chief Financial Officer Dan Wunderlich Chief Content Officer Claudia Duschek Managing Editor Nathalie Schüller n.schueller@dental-tribune.com Contributing editor Jeremy Booth Scientiﬁc Advisor Dr Carlo Fornaini Project Manager Melissa Brown Designer Ranef – mail@ralph-schueller.com Copy Editors Sabrina Raaff Ann-Katrin Paulick Executive Producer Gernot Meyer Advertising Disposition Marius Mezger Copyright Regulations All rights reserved. © 2022 Dental Tribune International GmbH. Reproduction in any manner in any language, in whole or in part, without the prior written permission of Dental Tribune International GmbH is expressly prohibited. Dental Tribune International GmbH makes every effort to report clinical information and manufacturers’ product news accurately but cannot assume responsibility for the validity of product claims or for typographical errors. The publisher also does not assume responsibility for product names, claims or statements made by advertisers. Opinions expressed by authors are their own and may not reflect those of Dental Tribune International GmbH. 62 aligners 1 2022

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