issn 1868-3207 • Vol. 6 • Issue 1/2021 ortho international magazine of orthodontics 1/21 case report Post-orthodontic restorative approach for young patients with missing anterior teeth: No-preparation and ultra-conservative techniques feature Recognising and avoiding negative stress and burn-out technique Inspired by the Maya—skull and tooth reconstruction with 3D printing

editorial | Prof. Mauro Labanca Prof. Mauro Labanca is an oral surgeon and the registrar of the European section and a councillor of the International College of Dentists. Per aspera ad astra We are unquestionably living in a difficult, complex time that will enter the history books. We are fortunate to be the first generation not to have experienced a major war, but instead we are living another kind of trauma through this pandemic. Too many words have been said and are being said, far too many, about what is happening. This verbal re- dundancy confuses, annihilates, saddens and adds despondency to what the pandemic is causing. If some of us have been affected, directly or indirectly, by the virus and disease, we all have certainly been affected by the media pressure bombarding us daily, adding a collective insecurity and depression that our psychiat- ric colleagues are struggling to manage. I believe that in order to stem this situation, we can and therefore must look for positive aspects that, even if difficult to imagine, can be considered in this period, when we are all being tested as humans. That our profession (especially the private segment) is among those that have only had to close temporarily and, when compared with others, has certainly not suf- fered as much financially; this is a primary aspect that should make us feel privileged and more positive than those who have really lost everything. As an international speaker, accustomed to lecturing around the world, I found myself returning to full-time dental practice, what I studied for. And now, with no meetings (if not virtual), interminable business dinners or even congresses, at times frankly useless, it has given me the opportunity to slow down, take a breath and look around. Looking around, I believe, is the most im- portant thing this pandemic has given us besides the physical suffering it has caused. Why not use this imposed professional slowdown to do something else? Why not use this moment, in which we maybe have fewer patients, to reorganise our practice, to review protocols, to check that our staff are adequately trained and informed, to learn whether we can do some- thing to improve the services we offer and be more pre- pared when things return to “normal”? We could use this time to organise our patients’ files, to concentrate on our continuing education (notwithstand- ing the continuing education required by law), to engage more with our team, to think about how to communicate to our patients that we have used this time to grow, to improve, to change, because in difficult moments we grow, and those who do not know how to grow succumb. We miss live events—there is no doubt—but above all, we miss the convivial aspect of these events. The scien- tific aspect can easily be found by reading a book or a scientific journal, or following a webinar (provided it is of quality). Finally, why not use these quiet evenings spent at home to perhaps improve your English, to read a novel, to rediscover the value of emotions, because we are forced to slow down the crazy rhythm, often not justified, that most of us experience in normal times? I hope that the SARS-CoV-2-wreaked havoc will be stopped as soon as possible, but even more so, I hope that when the virus is overcome, a better world will remain, more sensitive, more attentive, more aware of what true life values are—and then we could really say that, through hardship, we have reached the stars. Prof. Mauro Labanca Editorial note: This editorial was published as well in the Italian edition of implants—international magazine of oral implantology, volume 10, issue 1/2021. ortho 1 2021 03

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case report | Fig. 1a: Missing or impacted canines. The best option is space maintenance or opening with implant-supported restorations. During surgery, proper soft-tissue anatomy will need to be re- established. Fig. 2a: A 21-year-old patient completed orthodontic space opening after extraction of impacted canines. Fig. 2b: Intra-op views showing extreme bone defects extending all the way to the palate, which necessitated extensive guided bone regeneration. Implants were placed in a second phase (stepped approach). Fig. 1b: Missing lateral incisor. Space closure is a frequent treat- ment option and results in the following anatomical and aesthetic discrepancies: excessive canine coronal and cervical diameters (blue arrow), a deficient canine incisal profile (circle), an apically displaced gingival zenith (red arrow) and a premolar that is too short, both cervically and incisally (red and brown arrows). Fig. 2c: Zirconia abutments in place. Fig. 2d: Post-op view showing good gingival and anatomical inte- gration. Space opening and implant-supported restorations are nowadays the most appropriate therapeutic option. Fig. 1c: Missing central incisor. Space closure is less frequent- ly chosen. If it is, it will result in the following anatomical and aesthetic discrepancies: a lateral incisor that is too narrow and short, both cervically and incisally (red, blue and brown arrows), flat mesial and distal papillae around the lateral incisor (circles), and a canine and premolar with the same deficiencies as de- scribed for the space closure for a missing lateral. clude an orthodontic correction of the Class II relation- ship. It should be stressed that, in any clinical situation, a trial diagnostic set-up is mandatory for anticipating the influence of orthodontic treatment on occlusal, periodon- tal and dental conditions. Figures 1a to c depicts the most common clinical problems and their possible restorative solutions, after orthodontic space closure. Space maintenance or opening Depending on the occlusal conditions and particularly on the patient’s age at the time of treatment planning, the al- ternative option to orthodontic space closure is space maintenance or opening, followed by prosthetic replace- ment of the missing teeth. The three major treatment ortho 1 2021 07

case report | Figs. 3d & e: Post-op views after full smile enhancement using freehand direct bonding following the natural layering concept (inspiro, Edelweiss DR). Central incisors were restored mainly with a single layer of achromatic enamel. Note that the gingival profile correction shown in Figure 3a was not performed owing to the young age of the patient and limited gingival display (low lip line). options for anterior tooth replacement are implant- supported crowns (Figs. 2a–d), metal-based or all- ceramic adhesive bridges and removable dentures, which are mostly considered for provisionalisation, espe- cially in young patients when definitive treatment has to be postponed. Because implants will not follow alveolar bone growth, fixture placement should not be used in young patients until full jaw growth has been attained, from 18 to 25 years of age and even later.9, 10 Ultra-conservative restorative procedures after space closure The anatomical and aesthetic anomalies that result from spontaneous space closure or orthodontic procedures may be corrected by choosing the appropriate restorative modalities, often involving a multidisciplinary approach (Figs. 3 & 4)2. Recontouring Recontouring or odontoplasty may be performed during or after orthodontic treatment. For instance, when canines have to be moved into the positions of the lateral incisors, there is usually a space discrepancy. In this sit- uation, the careful reduction of canine diameter and palatal volume will improve the inter-arch relationship as well as reconstructive procedures (Figs. 4a & b). The ratio of the root diameter to the crown diameter will dictate the amount of tissue that can be removed interproximally, provided that corrections can be made entirely in enamel to avoid dentine exposition or root proximity. Whitening A problem of tooth colour often arises when the canines are in a more mesial position. These teeth present with a more saturated colour (normally, a similar hue but a higher chroma) compared with that of incisors (Figs. 3a & c). After the required odontoplasty has been performed, colour correction should be tried, using one of the available whitening techniques for vital teeth, namely chairside whitening or home whitening.6–8 Direct composite bonding Modern composite resin kits provide very performant re- storative materials. Besides the dramatic improvements made in their physico-chemical properties, modern com- posites have satisfactory colour stability and aesthetic potential.11–13 Among the various layering options, the which became the reference in reliability and simplicity is the natural layering concept, which corresponds to a bilaminar, anatomical application of dentine- and enamel- like shades which closely emulate natural hard tissue. ortho 1 2021 09

case report | When forms or dimensions have to be only slightly mod- ified, a mono-laminar approach can be followed, using an enamel shade (achromatic) exclusively (Figs. 3a & d). For larger corrections, the bilaminar approach with dentine and enamel masses is to be applied (Figs. 3d & 4d–f; e.g. inspiro, Edelweiss DR). Gingival and periodontal recontouring In many circumstances, gingival recontouring is indicated to correct minor defects of soft-tissue contours or to modify the clinical crown length. This can be achieved using electrosurgery, laser or traditional surgery (Fig. 4b), provided the procedures respect the biological width and do not result in an excessive loss of keratinised gingiva. Conclusion The two basic therapeutic approaches for the replace- ment of anterior teeth in young patients are space closure or maintenance, which require orthodontic or prostho- dontic procedures, respectively, to be applied. To satisfy new demands regarding tissue conservation, function and aesthetics, treatment decision parameters have to be redefined. An extended list of general, local and sec- ondary parameters have now to be taken into consider- ation to propose the best available solution to the patient. The most common problems after teeth have been or- thodontically transposed are unusual function, shape, di- mension and colour or deficient periodontal integration while with prosthetically replaced missing teeth, long- term maintenance will be critical, including implant- supported restorations. This article has also presented clinical outcomes demonstrating the benefits and posi- tive impact of direct composite application to improve aesthetics and function after orthodontic space closure. Editorial note: This article was first published in the September 2016 issue of the Italian Journal of Dental Medicine, and an edited version is provided here with permission from “il dentista moderno”. about Dr Didier Dietschi is a senior lecturer in the Division of Cariology and Endodontology of the section of dental medicine at the University of Geneva in Switzerland and an adjunct professor in the Department of Comprehensive Care at Case Western Reserve Univer- sity School of Dental Medicine in Cleveland in the US. He also runs a private education centre in Switzerland and is in private practice at the Geneva Smile Center. References: 1 Meng HP, Ingervall B, Hess D, Marmy O, Buser D. Kieferorthopädie: Nichtanlagen. Die Behandlungs- planung von Malokklusionen mit partieller Anodontie [Orthodontics: the absence of tooth primordium: treatment planning of malocclusions with partial anodontia]. Schweiz Monatsschr Zahnmed. 1990;100(2):188–204. French, German. 2 Dietschi D, Schatz JP. Current restorative modali- ties for young patients with missing anterior teeth. Quintessence Int. 1997 Apr;28(4):231–40. 3 Rohner F, Cimasoni G, Vuagnat P. Longitudinal radio- graphical study on the rate of alveolar bone loss in patients of a dental school. J Clin Periodontol. 1983 Nov;10(6):643–51. doi: 10.1111/j.1600-051x.1983. tb01302.x. 4 Tuverson DL. Orthodontic treatment using canines in place of missing maxillary lateral incisors. Am J Or- thod. 1970 Aug;58(2):109–27. doi: 10.1016/0002- 9416(70)90065-5. 5 Nordquist GG, McNeill RW. Orthodontic vs. restor- ative treatment of the congenitally absent lateral in- cisor—long term periodontal and occlusal evaluation. J Periodontol. 1975 Mar;46(3):139-43. doi: 10.1902/ jop.1975.46.3.139. 6 Hasson H, Ismail AI, Neiva G. Home-based chemically- induced whitening of teeth in adults. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD006202. doi: 10.1002/14651858.CD006202. 7 Heintze SD, Rousson V, Hickel R. Clinical effective- ness of direct anterior restorations—a meta-analysis. Dent Mater. 2015 May;31(5):481–95. doi: 10.1016/j. dental.2015.01.015. 8 Haywood VB, Heymann HO. Nightguard vital bleach- ing. Quintessence Int. 1989 Mar;20(3):173–6. 9 Balshi TJ. Osseointegration and orthodontics: modern treatment for congenitally missing teeth. Int J Periodontics Restorative Dent. 1993 Dec;13(6): 494–505. 10 Berten JL, Neukam FW, Wichmann M, Schliephake H. Fachübergreifende Behandlungsplanung zur Implantatversorgung während der Adoleszenz bei Hypodontie oder vorzeitigem Zahnverlust. Implantolo- gie. 1994;4:301–16. 11 Ardu S, Braut V, Gutemberg D, Krejci I, Dietschi D, Feilzer AJ. A long-term laboratory test on staining susceptibility of esthetic composite resin materials. Quintessence Int. 2010 Sep;41(8):695–702. 12 Dietschi D. Optimizing smile composition and es- thetics with resin composites and other conserva- tive esthetic procedures. Eur J Esthet Dent. 2008 Spring;3(1):14–29. 13 Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic restorations based on translucency and opacity of composite resins. J Esthet Restor Dent. 2011 Apr;23(2):73–87. doi: 10.1111/j.1708-8240.2010.00392.x. ortho 1 2021 11

case report | Figs. 1c–l: Patient 1. Inital photos. ortho 1 2021 13

case report | Figs. 5a & b: Patient 1. Final panoramic and cephalometric radiographs. Figs. 4a–e: Patient 1. Final ClinCheck photos. Figs. 6a & b: Patient 1. Final photos. ortho 1 2021 15

case report | After the first treatment plan had been completed 16 weeks later, there was still buccal inclination of tooth #12 and its root was lingually positioned. In addition to this, the mandibular aligner tracking was far from ideal, owing to insufficient use on the part of the patient. A new ClinCheck was generated to correct these prob- lems, resulting in 14 new active aligners (seven maxillary and seven mandibular). I also asked the technician for three overcorrection aligners for each arch in order to obtain alignment of the teeth. After nine more weeks, the treatment was completed, obtaining good alignment of the teeth and correcting the midline shift. A posterior open bite was generated in the molar region, which began correcting spontan- eously after one month of fixed anterior retainers. Patient 2–treated with in-office aligners The 29-year-old female patient presented with skeletal Class II, a brachyfacial biotype, maxillary plane canting, molar and canine bilateral Class I, a light deep bite, pal- atal inclination of the maxillary incisors, moderate maxil- lary and mandibular crowding, a thin mandibular anterior gingival biotype, nasal breathing and a Class II soft-tissue profile. The main concern was the lingually inclined max- illary teeth. Both intra- and extra-oral photographs were taken with a D3200 reflex camera (Nikon) using a twin flash. Panoram- ic, bitewing and profile radiographs of the patient were re- quested, and an addition-cured silicone impression was taken in one step using both light-bodied and putty con- sistencies. A cast model was obtained and then scanned. The STL file obtained from this model was uploaded to the Ortho Analyzer software (3Shape). A treatment plan for in-office aligners was created, ac- cording to which 12 aligners for each arch were needed. The set-up and sub-set-up programming, which allows a staging protocol, were performed by me using the soft- ware mentioned. Essix 0.5 mm thermoplastic sheets and a BIOSTAR vacu- um (SCHEU-DENTAL) were used to fabricate the aligners. This process, together with the trimming and polishing of the margins, was performed by a trained technician. The patient was instructed to use each aligner for two weeks, totalling a treatment time of 24 weeks. After the treatment, the overbite and overjet values had improved with the alignment of the anterior teeth. Both the molar and canine Class I had been maintained, and no posterior open bite was generated by the bite block effect of the aligners. Figs. 8a–f: Patient 2. Initial photos. ortho 1 2021 17

case report | Figs. 10a–g: Patient 2. Final photos. ortho 1 2021 19

case report | Figs. 10k–m: Patient 2. Final photos. Discussion Both clinical cases had many characteristics in common, the most important for me being the patients’ biotypes. A brachyfacial biotype is known for having short muscle fibres with the capacity of generating much greater mas- ticatory force than a mesofacial or dolichofacial biotype, and this could result in a posterior open bite after the use of clear aligners. In addition, both patients presented with nasal breathing, which would assure biomechanical behaviour character- istic of their biotype rather than that of a dolichofacial bio- type, which could have been the case if one of them was a mouth-breather. Conclusion Clear aligners have been shown to be as effective, and in some cases more efficient, than fixed appliances, and they constitute a completely different area of knowledge regarding biomechanics and treatment planning than what we have known before. The decision to use differ- ent commercial brands of aligners should be determined nowadays by the complexity of the case, Invisalign being the gold standard at the moment. Nevertheless, patient compliance regarding the number of hours of use per day remains one of the most important factors for achieving optimal results. In the case of other brands, the thermoplastic material used is vital, because it will determine the way the force is applied to the teeth. In combination with excellent ortho- dontic software, the appropriate thermoplastic material can produce a predictable appliance for treatments that can accomplish the goals of both clinician and patient. contact Dr Tomás A. Salazar ARTIS Centro Odontológico Av. Presidente Kennedy 7500, Piso 5 7650618 Vitacura Region Metropolitana Santiago Chile drtomas.salazar@gmail.com ortho 1 2021 21

case report | Fig. 2: Initial panoramic radiograph. of 10 mm. The roots of teeth #31, 33 and 43 appeared to be close to the buccal border of the cortical bone. Both arches were constricted in the premolar–molar area. Radiographic analysis revealed normal root structure and morphology. A root remnant present in the area of ex- tracted tooth #38 was discovered (Fig. 2). Cephalometric analysis exposed a Class I skeletal pattern with slightly increased proclination of maxillary and mandibular inci- sors (Fig. 3). The treatment of choice for this patient was Invisalign clear aligners (Align Technology). The orthodontic treat- ment plan was formed based on the following objectives: • to eliminate the cross bite on the left side and establish a Class I molar and canine relationship; • to expand the arches and provide an anatomical form; and • to resolve the crowding and align the maxillary and mandibular incisors with the minimum amount of in- terproximal reduction and without further increase of incisal proclination. The first ClinCheck plan consisted of 53 aligners for planned posterior sequential distalisation of approxi- mately 4 mm on the maxillary left side, expansion of 2 mm per quadrant and alignment in the anterior area, as Figs. 4a–c: Initial ClinCheck simulated outcome. Fig. 3: Initial cephalometric radiograph. well as selective interproximal reduction (IPR) of 0.25 mm per tooth surface in the mandibular arch and between 0.10 mm and 0.15 mm in the maxillary right mandibular arch (Fig. 4). Topical fluoride application was planned in the areas of IPR after the procedure. Class II elastics were used on the left side to assist with distalisation. The aligner change interval was seven days and subsequently five days, and an accelerating vibratory orthodontic device was used in order to increase speed and predict- ability of the movement. Overcorrection aligners were not used. ortho 1 2021 23

case report | Figs. 6a–e: Final intra-oral photographs. the vibratory appliance, and the aligner interval was set at five and then three days. The final aligners were used only for 12 hours per day in order to allow the final passive posterior open bite closing. would have been able to confirm this finding). The ceph- alometric analysis revealed that the maxillary and man- dibular incisors had maintained their positions (initial mandibular incisor to APog line: 14 mm; final mandibular incisor to APog line: 13 mm; Fig. 8). Treatment results Conclusion After a period of 11 months and a total number of 66 max- illary and mandibular aligners, the case was finished and all the treatment goals had been accomplished. A bilat- eral Class I relationship had been achieved, the arches were symmetrical and the crowding had been resolved (Fig. 6). According to the final panoramic radiograph (Fig. 7), the roots were parallel and there was no evidence of root resorption (although only periapical radiographs Clear aligners were efficient in satisfying our treatment goals. During the distalisation phase, as the aligner en- capsulates the incisors, it provides good control of the position of the crowns and helps avoid unwanted procli- nation. Controlled movement of the mandibular incisors in a lingual direction while alleviating the crowding with the help of IPR helps prevent buccal displacement of the Fig. 7: Final panoramic radiograph. ortho 1 2021 25

is coming to PRAGUE 26–29 May 2022 Prague, Czech Republic www.ROOTS-SUMMIT.com Tribune Group GmbH 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. Tribune Group GmbH designates this activity for 18.5 continuing education credits. 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 GmbH and Dental Tribune International GmbH. 27 ortho 1 2021

interview | “Today’s patient is more inclined to desire freedom, efficiency, and a clear understanding of the treatment plan and its logic; he or she needs to be a part of the treatment and needs the promises made to be fulfilled.“ benefits. People are reluctant to implement changes if something is working. But we are now facing a new sce- nario, and it forced all of us to revisit how we treated pa- tients. I am sure that orthodontics will never be the same after SARS-CoV-2. We used to see patients before the pandemic to boost their cooperation and to reassure them that the treatment was progressing well. This can still be done remotely. Remote treatment is easy for the initial stage of the treatment plan, converting a Class II or Class III case to Class I, but for the second stage, using either fixed appliances or aligners, is minimum touch orthodon- tics also changing the way you treat your patients and reducing the number of in-office visits? The Motion appliance is employed in the first stage of the treatment. Its aim is to convert a Class II or Class III case to Class I to obtain a perfect occlusion, without overcor- rections. When the patient comes in the first time, we explain the treatment, and he or she can start the treat- ment the same day. The patient is able to place the elas- tics himself or herself, and the dentist is able to monitor the progress without the need for the patient to come in. The appliance is bonded to the teeth at the first visit and is taken out when its goal has been achieved, moving by itself to correct the position. The only reason the ortho- dontist would intervene during that time is if there is a problem. On average, the treatment time with the Motion appliance is between three and four months. At the second appointment, we scan for the aligners, or place the brackets and the wire. We let the wire do its work, and the patient only needs to see us to change one wire for the next one. When using fixed appliances, we use the SLX 3D bracket and wire system—we have de- veloped a three-wire sequence. We can normally finish a case with three wires, but in 35% of our cases, we finish the case with only two wires. to let the patient replace elastics on the hooks of the wire, eliminating the need to change the power chain and therefore keeping the number of visits to a minimum. In the end, the improvement is switching the ball from the dentist to the patient. It seems then that it would be even simpler with align- ers to use the minimum touch orthodontics approach. It is indeed. Kim-Berman et al. showed that the Motion appliance is an efficient and effective appliance for cor- rection of Class II malocclusions.1 After three to four months of treatment, once the case has become Class I, the patient comes in, the appliance is removed, and his or her mouth scanned, and then you can treat the patient with predictability using aligners. According to Patterson et al.’s study published in the American Journal of Orthodontics and Dentofacial Or- thopedics in 2020, a Class II malocclusion is not predict- ably treated with aligners only.2 This means that, in order to succeed in terms of predictability in using aligners, it is ideal to correct the sagittal segment with the Motion ap- pliance first, so that you start the treatment with aligners on a Class I and have a predictable result. It is actually quite easy to understand. In orthodontics, we work with a catenary arch. It is a stable and strong struc- ture because it redirects the vertical force of gravity into compression forces pressing along the arch’s curve. Therefore, when we want to distalise, we are trying to bend mother nature’s work, and we need a lot of power to distalise, to correct the sagittal segment. With the Motion appliance, we make corrections to this catenary arch and work only on the posterior segment, not the an- terior segment. The anterior segment is what causes re- sistance to correction. This is how we succeed, because we are not faced with any kind of resistance from the an- terior segment. The third appointment is for retraction of the anterior segment. For this purpose, we normally use a power chain, but it loses its strength very quickly, resulting in the need for more visits. The solution we came up with was How do you communicate with patients for a success- ful treatment outcome? Even before the coronavirus, because I have patients in many different countries, I had already started to interact ortho 1 2021 29

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feature | Stress is energy, adrenaline. Stress is what makes us achieve goals, what gives us butterflies, what drives us to go beyond our comfort zone. Stress has no value; it is neither good nor bad; it is just energy. An example is the Olympic Games, an atomic stress bomb which of course motivates athletes to achieve incredible results. Starting a new job, moving house, having a baby all at the same time? It is a great deal of energy, a great deal of stress, what we call positive stress or eustress. If we can direct it well, we can manage all these things at the same time. Of course, if we lived 24/7 in a context such as the Olympic Games or had too many challenges daily and si- multaneously to deal with, then this overwhelming amount of energy would become negative for us. It is what we often refer to when we speak about stress, neg- ative stress or distress. It is like a glass of wine, delicious; however, if you were to drink ten bottles a night, the wine would become something bad for you. The same is true of a delicious piece of chocolate, especially Belgian chocolate. If, however, you were to eat 10 kg in one day, it would definitely have negative consequences. The stress curve Fig. 1: Holmes and Rahe stress scale. As you can see, we need positive stress, since it is what gives us the energy or motivation to address challenges and experience the pleasure of the challenge and the result. If we take away these challenges completely, that is when we go into being under-stressed, or bored. This might lead to depression. Many people who have been unemployed for a long time have chronic depression. As a society, we have told them that we do not need their talents and that they are not a necessary part of building our society; they are not being challenged and have a really hard time because of it. period, but an exciting one as well. If we stay at this level for too long, we might fall in the red zone, the zone of neg- ative stress and distress. This is when we start experienc- ing all different kinds of symptoms. If we stay in that stage for too long, we can experience burn-out. People with burn-out are not lazy people; they think that they can do it all, all the time, and think of themselves as the least likely to experience burn-out. Then the body pulls out the plug without warning. Burn-out is not cured by staying home for two weeks; recovery involves a process that endures for many months and has an impact that can be life-changing. The message is not do not go into the red zone. In society nowadays, we often are in the red zone, often owing to work and private circumstances. The real message is make sure you can get out of the red zone. It is very pos- sible to be in that zone for a few weeks if you know that a project you are working on will be over soon, if you have a holiday coming up or if a colleague is scheduled to return from maternity leave to help you, for example. However, when you do not have a solution in the near future coming your way, then you may stay in that red zone for too long. Recognising symptoms Now that I have defined stress, when I refer to stress in the remainder of this article, I mean negative stress. Stress can have an impact on four levels: • physical (such as an irregular heartbeat, headaches, a digestive system that is out of balance, a sore neck and shoulders, and shallow breathing); • mental (for example, negative self-talk, negative thoughts, narrow-mindedness or a single pointed focus, and no longer seeing the light at the end of the tunnel); • emotional (crying a great deal, feeling desperate, feel- ing lonely, bursting into tears with no clear cause and feeling like a loser, among others); and • behavioural (for example, lack of contact, communica- tion, and addictions and destructive behaviours, such as excessive alcohol, drugs, sex and spending). Some will experience stress in only one level and some in more than one. If you notice in yourself or people around you any of these indicators, it is time to have a serious conversation. We cannot let anybody suffer burn-out if we can help. The price and the impact of burn-out are too high. Of course, many may say that they are fine and that they are not under stress and can handle it, but some- times we need to take decisions for others, to protect them. At the top performance level, we need to breathe deeply to stay in balance. This is when we feel we need to juggle to keep up with all the tasks and responsibilities we have in order to move forward. This can be a challenging Our stress responses are related to our sympathetic and parasympathetic nervous systems. The sympathetic nervous system is activated when we are faced with ortho 1 2021 33

feature | others for red zone symptoms. Create some daily rou- tines to take care of yourself, to treat yourself well and to return to your natural state with activities that bring you some inner calm and peace. We have seen during the past year that, owing to COVID-19 and its implications, many people have started taking care of themselves. Never before have so many people started walking in nature, taking up hobbies and learning new things, spending more time with family, cooking and working from home, and thus spending less time in traffic and starting to question themselves about their lives and the directions they want to take. If that is a lasting positive COVID-19 outcome, 2020 might have been a good year in that regard. If you have been inspired by this article, but tell yourself you do not have time to do all these things to find your balance, let me tell you something: the reality is that nobody has time, really. Most have more tasks on their to-do list than the time they have to do it. Yet, some people seem to have more time to do all these things than others do. The reality is that we all have only 24 hours in a day, so it is helpful to look at how you manage your time, but more importantly, you should realise that it is not about not having time but more about making it a priority to make it happen. If I feel I do not have time, I fall into a victim role and find all the reasons to justify why I do not have time. However, if I realise I can change my priorities and choose what I want to do, I become responsible for my time and the outcomes I want to create, and that awareness and these choices are key to staying away from that red zone on the stress bow. about Jerko Bozikovic is a specialist in communication skills, emotional intelli- gence, time and stress management, leadership and change management. He is fascinated by human behaviour and finds working with people on personal development to be a daily challenge and blessing. He speaks seven languages and has offered his training courses in four languages since 2001. He embraces and embod- ies the motto “Love the life you live; live the life you love”. He can be contacted via LinkedIn. Image: G-Stock Studio/Shutterstock ortho 1 2021 35

feature | Invisalign. Align has since sharpened its focus on social media influencers in order to further establish the clear aligner system in the lucrative teenage orthodontic market. “It is official—Charli D’Amelio got fitted for her Invisalign and started on August 26th, 2020,” Gladwell Orthodontics announced on its website last year. Gladwell is the second largest provider of Invisalign treatment in the US, and it posted videos on its website that D’Amelio had shared concerning her orthodontic treatment. “If you want to know more about getting fitted for Invisalign, contact us today,” the dental group said. US-based D’Amelio, a 16-year-old former professional dancer who is now a prominent social media influencer, documented the start of her treatment in a video ad- dressed to her more than 110 million TikTok followers. In the first video related to her clear aligner treatment, D’Amelio says: “Today I am getting my Invisalign,” gestur- ing with a thumbs-up. After her make-up, the video shows D’Amelio seated in a car with her mother, on the way to the orthodontist’s office. Inside the clinic, wearing a face mask, she says: “So right now the orthodontist is explaining to me how to properly clean the Invisalign, and [how] to use them.” From the dental chair, she gives a quick promotion of another multinational company to her followers—“Look, my shoes light up,” she says of her Nike trainers—before turning the camera on herself, showing that she is fitted with a cheek retractor. “I’m about to put my aligners in for the first time,” D’Amelio says and fits the trays over her upper and lower teeth, smiling and giving a double thumbs-up. The video ends with D’Amelio, seated back in the car, explaining: “They’re in.” At the time of writing, the video had received seven million likes from TikTok users and had been shared more than 37,400 times. In a later video, D’Amelio shows her followers how her clear aligner have become part of her morning routine and how easily they can be removed and cleaned. This video has received over ten million likes, and D’Amelio has also tweeted about her treatment to her more than five million Twitter fans. The smile of a champion Now 31, basketball star Draymond Green is around twice the age of D’Amelio, but the major sporting personality nonetheless commands influence over younger US con- sumers—particularly males. Green has become a highly visible cheerleader for tele-orthodontics company SDC, and the power forward has also invested in the company and lobbied against efforts by California to regulate teledentistry. A most notable fact for younger consumers Image: Leonard Zhukovsky/Shutterstock Basketball star Draymond Green, pictured here playing for Team USA at the 2016 Summer Olympics in Rio de Janeiro, has invest- ed in SmileDirectClub and appeared in advertisements speaking about his clear aligner therapy. is that Green has associated his clear aligner treatment with his sporting success. In an advertisement posted on YouTube by SDC, Green’s mother explains that, when he was a teenager, it was obvious that her son would need treatment for malocclu- sion. She said that having Green fitted with a fixed appli- ance was delayed for several years because he was so busy with his sporting commitments. When fitted with a fixed appliance in his college years, Green was unhappy with his appearance and the appliance was unsuitable for the basketball court. “When he got to Michigan State, he broke the retainer,” she says of her son. Green’s tooth crowding persisted, and he states in the video that he was not interested in continuing with the therapy. “When I do photo shoots with my aligners in, you can’t see them,” Green says. Green has tweeted numerous times about his clear aligner therapy, making use of product placement for SDC aimed at his 1.4 million Twitter followers. In another video advertisement, posted on YouTube and shared over the athlete’s social media channels, Green talks about physical and personal transformation, and he is pictured—smiling—while putting in his clear aligner during training. “Confident is the new you; it’s a better you,” he says. Fortune Business Insights estimates that global sales of clear aligners were worth around $2.41 billion (€2.02 billion) in 2020. It remains to be seen how much value celebrities and social media influencers can add to the category. ortho 1 2021 37

technique | Fig. 1: A Mayan child with growth plates. Fig. 2: Facial reconstruction. Fig. 3: Reconstruction of the skull. Fig. 4: Virtual Mayan skull. Mayan skulls Surprisingly, the Maya already practised craniofacial orthopaedics in their day. When we look at the skeletons today, we can determine that these people had a partic- ular profile. The skull was elongated and lengthy, the fore- head receding and the bridge of the nose even with the forehead until it reached the crown of the head. These craniofacial criteria were the result of a ritual practice: women applied rigid plates to the heads of their children that were bound together in order to steer craniofacial growth (Fig. 1). The Maya employed fontanelles, tissue areas between the skull bones, to shape the heads of their young children. The result was a flattened skull in the forehead and occipital bone, as well as an overall egg-like shape. This arbitrary deformation was not performed for therapeutic reasons, but rather for aesthetic purposes. It was a cultural practice that permitted the ethnic and social group of the individual to be identified. 3D-printed Mayan skull We attempted to synthesise a Mayan skull with the latest technology. To do so, we took three main steps: data ac- quisition, design and printing. The acquisition step con- sisted of using data acquired by cone beam computed tomography (i-CAT, KaVo Kerr). We worked on a scan from our database, for which the patient gave his consent. The result was a DICOM file that included all the informa- tion on tissue density (Fig. 2). Consequently, it was pos- sible to practically remove all the soft tissue, just leaving mineralised tissue, such as bones and teeth (Fig. 3). We isolated the skull of the patient and exported it to an STL file. The design step included importing the STL file into 3D-modelling software in order to distort the skull vir- tually. The frontal bone was flattened, ensuring that the nose tip was in contact with the crown of the head. The occipital bone was less curved, in order to simulate the effect of a rigid plate behind the head. Finally, the skull was modified to give it an overall egg shape. This resulted in a skull that met the canons of Mayan beauty (Fig. 4). The digital file was sent to a 3D printer (SolFlex 650, Fig. 5: SolFlex 650 (VOCO). VOCO; Fig. 5) loaded with transparent resin (V-Print splint, VOCO; Fig. 6), to reflect the internal bone struc- tures better. This produced a transparent skull with fine details and a global shape (Fig. 7), which resembles the Mayan skulls on display in museums. Mayan smiles Mayan skeletons have been closely examined by multi- disciplinary teams of anthropologists as well as by den- tists. The teeth do in fact reveal special modifications: they are filed, striated or studded with precious stones (Fig. 8). The changes in shape may include the incisal edges, the vestibular surface, and the mesial and distal angles of the teeth. The inlays are composed of various stones: jade, obsidian, serpentinite, haematite, etc. However, one should bear in mind that these changes were confined to the smile, that is, chiefly the anterior teeth and normally the buccal surfaces of the teeth. These operations were performed for aesthetic pur- poses. The teeth were both a symbol of social identity as ortho 1 2021 39

technique | Fig. 10: Virtual sectional plane of the dental model base. Fig. 11: SolFlex 170 (VOCO). Fig. 12: Dental model before characterisation. Fig. 14: Dental model after characterisation. inspired by Mayan smiles. The shape of the anterior teeth was modified to meet Mayan aesthetic criteria. The incisal edges were filed, and a step applied to the central inci- sors. The teeth were coated with flowable composite (Admira Fusion Flow, VOCO) in Shade A3.5 for the molars, Shade A3 for the premolars, Shade A2 for the canines and Shade A1 for the incisors. Effect composite (Final- Touch, VOCO) was used to achieve a realistic reproduc- tion. The brown composite was introduced into the grooves, and the orange into the embrasures. Inlay work Fig. 13: Ultraviolet flashlight device for light polymerisation. was performed with green and blue composite (Twinky Star, VOCO) on the buccal surfaces of the teeth in order to simulate precious stones, and finally, the gingivae were simulated using pink composite (Amaris Gingiva, VOCO). The final result was a realistic Mayan dental arch, pro- duced 50% digitally and 50% manually (Fig. 14). Mayan mock-up Reproducing a wax-up in the mouth is possible using a mock-up. To do so, we implemented two different work- flows. The first workflow involved acquiring the dental arch using an intra-oral scanner (TRIOS MOVE, 3Shape; Fig. 15). The STL file was sent to a dental technician, who developed a digital wax-up. This wax-up was produced according to the criteria of Mayan aesthetics: a mesial cut on the central incisors, an incisal reduction on the lateral incisors and dental jewellery from canine to canine (Fig. 16). The digital wax-up was converted to an STL file, which was printed in 3D using a special printer (SolFlex 170 and V-Print model; Fig. 17). A silicone key was pro- duced from the 3D-printed model (V-Posil Putty Fast and V-Posil X-Light Fast, VOCO; Fig. 18). ortho 1 2021 41

technique | Fig. 18: Silicone key. Fig. 19: Trying out the Mayan mock-up. Fig. 20: Virtual Mayan mock-up. Fig. 22: Trial of the Mayan mock-up after 3D printing. Conclusion To this day, the Maya have kept their capabilities and ex- pertise secret. In view of the longevity of their operations and their technical inventiveness, their dental aesthetic capabilities are breathtaking. Current dental technology has made it possible to design a smile with extremely de- manding aesthetic criteria. Today, many dentists are looking for ways to meet their patients’ requirements. Digital dentistry provides tools that are affordable and accessible to everyone, enabling all requirements to be met. Whether in general dental practice, implant dentistry or orthodontics—digital tech- nology has its place in everyday practice. It is up to the practitioner to find the right dental technology to compete with the Mayan dental artists. Editorial note: This article was first published in cosmetic dentistry—Magazin für innovative Zahnmedizin, volume 19, issue 1/21. contact Dr Yassine Harichane yassine.harichane@gmail.com Fig. 21: Mayan mock-up printed in 3D after characterisation. simulate the therapeutic result on the computer and even print out the skull of the patient after treatment. This is a great way of checking the appropriateness of the treat- ment plan and obtaining the support of the patient. The dentist can also simulate treatment plans in general dentistry or even allow the patient to try out the end result. After scanning the dental arch, the dentist can simultane- ously display the digital wax-up using the digital smile design on the screen. After validation by the patient, a 3D printer can be used to print out the wax-up or, even better, the mock-up. Within minutes, we obtain a specific way for the patient to check and approve the therapeutic proposal. ortho 1 2021 43

and required a substantial time investment in terms of education and management back then and now, ended up paying off extraordinarily well. Why? Because from then onwards, our first appointment was far more com- prehensive. We began taking full-mouth radiographs of all of our first patients, allowing us to create a much more comprehensive treatment plan, which obviously allowed us to treat more extensive and complex cases and perform better dentistry—great practice builders. As we move forward, we understand that digital technol- ogy is a growing part of the workflow in the modern dental practice. It truly speeds things up and allows us to do so much more with a higher degree of precision. So, if speed is one of the objectives of digital dentistry, should it mean seeing more patients a day? How can I promote the core values of Slow Dentistry and of digital dentistry at the same time? Slow Dentistry understands that the incorporation of these technologies, which cover a range, including con- verting to a paper-free clinic with practice management software, incorporating and using digital radiographic technologies, acquiring an in-house CBCT device and intra-oral scanner, and working with a digital laboratory, or establishing one in-house, requires a huge investment not only financially but also in training and time. It takes time to process and manage these technologies and to educate not only your team but also the patient. That is where Slow Dentistry comes in. Slow Dentistry clinicians believe that these technologies are a great tool in patient education and awareness, truly help them to understand their diagnosis and treatment planning, and may help mitigate complications as well as any legal issues that might arise in the future. Valid consent is a fundamental cornerstone of Slow Dentistry. Technically, the more advanced your digital diagnosis, the better your diagnosis and explanation to the patient—if you invest the proper time to do so. We also believe that all digital files, including the digital impressions taken and processed by dental laboratories belong to the patient. It is his or her right to ask for these files at any time, to be able to check via a third-party opinion or software whether the work was properly exe- cuted. Many clinics, despite acquiring the latest technologies, fall short by not spending the appropriate amount of time in the daily workflow to adapt these advancements to the benefit of the patient. Many dentists still have not under- stood that in many cases it takes a little bit longer to take a proper intra-oral scan compared with a traditional im- pression. Explaining the technology, preparing the com- puter, setting up a cheek retractor, keeping the teeth dry and so on, actually takes a little more chair time than practice management | ortho 1 2021 45

practice management | when possible, a surgical guide or some form of dynamic navigation will be used. This will be shared and discussed with the patient as part of the valid consent, allowing him or her to be a part of the risk assessment. 3. Before any dental work that involves mechanical tooth reduction for prosthetic or cosmetic dentistry, a digital analysis will always be performed using software that allows the creation of a digital 3D mock-up to study the mechanics and possible final outcomes. This will also assist in communicating to the patient the need for pre- treatment orthodontics to reduce the need for excess- preparation of healthy enamel. This information will always be shared with the patient prior to preparing healthy enamel as part of valid consent, and the patient can then choose to accept either option. 4. Clinics are paper-free and always use practice man- agement software to securely house all data, including all radiographs, CT and CBCT scans, photographs and patient information. This means that all radiographs have to be digital. These files belong to the patient, who at any time can request his or her files for whatever reason. Conclusion The Slow Dentistry Global network is part of the Founda- tion for Excellence in Dentistry, which is a non-profit or- ganisation based in Switzerland. Part of its mandate is to improve the standards of care globally around the world and help the general public understand their basic rights regarding dental care. For too long now have some den- tists been performing substandard dentistry by cutting corners to save time. Hopefully in the coming years, thanks to the efforts of our honorary global ambassa- dors, member clinics and partners around the world, this message will become more ubiquitous, and we will be able to create a more equitable world, one where patients can have fair access to quality dentistry no matter what their demographic. Is also the aim of Slow Dentistry to help dentists improve their work by showing them that by performing quality, patient-centred care instead of exclu- sively financially driven dentistry they can have a more fulfilled and influential career as well as sounder mental health—no dentist can feel good about not using a dental dam or not properly preparing the patient for treatment. Slow Dentistry is for beginner general dental practitioners as well as for advanced dental clinics that make huge in- vestments in technology. If you would like to hear more on this topic, feel free to listen to my podcast, “Biting into healthcare”, available anywhere you get your podcasts as well as on my website, miguelstanley.com, and for more on Slow Dentistry, visit slowdentistry.com. All images courtesy of White Clinic. about Dr Miguel Stanley is the clinical director of the White Clinic, a high- technology, advanced dental clinic founded 21 years ago. He is a passion- ate advocate for high-quality minimally invasive dental care. Based on his train- ing in implant dentistry, cosmetic den- tistry and functional occlusion, Dr Stanley has developed an advanced biological comprehensive dentistry approach to his work that incorporates the full scope of action of modern dentistry. Dr Stanley has given over 200 keynote lectures in more than 50 countries, including a TEDx Talk, and his lectures are critically acclaimed by dentists of all ages and specialties for the open dialogue and simple and engaging manner in which complex cases are presented. Dr Stanley is the only dentist to ever host a National Geographic documentary on dentistry. He founded Slow Dentistry to help improve the standards of care globally. He was nominated one of the top 100 dentists in the world by his peers in 2020. ortho 1 2021 47

research | “One in five people with COVID still present with less common symptoms that don’t get on the official [Public Health England] list” patients experienced swelling in the oral cavity. Accord- ing to the study, a change in tongue sensation correlated strongly with swollen palate and changes in the candidi- asis. factors,” she said. “It is worth mentioning that these oral manifestations could be the only signs of COVID-19, and that they are also likely to manifest before general symp- toms.” The authors identified six cases of recurrent herpes simplex virus—two on the tongue and four on the hard palate. “Four patients developed erythema multiforme- like eruptions, three of whom had palatal macules and petechiae and one of whom showed three blisters in the inner lip mucosa. Erosions, erythema, ulcers, necrotising ulcerative periodontitis, and aphthous-like lesions were also observed in single cases,” the study read. The findings were presented in a review article, titled “COVID-19 from the perpective of dentists: A case report and brief review of more than 170 cases”, published online on 26 December 2020 in Dermatologic Therapy, ahead of inclusion in an issue. Spanish study finds a quarter of COVID-19 patients had oral symptoms The onset of the oral manifestations was detailed in 95 of the total 170 cases, and the researchers found a mean of 7.21 days between the onset of systemic symptoms and that of oral manifestations. The onset of the latter varied from ten to 42 days after systemic symptoms. The authors concluded: “The oral symptoms often appeared after general symptoms such as fever and asthenia, but can still be the initial or only sign of COVID-19. Thus, a careful clinical intra-oral examination must be performed on COVID-19-positive patients and equally on any patients who need dental care thoroughly and systematically to ensure that no parts are missing and to obtain further clinical data, which could pave the way for further studies. Corresponding author Dr Pegah Hosseinzadeh, post- graduate resident of orthodontics at the Faculty of Den- tistry at Guilan University of Medical Sciences in Iran, told Dental Tribune International that it was important for den- tists to check for COVID-19 symptoms in the oral cavity. She explained: “Certainly, awareness of the symptoms, especially oral manifestations, is important to identify and manage COVID-19 patients, but also to protect the dentist and other dental patients. For this reason, dentists must stay up to date with the latest research and knowl- edge of mucosal COVID-19 symptoms. A careful clinical intra-oral examination must be performed prior to any other dental treatment in every visit.” Hosseinzadeh said that the study showed that COVID-19 symptoms in the oral cavity were multifactorial. She added, however, that it was certain that the immune system was playing a significant role. “Medicine, stress, opportunistic infections like candida albicans and herpes simplex, and the virus, could be considered as possible A cross-sectional study conducted by dermatologists in Spain in April 2020, found that a quarter of patients had one or more symptoms in the oral cavity. The study was undertaken at a temporary field hospital established to treat mild to moderate cases of COVID-19-associated pneumonia during the peak of SARS-CoV-2 infections in Madrid. It included 666 patients who had either a positive reverse transcription-polymerase chain reaction test or bilateral pneumonia. According to the study, symptoms in the oral cavity were present in 78 cases (25.7%), and the authors listed these as follows: transient lingual papillitis (11.5%), glossitis with lateral indentations (6.6%), aphthous stomatitis (6.9%), glossitis with patchy depapillation (3.9%), and mucositis (3.9%). A burning sensation in the oral cavity was re- ported by 5.3% of participants and was found to be com- monly associated with dysgeusia. The study, presented in a research letter published online in the British Journal of Dermatology, stated that symp- toms in the oral cavity such as glossitis or papillitis had not previously been associated with COVID-19, but hy- pothesised that the contagion risk of examining the oral cavity may have prevented a thorough examination of the oral cavity of COVID-19 patients. The authors acknowledged the study limitations that all study participants were adults with only mild to moderate COVID-19 pneumonia and that the study was conducted during a two-week period; thus, the researchers may have missed previous or later symptoms of the disease. Despite these limitations, the authors stated: “The oral cavity was frequently involved and deserves specific ex- amination under appropriate circumstances to avoid contagion risk.” ortho 1 2021 49

interview | Excellence in dentistry should not only be limited to what we do within the oral cavity, nor should it be justified at any price. Excellence should also encompass everything that happens in the clinic and the impact our work has on society. Excellence must be accessible to the patient, profitable for the professional and sustainable for the en- vironment. If it is not accessible, we cannot provide pa- tients with our high-quality care; if it is not profitable, we will not be able to expand our service over time or con- tinually re-invest in improvements; and if it is not sustain- able, we will punish others and, in turn, ourselves with a more toxic and harmful world and work environment. What are the measures you have implemented in your practice that contribute to a greener future? I would like to clarify in my answer that, for me, the green aspect is just another pillar in a different way of practising dentistry. Sustainable dentistry must be more respectful to the environment as well as to people and their physical and mental well-being. In our clinic, we have implemented an entire philosophy and management model that includes several measures. In terms of the environment: use of recyclable and eco- friendly materials in all possible processes; reduction of plastic as much as possible; recycling of waste; elimina- tion of paper thanks to complete digitalisation in manage- ment and communication tools; and organisation of the agenda with a slow approach that reduces patient visits to the office and therefore reduces environmental pollu- tion and the use of resources. And in terms of personal care: work schedules that are compatible with work–life balance; organisational charts with defined roles; individual professional development and support programmes; periodic networking and mo- tivation sessions; thorough monitoring of patient and professional satisfaction through evaluation tools; and periodic productivity, quality and profitability analyses. In my opinion, a professional who does not know how to take care of his or her practice, his or her team or him- or herself will hardly be able to take care of the environ- ment. That is why, in our model, we pay special attention to making the change towards a greener dentistry by changing our way of working and our style of living. And what advice would you give a colleague who is hesitant about implementing them or to someone who is not fully convinced of the effects of climate change? I think the main challenge lies in the fact that we, as pro- fessionals, must slow down the pace of our work and life- style so that we can take better control of our agendas and give ourselves the opportunity to be able to perform with much greater calmness and awareness. I like to say that we live in a very fast world, so living slower will help us to take better care of everything and everyone. Each person must know that his or her contribution, no matter how small, adds up to the common mission. I am totally convinced that there is a much brighter, much more enriching and much more beneficial way of dentistry for everyone. Presently, there is no official body that governs what green dentistry really means. It is an optional step to take for dental professionals. Do you think there should be laws in this regard in order to enforce change? Any organisation or project aimed at improving dentistry should always be welcomed. However, in my personal opinion, I am not really convinced that green dentistry should be championed by a specific body. Although it would be a great contribution if it existed, I think that the change should rather be led by regulatory bodies, univer- sities and institutions already in existence. Undoubtedly, I think they are the ones who should motivate the change by regulating professional practice in order to facilitate a change that is certainly necessary and beneficial. Dentistry and dental professionals should never be a problem for anyone or anything; on the contrary, we should set an example and be part of the solution. Why then do we not pay sufficient attention to an aspect as important as the impact made by our profession? It is not easy, and one cannot always set an example, but trying to improve every day and striving to contribute increases the reward of practising dentistry. Is there anything else you would like to add? We live in a fast-paced world, where multitasking, uncon- trolled speed, stress, the need to be in multiple places at once and the lack of time can be considered as some of the viruses that almost no one talks about. Slowing down the pace of work in search of a greater balance where calmness and control gain ground over stress and chaos is possibly the greatest challenge we are facing and the greatest need we have in order to achieve a more sus- tainable dentistry. There are many ways to refer to the model of dentistry which I call Slow Dentistry. We were global pioneers in developing a method inspired by the Slow movement and this has helped us channel excellence regarding the pro- fessional, the patient and the environment in a much more sustainable way. The Slow movement has been in motion for many years, and dentistry is, and should be, a participant in a global movement shared with such diverse industries as fashion, gastronomy, health, education, tourism and lifestyle. For some, it is not important to do more, but to do better, and that is the best motivation to continue channelling excel- lence towards a much more sustainable model. ortho 1 2021 51

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