issn 1868-3207 • Vol. 3 • Issue 1/2024 aligners 1/24 F DENTAL T RIB O S R A E Y 0 2 & E DIA UN E I N T . • 3 0 Y E A R S OF OE M U S M international magazine of aligner orthodontics case report Solving sagittal discrepancies in orthodontics is probably the most energy-demanding movement you can do with aligners case report Orthodontics and botulinum toxin: Integrated care of a patient with bruxism and occlusal alteration technique How to safely speed up tooth movement and reduce the duration of orthodontic treatment

editorial | Dr Gina Theodoridis President-elect of the European Aligner Society for 2025 The future of aligner orthodontics More than two decades ago, a new technique emerged, one that no one ever thought would rock the stage of orthodontics. Advancements in orthodontic tooth move- ment had always been about control. Throughout the progression from removable to fixed appliances and from Begg to edgewise appliances and the straight wire tech- nique, there has been a consistent effort to develop a sin- gle appliance that incorporates multiple predefined me- chanical properties. Clear aligners did not seem suitable at first for all treatments, for two reasons: they were not fixed on the teeth, so their performance could be affect- ed by displacement, and the process used to produce their prescribed characteristics was indirect and some- what mysterious, contrasting greatly with the manual wire bending that we were all familiar with. Yet, here we are, more than 20 years later, witnessing the reality of almost all orthodontic malocclusions being successfully treated largely with aligners. The evolution of aligner material and the tremendous advancement in digitally designed mechanical implementation of forces are the power duo that has brought success in aligner treatment. Nevertheless, there has always been some dispute in the literature as to whether aligner treatment is really effective. Multiple studies have sought to determine which aligner movements are predictable and which tend to fail. Most of these studies are largely influenced by two important variables: patient cooperation on the one hand and treat- ment planning by the orthodontist on the other. In past years, customisation with aligner planning soft- ware was generally limited, and planning was to a large degree guided by an automated sequence and automatic determination of attachment use. As dentists enhanced their proficiency in aligner treatment, the degree of custo- misation through greater control of the software steadily increased. We can now choose the type of attachment and segregate, separate and sequence tooth move- ments, resulting in higher predictability and better clinical outcomes with aligners. Additionally, hybrid techniques, such as the combination of fixed auxiliaries or mini-implants with aligners, made aligner treatment possible even in complex cases. Never in the history of orthodontics has there been such crea- tivity in combining different methods, including bonded auxiliaries, expanders and distalisers, all for the purpose of providing an overall effective and aesthetic treatment. Although the advancement of software is without a doubt a very important reason for the evolution of aligner treat- ment, I believe it is the increasing proficiency in treatment planning by dentists that has led us to the golden age of aligners. Without a doubt, artificial intelligence too will continue to evolve, being constantly trained on data and metadata that are collectively accumulated in the system, as well as research data from published studies. How- ever, a successful treatment outcome often stems from circumventing the software’s algorithm, deviating from the established procedure and challenging the existing rules—and this can lead to evolution of the technique. As the fifth congress of the European Aligner Society, held in Valencia in Spain, demonstrated, the limits of aligner orthodontics are indeed continually being surpassed. During this outstanding meeting, we enjoyed seeing the excellent treatment outcomes produced either by align- ers alone or by hybrid techniques. This should not cause doubt about the use of aligners. The question need not be whether one technique outweighs the other; it must be how to better serve our patients by treating them with the most suitable modalities for their malocclusion, giving them an excellent orthodontic outcome and, very impor- tantly, offering them a positive experience and the best possible aesthetic treatment. So, if you are ever wondering about our role in the future of aligner orthodontics, the answer is simple: being cre- ative. Sometimes creativity is the ultimate sophistication. Dr Gina Theodoridis President-elect of the European Aligner Society for 2025 aligners 1 2024 03

Xxxxxx | N E W Others imitated. We innovated. While everyone else was busy copying our original design, we were taking it to the next level. Motion Pro Video *Patent pending. Carriere Motion Pro Bite Corrector not available in all countries. See your local distributor for more information © 2024 Ortho Organizers, Inc. All rights reserved. Patent pending. M3338 03/24 aligners 1 2024 05

case report | 2a 2b Figs. 2a & b: Case of a Class I occlusion accomplished in two months with the Carriere Motion Pro. sagittal dimension by moving groups of teeth, generating a Class I occlusion before any comprehensive orthodon- tic treatment. In this manner, the molars, premolars and canines are brought into a Class I relationship where the maxillary and mandibular first molars exhibit adequate distal rotation and adequate uprighting, depending on whether the clinician is treating a Class II or Class III mal- occlusion.5–7 This Class I occlusion is usually accom- plished during the first four months of treatment with the Carriere Motion Appliance. This approach of achieving a Class I occlusion with the Carriere Motion Appliance prior to any further orthodontic treatment is described as the Sagittal First approach in the Carriere system. Today, patients request solutions for their malocclusion that are both aesthetic and efficient. The new Carriere 3b 3d 3a 3c 3e Figs. 3a–e: Case demonstrating the long-term stability of the Carriere Motion Appliance. Sixteen (16) years of follow-up of a Class II case. aligners 1 2024 07

case report | Be sure with SureSmile® SURESMILE® CASES 75% NO REFINEMENTS WERE REQUIRED Delivering healthy smiles to over 1 million patients2 Works with most scanners Expert practice support Expect a Better Experience. Switch to SureSmile® Aligners. Partner with the aligner brand that delivers predictable results and happy patients from their first aligner to their final smile. Visit: www.SureSmile.com 1. Based on an internal analysis in excess of 150,000 global SureSmile® aligner cases started and completed between Jan 2021 - June 2023. 2. SureSmile® treated cases - data on file 2023. aligners 1 2024 09

case report | 2a 2b 2c Figs. 2a–c: Initial intra-oral photographs. 3a 3b 3c Figs. 3a–c: Initial occlusal photographs. 4a 4b Figs. 4a & b: Initial cephalometric radiograph and dental panoramic tomogram. aligners 1 2024 11

case report | 8a 8b Figs. 8a & b: Final extra-oral photographs one month after botulinum toxin administration. 9a 9b Figs. 9a & b: Final profile and smile. 10b 10a Figs. 10a & b: Final cephalometric radiograph and dental panoramic tomogram. aligners 1 2024 13

patient’s profile and reducing bruxism, along with its as- sociated signs and symptoms. Orthodontic treatment using aligners was planned, together with the adminis- tration of botulinum toxin for the bruxism signs and symptoms and to improve the facial aesthetics. Before the aligner treatment began, the maxillary and mandibular second premolars were extracted to create space. With orthodontic treatment, distalisation of the anterior teeth was achieved by employing maximum mandibular anchorage and moderate maxillary anchor- age (Figs. 5–7). At the end of the treatment, a stable bi- lateral Class I occlusion had been achieved, as well as normal inclination and retrusion of the anterior teeth, consequently improving the profile (Figs. 8–10). Among the post-treatment recommendations was a mouth guard, which the patient was advised to wear every night to protect the teeth from the excessive occlusal force of bruxism. Once the orthodontic treatment had been completed, botulinum toxin was injected bilaterally into the masseter muscle and an anterior portion of the temporalis muscle. In the first session, three injections were performed in the masseter muscle, administering 2.5 U in the most superior point and 5.0 U in each of the two lower points, a total of 12.5 U per masseter. Then, 10 U of botulinum toxin was injected into the anterior portion of the tem- poralis muscle in this same session. After 14 days, a second session was performed. Because the patient presented with slightly greater hypertrophy on the right side compared with the left side, 5.0 U of botulinum toxin was injected into the right masseter and 2.5 U into the left masseter. At the end of the treatment, the patient showed a signifi- cant improvement in her profile thanks to the orthodontic treatment (Fig. 11) and an improvement in her facial shape thanks to the injection of botulinum toxin into the elevator muscles (Fig. 12). She also had a decrease in bruxism and its symptomatology thanks to the combina- tion of both treatments. Conclusion This case report demonstrates that a comprehensive and holistic approach to treatment is essential to achieve the desired outcomes for the patient. Neither of the two treatments alone could have resolved the patient’s complaints at the first consultation, demon- strating the importance of listening carefully to the patient during his or her first appointment to understand his or her concerns and expectations and using all the treat- ment options available not limiting treatment to one specialty. case report | about Dr Tomás A. Salazar holds a DDS from the Universidad de los Andes and an MSc in orthodontics and dento- facial orthopaedics from the Universidad Andrés Bello, both in Santiago in Chile and a MSc in aligner orthodontics from the University of Turin in Italy. He is an adjunct assistant professor in the post- graduate programme in the department of orthodontics and dentofacial orthopaedics at the Universidad Andrés Bello and runs a private practice in Las Condes in Chile. Dr Salazar is also an ambassador of the European Aligner Society in Chile. Dr Belen M. Perretta holds a DDS from the Universidad Finis Terrae in Providencia in Chile. She is a prostho- dontist and also has qualifications in oral rehabilitation and facial aesthe- tics. Dr Camila Reino holds a DDS and a master degree in ortho- dontics from the Universidad de los Andes in Santiago in Chile. Dr Kristen Kock holds a DDS from the Universidad San Sebastián and a master degree in orthodontics from the Uni- versidad de los Andes in Santiago in Chile. References 1 Aragón Niño Í, Niño Aragón ML, Pampín Martínez MM, del Castillo Pardo de Vera JL, Cebrián Carretero JL. Tratamiento de la hipertrofia del músculo masete- ro con toxina botulínica. Consideraciones y manejo [Treatment of masseter muscle hypertrophy with bo- tulinum toxin. Considerations and management]. Med Estética. 2022 Jun 15;71(2):45–50. 2 Kim NH, Chung JH, Park RH, Park JB. The use of botulinum toxin type A in aesthetic mandibular contou- ring. Plast Reconstr Surg. 2005 Mar;115(3):919–30. 3 González Magaña F, Miranda LM, Malagón Hidalgo H, González Amesquita V. Uso de toxina botulínica para tratamiento de la hipertrofía del músculo masetero [Use of botulinum toxin for treatment of hypertrophy of the masseter muscle]. Cir Plast Ibero-Latinoam. 2012 Jul–Sep;38(3):297–302. 4 Fedorowicz Z, van Zuuren EJ, Schoones J. Botulinum toxin for masseter hypertrophy. Cochrane Database Syst Rev. 2013 Sep 9;2013(9):CD007510. 5 Kim DH, Hong HS, Won SY, Kim HJ, Hu KS, Choi JH, Kim HJ. Intramuscular nerve distribution of the mas- seter muscle as a basis for botulinum toxin injection. J Craniofac Surg. 2010 Mar;21(2):588–91. aligners 1 2024 15

case report | 2 3 4 Fig. 2: Initial extra-oral analysis, showing the maxillary midline aligned with the facial midline. Fig. 3: Initial transversal analysis, showing facial symmetry. Fig. 4: Arnett’s profile analysis, showing a protruded maxilla. 5 Fig. 5: Initial vertical and sagittal analysis, showing a balanced lower third. 6a 6b 6c 6d 6e Figs. 6a–e: Initial intra-oral photographs. 7a Figs. 7a & b: Curve of Spee analysis, showing the deep curve. 8a 7b 8b Figs. 8a & b: Initial midline analysis, showing the deviated mandibular midline. aligners 1 2024 17

13 Fig. 13: 3D radiographic analysis. 12 Fig. 12: 2D radiographic analysis. 15a 15b 15c 14 Fig. 14: Initial Perrotti cephalometric analysis. 15d 15e Figs. 15a–e: Suture analysis. case report | aligners 1 2024 19

case report | The dental panoramic tomogram revealed that the four third molars had not erupted (Fig. 12). We used the 3D scan to complete the diagnosis (Fig. 13). The Perrotti total face approach cephalometric analysis was conducted with the Planmeca Romexis software, and it found that the patient was slightly brachyfacial and skeletally symmetrical and presented with a skele- tal Class II malocclusion due to mandibular retrusion (Fig. 14). She exhibited maturation Stage C of the mid- palatine suture (Fig. 15),6 no transverse maxillary concerns and a good airway volume of 19.3 cm3 (Figs. 16 & 17). Treatment Our treatment focused on solving the issues identified in the three planes of space using the Sagittal First ap- proach with Carriere Motion Appliances and clear align- ers (Reveal, Henry Schein Orthodontics). We conducted digital planning using the Reveal software to design the mandibular aligners. These aligners are intended to provide additional negative torque on the mandibular in- cisors, thereby counteracting the adverse effects of the Carriere Motion Appliances due to elastic use (Fig. 18). Additionally, these aligners served as a retention method after the standard Carriere Motion Appliance protocol. We do not schedule patient appointments for placement of Carriere Motion Appliances until we have the mandi- bular aligners in our office. In approximately 15 minutes, we completed the cementa- tion of the Carriere Motion Appliances and provided patient education regarding the 22-hour daily elastics protocol. The protocol was 6 oz elastics during the first month and then 8 oz elastics until Class I canine overcorrection had been achieved. A mandibular aligner was to be worn to prevent adverse effects whenever the patient was wearing the elastics and was only to be removed for eating. We placed mandibular tubes on teeth #36 and 46 and ce- mented transparent Carriere Motion Appliances from canine to first molar bilaterally in the maxillary arch (Fig. 19). Following the placement of the Carriere Motion Appli- ances, using our MTO system, both appointments and chair time for the patient are minimised, as no further review is conducted until the third month, when progress is assessed (Fig. 20). If satisfactory progress is observed during this visit, the patient is scheduled for the following month. By the fourth month (Fig. 21), if a bilateral Class I occlusion has been achieved at both the molar and canine levels, we proceed to the second phase of treatment. The next step involves performing a new intra-oral scan with the Carriere Motion Appliances in place. However, technicians are instructed to virtually remove these. It is crucial to avoid physically removing the Carriere Motion Appliances, as this could compromise the Class I occlu- sion achieved, leading to relapse. During this phase, the patient continues to wear the Carriere Motion Appliances and the last aligner. Elastics (6.5 oz, ¼ in.) are only worn at night, serving as anchorage until the first aligners for the second phase of treatment arrive (Fig. 22). For the second phase of treatment (Figs. 23 & 24), we had the technician design the aligner sequence to close the remaining maxillary spaces through distalisation and re- traction of the anterior teeth, applying lingual crown torque to the maxillary incisors and incorporating Class II elastics. To ensure the retention of the Class I occlusion, we instructed the patient to wear Class II elastics (2.5 oz, 3⁄16 in.) nightly. This strategy aimed at closing the maxillary anterior spaces by crown retraction and loss of torque, facilitating relative extrusion to improve the maxillary incisor exposure (Figs. 25–28). Treatment outcome The outcomes proved highly satisfactory for the patient, meeting all the treatment objectives. Noteworthy skeletal alterations were not evident, as the majority of changes observed were primarily dentoalveolar in nature, and the enhancement in the positioning of the maxillary incisors did not affect the patient’s facial profile. From an anterior– posterior perspective, the bilateral Class II malocclusion had been successfully rectified, along with the correction of the overjet (Figs. 29–32). The final transversal arch di- mensions attained displayed parabolic and symmetrical arches, demonstrating excellent alignment. The cephalo- metric measurements displayed minor variations, likely attributable to the patient’s ongoing growth phase, given her stage of cervical maturation (Fig. 33). The patient presented with a Bolton discrepancy, having excess of the mandibular arch due to the peg-shaped maxillary lateral incisors. Because of the young age of the patient and aesthetic requirements, we decided on bonding veneers on teeth #12 and 22 in a future pros- thetic phase instead of mandibular interproximal reduc- tion. Conclusion The MTO system stands out as a highly effective and ef- ficient approach for addressing severe Class II cases, providing an alternative to extraction and significantly re- ducing treatment time, appointments and chair time. In cases of Class II malocclusion that require numerous aligners or aligner stages, the adoption of hybrid treat- ments such as the one we offer emerges as an advanta- geous strategy. Within a period of four to five months, we can correct the Class II malocclusion using the Carriere Motion Appliance—this represents the most time-consuming part of the treatment—and then proceed to the Class I phase using aligners to successfully con- clude the case. aligners 1 2024 21

case report | 23a 23b Figs. 23a & b: Superposition before and after the second phase of treatment. 24a 24b 24c Figs. 24a–c: Models for the second phase of treatment. 25a 25b 25c Figs. 25a–c: Situation in the sixth month of treatment. aligners 1 2024 23

case report | 31a 31b 31d 31e Figs. 31a–f: (a–c) Initial models, and (d–f) final models. 31c 31f 32 Fig. 32: Final Perrotti analysis. Editorial note: Please scan this QR code for the list of references. about Dr Carlos Colino holds a master’s degree in dentofacial orthopaedics and clinical orthodontics from the Catholic University of Murcia in Spain and is an associate teacher at the same univer- sity. He won first prize for best clinical case at the VIII Congreso Internacional de Alineadores in 2023. He runs his own practice in Malaga in Spain. Dr Laura Castillo earned her master’s degree in orthodontics from the Univer- sity of Alcalá in Alcalá de Henares in Spain. She is an associate professor in the orthodontics and dentofacial ortho- paedics master’s programme at the Catholic University of Murcia in Spain. She practises orthodontics exclusively at Dental Colino clinic in Villanueva de la Serena in Spain and is a member of the European Orthodontic Society. 33 Fig. 33: Initial and final sagittal CBCT scans. Dr Isabel Drewling undertook her dental degree in 2006 at the University of Barcelona in Spain. She continued her orthodontic and dentofacial ortho- paedic training in 2013, and since then, her practice has been limited to ortho- dontic treatment. Dr Pedro Colino obtained his PhD summa cum laude from the University of Extremadura in Badajoz in Spain and his MSD in orthodontic and dentofacial orthopaedics with extraordinary award from the University of Alcalá in Alcalá de Henares in Spain. He is head of the orthodontics and dentofacial orthopae- dics master’s programme at the Catholic University of Murcia and an associate professor at the Miguel de Cervantes Euro- pean University in Valladolid, both in Spain. Dr Colino is the author of three orthodontic textbooks and an active member of the Spanish Society of Orthodontics and the European Orthodontic Society. He maintains two private prac- tices in Spain, one in Villanueva de la Serena and another one in Malaga. aligners 1 2024 25

technique | 1c 1d Figs. 1c & d: Clinical situation after 20 weeks of orthodontic treatment with 20 aligner pairs in combination with photo-biomodulation, occlusal view of the (c) maxilla and (d) mandible. The periodontal ligament is rich in cells and blood ves- sels. It is made up of undifferentiated stem cells, which have the potential to develop into osteoblasts, cemento- blasts or fibroblasts. For bone remodelling, osteoblasts, osteoclasts and fibroblasts communicate via the RANKL–RANK–OPG signalling pathway, which involves the interaction of receptor activator of nuclear factor kappa B ligand (RANKL), receptor activator of nuclear factor kappa B (RANK) and osteoprotegerin (OPG). secrete OPG. This molecule binds to RANKL, preventing it from attaching to its RANK transmembrane recep- tor and stopping osteoclastic activity. Osteoblasts there- fore play a key role in bone remodelling, as they are involved in activating osteoclastogenesis, inhibiting re- sorption and synthesising new bone matrix. Thus, in areas of compression, RANKL levels are high, and in areas of tension, TGF-β and OPG levels are much higher. The most abundant cell in the ligament is the fibroblast, which is responsible for its structure by producing colla- gen. It also secretes RANKL and transforming growth factor β (TGF-β) under mechanical stimulation. Stem cells differentiate into osteoblasts under the influence of the growth factor TGF-β. Osteoblasts (responsible for bone formation) secrete RANKL, OPG, macrophage colony-stimulating factor (M-CSF) and several other molecules. Osteoclasts (responsible for bone resorption) differenti- ate into pre-osteoclasts from haematopoietic stem cells present in the vascular system. These pre-osteoclasts migrate to bone sites and fuse into osteoclasts in the presence of RANKL and M-CSF. When mechanical force is applied, an acute inflamma- tory response is triggered, inducing vasodilation and al- lowing leucocytes to penetrate from the capillaries into the ligament matrix. Leucocytes produce cytokines, which initiate the signalling pathway. The osteoclasts remain active for as long as the adjacent cells are pro- ducing RANKL. Under the influence of anabolic and hormonal (calcito- nin, oestrogen), immunological (TGF, interleukin 17 and 4) or inorganic (calcium) factors, osteoblasts produce and Photo-biomodulation therapy can play a key role in ortho- dontic movement, since it has the effect of increasing cell proliferation, collagen synthesis and the release of growth factors and other cytokines that stimulate the activity of osteoblasts, osteoclasts and fibroblasts in- volved in bone remodelling. For the past year, we have exclusively been using the ATP38 photo-biomodulation device, and it has been very well accepted in our daily workflow. We are manag- ing to streamline planning for complex cases, from smile design to orthodontic treatment planning and implant placement (when necessary), but what really makes this ecosystem remarkable is the regular combi- nation with the ATP38. We have already had almost ten years of success with this protocol and believe it should be the benchmark in orthodontic therapy, whether with fixed appliances or aligners (Figs. 1–3). Establishing new protocols is always challenging, espe- cially when including new technology in the workflow. Nevertheless, it is helpful to regard this in light of the metaphor of bamboo growth: it usually takes five years to see growth, so initially it will be difficult to see the real advantages, but as you obtain more cases and see the benefits clinically and receive feedback from patients, it will become clear that all the effort is worth it. aligners 1 2024 27

technique | aligners 1 2024 29

opinion | Where might AI have an immediate impact on these spe- cific areas? Diagnosis and treatment plan There are already several online platforms available to help in diagnosis. Of course, they are not perfect, but they are already able to very quickly through a panoramic radiograph or CBCT scan segment all the teeth and iden- tify problems such as caries, endodontics and missing teeth. Some of these platforms also assist the dentist in- credibly quickly in preparing a treatment plan beyond di- agnosis. We are still in the early days of this technology, but I believe that within a very short time the application of AI in the diagnosis and treatment planning of our pa- tients will be the norm, and for those who work for insur- ance or large dental groups, it will almost be a require- ment. The advantages implicit in this technology are that we can often miss small details because we might be looking at more complex problems in our patients’ mouths and for example miss a small cavity between two teeth or because we do not have the requisite amount of time in our initial appointment to look at everything or are focused on the primary reason the patient came to us and might overlook broader aspects. This technology will help mitigate error incredibly in this very important pro- cess when we are diagnosing a patient for the first time or re-evaluating our case after a few years. We all know that our eyes can sometimes deceive us. Here this technology will play an incredibly powerful role in help- ing to analyse CBCT scans and radiographs, and I believe that intra-oral scanners and laboratory scanners will also be a part of this process, as well as the various soft- ware programs available for the dental laboratory. AI will also play a predominant role in the preparation of a treatment plan, as well as in the sequence of treatments to be performed, making sure that the right methods are in place. Depending on the technology used, the soft- ware will serve the clinic or the patient. Different groups may create AI programs according to their various goals, such the promotion of biomimetics or all-on-four or aes- thetic treatment. This means that programs are going to be trained to prompt a specific outcome by whoever programmed them. AI software does only what it is pro- grammed to do, so whoever creates these AI programs can set whatever parameters they want. Imagine an AI program available to the patient through which the patient could influence the dentist’s treatment plan and the materials used. The second the dentist presents the treatment plan based on his or her diagno- sis, the patient would be able to ask for that report and enter it into the program on his or her smartphone and instantly critically analyse whether the dentist’s goal is financial only rather than the pursuit of optimal treatment. This program might enable instant recommendations from nearby clinics that can perform the same type of treatment at a lower cost and with greater proficiency because they have better means and materials to do so. It appears that soon all this information will be available to everyone, not just dentists. That is why I have been warning for some time in my lec- tures and at international conferences that this is a very good time to start investing in quality and to be as ethical as possible in our professional conduct, because sooner or later there will be technological entities controlling the way we work. It is going to be very difficult to deceive your patients, and we all know that there are many today who practise dentistry that is not congruent with current science and clinical evidence in order to save time or money. It will certainly be very interesting to see the evo- lution of all these technologies in our industry. Personally, I think that this is great! Since the beginning of my career, I have been putting myself on the side of the patient and not on the side of the industry. I practise empathy every day when I have a patient in front of me. I am sure that every patient in the world wants the same thing: good treatment performed with the best materials, painlessly and with care and that lasts a lifetime with high aesthetics. Of course, this magic formula does not exist, but surely the incredible tension that exists between pa- tients and the industry will dissipate if we have a techno- logical referee in our midst. We all know that there are patients with unrealistic expec- tations who have a very complicated phenotype and want complex mouth treatments that are unachievable. An AI program will be able to immediately mediate in the conversation by introducing an objective examination so that the dentist can have more tools to demonstrate the facts of the case based on science and to support a challenging explanation to the patient and, by the same token, so that the patient will have extra support to ensure that he or she is not being misled and that the dentist is not trying to sell something outside of the necessary scope, in defence of the patient’s oral health and wallet. I think that it will be an incredible help to many. Of course, clinics that practise dentistry without regard to quality and ethics should be very concerned about these new technologies. I think that this mediation is something that is missing in our industry. I have already been working with companies and been helping some of them, learning from them and trying to ensure that decision-making and implementation are based only on ethics, science and clinical evidence. To summarise, I think that AI will provide an incredible means to improve the effectiveness of diagnoses and aligners 1 2024 31

Xxxxxx | opinion | include redundancies in these tasks, and there are many possibilities for error. All these errors come at a great cost as well. Surely, it will be incredibly welcome for practice owners, insurers and all those involved in managing practices to have support that can enable them to reduce error and increase efficiency. Let us consider an example. Imagine a healthcare group that has one dentist. This dentist works in three different clinics and, at the end of the month, is remunerated based on a calculation of the treatment activities per- formed. It is necessary for an accountant or an account manager to confirm all the facts described and entered into the system by the dentist. Now, the healthcare group must confirm that the dentist has indeed performed these tasks, but how can it know whether he or she has done them well? How can it be sure that he or she has not made a mistake? An AI program used by the clinic management could very quickly go through the radio- graphs, the photographs, the clinic’s and dentist’s emails, all communication between the parties involved, the stock record for the materials removed from the stock for the treatment, the chair time allocated for the treatment and the laboratory workflow around the treatment and calculate immediately whether in fact what the dentist claims to have done was in fact done and done well. Nat- urally, the dentist will feel more secure because his or her entire effort will be validated and confirmed by manage- ment, and his or her payment will be effected without problems. The problem arises if the dentist has not been correct in his or her conduct, because the AI program will quickly warn both parties of an error and help correct it to the benefit of both parties. Surely no dentist will want to be paid for work he or she did not do, and no organisation will want to pay for work not done. Certainly in the future there will be a discussion about whether organisations should pay for poorly performed work, but that is another discussion for another time. I think that AI may make things more difficult for some but also much easier for others. We are still a long way from seeing all this happening, so do not become worried just yet. It is important, however, to keep an eye on how things are developing because it is not a matter of whether it will happen but when. contact Dr Miguel Stanley Rua Dr. António Loureiro Borges 5 1o Andar Arquiparque Miraflores 1495-131 Algés Portugal Whiteclinic.pt Miguelstanley.com Missinglink.ai info@whiteclinic.pt aligners 1 2024 33 ©️ SomYuZu/Shutterstock.com

opinion | expectations that can arise through social media,2 where posts may be unrealistic and not representative of the day-to-day dentistry achieved by most practi- tioners. By engaging in authen- tic and ethical marketing, dentists can contribute to a more inform- ed and healthy view of aesthetic dentistry. Furthermore, it is important for dentists to continue to update their knowledge of and skills in using new technologies to offer the most effective and tailored care possible. Continuing pro- fessional development is crucial for maintaining a high standard of patient-centred care. Challenges with product-centred marketing An excessive focus on specific products, often seen in mar- keting campaigns for dental products, can lead to the over- shadowing of dentists’ professional judgement and of indi- vidual patient assessments. This type of marketing risks minimising the clinical and functional aspects of orthodon- tics, crucial for the patient’s long-term health and well-being. It is important that dentists balance the need to be in- formed about new treatment options with the responsi- ble presentation of these products. If not handled cor- rectly, product-centred marketing can lead to patients choosing treatments that may not be the best option for their specific situation. aligners 1 2024 35 ©️ Drozd Irina/Shutterstock.com©️ Natali_Mis/Shutterstock.com

about Dr Anna Hajati his a prominent ortho- dontist, entrepreneur and pioneer in in- tegrating innovation and science with a human-centric approach in orthodon- tics, and her work emphasises ethical communication, patient-focused care and the transformative power of a smile. She is the founder of OrtodontiAkade- min, an orthodontic practice in Stock- holm in Sweden, and has long been employing digitally sup- ported treatment processes to improve treatment outcomes and the patient experience. She obtained her DDS and PhD from Karolinska Institutet in Stockholm and her certification in ortho- dontics from the centre for orthodontics and paediatric dentistry in Linköping in Sweden. Dr Hajati is a member of the World Federation of Orthodontists, European Orthodontic Society, Swedish Association of Orthodontists, and Dental and Cranio- facial Bionetwork for Image Analysis. She is a member of and elected ambassador for the American Association of Orthodon- tists in Sweden. References 1 Beauchamp T, Childress J. Principles of biomedi- cal ethics: marking its fortieth anniversary. Am J Bioeth. 2019 Nov;19(11):9–12. doi: 10.1080/15265161. 2019.1665402. PMID: 31647760. opinion | 2 Smorthit K, Cooper J. Social media influence. BDJ In Pract. 2020;33(6):5. doi: 10.1038/s41404-020- 0427-3. 3 Holden AC, Adam L, Thomson WM. Dentists’ per- spectives on commercial practices in private dentis- try. JDR Clin Trans Res. 2022 Jan;7(1):29–40. doi: 10.1177/2380084420975700. 4 Hayer N, Wassif HS. General dental practitioners’ perceptions of shared decision making: a qualitati- ve study. Br Dent J. 2022 Feb;232(4):227–31. doi: 10.1038/s41415-022-3980-9. 5 Devetziadou M, Αntoniadou M. Branding in dentistry: a historical and modern approach to a new trend. GSC Adv Res Rev. 2020;3(3):51–68. doi: 10.30574/ gscarr.2020.3.3.0038. 6 Sellars S, Wassif HS. Is dentistry the orphaned field of medicine? Ethical consideration for evidence-based dentistry. Br Dent J. 2019 Feb 8;226(3):177–9. doi: 10.1038/sj.bdj.2019.145. 7 Hartshorne J. Trust and the dentist-patient relation- ship. Int Dent Afr Ed. 2022 Aug–Sep;12(4):26–37. 8 Chakaipa S, Prior SJ, Pearson S, van Dam PJ. Im- proving patient experience through meaningful enga- gement: the oral health patient’s journey. Oral. 2023 Dec;3(4):499–510. doi: 10.3390/oral3040041. 9 Lin E, Julien K, Kesterke M, Buschang PH. Differen- ces in finished case quality between Invisalign and traditional fixed appliances: a randomized controlled trial. Angle Orthod. 2022 Mar 1;92(2):173–9. doi: 10.2319/032921-246.1. aligners 1 2024 37 ©️ Jirsak/Shutterstock.com

interview | uses aligners and sees their importance, she still feels that fixed appliances have application and value. What is your response to that? Understanding the fundamentals of orthodontics is crucial. It involves the manipulation of teeth and bone to enhance the smile and alter facial structure, sometimes through surgical means. Aligners serve as a powerful tool, particularly valued for their aesthetic appeal and versatility. They have numerous applications, simplify tooth care compared with fixed appliances and have been widely embraced by orthodontists and patients worldwide. Sometimes, when you have small teeth, the aligners’ plastic may not be able to engage well on the teeth, so you might need to use some kind of auxiliary or fixed appliance—these are what we call hybrid treatment cases. Aligners work fine, but like most things, there are limits, and you have to know them and what works. You must keep on learning. I liked what you said in your lecture about there being no complex cases, only questions of good planning. What strategies do you employ to optimise your digital treatment planning process, particularly in terms of integrating your own preferences and streamlining the workflow? Indeed, planning is paramount in our field; insufficient preparation can lead to errors. As orthodontists, we draw upon the bag of tricks at our disposal based on the unique challenges presented in each situation we en- counter. I engage in digital treatment planning on a daily basis. Upon receiving the initial ClinCheck plan from Align Technology, the AI algorithm is already acquainted with my thought process. Consequently, certain details may not be necessary to provide, as the AI has been programmed to understand my approach and preferen- ces. By inputting a substantial amount of fundamental information, I have tailored the system to align with my requirements, thereby streamlining the planning process and saving valuable time. What specific advancements in materials, tech- niques, or technologies do you believe will have the most significant impact on improving treatment planning and result visualisation in our field? And how do you envision these advancements contribut- ing to achieving superior outcomes for patients? I wholeheartedly agree that the trajectory of technology in our field, particularly in planning and result visualisa- tion, is promising. With ongoing advancements in mate- rials and techniques, we can anticipate continual im- provement. The future holds even greater potential for enhancing our capabilities and achieving superior out- comes. Do you have any fears about AI and the speed at which technology is evolving? I share the sentiment that many others have expressed that AI won’t replace us in our field. Our expertise, our cognitive abilities and the irreplaceable human touch will continue to be indispensable. While AI can enhance our capabilities, it cannot replicate the intuition, empathy and creativity that define our profession. aligners 1 2024 39

interview | Image: EAS Can you share what your vision is for the next con- gress, what delegates might expect, or is it too soon to ask? I regard my new role as president-elect of EAS for 2025 with enthusiasm, optimism and responsibility. EAS has grown and has an ongoing obligation to give back to the orthodontic community. We are looking forward to a great sixth congress on the beautiful and sunny island of Rhodes. No, indeed, the vision for the congress has already been established, and most speakers have already been booked and are very enthusiastic to par- ticipate! How does the independence of EAS from any spe- cific company influence the content and focus of its events, particularly regarding the balance bet- ween scientific advancements and product promo- tion? At this congress, the concept of the AlignerLab Innova- tion Village was reintroduced, and I believe it is here to stay. This is a section within the congress where compa- nies bring their best speakers to showcase the company innovations. We found this to be a fair way of making it clear to delegates which lectures are sponsored. The company workshops were a great success as well. During this congress, I have had the chance to collect some feedback regarding what delegates wish to learn more about. It seems like 3D printing, in-house aligners, and hybrid and interdisciplinary treatment will be major topics at the next congress. I believe that CBCT integration with aligners should be included again because this is a tool that is of immense diagnostic value, and we must use this with ethical re- sponsibility as part of our orthodontic diagnosis. The scientific chairman, Dr Chris Laspos, and I would also like to include a section tailored to orthodontic staff and practice management. Much of the practice’s operation relies on delegation to staff, so we have an obligation to educate our staff. The same standards and quality as the Turin and Valen- cia congresses will be maintained. The third EBAO exam will take place during the congress. For sure, the sixth congress is not to be missed! At this event, EAS has prioritised sustainability, such as the decision to forego printed programmes in favour of a digital version. Does the board plan to do more for the next congress, and how have delegates received the congress app? EAS’s commitment to sustainability is a core value. As aligner users, we use a lot of plastic, so we are urging companies to start thinking about sustainable produc- tion and appropriate disposal of aligners. I believe that this will come into effect in the future, and I am glad to share that EAS will be donating funds for research that hopefully will address this issue, among others. Congresses tend to create a lot of waste, and we will continue to pursue sustainable development goals by re- ducing the paper and plastic used. We have received very positive feedback on the congress app, and we will continue to use it. EAS’s commitment to sustainability is a core value, and we will continue to have this as a prior- ity in the future, a future that is digital. aligners 1 2024 41

interview | in the practice plays an important role. It is now much more efficient and productive to have a strong team. This teamwork helps us to make clearer to the patient what he or she can expect regarding the possible out- comes of treatment. Teamwork makes for dream work. Regarding the Align digital workflow, I can tell you that the tools available for this modality are amazing. They make it much easier for the practitioner to present the issues at hand and what can be done to solve them. The power of visualisation is critical. Our brains are very sensitive to taking in visual information directly or indi- rectly. These digital tools are very helpful in our everyday work. If you embrace the Align digital workflow and what it can give you, if you create a digital culture in your practice, it will make the work of every member of your team easier. The practitioner no longer has to take the photos or scan—there are many tasks that they can nowadays delegate. The digital workflow is a completely different way of doing things. We need to embrace these positive changes. It seems to be not only a positive change for the patient but for the whole dental team as well. New responsibilities foster a feeling of inclusion and being valued, don’t you think? Indeed, it is a two-way process. Up until a few years ago, the dental assistant’s job was to clean up after the dentist was done and to put out clean instruments for the next patient, every day, five days a week. Now, the assistant interacts with the patient and plays a part in the patient’s treatment journey. The clinician takes care of the clinical aspects of the treatment, but the assis- tant can share with the patient the expected outcome on the screen and has a closer connection to the patient than previously, being in the position to gain his or her trust. How do digital tools contribute to different stages of orthodontic treatment, and what specific advance- ments have you observed that have significantly af- fected clinical outcomes? I will answer your question with reference to a clinical tool and a marketing tool. The ClinCheck platform, a clinical tool, has given us the ultimate means of treatment planning. It gives control to the clinician, and this is very important, especially for those who are resisting chang- ing to a digital workflow for fear of being replaced at some point. This is an unfounded fear; ClinCheck is a tool in your hands. It gives you the control back, because you are the doctor in charge, and you are the one who makes the decisions. At the same time, this dental soft- ware supports you in achieving excellent treatment out- comes through continuous updates and new features. Regarding the marketing tool, Invisalign Outcome Simulator Pro simulates the expected final treatment result. It gives you the visualisation of the patient’s smile in the context of his or her face at the end of treat- ment, and that is absolutely motivating for the patient to go ahead with treatment, boosting acceptance of the treatment plan. In your opinion, what are the primary reasons that clinicians should embrace these new working stan- dards involving aligners and digital orthodontics, and how do these contribute to staying at the fore- front of orthodontic care? The simple answer is that it makes their work easier. Care needs and standards are very different nowadays, especially regarding aesthetics. We cannot accept any- thing other than excellence. Patients have become much more demanding in terms of their treatment expectations and the technologies used and will even notice the smaller details. The quicker the clinician adopts these new technologies and ways of working, the quicker (and easier) they will meet patients’ standards and expecta- tions. What about you personally? It is human nature to hesitate in the face of novelty at first. So with new tools and new applications constantly evolving, you just jump in? I am all about technology. I love technologies that are easy to use and make my work easier. To me, it seems obvious that one should take advantage of technology. I have heard it argued that we need to safeguard the specialty of orthodontics. In my eyes, the only way to protect our specialty is to make sure that we are central to it by embracing technology-driven changes and adapt- ing to them. Given the emphasis on the patient experience in modern healthcare, how do aligners and digital or- thodontics contribute to enhancing patient engage- ment and satisfaction throughout the treatment journey, and what strategies can practices imple- ment to maximise this aspect of care? I wore fixed appliances for five years, and I still remember the day the orthodontist took them off. I smiled at every- one, even if I did not know them. I still remember every visit, the pain, the numbness. We must make sure that we give our patients the best, and aligners have too many pros not to take advantage of them. As clinicians, our basic knowledge and orthodontic decisions remain the same, but we can approach our end goal in more patient-centred ways. My belief is that all treatment can be done with aligners, and we will get to the point of all cases being treated with aligners—it is part of the evolu- tion of orthodontics. If one compares brackets 50 or 60 years ago with brackets today, one can understand this evolution. aligners 1 2024 43

Communication is key In my 22 years of experience working with companies and teams as a trainer and coach, I have often heard from employees leaving the company that a lack of (clear) communication is one of their top three reasons for doing so. Be clear in communicating your expectations and obtain a commitment to these from your employees. Ensure communication is a two-way process by involving your team in making decisions about the future direction of the dental practice. Establishing clear communication includes creating an open feedback culture. How has that been rolled out in your practice? Are there regular feedback moments during the day/week/month with your staff? Does feed- back include good points, compliments as well as points of improvements? This feedback can be given in an in- formal way, in between patients, for example, or at the start or end of the working day, as well as in a formal way individually or in a group during meetings. Regarding meetings, do you have a clearly set-out meet- ing structure? The other day I was working on team communication with a practice in Belgium, and one of the major takeaways for management was that they had no structured meeting culture, so feedback was given sometimes and sometimes not. Decisions were shared sometimes and sometimes not. Half of the staff were aware of certain information, decisions and changes, and the other half not. The staff thus decided to establish different meeting structures with different time frames: meetings in small- er groups, depending on roles and responsibilities, on a more regular basis, and then entire staff meetings on a monthly basis. They decided not to book patients during the timings of these meetings in order to be completely focused. The encouraging thing about that team com- munication day was that it was the team members who asked to set up more meetings, and the orthodontists and management staff listened. How you motivate your team matters How do you motivate your team? This question is one I love to ask during training and coaching sessions. I ask people to write down all the things they do, or their clinic does, to motivate their team. Actually, you might want to do this exercise as well quickly. The answers we normal- ly get—and maybe you will give similar ones—are things like: – offering good working hours; – providing an adequate salary; – respecting employees; feature | – listening to employees; – giving employees the flexibility to choose their holiday dates; – giving employees nice work clothing; – arranging team-building activities; – celebrating birthdays and big holidays, such as with the giving of Christmas gifts; – communicating a clear vision of the direction the clinic is evolving in; – being open to feedback; – empowering employees by giving them responsibilities and autonomy; and – offering employees training. Herzberg’s motivation–hygiene theory with examples. ©️ Skyline Graphics/Shutterstock.com Do you have any others? Now let me introduce you to the motivation–hygiene the- ory. Frederick Herzberg et al. developed this theory and published it in the book Motivation to Work. Influenced by Maslow’s hierarchy of needs, Herzberg et al. concluded that satisfaction and dissatisfaction could not be mea- sured reliably on the same continuum and conducted a series of studies in which they attempted to determine what factors in work environments cause satisfaction or dissatisfaction. On the basis of their findings, they grouped these factors into motivators and hygienic factors. Motivators are as- pects that are intrinsic to the work itself, fulfilling needs concerning achievement and recognition, for example, and really motivate people, keep their focus and energy high, create a good work atmosphere and increase job satisfaction. Hygienic factors are basic needs that must be met at work to enable people to do their jobs. These are assumed to be obligatory and are extrinsic to the work itself, such as salary and work environment. When fulfilled, they can prevent dissatisfaction, but do not nec- essarily increase satisfaction. aligners 1 2024 45

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research | The Only Bondable Buttons Designed Specifically For Clear Aligners G2 METAL #10-PAB10210 Nickel-Free Alloy More Comfortable Button Head Maximized Base Precisely Matches Molar Curvature Lower Profile Stem For Patient Comfort METAL MINI #10-PABMINI Nickel-Free Alloy deal or s r artiall Erupted 1st Molars 15% Smaller Base Pad METAL MINI #10-PABCLR2 More Retentive Base Pad Sturdier Button Stem With Less Breakage Same Precise Base Shape For Superb Retention Lower Profile Stem For Patient Comfort “My team and my patients love the Precision Aligner Buttons®. The large bonding pad, ease of use, and the shape make it a perfect match for my aligner patients and a perfect match for my practice. They truly are rockstar buttons!” Dr. Dovi Prero | Beverly Hills, CA “The Precision Buttons® have allowed me to use what I want - orthodontic buttons - without the headaches of frequent breakage and it has really changed the way I practice. The low profile and smooth corners provide spectacular comfort” Dr. Bryan Lockhart | Charlotte, NC www.dynaflex.com | 866-346-5665 010924 © 2024 DynaFlex®, Lake St. Louis, MO 63367. Printed in U.S.A. Clear: Design Patent (USD910,191) Metal: Design Patent (USD859,663) Utility Patent (US11,564,778) 1 2024 aligners Scan To Learn More 51

business news | US$5 million in cash, despite having been valued at close to US$9 billion when the company went public in 2019. Lawyers acting for the company told UK magazine Den- tistry in October that the bankruptcy filing only affected its US business and that its UK and “other international affili- ated entities have not sought any bankruptcy protection”. Too good to be true Despite being laden with debt, SDC continued to ship thousands of clear aligner cases to customers in Austra- lia, Canada, Ireland, New Zealand, the US, and the UK throughout 2023, and reports suggest that it continued to advertise and sell treatment even into the final throes of its global business. Public information shows that the company shipped 106,419 unique clear aligner orders in the first half of last year, and The Guardian highlighted the plights of US consumers who responded to SDC promo- tions as late as November. Kat Fernandez of Texas told the newspaper that she received an offer for SDC aligners that was “too good to be true” and paid in full for the treat- ment on 3 November. “It infuriates me to know that they were aggressively pursuing [customers] so close to when they were going to pull out. I feel scammed and conned,” Fernandez said. Rebekka Reynolds of Oklahoma, who paid in full for her treatment in October, told the newspaper that she re- ceived news about the closure via social media and not from SDC. “I found out because a bunch of my TikTok followers started tagging me in videos, asking me what I was going to do. Then I looked it up and found out. That kind of blows my mind,” Reynolds said. In December, the UK’s Oral Health Foundation voiced its concern about the ongoing orthodontic care of SDC pa- tients. Dr Nigel Carter, OBE, chief executive of the foun- dation, said: “The closure of SmileDirectClub has created an upsetting situation for many patients who were under- going dental treatments. We are extremely worried about what impact this will have on the oral health and mental well-being of thousands of people currently undergoing treatment.” “It all leaves a very bitter taste,” Dr Carter said, adding: “Patients have been left in the lurch and it will now no doubt fall on orthodontists to rescue the situation for those SmileDirectClub customers who remain unhappy with their smile.” Founded in 2014, SDC was on a strong upward trajec- tory in 2019 when it went public on the Nasdaq stock exchange and installed 49 HP Multi Jet Fusion 3D print- ers at a new manufacturing facility. Running non-stop, the printers enabled SDC to produce 20 million clear aligner trays annually and made the company the largest user of this 3D-printing technology in the US. Prior to the SARS- CoV-2 pandemic—which hit the company particularly hard, owing to its disproportionate financial impact on its target market—SDC was a major employer in Tennes- see and other US states and had a global headcount of 6,300 staff. aligners 1 2024 53 ©️ Rawpixel.com/.com

manufacturer news | ClearX ushers in a new era of eco-friendly orthodontic care with revolutionary clear aligners ClearX is thrilled to announce the introduction of its in- novative clear aligners, marking a significant advance- ment in orthodontic treatment that prioritises both treatment efficiency and environmental sustainability. Utilising cutting-edge technology initially inspired by NASA’s laboratories, ClearX aligners are poised to re- define the standards of orthodontic care with their eco- conscious design and superior performance. Innovative technology for a greener future Crafted from high-temperature, shape memory polymers, our aligners embrace the power of 4D shape-shifting technology, a leap forward in orthodontic precision and environmental responsibility. This technology, highlighted in recent studies published in Frontiers in Materials and on Dental Tribune International, not only enhances the effectiveness of treatment but also significantly cuts down on plastic waste, aligning with the values of eco- conscious patients and dental professionals. A commitment to sustainability “Our clear aligners are a testament to our dedication to eco-friendly dental solutions,” Dr Kandil remarked. “By incorporating heat-boosting, shape-shifting technol- ogy, ClearX ensures rapid and precise treatment with fewer adjustments needed, thereby minimising aligner waste.” Reducing carbon footprints with advanced orthodontics With over 1.2 million aligners produced daily worldwide, the push towards sustainable alternatives is imperative. ClearX’s initiative is a significant step in this direction, potentially reducing plastic waste by up to 50%. Insights into the environmental impact of aligner production published by dental industry market research company insightsZ underscore the importance of such innova- tions in decreasing the carbon footprint associated with orthodontic treatments. Join the sustainable orthodontics revolution Dr Sherif Kandil, CEO of K Line Europe, the parent company of ClearX, emphasised the dual focus of these aligners: the achievement of dental perfection and ad- vancement of sustainable practices within the industry. ClearX invites dental professionals to experience this pioneering technology that not only promises an ideal smile but also contributes to a healthier planet. For more details and to become part of this eco-friendly move- ment, visit www.clearxaligners.com. aligners 1 2024 55 ©️ ClearX

manufacturer news | printer fleet remotely. These abilities allow Dr Alvetro’s staff to focus their time on more complex tasks that drive the business forwards. Commenting on her staff’s work, she said: “Two-thirds of their job has changed. They’re doing more digital set-ups and different parts of the digital workflow. Before, their main task was peeling prints off. The turn- around time for delivery of aligner cases has gone from one or two weeks to 24–48 hours. This is because the printing employee is freed up for fabrication, since Form Auto is doing the printing.” Form Auto extended the weekly active hours of produc- tion for the Form 3B+ printers to around 75–90 hours with zero additional labour by enabling them to run continuously at night and on weekends. This enabled a true third shift so that production does not end when the workday or workweek does. Dr Alvetro said that, before Form Auto, “I’d be here on the weekend because we had so much going on.” This is typical for those man- aging 3D printer fleets. After Form Auto, though, that all changed, and Dr Alvetro said, “I have not been here on a Saturday or Sunday since we bought Form Auto. Nobody has.” Even when she was first exploring how employing new technologies could help her practice, Dr Alvetro recognised that a digital workflow went beyond intra-oral scanners. “The thing we really dove into was 3D printing,” she said. Early adoption of digital dentistry technologies provided a valuable lesson. “Once you’ve bought the scanner, you’ve already made the major investment,” she explained, “and if you’re not 3D-printing in-house, you’re wasting it.” A completely digital workflow enables Dr Alvetro to see as many patients as possible and, more importantly, to provide them with the highest quality of care. For example, before Alvetro Orthodontics brought efficient production in-house, patients often needed to wait three or more days for an appliance after being scanned. Now, they can be scanned in the morning and have their appliance delivered in the afternoon. Entire aligner se- quences can be produced on the same day thanks to a digital workflow. Automated 3D printing is a major part of that but not the only part. Dr Alvetro accounts for the whole digital work- flow when deciding which products to use and how to use them. “One of the things that really helped efficiency is the ability to scan in every chair,” she said. “When people say, ‘Digital doesn’t help with my efficiency,’ the problem is the way they’re using it. They can only scan in one spot, or they just have one printer. You always need redundancy in your system.” As an example of how a digital workflow can improve the in-office experience, Dr Alvetro recounted the story of a patient who was moving to Chicago the day after her ap- pointment at the practice. The patient’s teeth had shown a little bit of movement since the last time she’d seen Dr Alvetro, and she was worried that she’d have to come all the way back from Chicago for the new aligners and to check the fit. Thanks to digital scanning, Formlabs’ printers, Fast Cure and Form Auto, that scenario could be avoided. Dr Alvetro said, “We were able to scan the patient, do the set-up, export the file, print the models and make the aligners. I said, ‘You don’t have to come back from Chicago. Come back later today.’ ” For Dr Alvetro, in-house digital orthodontics has become a major driver of practice growth. She pointed out that many of her peers who use intra-oral scanners still out- source the manufacturing of aligners, retainers and indi- rect bonding trays. In many cases, the laboratory bill for one month is equal to the cost of a printer. Often, when it comes to bringing production in-house, “The biggest expense in any office is personnel time, and it’s getting harder and harder to find people,” Dr Alvetro lamented, but with Form Auto, less labour time is needed to operate a printer fleet. “Your clinical staff will love you because they won’t always be thinking, ‘I have to go get the printer’,” she said. “It’s going to free up so much time.” Even practices that do not need to print as often as Alvetro Orthodontics does could see benefits from Form Auto, according to Dr Alvetro: “If you’re trying to make your front desk staff or your clinical staff jump in and 3D-print in between patients, you need a Form Auto more than me, because I’ve got dedicated digital staff. I think it’s for everyone who wants to print and wants to maximise the efficiency of their printer.” She pointed to reliability as a major reason Form Auto has made such a difference in her practice, saying: “It’s 100%. I mean, it does not fail.” Alvetro Orthodontics runs its two Form Autos around the clock. “They are third-shift workers,” Dr Alvetro joked. “They never call up sick. They’re in the basement working. Our invisible employees work 75–90 hours per week. Reliability, convenience and the ability to expo- nentially grow printing capacity overnight have cata- pulted Alvetro Orthodontics from a thriving practice to a digital dentistry powerhouse. Form Auto, Fleet Control and Resin Pumping System have enabled automation for Alvetro Orthodontics, allowing Dr Alvetro and her staff to spend less time working with printers. This equates to seeing more patients every day while adher- ing to the highest standards of care. Speaking about Alvetro Orthodontics, Dr Alvetro said: “We do all the printing in-house. It’s a phenomenal way to grow your practice.” For this purpose, she recom- mends the Form 3B+ printer: “If you invest in a printer, you should invest in this.” aligners 1 2024 57

Y R T S I T N E D F O E R U T U F E H T G N I L I E V N U • W O H S Y R T S I T N E D L A T I G I D 28 & 29 JUNE 2024 manufacturer news | D I G I DIGITAL DENTISTRY SHOW S T R Y S H O W • T A L D E N T I Register at www.dds.berlin Digital DentistHy Show In collaboration with Digital Dentistry Society U N V E I L I N G T H E F U T U R E O F D E N T I S T R Y 59 aligners 1 2024

industry report | Fig. 2: IData clear aligner research shows that the market share of D2C aligners is forecast to increase. (Image: iData Research) ed their business model. Whereas the D2C business model previously involved no visits to a dentist or an or- thodontist, it is now common for D2C aligner patients to consult either an orthodontist or a general dentist who is employed by the company for an intra-oral scan. This adaptation to the business model results in higher costs for the patient. Customers will still receive their aligners through the mail. Expansion of the aligner market to general dentists Some orthodontists are sceptical about the efficacy of aligners in treating malocclusion. In some cases, for greater efficacy, patients need to switch from aligners to fixed appliances during the course of treatment. For example, one in six patients switched from aligners to fixed appliances to finish treatment because the aligner treatments could not adequately achieve certain tooth movements or correct common malocclusions.5 Aligner companies are therefore expanding their prod- ucts to general dentists for treatment of mild malocclu- sions or those requiring less complicated movement. Align Technology continues to increase its presence globally by making its Invisalign products available to more customers in more countries. Among other growth strategies, the company is seeking to enable general dentists, who have access to a larger patient base than orthodontists do, to easily identify potential cases they can treat with the Invisalign system and monitor patient progress while providing high-quality restorative, ortho- dontic and preventive oral care. Align is accomplishing this strategy by providing training and clinical education to general dentists and by offering digital tools such as iTero scanners. Conclusion The aligner market is forecast to grow at a double-digit rate in the coming years, and that growth is expected to be driven by the popularity and practicality of aligners, along with various efforts by companies to expand their market share. Although D2C companies have been criticised for addressing malocclusion inadequately, they are adapting their business model to involve con- sultations with dental professionals. Considering the sceptical stance taken by some orthodontists towards aligners, treatment providers are planning to expand their businesses to general dentists who have larger patient bases than orthodontists do. Editorial note: Please scan this QR code for the list of references. about Dr Kamran Zamanian his CEO and founding partner of iData Research. He has spent over 20 years working in the market research industry with a dedica- tion to the study of dental implants, dental bone grafting substitutes, pros- thetics, as well as other dental devices used in the health of patients all over the globe. Federica Cogoni is a research analyst at iData Research. She develops and composes syndicated research projects about various fields within the medical device industry. aligners 1 2024 61

meetings | Jerko Bozikovic. (All images: EAS) Dr Gina Theodoridis. Dr Tommaso Castroflorio. aligner space. These and others also participated in the specialist exhibition, presenting their products and inno- vations. Some of the topics addressed were finding efficient solutions to challenges clinicians face, using shape memory aligners and taking an evidence-based approach for increased efficiency and predictability. On the second day of the congress, EAS President Dr Jose Gandia and scientific chairperson of the fifth EAS congress Dr Gina Theodoridis gave the opening address. Dr Theodoridis told the audience that EAS is committed to advancing the knowledge and practice of aligner orthodontics towards greater quality of care and successful treatment outcomes. The goal of the plenary sessions, she told the audience, was to highlight science rather than products. That day’s plenary sessions dealt with the themes of “The next level of aligner orthodontics” and “Growing patients and early treatment”. In his lecture on aligner orthodontics of the future, Dr Chris Laspos, an ortho- dontist specialist in craniofacial malformation, told the audience that “there are no complex cases, only ques- tions of good planning” and that it is important to focus on the fundamentals of care and to spend time on plan- ning cases in detail employing the digital technologies available. Speaking on biomechanics in aligner treat- ment, Dr Tommaso Castroflorio, a founding member of EAS, said that it is essential to be familiar with the aligner material’s physical properties, for optimal planning and successful treatment outcomes. Dr Ki Beom Kim, ortho- dontic programme director at Saint Louis University in the US, talked about the integration of in-house aligner printing using shape memory polymers, which enhance aligners 1 2024 63

3M™ Clarity™ Esthetic Orthodontic Solutions meetings | 3MTM Annual Excellere Summit to get greater ClarityTM GRAND LAUNCH of ClarityTM Aligners 2-DAY IMMERSION Lectures & workshops on the latest innovations in orthodontics Full 2-day event ticket incl. Clarity White Night dinner Early bird ticket (until July 1st) Ticket for students and staff 660€ 330€ 330€ AUDITORIUM DELLA TECNICA Rome Italy 13-14 Sept 2024 Friday - Saturday NETWORKING DINNER Historical Galleria del Cardinale Colonna of the Colonna Palace SECURE YOUR TICKET go.3M.com/ClarityEvent aligners 1 2024 65

meetings | with a special focus on digital products and the digital workflow in dentistry. Through live product presentations, workshops, discussion sessions and an exhibition, the 2024 Digital Dentistry Show seeks to provide attendees with first-hand knowledge of digital dental products and services and to offer space for personalised advice and face-to-face interactions with industry leaders. With the focus on robust research evidence, the scientific programme will feature presentations by pro- minent opinion leaders, including Drs Henriette Lerner, Alessandro Cucchi, Mirela Feraru, Howard Gluckman, Fabrizia Luongo and Setareh Lavasani, and cover a wide range of topics, such as artificial intelligence, the digital workflow in maxillofacial surgery and full- arch rehabilitation, and digital bone surgery. Attendees will have the opportunity to earn valuable continuing education credits. Besides a strong educational aspect, the 2024 Digital Dentistry Show will serve as a social hub for dental experts, professional organi- sations, manufacturers and publishers who are looking to form or expand their network of like-minded, future-oriented individuals. To be hosted at one of Berlin’s industrial pearls, the unique event location offers a rich history and a distinctive modern feel. The 2024 Digital Dentistry Show is expected to attract over 2,000 eminent dental professionals from around the world. You are invited to be one of them! The adjacent Escobar and the Badeschiff spaces will enhance the relaxed and jovial atmosphere, underlining the informal and engaging nature of the show. More information on registration and the scientific programme can be found online at the event’s official website at dds.berlin. The Badeschiff is a picturesque floating public swimming pool area overlooking the Spree river. aligners 1 2024 67

m o c . k c o t s r e t t u h S / s l i e x p 2 3 © meetings | product feature | submission guidelines | 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. · These image files must be no smaller than 80 KB in size (or they will print the size of a postage stamp!). Please contact Nathalie Schüller at n.schueller@dental-tribune.com. aligners 1 2024 69

AlignerFlow LC FLUORESCENT COMPOSITE FOR ALIGNER ATTACHMENTS • Secure grinding and removal under UV-A light • Precise application with perfect flow • Light-curing through the transparent template • Stable and abrasion resistant throughout the entire treatment period • Pleasant aesthetic in tooth shades scan QR code to learn more Available from 1 May 2023 VOCO GmbH · Anton-Flettner-Straße 1-3 · 27472 Cuxhaven · Germany · Freecall 00 800 44 444 555 · www.voco.dental