Hi, everybody. Good evening. Welcome to tonight's Q&A session with Dr. Brent Bankhead. Thanks for joining us. We've got quite a few cases, I think, tonight, somewhere around five or eight. Five, six. Five, five or six. Yeah. And a general question. So. Okay, well, thank you for joining us, Dr. Bankhead. Thanks for being here with us. And just feel free to start whenever. Oh, I do have to say this session is being recorded for internal purposes only, okay? So thank you. I will unmute you all. You will be able to unmute your own mics if you want to ask a question. Feel free to unmute yourselves and ask directly, or if you want, use the Q&A or the chat section because I'll be keeping an eye out for that, okay? Great. Thank you. Okay. All yours, Dr. Bankhead. Great. This first case is really a wonderful discussion to kick off tonight's session, and the question is, the patient's Class II and their mandible is sort of retrognathic, but they're not willing to go through surgery, and the question is, how do we reduce the overjet? How do we evaluate the plan, and how do we achieve an improvement if it's not going to be as perfect as if we did surgery, and I think that's a very valid question. I always like to start sort of with an assessment as to where the smile is beginning, and oftentimes, I'll click off the mandible so that I can more distinctly evaluate how we're going to position the teeth, and this is at stage 1, so we'll just jump over to stage R for the maxilla, and we can watch them morph into the projected smile. Now, in my opinion, I think this is not done enough. What I mean by that is, if you look at the transition from the posterior to the anterior, there's a tremendous vertical step at the canines to the first premolars. And so we really have a posterior occlusal plane and an anterior occlusal plane. And I think the positioning vertically is pretty good in the anterior. But in general, I'd really like to see the bite more open. So if we jump out of the face for just a minute and just look at the straight-on occlusion, to me, we've left a lot on the table. We're still really deep. I feel like over time, this will just cause the patient to wear their anterior teeth more dramatically. And so I think it makes sense for us to go ahead and do some modifications. Now, we can give the digital lab some information, so we can select, modify the case, and we're given the opportunity to modify the plan as needed, and I don't know if I have the authorization to modify this plan or not. Let's try that one more time. There we go, so we can just move that up to the very top. There we go. Great, so let's start with just a little bit of modification that we may want to treat. If we click on the canine in the maxilla, so we're going to click on the maxillary canine, you can move the tooth just by intruding if you want, and you just basically can move this up or down, and I think in general, I want to do a combination of intrusion, canine to canine, and some extrusion on the first bite. That doesn't mean we can't send that off to the lab and have them do it, but let's just intrude occlusal gingivally, and we'll go to the square, and we can either use the down arrow box on our keyboard, or we can click on the negative, and let's just make this -1, so let's go all the way 1.0. Sorry, Dr. Campion, so let's just bring these up another millimeter. That's 0.1, so let's keep going. Negative. Yeah, negative, so a negative is going to be intrusion, and so let's jump to the lateral. Let's make it -1, and you can also type in a negative sign and one, however you want to do it, but I think we're still perhaps about a millimeter deep. Let's make this one maybe - 1.5, so we'll just do a little more intrusion. There's already 0.3. And we'll go all the way up to 1.5. And that may be a little bit more intrusion than we need. But you can see that we're already starting to open the bite quite a bit. We'll leave the left quadrant alone. Let's go to the first premolar. Let's bring it down. You can just probably click on the arrow if you want and hold the down arrow and just drag it down. Perfect. And then we can do the second premolar. And to me, this transition is a lot more attractive. And I think we can jump back to the smile photo. And we'll go with just the maxilla and the smile. So if we were to compare the two smiles, I really think that the right side is going to be way more aesthetic and way more pleasing. So I would ask for additional bite opening. Now, we're still deep, so if we bring the teeth back together and jump out of the smile photo, we still have a very deep bite, and when we look at the posterior occlusion, you can see that we're still Class II, and ways to reduce overjet, you could definitely add IPR and retract, but it's going to be very limited in what you can accomplish. In my opinion, I would intrude the mandibular teeth so that we have the proper depth of bite, and I would add Class II correction, and you can do that dentally, and you can do that somewhat skeletally. Dentally would mean that we would move the maxillary molars distally, and we call that distalization, and typically, up to about 2 mm is what you can retract the maxillary molars and execute a pretty good improvement. Secondarily, you can add elastics that would typically be worn from the canine to the mandibular molars, and that's going to add up to about two more millimeters of correction. So I don't believe much beyond 4 mm, and it definitely makes it more difficult. But I think long-term, this patient will do much better if we add some Class II correction, some additional bite opening. I don't think the mandibular bite opening is sufficient. And we can see that there's wear on these incisors already. And so this malocclusion is somewhat destructive to the patient. Now, when we wear elastics, there's a couple of things to consider. One is your treatment time is going to be longer than the 14 stages we see here. And obviously, if we do additional intrusion, it's just going to take more time. But there's no correlation between wearing elastics and the number of aligners. We sometimes finish the number of aligners, and we're still Class II. So we either do a refinement and order more aligners with minimal adjustments and just mainly focus on wearing elastics. Other times, you may finish your elastic wear earlier than the number of aligners. And so when you bring into play these bite corrections, it's important to keep an eye on both of them independently. Most of the time, your elastic correction is not going to happen overnight. And so you can feel pretty comfortable that it's going to take a good portion of the treatment. As far as when to start treatment, if we go back to stage 1 and we look at the occlusal contacts, and I think it's right here. Yep. Let's go to the mandible. Yep. Cool. We can see that there's contacts on the buccal surfaces of the lower incisors. And so we're going to have some bite interference, and it's going to take a few stages before we start to see the bite open up. And so what I'm getting at is there's no sense in applying the Class II correction probably till aligner five or six, knowing that we're still in contact. You really want bite opening before you actually apply the anterior-posterior correction. The last thing we'll look at is when to do the IPR. In this particular case, the IPR is all scheduled from the very beginning. And as we look, it looks like there's pretty good access in the mandible to do the IPR. And so I wouldn't have a problem doing it all upfront. The other option is if you would want to treat this case without IPR, then you absolutely could do so and save the IPR for your refinement. Reasons that traditionally aligners and IPR are very famous is the Scalloped Trim just had very limited abilities to develop the arch form and to create the space. In this particular case, the crowding perhaps is a little more severe on the lower right, and we're probably applying some IPR to help with the midline coordination. So in general, I think this is a good case. I would encourage more elastic and distalization. I think this would give you a better result and definitely open the bite significantly more than what you see now. Now, if you were to spend a lot more time setting up the case, you'd want to type some notes here. And usually, I'm going to say, "I have corrected." Whoops. Close on us. Okay. Let's try it again. We'll go into their site 54072. Sorry, guys. We got logged out. But I think I got one extra number. There we go. Anyway, so I would tell the digital lab, "Clean up what I didn't do properly. I've set the maxillary right canine, the maxillary right lateral, the maxillary right central. Please set the new bite according to what is a reference." And if you're not intending to do any IPR, but you may have created a little bit of IPR, tell them to clear out any intersections that might have happened in the process. As I would move into refinement, so let's say this case goes to refinement, and we still have some overjet that we want to reduce, and we want to wear elastics, but the alignment's looking good, then in those cases, I'm going to say, "Extend the trim height to 1 mm or 2 mm" which provides a stiffer aligner and which is better at controlling the emergence profile of the incisors as well as opening the deep bite and executing the Class II correction. So in general, Scalloped is preferred of a trim type, and the studies show that you only get about 0.75 mm of Class II correction when you use a Scalloped Trim. And the reason is the aligner's just too weak. It doesn't execute that. Any questions about this case before we move to the next one? Okay. We'll move to the next case. And this case, would I perform all the IPR according to the plan to shift the midline? And in this particular case, I think if we start with the smile, we can see that there was a lot of eruption on the anterior maxillary teeth initially. So we've got sort of this occlusion at the lateral to the second molars, and then our centrals are somewhat extruded and worn. And I think this is a good start. So as we look at the plan, I think we're making progress. But I would probably do a little more intrusion and maybe even consider if the patient wanted to do some lengthening of the incisal edge on the maxillary right for our central incisor. But I think vertically, the case is pretty good except for maybe dealing with that issue with the central. If they're going to leave it alone, then we're going to just have a gingival discrepancy in heights between the lateral, central, central. They're just going to zigzag because they're not perfect. Now, how do we correct the midline without IPR? This is once again a Class II case. So the case has some protrusion to the upper jaw. And so in lieu of doing the interproximal reduction to improve the midline to the right, you could just wear elastics on the right side, let's say full-time, and in the mandible or on the left side, part-time. And once the maxillary midline coordinates, then you could wear both sides full-time. And so I don't think the IPR is mandatory. When we look at the timeline, all the IPR is requested on stage 1. You have to ask yourself, "Are you comfortable doing all that IPR on the first visit?" Typically, what I'll do is I'll look at the occlusal view and say, "I could probably do between the premolars and the molars and the distal of the canine, but I don't feel comfortable doing the distal of the lateral, the mesial of the canine, and the distal of the central, mesial of the lateral." You could ask for the staging of the IPR to be once the teeth are straightened or the contacts are approximated, and that would give you a great opportunity. Once again, to recap this case, if you'd like to improve the overjet on this case, then we can apply some molar distalization, some Class II elastics. We do more on the right than on the left. We could avoid any IPR in this first round, and we can save the IPR depending on how compliant the patient is. If they're making great progress or if we're having trouble with keeping the midlines coordinated, then we could apply it more in the refinement. But it would definitely make this a more complex case should you go that route. Any questions about this case? Did I cover everything? Yes. Okay. Great. Let's go to the next one. And if questions come up later, we can always jump back to the questions. Now, this question's a great one, and it's revolving around the starting position of this maxillary left lateral. And there's some staging that's involved in this case. The tooth needs to come buccally. It also needs to rotate the mesial towards the facial surface. And then it needs to extrude as we get to the final treatment. So if we click on the R stage, we can kind of see how this is all supposed to unfold. And let's click off the toggle. There we go. So we can see the progression of the teeth. Now, there's a couple of things that we need to think about. The attachment is placed vertically, and we'll just go to the last stage. Because typically, extruding the lateral incisor is one of the most difficult things that we do. And so this is beveled to help with the extrusion. We could modify the attachment. So we could make it bigger. So if you click on the attachment and then click on the menu bar and do type, now we could pick the next size up, and we could increase the size of the attachment. And it's going to be a bigger attachment as it starts to think. Now, because we're also rotating the tooth, we can rotate the attachment about 45 degrees. We're just going to go counterclockwise. I think the other way. There we go. And we can call that a sash attachment and maybe rotate back just a little bit, a little bit more. Perfect. And now, if we toggle back to our starting position, we can see we can still fit the attachment on, but this attachment will help with the derotation of the lateral as well as the extrusion. And so I think the IPR associated with the tooth, the attachment associated with the tooth, they're all appropriate. If you didn't want to do the IPR at the very beginning, we could stage it for once the teeth are more properly positioned. Obviously, the earlier you do it, the better. And you just have to ask yourself, "Can I do a good enough job guessing on how to set that up?" Now, when you do rotation and extrusion of an incisor, you always want an attachment. It's super important to have that attachment in place. If you're doing intrusion and rotation, it's not as important to have the attachment. Intrusion is like the secret magic sauce that always works and improves your rotational correction. But because we're extruding and rotating, you definitely need the attachment. And I think for a lateral, it's important. The last thing we need to talk about is the trim type. The trim type, you have to have some flexibility within the aligner. So we wouldn't want to do an Extended Trim by any means. We could consider a Scalloped Trim, and that wouldn't be too terribly inappropriate. But there is some mild arch development and some mild expansion built into this case. And so I think the 0 mm S traight is a really good idea. Now, if we look at the tooth movement details on the bottom right, and we click on the cumulat ive, and we click on the mandible now, this tells us the total amount of movements for the mandible. And the canine has an attachment for 13 degrees of rotation on the lower right. And on the lower left, there's 10 degrees. There is some rotational correction on the lower incisors, and we do have some extrusion as well. So typically, because most cases have deep bites and we're intruding the lower incisors, I wouldn't be so worried about having attachments on the laterals. But in this case, I think the lower incisors ought to have attachments as well. And so I would ask the lab to apply attachments onto the 4-2, the 4-1, and the 3-2. I think those three areas could definitely benefit from having attachments, mainly because we're rotating 17 degrees, 22 degrees, and 19 degrees, and we're doing some extrusion. Once again, extrusion is the game changer. Anytime you're trying to do extrusion, it makes your rotation harder. It makes everything harder about the case. So this particular case, let's add a few attachments on the mandible. If you want to not leave out the lower left central, then just add attachments lateral to lateral. And I think you're going to be okay. Any questions about the case? No. On the case now, there's a general question for you, but I guess we could do the other patients and then come back to that question. Okay. Great. Sounds good. Okay. We'll go to our next case. Okay, and this question is, this is one of the employees. So this is a staff member on the team of a dental team, and there's a lot of IPR. And do we need to do it? And I think that's a very good question. Let's start back at stage 0, so we're going to go back to pretreatment. We'll go back even one more step if we can. Sometimes if you click, there you go. Perfect, and you can see there's a very deep bite. And if we take off the maxilla and just look at the mandible for a second, there's a tremendous amount of Curve of Spee. And if we tilt that down so we can look from the occlusal view, and we take off the gingiva, and let's superimpose the reference. So we're going to put where we're starting, sorry. We'll go to stage 14. We're going to superimpose where we're starting from. We can take off the trim line to where we're headed. In spite of all this amount of movement, it's going to happen buccally. Let's flip this so we're looking from the occlusal view now. Yeah. So in spite of the fact we've got all this movement taking place, we pretty much have set the case up to converge back towards the original position of the roots. So if we look at the lower lateral on the right, the lower canine on the right, there's a lot of buccal movement, but we shouldn't be worried about inducing more recession, mainly because we've tried to keep the root position pretty much stationary with the original spot. I think because of the amount of crowding that starts initially, this case would be better treated if it was treated with the IPR than without the IPR. I think the lab did a really good job of setting up the case. Now, my biggest concern is that the aligners are going to be very difficult to remove. So if we take off the reference model here, sorry. Put the mandible back on. I really think that the case is going to be tricky. And what I mean by that is our current plan for the trim height is a 0 mm Straight. In this particular case, you could warrant a couple of modifications. One is the movement of the canines is not so tremendous that we couldn't decrease the size of the attachment. So one change is we could click on the attachment, and these are things that you can do on your own. You don't need the lab. We can go to type. And we can just downsize each of the canine attachments. The smaller the attachment, the less retentive the aligner is going to be. And so it's just thinking about it, and it's made it smaller. Same thing on the opposing canine. We can click on it, and we can make that attachment smaller. Now, the premolar attachments, I think, are more for opening the bite. So a lot of times when you're intruding your anterior teeth, you really need some attachments in the posterior to help open the bite. So those are appropriate, as well as the rotation of the mandibular right first premolar. Now, how would I deal with this? Long term, when you're opening the bite, Straight Trim does better than Scalloped, but for the first few aligners, so if we just click on aligner one, you can see we've got a tremendous amount of crowding, and there's going to be increased retention of the aligner, so a clinical pearl that we could consider is you just take out a pair of scissors, and you'd cut off the buccal surface about 2 mm off the aligner so that you're extending closer to the crown and less at the root junction, and that will remove a tremendous amount of undercut that can happen when you have these cases with crowding and recession. If you'd rather start easy, then you could do Scalloped Trim, but it's going to be a little bit less effective at opening the bite. But as you do your refinement, then you could jump back to maybe even a 1 mm Extended Trim, knowing that most of your crowding has already been alleviated. So ways to fix this would be modify some of the initial aligners. And this is an employee of a doctor, and so I don't see modification as being a bad thing because the patient's going to be at work on a regular basis anyway. And maybe leaving it at the Straight 0 mm T rim. If you have a patient you're worried about their ability to take the aligners in and out, then definitely consider the Scalloped. This is a great opportunity because Scalloped works well with recession, severe crowding, and lots of attachments. Now, let's look at the maxilla for just a minute, and we'll just look at the initial Straight-on view. We can see we have a reverse smile. And our goal is to maybe follow the contour of the lower lip. So if we click on our last stage and we click on our smile photo, we can see that as we transition from the initial to the final, we're making a very good improvement in the aesthetics of the smile. There's a tremendous amount. Let's click off that. And we'll click on the toggle one more time. So I think we're making a good improvement in the smile aesthetics. And I think the IPR, once again, is appropriate, mainly because there is a lot of crowding. We're going to have a risk of getting some gingival abrasions as we expand and align the teeth. But there is one area of concern, and we could probably go into our modification of the setup. And one of the things that I like to do as I evaluate the case is we go ahead and we look at the symmetry. So the centrals look pretty symmetric. The laterals look maybe not as symmetric as I'd like them to be. The maxillary right lateral, the mesial seems to be a little bit more to the buccal than it is on the left side. But the canine is where it stands out the most for me. So if I was to click on the canine, I would probably want to rotate the mesial in. And so I'm going to make this instead of - 17, maybe - 12 or something, and take out some of the correction to enhance the mesial surface coming more towards the lingual side. I might do the same thing on the lateral. Instead of just accepting 10 degrees, I'm going to probably bring it up to 15 and see if I can get that a little bit more symmetric with the other side. Now, once again, this is something you can easily request from the lab. We can look at it from a different perspective, and we can see that the canines and the laterals were just a little bit asymmetric as far as the way they're positioned. But I think a little tweaking and making sure that they're more mirror images of each other makes a lot of sense. Now, the last question is, what about taking out the wisdom teeth? If we took out the wisdom teeth, could we reduce the amount of IPR? And once again, getting back to it, I see no problems in treating the case without IPR. But I think in this particular situation, you're going to need it by the time you get to refinement. And if you want to reduce the IPR to a lower amount, like 0.2 mm or something like that, and be more conservative in the beginning, that's totally fine. But in my opinion, the wisdom tooth is not the problem. The crowding and the midline coordination is all in the anterior portion of the jaws. And so these problems are going to be better dealt with using IPR. And I think you'll have less likelihood of opening up gingival abrasions if you do it. In the long run, 0.4 mm really means 0.2 mm off of each surface at that contact point. And in this case, the IPR is staged throughout treatment. And so we're only picking the areas where we have good access. And you basically will need to see this patient after stage 8, every four aligners for a little while so that you apply the appropriate IPR at the right point. And once again, there's not a tremendous amount of round tripping associated with it because we might tip the crown buccal, but we keep the root lingual when we create that extra space to align the teeth before we do the IPR. So a really great case. I think this patient is going to love their new smile. And I think things will look really great when it's all finished. But I do think that in the long run, you're going to need the IPR. And I think the biggest issues in the short term are cleaning up the setup just a little bit and then deciding whether you want to do Scalloped on the mandible or Straight. And if you're okay with modifying and just trimming a little off the buccal, that will do a tremendous amount of improvement. The other things that you can do is you could delay your attachments for the first eight aligners. So you could have in the mandible the Straight Trim and no attachments until stage 8 and place them at that point. And there's enough biological contours. You can see deep embrasures. There's going to be a "biological attachment" with this case. And so a third option would be just delay putting the attachments on in the plan and not necessarily delay applying them. So I would tell the lab, "No attachments in the mandible until stage 8. Attachments in the maxilla are fine from day one." And that's another way to sort of allow the patient to get used to aligners. Some doctors like to have their first two or three aligners without attachments just so the patient has a little easier way of getting integrated and a little smoother first visit with coming into the office as well. Any questions about this case? Did we cover the questions? We did. Okay. Great. Yes. All right. Let's move on to the next one. How are we doing on time, Susan? Yeah. We've done the half hour, so. Great. Now, this case is a great case. We'll go back to stage 0 on this case. And the case was originally rejected because of the amount of crowding. And so in the plan, we can see. Let's go back to the therapeutic model. So we'll just drop down. We'll go to the initial. Oh, I guess it doesn't show our initial records, does it? Okay. But there's quite a bit of crowding on this plan. And sometimes what happens is it's not that we're trying to tell you you can or can't treat the case. That's not what we're trying to show you. What we're trying to show you is that when we manufacture the case, sometimes there's so much retention on the case that the aligners will break, and it's a manufacturing problem. And so in those particular cases, you have a couple of options. One is you can do some initial alignment with braces. And SureSmile is one of the few companies that will actually let you scan the mouth with the braces on, and we'll digitally take them off. And then you can bring the patient in and take the braces off and slip the aligners on the same day that you remove the braces. But in this particular case, this is more of a crowding issue where we may want to, on an adult, just consider extraction of premolars. And so that's exactly what this case has been set up for, is extraction of the premolars. If we look at the maxilla, really kind of similar situation, not as severe as what we're dealing with in the mandible. And now we can jump over to the plan, and we can look at how this plan is set up. Now, personally, I don't know if I'd rather have a surgical procedure or treat cases with aligners and extractions. Maybe appendectomy, sure, I'd have the surgery. And I'd say this jokingly because they're just harder to treat, and they take a lot more time than what you would really want the case to take. And so personally, if I have an extraction case, I really try to talk the patient into spending six to 12 months in braces and then transition into aligners to finish up. And the reason being is that it's really difficult to keep your roots parallel adjacent to the extraction sites. Do I think the setup is done properly? Absolutely. Do I think the patient would benefit from extractions? Absolutely. And my advice to the doctor treating this case is if you're new to aligners, save yourself some grief and don't treat it. Refer it out to a local orthodontist or someone else. And sometimes the best decisions you can make in treatment have to do with the fact that you've not treated a case versus whether to treat them or not. And I think in the long run, I definitely see justification in this case for extraction. But if I only was limited to aligners, I would really want to make sure that the patient understands that this is going to be a slow and drawn-out process. Obviously, they're going to love their smile within a year, and their teeth are going to look good. But getting everything to line up perfectly with the bite and the extraction space is a much more difficult process. And I'm just not as skilled. I don't have the patients. I worry that my patients that I'll be dead before they're done at my age. And so I prefer, whenever possible, to treat extractions with fixed appliances and maybe roll into brackets, I mean, aligners, to finish up the case. We did a really great study here at the university. And what we found is cases treated with braces and aligner, whether it was extraction or non-extraction, actually had better outcomes than cases just treated with braces or just treated with aligners. And so I think hybrid therapy is definitely a component of the future. Any questions about this case or about extraction cases in general? Hi, Dr. Brown. This is Peter. I just got a question about the class correction there with the buttons on the case there. I was a little bit— Yes. What's the rationale behind it? Yes. Okay. So sometimes what doctors will do is they'll use them actually from, let's say, the canine to the molar in each quadrant. And this one attachment sort of disappeared in the mandible. And what I mean by that is getting the teeth to migrate towards the extraction space can be augmented by wearing an elastic from the canine to lower molar. And let's extrude that a little bit. Let's click on that one and just bring it up into play. Yeah. There you go. And then you're going to have to move the attachment up as well. It'll turn red when they're too close. Use the arrow right there. There There you go. Perfect. So I think that's the rationale, is how to do it. And then also, you're going to get tipping of the molar. As the molar starts to tip, you can run a vertical elastic from the maxillary molar to the maxillary molar, and that'll sort of upright and get the aligner to fit better. I would add some additional attachments in this particular case. So I would try to put an attachment on the first premolar or second premolar and make it a vertical rectangular attachment to encourage parallelism at the extraction site. And I'd do the same thing for the maxillary canine on the right side. If we look at the other side, we can see that the vertical elastics are there to help encourage the vertical movement as well as the anterior-posterior movement. And like I said, I didn't put a lot of effort into reviewing this case, mainly because it really takes a bigger thought process about wanting to do this. So initially, the doctor would probably wear elastics from upper canine to upper molar, lower canine to lower molar to help with retraction to get the teeth right. And then you just switch to vertical as needed if you get some tipping. And I would encourage on this case to have vertical rectangular attachments on all the second premolars to assist with that. Does that help you with the question? Yes. Thank you. I think I understand the idea now. Thank you. Okay. Great. If I had time, I could pull up to my own cases, and I could show you how vertical elastics have really helped to keep those teeth tracking when they start to tip over. And the aligner provides a wonderful template for keeping those in place. All right. How are we doing, Nate? We got any more? Maybe one more patient? Yeah. Okay. Yeah. And And then the question. Okay. Great. So this question was, so we've already gone through the case, already aligner, should have been a better time for the IPR, and avoid round tripping. So this is a great question. And I really like this question because it's a legitimate concern. And I would say that I usually do my IPR before I scan or once the teeth are Straight. And the reason for it is it's very hard to predict how much you've taken off the teeth when they're not Straight. So let's just start with one arch, Nate or Gabe. I'm changing your name. And so if we look at this from the occlusal view, and let's go to stage 0. So we can see that if I was to try to project to reduce the amount of tooth structure between the laterals and the central incisors, especially on the lower right quadrant, it's going to be more difficult to perform that IPR right off the bat. And so what happens is the software will automatically, let's do the orange tab, say, "Okay. Here's where you can do your IPR." And then you just see the patients later. Now, in this particular case, there's 18 stages of IPR. We could ask the lab to break this down into IPR that's available at stage 0, at stage 9, and stage 18. And we could get rid of the IPR at stage 4. The advantage is that long-term, we want to reduce the amount of visits to the office if possible. And so I would rather do, let's say, a telemedicine phone call around stage 4 with one of my employees to check in and see the patient one less time and be able to perform the IPR at the halfway point at stage 9 and at stage 18. Now, if we go back to our original reference, so if we reference where we started and we turn it on, we flip that upside down, we're doing a really good job to make sure that the root apices are approximated within the alveolus to the original spot. So it doesn't matter which stage we start at. If we jump to stage 12 from stage 4, you can see we're very cognizant about where we have the roots. Even though we're flaring the crowns, so if we flip this back around, the crowns, the white crowns, are where the teeth are headed, and they're more buccal in most cases than where we started from. But we're very good about measuring where the roots are going to be. So when we designed the software, we already had a tremendous amount of experience because we already allow CBCT integration. And so as we played out our formulas, we applied these to cases where we had CBCT data. And we were able to come up with a proper balance of buccal movement and root torque in order to preserve that in the round trip. So personally, if I approved the plan originally, and I think the plan is sound, I'm not worried about the round tripping associated with applying the IPR. I think you're going to feel very comfortable that SureSmile is going to give you exactly what you want. Let's see. Was there another question on that? You said something about scanning before doing the IPR. Yeah, so sometimes what I will do in a case is I might perform some IPR upfront. The advantage is that if I don't know exactly how much I've taken off because the teeth are not properly aligned and I can't get a gauge, at least I've gone in and done some of the reductions so that they're going to fit better, and so don't underestimate the advantage of doing some IPR early on, and let's look at this occlusal view one more time, and let's toggle, so if we look back at the start, let's turn this up just a little bit, so the mandibular right, let's go halfway down. There we go. The mandibular right lateral, you can see the contact point is totally buccal, so I could get a fine diamond and a carbide on the mesial of the lower right tooth. And I could recontour and take some of that enamel off. I couldn't quantify it. So if I'm saying, "Did you take off point three or point five or point two?" I wouldn't be able to do this. But if I was to reduce that, knowing that I wanted to take some tooth mass off early or at least in my therapy, this would definitely be a tooth that I could gain some access. Same thing on the distal of the lower right central. I can get a high-speed burr back there and reduce a little bit of the contour and alleviate some of that crowding before I even scan. So don't underestimate the ability to use pre-scan IPR as a formula to reduce some of the crowding. And then also, when you get into therapy, I prefer to stage the IPR once the teeth are Straight so that I can quantify that I've taken the right amount off. Oftentimes, when we troubleshoot cases that are not going well, the doctor is underproducing or underproviding the appropriate amount of IPR. They either totally forget to do it or they're just doing a small fraction of what's required. And so it's very important. All of us come back from Christmas holiday and New Year's celebration, and our pants are a little tighter than when we went into it. Well, aligners are no exception. If we don't produce the amount of reduction required, it's going to be hard to get the aligner to seat properly and to allow the teeth to track and to fit together when we set ourselves up with failure. Okay. What's that? Okay. Oh, yeah. So we had a question about. Yeah. We did have a question. Yeah. Hi. From Dr. Callegi. I don't know if I'm pronouncing his last name right. But anyway. He normally treats a lot with fixed appliances in combination with osteotomies. What do you think, or what about aligners in combination, aligner therapy in combination with osteotomy? I think it's a great treatment option. And when you do cortical perforations with bone graft, you can get an acceleration of treatment as well as you can ignore the confines of the current alveolus. So in cases where you really want arch expansion and the patient's willing to go through a surgical procedure of buccal perforations and bone grafting, I think that's a great way to enhance your ability to expand the arch healthily in a healthy fashion. And they show long-term that your gingival tissues actually increase and attached gingiva, and it's very well received by the biology. Now, when you look at conventional orthognathic surgeries like Class II, Class III, that's more of a situation where I have very limited experience. And I know there are several very good lectures that are done, in particular by Dr. Moshiri, that would have been done at the AAO. I'm sure you can find them on the Invisalign website, or you could reach out to Dr. Moshiri directly. But he's a wonderful expert in orthognathic surgeries where you actually fix your Class II, your Class III, or your transverse cross bites, things like that, and you combine aligner therapy with that. I am not very adventurous in life, and so I have not done that to this point in my life. So I'm very limited. Although I'm very experienced with the buccal perforations and bone grafting, I think that's a wonderful option. Any other questions? There is a Dr. Jokinen. Do you have your hand up? Yeah. Hi. Hi. Hi. Hi. Yes, please. Can you hear me? Yes. Yes. Perfect. Yes. I was going to ask about this case. So we already made the aligners, and they were absolutely impossible to set them in the lower jaw. So. Because they were so tight. So tight. Yes. Yeah. So that's what I commonly experience when you have teeth to the lingual and to the buccal. The easiest way to deal with that is to trim off a dramatic amount of the aligner on the buccal. And you could go, "Let's look Straight on here." Yep. Let's look Straight on. There we go. And let's turn the gum tissue on and the trim height. So for example, in this case, you can see that the trim height is absorbing a lot of this area right at the junction of the gingiva with the root surface. And so you've got this tremendous amount of undercut. If you think about reducing the aligner all the way up to the base of the attachments, in some areas, that's 4 mm or more, you'll be surprised how much easier you can get the aligner off by just only reducing the buccal. The reason I don't touch the lingual is I don't want to have to polish it so that the patient can tolerate it. The second option is you can order the same plan. So if you get into trouble and say, "I want the same plan. I'm going to send you my original records, and I want Scalloped Trim now," then what you can do is use scalloped while you're trying to get the alignment done and then just transition over to the Straight Trim as you get your alignment. So I might finish, let's say, aligner number eight, and I see the teeth are in pretty good shape. And I might, at that point, decide that that would be the right time to transition to the Straight, and let's take off the toggle. So if I got to stage 8 and I had pretty good alignment, then that would be a good time to transition over from the Scalloped and side where the Scalloped 8 and then the Straight 8. The other option is you can definitely remove the attachments in the short term. And so if I was going to wear the first eight aligners without the attachments, then I'm going to use aligner eight as the vehicle to apply the attachments and then transition into nine with the attachments on. So there's many ways to deal with this. But the aligner is two times harder to remove with a Straight Trim than it is with Scalloped. And so if you struggle with that in these cases where you see recession and crowding and attachments, don't be hesitant to manually cut it off or just settle for the Scalloped in your first round. And in this case, you've got only 12 aligners in the mandible, and you've got many more in the maxilla. You could conceivably do a refinement even earlier on and do it at the end of stage 12 in an effort just to get a stiffer trim height if you're having troubles. But in this particular case, I think you can try any of those options, and you'll see definitely some improvements from what you're dealing with right now. Yes, but the problem was you can't order Scalloped aligners and use the same plan. It was not possible to change, so you. Well, what I mean. It's all that I have to rescan to do the Scalloped. Yeah. You actually can just submit your original records, but you can't modify this current plan. You have to do a refinement plan. And the refinement plan can be off the original records, and you can tell the technician, "Give me the exact same setup that you gave me in plan one." When you do a refinement scan, and it's a whole new scan, the reference is a little bit lost when we upload the model. And so you're better off just doing an upper and lower start from scratch new. But one thing you can do if you decide to bring this patient back and do a refinement right away, go ahead and pull out this current plan and just cut off a bunch of the aligner on the buccal surface, and you'll be shocked at how much easier it is to go on and off just for educational purposes. Okay? Okay. Yes. Okay. Thank you. But one more. Did I understand right that I don't have to rescan if I want to make the Scalloped? You don't have to, but you do have to submit a refinement, and a refinement would be, "This didn't fit. It was too tight. Give me the same plan with the Scalloped Trim." And we can do that as long as you send the original records. If you send new records, the references are not a perfect transfer, and so you're better off just doing a whole new plan, and you can have the lab reference the original setup, so if you really like the original setup, we can look at that setup and create a new setup very similar, but we can't have it be exactly the same just because of those limitations. Okay, but I think in my own personal experience, usually aggressively trimming the aligner is sufficient, and then I might secondarily reduce a couple of the attachments and then generally add them back on. So rarely do I personally ever rescan. And I think the key in this case is just to look at the original plan and say, "Is there a lot of crowding? Is there a lot of undercuts? Is there a lot of retention associated with the case?" And that's when you could learn going to the scalloped for the first batch. When you want to finish a case, Extended Trim is much better at expressing the setup than the Scalloped will. From the studies, we know that when we do a plan and we use Scalloped trim, we're going to probably only achieve 50% of the original plan. So Scalloped is just not going to be as effective. But sometimes it's the only option in order to get the patient to get the tray on. And often, most of us aren't willing to do house calls. We'll say, "Good morning. Let's take off your aligner. Go eat. We'll put it back on, and I'll be back this afternoon to do the same," and so it's just a challenge that we have to deal with in the short term. Okay. Okay. Thank you. Thank you for participating. Any other questions, Susan? I don't see any questions. There's a thank you. Can I, sorry. It's Peter here. Just to clarify. Of course. Of course. Can I clarify the workflow? Let's say you have this, he has now. The patient comes in. He places the attachments, and after he places the attachments, the patient cannot get the aligners on. How would you process that? Would you then remove the attachments and ask for a new plan? Not normally, so usually the way I deal with it is I just trim down the buccal surface of the aligner 2 mm at least, and all you're trying to do is eliminate some of the undercuts that are engaged on the embrasures between the teeth and the curvature of the crown as it transitions from the middle third to the cervical third. You're just eliminating some of those undercuts, so in most cases, the problem is only going to be the first few stages, and I would remove the attachments as a last resort. I usually just trim the buccal surface of the aligner, and that's sufficient. The second aligner will be way easier than the first aligner for the patient to get used to, to practice, and they get better at removing the aligners. Strategies if this becomes a consistent problem for you and you don't want to always trim the aligner, and then we can also look to the future. I can tell you some of the developments that are going to come in the future is you could avoid placing any attachments at all for your first three or four aligners. So you could say, "I don't want any attachments." And that gives the patient the ability to take the aligner on and off without having to deal with the added retentiveness of having an attachment. And if you're worried about some movements, you could just ask the lab, "Give me the minimum amount of movement for those first few stages." Now, if you don't want to do that, I'm kind of a jump in, get them scheduled, and I like to let them go eight weeks before I see them again. Then I'm going to trim the buccal surface of the aligners. And I'm going to show the patient, and I tell the patient, "There's nothing sacred about 2 mm or 3 mm of the aligner on the buccal surface." And usually by us just trimming the first three aligners, they're going to transition quite nicely into being able to do that. The last option is, yes, take off the attachments or consider a refinement and just order Scalloped. Now, one of the things that's going to happen in the future is you may have the ability to say, "Give me scalloped for the first three aligners, then go to 0 mm for the next aligners, and the last, give me 2 mm Extended." And so we'll have what we call variable trim types and heights throughout a series of aligners. And in orthodontics, that's a very common approach. We don't just put braces on and use one wire and say, "See you when we're done." We strategically plan different wires for different types of rotation, leveling of the bite, expansion, etc. And the properties of the aligners are greatly affected by whether we do Scalloped, Straight, and Extended Straight. And for me, I probably use zero—like in this particular case, I use 0 mm in 90% of my cases. But my refinements are usually Extended Trim, so I'll go up to 1 mm if I'm trying to open the bite or just change torque or root position a little bit. Or I could actually drop down to Scalloped if I have an isolated tooth that needs some eruption, but I've got my arch form from my original series. So there's many ways to approach these cases. And unfortunately, it's somewhat difficult to calculate in every case, but we learn and we develop strategies based on this lesson. On this particular case is more pertinent because we felt like we had a failure launch. We didn't get the patient started as planned. But it's an important concept, and I could see a rationale for treating this case with Scalloped trim from stage 1. But normally, in my own office, I would probably just reduce the buccal surface, and it would be fine. Does that help you at all? Thank you for clarifying. Thank you very much. No problem. Susan, what's your question for the night? Oh, what's my question for the night? I know you're opening up. Are you ready for Christmas? I'm not. I am Santa Claus this year, and I've got Mrs. Claus taken care of, but I've got my parents I still have to figure out and a few of the neighbors and friends and things like that. Yeah. Yeah. I'll always have Miranda. Dr. Miranda is my mouse man. And what kind of a gift could you give to such a vital guy who's running the show on the computer? Oh, yeah. Okay. Well, thank you for. For another evening and. Thank you very much, Dr. Bankhead, for joining us, and thank everyone else. Are we back this year? Are we back next year? We're back next year. Okay. In that famous email that I just sent you, that's one of my questions. Oh, gosh. About the 2023 schedule. So if you can all look at that quickly, that would be great. Okay. Okay. Super. For the rest of this year, we're finished. Happy holidays to everyone. Okay? Happy Holidays. Thank you. Okay. Okay. Bye-bye. Bye. Bye. Thank you. Bye. Thank you all. Oh, thank you. you all. Oh, thank you.