DENTSPLY SIRONA Inc. (XRAY) Earnings Call Transcript & Summary

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 5, 8.

Five or six.

Five or six, yes, and general questions. So okay, well, thank you for joining us. Dr. Bankhead, thanks for being here with us. And just feel free to start whenever -- 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 yourself and ask directly or if you want to 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 if we did surgery? And I think that's a very valid question. And 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 I. So we'll just jump over to stage R for the maxilla, and we can watch the 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 formation. 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 tuck -- let's 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 gingerly, 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 minus 1. So let's go all the way 1.0, sorry, Dr. [ Gabe ]. So let's just bring this up another millimeter, that's 0.1. So let's go, keep going. Negative. Yes, negative. So negative is going to be intrusion. And so we look -- let's jump to the lateral. Let's make it minus 1. And you can also type in a negative sign and 1, however you want to do it. But I think we're still perhaps about 1 millimeter deep. Let's make this one maybe minus 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 this first premolar and let's bring it down and 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 lip. So if we were to compare the 2 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 millimeters 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 2 more millimeters of correction. So I don't believe much beyond 4 millimeters, 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. And 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 pretty feel comfortable that it's going to take a good portion of the treatment. As far as when we start treatment? If we go back to Stage I, and we look at the occlusal contacts, and I think it's right here, yes. Let's go to the mandible. Yes, 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 to aligner 5 or 6, 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 on the mandible to do the IPR, and so I wouldn't have a problem doing it all up front. 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 a scalloped trim just had very limited abilities to develop the arch form and to create the space. In this particular case, the crowning 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 make -- spend a lot of more time setting up the case, you'd want to type some notes here. And usually, I'm going to say, I have corrected -- looks close on us. Okay. Let's try it again. We'll go into the site 54 or 72. Sorry, guys, we got logged out. But -- I think you 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, maxillary right lateral, the maxillary right central. Please set the new bite according to -- as 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 is looking good. And in those cases, I'm going to say, extend the trim height to 1 millimeter or 2 millimeters, 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 study show that you only get about 0.75 millimeters of Class II correction when you use a scalloped trim, and the reason is the aligner is 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 to 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 first or 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 -- in a proximal 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 especially 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 time line, all the IPR is requested on Stage I. So 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 it between the premolars and the molars and the distal to canine, but I don't feel comfortable doing the distal, the lateral, the medial of the canine, and the distal, the central, mesial, the lateral. So 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. So once again, to recap this case, if you'd like to improve the overjet on this case, and we can now apply some molar distalization, some Class II elastics, we do more on the right than on the left, we could avoid any IPR in the 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? I cover everything. Okay. Great. Let's go to the next one. And if questions come up later, we can always jump back to these questions. Now this question is 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 you 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 incisors is one of the most difficult things that we do. And so this is double 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 are 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-millimeter straight is a really good idea. Now if we look at the tooth movement details on the bottom right, and we click on the [ key motive ] 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 on to the 3 -- the 4-2, the 4-1 and the 3-2. I think those 3 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. Any time you're trying to do extrusion, it makes your rotation harder, it makes everything harder about the case. So this particular case was add a few attachment 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, no. 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. That's 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 the 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, and 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 40. Superimposed where we're starting from, we can take off the trim line. So where we're headed? In spite of all this amount of movement that's going to happen buccally -- let's flip this, so we're looking from the occlusal view now. Yes. So in spite of the fact we've got all this movement taking place, we're pretty much have set the case up to converge back towards the original position of the roots. So if we look at the lower-end 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. And 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. And 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 -- the demandable 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-millimeter straight. In this particular case, you could warrant a couple of modifications. One is the movement of the canine 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. You 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. 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 1, 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, off the buccal surface about 2 millimeters 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 it 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-millimeter 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 is going to be at work on a regular basis anyway. And maybe leaving it at the straight 0-millimeter trim. If you have a patient, who is 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 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 small 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 embrasures 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 is I evaluate the case as 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 minus 17, maybe minus 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. And 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 there are 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 millimeters 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, with using IPR. And I think you'll have less likelihood of opening up gingival embrasures if you do it. In the long run, 0.4 millimeters really means 0.2 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 the patient after Stage 8, every 4 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 employee 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 set up 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 thing that you can do is you could delay your attachments for the first 8 aligners. So you could have in the mandible the straight trim and no attachments into 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 apply them. So I would tell the lab no attachments in the mandible until stage 8. Attachments in the maxilla are fine from day 1. And that's another way to sort of allow the patient to get used to aligners. Some doctors like to have the first 2 or 3 aligners period without attachments, just so the patient has a little easier way of getting integrated and a little smoother first visit coming into the office as well. Any questions about this case? Did we cover the questions? Okay. Great. Yes. All right. Let's move on to the next one. Are we doing on time?

We've got about half hour or 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, go to the initial -- I guess, it doesn't show initial records, does it? Okay. But there's quite a bit of crowding on this plan. And sometimes what happens is not that we're trying to tell you can or can't treat the case, that's not what we're trying to show you. 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 them out with the braces on and will digitally take them off. And then you can bring the patient in and take the braces off and set the aligners on the same day that you removed 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 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 to patient into spending 6 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. So I think the setup is done properly. Absolutely. So 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, referred 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 in the extraction space is a much more difficult process. And I'm just not as skilled. I don't have the patience. 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, the 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 nonextraction, 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?

Dr. Bankhead, this is Peter here. I just got a question about the class correction there with the buttons on the case -- little bit..

Yes. What's the rationale behind it?

Yes.

Okay. So sometimes what doctors will do is they'll use them actually from like, 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 lower canine to lower molar. And let's bring -- let's extrude that a little bit. Let's quick on that one and just bring it up into play. Yes. There you go. And then you're going to have to move the attachment up as well. It will turn red when they're too close. Use the arrow, right. 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. And so as the molar starts to tip, you can run a vertical elastic from the maxillary molar to the maxillary molar, and that will sort of up right 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 and to encourage parallelism at the extraction site, and I 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 the -- in this case, to have vertical rectangular attachments on all the second premolars to assist with that. Does that help you with the question?

Yes. I think I understand the idea now.

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.

Yes. Okay.

And then the question.

Okay. Great. So this question was -- so we've already gone through the case on the aligner, like should have been a better time for the IPR and avoid round tripping. So this is a great question. 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 name or game of 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 where to reduce the amount of 2 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 can get rid of the IPR at stage 4. The advantages 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 last time and be able to perform the IPR at the halfway point at stage 9 and stage 18. Now if we go back to our original reference. So if we reference where we started and we turn it on, we flipped 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. And we're not -- even though we're flaring the crown. 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 design 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 2 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 can feel very comfortable that SureSmile is going to give you exactly what you want. Let's see, was there another question on that?

I think you said something about [ getting ] or doing IPR.

Yes. So sometimes what I will do in a case as 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, have gone in and done some of the reductions, 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. 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 too, 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 0.3 or 0.5 or 0.2, 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 or the lower right central. I can get a high-speed bur back there and reduce a little bit of the contour and alleviate some of that crowning 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 are not going well, the doctor is under producing -- under providing 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 see properly and to allow the teeth to track and to fit together when we set ourselves up with failure. Okay. What's that? So we had a question...

Yes, we did have a question -- from Dr. [indiscernible], I don't know if I'm pronouncing his last name right. But anyway. Do you normally treat 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 is 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 attach 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 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 bite, 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 Dr. [indiscernible]. Raise your hand up.

Can you hear me?

Yes.

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...

Because they were so tight.

They are so tight.

Yes, so that's what I commonly experience when you have teeth to 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. Yes, let's flip straight on, here we go and let's throw 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 millimeters 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 8, 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 inside 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 8 aligners without the attachments, then I'm going to use aligner 8 as the vehicle to apply the attachments and then transition into 9 with the attachments on. So there's many ways to deal with this. But the aligner is 2x 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 attachment, 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 us a different trim height if you're having troubles. But in this particular case, I think you can try any of those options. You'll see definitely some improvements from what you're dealing with right now.

Yes. The problem was you can't order scalloped aligners and use the same plan, it was not possible to change. So you -- but I have to rescan to remove the scalloped.

Yes. 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 1. When you do a refinement scan, and that'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 in [ diff ] and what you can do, if you decide to bring this patient back and do you find that 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 on, just for educational purposes. Okay?

Yes. Okay. But one more. 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 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 set up and create a new setup very similar, but we can't have it be exactly the same just because of those limitations. 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 every re-scan. 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 warrant going to the scalloped from -- 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. Any other questions, Susan?

I don't see any questions. Thank you.

Sorry, it's Peter. Can you clarify the workflow? Let's say you have this -- has now -- the patient comes in, he places the attachments and asks to replace the attachments, the patient cannot get the aligners on. How will you put 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 millimeters 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. They get used to it, they get practice and they get better off at removing the aligners. Strategy is 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 3 or 4 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 8 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 or 3 millimeters of the aligner on the buccal surface. And usually by us just trimming the first 3 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 3 aligners, then go to 0 millimeter for the next aligners and the last 3 aligners give me 2 millimeters 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 to 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, et cetera. And the properties of the aligners are greatly affected by whether we do scalloped, straight and extended straight. And for me, I probably use 0 like -- in this particular case, I use 0 millimeter in 90% of my cases. But my refinements are usually extended trim. So I'll go up to 1 millimeter if I'm trying to open the bite or just change torque or reposition a little bit. Or I could actually drop down to scallop if I have an isolated tooth to need 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 to launch. We just -- 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? Susan, what's your question for the night?

What's my question for the night?

I know you're open...

Are you ready for Christmas?

I am not. I have got to pause this year, and I've got Mrs. [indiscernible] taking 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. 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. Thank you for another evening.

Thank you very much, Dr. Bankhead, for joining us, and thank you, everyone else.

Are we back this year or we back next year?

We're back next year. And in that famous e-mail that I just sent you, that's one of my questions, of the 2023 schedule. So I hope you will look at that quickly, that would be great. For the rest of this year, we're finished. Happy holidays to everyone. Okay.

Happy holidays. Thank you.

Okay. Bye-bye.

Bye.