Expand podcast: Setting the perfect staging

This transcript has been reviewed by AI and may contain inaccuracies.

Daniel Ramos: Welcome everyone to Expand podcast. Today's topic, we're going to discuss something very important for those who want to practice orthodontics with aligners with the best quality possible, how to set the perfect staging. And to discuss this with me, I invited one of my colleagues and friends that I admire most, a person who is passionate about technology, cars, wellness, exercise. He's very active, who already saw him in a congress speaking, knows the energy he can put in the room. Pedro Costa Monteiro, welcome. Thank you so much for accepting my invitation, for being here with me. Well, thank you.

Dr. Pedro Costa Monteiro: Thank you, Daniel. Wow, what a presentation. I'm not so big as you said, so I'm really happy to be here. It's always a pleasure to share experience with you, with your team, and I will never forget that for a long time. You also support me. So it's really a pleasure to be here with you.

Daniel Ramos: The pleasure is all mine, Pedro. Well, we know each other for a while, right?

Dr. Pedro Costa Monteiro: Yeah.

Daniel Ramos: When I was in Brazil, we started discussing creating projects together and now that we are close and we can see each other more frequently in the congresses, I think you are the best person to bring your expertise about aligners and these strategies that we need to know to make the treatment more predictable, to make things happen. Right? Because there is a lot of misunderstanding, a lot of doctors who are starting using aligners, sometimes they believe only in what the companies are saying. They are not going to discuss the details. They are almost like forgetting what they learned in the past. Right. The biomechanics, of course, this is something we need to use. Right. When we are talking about staging, right. This is how, when we plan a case, regardless of the system, the software, the company, when we move teeth inside a software, we are not moving teeth. We are creating a force system. I don't know if you agree with.

Dr. Pedro Costa Monteiro: I totally agree. Let me go a little bit earlier on time, and I think it's really important for the ones that are hearing us. This is all about orthodontics. So we change the way to practice. So we move for plastic. But 80% of the success of any orthodontic treatment is about the orthodontists, the planning, the staging, as you said. So, to be honest, it's not about the brand. It's not about only the kind of plastic. But as you said, it's about force design. And what you said, that I am really passionate about this, and I really am. What for me is incredible when we are using aligners, is that you can apply any orthodontic technique and related with this topic of staging. For example, for the ones that come from the Bernstein ideas, they can apply exactly the same. If you come from, if you came from edgewise therapy, you can apply exactly the same. I know a lot of doctors using aligners, and they apply for tip back on all the molars, so you can do whatever you want. And this is what I really love in this profession, is that you have your ideas, you have the way you like to treat your patients, the way you like to apply your biomechanics, you can do it with aligners. So it's only that. And for probably in your podcast, we will probably have some young doctors listening to us. And please do not think that this is an easy way. This is not an easy way. And as you said, there is a lot of advertising around the brands. They are saying, hey, we are faster, we are easier. We don't need attachments, or we don't need that or that. It's not true. Come on, let's be honest. You have to be the one that decides for each case what you need and what works better for each patient. And if you think like this, you will succeed for sure.

Daniel Ramos: Well, yeah, I agree 100%. And the companies are there to sell, right? Of course, there is a war going on, claiming the best material, the best software, the best AI. But in the end, if we don't have a good pilot there, this car is not going to move. Right. To understand what we are doing and to believe that just by doing a certification that you are going to practice orthodontics, this is a huge mistake. One of the biggest mistakes, misunderstandings that I can hear even in papers, is to understand that just by moving teeth in the software to the final ideal position and allowing the software to move in the sequence, the technician or the AI believes it's the best. It's going to be enough to get there. And then when we don't get there, the papers are saying, look, aligners, they are not predictable, they're not moving, they are not working as well as braces. So this is completely unfair. Right? Predictability. Even though staging, a good staging will increase the predictability, but it's not the main topic today. But when talking now about staging, Pedro, a good analogy that I like to say, to repeat for my students, to my colleagues when I'm lecturing, is that when we set the final position, regardless if we are overcorrecting or et cetera, et cetera, we are defining our destination, right? And we are defining where we are going. And the staging is more or less together, the vehicle. Right. If we're getting by plane, by boat, and depending where we are going, we need to understand the best transportation we.

Dr. Pedro Costa Monteiro: Need to use to get there. Yeah. I have some nice idea to share with you about it. Probably you will also agree with me. Usually when I am talking with my students, I tell them, because nowadays everyone use Waze as an app to drive, or even if you walk from one city to another city, you like to use the Waze app. Why? Because it will tell you exactly where should you go. And more than that, it will tell you if there is, for example, an accident and you cannot go through this road, you can change your plan. And this is made by artificial intelligence, so it's not so different about our treatment plan, obviously. And we can discuss, go a little more deeper on this, because you are talking about companies, and I can give you my view on that, putting myself as a CEO of a company. So if we think about the big companies on aligners, they have thousands of employers, which is really expensive, and they are investing, I think, almost everything on artificial intelligence. Why? Because they want to reduce the number of employers. Of course, if I was a CEO, I would say, well, I don't need that 10,000 cad designers. I prefer to invest a lot on a computer that maybe could do the same job. I'm not saying it will do the same job, but maybe can do something like that. And on the other hand, we have the orthodontists working every day and giving all the data to the company. So nowadays they have the initial position, they have all the process, and most of them even have the final position, because you will ask for retainers, so they can exactly analyze all the data and understand what works better. So if they have this data, they apply this data to the artificial intelligence, probably they will have very nice treatment plans in the future. So this is how I see the future. And because we are talking on a specific topic of staging, and if we think about data again and staging, so let's imagine that, for example, they are following my cases on sequential distalization. Then they pick up another orthodontist from Spain, for example, and they will see how is it distalizing, and then they will see, okay, Pedro is wasting 90 aligners to achieve this position. This one is only using 60 achieving the same final position. So let's follow this protocol. And that's why we have nowadays so many protocols bringing in by the companies to help us. Of course, I see the artificial intelligence always helping us. So for me, it's not a problem. It's a very nice weapon. But always with this idea that we are giving a lot of data to all the companies, which is nice on one hand, and is not so nice on the other hand, but I try to pick up the best of it. Let me give you a very special example on staging, probably, obviously, you have heard about the Frog protocol, which was created by a doctor that after repeating so many times the same protocol for the company, they said, okay, we will create your own protocol, and we will call it Frog because of the design it has on the screen. And now you can call any company and say, please apply the Frog protocol. So I think that in the future, we will have this, and I know that companies are working on this. Even maybe in the future, we, as an orthodontist, we can, like, make a patent of our protocols. Why not? So the staging is really the base for success in alignment therapy, in my opinion. It's something that you need really to understand and to manage really well, otherwise you will fail.

Daniel Ramos: Yeah, we came from an era that we didn't have artificial intelligence, right, when we started, and the companies learned a lot from us, actually, and we made a lot of mistakes. And the AI here, now, it's helping these new doctors to avoid these same mistakes we did in the past, because the software is learning bus as any other artificial intelligence, at least for now. And this is what I feel, is that we need to fill, we need to feed with our information. Of course, patient is different, right. And we need to understand when sometimes we need to use this rock pattern for lower anterior intrusion, for example, to extrude posteriors that we don't have many anchorage. So for those who are starting with aligners and even for the most experienced ones to understand the weapons we have, it's very important. And also, this correlation between staging and predictability, because my first cases with aligners, with the company aligners within Visa line, I believed 100% what the technician was doing for me and didn't change anything and simply didn't happen. And then, of course, as an orthodontist, I started looking to the software and seeing not teeth moving, but plastic shaping. And this is what we are doing. We are bending wires with a software to create the plastic in the shape we need promoted for. So these types of staging, I believe you agree with me. It's impossible for us to explain with details. It's very visual, right? Yeah, but have several, like the frog explosion pattern, sequentialization.

Dr. Pedro Costa Monteiro: I think the most important thing around this is, again, don't forget that we are talking about orthodontics. So you have to understand which tooth will work as anchorage? Which tooth should we move at a time? When can we move more than one tooth? This is always the way we think. I think, for example, I will give you my way of thinking about staging, which is not the same of other doctors. So I have my own way of thinking. First, one of the good things of the staging is that you can completely manage the number of appointments. So I know exactly when I need to see the patient, and this is really important. So, for me, in my practice, my goal is not to see the patient. So I invest a lot of time on the first treatment plan. I create a staging that is more predictable than anything. So I don't want it to fail, and I don't want to see the patient. And the only way for me that it works is to reduce the velocity. So usually, I go really slow to move the less number possible of this at a time. So, for example, if I want to digitalize, many times, I use the 100% protocol, which people think, hey, but are you crazy? You are doing, like, 90 aligners for kids. Yes. I prefer to do 90 aligners and do not touch him and do not see him and do not have to do a new scanner and restart the case. And I know that in 90 aligners. It will be predictable. It will be slowly but predictable. So this is just one example of seeing the staging, but that for me, it really works. You were talking about also the frog protocol. I use the frog protocol for interior correction of the speaker on the lower arch, as you said. But I also use it, for example, when I want to close spaces. So if I want to distalize canines and incisors, I do not use. Usually I do not distalize everything at once. So I prefer to go slowly. And I have a nice experience working like that. And again, I work with many brands, and the staging makes it predictable. So it's not about the plastic. Yes. Sometimes you use one brand that combines different plastics and things go better. Other times you use another one. It goes slowly but with the same results. So no worries. It's very important for the orthodontist to invest time, and it's not only time, it's experience on understanding the staging, and many times you fail. As you said, I remember my first cases of invisalign were done in 2004, and it was crazy. I had to end up all the cases with braces, but it was not their fault. It was my fault because I do not understand the system, and I just click the proof and it's done. So obviously it doesn't work

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Daniel Ramos: Exactly. Yeah, no, I agree. And more than this, how hard for us with braces was to calculate the ideal force, right? Of course, we're talking about a complex movement that for each direction there is a specific amount of force. Ideal. And with softwares now, it's something that the software can calculate for us. And we cannot compete when we are talking about numbers and data. Compete with a computer and artificial intelligence is not a competition. We need to use in our benefits for the patient, actually. So, yeah, I completely agree. At this moment, we are going to receive more and more the plan clincheck or any other software very close to the ideal, sometimes ideal. And we are going to personalize according to the patient, their wishes and limitations. And we may need to do a final touch, but saving a lot of time and using the time better, right? Yeah, no doubt, Pedro, that you mentioned about the staging. 100%. As you know, we have here in DSD TPS, and we partnership with several dentists all over the world, orthodontists. And when we plan a case and we implement a sequential distalization, 50%, 75, 100%, whatever. Normally doctors, they complain about, oh my God, increase a lot the number of aligners. I prefer the previous one, that is shorter, but when more is less, when more aligners means less treatment time in the end.

Dr. Pedro Costa Monteiro: Yeah, I totally agree with that. That was my idea that I shared with you before. So this is something that I have been studying the last years, and it's very important for our colleagues to understand. One thing that I like to ask to my colleagues when we are talking about our way of working, is how many hours a patient spends to see you. So we have to understand that he has to go from his home or his work to your clinic, which can take ten minutes, 1 hour, 2 hours, we don't know. Then they have to wait a little bit at the waiting room, then they go into your office. Sometimes you check, you look at the liners and you say, it's perfect, you can go. And then they took another 2 hours to get home. So there is people losing one morning to see you, and people don't like this. No one's like this. So if you give them the chance of giving a predictable treatment with everything under control, that during one or one year and a half, you only see them twice or three times, they will be really happy. Because again, time is money for everyone. They have time to work, to spend with their family, to enjoy, to do whatever they want, not to see the dentist or the orthodontist. So if you have the chance to apply a protocol that is really predictable, this is what they are asking for. Let me give you a quick example. Yesterday, I saw a patient. She came to my office because she was not happy with treatment. She was using aligners. She was combining aligners with tats. They are trying to distalize. She was really with a high level of compliance, so she wasn't using elastics, everything. And she said, hey, I don't know what is happening, but I'm every month seeing the doctor, and I'm here for three years, and I don't see any changes. Okay. And, okay, we don't have to go deeper on the case, but this is just to give you how people feel when things are not going well. And all of us have wrong cases, so we are not the special ones. All of us have them. But if you invest on a very good treatment plan, and as you said, you can do it, or. Or even you can delegate on a center like yours, you will be very happy, because your patients will be happy. All the treatment will happen as you planned, so there is no emergency. This is what we are looking for as an orthodontist. So don't be afraid of reducing the velocity of the aligners. Don't be afraid of using protocols that took more aligners. Just focus on predictability and fitting, because when they come into your office and you see a misfitting of 2 mm, for me, this is kill me. So I hate this. So, yes, I believe that, in my opinion, going slowly makes things easier. No doubt.

Daniel Ramos: Yeah. The thing is, the software can do everything. We can simulate anything, the software. And in the software, things will happen.

Dr. Pedro Costa Monteiro: I have a very nice idea to share with you about it. I always call the movies that we see from any brand a romantic movie. And as you know, in our life, unfortunately, life is not so romantic. So if you still believe in romantic movies, maybe you can approve the first treatment plan. If not, be careful. And more than that, I think all the brands also have this, which they call the TMA button, where they put that small callers saying, hey, this is a black movement. You cannot do it only with aligners. They are telling you, be careful. You know that I see a lot of treatment plans from my students, and they remove it. They remove the TMA button, not just. Just not to see it, which is crazy. So be careful on that, because even being a romantic movie, they are saying, hey, be careful. It will not happen. And you accept it. It's very easy. To accept. And another thing that I always say, I don't know why, but probably you have the same opinion when you talk with doctors all over the world. I know very good orthodontists that during many years, invest a lot of time on diagnosis. And then when they start with the liners, they stop doing all the diagnosis and focus only on the treatment plan and on the romantic movie, and it will not happen. So be careful on this. This is my fight for a long.

Daniel Ramos: Time.

Dr. Pedro Costa Monteiro: Nowadays, to be honest, I am not even touching my patients. Most of the things I can delegate, but the diagnoses, I'm doing it every day, every, every day.

Daniel Ramos: To neglect, to skip this step. Diagnosis is the fastest way to fail, right?

Dr. Pedro Costa Monteiro: To kill.

Daniel Ramos: Yeah, because this is still the basis.

Dr. Pedro Costa Monteiro: And it will be forever. Even with artificial intelligence helping us. Even that. Because as you know, even nowadays with artificial intelligence, we can invest, reduce the time we invest on diagnosis, because we have artificial intelligence working on cephalometrical analysis, all the data around the diagnosis. But you need to understand it. You need to look at it and say, okay, this is a problem on the bandeval. It's not on the maxilla. This is not for extraction, this is for surgery. So I think that giving you the full treatment plan and diagnose will be never possible. With artificial intelligence, there will be always an orthodontist, at least looking at the data.

Daniel Ramos: Yeah. It's like traveling without destination, right?

Dr. Pedro Costa Monteiro: Yeah, yeah, yeah, yeah.

Daniel Ramos: Flying blind. You are getting somewhere. You don't know if it's going to be good or bad in the middle of the ocean. Right. And this is not good. But I like the movie analogy. I love analogy. To use it saying that it's yours. It's nice. I asked who invented analogy. For now, it's going to appear. You mentioned about the dots, right. And I really like to use these as an example because I had a paper here that we're going to post in the notes for everyone who is listening to. Take a look from Weir, an Australian doctor. He reviewed all types of movements and the complexity of each one. Right. And for intrusion, posterior intrusion, for example, up to 0.5, it's difficult, it's predictable. More than 0.5, up to one moderate, more than one, very complex. And this way on. And for digitalization, since you mentioned the 100%, more than 2 mm is moderate and more than four, they consider complex difficulty. The black dots, right? Yeah, I agree that I see a lot of people, colleagues, once they see the black dots. Oh, we need to reduce. We need to limit. And then we start limiting the. The outcome, right? The same way as now with CDC, when the roots are moving out. Oh, no, let's move in. But if you need to move out, we need to find ways to get there and expand. But when we're talking about stylization specifically, and we have this black dot, a movement. I don't know if you agree with this paper. Maybe your data is a little bit different. You consider difficult three or five, I don't know. But these difficult destabilizations, do you think only a good staging can be enough or the kind of space that we need to bring back all the concepts and bring adjunct therapies and strategies?

Dr. Pedro Costa Monteiro: I think there is a lot of issues around it. And again, for example, I will give you an example. A colleague of mine was using a system to distalize 50% protocol. The patient was using the elastics. So she said, Pedro, I think I'm doing everything perfect. Why doesn't. It is distalizing. Why? And I just told her, hey, can I see the panoramic x-ray? Can I just check it? Yes. And what happened is that on the distal surface of the seven, there was no bone. There was no bone. So you can do whatever you want. It will never distalize, because we know that roots only go where there is bone. So if there is no bone, you cannot distalize. And she said, but how will I solve it? How would you do it with braces or probably I would extract. So you have the answer. So it's very difficult to say. Okay, in my case, I can distalize without TADs until 2.5 mm or it depends. It's very difficult to give you a rule. What is important? As you said, there are, thanks God, a lot of papers now. And we have to be very careful analyzing the papers because this is a big issue. My father is a professor of engineering, and he helps a lot of dentists in thesis of master degrees and doctoral degrees. And sometimes it stays crazy because how can you publish things like this where you only have a clinical case or ten clinical cases? This has no validity when we are talking about science. So these are not real studies, these are clinical cases. Unfortunately, in our profession, we accept a lot of papers that are not so valid. So we have to be very careful first around companies, because companies publish a lot of things that sometimes are not the best ones, and be careful when you analyze each paper. So I'm very careful about that. Obviously, there are still not too many papers around some of the features that we are using. So we are like MacGyvers, trying and going the right or the wrong way. But, for example, you are talking about distalization or class two patients. I love a paper published by Tommaso Castro Florio, where he was talking about the use of mandibular advancement combined with elastics. And with a very nice study doing on a lab, they proved that you should not use elastics at the same time you are using Matt, because the deformation you will apply to the plastic can completely change the biomechanics and the forces you are applying. And sometimes we try to go by our minds and, okay, I will try this or that, and sometimes we are not going on the right way. So I think we should follow the real science around this, be careful analyzing it. But there is more and more science now, more professors, more universities investing time, and having students full time on aligner therapy, which I think is very helpful for us as clinicians at least, to have some science-based opinions, and not only our opinions. So it's difficult to give you a rule, but if I want to say a number, for example, for distalization, usually without TADs, I do not distalize more than 3. Still do a lot of extractions when it's time to do it. Why not? If the problem is in the premaxilla and it is an extraction case, why shouldn't we extract? So I still apply the same concepts from when I was working with braces.

Daniel Ramos: But you gave the answer I was looking for. Diagnosis, right?

Dr. Pedro Costa Monteiro: Yeah.

Daniel Ramos: That's it for us to start summarizing and getting to our conclusions on how to be good in staging, to set the perfect stage. You start mentioning the basics to be an orthodontist, to not forget what you learn and invest time diagnosing properly. So by doing this is the first step for you to achieve a successful final outcome, right?

Dr. Pedro Costa Monteiro: Yeah.

Daniel Ramos: To understand the biomechanics and to understand that we have now new tools, artificial intelligence, that it is like having many, many other orthodontists helping you with their protocols, being collected and selected the best ones so you can use to save time, which is very important. Right? And finally, the whole idea that this is something we need to. To not miss the opportunity here, to read the papers that they are important, right? They bring some information, but this is happening to me because for several years, the papers are saying that aligners, they are not working, and then you are going deep and you are seeing that, okay, but they are using just one set of aligners, or they are not overcorrecting, or they are distalizing. Altif at the same time. So you need to filter, you need to invest time in diagnosis and use the new tools to achieve these ideal outcomes. Ideal is difficult, right? But a good functional status for the patient that is going to be as stable as it can be. I believe this is our goal in the end for the patient to be happy. Pedro, I can’t thank you enough for being here and sharing all these amazing insights. Your experience is incredible and the way you share it brings analogies, bringing clinical examples. I believe everyone, even just listening without seeing any image can close their eyes and actually from you today. Right. And I'm excited to hear the feedbacks and thank you so much. Any final thought about this topic? Anything you'd like to share before we finish?

Dr. Pedro Costa Monteiro: Yeah, so just thank you for the opportunity. Hope at least we can inspire some young orthodontists with our ideas. I think there is a long way to go, but a beautiful road to go. So keep on pushing the liners because I think we are really making something beautiful around orthodontics nowadays. Thank you one more time for having me here.

Daniel Ramos: Thank you, Pedro. Thank you everyone for listening to us at Expand podcast and hope to have you here with us in the next episode. See you there. Bye bye.

Dr. Pedro Costa Monteiro: Bye.