Orthodontics in General Practice

In this article, Tif Qureshi, Clinical Director of the IAS Academy discusses how to incorporate orthodontics into your repertoire as a GDP

Dr Tif Qureshi | BDS

GDP & Clinical Director IAS Academy

Editorial Board, Dental Update

Past President BACD

Tif Qureshi qualified from Kings College London in 1992. He is the Past President of the British Academy of Cosmetic Dentistry, Tif has a special interest in simple orthodontics using removable appliances. Tif also pioneered the concept of Progressive Smile Design through Alignment Bleaching, Bonding and is also an experienced teacher in the Dahl concept to assist in minimally invasive dentistry. Tif now lectures nationally and internationally and has had many articles published on all these subjects. Tif sits on the Editorial board of Dental Update. He is a Clinical Director of IAS Academy.

I developed the concepts of Align, bleach and bond and Progressive Smile Design (PSD)-both of which have had a profound effect on cosmetic dentistry here and abroad- I also have treated and followed up hundreds of cases using the Dahl principle for the interceptive and minimally invasive treatment of wear over 20 years. Align bleach bond and PSD have dramatically changed thousands of dentists approach to cosmetic dentistry around the world and very likely prevented thousands of unnecessary veneer preparations- I am very proud of that 

I have been very lucky in being able to develop a concept within aesthetic orthodontics and even though I’ve spoken all around the world at many huge conferences on pretty much every continent, but I have to say, going back to Kings College, where I trained and lecturing there was probably one of the main highlights. It was a real privilege and probably won’t get any better than that. Of course the development of IAS Academy, an international faculty of dentists and orthodontists, teaching appropriate orthodontics to general dentists through courses and long term mentoring, is also a highlight and I’m very proud to have started it and be part of its growth.

I probably would not have bought into my practice when I did. That is not to say buying a practice is a bad thing, but it just happened at the same time that suddenly I was lecturing and developing a concept that has gone right round the globe. So it meant I really have not developed the practice the way I had dreamed. I really use it as a place to practice dentistry and capture cases for teaching and to keep learning from follow up cases. But it could really have been so much better!

Within dentistry Sverker Toreskog, Bjorn Zachrisson, , Erik Svendrud, Pascal Magne, Didier Dietche. Professor Ross Hobson, Martin Kelleher, Brian Millar, ( I was a student)

Outside, really anyone who goes against convention for the right reasons, people who think outside the box.  It’s a cliché but Muhammad Ali, is hard to beat as an inspirational person.

To keep developing IAS Academy promoting ethical minimally invasive dentistry and also to try to help the situation of dentistry in the UK. I believe we have a lot to do to pull our profession back to the respect and position it deserves

My dental SLR camera (nothing comes close/ other than perhaps my Intra Oral camera)In reality I cannot see how you can really practice without using a camera, as you will learn so much about your work, what goes right and what goes wrong. Self-critical appraisal has been the place I have learned most in dentistry.

Always consider in adult orthodontics, something I call the landmark tooth – it is a tooth or a point of a tooth that is already well-placed and positioned for function. When moving teeth, it is vital that point remains. It is too easy in orthodontics to move everything and lose correct function and guidance. Landmarks help you protect against this problem and I believe should be added to every orthodontic adult examination.

Orthodontics in General Practice

Orthodontics in General practice can be a very wide spanning range of treatments but it is critical dentists carry out treatments appropriate to their skill set. There are some GDPs with extensive training who have for years, provided a very high standard of orthodontics, working alongside orthodontists treating complex cased in children and some adults.  Also In the last 20 years, many adult patients started looking for aesthetic improvements so cosmetic dentistry exploded from the late 90s and thousands of people started having veneers placed. Many of these patients would not accept comprehensive orthodontics and accepted aggressive tooth preparation instead.  And for a time many patients were not given many other options other than comprehensive orthodontics. Anterior focused tooth alignment widely appeared around 2004 with a range of options to just treat the social six. Much of this has been carried out by GDPs and as a result some issues arose- but were often due to some inexperienced GDPs attempting to treat cases that were well beyond their scope and that perhaps were not properly diagnosed or consented correctly. With the right teaching and mentoring it should be perfectly possible for any dentist to do some simple anterior orthodontics, and then through time and continued education, start to explore a wider range of appliances. However unless a general dentist has undertaken a long, mentored comprehensive course of orthodontics, complex cases should always be referred to a specialist.

  • One of the most fundamental reasons for doing orthodontics is that teeth that are currently crowded, often continue to move and get worse through life. This does not just have an orthodontic significance, it has a potential affect on function/ guidance/ wear/ overlap/ ease of cleaning/ and aesthetics. Many dentists simply do not realize this but there is strong evidence * that all teeth that are now crowded are likely to get worse. The restorative, occlusal and functional implications for this are immense, but have not been widely acknowledged in dentistry. *Br J Orthod. 1990 Aug;17(3):235-41. Stability and relapse of dental arch alignment.
  • Of course this means that you can start to intercept simple crowding cases with early wear, rather than allowing cases to continually crowd and worsen
  • You can carry out cosmetic/ aesthetic dentistry without having to prepare teeth and take less risk. Because teeth can be moved into a far more ideal position simply and cost effectively rather than taking a drill to them.
  • One becomes far more aware of what is actually dynamically occurring in a patients mouth rather than just concentrating on ortho, or occlusion or perio… these things are  actually connected extremely intricately.
  • This will enable you to expand your skill in dealing with complex cases and help you also move into further education based on good  real experience VS just doing a course for the letters after your name.

Dentists who start with inappropriate treatments for their skills will eventually get into trouble. I would strongly advise against any course that can profess to teach you “80 percent of comprehensive orthodontics in a weekend.” As orthodontics is not just about a clever bracket, it is about understanding assessment, diagnosis, treatment planning, development, and learning from experience.  Start very simple, pick your course based on its mentoring, and do things correctly. There are no shortcuts.

Getting Started

Wherever you go and look at what is being taught…is it appropriate for your understanding. Are you being fully mentored? Do you know where your work is being made? Are you able to speak to a mentor to feed back on your case setups? Is your mentor actually a dentist or orthodontist or perhaps not?!  Free courses are free for a reason, quality costs and doing things properly takes time and ethics.

Overview of Orthodontic Systems

You have two basic modalities; Removable or Fixed.

Removable braces like Inman Aligners, Clear Aligners, Invisalign, are made using a  “closed system”- that means they are build on models (normally 3D printing). This means the teeth move within a range of controlled position, and as long as you have assessed and planned correctly, the most common complication is that nothing happens (usually due to lack of compliance or enough space creation).

With Fixed Braces, you can incur more movement, however in inexperienced hands, this can result in a lot of unwanted movement and loss of anterior occlusal control unless dentists are able to protect functional points and understand fully the space needed. This can easily result in flaring.  I would recommend people start removable and understand how simple movements occur and how to control them before jumping into fixed orthodontics straight away.

I won’t comment about any individual systems other to say that many of the current systems out there are run by people who came on an IAS Academy course, and some of their lead trainers are still taking our courses or trying to!!

Example Cases

 

This case shows how orthodontics, with correct OB/OJ and retention, allows for the placement of edge bonding without the worry of later failure

The patient was initially requesting 10 veneers. However, she eventually decided to have ortho (16 weeks), bleaching, four composite ‘edge bonds’ and one crown. Also, she was ‘dahled’ on the wire/composite to open the bite.

 

A case highlighting the control of tooth position for anterior guidance.

Integration of ortho into restorative treatment

You can take many year courses in orthodontics after learning about simple AAO- these include Professor Ross Hobson’s IAS course,  Johnathan Sandler’s Year course and Murtaza Hasnaini’s course amongst others.

Personally I feel that all dentists should practice dentistry for 5-7 years before even thinking about specializing. The reality is that you don’t really understand dentistry fully until you have a few years of following your patients, facing the work you did in the past and learning from your mistakes. I’ll say something quite controversial, but the best specialists I have met in all fields of dentistry always seemed to be people who did dentistry for a few years first before making that jump.

As I have mentioned, start very simple, learn the basics, and ensure you are going to get properly mentored throughout the process. Also, from the start don’t think of orthodontics as just orthodontics alone, – it is actually intricately linked with restorative, functional and occlusal dentistry. It is a powerful tool in your armoury to be able to treat a patient over a lifetime and that as general dentists is what we should aspire to be.

Conclusion

I was lucky to enter dentistry at a time where being a little different, maverick, taking risks was perhaps a bit easier than it is now. But despite the changing times, legal climate, rules, regulations, it is still potentially a fantastic career, but it won’t happen automatically. You have to make that happen and chose the right pathway. One final piece of advice, that has got me this far (25 years) with no issues. Just be a good person, be kind to your patients, and if you do something wrong, admit it and put it right.  Don’t dig your heels in and don’t be bloody minded – Be open minded and you will flourish.

Further Information

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