Occlusion with Your Patients’ Growth & Development

Episode #528 with Dr. Curt Ringhofer

Countless people are affected by temporomandibular joint disorders. Fortunately, you have the opportunity to correct it. If you want to be a valuable resource for your TMD patients, don't miss today’s episode! Kirk Behrendt brings in Dr. Curt Ringhofer, an instructor from the Chicago Study Club, to talk about recognizing, diagnosing, and treating growth deficiencies early so you can set patients up for proper growth and development. To learn more, and to find out how to join the Chicago Study Club, listen to Episode 528 of The Best Practices Show!

Episode Resources:

• Dr. Ringhofer’s email: [email protected] 
• Dr. Ringhofer’s office number: (708) 349-0022
• Chicago Study Club: https://chicagostudyclub.com
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Links Mentioned in This Episode:

The Bruxism Triad by Dr. Jeff Rouse: https://c1-preview.prosites.com/temp2bngb078h1/wy/docs/Dr.%20Jeff%20Rouse%20-%20Inside%20Dentistry%20Bruxism%20Triad%20Article.pdf

Finding Connor Deegan: https://www.aapmd.org/aapmd-blog/finding-connor-deegan-video

Main Takeaways:

Find the Connor Deegans in your practice.

Set young patients up for proper growth and development.

Recognize, diagnose, and treat growth deficiencies as early as possible.

There are more TMJ patients than you might think, and they will seek you out.

Remember that what we know today about occlusion may be wrong tomorrow.

Quotes:

“If we set people up for success, in any aspect of life, we’re setting them up in a way that they can grow. And it’s no different in growth and development. If we notice that there's a growth defect, whether it’s at the maxillary level or the mandibular level, we’re setting them up to grow properly. And when we set them up to grow properly, it’s going to affect the airway. And we all have heard the stories from Jeff Rouse — and airway seems to be the sexy topic nowadays — and the effects it can have on not only development of kids, but as we get older, there's more diabetes and heart disease.” (5:55—6:37)

“I read an article not too long ago that the highest incident of airway-disordered sleep is from about three to eight years old. Well, that's when the brain is developing. And if we’re suffocating the brain of oxygen, it’s not able to develop as well. And a lot of that has to do with the exoskeleton, which I learned from Mark Piper, that if we can grow the exoskeleton, now we don't encroach on the airway and kids can sleep better.” (6:37—7:08)

“What I've learned from Dr. Piper and Dr. McKee is that we have imaging to back up when there's lack of growth at the joint level. You have less projection of the mandible, which then gives you a smaller airway size. And so, if you can back that up with actual science and facts, it’s hard to dispute that. But I think maybe, then, the dominoes start to fall. If you have a smaller mandible, the tongue is encroaching on the airway. So, now, you become an open-mouth posture, which causes a narrow maxilla because the tongue is not occupying the mouth and advancing the premaxilla and widening the maxilla. So, what came first? Quite frankly, I don't really care. I think we need to diagnose it all, and then treat it as necessary.” (10:25—11:14)

“Jeff Rouse wrote an article on the bruxism triad. People with airway-disordered sleep are going to grind their teeth more. I always saw those kids with all that wear on their teeth, and I thought it was occlusion. Going through The Dawson Academy, I thought, ‘Oh, okay. The teeth don't match up. They're not in centric relation.’ Well, Dr. Rouse — really credit him for bringing that to the forefront — showed that, no, that could be an airway issue, and we need to look past the second molars, and are there enlarged tonsils and adenoids and things that are inhibiting the children from sleeping well.” (11:42—12:19)

“Did you ever read the article, Finding Connor Deegan? It’s about a kid who grew up in Chicago, and his mom wouldn't accept the fact that he had ADHD. Making a long story short, when he would test, he was testing cognitively gifted. But they kept saying he had ADHD. And it turned out he had an airway problem. They went through and they expanded his arches, took his tonsils and adenoids out — and the mom was adamant. Now, he’s an A and B student. And he doesn't have the stigmatism of having attention-deficit disorder.” (13:03—13:42)

“Talking to some of the physicians at that pulmonology group I work at, their hands are tied because they have about 15 minutes to talk to each patient. In dentistry, we’re lucky. I have a fee-for-service practice, so I can sit and talk to patients as long as I need to get that diagnosis and find out their history. And when I'm evaluating someone for growth or temporomandibular joint disorders, or any new patient, for that matter, the first thing I'm doing is sitting in my consultation room to find out what they want. And then, we go into the treatment room and we take a look. Because you can almost get as much, if not more information, by talking to the person rather than just looking in their mouth.” (13:49—14:34)

“One of the things that you'll hear when you're sending a young kid to an orthodontist and they have that Class II bite, or the discrepancy between the upper and lower jaw, is you hear a lot of reasons why. And my favorite one is, ‘Oh, they’ve got the upper jaw of the father and the lower jaw of the mom.’ And it’s like, no — this is a growth deficiency. And when you get the images, they have an anterior displaced disc, which disrupts the growth center sitting on top of the condyle, so then you can't get that projection of the mandible. Because when we think about growth, the maxilla is going to grow first, and then the mandible follows.” (16:44—17:27)

“Dr. Piper talked about the first permanent molars, which are the smart molars. And if we all visualize, what happens is as the maxilla is growing, the mesial inclines of the maxillary first molar interdigitate with the distal inclines of the lower, causing distraction osteogenesis of the condyles. I think of it like nature’s Herbst appliance. It’s causing the mandible to come forward. But if we lose the ability for the condyle to grow, what happens is then, if you clench the teeth together, it can hold the maxilla back from growing as well. So, that really doesn't ever hold true. Because I'll be at meetings and orthodontists get a little uncomfortable because they're like, ‘Well, some kids grow and some kids don't, and we’ve just got to try it.’ And I'm like, ‘No, we don't have to try. We can image and find out where the disc is.’” (17:28—18:20)

“The other [misconception] you hear is, ‘They have an anterior tongue thrust.’ Well, the question becomes, was the tongue there that caused the bite to open, or were they pushing their tongue forward because their airway was constricted, so they had an open-mouth posture where the tongue didn't occupy the roof of the mouth, so now we can't advance the premaxilla and expand the arch? So, I think that's where people get confused.” (18:21—18:50)

“One thing I heard Pete say when he was speaking one time, he goes, ‘If you're going to quote me, quote me on when I said it because things are going to change and I'm going to be proven wrong if I said something 10 years ago.’ And I love that line because it’s 100% true. What we’re talking about today could be wrong tomorrow, for all we know.” (19:19—19:39)

“There was a study club that I was involved with with [Dr. Piper], and it was about how the mandible gets ignored. There was so much out there that the temporomandibular joint is really a growth center that helps everything else develop. And it’s like the red-headed stepchild, if you will. Nobody wants to talk about it because we’ve got implant dentistry, we’ve got esthetics, and now airway seems to be the one. But there are so many people that are affected by temporomandibular joint disorders. And whether it’s from pain — and those are the easy ones. It’s the occlusal discrepancies that make it the most difficult. The vast majority of Class II patients have some type of growth deficiency at the joint level because their mandible didn't project. And when you think back to the most difficult cases, it’s the ones where the upper and lower teeth don't match together. They don't line up correctly. And those are the ones where we can't develop an occlusal relationship.” (21:06—21:14)

“We think of occlusion as the static relationship between the upper and lower teeth. But it’s the dynamic relationship that really gives us difficulty. We can get the patient to grind right and left and get everything adjusted perfectly. And as soon as they start chewing, you get that elliptical movement, things start to go haywire. And it’s the ones that go haywire, the Class IIs. And if we can diagnose those patients ahead of time, whether they accept treatment to correct it or manage it, whatever they do, they're taking ownership of it. And it’s not the dentistry I gave them, it’s their skeletal relationship. It’s their condition of their body. So, they're assuming the risk with us. And we’re not writing checks back because of dentistry that didn't work.” (22:14—23:01)

“Jim and I practice a half-hour from each other, and we are both busy. There is more of this out there than people — and they seek you out. I've never, in a million years, thought I would have a practice that dentists are referring to me. And, at first, it was a little uncomfortable because I didn't know what to do after I diagnosed them. But to speak to the point that these patients are crazy, they're not crazy. They just don't know where to go, and they’ve never gotten an answer. Because what did we learn in dental school? Give them a splint and, hopefully, they got better. But we were just hoping. Where, now, we can understand what the anatomy is. Is it structurally intact? Is it structurally altered? Is there an anterior displaced disc? Is there inflammation in the joint? All the different aspects that we would do for dentistry, no different than periodontal disease. We need to figure out why is there gingival inflammation, because it can come from plaque and calculus, it can come from a poor restoration. We need to figure out the why before we can figure out the how. And then, the patient needs to accept the risk with us. And that's really where I think people seek us out.” (23:52—25:03)

“If you have a Class II patient that is evaluated in the seated condylar position, so not MIP, by manual leaf gauge, anterior deprogrammer, whatever camp you came from and however you're going to get that patient to centric relation, or what we’ll call the fully seated condylar position, evaluate the anterior teeth. And if you have greater than a two-millimeter discrepancy in the horizontal or vertical dimension, or midline discrepancy, those are the patients that we need to start to think there's a loss of dimension or a lack of growth at the joint level. And we need to evaluate that because, especially in growing kids, if they can't grow, we’re setting them up for failure. And that's a concept that Dr. Piper taught me, called the rule of twos. And where it came from was the disc thickness is two millimeters. So, if you have a two-millimeter anterior open bite in any of those three dimensions, that could be an issue of a disc displacement.” (26:52—27:59)

Snippets:

0:00 Introduction.

1:47 Dr. Ringhofer’s background.

3:08 How he got Terry Bradshaw’s jersey.

5:17 Why growth and development in occlusion is an important topic.

7:10 How his practice has evolved.

8:35 Why aren't humans forming properly to breathe?

11:14 The bruxism triad.

12:19 Find the Connor Deegans in your practice.

14:35 Working with pulmonologists.

16:29 What most dentists get wrong.

20:17 The vision for his study club.

23:06 Myths around TMD patients.

25:25 What we can expect to learn in the future.

26:40 Last thoughts on growth and development in occlusion.

28:02 More about Chicago Study Club.

29:55 How to get in touch with Dr. Ringhofer and how to join the study club.

Dr. Curt Ringhofer Bio:

Dr. Curt W. Ringhofer graduated from the University of Illinois Dental School, and has committed himself to providing only the finest dental care. He and his team have continued to educate themselves, assuring that you will only receive the latest state-of-the-art, personalized care.

Dr. Ringhofer has pursued advanced dental education at the Dawson Center, The Kois Center, Misch International Implant Institute, and The Piper Clinic. He is also a member of two study clubs in which he meets with dentists from both the United States and Canada throughout the year. He lectures extensively throughout the country on TMD, Occlusion, and Sleep Apnea.

Dr. Ringhofer is a member of the American Dental Association, American Equilibrium Society, Academy of General Dentistry, American Academy of Restorative Dentistry, as well as a Fellow in the International Congress of Oral Implantology.