Join me for part 2 of Adith’s lecture looking at the vertical dimension in orthodontics and its management.

Part 2 looks at 6 cases with vertical management of impacted canines, the use of TADs including buccal shelf and infrazygomatic TADs.

4th case impacted canine

· Avoid continuous archwire as it can cause:

o Iatrogenic root resorption

o If stubborn canine = greater  occlusal side effects

· Resolution: TAD opposing arch

o Traction hook bonded to canine

o 150g elastic from lower TAD to traction hook on upper canine

o Providing intermittent forces

5th case scissor bite

· Buccal shelf TAD – placed vertically buccal to lower 6-7

· Anterior bite blocks to disocclude

· Mechanics:

o Buccal movement of molar with powerchain from BS TAD - molar

o Intrusion of molar with vertical vector to TAD

6th case cant

· TAD x 2, between U2-3 and U5-6 – placed high

· 19*25 NITI continuous

· Powerchain from TADs to brackets for intrusive force

7th case gummy smile

· Posterior TADs in conventional mucogingival junction with vertical vector not likely to achieve clinical improvement.

· Require TAD anterior region, and infrazygomatic TAD for retraction and intrusion

8th case class 3 with AOB

· Buccal shelf TADs

o Powerchain BS to hooks distal to lateral incisors on archwire:

§ Distalise lower molars

§ Intrude lower molars

§ Extrude lower anterior teeth – change to occlusal plane

· Extraction of 3rd molars

· TADs left in situ in retention in case of relapse.

9th case periodontally compromised patient

o 014NT, not all teeth ligated, alternate teeth ligated = increase inter-bracket distance = less force

References

Venugopal, A., Manzano, P. and Rengalakshmi, S., 2020. A Novel Temporary Anchorage Device Aided Sectional Mechanics for Simultaneous Orthodontic Retraction and Intrusion. Case Reports in Dentistry, 2020.

Venugopal, A., 2020. Interarch traction for impacted canines. APOS Trends in Orthodontics, 10(1), pp.60-61.

Venugopal, A., Manzano, P., Arnold, J., Ludwig, B. and Vaid, N.R., 2020. Treating a severe iatrogenic gingival exposure and lip incompetence–a challenge worthwhile. International orthodontics.

Join me for part 1 of Adith’s lecture looking at the vertical dimension in orthodontics and its management.

Part 1 looks at 3 cases with vertical management through TADs, TPAs and a re-visit of the management of the Curve of Spee.

1st case TADs for extraction of 4s case

· Without TADs can result in ‘bowing effect’ – extrusion of incisors and molars.

· TAD placed between the upper 5- 6 root

o Direct retraction of the labial segment to the TAD

o Ligature wire from TAD to archwire 5-6 region, to prevent molar extrusion

2nd case low TPA

o ‘Low’ TPA =  5mm clearance from the palate

o Tongue presses on TPA resulting in intrusive force to molars

o Swallow 800/day = 500gm intermittent force

o Not enough force to intrude, but enough to provide vertical anchorage (i.e. prevent molar extrusion)

3rd case Curve of Spee

1. High angle =  Weak muscles = COS levels with posterior eruption.

§ Tailored COS treatment = Intrude the incisors

2. Low angle  = Strong muscles = COS levels with anterior proclination (due to posterior teeth prevented from erupting with strong muscles)

§ Tailored COS treatment = extrusion of posterior teeth

One piece intrusion arch

o TAD in upper 1-1 region and in 5-6 region

o Sectional 19x25ss archwire in upper 2-2 brackets

1. Powerchain from archwire to anterior TAD

Three piece intrusion arch

o TAD in upper 1-1 region and in 5-6 region, with ligature wire from TAD to archwire in 5-6 region

o Sectional archwire in upper 2-2 brackets with distal hooks, as well as sectional wire 3-6

o Intrusion:

o Powerchain from archwire to anterior TAD

o Powerchain from distal hooks (distal to U2s) to TAD U5-6 region

Retention tip for anterior intrusion

o Leave TAD between upper anterior teeth

o Lingual button in VFR

o Patient wears light elastic 2Oz from labial TAD over the incisal edge and VFR to the lingual button

References

Venugopal, A., Manzano, P. and Rengalakshmi, S., 2020. A Novel Temporary Anchorage Device Aided Sectional Mechanics for Simultaneous Orthodontic Retraction and Intrusion. Case Reports in Dentistry, 2020.

Venugopal, A., 2020. Interarch traction for impacted canines. APOS Trends in Orthodontics, 10(1), pp.60-61.

Venugopal, A., Manzano, P., Arnold, J., Ludwig, B. and Vaid, N.R., 2020. Treating a severe iatrogenic gingival exposure and lip incompetence–a challenge worthwhile. International orthodontics.

Simon described the concept of ‘no retention’, the methodology and literature on the topic, with his expert option included.

Conclusion

· Controversial to not wear retainers

· Simon still asks patients to wear retainers

· Interproximal reduction helps but we don’t know why

Classic study

Riedel and Little

· 10 years out of retention

· 70% relapse – require retreatment, 30% no retainers and no treatment needed

· No identifiable factors – therefore to keep teeth straight require retainers

Treatment protocol and retrospective study of no retainers

Aasen EJO 2005

· During treatment

1. Respect lower archform

2. Maintain lower incisor position

3. Overcorrect of rotations

4. Heavy final wire 21x25 SS for 2-3 months

5. Relapse ‘test’: 4 weeks no archwire

· Results

1. After 3 years 1.1mm (Little’s Index)

§ Not significant clinical change

Randomised control trial Lower arch

Tynelius 2010, 2013

· Lower bonded retainer Vs IPR and no retainer

· 2 years = no difference in stability

Randomised control trial Upper arch

Naraghi 2020

· Upper VFR Vs no retainer

· 1 year follow up

o Relapse with retainer 0.4mm

o Relapse without retainer 1.3mm

· Not clinically significant

Post – treatment changes

1. Relapse

2. Age related changes

a. Abdulraheem 2020, 12 year follow up

i. Tooth displacement index

1. 25% = age related

2. 75% orthodontic relapse

Reference

Aasen, T.O. and Espeland, L., 2005. An approach to maintain orthodontic alignment of lower incisors without the use of retainers. The European Journal of Orthodontics, 27(3), pp.209-214.

Edman Tynelius, G., Bondemark, L. and Lilja‐Karlander, E., 2013. A randomized controlled trial of three orthodontic retention methods in C lass I four premolar extraction cases–stability after 2 years in retention. Orthodontics & craniofacial research, 16(2), pp.105-115.

Naraghi, S., Ganzer, N., Bondemark, L. and Sonesson, M., 2020. Comparison of post-treatment changes with and without retention in adolescents treated for maxillary impacted canines—a randomized controlled trial. European Journal of Orthodontics.

Tsiopas, N., Nilner, M., Bondemark, L. and Bjerklin, K., 2013. A 40 years follow-up of dental arch dimensions and incisor irregularity in adults. The European Journal of Orthodontics, 35(2), pp.230-235

Abdulraheem, S., Schütz-Fransson, U. and Bjerklin, K., 2020. Teeth movement 12 years after orthodontic treatment with and without retainer: relapse or usual changes?. European Journal of Orthodontics, 42(1), pp.52-59

Join me for a summary of the day 3 lectures from this year’s virtual IOC.

10 lectures covering: aligners, miniplates, root resorption, occlusion and bruxism.

Speakers: Benedict Wilmes, Hugo J.J. De Clerck, Anne Marie Kuijpers Jagtman, Ali H. Hassan, Zhihe Zhao, Carlalberta Verna, Glenn Sameshima, Ambra Michelotti, Shouichi Miyawaki, Mauro Farella

Individual lecture summaries will be available soon from the website www.orthoinsummary.com

Lectures titles:

1. Improving The Predictability Of Clear Aligner Therapy With Mini Implants Benedict Wilmes

2. The Defects, Risks And Countermeasures Of Clear Aligner Zhihe Zhao

3. Clear Aligner; How Predictable It Is Ali H. Hassan

4. The Influence Of Bone Density On Tooth Movement Biomechanics Carlalberta Verna

5. Miniplate Anchored Class Iii Orthopedics With Control Of Maxillary And Mandibular Rotations Hugo J.J. De Clerck

6. Orthodontic Root Resorption An Update For The Clinician Glenn Sameshima

7. An Evidence Based Approach To External Apical Root Resorption Anne Marie Kuijpers Jagtman

8. Occlusal Vulnerability Hypervigilance, Neuroplasticity And Adaptation Ambra Michelotti

9. Importance Of Occlusion And Physiological Significance Of Sleep Bruxism Shouichi Miyawaki

10. Bruxism An Orthodontist's Perspective Mauro Farella

Join me for a summary of the day 2 lectures from this year’s virtual IOC.

9 lectures covering: Retention, accelerated tooth movement, Airway, OSA, Patient expectations

Speakers: Padhraig Fleming,  Martyn T. Cobourne, Carlos Flores Mir, Leslie A. Will, Won Moon, Juan M. Palomo, Seung Hak Baek, Steven j. Lindauer, Susan J. Cunningham

Individual lecture summaries will be available at the end of the week, with written notes on each lecture!

Lectures titles:

Join me for a summary of the day 1 lectures from this year’s virtual IOC.

14 lectures covering: TADs, Facial aesthetics, Biomechanics, Class 2, Early treatment, Expansion, Impacted teeth, Self ligating brackets, Periodonics

Speakers: Chris Chang, David Sarver, James Mcnamara, Ravindra Nanda, Junji Sugawara, Noriaki Yoshida, Lorenzo Franchi, Peter Ngan, Sylvain Chamberland, Ewa M. Czochrowska, Yves G. Bolender, Chun-Hsi Chung, Dimitrios kloukos, Mitsuru Motoyoshi

Lectures titles:

1. Biomechanics Smart And Visible Biomechanics - Optimizing Treatment Mechanics Based On Prediction Strategy For Long-Term Tooth Movement Noriaki Yoshida

2. Relevancy Of Biomechanics In Clinical Orthodontics In 2020 Ravindra Nanda

3. Class 2 Patient Dependent Factors For The Efficient Treatment Of Class Ii Malocclusion Lorenzo Franchi

4. Early Treatment Of Class Iii Malocclusion With Tads Peter Ngan

5. Expansion In The Early Mixed Dentition Is It Worth The Effort James A

6. Facial Aesthetics Macro To Mini-Explore The Possibilities David M. Sarver, Dmd,Ms Birmingham, Alabama David M. Sarver

7. Facial Aesthetics Vertical Dimension And Facial Aesthetics Sylvain Chamberland

8. Impacted Teeth. Trans Alveolar Transplantation For Impacted Teeth Scientific Evidence And Clinical Practice Ewa M. Czochrowska

9. Is There Any Difference Between Conventional, Passive Self-Ligating And Active Edgewise Self Ligating Brackets A Systematic Review Of The Literature And Network Meta Analysis.Yves G. Bolender

10. Perio Periodontal Considerations In Orthodontic Treatment Chun-Hsi Chung

11. Periodontics And Orthodontics. Long-Term Development Of Gingival Recession In Orthodontically Treated Patients In Comparison To Untreated Individuals. Dimitrios Kloukos

12. Smile Gummy Smile Correction Chris Chang

13. Tads How Has Skeletal Anchorage Changed The Orthodontic Strategies For Class Iii Correction In Adults Junji Sugawara

14. Tads Safety Placement Of Orthodontic Anchoring Screws Mitsuru Motoyoshi

Join me for part 2, where Jae Park describes how to plan either extrusion or intrusion movements, the key evidence around AOB closure and TADs, aligners and orthognathic surgery.

Conclusion

How to plan intrusion posterior teeth  Vs extrusion of anterior teeth

CONSIDER EFFECTS ON OCCLUSAL PLANE WITH POSTERIOR INTRUSION

How to plan extrusion / intrusion:

Evidence of AOB closure with TADs

Aligners

Orthognathic surgery

Reduced stability due to Stylomandibular and medial pterygoid muscles.

Solution

Join me as I summarise Jay Park’s lecture looking at the anterior openbites and their management, with a focus on TADs, the good and the bad.

Part 1

Soft tissue aetiology and controversy

Dental-alveolar correction focus on posterior intrusion

Theories of tongue aetiology and AOB

· Tongue thrust = persistent visceral swallowing pattern for AOB Subtelny 1965

· Resting anterior tongue posture main factor Proffit 1993

Correct theory relates to resting tongue position:

· Anterior resting tongue position remains in between incisors many hours of the day, impedes incisor eruption and maintains AOB R.Juestus 2001

Anterior tongue posture correction

· Tongue anterior and high =  palatal crib.

· Tongue anterior in low = tongue spurs.

Indications for dental correction

1/ Posterior intrusion 2/ Intrusion of anterior teeth

· Intrusion posterior teeth

o Increased LAFH

o Excessive posterior gingiva

o Mild skeletal discrepancy

· Extrusion of anterior teeth

o Normal / decreased LAFH

o No excess gingival display

Posterior intrusion: Bite props as posterior bite plane affect

· 2-3mm of composite placed on the palatal cusp.

· Molar intrusion achieved =  1.5mm Hernandez 2017 17 months

TADS placed in the palate for intrusion

Jae Park combines bite plane effect with TADs

· RME bonded design acrylic capping on posterior teeth , 2 x TADs dento-alveolar region of the palate, between 5-6.

· Powerchain placed over the occlusal surface, from the palatal TAD to the buccal arm on the appliance

TADS with modified TPA

TPA placed with posterior hook for elastic traction

Position of TAD with modified TPA

Palatal dento-alveolar region of the 1st and 2ndmolars

· Ideal place for upper intrusion: Palatal U6-7, as intrusion vector ideal.

· Small interradicular space = challenge to place

· As molars intrude, space reduces in between molars Kuroda 2007

Palatal dento-alveolar region of the 2nd premolar / cuspid and 1st molar

· Easier location for placement

· However tipping of molars mesially occurs due to anterior vector from TAD

· Solution: Intrusion bend on 7s

Negative effects of palatal TADs and intrusion

Palatal cusp intrudes point of application, but buccal cusp doesn’t intrude / hangs down maintain occlusal vertical contact

Solution to negative effects

· Expand with QH and then palatal tad intrusion 2 stage approach, similar to QH, tipping movement then intrusion

· Approx. 300g per side for intrusion

Anterior extrusion

· Tads labially placed distal the upper and lower laterals with pt wearing elastics.

Orthodontics In Interview: NEAL KRAVITZ. USA

Join me as I interview Neal Kravitz, who is the associate editor for the Journal of Clinical Orthodontics, Edward Angle Society member NA and diplomate of the American Board of Orthodontics.

Neal Kravitz is an international speaker, he has published landmark papers, including a recent publication on the efficacy of aligners in the AJODO https://www.ajodo.org/article/S0889-5406(20)30303-6/

Neal discusses how his interest in aligners began, his thoughts on direct to consumer devices as well as more about Neal and his life.

We get to hear Neal’s one piece of advice to all orthodontists about a career in orthodontics.