Orthodontics and the airway

“Lots of patients are struggling with the symptoms (of obstructive sleep apnoea) when a little kid doesn't sleep it's not just the child's problem, their parents and other family member who also become sleep deprived”

Audrey describes her motivation in the young field of dental sleep medicine, the role of orthodontics in the management of paediatric obstructive sleep apnoea, the patient’s orthodontic treatment is appropriate in managing OSA, as well as those patients it is inappropriate for. Audrey explains her thoughts on why the field of airways and orthodontics is controversial, and answers critical questions regarding orthodontics and sleep medicine.

We get to hear of Audrey’s take on the AAO White paper on obstructive sleep apnoea.

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Farooq Ahmed

Join me for a summary looking at impacted teeth and key components of timing which affect not only the success of alignment, but also root formation. This podcast also explores the occurrence of asymmetries of both dental and facial due to impacted teeth, and what can be done about it. This podcast is a summary of the AAO lecture by Stella Chaushu and Adrian Becker.

Timing

Role of timing to the impacted tooth, the adjacent teeth and alveolar and skeletal growth.

Implications of timing on impacted teeth:

1/ Eruptive potential and timing

Timing of impacted maxillary canine interceptive treatment

Timing of impacted maxillary incisor interceptive treatment

(Sun et al AJODO 2006)

Root development

Timing of impacted premolar interceptive treatment

Timing of obstruction management

2/ Root development 

Canine root development

Arrested root development

Implication of impacted tooth and asymmetry

Join me for the next interview in orthodontics with Dr Diego Peydro

“The (aligner) protocols of the companies don’t work…my protocol shows expansion, the way I manage the roots, constriction of second molars…and have 95% predictability”.

Diego explains his journey in orthodontics, the challenges with aligners and why he believes they are superior to fixed appliances now, also we hear his opinion on in-house aligners.

We get to hear of Diego’s opinion on aligner research. 

Diego is the co-director of The clear aligner training programme “Clear Ortho International Program - Master COIP (I have no financial interest).

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Join me for a summary looking at the use of botox for deep bite management and bruxism. This was an interesting lecture by Dr Nan Hatch from Seattle, which was presented at this year’s AAO 2023. She explored the use of Botox for masseter hypertrophy and the evidence around it.

Masseter hypertrophy when combined with bruxism can result in:

o  Long term changes in

o  Fixation breakages

o  Orofacial pain, tmd,

How does it work?

·        Injection of neurotoxin

·        Temporary partial paralysis

·        Most common Botulinum toxin

·        Mechanism of action

o  Block acetylcholine (neuromuscular

o  Also inhibit pain sensory

How to inject

·        Extra oral – use of facial

·        Intra-oral Use MRI / EMG

What are the effects

·        Anticipate change facial

·        Greater facial contouring

·        Last up to 180 days

·        Greater complications with

Anticipated change from botox

·        Treatment for masseteric

o  35 units to masseter , two

o  91% reported improvement

o  Duration 25 months

Decrease bite force Ahn 2007

·        25 units to each massenteric

·        Mean bite force 51kg /cm

o  Reduced to 30-36kg/cm for 8

o  After 41kg after 12 weeks ,

·        Significantly reduced bite

Potential adverse effects

·        Chewing weakness

·        Sunken cheeks – high volume

·        Headaches

·        Sagging skin

·        Asymmetry

·        Paradoxical Bulging – miss

·        Distant spread of toxin

·        Speech disturbance

·        Muscle fiber atrophy 4-6

Chemical denervation protocol

·        25 units per muscle, both

·        Interval 4-5 months and

·        3-5 serial injections

o  Some patients changes can

Join me for a summary of a lecture by Ramesh Sabhlok,

The most common site in maxilla for implant placement

Two factors

1.   

2.   

Bone thickness:

·     

Inter-radicular distance

·     

·     

·     

·     

‘SAFE DEPTH’

·     

·     

o  

Angulation

·     

Extraction of 3rd molars

·     

·     

Concept of biologic width

1-1.5mm of periodontium surrounding the implant,

Lecture title

Summary from AAO 2022 lecture: Non- compliance &

Dedication

Episode is dedicated to the late Dr Anam Humdani, a

https://www.justgiving.com/fundraising/zayaan-humdani

·      

·      

Join me for a summary looking at accelerating orthodontic tooth movement, this podcast is a summary of two lectures from the AAO, by Ali Darendelier and Peter Buschang. Mechanical acceleration through vibration, photobiomodulation, minisurgery (Peizocision and Micro-Osteoperforation MOP) and Distraction.

Mechanical removal of the bony obstruction

What do we know reliably extents treatment duration are 3:

Conclusion:  

Distraction is the most reliable method at increasing tooth movement but the most invasive

Peizocision / Micro-osteoperforation: Increases tooth movement but greatest risk of root resorption

Photobiomodulation: Modest increase in tooth movement, no root resorption

Vibration: No increase in tooth movement or root resorption

Contributions

Content creation: Shanya Kapoor

Editing and production: Farooq Ahmed

Join me for the next interview in orthodontics with Benedict Wilmes

“Find a balance between clinical tips and evidence, if we only look at evidence there will be no innovation, if we only look at clinical tips we will make lots of clinical mistakes”

Benedict describes his journey into mini-screws and what keeps him motivated to continue innovation in orthodontics. He describes his passion for sports and how he adopts these lessons in his work.

We get to hear of Benedict’s thoughts on the future of orthodontics.

Benedict is the pioneer behind the Benefit TAD system, the next annual user’s meeting will be the 2nd – 3rd June 2023 in Duesseldorf, I have no financial interest and am looking forward to attending this year’s meeting.

Course details: https://www.benefit-user-meeting.de/

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Farooq Ahmed

Join me for a summary of Oliver Liebl’s lecture looking at digital orthodontics, through both digital indirect bonding and in-house aligners. The workflow Oliver described was through Onyxceph in a step by step process, however the modules used are similar to other available software modules.

Oliver described the ‘digital orthodontist’ who uses

1. Digital bracket positioning with Indirect Bonding Trays IDB

2. Finishing with in-house aligners

Digital bracket positioning

Advantages

· Automatic placement of different heights, MBT, Andrews etc

· Virtual simulation = visualise effects of changes

Digital model, AI segments dentition, but requires some manual adjustment for the Gingival, occlusal and lingual aspects

1. Bracket selection

· Bracket library of commercially available brackets

2. Bracket positioning

· Select placement philosophy – automatically place brackets, MBT, Andrews, Alexander

· Customise

o Change bracket position

o Change prescription

· Visualise changes with automatic alignment on 3D pane

·  Select archform

3. Indirect bonding trays

· Transfers virtual position through a 3D printed tray to the patient

i. Change geometry of tray, thickness, cutting guide

i. Values of the tray Oliver shared for the brackets he commonly uses – Experience SLB by GC

· Active STL file export to 3D resin printer

i. Resin – fits to each bracket system and printer, trial and error

4. Print IDB tray

· Horizontal position

· Remove IBT trays

· Wash – isopropanol

· Light cure – 50 minutes in glyceryl

· Placement of brackets in tray

· Use separator / releasing agent such as oven spray

· Place bracket into IDB tray

5. Clinical steps

· Etch, bond, conventional bonding

· Use of acetone to remove finger prints on bracket base

· Butter in adhesive to the mesh base

· Light cure

Finishing with aligners

Virtual debonding, however not great results, better to debond and re-scan to plan

Aligner 3D module set up Onyxceph

· Modify tooth position

· Settling process – like a Hawley

a. Leave small occlusal gap for posterior settling

Aligner attachment 3D

· Select any available shape

· Can add SARA wings, act as class 2 correctors, developed by Aladin Sabbagh

Staging of aligner movement

a. Parameters programmed per aligner

i. Chose values which are predictable, depends on clinician and size of aligner

Print working model

b. Horizontal model 25 minutes or vertical 60-70 minutes

c. Wash residual resin

d. UV light

Trimline choice

e. Straight Vs scalloped

f. Prefer straight. Cowley 2012

i. Less attachments

ii. Greater force delivery

iii. Greater predictability

GET ORTHODONTIC SYMPOSIUM SEPT 8-9/2023, Aligners, bracket or both

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Join me for a topic summary looking at anterior openbites from the AAO. This summary looks at the differences in key diagnostic criteria, the options for treatment planning, and the evidence to support time. The summary is taken from Roberto Carrillo, Flavia Artese and Ravi Nanda’s lectures.

Separate treatment plan:

· treatment of the aetiology

· Treatment of mechanics

Aetiology

Tongue posture / thrust or mouth breathing, alter equilibrium of AP and vertical tooth position.

· Tongue posture / thrust

o Forwards position, not thrust / swallowing, as low intensity and duration

o Different positions of tongue being forwards, results in different presentations of AOB, high = proclined uppers, horizontal bi-proclination, low procline lowers

o See previous podcast on Flavia Artese in her Power2Reason lecture

· Mouth breathing

o Mouth breathing in itself is not considered factor for Tonsillectomy AAO-HNS guideline

Treatment

Extend of AOB does not determine treatment, Facial type and extent of AOB poor correlation r=0.2 Duplat 2016

o

· Habit dissuader crib or spurs:

o High tongue block tongue

o Low tongue block and redirect

o Removable – Aligner with lingual attachments, poke probe through and becomes uncomfortable

· Adults like as removable, bonded is difficult to accept Voudouris 2022

o Cribs and spurs- relapse 17%  Huang 1990

§ Effective reduction in tongue forces and position at 1 year Taslan 2010

· Myofunctional therapy

o Speech and language therapy – relapse 4% Smithpeter 2010

· Dental:

o Incisor extrusion - relapse 38% Janson 2003

o Molar intrusion - relapse 27% Espinosa 2020

o Extractions – relapse 25% Janson 2006

· Skeletal:

o Surgery – relapse 25% Greenlee 2011

Posterior intrusion

· Screws / plates = depends on anatomical limitations

Skeletal anchorage with aligners

· Ct approach = C cuts and T-triangular elastics

· C-cuts – through OCCLUSAL and buccal surface to prevent deflection premolar to molar

· Pre-load elastics and then insert into the patients mouth

· Posterior intrusion

Lecture titles from AAO 2022

Key factors for vertical control with clear aligners Roberto Carrillo

Game changers in open bite treatment – Dr Flavia Artese

Biomechanic & Esthethic based management of open bite - Dr Ravi Nanda

Join me for the next interview in orthodontics with Luis Carrière

“The Carrière Motion Appliance is a story of simplicity, but not simplism”

Luis describes how he conceived the Carrière Motion Appliance, and addresses in his own words addresses claims regarding changes to the occlusion, TMJ and airway. He describes the limited research regarding the appliance, as well as why he does not conduct the research himself.

We get to hear of Luis thoughts on what he sees as the future of orthodontics.

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www.carrieresystem.com/

Instagram @instagram.com/luiscarriere

Facebook @luis.carriere.1

Farooq Ahmed