What goes wrong with MARPE? Audrey Yoon

Join me for a lecture summary from this years AAO by Audrey Yoon. Don’t Make the Same Mistake I Did/ MARPE Complication.

Success MARPE

Overall separation: 87.8% Success rate of sutural separation: (Jeon 2021)

· 61.05% in male

· 94.17% in female

· Average expansion: 7.8 ± 2.4 mm.

Variation with age and gender

MARPE efficacy = Achieved Vs planned expansion

· Greater negative correlation with age in general

o More male than female

o Planned Vs achieved

a. 20 years old = 1:1  M:F

b. 30 years old = 0.5:1  : 0.8:1

c. 40 years old = 0!  : 0.6:1 BUT NO DATA – extrapolation

No relationship with bicortical engagement

Asymmetric expansion

· = 50% of cases ANS level greater than 1mm

· 27% Greater than 2mm at ANS

· Severe: Similar to tripod fracture

· Causes of asymmetry Kim 2019

· Nasal-maxillary suture opening / remain closed

· 30% of case unilateral opening of suture

SARPE = 3-13% asymmetric expansion Williams 2012, Smeets 2020

Pain

· 45% report pain

· 19% Around band of 1st maxillary molar band

· 10% headaches

Gingival inflammation

· 83.9% of patients

· Design = flush

o Change to 1mm from palate and arms 3mm from palate = reduce

· Greater inflammation in retention

o Possibly due to palatal vault relapse and therefore TADs imbed in palate

Breakages

· 10%

· Usually guide rod / arm

Rare:

Loss of vitality 2%

· Required RCT maxillary incisors (SARPE 4.5%)

Fractures - potential tripod fracture

Infra-orbital numbness

· Temporary numbness 6 weeks

· 3 cases

· Management

· Turn backwards slowly

· Facial massage / myofascial

· Folate, Vit b – aid nerve regeneration

Hearing loss

· Zygomatic arch = hearing loss temporary, tetanus, trismus

Unexplained tears

· Lateral orbital rim = sagging eyeball, lacrimal gland

Popping in the ear

Lateral pterygoid fracture

· Click and popping to the ear – cheek shooting pain

· Lateral pterygoid plate fracture – asymmetric expansion

Consent

Audrey Yoon – youtube patient instruction video / leaflet

Growing consent

Audrey Yoon paper AJODO clinical companion – open access

A retrospective analysis of the complications associated with miniscrew-assisted rapid palatal expansion` Audrey Yoon 2022

Join me for a summary of this years American Association Meeting from the summer looking at AI and imaging. The topics covered at CBCT the facts, use in transverse and incidental findings. Other topics of facial imaging or 4D as a diagnostic tool. Finally looking at AI, its application currently and potential use of blockchain technology in orthodontics.

CBCT Shaza Mardini

Myths

Accuracy

Asymmetry

CBCT and Transverse assessment Onur Kadioglu

PA Ceph should not be utilized for transverse discrepancy. {Cheung et al Aust orthod 2013}

CBCT as gold standard and compared PA ceph to it and has quoted that it has

landmark system for transverse measurements using CBCT images. Onur Kadioglu

Used transverse discrepancy limit of 20mm to assess the outcomes of cases.

Incidental findings with CBCT Onur Kadioglu

Facial imaging William Harrell

2D Vs 3D  Vs 4D

Study’s on facial imaging 3D

AI Veerasathpurush Allareddy

1. Big data landscape –

2.  Machine learning (subfield of Artificial Intelligence)–

AI and craniofacial genomics –

Blockchain Technology –

Orthodontics in Review Blog: Direct to Print Aligners: Björn Ludwig

www.orthodonticsinsummary/blog

Contents: Shanya Kapoor

Editing and Production: Farooq Ahmed

Breathing disorders and orthodontics AAO 2022

Join me for a topic summary of breathing disorders and orthodontics, from this year’s American Association of Orthodontics meeting.

Two lectures were covered, the first by Takashi Ono which looks at the issues surrounding mouth breathing and its consequences, the second lecture was by Martin Palomo looking at OSA and busy offices, our role and how new technologies are helping.

Nasal breathing Vs mouth breathing

· Nasal Vs mouth breathing, which is better: Nose = air is humidified, pressurized and filtered than the one come through mouth.

· The tongue pressure is 10 times more with mouth breathing than nose breathing in sitting position

· Even greater in supine position.

= That means tongue pressure increases during mouth breathing especially while sleeping.

Memory and Nasal breathing

· Normal nasal breathing

o = air flow stimulates sensory nerve ending via olfactory to prefrontal cortex and hippocampus region of brain = responsible for memory function.

· Memory consolidation was better in subjects who breathe through nose Ribeiro 2016SR

o 10 papers, largest paper non-validated questionnaire and half of studies no controls. Variety of outcome measures.

· Takashi’s own study into rats showed less O2, and their opinion was this results in impairment in development

Nasal obstruction and other consequences

· Taste: Taste disturbed by breathing dysfunction, alters shape of lingual papillae Hsu 2017

o Mouth breathing group had increased threshold for sweet and sour taste

· Muscles of mastication:  Decreased in cross sectional area of masseter and temporalis muscle, with increase in type 2 muscle fiber.

o Reduced muscle size and strength & decreased efficacy of masseter muscle strokes

· Shape of palate

§ Altered shape of palatal shape, smaller volume Lione 2015

· Halitosis increased prevalence Motta 2011

· Actopic dermatitis Yamaguchi 2015

New technologies to manage OSA in busy orthodontic office Martin Palomo

Prevalence of sleep obstructive sleep apnoea

· 42 million adults USA

· 1 in 5 mild OSA

· 1 in15 moderate OSA

· 75% severe sleep disorder = undiagnosed

Diagnosis and the orthodontist

· Orthodontists cannot diagnose: White paper from AJODO Rolf Behrents 2019

· CAN carry out a Risk assessment= onwards

Risk assessment: Adults

· STOPBang (Questionnaire for Risk assessment): http://www.stopbang.ca/osa/screening.php

· 8 questions, yes / no and physical details

· 100% accurate for high risk apnoea patient

· University of Toronto Canada

Risk assessment: Children

· Paediatric sleep questionnaire (PSQ). Available University of Michigan

· Children who snores loudly = poor academic performance,.

o Tools for tracking whether your child is snoring or not –

1. Apps Snorelab, Snoreclock

a. Mobile apps that records fractions of snoring and categorizes into quite, light, loud and epic snoring - Validited = close to PSG

b. Results vary with distance in which phone is kept, or microphone issues

Please donate to the Flood Relief Charity for Pakistan

https://www.justgiving.com/fundraising/farooqorthodontist1

Join me for a summary of Dr Nikhilesh Vaid’s lecture entitled More Than Meets The EYE!    Aligner Evidence Through Clinicians Eye It was part of the first International Orthodontic Foundation online symposium, with Ravi Nanda and co.

Evidence available

There are about 7000 papers available on clear aligner therapy

What do the systematic review and meta-analysis conclude?

Systemic review topics

Treatment outcomes

Deleterious effects

Other effects

Nikhilesh conclusion: Although stated in one of systematic review (Papageorgiou) the current evidence doesn’t supports the use of clear aligner therapy.

Nikhilesh’s research: Effectiveness, wear, refinement

1st study - Are aligner effective

Does wear protocol makes a difference? Nadawi 2021

3rd study- Can we predict the number of refinements needed?

Nikhilesh’s conclusion:

Contributions

Contents: Shanya Kapoor

Editing and production: Farooq Ahmed

Join me for the next interview in orthodontics with Carlos Flores-Mir

Carlos is a Professor in orthodontics with an exceptional contribution to the field. He has published over 350 peer review papers and is an award winning educator within dentistry. He is an associate editor for the Angle Orthodontist journal and JWFO.

We get to hear of Carlos’ story of how he came to be a leading authority in orthodontics, his opinion on class 2 correction, why he chose to present clinical failures at this year’s AAO meeting, and his favourite hobbies.

Join me for a summary of Dr Bing Fang’s lecture entitled: Biomechanical Research and clinical application of orthopaedic Treatment on Adolescent mandibular retrognathia.   It was part of the first International Orthodontic Foundation online symposium, with Ravi Nanda: https://www.iofglobal.org

Intrusion with aligners

Clinical risk of anterior intrusion, can cause retroclination / proclination.

Advanced Mandibular Spring AMS with aligner

#alignerorthodontics #class2 #Bingfang #farooqahmed

Join me for a summary of early treatment lectures from this years AAO meeting from May 2022. Topics will cover trauma, airway diagnosis and orthodontic treatment, and optimal timing of class 2 correction

Lectures:

Dental Trauma Eustaquio A. Araujo

Trauma protocol

Re-implantation of avulsion success

Airway-centered Orthodontic Diagnosis & Treatment for Pediatric Patients Hong He

Nasal breathing Vs mouth breathing

Tonsillar hypertrophy

Caution as limited studies pre-pubertal and controls also improved in scores

Predictors of Success for Early Mixed Dentition Treatment Heesoo Oh

When is it best to treat class 2 cases

Study: optimal timing of the effectiveness and efficiency

Treatment protocol

Results

Managing Complex Cases in Orthodontics. Kleber Meireles and Andre Machado

Join me for a summary of a dynamic conversation between Kleber and Andre, It was a lecture full of biomechanics and the podcast will focus on specific examples with fixed appliances and aligners.

Fixed appliance mechanics

1. Canine retraction in extraction case with buccal canine: sectional mechanics

o Conventional sliding mechanics retract canine but also distally tip and rotate distal in

o Loop mechanics

§ Mechanics = canine retraction – line of force buccal

§ Side effects = no distal in rotation due to line of the force buccal

§ Mechanics = sectional mechanics allows counter moment to increase as canine retracts = bodily retraction

§ Side effect = no distal tipping of the canine

2. Retraction of upper anterior teeth in extraction cases

o Loss of anterior torque on retraction,

o Torque mechanics:

§ Stop active space closure

§ Apply anterior buccal crown torque

§ When recovered, continue final space closure

Aligner biomechanics

Comment:  Physics is physics & there is nothing magical appliance

Distalisation with aligners

· Not effective with aligners

· Mechanics: Distal tip

· Side effects: No root movement

Solution

· Attachments for molar distalisation:

o 6mm:  horizontal requires 120g, 10mm from the CoR = 1200gm force required for counter moment, however no aligner material can deliver this force or provide retention to the force, therefore not effective tooth movement

o 4mm attachment requires greater force, 1200/4 = 300g

Issues with aligners

· Rely more on companies to do the treatment planning

o AI does not have knowledge of the roots and its angulation – which is difficult to correct even with conventional braces

· Lack of stiffness in the aligners make it difficult to apply counter moment

o For example incisor retraction in extraction cases

Thank you to our sponsors for supporting this episode

I hope to see you Porto for the Simply Ortho congress on the 9-11 of June

Join me for a summary looking at Dental Sleep Medicine and NICE guidelines. This summary describes obstructive sleep apnoea and the new guidelines of its management. There is a focus on the Mandibular Advancement Splint and the occlusal outcomes for patients using this appliance. This lecture was given by Professor Ama Johal. Ama is a member of the advisory committee to NICE sleep apnoea/hypopnoea syndrome

Introduction

Obstructive sleep apnoea –

· Sleep related breathing disorder

· Poorly understood

· 70% collapse retroglossal area

· Stops breathing

· Body movement occurs – body tries to wake patient up as suffocating

o = disturbed sleep

Health consequences

· Day time sleepiness

· Hypertension, heart disease, stroke – all stroke patients screened for OSA

Treatment

· Severe / mod- gold standard Continuous positive airway pressure CPAP

o Filters air and pushes at high force

o To be effective 4-6 hours, 7 days a week – NOT curative

o Compliance / adherence 30%

NICE guidelines 2021

· Symptomatic receive CPAP

· if not comply then if a person Mandibular Advancement Splint

· Require good dental and periodontal health

· Age 18 +

MAS appliance

1. Anatomical – increase size of pharyngeal airway

a. Mandible move forwards, tongue advances with it

i. Post lingual - Best impact of patients who have tongue contribution to collapse 70% of patients

2. Reduces airway collapsibility

3. Physiological role – stimulate dilation of upper airway muscle – improving muscle strength and control

MAS appliance

semi customised Vs customised

Johal 2018 S/R

o Overall effects better with customised Vs semi customised

§ AHI 3

§ Daytime sleepiness 1

§ Self reported wear: 7 Vs 3 nights per week

§ Pt preference 95% prefer customised to semi-customised

Ideal design features  customised Johal 2018

· Good retention - customised

· Semi adjustable – incremental advancement

o Allowing for further advancement and slow increase in airway

· Full occlusal coverage

· Minimal vertical opening

In high angle cases clockwise rotation of mandible – compresses post-palatal area and worsens airway IF increase vertical opening. Minimal occlusal opening prevents clockwise rotation

Follow up long term

· Unwanted occlusal change

o Mesial molar movement

o Reduction of OJ and OB approx. 1mm

o Proclination of 1mm lower incisors

Thank you to the sponsors who have allowed the podcast to continue, Triple O, Orthocare and the Aligner Intensive Fellowship.

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Join me for the next interview in orthodontics with Steffen Decker

Steffen is a leading lingual an aligner provider and a Kois recognised specialist. He has been a global advisor for 3M and is a key opinion leader for Align technology.

We get to hear of Steffen’s story of how he came to use lingual appliances and aligners, his opinion on interceptive / phase 1 treatment and where he sees the future of orthodontics.

Facebook: @steffen.decker.503

Instagram @theorthodonticspecialist Instagram