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

Join me for a summary of Björn Ludwig’s lecture exploring Miniscrew Assisted Rapid Palatal Expansion (MARPE) and Surgically Assisted Rapid Palatal Expansion (SARPE). Björn described how MARPE works, aspects of design and his clinical process.

Effects of MARPE

Age

MARPE  Vs RME

Retention after MARPE

At 7 months: suture has not fully remodelled

Expansion rate of MARPE

Activation process: Force controlled polycyclic activation

Airflow

Class 3

SARPE Vs MARPE

Take home messages

For more information see  Benedict Wilmes guest blog on Kevin O’Brien’s Orthodontic Blog

Join me for the next interview in orthodontics with Ravi Nanda

Ravi is an authority in orthodontics, having authored 10 textbooks and published over 200 peer review publications, he is also the current editor-in-chief of Progress in Orthodontics

We get to hear of Ravi’s story of how he came in to orthodontics, his drive to ask research questions and how he has achieved so much. Ravi describes his mentors, and explains why he has never stopped learning, and why no orthodontist should either.

Facebook: @ravi.nanda.35

Instagram: @ravinanda

Textbooks

Esthetics and biomechanics in orthodontics

https://www.elsevier.com/books/esthetics-and-biomechanics-in-orthodontics/nanda/978-1-4557-5085-6

Principles and biomechanics or aligner treatment

https://www.elsevier.com/books/principles-and-biomechanics-of-aligner-treatment/nanda/978-0-323-68382-1

Join me for a summary of Madhur’s lecture on the biomechanics and aligners, where he describes the fundamentals biomechanics of aligners, explains the reason for the shortcomings of aligners and his tips to reduce them.

How do aligner work?

Two approaches

How to aligners treat malocclusions

Deep bite

Openbite

Advantages in aligners when compared to fixed

Space closure

How good are aligners at moving teeth

Root movement

Space closure

Root movement

Why can’t aligners move teeth as efficiently as braces?

First principles based understanding

Material factors

Biomechanics is the law – everything else is just a recommendation

Madur’s lecture in full available on youtube:

https://www.youtube.com/watch?v=ycNokW1ojIY&t=3s&ab_channel=orthobites.org

Join me for a summary of Dalia El-Bokle’s lecture looking at disarticulation, and how they can be utilised to correct malocclusions in 3 planes of space. In this summary a novel use of disarticulation is described for class 2 and class 3 correction. This lecture follows Dalia’s publication in the AJODO 2020.

Definition:

disocclusion by using bite turbos or so the teeth has freedom to move in the three planes of space

Indications:

Vertical

1. Deep bite: Anterior bite block to enable posterior eruption

2. AOB: Posterior bite blocks to enable posterior intrusion

a. 1mm intrusion posterior 4mm OB increase Hernandez et al 2017

Transverse

1. Correction of functional displacement / shift : Posterior bite block in conjunction with expansion appliance – bite blocks preventing inteference

2. Pseudo class III: With a Catlan’s appliance or resin blocks Kravitz 2019, mindful when using on lower arch to include multiple teeth as it may result in mobility of the lower incisors f placed an 2 only.

Using an anterior bite block will help in the clockwise rotation of the mandible that will help in Class III correction Liou et al 2018 APOS

Other

1. Anchorage reinforcement, large amounts of bite block create deep intercuspation between upper and lower teeth, preventing mesial movement of the posterior segment Georgio Fiorelli et al 2013

2. Unlocking the occlusion.

New methods

1. D-BIBRE AP correction AlBokle 2020

2. Transverse correction Georgio Fiorelli 2013

Bonded inclined bite raisers elastics D- BIBRE .

Use of disarticulation as a functional appliance for class 2 correction

What is it?

Flowable composite Triad Gel placed on the upper and lower 1stpremolar

How does it work?

· 45 degree Inclined planes are formed from the RMGIC which disarticulate the patient in a forward direction.

· Activation 2mm

· Indirectly made on models, transferred by transfer tray

· Reactivate chairside with Triad gel

· Removed after 7 months

· Night time class 2 elastics guide the patient into a forwards position

Occlusal cant and Asymmetries

Mild mod cases, Georgio Fiorelli 2013

· Mandibular repositioning with triad gel, full coverage bonded in the lower arch buccal cusps group guidance

· Results  22/32 stable TMJ 2 years after treatment follow up.

Recommend CBCT for condyle assessment

Bite turbos:

Anterior bite turbos:

· Bonded Resin or Metal turbos (High incidence of Debonding)

· Acrylic plane with modified Nance

· Digitally designed – even occlusion

Increased overjet

· Bite turbo extended = increase fracture and trauma

· Apply turbo to caninex

Placement tip

· Use Articulating paper to mark contact (so minimize the area covered by turbo)

· Don’t etch the fossa so easily removed

· Bite turbos need to be planned based on the estimated CR and the movement required,

Link to full lecture

The Art of Disarticulation in Orthodontic Therapy - YouTube

Content by AbdAllah Sharafeldin

Edited and produced by Farooq Ahmed

Join me for the next interview in orthodontic, with video!

Simon is an orthodontic innovator and contributor of research, based in private practice in Bern with a commitment to digital technology in orthodontics, having lectured 61 times on the topic.

We get to hear of Simons’ story of how he came across digital technology in orthodontics and what drives him to continue to innovate in orthodontics. Simon describes his mentors, what he took for them and how he applies these principles to his decision making. We discuss expansion in orthodontics and how Simon uses a skiing hardware to motivating patients!

Facebook: @Simon.Daniel.Graf

Instagram: @simon_graf_at_smile_ag

www.orthoinsummary.com

Join me for Neal Kravitz’s lecture on canine substitution and the clinical management of it. Focusing on bracket selection and canine recontouring

Case selection

· 2 key factors

o Profile

o Mandibular crowding

Bracket selection

· Goal:

o Canine substitution:

§ Reduce canine root prominence

o Premolar substitution:

§ Hide palatal cusp

o Molar interdigitation:

§ class 2 cases

4 bracket choices for canine

· UR1 (+17 tq, + 4 tip)

· Achieves ideal torque

· Requires flattening of canine labial face = plasty

· UR2 (+10 tq, + 8 tip)

o plasty and step out

· UR3 inverted (+7tq, +8 tip)

o Flipped U3

o Likely require addional torque

· LL5 inverted (+17 tq, +2 tip)

o Suggested by Marco Rosa

o Same torque but no reduction labial face – compound contour

Upper 1st premolar bracket selection

· U3 or U4 slightly distal – palatal cusp hidden

· See orthoinsummary blog on Premolar substitution

Upper molar tube selection for class 2 finish

· Achieve good interdigitation, the U6s tubes have 10 degree rotation labially, which does not interdigitate with the lower 5/6 embrasure space well, the 0 degree offset on lower 6s / 7s (-20 / -10 torque)

· No change in tip and torque

Tooth reshaping

· Canine morphology frequently triangular, more so mesial then distal

· Reduction – frequently underdone

o Mesial IPR – Kailasam 2021 1.2mm enamel mesial

o Incisal reduction

o Palatal reduction

Interproximal reduction for Bolton’s discrepancy

Class 1

· Canine substitution with lower extractions = maxillary excess

o = IPR uppers to correct Bolton’s discrepancy (U 1, 3, 4)

Class 2

· Canine substitution, lower non-ext = Mandibular excess

o = IPR lower anterior to correct Bolton excess (U 1, 3, 4)

Cosmetic bonding

· Step 1: Mesial step out

o Improve marginal ridge with central

o Reduce occlusal interference lower arch

· Step 2: Mesial build up

o Mesial incisal

o Line angle not that I practice it but they are essentially

§ Transition between proximal and labial face

§ Can make canine look narrower through altering this transition, ie the shallower gradient  narrower the tooth

Retention and review

· Group function and lateral clearance

· Long term fixed retention 4-4

o Length of bonded retainer

§ Lower canine mid to distal lateral incisor labial measurement = lingual 3-3 measurement

o Material – memotain Custom NiTi

References

Rosa, M.A.R.C.O. and Zachrisson, B.U., 2001. Integrating esthetic dentistry and space closure in patients with missing maxillary lateral incisors. Journal of Clinical Orthodontics, 35(4), pp.221-238

Kokich Jr, V.O. and Kinzer, G.A., 2005. Managing congenitally missing lateral incisors. Part I: Canine substitution. Journal of esthetic and restorative dentistry, 17(1), pp.5-10.

Kravitz, N.D. and Shirck, J.M., 2017. Measuring Bonded Lingual Retainers. Journal of clinical orthodontics: JCO, 51(5), pp.294-294.

Kravitz, N.D., Miller, S., Prakash, A. and Eapen, J.C., 2017. Canine bracket guide for substitution cases. J Clin Orthod, 51, pp.450-453.

Join me for the next interview in orthodontic, with video!

James is a private orthodontist from Perth Australia, a clinician with a passion to share, teach and learn. James has authored a chapter on 3D diagnosis and treatment planning and has 22,000 followers on Instagram with 625 posts relating to orthodontics on a variety of topics including biomechanics, TADs, orthodontics and restorative / periodontal management

We get to hear of James’ thoughts on social media Vs conventional orthodontic education, his thoughts on biomechanics, and advice for orthodontists.

Facebook: @jamesandrewsortho

Instagram: @dr.jamesandrews

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