Join me for a summary of Dalia El Bokle’s lecture exploring finishing in orthodontics. Part 1 focuses on bracket positioning concepts and Dalia’s own take to achieve more predictable ideal outcomes

Current bracket positioning technique

1. Middle middle – middle vertically and horizontally (FA point)

o Challenges

§ Accuracy = measure each tooth

§ If gingival swelling / not fully erupted = inaccuracy

2. Bracket charts – use of bracket gauges

o Accurate and reproducible, introduced in 1994

§ Typical chart

· Upper incisor 4-4.5mm from invasive edge

· Lateral 0.5mm incisal than lateral

· Canine 1mm more gingival than central

o Challenges

§ Appropriate for ideal tooth sizes only, can result in uneven marginal ridge heights if tooth size discrepancy present = bone loss, food impaction, premature contact and relapse

§ Can flatten smiles

3. Smile arch protection (SAC) Tom Pitts

o Bonding for consonant arch

o Method

§ Canine gingival to the contact point

§ Lateral 0.75-1mm cervical to the canine

§ Central 1.5mm more cervical to the canine

· Side effects – oral hygiene and deep bite

Solution by Dalia

Customised approach

· Factors

§ Marginal ridge heights, Upper incisor show, tooth size and shape, Incisor inclination, Overbite

· Method of positioning

1. Mesiodistal

§ All teeth bond in centre of the teeth

§ Molars – if extra cusp = tube design = mesial position and distal in rotation

· Solution = bond centre of the tooth, even if not in Mesiobuccal grove = extra composite used or modify bracket

§ Canine = EXCEPTIONS

· Place bracket mesial to long axis

· Mesial in rotation if placed in the centre

o Requires mesial out rotation to align with the lateral incisor

o Solution

§ Place upper and lower canines mesially

2. Axial (tip)

§ Draw long axis on the model

§ Use of OPG / CBCT to draw long axis

§ Modifications

· Overcorrect 5 degrees adjacent to extractions = prevent dumping in

· Overcorrect severely tipped teeth (usually in case of early loss of 1st molar)

3. Vertical

§ Posterior bond first 7-3

· Bond relative to marginal ridges – not incisal edges Kelange technique 2007

· Draw marginal ridge height line, then slot line

· Canine same level as premolars for marginal height

§ Anterior positioning

·  Lateral = bracket gauge of the canine to tooth tip, add 0.25mm (more cervical)

· Central – add 0.25-0.5mm than canine

o = subtle smile arc protection

o Subtle smile arc – less steep difference in connectors when compared to SAP by Tom Pitts

§ Modifications

· 3-3 bonded 1mm more gingival = AOB / reduced incisal show, or 1mm more incisal for deepbite / gummy smile

§ Lower arch

· Canines are bonded 0.5mm more cervical for canine guidance

· Deep bite = 1mm more incisal

Incisal recontouring

· At the beginning of treatment = visually aid final position and improve aesthetics for patient

Join me as I summarise Mona Ghoussoub’s lecture looking at the excessive gingival display (EGD).

Mona looked at the diagnosis and treatment of EGD, with a focus on aetiology leading to treatment method, effect of age, and input of multidisciplinary care for appropriate cases.

Definition Kokich 1999, Machado 2014

· Negative effects = 4mm + gingival display

Treatment approach

Early treatment

o Medical  ENT allergology

o Excessive gingival show age 7-8 years

o Nasal obstruction causes decrease in lip closing force Sabashi 2011

o Detect and refer ENT if suspect nasal obstruction

§ Dark eyes

§ Flat cheeks

§ Increase LAFH

o Orthodontic – prevention

o Utility arch

§ Intrusion upper anterior teeth

§  4 brackets and molar bands

§ Retain with 2 layers of Essix + brass wire – for rigidity

Late treatment

o Orthodontic

o Alignment

§ 2 occlusal planes in maxilla in 2 div 2, posterior higher, anterior lower

· Straight wire – reciprocal effects

o Intrusion of anterior teeth

o Extrusion of posterior teeth

o Expansion

§ RME

· Posterior expansion = gingival position moves upwards

o When constricted, greater posterior gingival show

o Intrusion

§ Ricketts / Burstone 3 piece intrusion arch

§ Headgear – J hook intrude upper anterior teeth

§ TAD placement for anterior intrusion

·  UR1-UL1 labial

· Powerchain archwire to TAD

§ TAD for posterior intrusion

· U5-U6 region buccal

· Direct retraction U3- TAD

o Below centre of rotation = posterior intrusion

o MDT

o Periodontics

§ Gingivectomy – passive over-eruption of dentition

· Ideal where tooth width:height ratio increased

§ Guided Tissue Regeneration for VME

· Stable after 1 year

· 40-60% improvement in excessive gingival growth, with crown lengthening

· Bony cavity at anterior superior aspect of maxilla

o Results in the lip raising higher

o Bone augmented at the level of the Le-fort 1

o Can be clinically simulated with cotton wool rolls in upper labial sulcus and taking photos

o Orthognathic surgery

§ Decompensate

· Maxillary impaction

o Plastic surgery Pierre 2020

§ Short lip / mild VME = lip repositioning surgery Rubinstein 1973

· Limit the smile muscle pull by reducing the depth of the upper vestibule– zygomaticus minor, levator Angulo, orbicularis oris, levator labil superior Tawfik 2018

· Conservative when compared to OGN

· Technique

o Split thickness flap – expose connective tissue

o Advance mucosa and suture at mucogingival junction

· Limited studies

· Overcorrect as some relapse expected

· Systematic review improve EGD 3-4mm Tawfik 2018

§ Hypermobile lip – Botox Cengiz 2020

· Reduce muscle activity – levator labil superios LLSAN, zygomaticus minor / major, risorius muscle

· NOT classified as an alternate treatment for EGD

o Use = indication for patient outcomes possible for lip reposition

· Temporary effects – relapse at 6 months

· Problems

o Dose related results

o Excessive upper lip ptorsis

o Too little – not achieve desired result

o Smile effected if erroneous

§ = require expert to use

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

‘One to watch for 2022’

Grant Isherwood is a recently qualified orthodontist from 2019, Liverpool UK. He is a member of the Royal College of Surgeons of Edinburgh and qualified as a dentist in 2011. Grant has published some exceptionally high quality clinical cases on social media @dr.grant.isherwood. Grant and has been working in both the public national health service and in the private sector as an orthodontist.

We get to hear of Grant’s experiences following qualification, how he navigated the pandemic as a new graduate and how he is developing his skills.

@dr.grant.isherwood

youtube video of interview

Join me for the summary of key lectures from the final day of this year’s American Association of Orthodontics Summer Meeting

10 key lectures are covered in this podcast from day 3 of the AAO meeting, on the topic of TADs, Carriere, Orthognathic surgery first, Skeletal TAD expansion, orthodontic uncertainty

Speakers:Jay Bowman, Kevin O’Brien, Luis Carriere, Bjorn Ludwig, Maschos Papadopoulos, Beom Kim, Jungi Sugawara

Individual lecture podcasts are available in the description from the website www.orthoinsummary.com

Lectures titles:

1. TADs- Keeping it simple while being successful Sebastian Baumgaertel

2. Uno, Dos, Tres/ All the Screws in the Same Place Jay Bowman

3. Class II Minimum-Touch Approach in an Evolving Orthodontic World Luis Carriere

4. The Management of Occlusal Plane with Extra-Alveolar Miniscrews. Marcio Almeida

5. TAD Supported Space Closure in Agenesis Cases Bjorn Ludwig

6. Maxillary Molar Distalization with Mini-screw Implant Supported Appliances Maschos Papadopoulos

7. Navigating Complexities in Surgical Orthodontic Cases Jerry English & Kurt Kasper

8. Tooth Bone vs Tissue Bone MSE Does it matter? Beom Kim

9. Less Invasive Surgery First Approach Jungi Sugawara

10. Orthodontic uncertainty. Research, core outcomes and snake oil. Salzmann Lecture Kevin O’Brien

AAO Virtual Annual Session June 2021 Day 2

Join me for the summary of key lectures from this year’s American Association of Orthodontics Summer Meeting

14 key lectures are covered in this podcast from day 2 of the AAO meeting, on the topic of Maxillary Skeletal Expansion, TADs, Bone plates, Carriere appliance, Digital Orthodontics,  Phase 1 treatment, Facemask, Aligners,

Speakers: Hugo De Clerck, Jonathan Nicozisis , Carlos Flores-Mir, Jason Cope, James McNamara, Peter Ngan, Benedict Wilmes, Stella Chaushu, Brandon Owen, Juan Fernando Aristizabal, Roberta Lione, Tung Nguyen

Individual lecture podcasts are available in the description from the website www.orthoinsummary.com

Lectures titles:

1. Long-term evaluation of class 3 orthopedics using skeletal anchorage. Tung Nguyen

2. Growth Modulation by class 2 and class 3 orthopedics Hugo De Clerck

3. When you play the games of Thrones, you win, or you die. Is there a middle ground Carlos Flores-Mir

4. Can Changing the Transverse Dimension Improve the Quality of Orthodontic Treatment in Children? Dr. Roberta Lione

5. How To Become An In-House Aligner Power House. Jason Cope

6. Carriere 3 Treatment in minimally growing patients- How does it work? James McNamara Management of the Carriere Motion Appliance for Class III Correction in the Mixed and Permanent Dr. Laurie McNamara McClatchey

7. Treatment of maxillary deficiency with facemask and TADs Peter Ngan

8. Maxillary Expansion & Treatment of Class III Malocclusion in the Digital Age Dr. Benedict Wilmes

9. Clear Aligners in Orthognathic Surgery Flavio Uribe

10. Growing and Redirecting the Roots of Impacted Teeth Stella Chaushu

11. Surgery First Combined with CAD/CAM Brackets and 3D Predictions Juan Fernando Aristizabal

12. Clear Aligner Treatment- One Size Does NOT Fit ALL Dr. Clark Colville

13. Efficiencies of Aligner Treatment in Teens and Early Treatment Jonathan Nicozisis

14. The 'How to' Guide of Digital Braces/Teledentistry Brandon Owen

Please like and subscribe if you find it useful!

Join me for the summary of key lectures from this year’s American Association of Orthodontics Summer Meeting

13 key lectures are covered in this podcast from day 1 of the AAO meeting, on the topic of Aligners, TADs, Miniscrew assisted expansion MSE, Biomechanics, AOB, 3D Metal printing, aging dentition, Forsus

Speakers: Chris Chang, Won Moon, Ravi Nanda, Daniela Garib, Brent Larson, Maz Moshiri, Lorenzo Franchi, Lorenzo Franchi, Kenji Ojima, William Dayan, Simon Graf, Lisa Alvetro, Flavia Artese, Jae Hyun Park

Individual lecture podcasts are available in the description from the website www.orthoinsummary.com

Lectures titles:

1. Simplified Mechanics for Aligners in Treating Complex Cases Dr. Chris

2. The Evolution of Mini-implant Assisted Midfacial Expansion, the Latest Developments and Advanced Applications Won Moon

3. Biomechanics and Force Delivery Systems- Wires to Screws to Plastic Ravi Nanda 2021 Edward H. Angle Award Lecture

4. Aging of the Occlusion- What Should We Know? Daniela Garib

5. Applying Science to Aligner Mechanics and Design Brent Larson

6. Suggestions for Systematic Treatment of Orthognathic Surgical Patients with Clear Aligners Maz Moshiri

7. Jacob A. Salzmann Award Lecture; Efficient and Effectively. Lorenzo Franchi

8. Type of Approach for Biomechanics of Aligner Orthodontics Kenji Ojima

9. Ideal Occlusion is Not Always the Ideal Treatment Plan William Dayan

10. 3D Metal-printed Bone Borne Appliances Simon Graf

11. Tips to Optimize Treatment Results Using Forsus Class II Corrector Dr. Lisa Alvetro

12. Key Factors to Consider when Correcting the Vertical Dimension Flavia Artese

13. Anterior Open Bite Correction- Conventional Treatment vs. TADs Jae Hyun Park

Join me as I summarise Ute Schneider’s lecture exploring early interceptive treatment. Part 1 explores signs of patients appropriate for interceptive treatment, the treatment options available with a focus on an adaptation of serial extractions which Ute is a proponent of.

Signs of hereditary tooth size jaw discrepancy in the younger patient

· Premature exfoliation of one or more deciduous lateral incisors

· Gingival recession on a prominent lower incisor

· Splaying of the maxillary or mandibular lateral incisors

· Ectopic eruption of U6, with premature exfoliation of E

· Impacted L7s

Treatment strategy for young patients

1. Wait for growth – natural skeletal discrepancy

2. Arch development: expansion , distalisation , proclination

3. Leeway space

4. Serial extractions

1/ Wait for growth

· Arch length and depth decreases with age, especially mandible decrease in arch length from age of 8 Bishara 1998

· Compare arch length 1930 Vs 1990s, smaller arch length and worse crowding in 1990s Bishara

2/ Arch development

· Rapid maxillary expansion

o Questionable stability

§ Meta analysis loss of RME 2.4mm Schiffman 2001

· Limited evidence of stability of RME

· Lip bumper, Quadhelix, 2 x 4, removable appliance

o 6 years severe relapse greater than other strategies

o 89% Significant relapse of mandibular anterior crowding Little et al

3/ Leeway space management

o Is crowding is equal or less than the leeway space Nance 1947

o Wide range of the leeway space available 0-8mm

o Lower premolars are larger now that 1930s – Evidence of reduced leeway space in 1930s Vs 1990s Allen 2017. Reduced 0.42mm per quadrant

· Lip bumper

o Impaction of 7s 10-20 x more prevalent than in the general population Sonis 2011

4/ Serial extractions

Advantages

· Immediate spontaneous improvement

· Reduces appliance time

· Reduces cost

· Reduces discomfort

Best candidates

· Severe hereditary tooth size discrepancy

· Orthognathic or bimax cases

· Minimal OJ and OB

· Class 1 malocclusion

Significant relief of crowding spontaneously?

· Extraction of Cs and 4s = Littles index improves from 11.8-2.74 Yoshihara 1999

Profile changes with serial extractions

· No evidence supporting adverse profile changes with serial extractions

· Non-extraction: consider possible negative aspects of non extraction Bowman 2000

Protocol for serial extraction

· Extraction of Cs

· Monitor every 6/12

· When 4s erupt, extract

Conclusions of serial extractions:

· Early non appliance orthodontic treatment

· Eruption guidance

· Limited to select group of patients

· Still has a place in orthodontic clinical practice

Invisalign: Virtual Orthodontic Summit 2021

Join me for the summary of key lectures from this year’s Invisalign UK Virtual Orthodontic Summit meeting

4 lectures are covered in this podcast on the topic of biomechanics and aligners, using tuberosity TADs and troubleshooting with aligners

Speakers: John Morton, Willy Dayan, Susana Palma, Graham Gardner

Individual lecture podcasts are available in the description from the website www.orthoinsummary.com

Lectures titles:

1. Biomechanics of the Invisalign system 2021 John Morton

2. Treating complex aligner biomechanics. Willy Dayan

3. Overcoming difficulties in class 2 correction with TADs in tuberosity and aligners. Susana Palma

4. Monitoring and troubleshooting Graham Gardner

The podcast is opinion and may not be 100% accurate or representative of the lecture / speaker, the podcast is not endorsed by an institute or the speaker and is the independent work of Farooq Ahmed and the Orthodontics in Summary team. It is not intended to over-ride or replace the requirement clinicians have in being familiar with the relevant training and guidelines for the treatment they provide

#orthodontics #farooqahmed #almuzian #orthodonticsinsummary #aligners, #TADs #tracking

#orthodontics #farooqahmed

@farooqahmed_orthodontist

Join me for the next interview in orthodontic.

Kleber Meireles is a Professor in Orthodontics at the Instituto Prime Cursos, Salvador Brazil, he studied orthodontics at the HRAC/Centrinho University Sao Paulo Brazil. He is a visual educator in orthodontics with 500 + videos in orthodontics

We get to hear of Kleber’s commitment to education leading him to produced dynamic videos in orthodontics. I explore his treatment approach and his role models, as well as his one piece of advice to all orthodontists

Please find the link to Kleber’s Instagram and youtube where his videos are freely available

@klebermeirelesortodontia

Youtube channel: Kleber meireles 

Join me as I summarise Pater Miles lecture exploring myofunctional appliances and the literature of the appliance

Claims by some manufacturers of myofunctional appliances:

· incorrect breathing from 2 years of age

· Incompetent lips & mouth breathing – aesthetic effects

· Crooked teeth

· Long face

· Behavioural changes, tired / hyperactive

Claimed effects of appliances treatment

· Improve facial growth

· Skeletal growth

· Better alignment

· Stable

Myofunctional Appliances what are they?

Design – off the shelf design

· Monoblock Kesling positioner type appliance 1945:

· Double mouthguard postured into edge to edge position

· Postured edge to edge

· Example Occlus-o-guide, LM activator, Myobrace

Effects:

· Retrocline uppers, procline lowers

· Disocclusion posterior teeth = overeruption of posterior teeth, overbite improvement

Evidence

Occlusal changes with appliances

· Eruption Guidance Appliance, T4K, LM activator AJODO 2008 Angle 2019

· Overjet 2mm improvement

· Overbite 2mm improvement

· Crowding reduction 2mm

· Relapse towards baseline Janson, significant for OB crowding and 25% for OJ 2007

· Time 13-43 months

o Small changes over a long period, options to treat later Obrien 2003

Myobrace Vs Activator EJO 2015

· Poor compliance: PFA 70% non-compliance, 53% Activator non-compliance (Twinblock 84% compliance AJODO 2003)

· 2018 cost benefit analysis: PFA minimised costs

Airway evidence

Difficult to show direct changes, so related parameters are used.

Claimed issues with narrow airway and mouth breathing:

1. Dental: Crooked teeth and arches

2. Lip incompetence

3. Skeletal: long face

4. Behaviour tired and hyperactive

1: Crooked teeth and narrow arches

o Prevalence of malocclusion similar in Paediatric sleep disorder breathing in the population J den Sleep Medicine 2017

2: Lip incompetence

· Vig 1979

o Lip growth accelerate sand overtakes facial height 9-13

o Lip incompetence will improve with age

· Vig 1881

o Lip incompetence no difference in nasal airflow

§ Cannot conclude lip incompetence = mouth breather

o Proffit – long face still use nose to breath, but less than normal face type

3: Skeletal: long face

· Craniofacial morphology metal analysis: AJODO 2013

o Paediatric OSA statistically significant in class 2, 1.5-1.6o – NOT clinically significant or diagnostically useful

§ Direct casual relationship of craniofacial structure and paediatric sleep disorder is unsupported in meta analsysis

Myofunctional therapy

Oropharyngeal exercises

· Aim to improve tone of surrounding muscles, phalangeal muscles, soft palate,  airway – increase patency

o Reduce AHI index by half short term studies 3 months Am J resp Crit Car Med 2009, Sleep Med 2013

Orthodontists role in SDB

· We are not the primary care giver

· Main role: Screening / Assessment, questionnaire

o Paediatric sleep questionnaire

§ Effective ruling out OSA / SDB