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Join me for a summary looking intodifficult movements with aligners, why they are difficult, and a protocolderived from research on how to manage tooth movements with aligners. Thislecture was given by Bill Layman at this year’s AAO, where he describes maxillaryincisor extrusion, posterior intrusion, and controlled expansion.

Introduction

· Rate of refinement: 2.5 perpatient Kravitz 2022

· 41% of aligner cases 3refinements +

· Switch to fixed appliances fromaligners 1 in 6 Kravitz 2022

Staging and synergistic movements can reducerefinement rates

Incisor extrusion

Why is Incisor extrusion difficult?

· Lack of undercut

· Sqeeze teeth to engage, creatingopposite effect due to V shape of a tooth – leading to loss of retention of thealigner

· Interproximal binding through verticalcontact point overlap or slipped contact points and a closed system of aligners

Incisor extrusion staging steps:

1. Create undercut: Horizontalattachments are most effective, regardless of design Groody 2023

2. Create 0.1mm between teeth torelieve interproximal binding

3. First procline the incisors toincrease surface contact

4. Then Extrude and retract

Posterior intrusion

Why is it difficult?

· Multiple teeth and lack of anchorage,through anterior teeth

· Crowns tip mesially duringintrusion as an unwanted effect

· What happens when we intrude:

o Mesial tipping of posteriorteeth Fan 2022 Finite element

o Buccal and palatal attachments= less tipping buccal or lingual

How to improve posterior intrusion

· Sequential intrusion – 1stpremolars

· Tip posterior teeth 5-10 degreesdistally

· Horizontal attachment buccal /palatal

· Consider attachment lingualUpper molars

· Sequential intrusion

· TADs not always needed, 5200 timesbite on hard surface, enables posterior intrusion through masticatory forces

Controlled expansion

Why is it difficult

· Aligners tip teeth buccally =creates occlusal interferences

· Lack of rigidity of tray toexert forces = straight finish trays increase rigidity

· Attempting to correct skeletalproblems with dental solution

· Greatest expansion in the premolarregion

· Expansion from the researchshowed progressive less posterior expansion

o Molars expand less due toanchorage loss

· Expansion through tipping

How to improve posterior intrusion

· Plan around premolar expansion

· Expect 70% in premolar region,55% molar and 46% canine

· Overcorrection of canines 1.7mm(premolar region 3.4mm) Zhou 2020

· Maximum expansion seen is 4mm

Conclusion:

· Incisor extrusion: proclineteeth with attachment, then extrude and retract

o Include iPR

· Posterior intrusion: Start withpremolars and sequentially intrude posterior teeth

o Add distal tip

· Controlled expansion: Effectivein premolar region

o Plan with overcorrection

Jay Bowman

· “If you don’t build-inovercorrections you can’t get corrections”

· “there many things that needimprovement at the end that aren’t hard to do if start treatment with theovercorrections in mind”

Contributions

Contents:Shanyah Kapour

Editedand produced: Farooq Ahmed

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Join me for asummary looking at fixed versus removable functional appliances. This podcastsheds light on recent research comparing the main two types of functionalappliances, which appliance offers the most advantages, and what patients thinkabout the two appliance types. This was a lecture given by Ama Johal at lastyear’s British Orthodontic Conference, where the most recent evidence carriedout by his PhD student Moaiyad Pacha.



Moaiyad Pacha’sRCT 2023 – received Dewel 2024 clinical research award

· Hanks Herbst Vs Modified Twinblock

o Rollo bands

o Expansion

o No fixed appliances

o Incremental advancement – no evidence to supportbut patient-centred

· Overjet correction: More effective Herbstat 7mm Vs 5.8mm Twinblock ,

· Molar and skeletal changes: no difference

o Twinblock = greater residual overjet aftertreatment p=0.2

· Dental changes: Herbst advance lowerincisor greater 3mm Vs 1mm

· Failure to complete: 17% Herbst Vs 37%twin block

o 3 times greater likelihood of discontinuetreatment OR 2.8

· Treatment duration: longer with Twinblock1.5 months 8.8 Vs 10.3, and quicker rate of correction with Herbst

· Chairside time : Greater than Twinblock2.7 hours longer, 7.6 Vs 4.9

· Emergency appointments greater with HanksHerbst 2.7 Vs 0.3

o Herbst mainly

· Severe complications = same 0.5

o Severe complications – previously defined asinvolving lab work or break in appliance wear from Pasha’s SR 2020

Advantage of Hanks Herbst

· Greater completion of treatment, 3 times lesslikely to discontinue

· Quicker rate of correction, shorter duration,

Disadvantages

· Greater chairside time of nearly 3 hours

· Greater emergency appointments, each patientneeding 2-3 emergency appointments

Qualitative

· Both appliances – very negative to QoL and dailylife

· Aesthetic and self-image – worse with Twinblock

· Patient preference – Herbst

o Due to non-compliance and likely to get to theend

· Positive Twinblock is flexible and easier to eat

Conclusion was profound

· Patients prefer Herbst, based on aesthetics,self image and non-compliance

· Clinicians are likely to prefer Twinblock,quicker, easier, less emergencies

Time to reconsider, and having both options, as well as bothdiscussing of clinician Vs patient preferences, should decide which appliance

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Join me for a summary podcast exploring the topic of white spot lesions, and up-to-dateresearch looking at how to manage lesions when they occur, when the right timeis to treat the patient, and what minimally evasive options can be used in clinic. This was an excellent lecturefrom Gayle Glenn earlier this year at the AAO winter meeting.

Four treatmentoptions are discussed, Fluoride, CPPACP (Mi paste), resin infiltrate andmicroabrasion.

Whitespotlesion background WSL
Definition - subsurface deminieralization,intact outer layer, 1st sign of carious lesions

Remineralisation– no additional agents

Most rapidrepair first 6 weeks without use of additional agents

· Upto 6 months spontaneous improvement with good oral hygiene

· Recommend3-6 months monitor after debond: BEFOREconsider additional treatment

Fluoride

· Decreaseenamel dissolution

· Increasereminerazation

· Formationof fluorapatite

· Products

o Fl varnishreduce WSL occuring by 44%:

§ require plaque removal and wire removal

§ Not often used in clinical practice and requiresrepeat application

· TREATMENTWSL

o Fluoride low dose (toothpaste)

o High Fluoride – hyperminerasied surface layerforms = seal off subsurface layer which remains demineralized. Bishara 2008

Resin infiltration Gray 2002

· Remove outer hypomineralised area with 15% HFL

o Infiltrate with low viscosity

o Improves aesthetics

o Arrest lesion – however some demineralisationmay remain

o Lack long-term evidence

o Most effective in research (RR:121.50, 95%CI:51.45-191.55 Jiang 2023)

MI paste (CPPACP) Frencken 2012

· Milk protein derived

· Stabilizes Ca PO4 – ideal of for formed WSL

· Creates Ca PO4 reservoir around bracket

· Applied:

o Brush above and below bracket or finger

o Distributed by the tongue

o Can be swallowed

o Avoid eat and drink 30-60 minutes

· Effectiveness for reminersation

o Evidence unclear – conflicting sustematicreviews AlBukaiki 2023 no difference, same year Jiang 2023, it is effective, however exceptionally large rangeof values (RR:49.69, 95%CI: 0.87-98.51 and although RCTs, limited to assessingpremolars only and different methods of assessment and duration of treatment.

· TREATMENT FOR WSL

o Wait 3-6 months following removal of braces

o In retainer 3-5 minutes

o Rinse out

o Nothing to eat 30-60 minutes

Microabrasion

· Combination of acid and abrasive particles

· Burinsh into enamel with slow speed handpiece

· opalustre = 6% HCL + silica (low particlesize, lower concentration with larger particle size than prophy paste = 12-160 particle size 1986 Krol)

o 1 mm size of use

o Burnished in using a polishing cup and slowhandpiece

o 1 minute

· Not widely accepted

o Partly due to variations in protocol

o Use of rubber dam

· Microabrasion and CPP-ACP proposed idea Ardu2007

2022 Lammert

· CPP-ACP both sides, with half of mouth alsoreceiving 1 visit of microabrasion

· After 6 months post debonding

· Evaluate and repeat up to 8 times

· Results

o Mi paste group 9.3-8.1 size of lesion –statistically significant

o Microabrasion and Mi paste group

§ 13.2 – 4.3and reduce to 2.1

· Most improvement immediate after microabrasion

o Compared difference of size of the initiallesion

§ 5.5 xreduction in CPPACP

§ 7.4 Xreduction in microabrasion

Clinical implication

· Microabrasion = significant clinical time

o Up to 8 minutes per tooth, can be up to 1 hour

o Therefore clinical application

§ Perhapsisolated 1 or 2 teeth

Conclusions:

1. Patientswith WSL are usually not great compliers, giving additional products whichrequire significant compliance, is practising research in isolation.

2. Microabrasiontakes nearly 1 hour, role in clinical practice limited to isolated areas

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Join me for a summary exploring bullying and itsrelationship with malocclusion, with a contemporary review of evidence showingthe psychological effects various malocclusions can cause young people. Thispodcast is a summary of Andrew DiBiase’s lecture last year at the BritishOrthodontic Conference. Andrew’s research explores what factors moderatebullying, and what factors can be protective against bullying.

Introduction

· Nearly 1 in 3 patients report teasing or fear ofteasing as a motivating factor for orthodontic treatment Bauss 2023 AJODO

· 1 in 7 patients attending our clinics arebullied Seehra et al., 2011

· Most upsetting feature of bullying teeth 60.7%Shaw

· 13, 387 teenagers 25% report bullying

o Around 7% related to teeth

Definition of bullying: Olweus 1984

· Unprovoked and sustained campaign of aggression,towards someone in order to hurt them

· Student exposed repeatedly to negative action onthe part of one or more students

o Harm, imbalance of power, organised, repetitive,harm experienced

Who gets bullied and how?

· Younger more – 10 year olds 22%, 15 year olds 7%

· Girls are greater than boys by 5%

· Boys low athletic competence

o Judged on homour as well Langlois 2000

· Girls appearance

o We do judge girls on physical appearance Langlois2000

o 80% verbal - Cyber bullying – doest stop at theschool gate

Consequences of bullying

· Short term and long term effects

o Poorer academic performance

o Crime

o Self harm

§ 26% within young population and teeth occupyingthe reason in 1 in 5 young people Bitor 2022 AJODO

o Low self esteem

o Structural changes, medulla – related to fear(peer victimisation and its impact on adolescent brain)

What features are more likely to result in bullyingDibiase, Jad Seehra 2014

· Greater rate of bullying

· 2 div 1: 18%

· Increased overjet 16% Tristão SR 2020

· Deep overbite

· Missing teeth, anterior spacing

· IOTN AC 9 and 10

· Regression – younger worse

· Low athletic competence p 0.019

Conclusions

· Relationship between bullying and severemalocclusion

· Schoolchildren who report being bothered bytheir teeth report being lonelier at school and lower self-esteem

· Malocclusion has a greater impact on femalesthan males

· Malocclusion and peer relations is moderated byself-esteem in girls, but not boys

· Good peer relations protect against the negativeimpact of malocclusion in girls with low or average self-esteem

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Orthodontics and TMD, what is the role of orthodontics?

“if you give a splint, it will not cure the TMD”

“It depends on the adaptability of the patient”

“The role of the patient in the treatment is very, very important”

Roxana describes her journey into TMD and orthodontics, what led her to attend courses worldwide and also set up her own course on TMD.

Roxana describes what has created the controversy in TMD management, and answers recent questions from the literature of the role of both orthodontics and splints in TMD management

To book onto Dr Roxana Petcu’s courses please visit www.lazarlearning.ro/cursuri/ or roxanapetcu_ (I have no financial interest)

Click on the link below to view previous episodes, to refresh topics, pick up tricks and stay up to date.

Please like and subscribe if you find it useful!

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Does whitening have a role in orthodontics? A popular cosmetic procedure which 1 in 4 adults partake in, and was proposed recently at a conference as part of finishing in orthodontics. So this podcast reviews whitening as a topic and the latest evidence in combining whitening with aligners.

Reminder the podcast is an opinion piece and is the independent work of myself and the orthodontics in summary team.

24% of adults have whitening their teeth (dentalhealth.org)

How does it work:

Bleaching is the chemical changing of darker staining on teeth termed chromogens, with the active ingredient hydrogen peroxide.

Hydrogen peroxide reacts to oxidize the chromogen, which becomes a lighter colored compound.

Hydrogen Peroxide is not a stable chemical, so Carbamide peroxide is used, which roughly breaks down to 1/3 H2O2 when mixed with water.

Hydrogen Peroxide UK limit 6%, or Carbamide peroxide 16% is used, USA, greater concentrations are used with 10% hydrogen peroxide for at home whitening, and 35% hydrogen peroxide for in office bleaching.

Children

UK guidelines GDC 2014 – no bleaching until 18, unless purpose of treating or preventing disease.’

USA: The AAPD 2023 s Safe and effective for whitening discolored teeth of children and adolescents. Avoid full-arch bleaching mixed dentition and primary dentitions

Risks

Sensitivity -

about 80% of patient’s experience sensitivity

• Tooth sensitivity usually occurs at the time of treatment and can last several days
• Upper lateral incisors – greatest sensitivity
• Directly correlated with concentration
• Greater intensity if tooth was restored Bonafe 2013

Gingival irritation

• gingival irritation begins within a day of the treatment and can also last several days

Susceptibility to demineralisation

• Suggested surface demineralization occurs as the pH of the whitening agent are acidic and hydrogen ions affect the enamel crystals,
• No difference when using manufacturers protocols including 35% H202 Tompkins 2014
• However aggressive whitening: excessive use of in office whitening Shi 2012

How long does the whitening last

Duration of correction, depends on lifestyle, with smoking and coffee reducing the correction. Expected 6-12 months of stable colour change. Wiegand 2008

Aligners

• Bleaching tray is different – reservoir for bleach, 1 or 1.5mm soft ethylene-vinyl acetate (EVA), Straight cut 2mm beyond gingiva or scalloped, with 2 mm extension onto the gingiva giving a better seal and greater patient comfort. Dosage dots to limit application beyond 2mm
• Aligners
• Usually gingival bevelled, but as effective as bleaching trays, Levrini 2020 improvement of 3.5 shades on average Seleem 2021
• tooth sensitivity and gingival irritation does not disrupt of treatment 16% Carbamide peroxide Oliverio 2019, Levrini 2020
• 2 mm thick layer of gel is advised at incisal or facial central surface of the aligner
• Bleaching with attachments present, when bleaching complete attachments removed:
• hydrogen peroxide diffuses through spaces between enamel prisms
• The composite attachment was thought to affect pigment infiltration, however with enamel polishing after composite removal, color equalization occurs without discrepancies Staley 2004
• Minimal change to aligner structure Oliverio 2019

Retainers as bleaching trays?

Use of 0.8mm Zendura, no resivoir, effective bleaching with marked or extremely marked improvement in 78% of cases with 10% Carbamide peroxide, however but this changed the VFRs’ biomechanical properties, decrease in tensile strength and an increase in hardness and internal roughness, unclear what the medium and long term effects are .Jin 2024

Bond strength

• By Bleaching a tooth there is enamel bond strength reduction by 25 % Miguel 2006
• Wait 2 weeks after bleaching for aligner attachment placement.
• Bonded retainer has not been researched

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Join me for a summaryof direct to print aligners. This lecture explores the application of a relativelynew resin material which can be used for aligner fabrication, without the needof a 3D printed model. The lecture was given by Simon Graf who expertlycompared the differences between conventional and direct to print aligners, aswell as the clinical application of specific features of direct to printaligners.

Limitations ofcurrent aligner material:

1. Only smallundercuts

2. Limitedaligner thickness to sheet thickness / no selective thickness

3. During themanufacturing process material can get thinner or thicker depending on heat distributionand stretch, 54% change in thickness of the aligner Lee 2022

4. Plasticand resin waste, (122 million aligners and models in 2022 Slaymaker 2024)

Advantages of directto print aligners

· Select thickness, 0.5-0.7mm, conventionalaligners 0.75mm+

· Gingival margin

· Dentist incharge of design, not company

Manufacturing stepsof Direct to Print aligners (Tera Harz ‘Graphy’)

1. 3D printingof resin aligner

2. Centrifuge:Spin remove excess resin

3. UV Lightcure in Nitrogen chamber

4. Washedtwice, hot distilled water

Characteristics ofDirect to print aligners

· Greater accuracy: (Zendura, EssixAce and DTP were compared and DTP were 20-30% more accurate Koenig 2022)

· Less with DTP (Hertan 2022)

o DTP 50%less still (2.59 Vs 5.26 N)

o DTP Lessforce as strain increases

Shape memory effect

· DTP Polymer chains crosslinked, not case in conventional aligners

o The shape recovers in DTP whenstrain is removed, which does not occur to the same degree in conventional alignersLee 2022

o Accelerated by placing in water

Unknowns

· How effective shape memory is remains unclear

· Cytotoxicity – not enough data, although manufacturerprotocols, lack of studies

· Changing thickness, unclear how much of adifference in force it makes

Clinical points

Teeth extrusion

Lateral incisors

· Difficult to do with conventional aligners,

· Create ‘wedging’ gingival pressure columns tosqueeze the teeth to cause an extrusive force.

Elastic Hookswithout loss of force delivery on single tooth

· Hook printed into aligner with DTP, instead of cutout which alters the force of the aligner instantly, maintain tooth control

· Tip aligners and elastics: Still add attachmentto tooth to prevent aligner displacing

Mandibular advancement

· Problem of mandibular advancement with aligners

o Wings softand not maintaining the AP position

o Hard blockmany breakages

· DTP choice of thickness of block

Bite ramps

Conventional biteramps: limited length and often too short

DTP no limit to sizeand thickness, and can be designed to not contact upper palatal surfaces, maintainingfull tooth control

In the Transverse

o Palatalcoverage can be added as feature, similar to a TPA

o Stillbeing researched how much force can be delivered with palatal coverage

Concluding statement

Enjoy the variabilityof direct printed aligners.

Contributions

Contents:Abdallah Sharafeldin

Editedand produced: Farooq Ahmed

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Join me for a summary looking at gingival recession in orthodontics, and whether it is detrimental or beneficial. This lecture was given by James Andrews, he explored the effect of orthodontics on the periodontium, an area under increasing interest within aesthetics to achieve the ideal ‘pink aesthetics’ with the increasing adult population receiving orthodontic treatment. His lecture was based on, is orthodontics good or bad for the gingiva?

What is the starting point ?

• Increase in adult orthodontics from 1970 by 800%
• 50% of adults have some element of periodontal disease
• Untreated adult population 51% dehiscence 37% areas of fenestration Evangelista 2010

Facial type and bone morphology Tunis 2021

• Dolichocephalic = narrow alveolus and elongated to compensate for vertical growth
• Brachycephalic = larger alveolus
• Dolichocephalic - Red flag patients

Tooth movement:

What happens when teeth move buccally?

• facial tooth movement Wennström 1996
• Reduced bucco lingual width
• Therefore, reduced free gingiva
• Increased risk only if tooth is moved out of the alveolar housing

What type of movement

• Tipping (uncontrolled) increase likelihood of recession Condo 2017
• Proclination causes recession, but inconclusive
• Thickness more relevant than final inclination Yared 2006

How to decide what to do?

WALA line – Will Andrews Larry Andrews ridge Andrews 2000

• Limit of labial bone – shape is coincident with the mucogingival junction, coincident with centre of resistance
• Upper incisors – located anterior 1/3 of alveolus
• Mandibular incisors – cantered within the alveolus
• Gingival recession did not increase in treatment orthodontic population with segmental mechanics Melsen 2005

Aligners any different?

• Association between non-extraction clear aligner therapy and alveolar bone deficiency and fenestration
• Presence of both fenestration and dehiscence

What do we do to correct extra-alveolar teeth?

If teeth pushed outside of cortical plate then retracted, what happens

• Monkey – moved teeth outside of bone for 8 months, then reposition within bone with appliances = repair bony dehiscence and fenestration
• Morten Laursen and Melsen 12 consecutive patients 2020
• Teeth moved towards the centre of the cortical plate = improvement in gingival height of depth decrease of 23%, the width with 38%

Intrusion

• Use of intrusion arch increases the thickness of the periodontal fibres 0.7 to 2.3 mm Melsen 1988

Gingival graft when to move teeth

• Free gingival graft – 6 weeks
• Connective tissue graft – 12 weeks

“Diagnose and treat each tooth no miracles shortcuts for good orthodontics” Peck 2017

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Join me for a summary looking at miniscrews, looking atwhere the answer to successful TAD placement lies, in research or clinicalpractice. The reasons for higher failure rates than others with TADs wasexplored through 3 key factors; insertion torque, site selection and rootproximity. Evaluation of both scientific and clinical processes were describedby Sebastian Baumgartel at the British Orthodontic Conference, as theNorthcroft lecture.

Is torque a factor in TAD success?

Torque study – compression during insertion Motoyoshi 2006

· High torque – 60%

· Low torque = 72%

· Medium torque – 92%

Understanding

· Low torque = low compression, low primarystability - early failure as not engagement with screw

· High torque = high compression, early success,but greater resorption after insertion, remodelling results in a resorptionprocess

· Medium = best of both = sufficient compressionfor primary stability, not high enough to cause resorption remodelling

Ideal

· Ideal torque range – 10 Ncm Shantavasinkal 2016

o Study of buccal tads

· Sebastian’s empirical experience between10-25Ncm depending on site

Rules:

· Aim for medium torque

· Target 10Ncm

· Exceed 10Ncm on palate acceptable

What is the best site for TAD insertion?

Keratinised gingiva

· Evidence - states no difference Lim 2009, Chen 2008, Park 2006, Cheng 2004

· Non Keratlised – depends on mobile or nonmobile, with non-mobile higher success rate Viwattanatipa 2009

· 2mm apical to muco-gingival junction

o zoneof opportunity

Target zones and site

o No roots

o Consistent cortical bone

o More tolerant to higher torque

o Attached gingiva with low mobile mucosa

Is there ideal bone?

· = ifideal torque = ideal cortical plate thickness

§ 1-1.5mm cortical plate thickness

· CBCT can be overkill, using research sites foraverage sites

Ideal site:

– 1st premolar region (transverse) Sebastian 2009

– 2 mm away from mid-palatal suture

o = creates ideal zone ‘Mx1’

Evidence of site selection success

· 98% Vs buccal 71% Houfar 2017

· 84% Trainee success Sebastian 2020

· Success of Sebastian anterior palate 100%, maxillarybuccal lowest 85%

Does root proximity influence TAD success?

· Not just contact with roots, but proximity toroot also causes failure Kuroda 2007, Asschericks 2008, Chen 2008

Understanding

o Increase root and PDL proximity = bone stress increases = increase bone turnover= increase failure of TAD

· 4mm interradicular distance needed (depending onsize of tad) to achieve 1 mm clearance from roots

· Most buccal sites have less than 4mm (resolvethrough diverging roots, or sites with no roots)

What happens if TADs fail and we try again?

– Secondary insertion success

o 58% (reduced by 33%) Park 2006

o 44.2% (reduced by 36%) Uesugi 2017

o 58.1% buccal (reduced by 21%), 88.9% palatal(increased by 4%) Uesugi 2018

§ Uesugi 2018 showed buccal failure increases forsecondary insertion, but palatal insertion increases success

For more education see Sebastian’s TAD course:

https://tadchallenge.com/tad-certification-course

I have no financial interest

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Join me for a summary of Tommaso’s lecture on aligner treatment, exploring questions on the use of aligners. Tommaso described how compliant patients are with the use of aligners, who is more likely to wear aligners well and methods to increase compliance. He critically reviewed the use of attachments, and revealed aligner deformation and staging as key areas of treatment. This podcast is a summary of the WFO online webinar from November patient compliance, biomechanics , rotation, distalisation and intrusion

Patient Compliance

Sample of over 200 patients treated with aligners under remote monitoring, Thirumoorthy 2021:

• 36% of the sample was fully compliant
• 25% has poor compliance
• 1st time Ortho patients are more compliant
• Conclusion: early detect non compliant patients with remote monitoring

Patient factors which vary compliance of removable appliances Fleming 2019

The study came with some recommendations:

1. Effective communication with our patients, with visual aid, pictures or movies.
2. Using of tracking sensor included in the device
3. Using some reminding tools – remote monitoringBiomechanics and material properties.Distalisation class 2Incisors intrusionConclusion
4. We need to consider the lines of forces and aligner deformation not only on the attachments
5. Any malocclusion that can be corrected by tipping has better predictability
6. Add less activation Per aligner (to help flattening the steep decline in force over time and create consistent and continuous force system)
7. Attachment driven mechanics are not always effective, aligner Activation is more effective
8. Graphy is the trending technology in aligner activation

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Join me for a podcast summary looking at the grey topic oflower third molar management. The podcast explores the different guidelines of removal,factors for consideration for removal as well as the effect orthodontics canhave on third molar pathology. The lecture was given by Flavia Artese at thisyear’s British Orthodontic Conference in my city London.

Flavia Artese began with asking the clincal question weface, what would you do with an impacted 3rd molar?

Difference in international practice

· UK NICE guidelines 2000: Surgical removal ofimpacted third molars should be limited to patients with evidence of pathology

· AAOMS White paper USA 2016: currently or likelyto be non-functional associated with disease or at a high risk of developingdisease

What factors in decision making

1. Eruption path

· Mandible = mesial, whereas Maxilla = distal

o Rate of impaction Mandible 25%, maxilla 14%Worthington 2016

1. Mechanism of tooth eruption – explained byFrazier-Bowers

· A pathway created by the dental follicle

o Triggers eruption of intraosseous eruption

o Genetic control of cell differentiation indental follicle

§ Requires root elongation, vascular pressure andDL ise 2008

Orthodontic influence = SPACE

· Decrease with distal movement of posterior teeth

o Distalisation, elastics

§ Kim 2014 = limit of lower molar distalisation

§ 35% of cases already have contact with lingualcortical plate

· Increase through mesial movement

o 80% of 3rd molars erupted in premolarextraction cases Kim 2003

o Increase in retromolar area

o 2nd molars – removal of guidance =unpredictable alignment of 3rd molars, tipped, therefore will likelyrequire orthodontic alignment Gooris 1990

§ Flavia suggested if 7s impacted, removal of 8sand 2nd molar uprighting, as no delay until full root development

Prediction method

· Mandibular morphology

o Longer the mandible = greater chance of 3rdmolar eruption: Begtrub 2012

· Retromolar space

o OPG - size of crown and space available: If space greater then size of thetooth = 75% eruption, if less space available than the tooth size = 75% ofimpaction Olive

Prediction of orthodontists and surgeons Bastos 2016

· Orthodontists 38% extract

· Surgeons 50% extract

· Surgeons extract more

o Surgical morbidly 10% Yamada 2022

o Greater pathology: 82% when erupted, 74% in softtissue, bone 33%

Surveillance protocol

· No complaints from patients

Fully erupted

· No consensus of protocol pathology

Review of guidelines Gadiwalla 2021

Only 2guidelines were recommended , RCS and SIGN

· Recommended guidelines

Conclusion

· Limited evidence

· Orthodontists can influence the space

· If second molars require extraction, willrequire time to erupt as well as

· CBCT should be used for diagnosis

· Refer to oral surgeon for assessment ofdifficulty in removal

Please join Flavia Artese at the 2025 InternationalOrthodontic Conference in Rio De Janeiro

Contributions

Contents: AbdAllah Sharafeldin

Contents edited andproduced: Farooq Ahmed

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Join me for a podcast exploring the limits oforthodontic tooth movement. This podcast is a summary of two intriguinglectures, by Dr Yanqi Yang and Carlos Flores Mir from this year’s InternationalOrthodontic Symposium by the IOF. This podcast explore the anatomical andperiodontal boundaries of orthodontic tooth movement

Anatomical boundary

· Distalisation: Alveolar boundary lowermolar distalization

· Horizontal: Atrophic ridge.

· Vertical: Maxillary sinus

boundary for lower molar distalization.

o Coronal level: Anterior border ofmandibular ramus

o Apex level: lingual plate

o Variable – distance from secondmolar distal root and inner lingual cortex

§ Favourable Class 3 greater retromolarspace, class 2 least Fan 2022

§ Unfavourable High angle haveshorter distance Kim 2021, Victoria 2022

Side effects of lower molar distalisation

o Mainly tipping

o Distalisation achieved at apicallevel approximately 1mm AJODO 2016

o Lingual plate contact 1/3 of cases Kimet al 2014

Horizontal movement: atrophic ridge

· Change in width and height ofextraction site

o Loss of 40-60% width and heightPagni 2012

§ Width 3.79mm Tao 2012

§ Height 1.24mm Tao 2012

o Mostly within 6 months Schrepp 2003

· Changes when orthodontic toothmovement into atrophic edentulous site

o Increase bone height 2.2-5.2mm,duration 24 months Elif 2004

o Increase in width 0.8-1.6mmStokland 2011

o Greater height increase buccally,less lingually Dos Santos 2017

· Side effects

o Root resorption – lateral

§ 0.7mm

o Dehiscence

§ Slight in all cases, thinning ofalveolar bone Patricia dos Santos 2017

o Reduced bone height compared tonon-edentious area

Vertical:

· Maxillary sinus prevent toothmovement?

o Increased tipping, slower rate of toothmovement

· Side effects

o Mild increase in RR

o No difference in relapse, vitalityor periodontal differences

o 6 buccal roots closest . (Qin et al2020)

· Understanding

o Maxillary sinus remodels itselfwith tooth movement

o Increase in resistance to toothmovement, greater tipping.

Periodontal boundaries

Carlos Flores Mir started the topic with a thought provingquestion, that we are well aware of Proffit’s envelope of lower incisor dentalmovements; but the question of whatis the periodontal limit, is still yet to be clearly defined.

The difference between the gingival biotype and phylotype,there has been a focus on biotype but it

· Biotype – thickness of gingiva inbucco-lingual direction

· Phenotype – contour gingiva,underlying bony architecture, and width of keratinised tissue

Thin gingival biotypes are likely to have more chancesof recession.

Factors to consider

· Extraction Vs non-extraction: inboth scenario the bone height decreases, but in different locations, anteriorextraction treatment = 2mm reduction, non-extraction = 1.2mm. www.orthoinsummary.com/blog

· Dehiscence exist pre treatment

· Thicker the gingiva, the better Yared2006

· Initial position of the toothdecides its periodontal future

· Thickness varies in various areasof the mouth.

· Oral hygiene major factor ofrecession Melsen 2005.

CBCT

· Aren’t really telling us the wholestory –

· Size of the image of a CBCT islimited by the radiation dose, and typically is 0.3-0.6mm3 of voxel size

· Tissue less than 0.6mm appears as aabsent in CBCT giving false positive results ( Redua 2020)

Lower incisor proclination and recession:

· Systematic review Kalina no correlationbetween proclination and gingival recession. (Kalina 2022)

Understanding

Recession = Thin gingiva + proclination +periodontitis

Contents– Shanya Kapoor

Editing and Production – Farooq Ahmed

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Orthodontics In Interview: RICHARD COUSLEYDigital orthodontics, miniscrews and aligners“Aligner set ups need to be orthodontically checked to make sure it is realistic, and an accurate representation of what you are trying to achieve”Richard describes his journey into digital orthodontics, what led him to create his own successful miniscrew system, and why he has continued to innovate in orthodontic with 3D printing.Richard describes what he thinks stifles innovation in orthodontics, as well as how CBCTs have improved his miniscrew success rates. Please like and subscribe if you find it useful!To book Dr Richard Cousley’s 3D orthodontic course, please see: https://www.3dorthodonticscourse.com(no financial interest)#orthodontics #farooqahmed #richardcousley #aligners #digitalorthodontics #infinitas #miniscrews #orthodonticsinsummary#orthodonticsininterview Farooq Ahmed

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Join me for a summary of two lectures from this year’s international orthodontic symposium (IOF), looking at mouth breathing and paediatric obstructive sleep apnoea, by Hong He and Carlos Flores Mir. The lectures explore this controversial area in both medicine and orthodontics and review the current understanding of the topic, the relationship with facial features and current recommendations for orthodontists.

OSA is defined disruption to breathing American Academy of Sleep Medicine

• Adult > 5 apnoea/hour & 10 seconds
• Child apnoea for duration of 2 breaths 1

Defining mouth breathing at airflow over 25% through the mouth

Evidence of craniofacial effects

1. Mouth breathing

2. Retrusive maxilla -1.33o (SNA -2.03 -0.63)

3. Retrusive mandible -1.4 (SNB -2.20—0.6) Zhang 2020 SR
4. Increased mandibular angle 3.38o (2.77-3.98)

5. But is mouth breathing pathological?

6. pOSA

7. no craniofacial difference in pOSA vs controls SR Fagundes 2022

8. Recent study by Carlos Flores Mir, combine factors
9. Demographics, lifestyle, craniofacial features and sleep features. Investigating effects of treatment on these categories

Treatment

• Twinblock improves pOSA AHI 14.08 to 4.25 in the short term, severe to mild Zhang 2012
• MARPE increases cross sectional area, by 40% oropharynx, 7% nasopharynx Zhao 2020
• RME increases nasal airway volume initially of 1604 mm3, but reduce to 579mm3 after 3-5 months and non-significant SR Zhao 2021

• Tonsillectomy

• Does not stop mouth breathing, even if OSA resolved Bae 2020

Conclusions

• Breathing involves complexity of 3D structures and fluid dynamics is not well understood

• Mouth breathing does seem to have craniofacial influence, however OSA does not

• Orthodontists role in OSA

• screening for OSA
• Refer to physician if risk factors present
• Refer adenoid hypertrophy to ENT

Contributions

Contents and video editing – Shanya Kapoor

Editing and Production – Farooq Ahmed

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Orthodontics In Interview GUEST HOST Björn Ludwig with Ralf Radlanski

Guest podcast hosted by Dr Björn Ludwig, he interviews the anatomist and orthodontist Ralf Radlanski, he explores the career of the founder of the International Orthodontics Symposium (IOS) and president of the EurAsian Association of Orthodontists.

The two questions close to Bjorn’s heart are explored: do you drink wine, and do you listen to music.

YouTube

https://youtu.be/vcAzjWa507Y

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ralfradlanski

IOSmoselle23

orthodonticsinsummary

orthodonticsininterview

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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.

Click on the link below to view previous episodes, to refresh topics, pick up tricks and stay up to date.

Please like and subscribe if you find it useful!

Instagram:  www.instagram.com/draudreyyoonhappycamper

Facebook: https://www.facebook.com/audrey.yoon

@audrey.yoon

@draudreyyoonhappycamper

Farooq Ahmed

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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
2. Root development

1/ Eruptive potential and timing

• Interceptive treatment Ideal time for spontaneous eruption is ½ to 2/3 of final root length.
• Orthodontic traction: Ideal time for active (orthodontic traction) eruption is 2/3 to ¾ final root length.
• Principle:
• Peak of eruptive potential is at 2/3 to ¾ of final root length
• Root completed within 2.5 to 3 yrs post eruption

Timing of impacted maxillary canine interceptive treatment

• Dental age of 9-10 years
• Interceptive treatment includes: extraction C, D, distalisation molars, RME
• Prognosis of treatment of impacted canines is uncertain and reduces with age.
• Ideal early adolescence

Timing of impacted maxillary incisor interceptive treatment

• Before age of eruption 7-8 years

• Likely spontaneous eruption, but risk of damage to permanent incisor in surgery

• After age of eruption > 8 years

• Spontaneous eruption not predictable, likely require active (orthodontic traction)

• Interceptive treatment

• Removal of obstruction, spontaneous eruption 36-75%
• Removal of obstruction + space creation spontaneous eruption 82-89%

(Sun et al AJODO 2006)

Root development

• Impacted incisor due to obstruction – ideal time =7-8 yrs
• Dilacerated upper incisors – ideal time – at ½ root or less = 6-7 yrs, as removal of root proximity to the anatomical barrier can reduce the dilaceration of the forming root

Timing of impacted premolar interceptive treatment

• What to do when premolar root formation has not occurred in adolescent patient
• If apex is open = root formation occurring

Timing of obstruction management

• Removal: As early as possible
• Orthodontic traction: Delay until bony infil, otherwise loss of gingivla and alveolar supoort

2/ Root development

Canine root development

• Hooked apex 3-4 times more likely with impacted canines
• Shorter root
• impacted incisor 2.3mm shorter root Sun 2016, Impacted canine 2.3mm shorter roo Cao 2021

• Total volume unaffected (length + hook)

• Prevalence and severity of dilaceration increase with age until apex closed

• Dilacerated root respond to traction/
• Yes but increased treatment difficulty and duration , example of 2 years

Arrested root development

• Can arrested root development be reversed?
• If root abuts with an anatomical barrier. Such as nasal floor, it is the cause of the arrested development
• Orthodontic traction and movement away from the barrier = continued root development
• Early exposure and orthodontic traction

Implication of impacted tooth and asymmetry

• Impacted tooth can affect alveolar and skeletal growth
• Cases with asymmetry significantly higher in impacted group.
• Asymmetry index 27% Vs 3.4%
• Chin asymmetry 52% Vs 14%

• Occlusal cant 38% Vs 10%

• Timing of treatment, if delayed = occlusal cant increased with age.

• After treatment, asymmetry can persist = treat as early as possible to limit asymmetry (managing impaction will not correct asymmetry)

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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).

Click on the link below to view previous episodes, to refresh topics, pick up tricks and stay up to date.

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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 infunction

o Fixation breakages

o Orofacial pain, tmd,mobility

How does it work?

· Injection of neurotoxininto muscle

· Temporary partial paralysisthrough chemical denervation

· Most common Botulinum toxinor Botox

· Mechanism of action

o Block acetylcholine (neuromusculartransmission) release.

o Also inhibit pain sensoryneuron

How to inject

· Extra oral – use of faciallandmarks

· Intra-oral Use MRI / EMGguided injection

What are the effects

· Anticipate change facialaesthetics

· Greater facial contouringachieved with higher dosage Review Wu 2023

· Last up to 180 days

· Greater complications withgreater dosage

Anticipated change from botox

· Treatment for masseterichypertrophy

o 35 units to masseter , twoinjections

o 91% reported improvementheadaches

o Duration 25 months

Decrease bite force Ahn 2007

· 25 units to each massentericmuscle

· Mean bite force 51kg /cmusing bite block attached to a transducer

o Reduced to 30-36kg/cm for 8weeks (29%-41% reduction)

o After 41kg after 12 weeks ,no longer statistically significant

· Significantly reduced biteforce up to 8 weeks

Potential adverse effects

· Chewing weakness

· Sunken cheeks – high volume

· Headaches

· Sagging skin

· Asymmetry

· Paradoxical Bulging – missmasseter and affect other muscles

· Distant spread of toxin

· Speech disturbance

· Muscle fiber atrophy 4-6weeks, remover 4-6 weeks

Chemical denervation protocol

· 25 units per muscle, bothmasetter and temporalis

· Interval 4-5 months andpatient response

· 3-5 serial injections

o Some patients changes canbe permanent

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Join me for a summary of a lecture by Ramesh Sabhlok,looking at one of the most popular sites for TAD placement, the maxillary buccalinterradicular site.

The most common site in maxilla for implant placementis between 2nd premolar and 1st molar in the keratinized gingiva.

Two factors

1. Buccal bone thickness

2. Inter radicular distance

Bone thickness:

· Greatest bone width of bone isbetween 2nd premolar and 1st molar, and considered ‘safezone’ thickness of bucco-palatal bone 10.2-11.4mm ( Pogio 2006 Angleorthodontics )

Inter-radicular distance

· 2nd premolar and 1stmolar: 3.2mm (SD 0.6mm)- 3.5mm (SD0.8mm) when 4-6mm from the CEJ, largest clearance of interradicular space inthe buccal aspect of maxilla Lee 2009

· Gradually decreases apically,therefore it is advised to place the mini implant at height of 4-6 mm from CEJ,at 2 mm height only 2.7mm interradicular

· In the maxilla, the more anteriorand the more apical, the safer the location becomes.

· Increased after levelling andalignment, delay placing if possible

‘SAFE DEPTH’proposed by Ramesh

· depth of from the bone surface tothe narrowest interradicular space at a given height which is safe = 3.2mminterradicular distance for 1.2mm width TAD AND 3.5mm for a 1.5mm TAD.

· Safety depth (height) is 4mm.

o 2mm depth the greatest interradicular distance 2.4mm, not safe

Angulation

· A 20-30o angle, placesthe interradicular aspect of the miniscrw apically, where the interradicular isthe greatest. This reduces root contact, increases retention with more corticalplate engagement, allows use of longer miniscrews as well as greaterdistalisation prior to relocation Deguchi 2006.

Extraction of 3rd molars

· Classic papers looking at thePendulum appliance by Kinzinger 2004 showed extraction of 3rd molarsresulted in greater bodily distalisation on the maxillary arch.

· However recent CBCT paper by Lee2019 show that with miniscrew distalisation there was no difference bodilymovement with extraction of 3rd molars and non-extraction.

Concept of biologic width

1-1.5mm of periodontium surrounding the implant,

Lecture title

Summary from AAO 2022 lecture: Non- compliance &Predictable class II correction with Micro implant Anchorage

Dedication

Episode is dedicated to the late Dr Anam Humdani, aLondon based dentist who tragically died aged 29

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

· Contents: Shanya Kapoor

· Editing and Production: Farooq Ahmed

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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.

1. Vibrational mechanical
2. Low magnitude / high frequency, used for 20 minutes per day 25g at 30Hz/ 50 Hz,
3. Canine retraction: 30Hz NS, 50Hz 15% quicker, Significant but not clinically
4. No increase in root resorption - split mouth study, except for 50Hz, reduced RRRR Tan 2011, Yilmaz 2021
5. Photobiomodulation (PBM)
6. Low level laser therapy: LED device used for 20-30 minutes her day
7. Tooth movement increase rate of 1.73mm over 2-3 months Yavagal 2021 SR
8. Root resorption no difference Sambevski 2022
9. Minisurgery: Piezocision/ Micro-osteperforation(MOP)
10. Piesocision – series of vertical bone cuts of 2-3mm depth vary lengths,  Vs MOP – round punctures of 2-3mm depth. With or without flaps.
11. The movements were twice as fast (Lino et al 2017, Cho et al 2007, Mostafa et al 2009)
12. But limited duration of effect  Buschang 2010
13. Peak at around 3-4 weeks

14. No differences after 6 weeks - Similar to human trials: Aboul-Ela 2011

15. Root resorption Patterson 2017

16. Peizocision and MOP produced significantly (44% / 42%) MORE root resorption.
17. Peizocision 36% additional iatrogenic damage (performed by periodontist)
18. Distraction

Mechanical removal of the bony obstruction

• Remove all or most of the bone in a way so that you can move teeth faster reliably
• Osteotomy, callus formation followed by Rapid separation of distal and proximal bone and healing with new bone formation.
• 1mm per day Moore 2011
• Teeth vial with Dappler meter
• Vitality through histology as electronic pulp test not reliable during orthodontic treatment, Alomari 2011, increase in treatment but return to normal in retention.

What do we know reliably extents treatment duration are 3:

1. Wrong diagnosis
2. Wrong mechanics
3. Bracket position

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

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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/

Click on the link below to view previous episodes, to refresh topics, pick up tricks and stay up to date.

Please like and subscribe if you find it useful!

orthodontics #farooqahmed # BenedictWilmes #TADMAN #benefit #miniscrews

aligners #orthodonticsininterview #farooqahmed

https://www.tadman.de/

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Farooq Ahmed

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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

1. 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

1. 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

1. 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

1. 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

We are raising money worsening humanitarian crisis taking place in Turkey and Syria, please donate

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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

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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.

Click on the link below to view previous episodes, to refresh topics, pick up tricks and stay up to date.

Please like and subscribe if you find it useful!

www.carrieresystem.com/

Instagram @instagram.com/luiscarriere

Facebook @luis.carriere.1

Farooq Ahmed

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Lower arch missing lower 2nd premolars

• Hemisection lower E – distal half – Old school
• Allow mesial drift of 6s, L4s do not distally tip, important in class 2 cases
• Use mesial aspect for anchorage if ankylosed
• Remove remaining

Other options

• TADs 30% failure in the mandible in Caucasian
• Herbst
• Mini-plates – very evasive
  • But hemisection is simple

Gingivectomy

After extrusion of impacted tooth, need for gingivectomy

• Orthodontists should learn as common need
• Process
  • Scan
  • Plan a gingivectomy guide
  • Laser or electrosurgery for gingivectomy

Cant and TADs

• adult cases are the future of orthodontics, more challenging
• RHS>> Gincevectomy
• LHS>> extrusion using TADs TAD – opencoil to bracket on the tooth, and aligner to guide the tooth, cover incisal edges only
• And few aligners
• Patient did not want perfect result

Space closure and TADs Georgios Kanavakis 2014

• Space closure and mesial slider
• 2 x palatal tads
• SS spring close
• Mesialization of molars
• High tech
  • But Space closure can be achieved with timely extractions, such a smissing UEs and extractions with mesial drift..
  • Less likely lower arch, miniplates used to mesialise

Expansion

Digital planning

• Digitally decompensate the lower arch.

MARPE

• Changes to the midface through MARPE
  • Hard tissue changes to the midface and nasal complex
• Caution in use, for selective cases only, and critical in use

SARPE

• Indicated due to resistance for Maxillary expansion in adults from 3 potential structures
• Zygomatic buttress, Pterygoid plates, Sutures from the mid face Published 1984 by Andrew Glassman
• Using a finite element analysis programme, fusion 360, identify the resistance individual to patient
• Case: Surgical guide to do a small lateral osteotomy under local = future as it is individualized to each patient

Hybrid treatment brackets Vs aligners

• Class 2 correction
• Change from fixed to aligners with Onyx Ceph planned wings for class 2 correction – like functional appliance

Problems

• Distalisation with Miniscrews
  • Later on posterior crowding of 2nd molars and risk anterior recession
• Fracture of palatal appliance
• Failure at welding point between expander and abutment
• Can stop people using designs
• Solution
  • print 1 piece appliance CADCAM
• Overuse

TAKE HOME MESSAGE BY ME FROM THE LECTURE

• Sometimes effort is not equal the benefit so always evaluate your benefit
• Always assess your outcome and see if technology you invested in worth it
• Orthodontists are Dentists and should do some gingival contouring and temporaries ..etc
• Always match arch before and after treatment and maintain your arch form
• Future is Hybrid Therapy … using strength of both aligners and fixed braces

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Join me for the next interview in orthodontics with Padhraig Fleming

“Innovation has made treatment more accessible, but has not necessarily translated into better outcomes”

Padhraig is a Professor in Orthodontics based in Ireland. He has published over 150 peer review papers, 4 textbooks including the recent edition of Graber’s ‘Orthodontics: Current Principles and Techniques’. He won the 2021 Turpin Award from the AAO. He is an associate editor for the AJODO and Progress in Orthodontics.

We get to hear of Padhraig’ story, what led him to pursue research and what pitfalls he sees ahead for orthodontics

Professor Padhraig Fleming’s next course: Orthodontic Fundamentals: February 11-12 2023

http://www.orthodonticfundamentals.com/ 

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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

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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

• It is new developed 1990s, used 2001
• Dose is too high – now just over the dosage of cephalogram and OPG, as low as 46uSv Buckley 2018 – 5 hour flight
  • Children sensitive due to growth
  • ALARA, ALADA to bear in mind

Accuracy

• Small deviation of true size compared to 2D images Gregory 2004
• Panoramic = not accurate and only screening tool Lione 2000

Asymmetry

• Accurate measurements for bilateral structure is possible
• Degenerative changes in condyle is often responsible for open bite which can be detected by
• Example of twins wherein one child with condylar degenerative issue had retro gnathic mandible leading to malocclusion

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

• ↓False positives and high degree of sensitivity and specificity
• Correctly predicts 88.7% of crossbite; 91.25% no crossbites.

landmark system for transverse measurements using CBCT images. Onur Kadioglu

• Maxillary teeth Trifurcation of molar (less likely to change in angulation changes)
• mandibular teeth midpoint of root
  • 20 mm discrepancy = crossbite

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

• 2D helps to precisely measure INACCURACY and its reproducible
• Accurate in 3D space; one needs to be careful in locating landmarks
• 4D imaging allows us to have shape analysis of a structure in dynamic state with aid of colour coding

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

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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

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Join me for a summary of Dr Nikhilesh Vaid’slecture 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

• 39 are prospective clinical trials
• 20 are systematic reviews

What do the systematic review and meta-analysis conclude?

• Overall we don’t have sufficient good quality trials and there is a need of more such trials
• In addition to that ratio of prospective trials to systematic review is merely 2: 1.

Systemic review topics

Treatment outcomes

• Aligners work well for mild to moderate cases.
• Alignment with aligners is reasonably competent.
• In Vertical sagittal and transverse dimension possess a bit of challenge.
• If compared with fixed appliances – doesn’t fit well.
• *** Outcomes mainly depend on the measurement criteria.

Deleterious effects

• Slight improvement in terms of periodontal effects
• Advantageous in external apical root resorption
• Some of periodontal indices improved, also no adverse effect was found
• Overall need for more studies.

Other effects

• Force levels, only in vitro studies available with conflicting results.
• Pain level, it was initially lower, thereafter similar, short term
• QoL (Quality of life) there were less incidences of eating disturbances.

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

• That this doesn’t meant that it never worked.
• So according to Dr Vaid its on us to be able to gather some evidence.

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:

• Refinements are non-negotiable.
• Patients will be requiring nearly double the number of initially decided aligners.
  • Planned Vs total aligners 108.11%
• Greater refinements class 3, deep bite, crowding, posterior crossbites

Contributions

Contents: Shanya Kapoor

Editing and production: Farooq Ahmed

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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.

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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.

• Plan with assessing lower incisor inclination relative to skeletal structure from a cephalogram
• To figure out this problem they designed a finite element study to figure out what happens for different lower incisor inclinations
• If the IMPA angle exceeded 100 the intrusive force will be in front of CR resulting in a moment causing lingual root torque and buccal crown torque
• If the IMPA angle less than 100 the intrusive force will be behind the CR resulting in a moment causing buccal root torque and lingual crown torque
• Plan intrusion:
  • Proclined teeth: intrusion and retraction at the same time with lingual crown torque
  • Retroclined teeth: Intrusion, with labial crown torque

Advanced Mandibular Spring AMS with aligner

• Telescopic arm with spring.
• Distalization of posterior and no movement in the anterior along with anterior bit turbos
• Class II elastics are used day time, appliance at night
• Inserts into connectors which are imbedded into the aligner
• How does it work
  • Finite model analysis, favourable for advancing the mandible – PDL even stress, promote mandibular growth, stress on condylar anterior aspect and posterior glenoid fossa

alignerorthodontics #class2 #Bingfang #farooqahmed

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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
• Airway-centered Orthodontic Diagnosis & Treatment for Pediatric Patients Hong He
• Predictors of Success for Early Mixed Dentition Treatment Heesoo Oh

Dental Trauma Eustaquio A. Araujo

Trauma protocol

• Reposition with firm grip
• 16x22NT
• Bite props to eliminate occlusal interference
• Soft diet
• Recall 2 weeks

Re-implantation of avulsion success

• Less than 1hour 75%

• Up to 24 hours 25%

• Conclusion – look at the neighbours

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

Nasal breathing Vs mouth breathing

• NB = Tongue rests on the palate. MB = Tongue floor of the mouth
• NB = Pressure of the cheeks is balanced with the tongue. MB Pressure of the cheeks is unopposed by tongue
• NB = U shape upper arch (normal). MB = V shaped arch

Tonsillar hypertrophy

• Oropharynx obstruction
• Ventilation impaired
• Occlusal effects
  • Tongue and mandible forwards Iwasaki 2017
  • Mandibular protrusion
    • Class 3 malocclusion
• He’s study n=1776
• Greater tonsillar hypertrophy in children with class 3

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

• Early class 2 equally effective not as efficient
• BUT
  • Mean changes = mask individual response
  • Philosophy – correct some / all features of malocclusion
    • Reduce / eliminate need for phase 2
• Angle orthodontist Oh 2017

Treatment protocol

• 7-9 years
• Headgear night wear 11 hours
• RME
• 2 x 4 fixed appliances
• Lingual arch
• Greater 33 months = unsuccessful (time only marker of success, as occlusal and skeletal the same at the end)

Results

• 15/54 (28%) phase 1 only
• Comparison
  • No differences in occlusal and skeletal outcomes
• Time
  • Total treatment times (phase 1 + phase 2):
    • 67% less than 18 months in treatment active treatment
    • 20% 4-5 years of total treatment time

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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

1. 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

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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

1. Reduces airway collapsibility

2. 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

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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

• Parallel opening of suture 2mm greater at 6 region than RME (S/R Krusi 2019)
• Facial changes
  • Widens Zygoma
  • Nasal base expands
  • Changes to the orbit – no significant but beware Brutally evasive!
• No periodontal side effects with MARPE (limited evidence) S/R Vidalon 2021
• RME Vs bone borne, hybrid = bone borne no dental side effects: Canan 2017

Age

MARPE Vs RME

• Age up to 11, no difference in outcomes Bazargani 2021

Retention after MARPE

At 7 months: suture has not fully remodelled

• Retention is needed for 1 year to allow full remodelling
• Type of retainer
  • TPA does not maintain bony changes Prado 2014
  • TPA with TADs = prevent bony relapse

Expansion rate of MARPE

• Fast Vs slow bone borne
  • Fast (2-3 x activation per day) Vs slow (2 activations per week)
    • Slow expansion MARPE: Sutural opening still occurs Pulver 2016 (Rabbit study)
    • No diastema

Activation process: Force controlled polycyclic activation

• Activation occurs if the force is 500g, key indicates activation Winsauer 2021

Airflow

• Increase in airflow with MARPE
• White paper from AJODO on OSA – limited evidence
  • Our job is to get rid of crossbites NOT to resolve OSA
• MARPE effective at resolving crossbite S/R: Kapetanović 2019
  • MSE reduce OSA: Brunetto and Moon 2022
    • Björn considered a good side effect, not the main cause

Class 3

• RME most effective in class 3 cases
• Alt-Ramec Eric Liou 2005
• 3 x day = maxilla moves downwards and forwards due to position of buttress
• Facemask
  • Facemask in the night, and class 3 elastics in the day
    • A point advance 3mm: MARPE + facemask study: Maino 2018
    • Realistic ½ unit correction – borderline correction

SARPE Vs MARPE

• SARPE mainly changes maxilla, maintains aspects of midface
• MARPE changes to midface

Take home messages

• Hi tech is good but low tech is key
• No body said it was easy, and orthodontics is not easy

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

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Join me for a summary of  Akram Alhuwaizi’s lecture on MARPE – Miniscrew assisted rapid palatal expansion. This summary explores MARPE from a clinical aspect, assessing the advantages and disadvantages, followed by a case discussion of success and failure, a discussion of MSE and lessons learned for designing MARPE. The full lecture is available on Akram’s youtube channel: Maxillary Skeletal Expansion using MARPE from A to Z (Updated) - YouTube Introduction Purpose of expansion

Correction of crossbite Creating space Pre myofunctional treatment Widening smiles

Methods available

Removable appliance Quad Helix Rapid Maxillary Expander RME Surgically assisted Rapid Palatal Expansion SARPE

Expansion methods Ideal features of expansion appliances are to achieve bodily movement, minimal compliance required from the patient, applicable to a range of ages and straightforward for patients MARPE experience Case 1

Attended Peter Ngan lecture Arab conference Surgical case requiring expansion – 2019 4 palatal TADs FAILIURE – TADs moved, one got embedded into the palatal tissue, no significant expansion occurred

Cause of failure Hyrax position:

Too posterior = near to Pterygo palatine suture and the zygomatic buttress which causes more resistance to the expansion No guiding arms, greatert risk of dental movements but they help in seating of the appliance Lack of guiding arm allowed rotation of the device by failure of only one TAD.

TADs

Length: Short: Ideally bi-cortical engagement to avoid bending and increase retention

Appliance design

There was a play between the TAD and the device Lab fabricated loops, not precision fit

Case 2 Design

Used 2 TADs 2mm D/12mm L Guiding arms to the 1st molars Hyrax more anterior Good fit abutment / screw and expander Longer screws – bicortical engagement Younger patient and female

Successful palatal expansion

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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

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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

1. Shape moulding effect – shape driven
   1. Move position of teeth to ideal
   2. Invisalign 80% through shape moulding
2. Attachments
   1. 20% force delivery
   2. Perpendicular surface with Invisalign
   3. When shape moulding is considered 2g/mm2 of stress, with attachments 20g/mm2, higher stress to aligner, which is a downside

How to aligners treat malocclusions

Deep bite

1. “Water-melon seed effect” – squeeze a seed and it compression it moves left or right

2. Squeezing through shape moulding effect

3. Aligners can apply force through to the centre of resistance of the tooth

Openbite

Advantages in aligners when compared to fixed

1. Draw bridge effect
   • Relative extrusion through Retroclination 60% drawer bridge effect Harris 2020
2. Lever principle
   • Autorotation effect 28% Harris 2020

Space closure

• Common lateral openbite in space closure, why this happens
  • Equal moment to posterior and anterior segment during space closure
    • Counterclockwise posterior segment, clockwise anterior segment = BOWING EFFECT
  • Does not commonly happen in fixed due to archwire rigidity

How good are aligners at moving teeth

Root movement

• NOT OBSERVED!

Space closure

• Extraction of 4 premolars - Dai 2019
  • Molars
    • 2mm unplanned anchorage loss
    • 6 degree molar tipping
  • Incisors
    • Retrocline 6 degrees more
    • No incisor root retraction – uncontrolled tipping

Root movement

• Conclusion: Roots cannot be moved with aligners such appliances cause tooth movement by tilting motion Zhang 2015

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

First principles based understanding

• Interplay of dumping and counterplay of moment = bodily tooth movement
  • Braces – create AND CHANGE couple and counter couple through size of wire, material
  • Aligner – cannot change material properties

Material factors

• Stress-relaxation 80% of force lost after 100 minutes Fang 2019 AJODO
• Modulus of elasticity – ability to transfer energy
• Higher modulus – greater tooth movement
  • Niti 45GPa, Aligner 1-2GPa Khoda 2013
    • Inferior in delivering energy
• Viscoelastic material
  • Absorbing shock, dissipating energy in the form of heat
  • Ideal for retainer – force dampener

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

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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

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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

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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.

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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

Youttube video

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Indications and application of minimum anchorage mechanics Vishnu Raj

VIDEO NOW AVAILABLE : https://youtu.be/UMFlDdPCopY

Join me for a summary of Vishnu Raj’s lecture looking at minimum anchorage mechanics, with a focus on utilising Burstone’s Geometries for a simple and effective way to manage anchorage, a well explained lecture with useful tips.

Indications

Classification

· Group C minimum anchorage

o 75% or greater posterior movement into the extraction space

o Incisor movement minimal

Indications

· Mild anterior crowding

· Posterior crowding, ectopic 2n molars

· Missing 5s

Aetiology of crowding

· Compared to pre-historic man = 30% increase = greater likelihood of impaction of 8s and 7s

2nd molar eruption – posterior crowding associated with Hwang 2017

· Wider teeth and crowding

· Maintenance of E space

Premolar extraction and posterior crowding Turkos 2013

· Increase space for 3rd molars

· Mesial movement of 1st and 2nd molars

· Mesial movement molars = 3.2-4.6mm

Biology and mechanical considerations

Anchorage considerations

· Upper molars move more mesial then mandibular molars due to :

o Growth of mandible

o Bone type and density

§ Cortical bone more resistance to tooth movement Devlin 1998

· Posterior maxilla = 0.31gcm2

· Anterior maxilla 0.55 gcm2

· Mandible 1.11gcm2

· Upper incisors tend t retract less then lower incisors Gu 2017

o Large root surface area upper 2-2

o Prescription torque upper high – anchorage loss

Preparing anterior anchorage

· Allow working archwires to be passive for 4-6 weeks

· Start space closure 1-2 weeks after extractions

· Curve in archwire to accentuate inclination to resist over retraction

·

· Increase 2nd order 2-2

· Increase 3rd order 2-2

· Elastics

2nd order bend what is it

· Gable bend or V bend 15-25 degrees

· Bend closer to anterior segment

· 6 geometries between slots Burstone 1988

· Effects:

o Increases anterior anchorage

o Root parallelism

Increase 3rd order

· Increase stiffness SS,

· Torsional stiffness SS:TMA:NitI 10:3:1

· increase cross section 21x25

Decrease wire slot engagement angle

3rd order bend

Conclusion

· Posterior crowding to be considered

· Mesial movement 1st molre more predicable to resolve posterior crowding

· Anterior anchorage

· Control of incisor and lip position

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Join me for the next interview in orthodontic,

Maz is a private practice orthodontist from Saint Louis, a Diplomate of the American Board of Orthodontics and a Key Opinion Leader for Align Technology

We get to hear of Maz’s interest in aligners, his thoughts on aligners Vs fixed appliances, and on key opinion leaders in orthodontics.

@mazmoshiri

To watch the video click below

Dr Maz Moshiri interview video

Please do subscribe to catch the next episode and see the website for more episodes

www.orthoinsummary.com

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Orthodontic treatment in stage IV periodontitis patients. Spyridon Papageorgiou. EFP Euro series

Join me for a summary of the EFP’s lectures on periodontitis and orthodontic treatment. The orthodontic lecture was by Spyridon Papageorgiou and two lectures from periodontists, The topic explored related to stage IV periodontitis and orthodontics

Stage IV – new classification from world workshop Papapanou 2017

· Clinical attachment loss 5mm+

· Bone loss extend to mid third of root

· Malocclusion / masticatory dysfunction

o Bite collapse: Loss of posterior support resulting in tooth movement in the direction of force – (complex), over-eruption and incorrect relationship with antagonistic teeth

o Drifting Due to mastication forces

o hypermobility due to secondary occlusal trauma

o Even if periodontally stable Further tooth movement 33% at 2 years Zhang 2017.

§ Orthodontic pathological tooth movement: Loss of space in the arch, mesial migration, crowding, crossbites

Periodontal Treatment for stage IV Sanz 2020 Kloukos 2021

1. Stage 1 : Supragingival debridement, oral hygiene, professional plaque removal, risk factors

2. Stage 2 – Supra and subgingival debridement – change the subgingival biofilm Interventions: Repeat subgingival therapy, surgical: flap, reactive, regenerative (Barrier membrane, Enamel matrix derivative)

3. Supportive periodontal care

Effects of appliances on the periodontium R/V Papageorgiou 2018 / 2021

· Transient change in microbiology from orthodontic appliances

· Bone loss marginal 0.5mm

· Clinical attachment loss 0.11mm

· Recession

o Greater recession 1.9mm

o Gingival recession and loss of attachments Salti 2017

· Greater if hyperdivergent

· GTR no consistent clinical benefit

· Fixed better than aligners PPD 1.6mm – small study

· No difference in ligation, conventional self ligating

· 1-3 months periodontal intervals in orthodontic treatment better outcomes than 6 monthly Jiang 2021

Biomechanics

Adapting orthodontic treatment

· Centre of rotation moves apically

o Same force = larger moment

o Greater extrusion forces

· Simulate intrusion in normal periodontal support vs reduced Kettenbeil 2013 Bagdadi 2019

o Centre of resistance moves apically 2-3mm

o Increased tooth movement 1.6-2.5, increase strain in PDL 1.4-2 possible harm to periodontium

Retention

· Generally different fixed retainers compatible with periodontal health and not detrimental Arn 2020

· Metal bonded retainers still allow physiological movement

· Effect of mobility – UNKNOWN

· Greater failure of bonded retainers in more severe periodontal cases (up to stage 3) Han 2021

· 10 year follow up of ortho and perio = no significant recession or tooth loss BUT increase in root fracture – possibly due to increased forces?

Conclusions

· Orthodontics does not negatively impact periodontal condition

· Initial anti-infective periodontal treatment

o Unsure type of periodontal treatment, GTR unclear, unsure what time to start after perio

· Appliances

o Fixed maybe better

o Segmental better than continuous archwire

o Adapt biomechanics due to attachment loss

· In orthodontic treatment – patients attend periodontics at 1-3 months

· Retention after orthodontic treatment – greater failure rates

· Possible increase in root fractures

· Limited evidence

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ORTHODONTICS IN CONFERENCE

Join me for DAY THREE of the BOC 2021. Day 3 covers 4 lectures; the lectures covered the following topics; Research, Chapman Prize 2021, Timing of functional appliances and Clinical Pearls

· Searching for a needle in a haystack Kevin O’Brien

· Chapman Prize 2021 - Orthodontic trials: Are we measuring the right things? Aliki Tsichlaki

· Functional appliance treatment: Do long waiting lists really matter? A multicentre RCT. Nicky Mandall

· Clinical Pearls session: Preetpal Bhogal, Ian Murphy, Mohammed Al -Muzian, Safoora Keshtgar, Megan Hatfield

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

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Join me for day TWO of the BOS 2021. Day 2 covers 5 lectures; Trauma and the orthodontic patient, periodontal management, impacted canines, orthognathic surgery, 2021 Northcroft lecture,

Speakers: Susan Kindelan, Claire Rooney, Ian Dunn, John Scholey, Lucy Davenport-Jones, Johnathan Sandler

Lectures covered

1. Paeds/trauma - what I wish I'd known Susan Kindelan, Claire Rooney

2. Are we heading into a recession - periodontal considerations in orthodontic management Ian Dunn

3. Canines - what I wish I'd known John Scholey

4. What I Orthognathic surgery - what I wish I'd known Lucy Davenport-Jones

5. Northcroft lecture And all the roads we have to walk are winding. Johnathan Sandler

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

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Join me for day one of the BOS 2021. Day one covers 5 lectures; research presentations, the Chapman prize looking at full or part-time functional appliances, retention and what’s new, paediatric orthodontic management and lingual appliances

Speakers: Pratik Sharma Padhraig Fleming, Simon Littlewood, Sarah Good, Esfandiar Modjahedpour

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

Lectures covered

1. Research presentation: University Teachers Group

2. Chapman Prize 2020: Prescription of full or part-time Twin Block wear: A randomised controlled trial and qualitative evaluation Pratik Sharma Padhraig Fleming

3. Retention – science, clinical tips and comedy disaster Simon Littlewood

4. Things I have learned from hanging out with the kids. Sarah Good

5. From diagnosis to retention. Is it clinically that easy? Esfandiar Modjahedpour

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Join me for a summary of Dalia El Bokle’s lecture exploring finishing in orthodontics. Part 3 focuses on digital indirect bonding, from scan to tray production

Introduction

Straight wire appliance – based on bracket placement will correct tooth in 3 planes of space

· Not true – evidenced by finishing bends

Ideal bracket placement through indirect bonding IDB

· Level marginal ridges posteriorly

· Constant smile arc anteriorly

Digital indirect bonding time saving

· Brackets placed Layman 2019

o Time saving

§ 21 minutes – digital indirect bonding Vs manual direct bonding

§ 8 minutes – clinical time indirect Vs direct bonding

Different methods of making an indirect digital bonding tray

Method 1:

· Printed model

· VFR transfer tray

· Transfer tray made from the model

Method 2

· Printer tray (not model)

· Cost $105

· Tray biocompatible tray

· Cover occlusal half of the teeth and lingual aspect

· Insert bracket into model

· Advantage

o No model printing

o Clean base technique

Method 3 –

· Key pads – digitally planned material between bracket base and tooth

o Customises the bracket base

o Advantage

§ Less flash

§ Accuracy of bracket position in on the keypad

§ Torque + in and out can be customised per tooth

· Models printed

· Lab place the brackets manually with composite onto the model with jigs

· Transfer tray made from the model

Case submission for DIDB

· Send STL file to lab

· Prescription for set up, e.g.

o Bracket selection customisation: Standard Damon Brackets, low torque lower incisors, high torque LL4.

o Teeth bonded: 7-7 Upper and lower

o Bracket positioning customisation: Smile arc – 0.5mm incisal U1s Vs U2s

· Clinician approval of set up

o Library of brackets – specify which type of bracket

Digital indirect bonding workflow overview

1. Scan patients

2. Orthodontist prescription

3. CAD –Software system to place bracket and customise base / bracket

4. Print model

5. Brackets placed on model: allowing for bracket base customisation through either keypads or jigs, customising bracket base with composite

6. CAM - Lab design indirect bonding tray (IBT)

a. VFR

b. Silicone transfer tray / Memosil material

1. Process IBT

2. Post processing chemical and UV light

3. Insert bracket into tray with key holes as guides

Advantages of DIDB

· Full digital pathway with scanning

· Less working time

· Fewer appointments

· Can alter prescription

Disadvantage

· Cost

· Learning curve

· Production waste

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Join me for a summary of Dalia El Bokle’s lecture exploring finishing in orthodontics. Part 2 focuses on indirect bonding, a step by step process from model analysis to clinical delivery

Mark position on models

Intersection of horizontal and vertical lines

· Posterior teeth

o Vertical line: Long axis using OPG buccal, occlusal and lingual

o Horizontal line x 2

§ 1/ Marginal ridge line (outcome of treatment)

§ 2/ Slot line (position of bracket, depending on bracket system 2mm from marginal ridge line

§ Start with 1st molar

§ Measure cusp to slot line using gauge distance marginal ridge to slot line

§ Mark slot line for rest of the teeth, using the difference in height from marginal ridge to slot line from the 1stmolar measurement

§ Ensure gauge is used perpendicular to the teeth

· Anterior teeth

o Vertical line: Draw long axis using OPG, labially and lingually

o 1/ Horizontal line start with canine

§ Slot line marginal ridge level distal canine and mesial 1st premolar

§ Position canine mesial to the long axis

o 2/ Lateral = bracket gauge of the canine to tooth tip, 0.25mm more cervical or same as canine if lateral small

o 3 / Central – add 0.25-0.5mm than canine

§ = subtle smile arc

Transfer tray

· Intersection of long axis to slot line – mark with wax knife

o Mark where brackets should go

· Tacky Glue to stick bracket to the model – water soluble glue, remove excess with probe

o Tip – use loupes / magnifying lens

· Allow set for 10 minutes

· Check occlusally, vertically and tip

o Digitally check glue is set

o Marginal ridge to slot line should be consistent

o Visualise tooth movement

· Relieve over the bracket hooks – wax or Tachy glue

· Vacuum forming machine

o 1mm soft sheet

· Check brackets have not moved – check vertical and horizontal lines

· Trim excess retainer material

· Soak 10 minutes, wash with water and interdental brush (ensure mesh of brackets clean)

· Slits from the gingival aspect of the retainer to the gingival aspect of the bracket

o Purpose is to expose the hooks of the brackets – difficult to remove when bond, aiming to uncover the hook from the retainer

· Wax placed under the hooks – prevent composite

· Section the tray if significant crowding

Clinical bonding IDB

· Etch bracket surface only – looking at model of the tooth

· Composite (light cure)

o Small quantity on mesh base of each bracket

o Microbrush to cover all surface and imbed into bracket mesh base

· Bond

· Seat IDB tray

o Apply perpendicular pressure on each bracket with scaler

§ Avoids excessive composite on the bracket base

· Light cure 20 seconds each tooth

· Remove tray – from palatal aspect from distal molar

· Flash removal

Trouble shooting

· Bracket off

o Don’t panic!

o Maintain isolation

o Remove excess composite, sharp scaler

o Trim tray

o Replace bracket in tray and re-insert transfer tray

· Bracket positioning incorrect

o Defective impression

o Bracket not glued well on model

o Defective vacuum forming

o Ensure no drags

Disadvantage of IDB

· Extra lab time

o 1 hour lab time

§ However reduced time in treatment and repositions / bends

o Extra cost

§ $12 if in house

o Excess flash

o Technique sensitivity

§ Multiple check points

o Accuracy

§ In Dalia’s opinion more accurate than direct bonding

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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

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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

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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

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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

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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

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

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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

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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

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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

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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

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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

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Join me for the second interview of 2021

Adith is a Consultant and Assistant Professor in Orthodontics at the University of Puthisastra South Korea, adjunct faculty Professor Chennai India, Co-editor of Kieferorthopaedie journal (International Orthodontics).  

We get to hear of Adith’s journey into using TADs, his one piece of advice to all orthodontists and what questions Adith hopes will be answered in orthodontics, as well as Hollywood Vs Bollywood!  

Please find the link to Adith’s up coming editorial in the AJODO entitled: ‘The Quagmire of Collegiality Vs. Competitiveness’ 

We hear of Adith’s thoughts on case reports and where evidence based practice fits in to the unique field of orthodontics

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Join me as I describe Jassin Arnold’s lecture describing lower incisor extraction, its indications and management

Why should we use it?

o Reduces anchorage demand, entact posterior segments

o Improve dental occlusion in a shorter time frame

o Profile improves in mandibular protrusion cases Levin 1964

When should we use it? Systematic review Zhylich 2011

o Mild-moderate class 3

o Edge to edge anterior occlusion

o Crossbite with mild anterior mandibulae excess

o 4.5mm tooth size discrepancy of lower to upper Matsumoto 2010

When should we not use it?

o Severe OB

o Bimaxillary crowding

o Triangular lower incisor and minimal crowding 3mm less

o High insertion of labial frenum = gingival recession I removed

Risks of lower incisor extraction

o Black triangle

o Increased overjet and overbite

o Tendency for spaces to reopen an aesthetic zone

o Create tooth size discrepancy

Bolton’s anterior analysis

o Anterior ratio 77% 3-3 lower Vs 3-3 upper

Cases:

o Class 1

o 4mm of crowding of the lower incisors

o Bolton’s anterior analysis 87% - excess lower incisor tissue

§ = Extraction 1 lower incisor = 74.8% – TOO LOW (ideal 77%)

· = Solution strip upper 2-2 by 2mm = 78% Bolton’ ratio

o Case 2

o Molars ½ II, increased overjet 6mm, lower incisors 4mm of crowding

o Bolton’s anterior analysis 87% - excess lower incisor tissue

§ = Extraction 1 lower incisor and stripping of upper incisors = 77%

§ = Extraction of 2 upper premolars as well

· Stripping upper 2-2 to achieve ideal occlusion in the anterior 3-3 segment

· Extraction of Upper 4s to correct the increased overjet

References

Zhylich, D. and Suri, S., 2011. Mandibular incisor extraction: a systematic review of an uncommon extraction choice in orthodontic treatment. Journal of Orthodontics, 38(3), pp.185-195.

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Join me for part 2 where we explore Mohammed’s rules on which teeth to extract, anchorage assessment and management, Bonding 2nd permanent molars, elastics and treatment planning adults Vs children

Which to extract 4 or 5

o CAT-V principle

§ C: Clinical condition of the teeth

§ A: Anterior crowding: 8mm + extract the 4s, 8mm – 5s or 4s

§ T: Transverse: Lower 5 will help narrow the arch

§ V: Vertical: Extraction of 5s for high angle cases will improve the overbite

Molar outcomes in treatment planning

o Non-extraction or extraction of 4 premolars = class 1

o Extraction of 2 upper premolars: Class 2

o Extraction of 2 lower premolars: Class 3

o Extraction of 1stmolars: Ignore them! Will not change the final molar relationship

Anchorage o Type A (absolute) No movement of the posterior segment

o TADs – HG – extraction pattern

o Type B posterior movement moves mesially by 25%

o Nance, sectional archwires, intermaxillary elastics, HG

o Type C posterior movement moves mesially by 50%

o Reciprocal movement of anterior retraction

o Type D posterior movement moves mesially by 75%

o Anterior anchorage (reverse HG, TADS)

o Biomechanics: intermaxillary elastics – 2nd order bends – inverted lower brackets

Anchorage loss in the lower arch is less than upper arch

· Differential alveolar bone density

· differential root surface area

· differential Buccolingual width of molar

· differential anterior palatal root torques

Bonding upper 7s o Don’t bond to for anchorage

o Bonding results in loss of anchorage due to 7s distally tipped, uprighting results in loss of anchorage

Elastics o Elastics = rotation of mandible

o Overjet 0.5mm correction per month with class 2 elastics

o 1:3 ratio of vertical: horizontal effects

o Unilateral intermaxillary elastics in one side only = cant

o = Use vertical part time elastics on the other side

o Elastic should be stretched 3 times its diameter to give the force

Distalisation Rule o Don’t expect you can distalize more than 2.5 mm unless you extract 7 OR 8

o Distalization lowers without TADS is very limited

Adults Vs growing patients

· Growing patient:

o Elastics +++

o Distalisation +++

o Functional appliances +++

o Extractions +++

· Adult

o Extractions +++

o Elastics ++

o Distalisation +

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Join me for Mohammed Al Muzian’s rules in orthodontic practice

Part 1 we will cover half of the 32 tips the following topics: Knowledge Vs confidence, space requirements and creation, IPR, expansion, inclination changes and treatment planning

Knowledge Vs confidence

· We tend to be overconfident at the beginning of our careers, and under-confident in the middle. Kruger’s curve

Space assessment

Calculate space requirements in the lower arch Use T-SCOTAR

o Torque

o Spee curve

o Crowding

o Overjet

o Teeth size discrepancy

o Angulation of teeth

o Rotation

Space creation

Use SPEEDAR for space provision

o Stripping

o Proclination of incisors

o Extraction

o Expansion

o Distalisation

o Angulation

o Rotation

IPR

· A maximum of 0.75mmof IPR per tooth can be tolerated depending on the shape and size

· Up to 4-6mm can be achieved sometime, but you need to balance that with the opposing to avoid TSD

Inclination change and effects

o 2 mm of crowding= 50 of proclination =1 mm change in the overjet and overbite (draw bridge effect)

o 2 mmof spacing= 50 of retroclination=1 mm change in the overjet and overbite Eberhart et al (1990), Sangcharearn and Hob (2007), Kapoor 2014, Aziz et. al 2011

o All cases can be retroclined or proclined by 5 degrees without affecting the PDL..

o Some may accept 10 degrees if I have good gingival biotype, thick symphasis, no recession, no PDL problem and Avoid Jiggling forces.

o Do not procline the uppers more than 1200

o Do not retrocline the lowers to less than 800

Expansion · Lower arch: Cannot expand (unless Class II/2 and canines trapped )

· Upper arch: Can expand

o Maximum 0.5mm of space per 1mm expansion

o Why do you lose half of the expanded space? Due to the backward movement of the anterior teeth.

· Expansion retainer:– wire reinforcement of essix retainer

· Bonded RME

o Design with big hole in housing: to easily remove the RME

o Expansion amount guided by lower arch ideal alignment (Andrews plane)

o Use Monoject or Water jet (flosser) with CORSYDOL to clean under the RME

Treatment planning o Plan around the lower arch

o Rationale:

§ Limited labio-lingual alveolar bone

§ Upper arch labio-palatal bone can be remodelled

o MOOH – planning around the lower arch

o Midline

o Overjet

o Overbite

o Health of PDL

§ If ALL above cannot be achieved non-extraction = extractions required

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Join me as I summaries Kleber’s lecture on the use of intermaxillary elastics in orthodontics, topics of force magnitude, side effects and how to counter them, use of a sliding jig and stability are described.

Force magnitude more important than the size of the elastics

· Large variation forces used by orthodontists in Kurol 1996

· Use a gauge on every patient

· Excessive = damage to PDL and RR

· Force required

o Retraction of upper incisors = 250g each side Oesterle 2012 / 350 g Proffit

o Individual

Class 2 elastics effects

· Distalise anterior teeth

· Mesial of lower posterior teeth

· Extrusion of upper anterior teeth

· Extrusion of lower posterior teeth

· Rotate occlusal plane clockwise

· Retrusive upper lip

· Protrusive lower lip

How to avoid side effects

· Case selection: avoid high angle cases

· Avoid upper arch retraction on round wire

· Reduce vertical vector

o Increase horizontal distance mesial of U2s and L7s

o Change the vertical vector by using a sliding jig

§ Sliding jig moves vector from above the brackets upper, to below the bracket, lower arch force from below the bracket to above the bracket

§ Sliding jig – directs upper arch forces to the molars – more efficient than to archwire only or canine

Class 2 subdivision

· Class 2 one side, class 1 other side.

· Of dental origin, no skeletal

· Usually cant on class 2 side, with arch up on the RHS

· Class 2 elastic on effected side

· Distalisation on URQ with sliding jig

· Retraction of the arch – on rectangular SS – 350g

Torque

· Can be lost upper incisors

· Place torque into the archwire during the retraction – not after retraction

Finishing

· Triangular elastics

Class 2 elastic stability

· Patient may posture: assess displaced mandible / CR

· Tooth movement:

o Bony formation may not be complete

o PDL may not be reorganised

§ REQUIRE 3 months of wear for stability, bone growth and PDL

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Join me as I interview Daniela Storino. Dainiela is dual trained in both pedodontics and orthodontics and has been in private practice for 21 years. She is a guest Professor at Vienna School (VieSID) and studied under Professor Sadao Sato and Dr. Rudolf Slavicek. She is an expert in craniofacial medicine and occlusal medicine.

We get to hear Daniela’s one piece of advice to all orthodontists and where she hopes orthodontics is going in the future, as well as more about Daniela's thoughts on extractions and IPR.

Want to know more, please see the link  Vienna School of Interdisciplinary Dentistry

Daniela’s lecture on the aetiology of malocclusion was also the very 1st podcast  with orthodontics in summary in April 2020, see the link below

True Aetiology of Malocclusion

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Join me as I summarise day 3 of the Saudi Orthodontic Clear Aligner meeting, where class 2, class 3, Invisalign first and SLX aligners  are discussed.

NOTES FOR EACH LECTURE ARE AVAILABLE FROM THE DESCRIPTION ON THE WEBSITE WWW.ORTHOINSUMMARY.COM

The following lectures are covered:

1. Biomechanical protocols and strategies for the correction of sagittal malocclusions part 1 and part 2 Juan Carlos Rivero Lesmes

2. Invisalign First - after 50 cases. Pedro Costa-Moneiro

3. The Keys of Sagittal Treatment with Aligners Flores Allen

4. How to plan the perfect clincheck. Pedro Costa-Monterio Isabel Flores Allen

5. A new paradigm for clear aligner therapy. Mario Chorak

Please like and subscribe if you find it useful!

Important to note the information is from our interpretation as individual professionals, and may incorporate our opinions

orthodontics #farooqahmed #almuzian #orthodonticsinsummary #aligners, #invisalign, #occlusion #class2, #class3, #SLX # PedroCostaMoneiro, #JuanCarlosRiveroLesmes, #MarioChorak, #FloresAllen

#orthodontics#farooqahmed

@farooqahmed_orthodontist

@orthoinsummary

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Join me as I summarise day 2 of the Saudi Orthodontic Clear Aligner meeting, where basic biomechanics, in house aligners and aligner research is discussed.

NOTES FOR EACH LECTURE ARE AVAILABLE FROM THE DESCRIPTION ON THE WEBSITE WWW.ORTHOINSUMMARY.COM

The following lectures are covered:

1. Aligner orthodontics. from basic research to clinical application. Tommaso Castroflorio

2. Aligner orthodontics. in growing patients. a research based approach. Tommaso Castroflorio

3. Overcoming aligner limitations by using palatal mini-implants. Benedict Wilmes

4. Important pearls for in house aligners. Renato Martins

5. Clear aligner therapy. Empty promises or wishful thinking. Ki Beom Kim

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Join me as I summarise the 1st day of the Saudi Orthodontic Clear Aligner meeting, where Mazyar Moshiri delivered a masterclass on biomechanics with aligners.

Conclusions:

· Attachment design: perpendicular to resultant force

· Rotations: Place oblique attachment to counter intrusive force of aligner

· Overcorrect torque, add mesial crown tip due to wagon wheel effect

· Deep bite: synergistic movements: proclinatiion and extrusion

· AOB: synergistic movements: retroclination and extrusion

Concepts

Intrusion attachment

1. Intrusion on aligners

a. No intrusion attachment

o Require attachments on adjacent teeth

o If loss of tracking = occurs on adjacent teeth, with the aligner extruded off the teeth

Rotation and intrusion

· Force labial face and palatal face to create rotation moment.

· ‘Squeeze force’ occurs = vertical force = intrusion force.

· Solution

o Optimised attachment = Extrusive vector, usually gingival bevel and oblique

o Resolve resultant force, horizontal and vertical = oblique attachment

Torque

· Wagon wheel effect, for every 4 degrees of lingual crown torque there is distal crown tipping / mesial root tipping.

o Solution: OFFSET with 1 degree of mesial crown tip

· Torque lags behind, takes longer , like rectangular NiTi archwire

· Buccal root torque: Upper molar buccal attachment to provide extrusive buccal force to create moment.

Design of attachment

· KEY CONCENT: Attachment perpendicular to the force

· Perpendicular force to rotation = Long vertical attachment

· But rotational force has intrusive force the ‘squeeze force’

o Therefore horizontal and vertical force = attachment perpendicular to the force = oblique attachment

Root tip

· Open space 0.2mm interproximal = so more plastic wrap around tooth

· Then start root movement in staged way.

Deep bite

Concept:

Synergistic movements, procline = relative intrusion

Staging AP movements

o Proclination 1st to open the bite

o Then IPR

§ Not at the same time as IPR = retroclination, therefore should not procline and iPR at the same time as bite will not open

§ Does round trip – procline and intrude, then IPR and align

Staging deep bite

· Staging of OB, canines intrude 1st, then 2-2

· Likely loose tracking on lower incisors or 4s – anchorage horizontal G5/G7 attachments

Curve of Spee

· If COS not corrected, then AP also difficult to correct

· If not correct COS:

o Posterior openbite – caused by anterior interferences

§ Caused by inadequate attachment

§ Lack of over correction

OGN case deep bite

· Order 10 passive aligners near end stage pre surgery = minimum 2 months to make up for ‘lag’ or vivera retainer / essix – thicker, greater expression of torque

· TAD – intermaxillary elastics x 2

o TAD maxilla:

§ Buttons lower premolars

§ Intermaxillary elastics to guide lower premolar teeth into the tray

Openbites

Concept

Synergistic movement: Retrocline and extrude

· Aligners do not extrude along the long access

· Aligner pushes tooth lingually and extrudes in the process, retroclines

Posterior intrusion is unpredictable, anterior extrusion is more likely

Thank you to the Saudi Orthodontic Society for facilitating this podcast

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Join me as I summarise Kevin O’Brien’s lecture looking at class 2 treatment, and answering the question of early Vs late treatment and fixed Vs removable appliances.

Kevin answered 3 main questions looking at systematic reviews:

1. Early Vs late treatment

2. Fixed Vs removable treatment

3. Patient relevant outcomes of Class 2 treatment

1. Early treatment (8-10 years) Vs late treatment (2-phase Vs 1-phase)

Cochrane Review: Orthodontic treatment for Class 2 Batista 2018

o No difference OJ ANB, PAR, Self concept Small order overjet 0.21mm

o No benefit to early treatment for most, and KOB suggests treatment at conventional timing in adolescence is appropriate

o Statistical difference in Trauma:

§ Experience of trauma:

· Adolescence 31.7%, Early 19.7% = 12% difference

o Relative risk reduction: 33%. Define terms, 12% is absolute risk, looks at total sample, those who have trauma and not. Relative risk is looking at the trauma sample, and what is the reduction through the intervention in the chance of it.

§ Through the intervention, 1/3 of those who would have has trauma as an adolescent, wont with early intervention

o Numbers needed to treat 1:10,

Information of benefit of early treatment

o Reduction in trauma is clinically significant

o Overall treatment time, nearly 2 x longer

o Greater cost

o Poorer occlusal outcomes

§ Patients ‘burn out’

· Moderate uncertainty in early Vs adolescent treatment

o Repeat study as lots has changed

2. Fixed Vs removable in late treatment (1-phase)

Cochrane review 2018 Batista

· Skeletal changes ANB:

o Removable: 2.37o = Statistically significant

o Fixed: 0.53 o = Statistically significant

§ Removable greater difference = 1.84, clinician to decide if clinically

· Overjet:

o Removable: 4.6 = Statistically significant

o Fixed: 5.4 = Statistically significant

§ No real difference

· Uncertainty was high in this review repeat studies

3. Patient outcomes

· Trials focus on treatment outcomes, but RCTs in orthodontics describe QOL in only 10% of trials, smaller number of functional improvement

· Might be missing effects of treatment

o Example of missed effects: KOB Twinblock Vs Herbst 2003

o Compliance:

· Herbst 2 x greater chance complete treatment

· Patient perception: TB worse

o Non-compliance of twinblock

§ Problems eating (speech, sleep)

§ Influenced school work

§ Bullying (embarrassed)

References

Batista, K.B., Thiruvenkatachari, B., Harrison, J.E. and D O'Brien, K., 2018. Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children and adolescents. Cochrane Database of Systematic Reviews, (3).

Thiruvenkatachari, Badri, Jayne Harrison, Helen Worthington, and Kevin O'Brien. "Early orthodontic treatment for Class II malocclusion reduces the chance of incisal trauma: Results of a Cochrane systematic review." American Journal of Orthodontics and Dentofacial Orthopedics 148, no. 1 (2015): 47-59.

Tsichlaki, A. and O'Brien, K., 2014. Do orthodontic research outcomes reflect patient values? A systematic review of randomized controlled trials involving children. American Journal of Orthodontics and Dentofacial Orthopedics, 146(3), pp.279-285.

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Join me as I summarise Roberto’s lecture looking at transpositions.

Roberto describes 2 cases of true transpositions, treatment options, mechanics and methods of camouflage.

Transposition: defined an anomaly in which 2 adjacent teeth have interchanged their position in the arch Peck 1993

Classification: 1995 by Peck and Peck

1. True transposition: root and crown

2. False transposition: crown only

Up to 2003 the majority of orthodontists accept transposition and this figure changed as currently most orthodontist tend to correct transpositions.

Case 1 Maxillary canine-premolar transposition - camouflage

Treatment:

1. Interceptive early RME spontaneous correction of maxillary canine-premolar transposition Maspero 2016 86% corrected.

2. Premolar camouflage: Although Sandler 2017 no difference in canine and premolar aesthetics for professionals and lay people transposition are different:

· Gingival height of the canine high compared to the premolar, if we don’t grind the canine tip,

a. Check smile line, low smile line = result will be acceptable by the patient.

b. End with slight intrusion in the premolar – so gingival height matches the canine Build up the premolar to make It look longer

Case 2 Maxillary canine-premolar transposition, canine high - correction

Treatment:

· Cannot apply conventional mechanics through the center of resistance of the canine due to vertical position

· Sectional wire:

· Wire from 1st molar to 1st premolar (bypass canine)

· Bent back on itself to then engage the canine (in the premolar position)

· = Class 6 Geometry (burstone) allowing intrusion of the canine during meisalization and by passing the premolar

· Torque: Need to keep the root palatal

· Apply couple one wire and with another wire he prevents the crown movement

· Auxiliary springs like warren spring or Goodman springs

· Single root torque to a tooth

Mandibular arch transpositions

· Less demanding to correct the lower arch transpositions due to decreased aesthetic requirements

· Word of caution to correct transition: Limited bucco-lingual width

Danielsen JC, Karimian K, Ciarlantini R, Melsen B, Kjær I. Unilateral and bilateral dental transpositions in the maxilla—dental and skeletal findings in 63 individuals. Eur Arch Paediatr Dent [Internet]. 2015 Dec 1 [cited 2020 Nov 18];16(6):467–76. Available from: https://link.springer.com/article/10.1007/s40368-015-0196-6

Leonardi R, … MF-TEJ of, 2011 undefined. An association between sella turcica bridging and dental transposition. academic.oup.com [Internet]. [cited 2020 Nov 18]; Available from: https://academic.oup.com/ejo/article-abstract/33/4/461/398881

Maspero C, Giannini L, Galbiati G, … MF-M, 2016 undefined. Effect of rapid palatal expansion in early tratment and spontaneous correction of maxillary canine-first premolar transposition. europepmc.org [Internet]. [cited 2020 Nov 18]; Available from: https://europepmc.org/article/med/27075370

Shapira Y, Finkelstein T, Kadry R, Schonberger S, Shpack N. Mandibular Symmetrical Bilateral Canine-Lateral Incisors Transposition: Its Early Diagnosis and Treatment Considerations. Case Rep Dent [Internet]. 2016 [cited 2020 Nov 18];2016:1–6. Available from: https://www.hindawi.com/journals/crid/2016/5043801/abs/

Sandler P. Extraction of maxillary canines: Esthetic perceptions of patient smiles among dental professionals and laypeople. 2017 [cited 2020 Nov 19]; Available from: http://derbyhospitals-nhs.archive.knowledgearc.net/handle/123456789/1160

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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.

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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.

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Join me as I interview Mohammed Almuzian, who has had over 35 scientific publications, 300,000+ downloads of his orthodontic notes, MOrth / board exam gold medalist , creator of Ortho PAR app. Mohammed discusses what led him to freely publish his orthodontic notes, what led him to carry out research into orthodontic expansion and Alt RAMEC. We get to hear Mo’s one piece of advice to all orthodontists about a career in orthodontics.

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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

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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

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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:

1. Adjuncts To Orthodontic Tooth Movement Are They Really Worth The Bother Martyn T. Cobourne
2. Orthodontic Retention Not Letting Go Padhraig Fleming
3. Application Of Evidence Into Daily Orthodontic Clinical Decisions The Unerupted Teeth Story Carlos Flores Mir
4. Update On Orthognathic Surgery Long Term Stability And Relationship To Airway Leslie A. Will
5. Non-Surgical Expansion With Midfacial Skeletal Expander (MSE) For Upper Airway Obstructive Patients Won Moon
6. Sleep apnea and the orthodontist Juan M. Palomo
7. Treatment Guideline For Adult Obstructive Sleep Apnea Patients In Perspective Of Sleep Function And Facial Aesthetics Seung Hak Baek
8. Patient expectations and the future of orthodontics Steven j. Lindauer
9. Great Expectations - Understanding Patient Expectations In Orthodontics

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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

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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

• Resting tongue position is the main soft tissue factor.
• For increased LAFH, posterior intrusion with tads is indicated.
• Invisalign for mild AOBs, correction is achieved with incisor extrusion mainly.
• TADs for intrusion should be placed in the palate should be as distal as possible.
• If intruding upper molars with TADs, lower molars will erupt unless an appliance is used.
• 80% of vertical relapse with posterior intrusion occurs in 1st year after debond.

How to plan intrusion posterior teeth Vs extrusion of anterior teeth

• Extrusion:

No autorotation

Increase incisal show * Effects of intrusion:

Autorotation of mandible

Reduction in LAFH

Reduced posterior tooth show

CONSIDER EFFECTS ON OCCLUSAL PLANE WITH POSTERIOR INTRUSION

1. If too steep = occlusal interference
2. If too flat = reverse smile

How to plan extrusion / intrusion:

• Upper incisor tip positioned 4mm from the upper lip tip

Evidence of AOB closure with TADs

1. Posterior intrusion of 2mm in the upper and 1mm in the lower 1mm, with 3mm of autorotation. Deguchi 2011
2. TADs and intrusion less stable, 1mm or 30% relapse Sugawara 2002
3. If intrude upper posterior teeth, use lower fixed or VFR to prevent lower posterior over eruption.

Aligners

• Correct AOBs through 1.5mm incisor extrusion, minimal posterior changes. Khosravi 2017

Orthognathic surgery

Reduced stability due to Stylomandibular and medial pterygoid muscles.

Solution

• Strips muscles in surgery

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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.

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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.

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Chris Chang describes the use of aligners (Invisalign), and how to resolve common aligner issues and incorporate TADs to achieve predictable outcomes. Aligners work as a pushing appliance: · Pushing surface (active surface) should be at 90 degrees to the direction of tooth movement. · Pulling movements can be achieved through combining with TADs. Reduced aligner predictability: 1. Distalisation 2. Expansion 3. Extraction 4. Incisor intrusion 5. Deep bites The details below describe how to resolve the reduced predictability of aligners. 1. Distalisation · Aligners cannot distalise teeth en-mass, and require sequential distalisation but with incorporating TADs it is possible, for example: o Distalisation in the lower arch: § Buccal shelf TAD in the lower arch (vertically placed, lateral/ buccal to the lower molars). § Intra-arch elastic wear (4.5 ounces) from the lower canine to terminal molar. 2. Expansion · Aligners result in tipping (buccal flaring) with expansion, this can be resolved through attachment placement: o Long horizontal attachment placed buccally with a gingival bevel. § Stage 1 of expansion = Buccal flaring. § Stage 2 of expansion = Attachment aligner interaction results in pushes force palatally, the balancing of moment results in - Buccal root torque = uprights tooth = bodily expansion 3. Premolar / bicuspid extractions & 4. Incisor intrusion · Aligners result in tipping of teeth into the extraction site, this can be resolved through creating a counter moment through attachments o G6 optimised attachments have their pushing surface / active surface positioned to counter the tipping movement and bodily translate the tooth o G6 attachments are located at different heights to generate a force in the direction desired and creating a counter moment. o Kenji formula: change G6 attachments to  long vertical attachments · Aligners and extractions can also result in (Fan-fan Dai 2019): o Incisor extrusion and torque loss. o 3mm of posterior anchorage loss and intrusion of molars. Correction · TAD placed in upper incisor region, and elastic wear: o 2 anterior labial TADs – intrude anterior teeth § Elastic from palatal cut out of aligner over occlusal surface to labial TAD. o 2 posterior buccal TADs preserve anchorage § Elastic wear from canines to TAD for retraction 5. Deep bite · Aligners under correct deep bites due to the bite plane affect, this can be resolved with a 3 stage approach 1. Overcorrection of Deep bite in planning. 2. Chewies – on the anterior teeth. 3. Incisor screw – incisor intrusion with elastics. Anterior Crossbite tips 1. Occlusal attachment – to open the bite. References Grünheid, T., Loh, C. and Larson, B.E., 2017. How accurate is Invisalign in nonextraction cases? Are predicted tooth positions achieved?. The Angle Orthodontist, 87(6), pp.809-815. Dai, F.F., Xu, T.M. and Shu, G., 2019. Comparison of achieved and predicted tooth movement of maxillary first molars and central incisors: First premolar extraction treatment with Invisalign. The Angle Orthodontist, 89(5), pp.679-687.

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Part 2: Nikhilesh explores the use of class 2 elastics, myobraces, growth and success.

Conclusions from part 1 and 2

o No advantage of early treatment

o No difference in self esteem with early treatment

o 20% failure of removable class 2 appliances

o Patients prefer fixed functional appliances

Question 9 Dento-alveolar correction worth it?

· If the results are stable = yes

· Drop outs for removable appliances 19%

Question 10 Use of class 2 elastics?

· Duration to achieve overjet correction

o 6.8/12 Vs Forsus 4.5/12 Arora 2018

o Side effects of class 2 elastics

§ Extrusion and palatal tipping of Ui

§ Clockwise rotation of occlusal plane (forsus anticlockwise rotation)

Question 11 Myobraces – off the shelf appliances?

· Activator appliances is more effective than Myobrace by 1.1mm Idris 2018

· Cost-benefit analysis however favours myobraces: Cirgic 2018

Question 12 Future growth

· No consensus about future growth prediction

· Relapse is unpredictable

o Nikhilesh recommends 1 year appliance use due to:

§ Minimising subnormal growth affects

§ Time for bone to mature

§ Minimise relapse

Question 13 Criteria for success:

o Cervical Spine Maturation 3 (CM3)

o CL2 molars

o CO-GO-ME 1250 - reduced vertical component Franchi & Bacetti

References

Arora, V., Sharma, R. and Chowdhary, S., 2018. Comparative evaluation of treatment effects between two fixed functional appliances for correction of Class II malocclusion: A single-center, randomized controlled trial. The Angle Orthodontist, 88(3), pp.259-266.

Idris, G., Hajeer, M.Y. and Al-Jundi, A., 2012. Acceptance and discomfort in growing patients during treatment with two functional appliances: a randomised controlled trial. European journal of paediatric dentistry, 13(3), pp.219-224.

Franchi, L. and Baccetti, T., 2006. Prediction of individual mandibular changes induced by functional jaw orthopedics followed by fixed appliances in Class II patients. The Angle Orthodontist, 76(6), pp.950-954.

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Part 1 explores key themes around the effectiveness of class 2 correction, how they work, different times, the role of headgear and fixed functional appliances.

Q1 & 2 Do we have the evidence, and is it effective?

Phase 1

o Phase 1 there is no advantage, no difference in clinical outcomes: Cochrane review Harrison 2007.

o 9-10% of patients benefit from phase 1 through a reduction in trauma, Gianelly 1995.

o “Just because we can doesn’t mean we should” Jay Bowman

Trauma

· Increased OJ greater than 3mm = 2 x risk of trauma Nguyen 1999

Questions 3 Growth can we predict it?

· No restraining effect on Maxilla, slight growth of the mandible and increase vertical growth Mills 1991

o 3mm growth Pg-Go

o SNB improvement of 4o

o NO we cannot - Unpredictable

Question 4 When to treat and which on?

· When: CVM 3-4 is where peak growth occure, (PHV): however only 25% of patients have 1 single peak, most have ‘multiple peaks’

· Which one: Efficiency- Herbst 0.28mm, TB 0.23mm, Herbst more efficient - fixed more efficient

Question 5 What changes take place?

Functional appliances don’t all work the same:

· Removable:

o Upper molar distalisation / upright

o Upper incisor uprighting

· Fixed

o Upper molar distalisation / upright

o Increase mandibular length (Po-Go)

Question 6 Do they grow mandibles?

· AAO Council statement 2005 – “No scientific evidence of increase in mandible”

o Lengthening of condyle and ramus does occur.

o Glenoid fossa remodelling does occur.

o No evidence shows:

§ Insignificant overall increase in length .

§ Condyle growth cannot be permanently increased.

Question 7 Does HG still have a role?

· Vertical and AP changes do occur with HG after 6/12 Burke 1992, Nanda 2006,

· Compliance however is 56% Brandao

Question 8 Effectiveness of fixed functional appliances?

· Compliance nearly 100%

· Phase 1 shorter 4.5 months

· Forsus Vs Powerscope:

o More AP change with Forsus Arora 2018

· New ideas of fixed functional and TAD / miniplates

References

Harrison, J.E., D O'Brien, K. and Worthington, H.V., 2007. Orthodontic treatment for prominent upper front teeth in children. Cochrane Database of Systematic Reviews, (3)

Nguyen, Q.V., Bezemer, P.D., Habets, L.L.M.H. and Prahl-Andersen, B., 1999. A systematic review of the relationship between overjet size and traumatic dental injuries. European Journal of Orthodontics, 21(5), pp.503-515.

Mills, J.R.E., 1991. The effect of functional appliances on the skeletal pattern. British Journal of Orthodontics, 18(4), pp.267-275.

Vaid, N.R., Doshi, V.M. and Vandekar, M.J., 2014, December. Class II treatment with functional appliances: A meta-analysis of short-term treatment effects. In Seminars in Orthodontics (Vol. 20, No. 4, pp. 324-338). WB Saunders.

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Nelson describes 4 cases of alternative approaches to conventional orthognathic surgery processes.

1. Facial asymmetry due to condylar hypoplasia:

a. Genioplasty Propella

i. 2 cuts, 1 horizontal, 1 angular and rotate the middle component

1. Class 2 due to retrognathic mandible

a. Corrected by 4 stages

i. Genioplasty

ii. Start anterior subapical osteotomy

iii. BSSO advancement

iv. Complete subapical and inferior repositioning = prevent lateral openbites

1. Class 3 due to maxillary hypoplasia AP and vertical.

a. 3 Stage process with segmental maxillary osteotomy

i. Maxillary advancement

ii. Extraction of U4s, anterior subapical osteotomy, retracting and rotation to surgically decompensate

iii. Mandibular set back

1. Class 2 due to maxilla hyperplasia

a. Maxillary osteotomy 2 part: horse shoe shaped osteotomy

i. Separating dental and skeletal components

ii. Allow set back of dentoalveolar component and upward positioning of the maxilla

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Join me as I interview Kevin O’Brien, who has over 110 publications, the Emeritus Professor at the University of Manchester, has received the Turpin and Jarabak awards as well as being the first to deliver the Proffit lecture at the AAO.

Professor Kevin Obrien is one of the leading experts in research in orthodontics, , having published landmark clinical trials and Cochrane reviews.

Kevin discusses his blog, his opinion on key opinion leaders, as well as describing those who influenced his career.

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

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Part 2: Mark describes the clinical factors of space closure and an method of maintaining bone in space opening using miniscrews

Space closure aesthetic challenges

1. Gingival height: Canine’s height is superior to lateral incisor’s

2. Torque: Canine is of buccal root torque, and a lateral is palatal root torque

3. Morphology: Canine is wider and thicker than a lateral incisor.

4. Gingival height solution:

a. Bracket placement

· Canine bracket placed gingical = extrude gingival margin

· Premolar / bicuspid bracket placed incisal = ,intrude gingival margin

1. Torque

· Using a lower contralateral 2nd premolar bracket inverted:a achieves 17 degrees of palatal root torque and fits onto the surface of the canine

· Mophology

· Minimal prep veneer

· Narrow buccal lingual via reduction

Mechanics – tips for space closure

· Always push mechanics

· If pull mechanics– distort archform, and alter centreline

· TADs can be usedfor anterior anchorage

Space closure advantages over space opening

· Stable

· immediately finish, no 2 stages

· Predictable periodontal health

· Possible in all malocclusions

· Maintains bone

· No prosthesis

· No evidence of functional problems

Space opening miniscrew to maintain bone

Does it work?

Miniscrews: increase density Al Maaitah AJODO

· 3/12 after placement

Follow up for 5 years = maintained bone and prosthesis, Ciarlantini 2017

How to insert?

o Lateral insertion = as vertical insertion of miniscrew shows infraocclusion

o Use of spring to maintain prosthesis

References

Al Maaitah, E.F., Safi, A.A. and Abdelhafez, R.S., 2012. Alveolar bone density changes around miniscrews: a prospective clinical study. American journal of orthodontics and dentofacial orthopedics, 142(6), pp.758-767.

Ciarlantini, R. and Melsen, B., 2017. Semipermanent replacement of missing maxillary lateral incisors by mini-implant retained pontics: A follow-up study. American Journal of Orthodontics and Dentofacial Orthopedics, 151(5), pp.989-994.

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Part 1

Mark explains the dilemmas and dogmas behind hypodontia management.

Dogma / idea influence opening vs closing

1. Canine guidance

o Dogma: Canine guidance better than group function

§ Only evidence of negative affects relate to canine inclination, when tucked in = greater muscular activity, seems to relate to degree of freedom in occlusion Sugimoto 2011

o Dogma: Proprioception from canine essential / special

§ Some have considered the proprioception of canines to be essential in the reflex arc of chewing.

§ However the ‘special’ proprioception not been shown to be of consequence.

SR on occlusal schemes: Abduo 2015

· Neither canine vs group function occurs naturally

· Occlusal schemes are dynamic

· Neither scheme pathological or therapeutic

· Crucial factor = degree of freedom in occlusion Sugimoto 2011

1. Implants:

§ Idea / dogma: Implants are ideal prosthesis / without risk

1. Infraposition of implant – vertical growth of adjacent teeth and dentoalveolus, result in relative infaocclusion / position of implant

o Between age of 10-30 = infraposition phenomenon of implants more obvious than 30-40 Schwartz-Arad 2015

o Ideal age of implant placement varies

§ Delay until growth complete to prevent infraposition of implant assessed through serial radiographs

2. Implant problems

o Tooth wear, loss of contact points Papageorgiou 2018 SR

o 5-10% implants fail LONG TERM Pablos 2019

Timing of orthodontic treatment

o Idea / dogma: treat hypodontia patient at the usual age i.e. adolescence with 2 stages

§ In between stages the following can occur: risk of root change, boney changes -most significant is of spaces are greater than 6mm = likely to require bone augmentation in 60-80% of cases Bertl 2017

o One should delay to treat in single phase or space closure Beyer 2005

Literature consistent

§ Nordquist 1975 - Silveira 2016 SR, supporting space closure better aesthetics, periodontal outcomes, and no TMD.

Lay people perception

Prefer space closure Qadri 2016

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Dr Nicolas Salesse talks us through 2D lingual appliances in the lower arch for alignment, how the appliances work, the application as well as his protocol.

Advantages:

2d Vs 3d

· Direct bonding

· Unlikely to debond, due to low profile

· No complex bonding required (same as conventional labial brackets)

· 0 prescription bracket – no torque treatment conducted round wires round wires only

Cost

· Headway 2 dollars

· forestadent 2d 10-20 dollars per bracket

Disadvantages:

· Metal bracket can deform on opening / closing

· Complete alignment if required with aligners

Lower incisor alignment ideal:

· Bracket positioning lower arch

o Same height of centrals and laterals

o Relatively upright teeth, no significant tip

· Upper arch difficult for 2D brackets:

o large variation in bracket positioning between 1s and 2s

· Patient expectations: Lower expectation of lower arch

Challenges lingual appliances:

1. Reduced inter-bracket distance

2. In out discrepancy on the labial face due to lingual bonding

3. Bracket position height

4. Prescription

1/ Inter-bracket distance

· Smaller distance = wire is stiffer = greater force

· 2d brackets can have the archwire placed above the 2D bracket, increasing the interbracket distance, similar to Incognito

2/ In out discrepancy on the labial face due to lingual bonding

· Lingual appliances align lingual surfaces = discrepancy labial aspect due to variation in AP anatomy.

· Further from labial face – harder to control labial alignment

· Anterior teeth increase in thickness more Gingival

Height of bracket position

· Ideal 2D lingual bracket position = incisal as possible, less AP in out thickness, less variability.

· Lower arch incisal heights 2-2 same, no bend required

Prescription

· Only bend required is 2-3 in out direction

o Only bend lower 2-3 region = 2 bends

Protocol lower 2D brackets

· Digital set up plan IPR

· Bonddirectly, close to incisal edge. (no overcorrection)

· IPR

· Bond canine and premolar together: bonding composite prevent adverse affects on 3s

· Wires:

o Initially straight wire: such as 012NT

o 016NT + wire bends

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Orthodontics In Interview: Jay Bowman USA

Join me as I interview Jay Bowman, who has over 150 publications, is an Angle Society member. World Federation of Orthodontists member. A university faculty member and reviewer for AJODO.

Jay Bowman is an expert of orthodontics, having innervated several products and appliances as well as having published 5 textbooks.

Jay discusses his journey into publishing on miniscrews and his interests.

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

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Dr Flavia Artese describes one of the main causes of anterior open bites, tongue position, and the use of tongue cribs and spurs. Conclusion: Use of palatal cribs and tongue spurs are effective at managing AOBs, where the aetiology is anterior tongue position. however stability is related to resting tongue position long term. Aetiology

Anterior tongue position at rest, not in swallowing, as low intensity and duration.

What is normal tongue posture?

The tongue should be behind the upper incisors, in both a AP and vertical plane.

Treatment for anterior tongue position involves changing the AP and vertical position

Correct tongue position: Proffit equilibrium theory, form follows function of resting tissues.

4 vertical tongue positions: High: Protrude upper incisors Horizonal tongue ideal vertical but anterior Procline upper and lower incisors Low tongue Not maintain transverse palate = constriction Proclined lower incisors Very low tongue Severe AOB Lowers retroclined and 2 occlusal planes

2 treatment types based on altering posture of tongue, both retract the anterior tongue (considered myofunctional appliances) 1. Cribs (LOWER TONGUE and AP RETRACT): a. Upper arch appliance with loops b. Type of tongue position correction: high and horizontal 2. Spurs (RAISE TONGUE and AP RETRACT): a. Lower arch appliance with spikes

Changes in tongue position with cribs / spurs · Less AP movement of the tongue (AP retraction), · Raises tongue (for spurs) Schwestka 1995 · Reflex arc - Contact = pain = retract tongue AP

Does it hurt? · VAS 0-10 = very low = 0-2 Pts had spurs upper and lower

Protocol 1. High or horizontal  tongue position: · Use fixed palatal cribs, used through mixed dentition 2. Low or very low tongue: · RPE (tongue raises following RPE Ozbek 2009) · Spurs lower arch, used through mixed dentition

Stability protocol: · 2 stage approach – assess in interval between myofunctional appliance and fixed appliances

Retention protocol: Stable · Bonded retainers Unstable · Bonded retainers + spurs lower arch

Treatment stability relapse · 25% orthodontics only Greenlee · 18% orthodontics and surgical treatment Greenlee · 0-17% Myofunctional Huang 1990

Quality of Life · OHR QOL AOB management with palatal cribs correction = positive change more than 10 points: Pithon 2019

References Stability of AOB treatment, surgical Vs non-surgical Greenlee, G.M., Huang, G.J., Chen, S.S.H., Chen, J., Koepsell, T. and Hujoel, P., 2011. Stability of treatment for anterior open-bite malocclusion: a meta-analysis. American journal of orthodontics and dentofacial orthopedics, 139(2), pp.154-169. Diagnosis and treatment Dr Artese paper Artese, A., Drummond, S., Nascimento, J. and Artese, F., 2011. Criteria for diagnosing and treating anterior open bite with stability. Dental Press J Orthod, 16(3), pp.136-61

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I summarise Cesare's lecture looking at Class 2 subdivision cases with treatment options

classification:

· Type 1: Mandibular midline deviated from facial midline, Maxillary correct: 56-62%

· Type 2: Maxillary midline deviated facial midline, Mandibular correct 29% Cassidy 2014

Aetiology

· Type 1 subdivision: shorter mandible on affected side: Sanders 2010

Interceptive management

· RME = improved mandibular asymmetry by a mandibular rotation: Evangelista 2020:

Treatment: Non extraction:

1. Asymmetric Class 2 corrector / functional appliance

o Type 1 case (mandibular asymmetry)

o Single sided class 2 corrector, e.g. Monoscope

· Address aetiology: of a shorter mandible

1. Asymmetric distalisation with modified pendulum + TAD · Type 2 case (maxillary asymmetry)

· Palatal finger spring active on the 1stmolar to distalise

· Pendulum appliance with occlusal rest on U4s

· TADs

o Placed: buccal 5-6

o Ligation: Indirectly ligated to premolars

Extraction:

1. 1 premolar extraction

· Type 1 and type 2 cases

· Extract on the unaffected side

o Distalisation, Unilaterally activated TPA

o No cant Janson 2004

4. 3 premolar extractions

· Type 1 (mandibular asymmetry)

· 3 units:

o 2 upper units to manage class 2,

o 1 unit in the lower arch on unaffected side

· Outcome: Coincident CL and predicable Turpin 2005

References

Distalisation of intra-oral appliances + TADs

da Costa Grec, R.H., Janson, G., Branco, N.C., Moura-Grec, P.G., Patel, M.P. and Henriques, J.F.C., 2013. Intraoral distalizer effects with conventional and skeletal anchorage: a meta-analysis. American Journal of Orthodontics and Dentofacial Orthopedics, 143(5), pp.602-615.

Class 2 subdivision CBCT

Sanders, D.A., Rigali, P.H., Neace, W.P., Uribe, F. and Nanda, R., 2010. Skeletal and dental asymmetries in Class II subdivision malocclusions using cone-beam computed tomography. American Journal of Orthodontics and Dentofacial Orthopedics, 138(5), pp.542-e1.

Class 2 subdivision classification

Cassidy, S.E., Jackson, S.R., Turpin, D.L., Ramsay, D.S., Spiekerman, C. and Huang, G.J., 2014. Classification and treatment of Class II subdivision malocclusions. American Journal of Orthodontics and Dentofacial Orthopedics, 145(4), pp.443-451.

Extraction of 2 units Vs 1 for class 2 subdivision

Janson, G., Cruz, K.S., Woodside, D.G., Metaxas, A., de Freitas, M.R. and Henriques, J.F.C., 2004. Dentoskeletal treatment changes in Class II subdivision malocclusions in submentovertex and posteroanterior radiographs. American journal of orthodontics and dentofacial orthopedics, 126(4), pp.450-462.

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Orthodontics in Interview: Mark Wertheimer

Join me as i interview Mark Wertheimer and discuss his journey into interdisciplinary care,

Mark describes his bug bears and we find out more about Mark the cyclist and football fanatic.

We get to hear Mark's one piece of advise to all orthodontists about a career in orthodontics.

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Dr Sergio Sambataro describes the bioprogressive approach to managing the class 2 case

Class 2 aetiology: Sato 2008

· Upper molars less erupted

· Lower molars more erupted

Occlusal objective for class 2 in bioprogressive technique:

· Lower the posterior occlusal plane

Unlocking of growth:

· Decompression theory

o Increased interarticular space = vertical growth at the condyle

· = mandible grows forwards

· = counterclockwise rotation of mandbile

Principles of treatment:

· Extrude upper molars – correct steep posterior occlusal plane

o = Decompress condyle through creating interarticular space

· Correct overbite

o = if not anterior interference prevents forward growth of mandible

Distalise

1. Utility arch with tip back bend

a. = distally tip upper molars

2. Utility arch with activation:

a. By obtuse bend (instead of perpendicular band) – activate by compressing wire on insertion

i. distalisation force on posterior teeth

ii. advance anterior teeth - Counter affects by class 2 elastics

Utility arch: 16x16 Elgiloy = low forces

Overall treatment entails the following:

· Diagnosis 75%

· Unlocking 20%

· Mechanics 5%

References

Occlusal plane and aetiology

Tanaka, E.M. and Sato, S., 2008. Longitudinal alteration of the occlusal plane and development of different dentoskeletal frames during growth. American Journal of Orthodontics and Dentofacial Orthopedics, 134(5), pp.602-e1.

Ricketts textbook

Ricketts, R.M., 1998. Orthodontic treatment in the growing patient. Vol. I, pp.16-21.

Cervial headgear = greater AP change in class 2

Zervas, E.D., Galang-Boquiren, M.T.S., Obrez, A., Viana, M.G.C., Oppermann, N., Sanchez, F., Romero, E.G. and Kusnoto, B., 2016. Change in the vertical dimension of Class II Division 1 patients after use of cervical or high-pull headgear. American Journal of Orthodontics and Dentofacial Orthopedics, 150(5), pp.771-781.

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Orthodontics in interview!

Listen and enjoy the story of Flavia Artese: Associate Professor in orthodontics and editor-in-chief of Dental Press Journal of Orthodontics.

She describes her journey which led to a career in orthodontics and an interest in anterior open bites.

Flavia speaks of her role models and pet peeves. 

Flavia is looking forward to welcoming all to the 2025 WFO (World Federation of Orthodontics) 10th International Orthodontic Congress in Brazil

https://www.wfo.org/

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Summary of Webinar: Simplified Orthodontic Biomechanics with Double Slot Bracket - Thaer Hamid Brazil

Conclusion

New bracket concept, could reduce anchorage demand for specific mechanics

What is it?

· Metal bracket with 2 conventional slots (1 passive, 1 active ligating) in a vertical arrangement

How does it work?

Passive incisal slot 022 x 028

· More liberty between archwire and slot

· Greater force (when compared to 018x025 slot)

Active gingival slot 018x030

· Better rotational control

· Quicker torque expression

Advantage in anchorage and less auxillaries

· Base archwire can be 19x25ss: high rigidity

o active wire can be larger:  16x22NiTi

Archwire sequence

012 CUNiTi initially 1 slot

012 CUNITI Both slots

016 CUNITI Both slots

16x22 CUNITI Both slots

17x25SS (working archwire) in 18x30 slot

Issues: Friction

Yes could be increased

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Summary of webinar: Power2Reason - Orthodontics in periodontally compromised patients: Morten Laursen

Conclusion

orthodontic treatment can achieve:

• Greater cleansability through alignment

• Potential reduced periodontal pocketing through long junctional epithelium formation

• Rehabilitation through idealising tooth position for their eventual loss and prosthetic replacement in ideal position

Risk of not factoring in periodontal disease

1. Increased force = root resorption

2. Increased force = loss of anchorage

1. Active disease = increase loss of periodontal tissue

1/ Treatment protocol: Anterior intrusion with mini implants with TADs

· TAD Where

o Distal to canine

· TAD How

o Indirect ligation to canine bracket

· Biomechanics

o Absolute intrusion of 2-2 = 3mm

2/ Treatment protocol: Lingual root torque of incisor with Auxiliary torqueing archwire

· Attachments x 3

o 1st molars R and L

o Affected lower incisor

· BASE ARCHWIRE - prevent AP and vertical changes to lower incisor

o 020 ss

· AUXILIARY ARCHWIRE

o 19x25TMA

o Down bend or RCOS = lingual root torque

· Biomechanics

o Lingual root torque to lower incisor

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Simon Littlewood tells his story of orthodontics in his charismatic way.

Simon walks us through his achievement of the Cochrane Systematic Review on retention, what ideas led to the large body of work (link below).

Simon led the British Orthodontic Society's 'Hold that smile' campaign, and describes the process of how he did this, and also why he did it (link below).

We learn who Simon admires in orthodontics and outside the field.

We ask Simon your question on what retention regime he advises patient to use

And Simon gives his advise to a career in orthodontics

There were some light-hearted  outtakes which we hope you will enjoy!

Links below:

BOS hold that smile campaign

• https://www.bos.org.uk/Orthodontic-Retention

Cochrane Review in retention

• https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002283.pub4/abstract

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Invisalign European Scientific Symposium Part 4- Data mining and new innervations

Data and Science Based & Introducing the New Product Innovations Dr Mitra Derakhshan & John Morton

How does Invisalign work?

Force driven system: Contact in certain location, another force for root movement

1. Smart force

· Allows controlled force to the tooth through:

o Changes shape of the tooth (attachments)

o Changes shape of aligner (power ridges , pressure areas)

2. Smart track

· Highly elastic material with high working range – LIKE NITI

3. Smart stage

· Calculation of force required to move tooth

· Staging of tooth movement to manage anchorage, ie 1st molars in expansion cases are moved first (greatest resistance due to surface area)

Data

Effectiveness of distalisation

· Sequential distalisation ( ½ movement achieved prior to next tooth moving) n= 2000

· Modified distalisation (1/3 movement achieved prior to next tooth moving n =) 4000 Simultaneous distalisation (all teeth move at the same time) n = 800

Bite ramps

· With bite ramps 30% greater intrusion of lower incisors in severe cases (1mm Vs 1.4mm)

New products

· Clincheck pro 6.0 cloud based

· In smile visualisation - smile integrates actual clincheck,

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Summary of studies looking at expansion of aligners using invisalign First

Overall conclusions

· Greater expansion anteriorly

· Greater predictability of expansion anteriorly Vs posteriorly

· Greater predictability of expansion buccally, unpredictable palatally

Summary of webinar: Invisalign European scientific symposium part 3: Expansion

Arch expansion pattern using clear aligners: a three-dimensional retrospective study in paediatric subjects with posterior crossbite. Dr. Silvia Caruso

WHAT’S THE QUESTION?

How effective is the Invisalign system at expansion

Previous papers: not predicable but change in material to smart track since

WHO DID THEY TREAT?

N20

Age 6-10

Mod-severe crowding

WHAT DID THEY DO?

Retrospective

Maxillary dentition

Gingival width and buccal cusp width of teeth

WHAT DID THEY FIND?

Buccal expansion

· C-C expansion: very predicable: 99% achieved (4mm)

· 1st permanent molar-molar expansion: predicable 88% achieved (3.8mm)

· Primary molar expansion: least predicable buccal and palatal

Palatal expansion

· Primary molar expansion: unpredictable 42% achieved (1.9mm)

· 1st permanent molar-molar unpredictable 38% achieved (1.4mm)

CONCLUSION

· Buccal expansion predictable with invisalign

· Palatal expansion predictable at C-C region, unpredictable Molar regions

Summary of webinar: Invisalign European scientific symposium part 3: Expansion

First maxillary expansion with aligners in growing patients. Dr. Tommaso Castroflorio & Dr. Francesco Garino

WHAT WAS THE QUESTION?

What expansion can be achieved with Invisalign first

WHO DID THEY TREAT?

N = 43

Age 8

Morphological superimposition

WHAT DID THEY DO?

Expansion using Invisalign protocols

WHAT DID THEY FIND?

· C-C expansion: Greatest: 3mm +

· Primary molar expansion: 3mm

· Permanent molar-molar expansion: Least: 2mm

· 19% area increased

· 38% volume increase

CONCLUSION?

1. Expansion greater anterior, less posterior

2. Increase in volume and area

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CONCLUSIONS FROM DISTALISATION (AND CLASS 2 ELASTICS) AND MANDIBULAR ADVANCEMENT (MA)

1. No significant changes in inclination upper or lower
2. Mandibular growth enhanced 3-4mm
3. No adverse vertical changes

CRITIQUE:

1. No controls
2. No reporting on buccal segment movements

Skeletal and dentoalveolar effects produced by Aligners and Elastics in Class II growing patients Federico Migliori

WHO

· 14 pts 13.6 years old

· Co-Go-Me 125 – hypodivergent

· Cervical spine C3

WHAT DID THEY DO IT

· Invisalign protocols for distalisation

o Sequential distalisation, ½ distalised, following tooth distalised - anchorage

o Class 2 elastics

WHAT DID THEY FIND

· Distalisation achieved in 15 months

· proclination of lowers did not occure IMPA: -2.2 – reduction

· Vertical control proportions FMA -1.7

· Co-Gn increased by 3mm

Correction of Class II malocclusion in growing patients with Aligners Dr. Simona Dianiskova

WHO

· Age 12, OJ 4mm, ANB 3

WHAT DID THEY DO IT

· De-rotate upper 1st molars – up to 2mm

o 85% of class 2 cases have rotated upper 1st molars

· Expansion – usually required

· Distalisation -2.5mm predictable Simon 2014 87%

· Class 2 from outset, no IPR

· Overcorrect upper inc by 5 degrees of palatal root torque – prevent undertorquing

analysis dolphin – Mcnamama

WHAT DID THEY FIND

Duration of tx 16-21 months

· Results no change ANB,

· Co-Gn 4 – stat sign

· Witts stat improve -1.8

· Ui and lLi 1-2 degrees change

· No vertical change FMA

II malocclusion treated with Invisalign with Mandibular advancement feature and twin block appliance compared with historical controls Dr. Sandra Tai

WHO

N32

Age 13

WHAT DID THEY DO IT

Outcome Ceph study

WHAT DID THEY FIND

SNB - stat sign for invisalign

Ui and Li procline 3.5 - stat sign t/b

No difference in vertical change both

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Summary of the Invisalign European Scientific Symposium, with Dr Alessandro Mario and Dr Dieter Brothag presenting their studies

Alessandro Mario

Aligners resolve deep bites by

· Anterior bite turbos - allow posterior extrusion, and progressively move incisal

· Anterior intrusion

· Pressure areas - force through indentations into the aligner

WHO

· N = 44 with complete OB of 7mm+

· hypodivergient SnGoGn less 25

WHAT DID THEY DO IT

· Prospective follow up

· Treatment protocol

o Anterior bite ramps, lingual pressure areas, class 2 / vertical elastics, extrusion 1mm of posterior teeth, Lower premolars - rectangular long attachments, Heavy posterior occlusal contacts

· No overcorrection

WHAT DID THEY FIND

· Overbite corrected in every case 3.5mm

· Average time 11 months. 26 aligners

CONCLUSION

· Aligners effective at correcting deep bites, if posterior extrusion is planned

IMPROVEMENTS / COMMENTS

· Did extrusion occur? – Rossinia 2015 SR stated most difficult movement with aligners?

Changing the paradigm of deepbite treatmentDieter Brothag

WHO

· N = 50 with complete OB of 7mm+

· IOTN 3+

WHAT DID THEY DO IT

· Retrospective follow up

· Normal practie protocols for both treatments

· Fixed labial Vs Aligners

· Non-extraction

WHAT DID THEY FIND

Effectiveness - PAR changes

· Labial fixed: 20 – 4

· Invisalign: 18 – 3

NO STATISTICAL DIFFERENCE

Efficiency - duration

· Labial fixed: 30+ months

· Invisalign: 20 months

STATISTICALLY SIGNIFICAN DIFFERENCE

CONCLUSION

1. Aligners as effective at correcting deep bites as labial fixed

2. Aligners are more efficient than labial fixed

IMPROVEMENTS / COMMENTS

· Why did labial fixed cases take 30+ months non-extraction

· Retrospective study, RCT would be more robust

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Dr Neal Kravitz gives the audience at the AAO advise from his clinical and professional mistakes

Clinical advise

1. 2 phase / early treatment - AVOID

a. It builds expectations of non-extraction treatment

2. All treatments none- extract - AVOID

a. If avoid due to patient pressures, can result in proclination, relapse, but most significantly impacted second molars

b. He extracts in 50% of adolescent cases

3. Inconsistent records - AVOID

a. Take photos every other visit

b. It will give opportunity for reflection on treatment

c. It will slow one down – therefore less mistakes

4. Only using bonded retainers - AVOID

a. consider temporary due to failure rates 20-50%

b. Always use a essix / VFR

Career advise

· Make your goal clinical, not financial

· Humility is the path to being a good clinician

· Focus on being better everyday

Conclusion

Take pride in your work, but stay humble

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Dr Claudia Cruz and Roberto Stadi describe the predicability of aligners, indirect bonding for labial and lingual appliances

Summary

Aligners

Factors which reduce the predictability of aligners

· Manufacturing process: 0.1mm

· Force delivery

o Thermoforming force decay

o Inconsistent thickness of aligner

· Anatomy of teeth: Rounded teeth (Canines and Premolars / Bicuspids)

How to improve predictability

Clinical:

· Increase attachment size, alter attachment orientation, stage movements

Technological – not achieved yet!

· Use actual root information (CBCT), control thermoforming features, calculate forces required and ideal attachment for tooth movement

Indirect labial bonding

· Up to 1mm error in bracket placement in indirectly

· Up to 1 mm error in robotic archwire formation

· Outcomes worse than conventional direct bonding

· Tooth morphology anterior 2-2 will usually require manual wire bending

Lingual appliance

· Accurate to 40 and up to 1 mm

· Torque discrepancies manifest in greater 2nd order error than labial

· Extraction cases: more critical to control moment force ratio, if not = greater retroclination / loss of torque of upper labial segment

Conclusion:

New technology have discrepancies which the clinician should factor into treatment planning

References

Customised labial brackets accuracy

Alford, T.J., Roberts, W.E., Hartsfield Jr, J.K., Eckert, G.J. and Snyder, R.J., 2011. Clinical outcomes for patients finished with the SureSmile™ method compared with conventional fixed orthodontic therapy. The Angle Orthodontist, 81(3), pp.383-388.

Morphology of teeth and outcomes of orthodontics

Miethke, R.R. and Melsen, B., 1999. Effect of variation in tooth morphology and bracket position on first and third order correction with preadjusted appliances. American Journal of Orthodontics and Dentofacial Orthopedics, 116(3), pp.329-335.

Effectiveness of aligners

Papadimitriou, A., Mousoulea, S., Gkantidis, N. and Kloukos, D., 2018. Clinical effectiveness of Invisalign® orthodontic treatment: a systematic review. Progress in orthodontics, 19(1), p.37.

Accuracy of lingual appliances

Grauer, D. and Proffit, W.R., 2011. Accuracy in tooth positioning with a fully customized lingual orthodontic appliance. American Journal of Orthodontics and Dentofacial Orthopedics, 140(3), pp.433-443.

Loss of torque affects,labial and lingual

Liang, W., Rong, Q., Lin, J. and Xu, B., 2009. Torque control of the maxillary incisors in lingual and labial orthodontics: a 3-dimensional finite element analysis. American Journal of Orthodontics and Dentofacial Orthopedics, 135(3), pp.316-322.

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Summary of Dr Elie's research regarding space closure mechanics for missing upper lateral incisors

· Patients with missing upper lateral incisors usually have hypoplastic maxilla

· Clinical trial investigating mechanics to advance maxilla and close space

P: Class 1 / class 3 cases, non-extraction lower arch

I: Fixed appliances to close space in the upper arch

C: Nil

O: Maxillary advancement and inclination change in the upper arch

Method

· TADs in lower 3-4 region

· Class 3 elastics from TAD to upper 7s

Results

· Advancement of maxilla, SNA increase by 1.3o

· No changes to upper incisor inclination

· Mesial movement of upper molars 5mm

Conclusion

· Using treatment protocol, it is possible to advance the maxilla and close space for missing upper lateral incisors

Critique

· Side affects of counter clockwise rotation of maxilla

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Summary of webinar from the AAO, looking at lower incisor change and orthodontics

Expanding the Lower Arch Is it Really a Forbidden Frontier: Flavia Artese

· 4 indications to change lower incisor position:

1. Good profile with arch length discrepancy

2. Level lower arch curve of Spee

3. Class 3 dentoalveolar decompensation

4. Class 2 compensation

· 3 Factors which determine gingival recession for orthodontic patients

o Visible plaque – most important

o Amount of proclination – least understood

o Periodontal biotype / phenotype – can be altered

· 3 biotypes

o Thick -flat : Broad zone of KT, thick gingiva, square teeth

o Thick- scalloped: Narrow zone of KT, Thick gingiva, Slender teeth

o Thin – scalloped: Narrow one of KT, thin ginviva, triangular teeth

· Assessment of biotype

o Clinical, including probe to assess translucency

o CBCT

§ CBCT studies show greatest recession in Canine and Premolar region

Conclusion

o Avoid expanding / proclining lower arch, if required then indication for periodontal surgery

#orthodontics#farooqahmed#almuzian#morth#omg

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Mazyar Moshiri;s lecture from the AAO describes how to modify aligners and clinical pearls.

#orthodontics#orthodonticsmasterygroup#farooqahmed#almuzian#glasgoworthodonticacademy#morth#omg

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Modifications to consider to aligner

o Change attachment – changes tooth shape

o Change aligner shape – e.g. power ridge

o Change sequence of tooth movement

· Aligner force should be directed perpendicular to the resultant tooth movement required

· Vertical control is key

o if not can result in heavy anterior contact – curve of spee due to loss of vertical anchorage and a LATERAL OPENBITE

o Resolve with anterior intrusion

· Deep bite cases should be over treated to AOBs

· Clincheck is a force delivery representation, not a virtual treatment objective

· AOB cases

o Attachments on the occlusal aspect without composite, aids intrusion

· Class 3

o TADs in buccal shelf region

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Summary of webinar looking at 2 phase treatment 

Functional shift

· Should be treated early

· Use of RME, bonded to Es

· More stable expansion in younger patients

Crowding (mandibular arch)

· Should be treated in up to 5mm of crowding and patient concerns

· Use of leeway space

· Tool: Lingual arch

Overjet

· Treat if patients have concerns

· Preferred method 1 phase for growth and reduced treatment times

Class 3

· Treat if maxillary deficiency only

· Protraction face mask – limited improvement

· Least favourable interceptive treatment

Orthodontics #farooqahmed #morth  #glasgoworthodonticacademy 

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Summary of Nikhilesh Vaid's lecture at the AAO 2020 looking at technology in orthodontics.

orthodontic

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Summary of Chris Chan's lecture at the AAO, looking at TADs and their use.

Orthodontics #farooqahmed #morth #omg #glasgoworthodonticacademy #omg

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Summary of the webinar exploring the role of the occlusal plane and the aetiology of the malocclusion

orthodonticsinsummary

orthodontics

podcast

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