orthodontics In summary

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/

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

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 2. 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

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

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.

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

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.

Join me for a look at CBCT and its use in the diagnosis of the transverse problem, and if it offers the solution to the debated topic. The podcast is based on a lecture by Chun Hsi Chung at this year’s AAO and appraises established methods of assessment, the Curve of Wilson and the WALA ridge line through the lens of a CBCT, as well as how to use a CBCT to assess the maxilla and mandible, which although revealed an ideal measurement, may not be telling the full story. What is ideal? inclination  Curve of Wilson – CBCT study  Vertical distance buccal and lingual cusp, 1mm vertical difference  Buccal inclination upper 5 degrees Alkhatib 2017 Lingual inclination lower 12 degrees Alkhatib 2017 Andrews WALA ridge 2000 Bucco-lingual distance from crown ( FA point) to the most prominent portion of mandibular buccal alveolar bone (coincident with mucogingival junction) Hypothesised teeth over the basal bone , Glass 2019 1st molar = 2mm Ideal mandibular intermolar width FA – FA = WALA-WALA distance minus 4mm Normal width  CBCT CBCT age 13 N = 79 Miner 2012 Maxilla slightly smaller mid point molar root on lingual bone -1.22 +/- 2.91mm CBCT Age 22.7 years Koo 2017 Measure CoR furcation 1st molar Mx – Mn = -0.39+/- 1.87mm CBCT 56 adults normal occlusion  Lee 2022 PENN STUDY Buccal – buccal on crestal bone, furcation, 6s Lingual – lingual crestal furcation 6s Reliable reading on lingual aspect – buccal shelf bone prevents reliable readings Maxilla narrower than mandible -1 +/- 3mm Previous literature  Tamburrino 2010 describes  5mm cortical plate level of furcation buccal aspect, however Lee 2022 showed for males 1.1mm +/- 4.5mm and 1.6mm +/- 2.9mm Without cbct can transverse diagnosis occur? Models = lingual surface at furcation level (4mm vertical below gingival margin) maxillary width slightly narrower than mandible -2+/- 3mm Issue with CBCT for diagnosis Standard Deviation is large = +/- 3mm, range from -4mm-+2mm falls into SD Issue with study model transverse analysis from 4mm at the gingiva Not validated

Join me for a summary looking into the increasingly popular topic of paediatric obstructive sleep apnoea, a review of orthodontic treatments available, and how effective they are in this growing field of both medicine and dentistry. This episode is a summary of Alberto Capriglio’s lecture from the AAO and Carlos Flores Mir’s lecture at the IOF earlier this year.     OSA - Defined upper airway dysfunction causing complete or partial airway obstruction during sleep   Sleep = Slow wave sleep – constructive phase of sleep (recuperation of the mind) ·      Growth hormones secreted ·      Glial cells within brain restored ·      Cortical synapses increase in number – Moberget 2019   Outcomes to paediatric patients of SDB: (AASM) ·      delays in development,  Poor academic performance, Aggressive behaviour, attention- deficit/hyperactivity disorder, , emotional problems in adolescence   First line medical treatment – adenotonsillectomy  ·      40% residual  OSA       Effect palatal expansion 1.        Roof the mouth = base of the nose - Increase in nasal airway volume - Reduction in OSA, if obstruction in naso-pharynx, 2.        Short term reduction in OSA (not cure AASM) a.        20% improvement in AHI, 85% of cases Villa 2015 b.        15% got worse by 20% c.        57.5% residual AHI greater than 1 - not resolution 3.        Caprioglio 2019 long term AHI return to initial scores, from 7 to 5 long term 4.        Change in metabolism when combined with Vit D3 a.        Vit D3 with RME increases reduction in AHI, sustained long term, Caprioglio 2019 AHI 61.9% Vs 35.5% long term     Expansion other outcomes -  school performance  Bariani 2024 ·      AJODO – RME improves academic performance – o   BEHAVOUR 1 of 8 parameters improved only for academic performance  - change small 0.68 o   COGNITIVE 1 in 8 improve       Mandibular advancement Move mandible forwards and open space behind the tongue – oropharynx ·      Anatomical – increase size of oropharangeal airway ·      YAnyAn 2019 mandibular advancement for pOSA systematic review:  1.75 AHI reduction (CI) −2.07, −1.44) – modest change ·      However long term use required of the paediatric patient     Orofacial features in children with obstructive sleep apnea.  Fagundes Flores-Mir 2022 o   No craniofacial features specific to pOSA – ANB, o   However medical diagnosis through polysomnography may under-estimate incidence, o   Broader diagnosis such as snoring, may over-estimate OSA   AADSM 2024 – consensus statement ·      Expansion o   Prevention: No consensus o   Management: No consensus o   Cure: Insufficient ·      Mandibular advancement o   Prevention, management, cure – unclear   More about OSA? To hear more about OSA, please check out the last interview on orthodontics in interview with Sanjivan Kandasamy, where we had a deep dive into OSA and where we are in our understanding today from the research Interview with Sanjivan Kandasamy on OSA                          

Join me for a summary looking at The Posterior Bolton Discrepancy, a new take on the classic Bolton discrepancy. Wayne Bolton’s analysis has been critically appraised and the outcome from Patrick Foley and his team has been the formation of the posterior Bolton analysis, a new perspective on an established tool in orthodontics which seeks to give better insight into the location of tooth size discrepancies. He has also explored through his research the effects of premolar extractions and the likely outcomes of compromised occlusal outcomes, and where we should expect to see it within the posterior segment.     Wayne Bolton established the Bolton’s ratio: ·      Mesial distal widths of teeth ·      Original study 55  well treated cases ·      Anterior – ideal 77.2% ·      Overall 91.3% - Anterior tooth size discrepancy maybe masked by a compensatory posterior discrepancy   What is the posterior Bolton’s ratio ·      Not included in original study ·      Formular sum of mandibular 4s, 5s, 6s,/ maxillary 4s, 5s, 6s x 100 = 105.27% - data from original Bolton’s study   Ratio confirmed by Mongillo 2021 ·      N=55 patients ideal outcomes ·      Digital casts (from plaster) ·      Posterior ratio 105.77% +/- 1.99%   Vs Bolton’s data of 105.27%     The effect of 4 premolar extractions on the posterior Bolton ratio   Study: Mongillo 2021 (extraction of all 4s) Holton 2023 (extraction of upper 4s, lower 5s)   ·      Posterior Bolton increases 107% +/- 2.23% (or U4s and L5s 106.52 +/-  2.52%),  ideal digital removal of teeth ·      Observed Bolton’s was 110.48 % =  3.18% above Bolton’s ideal ·      Space of 1.1mm – 1.28mm remains in mandible when ideal arch – only 1 patient did not have space       Clinical options                                                                                              i.         compromise occlusion 1.        slightly class 3 molar and class 1 canine 2.        class 1 molar and  slightly class 2 canine                                                                                           ii.         IPR upper arch                                                                                        iii.         Bonding   ·      Anterior and posterior Bolton may be valuable in diagnosis and prediction than an overall Bolton                

 Join me for a look into a recent digital innovation within orthodontics, Lightforce. I explore how the 3D printed labial bracket system works, the features and what the proposed advantages. Recent research exploring the advantages of Lightforce is discussed as well as my comparison to other digital innovations within orthodontic appliances.   What is Lightforce   ·      Manufacturing: 3D printed brackets Cad/Cam ·      Material: ceramic polycrystalline labial ·      Planning: Digital planning using Lightplan, visualisation of the outcome, alter both tooth position and bracket position, individualise prescription per bracket as a result of planned movements ·      Flexibility in positioning:  Brackets do not have to be in the Facial Axis of the Clinical Crown, through altering the base thickness, the resulting moment can be achieved through the center of resistance ·      Torque expression is  independent of the vertical position,  for the same reasons ·      0.018", 0.020", and 0.022", including combinations   Stages 1.        Submit records 2.        Digital planning using lightplan, visualisation of the outcome,  3.        Case approval 4.        Indirect bonding tray – light-Tray, with brackets in situ   Other advantages ·      Accuracy of 3D printed slot ·      Adapted base, less adhesive ·      Minitubes, biteturbos   What are the proposed advantages and claims around Lightforce with evidence 1.        Shorter duration of treatment due to precision a.        JCO 2024 Wheeler 2024 Retropsectice study, 900 lightforces cases and over 300 conventional cases,  30% shorter and 30% fewer appointments. significant floors, with a lack of outcome measure and matching of controls Proposed advantages and claims around Lightforce ithout evidence   2.        Reduced complications white spot lesions, dehiscences and root resorption as relate to duration 3.        Remove issue of compliance or biomechanics as limitations to treatment outcomes   4.        Saving Doctors time and money, remove repositions 5.        Reduce or eliminate wire bends         What are my thoughts? ·      Labial fixed appliances are catching up with aligners and lingual appliances ·      New possibilities of varying biomechanics, slot size, bracket position and customised prescription ·      Presence of Lighforce features within other appliances: o   Customised brackets Insignia / Incognito o   Digital planning: aligners, Insignia ·      No customisation of archwires with Lightforce ·      Not sure how Lightforce would reduce appointment intervals, ligation is conventional ligation through elastomeric modules, with plastic deformation   Papers and videos on Lightforce https://www.jco-online.com/media/42415/2023_09_500_waldman.pdf   JCO retrospective study https://www.jco-online.com/media/43897/2024_05_273_wheeler.pdf   Youtube videos from Lightforce company, Alfred Griffin https://www.youtube.com/watch?v=zSNkYVgZ69I&t=2s&ab_channel=People%2BPractice   Disclaimer   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.   Contributions Contents and editing Farooq Ahmed        

Join me for a podcast summary looking at the effects of aligners when expansion occurs. In this podcast we will explore if bone loss occurs with expansion and why bone loss doesn’t necessarily cause recession. The podcast is based on the lecture and research by Greg Huang presented at this year’s AAO, and includes some more recent research on the topic     PICO Population adults, 22 maxillary arches, 20 mandibular arches Intervention – expansion with aligners, average 3.7mm Control – minimal expansion, average 0.6mm Outcome – bone height and width from CBCT   What was the bone loss?   Maxilla ·      Minimal bone loss ·      Minimal bone height and width change   Mandibular ·      Significant bone loss ·      1.5mm height mandibular centrals ·      1.4mm height premolars   What movement took place of the incisors? Maxilla ·      Little change in bucco-lingual inclination   Mandibular ·      Labial and buccal tipping increased   What were the overall changes?   Dental changes ·      3-4mm of expansion ·      Mainly  at premolars ·      Mainly buccal tipping, not bodily movement ·      Lower incisors procline   Similar bone loss with aligners expansion from other studies, Zhang 2023 , Allahham  2023   Should CBCT’s debate within the literature regarding voxel size of a CBCT and false negatives. Accuracy of alveolar height CBCT 2019 Yuan Li BA systematic review showed ·      CBCT Vs skulls/patients ·      Bone height 0.03mm ·      Bone width 0.11mm   My thoughts: no difference in cbct and gold standard, however the measurements were all of large structures, not bone height or thickness of less than the voxel size   Predict bone loss ·      Upper arch no predictors as limited changes ·      Lower arch, same as for fixed appliances, but the quantity was missing o   Proclination o   Expansion o   Buccal expansion and tipping   Systematic review of orthodontics 48 articles de Llano-Pérula 2023 ·      Proclination ·      Less keratinised tissue ·      Thin biotype ·      Prior recession ·      Crossbite ·      Previous recession ·      Age     Does bone loss = gingival recession? ·      Not generally found from Greg’s study ·      When significant bone loss of 3mm, far less than 3mm gingival recession     Significant retraction of upper incisors and intrusion Kim 2024. Loss of Palatal bone however in retention palatal bone recovered   Hypothesis ·      If PDL and periosteum are maintained  epithelium is maintained ·      If the root moves back into the bone, the bone recovers – as PDL and periosteum osteogenic, and tension generated between PDL and periosteum ·      PDL-periosteum hypothesis – proposed by Greg Huang   What I liked about Greg’s lecture was that he started with declaring his conflict of interest as an academic, both the royalties he receives for his books as well as research funding, which was great to hear and a trend I hope continues. Acknowledged the hard work of the research lead, his trainee and the  time-consuming process of orientating CBCT slices of 1000s of images

“Airways are like TMD controversy on steroids” “it amazes me we still think we can grow mandibles” “We have an appliance (expansion) and are trying to fit it into a diagnosis” “it is unethical to call yourself an airway orthodontist”     Sanjivan describes why there is controversy in airways and orthodontics, where the research stands on treatment with expansion and mandibular advancement, can mouth breathing cause adverse development, the effects of extractions on the airway, as well as ethics within current practice of airway orthodontics.       Click on the link below to view previous episodes, to refresh topics, pick up tricks and stay up to date.   YouTube https://youtu.be/m2NIp1XhnxQ     #orthodontics #farooqahmed #sanjivankandasamy #westaustralianorthodontics #airwayorthodontics #airway #OSA #SDB

Join me for a summary exploring an innovation of the use of bone-anchored plates in class 2 correction. This was a clinically novel idea presented by Hugo De Clerck, who has been an innovator in the use of bone-anchored plates and has published seminal papers on the topic for class 3 treatment. Hugo explores the use of bone-anchored plates in the mandible, combined with a Herbst appliance. He presents his data of 90 patients treated in Brussels by his research team. PROTOCOL Customised bone anchored plates in lower anterior mandible – digitally designed per patient with surgical guide Transmucosal between lower canine and 1st premolar Herbst: modified to attach from upper 1st molar to the lower bone anchored plates Procline upper incisors prior to fitting Bone anchored-Herbst Expansion of the upper arch 2-3 modifications to Herbst piston to lengthen during treatment Duration 10 months HOW DOES IT WORK Growth of the mandibular body: mainly, bone modelling. Average growth 5-7mm, whereas conventional herbst 2-2.5mm of chin projection. New growth of bone as ramus moves backwards, resulting in lengthening of the mandible Force generation: in similar to the conventional functional appliance, with contraction of medial and lateral pterygoid and stretching of the suprahyoid and temporalis muscle Lower incisor proclination: No lower incisor proclination: There is a distal force on the mandibular dentition instead of a forward force from conventional functional appliances, due to the appliance attaching to the mandibular body, not the dentition Condylar displacement: Longer duration, of up to 10 months which results in stimulation of growth of the body of the mandible, conventionally this stops with a herbst as the lower incisors procaine, resulting in only 2 months of condylar displacement and therefore less stimulation of growth Glenoid fossa remodelling. The glenoid fossa remodelled in a forwards direction, however it was small and unpredictable, with some posterior remodelling Rotation of mandible – similar to the conventional functional appliance, a posterior rotation reduces the effects, anterior rotation enhances, for every 1 degree 1.1mm increase projection. Achieve via expansion and removable appliance Upper molar distalisation: Hugo saw this as unfafourable and advised lengthening the herbst piston to reduce upper molar distalisation, therefore maximising mandibular lengthening Age 13-15 Not possible with miniscrews, due to the quantity of force Breakages of Herbst still occur Is growth maintained long term – unable to state No control as requirement for cbct of untreated patients. Contributions Contents: Farooq Ahmed Edited and produced: Farooq Ahmed

Join me for a summary looking into difficult movements with aligners, why they are difficult, and a protocol derived from research on how to manage tooth movements with aligners. This lecture was given by Bill Layman at this year’s AAO, where he describes maxillary incisor extrusion, posterior intrusion, and controlled expansion. Introduction ·       Rate of refinement: 2.5 per patient Kravitz 2022 ·       41% of aligner cases 3 refinements + ·       Switch to fixed appliances from aligners 1 in 6 Kravitz 2022 Staging and synergistic movements can reduce refinement rates Incisor extrusion Why is Incisor extrusion difficult? ·       Lack of undercut ·       Sqeeze teeth to engage, creating opposite effect due to V shape of a tooth – leading to loss of retention of the aligner ·       Interproximal binding through vertical contact point overlap or slipped contact points and a closed system of aligners Incisor extrusion staging steps: 1.     Create undercut: Horizontal attachments are most effective, regardless of design Groody 2023 2.     Create 0.1mm between teeth to relieve interproximal binding 3.     First procline the incisors to increase 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 during intrusion as an unwanted effect ·       What happens when we intrude: o   Mesial tipping of posterior teeth Fan 2022 Finite element o   Buccal and palatal attachments = less tipping buccal or lingual How to improve posterior intrusion ·       Sequential intrusion – 1st premolars ·       Tip posterior teeth 5-10 degrees distally ·       Horizontal attachment buccal / palatal ·       Consider attachment lingual Upper molars ·       Sequential intrusion ·       TADs not always needed, 5200 times bite 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 to exert forces = straight finish trays increase rigidity ·       Attempting to correct skeletal problems with dental solution ·       Greatest expansion in the premolar region ·       Expansion from the research showed progressive less posterior expansion o   Molars expand less due to anchorage 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: procline teeth with attachment, then extrude and retract o   Include iPR ·       Posterior intrusion: Start with premolars and sequentially intrude posterior teeth o   Add distal tip ·       Controlled expansion: Effective in premolar region o   Plan with overcorrection Jay Bowman ·       “If you don’t build-in overcorrections you can’t get corrections” ·       “there many things that need improvement at the end that aren’t hard to do if start treatment with the overcorrections in mind”   Contributions Contents: Shanyah Kapour Edited and produced: Farooq Ahmed        

Join me for a summary looking at fixed versus removable functional appliances. This podcast sheds light on recent research comparing the main two types of functional appliances, which appliance offers the most advantages, and what patients think about the two appliance types. This was a lecture given by Ama Johal at last year’s British Orthodontic Conference, where the most recent evidence carried out by his PhD student Moaiyad Pacha.      Moaiyad Pacha’s RCT 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 support but patient-centred ·      Overjet correction: More effective Herbst at 7mm Vs 5.8mm Twinblock , ·      Molar and skeletal changes: no difference o   Twinblock = greater residual overjet after treatment p=0.2 ·      Dental changes: Herbst advance lower incisor greater 3mm Vs 1mm ·      Failure to complete: 17% Herbst Vs 37% twin block o   3 times greater likelihood of discontinue treatment OR 2.8 ·      Treatment duration: longer with Twinblock 1.5 months 8.8 Vs 10.3, and quicker rate of correction with Herbst ·      Chairside time : Greater than Twinblock 2.7 hours longer, 7.6 Vs 4.9 ·      Emergency appointments greater with Hanks Herbst 2.7 Vs 0.3 o   Herbst mainly ·      Severe complications = same 0.5 o   Severe complications – previously defined as involving lab work or break in appliance wear from Pasha’s SR 2020     Advantage of Hanks Herbst ·      Greater completion of treatment, 3 times less likely to discontinue ·      Quicker rate of correction, shorter duration,   Disadvantages ·      Greater chairside time of nearly 3 hours ·      Greater emergency appointments, each patient needing 2-3 emergency appointments   Qualitative ·      Both appliances – very negative to QoL and daily life ·      Aesthetic and self-image – worse with Twinblock ·      Patient preference – Herbst o   Due to non-compliance and likely to get to the end ·      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 both discussing of clinician Vs patient preferences,  should decide which appliance

Join me for a summary podcast exploring the topic of white spot lesions, and up-to-date research looking at how to manage lesions when they occur, when the right time is to treat the patient, and what minimally evasive options can be used in clinic.  This was an excellent lecture from Gayle Glenn earlier this year at the AAO winter meeting.   Four treatment options are discussed, Fluoride, CPPACP (Mi paste), resin infiltrate and microabrasion.   Whitespot lesion background WSL Definition - subsurface deminieralization, intact outer layer, 1st sign of carious lesions   Remineralisation – no additional agents Most rapid repair first 6 weeks without use of additional agents ·      Up to 6 months spontaneous improvement with good oral hygiene ·      Recommend 3-6 months monitor after debond:  BEFORE consider additional treatment   Fluoride ·      Decrease enamel dissolution ·      Increase reminerazation ·      Formation of fluorapatite ·      Products o   Fl varnish reduce WSL occuring by 44%: §  require plaque removal and wire removal §  Not often used in clinical practice and requires repeat application ·      TREATMENT WSL o   Fluoride low dose (toothpaste) o   High Fluoride – hyperminerasied surface layer forms = 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 demineralisation may 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 sustematic reviews AlBukaiki 2023 no difference,  same year Jiang 2023, it is effective, however exceptionally large range of values (RR:49.69, 95%CI: 0.87-98.51 and although RCTs, limited to assessing premolars 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 particle size, 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 slow handpiece o   1 minute ·      Not widely accepted o   Partly due to variations in protocol o   Use of rubber dam ·      Microabrasion and CPP-ACP proposed idea Ardu 2007     2022 Lammert ·      CPP-ACP both sides, with half of mouth also receiving 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 – 4.3 and reduce to 2.1 ·      Most improvement immediate after microabrasion o   Compared difference of size of the initial lesion §  5.5 x reduction in CPPACP §  7.4 X reduction 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 §  Perhaps isolated 1 or 2 teeth Conclusions: 1.    Patients with WSL are usually not great compliers, giving additional products which require significant compliance, is practising research in isolation. 2.    Microabrasion takes nearly 1 hour, role in clinical practice limited to isolated areas

Join me for a summary exploring bullying and its relationship with malocclusion, with a contemporary review of evidence showing the psychological effects various malocclusions can cause young people. This podcast is a summary of Andrew DiBiase’s lecture last year at the British Orthodontic Conference. Andrew’s research explores what factors moderate bullying, and what factors can be protective against bullying.     Introduction   ·      Nearly 1 in 3 patients report teasing or fear of teasing as a motivating factor for orthodontic treatment Bauss 2023 AJODO ·      1 in 7 patients attending our clinics are bullied 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 on the 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 Langlois 2000 o   80% verbal - Cyber bullying – doest stop at the school 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 occupying the 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 bullying Dibiase,   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 severe malocclusion ·      Schoolchildren who report being bothered by their teeth report being lonelier at school and lower self-esteem ·      Malocclusion has a greater impact on females than males ·      Malocclusion and peer relations is moderated by self-esteem in girls, but not boys ·      Good peer relations protect against the negative impact of malocclusion in girls with low or average self-esteem            

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!

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