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 summary looking at remote monitoring in orthodontic clinical practice, and if it can improve, quicken and enhance orthodontic clinical practice. This podcast is based on an excellent webinar by Jonathan Sandler and Juan Carlos Varela, as part of the Angle-net webinar series. I discuss how Dental Monitoring works, the proposed advantages and a review of the emerging research on this innovation in orthodontics.  What is Dental Monitoring? AI software which assesses occlusal and dental changes through a series of intra-oral photographs taken by the patient using their smartphone  How does it work? Upload STL / digital study model Ai segmentation of teeth which maps digital study model to the photos Aligner fit analysis: Discrepancy between tooth surface and aligner fit  Either proceed, continue wear or see clinician Fixed appliances  Assess rate of movement and schedule appointment Other proposed benefits Oral hygiene assessment Breakages Retention changes What do patients think of it? Patients attitudes to remote monitoring 81% interested in reducing number of appointments due to telemonitoring – Dalessandri 2021 25% of patients found scans difficult to perform, with duration of scan 2-17 minutes Hansa 2020 Does it reduce appointments and make treatment quicker? Sangalli 2024 Decrease the number of in-office visits by 1.68–3.5 visits  No difference in treatment duration  No statistical reduction in emergency appointments Are treatment outcome better (aligners)?  No difference in tooth movements  Hansa 2021 No difference in number of refinements  Hansa 2021 PAR changes – no difference in quality of outcomes Jarad Marks 2024 Is oral health better?  DM reduced plaque scores Costi 2019 31% Improved hygiene  Manzo white paper Other innovations with remote monitoring? Remote STL files Scan taken without patient attending the practice  Scanbox  Formulate STL file and fit aligner in surgery Is Dental Monitoring accurate? Ferlito 2022 80% repeatability from 2 scans 44.7% repeatability and reproducibility  Discrepancy between scanbox and intra-oral scan varied between 0.5-1.9mm, angular measurements maximum error 8.9 degrees Conclusion 2-3 appointments less No difference in overall duration Some people struggle to use Accuracy and repeatability variable No difference in the quality of the outcome Areas which are of concern Unknown accuracy of occlusal assessments from a reliable retruded contact position Patient motivation maybe better delivered in person Ai environment cost 2-3% of energy used by data centres Other ways to reduce time? Diagnostic and treatment planning acumen Identify main aspect of malocclusion and address through efficient mechanics

“We do not accept the weaknesses of out appliances as absolutes, but rather we adjust out treatment mechanics to account for them Mazyar Moshiri, “If you are not willing you use elastics – you are not able to get finishing like braces” Mazyar Moshiri “We cannot have a reasonable discussion of efficacy and accuracy until we study the appliance as orthodontic clinicians, and not as scientists Mazyar Moshiri Join me for the first summary of 2025, exploring finishing with clear aligners. Mazyar Moshiri explores overcorrection with aligners, when they should be used and his protocol. It was a lecture from last year’s AAO winter meeting.. This episode consists of overcorrection methods of 4 malocclusions: deep bite, anterior openbite, class 3, and expansion. Maz also shares his pearls on what to watch out for when using clear aligners with overcorrection. EXTRAS: Mazyar Moshiri has kindly given permission for the summary slide of his overcorrection protocol to be included in the podcast notes, please see the podcast website https://orthoinsummary.com/ Overcorrection Deep bite - achieve AOB Over-intrusion lower incisors to achieve a 50-100% of total movement predicted Favourable if proclaining teeth, unfavourable if retroclining Use of attachments on premolars, note the hierarchy of attachment design places anchorage for anterior intrusion 5th, “Drs have to doctor the Clincheck”. Anterior openbite Posterior intrusion – overcorrect with occlusal bite blocks class 3 triangular elastics canine and premolars Force down on posterior bite blocks May require controlled relapse following overcorrection, done in refinement NOTE – aligners continuous force system, reciprocal extrusion of anterior teeth is expected Class 3 case Retract lower incisors with retromolar tads and 6 Oz 3’16th Side effect – increase in curve of spee – similar to retraction on a NiTi wire, aligner is not stiff enough to resist Correction in refinement with anterior intrusion to eliminate premature contacts, DO NOT EXTRUDE POSTERIOR TEETH, as aetilogy is anterior iatrogenic extrusion Expansion Overcorrection of 1-2 mm, greater the further posterior Attachments, plan buccal attachments +/- palatal attachments, to account for likely buccal tipping, ensuring buccal root torque and preventing palatal cusp dropping Tip: for palatal cusp dropping place occlusal attachment on the palatal cusp to prevent extrusion during expansion Caution – if already in buccal version, consider limited correction

“it's a platform for mass customization” “I think Lightforce system has more friction than it should right now.” “We operationalize great outcomes.” “People that need to have a Cochrane review to prove to themselves the sky is blue, those are not the people that should be using Lightforce right now” Alfred and I discuss his digital bonding system, Lightforce, we explore the product as well as the strength of the claims around it. Alfred replies to criticisms of the product as we explore the emerging evidence of his digital bonding system.  Alfred gives his opinion on the digital evolution within orthodontics, we have a candid discussion on the use of digital orthodontics and where there are still areas of significant improvement needed.

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