Afleveringen

  • 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

  • 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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    Klik hier om de feed te vernieuwen.

  • 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

  • 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:

    Effective communication with our patients, with visual aid, pictures or movies.

    Using of tracking sensor included in the device

    Using some reminding tools – remote monitoringBiomechanics and material properties.Distalisation class 2Incisors intrusionConclusion

    We need to consider the lines of forces and aligner deformation not only on the attachments

    Any malocclusion that can be corrected by tipping has better predictability

    Add less activation Per aligner (to help flattening the steep decline in force over time and create consistent and continuous force system)

    Attachment driven mechanics are not always effective, aligner Activation is more effective

    Graphy is the trending technology in aligner activation

  • 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

    2. 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

  • 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

  • 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

  • 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

    Mouth breathing

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

    Retrusive mandible -1.4 (SNB -2.20—0.6) Zhang 2020 SR

    Increased mandibular angle 3.38o (2.77-3.98)

    But is mouth breathing pathological?

    pOSA

    no craniofacial difference in pOSA vs controls SR Fagundes 2022

    Recent study by Carlos Flores Mir, combine factors

    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

  • Orthodontics In Interview GUEST HOST Björn Ludwig with Ralf Radlanski

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

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

    YouTube

    https://youtu.be/vcAzjWa507Y

    #bjornjudwig

    #ralfradlanski

    #IOSmoselle23

    #orthodonticsinsummary

    #orthodonticsininterview

    Instagram: https://www.instagram.com/bjoernludwig1

    Facebook: https://www.facebook.com/bjorn.ludwig.961

    @bjoernludwig1

    @bjorn.ludwig.961

  • 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



  • 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:

    Eruptive potential

    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)



  • 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.

  • 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

  • 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

  • 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.

    Vibrational mechanical

    Low magnitude / high frequency, used for 20 minutes per day 25g at 30Hz/ 50 Hz,

    Canine retraction: 30Hz NS, 50Hz 15% quicker, Significant but not clinically

    No increase in root resorption - split mouth study, except for 50Hz, reduced RRRR Tan 2011, Yilmaz 2021

    Photobiomodulation (PBM)

    Low level laser therapy: LED device used for 20-30 minutes her day

    Tooth movement increase rate of 1.73mm over 2-3 months Yavagal 2021 SR

    Root resorption no difference Sambevski 2022

    Minisurgery: Piezocision/ Micro-osteperforation(MOP)

    Piesocision – series of vertical bone cuts of 2-3mm depth vary lengths, Vs MOP – round punctures of 2-3mm depth. With or without flaps.

    The movements were twice as fast (Lino et al 2017, Cho et al 2007, Mostafa et al 2009)

    But limited duration of effect Buschang 2010

    Peak at around 3-4 weeks

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

    Root resorption Patterson 2017

    Peizocision and MOP produced significantly (44% / 42%) MORE root resorption.

    Peizocision 36% additional iatrogenic damage (performed by periodontist)

    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:

    Wrong diagnosis

    Wrong mechanics

    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

  • 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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    Instagram:  www.instagram.com/tadman.de/

    Facebook: www.facebook.com/benedict.wilmes

    @tadman.de

    @benedict.wilmes

    Farooq Ahmed

  • 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

    2. 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

    3. 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

    4. 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

    5. 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

    https://www.justgiving.com/fundraising/farooq-ahmed5

  • 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

  • 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

  • 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