Orthodontic Practice US July/Aug 2020 Vol 11 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews July/August 2020 – Vol 11 No 4 • orthopracticeus.com

PROMOTING EXCELLENCE IN ORTHODONTICS Treatment and delivery methods for myofunctional therapy

Lifetime effects of mouth breathing Michael Flanell, RDH, MBA

Nicole Cavalea, MS

Idiopathic condylar resorption: a case report Dr. Bradford Edgren

Practice Profile

Bandeen Orthodontics and Center for Dental Sleep Medicine

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EDITORIAL ADVISORS

A new approach for a new normal: better treatment, fewer office visits

Lisa Alvetro, DDS, MSD Daniel Bills, DMD, MS Robert E. Binder, DMD S. Jay Bowman, DMD, MSD Stanley Braun, DDS, MME, FACD Gary P. Brigham, DDS, MSD George J. Cisneros, DMD, MMSc Jason B. Cope, DDS, PhD Neil Counihan, BDS, CERT Orth Bradford N. Edgren, DDS, MS, FACD Eric R. Gheewalla, DMD, BS Dan Grauer, DDS, Morth, MS Mark G. Hans, DDS, MSD William (Bill) Harrell, Jr, DMD John L. Hayes, DMD, MBA Paul Humber, BDS, LDS RCS, DipMCS Laurence Jerrold, DDS, JD, ABO Chung H. Kau, BDS, MScD, MBA, PhD, MOrth, FDS, FFD, FAMS Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Andrew McCance, BDS, PhD, MSc, FDSRCPS, MOrth RCS, DOrth RCS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Atif Qureshi, BDS Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD (Abstract Editor) Lou Shuman, DMD, CAGS Scott A. Soderquist, DDS, MS John Voudouris (Hon) DDS, DOrth, MScD Neil M. Warshawsky, DDS, MS, PC John White, DDS, MSD Larry W. White, DDS, MSD, FACD CE QUALITY ASSURANCE ADVISORY BOARD Dr. Alexandra Day BDS, VT

vercoming COVID-19 and getting back to work is a challenge that we all face together. As communities, we are missing each other. As doctors and business owners, we are eager to be back in the office doing what we love. Maybe this time has given you a deeper appreciation for your career, or maybe it has given you a deeper appreciation for your master chef husband and house full of children! This pandemic has presented several unexpected obstacles and changing patient priorities. But this is what we, as orthodontists, are made for. We are made for change. We are made for innovation. We are made to adapt. At Minnesota Orthodontics, Dr. Regina Blevins we are embracing a new way of doing business and are looking toward the future. So, where to begin? With 13 locations, reviewing logistics and securing proper PPE and in-office protocols are no small tasks. Getting through our backlog of overdue patient appointments initially seemed daunting. The first thing that we tackled was our jump to virtual consultations and check-ins. We had been preparing to move to a more digital format for some time, and COVID-19 gave us the final push. We are grateful for technology that allows patients to send us photo updates, enabling us to execute virtual patient monitoring while maintaining a high standard of care. Another technology that’s proven to be essential during this time is Propel’s VPro™ high-frequency vibration device. It has been a part of our practice for many years, but now its value during this new normal is only increasing. Our patients use the VPro for 5 minutes a day to increase comfort, to accelerate treatment, and most importantly, during the extended time out of the office, to ensure that aligners are tracking. Propel’s VPro vibration device offers a solution that fits perfectly into our new virtual landscape. To keep patients and staff safe, as well as to comply with local social-distancing regulations, we prescribe VPro to reduce office visits. To manage the inevitable overflow and backlog of patients that need care, we prescribe VPro to jump-start treatment and deliver on treatment goals. To manage patients who have been less compliant during this understandably frustrating time, we prescribe VPro to ease resulting discomfort and get treatment back on track. From predictability to comfort, VPro is still our go-to, and it’s clear that patients value our support and expertise. Just as it’s important to find the right mix of team members to create a more perfect synergy, it’s important to find the right mix of tools so that we can deliver our best work. COVID-19 has made all of us proactive in our search for those tools. We’re confident that we will emerge from this hardship stronger, more thoughtful, and more efficient than before, and we have an unlikely cause to thank for it.

Julian English BA (Hons), editorial director FMC Dr. Paul Langmaid CBE, BDS, ex chief dental officer to the Government for Wales

Dr. Regina Blevins

Dr. Ellis Paul BDS, LDS, FFGDP (UK), FICD, editor-inchief Private Dentistry Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

© FMC 2020. All rights reserved. The publisher’s written consent must be obtained before any part of this publication may be reproduced in any form whatsoever, including photocopies and information retrieval systems. While every care has been taken in the preparation of this magazine, the publisher cannot be held responsible for the accuracy of the information printed herein, or in any consequence arising from it. The views expressed herein are those of the author(s) and not necessarily the opinion of either Orthodontic Practice US or the publisher.

Regina Blevins, DDS, MS, started her career in dentistry in 1980 as a Dental Hygiene graduate of Charles Stewart Mott Community College. She attended the University of Michigan, where she received her degree in dentistry in 1987. Her appreciation and love for the fine art of the cosmetic side of dentistry led her to pursue her orthodontic graduate training at the University of Minnesota, where she received her Master of Science degree and a certificate in orthodontics in 1991. Dr. Blevins enjoys staying up-to-date on the latest developments in orthodontics by maintaining a rigorous continuing education schedule. When she is out of the office, Dr. Blevins enjoys living an active lifestyle and spending time with her husband, Tom, and their four children: Noah, Rachel, Lucy, and Will. As a family, they enjoy doing yoga, Taekwondo (Dr. Blevins is a black belt!), and spending time in their backyard cooking, gardening, and relaxing. Dr. Blevins is an active member in her community and enjoys giving back to those who bring her so much happiness.

ISSN number 2372-8396

Volume 11 Number 4

Orthodontic practice 1

INTRODUCTION

July/Aug 2020 - Volume 11 Number 4

TABLE OF CONTENTS

Publisherâ&#x20AC;&#x2122;s perspective Thoughts of business health, optimism, clarity, and prosperity Lisa Moler, Founder/CEO, MedMark Media................................6

Practice profile

Bandeen Orthodontics and Center for Dental Sleep Medicine Drs. Timothy and Emily Bandeen bring beautiful smiles and peaceful sleep to patients

Book review Evidence-Based Clinical Orthodontics Edited by Drs. Peter G. Miles, Daniel J. Rinchuse, and Donald J. Rinchuse, 2012, Quintessence Publishing Company........................................17

Case study Fewer office visits using highfrequency vibration to close an anterior open bite Dr. Esther Feldman ponders what came first, the open bite or the habit? .......................................................18

Case report

Case study Simple treatment mechanics for a highly esthetic result Drs. Todd Bovenizer and Christopher Baker discuss brackets that offered precise control for efficient treatment

2 Orthodontic practice

Idiopathic condylar resorption: a case report Dr. Bradford Edgren illustrates a patient with dysfunctional remodeling of the condyle..................................20

Volume 11 Number 4

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TABLE OF CONTENTS

Continuing education Lifetime effects of mouth breathing Michael Flanell, RDH, MBA, discusses mouth breathing and how clinicians can help patients make informed decisions regarding treatment .......................................................28

Step-by-step Perfect band transfer and appliance every time using Aquaform

Continuing education

Treatment and delivery methods for myofunctional therapy

Nicole Cavalea, MS, discusses co-treatment goals of myofunctional therapy

Dr. Lloyd Taylor presents the complete Aquaform transfer technique...........35

Technology Diagnosis and treatment plan of maxillary impacted canines using CBCT DICOM data

Practice management Service profile

Drs. Laura Nicolas, Alberto Teramoto, and Manuel Hinojosa discuss how segmentation can provide an essential diagnostic function......................... 36

Dr. Amy B. Jackson offers guidance on how to leave a time of uncertainty and get on the path to profitability .......................................................38

The power of efficiency

The clock is ticking on practice values Chip Fichtner discusses how to grow a practice bigger, better, and faster .......................................................40

www.orthopracticeus.com READ the latest industry news and business WATCH DocTalk Dental video interviews with KOLs LEARN through live and archived webinars RECEIVE news and event updates in your inbox by registering for our eNewsletter

CONNECT with us on social media Connect. Be Seen. Grow. Succeed. | www.medmarkmedia.com

4 Orthodontic practice

Volume 11 Number 4

PUBLISHER’S PERSPECTIVE

Thoughts of business health, optimism, clarity, and prosperity

s I write this message, COVID-19 is still driving many of the operational aspects of the dental office, and dentists are trying to navigate the challenges and restrictions related to maintaining safety and health. Recently, I attended the ADA’s press conference on reopening — a meeting that gathered dental leaders to discuss CDC guidelines, dentists’ concerns, and the ADA’s direction on how to navigate with “cautious optimism” out of this crisis. Seeing these visionaries of the dental community all working to provide information and guidance to their peers empowered us at MedMark Media as well to work even harder to be an advocate for the dental community. In these times, when it seems we are reinventing dentistry Lisa Moler Founder/Publisher, MedMark Media to accommodate new and evolving needs, we need to call upon the strengths and creativity that have navigated us out of other very difficult times in our lives and our careers. As different types of information swirl around us on the news, on social media, and in our own social circles, it is important to keep the team informed and involved in the decisions that will affect their health and safety. Keep those team meetings ongoing, so the team is aware of your consistent support. Formulate and be proactive on what steps will be taken if a team member is exposed to the virus, or if a patient with COVID-19 has entered your office. Now is the time to use your social media to show patients your dedication to a safe environment for them and your staff. Keep them apprised of your technologies that will offer them the most comprehensive care, even after COVID-19 abates and life returns to the “new normal.” Take a look at all of the telehealth options that are possible for the dental practice. This tool can be useful for prescreening patients, as well as scheduling and check-in, to reduce the amount of people at your front desk or in your waiting rooms. Make sure that you have clear instructions on your online presence as well as in the waiting area and any area that requires social distancing or face masks. And be clear on when face masks are required in your office (for example, removing the mask in the operatory and putting it back on when leaving the room or in the presence of others). In this issue, we continue to provide articles on subjects that can expand your orthodontic practice far into the future. With myofunctional therapy as an increasingly popular tool in the orthodontic office, the CE by Michael Flanell, RDH, MBA, discusses the lifetime effects of mouth breathing and ways to help patients make informed decisions on myofuctional therapy-related treatment. Nicole Cavalea, MS, further delves into myofunctional therapy and its delivery methods for co-treatment between orthodontist and myofunctional therapist. Dr. Bradford Edgren shares an interesting case regarding idiopathic resorption, and Drs. Laura Nicolas and Alberto Teramoto show how adding the third dimension of CBCT data can result in an improved diagnostic approach and treatment outcome. During COVID-19 and after, we strive to keep bringing you ideas and information for clinical and business aspects of your practice. Wishing you and your business health, optimism, clarity, and prosperity in these everchanging moments we are all facing. To your best success! Lisa Moler Founder/Publisher MedMark Media

6 Orthodontic practice

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA mali@medmarkmedia.com | Tel: (727) 515-5118 ASSISTANT EDITOR Elizabeth Romanek betty@medmarkmedia.com MANAGER CLIENT SERVICES/SALES Adrienne Good agood@medmarkmedia.com CREATIVE DIRECTOR/PRODUCTION MANAGER Amanda Culver amanda@medmarkmedia.com MARKETING & DIGITAL STRATEGY Amzi Koury amzi@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez medmarkmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com

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Volume 11 Number 4

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PRACTICE PROFILE

Bandeen Orthodontics and Center for Dental Sleep Medicine Drs. Timothy and Emily Bandeen bring beautiful smiles and peaceful sleep to patients What can you tell us about your backgrounds? Dr. Timothy Bandeen took over Bandeen Orthodontics in Battle Creek, Michigan, from his father, Dr. Roger Bandeen, in 2006. In late 2009, Dr. Emily Bandeen became a part of Bandeen Orthodontics. Dr. Emily Bandeen is a general dentist from Chattanooga, Tennessee. She attended the University of Richmond where she graduated with a BA in Religious Studies with a concentration in ethics and a minor in biology. She then went to The University of Tennessee College of Dentistry where she earned her DDS in 2006. Dr. Timothy Bandeen attended Central Michigan University for his undergraduate degree in Biology and then went on to complete his DDS from the University of Michigan. Dr. Timothy completed his orthodontic residency and MS at The University of Tennessee. The two doctors met while attending The University of Tennessee, and they married during their second year there. After graduation, the couple moved to Battle Creek, Michigan. They now have three locations in southwest Michigan: Battle Creek, Kalamazoo, and Three Rivers. In addition to working as doctors at Bandeen Orthodontics, both Dr. Timothy and Dr. Emily are

Drs. Timothy and Emily Bandeen

active in the community through church and through their side business, Cereal City Athletics. They host triathlons, half marathons, and other running and multisport events in their area.

Is your practice limited solely to orthodontics, or do you practice other types of dentistry? Bandeen Orthodontics has been practicing modern orthodontic techniques for over a decade to make treatment at our office simplified and streamlined. We embrace technology, but we try very hard not to fall into gimmicks, so we utilize only technology 8 Orthodontic practice

Volume 11 Number 4

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PRACTICE PROFILE to make our practice better. For the past 11 years, we have been using custom digital systems to improve our patients’ care — for example, systems such as Insignia™ Custom Smile Design™ for braces, and Invisalign® and Spark™ for aligners. We are so passionate about this practice philosophy that we have helped train and educate others on the process of Insignia™ (Ormco Corporation) around our country and internationally as well. In 2015, we decided to delve into the world of dental sleep medicine. We were having a conversation with our triathlete buddy, Chris Gillette, about his experience as a registered polysomnographic technologist working for many years in a sleep lab. More and more we were hearing the subject of obstructive sleep apnea (OSA) coming up in conferences and courses. We wanted to know what more we could do in our practice to treat sleep apnea. We hired Gillette as our director of dental sleep medicine and changed our practice name to Bandeen Orthodontics and Center for Dental Sleep Medicine. Over that next year, we developed our complete care model that not only fit patients for sleep apnea appliances, but also provided follow-up care to ensure that their sleep apnea was being treated as well as possible. We felt as though we had a great plan in place, but to execute the plan was more difficult. We tried multiple different “popular” appliances but never really felt satisfied with the products we were using. After countless hours in our lab, Gillette developed a sleep apnea appliance that rose above all the others in its simplicity, its superior fit, and its decreased tendency to cause secondary problems (bite issues and TMJ discomfort). The Bfit™ Sleep appliance was

Bandeen use of technology includes digital scanners and the i-CAT™ FLX

born. We patented our appliance and set out to gain FDA approval. As of April 2020, we’ve been FDA approved, separated Bfit Sleep out as a distinct company from our orthodontic practice, and are now able to sell the appliance to other offices around the country and around the world.

What is the most satisfying aspect of your practice? The most satisfying aspect of practicing both orthodontics and dental sleep medicine is that we don’t have to compromise what matters most to us — providing state-ofthe-art care for our patients. We work for ourselves, so we get to set our own rules, our own core values. Our mission is to “provide beautiful smiles to our patients by providing them excellent care with the most up-to-date techniques and technology.” We can indulge in the cool factor of all the latest tech gadgets, such as digital scanners and 3D printers, and put them to good use for improving our patients’ experiences and outcomes. If we worked for a corporation or a clinic, we wouldn’t have those choices. We would be beholden to the bottom-line as

Chris Gillette, director of dental sleep medicine, discussing the Bfit Sleep Appliance with a patient 10 Orthodontic practice

put forth by a board of directors. As leaders of our own clinic, we can put our patients first with the kind of care and experience that we enjoy providing.

Professionally, what are you most proud of? As a practice, we couldn’t be happier that we finally completed the arduous task of getting an FDA-approved sleep appliance (the Bfit Sleep appliance). When we started venturing into the realm of dental sleep medicine, we knew we didn’t want to go halfway. We hired a sleep technologist right from the start to help direct the path that our obstructive sleep apnea patients would take. We made contacts with our local sleep physicians and began the hard work of integrating a new demographic into our practice. We promised our team that deliveries of these appliances would be just like retainer deliveries — just as they were used to doing all day, every day. Day after day and appliance after appliance, it became clear that we weren’t able to keep that promise to our team without making something change from the typical appliances that had been available. The previous appliances that we were delivering to our patients were requiring hours of adjustments and chair time, and our team and our patients were frustrated with the status quo. When we honed in on the problem set we were encountering with those appliances, we were able to create our own solution:

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PRACTICE PROFILE

Top 10 favorites Bandeen Orthodontics team

our Bfit Sleep appliance. We’ve been using our own Bfit Sleep appliance for years for our own patients, and we can finally offer that solution to dental and orthodontic offices around the country — to whoever wants a stress-free approach to treat sleep apnea patients (getabfit.com). With our new appliance, we are able to keep that promise to our team for an easy in-office delivery. Once we knew how great our appliance was fitting and working for our sleep apnea patients, we went back through our patient list and offered them all the opportunity to switch to a Bfit Sleep without cost to them. Now each of our sleep apnea patients wears a Bfit Sleep appliance.

Do your patients come through referrals? The majority of our patients come through referrals from our sleep physicians. They may have patients who can’t tolerate a CPAP machine, or who have mild-tomoderate sleep apnea. An oral appliance is a great alternative to CPAP for these patients. We also have some sleep apnea patients that have heard about us from other Bfit users, and they’ve sent their friends in to get an oral appliance. Of course, sleep apnea is a medical diagnosis, and we have to include the physicians in any treatment we provide.

What advice would you give someone starting out in dental sleep medicine? How do you eat an elephant? One bite at a time. Integrating a new department of your practice is hard work. The most important 12 Orthodontic practice

1. Bfit™ Sleep Oral Appliance 2. Insignia™ custom smile design (Ormco) 3. Damon® System braces 4. Spark Aligners (Ormco) 5. 3Shape TRIOS® intraoral scanner 6. CraftBot printer by Craftunique 7. MediByte home sleep testing unit Braebon Medical 8. DentiTrac by Braebon Medical 9. 3Shape OrthoAnalyzer™ 10. i-CAT™

aspect for us was to make sure we were all in. You can’t dip your toe in the dental sleep medicine pool and expect it to go smoothly for you. You have to show commitment to your team and lead them through all the changes. You have to show commitment to your potential patients that you aren’t just trying something out on a whim but, rather, that you are sincere in providing quality treatment for each and every one of them.

What are your top tips for maintaining a successful specialty practice? Every practice has its own identity, and ours is based upon the patient’s experience. We established our core values as a practice, and we hung them on the wall for anyone to see. When there is a decision to be made, we go back to our core values and make a decision based on if it upholds those values. When there is an opening in our team, we interview based on those core values. When there is a new hire, we train based on those core values. When patients can feel that consistency, they feel that you’ve taken care of them well, and they continue to support you.

The Bandeen family out kayaking and mountain biking

What are your hobbies, and what do you do in your spare time? We have four kids: a 13-year-old daughter, an 11-year-old son, an 8-year-old son, and a 5-year-old daughter. We love being active with them and promoting community. Our kids are in Tae Kwon Do, play soccer, and swim on their own individual teams, but we also try and do activities together. Through our side business, Cereal City Athletics, we host some running events, a triathlon, and youth triathlon in our community. Our kids all take part in training and competing in those events with us. During this time of quarantine, we’ve loved being able to get out and kayak on our river, and we’ve taken up the sport of mountain biking with our fat-tire bikes. We love camping and being outdoors, and thankfully, those opportunities are still available to us even in the middle of a pandemic. OP Volume 11 Number 4

CASE STUDY

Simple treatment mechanics for a highly esthetic result Drs. Todd Bovenizer and Christopher Baker discuss brackets that offered precise control for efficient treatment

s we reopen our offices, treatment efficiency will be more important than ever. If we can get patients out of treatment faster and in fewer visits, we will be able to keep our patients, our staff, and their families safe while maximizing our practice throughput. The excellent control that the Damon Q2 bracket provides, due to enhanced rotation control and variable torque brackets, is helping to significantly improve our practice efficiency. The following simple case that we all encounter illustrates how effective bracket prescription and stainless steel (SS) mechanics can drive good results and efficiency. We achieve that efficiency by selecting the proper variable torque Damon Q2 brackets, using bite turbos to disarticulate the occlusion, prescribing early light elastics, and of course, using high-tech copper nickel-titanium archwires. All of this is done using simple treatment mechanics, resulting in a highly efficient esthetic finish, and making sure that the health and safety of the patient is paramount. Patient “RH” presented to our office at a young age when we applied tongue tamers to aid in correct tongue position. She was in our growth and development program until comprehensive care started. Our biggest concern was the open-bite tendency and exacerbating this with treatment as we often can do. We therefore estimated 16 to 18 months of total treatment time.

Diagnosis RH was 13½ years old when we initiated orthodontic care. We prefer permanent dentition, including 12-year molars, and we like

Figure 1: Initial photos, ceph, and pan

Todd Bovenizer, DDS, graduated from Virginia Tech with his Bachelor of Science in Biology and from West Virginia with his Master’s in Orthodontics and Doctor of Dental Surgery. He is a Board-certified orthodontist from the American Board of Orthodontics. Dr. Bovenizer is part of Damon’s Mentor Program and lectures nationally on the Damon® System. He serves on the Ormco™ Insider’s Group Product Development Team, where he meets with top clinicians to discuss product research and development. Outside of orthodontics, Dr. Bovenizer spends his time with his wife, Megan, and their three wonderful young girls. Christopher Baker, DDS, is a Board-certified orthodontist from the American Board of Orthodontics. He serves as Vice President of the North Carolina Association of Orthodontists and is the North Carolina Political Outreach Leader for the American Association of Orthodontists Political Action Committee (AAOPAC). His father is a retired orthodontist and previously had practices in southern Indiana and Hilton Head Island, South Carolina. Dr. Baker and his wife, Brooke, have two sons, Cooper and Cruz Duke. When not doing orthodontics or working on patients, the Bakers love traveling, especially around the islands of the Caribbean. Disclosure: Dr. Bovenizer is a paid consultant for Ormco™.

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Volume 11 Number 4

Objectives One of our top treatment goals was to increase the inter-incisal angle by uprighting the patient’s incisors and therefore gaining more overbite for functional anterior guidance.

Case progression Figure 2: After bonding photos

Figure 3: Progress photos and pan Volume 11 Number 4

Appointment 1: We selected our variable torque prescription with our treatment goals in mind. We bonded her U/L 6-6 with low-torque Damon Q2 on the maxillary and mandibular incisors. We placed bite turbos on the mandibular 6s, placed 0.014 CuNiTi wires, and began Quail delta elastics and an anterior box with a Parrot (Ormco Zoo Pack Elastics). Appointment 2: 10 weeks into treatment, we bonded U/L 7s and placed 0.018 CuNiTi wire and kept same elastic pattern. Appointment 3: 4 months into treatment, we placed U/L 0.14 x 0.025 CuNiTi, kept same elastics, and scheduled progress pan and repositions for 8 weeks out. Appointment 4: 6 months into treatment, no repositions were deemed necessary, and we moved into stainless steel (SS) wires: 0.19 x 0.025 SS on upper and 0.16 x 0.025 SS on lower. Trillium hooks were placed on the wire, and tiebacks were used to keep space closed. One elastic was used — an anterior box with a Zebra (Ormco Zoo Elastics) tied to the posts and not the teeth on the maxillary wire. Take note here that the patient’s overbite was not sufficient, and the incisors were still a little proclined. Our plan was to manipulate her wires by expanding the posterior to upright the anterior. We also planned interproximal reduction (IPR) with sling chain to aid in uprighting the incisors. Appointment 5-8: Manipulation of the wires to expand and IPR with sling chain (power chain run under the wire and to torque the incisors in under the brackets in the anterior). We did not bend wire in these detailing appointments. We used an archwire grid from Ormco at each SS wire appointment. The doctors coordinated, expanded, and contracted the wires as needed, based on Orthodontic practice 15

CASE STUDY

to treat during adolescence to utilize growth when needed. She presented with a Class I skeletal and dental. There was mild maxillary and moderate mandibular crowding. She had minimal overbite and mild overjet. Again, our biggest concern was the openbite tendency, and to further complicate this, her maxillary and mandibular incisors were proclined slightly.

CASE STUDY clinical observations. IPR was completed once on the lower 2-2. We used a settling elastic protocol with Kangaroo elastics 3/16, 4 oz. (Ormco Zoo Pack Elastics). Appointment 9: 12 months into treatment — debond, removal of appliances.

Summary

Figure 4: Progress photos

We have really enjoyed the increased control of the Damon Q2 appliances. We have always enjoyed the passive self-ligation for early light elastics and arch from development. There is also a degree of “slop” that we have always appreciated when interdigitating the teeth together. That was why we finished in a lower 0.16 x 0.025 SS. The photos presented here were the actual photos taken at debond, which is what we always do. They display how the orthodontist was able to finish the occlusion. With patient RH, we enjoyed that little bit of extra control in how we were able to control the maxillary and mandibular incisor position. We were very pleased with the overbite for anterior guidance and also the inter-incisal angle that was controlled with treatment. Lastly, this treatment took us nine appointments from start to finish. The majority of these appointments occurred in SS wires.

Conclusion We have successfully addressed the patient’s chief complaint for seeking treatment and have exceeded our treatment objectives for the case. Most surprising to us was the treatment time of 12 months. This was 4 to 5 months ahead of anticipated finish. We attribute this to the efficiencies that the Damon Q2 bracket brings to our practice, allowing us to achieve excellent rotational control for improved precision, predictability, and reliability. Using variable torque options with the Damon Q2 bracket reduces our total treatment time and overall appointments, because it allows for quicker coupling and when chosen correctly can make up for the “slop” that all brackets exhibit in the slot. We pick the appropriate torque during treatment planning when we forecast the impacts of our treatment mechanics. Picking the appropriate torque at the outset allows us to stay out of poor torque situations that will need to be corrected later in treatment. Overall, the Damon Q2 bracket allows us to treat cases with the precise control we require, so we can finish cases efficiently while using simple mechanics. OP Figure 5: Debond photos, ceph, and pan 16 Orthodontic practice

Volume 11 Number 4

BOOK REVIEW

Evidence-Based Clinical Orthodontics Edited by Drs. Peter G. Miles, Daniel J. Rinchuse, and Donald J. Rinchuse 2012, Quintessence Publishing Company www.quintpub.com

he editors for this seminal publication have enlisted the knowledge, skill, and expertise of 16 colleagues to aid in their superlative effort to acquaint orthodontic clinicians with orthodontic subjects based on fact rather than supposition, and they have succeeded in a spectacular manner. They begin with the genesis of evidencebased clinical practice followed by some contentious and present-day topics such as: • early intervention • bonding and adhesives in orthodontics • clinical wires available for clinical practice • Class II malocclusions: extraction and nonextraction • Class III malocclusions • subdivisions and treatments of asymmetries • TSADs and the evidence for their use • impacted canines and procedures for dealing with them • orthodontic-induced inflammatory root resorption • orthodontics and TMD • orthodontic retention • accelerated orthodontic tooth movement. All of the chapters hold nuggets of useful information, but some hold special interest for this reviewer because they continue to serve as highly disputable topics, such as, the evidence that early intervention should be reserved only for special patients with unusual needs. Although bonding and adhesives do not provoke much controversy, the authors of that chapter bring an unusual clarity to the subject, which every orthodontic clinician and their staff need to commit to daily use. The section on wires contains information and descriptive knowledge on particular wire and their uses, whereas the portions devoted to Class II, Class III, and subdivision malocclusions present currently well-known facts that are often taught and used in clinical practice. Evidence-based use of TSAIDs presents readers with sound advice backed by Volume 11 Number 4

credible research and offers several illustrations how to best employ them. The portion devoted to the handling of canine impactions has several clinical useful techniques to uncover and bring canines into alignment as well the best knowledge about preventing canine impactions from occurring. The section of orthodontically induced inflammatory root resorption contains excellent advice about this generally occurring result of orthodontic therapy. However, the most thoroughly researched and published evidence-based topic in the book is that on orthodontics and TMD. Without a doubt, TMD has more published errors than perhaps any topic in dentistry. Drs. Donald Rinchuse and Sanjivan Kandasamy systematically destroy many of the most egregious errors associated with this controversial, but consequential, discipline. This one chapter provides reason enough to own the book. The chapter on retention and stability considers all of the random controlled trials done on the subject and comes to the

conclusion that reliable retention of orthodontic treatment outcomes should have lifetime retention, at least in the evening hours. The final topic considered is on the acceleration of orthodontic treatment — for example, battery-supplied electrical energy, vibration, pulsation, and surgical techniques that result in the creation of Rapid Acceleration Phenomenon (RAP). RAP does provide a temporary acceleration in tooth movement but needs repeated applications, which to me, seems a little invasive, expensive, and traumatic for the patient. All of the chapters of this useful book have, as one might expect, large and complete bibliographies, which provide readers with additional publications that will prove useful. Readers also receive the typical features of Quintessence books — for example, thick durable pages, clear narratives with easy-to-read fonts, and exemplary illustrations. OP Review by Dr. Larry White. Orthodontic practice 17

CASE STUDY

Fewer office visits using high-frequency vibration to close an anterior open bite Dr. Esther Feldman ponders what came first, the open bite or the habit? Which came first, the chicken or the egg? Open bites are one of the most difficult classes of malocclusions that orthodontists are faced with in practice. That’s because the success of their resolution is entirely dependent on correctly addressing the etiology. The root cause can be skeletal, which most often requires surgical intervention; it can be dental or a combination of the two. Open bites develop as a result of the interaction of many different etiologic factors, including thumb- and finger-sucking, tongue habits, airway obstruction, and true skeletal growth abnormalities. All anterior open bites present with an accompanying tongue thrust to prevent drooling upon swallowing. It’s not always obvious to determine which came first — the open bite or the habit. Vertical growth is the last dimension to be completed, asnd therefore, treatment may appear to be successful at one point and fail later, in spite of good retention. In the case of relapse, these cases tend to seek retreatment in adulthood.

presented as a Class I, and his anterior open bite was determined to be of dental origin. This relapse case had a problem list that included a 4 mm anterior open bite, a Bolton discrepancy (upper lateral incisors were deficient), mild crowding in both arches, mild overjet of 2.5 mm, and a mild Class II malocclusion on both sides. The lower midline deviated 1 mm to the right, and a tongue thrust was observed. We discussed treatment options, and the patient desired clear aligners with high- frequency vibration (HFV) for acceleration, comfort, and increased predictability. Like most young professionals, Paul wanted the outcome to be achieved as quickly and predictably as possible. In order to meet these objectives, he was aware of the number of attachments needed to help

with the bite-closing mechanics and the placement of elastics. We discussed utilizing buccal and palatal attachments on the upper anteriors to help discourage his tongue habit. Finally, Paul was not concerned with his small lateral incisors and rejected the possibility to build them up. He instead opted for lower interproximal reduction (IPR) to help manage his tooth size discrepancy.

The catalyst: HFV In the case of anterior open bite and aligners, the anterior teeth do not get seated into the aligners by the force of occlusion. Therefore, it’s imperative to use adjunctive measures to obtain some vertical force to help properly seat the aligners on these teeth. The VPro™ high-frequency vibration

Diagnosis and plan Paul, a 30-year old male, presented to my office last March. He had noticed his bite getting progressively worse and was frustrated that he was unable to bite into a slice of pizza. He had no significant medical history and had been treated by an orthodontist in his early teenage years. Skeletally, Paul

Esther Feldman, DMD, grew up in Montreal, Canada, and is a bilingual speaker of English and French. She is a Canadian-trained specialist, earning her Doctor of Dental Medicine from McGill University and her combined diploma in orthodontics/MSc in craniofacial science from UBC in Vancouver. She is both a Diplomate of the American Board of Orthodontics (ABO) and a Fellow of the Royal College of Dentists of Canada (RCDC), making her the only practicing orthodontist in Los Angeles with double-board certification. Dr. Feldman started her patientcentric solo practice in mid-2017. Her goals are to focus on a very personal patient experience and to provide an individually tailored treatment that suits each patient’s needs and lifestyle. She has been published in the AJODO and continues to lecture to study clubs in her area. Disclosure: Dr. Feldman is not compensated by any of the products or techniques mentioned in this article.

Figure 1 18 Orthodontic practice

Volume 11 Number 4

CASE STUDY

Figure 2

(HFV) device from Propel Orthodontics is my go-to solution to increase predictability and reduce pain. It is both efficient and effective, while simultaneously soothing to the patient’s tender dentition due to the increased blood flow in the mouth. For this case, I instructed the patient to bite down on the VPro for 5 minutes to achieve full mouth seating, as well as an additional 5 minutes isolating it to each anterior tooth. We also discussed rotating the device, if necessary, so that the high frequency vibrational force could engage

Figure 3

every single tooth and cause the catabolic reaction of recruiting cytokines and activation of periodontal ligament cells to assist with bone remodeling.1 In order to achieve his treatment objectives, the emphasis was placed on compliance, both with the VPro and his aligner wear. As a result of using the VPro, which served as the biological and physical catalyst, Paul was able to progress on a 5-7 day aligner change interval. The VPro also made it possible to reduce office visits, as we delivered more aligners to swap through between visits.

Results We reached our goal of closing Paul’s anterior open bite and correcting the mild Class II in eight total visits, including refinements. A treatment, which normally would have taken 12 to 18 months and several more visits, was completed to the highest clinical standards in a quick 9 months. This was a direct result of excellent patient compliance in conjunction with HFV. The use of HFV allowed for fewer office visits, reduced chair time, and a seamless treatment experience. The VPro was key to engaging his maxillary anterior teeth into the aligners and keeping his case tracking accordingly. Paul is retained with Vivera® (Invisalign®) retainers. He still uses his VPro in retention to take advantage of the anabolic effects of HFV. When used without orthodontic force, HFV helps to increase bone density1 while maintaining the correct fit of the retainers over his teeth.

Conclusion The success of treating an anterior open bite with aligners is dependent on patient compliance and the correct fit of the aligners over the teeth. To achieve this, adjuncts to treatment, particularly HFV devices such as the VPro, are necessary to keep the case on track and to achieve treatment goals in a predictable and timely manner. Now more than ever, reducing patient visits is of the utmost importance. VPro affords me the confidence to see patients less and deliver more aligners between visits. Concerning retention, we know that all cases have a chance of relapse, especially open-bite cases. VPro is used for all my cases in retention — if the case goes off track at all, the patient uses the VPro to vibrate the case back into place. OP REFERENCE

Figure 4 Volume 11 Number 4

1. Alikhani M, Alansari S, Hamidaddin MA, et al. Vibration paradox in orthodontics: Anabolic and catabolic effects. PLoS ONE. 2018;13(5):e0196540.

Orthodontic practice 19

CASE REPORT

Idiopathic condylar resorption: a case report Dr. Bradford Edgren illustrates a patient with dysfunctional remodeling of the condyle

healthy 16-year 10-month-old female presented for a clinical evaluation of her temporomandibular joints with chief complaints of headaches (tension 2-to3 times per week and migrainous once a week), perceived reduced opening, right temporomandibular joint (TMJ) clicking, history of closed lock, nocturnal clenching and bruxism, and jaw pain of 5 months’ duration. The patient noted that she had experienced trauma at age 10 to the left side of the face resulting in a concussion. Previous conservative TMJ treatment included muscle relaxants and NSAIDs. Extracurricular activities included only marching band. Clinical examination revealed a Class I molar dental relationship, mild crowding, retained maxillary left second deciduous molar (tooth J) and upper dental midline deviation to the right. Her profile was mildly convex with lip competence. Overjet and overbite were 3 mm and 4 mm, respectively (Figure 1). Palpation of the TMJs elicited pain bilaterally lateral to the joints and posterior joint pain on the right during opening. Maximum interincisal opening was recorded at 45 mm with a lateral deviation to the right. Lateral jaw excursive movements were 8 mm to the right and 6 mm to the left. Protrusive movement was 7 mm with no lateral deviation. Mandibular excursive movements from intercuspal position exhibited balancing interferences on the left and working interferences on the right. A corrected coronal view with cone beam computed tomography (CBCT) revealed significant erosion of the right condyle medial Bradford Edgren, DDS, MS, FACD, FICD, earned both his Doctorate of Dental Surgery, as valedictorian, and his Master of Science in Orthodontics from the University of Iowa, College of Dentistry. He is a Diplomate, American Board of Orthodontics, and treasurer of the Southwest Component of the Edward H. Angle Society. Dr. Edgren has presented nationally and internationally to numerous orthodontic groups on the importance of orthodontic diagnosis, early interceptive orthodontic treatment, CBCT, and upper airway obstruction. He has been published in the American Journal of Orthodontics and Dentofacial Orthopedics, The Angle Orthodontist, the American Journal of Dentistry, as well as other orthodontic publications. Dr. Edgren currently has a private practice in Greeley, Colorado.

20 Orthodontic practice

of the midline to the lateral pole, cortical breaks, and increased joint space. Corrected sagittal views showed significant flattening and loss of cortical bone continuity (Figure 2). The corrected coronal and sagittal views of the left condyle demonstrated cortical irregularity anterior superior to the lateral pole and small subchondral cysts (Figure 3). Reconstructed panoramic CBCT imaging displayed mucosal thickening in both sinuses, a missing mandibular left third molar, congenitally missing maxillary left second premolar, and retained maxillary left second deciduous molar (Figure 4). The combined height of right ramus and condyle, measured from the superior aspect of the condyle to antegonial notch, was 61 mm. The height of the left ramus and condyle was 63 mm.

The cephalometric analysis demonstrated a Class I skeletal pattern (ANB of 1º), a low mandibular plane angle (FMA 19º), and upright maxillary and mandibular incisors with an interincisal angle of 138º. The temporomandibular disorder (TMD) diagnosis was myofascial pain dysfunction syndrome (MPD), bilateral capsulitis, and erosive arthritis of the right temporomandibular joint associated with juvenile idiopathic arthritis (JIA); formerly known as juvenile rheumatoid arthritis. The combined splint and orthodontic treatment plan included orthotic therapy to resolve the MPD prior to orthodontic treatment, referral to a rheumatologist for screening for juvenile idiopathic arthritis, followed by comprehensive orthodontics and prosthetic implant replacement

Figure 1: Patient was a 16-year-old female with mild crowding, Class I molar relationship, and retained maxillary left second deciduous molar. The maxillary dental midline was deviated to the right Volume 11 Number 4

CASE REPORT Figures 2 and 3: 2. Initial corrected coronal and sagittal views of the right condyle. The coronal view revealed significant erosion of the right condyle medial of the midline to the lateral pole, cortical breaks, and increased joint space. Corrected sagittal views showed significant flattening and loss of cortical bone continuity. 3. Initial corrected coronal and sagittal views of left condyle demonstrating cortical irregularity and small subchondral cysts

of the missing maxillary left second premolar (tooth No. 13). A full-coverage, mandibular gnathological splint was fabricated, and the patient was instructed to wear the orthotic full-time. The patient was placed on 4- to 5-week recalls for splint adjustments. After 2 months of splint therapy, the patient reported no headaches but still reported crepitus in the right joint. Serologic tests for JIA, taken 6 months after the initiation of splint therapy, were negative for JIA. Given that serological testing and medical history were not suggestive of an underlying inflammatory disease, systemic medical therapy was contraindicated. Following a consultation with her rheumatologist, it was determined that barring further progression of the condylar erosion, no medical intervention would be rendered.

Figure 4: Initial reconstructed panoramic image displaying mucosal congenitally missing maxillary left second premolar and retained maxillary left second deciduous molar

Figures 5 and 6: 5. Progress corrected coronal and sagittal views of the right condyle. Note the recortication of the superior surface in the sagittal views, widened joint space, and subchondral cyst on posterior aspect of condyle. 6. Progress corrected coronal and sagittal views of the left condyle Volume 11 Number 4

Orthodontic practice 21

CASE REPORT

Figure 7. Progress reconstructed panoramic image.

A progress CBCT was made 8 months after the start of splint therapy. The corrected coronal view of the right condyle showed additional loss in height superior to the medial pole, loss of condylar volume, flattening of the superior articulating surface, cortical irregularities, and cortical breaks. The corrected sagittal view also demonstrated flattening and cortical irregularities. However, the right condyle did demonstrate some bone formation with recortication on the superior surface of the condyle. Widened joint space persisted, and a subchondral cyst was present on the posterior aspect of the right condyle in the sagittal images (Figure 5). Corrected images of the left joint displayed cortical irregularities but no significant changes in volume (Figure 6). The combined height of right ramus and condyle demonstrated a loss of 1 mm to 60 mm

Figure 8: Orthodontic retention photos displaying Class I occlusion over 8 months. The height of the left ramus and condyle was unchanged at 63 mm (Figure 7). Upon clinical appropriate canine guidance and function examination, the patient was doing well; no (Figure 8). Maxillary and mandibular Hawley headaches, crepitation, or jaw pain, and retainers were fabricated with a pontic on range of motion was within normal limits. maxillary left to maintain the 7 mm of space mesiodistally until an implant was placed to Orthodontic treatment commenced 16 months after the initiation of splint therapy. replace tooth No. 13. During orthodontic treatment, the patient did not experience Initially, the upper arch was bonded, and the mandibular splint continued to be worn any of the previous symptoms, including joint full-time. Six months later, the lower arch pain, crepitus, or headaches associated with was bonded, and splint therapy ceased. her TMJs. Extraction of the teeth Nos. 1, 16, 32, and Retention records, including CBCT J was performed 18 months after start of imaging, were made 49 months after the initial orthodontic treatment. Light Class II elasdiagnostic TMD records. Corrected coronal tics were utilized near the end of treatment and sagittal views from the CBCT imaging for 4 months to solidify the Class I result. revealed significant improvement of the right After 30 months of treatment, the patient condyle anatomy, including rounded condylar was debanded. head surface and decreased joint space. A Class I occlusion was obtained with Recortication and an increase in the volume

Figures 9 and 10: 9. Corrected coronal and sagittal views at retention demonstrating improvement in right condyle anatomy, including recortication and increased condylar head volume. 10. Corrected coronal and sagittal views of the left TMJ at retention demonstrated improvement in the cortical surface 22 Orthodontic practice

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CASE REPORT

of the right condylar head were evident both in the coronal and lateral tomograms (Figure 9). Corrected coronal and sagittal views of the left TMJ demonstrated improvement in the cortical surface (Figure 10). Reconstructed panoramic CBCT imaging displayed 7 mm of space for implant placement and good root parallelism (Figure 11). The combined height of right ramus and condyle was unchanged from the progress scan taken 40 months prior. The height of the left ramus and condyle was also unchanged. The implant for the edentulous space for tooth No. 13 was placed with a small indirect sinus elevation 5 months after active orthodontic treatment. A periapical radiograph taken 3 months after implant placement shows appropriate parallelism with adjacent teeth and integration (Figure 12). Restorative therapy with a PFM crown occurred 10 months after initial implant placement. The follow-up radiograph taken 10 months after restorative therapy showed continued integration of the implant (Figure 13). In total, the patient was followed in retention for 24 months. Since the patient’s occlusion was stable and she reported no jaw symptoms, she was dismissed.

Figure 11: Reconstructed panoramic image at retention demonstrated 7 mm of space for implant placement and good root parallelism

Discussion A number of factors can result in dysfunctional remodeling of the condyle, including hormonal influences, systemic illnesses such as autoimmune and endocrine disorders, trauma, parafunction, unstable occlusion, and genetic predisposition.1 Changes in condylar form often results in skeletal, occlusal, and functional instability, dentofacial asymmetries and deformities, anterior skeletal and dental open bites, TMJ pain, and dysfunction. In this particular patient, it was initially thought that the erosive arthritis of the right temporomandibular joint was associated with JIA. JIA occurs in children between ages of 6 months to 16 years of age, having a mild female predilection. Of the children that develop JIA, 40% to 96% exhibit arthritis of the TMJ.2 However, serology, medical history, and physical examination ruled out an underlying inflammatory disease in this case study. Idiopathic condylar resorption (ICR) is an unusual, aggressive, and progressive disease process with a strong predisposition for teenagers, especially teenage girls with a 9:1 female-to-male ratio during their pubertal growth stage.3,4 There is an indication that ICR has a hormonal component3,4 and a genetic predisposition, especially if the more common bilateral pattern is involved.4 Volume 11 Number 4

Figure 12: Periapical radiograph of implant replacement for tooth No. 13 taken 3 months after placement. (Image courtesy of Dr. George Holling)

Figure 13: Periapical radiograph taken 10 months after restorative therapy with PFM crown (Image courtesy of Dr. George Holling)

ICR often results in TMJ dysfunction, pain, dentoskeletal changes, and occlusal instability.5 This disease process, which can have either unilateral or bilateral involvement of the TMJs, is poorly understood and often begins before age of 20.3 Unilateral involvement of ICR can result in significant facial asymmetries.4 ICR has also been referred to as progressive condylar resorption,5,6 idiopathic condylysis,5,6 aggressive condylar resorption,6 condylar atrophy,5 and “cheerleaders syndrome.”3 According to Young, it is a diagnosis of elimination; meaning, when all other etiologies are excluded, including trauma, avascular necrosis, infection, systemic disease, autoimmune disorders, and other pathologies, the final diagnosis is ICR.7 This patient most likely suffered from ICR and timely conservative treatment, including several months of splint therapy, improved the outcome in this case. It is theorized that splint therapy helped minimize compressionrelated resorption of the TMJ1 and allowed healing of the condylar head, demonstrating that condylar deterioration with subsequent

cortical remodeling can improve over time. Additionally, a stable orthodontic result was achieved.

Acknowledgments The author thanks Seuss Kassisieh, DDS, MS, for reviewing the manuscript and George Holling DDS, MS, for reviewing the manuscript and providing the implant radiographs. OP

REFERENCES 1. Arnett GW, Gunson MJ. Risk Factors in the Initiation of Condylar Resorption. Semin Orthod. 2013;19(19):81-88. 2. Stoll ML, Kau CH, Waite PD, Cron RQ. Temporomandibular joint arthritis in juvenile idiopathic arthritis, now what? Pediatr Rheumatol Online J. 2018;16(1):32. 3. Wolford LM. Idiopathic condylar resorption of the temporomandibular joint in teenage girls (cheerleaders syndrome). Proc (Bayl Univ Med Cent). 2001;14(3):246-252. 4. Handelman CS, Greene CS. Progressive/idiopathic condylar resorption: an orthodontic perspective. Semin Orthod. 2013;19(2):55-70. 5. Wolford LM, Cardenas L. Idiopathic condylar resorption: Diagnosis, treatment protocol, and outcomes. Am J Orthod Dentofacial Orthop. 1999;116(6):667-677. 6. Sansare K, Raghav M, Mallya SM, Karjodkar F. Management-related outcomes and radiographic findings of idiopathic condylar resorption: A systematic review. Int J Oral Maxillofac Surg. 2015;44(2):209-216. 7. Young A. Idiopathic condylar resorption: The current understanding in diagnosis and treatment. J Indian Prosthodont Soc. 2017;17(2):128-135.

Orthodontic practice 23

CONTINUING EDUCATION

Treatment and delivery methods for myofunctional therapy Nicole Cavalea, MS, discusses co-treatment goals of myofunctional therapy

rthodontists and pediatric dentists are often the first professionals to identify a patient’s abnormal patterning of the mouth and tongue, as these abnormalities interfere with the structural integrity of orthodontic treatment. A visual assessment of the following characteristics can indicate the need to co-treat with an orofacial myofunctional therapist: • forward tongue protrusion during resting, speech, and/or swallow • open mouth posture • weak lip seal • postural changes to face • open bite • distorted speech • jaw instability • dark eye circles • long face • high, narrow palate When a patient presents with a tongue thrust, the clinician will observe resting the tongue against the teeth, swallowing with the tongue pushing against the teeth, and making sounds (meant for placement on the alveolar palate) with tongue pressure against the teeth. Having a tongue thrust will apply pounds of pressure on the anterior teeth daily.

Nicole Cavalea, MS, is the founder of Strategies for Success, a speech-language pathology practice and myofunctional therapy clinic. She has worked in the field of communication disorders for 19 years. She received her MS degree in Speech and Language Pathology from San Jose State University. Cavalea has extensive expertise working with children of all ages in the assessment, treatment, and management of speech and language disorders, auditory processing delays, and myofunctional disorders. After incorporating myofunctional techniques into her practice, she began noticing her patients improving with quicker and more precise results, leading her to further her training in myofunctional disorders and treatment, and attending multiple intensive training courses from the Academy of Orofacial Myofunctional Therapy. Recent studies include an advanced course on breathing re-education, focusing on restoring adequate breathing in sleep apnea patients. Recently, Cavalea has expanded her practice nationwide through telepractice, and values and enjoys collaboration and cotreatment with multidisciplinary teams across the country. Nicole Cavalea can be reached at ncavalea@gmail.com.

24 Orthodontic practice

Educational aims and objectives

This article aims to identify some orofacial characteristics that may necessitate myofunctional therapy and also describes exercises designed to facilitate myofunctional therapy.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 27 or take the quiz online at orthopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify some characteristics of the orofacial area that may indicate a need to co-treat with a myofunctional therapist.

•

Identify some causes and therapy targeting tongue thrust.

•

Recognize some causes and therapy for improper oral resting posture of the tongue.

•

Recognize the connection between myofacial functioning and OSA.

•

Recognize the co-treatment goals of the myofunctional therapist.

This postural and functional imbalance may cause serious dental problems and greatly interfere with the efficiency of orthodontic treatment. If incorrect muscle patterning or swallowing has created a malocclusion, learning proper techniques to correct these imbalances may prevent further damage as special orthodontic appliances or braces will be needed to reposition dental problems that have already occurred. If atypical swallowing is not corrected early, it can cause alterations in the development of the stomatognathic apparatus. Furthermore, the improper function of the tongue, in conjunction with dental malocclusion, will often lead to jaw instability, thus causing pain and headaches for the patient. For these reasons, myofunctional therapy is a useful adjunct treatment to orthodontics in subjects with myofunctional dysfunction.7 Two important factors in the correction of tongue-thrust swallowing are 1) growth and 2) orthodontic treatment to place the teeth in their proper positions and thus simplify proper tongue placement. However, growth and orthodontic treatment alone will not correct tongue-thrust swallowing. In correction therapy, the 22 muscles that are used in normal swallowing should be re-educated to eliminate the tongue-thrust swallowing habit in order for the patient to be able to unconsciously swallow in the correct manner.8

Figure 1: Symptoms of apraxia

Figure 2: Child with expressive and receptive disorders Volume 11 Number 4

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CONTINUING EDUCATION

Therapy targeting a tongue thrust is aimed to strengthen, coordinate, and retrain the muscles involved in swallowing, resting posture, and speech. First, an assessment is used to determine the nature of the postural imbalances that are present and how they affect craniofacial development. Next, the patient is given a set of exercises to activate and strengthen the weakened muscles used incorrectly during swallow and involved in postural imbalances. Proper placement and precision are taught in regard to the function of swallowing. When swallowing correctly, the patient is instructed to voluntarily place the tongue against the roof of the mouth while bringing lips together and creating a suction to swallow. The patient is then taught correct resting posture and speech. Lip exercises to strengthen the lip seal and to habituate a closed-mouth posture are elicited. The nature of therapy is to correct habitual use of the tongue while working on strengthening and patterning of the soft tissue involved. Treatment will last anywhere from 4 to 6 months with exercises and practice daily. Improper oral resting posture of the tongue will have a negative influence of the oral cavity and airway. The anatomy of the upper airway in turn guides the growth and development of the nasomaxillary complex, mandible, temporomandibular joint, and ultimately, the occlusion of the teeth; thus, malocclusion and facial dysmorphism may be the result of compensation for a narrowed airway.5 Short lingual frenulum is a known factor in altering orofacial growth particularly impacting development of the maxilla due to the low placement of the tongue. It leads to the abnormal development of a high and narrow hard palate, and secondarily, mouthbreathing during sleep.4 Obstructive sleep apnea (OSA) has become increasingly recognized as a notable health concern in children, given its consequences on behavior, function, and quality of life. Statistically, 40% of children who suffer from sleep-disordered breathing (SDB) develop ADD, ADHD, and/or a learning disability. Additionally, children are diagnosed with SDB in the first 5 years of life, and left untreated, they are 60% more likely to require special needs education by age 8.1 Most children with OSA have difficulty breathing through the nose. Allergic rhinitis is the most commonly cited disease, followed by hypertrophy of the tonsils and adenoids.1 Orofacial and pharyngeal muscles

Figure 3: Before treatment. Here, a tongue thrust is visible by the anterior tongue placement (pushing against teeth)

Figure 4: After 11 weeks of treatment. Noticeable postural changes after 11 weeks of a tongue-thrust treatment protocol

Comprehensive management requires an integrated effort of the sleep physician, otolaryngologist, allergist, orthodontist, pediatric dentist, and myofunctional therapist. are involved in important functions including breathing, with the vital role of maintaining airflow. Any upper airway (UA) obstruction may induce changes in neuromuscular function in order to ensure the passage of air. The most common consequence of UA obstruction is mouth breathing, a functional adaptation that may affect craniofacial growth and development during childhood. Another possible consequence is obstructive sleep apnea (OSA).1 Myofunctional treatment is aimed at correcting abnormal breathing patterns and muscular dysfunction that may impair upper airway patency.1 Adenotonsillectomy (T&A) and palatal expansion have established roles in the treatment of OSA after demonstrating considerable improvement related

to adenoid or tonsillar hypertrophy, maxillary or mandibular deficiency, and orthodontic or craniofacial abnormalities. However, the implementation of other modalities such as myofacial re-education also plays a crucial role in the optimization of sleep-disordered breathing, as maladapted orofacial functions may be irreversible or present insufficient improvement even when their original cause is eliminated.1 If nasal breathing is not restored, despite short-term improvements after adenotonsillectomy, continued use of the oral breathing route may be associated with abnormal impacts on airway growth and possibly blunted neuromuscular responsiveness of airway tissues, both of which may predispose to the eventual return of upper airway collapse in later Orthodontic practice 25

CONTINUING EDUCATION childhood or in the full blown syndrome of OSA in adulthood.2 Co-treatment goals of the myofunctional therapist follow: First, determine the nature of the postural imbalances that are present and how they affect craniofacial development and functional ability. Next, correct muscular imbalances of the lips, tongue, and jaw through exercises meant to re-pattern, coordinate, and strengthen these areas involved. Children with OSA were found to have relative impairments in orofacial functions and lesser muscular coordination.1 The therapist activates and strengthens the oral facial muscles of mastication to support the mandible and the genioglossus at night. Approximately 30% of OSA patients have poor genioglossus muscle responsiveness to airway narrowing during sleep.6 The tongue muscles are trained to achieve palatal tongue rest position (aiding in correct tongue posture during rest, speech, and swallow). Proper placement and precision are taught in regard to the function of swallowing. When swallowing correctly, the patients are instructed to voluntarily place their tongue against the roof of the mouth while bringing lips together and creating a suction to swallow. Finally, correct nasal breathing, along with a proper resting

oral posture, is established. Achieving proper nasal breathing will result in improving lung volume, increasing nitric oxide through the body, improvement in sleep, and the reduction of allergies and illnesses. To restore efficiency in breathing, first, the myofunctional therapist will educate patients on proper nasal/diaphragmatic breathing. Once coherence is established, they will learn a series of exercises that focus on the biomechanical and biochemical aspects of breathing. Biochemically, patients are instructed to breathe in a way that creates a desire for air (such as narrow, light breaths). This technique will decrease their sensitivity for CO2, therefore creating a larger threshold to eliminate sleep disturbances. Biomechanically, patients are instructed on ways to practice techniques that maximize breathing skills. For example, they learn deep, slow breathing through the nose where the air effectively expands the diaphragm. Treatment will last anywhere from 4 to 6 months, with exercises and practice daily.

Conclusion Research indicates that successful treatment of functional postural abnormalities depends on the collaboration of multidisciplinary

teams. Comprehensive management requires an integrated effort of the sleep physician, otolaryngologist, allergist, orthodontist, pediatric dentist, and myofunctional therapist. Treatment of myofunctional therapy can be carried out in office or through telepractice (i.e., telemedicine or telehealth). Both modalities provide effective measures of intake, assessment, collaboration, and treatment for the patient. OP REFERENCES 1. De Felicio CM, da Silva Dias FV, Folha GA, et al. Orofacial motor functions in pediatric obstructive sleep apnea and implications for myofunctional therapy. Int J Pediatr Otorhinolaryngol. 2016;90:5-11. 2. Guilleminault C, Sullivan SS. Towards restoration of continuous nasal breathing as the ultimate treatment goal in pediatric obstructive sleep apnea. Enliven: Pediatr Neonatol Biol. 2014;1(1):001. 3. Huang YS, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: Evidences. Front Neurol. 2012;3:184. 4. Huang YS, Quo S, Berkowski A, Guilleminault C. Short lingual frenulum and obstructive sleep apnea in children. Int J of Pediatr Res. 2015;1:1. 5. Moeller JL, Paskay LC, Gelb ML. Myofunctional therapy: a novel treatment of pediatric sleep-disordered breathing. Sleep Med Clin. 2014;9:235-243. 6. Osman AM, Carter JC, Carberry JC, Eckert DJ. Obstructive sleep apnea: current perspectives. Nat Sci Sleep. 2018;10:21-34 7. Saccomanno S, Antonini G, D’Altari L, et al. Patients treated with orthodontic-myofunctional therapeutic protocol. Eur J Paediatr Dent. 2012;13(3):241-243. 8. Straub WJ. Malfunction of the tongue. Am J Orthod. 1962;48(7):486-503.

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26 Orthodontic practice

Volume 11 Number 4

REF: OP V11.4 CAVALEA

FULL NAME

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Treatment and delivery methods for myofunctional therapy CAVALEA

1. When a patient presents with a tongue thrust, the clinician will observe _______. a. resting the tongue against the teeth b. swallowing with the tongue pushing against the teeth c. making sounds (meant for placement on the alveolar palate) with tongue pressure against the teeth d. all of the above 2. In correction therapy, the _______ that are used in normal swallowing should be re-educated to eliminate the tongue-thrust swallowing habit in order for the patient to be able to unconsciously swallow in the correct manner. a. 10 muscles b. 22 muscles c. 30 muscles d. 34 muscles 3. Therapy targeting a tongue thrust is aimed to _______ the muscles involved in swallowing, resting posture, and speech. a. strengthen b. coordinate c. retrain d. all of the above

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4. (For therapy targeting a tongue thrust) Treatment will last anywhere from _______ with exercises and practice daily. a. 7 to 10 days b. 2 to 6 weeks c. 4 to 6 months d. 12 to 18 months 5. _________ is a known factor in altering orofacial growth particularly impacting development of the maxilla due to the low placement of the tongue. a. Short lingual frenulum b. Open bite c. Tongue thrust d. Muscle patterning 6. Statistically, _______ of children who suffer from sleep-disordered breathing (SDB) develop ADD, ADHD, and/or a learning disability. a. 15% b. 26% c. 40% d. 65% 7. Children are diagnosed with SDB in the first 5 years of life, and left untreated, they are ______ more likely to require special needs education by age 8.

a. 45% b. 60% c. 72% d. 80% 8. ________ is/are aimed at correcting abnormal breathing patterns and muscular dysfunction that may impair upper airway patency. a. Myofunctional treatment b. Strategic extractions c. Non-diaphragmatic breathing exercises d. Open-mouth postures 9. Approximately _______ of patients have poor genioglossus muscle responsiveness to airway narrowing during sleep. a. 15% b. 25% c. 30% d. 55% 10. Biochemically, patients are instructed to breathe in a way that creates a desire for air (such as _______ ). a. narrow, light breaths b. wide, panting breaths c. short, strong puffs of air d. shallow, fast breathing

Orthodontic practice 27

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Lifetime effects of mouth breathing Michael Flanell, RDH, MBA, discusses mouth breathing and how clinicians can help patients make informed decisions regarding treatment Introduction From birth we are designed to breathe through the nose. Infants take their first breath through their noses once they are born. Newborn infants are considered obligate nasal breathers, hence dependent on a patent nasal airway for ventilation.25 This does not mean that under certain conditions, infants cannot breathe through their mouths. Throughout life, there are conditions that can change a person from properly breathing through the nose to breathing through the mouth. The nose is the correct orifice to breathe through, and nasal breathing brings benefits for maintaining a person’s health that mouth breathing does not. Besides limiting a person’s ability to perform healthy functions, mouth breathing adversely affects the development of the craniofacial features and proper function of the dental occlusion as well as mandible and maxillary growth. This article will examine breathing during the different stages of life and summarize some of the deleterious effects of mouth breathing and the benefits of nasal breathing. The dental team is in an exceptional position to address these concerns with patients since they often observe the adverse effects of mouth breathing during routine dental visits. Identifying some of the changes that result from mouth breathing will help dental professionals guide their patients to make informed decisions for improving overall health for themselves as well as family members.

Infants from 1 month to 2 years old Infants are born obligate nasal breathers depending on a patent nasal airway for ventilation.25 Newborns depend on nasal breathing to adapt to behavior competently in relation to ingestion and sucking. This specialization of

Educational aims and objectives

This article aims to identify some of the changes in various age groups that result from mouth breathing to help dental professionals make informed decisions for guiding patients to improving their overall health.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 34 or take the quiz online at orthopracticeus.com to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify airway and dental anatomy during various stages of life.

•

Realize the benefits of nasal breathing.

•

Realize the issues related to mouth breathing.

•

Realize how the proper development of the craniofacial features is related to nasal breathing and mouth breathing.

•

Recognize some possible treatments for adjusting breathing habits.

oral behavior evolved in infants in response to breastfeeding.41 Anatomically, the oral airway of the infant is comparatively smaller than the airway of the adult (Figure 1). The epiglottis of an infant nearly touches the soft palate. The descent of the epiglottis is not complete until about 15 years of age, or when the vocal cords are fully matured.25 The infant’s tongue, in ratio to the oral cavity of the mouth, is larger than in the adult mouth, and the infant has an elongated, more rigid omega-shaped epiglottis and a smaller opening between the soft palate and the epiglottis.42 The position of the infant’s tongue is entirely within the oral cavity, allowing the distinctly omega-shaped epiglottis to interlock with the soft palate when breastfeeding. This forms a barrier, creating a straight route for air to travel from the nose to the lungs while breast milk flows through the faucium channels, thus allowing the infant to breathe and swallow simultaneously.42 This is an important feature for an infant’s growth and well-being as it optimizes the ability to nasal breathe and to take in nutrition concurrently.

Michael Flanell, RDH, MBA, is a Certified Sleep Apnea clinician from the Academy of Clinical Sleep Disorders Disciplines, a Myofunctional Therapist, and a Breathing Coach. She is a professor to the Department of Healthcare Management at St. Joseph’s College in Patchogue, New York, where her responsibilities include designing and teaching healthcare administration online. Previously, she taught at Briarcliff College in the Dental Hygiene and Healthcare Management Department. Presently, she is an Operations Manager at Sleepwell Orthotics and a clinical consultant at Advanced Dental Sleep Consultants.

28 Orthodontic practice

Figure 1: Frontal, open mouth view of a newborn. Interlocking of soft palate and epiglottis illustrates intranarial airway. Breast milk flows through faucium channels, infant's lips are sealed on breast, and child can breathe and swallow at same time. Source: Crelin ES. Development of the Upper Respiratory System, Clinical Symposia, Vol. 26, No. 3, 1976

The proper development of the craniofacial features has been attributed to breastfeeding and the simultaneous ability to breathe nasally. The jaw movements involved in extraction of milk from the breast provide major stimuli for growth of the temporomandibular joint and, consequently, encourage harmonious growth and development of the facial region. When performed correctly, nasal breathing also plays a role in the development of the maxilla and mandible to stabilize the dental occlusion, function, and Volume 11 Number 4

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Craniofacial development is largest within the first 4 years of life with 90% of development complete by 12 years of age. This proper formation is the beginning of a healthy craniofacial development that can support lifelong nasal breathing. nose does not rise accordingly, there is a decrease in the total nasal space. This can have a dramatic effect on the individual’s breathing efficiency because the size of the nasal chamber is reduced. Studies have shown that a high palate and narrow arch are good predictors of snoring and obstructive sleep apnea.35 This eventually leads to the poor alignment of teeth and the “V-shaped” palate found in many people with malocclusions. This dynamic also explains how the upper back teeth are pulled inward to cause a mismatch or crossbite. Once a malocclusion develops, it can create a domino effect that can damage the rest of the teeth.40 Individuals with proper palatal placement of the tongue normally have a well-rounded and full "U-shaped" arch. Excessive thumb-sucking can have the same impact on the oral cavity as bottle feeding. When the tongue is driven back by force, this can extend the distance between the soft palate and the epiglottis as well as block off the airway.23 The downward displacement of the mandible to keep the oral airways open encourages the start of oral breathing. Sasaki, et al. (1977),38 noted that “Age group 4 to 6 months seemed to represent a transitional period from obligate nasal breathing to potential oral tidal respiration. … This transition is important because it reflects a period of potential respiratory instability.” Tongue-tie (ankyloglossia) is a condition present at birth that affects the oral development in restricting the tongue’s range of motion, affecting nursing/eating, speaking, swallowing, and breathing.29 Tongue-tie is the name given to the condition arising when the frenulum is unusually thick, tight, or short. There are many variations and differing degrees of severity.16 The tongue may not have the ability to rest in the palate, causing incorrect development of the palate/ nasal septum. The downward resting position of the tongue could then contribute to the development of mouth breathing. Nasal breathing benefits infants since the nose is

the preferred route of breathing in infants because of its ability to humidify, warm, decontaminate, and regulate the air; thus, air reaches the lungs at the ideal temperature and favors oxygenation.4 Treatment for infants includes, but is not limited to, surgery for frenectomies, ENT evaluations to determine nasal obstructions, myofunctional therapy for teaching infants to keep a lip seal when not bottle feeding, adenotonsillectomy (T&A), and adenoidectomy.

Children from 2 to 12 years Nasal breathing is associated with normal functions of chewing, swallowing, tongue posture, and lips, as well as providing correct muscular action that stimulates adequate facial growth and bone development.10 Mouth breathing (MB) is an etiological factor for sleep-disordered breathing (SDB) during childhood. The habit of breathing through the mouth may be perpetuated even after airway clearance. Both habit and obstruction may cause facial muscle imbalance and craniofacial changes.34 Mouth breathers demonstrated considerable backward and downward rotation of the mandible and increased overjet, causing an increase in the mandible plane angle, a higher palatal plane, and narrowing of both upper and lower arches at the level of canines and first molars when compared to the nasal breathers’ group. The prevalence of a posterior crossbite and an abnormal lip-to-tongue anterior oral seal was significantly more frequent in the mouth breathers’ group than with the nose breathers.17 Mouth breathing also causes dryness of the oral tissues, compromising gingival health. In addition, mouth breathing causes pathological changes in the nasopharyngeal and other respiratory tissues as well as muscle alterations, which influence deglutition, digestion, and phonation.9 In oral breathers, the chance of finding an asthmatic individual was almost 8 times greater than in the control group.37 This increased prevalence of asthma in oral Orthodontic practice 29

CONTINUING EDUCATION

muscle balance.15 Craniofacial development is largest within the first 4 years of life with 90% of development complete by 12 years of age.40 This proper formation is the beginning of a healthy craniofacial development that can support lifelong nasal breathing. Improperly formed craniofacial features can be a strong indicator of risk for the development of obstructive sleep apnea.16 The principal nongenetic determinant of maxillary growth is the route of breathing — nasal versus mouth breathing. Mouth breathing in infants results in a narrow maxilla, higharched palate, and increased lower facial height and facial esthetics. This craniofacial pattern has been termed the “long-face syndrome” and is associated with obstructive sleep apnea (OSA). Thus, nasal obstruction causing mouth breathing affects maxillary growth and predisposes toward ensuing OSA. Infants with midfacial hypoplasia may develop life-threatening OSA in the first year of life.20 One common cause of mouth breathing and disruption of nasal breathing is the use of bottle feeding. Bottle feeding can separate the epiglottis/soft palate connection, elevate the soft palate, and drive the tongue back and down, altering the action of the tongue during rest, swallowing, speaking, and breathing. The infant then cannot suckle and breathe simultaneously, causing the gulping of liquids and the need to take in air through the mouth to sustain breathing while feeding. The lower the tongue, the smaller the pharyngeal airway. The largest oropharyngeal airway is created when a person is breathing nasally with the lips sealed, and the dorsum of the tongue is as far forward as possible sealed against the hard and soft palate.25 When the mouth must adjust to an object other than the breast, the unnatural forces that develop can impact the shape of the palate.39 Weber, et al. (1986)43 noted that in breastfed babies, the tongue action appeared to be a rolling or peristaltic motion. However, the tongue action for bottle-fed babies was more piston-like or a squeezing motion. Picard (1959)35 wrote that in order to stop the abundant flow of milk from a bottle with an artificial nipple (with a large hole in the end), the infant was forced to hold the tongue up against the hole in the nipple to prevent the formula from gushing forth. This abnormal motor activity of the tongue is referred to as a tongue thrust or a deviate swallow. Due to downward placement of the tongue instead of palate placement, the floor of the nasal cavity rises as well. Since the bridge of the

CONTINUING EDUCATION breathers was already described in literature. This may be due to the fact of that there is a contiguous relationship between the upper and lower respiratory tract, beyond a higher prevalence of atopy in oral breathers. This way, the oral breathing allows the allergens, or the irritant agents, to reach the lower airways, causing bronchial hyperresponsiveness and asthma induced by exercise.37 The mouth-breathing syndrome (MBS), also known as long-face syndrome (Table 1), is the set of signs and symptoms of those who breathe partially or totally through the mouth. Felcar, et al. (2010),10 recognized that mouth breathing has multifactorial etiologies, such as hypertrophy of the palatine tonsils, adenoid hypertrophy, nasal septum deviation, nasal polyps, respiratory allergies, sinusitis, turbinate hypertrophy, sleeping position, and artificial feeding. He noted that mouth breathing may be caused by deleterious oral habits, such as digital sucking or pacifiers that, depending on the intensity and frequency, deform the dental arch and alter the whole facial balance. Some obvious facial features of mouth breathers are dark circles under the eyes, dry/cracked lips, head forward position, lips hanging open and flaccid, and constantly licking lips. Mouth breathing is one of the most cited characteristics of sleep-disordered breathing (SDB) during childhood, but symptoms are often inadequately recognized. Pacheco, et al. (2015),33 stated that SDB encompasses a wide clinical spectrum, such as snoring, upper airway resistance syndrome (UARS), and obstructive sleep apnea (OSA). The authors noted that snoring during sleep was estimated to occur in between 8% and 27% of children, 2% of which present with OSA. Prevalence of UARS remains unknown and is most likely to be underdiagnosed. Findings for clinical diagnosis of UARS are considered nonspecific but

strongly resemble clinical aspects of chronic mouth breathing and nasal obstruction.33 (See Table 1 for screening for MB.) Mouth-breathing syndrome (MBS) is related to an adverse quality of life, especially as it refers to nasal problems, and sleep and eating concerns or difficulties. Treatment for mouth breathers includes, but is not limited to, adenotonsillectomy, myofunctional therapy, allergy evaluation, airway centric-orthodontics, or a combination of any of these. It is important to consider a sleep evaluation pre- and post-therapy. Long-term follow-ups to treatments are recommended.

From teenage years through early adulthood The most common cause of mouth breathing is the presence of obstacles in the nasopharyngeal region, which increases nasal resistance (decreases nasal airflow) that can be induced by various mechanical factors, including tonsil hyperplasia, hypertrophied turbinates, rhinitis, tumors, infectious or inflammatory diseases, and changes in nasal architecture. However, even after these mechanical factors are removed, MB continues in most cases due to the patient’s mouth breathing habit. Unbalanced facial musculature occurs as a result of MB, which causes changes in tooth positioning, lips, tongue, palate, and jaws, to counterbalance the new breathing pattern.34 Attention deficit hyperactivity disorder (ADHD) is commonly found among mouth breathers. When assessing for ADHD and complaints about school underachievement, da Costa, et al. (2015),9 found characteristics of snoring, nocturnal MB, rhinitis, tonsillitis, drool on the pillow, dark circles, and dry lips in more than half of their sample. Both ADHD and MB can trigger SDB, which, together

Table 1: Screening for mouthbreathing syndrome • • • • • • • • • • •

Severe dentofacial deformity Long-face syndrome Gummy smile (vertical max excess) Narrow maxilla Deep palatal vault Class III malocclusion Distorted arch form Severe crowding Extraction space Uncoordinated arches Traumatic occlusion

with daytime sleepiness, directly interferes in school performance. Based on the assumption of a possible relationship between body posture and breathing muscles, Okuro, et al. (2011),31 compared the maximal respiratory pressures (which are direct measures of respiratory strength) and head posture among mouthand nasal-breathing children. The authors observed a decrease in maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) in mouth breathers, causing the formation of forward head posture (Figure 2) — the flexion of the lower cervical spine and extension of the upper cervical spine, which acts as a compensation mechanism for better performance of the respiratory muscle’s strength.21 Mouth breathers have difficulty in coordinating breathing and swallowing because they must stop chewing or chew the food faster to be able to breathe. Thus, the observed responses confirm the findings in another study by Canuto, et al. (2016),7 who found that the changes that occur in the respiratory pattern may lead to faster chewing: Chewing and swallowing take place in the same period of time that breathing

Forward head posture has been linked to the following conditions: • • • • • • • •

Headaches/migraines Dizziness/vertigo TMJ issues Shoulder and rotator cuff problems Chronic cough Upper back pain Lower back pain Sciatica

• • • • • • • •

Neck pain Radiating pain into arms Degenerative disc disease Acid reflux Sleep apnea Carpel tunnel syndrome Chronic fatigue Vision problems

Figure 2: Forward head posture 30 Orthodontic practice

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Table 2: Possible adverse consequences of chronic mouth breathing • • • • • • • • • • • • • • •

Introduction of unfiltered, poorly humidified air into the lungs Upper-chest breathing (inefficient and tiring) Chronic over-breathing Greater incidence of snoring and sleep apnea Bad breath, dental decay, gum disease Dysfunction of the jaw joint (temporomandibular joint disorders) Narrowing of the dental arch, jaw, and palate Crowded or crooked teeth Open bite, malocclusion (teeth not fitting together properly) Greater potential for relapse of orthodontic corrections Dysfunctions of the muscles around the jaw and lips Loss of lip tone with the lips becoming flacid Noisy eating, speech, and swallowing problems Trauma to soft tissues in the airways Enlarged tonsils and adenoids

overweight. The ever-increasing waistlines put children at risk for heart disease, Type 2 diabetes, and high blood pressure. But there is another problem, often overlooked, accompanying the grim statistics from the U.S. Surgeon General’s office. Those extra pounds around and in the oral pharyngeal also put children at risk for sleep apnea — a serious, debilitating and potentially lifethreatening sleep disorder, according to the National Sleep Foundation.30 Sleep apnea symptoms include mouth breathing at night among other symptoms such as snoring, pauses in breaths while sleeping, difficulty getting up, behavior problems, and tiredness during the day. Recommendations for care may include, but are not limited to, the following: myofunctional therapy, airway centricorthodontia, administration of a sleep-test, CPAP, oral appliance therapy (if the patient is old enough), taping of the mouth, weight loss, dental examination, and oral homecare instructions.

Adults Increased upper airway resistance was associated with oral breathing during stable sleep, as compared with nasal breathing, irrespective of central or obstructive sleep apnea. Fitzpatrick, et al. (2003),13 confirmed that during sleep, upper airway resistance during oral breathing was 2.5 times higher than during nasal breathing. The route of breathing has a profound influence on upper airway resistance during sleep, with resistance being much greater during oral breathing than during nasal breathing.18 The substantially higher resistive load posed by the oral breathing route provides a plausible explanation for the observation that inhaled ventilation occurs almost exclusively via the

nasal route during sleep in subjects with normal nasal resistance.11 Mouth opening has been shown to increase the propensity to upper airway collapse. Jaw opening is associated with a posterior movement of the angle of the jaw, which can compromise the oropharyngeal airway diameter. Also affected is the posterior and inferior movement of the mandible, which may shorten the upper airway dilator muscles located between the mandible and hyoid, compromising their contractile force by producing unfavorable length-tension relationships in these muscles.23 Mouth breathing is also considered one of the predisposing factors for initiation of periodontal disease and/or its progression. The anterior dental open bite produced by chronic mouth breathing is associated with high incidence of periodontal disease and high risk of losing the anterior teeth in early ages, causing the absence of anterior guidance, which predisposes the patients for temporomandibular disorders (Table 2). The precise mechanisms are not fully understood, but probable causes are gingival surface dehydration, decreased epithelial resistance to bacterial plaques, and lack of salivary auto-cleaning.12 Mouth breathing at night dries the tissues, causing the mouth, teeth, tissues, and throat to be dry upon waking. The forward head posture (Figure 2), common among mouth breathers, facilitates the air to enter the mouth which could lead to a deterioration of the pulmonary function. In the long run, the hyperactivity of the neck muscles may be associated with cervical changes that consequently can cause temporomandibular disorders (TMD) and cervical spine disorders. Considering all these aspects, a cycle seems to be Orthodontic practice 31

CONTINUING EDUCATION

occurs, causing the feeling of suffocation in the individual. However, the findings also indicate that most people consume liquids during meals while food is still in their mouths in order to ease the intake of solids, which aid in swallowing food faster and reducing the sensation of breathlessness and suffocation. Saliva has many important functions. Garcia, et al. (2016),14 explained that saliva’s many functions are self-cleaning of the mouth, buffering and clearing acids, acquired pellicle formation, antimicrobial actions, and provision of ions for remineralization of demineralized enamel. Saliva protects the teeth from organic acids produced by bacteria that cause dental caries, and the extrinsic and intrinsic acids that initiate dental erosion. The depressed resting salivary flow is associated with lower plaque pH, increased numbers of lactobacilli and candida species, and greater caries risk. This could have serious consequences for caries activity and will also increase the risk of tooth loss via dental erosion.12 This study further explains how mouth breathing can cause water loss — a potential factor that could contribute to oral dryness. Some studies have failed to find associations between mouth breathing and caries risk or salivary patterns. For example, KogaIto, et al. (2002),22 found no differences in caries risk between treated and untreated children for mouth-breathing syndrome, although the level of IgG antibodies to Streptococcus mutans (cariogenic bacteria) was higher in the treated group. Another study by Mummolo, et al. (2018),29 did not find differences in flow rates or buffering capacities of resting and stimulated saliva between mouth- and nose-breathing adolescents aged 10 to 19 years. However, Al-Awadi and AI-Casey (2013)3 found lower salivary flow rate among male patients 18 to 22 years old with mouth breathing associated with nasal obstruction in comparison to nose breathers. Mouth breathing was also associated with lower salivary pH, higher plaque index, and increased salivary S. mutans counts. Other studies also reported association between mouth breathing and dental caries. These findings are important since teenagers make more food choices outside the home, which usually include foods with a high sugar content and simple carbohydrates, which break down into glucose. These foods tend to be sticky, and the reduction in salvia to neutralize the pH and wash off debris from teeth increases the likelihood of promoting an environment ripe for dental cavities. Some 13% of children aged 6 to 11 and 14% of adolescents aged 12 to 19 are

CONTINUING EDUCATION established where mouth breathing alters the respiratory function and mechanics and produces postural compensations, which in turn perpetuate the respiratory changes.21 The low carbon dioxide levels associated with mouth breathing lead to overbreathing or hyperventilation. With less oxygen being delivered to the brain, muscles, and all the cells of the body, the body functions less than optimally. A large population of people became mouth breathers with the onset of sleep apnea. When an apnea episode occurs, a person stops breathing. As oxygen levels dip, the brain sends a signal to start breathing again, resulting in the loud snore and/or a sudden gasp to gulp in air. When an apnea event occurs during the night, the habit of sleeping with the mouth open can occur to accommodate the need for oxygen.31 Nose breathing is associated with many health benefits such as humidifying and cleansing/filtering the air to prepare it for the lungs. The structure of the nose is unique in that it regulates the direction and velocity of the airstream using turbinate’s maximizing exposure to the many arteries, veins, and lymphatics as well as to the nervous system and the mucous blanket. The turbinates also mix the air with nitric oxide, acting as vasodilators and increasing the opening of the veins for more oxygen/carbon dioxide exchange. Breathing through the nose increases the oxygen uptake ranging from 10 to 20 times greater when compared with mouth breathing. Finally, nasal breathing increases the circulating blood oxygen and carbon dioxide levels, slows the breathing rate, and improves overall lung function2 (Table 3). Correcting mouth breathing in adults involves many of the same treatments as mentioned previously. Implementing myofunctional therapy is usually harder for adults than for children as children have a parent who motivates/prompts the therapy. Mouth taping at night may be easier in adults than in children as adults may not feel as “claustrophobic” as children. A thorough ENT evaluation should be included to determine if any nasal obstruction exists and should be completed before other treatments are considered. Adults may also need airwaycentric orthodontics to correct malocclusion, which prevents the complete seal of the lips. Certain surgeries may be necessary as well. A sleep test should also be done to rule out and/or treat any sleep-breathing disorders prior to orthodontics, myofunctional therapy, or taping. 32 Orthodontic practice

Table 3: Benefits of nose breathing • Warms and moistens, and filters the air • Traps large particles with the nose hairs and small particles via mucous membranes • Facilitates inhalation of nitric oxide — a vasodilator and bronchodilator that increases oxygen transport throughout the body • Helps prevent colds, flu, allergic reaction, hay fever, irritable coughing • Retains some moisture from exhaled air, preventing nasal dryness • Provides a sense of smell • Regulates (slows) airflow because of the nose's intricate structures • Facilitates correct action of the diaphragm • Promotes activity of the parasympathetic nervous system, which calms and relaxes the body, slows the breathing and the heart, promotes digestion • Allows the correct position of the tongue (against the upper palate) and lips (together), assisting formation of the natural dental arches and straight teeth • Reduces likelihood of snoring and apnea

Clinical guidelines • Having difficulty in school? • Having difficulty concentrating?

q Yes q Yes

q No q No

Breathing tests The child must be sitting. At least two tests should be performed. a. Graded mirror test After the second output of air on the mirror, mark the halo area with a marker (Low nasal flow: up to 30 mm; Average nasal flow: 30-60 mm; High nasal flow: above 60 mm) b. Water retention test Place water in patient's mouth (approximately 15 ml) and ask him/her to hold it for 3 minutes. b. Lip seal test Seal the patient's mouth completely with a tape for 3 minutes. Training to eliminate the habit of mouth breathing Training should be performed at home on a daily basis until the child is able to return to nasal breathing. a. Lip seal test Seal the child's mouth with masking tape when he/she is distracted or focusing his/her attention on another activity. Progressively increase the time each day until the child is able to breathe only through the nose for at least two consecutive hours.

Senior Adults Complaints of a dry mouth (xerostomia) and diminished salivary output (salivary hypofunction) are common in elderly people as a result of a plethora of salivary gland disorders, medication use, and medical disorders. Dry mouth problems have a clinically significant deleterious impact on oropharyngeal health. Clinicians must be able to diagnose dry mouth disorders in their elderly patients and provide preventive and interventional treatments to reduce the impact of these disorders on an older person’s quality of life. Mouth breathing in the elderly population can be an extreme contributor to the already

debilitating effects of decreased salivary flow. Thus, it is especially helpful to identify if the patient is also contributing to these effects with mouth breathing, causing even more dryness. Establishing that a patient wakes up with a dry mouth may indicate the presence of a sleep-breathing disorder. Experiencing dry mouth upon awakening is a frequent symptom of OSA. Patients reporting dry mouth upon awakening have a 2.33-fold greater risk of having OSA rather than having primary snoring and are even at a higher risk of having severe OSA.33 Among patients with OSA, the collapsibility of the pharyngeal airway worsens Volume 11 Number 4

REFERENCES 1. American Sleep Apnea Association. Sleep Apnea.org. https://www.sleepapnea.org/treat/cpap-therapy/troubleshooting-guide-for-cpap-problems/mouth-breathing-oncpap/. Accessed June 15, 2020. 2. American Sleep Apnea Association. Sleep Apnea.org. https://www.sleepapnea.org/treat/cpap-therapy/troubleshooting-guide-for-cpap-problems/mouth-breathing-oncpap/. Accessed June 15, 2020.

or a traditional nasal mask/nasal pillow mask with the addition of a chin strap.31 Patients with moderate-to-severe sleep-disordered breathing and a high percentage of mouth breathing during sleep were less adherent to CPAP therapy than patients exhibiting a low percentage of mouth breathing.3 Recommended treatments for the elderly include a sleep test to rule out a sleep breathing disorder, identifying if dry mouth is related to factors other than mouth breathing, ensuring that a nasal obstruction does not exist, and providing other therapies to support nasal breathing.

Conclusion The dental care team should first understand that breathing was designed to be through the nose only. Many people lead their lives as mouth breathers without identifying

mechanisms involved. Revista Habanera de Ciencias Médicas. 2016;15(2):200-212. 15. Giugliani Justo PR, Caramez da Silva ER, Capsi Pires S. Influence of the duration of breastfeeding on quality of muscle function during mastication in preschoolers: a cohort study. BMC Public Health. 2012;12(1):934. 16. Grippaudo C, Paolantonio EG, Antonini G, et al. Association between oral habits, mouth breathing and malocclusion. Acta Otorhinolaryngol Ital. 2016;36(5):386-394.

3. Al-Awadi RN, Al-Casey M. Oral health status, salivary physical properties and salivary Mutans Streptococci among a group of mouth breathing patients in comparison to nose breathing. J Bagh College Dentistry. 2013; 25(special issue 1):152-159.

17. Guilleminault C, Parinen M, Hollman K, Powell N, Stoohs R. Familial aggregates in obstructive sleep apnea syndrome. Chest Journal. 1995:107(6):1545-155.

4. Allen R. The health benefits of nose breathing. Nursing in General Practice. 40-42. https://www.lenus.ie/bitstream/ handle/10147/559021/JAN15Art7.pdf. Accessed June 10, 2020.

19. Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect of mouth breathing versus nasal breathing on dentofacial and craniofacial development in orthodontic patients. Laryngoscope. 2010;120(10):2089-2093.

5. Bachour A, Maasilta P. Mouth Breathing Compromises Adherence to Nasal Continuous Positive Airway Pressure Therapy. Chest Journal. 2004;126 (4):1248-1254. https:// pubmed.ncbi.nlm.nih.gov/15486389/. Accessed June 10, 2020.

20. Hollowell DE, Surratt PM. Mandible position and activation of submental and masseter muscles during sleep. J Appl Physiol. 1991;71(6):2267-2273.

6. Bergeson PS, Shaw JC. Are Infants Really Obligatory Nasal Breathers? Clin Pediatr. 2001;40(10):567-569. https:// pubmed.ncbi.nlm.nih.gov/11681824/. Accessed June 10, 2020. 7. Canuto MSB, Moura JB, Anjos CAL. Feeding preference of mouth breathers of an elementary school. Rev CEFAC. 2016; 18(4):811-817. 8. Catalano P, Walker J. (06/2018) Understanding Nasal Breathing: The Key to Evaluating and Treating Sleep Disordered Breathing in Adults and Children. Department of Otolaryngology, St. Medical Center, Tufts University School of Medicine Medical, MA, USA. Gavin Publishers Lisle Illinois 9. da Costa M, Valentim AF, Gonçalves Becker HM, Rodrigues Motta A. Findings of multiprofessional evaluation of mouth breathing children. Rev CEFAC. 2015;17(3):864-878. 10. Crelin, ES. Development of the Upper Respiratory System. Clinical Symposia. 1976; 28(3). 11. Farid MM, Metwalli N. Computed tomographic evaluation of mouth breathers among pediatric patients. Dentomaxillofac Radiol. 2010;39(1):1-10. 12. Felcar JM, Bueno IR, Massan ACS, Torezan RP, Cardoso JR. [Prevalence of mouth breathing in children from an elementary school] [article in Portuguese]. Cien Saude Colet. 2010;15(2):437-444 13. Fitzpatrick MF, McLean H, Urton AM, et al. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J. 2003;22:827-832. 14. García Triana Elena Bárbara, Ali Ahlam Hibatulla, Ileana Bárbara, Grau León. Mouth breathing and its relationship to some oral and medical conditions: physiopathological

Volume 11 Number 4

18. Hall DMB, Renfrew MJ. Tongue tie. Arch Dis Child. 2005;90(12):1211-1215.

21. Katz ES, Mitchell RB, D’Ambrosio CM (April 2010) Obstructive Sleep Apnea in Infants. American Journal of Respiratory and Critical Care Medicine. 185(8):805.

why they experience certain changes in how they feel, how they look, or why they experience certain head and neck pains. Breathing is the first function for survival, and the body will do whatever it needs in order to support breathing, including prioritizing function over form. Thus, disfigurement of the face and neck may result from the body’s primary drive to inhale oxygen through whatever means it can. Dental teams that understand the functions and benefits of nasal breathing are empowered to help patients of all ages breathe and develop optimally. Identifying mouth breathing and why it is occurring in a patient are the first steps toward restoring proper breathing function and correcting anatomical formation. Sometimes it’s as easy as closing the mouth and starting to take in one breath at a time through the nose. OP

30. National Sleep Foundation: Sleep for Kids. Information about children’s sleep for Parents and Teachers. Children, Obesity, and Sleep. http://sleepforkids.org/html/obesity. html. Accessed June 15, 2020. 31. Okuro RT, Morcillo AM, Sakano E, et al. Exercise capacity, respiration mechanics and posture in mouth breathers. Braz J Otorhinolaryngol. 2011;77(5):656-662. 32. Oksenberg A, Froom P, Melamed S. Dry mouth upon awakening in obstructive sleep apnea. J. Sleep Res. 2006;15(3):317-320. 33. Pacheco MC, Casagrande CF, Teixeira LP, Finck NS, de Araújo MT. Guidelines proposal for clinical recognition of mouth breathing children. Dental Press J Orthod. 2015;20(4):39-44. 34. Palmer B. The Influence of Breastfeeding on the Development of the Oral Cavity: A Commentary. J Hum Lact. 1998;14(2):93-98. 35. Picard PJ. Bottle feeding as Preventive Orthodontics. J Calif State Dent Assoc. 1959;35:90-95. 36. Popoaski C, Marcelino TF, Sakae TM, Schmitz LM, Correa LHL. Evaluation from the quality of life in the oral breathers patients. Int Arch Otorhinolaryngol. 2012;16(1):74-81.

22. Koga-Ito CY, Unterkircher CS, Watanabe H, et al. Caries Risk Tests and Salivary Levels of Immunoglobulins to Streptococcus mutans and Candida albicans in Mouth Breathing Syndrome Patients. Caries Res. 2003;37(1):38-43.

37. Fayez S, AIhamadi W. Orthosurgical Correction of Severe Vertical Maxillary Excess: Gummy Smile. Approaches to Orthodontics. 2018. https://www.intechopen.com/books/ current-approaches-in-orthodontics/orthosurgical-correction-of-severe-vertical-maxillary-excess-gummy-smile. Accessed June 15, 2020.

23. Lopes Veron H, Antunes AG, Milanesi JDM, Corrêa ECR. Implications of mouth breathing on the pulmonary function and respiratory muscles. Rev CEFAC. 2016;8(1):242-251.

38. Sasaki CT, Levine PA, Laitman JT, Crelin ES Jr. et al. Postnatal Descent of the Epiglottis in Man. A Preliminary Report. Arch Otolaryngol. 1977;103(3):169-171.

24. Matsuo K, Palmer JB. Anatomy and physiology of feeding and swallowing: normal and abnormal. Phys Med Rehabil Clin N Am. 2008;19(4):691-707. 25. Mayo Clinic. Tongue-tie. https://www.mayoclinic.org/ diseases-conditions/tongue-tie/symptoms-causes/ syc-20378452. Accessed June 15, 2020. 26. Meurice JC, Marc GCI, Carrier G, Sériès F. Effects of mouth opening on upper airway collapsibility in normal sleeping subjects. Am J Respir Crit Care Med. 1996; 153:255-259. 27. Miller MJ, Martin RJ. Carlo WA, et al. Oral breathing in newborn infants. J Pediatr. 1985;107(3)465-469. 28. Moses AJ, Kalliath ET, Pacini G. Evolution of the Human Oral Airway. Dental Sleep Practice. 2017;(Winter):32-37 https://dentalsleeppractice.com/ce-articles/evolutionhuman-oral-airway-apnea//. Accessed June 15, 2020. 29. Mummolo S, Nota A, Caruso S, et al. (2018). Salivary Markers and Microbial Flora in Mouth Breathing Late Adolescents. Biomed Res Int. https://pubmed.ncbi.nlm. nih.gov/29693018/?from_single_result=26.+Mummolo+S %2C+Nota+A%2C+Caruso+S%2C+et+al.+%282018%2 9.+Salivary+Markers+and+Microbial+Flora+in+Mouth+Br eathing+Late+Adolescents.+Biomed+Res+Int. Accessed June 15, 2020.

39. Shepard JW Jr, Gefter WB, Guilleminault C, et al. Evaluation of the Upper Airway in Patients with Obstructive Sleep Apnea. Sleep. 1991;14(4):361-371. 40. Trabalon M, Schaal B. It takes a mouth to eat and a nose to breathe: abnormal oral respiration affects neonates’ oral competence and systemic adaptation. Int J Pediatr. 2012. https://www.hindawi.com/journals/ijpedi/2012/207605/. Accessed June 15, 2020. 41. Tsui BCH. Physiological considerations related to the pediatric airway. Can J Anaesth. 2011;58:476-477. 42. U.S. National Library of Medicine. Effect of Added Varnum Mouthpiece on Pharyngeal Collapsibility and Sleep Apnea Severity in Mouth Breathers. Published April 2016. Clinicaltrials.gov. https://clinicaltrials.gov/ct2/show/ NCT02738255. Accessed June 15, 2020. 43. Weber F, Woolridge MW, Baum JD. An ultrasonographic study of the organization of sucking and swallowing by newborn infants. Dev Med Child Neurol. 1986;28:19-24. 44. Wu JC, Dubois NMG. 2005. Role of Oral Devices in Managing Sleep-disordered Breathing Patients. Position Statement. American College of Prosthodontists: Chicago, IL. 2005.

Orthodontic practice 33

CONTINUING EDUCATION

with aging. Upper airway obstruction is caused by collapse of pharyngeal structures during sleep. It is known that mouth breathing increases upper airway collapsibility during sleep and may contribute to the occurrence of sleep-disordered breathing.33 The presence of hypertension, cardiovascular disease, stroke, diabetes, and thyroid disease has been identified as factors that both result from and aggravate OSA.44 Mouth breathing in newly diagnosed sleep apnea patients is so prevalent that many sleep doctors start all their patients on CPAP therapy with a full-face mask. Fullface masks can be more challenging due to their sheer size. A larger mask frame and cushion create the greater possibility of leak simply because there is more surface area for potential leak. A mouth breather on CPAP has two choices — a full-face mask

REF: OP V11.4 FLANELL

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

Please allow 28 days for the issue of the certificates to be posted.

Lifetime effects of mouth breathing FLANELL

1. When performed correctly, nasal breathing also plays a role in the development of the maxilla and mandible to stabilize the _______. a. dental occlusion b. function c. muscle balance d. all of the above 2. Craniofacial development is largest within the first 4 years of life with ________ of development complete by 12 years of age. a. 25% b. 45% c. 75% d. 90%

a. “U-shaped b. “V-shaped” c. horseshoe-shaped d. both a and c 5. Sasaki, et al. (1977), noted that “Age group _______ seemed to represent a transitional period from obligate nasal breathing to potential oral tidal respiration. … This transition is important because it reflects a period of potential respiratory instability.” a. 4 to 6 months b. 12 to 14 months c. 18 to 20 months d. 24 to 26 months

3. Weber, et al., noted that in breastfed babies, the tongue action appeared to be a ________. a. rolling or peristaltic motion b. piston-like or squeezing motion c. deviate swallow motion d. tongue-thrust motion

6. In oral breathers, the chance of finding an asthmatic individual was almost _______ greater than in the control group. a. 4 times b. 8 times c. 12 times d. 20 times

4. Studies have shown that a high palate and narrow arch are good predictors of snoring and obstructive sleep apnea. This eventually leads to the poor alignment of teeth and the ________ palate found in many people with malocclusions.

7. When assessing for ADHD and complaints about school underachievement, da Costa, et al. (2015), found characteristics of snoring, nocturnal MB, _______, dark circles, and dry lips in more than half of their sample.

34 Orthodontic practice

a. rhinitis b. tonsillitis c. drool on the pillow d. all of the above 8. Fitzpatrick, et al. (2003), confirmed that during sleep, upper airway resistance during oral breathing was ________ than during nasal breathing. a. 2.5 times lower b. 2.5 times higher c. 4 times higher d. 10 times higher 9. Breathing through the nose increases the oxygen uptake ranging from _________ greater when compared with mouth breathing. a. 2 to 3 times b. 5 to 6 times c. 10 to 20 times d. 25 to 30 times 10. Patients reporting dry mouth upon awakening have a _______ risk of having OSA rather than having primary snoring and are even at a higher risk of having severe OSA. a. 2.33-fold greater b. 5.23-fold greater c. 8.65-fold greater d. 10.75-fold greater

Volume 11 Number 4

CE CREDITS

ORTHODONTIC PRACTICE CE

STEP-BY-STEP

Perfect band transfer and appliance every time using Aquaform Dr. Lloyd Taylor presents the complete Aquaform transfer technique

100%

accurate transfer models are required to produce perfectly fitting transpalatal bars, lingual arches, and palatal expansion appliances. When appliances do not fit, orthodontists and technicians blame each other. The problem is always the relationship of the molar bands to the transfer model. Aquaform easily and consistently solves this problem. Many orthodontists simply seat the bands in the impression or use sticky wax and wires to maintain band position. Unfortunately, bands often move as the impression is being poured. Using thermoplastic Aquaform as a lockedon transfer key positions the bands precisely in their correct relationship in the impression, resulting in a perfect transfer model every time.

Figure 1: Aquaform

Figures 2A and 2B: 2A. Fit well-adapted molar bands with welded buccal tubes. A lingual attachment will also help to retain the Aquaform cap. 2B. Drop 1/2 scoop of Aquaform into 180°F (always less than boiling water) for 20 seconds. Carefully remove the hot-fused Aquaform. Then knead with lightly wet or Vaseline®-coated gloves until the color is even

Figures 2C and 2D: 2C. Press a dime-sized piece of Aquaform firmly onto each buccal tube, across the occlusal surface and onto the lingual of the band. Use an air syringe to cool the Aquaform. 2D. Take a full-arch impression with either alginate or polyvinyl siloxane

Figure 2E: Remove the impression. The molar bands may remain on the teeth or may be removed with the impression

Figure 2F: If the Aquaform-capped bands remain on the teeth, each can be gently and carefully teased off the tooth as a single unit

Figures 2G and 2H: 2G. The Aquaform-capped bands can be accurately seated in the impression. The irregular Aquaform shape will both key and lock into the impression exactly as they were located on the teeth. 2H. Pour the impression, and then remove the model from the impression. The position of the bands on the model will be identical as they were in the mouth

Figures 2I and 2J: 2I. Place transfer model with Aquaform caps occlusal surface down into a mixing bowl with 1 inch of hot (always less than boiling) water for about 20 seconds to soften the Aquaform. Carefully pry off the Aquaform caps. 2J. The Aquaform caps have been removed from the molar bands. The molar bands are perfectly related to the transfer model

Lloyd R. Taylor, DDS, received his DDS degree from Fairleigh Dickinson Dental School. He first completed a 3-year residency in Oral and Maxillofacial Surgery and Anesthesiology and was Chief Resident at the Albert Einstein College of Medicine/Jacobi Hospital in New York City. Dr. Taylor then completed a 3-year Fellowship in Orthodontics at the Harvard School of Dental Medicine. He also completed an additional 3-year Fellowship in Orthodontic Teaching and Research at the Forsyth (Harvard) Dental Center. Dr. Taylor has practiced both Oral Surgery and Orthodontics in North Hollywood, California, for more than 50 years. Disclosure: Dr. Taylor is both the founder and president of OrthoSource since 1985.

Volume 11 Number 4

Figure 2K: A transpalatal bar is fabricated and soldered on the transfer model

Figure 2L: The custom appliance will seat perfectly on the teeth OP Orthodontic practice 35

TECHNOLOGY

Diagnosis and treatment plan of maxillary impacted canines using CBCT DICOM data Drs. Laura Nicolas, Alberto Teramoto, and Manuel Hinojosa discuss how segmentation can provide an essential diagnostic function Introduction An adequate treatment plan for resolving impacted teeth could be very difficult if the necessary information is not available. It is mandatory to know the exact location and, more importantly, the immediate relationships of the impacted teeth to surrounding teeth, roots, and even the mandibular nerve. After the third molars, maxillary canines have the highest frequency of impacted localization, with a prevalence ranging from 1% to 3%,1-4 and are more frequent in female patients by a ratio of 2:1.5 Surgical treatment, when necessary, is difficult and time-consuming when the clinician doesn’t have enough information. Thus, the accurate localization of impacted maxillary canines is very important when the clinician has to decide to treat orthodontically and especially if surgical intervention is required. Most of the time in daily practice, the first radiographic image required to support the clinical examination is the panoramic radiograph. And sometimes in order to have a better localization of impacted teeth, clinicians can improve diagnosis by using a combination of two or more bidimensional images — occlusal and periapical, which allow the localization of impacted canines, treatment planning, and evaluation of the treatment result.

Importance of CBCT It is well-known that the diagnostic accuracy of these bidimensional radiographic techniques presents many limitations, increasing the risk of mistakes. Adding a third dimension to the radiographic information may result in a better diagnostic approach and an improved treatment outcome — using

cone beam computed tomography (CBCT), clinicians can take advantage of 3D information provided by a low radiation dose and at relatively low cost. CBCT provides information that is not revealed during traditional radiographic analysis and is therefore indicated in case of impacted teeth or craniofacial structural anomalies. Sometimes even all of the 3D images are not enough because clinicians can use the CBCT data more efficiently. Another use of DICOM data is using segmentation — a process that separates structures of interest from the background and from each other. This process provides an essential analysis function for which numerous algorithms have been developed in the field of image processing; segmentation of an object is achieved either by identifying all pixels or voxels that belong to the object or by locating those that form its boundary. Segmenting teeth from CBCT images is not an easy procedure. Complications include the following: 1. DICOM data is acquired with the upper-lower jaw in occlusion, so it is hard to separate a tooth from its opposing teeth along their occlusal surface because of the lack of changes in gray values. 2. Separating a tooth from alveolar bone with similar densities is difficult. 3. Identifying and differentiating various teeth types is difficult when teeth possess a similar shape.

Some open-source software for segmentation is available on the market; however, the software entails a long learning curve and time to perform a high-quality segmentation. Recently, Artificial Intelligence technology, ORCA Dental AI, created a unique system in a 3D-controllable STL format that offers not only a teeth segmentation service, but also cephalometric and airway volume analyses and videos of teeth segmentation, making this process much more complete, easy to use, and completely informative in disclosing all the impacted relationships. For a better diagnostic approach and an improved treatment outcome, with the available data, it is also possible to convert the DICOM files of the CBCT to a model using a 3D printer (Zenith D DENTIS CO. LTD., La Palma, California). This very useful tool helps visualize and provide 3D visualization of conditions of impacted teeth and can help the clinician choose the best treatment plan. For example, it can offer more information on whether to perform orthodontic treatment to align an ectopic canine or whether the patient needs a surgical procedure because of the difficulty of aligning ectopic maxillary canines.

Figure 1A: Initial intraoral photos

Figure 1B: Panoramic X-ray

Cases Case 1 Because the position of the impacted canine root is close to the vestibular side, with extraction of the first premolar, it is easy to move the canine to its ideal position (Figures 1A-1H).

Drs. Laura Nicolas and Alberto Teramoto are from the Department of Orthodontics at the Universidad Latinoamericana Mexico City, Mexico. Dr. Manuel Hinojosa is from the Universidad Tecnológica de Mexico. Disclosure: The authors disclose that they have no financial interest in the products or techniques mentioned in this article.

36 Orthodontic practice

Volume 11 Number 4

TECHNOLOGY

Figures 1C-1E: 1C. Impacted upper canine CBCT image. 1D. Impacted upper canine segmentation (ORCA Dental AI). 1E. Impacted upper canine 3D impression

Case 2 The horizontal-position surgical option is the best choice for this right impacted canine. This is more obvious with this imaging option (Figures 2A-2F).

Conclusions CBCT is a useful tool for clinical situations such as impacted canines, craniofacial anomalies, TMJ assessment, and upper airway analysis. CBCT images in combination with 3D segmentation, impressions, and videos provide a better diagnosis and are useful in deciding whether to treat these cases orthodontically or surgically. Figures 1F-1H: 1F. Leveling and aligning of impacted canine in 4 months. 1G and 1H. CBCT Segmentation — before and after (ORCA Dental AI)

Adding a third dimension to the radiographic information may result in a better diagnostic approach and an improved treatment outcome.

Acknowledgments Special thanks to ORCA Dental AI for the segmentation process in STL format, video, airway, and cephalometric analysis and to Ideas Dentales, Mexico City, Mexico, for printing 3D models. OP REFERENCES 1. Mason C, Papadakou P, Roberts GJ. The radiographic localization of impacted maxillary canines: a comparison of methods. Eur J Orthod. 2001;23(1):25-34. 2. Preda L, La Fianza A, Di Maggio EM, et al. The use of spiral computed tomography in the localization of impacted maxillary canines. Dentomaxillofac Radiol. 1997;26(4):236-241. 3.

Stewart JA, Heo G, Glover KE, et al. Factors that relate to treatment duration for patients with palatally impacted maxillary canines. Am J Orthod Dentofacial Orthop. 2001;119(3):216-225.

4. Walker L, Enciso R, Mah J. Three-dimensional localization of maxillary canines with cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2005;128(4):418-423. 5. Peck S, Peck L, Kataja M. The palatally displaced canine as a dental anomaly of genetic origin. Angle Orthod. 1994;64(4):249-256. 6. Ericson S, Kurol J. CT diagnosis of ectopically erupting maxillary canines — a case repost. Eur J Orthod. 1988;10(2):115-121.

Figure 2A: Intraoral photos

Figure 2B: Panoramic X-ray

Figure 2C: CBCT image of bilateral impacted canines

Figures 2D-2F: 2D. Impacted right and left 3D impressions — frontal view. 2E. Impacted right and left 3D impressions — occlusal view. 2F. Impacted right and left 3D impressions — right side view

Volume 11 Number 4

Orthodontic practice 37

PRACTICE MANAGEMENT

The power of efficiency Dr. Amy B. Jackson offers guidance on how to leave a time of uncertainty and get on the path to profitability

here is no question that COVID-19 has taught us a few things about how we live life and take things for granted. On the other hand, this pandemic has also taught us how to be creative again! Some of us have converted to a work-from-home lifestyle, while others were compelled to be resourceful and find new ways to make money altogether. Virtual meetings and hangouts have become the new norm, and most of us have taken a crash course in homeschooling our kids. In short, COVID19 has changed our lives.

If you spend all of your time on the less significant appointments, you will run out of room for those that are vital to the success of your practice.

Keep swimming We are leaving a time of certainty and entering a time of equal uncertainty. Many of us are left wondering how we will approach the same “business as usual” mindset as before. The answer may not be that simple. Two dozen species, including the great white, the whale shark, and the mako shark, are known as “obligate ram ventilators,” meaning it is essential for them to keep moving to stay alive. Obligate ram ventilators pass water through their opened mouths and over the gills while in constant swimming motion so as not to asphyxiate. However, if for some reason the sharks decided to stop swimming, oxygen could not pass through their gills, and they would sink and die. Much like the sharks, as orthodontists we must keep moving forward and continue engaging. Nevertheless, in this post-COVID-19 atmosphere, we must also evolve and seek solutions to patient and practice problems. Adaptability will be the key to success, and that starts with efficient scheduling.

Scheduling efficiently With the unwelcome guest of COVID19, we were forced to close our offices for

weeks, causing a backlog of patients. Now, as we reopen, we must somehow find a way to accommodate existing appointments and the patients who were canceled, all the while making room for production. Whether you are a young practitioner with a lean team or a seasoned orthodontist with limited openings in your schedule, it is imperative to your financial success that you leave space in your schedule to accommodate lengthier, more productive appointments. Consider your daily schedule to be like a jar of time, which will be filled with rocks, sand, and pebbles. In this example, the sand represents the small and sometimes unnecessary appointments; the pebbles are the necessary appointments; and the rocks are important and productive appointments. If you fill up the jar with sand and spend all of your time on the less significant appointments, you will run out of room for those that are vital to the success of your practice.

Dr. Amy B. Jackson is a Board-certified orthodontist who graduated Magna Cum Laude from Baylor University and began her dental career in Houston where she attended The University of Texas Health Science Center. While at Houston, she was awarded a summer Research Fellowship from the AADR and the Barnard G. Sarnat Award in Craniofacial Biology from the IADR. Dr. Jackson continued her specialty training for orthodontics at The University of Texas Health Science Center in San Antonio. Her resident training included a master’s degree through the periodontal department and a research grant through the AAED for her published work with midpalatal implants. Disclosure: Forestadent has partnered with her and her program Retainers For Life®/After Ortho Revenue™

38 Orthodontic practice

In other words, maximize every face-toface interaction with your patients, and put considerable thought into ways to free up chair time. As I work to redefine my schedule building on rocks and pebbles, I have found a few of the strategies below helpful: • Deliver all aligners to the patient on the day of attachment delivery — with emphasis on patients carrying their attachment template and bringing it in when a repair is needed. • Instruct your front-desk administrators to triage patient calls and communicate those appointments that do not need immediate attention. We use the Weave software (Lehi, Utah) and ask patients to send images for more detailed correspondence. • Fully implement and utilize Voice over Internet Protocol (VoIP): VoIP is a method that utilizes a group of technologies for the delivery of voice communications over Internet Protocol networks, such as the Internet. This allows the team to text/ communicate with a phone or office computer. The average phone call takes 2 minutes, whereas a single text takes only 4 to 5 seconds. This change in protocol has allowed for 10 Volume 11 Number 4

•

the bonding process to minimize breakage from occlusal interferences. • Partner with After Ortho Revenue™ powered by Retainers for Life® to eliminate nonessential retainer appointments and minimize retainer emergencies. • Deploy self-ligating brackets into the practice with an emphasis on educating the patients about their value in combination with memoryshape wires to minimize the in-office appointments needed. Time is the great equalizer. Choose how you spend your time wisely in order to position yourself to achieve your goals and maximize your practice profitability and customer satisfaction. It is time for all of us to redefine what we do, how we do it, and take back our time.

Summary In a post-COVID-19 world, we need to make decisions that are smart, save time, and lead us to financially solid ground. As

we move forward, this is an opportunity to set our intentions for the future, so take this time to improve your office systems. • Implement a plan to reduce chair time. • Eliminate paper in your office. • Weave virtual assessments into your everyday routine. • Add additional revenue without adding additional patients to your practice with After Ortho Revenue® powered by Retainers for Life™. Although we all need to keep moving forward, the objective is to do so in a more thoughtful, productive, and streamlined manner. Don’t tread water — swim so that your business will not only survive, but also THRIVE! For more information about Virtual Orthodontic, text or call 707-365-5622; Weave software, text or call 210-493-6067 after 6 p.m. CST for a complimentary consultation; and Retainers for Life, visit afterortho revenue.com. OP

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times the efficiency in inbound and outbound communications. Arrange virtual visits for every other observation appointment, retainer checks, expander evaluations, and aligner advice. We have used WhatsApp and Virtual Orthodontic Visit (VOV) (San Antonio, Texas) at virtual orthodonticvisit.com Eliminate as much paper as possible and create a portal so that all necessary paperwork is completed before the patient arrives at the office. With the help of your management software and DocuSign®, this can become a reality. Offload color-change appointments and hygiene checks to nonessential days or virtual interactions. Hire a dental professional to handle appointments that don’t require your expertise such as scans and braces removal. Make bite turbos a regular part of

Orthodontic practice 39

SERVICE PROFILE

The clock is ticking on practice values Chip Fichtner discusses how to grow a practice bigger, better, and faster

ery profitable orthodontic practices have achieved values of 2 times and 3 times plus collections from silent partners when properly advised, even during the COVID era. Practice values vary based upon multiple factors including profitability, growth rate, location, response to COVID-19, and most importantly, the doctor or doctors. Many orthodontists are considering monetizing part of their practices in 2020. Reasons include expected tax increases in 2021, help navigating the impact of COVID19, a desire to put millions in their pockets, and the security of having a large and resourceful partner eager to drive growth. Silent partners are continuing to invest in great orthodontic practices today at what is close to 2019 bubble values. The Invisible Dental Support Organizations (IDSO) are buying between 60% and 90% of larger practices for cash now, with the doctor retaining ownership in either the practice, the IDSO, or both. The essential business model of an IDSO is doctor ownership in the practice. While doctors own part of dozens or hundreds of practices across the country, each practice has an owner-doctor and operates under the doctor’s brand, team, and strategy. Ownerled practices outperform employee-doctor managed practices. The IDSO is also the known buyer for the doctors’ retained ownership when ready to retire. The benefits to orthodontists of an IDSO partner are even more powerful as practices navigate the COVID-19 era. Their resources now include assistance in compliance with a myriad of new rules, procedures, and regulations. Historically, doctors were thrilled to monetize a part of their life’s work with cash at low capital gains tax rates, yet retain significant upside potential through equity ownership. But today, an IDSO partner is even more valuable.

Chip Fichtner is the founder of Large Practice Sales, which specializes in invisible DSO transactions for large practices of all specialties. The company has completed more than $100 million of transactions in the past 6 months. Learn more at www.findmyorthodonticidso.com.

40 Orthodontic practice

While an IDSO adds value from reductions in supplies and team benefit costs, many orthodontists are also excited to gain a partner with experienced, internal marketing teams. Direct-to-consumer newpatient generation tactics are needed now more than ever to drive the growth of your practice. An IDSO’s professional marketing and management team can enable doctors to increase market share in their community and ride the new wave of adult orthodontics created by SmileDirectClub and others. Interestingly, doctors as young as in their 30s are discovering that IDSO relationships can help them grow “bigger, better, faster” with an IDSO partner’s capital and resources. The right IDSO can help the doctor create more long-term net worth than remaining independent. In part thanks to COVID19, young doctors with a growth plan will have the opportunity to buy older doctors’ complementary or competitive practices at bargain values. An IDSO partner can finance and facilitate these transactions for their partner doctors. A common question among doctors exploring an IDSO partnership is, What changes? The answer depends upon the IDSO chosen by the doctor as each one is

different. However, without exception, the doctor makes 100% of the clinical decisions impacting patient care. Finding the right IDSO is similar to a dating process. You will want to meet with several, not only to find the right fit, but also to create a competition between the IDSO bidders to ensure that you achieve maximum value. Value in an IDSO transaction is not only a function of the up-front cash, but also the long-term value of your retained ownership. Many doctors have made far more profit on the retained ownership than the gain on the initial transaction. The key is to choose the right partner and fully understand the future. Financial stability at the moment is critical. The process to understand the potential value of your practice in an IDSO transaction is confidential, simple, and without cost, obligation, or risk. In the worst-case scenario, you will learn something new. Many doctors are shocked at what is possible. While the dental industry is changing, it will pay for doctors to explore all options to grow and prosper in the coming years. IDSOs may or may not be an avenue for every doctor, but now that IDSOs are in all 50 states, every wise doctor will want to understand them. OP Volume 11 Number 4

NOW IS THE TIME... To Monetize Part of Your Practice Value (While Silent Partners are Still Eager to Invest) Invisible Dental Support Organizations buy 60% - 90% of your practice for cash up front. You remain as an owner, operating under your brand with your team. Stay for five to 20+ years with a known exit. Large partners provide you with the resources to grow bigger, better, faster, cheaper and compete more effectively. Register for the upcoming webinar exclusively for Orthodontists. Live Q & A after presentation.

August 6, 2020 at 7:00 PM EDT

www.FindMyOrthodonticIDSO.com

COVID-19 Update - Orthodontic Practice Values NOW - Why it’s Changing

We are still achieving incredible values for practices.

Recent Orthodontic Practice Transactions One-Doctor Practices:

Two-Doctor Practices:

Three-Doctor Practices:

2.4X Collections

1.7X Collections

2.2X Collections

2.6X Collections

2.1X Collections

3.0X Collections

3.5X Collections

3.4X Collections

Every Transaction Customized

Gain Capital For Growth • Known Exit When You’re Ready • Remain as Practice Owner • Your Team, Your Brand Visit FindMyOrthodonticIDSO.com to register for the next webinar. Call 844-734-8533 or email OPUS@LargePracticeSales.com to arrange a confidential discussion with an LPS principal. You may be surprised...

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