Orthodontic Practice US Fall 2021 Vol 12 No 3

PROMOTING EXCELLENCE IN ORTHODONTICS

Asking the right questions about airway in orthodontics Drs. Barry D. Raphael, Mark A. Cruz, Richard D. Roblee, and Ellen Crean-Binion

Chronic pain and sleep — it’s not that simple

Sleep, orthodontics, and myofunctional therapy Sharon Moore

Scott Peterson

Sleep medicine is a young science Drs. Barry Glassman and Don Malizia

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Airway = where optimal Health and Beauty intersect

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INTRODUCTION

Skeletal deficiency treatments yield positive results

Fall 2021 - Volume 12 Number 3

EDITORIAL ADVISORS Lisa Alvetro, DDS, MSD

O

bstructive sleep apnea (OSA) and chronic facial pain are highly comorbid and common.

In the United States and throughout the world, the prevalence of OSA is increasing.1 Approximately 34% and 17% of middle-aged men and women, respectively, meet the diagnostic criteria for OSA.2 OSA is widely underdiagnosed — 86% to 95% of individuals found in population surveys with clinically significant OSA report no prior OSA diagnosis.3 OSA prevalence is as high as 40% to 80% in patients with hypertension, heart failure (HF), coronary artery disease, pulmonary hypertension (PH), atrial fibrillation (AF), and stroke.4 One in six adults who visited a general dentist during 2015 experienced chronic facial pain. Pain in the muscles and temporomandibular joints was reported as frequently as that in the teeth and surrounding tissues in patients visiting general dentists.5 A meta-analysis of world literature has found that one in six children and adolescents has clinical signs of temporomandibular joint (TMJ) disorders.6 Over 23% of preschool-aged children have pain when chewing and jaw joint noises.7 All jaw joint noises are pathologic.

An established relationship exists between OSA and TMD that is evident in the prevalence rates that are bidirectional. There is an increased prevalence of TMD in patients diagnosed with OSA.8 There is an increased prevalence of OSA in patients diagnosed with TMD.9 Two studies10 tested the hypothesis that OSA signs and symptoms were associated with TMD: The Orofacial Pain Prospective Evaluation and Risk Assessment Study (OPPERA) prospective cohort study of adults aged 18 to 44 years at enrollment (n 2604) and The OPPERA case — control study of chronic TMD (n 1716). Both studies supported a significant association between OSA symptoms and TMD, with prospective cohort evidence finding that OSA symptoms preceded first onset of TMD. Patients with two or more signs and/or symptoms of OSA had a 73% greater incidence of first-onset TMD. Nasal obstruction that results in mouth breathing has recently been found to be highly comorbid with chronic facial pain. A study of almost 1,400 patients that has been accepted for publication (General Dentistry) found that patients with nasal valve compromise had a 7 times greater risk of facial pain. Nasal valve compromise is the result of an undeveloped maxilla. A recent study showed that maxillary expansion resulted in improved internal nasal valve and obstructive nasal symptoms in children evaluated by Nasal Obstruction Symptom Evaluation (NOSE) scores.11 Forward Head Posture (FHP) has also been found to be related to bruxism and nasal obstruction in children. “Bruxism seems to be related to altered natural head posture and more intense dental wear. A more anterior and downward head tilt was found in the bruxist group, with statistically significant differences compared to controls.”12 Bruxism in children has been found to be related to RERA and OSA.13 Expansion of the maxilla in mouth-breathing children restores proper nasal breathing and uprights the head.14,15 Surgical retrusion of the mandible in prognathic conditions results in significant FHP, perhaps in defense of a compromised oropharyngeal airway.16 Children diagnosed with migraine are 8.25 times more likely to have a sleep-breathing disorder, whereas children diagnosed with chronic tension-type headache are 15.23 times more likely to have a sleep-breathing disorder.17 Breathing disorders worsen with time. We must screen every child currently in orthodontic/orthopedic care, and those that are in need of such care. The BEARS screening tool or the validated Pediatric Screening Questionnaire (PSQ) are excellent for this purpose. The question that we are left with is, What are we treating to? The answer to that was given to us by the seminal figure in pediatric sleep medicine, Dr. Christian Guilleminault (Stanford).

He states, “Elimination of oral breathing, i.e., restoration or nasal breathing during wake and sleep, may be the only valid end point when treating OSA.”18 Treatment for skeletal deficiency (orthopedic/orthodontic development), will result in improved breathing, reduction of facial pain, headaches, and bruxism. Dentofacial orthopedics started as early as possible is the key to improving quality of life.

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 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 Laurence Jerrold, DDS, JD, ABO Marc S. Lemchen, DDS Edward Y. Lin, DDS, MS Thomas J. Marcel, DDS Mark W. McDonough, DMD Randall C. Moles, DDS, MS Elliott M. Moskowitz, DDS, MSd, CDE Rohit C.L. Sachdeva, BDS, M.dentSc Gerald S. Samson, DDS Margherita Santoro, DDS Shalin R. Shah, DMD 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 Bradford N. Edgren, DDS, MS, FACD Fred Stewart Feld, DMD Gregori M. Kurtzman, DDS, MAGD, FPFA, FACD, FADI, DICOI, DADIA Justin D. Moody, DDS, DABOI, DICOI Lisa Moler (Publisher) Mali Schantz-Feld, MA, CDE (Managing Editor) Lou Shuman, DMD, CAGS

References available upon request.

Steven Olmos, DDS, has been in private practice for more than 30 years, with the last 25 years devoted to research and treatment of craniofacial pain and sleep-related breathing disorders. He obtained his dental degree from the University of Southern California School of Dentistry and is Board Certified in both chronic pain and sleep breathing disorders by the American Board of Craniofacial Pain, American Board of Dental Sleep Medicine, and American Board of Craniofacial Pain and Dental Sleep Medicine. Dr. Olmos is the founder of TMJ & Sleep Therapy Centres International, with over 60 licensed locations in seven countries dedicated exclusively to the diagnosis and treatment of craniofacial pain and sleep disorders.

© MedMark, LLC 2021. 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.

ISSN number 2372-8396

2 Orthodontic practice

Volume 12 Number 3

Take the next steps in running a better business Visit Gaidge.com or Call 800.287.3396

TABLE OF CONTENTS

Before

3 month progress

Cover story

10

Asking the right questions about airway in orthodontics

Drs. Barry D. Raphael, Mark A. Cruz, Richard D. Roblee, and Ellen CreanBinion discuss how structure, function, and behavior affect airflow

Publisher’s perspective Off the roller coaster — a positive outlook, fresh goals, and renewed focus on success Lisa Moler, Founder/Publisher, MedMark Media................................8

Orthodontic concepts Chronic pain and sleep — it’s not that simple Scott Peterson discusses the complicated connection between sleep and chronic pain..................... 24

Orthodontic concepts

16

Facemask midfacial protraction — an overview Dr. Duane Grummons discusses the benefits of Facemask therapy ON THE COVER Cover image courtesy of Airway Collaborative. Article begins on page 10.

4 Orthodontic practice

Volume 12 Number 3

TABLE OF CONTENTS

Continuing education Sleep, orthodontics, and myofunctional therapy Speech pathologist Sharon Moore discusses orofacial-nasal-pharyngeal function in the management of sleepdisordered breathing....................... 32

Event recap LF FUTURE conference LightForce Orthodontics first user conference focuses on customer collaboration....................................40

Continuing education Basic principle review of sleep medicine

26

Drs. Barry Glassman and Don Malizia delve into sleep-breathing disorders and the orthodontists’ role in this medical subspecialty

Service profile Data-driven decision-making for competitive advantage Suzanne Wilson discusses how the right information can affect real, positive change in your business ....................................................... 44

News and views LightForce Orthodontics welcomes new chief operating officer, Kelly Cunning Riedel

Product profile Retainers For Life® Stop saying goodbye to your patients ....................................................... 48

....................................................... 46

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

6 Orthodontic practice

Volume 12 Number 3

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PUBLISHER’S PERSPECTIVE

Off the roller coaster — a positive outlook, fresh goals, and renewed focus on success

I

n looking back, most of us felt that last year was a roller coaster ride. We got shoved into that buggy, fastened our seat belts, and hung on. Dentists hurtled around all of the new rules and regulations that were unveiled each day. You skidded around corners that held unknown aerosol dangers, careened past roadblocks to business operations, and avoided the twists and turns of offering emergency care to patients when the definition of emergency care was still evolving. It was a white-knuckle ride, for sure. But through the highs and lows and learning curves, we emerged definitely wiser and more resilient.

Here at MedMark, even at the height of the pandemic, Lisa Moler we brought you the most up-to-date information on how to Founder/Publisher, MedMark Media protect your patients and staff and prepare for reopening. We anticipated and tracked the new trends and technologies that patients would be expecting. We checked on our readers and authors through emails, texts, and Zooms. We saw you calmly focus on keeping in touch with patients through teledentistry, informative texts, and website updates. You prepared protective equipment to be able to provide emergency care, consulting, and treatment plans for when the crisis was over.

Now we are joyfully hearing about your safe returns to business. And our articles reflect our goal of helping you flourish in the future. Our cover story by Dr. Barry D. Raphael and colleagues delves into airway issues, and how structure, function, and behavior affect airflow.

Our two CEs are related to the evolving subspecialty of sleep dentistry. Drs. Barry Glassman and Don Malizia offer a close-up view of sleep-breathing disorders, from signs and symptoms of sleep-disordered breathing to the role of dentists in the treatment process. Speech pathologist Sharon Moore discusses the orofacial-pharyngeal function in the management of sleep-disordered breathing and how myofunctional therapy can provide solutions for sleeprelated breathing disorders. Dr. Duane Grummons’ article describes Class III nasomaxillary respiratory corrective orthopedics with the Grummons Facemask.

With this fall issue, the new view from the top is exciting. We are thrilled to be able to say that we made it. We’re no longer anticipating what is coming around each bend. And we are ready to take a new plunge — into the future. I’m proud and amazed at the perseverance and courage that we all saw in the dental profession. With a positive outlook, fresh goals, and renewed focus on success — the MedMark team is bracing for new adventures!

To your best success, Lisa Moler Founder/Publisher MedMark Media

Published by

PUBLISHER Lisa Moler lmoler@medmarkmedia.com DIRECTOR OF OPERATIONS Don Gardner don@medmarkmedia.com MANAGING EDITOR Mali Schantz-Feld, MA, CDE 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 WEBMASTER Mike Campbell webmaster@medmarkmedia.com EMEDIA COORDINATOR Michelle Britzius emedia@medmarkmedia.com SOCIAL MEDIA & PR MANAGER April Gutierrez socialmedia@medmarkmedia.com FRONT OFFICE ADMINISTRATOR Melissa Minnick melissa@medmarkmedia.com MedMark, LLC 15720 N. Greenway-Hayden Loop #9 Scottsdale, AZ 85260 Tel: (480) 621-8955 Toll-free: (866) 579-9496 www.medmarkmedia.com www.orthopracticeus.com SUBSCRIPTION RATES 1 year (4 issues) $149 Subscribe at https://orthopracticeus.com/subscribe/

8 Orthodontic practice

Volume 12 Number 3

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COVER STORY

Asking the right questions about airway in orthodontics Drs. Barry D. Raphael, Mark A. Cruz, Richard D. Roblee, and Ellen Crean-Binion discuss how structure, function, and behavior affect airflow The wrong question The amount of time orthodontists have wasted polarizing around issues such as extraction versus nonextraction, one-phase versus two-phase, and now around the issue of “airway orthodontics” attests to an overall lack of understanding of the bigger picture of a patient’s health. It’s like arguing over whether light is a particle or a wave.

The duality around airway that is causing so much consternation is whether the problem is 1) obstructive sleep apnea — a condition that causes momentary and repeated cessation of breathing throughout the night, or 2) airway flow limitation leading to sleep fragmentation, in which narrowing of the airway anywhere from the tip of the nose to the bottom of the throat makes it harder to breathe day or night.

Nobel-winning biochemist Albert SzentGyorgi said, “Science is built on the premise that nature answers intelligent questions intelligently; so if no answer exists, there must be something wrong with the question.”

Barry D. Raphael, DMD, has been an orthodontist in Clifton, New Jersey, for over 30 years. He is the owner of the Center for Integrative Orthodontics and the newly opened Center for Integrative Education. His concentration on airway-focused orthodontics came late in his career but has now dramatically changed the way he practices. He teaches these concepts for the Mt. Sinai School of Medicine in New York City, on the lecture circuit, and at the Center.

Mark A. Cruz, DDS, graduated from the UCLA School of Dentistry in 1986 and has served on the National Institute of Health/NIDCR grant review Committee) as well as the editorial board for the Journal of Evidence Based Dental Practice (Elsevier). More recently, Dr Cruz sat on the ADA task force looking at pediatric airway health and is focused on the medical indications for airway focused dental interventions for both pediatric and adult patients.

Ellen Crean-Binion, MS, DDS, PhD, is the cofounder and Chief Operating Officer of Be Well Collaborative Care. Dr. Crean-Binion holds a bachelor’s degree in Dental Hygiene, a master’s degree in Healthcare Administration, a doctorate in Dental Surgery, and a doctorate in Neuro0biology with an emphasis in sleep medicine.

She has spent over 25 years in the medical, dental, and allied health fields creating and providing interdisciplinary collaborative approaches to patient care.

Richard D. Roblee, DDS, MS, graduated from Baylor College of Dentistry and quickly became renowned for his work in Esthetic and Restorative Dentistry in Dallas, Texas. He is a Diplomate of the American Board of Orthodontics, a distinction that less than 20% of practicing orthodontists receive. He has given more than 500 lectures around the globe. He is also a leader in several exciting new areas of dentistry, including Surgically Facilitated Orthodontic Therapy and Airway Centered Growth and Development.

10 Orthodontic practice

So let’s take a look at the question surrounding airway orthodontics, and how changing our approach may lead us to some useful clinical guidelines.

Many orthodontic thought leaders, including the American Association of Orthodontists, frame the question of airway in terms of the teeth and malocclusion. They ask: Does sleep apnea cause malocclusion?

Does malocclusion cause sleep apnea? Can orthodontics cause or cure sleep apnea?

Since the evidence is equivocal, many have stopped their questioning there and dismissed the issue of airway altogether. But perhaps there is something wrong with the questions.

Reframing the question The question does not directly involve the teeth or malocclusion at all. And it only tangentially involves sleep. The question involves breathing and only breathing. The operant question is: What is a healthy, functioning airway? And what perturbs it?

Breathing, as we all know, is a biological imperative. Moment to moment, it is the most important behavior we do since it feeds every cell in our body with the oxygen it needs and helps to regulate blood pH, which controls the delivery of oxygen to the cells.

An optimal breathing pattern is done through the nose, where the air is conditioned before entering the lungs, powered by the diaphragm so as to fill the entire lung with little effort, and at just the right rate and volume, to get just what the body needs. Breathing should be easy, silent, and through the nose most of the time.1,18 These optimal behaviors, or competencies, have developed through evolution (or by creation, if you will) to allow us to survive.

If our breathing suddenly stops, we can’t go for more than a few seconds before our brains go into survival mode and activate the sympathetic nervous system. The hypothalamic-pituitary-adrenal (HPA) axis is extremely sensitive to blood oxygenation and will react immediately to protect the body in any way possible if breathing falters.2 Behaviors that are adopted by the body to protect or restore oxygen levels are necessary

for our survival. If someone blocks your nose and mouth, for instance, you will immediately go into fight/flight/fix mode to change that condition. The same thing happens at night if the airway narrows. The response is immediate and sometimes extreme. In obstructive sleep apnea, there is a delayed response to this threat (hence the cessation of breathing), but eventually, the body will arouse itself and continue breathing if it is to survive.3,4 Frequently, however, there are chronic threats to the airway that don’t rise to the level of immediate survival but do challenge the level of blood oxygen and oxygen delivery on a chronic basis. Chronic threats to airflow include anything that narrows the airway and makes breathing more effortful, which is very pro-inflammatory. We will look more closely at these threats in a moment.

It is important to note that chronic threats to breathing require persistent, chronic behaviors to mitigate oxygen level over time. These suboptimal behaviors are called compensations, and they successfully overcome the chronic threat. When compensations need to be used habitually, they have side effects — unintended consequences — that become chronic problems themselves. It is important to look at both the compensations and their consequences in order to frame our questions about the airway properly.

Compensations and consequences Both compensations and consequences can be characterized in three domains: structure, function, and behavior. Here is a brief description of how each relates to breathing.

Structure refers to the anatomy of the airway — specifically it’s size, shape, and contours. Ideally, air should flow from the tip of the nose to the bottom of the throat in an easy, laminar flow pattern.1 Even around the nasal turbinates that “turbulate” the air to spin particulate matter into the mucous for filtering, the air should flow easily.

Where there is a narrowing of the airway, the air will swirl and become turbulent. This creates a negative pressure gradient that pulls on the sides of the airway making it even more narrow. If the tissue is resilient, it might flutter (i.e., snoring), but if it is not, it might Volume 12 Number 3

Volume 12 Number 3

the face and a suboptimal face that worsens airway function.10 Poor airway function can lead to chronic intermittent hypoxia that can affect any and all systems of the body. In children, it can damage the growing brain, interfere with sleep, and aggravate neurocognitive and behavioral development.11 In adults, it can lead to comorbidities in any system of the body, along with global pain and dysfunction. It is a vicious cycle of compensation and consequence that must be interrupted if a patient is to have their distress relieved.

Another unintended consequence of poor skeletal form is malocclusion. Teeth cannot fit into a container that is misshapen. The symptom of malocclusion is completely independent of the symptom of air flow limitation. Malocclusion and flow limitation may have a common origin in skeletal distortion, but there is no direct connection. This is why the research is equivocal. Studies that look to prove a connection (or lack thereof) between two things that are not connected are looking in the wrong place.

The role of the orthodontist: breaking the cycle All orthodontists are familiar with the term “adenoid faces.” It is a condition that has been described in the literature for over a hundred years and has been researched extensively. We know that this phenotype (the final expression of the genes) produces a particular dental malocclusion — the high angle open bite — that is particularly difficult to correct. This phenotype did not exist in our ancestors. 21-25, 27 The adenoid face is not the only phenotype that occurs with airway dysfunction.

Various compensations can lead to a variety of phenotypes, including open bites, deep bites, vertical excess, and the full range of angle classifications.12-16 This phenomenon was amply demonstrated by Egil Harvold’s monkey studies where each monkey developed a different facial distortion from the one experimental etiology: complete nasal obstruction. We also see this in humans who have mouth breathing and open mouth posture. How can it be that one etiology can lead to so many different facial phenotypes?

To solve this dilemma, we must revise yet another concept that orthodontists have been polarizing about since the profession began: nature vs. nurture.

While there are genetic influences to facial shape, the modern study of epigenetics only describes how genes are expressed based on their interaction with the environment, making this duality moot. As stated by Susan Herring, the idea that “bone genes’’ determine a person’s facial shape is not only simplistic but also, for the most part, false.

Both genetic and environmental factors are at play.17 We cannot control the genetics, but we can control the environmental input to the genes. The role of the orthodontist must focus on optimizing facial growth by changing the inputs that influence it. That is, by reducing the need for compensations and by guiding the behaviors that stimulate growth and its vector, we can change the way the entire face grows. Another way of saying the same thing is that there are no genes that code for crooked teeth or dental crowding per se.

The teeth are just innocent bystanders of a form/function/behavior cycle. The way teeth settle into place is just an unintended consequence of the way the jaws take form; the way the jaws take form is an unintended consequence of poor function; and poor function is most often a consequence of a struggle to breathe easily from very early on in life. Malocclusion is just a symptom of this process.

Interrupting the form/function/behavior cycle is the most important thing an orthodontist can do for people’s health, no matter their age or stage of dental development; but the earlier the problem or trend is recognized, the better. No longer can we polarize around the form versus function issue. To get a child on a trajectory toward an optimal airway, we must address both form (by reshaping anatomy toward ideal) and function (by improving physiology and behavior).

When the American Dental Association says that we must help children “develop an optimal physiologic airway and breathing pattern,” we have to lessen constriction of the airway anatomy, mitigate harmful physiological challenges, and teach appropriate behaviors for optimal wellness not only when we treat malocclusion, but throughout life. This is how the cycle is broken and redirected toward health.

Yes, creating a beautiful smile and a pretty yearbook picture has its value, but it can no longer be a justification for ignoring other matters. Good structure can be beautiful, but straight teeth in a deficient structure is itself a compensation and prone to relapse over time. Focusing on optimizing the airway gives the orthodontist a better foundation for a beautiful smile and optimal facial balance beyond the dental component/teeth.

Seeing the problem Once we learn to see the compensations and consequences of poor breathing, we never look at a growing face in quite the same way. Instead of seeing a child’s face as a static phenotype, we now see the dynamic process a child is going through. We don’t just see what a child is but what they are Orthodontic practice 11

COVER STORY

close up. In either case, it takes more physical effort to pull air through the narrow spot. (Try breathing through a drinking straw to feel it.) During the day, this leads to fatigue. During the night, it leads to fragmented sleep.5,6 Turbulence makes it all the more effortful to breathe and triggers compensations.

Structural malformations that cause turbulence include: • collapsed or narrow nostrils • a deviated nasal septum • a narrow nasal aperture (as part of a narrow maxilla) • a constricted pharynx (as a result of a deficient maxilla and/or retrognathic mandible)19,20 These anatomic distortions are primary risk factors for airway flow limitation.

Function refers to the physiology of the airway. Any soft tissue enlargement that narrows the airway with swelling, mucous, adipose tissue, and inflammation leads to more turbulence. Allergies and food sensitivities, frequent colds and infections, swollen lymph tissue, fat deposits at the base of the tongue, swollen mucosa around the turbinates, polyps, cysts, and tumors get in the way. Acid from reflux irritates the throat, nose, and sinuses, making them swell.

Narrow airways can lead to eustachian tube stenosis, conductive hearing loss, recurrent otitis media, and dysfunction.7 Obstructions are risk factors for airway flow limitation.

Behavior is the most overlooked and misunderstood component of airway dysfunction. Orthodontists, in their quest for a perfect occlusion, do everything they can to eliminate cooperation from the equation of their treatment planning. Talking about “behavior” is anathema. Unfortunately, this resistance has blocked progress on this issue.

Airway-focused orthodontists, however, realize that compensations and behaviors lie at the root cause of breathing dysfunctions and, therefore, must be considered when trying to establish a long-term cure. Leaving compensations at play means leaving their consequences at play, including treatment instability. Dysfunctional breathing and poor tongue posture and function are risk factors for airway flow limitation.

Common examples of compensations at night include mouth breathing, faster breathing, a faster resting heart rate, short bursts of very rapid heart rate, heavy breathing, forward head posture, stomach sleeping, tossing and turning, frequent awakenings, nightmares, and more.8,9 Any time the lips are apart or any time you can hear breathing — snoring or not — that person is in airway distress.

The unintended consequence of airway dysfunction is a distortion of the shape of

COVER STORY becoming (and will continue to become if nothing is done).

The tools for assessment focus not on the teeth, but on anything that causes turbulence in the airway.

We measure the way they breathe during the day as well as at night and understand the compensations they have adopted (behavioral capnometry). We have to be able to spot open mouth posture from

across the room. We try to figure out why they adopted their compensations, and why their habits linger. We understand the pervasive influence of soft tissue dysfunction on the entire system. Videos help us learn to

Structure (Figure 1) The CBCT allows us a better view of the midfacial collapse that so often occurs in orthodontic cases. We are able to see the nasal fossa from front to back and visualize obstructions. The shape and size of the airway is now readily apparent.

Many orthodontists that “do airway” talk about a “narrow palate,” as if that’s the key to the airway. It is an important finding, but we have to realize that the narrow palate is just one aspect of the collapse of the entire maxilla. The two photos on the upper right of Figure 2 are from the same boy. This is a deformity of the entire maxilla, not just the palate.

We now pay more attention to the overall shape of the face, comparing it to not just a random sample of peers, but to pre-industrial skeletal samples when there was very little malocclusion in the population, or to samples of children that grew up with naturally straight teeth from the Bolton-Brush database. Now we see just how deficient the lower third of the face has become in more modern times.

Figure 1: Structure

Function (Figure 2) The collapse of the airway happens most easily at night, so we need to be able to measure fragmented sleep (pulse oximetry), audible breathing (snore recording), and how airway collapse affects daytime and nighttime experience (sleep inventory).

History focuses on inflammation, swelling, allergy, mucous, or irritation in the airway. We need to know if a child has difficulty with nasal breathing at all. We look at the tongue as an airway dilator muscle and measure its function with pressure sensors.

We record and measure how the lips, chin, and cheeks are used for swallowing, and how they affect the balance of forces in the mouth. We look at not just the maxilla and mandible, but all 22 bones of the skull to be sure they work in concert to provide good development. We understand there is a body attached to the teeth, and that they mutually influence each.

Figure 2: Function

Behavior (Figure 3) If behavior is the cause of the problem, you have to be able to spot and measure the cause as well as the outcomes of the treatment. Outcomes are not just dental terms. They are quality of life terms. How are patients breathing, feeling, sleeping, and performing in life? More than being symptom-free, are they optimally well?

12 Orthodontic practice

Figure 3: Behavior Volume 12 Number 3

COVER STORY Figures 4 and 5: Case No. 1 — 4. 10-year-old boy with bimaxillary protrusion; CC: blocked out laterals; mouth breathing and snoring; Class I narrow maxilla; tongue tie; T&A age 4.

5. pharyngeal anatomy

read the face for clues about what’s going on inside.

And like it or not, we have to make peace with the tongue. The tongue is more than just something that makes the teeth wet, while we try to do our work. It guards and guides the airway and breathing. We learn its every move and train it to guide growth.

What would you do?

Here are three case examples for you to consider. If you were concerned about the airway and a child’s health, would you approach these cases any differently than you do now? In this limited space, we can only provide snippets of these real case examples, but we hope they stimulate further thinking about the topic for your patients.

Case No. 1: Bimaxillary protrusion Even for those of us that don’t use

extraction protocols as much as we used to, bimaxillary expansion seems to be one lingering application for it. The protrusion of the lips and the difficulty keeping the lips closed seems a perfect indication for retraction of the anteriors.

A 10 year-old boy’s story is illustrated in Figure 4. His airway history is significant from an early age. Figure 5 shows his pharyngeal anatomy.

Would retraction of the teeth be appropriate here? Would expansion be appropriate here? When weighing the priorities of facial appearance against an optimal airway, how do you make that decision? Would you feel comfortable decreasing available tongue space in this case knowing that the tongue has to go backward if it can’t be placed in the front of the face? Would extractions cause an airway problem here? Absolutely not. There is already an airway problem here, and it has

Figure 6: Case No. 2 — a 6-year-old boy with early mixed dentition, crowding, and ectopic eruption; hx allergies; frequent ER visits; medicated for asthma; fragmented sleep; and open mouth posture Volume 12 Number 3

been here for a long time. Would extraction and retraction ignore an airway problem here? Of course. Let us ask you this: If this was your child, what would you do?

Case No. 2: An easy expansion case The mom of a 6-year-old boy (Figure 6) brought him in “early” for the ectopic upper central incisor. He’s just beginning his transition, so even if you favor two-phase treatment, would you wait for more “growth and development” before starting? If you are confident in your nonextraction skills, would you wait for the permanent dentition? Or is it wise to start removing deciduous teeth to guide eruption?

Looking a little deeper may give you some clues. Even though his lips look competent, his mom, a nurse, sees that his mouth is often open as a compensation for his asthma and allergies. She is surprised to

Figure 7: Final exam for 6-year-old boy. Treatment included myofunctional trainer, breathing training, and lower partial fixed appliance to capture ectopic LR2 Orthodontic practice 13

COVER STORY learn that the crowding of the two permanent incisors (and surely more to follow) is related to that oral rest and breathing posture. So now what?

More significant than his teeth, his breathing pattern was exacerbating his allergies and asthma (Figure 7). We used a myofunctional training protocol to slow down his breathing and correct his tongue posture. Since then, the mom says there have been no more visits to the hospital, and he only uses his inhalers during the worst of pollen seasons. Look at the quality of life changes he achieved. The fact that we set up his occlusion for optimal development is just icing on the cake.

Case No. 3: Are aligners enough?

This young woman (Figure 8) said she came in to “straighten my lower teeth.”

Her narrow maxilla, history of snoring, and constricted airway begged for a closer look. She blamed her history of fatigue on her age and college curriculum.

Would aligners and IPR be enough to satisfy her chief complaint? Probably. But if you could offer her something more, would you do it? Mini-screw expansion along with aligners may seem like overkill in this case, but it overcame her flow limitation dramatically. And if needed, those limitations could be further improved with Surgically Facilitated Orthodontic Therapy (SFOT).28 While the difference in her facial appearance and broad smile were reward enough, she calls her treatment a “life-changing experience.” Now she is no longer fatigued, sleeps quietly, and wakes up refreshed. Here, form and function improvements complement each other.

In summary: the real question You cannot adequately treat airway problems without correcting the behaviors that caused them. This is a painful reality for mechanically-minded orthodontists who think perfection lies in our hands, our wires, or our aligners. Nonetheless, the imperative to give our patients “an optimal physiologic airway and breathing pattern” begs us as orthodontists to expand our thinking and expand our range of services to include structure, function, and behavior. Our efforts must include interdisciplinary collaboration with many practitioners in the wellness and medical communities as well.

Our questions must expand from “do we affect the airway?” to “how can we help the airway?” While we cannot treat OSA on our own, we can treat flow limitation better than anyone else. We must stop dithering about this subject because we are wasting precious time while many of our patients are needlessly 14 Orthodontic practice

Figure 8: Case No. 3 — 20-year-old college woman had improved Epworth score (12 to 5), improved Fatigue Severity Scale (48 to 19), improved NOSE score (7 to 0), and improved esthetics as well

suffering — now and into their futures — unless we do something about it. OP

REFERENCES 1. 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 2. Balbo M, Leproult R, Van Cauter E. Impact of sleep and its disturbances on hypothalamus-pituitary-adrenal axis activiy. Int J Endocrinol. 2010.

3. Edwards BA, Eckert DJ, McSharry DG, et al. Clinical predictors of the respiratory arousal threshold in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2014;190(11):1293-300.

4. Eckert DJ, Younes MK. Arousal from sleep: implications for obstructive sleep apnea pathogenesis and treatment.

J Appl Physiol. (1985); 2014;116(3):274-278.

5. de Godoy LB, Palombini LO, Martinho Haddad FL, et al.

New insights on the pathophysiology of inspiratory flow limitation during sleep. Lung. 2015;193(3):387-392.

6. Gold AR, Dipalo F, Gold MS, Broderick J. Inspiratory airflow dynamics during sleep in women with fibromyalgia. Sleep.

2004;27(3):459-466.

7. Eichenberger M, Baumgartner S. The impact of rapid palatal expansion on children’s general health: a literature review. Eur J Paediatr Dent. 2014;15(1):67-71 8. Guilleminault C, Chowduri S. Upper Airway Resistance Syndrome is a Distinct Syndrome; Am J Respir Crit Care Med. 2000;161(5):1412-1413.

9. Guilleminault C, Poyares D, Palombini L, et al. Variability of respiratory effort in relation to sleep stages in normal controls and upper airway resistance syndrome patients.

Sleep Med. 2001;2(5):397-405.

10. Stupak HD, Park SY. Gravitational forces, negative pressure and facial structure in the genesis of airway dysfunction during sleep: a review of the paradigm. Sleep Med. 2018;51:125-132.

11. Horne RSC, Roy B, Walter LM, et al. Regional brain tissue changes and associations with disease severity in children with sleep-disordered breathing. Sleep. 2018;41(2).

12. Banabilh SM, Samsudin AR, Suzina AH, Dinsuhaimi S. Facial profile shape, malocclusion and palatal morphology in Malay obstructive sleep apnea patients. Angle Orthod.

2010;80(1):37-42.

13. Kerr WJ, McWilliam JS, Linder-Aronson S. Mandibular form and position related to changed mode of breathing – a five year longitudinal study. Angle Orthod. 1989;59(2):91-96.

14. Peltomäki T. The effect of mode of breathing on craniofacial growth — revisited. Eur J Orthod. 2007;29(5):426-429.

15. Kim YJ, Hong JS, Hwang YI, Park YH. Three-dimensional analysis of pharyngeal airway in preadolescent children with different anteroposterior skeletal patterns. Am J Orthod Dentofacial Orthop. 2010;137(3):306.e1-e11 16. de Freitas MR, Alcazar NM, Janson G, et al.Upper and lower pharyngeal airways in subjects with Class I and Class II maloclussions and different growth patterns. Am J Orthod Dentofacial Orthop. 2006;130(6):742-745 17. Moss ML. The functional matrix hypothesis of mechanotransduction revisited. 1. The role of mechanotransduction.

Am J Orthod Dentofacial Orthop. 1997;112(1):8-11.

18. D’Ascanio L, Lancione C, Pompa G, et al. Craniofacial Growth in children with nasal septum deviation: A cephalometric comparative study. Int J Pediatr Otorhinolaryngol.

2010;74(10):1180-1183.

19. Yoon A, Abdelwahab M, Liu S, et al. Impact of rapid palatal expansion on the internal nasal valve and obstructive nasal symptoms in children. A Yoon, M Abdelwahab, S Liu, et al.

Sleep Breath. 2021;25(2):1019-1027.

20. G Felisati, C Meazzini, F Messina, MG Tavecchia, G Farronato. Orthopedic palatal expansion in the treatment of bilateral congenital choanal atresia: an additional tool in the long term follow up of patients? Int. J Pediatr Otorhinolaryngol.

2010;74(1):99-103.

21. Galland M, Van Gerven DP, Von Cramon-Taubadel N, Pinhasi R 11,000 years of craniofacial and mandibular variation in Lower Nubia. Sci Rep. 2016;9;6:31040.

22. Armelagos GJ, Van Gerven DP, Martin D, Huss-Ashmore R. (1984). Effects of nutritional change on the skeletal biology of Northeast African (Sudanese Nubian) populations. Clark J, Brandt S, eds. In: Hunters to farmers: the causes and consequences of food production in Africa. Berkeley, CA: University of California Press;1984.

23. Carlson DS, Van Gerven DP. Masticatory function and post-Pleistocene evolution in Nubia. Am J Phys Anthropol.

1977;46(3 PT 1):495-506.

24. Carlson DS. Temporal variation in prehistoric Nubian crania.

Am J Phys Anthropol. 1976;45(3):467-484.

25. Festa F, Capasso L, D’Anastasio R, et al. Maxillary and mandibular base size in ancient skulls and of modern humans from Opi, Abruzzi, Italy: a cross-sectional study.

World J Orthod. 2010;11:e1-e4.

26. The Role of the Dentist in the treatment of Sleep-Related Breathing Disorders. Adopted by the American Dental Association’s House of Delegates, 2017 27. Rose JC, Roblee RD. Origins of dental crowding and malocclusions: An anthropological perspective. Compend Contin Educ Dent. 2009;30:292-300.

28. Roblee RD, Bolding SL, Landers JM. Surgically Facilitated Orthodontic Therapy: A New Tool for Optimal Interdisciplinary Results. Compend Contin Educ Dent.

2009;30(5):264-275.

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ORTHODONTIC CONCEPTS

Facemask midfacial protraction — an overview Dr. Duane Grummons discusses the benefits of Facemask therapy

N

asomaxillary respiratory orthopedic applications of the Grummons Facemask with individualized protraction and slow palatal expansion show validated sutural responses and favorable airway flow benefits. Resolution is achieved with transverse and protraction movements of maxillae with circummaxillary sutural growth modification.1 Favorable effects follow: • more convexity of facial profile with forward relocation of maxillae • proclination of maxillary incisors • counterclockwise rotation of palatal plane2 • neutral posturing of mandible • clockwise rotation of mandibular plane • more upright lower incisors • improved airway width and flow characteristics Skeletal Class III patients have maxillary deficiency in 85% of cases; mandibular excess in 5% to 8%; combination in 7% to 10%.3 Airway and breathing disordered sleep (SDB) are priorities. Maxillae articulate through the following: • midpalatal (MPS) • frontomaxillary (FMS) • zygomaticomaxillary sutures (ZMS) • transverse palatine (TPS) • nasomaxillary • lacrimal • ethmoid.

Zygoma (malar) and external orbital regions are divinely designed to mature early to protect orbital vital structures. ZM sutural configurations are obliquely oriented, tortuous, and intermingled to withstand trauma and sustained compressive loading of the facemask. Maxillary complex research

used lateral implants from 4 to 21 years.4 Superimpositions of zygomatic processes proved no striking remodeling of the anterior surface in the anteroposterior direction.5 Malar stability permits facemask pads to rest here.

ZM sutures are resistive to remodeling.6 Complexity of interdigitations is greater in ZMS than other circummaxillary sutures. ZMS are longest and thickest of maxillary sutures, which limits change under protraction forces.

When mid-palatal and nearby sutures are orthopedically activated, the ZM suture does not respond in the same ways.Serial x-rays of children’s zygomatic/malar relationships and point A were reported.7 After these studies, the Grummons Facemask with frontal/ zygoma support was innovated.

Earlier intervention Facial growth is 60% completed by ages 5 to 6 and 80% by age 8. Earlier treatment involves a nasomaxillary orthopedic expander, facemask protraction therapy, a mandibular dentoalveolar expander, and occlusal composites on primary molars bilaterally. As primary posterior teeth expand, the alveolar processes remodel wider with increased arch perimeter for unerupted teeth and area for tongue volume away from pharyngeal region. Myofunctional therapy (MFT) corrects low tongue posture, abnormal swallow, and helps achieve nasal breathing.

Facial orthopedics or surgery overcome Class III underbite and midfacial mismatches.

Transverse sutural and alveolar remodeling occur with forward displacement of the maxillary complex from the pterygoid region.

Facemask therapy in primary dentition is 70% orthopedics and 30% dentoalveolar; mixed dentition is 30% orthopedics, 70% dentoalveolar; and permanent dentition is dentoalveolar.

Facemask shaping is individualized: 1. Facemask bendable to facial contours.

2. Bend malar supports by knuckle of finger to create malar contour.

3. Frontal support above eyebrows.

4. Bend frame longer, shorter, wider, or narrower to match face.

5. Place pads on frontal and malar regions; extra pads for comfort.

6. Place passively. If crib is on lips, add one to three pads on malar supports so crib clears lips.

7. Velcro headstrap to frame with light fit to occipital region.

Figure 1: Young midfacial deficiency

Duane Grummons, DDS, MsD, ABO, is U.S. Board-certified in facial orthopedics and orthodontics. He has authored and lectured worldwide for 40 years regarding his facial frontal analysis, orthopedic Facemask and nonextraction appliance innovations. He is a leader in adolescent airway resolutions.

Dr. Grummons is Associate Professor of Orthodontics at Loma Linda University Orthodontic Department in California. He developed two efficient and productive practices in Marina del Rey, California, and Spokane Washington.

Dr. Grummons can be reached at grummons@me.com.

Figure 2: Grummons Facemask (greatlakesdentaltechnologies.com) 16 Orthodontic practice

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“Treat earlier with Class III nasomaxillary respiratory corrective orthopedics with face-forward Facemask changes. It is better to shape the child’s developing facial structures for best physiologic airway than to repair or manage them as adults.”

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ORTHODONTIC CONCEPTS

Figure 3: Class III resolution in deciduous dentition phase

8. Place facemask from behind into place in one motion.

9. Readjust headstrap so mask is oriented to face and comfortable.

10. Elastics from molar band hooks or from buccal arms to crib. Traction is forward and downward.

11. Protocol: bilateral 3/8 or 5/16 inch, 8 oz. elastics for first 1 to 2 weeks; transition to ¼ or ½ inch, 6.5 oz. heavy, or 5/16 or ½ in 14 oz. elastics.

12. Begin 1 to 2 hours wear while awake; soon while sleeping 8 to 10 hours.

13. Optimum: 8 to 10 hours traction for maxillary orthopedics forward.

Week 1: Facemask, 1 hour awake; one elastic per side Week 2: Two hours awake; two elastics per side Week 3: One hour before bedtime and while sleeping, two elastics per side Midfacial orthopedics with transverse maxillae expansion can be skeletal (sutural), dentoalveolar, and/or dental arch. Thin-plate spline analysis of rapid maxillary expansion with facemask therapy in early Class III malocclusions shows forward displacement of the maxillary complex from pterygoid region with clockwise rotation of mandible.8 Nasomaxillary respiratory regions are better developed with protraction facemask therapy and orthopedic SLOW expansion of 2 to 3 turns per week.

Point A is most anterior point in convexity of maxillae in median sagittal plane. Wellbalanced adult faces have point A ahead of nasion perpendicular by 4 mm in females and 1.1 mm in males, reported by McNamara.9 Maino G, et al.,10 Ricketts and Grummons11 recommended forward placement of point A with convexity of +3-4mm (face forward).

18 Orthodontic practice

Figure 4: Point A +3-4mm forward

Figure 5: Occlusal rests secure appliance for less tipping of teeth; buccal arms for elastics

Figure 6: 3-way expander yields arch length at molars while facemask relocates maxillae forward

Figure 7: Slow FAN palatal expansion (PE), or EDO appliance (greatlakesdentaltech.com) with two screws, or MSE (Moon) with facemask develop nasomaxillary respiratory regions

Facemask and slow PE/ME Facemask protraction of the nasomaxillary complex with point A relocation forward is a key clinical objective. The maxillary

expander has bilateral buccal arms soldered to molar bands, extending forward to the region of maxillary canines. Slow activations best influence the circummaxillary sutures Volume 12 Number 3

ORTHODONTIC CONCEPTS and nasomaxillary respiratory regions.

Typically, maxillary skeletal deficiency patients demonstrate mandibular overclosure with lower facial vertical deficiency.

Occlusal molar composites lift the bite.

The 3-Way maxillae expander12 with molar springs provides derotation as maxillae-palatine structures are protracted with the Grummons orthopedic Facemask.

Movements are three-dimensional (tip, yaw, roll): molar extrusion/intrusion, occlusal plane leveling, and midline correction.

BAMP (bone-anchored maxillary protraction) RPE or MSE (Moon) palatal expander (MARPE) with facemask yields greater maxillary advancement compared to facemask with tooth-borne maxillary expansion.

Maxillary midline (yaw) correction is achieved with buccal arms shorter on one side, so the dental arch moves forward and midline improves by shifting to opposite side. Buccal arms are adjusted parallel to the occlusal plane (OP) for straight pull forward. One buccal arm can be bent higher at the canine region, so the dental arch moves inferiorly as occlusal plane levels (roll). Mandibular protraction of both arches corrects bidental retrusion. The upper arch can move forward in Class III malocclusion.

Elastics from lower molars to facemask crib relocate the lower arch forward to help correct Class II malocclusion to the extent periodontal support permits, Research on the Grummons Facemask13 showed decisive improvements in the sagittal-basal relations as upper molars moved forward 4.1 mm from pterygoid vertical with point A moved 2.2 mm forward.

Grummons Facemask relocated maxillary point A forward by 3.4 mm for the composite sample.14 The effectiveness of alternating expansion and constriction enhances maxillary protraction.

Surgically facilitated orthodontic treatment (SFOT) (premolars previously removed by colleague’s treatment) included a palatal expansion appliance with bilateral corticotomies (maxillae surgically mobilized), and TADS with facemask protraction.

Sustained TMJ compression is unfavorable to the TMJ components that are designed for intermittent loading during functional movements. A facemask with chin-cup delivers unfavorable compressive loading upon TMJ posterior attachment, collateral ligaments, and condyle-disc assembly. The chin-cup facemask caused 24% of TMJ internal derangements from forces that are non-physiologic and detrimental.15,16 Three types of protraction facemask headgear 20 Orthodontic practice

Figure 8: Slow PE with facemask; point A relocates forward and inferiorly

Figure 9: Airway (before/after) optimized by dual upper/lower expanders with protraction Gummons Facemask therapy

Figure 10: Nasomaxillary respiratory complex moved forward and inferiorly. (superimpositions: www.bioprogressive.org/RMODS) Volume 12 Number 3

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ORTHODONTIC CONCEPTS were researched17; the Grummons Facemask had no unfavorable TMJ effects.

Maxillary arch is template for lower Facemask with elastics to the upper molars neutralizes the distal thrust of a Herbst or Class II corrector, so point A remains well-placed in the face. The perimeter and shape of maxillary arch influences lower arch dimensions (like a lid on a box).

The lower arch has clinical limitations for arch expansion. The maxillary arch width is the template for mandibular arch width and lower arch emplacement. As the upper transverse is improved, the lower widens with decompensated and uprighted Curve of Wilson.

As the lower teeth move/angulate forward, this adds to upper arch movement forward with facemask.

Upper airway dimensional changes improve laminar airflow following maxillary

protraction upon craniofacial structures.18 Improvement was seen in sleep scores and symptoms after bimaxillary expansion with facemask protraction of arches forward.19

Summary Treat earlier with Class III nasomaxillary respiratory corrective orthopedics with faceforward facemask changes. It is better to shape the child’s developing facial structures for best physiologic airway than to repair or manage them as adults. Let’s copy nature in her fundamental majesty. OP REFERENCES 1. Ngan PW, Hagg U, Yiu C, Wei SH. Treatment response and long-term dentofacial adaptations to maxillary expansion and protraction. Semin Orthod 1997;3(4):255-264.

2. Angelieri F et al. Zygomaticomaxillary suture maturation: part II – the influence of sutural maturation on the response to maxillary protraction. Orthod Craniofac Res. 2017; 20(3):152-163.

3. Grummons D. Nonextraction emphasis: space gaining

efficiencies, part 1. World J Orthod. 2003;3:21-32,177-189.

4. Bjork A, Skieller V. [Growth and development of maxillary complex.] [article in German] Inf Orthod Kieferorthop.

1984;16(1):9-52.

5. Linge L. Tissue reactions in facial sutures subsequent to external mechanical influences; McNamara, JA: Monograph Number 6 Craniofacial Growth Series. 1976;256.

6. Angelieri F, Franchi L, Cevidanes LHS, et al. Zygomaticomaxillary suture maturation: A predictor of maxillary protraction? Part I — a classification method. Orthod Craniofac Res. 2017;20(2):85-94.

7. Petit HP. Adaptation following accelerated facial mask therapy. In: McNamara JA Jr, Ribbens KA, Howe RP (eds).

Clinical alterations of the growing face. Monograph No. 14, Craniofacial Growth Series, Center for Human Growth and Development, University of Michigan, Ann Arbor; 1983.

8. Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I. Skeletal effects of early treatment of Class III malocclusion with maxillary expansion and face-mask therapy. Am J Orthod Dentofacial Orthop. 1998;113(3):333-343.

9. McNamara JA Jr. An orthopedic approach to the treatment of Class III malocclusion in young patients. J Clin Orthod.

1997;21(9):598-608.

10. Maino G, Turci Y, Arreghini A, et al. Skeletal and dentoalveolar effects of hybrid rapid palatal expansion and facemask treatment in growing skeletal Class III patients. Am J Orthod Dentofacial Orthop. 2018;153(2):262-268.

11. Grummons D, Ricketts RM. Frontal cephalometrics: practical applications part 2. World J Orthod. 2004;5(2):99-119.

12. Grummons D. 3-Way maxillae appliance innovations. Orthodontic Practice US. 2019;10(5):20-23.

13. Hegmann M, Ruther AK. The Grummons facemask as an early treatment modality within a class III therapy concept.

J Orofac Orthop. 2003;64(6):450-456.

14. Beisiegel D. Masters Thesis; Loma Linda graduate school of orthodontics. 1994.

15. Sugawara J, Mitani H. Facial growth of skeletal Class III malocclusion and the effects, limitations, and long-term dentofacial adaptations to chincap therapy. Semin Orthod.

1997;3(4):244-254.

16. Grummons D. Orthodontics for the TMJ/TMD patient. Scottsdale, AZ: Wright & Company; 1994.

17. Hakan El, Ciger S. Effects of 2 types of facemasks on condylar position. Am J Orthod Dentofacial Orthop.

2010;137(6):801-808.

18. Gupta A. An evaluation of the sagittal upper airway dimension changes following treatment with maxillary protraction appliances. J of Contemporary Dentistry. 2011.

19. Quo SD, Hyunh N, Guilleminault C. Transverse aspects of bimaxillary expansion therapy for pediatric sleep-disordered breathing. Sleep Med. 2017;30:45-51.

Figure 11: Facemask with SARPE assisted maxillae protraction

Figure 12: Facemask chin cup affects the TMJs

Figure 13: Mixed dentition Grummons Facemask; distraction osteogenesis forward and inferiorly

Figure 15: Wider, uprighted arch perimeter with forward arch placement (two case examples) 22 Orthodontic practice

Figure 14: Superimpositions (www.bioprogressive.org/RMODS)

Figure 16: Lifetime benefits: midfacial facemask orthopedics forward Volume 12 Number 3

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ORTHODONTIC CONCEPTS

Chronic pain and sleep — it’s not that simple Scott Peterson discusses the complicated connection between sleep and chronic pain

I

t’s no surprise that living with chronic pain affects sleep quality. In fact, a growing body of research strongly suggests that sleep quality should be included in the initial assessment of all patients who present with chronic pain. Difficulty initiating sleep, disrupted sleep, early morning awakenings, and unrefreshing sleep are all associated with chronic pain. Recent studies estimate that 50% to 89% of patients with chronic pain describe sleep problems like these. Sleep neurologists are also reporting increased sleep disturbances and the misuse of sleep medications in people recovering from COVID-19 and in people whose lives have been beset by fear and isolation.

The T-Scan is a vital tool in treating force imbalances that contribute to chronic pain, headaches, and tinnitus which reduce sleep quality

Pain leads to bad sleep, right? It’s not that simple. Sleep and pain appear to have a bidirectional relationship. For instance, many people report their painful symptoms are somewhat alleviated after a better night’s sleep and worse after nights of poor sleep. Sleep loss not only amplifies the painsensing regions in the brain, but also blocks the natural analgesia center too. Another key brain region found to slow down in the sleep-deprived brain was the insula, which evaluates pain signals and places them in context to prepare the body to respond. If poor sleep intensifies our sensitivity to pain, then we need to put sleep much closer to the center of patient care.

Scott Peterson is the Director of Clinical Support for TruDenta, an FDA-cleared therapy system for chronic headaches, migraines, and jaw/neck pain.

24 Orthodontic practice

To establish normal function and relieve our patients’ pain symptoms, the neurology, muscle activity, and occlusion need to be reset or restored to homeostasis.

Our patients will have the best outcomes when the teeth, muscles, joints, neurology, pain, and force imbalances have been addressed.

As practitioners, we should evaluate and treat all the causes of our patients’ pain, not only the teeth, but also the muscles and joints because they are part of the problem.

This should include modalities that focus on resetting the neurology. In addition to treating musculoskeletal issues, resetting the neurology allows patients to sleep better faster and return to homeostasis more quickly than surgery or medication.

By treating all the causes of chronic pain, FDA-cleared therapies provided by TruDenta can provide pain relief for patients with sleep apnea, chronic migraines and headaches, tinnitus, and other neck/jaw pain — all of which can contribute to sleep loss. This latest diagnostic technology closely examines the musculoskeletal system of the head, neck, and jaw to find any signs of the inflammation and tension that can lead to chronic headaches or migraines. The diagnostic

process includes force and range of motion analysis, which hones in on the delicate nerves and ligaments that run through the head and jaw. In addition, a symptoms and headache history and muscle exam shed light on injuries that may have occurred in the past, which over time have radiated pain to surrounding areas. After discovering the hidden factors that contribute to pain, the gentle treatment plan can provide immediate pain relief and long-term rehabilitation.

FDA-cleared, painless treatment technologies include ultrasound, low-level photobiomodulation, microcurrent, and manual muscle therapy.

Patients dealing with chronic pain are often susceptible to rebound headaches, as the painkillers they rely on to control their symptoms can end up causing further headaches. Pain-relief medication for chronic headaches can be overused. When that happens, the brain begins to send ineffective pain indicators. As a result, the brain’s message center can send mixed-signals to the nerves, resulting in a lingering, persistent headache.

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CONTINUING EDUCATION

Basic principle review of sleep medicine Drs. Barry Glassman and Don Malizia delve into sleep-breathing disorders and the orthodontists’ role in this medical subspecialty Introduction Sleep medicine is a young medical subspecialty. The medical community, as well as the population at large, is becoming more aware of the significant role that quality sleep plays in patients’ general health. Physicians who treat sleep disorders clearly understand the relationship between sleep and chronic pain, and they appreciate the key role that sleep plays in healing from both micro-trauma and macro-trauma. While many physicians have always acknowledged a concern for the social problems associated with snoring, the more serious comorbidities associated with obstructive sleep apnea (OSA) have become a matter of great concern. Those comorbidities include but are not limited to hypertension, myocardial infarctions, stroke, weight gain, diabetes, acid reflux, and excessive daytime sleepiness (EDS). EDS can frequently lead not only to work and home injuries, but also to motor vehicle accidents. Medical professionals now understand that chronic sleep deprivation is related to a shortened life expectancy, and that quality sleep is potentially associated with improved overall mental and physical health.

Consequently, more are prioritizing the diagnosis and treatment of sleep disorders.

Although there is still much about sleep physiology that remains a mystery, the science of sleep medicine has improved dramatically in recent years. Yet 90% of people with sleep-disordered breathing Barry Glassman, DMD, maintained a private practice in Allentown, Pennsylvania, which was limited to orofacial pain and dental sleep medicine. He is a Diplomate of the Board of the American Academy of Craniofacial Pain, a Fellow of the International College of Craniomandibular Orthopedics, and a Diplomate of the American Academy of Pain Management.

He is a Diplomate of the Board of the American Academy of Dental Sleep Medicine. He teaches and lectures internationally on orofacial pain, joint dysfunction, and sleep disorders.

Don Malizia, DDS, limits his practice to orofacial pain and sleep-disturbed breathing at the Allentown Pain and Sleep Center in Wilkes-Barre, Pennsylvania. Among his recent publications, coauthored with Dr. Glassman, are “The Effect of Regional Anesthetic Sphenopalatine Ganglion Block on Self-Reported Pain in Patients With Status Migrainosus” in Headache and “The Curious History of Occlusion in Dentistry” in Dentaltown.

26 Orthodontic practice

Educational aims and objectives

This self-instructional course for dentists aims to inform readers about the many facets of sleep-breathing disorders and the role that dentists can play in this critical field.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions by taking 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: • Recognize the signs and symptoms of sleep-disordered breathing.

• Describe the role that dentists and orthodontists can play in conjunction with sleep physicians.

• Recognize the stages of sleep and identify altered sleep architecture.

• Identify the types of sleep disorders and the continuum of obstructive disorders.

• Employ validated screeners for adult patients.

• Complete an appropriate interview to identify the potential existence of a sleep disorder in a pediatric patient.

remain undiagnosed.1 The American Society of Anesthesiologists estimates that 16 million people have undiagnosed sleep disorders.2 The role that dentists can play in this critical field is extremely important.3,4 Many dentists tend to see their patients on a more regular basis than general physicians do.

With this advantage to assure that a proper referral can be made, it is very important that dentists learn to ask the appropriate questions. In the best interest of patients’ needs, it is equally important that dentists avoid the pitfalls that can lead to improper therapy or a competitive environment with the very sleep physicians with whom they need to function in harmony. Providing treatment for patients who snore without formulating a complete and accurate diagnosis is problematic. Any approach, based solely on a patient’s report of snoring, can be compared with treating gingival hyperplasia without a properly intensive diagnosis, including periodontal probing and radiographs. Once the snoring is resolved, the patient often will not seek further therapy. Consequently, a potential underlying obstructive disorder may continue in the absence of snoring, and the patient remains at risk for hypertension, stroke, diabetes, and the other associated comorbidities.5 Just as treating gingivitis without proper diagnosis would be considered below the standard of care, treating obstructive disorders carries the same diagnostic requirements. The consequences of sleep disturbances are potentially more severe than tooth loss from underlying periodontitis.6 In addition, any treatment of snoring without including the

medical profession widens the gap between the professions — the same gap that needs to be narrowed to appropriately treat the vast majority of patients with OSA.

Normal sleep stages Normal sleep is divided into two types: non-REM (NREM) and REM.7-9 REM sleep is rapid eye movement. NREM sleep is divided into three distinct stages. Stages 1 to 3 are distinguished by alterations in brain wave activity as recorded in an electroencephalogram (EEG).

Physiological changes occur with each sleep stage. During sleep the body is considered to be in a progressively inactive state while the brain remains active. A normal sleep pattern has four to five cycles throughout the night. NREM and REM sleep states alternate in cycles that usually last between 90 and 110 minutes. Normal NREM sleep occupies 75% of the night and is characterized by a decrease in body temperature, blood pressure, breathing rate, and most physiologic functions.7 REM sleep is characterized by a highly active brain in an essentially paralyzed body.10,11 As a result of this pattern, normal sleep presents with specific relative time spent in each stage.

Arousals (events that alter normal stage progression) cause alteration of this normal architecture and often are responsible for sleep disturbances and hypersomnolence, which is defined as excessive daytime sleepiness.7 Arousals can be caused by: • partial obstructions leading to snoring or difficult breathing Volume 12 Number 3

Volume 12 Number 3

CONTINUING EDUCATION

• complete obstructions defined as apneas • nonobstructive conditions such as pain • central apneas (a stoppage of breathing from lack of respiratory effort as opposed to an obstruction) • involuntary body movements • psychological situations7 Of extreme importance to dentists, arousals can be associated with nocturnal bruxism,12-14 which has been shown to be centrally mediated as opposed to related to occlusion.15 NREM stage 1 sleep usually occupies approximately 5% of the sleep cycle and is represented by a relatively active brainwave pattern.7 Stage 2 is represented by active brain waves that include specific EEG patterns called K-complexes and sleep spindles (Figure 1). This stage usually occupies 45% of the sleep cycle.7 Stages 3 and 4 are now considered one stage, stage 3, and is referred to as slow-wave sleep. This stage is identified by slow high-amplitude brain waves and usually occupies approximately 25% of the night’s pattern. These percentages do alter as patients age, with slow-wave sleep decreasing significantly in the sixth and seventh decades.7 Various medications, as well as the existence of chronic pain, also have effects on sleep architecture.16 REM sleep is characterized by rapid eye movement, irregular breathing, relative skeletal muscle paralysis, and an irregular heart rate. It is when most of the colorful and vivid dreaming occurs, and it occupies 20% to 25% of the normal sleep cycle.7 REM latency refers to the amount of time it takes from sleep onset to the first period of REM. Normal REM latency is about 90 minutes and can be compromised with significant sleep debt or specific sleep disorders, such as narcolepsy.7-9 The gold standard for diagnosis of sleep disorders is the polysomnogram (PSG.) These overnight studies take place in sleep laboratories. Patients are monitored through the night. The PSG monitors: • brain waves (EEGs to determine sleep stages) • eye movements (electrooculogram [EOG]) • muscle tone (electromyography [EMG]) • nasal airflow, blood oxygen levels • respirations • cardiac function • respiratory effort From these studies, physicians can determine if there is an alteration in patients’ normal sleep architecture.

The sleep studies then are scored, and among the plethora of information received

Figure 1: K-complexes and sleep spindles are EEG patterns specific to stage 2 sleep

Figure 2: Sleep-disordered breathing is a continuum. Diagnosis is required before treatment can be considered

and calculated is the respiratory disturbance index (RDI).17 The RDI represents the number of hypopneas (which has several definitions, the most common of which includes a 4% drop in blood oxygen levels) plus apneas (universally described as total obstruction of airflow for 10 seconds or longer) per hour plus respiratory effort related arousals (RERAs) (reduced oxygen levels associated with arousals that do not meet the criteria of an hypopnea).7 EMGs on leg muscles are used to evaluate the existence of periodic leg movements. Recently, the placement of the surface EMG electrodes on the elevator musculature has allowed physicians to look more closely at nocturnal bruxism.

Classification of sleep disorders Sleep disorders are classified as dyssomnias and parasomnias. Dyssomnias are disorders of initiating and maintaining sleep as well as disorders of excessive sleepiness.

Examples of dyssomnias are narcolepsy, insomnias, circadian rhythm disorders (such as jet lag), and obstructive sleep disorders, including sleep apnea.7 Parasomnias are undesirable physical phenomena that occur during sleep such as sleepwalking, nocturnal leg cramps, periodic leg movements, nightmares, and bruxism.7-9 Obstructive breathing disorders fall on a continuum beginning with snoring, continuing with upper-airway resistance syndrome and hypopnea with associated hypoxemia with severe sleep apnea at the other end of the continuum (Figure 2).

If the stoppage of breathing is caused by an obstruction in the airway, it is called an obstructive sleep apnea. Obstructive apneas are a result of the blockage of the airway, either at the junction of the oropharynx (soft palate and base of the tongue) or anywhere else in the pharyngeal anatomy (Figure 3).

When the blockage occurs in the pharynx because of muscular collapse at that site, the pharynx is said to be compliant. Most often obstructive apnea is a result of more than one site of obstruction.18 Central apnea refers to stoppage of breathing for 10 seconds or longer, not as a result of an obstruction but from the lack of respiratory effort.7 Often when there are central apneas, there are also obstructive apneas, and this condition is referred to as mixed apnea. For a diagnosis of central apnea to be made, 80% of the apnea events must occur centrally.7 Dentists can play a major role in the treatment of obstructive disorders. The next section will focus on an understanding of these disorders, the method of action of oral appliances, and the potential dental and nondental side effects of these oral appliances.

Dental sleep medicine Snoring is at the beginning of the continuum of sleep disorders. Snoring can be more than a social issue; not all snoring is benign and can be associated with arousals and sleep fragmentation. Therefore, treating snoring without a complete diagnosis is not advisable. An incomplete diagnosis could result in a missed opportunity to identify a more significant sleep-disordered breathing Orthodontic practice 27

CONTINUING EDUCATION condition and possibly protect the patient from the life-threatening comorbidities associated with obstructive sleep-disordered breathing.

It has been estimated that 90% of all patients with obstructive sleep disorders remain undiagnosed.1 The reasons are numerous. Most comprehensive diagnosis can be made after a polysomnogram, a laboratory-controlled all-night sleep study that is admittedly cumbersome, not entirely reliable, and often not available.19 Clearly, alternative available testing procedures need to be considered.20 Family physicians often do not ask questions related to sleep, and family physicians do not see patients at the rate patients are seen by dentists. When asked why questions about sleep, such a critical aspect of health, are not included during examinations or interviews, family physicians refer to the limited amount of time they have for an examination as well as their frustration with the diagnostic procedures and treatment options.21 Clearly, the dentist’s role can be significant in helping to identify patients with sleep-disordered breathing, as well as giving the many patients who have difficulties using continuous positive airway pressure (CPAP) a potentially successful alternative.

The dentist, therefore, can play a role in both diagnosis and treatment.

The dentist’s role in diagnosis No profession has been as successful as dentistry in the field of prevention. A patient is more likely to see his dentist on a regular basis than any other healthcare professional.3 It was long ago determined that dentists could play a major role in helping to uncover potential health risks in their patients. Medical updates on 6-month or yearly recall visits often include questions about basic health issues and blood pressure recordings. There is a movement in the dental and medical fields to educate dentists to ask basic questions about their patients’ quality of sleep.22 While there are no awake parameters or combination of parameters that can predict the existence of sleepdisturbed breathing,63 neck circumference alone has been shown to be an excellent predictor of apnea.23,24 The use of a validated screening tool empowers the dentists to refer the patient to the appropriate sleep specialist and/or other medical specialist. While there are no direct relationships between anatomy and the likelihood of having sleep disturbed breathing, a clinical exam can be useful. During the dental examination, dentists should look for excessive wear facets, which are likely to be a combination of some form of bruxism and oral acidity. Obvious enamel defects from acid, including dentinal pooling should be 28 Orthodontic practice

noted. Often the first signs of gastroesophageal reflux disease (GERD) are odontogenic, and there is a relationship between GERD and sleep apnea, with a proposed pathophysiology related to alterations in thoracic and abdominal pressure gradients.25,26 Positive responses should lead to referral to the sleep specialist. While the polysomnogram was once considered the gold standard in sleep medicine’s diagnostic regimen, various home-testing units are now validated and available. Many of these testing devices provide valuable information, yet they have some deficiencies as well.27 It is the position of the American Academy of Dental Sleep Medicine that while it may be, in some instances, in the patient's best interest to have this ambulatory screening study completed, it is the responsibility of the dentist to then refer the patient to a sleep specialist for diagnostic purposes.28 While the American Academy of Dental Sleep Medicine has recently suggested that it is within the scope of practice for a dentist to order an ambulatory test, it does not alter the fact that the diagnosis of the specific sleep disorder remains within the domain of the physician. It is essential to understand that there are nonobstructive sleep disorders that can be contributing history and/or screening testing is an excellent service dentists can provide their patients.

The dentist’s role in treatment It is generally accepted that the gold standard of treatment for patients with sleep apnea is the use of CPAP.29 This effective therapy uses positive airway pressure to create a pneumatic air splint, reducing pharyngeal compliance. The amount of pressure required for each patient is often determined in a titration procedure in a sleep

laboratory. While CPAP provides very effective therapy, patient compliance remains the most difficult obstacle to successful treatment. Despite recent improvements, which include a change from constant pressure to alternating pressures for inhalation and exhalation (BiPAP), the addition of warm air humidifiers and smaller, more portable, quieter units, compliance after 6 months on many studies is well below 50%.30 Patients report problems with the fitting of the mask, air leakage, skin reactions to the air pressure, stomach bloating, claustrophobia, noisy machines, inability to initiate and maintain sleep, and total inconvenience.32,33 Options to the use of CPAP include either a surgical procedure or the use of an oral appliance. At one time, surgery options were very often performed. While the reported rate of success for the various surgical procedures varies, there is a significant level of pain associated with the most common procedure (uvulopalatalphyrgolplasty), and the most recent rates of success measured at 6 months are reported to be below 50%, with the percentage dropping over time34 (Figure 4).

A laser-assisted procedure was also very commonly used, but essentially has been abandoned because of its low level of success.35 Other procedures include bimaxillary orthognathic surgery and in severe cases tracheostomies. Both of these procedures tend to be very successful but are, of course, not considered conservative therapies.36,37 Therefore, many careful considerations must be made before either procedure is recommended.

In 1995, a landmark study by SchmidtNorwarwa and colleagues reported that the use of oral appliance therapy was effective for mild to moderate sleep apnea.37 A 1999 follow-up study showed successful outcomes

Figure 3: Obstructive sleep disorders commonly have obstructions at more than one level. The velopharynx is commonly the site of the initial obstruction Volume 12 Number 3

Volume 12 Number 3

Figure 4: The uvulopalatalphygolplasty procedure can be effective for sleep-disordered breathing, but the lack of predictability of the success of the surgery combined with the difficult postsurgical course has decreased the frequency the surgery is recommended

Orthodontics and dental sleep medicine Obstructive sleep apnea occurs as a result of the collapse of the upper airway, which is a collapsible tube maintained by the dilators of the pharynx. Altered nocturnal neuromuscular physiology puts the airway at risk during sleep.52 Despite the fact that statistically patients without OSA will have an average volume of their airways larger than the average of those with OSA, there are many outliers.

Patients with large airways can have nocturnal collapse, while some patients with smaller airways have airways that remain patent.

“Reflecting the higher significance of neuromuscular control on airway function during sleep, it has been demonstrated that a narrow airway does not result in OSA, but rather it is an inability for a patient’s airway muscles to compensate adequately that leads to obstruction and sleep-disordered breathing.” 53 Empirical anecdotal evidence has been used to suggest that bicuspid serial extractions are likely responsible for a retrognathic mandible and a smaller area for the tongue, resulting in an increased potential for the patient to develop obstructive sleep apnea.

This logic in the absence of evidence has been refuted with a demonstration of no significant increased apnea in patients with bicuspid extractions.54 Two systematic reviews revealed no direct correlation between bicuspid extractions and the presence of obstructive sleep apnea.54,55 However, some work has been done to suggest that “Higher obstructive AHI scores were seen in an unselected population of orthodontic patients with posteriorly positioned and retroclined upper incisors, retrognathic mandible, increased length of the upper airway, decreased maxillary arch length, constricted maxillary and mandibular intercanine widths. …”56 As noted earlier, while much of the surgery to decrease anatomical obstructions at the oropharyngeal junction has not been shown to be predictably efficacious in the resolution of OSA in the adult population, “maxillomandibular advancement is an effective treatment for OSA.” 57 While there are indeed validated screening tools for the adult population,

there are no such validated screeners for our pediatric patients. The Pediatric Sleep Questionnaire may be used, but it only has a positive predictive value of 0.4.58 Children should not snore, and children who do snore should be referred for testing.58 Further questions about growth and development as well as mood instability, enuresis, and abnormal learning skills may lead to the referral to a certified pediatric sleep specialist.

Identifying sleep disturbed breathing in our pediatric population can be critically important since it has been recognized that undiagnosed obstructive sleep apnea has a significant impact on growth and development. Fragmented sleep can lead to mood instability and inability to learn and focus. Loss of stage 3 sleep can lead to decreased growth hormone contributing to altered physical development. Some learning disabilities and ADHD have been linked to sleep-disturbed breathing.59 Therefore, pediatric diagnosis is critically important.

The adenoids and tonsils often play a significant role in the cause of pediatric obstructive sleep apnea. It is true that the tonsils and adenoids become full size long before the pharynx does, creating a potential childhood obstruction that may over time resolve as the tonsils become smaller and the volume of the pharynx increases. It is for this reason that the “watch and wait” approach is sometimes considered when OSA is diagnosed in children.60 Unfortunately, the effect on the child’s growth and development may have long-term consequences even though the obstructive tendency decreases over years. When the risk-benefit quotient suggests treatment be considered while the removal of tonsils and adenoids can be very successful in resolving the OSA, there are instances when the surgery does not completely resolve the disorder.61 There is a degree of morbidity and mortality that needs to be considered when tonsil and adenoid surgery is an option.62 It has been noted that the upper airway is a collapsible tube, and that the collapse of the tube is often related to both neurological factors and anatomical factors in the form of atypical craniofacial features. Orthodontics Orthodontic practice 29

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using this therapy for severe apnea in some cases.38 In addition, many sleep specialists consider the use of oral appliance therapy the treatment of choice for primary snoring and upper airway resistance syndrome.39,40 Many patients who use CPAP therapy successfully use oral appliance therapy when traveling or in combination with their CPAP device, which allows lower pressures to be more effective.

When given the alternatives, many patients who do not comply with their CPAP therapy choose an oral appliance as their treatment of choice.41 The long-term compliance of oral appliance therapy is much higher than that of CPAP therapy.42-45 Clearly, oral appliance therapy plays a significant role in the treatment of patients with obstructive sleep disorders. Recent studies have demonstrated that the proposed use of AHI to determine the likelihood of success of an oral appliance is not warranted. It has been shown through several studies that oral appliances have been as effective as CPAP therapy in mean disease control, even in the presence of severe obstructive sleep apnea, most likely as a result of increased levels of compliance.46-48 Dentists without comprehensive training should avoid treating with oral appliance therapy.28,49 Dentists should understand the nature of patients’ dysfunctions and work in a coordinated effort with sleep specialists. Dentists should discuss at length with their patients the possible side effects of oral appliance therapy, which include excessive salivation, temporomandibular joint pain, muscular pain and soreness, morning maladaptive mandibular posture, and occlusal changes.41 Treatment of these side effects involves joint and muscular therapy, the use of a “morning aligner” or exercise on awakening as part of an occlusal maintenance program, and palliative therapeutic measures. Patient monitoring must be initiated with adaptation to the appliance, followed by guiding titration.49 Many of the joint- and muscle-related untoward effects tend to be exaggerated, are mild, and often easily treated or temporary.50,51 The patient and dentist must work together and make well-advised risk versus benefit decisions during the treatment process. Too often there is a tendency for the dentist to be overly concerned about dental changes that may not affect function or esthetics, causing therapy to be abandoned when it is essential to the patient’s health. The treating dentist must be aware of the anatomy and physiology of the temporomandibular joint so that strains created in the joint can be recognized and treated as opposed to possibly prematurely aborting oral appliance therapy.

CONTINUING EDUCATION to guide growth and development following the removal of tonsils and adenoids has been proposed as potentially helpful.52 Orthodontists then should be familiar with the signs and symptoms of OSA in both adult and pediatric patients. Orthodontists should be aware of the risk factors of OSA. They should screen their adult patients with validated screeners and should screen their pediatric patients with appropriate questioning. They should understand the key role of physiology and not make assumptions of the presence of disease based on any single awake parameter or any combination of awake parameters.63 Orthodontists may be called upon to guide growth and development in younger patients who have been diagnosed with OSA.

Conclusion Obstructive sleep disorders have the potential to negatively alter patients’ quality of life. Not only the associated snoring can be disruptive to the sleeping pattern of bed partners, but also excessive daytime sleepiness, altered sleep architecture, and the comorbidities of hypertension, cardiac disease, stroke, and GERD can debilitate patients further, decrease their quality of life, and significantly decrease their life expectancy. The vast majority of patients with sleep-disordered breathing are not diagnosed. Dentists have the potential to play a major role in both initiating diagnostic procedures and treating these patients.

Dentists should not be cavalier and treat snoring, the first stage of this disease continuum, without a proper diagnosis. They must learn to work hand-in-hand with the medical community. Dentists must learn how to communicate on a regular basis and learn how to keep sleep physicians in the treatment loop. The treatment of sleep-disordered breathing is an art and a science, and to be successful, the dentist must be adept at both. The role of the orthodontist should be to screen patients for OSA and consider their role in guidance of craniofacial growth and development in younger populations who have been diagnosed with OSA. OP

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58. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics. 2012;130(3):e714-e755.

32. Reeves-Hoche MK, Meck R, Zwillich CW. Nasal CPAP: an objective evaluation of patient compliance. Am J Respir Crit Care Med. 1994;149(1):149-154.

59. Murto K. Understanding Obstructive Sleep Apnea Syndrome in Children. Current Anesthesiology Reports.

2015;5(2):125-139.

2. Anesthesiologists, A.S.A. Wake up to the Effects of Sleep Apnea in Patient Education - What’s New? 2008; American Society of Anesthesiologists.

33. Waldhorn RE, Herrick TW, Nguyen MC, et al. Long-term compliance with nasal continuous positive airway pressure therapy of obstructive sleep apnea. Chest. 1990;97(1):33-38.

3. Bailey DR, Attanasio R. Dentistry’s role in the management of sleep disorders. Recognition and management. Dent Clin North Am. 2001;45(4):619-630.

34. van den Broek E, Richard W, van Tinteren H, de Vries N. UPPP combined with radiofrequency thermotherapy of the tongue base for the treatment of obstructive sleep apnea syndrome.

Eur Arch Otorhinolaryngol. 2008;265(11):1361-1365.

60. Kaditis AG, Alonso Alvarez ML, Boudewyns A, et al.

Obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management. Eur Respir J. 2016; 47(1):69-94.

REFERENCES 1. Finkel KJ, Searleman AC, Tymkew H, et al. Prevalence of undiagnosed obstructive sleep apnea among adult surgical patients in an academic medical center. Sleep Med. 2009;10(7):753-758.

4. Schmidt-Nowara W. A review of sleep disorders. The history and diagnosis of sleep disorders related to the dentist. Dent Clin North Am. 2001;45(4):631-642.

5. Marklund M, Franklin KA, Sahlin C, Lundgren R. The effect of a mandibular advancement device on apneas and sleep in patients with obstructive sleep apnea. Chest.

30 Orthodontic practice

61. Lipton AJ, Gozal D. Treatment of obstructive sleep apnea in children: do we really know how? Sleep Med Rev. 2003;7(1):61-80.

35. Sundaram S, Bridgman SA, Lim J, Lasserson TJ. Surgery for obstructive sleep apnoea. Cochrane Database Syst Rev. 2005;(4).

62. Black AP, Shott SR. Is adenoidectomy alone sufficient for the treatment of airway obstruction in children? Laryngoscope.

2014;124(1):6-7.

36. Aragon SB. Surgical management for snoring and sleep apnea. Dent Clin North Am. 2001;45(4):867-879.

63. Strauss RA, Burgoyne CC, Diagnostic imaging and sleep medicine. Dent Clin North Am. 2008;52(4):891-915, viii.

Volume 12 Number 3

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496 or visit https://orthopracticeus.com/subscribe/ to subscribe today.

To provide feedback on this CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

n To receive credit: Go online to https://iorthopracticeus.com/continuing-education/, click on the article, then click on the take quiz button, and enter your test answers.

AGD Code: 730 Date Published: September 21, 2021 Expiration Date: September 21, 2024

Basic principle review of sleep medicine GLASSMAN/MALIZIA

1. Those more serious comorbidities [associated with obstructive sleep apnea] include but are not limited to hypertension, myocardial infarctions, ______, and excessive daytime sleepiness (EDS). a. weight gain b. diabetes c. acid reflux d. all of the above 2. ______ of people with sleep-disordered breathing remain undiagnosed. a. 27% b. 56% c. 75% d. 90% 3. The American Society of Anesthesiologists estimates that ________ people have undiagnosed sleep disorders. a. 16 million b. 25 million c. 50 million d. 90 million 4. Normal NREM sleep occupies _____ of the night and is characterized by a decrease in body temperature, blood pressure, breathing rate, and most physiologic functions.

Volume 12 Number 3

a. 35% b. 58% c. 75% d. 90% 5. REM sleep is when most of the colorful and vivid dreaming occurs, and it occupies _______ of the normal sleep cycle. a. 10% to 15% b. 20% to 25% c. 35% to 45% d. 50% to 67% 6. _______ are disorders of initiating and maintaining sleep, as well as disorders of excessive sleepiness. a. Dyssomnias b. Parasomnias c. Bruxism d. Periodic leg movements 7. _________ are undesirable physical phenomena that occur during sleep, such as sleep walking, nocturnal leg cramps, periodic leg movements, nightmares, and bruxism. a. Dyssomnias b. Parasomnias c. Insomnias d. Circadian rhythm disorders

8. If the stoppage of breathing is caused by an obstruction in the airway, it is called _______. a. insomnia b. narcolepsy c. obstructive sleep apnea d. REM sleep behavior disorder 9. While the American Academy of Dental Sleep Medicine has recently suggested that it is within the scope of practice for a dentist to order an ambulatory test, it does not alter the fact that the diagnosis of the specific sleep disorder ___________. a. remains within the domain of the physician b. would best be done at the dentist’s office c. should be done in an urgent care center d. should be done after a psychological evaluation 10. _______ uses a positive airway pressure to create a pneumatic air splint, reducing pharyngeal compliance. a. Oral appliance therapy b. CPAP c. Nerve stimulation d. Uvulopalatalphygolplasty

Orthodontic practice 31

CE CREDITS

ORTHODONTIC PRACTICE CE

CONTINUING EDUCATION

Sleep, orthodontics, and myofunctional therapy Speech pathologist Sharon Moore discusses orofacial-nasal-pharyngeal function in the management of sleep-disordered breathing

T

his article outlines connections between medical and dental science, the wholebody health axis, the oral health-function axis, and sleep. The clinical relationship between the speech pathologist, who is dealing with processes and functions in the upper airway that govern alimentation and communication, is closely tied to the role of the orthodontist, who manages structural aspects of the stomatognathic system and dental-occlusal abnormalities in patients. These roles intersect with sleep and breathing.

Educational aims and objectives

This self-instructional course for dentists aims to show how orthodontics and myofunctional therapy combine to provide solutions for sleep-related breathing disorders.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions by taking 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 forms of sleep disorders and their prevalence.

•

Realize the connection between sleep disorders and growth and development of orofacial and dentofacial structures.

•

Identify OSA phenotypes.

•

Recognize the role that speech language pathologists and myofunctional practitioners have in treatment of sleep-breathing disorders.

The cost of poor sleep “Sleep is not optional; it is a biological necessity.”1 The importance of sleep is recognized increasingly, largely through the explosion of research outlining the detrimental effects of poor sleep.2,3 In the past 100 years, sleep time has eroded by 20%, with 33% U.S. adults trying to survive on 6 hours or less a night.1 This is not enough. Similarly, in Australia, the 2016 Sleep Health Foundation (SHF) Australia survey showed 33% to 45% of Australian adults get inadequate sleep.4 When it comes to the cost of poor sleep, figures from the SHF in 2021 on the cost of untreated sleep problems revealed the fiscal burden to society of $14.4 billion and $36.6 billion in nonfinancial costs related to lack of well-being.5 Meanwhile, in the United States, health care utilization costs were $94.9 billion annually.6 The cost of untreated sleep problems is estimated at 1% to 3% GDP.7,8 Beyond the financial, physical, and mental costs of poor sleep, there are measurable changes at the level of DNA and microcellular structure irrespective of cause or severity.9 Yet sleep myths and misperceptions abound (Figure 1). Sleep Sharon Moore is an author, speech pathologist, and myofunctional practitioner with 40 years of clinical experience across a range of communication and swallowing disorders.

Moore has a special interest in early identification of craniofacial growth anomalies in children, concomitant orofacial dysfunctions, and airway obstruction in sleep disorders.

32 Orthodontic practice

Figure 1

health is serially missed, dismissed, and misdiagnosed by health professionals and the community alike.1,10 Subsequently, many sleep problems are left untreated. The good news is that we as health professionals are able to bust these myths, impart essential sleep health messages, and provide treatment options to our patients.

Defining good sleep So, what is great sleep? Many believe getting plenty of sleep hours constitutes great sleep. However, good sleep means getting the right number of hours in addition to great sleep quality (Figure 2). Simply, you need both.11-14

What could go wrong?

What is preventing so many people from achieving consistent good sleep? Many factors influence our ability to sleep well, which can be divided into two categories: 1) diagnosable sleep disorders and 2) problems due to sleep health practices, including environment, behavior, and routines.11 Sleep problems due to unhealthy sleep practices may resolve relatively easily by modifying sleep habits and lifestyle. However, of the more than 90 sleep disorders, the most prevalent is insomnia, and the second most prevalent is sleep-disordered breathing (SDB). Obstructive sleep apnea (OSA) is the most serious form of SDB, requiring medical, Volume 12 Number 3

Figure 2: The sleep formula — To get great sleep you need the correct number of hours, which varies by age, of quiet, uninterrupted sleep. The result of great sleep is waking refreshed and able to manage natural energy peaks and troughs throughout the day

SDB and orthodontics Sleep medicine is embraced by many dental and orthodontic practices that are playing a critical role in assessing and treating patients suffering from SDB, in particular OSA.22,23 Orthodontists are well suited for treatment of SDB patients due to their expertise regarding the growth and development of orofacial and dentofacial structures, as well as orthopedic, orthodontic, and surgical correction of the jaws, and other supporting tissues.24,25 Upper airway collapsibility or impaired anatomy is the major driving force in the pathogenesis of OSA, including anatomical features like with microretrognathia or midface hypoplasia, which restricts the size of the bony compartment of the upper airway, leading to upper airway narrowing and closure during sleep independent of obesity for many individuals with OSA.26,27 Growth anomalies that limit oral space and hence tongue space, including those that limit transverse, anteroposterior, and/ or vertical dimensions, contribute to oral crowding, rendering the upper airway susceptible to collapse, crowding, or obstruction.28 Malocclusion is an anatomical factor signaling possible SDB.29,30 Anatomical factors beyond the oral cavity in the upper airway may also play a part — the nose, turbinate nasal passages, Volume 12 Number 3

Figure 3

paranasal sinuses, pharynx, and laryngopharynx.31 Narrowing can occur at one or multiple levels along the pharynx.32 The primary role of the orthodontist in SDB is oral appliance therapy (OAT) designed to bring the mandible and tongue forward to open the pharyngeal spaces, allowing for continuous breathing during sleep.33-35 There is a correlation between maxillomandibular size and nasopharyngeal width varying with the severity of OSA.36 There are a number of studies demonstrating the efficacy of expansion and bone growth guidance in children and adults.37-40 Environmental factors such as allergens and pollutants may be relevant considering their influence on soft-tissue health within the mouth and upper airway. Further, processes such as inflammatory, cerebral blood flow changes, hormonal changes, and postural alterations along with currently unknown

variables may also contribute to OSA pathophysiology.41 Functional upper airway impairments — e.g., hypotonia — may contribute to pharyngeal collapsibility in SDB. Appreciation of the functional aspects of upper airway health alongside anatomical factors is important, with orthodontists well-positioned to note both anatomical and functional risk factors for OSA beyond the oral cavity.

Neither gold-standard medical treatment for OSA nor oral appliance therapy is always tolerated by patients or successful, underscoring the importance of alternative treatment modalities like myofunctional therapy that improve upper airway patency.42,43

OSA phenotypes Consideration of the various OSA phenotypes, including the pathophysiology of OSA, assists treatment choices with patients, Orthodontic practice 33

CONTINUING EDUCATION

dental, or allied health expertise (Figure 3).

Interestingly, research by Krakow, et al., shows abnormal breathing is under-recognized in its role in insomnia with abnormal breathing leading to sleep fragmentation, suggesting SDB-OSA prevalence is likely higher than currently measured.15-18 Prevalence data for OSA across 16 countries, using American Academy of Sleep Medicine (AASM) 2012 diagnostic criteria and apnea-hypopnea index (AHI) threshold values, estimated that 936 million adults aged 30-69 years have mild-to-severe OSA, and 425 million adults aged 30-69 years have moderate-to-severe OSA. The number of affected individuals was highest in China, followed by the United States, Brazil, and India.19 Furthermore, OSA risk increases due to obesity and aging, and in some elderly groups, OSA prevalence was found to be as high as 90% in men and 78% in women.20 Studies suggest that up to 25% of adult males and 15% of adult females are habitual (every night or most nights) snorers, and the frequency of occasional snoring is even higher.21

CONTINUING EDUCATION including suitability of mandibular advancement splint treatment (MAS, also known also as OAT), prediction, and efficacy. Eckert, et al., propose a personalized approach to target therapy or a combination of therapies based on four OSA phenotypes, which can play a crucial role in OSA pathogenesis for some patients.44 While some degree of “impaired” upper airway anatomy is a prerequisite for OSA, impairment in the non-anatomical traits is also an important contributor to OSA pathogenesis.45 The malleability of soft tissues of the upper airway render it vulnerable to closure and collapse during sleep along with other influencing factors (Figure 4).

Four proposed phenotypes Anatomical 1. Pcrit: Pcrit is the critical closing air pressure below which the tissues collapse in the upper airway, unable to maintain an open airway during sleep, with measures linked to narrowing, crowding, or collapsibility in the upper airway.

Non-anatomical phenotypes 2. Low arousal threshold (AT): AT is the breathing effort measured via eosphageal or epiglottic pressure swings that will lead to arousal.

Impairment in OSA means waking with minor increases in breathing effort (low AT). Frequent arousals prevent deeper, more stable stages of slow wave sleep in conjunction with rapid changes in blood gases which destablize breathing patterns that may also interfere with recruitment of upper airway dilator muscles.

3. High loop gain (LG): Breathing during sleep is regulated by partial pressure of carbon dioxide (PaCO2).

LG refers to the magnitude of a ventilatory response to a ventilatory disturbance. High LG refers to high frequency of fluctuations between wake and sleep with unstable breathing and is thought to play a key role in OSA pathogenesis for at least 30% of patients.46,47 4. Upper airway dilator response (UADR): UA dilator muscles that maintain upper airway patency are primarily genioglossus and levator veli palatini.48 Poor UADR is impacted by the many pressure-sensitive chemo- and mechano-receptors in the UA. These in turn are influenced by different sleep stages and neural drive to the dilator muscles. Negative pharyngeal pressures and blood gas exchanges may

increase neural drive for dilator muscle activity influencing UADR. Further, snoring-induced changes in the distribution of muscle fiber types leave the UA more susceptible to fatigue.

The ideal candidate for MAS/OAT, based on current phenotyping concepts and the available evidence, is a patient with a mildto-moderate collapsible upper airway with minimal or no impairment in the other nonanatomical phenotypes (i.e., the patient does not have high loop gain).

SDB, speech language pathology, and myofunctional therapy While speech pathology and sleep may seem like unlikely bed partners, they fit together in two main ways. First, sleep problems interfere with a person’s memory, learning, thinking, behavior, emotional regulation, and communication skills.1 Given the nature and goals of speech pathology, treatments that address disorders of alimentation and/or communication, how can progress be possible when insufficient sleep is undermining the very learning faculties required to build skill, develop new patterns and behaviors, and ameliorate development?

Speech language pathologists and myofunctional practitioners look closely at the facial bones and muscle systems of the

Figure 4: SDB exists on a continuum. On the severe end of the continuum, OSA is a multi-factorial disorder, where anatomical and non-anatomical factors can contribute to pathophysiology or airway collapsibility, while mouth breathing is on the mild end of the continuum 34 Orthodontic practice

Volume 12 Number 3

Figure 5

for increasing muscle tone in a noninvasive manner.55 Further research outlined a role for myofunctional therapy as an alternative or adjunct to CPAP, oral appliance therapy, and adenotonsillectomy surgery to reduce snoring, modify tongue tone, and decrease the recurrence of SDB.56-61 Given the tongue is the primary airway dilator, research is exploring the role of tongue function and mobility in SDB.62-66

Interrupting a circle of disease This conversation is really about circles of health and disease. As we consider SDB within the context of our professional work, there are connections between oral and whole-body health, orthodontics, myofunctional science, and sleep. There are not only abundant physical and mental health impacts from untreated sleep problems, but

also signs and symptoms of SDB and other major health problems associated with SDB that are evident in the mouth. Let’s consider the reason many patients seek dentalorthodontic expertise: headaches, bruxism and clenching, facial esthetics, TMJD, pain, and periodontal disease — all of which can be comorbid with SDB.67 Further, when the stomatognathic system is not functioning optimally, there are concomitant impacts on body functions — e.g., digestion and breathing. It goes both ways.

A healthy mouth contributes to digestive, nervous, cardiovascular, skeletal, lymphatic, respiratory, neuromuscular, integumentary, and endocrine system health highlighting circular relationships between oral, systemic, and whole-body health, as does resolution of SDB.68 Oral function plays a critical role in the oral health paradigm (Figure 6).

Halitosis: Reflux Malocclusion: OSA Periodontitis: Depression​ Narrow throat opening: OSA Gum infection: Heart attack or stroke​ Papillomavirus: Oral/pharyngeal cancer Eroding enamel: Acid reflux or throat cancer​ Pregnancy gingivitis: Pre-term delivery or still birth Bleeding while brushing or flossing: Type 2 diabetes​ Figure 6 Volume 12 Number 3

Orthodontic practice 35

CONTINUING EDUCATION

upper airway critical for eating, breathing, and speech — the same system that supports healthy breathing during sleep. Research showed that OSA can be improved by up to 62% in children and 50% in adults just by working with the muscles in the upper airway.49 Considering these statistics, mildto-moderate OSA could be significantly improved, if not resolved, with myofunctional therapy intervention (Figure 5).

Eckert, et al., outline the complexity of underlying causes of airway collapse using four phenotypes. While anatomical features are highly relevant, the authors suggest ~30% may be a result of pharyngeal muscle collapsibility that may be responsive to oropharyngeal exercises.50 Another UADR strategy is stimulation of the hypoglossal nerve, which provides drive to the muscles of the tongue and reduces the AHI by up to 70% or more with accompanying improvements in OSA symptoms.31,51 Myofunctional therapy is a patientspecific tailored program of resistance-based isometric and isotonic exercises designed to improve upper airway patency.

Although the mechanism is not well understood, a study in the British Medical Journal 2005 showed regular didgeridoo playing is an effective treatment alternative well accepted by patients with moderate OSA.53 Other research highlighted the “favorable effects of playing certain wind instruments and singing in alleviating symptoms and risk of snoring and OSA.”54 Koka, et al., in 2021 concluded that orofacial myofunctional therapy offers good potential for the treatment of OSA as an alternative method

CONTINUING EDUCATION

Figure 7: The mouth is a litmus test for health and disease, including sleep health. We can break the circle of disease

As we discuss the circle of life, so too can we discuss the circle of disease (Figure 7). Just as the mouth is a mirror of health, it is a mirror for common medical ailments like chronic sinus, reflux, anxiety, depression, diabetes, and atherosclerosis, which all have links to oral health and function and SDB.69 Considering that the consequences of untreated sleep problems impact cardiovascular, endothelial, metabolic, immune systems, and more, the circle of disease emerges with the mouth a mirror for disease.

Multidisciplinary teams are required to break the disease cycle and promote health by addressing root causes of oralrelated health complaints, interrupting otherwise inevitable health problems.70 In doing so, assist identification of some of the many sufferers who go undiagnosed and untreated, until their disease becomes more serious.

There has never been a more important time for medical, dental, and orthodontic professionals to work together.

Summary An increasing number of adults are not getting the sleep they need, and this takes a financial, occupational, physical, and emotional toll. Fortunately, orthodontists are well placed to assist. With expertise in 36 Orthodontic practice

OSA is shown to be linked to both anatomical and functional features within the stomatognathic system, highlighting treatment options and a natural synergy between the disciplines of orthodontics and speech language pathology. orofacial and dentofacial structures, they have the knowledge required for diagnosing structural contributors to SDB, while their orthopedic, orthodontic skills, and surgical knowledge place them in a position to offer oral appliance or other therapy or recommend surgery. The importance of the orthodontist playing a role in management of sleep problems as a global health concern cannot be emphasized enough.

OSA is shown to be linked to both anatomical and functional features within the stomatognathic system, highlighting treatment options and a natural synergy between the disciplines of orthodontics and speech language pathology. Speech pathologists and myofunctional practitioners trained in re-educating the muscles of the upper

airway can provide valuable support for these patients, as an adjunct to orthodontic or medical interventions, or as a stand-alone treatment for the many patients who cannot tolerate CPAP or OAT. Ultimately, when all health professionals have sleep health on their radar as part of the overall care of their patients, taking a team approach to total patient care will achieve the best results. In doing so, we may interrupt the circle of disease and engage patients in the circle of health.

If you would like to learn more about sleep issues in kids and how to address them, please read Sleep-Wrecked Kids or visit http://www.wellspoken.com.au. Queries can be addressed to projects@wellspoken. com.au. OP Volume 12 Number 3

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2. Ramar K, Malhotra RK, Carden KA, et al. Sleep is essential to health: An American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2021. Online ahead of print.

3. Worley SL. The extraordinary importance of sleep: The detrimental effects of inadequate sleep on health and public safety drive an explosion of sleep research. PT. 2018;43(12):758-763.

4. Adams R, Appleton S, Taylor A, McEvoy D, Antic N. Report to the Sleep Health Foundation 2016 sleep health survey of Australian adults. The University of Adelaide: The Adelaide Institute for Sleep Health Foundation website. https://www. sleephealthfoundation.org.au/pdfs/surveys/SleepHealthFoundation-Survey.pdf 5. Rise and try to shine: The social and economic cost of sleep disorders in Australia. Sleep Health Foundation website.

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6. Huyett P, Bhattacharyya N. Incremental health care utilization and expenditures for sleep disorders in the United States. J Clin Sleep Med. 2021. Online ahead of print.

7. Streatfeild J, Smith J, Mansfield D, Pezzullo L, Hillman D. The social and economic cost of sleep disorders. Sleep.

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8. Mattei M. Zzzs to dollars: How much does sleep deprivation cost? Sleep Advisor Website. https://www.sleepadvisor.org/sleep-deprivation-cost/.

9. Irwin MR, Wang M, Campomayor CO, Collado-Hidalgo A, Cole S. Sleep deprivation and activation of morning levels of cellular and genomic markers of inflammation.

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10. Meaklim H, Jackson ML, Bartlett D, et al. Sleep Education for healthcare providers: Addressing deficient sleep in Australia and New Zealand. Sleep Health.

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14. Krause AJ, Ben Simon E, Mander, BA, et al. The sleep-deprived human brain. Nat Rev Neurosci.

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15. Sateia MJ, Doghramji K, Hauri PJ, Morin CM. Evaluation of chronic insomnia. An American Academy of Sleep Medicine review. Sleep. 2000;23(2):243-308.

16. Meira E Cruz M, Kryger MH, Morin CM, et al. Comorbid insomnia and sleep apnea: mechanisms and implications of an underrecognized and misinterpreted sleep disorder.

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17. Krakow B, Melendrez D, Ferreira E, et al. Prevalence of insomnia symptoms in-patients with sleep-disordered breathing. Chest. 2001;120(6):1923-1929.

18. Mendes MS, dos Santos JM. Insomnia as an expression of obstructive sleep apnea syndrome - the effect of treatment with nocturnal ventilatory support. Rev Port Pneumol.

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19. Benjafield AV, Ayas NT, Eastwood PR, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: A literature-based analysis. Lancet Respir Med. 2019;7(8):687-698.

20. Senaratna CV, Perret JL, Lodge CJ, et al. Prevalence of obstructive sleep apnea in the general population: A systematic review. Sleep Med Rev. 2017;34:70-81.

21. Pandya C, Guilleminault C. Snoring. In: Aminoff MJ, Daroff RB, eds. Encyclopedia of the Neurological Sciences (2nd edition). Academic Press: London, UK; 2018.

22. Stark TR, Pozo-Alonso M, Daniels R, Camacho M. Pediatric considerations for dental sleep medicine. Sleep Med Clin.

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23. Addy N, Bennett K, Blanton AO. Policy statement on a Dentist's role in treating sleep-related breathing disorders.

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24. Behrents RG, Shelgikar AV, Conley RS et al. Obstructive sleep apnea and orthodontics: An American Association of Orthodontists white paper. Am J Orthod Dentofacial Orthop. 2019;156(1):13- 28.

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26. Okubo M, Suzuki M, Horiuchi A, et al. Morphologic analyses of mandible and upper airway soft tissue by MRI of patients with obstructive sleep apnea hypopnea syndrome.

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27. Simpson R, Oyekan AA, Ehsan Z, Ingram DG. Obstructive sleep apnea in patients with Down syndrome: current perspectives. Nat Sci Sleep. 2018;10:287-293.

28. Ravesloot MJL, de Vries N. One hundred consecutive patients undergoing drug-induced sleep endoscopy: Results and evaluation.

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29. Miyao E, Noda A, Miyao M, Yasuma F, Inafuku S. The Role of malocclusion in non-obese patients with obstructive sleep apnea syndrome. Intern Med. 2008;47(18):1573-1578.

30. Aroucha Lyra MC, Aguiar D, Paiva M, et al. Prevalence of sleep-disordered breathing and associations with malocclusion in children. J Clin Sleep Med. 2020;16(7):1007–1012.

31. Koka V, De Vito A, Roisman G, et al. Orofacial myofunctional therapy in obstructive sleep apnea syndrome: A pathophysiological perspective. Medicina (Kaunas).

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35. Galeotti A, Festa P, Viarani V, et al. Correlation between cephalometric variables and obstructive sleep apnoea severity in children. Eur J Paediatr Dent. 2019;20(1): 43-47.

36. Wang SH, Keenan BT, Wiemken A, et al. Effect of weight loss on upper airway anatomy and the apnea–hypopnea index. the importance of tongue fat. Am J Respir Crit Care Med. 2020;201(6):718-727.

37. Sánchez-Súcar AM, Sánchez-Súcar FB, Almerich-Silla JM, et al. Effect of rapid maxillary expansion on sleep apneahypopnea syndrome in growing patients. A meta-analysis.

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38. Kim JE, Hwang KJ, Kim SW, Liu SYC, Kim SJ. Correlation between craniofacial changes and respiratory improvement after nasomaxillary skeletal expansion in pediatric obstructive sleep apnea patients. Sleep Breath. 2021. Online ahead of print.

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48. Saboisky JP, Butler JE, Fogel RB, et al. Tonic and phasic respiratory drives to human genioglossus motoneurons during breathing. J Neurophysiol. 2006;95(4):2213-2221.

49. Camacho M, Certal V, Abdullatif J, et al. Myofunctional therapy to treat obstructive sleep apnea: A systematic review and meta-analysis. Sleep. 2015;38(5):669-675.

50. Owens RL, Edwards BA, Eckert DJ, et al. An integrative model of physiological traits can be used to predict obstructive sleep apnea and response to non positive airway pressure therapy. Sleep. 2015;38(6):961-970.

51. Strollo PJ Jr, Soose RJ, Maurer JT, et al. Upper-airway stimulation for obstructive sleep apnea. N Engl J Med. 2014;370(2):139-149.

52. Eastwood PR, Barnes M, Walsh JH, et al. Treating obstructive sleep apnea with hypoglossal nerve stimulation. Sleep.

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53. Puhan MA, Suarez A, Cascio CL, Zahn A, Heitz M, Braendli O. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial.

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54. Baba RY. Role of playing wind instruments and singing in snoring and obstructive sleep apnea. J Clin Sleep Med. 2020;16(9):1429–1430.

55. Diaferia G, Badke L, Santos-Silva R, Bommarito S, Tufikand S, Bittencourt L. Effect of speech therapy as adjunct treatment to continuous positive airway pressure on the quality of life of patients with obstructive sleep apnea. Sleep Med. 2013;14(7):628-635.

56. Lee SY, Guilleminault C, Chiu HY, Sullivan SS. Mouth breathing, "nasal disuse," and pediatric sleep-disordered breathing. Sleep Breath. 2015;19(4):1257-1264.

57. Camacho M, Guilleminault C, Wei JM, et al. Oropharyngeal and tongue exercises (myofunctional therapy) for snoring: A systematic review and meta-analysis. Eur Arch Otorhinolaryngol. 2018;275(4):849-855.

58. Villa MP, Evangelisti M, Martella S, Barreto M, Del Pozzo M. Can myofunctional therapy increase tongue tone and reduce symptoms in children with sleep-disordered breathing? Sleep Breath. 2017;21(4):1025-1032.

59. Guilleminault C, Huang YS, Monteyrol PJ, Sato R, Quo S, Lin CH. Critical role of myofascial reeducation in pediatric sleep-disordered breathing. Sleep Med. 2013;14(6):518-525.

60. Wang W, Di C, Mona S, Wang L, Hans M. Tongue function: An underrecognized component in the treatment of obstructive sleep apnea with mandibular repositioning appliance. Can Respir J. 2018(30):1-7.

61. Villa MP, Brasili L, Ferretti A, et al. Oropharyngeal exercises to reduce symptoms of OSA after AT. Sleep Breath.

2015;19(1):281-289.

62. Zaghi S, Valcu-Pinkerton S, Jabara M, et al. Lingual frenuloplasty with myofunctional therapy: Exploring safety and efficacy in 348 cases. Laryngoscope Investig Otolaryngol.

2019;4(5):489-496.

39. Machado AJ Jr, Crespo AN. Cephalometric study of alterations induced by maxillary slow expansion in adults. Braz J Otorhinolaryngol. 2006;72(2):166-172.

63. Guilleminault C, Huseni S, Lo L. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Res. 2016;2(3):00043-2016.

40. Handelman CS, Wang L, BeGole EA, Haas AJ. Nonsurgical rapid maxillary expansion in adults: Report on 47 cases using the haas expander. Angle Orthod.

2000;70(2):129–144.

64. Yoon AJ, Zaghi S, Ha S, Law CS, Guilleminault C, Liu SY. Ankyloglossia as a risk factor for maxillary hypoplasia and soft palate elongation: A functional - morphological study.

Orthod Craniofac Res. 2017;20(4):237-244.

41. Dempsey JA, Veasey SC, Morgan BJ, O'Donnell CP. Pathophysiology of sleep apnea. Physiol Rev. 2010;90(1):47-112.

42. Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve.

J Otolaryngol Head Neck Surg. 2016;45:43.

43. Saglam-Aydinatay B, Taner T. Oral appliance therapy in obstructive sleep apnea: Long-term adherence and patients experiences. Med Oral Patol Oral Cir Bucal.

2018;23(1):e72-e77.

44. Carberry JC, Amatoury J, Eckert DJ. Personalized management approach for OSA. Chest. 2018;153(3):744-755.

45. Lai V, Carberry JC, Eckert DJ. Sleep apnea phenotyping: Implications for dental sleep medicine. J Dent Sleep Med. 2019;6(2).

46. Wellman A, Jordan AS, Malhotra A, et al. Ventilatory control and airway anatomy in obstructive sleep apnea. Am J Respir Crit Care Med. 2004;170(11):1225-1232.

65. Yuen HM, Au CT, Chu WCW, Li AM, Chan KC. Reduced Tongue Mobility: An Unrecognised Risk Factor of Childhood Obstructive Sleep Apnoea. Sleep. 2021 Aug 25:zsab217. doi: 10.1093/sleep/zsab217. Epub ahead of print. PMID: 34432065.

66. Schar MS, Omari TI, Woods CM, et al. Altered swallowing biomechanics in people with moderate-severe obstructive sleep apnea. J Clin Sleep Med. 2021;17(9):1793–1803.

67. NT Huynh, E Emami, JI Helman, RD Chervin. Interactions between sleep disorders and oral diseases. Oral Dis. 2014;20(3):236–245 68. Baiju RM, Peter ELBE, Varghese NO, Sivaram R. Oral Health and Quality of Life: Current Concepts. J Clin Diagn Res. 2017;11(6):ZE21-ZE26.

69. Maples S, Kightlinger Decouteau D. Blabber Mouth.

Blabber Mouth Press; 2015 70. Olshansky SJ. From lifespan to healthspan. JAMA. 2018;320(13):1323–1324.

Orthodontic practice 37

CONTINUING EDUCATION

REFERENCES

Each article is equivalent to two CE credits. Available only to paid subscribers. Free subscriptions do not qualify for the CE credits. Subscribe and receive up to 16 CE credits for only $149; call 866-579-9496 or visit https://orthopracticeus.com/subscribe/ to subscribe today.

To provide feedback on this CE, please email us at education@medmarkmedia.com Legal disclaimer: Course expires 3 years from date of publication. The CE provider uses reasonable care in selecting and providing accurate content. The CE provider, however, does not independently verify the content or materials. Any opinions expressed in the materials are those of the author and not the CE provider. The instructional materials are intended to supplement, but are not a substitute for, the knowledge, skills, expertise and judgement of a trained healthcare professional.

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AGD Code: 730 Date Published: September 21, 2021 Expiration Date: September 21, 2024

Sleep, orthodontics, and myofunctional therapy MOORE

1. In the past 100 years, sleep time has eroded by ______, with 33% of U.S. adults trying to survive on 6 hours or less a night. a. 20% b. 30% c. 40% d. 50% 2. Upper airway collapsibility or impaired anatomy is the major driving force in the pathogenesis of OSA, including anatomical features like _______, which restrict(s) the size of the bony compartment of the upper airway leading to upper airway narrowing and closure during sleep independent of obesity for many individuals with OSA. a. microretrognathia b. midface hypoplasia c. low arousal threshold d. both a and b 3. High LG refers to frequency of fluctuations between wake and sleep with periods of unstable breathing and is thought to play a key role in OSA pathogenesis for at least ______ of patients. a. 15% b. 30% c. 50% d. 65% 4. The ideal candidate for MAS/OAT, based

38 Orthodontic practice

on current phenotyping concepts and the available evidence, is a patient with _______ collapsible upper airway with minimal or no impairment in the other non-anatomical phenotypes (i.e., the patient does not have high loop gain). a. no evidence of b. a mild-to-moderate c. a severely d. an untreatable 5. Sleep problems interfere with a person’s memory, _______, emotional regulation, and communication skills. a. learning b. thinking c. behavior d. all of the above 6. Research showed that OSA can be improved by up to ______ just by working with the muscles in the upper airway. a. 40% in children and 50% in adults b. 50% in children and 62% in adults c. 62% in children and 50% in adults d. 75% in children and 78% in adults 7. Another upper airway dilator response (UADR) strategy is stimulation of the hypoglossal nerve, which provides drive to the muscles of the tongue and reduces the AHI by up to ______ or more with accompanying improvements in OSA symptoms.

a. 64% b. 70% c. 80% d. 94% 8. ______ is a patient-specific tailored program of resistance-based isometric and isotonic exercises designed to improve upper airway patency. a. Regulated breathing therapy b. Bruxism prevention therapy c. Myofunctional therapy d. Tongue-space expansion therapy 9. Further research outlined a role for myofunctional therapy as an alternative or adjunct to ____ to reduce snoring, modify tongue tone, and decrease the recurrence of SDB. a. CPAP b. oral appliance therapy c. adenotonsillectomy surgery d. all of the above 10. _______ trained in re-educating the muscles of the upper airway can provide valuable support for these patients, as an adjunct to orthodontic or medical interventions, or as a stand-alone treatment for the many patients who cannot tolerate CPAP or OAT. a. Speech pathologists b. Myofunctional practitioners c. Chiropractors d. both a and b

Volume 12 Number 3

CE CREDITS

ORTHODONTIC PRACTICE CE

EVENT RECAP

LF FUTURE conference LightForce Orthodontics first user conference focuses on customer collaboration

T

he LF FUTURE conference, June 25-26, 2021, was a compelling mix of industry experts, rising orthodontic stars, and the team behind the fastest growing company in the specialty. More than 100 orthodontists attended the first annual LightForce event at the headquarters in Burlington, Massachusetts, one of the first opportunities to attend an in-person conference since the COVID-19 crisis. Over the course of the 2-day event, the company’s mission and vision were exemplified in speeches from an impressive lineup of orthodontic innovators and clinicians who are successfully using the LightForce System in their practices.

The mission — to empower orthodontists with the best technology to create a bite and smile that is as unique as the patients. The vision — to be the trusted industry leader in the new era of personalized orthodontics.

The event spotlighted the company’s beginnings, its growth, and vision for the future. In his welcoming address, company cofounder, Dr. Alfred Griffin III, thanked attendees for their “trust and faith in taking this journey.” He reflected on the pioneers of technology in orthodontic history — Drs. Edward Angle, Larry Andrews, and David Sarver — saying they lived in times when technology didn’t exist to enable their vision of improved diagnosis and treatment planning. Dr. Larry Andrews once said, “Most orthodontic problems can be biologically treated in 6 months. Our inefficiency makes up the difference in treatment time.” Dr. Griffin noted that now LightForce is positioned to provide that efficiency — using 3D-printing technology for 100% customization. “That is what is unique about this company. We are in a place where we can bring 3D-printing technology into the orthodontic space.” He touted Dr. David Sarver, a speaker at the event, as, “one of the most famous orthodontists in the world, who has been a big part of LightForce.” Dr. Sarver’s visionary advice has helped to evolve “the technology that has finally caught up to what orthodontists have been asking for so long.”

Dr. Lou Shuman, cofounder of LightForce, orthodontist, and former VP at Align Technology, said that this conference reminded him of 20 years ago when he walked into Align Technology. He said, “It felt like the rocket ship that was getting ready to launch, and it is incredible to see where we are going.” Dr. Shuman recalled the excitement of the early 40 Orthodontic practice

Attendees received hands-on indirect bonding (IDB) training

Attendees and employees came together to share ideas at the Hackathon

Cherie Camacho, Dr. Blake Davis, and Patrick Toal

Dr. Maz Moshiri, Dr. David Sarver, and Chris Bentson

days of LightForce when he and Dr. Griffin traveled to Germany to meet Hans Langer, CEO and founder of EOS, one of the earliest and most successful 3D-printing companies.

Founded 30 years ago, EOS has 3D-printed components for some of the biggest companies in the world. At the time they visited, Langer had not yet heard about 3D-printing potential in orthodontics. After showing him their plans for a 3D-printed fully customized bracket system, Langer’s fundraising arm offered LightForce first-round funding. Dr. Shuman recalls, “That meant so much to us.”

LightForce innovators are not just following the crowd, but moving ahead with direction and suggestions from those who practice orthodontics every day. Some of the top names in orthodontics were involved in the conference without payment from LightForce just because they’re passionate about the product. Attendees came to the conference because they know LightForce is the future, and this is the technology everyone should be adopting, or else they’ll fall behind. Dr. Griffin noted, “After listening to orthodontists, our peers, we get feedback and move forward.

We take such pride by saying our company is ‘by orthodontists for orthodontists.’ ’’ Dr. Shuman emphasized the importance of the involvement by orthodontists. He said, “Orthodontists are not just end-users. Design development benefits from feedback — those are the ‘golden nuggets.’ ” Dr. Griffin said Dr. Shuman’s involvement gave him confidence to move forward. “Being with Lou, we got Volume 12 Number 3

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EVENT RECAP

Speaker Dr. Maz Moshiri (above left) and Speaker Dr. Bryan Lockhart (above right)

LightForce co-founders Drs. Alfred Griffin and Lou Shuman

instant trust and instant credibility.” That has contributed to the company’s phenomenal growth and orthodontic customer satisfaction. Dr. Griffin pointed out some milestones: • 400% company growth in the last year since June • 97% of the product updates for software and hardware can be directly tied to an orthodontist who uses LightForce • 2.5 days’ average from when the orthodontist takes the scan to when the LightPlan is returned.

• 4.7 out of 5 average rating on a LightPlan • Net promoter score (how likely you are to be promoted to your colleagues) 96 Also, attendees heard about the latest product developments that have created even better tools for treatment planning.

• Mixed dentition support • Rebond trays so orthodontists can delegate to well-trained staff • Increased bite turbo options • FaceMap — for diagnostic and patient engagement • Translucent bracket — for even greater esthetics • And for the future — fully custom buccal tubes Many expert speakers offered insights and information: Speaker Dr. Maz Moshiri’s session, “The Future is now — Digital Diagnostics and Treatment Planning” shared how digital technology contributed to the success of his practice. He said, “I honestly believe that my practice would be on the decline and my stress levels worse had I not invested in and focused on digital technology and systems.

That allowed me to jump easily into LightForce.” He said that the 3D-printed fully customized bracket aligns with the company slogan — “one size fits one.” He added, “Intuitively as scientists and orthodontists, how can this not be better for patients? 3D workflow specifically made for the patient’s teeth. You know what you want to do, and you don’t have to tinker much when it comes back — seamless and simple.”

Dr. Maz Moshiri and Dr. David Sarver receive the LF FUTURE award 42 Orthodontic practice

Speaker Dr. Bryan Lockhart’s session, “How LightForce Is Making My Community Better,” said that LightForce enabled him to focus on the details and develop a mindset for treating patients efficiently. He said, “LightPlan gives you every tool you need to diagnose and plan a case in one centralized location. And it is cloud-based, so you can open it anywhere.” He said that LightForce has allowed him to have a successful practice while working less and not seeing a ton of patients every day. He ended by quoting Zig Ziglar: “You don’t have to be great to start, but you have to start to be great!

Speaker Chris Bentson, who has been working with orthodontists regarding the business aspects of their practices for over 25 years, spoke on the “Financial Impact of Digital Orthodontics.” He said although COVID-19 presented challenges, it was a time to adapt, learn, and “prepare for the digital tsunami” in the aftermath. He advised, “The wave is coming. Get on your board and start paddling.” New rules and regulations have changed office procedures. Because of “the tremendous acceleration in the digital world,” he said, “LightForce is the answer for the adult patient. It is part of the future of this business.”

Attendees responded to the speakers with enthusiasm. Dr. Geoff Sudit said, “This confirmed what I was thinking — that digital/3D customization is the future, and if you don’t jump on the bus now, you’ll quickly get left behind. I also love how the early adopters are helping to shape the company.

The most impressive part is how you guys are listening!”

Dr. Jason Shoe said, “I love the culture of the LightForce team and your dedication to constant improvement.”

Dr. Griffin summed up the conference with a message to LightForce customers. “All of the leaders in our community gathered together in pursuit of one common goal — to usher in a new era of personalized orthodontics. The orthodontic industry will have its biggest pivot in the past 20 years because of the work that we are embarking on together. I get fired up thinking about what is possible.” OP Volume 12 Number 3

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SERVICE PROFILE

Data-driven decision-making for competitive advantage Suzanne Wilson discusses how the right information can affect real, positive change in your business

A

s all industries continue to progress toward data management and datadriven decision-making, who are the pioneers, and who are the followers who are working to catch up?

Robust data analysis and data-led decisions are not simply trends. Common sense tells us — and studies show — that practices that adopt data-driven decision-making enjoy clarity, a higher level of output and productivity. Specifically, there are some clear examples of why your orthodontic practice should make use of data, and how insights from this information can affect real, positive change in your business.

Understanding practice data can improve financial health While tracking your net collections is essential, most practices don’t dive deep enough to gain a true picture of their financial health. Collections are just one part of the equation, and simply tracking data doesn’t help you understand if there are problems.

Putting your data to work by leveraging insights from a grouping of data and putting it in a visual format helps you understand the next steps to take and how to ensure health in the short and long term.

For example, if you knew that the industry standard for net collections should be lagging production by 5% to 20%, and you started to see trends that your collections were consistently higher than your net production, you would realize that your practice has a growth problem. Without the visibility to the trend, you may not see the mounting problem from this lagging indicator.

Better practice data can reduce prospective patient attrition Another critical metric is new patient flow.

If you’re keeping an eye on the number of patients coming through your door, that should be good enough, right? Not quite.

Let’s say, in addition to new patients, you begin tracking initial phone calls as “patient adds” to your system. In doing so, you might Suzanne Wilson is Chief Marketing Officer at Gaidge, the leader in orthodontics business intelligence and practice analytics.

44 Orthodontic practice

Gaidge treatment starts

discover that the number of patients calling to learn more about your practice is only converting to 50% who schedule an exam.

This information suggests there may be work to be done on your initial greeting, your intake protocol, marketing messaging, and importantly, your availability for new consults. The concept of this issue is not novel but even more reason to make it easy to see and understand. Marketing spend varies, but if you are spending on the low-end around 3% of top line revenue, and that is only yielding a 50% ratio to exams, you want to be able to see it readily so you can then attack the issue with solutions.

Better practice data can enhance operational efficiency There’s a chance you’re already measuring some practice metrics, but that doesn’t guarantee the way you collect data is efficient. If you or your staff are manually gathering and inputting performance data into spreadsheets, pulling and sifting through reports, and spending significant time compiling, let alone interpreting the data, these are strong indicators that your practice is not being operationally efficient or effective. Even with robust practice management software in place, orthodontic practices that operate this way are still missing the comprehensive level of analysis necessary for clarity in how their business is performing. Though patient care is

top priority — your competition is waiting for the opportunity to eat your lunch. The solution is running your business with a better practice performance data analysis tool.

Save time and increase clarity by automating the process of measuring practice performance information with intuitive visual dashboards. The insights result in ideas and resources focused on improving your practice, shaving time off tasks, creating a better patient experience and team environment, and other operational efficiencies that will truly drive long-term happiness and profitability.

Get the metrics, benchmarks, and reporting you need to compete — and win No matter the size of your practice, you must harness the power of data to first sustain your success in a competitive market, but how else can you effectively manage without understanding what’s driving and, equally important, what’s dragging your practice?

Leveraging data takes out the guesswork and provides facts to build upon. Whether you’re focused on operational insights or industry benchmarks, the right data will augment your approach and help you understand why your practice performs like it does, support you in your efforts to implement the highest priority changes, measure your results, and follow a path of continuous improvement. OP This information was provided by Gaidge.

Volume 12 Number 3

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The Academy of Clinical Sleep Disorders Disciplines (ACSDD) is an ADA CERP Recognized Provider.

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ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider at info@acsdd.org or to ADA CERP at www.ada.org/goto/cerp.

NEWS AND VIEWS

LightForce Orthodontics welcomes new chief operating officer, Kelly Cunning Riedel

T

he new COO of LightForce Orthodontics — Kelly Cunning Riedel — brings her strategic thinking, bold vision, and resultsfocused approach to LightForce. A lawyer by training and background, Riedel previously led a more than 650 person team at Amazon Robotics, most recently serving as Director of Operations and Supply Chain.

Before that, she built and managed the legal team for Amazon Robotics. The LightForce team is excited to be led by Reidel, who brings her high level of expertise and breadth of experience from one of the top companies in the world. She has previously held the position of Senior Corporate Counsel at Houghton Mifflin Harcourt Publishing Company and an intellectual property transactions position at Skadden, Arps, Slate, Meagher & Flom LLP in Boston.

Riedel’s dedication to customers and exceptional leadership skills are perfectly aligned with the LightForce corporate philosophy to put their customers and patients first and to never stop improving.

Dr. Alfred Griffin III, cofounder and CEO of LightForce Orthodontics said, “Kelly Riedel will make a powerful addition to the LightForce executive team. This is the embodiment of the right leader arriving at the right time — Kelly’s extensive operations experience in automation, scaling new business units, and her legal background will help LightForce serve the orthodontic industry for years to come.” He adds, “Feedback on Kelly from peers, senior execs, direct reports, and customers she worked with at Amazon consistently raved about her as a strategic thinker, talented collaborator, and respected leader. Most importantly, I know she is someone who will always go to bat for our patients and doctors.”

The company’s earnest commitment to serving orthodontists and their patients and improving orthodontic treatment efficiency impressed Riedel. She says, “As soon as I met Alfred and his team, I just knew they were up to something special. He is super smart, unwaveringly driven, and he knows his industry deeply. His dad is an orthodontist, so he grew up thinking about this space — it’s in his DNA. His care is genuine, not commercially incentivized.”

Riedel is enthusiastic about helping to build LightForce’s scope and reputation in 46 Orthodontic practice

LightForce Orthodontics Chief Operating Officer, Kelly Cunning Riedel

the years ahead. She says, “I am joining LightForce at the right time in my career.

At this company, quality, safety, and speed matter. And the people here are inspiring.”

Her work philosophy, inspired by her time at Amazon, is “to be strategically patient and tactically impatient.” She says, “I strive to bring teams together, inspire them to action, while keeping the vision of the company and the customer always front of mind. We will continue to establish goals, drive towards them, and meet them on behalf of our ortho customers and their patients.”

LightForce Orthodontics customized braces are created with 3D-printing technologies that result in the only 100% custom braces system, providing complete personalization in 3D-bracket technology. LightForce technology’s FDA-approved bracket is fully customized from the slot to the base. The brackets are 3D printed to fit in a specific position on a specific tooth — exactly as they were digitally planned. The 3D-printed slots are more accurate and precise than injection-molded slots. The most recent addition to LightForce’s product portfolio is the Light Bracket, a translucent, more esthetic option that blends in with the color of the teeth. The Light Bracket offers all of the features and benefits of LightForce’s flagship white bracket — the Cloud Bracket. In

addition, “intelligent” indirect bonding trays are designed and 3D printed for each unique clinical situation, providing superior placement accuracy, efficiency, and convenience.

Riedel believes in the value of individualization provided by 3D-custom printing.

She says, “Our mission is to empower orthodontists with the best of Industry 4.0 to give patients a bite and smile that is as unique as they are. I’m inspired by this because it’s good for patients — they have less time in the chair, and that time can be returned to all the other things patients love to do. With lower overall treatment time, they can have their braces-free smile by whatever big event is up next for them. It’s also good for orthodontists — in addition to booking fewer and shorter visits, they can delegate more efficiently to their office staff, which gives them time to do all the other things pulling at their attention. Plus, using our digital-planning software, they can treat their patients with the end result in mind, achieving predictably healthy bites and delightful smiles.”

With a focus on operations, Riedel plans to spend time on the production floor, getting to know both the U.S. and international teams. She says, “I want a sense of what they are passionate about, what problems they are facing, and what they are doing to find solutions on behalf of our customers.”

Volume 12 Number 3

NEWS AND VIEWS

She wants to encourage the positive and responsive atmosphere. “We believe in listening to our employees and actively fostering a workplace that allows people to be themselves, do their best work, and thrive. This is a culture I’m excited to be a part of, and will continue to amplify. It’s an incredible group with a powerful mission on an exciting trajectory. There is still so much more for us to do.”

Members of the LightForce team are chosen for their specific skills at every level of the company. Riedel says, “This is a super creative group. At every level of our corporation, from engineers to operations and beyond, there is a sense of collaboration, teamwork, celebration of successes, and striving to delight our customers. The newest to the most tenured employees know our customers’ names, care about their problems and needs, and are encouraging to each other. This is what I want for this next stage of my career — to spend my days in an environment that is this customer-focused, fast-moving, innovative, and supportive.”

The wall outside of Riedel’s office is emblazoned with the principles behind LightForce. It says, “What is the future of

“It’s an incredible group with a powerful mission on an exciting trajectory.”

LightForce Orthodontics Chief Operating Officer, Kelly Cunning Riedel

orthodontics? We believe that the future is what happens when medicine, art, and technology converge. The patient is at the center of every decision, so the standard is raised to personalized care. The instrument becomes as sophisticated as the specialty, so that technology is in the hands of the experts. A community of trailblazers, doctors, designers

and engineers, united to materialize the vision. We are LightForce. And together, the future is ours to create.” Riedel says reading that sentiment validated her decision to join the team even more. She says, “That is not just marketing. These words are in the heart of the people here. Pinch me! What could be better than that?” OP

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Volume 12 Number 3

Orthodontic practice 47

PRODUCT PROFILE

Retainers For Life® Stop saying goodbye to your patients

I

have always loved the analogy that an orthodontist’s day looks like the flight pattern out of London Heathrow — you’re busy — in fact, you’re very busy. My name is Dr. Amy Jackson, a practicing orthodontist with four locations in San Antonio, Texas. After more years than I care to admit, I began recognizing problems associated with retainers. After trying a number of potential solutions, I ultimately realized they were Band-Aids® and resulted in further complicating my already busy day while not creating meaningful new revenue. This is how Retainers For Life® was born.

Company overview Retainers For Life® aims to achieve a simple goal: create positive experiences for doctors and their patients in retention.

Prior to Retainers For Life®, patients who lost, broke, or damaged their retainers had to miss school, work, or both to receive a replacement and keep their retention phase of treatment on track. Recognizing the success of companies like Amazon, we quickly realized providing easy, directto-door retainers was a value that patients need and want. With Retainers For Life®, orthodontists have a new tool to provide their retention patients with excellent care without sacrificing chair time or dealing

with disruptive retainer-related emergencies, while patients receive affordable, on-demand, direct-to-door retention care and products. And the best part? Doctors are never cut out of the process — Retainers For Life® does not believe in DIY treatment.

How does it work?

From the patients’ perspective: After membership enrollment, patients have access to replacement retainers — for life! If patients need a retainer or any other retention-related product, they need only log on to their Retainers For Life® account and place an order. The patient’s digital scan is retrieved, a new retainer is made, and it is shipped directly to the patient’s doorstep — no visit or call to their doctor required!

From the doctors’ perspective: After a less than 5-minute presentation, patients enroll in Retainers For Life®. From this point on, all retention phase, retainer-related headaches are transferred to Retainers For Life®.

As a Retainers For Life® practice, doctors are paid a quarterly profit-sharing disbursement, and all staff are bonused monthly for every membership sold.

we’ve become expert listeners. One key takeaway from working with doctors in almost every time zone, even Hawaii, is no two practices operate the same way.

More importantly, though, is our belief this is exactly the way things should be and is why we customize Retainers For Life® to perfectly fit into each doctor’s unique practice.

Put simply, our doctors know their patients best and are our best ally for creating positive retention treatment experiences. Forcing practices to adapt to a rigid, programmatic model of care is against our DNA. At Retainers For Life®, we want you to tell us how the program can best be used for your patients and, collaboratively, we work to make that happen!

Summary The retention phase of treatment should not be difficult for you or your patients. With Retainers For Life®, we are giving the gift of time back, not only to our doctors, but also to (my favorite) busy moms placing an order at 11:30 pm, who just want to finish the episode of their favorite show that they started watching 3 nights ago. OP

But what if my practice is different?

Dr. Amy Jackson, founder and practicing orthodontist 48 Orthodontic practice

As Retainers For Life® has expanded,

This information was provided by Retainers for Life®.

Volume 12 Number 3

LEAVE YOUR RETAINER HEADACHES BEHIND We understand better than anyone the number of ways patients can lose their retainers. In fact, it’s not a matter of if patients will lose them, but when.

Retainer issues steal chair time and create scheduling nightmares all while contributing little to no meaningful revenue.

Now...imagine those headaches GONE That’s what Retainers For Life® can do for you!

Premier Sponsor of the Women in Ortho Conference| Preferred Vendor of The Schulman Group Owned, powered & designed by orthodontists Patient site:www.myretainersforlife.com | Doctor site:www.afterorthorevenue.com 210-267-2070 | info@afterorthorevenue.com

The future of teen treatment is clear

95% of experienced Invisalign® orthodontists agree it’s the future of teen treatment.1 Experienced Invisalign orthodontists can treat nearly 70% of teens seeking treatment with Invisalign clear aligners.1 With technology like Mandibular Advancement and SmartForce® attachments, you get the control and predictability you expect while your teen patients get the smiles they want.

Learn more about the technology behind more than 2 million teen smiles at Invisalign.com/provider/teen.

1. Data from a survey of 78 orthodontists (from NA, EMEA, APAC) experienced in treating teenagers (minimum of 40 cases, prior 8 months) with Invisalign clear aligners, regarding teenagers with permanent dentition; doctors were paid an honorarium for their time. © 2021 Align Technology, Inc. All Rights Reserved. Align, the Align logo, Invisalign, the Invisalign logo, SmartForce®, among others, are trademarks and/or service marks of Align Technology, Inc. or one of its subsidiaries or affiliated companies and may be registered in the U.S. and/or other countries. | MKT-0006346 Rev A