Orthodontic Practice US July/August 2018 Vol 9 No 4 by MedMark, LLC

clinical articles • management advice • practice profiles • technology reviews July/August 2018 – Vol 9 No 4 • orthopracticeus.com

New

SureSmile®

Aligner PROMOTING EXCELLENCE IN ORTHODONTICS Making sense of temporomandibular disorders Dr. Harold Menchel

Dr. Daniel Klauer

Oral appliances — past, present, and future Dr. Steven R. Olmos and Matt Rago

How children breathe sets the stage for life Dr. Daniel S. Bruce and Bethany A. Bewley, RDH

Take a deep breath: sleep apnea and orthodontics

PAYING SUBSCRIBERS EARN CONTINUING EDUCATION CREDITS PER YEAR!

See page 11

Dr. Robert Waugh

Clinically Powered. Clinician Controlled.

Myofunctional therapy plays a key role in the orthodontic practice

TIME FOR CHANGE Introducing

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

Crossing the digital rubicon

t’s the rare orthodontist who isn’t interested in attracting more patients. As treatment times are generally reduced and capacity increased, this is of greater significance for the ongoing health and growth of our practices. What we really should have written is that those of us who seek more patients do so with the commitment to maintain or improve quality of care. More should never mean “too many.” Is that a statement of the obvious? No doubt, but it’s important to Drs. Michael Stewart and Melisa Rathburn with Oakley recognize that today we have technological options that allow us to treat not only faster, but better. Most of us have been able to take advantage of the ever-increasing standards of technology developed by our manufacturing and service provider partners to maintain our high standards. In our practice, the implementation of a digital treatment platform has made the difference. And when we write “made the difference,” we mean not only in maintaining our standard of care, but actually improving upon it. It’s not that we’ve suddenly become superhero orthodontists, but compared to 10 years ago, we have come pretty close, just without the costumes. It took some investment, time, and learning, but it was well worth the effort. Since implementing the SureSmile® system 14 years ago, we’ve managed to diagnose, treatment plan, and treat most of our patients in much less time than in pre-digital days and with consistently better results. In the battle of us (then) versus us (now), we win. That’s today’s us, the ones who switched our four Atlanta-area practices to a digital platform. Why is digital better? Working with digital scans, we diagnose each patient more efficiently and effectively, allowing us to visualize and design where we want to position teeth with much greater precision than previously possible. If we see a tooth or two wandering in a less than ideal direction during treatment, we can make adjustments “on the fly” and adjust the patient-specific, pre-bent arch wires at the chair with our “digital pliers.” As the patient demand for aligner therapy continues to increase, we not only provide it in many cases, we often do so with a hybrid or combination approach — starting with braces to get the teeth where we want them, then switching to aligners to finish the case to everyone’s satisfaction, including ours. It’s all in the plan, a plan which not only allows us to design treatment better than ever, but to communicate this treatment plan to patients and colleagues more effectively. Change is never without its challenges. Our digital conversion took time — it’s a process, not an event. It allowed both us and our staff to adjust to the new clinical world we had chosen to live in, enhancing both practice growth and quality of outcomes. If you’re considering moving to a digital platform, we can promise that you’ll see your patients differently, and if your experience is anything like ours, you’ll also see more of them! Drs. Melisa Rathburn and Michael Stewart

Dr. Chris Potts BDS, DGDP (UK), business advisor and ex-head of Boots Dental, BUPA Dentalcover, Virgin Dr. Harry Shiers BDS, MSc (implant surgery), MGDS, MFDS, Harley St referral implant surgeon

© FMC 2018. 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.

Melisa Rathburn, DDS, and Michael Stewart, DDS, are spouses who provide the leadership of Atlanta Orthodontic Specialists (AOS), a thriving six-doctor group serving four locations. They adopted SureSmile in 2004 and have generously shared their digital expertise and experiences with the specialty. To date, AOS has treated over 7,000 patients utilizing the SureSmile digital tool set.

ISSN number 2372-8396

Volume 9 Number 4

Orthodontic practice 1

INTRODUCTION

July/Aug 2018 - Volume 9 Number 4

TABLE OF CONTENTS

Case study Take a deep breath: sleep apnea and orthodontics

Dr. Robert Waugh discusses how an oral appliance can solve issues for patients with sleep apnea

Case study How children breathe sets the stage for life Dr. Daniel S. Bruce and Bethany A. Bewley, RDH, discuss the role of the airway in human development and at-risk patients for airway disorders

2 Orthodontic practice

Clinical Fixed and removable orthodontic appliance case study Dr. Andrew Wallace uses the principles of â&#x20AC;&#x153;smile designâ&#x20AC;? for a patient seeking cosmetic improvement of his upper and lower teeth.................................14

Clinical Myofunctional therapy plays a key role in the orthodontic practice Dr. Daniel Klauer uses MFT for his patients on a daily basis for malocclusion and OSA.....................22

Volume 9 Number 4

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TABLE OF CONTENTS

Continuing education Oral appliances â&#x20AC;&#x201D; past, present, and future

Dr. Steven R. Olmos and Matt Rago review oral appliances and their characteristics

Continuing education Making sense of temporomandibular disorders Dr. Harold Menchel discusses the elusive nature of TMD...................... 39

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Orthodontic insight Orthodontic treatment strategies for sleep apnea in children Dr. Satish Pai analyzes how orthodontists devise key strategies .......................................................46

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4 Orthodontic practice

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Volume 9 Number 4

The MKS Forum October 26-27, 2018 Hilton Anatole Dallas www.TheMKSForum.com

Announcing 2018 Speakers

~ See Next Issue For More Speaker Announcements ~ The MKS Forum is about the business of orthodontics, by and for orthodontists only. Learn how some of the worldâ&#x20AC;&#x2122;s best and most profitable doctors run their successful practices. These are not paid speakers pushing products, but rather doctors willing to share their success formula. The MKS Forum always has surprises, just ask the 700+ doctors who were there in 2018. Special 2018 Event: A panel of the largest orthodontic practice investors/buyers in the country will share what they believe makes the most valuable practices today and 20 years from now. This group has spent over $500,000,000 buying practices recently. Learn what makes the difference in orthodontic practice values.

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CASE STUDY

Take a deep breath: sleep apnea and orthodontics Dr. Robert Waugh discusses how an oral appliance can solve issues for patients with sleep apnea

he treatment of sleep apnea by orthodontists is a natural next step in the evolution of the specialty. My interest in the connection between the two began some years ago after attending courses on sleep medicine and realizing it was an emerging field that could help me become a better orthodontist. I later acquired a dental sleep practice from my mentor, Dr. Bob Ward, who also encouraged me to take my boards to become a Diplomate with the American Academy of Dental Sleep Medicine (AADSM). Reviewing my cases recently in preparation for the boards made me realize just how many patients had been treated for sleep apnea. Many had been referred by their GPs or physicians to have devices made for mild to moderate sleep apnea, which makes perfect sense. Orthodontists are already experts when it comes to fabricating appliances; when the conditions are right, and an oral appliance is made, we are often able to solve some problems for the patient that otherwise could be devastating (and most patients are grateful for a discreet sleep device rather than a loud, bulky CPAP machine). Unlike my younger patients, sleep patients are patients for life. Common to orthodontics, I rarely see children and teens once their orthodontic treatment is complete, and am often left wondering how their lives have been impacted by my work. However,

Robert Waugh, DMD, has practiced orthodontics full time in Athens, Georgia, since 1989 and is also an Assistant Professor at the Dental College of Georgia’s Orthodontic Residency program. Dr. Waugh’s interests include using new technologies that help deliver better care for his patients. In 2008, he merged three offices into one facility of 24 chairs that allows him to deliver care using a wide variety of advanced modalities in hygiene, patient scheduling, treatment delivery, and more. Dr. Waugh graduated from the Medical College of Georgia School of Dentistry in 1987 with both a DMD and a Masters in Oral Biology and was elected to Omicron Kappa Upsilon (OKU), the national dental honor society. He earned his orthodontic certification and a second Master’s degree at Baylor University in 1989. In 2000, he was board-certified by the American Board of Orthodontics. Dr. Waugh has served as President of the Georgia Association of Orthodontists and is a member of the International and American Colleges of Dentists.

The treatment of sleep apnea by orthodontists is a natural next step in the evolution of the specialty. I’ve found that there can be a connection between both fields — dental sleep medicine and orthodontics — that makes me a better doctor for both my older and younger patients.

A 56-year-old male patient presented on the sleep medicine side of my practice. A scare with atrial fibrillation had caused him to more seriously seek treatment for his sleep apnea, which was making him wake up at night gasping for air, leading to increased blood pressure and putting him at risk for stroke. A skeletal deficiency of the lower jaw resulting in an overbite was observed, which caused his tongue to block his airway while sleeping. The patient had expected a sleep appliance or CPAP to fix the problem; however, with the position of his mandible, an orthognathic procedure to bring his jaw forward was suggested. Of course, like any surgery, it carried certain risks, and the patient wanted to be sure it was the best course of action. A baseline CBCT scan was taken with the CS 9300 (Carestream Dental) with the patient

in his normal bite to serve as a predictor of success for either a sleep appliance or surgery (Figure 1). Then, following the recommendations of a poster presentation from the the AADSM 2017 Annual Meeting, “CBCT in the Study of Different Phenotypes of Responders and Non-Responders of Mandibular Advance Device Treatment: A Preliminary Study,”1 a second low-dose scan was taken with the patient’s mandible postured forward 8 mm as it would be with either an appliance or after mandibular advancement (Figure 2). After two clicks — one to define the upper limit and one for the lower limit — the airway was automatically segmented using the CS Airway module (Carestream Dental) to highlight constrictions in the pharyngeal airway. The software, with its illustrative color-coding of the airway, served as a powerful communication tool with the patient. He was then more comfortable pursuing mandibular advancement over CPAP or an oral appliance and accepted treatment. First, however, to compensate for the new position of the mandible, the patient opted for a micro-implant assisted maxillary skeletal expander (MSE), developed by

Figure 1: Maximum intercuspation

Figure 2: Protruded sagittal view

Case report

Disclosure: Dr. Robert Waugh is a key opinion leader for Carestream Dental.

6 Orthodontic practice

Volume 9 Number 4

UNLOCKING THE POTENTIAL OF CLEAR ALIGNERS with Dr. Duane Grummons

LEARN THE SECRETS TO BRING MORE CLEAR ALIGNER CASES INTO YOUR PRACTICE Dr. Duane Grummons will teach you that pre-aligner therapy can turn almost any orthodontic case into a clear aligner case. This lecture-style seminar explains how to identify and treat cases with pre-aligner therapy, and how to integrate this treatment into your practice. In addition, Dr. Grummons will teach you how to create success in your own practice. As an expert on building successful practices, he will show you how to: Inspire your team to be all in Get new patients in the door Increase patient acceptance Build reputation in your community

UNLOCKING THE POTENTIAL OF CLEAR ALIGNERS with Duane Grummons, DDS, MSD SEPT CHICAGO ILLINOIS SEPT SAN DIEGO CALIFORNIA OCT ORLANDO FLORIDA In his own practice Dr. Grummons experienced 90% youth and 80% adult conversion rates, with pre-aligner therapy being a key reason patients chose his practice.

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CASE STUDY

Figure 3: Frontal view of TADs for MSE

Dr. Won Moon. This new style of TAD-based palatal expander is quickly gaining popularity, as it is less invasive for adults. The expander was custom-made to receive four screws — two on the left, two on the right — and stabilized by bicortical engagement. The existing CS 9300 CBCT scans were used for planning to ensure safe placement of the TADs (Figures 3-5). After maxillary expansion, next, the patient will receive braces, followed by orthognathic surgery approximately 1 year into treatment to advance the mandible. Treatment will be finalized with postoperative detailing. Taking on sleep apnea cases such as these have made me a better clinician. I often find myself on the sleep medicine side of the practice consulting patients like this — in their 50s to 60s with a deficient lower jaw, struggling to breathe and with heart problems. Then I go to the orthodontic side of the practice to see a 7-year-old with a deficient mandible and need to decide between orthopedic treatment, extraction, or non-extraction — all of which have an impact on the tongue space. With the sleep apnea patient at the back of my mind, I may be encouraged to consider an orthopedic route with the orthodontic patient to give him/her a chance of unobstructed breathing for a lifetime. OP

REFERENCE

Figure 4: Sagittal view of TADS for MSE

1. Mayoral Sanz P, Contreras MM, Domínguez-Mompell R. CBCT in the study of different phenotypes of responders and non-responders of mandibular advance device treatment: a preliminary study. Poster presented at: 26th Annual Meeting of the American Academy of Dental Sleep Medicine; June 2-4, 2017; Boston, MA.

Figure 5: Surface volume for MSE 8 Orthodontic practice

Volume 9 Number 4

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Carestream Dental systems give you a fast, safe and efficient clinical workflow When every piece in the chain is designed to work together, your workflow, practice and patients all benefit. Carestream Dental’s digital software and systems offer infinite options for diagnosis, treatment planning and consultations—ultimately expanding your range of services and ability to treat patients with more confidence.

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CASE STUDY

How children breathe sets the stage for life Dr. Daniel S. Bruce and Bethany A. Bewley, RDH, discuss the role of the airway in human development and at-risk patients for airway disorders

hen adult patients with sleep-related breathing disorders come into my office for treatment, they often ask me why they developed sleep apnea in the first place. After all, it makes sense that natural selection should eliminate unfavorable traits, (such as choking in your sleep) and therefore, the genes that allow you to choke in your sleep should not exist. This apparent contradiction can be explained by delving a little deeper into the unique environment of modern man. Physical form is dictated not only by our genetic code, but also by

the pressures of our environment. When the environment changes, the physical human form can change. This is the classic nature versus nurture discussion. Also, the benefits of a certain characteristic may outweigh the drawbacks. For example, the ability to communicate through speech is highly valuable to humans despite the necessity of a collapsible airway to do so. I was first introduced to the concept of Darwinian medicine in college while reading the book Why We Get Sick.1 One aspect of the theory is that our bodies are suited to

Daniel S. Bruce, DDS, ABSDM, has a passion for treating patients with sleep-related breathing disorders and an even greater passion for helping children develop beautiful and functional airways. He enjoys creating interdisciplinary relationships with the health care community in order to provide the best outcomes for patients. Dr. Bruce practices in Boise, Idaho, and is a Diplomate with the American Board of Dental Sleep Medicine. He has lectured on the topic of dental sleep medicine. Outside the office, Dr. Bruce spends his time exploring the Idaho outdoors with his wife and 3 children. Bethany A. Bewley, RDH, BA, MS, is a full time mom and part time Director of Marketing for a private general dental practice in Boise, Idaho. While working as a clinical dental hygienist, she received her Master of Science in Dental Hygiene degree from Idaho State University. Her thesis research on incorporating sleep apnea screenings into dental hygiene appointments won an award as part of the DENTSPLY/ADHA Graduate Student Clinicians Program.

10 Orthodontic practice

ideally develop in conditions similar to those of Paleolithic times. Humans ate large quantities of raw, unprocessed food unfortified with nutrients and very little sugar. They had to deal with infections, bacteria, and parasites on a daily basis. Paleolithic humans lived in an environment with different types of stressors and different types of toxicities. Our bodies are designed to function in the Paleolithic environment. This concept was applied to the world of dentistry by Dr. Kevin Boyd in his article on Darwinian dentistry in 2012.2 He noted that the raw, hard food humans ate before the advent of agriculture created wide, more protrusive dental arches with a more balanced posture and thus a larger airway less prone to collapse. Reading this article was an â&#x20AC;&#x153;ahaâ&#x20AC;? moment for me that helped me understand the role our environment plays in the development of the human airway. Does this make you curious about ideal growth and development? It should! Understanding the topic helps dentists assess Volume 9 Number 4

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CASE STUDY where things can go wrong, why they went wrong, and what environmental and functional roadblocks can be removed to allow full expression of our growth potential. With this in mind, here are a few risk factors kids have for developing sleep apnea as a child or later on as an adult.

Tongue-tie A “tongue-tie” or “tethered oral tissue” or “ankyloglossia” occurs when a band of tissue tethers the tongue to the floor of the mouth. This situation can result in problems breast feeding, swallowing, and speaking. Very simply put, the tongue is a very good (actually the most ideal!) orthodontic expansion device. An ideal tongue posture occurs when the mouth is closed and the tongue is between the arches sitting fully on the palate. An ideal swallow occurs when the tongue pushes food to the roof of the mouth after chewing and peristaltically moves the food down the throat. The action of chewing and a tongue-to-roof-of-mouth swallow helps develop the maxilla and mandible in three dimensions. A tongue-tie restricts the ability of the tongue to support the maxillary arch. This often results in an underdeveloped maxilla and can affect the ability of the mandible to develop normally. The solution for a patient with a tongue-tie is a lingual frenectomy. However, this needs to be performed in conjunction with myofunctional therapy in order to re-train the tongue to function ideally. If this sounds like hard work, it is! However, it is necessary to restore function in most cases. Just because the tongue now has the ability to function ideally, does not mean it will forget the old swallow patterns. A myofunctional therapist is a hygienist or speech therapist with additional training in the function of the tongue. Finding and partnering with a

Figure 1: Tongue-tie in a 6-year-old 12 Orthodontic practice

The lethargic kids who snore and gasp for air at night are easier to identify, but you have to look beyond the teeth and at the whole patient. trained therapist greatly enhances any effort to shape ideal growth.

Mouth breathing Mouth breathing is incredibly common in children. Allergies, low muscle tone, tonsil and adenoid hypertrophy, and even tonguetie can cause mouth breathing. When a child breathes through his/her mouth, the tongue cannot sit between and develop the arches. The result is retrusion and collapse of the maxilla and often the mandible. Screening for mouth breathing is as easy as observing the child at rest. Also, crowded teeth or lack of space in the primary dentition are big red flags. Often kids who mouth breathe have heavy plaque levels, gingivitis (especially in the anterior teeth), and may have high caries rates due to xerostomia. Treatment involves referring for a sleep study if risk factors for sleep apnea are present or to an ENT to assess the reason for nasal congestion. The local myofunctional therapist can also be of assistance by teaching the patient exercises to change the resting posture of the tongue and aid in nasal breathing.

Adenotonsillar hypertrophy Hypertrophic adenotonsillar tissue has a direct correlation with sleep apnea in children. The benefits of removing the tonsils and/or adenoids can be seen dramatically and immediately. Improvement in school performance has been shown, as well as improvement in sleep disordered breathing.3

However, it is extremely important to realize sleep-related breathing disorder symptoms can recur in some patients, and tonsillectomy may not be the first line therapy for all patients. Myofunctional therapy can improve outcomes after surgery and reduce the risk of relapse later in life.4 In addition, orthodontic expansion has been shown to be helpful in necessary cases. Reasons for adenotonsillar hypertrophy are complex, and having a team treatment approach is necessary for persistent results.

Case study The following photos are of a 6-yearold female patient who presents with mouth breathing, adenotonsillar hypertrophy, tongue-tie, and maxillary crossbite. However, the parents do not report fatigue, snoring, or other issues associated with pediatric SRBDs. Since not all patients with risk factors have disease, we focused on dental arch development and removing barriers to ideal growth and development. The treatment plan therefore included orthodontic expansion, a lingual frenectomy, and myofunctional therapy. Pediatrician or pediatric ENT evaluation of tonsils was also recommended. Finally, the patient was referred to a pediatric functional medicine physician to assess environmental, food-related, or other interactions that might cause hypertrophy of the tonsils and adenoid tissue. Without parental observations of SRBD, we didn’t push for a sleep diagnosis, but focused on that ideal growth

Figure 2: Unilateral crossbite, likely a result of low tongue posture secondary to a tongue-tie Volume 9 Number 4

Where to go from here The risk factors for developing a sleeprelated breathing disorder in kids are often complex. Every child responds to resistance of the airway differently. The lethargic

Figure 3: Hypertrophic tonsils. Note the red and chapped lips, a common finding in mouth breathing children.

kids who snore and gasp for air at night are easier to identify, but you have to look beyond the teeth and at the whole patient. It is also important to remember every kid responds differently to airway stress. OSA may contribute to ADHD symptomatology, with these symptoms improving with ADHD treatment in a subset of patients.5 There are likely genetic, epigenetic, environmental, nutritional, digestive system, immune system, physiologic, and other factors at play. A holistic approach is helpful in getting kids on the best treatment path. I have found help in navigating this journey through the American Sleep and Breathing Association, the American Association or Gnathologic Orthopedics, the American Academy of Dental Sleep Medicine, and the American Academy of Physiologic Medicine and Dentistry, to name a few. SRBDs in children are a huge problem and appear to be getting worse, setting them up for life-altering challenges as adults. I hope to see the pattern of increased attention, research, and openminded thought in this area continue. The

best thing we can do as dentists is educate ourselves on treatment options, help educate parents about the problem so they can take ownership in finding solutions, and develop a comprehensive referral network. This is a complex problem in which the solutions may or may not be simple. However, I believe a truly integrative dental practice needs to have at least a baseline knowledge of the role of the airway in human development and the risk factors that can put our patients at risk for airway disorders. OP

REFERENCES 1. Nesse RM, Williams GC. Why We Get Sick: The New Science of Darwinian Medicine. New York, NY: Times Books; 1995. 2. Boyd K. Darwinian Dentistry: An Evolutionary Perspective on Malocclusion, Part I. Journal of the American Orthodontic Society. 2011;34-39. 3. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3):616-620. 4. Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R. Myofunctional Therapy to Treat Obstructive Sleep Apnea: A Systematic Review and Meta-analysis. Sleep. 2015;38(5), 669-675. 5. Youssef NA, Ege M, Angly SS, Strauss JL, Marx CE. Is obstructive sleep apnea associated with ADHD? Ann Clin Psychiatry. 2011;23(3):213-24.

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Volume 9 Number 4

Orthodontic practice 13

CASE STUDY

and development. I’m happy to report that she is currently in treatment — we felt that insisting on a sleep study might have delayed treatment, and it wasn’t necessary for this treatment plan.

CLINICAL

Fixed and removable orthodontic appliance case study Dr. Andrew Wallace uses the principles of “smile design” for a patient seeking cosmetic improvement of his upper and lower teeth

patient’s own self-perception and body image can be a motivating factor for cosmetic treatment, including cosmetic dentistry and orthodontics (Davis, Ashworth, and Spriggs, 1998), and patients expect to have an improvement in posttreatment (Pabari, Moles, and Cunningham, 2011). It has been shown most patients do see an improvement in body image and selfesteem after treatment (Pabari, et al., 2011) (Gazit-Rappaport, Haisraeli-Shalish and Gazit, 2010). Dental appearance can have a significant effect on the patient’s self-perception and social interaction (Davis, et al, 1998). Dental professionals in respect to cosmetic dentistry often focus on providing the patient with an idealized smile — translating the elements of a beautiful smile into proportions, ratios, rules, etc., that can be easily conveyed to a dental technician, easily reproduced, easily taught and remembered (Schabel, Franchi, Baccetti, and McNamara, 2009; Ward, 2007). This rigid adherence to smile design principles may in some circumstances result in patients having overtreatment and unnecessarily destructive dentistry (Qureshi, n.d.). Moreover several studies showed that the patient’s goal is a natural smile (Davis, et al., 1998), and that smiles that do correspond to these idealized principles are not actually viewed as any more esthetic (Schabel, et al., 2009). It has been shown that there can be a low correlation between what a clinician believes requires esthetic correction and the patient’s view (Tortopidis, Hatzikyriakos, Kokoti, Menexes, and Tsiggos 2007). Less invasive alternatives can offer significant advantages in financial and biologic cost (Burke, et al., 2011), and while they may not be viewed

by the clinician as the perfect result, they can satisfy the patient, particularly if they have been involved in the decision-making process (Nalbandian and Millar, 2009; Spear, 2004). Minor deviations from the ideal are generally not noticed (Kokich, Asuman Kiyak and Shapiro 1999). The knowledge of the principles of “smile design” should be used to aid in the planning process and help determine where a smile deviates from the ideal, but an ideal smile may not necessarily be the ultimate goal. In my view, our goal in esthetic dentistry should be a smile that the patients view as meeting their esthetic goals and requires the least amount of tooth tissue loss at a reasonable cost, rather than necessarily being able to stand up in front of our peers and present the perfect case or gain accreditation or praise from our colleagues in an organization or academy, although some more forwardthinking organizations are now updating their accreditation requirements. A progressive approach (Qureshi, 2002), where the smile is gradually improved and the patient is allowed to see and assess the improvement before committing to the next stage, is a sensible and pragmatic approach.

Case study Presenting condition A 22-year-old male attended the practice as a new patient seeking cosmetic improvement of his upper and lower teeth. His main concern was the crookedness of his upper and lower front teeth. He requested treatment with removable orthodontic appliances, if possible. He had not had any form of orthodontics prior to this. Examination was carried out, and

Andrew Wallace, BDS (QUB) MClinDent Prosthodontics (KCL), MFGDP (RCS Eng), is a general dentist with special interest in prosthodontics and orthodontics. Having qualified from Queens University Belfast in 1998, Dr. Wallace gained his master of clinical dentistry (MClinDent) in fixed and removable prosthodontics from King’s College London in 2015. He has been a partner in Bachelors Walk Dental since 2004 and also works in the multi-award-winning Cranmore Dental and Implant Clinic accepting referrals for restorative dentistry and endodontics. Dr. Wallace is a member of the IAS Academy and a lecturer, trainer, and mentor for Clearsmile Brace and Inman Aligner systems. He is the incoming president of the European Society of Aesthetic Orthodontics, a key opinion leader for Philips Oral Healthcare, and an honorary clinical teacher in King’s College London.

14 Orthodontic practice

orthodontic records were taken (see photos and assessment). Findings Dental Class 1 on a skeletal Class 2 with moderate upper crowding and moderate lower crowding. Dental midlines were noncoincident, and the upper midline was canted to the patient’s right. He had a minimally restored dentition with good oral hygiene.

Treatment options The treatment options were discussed for anterior alignment of the patient’s teeth. These options included: • Inman aligner • Clear aligners • Fixed appliances with tooth-colored brackets and wires. Other options discussed restorative treatment, including indirect porcelain restorations, including the possibility of elective endodontics on at least two teeth. The advantages and disadvantages of the alternatives were discussed, including the differences in outcomes and where the compromises of each outcome lay. The patient opted for orthodontics using fixed appliances with clear brackets, as the outcome we expected with these was closer to the patient’s goals. Potential adverse outcomes were detailed, as was the need for slenderizing the teeth using IPR and Predictive Proximal Reduction (PPR). The possibility of “black triangles,” the need for edge bonding, and lifetime retention were discussed, and the patient agreed to the treatment. I consulted with an orthodontic mentor about the case, and we agreed the treatment objectives were possible using the system, including that the right side crossbite was related to the angulation of the teeth on the right side and that this could be corrected by uprighting the teeth. A crowding analysis was carried out, and from this prescription, a predicted outcome was carried out using 3Shape® software by the lab, and these diagrams were used to further relay to the Volume 9 Number 4

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CLINICAL

Figures 1A-1L: Pretreatment images

patient the expected outcome. I feel this is an important step where the main objective in seeking treatment is a cosmetic one. An indirect bracket-bonding setup was carried out by the lab and was fitted at a subsequent appointment.

Treatment carried out Treatment took a total of 7 and a half months in fixed appliances; the patient was seen at 4 weekly intervals where progress was assessed, IPR was carried out as required with the total amount required having been determined by the laboratory beforehand, and the wires changed.

Records taken at each appointment included: IPR carried out, wires used, and patient complaints and questions were addressed. Particular attention was paid to the shape of the teeth during IPR and PPR so that they were detriangulated to reduce the risk of black triangles. Detriangulation of bulbous teeth allows for a longer contact point, closer to the underlying crestal bone, thus reducing the risk of lack of papilla infill in the gingival embrasures. At regular intervals, I consulted with mentors on case progress using digital photography and records. Following debonding of the appliances, the patient had removable retainers fitted

immediately, had in-surgery Zoom whitening shortly after, and subsequently, fixed bonded wire retainers were made and fitted. Removable retainers were fitted as well; the patient was instructed to wear full time for 3 months and during nighttime only after that. The patient was unhappy with the shape of the canine teeth, and these were reshaped using a single layer of VenusÂŽ Pearl (Heraeus) composite. The patient did not wish to have the incisal edge of the upper left central incisor bonded to address the minor tooth surface loss, even though this was part of the treatment plan from the outset.

Figures 2A-2F: 5-month review 16 Orthodontic practice

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CLINICAL

The outcome of the case is shown in the photographs. The molar and canine relation remains Class I with the incisor relation Class I with overjet 3 mm and overbite 3 mm. The canted midline is corrected, and the dental midlines are now coincident.

Patient testimonial

Figures 3A-3F: 6-month review

Dental appearance can have a significant effect on the patient’s self-perception and social interaction.

“I was considering getting braces for a few years as I noticed my teeth were getting worse. When I was in my teens, I was told that I needed braces by my dentist; however, I didn’t like the idea of the traditional metal braces. When I noticed a dental surgery was offering braces which were clear in color, I jumped at the chance. Before my treatment, I didn’t like smiling, and my teeth didn’t help my confidence at all. “My main concerns were my front teeth top and bottom, so I tried my best to hide them 6 months down the line, and that’s not the case anymore. My front teeth are completely straight, and even my back ones too, which I wasn’t expecting! I am amazed with the results, and I smile every chance I get now to show of my new teeth. I can’t thank the dental surgery enough; they have turned my life around, and I am extremely grateful for their help! I would definitely

Figures 4A-4B: Final retainers 18 Orthodontic practice

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CLINICAL

recommend this treatment to anyone else considering getting braces — it’s well worth the money.”

Conclusion We know from the literature that cosmetic dental procedures can improve patient’s own body image and self-esteem (Varela and García-Camba, 1995, Sarin, et al., 2004 ). Anecdotally, with this young man, I noticed a distinct change in attitude as his treatment progressed; he started becoming more outgoing, friendly, and confident. With a framework in place identifying clearly what should can be treated in general practice and what should be referred to specialist colleagues, with the mentoring and support from experienced colleagues and specialists, this sort of treatment is well within the remit of adequately trained general dentists and is a very rewarding type of dentistry to provide. OP

REFERENCES 1. Burke FJ, Kelleher MG, Wilson N, Bishop K. Introducing the concept of pragmatic esthetics, with special reference to the treatment of tooth wear. J Esthet Restor Dent. 2011;23(5):277-293. 2. Davis LG, Ashworth PD, Spriggs LS. Psychological effects of aesthetic dental treatment. J Dent. 1998;26(7):547-554. 3. Gazit-Rappaport T, Gazit E. Psychosocial reward of orthodontic treatment in adult patients. Eur J Orthod. 2010;32(4):441-446. 4. Kokich VO Jr, Kiyak HA,, Shapiro PA. Comparing the perception of dentists and lay people to altered dental esthetics. J Esthet Dent. 1999;11(6):311-324. 5. Nalbandian S, Millar BJ. The effect of veneers on cosmetic improvement. Br Dent J. 2009;207(2):E3. 6. Pabari S, Moles DR, Cunningham SJ. Assessment of motivation and psychological characteristics of adult orthodontic patients. Am J Orthod Dentofacial Orthop. 2011;140(6):e263-e272. 7. Qureshi A. Challenging the Diagnostic Sequence: Rethinking the order of smile design presents alternate treatment options. Journal of Cosmetic Dentistry. 2011;27(1), 86-96. 8. Qureshi A (n.d.). Who needs veneers. Retrieved June 25, 2011, from Chttp://www.towniecentral.com/MessageBoard/ UserUploads/Attachments/111958_Qureshi_939.pdf 9. Schabel, BJ, Franchi L, Baccetti T, McNamara JA Jr. Subjective vs objective evaluations of smile esthetics. Am J Orthod Dentofacial Orthop. 2009;135(4),S72-S79. 10. Spear FM. The esthetic correction of anterior dental malalignment: conventional versus instant (restorative) orthodontics. J Calif Dent Assoc. 2004;32(2):133-141. 11. Tortopidis D, Hatzikyriakos A, Kokoti M, Menexes, G, Tsiggos N. Evaluation of the relationship between subjects’

20 Orthodontic practice

Figures 5A-5L: Final photos perception and professional assessment of esthetic treatment needs. J Esthet Restor Dent. 2007;19(3):154-162. 12. Ward DH. 2007; A study of dentists’ preferred maxillary anterior tooth width proportions: comparing the recurring esthetic dental proportion to other mathematical and naturally occurring proportions. J Esthet Restor Dent. 2007;19(6):324-327.

13. Varela M, García-Camba JE. Impact of orthodontics on the psychologic profile of adult patients: a prospective study. Am J Orthod Dentofacial Orthop. 1995;108(2):142-148. 14. Sarin S, Gilbert D, Asimakopoulou K. Why simple aesthetic dental treatment in general practice does not make all patients happy. Br Dent J. 2 2014;216(12):681-685.

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Myofunctional therapy plays a key role in the orthodontic practice Dr. Daniel Klauer uses MFT for his patients on a daily basis for malocclusion and OSA

he TMJ & Sleep Therapy Centre of Northern Indiana (my practice) is limited to treating craniofacial pain, TMD, headaches, and sleep-disordered breathing for both children and adults. What started as a TMJ and Sleep Therapy practice for adults morphed into a wellness-driven practice ensuring all our patients are breathing adequately through the nose. I didn’t set out to incorporate myofunctional therapy (MFT)/ orofacial myology into my practice; this happened by necessity. The practice currently welcomes 75 new patients a month, presenting with chief complaints of fatigue and sleepiness to migraines and jaw locking — truly an array of presenting symptoms that typically have similar etiologies. As the practice started to expand, many of my adult patients began to inquire about their children and wanted to ensure that they didn’t grow up and develop the same issues their parents encountered. The parents described a very common situation: • “My son is wetting the bed as I did growing up. Is that related to what you just treated for me?” • “My daughter is constantly sick and congested as I was as a child. Can we address this now, so she doesn’t have the same issues I had for years?” By necessity I had to begin offering increased services for children related to sleep-disordered breathing, mouth breathing, and orthodontics.

Introduction Myofunctional Therapy (MFT)/Orofacial Myology can be defined as the study and

treatment of oral and facial muscles as they relate to breathing, speech, dentition, chewing/ bolus collection, swallowing, and overall mental and physical health (Holtzman, 2014).1 It used to be uncommon to need orthodontic treatment; now it is a regular phenomenon. The International Journal of Pediatric Dentistry in 2006 showed that 75% of children, ages 6 to 11 and 89% of youths 12 to 17, have some malocclusion.2 Furthermore, Evensen and Øgaard (2007) wrote that the prevalence of malocclusions in modern populations is higher than in excavated samples from ancient times.3 Proffit, Fields, and Sarver stated: “Respiratory needs are the primary determinant of the posture of the jaws and tongue [and head]. … Therefore, it seems entirely reasonable that an altered respiratory pattern, such as breathing through the mouth rather than the nose, could change the posture of the head, jaw, [teeth,] and tongue.”4 These manifestations include, but are not limited to, those listed in Table 1.

The younger patients with these symptoms can be treated, the better they will develop craniofacially and maintain healthy lifestyles into adulthood. Done correctly, MFT will allow for better results with orthodontic treatment in the future, if orthodontic treatment is needed at all. Proper tongue function is necessary for success with future braces. The tongue will be trained to function like a natural retainer that can minimize aggressive orthodontic work and relapse. Many clinicians have heard that patients’ teeth shift because they did not diligently wear their retainers for the recommended amount of time. Yet MFT trains the tongue to rest high in the roof of the patient’s mouth, which will naturally help prevent potential relapse of orthodontic cases. Clinicians should seek to answer the question of why teeth became crooked in the first place. If we know the patients need to wear retainers, and we know that their tongue is the culprit for the relapse, why not address that as part of treatment?

Table 1: Presenting symptoms of respiratory problems4 Mouth breathing (day and night)

Vaulted palate

Forward head posture

Enlarged tonsils and/or adenoids

Tongue scalloping

Tubes in the ears

Coated tongue

Fatigue

Bruxism (clenching and/or grinding of the teeth)

Snoring

Deficient midface

Low-resting tongue posture

Deficient mandible

Dental malocclusions (tooth crowding, overjets, overbites, open bites, and crossbites)

Narrow or collapsed dental arches

Lip incompetence

Daniel Klauer, DDS, earned a Bachelor of Science degree at the University of Notre Dame and his Doctor of Dental Surgery at The Ohio State University. He has completed over 2 years of postgraduate training and over 1,500 hours of continuing education in Craniofacial Pain, TMD, and Sleep Medicine. He is board certified with the American Board of Dental Sleep Medicine, American Board of Craniofacial Pain and the American Board of Craniofacial Dental Sleep Medicine. He is Diplomate Eligible with the American Board of Orofacial Pain. He is the only doctor in a 100-mile radius that carries these three board credentials.

Figures 1A and 1B: Myofunctional Trainer 22 Orthodontic practice

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CLINICAL Treatment Treatment includes a series of activities aimed at training (and retraining) muscles of the face and the oral cavity to function to their maximum benefit. These cannot be learned overnight. After all, patients have to unlearn a lifetime of habits. Activities may be supplemented with a Myofunctional Trainer (see Figures 1A and 1B) that is designed to help patients develop dental arches to their full genetic potential. Patients who are given a trainer to utilize while progressing through MFT will likely transition into a total series of three or four trainers throughout treatment. Photographs should be taken along the way to evaluate progress and make additional recommendations during treatment. Active treatment typically encompasses anywhere from 3 months to 1 year followed by maintenance visits. Ultimately, these activities can be utilized indefinitely. Training activities begin with proper education on where the tongue should rest at the incisive papilla (Figure 2) and to how to swallow without any extraoral muscle forces. Since malocclusion is caused by altered respiratory patterns and tongue position, as Proffit, Fields, and Sarver stated,4 then doesn’t it seem reasonable to state that all orthodontists should know or have a myofunctional therapist for their patients? That was my realization before my clinical team started to train and certify two

Figure 2: Proper tongue spot

Figure 4 24 Orthodontic practice

myofunctional therapists within our office. Now the practice has a full-throttle program for both children and adults to address these issues, and the results have been nothing short of incredible.

Case study A 9-year-old patient, D’Lyla, sought treatment to sleep better and to stay in her own bed. D’Lyla’s mother, a labor and delivery nurse, brought her in as a selfreferral because she noticed her daughter was sleeping with her mouth open, snoring, and waking up repeatedly throughout the night. Her mother knew something was off but couldn’t quite put her finger on it. Our staff gladly welcomed D’Lyla into our practice to solve this problem (Figure 3). My mentor, Dr. Steven Olmos, recently stated, “Why is the single most important thing to life, breathing, the least evaluated by doctors?”5 Clinicians have set out to change that. Our clinical evaluation process follows the medical model in first obtaining a detailed medical history and review of symptoms.

Medical history D’Lyla’s usual bedtime is 10 p.m. She awakens by 8 a.m., and her mother reports on average that D’Lyla gets 8 hours of sleep. She starts the night in her bed, but will always leave and go to her parents’ room. A parent has to be present for her to fall

Figure 3: D’Lyla, a 9-year-old patient

Figure 5: side view with mouth open

asleep, and she resists going to sleep every night. She has difficulty breathing throughout the night, snores, and is extremely difficult to wake in the morning. Her parents have tried numerous modalities to get her to stop sucking her thumb but have been unsuccessful. D’Lyla was prescribed 3 mg melatonin by her pediatrician for the sleep problems; however, the supplements proved to offer no benefits, although she has continued to take them. The pertinent negatives in her medical history review include no restless legs, no history of abuse, no thyroid problems, no cardiovascular disease, no bed-wetting, no recurrent infections, no excessive weight, no headaches, and no history of any surgeries or procedures. Her medical history is otherwise within normal limits.

Clinical examination Like all medical practitioners, the history of symptoms and chief complaints are reviewed, followed by a clinical evaluation to get one step closer to rendering a differential diagnosis. As the saying goes, 95% of effective treatment is an accurate diagnosis. With no disrespect to her pediatrician, D’Lyla’s problem was not an insufficiency of melatonin; otherwise, the supplement would have been effective. My practice’s exam is rather robust and, in this case, included evaluation of all oral structures at rest and in function; documenting range of motion; posture photos; cranial nerve evaluation; respiratory rate; resting lip, tongue, and mouth posture; and CBCT to evaluate the developing dentition, facial development, and patency of her airway. Right from the beginning, the clinical team noted lip incompetence. D’Lyla did not breathe with her lips closed and has an anterior tongue thrust (Figure 4). As a result, note the forward head posture and again the lips remaining open upon normal function (Figure 5). Upon viewing the width of her dental arches, it is clear there is not enough room for her tongue (Figure 6). Being that mouth

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CLINICAL breathing causes chronic forward head posture, this condition is of great concern in a developing child who now will have the net effect of increased weight distribution on the spine from the extra weight experienced from the head being forward. While the patient’s mandibular ranges of motion are adequate, her ability to open with her tongue touching her incisive papilla is limited — referred to as “tongue to the spot.” Clinicians typically want to see this at 75% of max opening, but the patient’s was 30 mm with a max opening of 53 mm (Figure 7). Thus, her percentage of opening with tongue to the spot was only 57%. Her tongue mobility is certainly limited and restricted. In evaluating the oral structures, clinicians noted attrition of the dentition, posterior tongue-tie, anterior open bite, malocclusion, and a coated tongue. The rest of her features were within normal limits. Her cranial nerve evaluation was thankfully unremarkable. A CBCT was taken and reviewed with the patient and her mother that same day. A 16 x 13 cm FOV CBCT was taken with the patient sitting upright. For our diagnostic CBCT, we instruct the patients to swallow once and then rest on their back teeth. We are more or less getting their image at maximum intercuspation. (Figure 8). I start my evaluation of the image by following the way the air is supposed to flow through the nose and down the throat. After all, people must breathe through the nose to warm, moisten, and purify the air they breathe. Guilleminault states that the “finish” line is ensuring children have functional nasal breathing,5 so clinicians want to evaluate this immediately as children are worked up for a differential diagnosis. As my clinical team began to evaluate D’Lyla’s CBCT, it was quite alarming. Her maxillary sinuses were nearly 100% full of

Figure 8: CBCT lateral pretreatment 26 Orthodontic practice

Figure 7: Tongue to spot

congestion bilaterally, yet her mother, who is a nurse, did not report any symptoms of sinus congestion. Furthermore, the patient had bilateral turbinate hypertrophy, ethmoid sinus congestion, and profoundly enlarged adenoids. The rest of the structures evaluated in the CBCT appeared to be healthy and within normal limits. At this point, the clinical team explained to the patient’s mother that her daughter’s situation is likely chronic in nature being that she feels normal and does not complain of congestion as she is seemingly just used to it (Figures 9-10).

Assessment/Diagnosis In review of her medical history, presenting symptoms, and clinical evaluation, D’Lyla was diagnosed with malocclusion (M264), mouth breathing (M2659), sleep

Figure 9: CBCT lateral with airway pre-treatment. Min Area: 42 mm2

disorder, unspecified (G4779), and snoring (R0683). This is the part of the appointment where clinicians have to ensure their explanation is heard and said in a fashion that the patient and parent can understand. The results from our evaluation proved that the patient’s obstructive breathing is contributing to her overall symptoms. It is clear that her nasal passages aren’t functioning properly as proven by her open mouth resting posture, anterior open bite, and coated tongue. Now her thumb sucking is also most likely contributing to her open bite. What’s interesting is that she can breathe only through her nose when her thumb is in her mouth. This, of course, forces nasal breathing and promotes incorrect tongue posture. However, it also brings the jaw forward, opening up the

Figure 10: CBCT Frontal sinus pretreatment Volume 9 Number 4

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CLINICAL posterior oropharynx. Maybe that’s why she “can” breathe through her nose when only thumb sucking but not at rest. We don’t know and can’t know for sure, but that is certainly plausible. At this point, I am fairly confident that the patient is suffering from sleep-disordered breathing, given her clinical presentations. This is likely the culprit for patient’s concerns. Furthermore, her impaired nasal breathing and open mouth resting posture are likely responsible for sleep disturbances. Thus, her respiratory patterns are contributing to her malocclusion. At this point, the mother was 100% onboard as answers were offered to problems she was searching to solve.

Treatment/Care plan The 2012 American Academy of Pediatric Guidelines for Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome clearly states in its conclusion: “The following recommendations are made. (1) All children/adolescents should be screened for snoring. (2) Polysomnography should be performed in children/adolescents with snoring and symptoms/signs of OSAS.6 My practice tries its best to follow the practice parameters set forth by our colleagues, and our clinical team followed these steps appropriately. 1. Ordered diagnostic Polysomnography at Memorial Sleep Lab 2. Ordered a follow-up office visit with an Ear, Nose, Throat (ENT) Physician and Sleep Medicine Physician. (In this case that happened to be one doctor.) 3. Initiate Myofunctional Therapy and Habit Eliminations immediately The patient and her mother were very compliant with treatment from the start and followed the treatment plan precisely. Her diagnostic sleep study showed the following: • mild obstructive sleep apnea • AHI: 1.2 • REM AHI: 3.8 • delayed REM sleep onset • decreased REM% of sleep • five central apneas D’Lyla followed up with the ENT/sleep physician, regarding these results, to review the adenoid hypertrophy and sinus congestion. Upon review, it was recommended that she utilize topical nasal steroid (Flonase® Sensimist™) and schedule for an adenoidectomy and turbinate coblation in 8 weeks. Prior to the scheduled surgery, it was recommended to get an updated CBCT to evaluate if the sinuses would need to be operated on 28 Orthodontic practice

Figure 11: MF Trainer

Proper tongue function is necessary for success with future braces. as well, given the profound sinus congestion noted on the CBCT. The ENT/sleep physician also encouraged her to initiate myofunctional therapy to help establish adequate nasal breathing in preparation for the adenoidectomy and turbinate coblation. He reviewed with the mother that following adenoidectomy, it is imperative that nasal breathing is established as 75% of children will redevelop sleep-disordered breathing within 2 years post surgery. (Guillinault study).6 At this time, the physician elected not to prescribe an antibiotic as the patient was clinically asymptomatic for any sinus symptoms. So the clinical team proceeded and started with myofunctional therapy and habit elimination as the patient began topical nasal steroid treatment. The mother elected to postpone her daughter’s surgery and scheduled it 6 months out in hopes to avoid the procedure. In my practice, two hygienists carry out our MFT treatment plans, so they got to work. My clinical team chose to utilize a myofunctional trainer as part of her treatment, which profoundly helps with thumbsucking habit elimination (Figure 11). The patient was also instructed to stay in her bed all night. D’Lyla was a champion right from the start and worked diligently throughout treatment. Our practice protocols for MFT

include a series of progressing exercises starting with tongue position awareness to proper swallowing technique. As the patient masters each step, he/she progresses to the next, always reviewing the basics. The clinical goal is habituation and having the patient establish adequate and functional nasal breathing while keeping the tongue in the correct position. D’Lyla eliminated her thumb sucking starting at the first appointment, and her symptoms improved tremendously fast. Within 3 months, the patient’s mother reported the following improvements in her chief complaints: • snoring – 100% resolved • restless sleep – 90% resolved • waking during the night – 90% resolved • daytime sleepiness – 98% resolved • sleeping with mouth open – 90% resolved At this time, the adenoidectomy surgery was scheduled, but clinicians were ordered to get an updated CBCT to evaluate the sinus disease. The patient’s mother was hopeful to avoid surgery as her daughter’s symptoms were nearly 100% resolved at this point. The results of the CBCT were quite impressive: The sinus congestion was completely resolved, and her adenoid hypertrophy was Volume 9 Number 4

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CLINICAL

Figure 12: CBCT lateral posttreatment

Figure 13: CBCT lateral with airway posttreatment. Min Area: 151mm2

Figure 15

greatly reduced (Figures 11-14). We immediately shared the results with the ENT/sleep physician along with the patient’s clinical improvement. He cancelled her surgery for the following week and recommended that she have an updated PSG to confirm that her obstructive sleep apnea was well under control. Needless to say, the mother was thrilled and proceeded on with the validation PSG. The ENT/sleep physician did say that if OSA was still present, then he would likely proceed with an adenoidectomy and turbinate coblation. D’Lyla went back to the sleep lab and completed the validation PSG. The results illustrated: • no presence of obstructive sleep apnea • AHI: 0.1 (only 1 event the entire night) • REM AHI: 0 • 98% sleep efficiency Overall, our clinical team was very pleased with the results. When utilizing MFT, patient and parent compliance is probably the single biggest determinant of success. 30 Orthodontic practice

Figure 14: CBCT sinus posttreatment

Figure 16

It is a game of compliance and, if educated properly by my entire clinical team, often stellar compliance is the result.

Review of treatment timeline • April 2017 — examination • June 2017 — Initial PSG (mild OSA) • August 2017 — treatment initiated with MFT and topical nasal steroid spray • November 2017 — post MFT CBCT • December 2017 — sleep/ENT physician cancelled surgery and ordered validation PSG • January 2018 — validation PSG showed complete resolution of OSA

Conclusion In closing, MFT is a great tool in our armamentarium for treating both children and adults with malocclusion or OSA. It can be a stand-alone treatment but typically is utilized as an adjunctive means of treatment. In this case, it proved to be effective in combination

with topical nasal steroid spray, but the true success was simply re-establishing adequate nasal breathing, and that’s what my clinical team helped D’Lyla achieve. Practitioners know maxillary expansion has been proven to treat OSA; but if we don’t establish functional nasal breathing and adequate tongue positioning, then how stable will that be long-term? OP

REFERENCES 1. Holtzman, SR. Orofacial Myology: From Basics to Habituation by Sandra R. Holtzman. 2nd ed. Morrisville, NC: NeoHealth Services, Inc.; 2014. 2. Zhang M, McGrath C, Hägg U. The impact of malocclusion and its treatment on quality of life: a literature review. Int J Paediatr Dent. 2006;16(6):381-387. 3. Evensen JP1, Øgaard B. Are malocclusions more prevalent and severe now? A comparative study of medieval skulls from Norway. Am J Orthod Dentofacial Orthop. 2007;131(6):710-716. 4. Proffit, WR, Fields FW, Sarver DM. Contemporary Orthodontics. 4th ed. Cambridge, MA: Elsevier Health Sciences. 5. Guilleminault C, Sullivan SS. Towards Restoration of Continuous Nasal Breathing as the Ultimate Treatment Goal in Pediatric Obstructive Sleep Apnea. Pediatr Neonatol Biol. 2014;1(1):001. 6. Marcus CL, Brooks LJ, Draper KA, et al. American Academy of Pediatric Guidelines for Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. 2012.

Volume 9 Number 4

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Oral appliances — past, present, and future Dr. Steven R. Olmos and Matt Rago review oral appliances and their characteristics

ral appliances designed for relief of facial pain and jaw dysfunction, sleep breathing disorders, and orthodontics have been utilized for many years with little change in materials until recently. This article will review indications/limitations of existing designs/materials, and how computer-aided manufacturing allows for better and healthier alternatives. There is always a reason for patients’ symptoms. Chronic face, jaw, head, and neck pain are all interrelated and are highly comorbid with sleep breathing disorders.1 Malocclusion, skeletal development deficiencies, and teeth crowding are symptoms of a functional breathing disorder.2-7 Oral appliances are used for each indication.

Educational aims and objectives

This article aims to discuss the potential benefits and drawbacks of oral appliances for facial pain and jaw dysfunction.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 38 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: •

Identify some potential appliances for acute or chronic pain.

•

Realize some reasons for night decompression devices.

•

Identify some devices for sleep breathing issues.

•

Recognize the benefits and disadvantages of some materials for fabrication of oral appliances.

Acute/chronic pain appliances Acute pain that is the result of trauma without history of signs or symptoms of TM-related pathology is usually temporary and best treated in that way. A clinical examination and imaging are necessary to rule out fracture. Reduction of inflammation/pain with NSAIDs and over-the-counter decompression oral devices (Aqualizer®/Myobrace®) are sufficient for a 2-week period. Symptoms lasting longer than 2 weeks or when combined with a history of signs or symptoms of limited opening or orofacial pain-headaches (craniofacial pain) often require therapy similar to other orthopedic or rheumatologic disorders. Treatment goals are to decrease pain, adverse joint loading, restoration of function, and resumption of normal daily activities. This is often accomplished by oral appliances, physical/

Figure 1A: Aqualizer®

Figure 1B: Myobrace® TMJ-MBV

medical regimens, and elimination the effects of all contributing factors. Finding the origin is key. It has been my experience that rarely is surgery necessary to treat most TM conditions that are not related to cancer, trauma, or systemic disease. It is commonly agreed that a conservative approach using reversible modalities should be the first approach in the treatment of chronic facial pain conditions. The ENT literature was the first to describe the loss of vertical height or the need to decompress the TM joints for relief of these symptoms. J. B. Costen in 1934

described the symptoms summarized in Arthur Freese’s paper published in the AMA Archives of Otolaryngology in 1959.8 1. Otological symptoms: loss of hearing, stuffiness in the ears, and tinnitus aurium. 2. Head and neck pain: pain in and about the ears, headaches in the vertex and occipital regions, and pain typical of “sinus disease.” 3. Miscellaneous symptoms: vertigo, tenderness of the temporomandibular joint to palpation, burning sensations in the tongue and throat, and a metallic taste. Various designs of appliances that are used for either day or night use for decompression purposes have utilized acrylic (methyl methacrylate) since the 1950s. Gelb, MORA appliances, Michigan splints, Farrar splint, stabilization splints, neuromuscular appliances, neural motor appliances (Stack), and many more variations are examples. The commonality is acrylic and often ball clasps — inflammatory base materials with retention that often create diastemas with long-term use. They can be milled from a methyl methacrylate puck using digital

Steven R. Olmos, DDS, DABCP, DABCDSM, DAAPM, DABDSM, FAAOP, FAACP, FICCMO, FADI, FIAO, has been in private practice for more than 30 years, with the last 20 years devoted to research and treatment of craniofacial pain, temporomandibular disorder (TMD), and sleep-related breathing disorders. He obtained his DDS from the University of Southern California School of Dentistry and and is board certified in both chronic pain and sleep breathing disorders by the American Board of Craniofacial pain, the American Academy of Integrative Pain Management, the American Board of Dental Sleep Medicine, and the American Board of Craniofacial Dental Sleep Medicine. Dr. Olmos is the founder of TMJ & Sleep Therapy Centres International, with 50 licensed locations in seven countries dedicated exclusively to the diagnosis and treatment of craniofacial pain and sleep disorders. Matt Rago has been working with Dr. Olmos for close to 10 years. He graduated from San Diego State University with a degree in Biology with the vision of going to dental school. After working with Dr. Olmos, he realized his real passion was the creation and development of oral orthotics to help those suffering from chronic pain and sleep-related breathing disorders. He is now the Director of Operations and head of Research and Development at Diamond Orthotic Laboratory and is continually working on the improvement of all oral appliances. Disclosure: Aqualizer, Mu:te, and Max Air are sponsors for Dr. Olmos' courses.

32 Orthodontic practice

Volume 9 Number 4

Figure 2B: Farrar

Figure 2C: Michigan

Figure 4A: Printed Night with ring

Figure 2D: MORA

Figure 4B: Printed without ring

Figure 3: PMT (Thermoform base with acrylic overlay)

technology; however, clinically, there are no differences from the lab-fabricated versions in terms of durability or wear characteristics. PMT (pressure molded technique) or thermoform material as a base with acrylic overlay has been a unique way to minimize thickness and eliminate the need for metal clasps. They are fragile, and careful instruction as how to insert and remove must be given to the patient to prevent fracture. Minimum thickness and full coverage are recommended to prevent tooth movement, comfort, and enhance speech in functional wear. Appliance recommendations for TMJ are: 1. Full coverage to prevent tooth movement 2. Minimal for speech during daytime use 3. Not to be worn longer than 12 weeks to prevent the possibility of posterior open bite as the condyle fossa grow with decompression9

Night decompression appliances Traditionally, the appliances made for daytime use have been used for night as well; however, there are significant differences in neurology, orthopedics, and functional breathing between day and night. Nociception travels to the brain or cerebrum during the day, but at night, only travels to the brain stem (cerebellum), so forces of contraction are 5 times greater at night than the day.10 Jaw joint locking and headaches are comorbid with daytime fatigue secondary to sleep breathing disorders.11 Volume 9 Number 4

Figure 5A: Lingual hinge/connector design

Figure 5B: Elastic Mandibular Advancement

Figure 5C: Herbst

Figure 5D: Dorsal design

Therefore, a device designed to reduce the forces of contraction in the unconscious state, prevent retrusion of the mandible, and open-closed nasal valves is ideal for this purpose. This type of device is now available in a printed form with and without lingual loop. Printing allows for custom fabrication digitally using Type 12 nylon, which is durable and unreactive. The collapse of the soft tissue Alar rim and the Columbella can block up to 90% of the nasal airway. It is the narrowest portion of the nasal airway.

Sleep breathing appliances Oral appliances for the treatment of OSA have the following requirements: • Maintain and/or advance the mandible in the supine position • Must be titratable (in protrusion)

• Durable material • Retentive and adjustable • Comfortable and minimally invasive • Minimal tooth movement • Does not create TMD or joint pain • FDA approved Most of these appliances are acrylic and use ball clasps for retention. It has been demonstrated that when treating sleep breathing disorders, utilizing oral appliance therapy (OAT) or using positive pressure therapy (PPT) alone or in combination will result in tooth and skeletal changes. Opening diastemas, the result of clasping, is in addition to these changes. The limitations of these appliances are reducing oral volume due to the thickness of material. This leads to problems with lip seal and patients drooling during sleep. In addition to acrylic solely, thermal acrylic and dual laminate versions Orthodontic practice 33

CONTINUING EDUCATION

Figure 2A: Gelb

CONTINUING EDUCATION

Figures 6A: Mu:te nasal device

are available in many appliance choices. A summary of the advantages and disadvantages are listed. OAT has been found to be more efficacious in all parameters in head-to-head with PPT except AHI reduction.12 Common disadvantage of all current FDA appliances is that they can only be titrated protrusively and not vertically. Studies have shown that the two biggest factors in MAD treatment success are body mass index (BMI) and nasal airway resistance (NAR).13 Nasal dilators have become a very important part of OSA therapy. Nasal valve dilation has been shown to decrease intraluminal pressures in the oropharynx, which reduces apneic events, via the Starling resistor model.14 Hard acrylic Advantages: 1. Can be adjusted or repaired easily at chairside (grind it if it’s too tight or add more acrylic if it’s too loose). 2. Easy to insert and remove with the use of ball clasps. 3. If the patient has minor dental changes, hard acrylic can sometimes be modified rather than fabricating a new appliance. 4. They complement most dentitions and clasps can be added for additional retention. Disadvantages: 1. Appliance is very rigid. Patients with sensitivities state these appliances feel tight and can irritate the gums/ teeth. 2. Because it is less forgiving, accurate impressions are required to prevent chairside adjustment. 3. Wear over time with patients who brux. 4. Bulky material forces tongue to move posteriorly; reduces oral volume. 34 Orthodontic practice

Figures 6B: Max-Air Nose Cones

Figure 7: Starling resistor model

5. Porous material and can leach giving bad taste and irritation. Causes discoloration and attracts bacteria.

3. Decreased shelf life due to composition of material; breaks down over time due to its porosity.

Thermal acrylic There is a learning curve for dentists when working with this material. Advantages: 1. Because thermal acrylic is soft and pliable at warm temperatures, it allows for comfort and easy seating, which helps engage undercuts that harder materials (acrylic) cannot. 2. Provides better retention with crowded dentition because the material can flex. Clasps can be added for further retention. 3. Pliability allows material to flex over crowns and bridges, making them a good choice for patients with restorations. 4. Recommended for patients with sensitivities and edentulous patients (provided they have a good bony ridge). Disadvantages: 1. Dentists must get a “feel” for how hot the water must be, or how long it must be left in the mouth before removing. 2. More frequent replacement may be needed when compared to hard acrylic appliances, especially for clenchers or bruxers.

Dual laminate Advantages: 1. These appliances possess the rigidity of hard acrylic on the outside with a soft inner liner that buffers the teeth/tissue. 2. Has more “give” which requires less blockout. 3. Recommended for patients with sensitive teeth or cosmetic work. Disadvantages: 1. Not as durable as hard acrylic. 2. The soft side can delaminate and absorb moisture. 3. Porous material yellows over time and depending on diet; more frequent replacement. 4. Clasps and acrylic cannot be added for further retention. 5. Can be difficult to adjust (material “gums up” using a high-speed bur; low-speed has little to no effect on soft material). Polyamide/nylon The introduction of Type 12 nylon appliances, a CAD/CAM printed device, has been a remarkable tool allowing us to reduce size, increase comfort, accuracy, and durability. These devices are designed using proprietary Volume 9 Number 4

Polyamide/nylon Advantages: 1. Can be adjusted chairside in seconds, easy to insert and remove, and has that “snap” fit. 2. Is extremely durable and resilient, thin and flexible. 3. Has not been proven to cause any allergic reactions — BPA and phthalate free. 4. Higher patient satisfaction and longer shelf life. Disadvantages: 1. Patients with short clinical crowns or lack of buccal or lingual undercuts may not be candidates. However, adjustments can be made to maximize retention. 2. Priced higher than most due to material cost. 3. Requires impeccable impressions; not an issue when scanning digitally. Volume 9 Number 4

Figure 8A: Narval™

CONTINUING EDUCATION

software specific to each manufacturer and printed using selective laser sintering (SLS) technology that guarantees a consistent and accurate device. Digital impressions are captured using intraoral or desktop scanners; offices are not required to own a scanner as laboratories can digitize stone models to a STL format. By transitioning to a digital process, offices can eliminate the discomfort and inconvenience of physical impressions and bite registrations, as well as having to store bulky physical models. The introduction of CAD design also allows laboratories to digitize their workflow. This greatly reduces the fabrication process and therefore turnaround times. Design changes can be made with superior accuracy and minimal effort, allowing a high degree of customizable devices to suit the complex anatomy of individual patients. Crafted from a lightweight, flexible, biocompatible material unlike any other oral appliance, these devices allow you the freedom and flexibility to talk and drink. Unfortunately, the existing nylon FDAapproved appliances do not adjust for vertical, nor do they address nasal valve resistance or tongue posture. The DDSO (Diamond Digital Sleep Orthotic), by Diamond Orthotic Lab, LLC., has all of these features and is currently in the process of FDA approval. It can be fabricated with and without vertical titration. Removable nasal pillows, modular tongue positioners, and MED-grade bands with different resilience allow for patient comfort and versatility.

Figure 8B: Panthera D-SAD

Figure 9

Figure 10

Figure 11A

Figure 11B Orthodontic practice 35

CONTINUING EDUCATION Table 1: DDSO Bands Physical Description/Benefits

FDA-Compliant

Diamond-shaped to reduce surface area and irritation to tissue

MED-Grade Sanoprene material

High tensile strength (tear resistant)

Soft/hard non-hygroscopic thermoplastic vulcanizate (TPV) in the thermoplastic elastomer (TPE) family

Can be recycled

Meets USP Class VI requirements for plastic

Lower cost to manufacture reducing overall cost

Material undergoes annual testing for cytoxicity and heavy metals

Free of phthalates and latex proteins (allergy-sensitive patients)

Drug master file maintained with FDA

Have shown increased long-term aging durability and physical stability after curing

Figure 12A: CPAP PRO

Figure 12B: Shirazi Hybrid (Diamond Orthotic Lab)

Figure 13: Quick disconnect and adjustable straps for titration

Figure 14A

Figure 15A 36 Orthodontic practice

Figure 14B

Figure 15B

Hybrid therapy The combination of oral appliance therapy (OAT) and positive pressure (CPAP, Bi-PAP, Auto PAP) has been found to be effective for the difficult to treat or patients that cannot tolerate positive pressure alone.15 This is due to the OAT preventing collapse, thus reducing the amount of air pressure needed to dilate the muscular walls of the airway. Patients using positive pressure devices often complain of the straps that are necessary to hold the mask to the face. Devices designed to eliminate the mask can be purchased OTC; however, they are not titratable. Combining a custom-fabricated titratable nylon printed appliance and nasal delivery positive pressure is the optimum treatment for these most difficult-to-treat patients (Shirazi Hybrid). Fit difficulties in delivery The number one reason for fit difficulties in delivery is poor impressions or pour-up techniques. Improper rations of alginate, double wash of vinyl polysiloxane (VPS) impressions, and inaccurate powder/water ratio of the stone can all result in distortions that make delivering the appliance impossible — a waste of valuable chair time. Mounting can also cause delivery issues. Transference of the maxilla in a 3D cant (pitch, roll, yaw), from the skull to the articulator, can make for error and facial pain complaints. Errors in the articulator as they wear in the laboratory or the fact that they are not used in the manufacture of these devices both create problems. Perhaps the lab does not use the same articulator as the clinician. Solutions for these errors are now simple. Scanning with systems such as Trios® or iTero® devices allow for electronic transmission of exact duplicates of soft and hard tissue. Orienting the maxilla utilizing soft tissue landmarks via facebow or skeletal relationships via Hamulus Incisive Papilla (HIP) can be duplicated digitally. CAD software carries a wide range of popular articulators to use in a virtual environment. This allows the designer to make a variety of changes to the bite as well as see if a cant is present. Articulators can also be used in the design process for verification or adjustments — removing material where collisions are detected. Bite registrations can be transferred electronically, eliminating the need for offices to send them to the lab via mail reducing turnaround times. Physical bite registrations can be created from digital scans using bar extrusion/subtraction tools. Volume 9 Number 4

Adjustments to appliances can be performed digitally using these accurate relationships.

Removable orthodontic appliances Orthodontic expansion appliances whether they be screw linear transverse, ALF (Advanced Light Force), coiled NiTi spring, or slimline, can be acrylic based. With the introduction of nylon orthodontic devices, patients can benefit from increased durability and comfort. Dentists will notice reduced costs and chairside time with the ability to reset expansion without having to remake the appliance. The evolution of knowledge from the 19th to the 21st century has elevated our ability to help our patients more from just dental health to medical health. We have evolved from vulcanite laborintensive appliances to Type 12 nylon printed appliances and now can generate anything we can conceive. Elimination of inflammatory materials to inert durable materials ensures a reduction of adverse reactions to soft tissue and health of the patient.

CONTINUING EDUCATION

Figure 16: Optimize occlusion in real time with virtual articulators

Figure 17

Each step in the production of oral appliances has the potential for error. From impressions to pour, to mounting to fabrication — the steps all are people dependent. By reducing these steps and digitally transferring data, eliminating error and standardization of optimal fit and quality of the final product will ensure the search for prevention of injury and optimization of function. OP

REFERENCES 1. Olmos SR. Comorbidities of chronic facial pain and obstructive sleep apnea. Curr Opin Pulm Med. 2016;22(6):570-575. 2. Huang Y, Guilleminault C. Pediatric obstructive sleep apnea and the critical role of oral-facial growth: evidences. Front Neurol. 2012;3:184. 3. Sweet JB, Butler DP, Folio J. Retrognathia and Sleep Apnea. JAMA. 1977;238(14):1497. 4. Lee RW, Chan AS, Grunstein RR, Cistulli PA. Craniofacial phenotyping in obstructive sleep apnea — a novel quantitative photographic approach. Sleep. 2009;32(1):37-45. 5. Roberts SD, Kapdadia H, Greenlee G, Chen ML. Midfacial and Dental Changes Associated with Nasal Positive Airway Pressure in Children with Obstructive Sleep Apnea and Craniofacial Conditions. J Clin Sleep Med. 2016;12(4):469-475. 6. Pirilä-Parkkinen K, Pirttiniemi P, Nieminen P, Tolonen U, Pelttari U, Löppönen H. Dental arch morphology in children with sleep-disordered breathing. Eur J Orthod. 2009;31(2):160-167.

Figure 18 7. Caprioglio A, Levrini L, Nosetti L, et al. Prevalence of malocclusion in preschool and primary children with habitual snoring and sleep-disordered breathig. Eur J Paediatr Dent. 2011;12(4):267-271. 8. Freese AS. Costen’s syndrome: a reinterpretation. AMA Arch Otolaryngol. 1959;70:309-314. 9. Voudouris JC, Woodside DG, Altuna G, et al. Condylefossa modifications and muscle interactions during Herbst treatment, Part 2. Results and conclusions. Am J Orthod Dentofacial Orthop. 2003;124(1):13-29. 10. Okeson JP. Management of Temporomandibular Disorders and Occlusion. 7th ed. St. Louis, MO: Elsevier Mosby; 2013 11. Olmos SR, Garcia-Godoy F, Hottel TL, Tran NQ . Headache and jaw locking comorbidity with daytime sleepiness. Am J Dent. 2016;29(3):161-165. 12. Phillips CL, Grunstein RR, Darendeliler MA, Mihailidou AS, et al. Health Outcomes of Continuous Positive Airway Pressure versus Oral Appliance Treatment for Obstructive Sleep Apnea. AJ Am J Respir Crit Care Med. 2013;187(8):879-887. 13. Zeng B, Ng AT, Qian J, Petocz P, Darendeliler MA, Cistulli PA. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. Sleep 2008;31(4):543-547. 14. Michels Dde S, Rodrigues Ada M, Nakanishi M, Sampaio AL, Venosa AR. Nasal involvement in obstructive sleep apnea syndrome. Int J Otolaryngol. 2014. 15. El-Solh AA, Moitheennazima B, Akinnusi ME, Churder PM, Lafornara AM. Combined oral appliance and positive airway pressure therapy for obstructive sleep apnea: a pilot study. Sleep Breath. 2011;15(2):203-208.

Figures 19A-19C: A. Screw transverse. B. ALF. C. Series 2000® (Diamond Orthotic Lab)

Figures 20A-20C: A. Screw transverse. B. ALF. C. Slimline (Diamond Orthotic Lab) Volume 9 Number 4

Figure 21 Orthodontic practice 37

REF: OP V9.4 OLMOS

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Oral appliances â&#x20AC;&#x201D; past, present, and future OLMOS

1. Acute pain that is the result of trauma without history of signs or symptoms of TM-related pathology is usually _______ and best treated in that way. a. temporary b. permanent c. long-term d. non-reversible 2. (For acute/chronic pain) Reduction of inflammation/pain with NSAIDs and over-thecounter decompression oral devices are sufficient for a ______ period. a. 2-week b. 4-week c. 2-month d. 6-month 3. It has been my experience that rarely is surgery necessary to treat most TM conditions that are not related to _______. a. cancer b. trauma c. systemic disease d. all of the above 4. Traditionally, the appliances made for daytime use have been used for night as well; however,

38 Orthodontic practice

there are significant differences in _______ between day and night. a. neurology b. orthopedics c. functional breathing d. all of the above 5. Nociception travels to the brain or cerebrum during the day, but at night, only travels to the brain stem (cerebellum), so forces of contraction are ______ greater at night than the day. a. 2 times b. 5 times c. 10 times d. 15 times 6. The collapse of the soft tissue Alar rim and the Columbella can block up to ____ of the nasal airway. a. 25% b. 42% c. 72% d. 90% 7. Oral appliances for the treatment of OSA have the following requirements: â&#x20AC;˘ ______ the mandible in the supine position. a. maintain b. advance

c. reduce d. both a and b 8. Digital impressions are captured using intraoral or desktop scanners; offices are not required to own a scanner as laboratories can digitize stone models to a/an ______ format. a. OBJ b. STL c. HTM d. FBX 9. By _______, offices can eliminate the discomfort and inconvenience of physical impressions and bite registrations, as well as having to store bulky physical models. a. transitioning to a digital process b. using acrylic and ball clasps c. using Michigan splints d. using the Farrar method 10. The combination of oral appliance therapy (OAT) and positive pressure (CPAP, Bi-PAP, Auto PAP) has been found to be effective for _________. a. those who tolerate positive pressure well b. the difficult to treat or patients c. those who cannot tolerate positive pressure alone d. both b and c

Volume 9 Number 4

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Dr. Harold Menchel discusses the elusive nature of TMD Abstract Significant confusion and controversy still exist in the dental community about temporomandibular disorders (TMD). Because of this, dentists and orthodontists must be aware of some distinct etiologies when these patients present in their practices. This article will review the etiology of TMD, the current diagnosis criteria for TMD (DC/TMD), and evidenced-based management principles. Since dentists often refer to orthodontists for TMD, it is essential that they can accurately diagnose these disorders and are able to manage orthodontic treatment in these patients according to these precepts. Dentists will be able to quickly recognize simple from complex patients so that they know whom to treat and whom to refer. Two cases will be presented to illustrate these points.

Introduction Misconceptions about TMD Orthodontists are often referred TMD patients because the misconception that TMD is an “occlusal disease” is still pervasive in the dental community and in public perception. There is no support for this anachronistic belief1,2,3,4,5: Mohlin B, et al., conducted a systematic review “to evaluate associations between different malocclusions, orthodontic treatment, and signs and symptoms of temporomandibular disorders (TMD).”6 Results included these findings: • “TMD could not be correlated to any specific type of malocclusion.” • “There was no support for the belief that orthodontic treatment may cause TMD.” • “Associations between specific types of malocclusions and development of significant signs and symptoms of TMD could not be verified.”

Educational aims and objectives

This article aims to discuss the etiology of TMD, diagnosis criteria, and evidence-based management principles.

Expected outcomes

Orthodontic Practice US subscribers can answer the CE questions on page 44 to earn 2 hours of CE from reading this article. Correctly answering the questions will demonstrate the reader can: • Define some characteristics of TMD. •

Identify some guidelines for treatment of joint-related musculoskeletal disorders.

•

Recognize some solutions for patients with inflammatory-orthopedic joint pain.

•

Identify some characteristics of chronic myofascial pain.

Orthodontists, however, are still in an ideal position to diagnose and manage uncomplicated TMD cases. They are best prepared because of their skills with removable appliances and their knowledge and skills treating malocclusions that have been changed by TMD disorders, especially osteoarthritis. They need to acquire the diagnostic acumen to distinguish what they should treat and what they should refer and, in more complex cases, coordinate treatment with an orofacial pain dentist. Facts about TMD TMD is a medical musculoskeletal disorder involving two different populations of patients, although these populations can overlap. It is important that dentists focus on this when triaging TMD patients and not other distractions. Some of these “distractions” are irrelevant occlusal considerations such as centric relation position, occlusal interferences, anterior guidance, and crossbites.7 There is also overemphasis on joint sounds in diagnosis of TMD. Painless clicking and popping is of no great concern if the patient has no locking. Painful clicking and popping associated with locking or joint crepitation are considerations, but these are

Harold Menchel, DMD, is a dentist in Coral Springs, Florida, who limits his practice to TMD, orofacial pain, and sleep-disordered breathing. Dr. Menchel teaches undergraduate and graduate education in TMD and orofacial pain at Nova Southeastern School of Dental Medicine in Ft. Lauderdale, Florida. He is the director of orofacial pain at Larkin Teaching Hospital in Miami and lectures both nationally and internationally. Dr. Menchel is a fellow of the American Academy of Orofacial Pain, a Diplomate of the American Board of Orofacial Pain, and a member of the American Academy of Dental Sleep Medicine.

Volume 9 Number 4

easily determined and managed in most cases. Simple stethoscopic or digital examination is all that is required without other expensive instrumentation such as Doppler, which can produce false positives.8,9,10 By assuming TMD is mainly a disorder of muscles, and that chronic muscle pain is caused by overuse, dentists are often further distracted from the actual evidence base that this is mainly a disorder of joints. This will be discussed in detail. Therefore, EMG measurements are not valid in diagnosing or managing TMD.11 The orthodontist has to recognize two distinct etiologies for TMD patients in order to manage these patients.

Population 1: Inflammatory-orthopedic joint pain TMD disorders are no different from all other musculoskeletal orthopedic disorders. Therefore, the etiology, diagnosis, and management should follow established evidenced-based medical-surgical treatment guidelines. These guidelines are simple and well-established for any joint-related musculoskeletal disorder. There is no reason that the stomatognathic system should not be included along with all other body joints. These guidelines follow12,13: • Control excessive forces on joints for both compression and hyperextension trauma • Reduce inflammation (anti-inflammatory medications) • Reduce muscle spasm (muscle relaxers) • Mobilize the joint Orthodontic practice 39

CONTINUING EDUCATION

Making sense of temporomandibular disorders

CONTINUING EDUCATION In refractory cases (10% or less) more invasive approaches may be necessary — e.g., arthroscopic surgery. In terms of TMD, there are a minority of patients with disc displacement, and/or TMJ arthritis that may require surgery.

Population 2: Chronic myofascial pain Thankfully, these patients are in the minority because they present diagnostic and management challenges for medical management. This population of patients often has widespread bilateral muscle pain and has generally poor prognosis.14,15 Comorbidities such as IBS, interstitial cystitis, chronic headache, anxiety, depression, chronic sleep disorders, restless leg syndrome, etc., are common. Fibromyalgia syndrome is an example. These patients require a comprehensive team approach with medical and psychological management, and if they have a TMD component to their pain, an orofacial pain dentist. Most dentists should not get involved in primary management of these patients and should work closely with an orofacial pain dentist if patients require any dental treatment. Oral appliances are often ineffective. Occlusal treatment should be approached with utmost caution and should be avoided unless necessary. It is essential that the orthodontist be able to distinguish between these two different populations and avoid getting involved with the latter.

The diagnostic criteria for TMD The first step for any dentist is to understand the diagnostic criteria first formulated in 199215,16,17 and then revised in 2010.

Table 1: Diagnostic criteria for TMD Type

Description

Muscle disorders only: Acute vs. Chronic

Disc displacements

III

Other joint issues: Arthritis, joint inflammations, etc.

Table 1: TMDs are divided into three groups: disorders of muscle, disc displacements, and other joint disorders such as inflammatory joint disease (capsulitis-synovitis, osteoarthritis). Source: Dworkin and Leresche 199215; Schiffman 201017

These criteria divide TMDs into muscle and joint disorders (Table 1). The joint disorders are further divided into disc displacements and joint inflammatory disease. Combinations of these diagnoses are common. A common misconception is that most TMDs are muscle disorders of common etiology. Actually, it is quite rare to find pain in the muscles of mastication without joint pain (Table 2). This belief is erroneously based in the unproven “neuromuscular” concepts that bruxism, occlusal interferences, and/or non-physiologic jaw position cause muscular hyperactivity leading to pain. Many dentists continue to believe this even today, although there is no support in the literature. There is even the mistaken belief that equilibration or occlusal therapy can eliminate bruxism. In fact, muscle pain is of two types: the most common, joint mediated muscle pain (JMMP) related to population 1, and chronic myofascial pain (CMP) in population 2. The etiology of JMMP is well researched and documented while the mechanism for CMP is as yet unknown (Figure 1).

Figure 1: This Venn diagram illustrates the two populations of TMD-associated muscle pain. Most muscle pain is jointreferred with only a minority of cases with chronic myofascial pain (MP). The mechanism of MP is unknown at this time although the best evidence is that the pain is mediated by the central nervous system. Notice that the prevalence of just Type 1 muscle disorders is very low

Joint-mediated muscle pain A basic principle of orthopedic medicine is that when a joint is painful or inflamed, this causes the muscles that move that joint to be painful and to spasm. This is known as “Hilton’s law” and has been taught in orthopedic programs since 1852.18 Patients who suffer from the most common musculoskeletal pain, lower back pain, are well aware of this. In terms of TMD, most masseter and temporalis pain is joint mediated and can be alleviated by reducing joint pain and inflammation (Figure 3). Treatment for an inflamed TMJ therefore follows basic orthopedic principles. Remove load from the joint with rest, soft diet, behavioral modification, and flat plane full coverage bite splints when necessary, along with the principles previously listed.

Table 2: Prevalence of RCD/TMD diagnoses RDC/TMD group

Patients (N) 199

Prevalence (%)

I Muscle

4.5

II DD

12.1

III Joint other than DD

19.1

I + II

2.0

I + III

19.1

II + III

21.6

I + II + III

21.6

Table 2: Notice in this table that “pure” muscle pain (without joint pain) was only 4.5% of the sample. Although most of the sample had combined muscle and joint pain, it cannot be assumed that most of the muscle pain is joint mediated. With Permission from Danielle Manfredini. 40 Orthodontic practice

Figure 2: Joint-mediated muscle pain. The mechanism of most masseter muscle pain and spasm is referred and mediated through the trigeminal ganglion illustrated here. When joint pain and inflammation are reduced, the muscle symptoms follow along Volume 9 Number 4

Bruxism needs to be controlled and is a factor in TMD joint inflammation.19,20 This treatment is highly predictable and successful and is applicable to the majority of TMD patients that will present in an orthodontic practice.

Chronic myofascial pain The mechanism of chronic myofascial pain is unknown, although it is believed to be centrally mediated from CNS sensitization and biochemical changes.21,22 In most cases, it is not an overuse syndrome or related to excessive.23 These patients often have normal EMG activity. These patients have “knots” or trigger points in the muscles referring to other body parts. The exact mechanism of trigger point referral of pain is uncertain. Splints are often ineffective.24 Occlusal therapy should be avoided.

Conclusions Orthodontists and dentists will succeed with basic conservative care with patients with joint pain and resultant muscle pain and myospasm. They should avoid treating patients with chronic widespread myofascial pain due to poor prognoses and refer these patients appropriately.

Case histories Two cases are presented to illustrate the role of the orthodontist. In the first case, the patient has DC/TMD Type III osteoarthritis but also requires orthodontic-orthognathic surgery as result of her TMD. This is a case involving TMD joint pain and can be easily managed in an orthodontic practice so that the patient can proceed with dental treatment. It should be emphasized that her occlusal changes were related to Volume 9 Number 4

Figure 4: Case 1: Imaging. 4A. Panorex 4B. Cephalometric film 4C. CBCT (note loss of cortical bone, flattening, and sclerosis of condyles in coronal view)

ramus shortening and distal rotation of the mandible and are not a cause but a result of her TMD. The second case is an illustration of a referral to an orthodontist of a patient with myofascial pain. This case should be referred. No occlusal therapy is indicated. A previous article in Orthodontic Practice US, “Management of TMD during orthodontic treatment: disc displacements,”27 has discussed the management of disc displacements and patients with limited opening (DC/ TMD) Type II.

Patient 1: Orthopedic-inflammatory diagnosis (TMJ osteoarthritis) Subjective history A 24-year-old female presents with history of TMJ pain and increasing anterior open bite. She had orthodontic treatment completed at age 14 and had relapse at age 17. She had orthodontics retreated but with relapse of the open bite. She was now treatment planned for orthognathic surgery. Objective findings The patient had severe pain to palpation of TMJ, masseter and moderate pain to temporalis palpation. The patient’s interincisal opening was limited to 34 mm (normal 45 mm – 55 mm). There was crepitation in both TMJs, and pain to loading was reduced with posterior placement of separator. The patient exhibited moderate wear with no tooth mobility. Her dental examination was otherwise unremarkable. Imaging findings Bilateral condylar loss of cortical bone, sclerosis, flattening, ramus shortening.

Diagnosis • TMJ osteoarthritis with concomitant occlusal changes • Protective myospasm (co-contraction) Treatment The appliances were removed, and an upper flat-plane orthotic inserted to be worn at night and as much as necessary during the day. The patient was prescribed meloxicam 15 mg QHS for 10 days and cyclobenzaprine 2.5-5 mg. QHS for 2 weeks The patient was given instructions in soft diet, moist heat, and behavioral modification as necessary (no gum chewing, impact exercise). Outcome The patient’s pain was reduced 80% in 6 weeks with her opening normal at 50 mm. Crepitation remains. She continues to wear the splint at night for evident bruxism. She was also instructed to modify her diet permanently to avoid hard chewy foods or to ingest smaller chopped pieces. Her general dentist was informed to avoid extended mouth opening procedures for routine dentistry. Orthodontics-orthognathic considerations The patient cannot proceed to final bite correction without condylar and occlusal stability being established. She is also informed of risks and benefits of treatment in regard to possible relapse. Autoimmune inflammatory arthritis must be ruled out. Protocol For patients with bilateral degenerative joint disease, inflammatory arthritis must be ruled out. The standard of care in patients Orthodontic practice 41

CONTINUING EDUCATION

Figure 3: Case 1: TMJ osteoarthritis. 3A. Full lower face. 3B Profile. 3C. Initial presentation with orthognathic appliances in place

CONTINUING EDUCATION with inflammatory arthritis would be alloplastic (metal) joint replacements to establish stability.25 The protocol in this case follows: • Referral to rheumatology for serology • CBCT scan • Follow patient on splint for 6-12 months of splint adjustment stability • Final CBCT scan Further studies, including nuclear medicine, MRI, etc., could be done but not chosen for this patient. This patient was followed for 12 months on her splint until there were minimal changes in the adjustment. A second CT was taken, which was diagnosed by the oral and maxillofacial radiologist as “stable arthritis”.26

Occlusal therapy • Final leveling and aligning • Lower bonded retainer with upper flat plane occlusal splint Outcome The patient has had stable occlusion 10-years postoperatively with minimal TMD and normal opening. Discussion Osteoarthritis is a common TMD diagnosis (25% of the patient presentation in my practice27). It is, of course, most predominant in older people but can present at any age. Osteoarthritis is a chronic disease with acute exacerbations as evidenced in Case 1.

Orthodontists need to recognize that most TMD patients are orthopedic-inflammatory patients with joint pain etiology.

Once the inflammation is controlled, the joint, muscle pain, and spasm are alleviated. This is simple case to treat, well within the ability of all dentists in terms of pain and dysfunction. The important points here are that this patient had a joint disorder, which was treated with basic orthopedic principles. The patient has had no TMD for over 10 years even after the orthodontic-orthognathic surgery.

Patient 2: Chronic myofascial pain with referral Subjective history A 16-year old girl presented with a 1-year history of chronic headache. She reports increased clenching and masseter fatigue. She was given an upper flat hard acrylic plane splint to be worn 24/7, which was well-made and adjusted. This was ineffective, and the patient reported that she felt it increased her clenching. She also was equilibrated by her dentist, which increased her symptoms. She reported that her pain was least in the morning and increased as the day progressed. She had insomnia and fragmented sleep. Her opening was normal. She had finished orthodontic treatment at 13 with upper splint and lower labial bow retainer. She recently saw another orthodontist who recommended retreatment. Tooth No. 15 was not completely erupted. Her medical history was significant for ADD, general anxiety, insomnia, and IBS. Her medications included Lexapro QHS, Adderall XR, alprazolam prn, and hyoscamine. She reported significant weight loss and was taking supplements to maintain weight. It was revealed that her symptoms were coincident with introduction of the stimulant because her school performance was poor. There was also a history of sexual abuse Objective findings The patient had severe pain to palpation of the muscles of mastication, cervical muscles, and reported lower back pain. There were a number of trigger points in the masseter muscles referring pain to the teeth. She had minimal pain to TMJ palpation. Her imaging was normal. Her occlusion was within normal limits. She did not respond to joint loading or load testing. There was no wear on her teeth or on the splint Diagnosis • Chronic myofascial pain with referral • Tension headache

Figure 5: Case 1 postoperative. A. Panorex B. Cephalometric film C. Front facial D. Side facial E. Intraoral view 42 Orthodontic practice

Management Much of the patient’s pain can be related to the introduction of the long-acting Volume 9 Number 4

amphetamine, which has an elimination halflife of 11 hours. Management was focused on this, and with the coordination of her psychiatrist, the patient was changed to a short-acting methylphenidate (Ritalin) with a half-life of 2 hours only when she needed to focus and not on weekends. This was of great benefit and also improved sleep. Because there was little evidence of nocturnal bruxism, the patient was given selfmanagement techniques to control daytime bruxism, including classical conditioning with interval timer training to keep her teeth apart. She was also given trigger point injections, but the benefit was of short duration. Botox was considered but was not given due to the patient’s improvement. Her headaches are reduced in frequency and controlled with OTC medications. She has an upper Essix retainer worn along with the lower labial bow retainer at night. The patient and her dentist were informed that any occlusal therapy was contraindicated.

as an “occlusal disease.” Continuing education institutions that are sincere but have ignored the evidence base further promote this concept by focusing on occlusion. This occlusal concept has also led to situations where TMD patients are subjected to unnecessary dental treatment for their pain.

Conclusions Orthodontists need to recognize that most TMD patients are orthopedic-inflammatory patients with joint pain etiology. These patients can be easily managed with basic medical principles by orthodontists. There also exist a minority of TMD patients with chronic myofascial pain who need to be referred for medical management. An orofacial pain dentist is an ally to coordinate any dental treatment in TMD patients. Occlusion plays only a minor role in TMD. OP

Outcome Overall the patient has 50% pain relief, improved coping skills, and improved sleep. Most importantly, she has come to realize that her headaches were not due to any “dental” or occlusal problems. There is no evidence of any bruxism. Discussion This patient, although in the minority of TMD patients, illustrates the continuing problem we have with dentists viewing TMD Volume 9 Number 4

11. Henderson J. Orthopedic Principles: A Resident’s Guide. Ann R Coll Surg Engl. 2006;88(1):86-7. 12. Raphael KG, Marbach JJ. Widespread pain and the effectiveness of oral splints in myofascial face pain. J Am Dent Assoc. 2001;132(3):305-316. 13. Murray GM, Peck CC. Orofacial pain and jaw muscle activity: a new model. J Orofac Pain. 2007;21(4):263-278. 14. Lim PF, Smith S, Bhalang K, De Slade GD, Maixner W. Development of temporomandibular disorders is associated with greater bodily pain experience. Clin J Pain. 2010;26(2):116-120. 15. Dworkin SF, LeResche L. Research diagnostic criteria for temporomandibular disorders: review criteria, examinations and specifications, critique. J Craniomandib Disord. 1992;6(4):301-355. 16. Dworkin SF, Huggins KH, Wilson L, et al. A randomized clinical trial using research diagnostic criteria for temporomandibular disorders-axis II to target clinic cases for a tailored self-care TMD treatment program. J Orofac Pain. 2002;16(1):48-63. 17. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Orofac Pain Headache. 2014;28(0):6-27. 18. Hebert-Blouin MN, Tubbs RS, Carmichael SW, Spinner RJ. Hilton’s law revisited. Clin Anat. 2014;27(4):548-555.

REFERENCES

Orders • Referral to endocrinology for endocrine panel and thyroid panel (negative) • Rheumatoid panel (negative) • Cognitive behavioral therapy added to psychiatric treatment

10. Mohl ND, Ohrbach RK, Crow HC, Gross AJ.Devices for the diagnosis and treatment of temporomandibular disorders. Part III: Thermography, ultrasound, electrical stimulation, and electromyographic biofeedback. J Prosthet Dent. 1990;6(0):472-477.

1. Gesch D, Bernhardt O, Kirbschus A. Association of malocclusion and functional occlusion with temporomandibular disorders (TMD) in adults: a systematic review of populationbased studies. Quintessence Int. 2004;35(3):211-221. 2. Rinchuse DJ. Does orthodontics cause TMJ disorders? Orthod Rev. 1987;1:11. 3. Ash MM. Occlusions: reflections on science and clinical reality. J Prosthet Dent. 2003;90(4):373-384. 4. Forssell H, Kalso E. Application of principles of evidencebased medicine to occlusal treatment of temporomandibular disorders: are there lessons to be learned? J Orofac Pain. 2004;18(1):9-22. 5. Reynders RM. Orthodontics and temporomandibular disorders: a review of the literature (1966-1988). Am J Orthod Dentofacial Orthop. 1990;97(6):463-471. 6. Mohlin B, Axelsson S, Paulin G, et al. TMD in relation to malocclusion and orthodontic treatment. Angle Orthod. 2007;77(3):542-545 7. Clark G, Tsukiyama Y, Baba K, Watanabe T. Sixty-eight years of experimental occlusal interference studies: what have we learned? J Prosthet Dent. 1999;82(6):704-713.

19. Raphael KG, Sirois DA, Janal MN, et al. Sleep bruxism and myofascial temporomandibular disorders: a laboratorybased polysomnographic investigation. J Am Dent Assoc. 2102;143(11):1223-1231. 20. Türp JC, Komine F, Hugger A. Efficacy of stabilization splints for the management of patients with masticatory muscle pain: a qualitative systematic review. Clin Oral Investig. 2004;8(4):179-195. 21. Milam SB, Schmitz JP. Molecular biology of temporomandibular joint disorders. J Oral and Maxillofac Surg. 1995;53(12):1448-1454. 22. Milam SB, Zardentata G, Schmitz JB. Oxidative stress and degenerative temporomandibular joint disease: a proposed hypothesis. J Oral Maxillfac Surg. 1998;56(2):214-223. 23. Sidebottom AJ. Alloplastic or autogenous reconstruction of the TMJ. J Oral Biol Craniofac Res. 2013;3(3):135-139. 24. Bag AK, Gaddikeri S, Singhal A, et al. Imaging of the temporomandibular joint: An update. World J Radiol. 2014;6(8):567-582. 25. Menchel H. Management of TMD during orthodontic treatment: disc displacements. Orthodontic Practice US. 2015;6(6):39-41.

8. Mohl ND, McCall WD Jr, Lund JP, Plesh O. Devices for the diagnosis and treatment of temporomandibular disorders. Part I: Introduction, scientific evidence, and jaw tracking. J Prosthet Dent. 1990;63(2):198-201.

26. Krisjane Z, Urtane I, Krumina G, Neimane L, Ragovska I. The prevalence of TMJ osteoarthritis in asymptomatic patients with dentofacial deformities: a cone-beam CT study. Int J Oral and Maxillofac Surg. 41(6):690-695.

9. Mohl ND, Lund JP, Widmer CS, McCall WD Jr.. Devices for the diagnosis and treatment of temporomandibular disorders. Part II: Electromyography and sonography. J Prosthet Dent. 1990;63(3):332-336.

27. Malki GA, Zawawi KH, Melis M, Hughes CV. Prevalence of bruxism in children receiving treatment for attention deficit hyperactivity disorder: a pilot study. J Clin Pediatr Dent. 2004;29(1):63-67.

Orthodontic practice 43

CONTINUING EDUCATION

Figure 6: Case history 2: Chronic myofascial pain. 6A. Intraoral presentation showing Angle Cl with minimal overjet and overbite, good alignment, minimal wear. 6B. Chart illustrating that the half-life of Ritalin is much less than Adderall XR and is less available during sleep to diminish bruxism

REF: OP V9.4 MENCHEL

FULL NAME

AGD REGISTRATION NUMBER

LICENSE NUMBER

ADDRESS

CITY, STATE, AND ZIP CODE

TELEPHONE/FAX

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

Making sense of temporomandibular disorders MENCHEL

1. Painless clicking and popping is _______. a. of great concern b. of no great concern if the patient has no locking c. seldom seen d. always a detrimental symptom 2. (For TMD) ________ is all that is required without other expensive instrumentation such as Doppler, which can produce false positives. a. Simple stethoscopic examination b. Digital examination c. Transillumination d. both a and b

treatment guidelines. a. etiology b. diagnosis c. management d. all of the above 5. These patients (with chronic myofascial pain) require a comprehensive team approach with _______ management, and if they have a TMD component to their pain, an orofacial pain dentist. a. herbal b. medical c. psychological d. both b and c

3. By assuming TMD is mainly a disorder of muscles, and that chronic muscle pain is caused by overuse, dentists are often further distracted from the actual evidence base that this is mainly a disorder of ______. a. joints b. teeth c. orthodontic treatment d. malocclusion

6. Most dentists _______ in primary management of these patients and should work closely with an orofacial pain dentist if patients require any dental treatment. a. should get involved in b. should not get involved in c. have all of the information needed for d. can specialize in

4. TMD disorders are no different from all other musculoskeletal orthopedic disorders. Therefore, the _______ should follow established evidenced-based medical-surgical

7. Actually, it is _______ to find pain in the muscles of mastication without joint pain. a. quite common b. always the situation

44 Orthodontic practice

c. quite rare d. impossible 8. A basic principle of orthopedic medicine is that when a joint is painful or inflamed, this causes the muscles that move that joint to be painful and to spasm. This is known as _______ and has been taught in orthopedic programs since 1852. a. Hilton’s law b. Angle’s law c. Fauchard’s law d. Gunnell’s law 9. The mechanism of chronic myofascial pain is unknown, although it is believed to be centrally mediated from _______. a. CNS sensitization b. biochemical changes c. bruxism d. both a and b 10. Orthodontists and dentists will succeed with ______ with patients with joint pain and resultant muscle pain and myospasm. a. basic conservative care b. orthognathic surgical solutions c. aligner therapy d. traditional braces

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ORTHODONTIC INSIGHT

Orthodontic treatment strategies for sleep apnea in children Dr. Satish Pai analyzes how orthodontists devise key strategies

noring during sleep is fairly common among people of all ages, but you shouldn’t just assume it’s normal. Adults who snore heavily or loudly may be suffering from sleep apnea, and the same may be true for a child who snores or has noticeable breathing sounds when they’re asleep. Snoring is usually the most noticeable indicator of obstructive sleep apnea (OSA), which is far from harmless. In addition to disturbing bed partners and family members, sleep apnea can have a wide range of longterm side effects on physical and mental health. These are particularly worrisome when they affect children. While OSA needs to be diagnosed by a specialist, orthodontists are well placed to diagnose growth and development problems that increase the risk of sleep apnea. They can also help devise an effective strategy for treatment.

What are the signs and symptoms of sleep apnea in children? Some common warning signs of childhood sleep apnea include: • Snoring, choking, gasping, or snorting during sleep

Dr. Satish Pai, an Ivy League-trained dentist and a professor at Columbia University, believes that a perfect smile makes a person not only look great, but also feel great. As the founder of Putnam Orthodontics, he is dedicated to not only creating perfect smiles for his patients, but also educating people with his engaging articles about all things related to a perfect smile and oral health. Spending time with his family always brings a smile on his face. In his free time, you can find him golfing, doing yoga or surfing. He can be reached through www.putnamorthodontics.com.

46 Orthodontic practice

Volume 9 Number 4

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ORTHODONTIC INSIGHT • Mouth breathing, difficulty breathing, or pauses in breathing • Grinding or clenching of teeth during sleep, which may lead to jaw joint pain or clicking/popping sounds in the jaw • Complaints of restless/poor sleep, daytime headaches, morning fatigue, drop in concentration, and lack of energy during the day • Secondary signs include nightmares/ night terrors, bedwetting, trouble paying attention, behavioral issues, and learning problems

What causes obstructive sleep apnea in children? There are many possible causes of childhood sleep apnea, including: • Enlarged structures causing obstruction in the back of the throat, such as the tongue and tonsils, or in the back of the nose, such as adenoids. • Growth deformities in the upper jaw or airway, such as a narrow palate or small patent airway, can also block air flow to the lungs. • Hay fever and long-term allergies, childhood obesity, and low muscle tone or weak muscles may also contribute to sleep apnea.

Effective orthodontic treatment strategies for childhood sleep apnea Sleep apnea is a medical condition that requires proper diagnosis by an ENT or sleep specialist. After diagnosis, the treatment for OSA will depend on the severity as well as underlying causes of the condition. In many cases, an orthodontist can help with prevention and treatment. Here’s how orthodontic strategies can help with childhood OSA: • Orthodontists and other dental health professionals play a key role in diagnosing sleep disorders, since they tend to be in contact with their patients more frequently than other health professionals. They can ensure that every patient is screened for OSA and other breathing disorders, no matter the patients’ age. • As a result of their specialist education and experience in facial growth and development, orthodontists are also in a unique position to identify sleep-related breathing disorders in patients of any age. They are also trained to guide the growth of 48 Orthodontic practice

It’s critical to screen every patient for sleep-related breathing problems no matter how young they may be. various facial structures in younger patients. • Almost half of all patients with obstructive sleep apnea have abnormalities in the bony structure around the airway, which could be corrected with early orthodontic treatment. This could potentially prevent and, in some cases, reverse the underlying causes of OSA in children as well as adolescents and adults. • Early orthodontic treatment for expanding the upper jaw or upper arch, advancing the mandible and otherwise modifying the bony structure of the face could help manage the condition. This can also eliminate clenching and grinding of teeth during sleep, or other habits that are associated with childhood sleep apnea. • Mandibular advancement, maxillomandibular advancement and slow or rapid maxillary expansion (RME/ SME) can be combined with orthodontics to expand the airway. These techniques help with reducing resistance in the nasal airway, normalizing tongue position and reducing or eliminating OSA symptoms.

• An orthodontist can also use oral appliance therapy (OAT) to improve breathing patterns for sleep apnea treatment in children and older patients. They may also suggest removal or tonsils/adenoids, if necessary, and refer patients with serious breathing disorders or behavioral problems to a specialist physician. Orthodontists are well-versed at managing OSA with dental appliances or modifications to the facial structure. As such, they are ideally suited for working as part of multidisciplinary team for sleep apnea treatment.

What should an orthodontist do? By asking critical questions while examining patients, orthodontists and other dental health experts can help with the diagnosis of developmental problems that may lead to sleep apnea. It’s critical to screen every patient for sleeprelated breathing problems such as OSA, no matter how young they may be. Ask parents to make note of sleep, snoring, and breathing patterns in children before bringing them in for a checkup. Most importantly, ensure that a specialist confirms the diagnosis before you commence any treatment. OP Volume 9 Number 4

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