orthodontics In summary Farooq Ahmed
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- Education
Farooq brings the key points, references and understandings from keynote webinars and papers in a concise podcast.
Providing easy access to gain the most from our esteemed speakers and experts.
*Important to note the information is from our interpretation as individual professionals, and may incorporate our opinions*
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White Spot Lesions, what should we do? 9 MINUTE SUMMARY
Join me for a summary podcast exploring the topic of white spot lesions, and up-to-date
research looking at how to manage lesions when they occur, when the right time
is to treat the patient, and what minimally evasive options can be used in clinic. This was an excellent lecture
from Gayle Glenn earlier this year at the AAO winter meeting.
Four treatment
options are discussed, Fluoride, CPPACP (Mi paste), resin infiltrate and
microabrasion.
Whitespot
lesion background WSL
Definition - subsurface deminieralization,
intact outer layer, 1st sign of carious lesions
Remineralisation
– no additional agents
Most rapid
repair first 6 weeks without use of additional agents
·
Up
to 6 months spontaneous improvement with good oral hygiene
·
Recommend
3-6 months monitor after debond: BEFORE
consider additional treatment
Fluoride
·
Decrease
enamel dissolution
·
Increase
reminerazation
·
Formation
of fluorapatite
·
Products
o
Fl varnish
reduce WSL occuring by 44%:
§ require plaque removal and wire removal
§ Not often used in clinical practice and requires
repeat application
·
TREATMENT
WSL
o
Fluoride low dose (toothpaste)
o
High Fluoride – hyperminerasied surface layer
forms = seal off subsurface layer which remains demineralized. Bishara 2008
Resin infiltration Gray 2002
·
Remove outer hypomineralised area with 15% HFL
o
Infiltrate with low viscosity
o
Improves aesthetics
o
Arrest lesion – however some demineralisation
may remain
o
Lack long-term evidence
o
Most effective in research (RR:121.50, 95%CI:
51.45-191.55 Jiang 2023)
MI paste (CPPACP) Frencken 2012
·
Milk protein derived
·
Stabilizes Ca PO4 – ideal of for formed WSL
·
Creates Ca PO4 reservoir around bracket
·
Applied:
o
Brush above and below bracket or finger
o
Distributed by the tongue
o
Can be swallowed
o
Avoid eat and drink 30-60 minutes
·
Effectiveness for reminersation
o
Evidence unclear – conflicting sustematic
reviews AlBukaiki 2023 no difference,
same year Jiang 2023, it is effective, however exceptionally large range
of values (RR:49.69, 95%CI: 0.87-98.51 and although RCTs, limited to assessing
premolars only and different methods of assessment and duration of treatment.
·
TREATMENT FOR WSL
o
Wait 3-6 months following removal of braces
o
In retainer 3-5 minutes
o
Rinse out
o
Nothing to eat 30-60 minutes
Microabrasion
·
Combination of acid and abrasive particles
·
Burinsh into enamel with slow speed handpiece
·
opalustre = 6% HCL + silica (low particle
size, lower concentration with larger particle size than prophy paste = 12-160 particle size 1986 Krol)
o
1 mm size of use
o
Burnished in using a polishing cup and slow
handpiece
o
1 minute
·
Not widely accepted
o
Partly due to variations in protocol
o
Use of rubber dam
·
Microabrasion and CPP-ACP proposed idea Ardu
2007
2022 Lammert
·
CPP-ACP both sides, with half of mouth also
receiving 1 visit of microabrasion
·
After 6 months post debonding
·
Evaluate and repeat up to 8 times
·
Results
o
Mi paste group 9.3-8.1 size of lesion –
statistically significant
o
Microabrasion and Mi paste group
§ 13.2 – 4.3
and reduce to 2.1
·
Most improvement immediate after microabrasion
o
Compared difference of size of the initial
lesion
§ 5.5 x
reduction in CPPACP
§ 7.4 X
reduction in microabrasion
Clinical implication
·
Microabrasion = significant clinical time
o
Up to 8 minutes per tooth, can be up to 1 hour
o
Therefore clinical application
§ Perhaps
isolated 1 or 2 teeth
Conclusions:
1. -
Can a malocclusion cause bullying?
Join me for a summary exploring bullying and its
relationship with malocclusion, with a contemporary review of evidence showing
the psychological effects various malocclusions can cause young people. This
podcast is a summary of Andrew DiBiase’s lecture last year at the British
Orthodontic Conference. Andrew’s research explores what factors moderate
bullying, and what factors can be protective against bullying.
Introduction
·
Nearly 1 in 3 patients report teasing or fear of
teasing as a motivating factor for orthodontic treatment Bauss 2023 AJODO
·
1 in 7 patients attending our clinics are
bullied Seehra et al., 2011
·
Most upsetting feature of bullying teeth 60.7%
Shaw
·
13, 387 teenagers 25% report bullying
o
Around 7% related to teeth
Definition of bullying: Olweus 1984
·
Unprovoked and sustained campaign of aggression,
towards someone in order to hurt them
·
Student exposed repeatedly to negative action on
the part of one or more students
o
Harm, imbalance of power, organised, repetitive,
harm experienced
Who gets bullied and how?
·
Younger more – 10 year olds 22%, 15 year olds 7%
·
Girls are greater than boys by 5%
·
Boys low athletic competence
o
Judged on homour as well Langlois 2000
·
Girls appearance
o
We do judge girls on physical appearance Langlois
2000
o
80% verbal - Cyber bullying – doest stop at the
school gate
Consequences of bullying
·
Short term and long term effects
o
Poorer academic performance
o
Crime
o
Self harm
§
26% within young population and teeth occupying
the reason in 1 in 5 young people Bitor 2022 AJODO
o
Low self esteem
o
Structural changes, medulla – related to fear
(peer victimisation and its impact on adolescent brain)
What features are more likely to result in bullying
Dibiase, Jad Seehra 2014
·
Greater rate of bullying
·
2 div 1: 18%
·
Increased overjet 16% Tristão SR 2020
·
Deep overbite
·
Missing teeth, anterior spacing
·
IOTN AC 9 and 10
·
Regression – younger worse
·
Low athletic competence p 0.019
Conclusions
·
Relationship between bullying and severe
malocclusion
·
Schoolchildren who report being bothered by
their teeth report being lonelier at school and lower self-esteem
·
Malocclusion has a greater impact on females
than males
·
Malocclusion and peer relations is moderated by
self-esteem in girls, but not boys
·
Good peer relations protect against the negative
impact of malocclusion in girls with low or average self-esteem
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Orthodontics In Interview: ROXANA PETCU
Orthodontics and TMD, what is the role of orthodontics?
“if you give a splint, it will not cure the TMD”
“It depends on the adaptability of the patient”
“The role of the patient in the treatment is very, very important”
Roxana describes her journey into TMD and orthodontics, what led her to attend courses worldwide and also set up her own course on TMD.
Roxana describes what has created the controversy in TMD management, and answers recent questions from the literature of the role of both orthodontics and splints in TMD management
To book onto Dr Roxana Petcu’s courses please visit www.lazarlearning.ro/cursuri/ or roxanapetcu_ (I have no financial interest)
Click on the link below to view previous episodes, to refresh topics, pick up tricks and stay up to date.
Please like and subscribe if you find it useful! -
Tooth whitening in orthodontics
Does whitening have a role in orthodontics? A popular cosmetic procedure which 1 in 4 adults partake in, and was proposed recently at a conference as part of finishing in orthodontics. So this podcast reviews whitening as a topic and the latest evidence in combining whitening with aligners.
Reminder the podcast is an opinion piece and is the independent work of myself and the orthodontics in summary team.
24% of adults have whitening their teeth (dentalhealth.org)
How does it work:
Bleaching is the chemical changing of darker staining on teeth termed chromogens, with the active ingredient hydrogen peroxide.
Hydrogen peroxide reacts to oxidize the chromogen, which becomes a lighter colored compound.
Hydrogen Peroxide is not a stable chemical, so Carbamide peroxide is used, which roughly breaks down to 1/3 H2O2 when mixed with water.
Hydrogen Peroxide UK limit 6%, or Carbamide peroxide 16% is used, USA, greater concentrations are used with 10% hydrogen peroxide for at home whitening, and 35% hydrogen peroxide for in office bleaching.
Children
UK guidelines GDC 2014 – no bleaching until 18, unless purpose of treating or preventing disease.’
USA: The AAPD 2023 s Safe and effective for whitening discolored teeth of children and adolescents. Avoid full-arch bleaching mixed dentition and primary dentitions
Risks
Sensitivity -
about 80% of patient’s experience sensitivity
Tooth sensitivity usually occurs at the time of treatment and can last several days
Upper lateral incisors – greatest sensitivity
Directly correlated with concentration
Greater intensity if tooth was restored Bonafe 2013
Gingival irritation
gingival irritation begins within a day of the treatment and can also last several days
Susceptibility to demineralisation
Suggested surface demineralization occurs as the pH of the whitening agent are acidic and hydrogen ions affect the enamel crystals,
No difference when using manufacturers protocols including 35% H202 Tompkins 2014
However aggressive whitening: excessive use of in office whitening Shi 2012
How long does the whitening last
Duration of correction, depends on lifestyle, with smoking and coffee reducing the correction. Expected 6-12 months of stable colour change. Wiegand 2008
Aligners
Bleaching tray is different – reservoir for bleach, 1 or 1.5mm soft ethylene-vinyl acetate (EVA), Straight cut 2mm beyond gingiva or scalloped, with 2 mm extension onto the gingiva giving a better seal and greater patient comfort. Dosage dots to limit application beyond 2mm
Aligners
Usually gingival bevelled, but as effective as bleaching trays, Levrini 2020 improvement of 3.5 shades on average Seleem 2021
tooth sensitivity and gingival irritation does not disrupt of treatment 16% Carbamide peroxide Oliverio 2019, Levrini 2020
2 mm thick layer of gel is advised at incisal or facial central surface of the aligner
Bleaching with attachments present, when bleaching complete attachments removed:
hydrogen peroxide diffuses through spaces between enamel prisms
The composite attachment was thought to affect pigment infiltration, however with enamel polishing after composite removal, color equalization occurs without discrepancies Staley 2004
Minimal change to aligner structure Oliverio 2019
Retainers as bleaching trays?
Use of 0.8mm Zendura, no resivoir, effective bleaching with marked or extremely marked improvement in 78% of cases with 10% Carbamide peroxide, however but this changed the VFRs’ biomechanical properties, decrease in tensile strength and an increase in hardness and internal roughness, unclear what the medium and long term effects are .Jin 2024
Bond strength
By Bleaching a tooth there is enamel bond strength reduction by 25 % Miguel 2006
Wait 2 weeks after bleaching for aligner attachment placement.
Bonded retainer has not been researched -
Direct to Print Aligners, are they really different to normal aligners? 8 MINUTE SUMMARY Simon Graf
Join me for a summary
of direct to print aligners. This lecture explores the application of a relatively
new resin material which can be used for aligner fabrication, without the need
of a 3D printed model. The lecture was given by Simon Graf who expertly
compared the differences between conventional and direct to print aligners, as
well as the clinical application of specific features of direct to print
aligners.
Limitations of
current aligner material:
1.
Only small
undercuts
2.
Limited
aligner thickness to sheet thickness / no selective thickness
3.
During the
manufacturing process material can get thinner or thicker depending on heat distribution
and stretch, 54% change in thickness of the aligner Lee 2022
4.
Plastic
and resin waste, (122 million aligners and models in 2022 Slaymaker 2024)
Advantages of direct
to print aligners
· Select thickness, 0.5-0.7mm, conventional
aligners 0.75mm+
· Gingival margin
·
Dentist in
charge of design, not company
Manufacturing steps
of Direct to Print aligners (Tera Harz ‘Graphy’)
1.
3D printing
of resin aligner
2.
Centrifuge:
Spin remove excess resin
3.
UV Light
cure in Nitrogen chamber
4.
Washed
twice, hot distilled water
Characteristics of
Direct to print aligners
· Greater accuracy: (Zendura, Essix
Ace and DTP were compared and DTP were 20-30% more accurate Koenig 2022)
· Less with DTP (Hertan 2022)
o
DTP 50%
less still (2.59 Vs 5.26 N)
o
DTP Less
force as strain increases
Shape memory effect
· DTP Polymer chains crosslinked, not case in conventional aligners
o
The shape recovers in DTP when
strain is removed, which does not occur to the same degree in conventional aligners
Lee 2022
o
Accelerated by placing in water
Unknowns
· How effective shape memory is remains unclear
· Cytotoxicity – not enough data, although manufacturer
protocols, lack of studies
· Changing thickness, unclear how much of a
difference in force it makes
Clinical points
Teeth extrusion
Lateral incisors
· Difficult to do with conventional aligners,
· Create ‘wedging’ gingival pressure columns to
squeeze the teeth to cause an extrusive force.
Elastic Hooks
without loss of force delivery on single tooth
· Hook printed into aligner with DTP, instead of cut
out which alters the force of the aligner instantly, maintain tooth control
· Tip aligners and elastics: Still add attachment
to tooth to prevent aligner displacing
Mandibular advancement
· Problem of mandibular advancement with aligners
o
Wings soft
and not maintaining the AP position
o
Hard block
many breakages
· DTP choice of thickness of block
Bite ramps
Conventional bite
ramps: limited length and often too short
DTP no limit to size
and thickness, and can be designed to not contact upper palatal surfaces, maintaining
full tooth control
In the Transverse
o
Palatal
coverage can be added as feature, similar to a TPA
o
Still
being researched how much force can be delivered with palatal coverage
Concluding statement
Enjoy the variability
of direct printed aligners.
Contributions
Contents:
Abdallah Sharafeldin
Edited
and produced: Farooq Ahmed -
Think pink – orthodontics a problem or solution to gingival recession. 6 MINUTE SUMMARY
Join me for a summary looking at gingival recession in orthodontics, and whether it is detrimental or beneficial. This lecture was given by James Andrews, he explored the effect of orthodontics on the periodontium, an area under increasing interest within aesthetics to achieve the ideal ‘pink aesthetics’ with the increasing adult population receiving orthodontic treatment. His lecture was based on, is orthodontics good or bad for the gingiva?
What is the starting point ?
Increase in adult orthodontics from 1970 by 800%
50% of adults have some element of periodontal disease
Untreated adult population 51% dehiscence 37% areas of fenestration Evangelista 2010
Facial type and bone morphology Tunis 2021
Dolichocephalic = narrow alveolus and elongated to compensate for vertical growth
Brachycephalic = larger alveolus
Dolichocephalic - Red flag patients
Tooth movement:
What happens when teeth move buccally?
facial tooth movement Wennström 1996
Reduced bucco lingual width
Therefore, reduced free gingiva
Increased risk only if tooth is moved out of the alveolar housing
What type of movement
Tipping (uncontrolled) increase likelihood of recession Condo 2017
Proclination causes recession, but inconclusive
Thickness more relevant than final inclination Yared 2006
How to decide what to do?
WALA line – Will Andrews Larry Andrews ridge Andrews 2000
Limit of labial bone – shape is coincident with the mucogingival junction, coincident with centre of resistance
Upper incisors – located anterior 1/3 of alveolus
Mandibular incisors – cantered within the alveolus
Gingival recession did not increase in treatment orthodontic population with segmental mechanics Melsen 2005
Aligners any different?
Association between non-extraction clear aligner therapy and alveolar bone deficiency and fenestration
Presence of both fenestration and dehiscence
What do we do to correct extra-alveolar teeth?
If teeth pushed outside of cortical plate then retracted, what happens
Monkey – moved teeth outside of bone for 8 months, then reposition within bone with appliances = repair bony dehiscence and fenestration
Morten Laursen and Melsen 12 consecutive patients 2020
Teeth moved towards the centre of the cortical plate = improvement in gingival height of depth decrease of 23%, the width with 38%
Intrusion
Use of intrusion arch increases the thickness of the periodontal fibres 0.7 to 2.3 mm Melsen 1988
Gingival graft when to move teeth
Free gingival graft – 6 weeks
Connective tissue graft – 12 weeks
“Diagnose and treat each tooth no miracles shortcuts for good orthodontics” Peck 2017