orthodontics In summary Farooq Ahmed

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

 

 

 

 

 

 

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!

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

 

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

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 

Join me for a summary looking at miniscrews, looking at
where the answer to successful TAD placement lies, in research or clinical
practice. The reasons for higher failure rates than others with TADs was
explored through 3 key factors; insertion torque, site selection and root
proximity. Evaluation of both scientific and clinical processes were described
by Sebastian Baumgartel at the British Orthodontic Conference, as the
Northcroft lecture.

 

Is torque a factor in TAD success?

Torque study – compression during insertion Motoyoshi 2006

·     
High torque – 60%

·     
Low torque = 72%

·     
Medium torque – 92%

Understanding

·     
Low torque = low compression, low primary
stability - early failure as not engagement with screw

·     
High torque = high compression, early success,
but greater resorption after insertion, remodelling results in a resorption
process

·     
Medium = best of both = sufficient compression
for primary stability, not high enough to cause resorption remodelling

Ideal

·     
Ideal torque range – 10 Ncm Shantavasinkal 2016

o  
Study of buccal tads

·     
Sebastian’s empirical experience between
10-25Ncm depending on site

 

Rules:

·     
Aim for medium torque

·     
Target 10Ncm

·     
Exceed 10Ncm on palate acceptable

 

What is the best site for TAD insertion?

 

Keratinised gingiva

·     
Evidence - states no difference  Lim 2009, Chen 2008, Park 2006, Cheng 2004

·     
Non Keratlised – depends on mobile or non
mobile, with non-mobile higher success rate Viwattanatipa 2009

·     
2mm apical to muco-gingival junction

o   zone
of opportunity

 

Target zones and site

o  
No roots

o  
Consistent cortical bone

o  
More tolerant to higher torque

o  
Attached gingiva with low mobile mucosa

 

 

Is there ideal bone?

·     
 = if
ideal torque = ideal cortical plate thickness

§ 
1-1.5mm cortical plate thickness

·     
CBCT can be overkill, using research sites for
average sites

 

 

Ideal site:

–     
1st premolar region  (transverse) 
Sebastian 2009

–     
2 mm away from mid-palatal suture

o  
= creates ideal zone ‘Mx1’

 

Evidence of site selection success

·     
98% Vs buccal 71% Houfar 2017

·     
84% Trainee success Sebastian 2020

·     
Success of Sebastian anterior palate 100%, maxillary
buccal lowest 85%

 

Does root proximity influence TAD success?

·     
Not just contact with roots, but proximity to
root also causes failure Kuroda 2007, Asschericks 2008, Chen 2008

 

Understanding

o  
Increase root and PDL proximity =  bone stress increases = increase bone turnover
= increase failure of TAD

·     
4mm interradicular distance needed (depending on
size of tad) to achieve 1 mm clearance from roots

·     
Most buccal sites have less than 4mm (resolve
through diverging roots, or sites with no roots)

 

What happens if TADs fail and we try again?

–     
Secondary insertion success

o  
58% (reduced by 33%) Park 2006

o  
 44.2%  (reduced by 36%) Uesugi 2017

o  
58.1% buccal (reduced by 21%), 88.9% palatal
(increased by 4%) Uesugi 2018

§ 
Uesugi 2018 showed buccal failure increases for
secondary insertion, but palatal insertion increases success

 

For more education see Sebastian’s TAD course:

https://tadchallenge.com/tad-certification-course

 

I have no financial interest