Airway OrthodonticsA lecture series prepared byDr. Barry RaphaelOf theRaphael Center for Integrative OrthodonticsClifton, ...
•Animations not included in this archive•As the information in these presentations isconstantly evolving, please consider ...
Three Airway Problems1. Children are having trouble breathing.2. Orthodontists are having trouble breathing.3. Healthcare ...
Troubled Breathing: Children“not congested”“snoring”Open MouthFlaccid Lips“ever so slightly”Thursday, June 6, 13
What are Eli’s Ishes?Issue Consequences• Sleep Disordered Breathing• Swollen Tonsils and Adenoids• Neck Hyperflexion• Mouth...
OSAS and swollen Tonsils•Tonsils swell > narrowed airway > airway collapses > OSASThursday, June 6, 13
Signs of OSAfrequencyMouth breathingThursday, June 6, 13
One year ago...Thursday, June 6, 13
“In this large, population-based, longitudinal study,early-life SDB symptoms had strong, persistentstatistical effects on ...
“The 2 clusters with peak symptomsbefore 18 months that resolvethereafter still predicted 40% to 50%increased odds of beha...
ATH and OSAS• 140 children with OSA•Avg 4.5yo•AHI ~ 17• Low pO2 ~ 80%Thursday, June 6, 13
Airway Stenosis• Normal:A&T hypertrophy peaks at age 5-6• In OSA, hypertropy at all ages•Airway stenosis caused by•A&T Hyp...
Airway Stenosis•“ In addition to soft tissue factors, skeletal abnormalityshould be considered a cause of upper airway ste...
Associations between sleep-disordered breathing symptomsand facial and dental morphometry,assessed with screening examinat...
Nighttime symptoms of SDB in kids•Abnormal sleeping position•Chronic, heavy snoring•Delayed sleep onset•Difficulty breathin...
Daytime symptoms of SDB in kids•Morning headache•Mouthbreathing•Morning thirst•Excessive fatigue•Abnormal shyness,withdraw...
Of the 600 orthodontic patients...16% had long facial form86% had convex profiles ( retrusive mandible)Over 50% had daytime...
Anatomic Determinants of SleepDisordered Breathing Across theSpectrum of Clinical and Nonclinical Male Subjects*•Apnea occ...
Anatomic Determinants of SleepDisordered Breathing Across theSpectrum of Clinical and Nonclinical Male Subjects*•It is the...
Dental Arch Morphologyin Children with SDBFinland,41 children with OSA41 children with snoring41 children with no obstruct...
OSA children have...• Significantly more:• Increased Overjet• Decreased Overbite• Narrow Maxillary Arches• Shorter Mandibul...
Caroline Rambaud & Christian GuilleminaultEuropean Journal of PediatricsDOI 10.1007/s00431-012-1727-3Pub Online:April 11, ...
Findings in all 7 casesAll had chronic indicators of abnormal sleep1.enlargement of upper airway soft tissues2.a narrow, s...
“all children present a visuallyrecognizable abnormal high andnarrow hard palate”What can we do to help our children breat...
Connecting the Dots• Adult SDB and OSA• Narrow Jaws and Faces• Soft Tissue Dysfunction• Early Parafunctional Habits, esp O...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum Thinking•The...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum Thinking“My ...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingHow ...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingIf w...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingWhic...
Why is malocclusion so stable?•Malocclusion is a Solution to provide Equilibrium andHomeostasisThursday, June 6, 13
Stack the BlocksRule:The Teal blockshould go right on topof theYellow blockfor best stabilityThursday, June 6, 13
Stack the BlocksRule:The Teal blockshould go right on topof the yellow blockfor best stabilityThursday, June 6, 13
Why is correction so unstable?•Malocclusion is a Solution to provide Equilibrium andHomeostasis•When we “correct” the occl...
Stack the BlocksMalocclusion: onesolution to be inequilibriumThursday, June 6, 13
Nature’s Solution:Adaptation (Malocclusion)Thursday, June 6, 13
Orthodontic’s SolutionRetainerRule:The Teal blockshould go right on topof the yellow blockfor best stabilityThursday, June...
Why is malocclusion so stable?•Malocclusion is a Solution to provide Equilibrium andHomeostasis•If we “rebalance” the occl...
Airway OrthodonticsTeeth and OcclusionTongue, MM,TMJCranial and CervicalWhole Body (resp,circ, musc-skel, etc)Thursday, Ju...
Why is malocclusion so stable?•Malocclusion is a Solution to provide Equilibrium and Homeostasis•If we “rebalance” the occ...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingExtr...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingExtr...
The Extraction WarsEdward Angle vs Calvin CaseWitzig vs McNamaraNewConn 2009 Extraction vs Non-extraction Debate1855-19305...
Tom GraberAJO, 1963“The Three M’s:Muscles, Malformation, and MalocclusionThe Two Groups of Disciples:Edward Angle: Edgewis...
Tom Graber•…they ignored “the balancing effect ofcontiguous muscle on the role of growth anddevelopment”•“…muscle plays a ...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingExtr...
Verdict: Phase I doesn’t help• Prospective Randomized Control Trial• Class II severe overjet (>7)mm• Early treatment with ...
Conclusion: Don’t bother with Phase Itreatment since both treatments turnout equally well.Is it possible thatboth protocol...
Is it possible that...•… malocclusion is not predetermined, but occurs as aresult of things that happen to us throughout e...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingExtr...
Which came first?TheChickenThe EggMakes...Grows into...Thursday, June 6, 13
Thursday, June 6, 13
No eggs, no chickensThursday, June 6, 13
No chickens, no eggsThursday, June 6, 13
No eggs, no breakfastThursday, June 6, 13
No chickens, no nuggets.Thursday, June 6, 13
Which came first?TheChickenThe EggMakes...Grows into...Thursday, June 6, 13
The SpiralTheChickenThe EggThe EggThe EggTheChickenIt’s not “Which Came First”, it’s “What Comes Next?”Thursday, June 6, 13
The Spiral of HealthForm FunctionOrthodonticsMyofunctionalThursday, June 6, 13
The Spiral of HealthFormFormFunctionFunctionFunctionDeclining HealthImproving HealthThursday, June 6, 13
The Spiral of HealthFormFormFunctionFunctionFunctionImproving HealthNasal BreathingPatent AirwayTongue on PalateWide Palat...
A Pathology CycleDeclining HealthFunctionMouthBreathing andLow TongueFormLong FaceFunction Weak MMusclesFormNarrow PalateF...
Breaking The CycleDeclining HealthFunctionMouthBreathing andLow TongueFormLong FaceFunction Weak MMusclesFormNarrow Palate...
Backed into a corner...•Changing Function is not mechanical!Thursday, June 6, 13
Breaking The CycleDeclining HealthFunctionMouthBreathing andLow TongueFormLong FaceFunction Weak MMusclesFormNarrow Palate...
Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum Thinking• Th...
A letter from a GP...•“Hi. This is so timely. I received a report from a cranio-facia/TMD pain specialist of one of my pat...
What GP’s think of the RO• Most orthodontists extract frequently• Extractions cause TMJ• Extractions ruin the face• Many s...
“Your Life, Your Smile”Campaign“Maintain the educational message on the two tothree years additional education required to...
What GP’s think of orthodontics• Malocclusion is a modern disease• Malocclusion is a symptom of a greater imbalance• You n...
Finding the Middle GroundSo it is said that if you know your enemies and knowyourself, you can win a hundred battles witho...
Thursday, June 6, 13
Troubled Breathing: Healthcare• Economics:• Politics :• Medical Education• EBD vs First-FollowerThursday, June 6, 13
Troubled Breathing: Healthcare• Economics: “Sickcare” cannot keep upwith CNDC’s• Politics• Medical Education• EBD vs First...
ObesityHypertensionCardiovascular DiseaseType 2 DiabetesFatty Liver DiseaseSome CancersOsteoporosisArthritisChronic Non-Co...
Troubled Breathing: Healthcare• Economics:• Politics :Everyone deserves healthcare buteveryone wants free healthcare.• Med...
Troubled Breathing: Healthcare• Economics:• Politics :• Medical Education is lacking in three areas:• Nutrition• Sleep• Ev...
Troubled Breathing: Healthcare• Economics:• Politics :• Medical Education is lacking in three areas:• Nutrition• Sleep• Ev...
Evidence-basedDentistry• Every day we make a thousand decisions• Only a small fraction have evidence to support them• Ethi...
Ethics-based Dentistry•ADA and ACD codes• How do we make decisions about issues for which thereis no precedent?• How do we...
First FollowerThursday, June 6, 13
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Airway ortho 1 the three airway problems

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A series of lectures by Dr. Barry Raphael on Airway-focused orthodontics from 2013.
Chapter 1: An editorial look at the forces that are changing orthodontics today and how they will influence what orthodontics is to become in the 21st century.

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Airway ortho 1 the three airway problems

  1. 1. Airway OrthodonticsA lecture series prepared byDr. Barry RaphaelOf theRaphael Center for Integrative OrthodonticsClifton, NJ.www.alignmine.comwww.myobracenj.com“Three Airway Problems” - 2013Thursday, June 6, 13
  2. 2. •Animations not included in this archive•As the information in these presentations isconstantly evolving, please consider the date of creationwhen reviewing the material.Thursday, June 6, 13
  3. 3. Three Airway Problems1. Children are having trouble breathing.2. Orthodontists are having trouble breathing.3. Healthcare is having trouble breathing.Thursday, June 6, 13
  4. 4. Troubled Breathing: Children“not congested”“snoring”Open MouthFlaccid Lips“ever so slightly”Thursday, June 6, 13
  5. 5. What are Eli’s Ishes?Issue Consequences• Sleep Disordered Breathing• Swollen Tonsils and Adenoids• Neck Hyperflexion• Mouth Breathing• Chronic Hyperventilation• Open Mouth PostureFragmented, unrestorative sleepObstructed N-P AirwayMuscular and Sutural StrainReduced Air ConditioningHypocapnia (Low CO2)Maxillary DysplasiaThursday, June 6, 13
  6. 6. OSAS and swollen Tonsils•Tonsils swell > narrowed airway > airway collapses > OSASThursday, June 6, 13
  7. 7. Signs of OSAfrequencyMouth breathingThursday, June 6, 13
  8. 8. One year ago...Thursday, June 6, 13
  9. 9. “In this large, population-based, longitudinal study,early-life SDB symptoms had strong, persistentstatistical effects on subsequent behavior inchildhood.Findings suggest that SDB symptoms may requireattention as early as the first year of life.”Sleep-Disordered Breathing in a Population-BasedCohort: Behavioral Outcomes at 4 and 7 YearsKaren Bonuck, PhD, Katherine Freeman, DrPH,Ronald D. Chervin, MD, MS, and Linzhi Xu, PhDPEDIATRICS Volume 129, Number 4, April 2012Thursday, June 6, 13
  10. 10. “The 2 clusters with peak symptomsbefore 18 months that resolvethereafter still predicted 40% to 50%increased odds of behavior problemsat 7 years.”Sleep-Disordered Breathing in a Population-BasedCohort: Behavioral Outcomes at 4 and 7 Years“...early childhood SDB effects mayonly become apparent years later.”Thursday, June 6, 13
  11. 11. ATH and OSAS• 140 children with OSA•Avg 4.5yo•AHI ~ 17• Low pO2 ~ 80%Thursday, June 6, 13
  12. 12. Airway Stenosis• Normal:A&T hypertrophy peaks at age 5-6• In OSA, hypertropy at all ages•Airway stenosis caused by•A&T Hypertropy• Skeletal Abnormality• Hypertrophy > Stenosis > Mouth Breathing > Skeletalabnormatility > OSAThursday, June 6, 13
  13. 13. Airway Stenosis•“ In addition to soft tissue factors, skeletal abnormalityshould be considered a cause of upper airway stenosis”So which is it? Does a blocked airway cause poorgrowth, or does poor growth block the airway?Thursday, June 6, 13
  14. 14. Associations between sleep-disordered breathing symptomsand facial and dental morphometry,assessed with screening examinationsHyunh, et.al.,AJODO, 2011, 140:762-70SDB associated with: Swollen Tonsils and AdenoidsLong and narrow faceAllergiesFrequent Colds and InfectionsHabitual Mouth BreathingDolicofacial shapeHigh mandibular plane angleNarrow palateSevere crowdingThursday, June 6, 13
  15. 15. Nighttime symptoms of SDB in kids•Abnormal sleeping position•Chronic, heavy snoring•Delayed sleep onset•Difficulty breathing•Difficulty waking up in AM•Drooling•Enuresis•Frequent awakenings•Insomnia•Mouth breathing•Nocturnal migraine•Nocturnal sweating•Periodic Limb movement•Restless sleep•Sleep talking•Sleep terror•Sleep walking•Witnessed apneaThursday, June 6, 13
  16. 16. Daytime symptoms of SDB in kids•Morning headache•Mouthbreathing•Morning thirst•Excessive fatigue•Abnormal shyness,withdrawn, anddepressivepresentation•Behavioral problems•ADHD pattern•Aggressiveness•Irritability•Poor concentration•Learning difficulties•Memory impairment•Poor academicperformanceThursday, June 6, 13
  17. 17. Of the 600 orthodontic patients...16% had long facial form86% had convex profiles ( retrusive mandible)Over 50% had daytime mouth open postureThursday, June 6, 13
  18. 18. Anatomic Determinants of SleepDisordered Breathing Across theSpectrum of Clinical and Nonclinical Male Subjects*•Apnea occurs due to craniofacial morphology and obesity,each with their contributions•The most important cephalometric variable in predicting AHIseverity was the horizontal dimension of the maxilla•SDB increased fivefold to sevenfold in non-obesesubjects and threefold in obese subjectsCHEST September 2002 vol. 122no. 3 840-851Jerome A. Dempsey, PhD; James B. Skatrud, MD;Anthony J. Jacques, BS;Stanley J. Ewanowski, PhD; B.Tucker Woodson, MD;Pamela R. Hanson, DDS, MS; and Brian Goodman, PhDThursday, June 6, 13
  19. 19. Anatomic Determinants of SleepDisordered Breathing Across theSpectrum of Clinical and Nonclinical Male Subjects*•It is the maxilla that determines the effectivehorizontal dimension of the pharynx, and inparticular the upper pharynx.•A constricted maxilla places the upper pharynx(pharyngeal isthmus) at increased risk of collapsewith loss of muscle tone.Thursday, June 6, 13
  20. 20. Dental Arch Morphologyin Children with SDBFinland,41 children with OSA41 children with snoring41 children with no obstructionOrtho exam and 13 study cast measurementsK.Pirilä-Parkkinen,et.al.,European Journal of Orthodontics 31 (2009) 160–167Thursday, June 6, 13
  21. 21. OSA children have...• Significantly more:• Increased Overjet• Decreased Overbite• Narrow Maxillary Arches• Shorter Mandibular Arches•Somewhat more:•Assymetric Arches (Cl II subdivision)• Mandibular Crowding•Anterior Open Bite“...can be explained by long-term changes in theposition of the head, mandible, and tongue in orderto maintain airway adequacy during sleep.”Thursday, June 6, 13
  22. 22. Caroline Rambaud & Christian GuilleminaultEuropean Journal of PediatricsDOI 10.1007/s00431-012-1727-3Pub Online:April 11, 2012Death, nasomaxillary complex,and sleep in young childrenAbrupt sleep associated death in seven childrenwith good pre-mortem historyThursday, June 6, 13
  23. 23. Findings in all 7 casesAll had chronic indicators of abnormal sleep1.enlargement of upper airway soft tissues2.a narrow, small nasomaxillary complex,with or without mandibular retropositionThursday, June 6, 13
  24. 24. “all children present a visuallyrecognizable abnormal high andnarrow hard palate”What can we do to help our children breathe better?Thursday, June 6, 13
  25. 25. Connecting the Dots• Adult SDB and OSA• Narrow Jaws and Faces• Soft Tissue Dysfunction• Early Parafunctional Habits, esp Open Mouth Posture• Environmental Stressors• CPAP, MARA,UPPP, SurgWhere’s the bestplace to starttreatment? Here?OrHere?Thursday, June 6, 13
  26. 26. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum Thinking•The Battle within the professionThursday, June 6, 13
  27. 27. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum Thinking“My two front teethstick out….they’reright THERE”Thursday, June 6, 13
  28. 28. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingHow can we offer patientswhat they want withoutgiving them less than ourbest?Thursday, June 6, 13
  29. 29. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingIf we no longer have tospend time on mechanics,what can we do with theextra time to improve whatwe do?Thursday, June 6, 13
  30. 30. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingWhich is more stable? Now?Thursday, June 6, 13
  31. 31. Why is malocclusion so stable?•Malocclusion is a Solution to provide Equilibrium andHomeostasisThursday, June 6, 13
  32. 32. Stack the BlocksRule:The Teal blockshould go right on topof theYellow blockfor best stabilityThursday, June 6, 13
  33. 33. Stack the BlocksRule:The Teal blockshould go right on topof the yellow blockfor best stabilityThursday, June 6, 13
  34. 34. Why is correction so unstable?•Malocclusion is a Solution to provide Equilibrium andHomeostasis•When we “correct” the occlusion, we disturb the equilibriumThursday, June 6, 13
  35. 35. Stack the BlocksMalocclusion: onesolution to be inequilibriumThursday, June 6, 13
  36. 36. Nature’s Solution:Adaptation (Malocclusion)Thursday, June 6, 13
  37. 37. Orthodontic’s SolutionRetainerRule:The Teal blockshould go right on topof the yellow blockfor best stabilityThursday, June 6, 13
  38. 38. Why is malocclusion so stable?•Malocclusion is a Solution to provide Equilibrium andHomeostasis•If we “rebalance” the occlusion, we disturb the equilibrium•There are always unintended consequences, even if subclinicalRelapseOcclusal WearOcclusal TraumaBruxismJoint DerangementReferred PainSleep ApneaAssorted physical ailmentsThursday, June 6, 13
  39. 39. Airway OrthodonticsTeeth and OcclusionTongue, MM,TMJCranial and CervicalWhole Body (resp,circ, musc-skel, etc)Thursday, June 6, 13
  40. 40. Why is malocclusion so stable?•Malocclusion is a Solution to provide Equilibrium and Homeostasis•If we “rebalance” the occlusion, we disturb the equilibrium•There are always unintended consequences, even if subclinical...•We must make compensations elsewhere (respiratory, musculo-skeletal, neurological, circulatory systems)How can we make straight teeth asstable as crooked teeth?By looking at what made them stable?Thursday, June 6, 13
  41. 41. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingExtraction Non-extractionOne-Phase Two-PhaseForm FunctionThursday, June 6, 13
  42. 42. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingExtraction Non-extractionThursday, June 6, 13
  43. 43. The Extraction WarsEdward Angle vs Calvin CaseWitzig vs McNamaraNewConn 2009 Extraction vs Non-extraction Debate1855-19305-10% extraction rateThursday, June 6, 13
  44. 44. Tom GraberAJO, 1963“The Three M’s:Muscles, Malformation, and MalocclusionThe Two Groups of Disciples:Edward Angle: Edgewise ExpansionistsCalvin Case: ExtractionistsMust take muscles into account oryou’re missing the problem.1917-2007Thursday, June 6, 13
  45. 45. Tom Graber•…they ignored “the balancing effect ofcontiguous muscle on the role of growth anddevelopment”•“…muscle plays a dominant role, affecting ourmanipulations whether we like it or not”.•“controlling abnormal perio-oral musclefunction” crucial in treatment•We must consider homeostasis, postural restposition, and the effect of function on the teethand bones.1917-2007Thursday, June 6, 13
  46. 46. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingExtraction Non-extractionOne-Phase Two-PhaseThursday, June 6, 13
  47. 47. Verdict: Phase I doesn’t help• Prospective Randomized Control Trial• Class II severe overjet (>7)mm• Early treatment with Headgear or Bionator• Improvements shown in Phase I• Improvements disappeared after braces put onAm J Orthod Dentofacial Orthop. 2004 Jun;125(6):657-67.Outcomes in a 2-phase randomized clinical trial of early Class II treatment.Tulloch JF, Proffit WR, Phillips C.Conclusion: Don’t bother with Phase Itreatment since both treatments turnout equally well.Thursday, June 6, 13
  48. 48. Conclusion: Don’t bother with Phase Itreatment since both treatments turnout equally well.Is it possible thatboth protocols….•… missed the etiology of the Class II malocclusion•… fail to control the etiology during treatment•… move the maxilla in the wrong direction•… even their “early” treatments start too lateinadequate.Thursday, June 6, 13
  49. 49. Is it possible that...•… malocclusion is not predetermined, but occurs as aresult of things that happen to us throughout early life?•… those things that happen can be modified so theoutcome can be modified too?•… thus reducing the need for correction?Question:What are we waiting for a 7mmoverjet to occur before we begin our PRCT?Thursday, June 6, 13
  50. 50. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum ThinkingExtraction Non-extractionOne-Phase Two-PhaseForm FunctionThursday, June 6, 13
  51. 51. Which came first?TheChickenThe EggMakes...Grows into...Thursday, June 6, 13
  52. 52. Thursday, June 6, 13
  53. 53. No eggs, no chickensThursday, June 6, 13
  54. 54. No chickens, no eggsThursday, June 6, 13
  55. 55. No eggs, no breakfastThursday, June 6, 13
  56. 56. No chickens, no nuggets.Thursday, June 6, 13
  57. 57. Which came first?TheChickenThe EggMakes...Grows into...Thursday, June 6, 13
  58. 58. The SpiralTheChickenThe EggThe EggThe EggTheChickenIt’s not “Which Came First”, it’s “What Comes Next?”Thursday, June 6, 13
  59. 59. The Spiral of HealthForm FunctionOrthodonticsMyofunctionalThursday, June 6, 13
  60. 60. The Spiral of HealthFormFormFunctionFunctionFunctionDeclining HealthImproving HealthThursday, June 6, 13
  61. 61. The Spiral of HealthFormFormFunctionFunctionFunctionImproving HealthNasal BreathingPatent AirwayTongue on PalateWide PalateProper SwallowingFormStraight TeethThursday, June 6, 13
  62. 62. A Pathology CycleDeclining HealthFunctionMouthBreathing andLow TongueFormLong FaceFunction Weak MMusclesFormNarrow PalateFunction Deviate SwallowFormSwollen T&ACrooked TeethFormThursday, June 6, 13
  63. 63. Breaking The CycleDeclining HealthFunctionMouthBreathing andLow TongueFormLong FaceFunction Weak MMusclesFormNarrow PalateFunctionSwallowing with ActiveFacial MusclesCrookedTeethFormFormSwollen T&AConventional OrthodonticsThursday, June 6, 13
  64. 64. Backed into a corner...•Changing Function is not mechanical!Thursday, June 6, 13
  65. 65. Breaking The CycleDeclining HealthFunctionMouthBreathing andLow TongueFormLong FaceFunction Weak MMusclesFormNarrow PalateFunctionSwallowing with ActiveFacial MusclesCrookedTeethFormFormSwollen T&AAirway-Centric OrthodontistHow can we improve 21st centuryorthodontics to be morecomprehensive?Thursday, June 6, 13
  66. 66. Troubled Breathing: Orthodontists• Social-six orthodontics• CAD-CAM techniques• Permanent Retention• Pendulum Thinking• The Battle within the professionThursday, June 6, 13
  67. 67. A letter from a GP...•“Hi. This is so timely. I received a report from a cranio-facia/TMD pain specialist of one of my patients who... wasreferred by the orthodontist that treated her... I originallyreferred the patient to the orthodontist who I used torespect...I met with him...about my concern for herextensive mandibular retrusion. He blew off my concernsand now she is having TMD issues after his headgeardirected treatment…. I felt that she should be treatedearly on but he waited until she was into her mixeddentition once her overjet increased to 11mm! Of coursethe headgear would protect the problem and in his opinionhe attained a great outcome except for the fact that shenow has TMD. I am going to screen her with the HRPO.”Thursday, June 6, 13
  68. 68. What GP’s think of the RO• Most orthodontists extract frequently• Extractions cause TMJ• Extractions ruin the face• Many sleep apnea patients have had extractions• Braces cause decalcification• Braces cause root resorption• Orthodontic treatment is unstable and needspermanent retentionThursday, June 6, 13
  69. 69. “Your Life, Your Smile”Campaign“Maintain the educational message on the two tothree years additional education required tobecome an orthodontist”Thursday, June 6, 13
  70. 70. What GP’s think of orthodontics• Malocclusion is a modern disease• Malocclusion is a symptom of a greater imbalance• You need to treat the imbalance (etiology)•The mouth is part of the body• Many malocclusions can be preventedThursday, June 6, 13
  71. 71. Finding the Middle GroundSo it is said that if you know your enemies and knowyourself, you can win a hundred battles without a single loss.If you only know yourself, but not your opponent, you maywin or may lose.If you know neither yourself nor your enemy, you will alwaysendanger yourself.Sun Tzu - “The Art of War”Thursday, June 6, 13
  72. 72. Thursday, June 6, 13
  73. 73. Troubled Breathing: Healthcare• Economics:• Politics :• Medical Education• EBD vs First-FollowerThursday, June 6, 13
  74. 74. Troubled Breathing: Healthcare• Economics: “Sickcare” cannot keep upwith CNDC’s• Politics• Medical Education• EBD vs First-FollowerThursday, June 6, 13
  75. 75. ObesityHypertensionCardiovascular DiseaseType 2 DiabetesFatty Liver DiseaseSome CancersOsteoporosisArthritisChronic Non-Communicable Diseases of CivilizationWestern Lifestyle DiseasesMetabolic SyndromeAsthmaAutismAsperger’sAlzheimersADD/ADHDDepressionChronic Back PainIs there a better approach to treatingpreventable diseases than symptomatic tx?Thursday, June 6, 13
  76. 76. Troubled Breathing: Healthcare• Economics:• Politics :Everyone deserves healthcare buteveryone wants free healthcare.• Medical Education• EBD vs First-FollowerWhat does our population NEEDto achieve a long and healthy life?Thursday, June 6, 13
  77. 77. Troubled Breathing: Healthcare• Economics:• Politics :• Medical Education is lacking in three areas:• Nutrition• Sleep• Evolution•EBD vs First-FollowerHow do we bring to the healthcare professionthe knowledge and desire to prevent disease?Thursday, June 6, 13
  78. 78. Troubled Breathing: Healthcare• Economics:• Politics :• Medical Education is lacking in three areas:• Nutrition• Sleep• Evolution•EBD vs First-FollowerThe ethical dilemma of being a practitioner.Thursday, June 6, 13
  79. 79. Evidence-basedDentistry• Every day we make a thousand decisions• Only a small fraction have evidence to support them• Ethics: How we choose to answer the restThursday, June 6, 13
  80. 80. Ethics-based Dentistry•ADA and ACD codes• How do we make decisions about issues for which thereis no precedent?• How do we evaluate someone who claims to have ananswer that hasn’t been tested?• How do we deal with the leading edge of knowledge?•Where does the leading edge become the bleeding edge?• How does someone with a new idea come to have it beworthy of being verified by evidence?AutonomyBeneficenceCompassionCompetenceIntegrityJusticeProfessionalismToleranceVeracityThursday, June 6, 13
  81. 81. First FollowerThursday, June 6, 13

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