Spreecast 2014 whats an ro to do

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A repeat of my presentation to the Orthotropics group in Calgary two weeks ago.

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Spreecast 2014 whats an ro to do

  1. 1. What’s an RO to do? A replay of the March, 2014 IAFGG Annual Symposium Calgary, Alberta dr. barry raphael the raphael center for integrative orthodontics the raphael center for integrative education www.alignmine.com bioblocnj.com drbarry@alignmine.com
  2. 2. IAFGG 2014
  3. 3. SOFT TISSUE DYSFUNCTION With Chronic Open Mouth Posture Comparison of Unsupported vs Supported Growth
  4. 4. The End
  5. 5. The Beginning
  6. 6. Everyday in my practice...
  7. 7. RO since1983 (30 years...yikes) Bucknell University 1974 University of Pennsylvania 1978 (ThreeYears in General Practice) Fairleigh-Dickenson University 1983 14 Instructors: 14 Techniques
  8. 8. RO since1983 (30 years...yikes) Bucknell University 1974 University of Pennsylvania 1978 (ThreeYears in General Practice) Fairleigh-Dickenson University 1983
  9. 9. My Dream Office, 2001
  10. 10. 1.Crooked teeth are THE PROBLEM. 2.The lower incisor must be upright. 3.Patients don’t want to cooperate. 4.Straightened teeth aren’t stable. In the RO’s Mind
  11. 11. 1.Crooked teeth are THE PROBLEM. 2.The lower incisor must be upright. 3.Patients don’t want to cooperate. 4.Straightened teeth aren’t stable. 1.Crooked teeth are A SYMPTOM. 2. The UPPER incisor directs treatment. 3.Patients don’t want to be exploited. 4.Teeth that grow straight are stable. A Change of Mind
  12. 12. 1.Crooked teeth are A SYMPTOM. 2. The UPPER incisor directs treatment. 3.Patients don’t want to be exploited. 4.Teeth that grow straight are stable.
  13. 13. George Catlin Are we developing the way our genes program us to be? Westin Price Kevin Boyd Peter Gluckman Neese and Williams Scott Gilbert Clark Spencer Larsen Darwinian Dentistry Me... James Sim Wallace
  14. 14. Obesity Metabolic Syndrome Celiac Intestinal Permeability Type 2 Diabetes Fatty Liver Disease Cardiovascular Disease Hypertension Some Cancers The Results of the Mismatch Between Genes and the Environment Chronic Non-Communicable Diseases of Civilization Western Lifestyle Diseases Asthma Autism Asperger’s Alzheimers ADD/ADHD Depression Chronic Back Pain Osteoporosis Caries Malocclusion Sleep Apnea
  15. 15. The Toothberg
  16. 16. Airway-Related Craniofacial Dysfunctions • Chronic Naso-pharyngeal Obstruction • Tongue form aberrations (Frenum and tongue-tie) • Open Mouth Rest Posture • Myofunctional disorders (Swallowing, chewing,etc.) • Chronic Hyperventilation and Hypocapnia • Breathing Disordered Sleep (OSA, UARS, snoring) • Bruxism and parafunctions • TMD and facial pain components • Cranial and postural issues • Malocclusion
  17. 17. Airway Orthodontics •Early Feeding and Nutrition •Allergies,Asthma, URT infections •Posture •Airway, Breathing, and Sleep Disorders •Soft Tissue Dysfunctions (Tongue Thrust, Open Mouth) Instead of crooked teeth being The Problem, They are just a SYMPTOM of something larger
  18. 18. Parent’s Private-eye Sheet
  19. 19. Parent’s Private-eye Sheet “There are many things about your child’s health that are important to know, but that I often don’t get to see at the office. Also, there are signs to look for that you may not have known were connected to your child’s teeth or health. By looking for and tracking these “signs and symptoms”, we can get a better handle on the problem and watch for resolution. You don’t have to spend a lot of time with this, but don’t rush either. Watch for certain things at different times of day. Try not to let your child know they are being watched. You want to see the most natural behaviors. Check off what you see. If you’re not sure, check it anyway and we’ll talk about it. Make comments if you want.”
  20. 20. While sitting around... While sitting around (watching TV, in the car), does your child: put “things” in the mouth alot (toys, sleeves, pencils, fingernails, etc.) ______________________________ lick or suck on the lips have the lips apart, even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open, even a little bit make noises when breathing have trouble sitting still
  21. 21. While talking... While talking, does your child: talk very fast talk very slowly gasp for air have a lisp take speech lessons
  22. 22. During a meal During a meal, does your child: gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin “crinkle” when swallowing bob the head when swallowing have trouble sitting still
  23. 23. While sleeping... While sleeping, does your child: have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes
  24. 24. S. R. , 10-10yo M •Missing 32,42 •Impacted 13,23 •Late mixed, 25 erupted •Soft tissue dysfunction •IL = 40 •Not compliant
  25. 25. S. Reardon, 10-7yo M
  26. 26. Impacted 3s, Missing 2s
  27. 27. Medical history • Reactive Airway Disease •“Bronchial Constriction” •Care of Pulmonologist • Preventil • Dad : OSA, CPAP for 11 years, diabetes • Grandfather: OSA untreated • ETCO2 = 36.1 at 10 bpm (acceptable) • Posture number - 18 (<10 ideal) • Father refuses sleep screening
  28. 28. Treatment Options 1. Extract upper premolars.. Align. 2.Open spaces for impacted canines. Open spaces for lower lateral implants. What’s more important? Ease of treatment. Or Breathing well at night.
  29. 29. Bolton Standards 15yo The Maxilla is Down and Back The Mandible is Retrognathic Nasal Cartilage Collapse Insufficient Facial Support Bi-maxillary Retrusion
  30. 30. Bimaxillary Retrusion Forward Growth
  31. 31. Mouthbreathers have significantly smaller airway space. (measurements PAS-OccL, PAS-UP, airway volume, area and minimum axial area) Mouth breather Nasal breather Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children Alves, M, et.al., Int J Ped ORL 75 (2011) 1195–1199
  32. 32. 1.Crooked teeth are A SYMPTOM. 2. The UPPER incisor directs treatment. 3.Patients don’t want to be exploited. 4.Teeth that grow straight are stable.
  33. 33. B. Hockel 2012 This is the profile Biobloc children start with: long and retrusive This is the profile Biobloc children finish with: Forward with lips together
  34. 34. B. Hockel 2012 Here’s the “inside” look. Notice how the upper front teeth are closer to the nose? (yellow arrows) Notice how the lower jaw rotates around the star so the chin comes up and forward? (red arrow) How do we make this happen?
  35. 35. From the tip of the Central...
  36. 36. ...To the Forwardmost Tip of the Nose 41mm
  37. 37. Maxillary Height • Indicator Line (Mew) • Distance from most anterior point on nose to upper incisal edge • Age + 23 • A variable number, but important to watch over time.
  38. 38. B. Hockel 2012 Here’s the “inside” look. Notice how the upper front teeth are closer to the nose? (yellow arrows) Notice how the lower jaw rotates around the star so the chin comes up and forward? (red arrow) How do we make this happen?
  39. 39. Using Indicator/ Cosmetic Line •To define a starting point •To set treatment goals •To track treatment progress •To gauge the effectiveness of treatment
  40. 40. Charting the In/Cos Line 50 40 30 20 mm y 5 6 7 8 9 10 11 12 13 14 15 girls boys
  41. 41. Incisor pulled away from nose. Not “undertorqued” or “gummy smile”
  42. 42. Hypothetical ClI Ortho/MARA 50 40 30 20 mm y 5 6 7 8 9 10 11 12 13 14 15 girls boys OJ = 7mm Starts Ortho “Great Headgear Effect”
  43. 43. Class II Elastics 50 40 30 20 mm y J F M A M J J A S O N boys Start Non-x Expansion Uncrowding Finished Start Cl II elastics OK, that’s enough...
  44. 44. Hypothetical Mouthbreather (Dr. Mew’s Hamster Boy) 50 40 30 20 mm y 5 6 7 8 9 10 11 12 13 14 15 girls boys Boy gets hamster MFT
  45. 45. Hypothetical BBO, 7yoM 50 40 30 20 5 6 7 8 9 10 11 12 13 14 15 girls boys Initial Start BB1 BB3 Night
  46. 46. •L.R. 11-9yF •Missing all 5s,6s,8s and upper 4s •Had ortho to close diastema… •InL = 39 •GP objects to deX, plan equil
  47. 47. L.R.Tx Plan 1.Preparation: Hang Expanser 2.deX 3.Training: BB3 to advance mandible 4.Myofunctional Therapy 5.Orthopostural Training 6.Myobrace to hold 7. Reevaluate for dental detailing
  48. 48. L.R. : Spotty progress 50 40 30 20 mm y 3/13 4 5 6 7 8 9 10 11 12 1/ 14 2 3 Expanser Parents dragging. 30 turns. Start Adv. Rx deX. GP objects After delays, Equil e’s, BB3
  49. 49. •L.R. 12-3 yF (6mo in tx) •InL = 37 (+2) • e’s equilibrated • OJ =10 •Appliance OJ = 5 • Still accommodating to BB3
  50. 50. Is there a calculus for the Indicator Line?
  51. 51. Treatment Goals Based on Indicator Line
  52. 52. Incisor Goals Type 1 Treatment: Place U1 in ideal position Biobloc Orthotropics, Orthognathic Surgery, Distraction Osteogenesis
  53. 53. Type 1: Ideal In/Cos line 50 40 30 20 mm y 5 6 7 8 9 10 11 12 13 14 15 girls boys
  54. 54. Y.Z., 9yo M •Lost upper d-space •InL = 36(+4) •OJ = 9mm •Lip entrapment •Lip Incompetence
  55. 55. Y. Z., 9yo M
  56. 56. Y. Z., 9yo M 9mm OJ
  57. 57. Y. Z., 9yo M
  58. 58. Treatment Options 1. Type 1: Reduce InL, open lost space, BB3 to advance mandible. 2. Type 2: Open lost space.Align. 3.Type 4: Extract four premolars.
  59. 59. Y.Z. 9yoM 50 40 30 20 m m y M A M J J A S O N D J F M A boys Hang Expanser Upper and Lower Brackets Hang Retainer BB3
  60. 60. Incisor Goals Type 2 Treatment: Develop arch just enough to uncrowd Biobloc, Myofunctional Ortho, Myofunctional Therapy, Crozat,ALF, Expansion Orthodontics
  61. 61. Type 2: Uncrowding 50 40 30 20 mm y 5 6 7 8 9 10 11 12 13 14 15 girls boys
  62. 62. •Lip incompetence •Lip entrapment •Hypermentalis •Mouthbreathing Type 2: Uncrowding
  63. 63. 12 month progress
  64. 64. 12 month progress
  65. 65. 12 month progress
  66. 66. After Treatment Bent-wire 6 months Myobrace 12 months Hey, Raphael...What about that profile?
  67. 67. Z.P., 9-5yoM i
  68. 68. After Expansion Phase
  69. 69. Incomplete profile improvement... better breathing, head posture and sleep.
  70. 70. Incisor Goals Type 3 Treatment: Maintain UI Functional Orthodontics, Expansion Orthodontics, Distalization Ortho or No Treatment
  71. 71. Type 3: Maintain 50 40 30 20 mm y 5 6 7 8 9 10 11 12 13 14 15 girls boys
  72. 72. Bimax retrusion
  73. 73. Successful dental result
  74. 74. Profile Unimproved
  75. 75. Incisor Goals Type 4 Treatment: Retract/Extrude UI Extraction Orthodontics, Retraction Ortho, Distalization Ortho
  76. 76. Type 4 : Retraction 50 40 30 20 mm y 5 6 7 8 9 10 11 12 13 14 15 girls boys
  77. 77. Bimax retrusion
  78. 78. Successful dental result
  79. 79. Failed Profile Result
  80. 80. Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of Class I bimaxillary protrusion Qingzhu Wanga; Peizeng Jiab; Nina K. Andersonc; Lin Wangd; Jiuxiang Line Angle Orthodontist, Vol 00, No 0, 0000 (pre-publication 2012) “the dimension of the velopharynx, glossopharynx, and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolars…” “Any factors that can influence the posture and position of tongue and soft palate may displace them backward and encroach upon {the pharynx}.” “the more the incisors were retracted, the more the pharyngeal airway was reduced.”
  81. 81. 1.Crooked teeth are A SYMPTOM. 2. The UPPER incisor directs treatment. 3.Patients don’t want to be exploited. 4.Teeth that grow straight are stable.
  82. 82. Backed into a corner... • Moving teeth faster, more efficiently… ...in the wrong direction
  83. 83. Now that we’ve made smoking unacceptable, could we not do the same with... • Sugar? • Processed food? • Cheap milk and meat? • Fast food? • Pill popping for symptomatic relief? • Looking for the cure instead of the cause? • Surgery as a quick fix? •Thinking braces are a status symbol? Each industry thrives on the status quo. Consumers must drive the change.
  84. 84. N.P. 10yM
  85. 85. N.P.
  86. 86. Sister’s non-x ortho She’s happy….but I’m not, so...
  87. 87. I make my pitch for BBO
  88. 88. The dilemma of progress. (I forgot the progress pictures….) Dad sells prosthetic parts to orthopedic surgeons. I selling the case against my previous work they loved... It takes me 3 hours to sell the case. They fret until the BB3 goes in...
  89. 89. 1.Crooked teeth are A SYMPTOM. 2. The UPPER incisor directs treatment. 3.Patients don’t want to be exploited. 4.Teeth that grow straight are stable.
  90. 90. Connecting the dots... • Adult SDB and OSA • Narrow jaws and faces • Soft tissue dysfunction • Early parafunctional habits, ie. open mouth posture • Environmental stressors • CPAP, MARA,UPPP, Surg Where’s the best place to start treatment? here? orhere?
  91. 91. 1. Prevention 2. Undo the damage already done 3. Establish good habits When to start? When damage from poor breathing is noticed and when bad habits are discovered. The strategies of Airway Orthodontics
  92. 92. Prevention • Remove ankyloglossia • Promote breastfeeding • Harden the diet • Develop masticatory strength • Discourage oral habits • Promote whole-foods, low sugar diet • Reduce oropharyngeal obstruction • Promote nasal breathing
  93. 93. Breathing retraining • Nasal rinsing • Nasal clearing • Decongesting
  94. 94. The goals of Airway Orthodontics 1. Breathing through the nose 2. Lips together at rest 3. Correct tongue position 4. No facial muscles moving on swallowing 5. Optimal forward facial development 6. Class I occlusion 7. Straight teeth 8. Better stability long term
  95. 95. Myofunctional Trainers Professors R. Soulet and A. Besombes Dr. Earl Bergeson Dr. Chris Farrell The Multi – Family System
  96. 96. Orofacial Myofunctional Therapy Oral Myology Myofunctional Therapy Tongue Thrust Therapy
  97. 97. B. Hockel 2012 Back Undoing Bimaxillary Dysplasia 1. Maxillary deconstriction 2. Maxillary advancement 3. Maxillary impaction 4. Mandibular advancement
  98. 98. 1. Maxillary Expansion Treatment for Bimaxillary Dysplasia ALF Crozat Bent Wire Hyrax Haas Niti Exp BioBloc Schwartz
  99. 99. The Farrell BENT WIRE System™
  100. 100. Recommended Age Group: 5-12 yrs Arch Development in conjunction with the TRAINER System™
  101. 101. Dr. John Mew
  102. 102. Establish Good Habits 1. Breathing through the nose 2. Lips together at rest 3. Correct tongue position 4. No facial muscles moving on swallowing 5. Stand and sit in balance 6. Breath gently using the diaphragm 7. Eat to nourish 8. Sleep to rest
  103. 103. Ortho-Postural Training Workshops Breathing Nutrition Posture Sleep
  104. 104. COPYRIGHT Roger L Price October 2012
  105. 105. Posture Number Forward head posture can be a compensation for a deficient airway
  106. 106. Sleep Screening and Hygiene SQI = 10 SQI = .98
  107. 107. Integrative Healthcare Function Professional Nasal clearing ENT, Pulm, MFT, Breathing Muscle balance and tone MFT, Myofunctional Ortho Undoing damage GP, Pedo, Ortho, OMFS Breathing dynamics OPT, MFT, Breath Physiologist Posture DC, OPT, PT, Osteopath Cranial balance Osteopath Nutrition RDH, Nutritionist, Dietitian Sleep ENT, Sleep Med, Dent Neurocognitive development Ped’n, SLP, Psych, Sp.Ed. The Interdisciplinary Center
  108. 108. 1.Crooked teeth are A SYMPTOM. 2. The UPPER incisor directs treatment. 3.Patients don’t want to be exploited. 4.Teeth that grow straight are stable.
  109. 109. Now that I know... My personal mission: To create, from what I’ve learned from the best, a model for others to follow…. ...especially the orthodontists.
  110. 110. Myofunctional Orthodontics Chris Farrell John Flutter German Ramierez Damien O’Brien Myofunctional Research Co. Rancho Cucamonga 2008-2012
  111. 111. Oral Myology Oral Myology Basic Course Joy Moeller NYC 2011 LA 2012 Oral Myology: Levels 2, 3 Kim Benkert Clifton 2012 Habit Cessation Shari Green Clifton, 2013
  112. 112. Biobloc Orthotropics BBO Mini-residency Bill Hang Agora Hills 2012-13 BBO Intensive Drs. John and Mike Mew LSFO 2013
  113. 113. Breathing and Sleep Buteyko Mentorship The Breathing Center Woodstock 2010 Breathing Well Programme John Flutter 2010 Ortho-Postural Training Roger Price 2013 Sleep Dentistry Michael Gelb, et.al NYU 2012
  114. 114. ALF and Cranial Jim Bronson 2013 Tasha Turzo Cranial Academy 2014
  115. 115. Bucket List •ALF and Crozat (Bronson’s course) •More on Biobloc (Hang’s Advanced, London School) • More Cranial (The Farm) •Chirodontics (Bob Walker) •Airway Dentistry with Marc Cruz, Jeff Rouse • Sleep Dentistry • Less-than-Six with Kevin Boyd • Intra-mandibular Distraction Osteogenesis (IMDO) Off My List Anything that moves the teeth faster in the wrong direction...
  116. 116. What’s an RO to do? To create, from what I’ve learned from the best, a model for others to follow…. ...especially orthodontists.
  117. 117. Teaching Mt. Sinai Pedo Residency Ali Attaie 2010-2012 Montefiore Ortho Residency Tony Maganzini 2012 2009-Present
  118. 118. Mt. Sinai School of Medicine Pedodontic Residency Guest Speakers Jim Bronson Mike Mew Kevin Boyd Sandra Kahn Jennifer Tow Roger Price Paula Fabbie Damien O’Brien First clinical program in myofunctional orthodontics
  119. 119. Airway and Facial Development Collaborative Webcast Mark Cruz
  120. 120. AAPMD Symposium www.aapmd.org Annual Meeting April 25-26, 2014 Westin Chicago North Shore
  121. 121. the raphael center for integrative orthodontics www.alignmine.com www.bioblocnj.com www.myobracenj.com
  122. 122. Integrative vs Conventional
  123. 123. Integrative vs Conventional
  124. 124. “With improvements in expansion orthodontics, advances in myofunctional orthodontics, and the growing recognition about sleep disordered breathing among children and adults, it is time for orthodontics to expand its horizons. There is now so much more we can offer.” The Raphael name has been associated with high quality orthodontics in New Jersey for over 60 years. Dr. Barry Raphael has been a university trained orthodontic specialist and a member of the American Association of Orthodontists for 30 years. He has a wide range of techniques and services to offer. He has studied oral myology, applied kinesiology, Buteyko breathing, Biobloc Orthotropics and Myobrace as part of his integrative training. He can offer Damon, Invisalign, Insignia and Incognito appliances designs as some of his many conventional orthodontic services, too. Dr. Raphael teaches his techniques at post-graduate residencies, study clubs, dental societies, and for the Myofunctional Research Co. He is available for presentations to any group interested in learning more about the benefits of integrative orthodontics. www.alignmine.com Learn about the choices you have in orthodontics dr barry raphael Why it's too Early... never 1425broadstreet clifton,nj07013 973-778-4222 fax973-778-9625 njspec#3684 1425 broad street, clifton, nj 07013 973-778-4222 www.alignmine.com the raphael center for integrative orthodontics theraphaelcenterfor integrativeorthodontics Learn about an important choice you need to make before starting braces.
  125. 125. the raphael center for integrative education
  126. 126. the raphael center for integrative education Ongoing Intro to Airway Orthodontics April Biobloc Study Group April Training Ortho-Postural Therapists w Roger Price June MRC Myobrace Basic Series August Airway Dentistry with Mark Cruz and company October Advanced MFT with Sandy Coulson October Less than Six with Kevin Boyd (who else wants to play?) Mission: to create a space for spreading the word about Airway and Orthotropic principles and practice.
  127. 127. Orthodontics in the 21st Century Esthetic Orthodontics Airway Orthodontics Genetic Tooth-Focused Dental: Perfection Esthetics Primary Treating Symptoms Airway Ignorant Adaptation Muscle-Focused Medical: Better Esthetics Secondary Treating Causes Airway Conscious
  128. 128. The End And The Beginning

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