tag:blogger.com,1999:blog-34294833284961839562024-03-21T20:57:27.498-07:00Dr Peter Miles - orthodontic mythbustersDiscussions of various often controversial topics on orthodontics.
Dr Miles is an editor and author of the textbook 'Evidence-Based Clinical Orthodontics'.Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.comBlogger22125tag:blogger.com,1999:blog-3429483328496183956.post-36063706103464908722018-06-12T00:28:00.001-07:002018-06-12T00:34:25.927-07:00Infant tongue ties – should I have my baby’s tongue cut?<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEht6v1BNNtwNnlP6RUqjlhPUq3e79tbbZWAnbS0VbPpVZ_AMScN3HWflMMTvnurb6O9rA72pcQLe4QrL674x43gdYW98TokAW0Ky0nPJyhmmlVvDQjR65OUZFIbP7-06abA5uuwcZxVZfT-/s1600/tongue_tie.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="334" data-original-width="434" height="153" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEht6v1BNNtwNnlP6RUqjlhPUq3e79tbbZWAnbS0VbPpVZ_AMScN3HWflMMTvnurb6O9rA72pcQLe4QrL674x43gdYW98TokAW0Ky0nPJyhmmlVvDQjR65OUZFIbP7-06abA5uuwcZxVZfT-/s200/tongue_tie.jpg" width="200" /></a></div>
Tongue-tie, or ankyloglossia, is a condition whereby the lingual frenulum (stringy bit under your tongue) attaches near the tip of the tongue and may be short, tight and thick. It is potentially a concern if it limits the range of movement of the tongue, interfering with feeding or speech. Tongue-tie is present in ~4% to 11% of newborns and has been cited as a cause of poor breastfeeding and maternal nipple pain. Frenotomy (cutting/removal of the tongue tie) has been promoted to correct restriction of tongue movement and allow more effective breastfeeding with less maternal nipple pain. Recently there have been dramatic increases worldwide in performing this procedure. Canada has reported an <a href="https://www.ncbi.nlm.nih.gov/pubmed/27280112" target="_blank">89% increase</a>, the USA a <a href="https://www.ncbi.nlm.nih.gov/pubmed/28168891" target="_blank">300% increase</a> between 2006 – 2012 and in Australia a <a href="https://www.mja.com.au/journal/2018/208/2/frenotomy-tongue-tie-australian-children-2006-2016-increasing-problem" target="_blank">420% increase</a> has been reported. Frenotomy may seem like a logical solution but is it supported by evidence?<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-4rUXm8VfBXiRo3G5w-54rujXSXWX8NWdolvQiRYDhA4bJnzGX7sKchC8RareueKqFGReVfWJhg1FZ032eo3A3in0W0nxRnUv1B_JWVrL7r6Yf0J31NJd9NR6uFNI7PidhsGzkBwL85sv/s1600/tongue+tie+surgery.jpg" imageanchor="1" style="clear: right; display: inline !important; float: right; margin-bottom: 1em; margin-left: 1em; text-align: center;"><img border="0" data-original-height="402" data-original-width="555" height="231" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-4rUXm8VfBXiRo3G5w-54rujXSXWX8NWdolvQiRYDhA4bJnzGX7sKchC8RareueKqFGReVfWJhg1FZ032eo3A3in0W0nxRnUv1B_JWVrL7r6Yf0J31NJd9NR6uFNI7PidhsGzkBwL85sv/s320/tongue+tie+surgery.jpg" width="320" /></a>A <a href="http://www.cochrane.org/CD011065/NEONATAL_surgical-release-tongue-tie-treatment-tongue-tie-young-babies" target="_blank">Cochrane review</a> based on older research found frenotomy reduced breastfeeding mothers' nipple pain in the short term but did not find a consistent positive effect on infant breastfeeding. However the evidence was based upon only a small number of studies with a small number of infants. More recent research in Australia has found an <a href="https://www.mja.com.au/journal/2018/208/2/frenotomy-tongue-tie-australian-children-2006-2016-increasing-problem" target="_blank">alarming increase in the number of frenotomies</a> or tongue-tie releases being performed and in <a href="https://www.dcnz.org.nz/resources-and-publications/publications/newsletters/view/26?article=8" target="_blank">New Zealand</a> it was found to be performed in 13% of newborn infants. With only 25-50% of babies with ankyloglossia having feeding problems, the target or suggested rate for tongue-tie release surgery is between <a href="https://www.dcnz.org.nz/resources-and-publications/publications/newsletters/view/26?article=8" target="_blank">0.2-5%</a>. This suggests many of these procedures are being performed without indication and potentially placing the child needlessly at risk of complications.<br />
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A recent <a href="https://www.medela.com/company/news/news/article~medela-com.think-twice-before-tongue-tue~" target="_blank">study in Western Australia</a> found instead of improving breastfeeding rates, the frenotomy was actually more likely to lead to early weaning! Their research revealed that the real problem in many cases was low milk production and not the baby’s tongue tie. Breastfeeding rates were NOT improving following surgery and some babies required hospitalisation for serious bleeding or infection. It therefore appears many may needlessly be receiving this procedure and being placed at harm. Frenotomy may seem like a ‘simple’ solution and for some it is appropriate but if you are unsure, then seek a second opinion from your Paediatrician.<br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="background-color: white; color: #818181; font-family: arial, helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px; text-decoration-line: none;" target="_blank">Dr Peter</a><span style="background-color: white; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="background-color: white; color: #818181; font-family: arial, helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px; text-decoration-line: none;" target="_blank">Newwave Orthodontics</a><span style="background-color: white; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"> in Caloundra, Australia and has taught orthodontics part-time at the University of Queensland and Seton Hill University in the USA for over 10 years. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" style="color: #818181; text-decoration-line: none;" target="_blank">Evidence-Based Clinical Orthodontics</a>'. Importantly, he has no financial interest in any products or techniques mentioned in these Blogs.</span><br />
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-86623940525298926072017-12-27T18:03:00.003-08:002017-12-27T18:03:28.963-08:00Vibration does not speed up extraction space closure<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQigHrwXmVmUxiMZkcpTYtO7VoDUZxXE-Ad7CJnvCcPWCsPS44oxT-_BU9hyKgDb4lQiO1ENjop2UJG6SWF7zJqwmd_JecMAAKNtJ_4tNqUIcMFHgs1Zb1Sud8Dms4rmXeu9QjGvUPk3T0/s1600/vibration.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="320" data-original-width="663" height="152" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQigHrwXmVmUxiMZkcpTYtO7VoDUZxXE-Ad7CJnvCcPWCsPS44oxT-_BU9hyKgDb4lQiO1ENjop2UJG6SWF7zJqwmd_JecMAAKNtJ_4tNqUIcMFHgs1Zb1Sud8Dms4rmXeu9QjGvUPk3T0/s320/vibration.png" width="320" /></a></div>
I have blogged previously on appliances claiming to accelerate tooth movement and shorten orthodontic treatment. One of these is micro-vibration and an appliance using this principal is AcceleDent. I have previously researched this topic during initial alignment and now Part 2 has been published on extraction space closure.<br />
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I strongly believe in an evidence-supported approach to clinical practice and this study (as with all my research) was conducted in my orthodontic practice to answer the clinical question of whether this was a worthwhile technique to consider implementing for my own patients. Forty Class II adolescent patients planned to have premolar extractions in the upper arch were randomly assigned to using either the AcceleDent appliance or no appliance. The extraction space closure was measured over time so a rate of movement in mm/month could be calculated. So what did I find? There was no clinically (0.05 mm per month) or statistically
significant difference in the rate of space closure (P = 0.74). Compliance was found to reduce over time and this is the subject of another paper to be published in the Journal of Clinical Orthodontics. However, even when compliance was accounted for there was still no clinically meaningful difference in the rate of space closure.<br />
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This article appears in the American Journal of Orthodontics and<span style="font-family: inherit;"> Dentofacial Orthopedics and a<span style="font-size: 11.5pt;">nyone clicking on
this link before </span></span><b style="font-family: inherit; font-size: 11.5pt;"><span style="color: red;">February 14, 2018</span></b><span style="font-family: inherit;"><span style="font-size: 11.5pt;"> will be taken directly to the final version
of my article on ScienceDirect. No sign up, registration or fees are required
– you can simply click, read and </span></span><span style="font-size: 15.3333px;">hopefully</span><span style="font-family: inherit;"><span style="font-size: 11.5pt;"> enjoy.</span></span><br />
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<span style="font-size: 13.5pt;"><span style="color: #007398;"><a href="https://authors.elsevier.com/a/1WHqw3AGXGWWNM" target="_blank"><span style="font-family: inherit;">https://authors.elsevier.com/a/1WHqw3AGXGWWNM</span></a></span></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb8KuC0MPxapn9gIT7B6TNVj9ND_lpRHjTWr7jgievRjxZ-58sI7CKOBhoSthkGf9W91nRgitZZE-dFynI18_l38nQKuQuNj687Ic4pcITa98MDJLuAdeQDeCbQoz1Ew8v3dLBTjcFwM36/s1600/Vibration_joke.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: inherit;"><img border="0" data-original-height="265" data-original-width="679" height="249" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhb8KuC0MPxapn9gIT7B6TNVj9ND_lpRHjTWr7jgievRjxZ-58sI7CKOBhoSthkGf9W91nRgitZZE-dFynI18_l38nQKuQuNj687Ic4pcITa98MDJLuAdeQDeCbQoz1Ew8v3dLBTjcFwM36/s640/Vibration_joke.png" width="640" /></span></a><span style="font-family: inherit;"><br /></span><br />
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com010 Mayes Ave, Caloundra QLD 4551, Australia-26.803265 153.122653-54.915881 111.81405900000001 1.3093509999999995 -165.56875300000002tag:blogger.com,1999:blog-3429483328496183956.post-86533751354656406352017-09-05T20:19:00.000-07:002017-09-05T20:19:01.926-07:00Digitally positioned brackets - are they any better?<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEje5XwZUU4GjTxy0yURhjmJ59nvi8CZ84knSMu17vzgVCWVFDqZ1hjm9oaXSvNXKhcHyxHTAfSfvNkNztFIYHq2z73UZAfNM4hmKoWb8uhGYHyBemf7jmO5XjTVhHCvJ5KFs24z2vSwWb2C/s1600/thinker.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="894" data-original-width="1600" height="111" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEje5XwZUU4GjTxy0yURhjmJ59nvi8CZ84knSMu17vzgVCWVFDqZ1hjm9oaXSvNXKhcHyxHTAfSfvNkNztFIYHq2z73UZAfNM4hmKoWb8uhGYHyBemf7jmO5XjTVhHCvJ5KFs24z2vSwWb2C/s200/thinker.jpg" width="200" /></a></div>
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<span style="color: windowtext; font-family: "Calibri",sans-serif; font-size: 11.0pt; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-hansi-theme-font: minor-latin;">In
orthodontics, the current trend is to find ways to accelerate treatment with
many appliances making these claims, even in the naming of their appliance or
technique (Fast, Quick, Rapid, Speed, 6-month, etc.). There is substantial
evidence now to demonstrate that simply changing to a different type of bracket
makes no difference – it is the skill of the operator that is most important,
otherwise the patient may be accepting a compromise. For example; if treating
only in round wires then the roots are not rotated, tipped or especially torqued
into their best and most stable positions or the occlusion or overjet not
addressed.<o:p></o:p></span></div>
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<span style="color: windowtext; font-family: "Calibri",sans-serif; font-size: 11.0pt; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-hansi-theme-font: minor-latin;">To overcome
this, some companies have suggested that digitally positioned brackets are the
answer as they reduce variability and take into account a lot of the skill and
variation of the operator. Systems such as Insignia, SureSmile and even
Invisalign are examples of these in orthodontics. However, there is a lot of
biological variation with individual patients varying in response as well as appliances
do not deliver 100% of what is built into them which is why detailing/finishing
is required (the fiddly part of orthodontics). Previous retrospective studies
have suggested that digitally customised appliances did deliver faster
treatment but these had the same flaws as the self-ligating bracket and
vibration appliance studies in that there is a high risk of bias and potential
confounding variables that can influence the result beyond just the appliance (the
later RCTs found no difference). This is why blinded, RCT’s are considered the
gold standard – but also take more time and cost to conduct. However, an RCT was
just published online in the Journal of Dental Research (considered the top
journal in dentistry in terms of the quality of the articles) and <a href="http://journals.sagepub.com/doi/10.1177/0022034517720913" target="_blank">this paper </a>looked at the Insignia system of digitally positioned brackets
compared with conventional placement. The results were interesting!<o:p></o:p></span></div>
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<span style="color: windowtext; font-family: "Calibri",sans-serif; font-size: 11.0pt; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-hansi-theme-font: minor-latin;">There were
180 patients in this RCT and when completed, they analysed 85 patients in the
customized group and 89 in the non-customized group. The authors found no
difference in treatment duration (digital = 1.3 years vs. conventional = 1.2
years) or quality of outcome as measured by the PAR (Peer Assessment Rating) index.
Most importantly, the Orthodontist <b><i>did</i></b> have a significant effect on
treatment duration, quality of treatment outcome, and number of visits (P <
0.05) - not the appliance used. Interestingly, the customized orthodontic group
also had more loose brackets, a longer planning time, and more complaints (P
< 0.05).<o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPoyrKYbnyyFUDOzdZhCDLJ8zpyUBXiulpGHfL-eNGWIKDBUhVR_oXdXDXzxHOBePmQQORUT_bZCQAY5hERwH4KdseU4jnIPbrj07p0M3s0jkGbc7jiRhgS0eduzVZwKW0Gau0LNWebURK/s1600/Carl_Sagan.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="300" data-original-width="220" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPoyrKYbnyyFUDOzdZhCDLJ8zpyUBXiulpGHfL-eNGWIKDBUhVR_oXdXDXzxHOBePmQQORUT_bZCQAY5hERwH4KdseU4jnIPbrj07p0M3s0jkGbc7jiRhgS0eduzVZwKW0Gau0LNWebURK/s200/Carl_Sagan.JPG" width="146" /></a><span style="color: windowtext; font-family: "Calibri",sans-serif; font-size: 11.0pt; mso-ascii-theme-font: minor-latin; mso-bidi-font-family: "Times New Roman"; mso-bidi-theme-font: minor-bidi; mso-hansi-theme-font: minor-latin;">In the rush
(pardon the pun) for faster treatment and to seem to be on the cutting edge, we
can leap into new technologies. Sometimes they deliver what they claim while at
other times they do not. Such systems usually involve additional cost with an
expectation by the patient of faster treatment but in this case, it wasn’t delivering
what it claimed. Some practitioners may prefer these systems and that is a personal
choice just as some prefer one bracket type over another, but when claims are
made of a faster or better outcome (and often at added cost)… proof rather than
opinion is required. As Carl Sagan (Astrophysicist) famously stated; ‘Extraordinary
claims require extraordinary evidence’.<o:p></o:p></span></div>
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com010 Mayes Ave, Caloundra QLD 4551, Australia-26.803265 153.122653-52.3252995 111.81405900000001 -1.2812304999999995 -165.56875300000002tag:blogger.com,1999:blog-3429483328496183956.post-58199173800407693322017-05-10T22:58:00.002-07:002017-05-10T22:58:47.747-07:00Fast Orthodontics - In Search of the Holy Grail<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBZVBKtWGEVoqh9tO6HJSDkKjpOgdnP8Sd4Ifu9c6iLIy-mZuZiuKT7HWMOy0DCEtM7lofB8u2ugPrlkCsBr_LLCORmu-2yve1KtH4ESyyy3beBZ5KpX-yA2S_4yvTXWXu6MEJ1cKqSom5/s1600/grail.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBZVBKtWGEVoqh9tO6HJSDkKjpOgdnP8Sd4Ifu9c6iLIy-mZuZiuKT7HWMOy0DCEtM7lofB8u2ugPrlkCsBr_LLCORmu-2yve1KtH4ESyyy3beBZ5KpX-yA2S_4yvTXWXu6MEJ1cKqSom5/s200/grail.jpg" width="148" /></a></div>
I recently wrote a review article in the <a href="http://onlinelibrary.wiley.com/doi/10.1111/adj.12477/full" target="_blank">Australian Dental Journal</a> supplemental issue on accelerated orthodontic treatment. In it I discuss the many claims by manufacturers of several appliances and proponents of various techniques that claim to accelerate treatment. This appeals to both the patient’s and the clinician’s desire to ‘speed’ up and shorten their treatment, however how strong is the evidence or is it just marketing hype? I am a little concerned as it would appear that in some respects, advertising claims in orthodontics are following down the path of the exercise fads claiming rapid results with little or no effort - I certainly find some effort and restraint is required :-). Mechanically and biologically, many of the claims of accelerating orthodontic treatment just do not make sense (such as with self-ligating brackets which I have <a href="http://newwaveorthodontics.blogspot.com.au/2016/03/passive-self-ligating-brackets-are.html" target="_blank">written about before</a>) or are quite invasive and/or expensive (some of the surgical techniques are ~$5000 and the effect lasts only ~3 months). This is discussed in more detail in the article.<br />
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One of the clinical trials I have been conducting in our office on vibration and accelerated treatment was also published recently in the American Journal of Orthodontics and Dentofacial Orthopedics and I was asked to produce a short video on that article which can be <a href="https://youtu.be/hEKFHnHAWos" target="_blank">found here</a>.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_OAzBphUNw6Yhj8PSpmux74D6ZOrDBo2mS6gKh_pOeD9vF-ktrYTd0hgdeakZ-rtc66hgXsTOmzMM1-7dAsVrI4hz_QnNT6lJXUAr_8vWT7hy9jRxZdAqUDQbmoziNOLkZf9h15GaS61T/s1600/honesty.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="117" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj_OAzBphUNw6Yhj8PSpmux74D6ZOrDBo2mS6gKh_pOeD9vF-ktrYTd0hgdeakZ-rtc66hgXsTOmzMM1-7dAsVrI4hz_QnNT6lJXUAr_8vWT7hy9jRxZdAqUDQbmoziNOLkZf9h15GaS61T/s200/honesty.jpg" width="200" /></a>This was included in the review article I wrote also. More recently we have just analysed the data on the 2nd part of this ongoing RCT when closing extraction spaces and I also found that there was no clinically or statistically significant difference in the rate of space closure – in other words, vibration had no effect. This is important for patient’s to be aware of as they can be asked to spend $500 - $1000 for various appliances which may have minimal or no effect. The problem with emerging techniques and methodologies is that there may be no trials examining their performance so we must then rely on our knowledge of biology and mechanics on whether we consider it ‘may’ have a positive effect or not. However, if we are unsure, then patient’s should be informed of this until research exists. They can then decide if they will gamble on the appliance/technique possibly working or stay with the current approach. So the Holy Grail of accelerated orthodontic treatment seems elusive and the honest answer about the various options to patients is ”There are many techniques and appliances claiming to accelerate orthodontic treatment but the current evidence is poor and some have been shown to have no effect”.<br />
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-42604801852151130532016-11-29T09:56:00.001-08:002017-01-08T15:57:56.727-08:00DOES THE ACCELEDENT AURA APPLIANCE SPEED UP THE INITIAL ALIGNMENT OF TEETH WITH BRACES?<div dir="ltr" style="text-align: left;" trbidi="on">
<iframe allowfullscreen="" frameborder="0" height="270" src="https://www.youtube.com/embed/hEKFHnHAWos" width="480"></iframe><br />
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<span style="background-color: white; color: #333333; font-family: Arial, sans-serif; font-size: 13px; white-space: pre-line;">This summary of my recent clinical trial published in the American Journal of Orthodontics & Dentofacial Orthopedics demonstrated no effect of the AcceleDent Aura vibrational appliance during the initial alignment of teeth with fixed appliances.</span></div>
Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-83905550983980901682016-09-04T19:44:00.002-07:002016-09-04T19:45:59.871-07:00ALLERGIES, HABITS AND MALOCCLUSION IN YOUNG CHILDREN - WHAT HAPPENS OVER TIME?<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDTFpEOCi21Hv7rzsBW9dmIocATCjffusnHEnkGg-rXaGWnKGEydH6gWx-YswH3kzPgyUEGhjr3Jr2bNZExK_5AhImNY8vytImWsOS9kUzYMc-y50M2Hm17wPwUA9wmkFa02IGOHUjYFsh/s1600/early_orthodontics.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="112" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDTFpEOCi21Hv7rzsBW9dmIocATCjffusnHEnkGg-rXaGWnKGEydH6gWx-YswH3kzPgyUEGhjr3Jr2bNZExK_5AhImNY8vytImWsOS9kUzYMc-y50M2Hm17wPwUA9wmkFa02IGOHUjYFsh/s200/early_orthodontics.jpg" width="200" /></a></div>
Some clinicians advocate very early treatment in the primary (~ages 3-5) dentition and recommend interventions claiming they will prevent future orthodontic problems. But what if we did nothing and observed them? This <a href="http://www.angle.org/doi/10.2319/080414-542.1" target="_blank">very interesting article</a> from Sweden followed 277 children from age 3 to age 11.5 and evaluated the presence of malocclusion, sucking habits, breathing problems, allergies and trauma over time.<br />
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There was quite a high prevalence of malocclusion at age 3 of 71% and although this improved by age 7 to 56%, it worsened again to 71% by age 11.5. However ~45% of subjects were considered in severe or moderate 'need' of treatment so ~55% had minor or no need. Many advocates of early treatment suggest intervention for open bites but interestingly this was one of the malocclusions that tended to self-correct as found by previous authors. Conversely deep bites did tend to worsen. As with previous studies trauma to the top front teeth was ~2.2 times more likely with increased protrusion/overjet.<br />
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Another re-emerging (previously in 1930's then 1960-70's) claim in orthodontics is the influence of habits and allergies on malocclusion and that early intervention is required to prevent adverse growth effects. This long-term observational study found sucking habits had little or no association with anterior open bite or posterior crossbite in the permanent dentition. As I have discussed in a <a href="http://newwaveorthodontics.blogspot.com.au/2014/10/what-to-do-about-thumb-sucking-and.html" target="_blank">previous Blog</a>, many children stop the habits themselves as they get older and an open bite can improve spontaneously so treatment may not be indicated except in those that persist longer term.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVA6x5KiNQgtMMLWLj1kU3PqP80cBg2-FLSGiXlmM7mnZHfWHGSrBrK8TuW6O3V9fuZHvQir8oz0MrVmGz7o6aGSfMwI4XByXGnQZByt3iJPcvhzHujwv8qkwXWpnk2JttU48G85au7wT1/s1600/Swedish_kids.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhVA6x5KiNQgtMMLWLj1kU3PqP80cBg2-FLSGiXlmM7mnZHfWHGSrBrK8TuW6O3V9fuZHvQir8oz0MrVmGz7o6aGSfMwI4XByXGnQZByt3iJPcvhzHujwv8qkwXWpnk2JttU48G85au7wT1/s200/Swedish_kids.jpg" width="200" /></a>Similarly allergies at age 3 had NO association with any future malocclusion at age 11.5. There are many good reasons for allergy, tonsil and adenoid treatments but to prevent abnormal facial growth is not one of them. I have personally had an ENT tell my wife that our 9 y.o. daughter (who suffers from allergies) required a turbinectomy otherwise she will undergo abnormal jaw growth - you can probably guess my response to that! My daughter has normal horizontal and vertical facial growth with mild crowding and although she will require some orthodontic treatment once all adult teeth have erupted for the mild crowding, her growth is proceeding just fine without the surgery. I feel sorry for those parents that do not have the knowledge of normal facial growth that I do as they may be 'scared' into having procedures for their children that they may otherwise think twice about. This article helps contribute to that knowledge so thanks to this Swedish team for following this group and presenting their findings.<br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px; text-decoration: none;" target="_blank">Dr Peter</a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px; text-decoration: none;" target="_blank">Newwave Orthodontics</a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px;"> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" style="color: #818181; text-decoration: none;" target="_blank">Evidence-Based Clinical Orthodontics</a>'. Importantly, he has no financial interest in any products mentioned in these Blogs.</span></div>
Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-33309742794805717812016-06-08T20:30:00.000-07:002016-06-12T15:27:59.287-07:00THE CVM METHOD AND THE IDEAL TIME FOR ORTHODONTIC TREATMENT.<div dir="ltr" style="text-align: left;" trbidi="on">
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The timing of treatment of Class II (protrusive top teeth &/or retruding lowers) patients has been debated for many years in orthodontics with some claiming you need to treat early, even as young as 5-8 (<a href="http://newwaveorthodontics.blogspot.com.au/2015/03/what-age-is-best-for-orthodontic.html" target="_blank">discussed in a previous Blog</a>) or 9-10 or wait until 12-13! Several indicators have been used to assess the ideal timing and a more recent one is the Cervical Vertebral Maturation method (CVM) which uses the maturational stages of the cervical vertebrae in the neck on a cephalogram x-ray.<br />
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The CVM method was first developed
by Don Lamparski along with Maria O'Reilly at the University of Pittsburgh where I trained and was <a href="http://www.angle.org/doi/pdf/10.1043/0003-3219(2002)072%3C0316%3AAIVOTC%3E2.0.CO%3B2" target="_blank">later modified</a>. However to be useful a method needs to be reliable and valid. <a href="http://www.ajodo.org/article/S0889-5406(09)00514-9/abstract" target="_blank">One article </a>demonstrated <50%
intra-rater agreement (in other words less than half the time you agree with
your own assessment). Another demonstrated that the
<a href="http://www.ajodo.org/article/S0889-5406(13)00828-7/abstract" target="_blank">CVM method offered no advantage</a> over chronological age.
Two recent papers concluded "CVM method <a href="http://www.ncbi.nlm.nih.gov/pubmed/26718383" target="_blank">could not accurately identify themandibular growth peak</a>" or "...<a href="http://ejo.oxfordjournals.org/content/38/1/1" target="_blank">cannot predict craniofacial growth in girls</a> with Class II malocclusion.". But let's say you do identify the ideal timing of treatment using the <a href="http://www.ajodo.org/article/S0889-5406(09)00221-2/abstract" target="_blank">CVM method with the Herbst</a> the study found ~1.9mm of
advancement of Pogonion. However another study in adults (who are not growing) found they could still gain <a href="http://www.ajodo.org/article/S0889-5406(04)00329-4/abstract" target="_blank">1.3mm of advancement of Pogonion </a> so the ideal timing
was only 0.6mm better and that is also assuming the change holds up long term
which we know from other trials it doesn't.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMrphMLWXNVwOEGAYmnkh7Kv7TCnrwXvnTljQm2aEve2YX9TUec4hrRVnDw4qXY4IiPB98DoM9aDDVvyVMk2BsgoieiQznBmG8tIdG8gxS8o_agQDGHV_z_wo89C5ia4x7PXjOaCJHF0XD/s1600/CVM.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="184" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMrphMLWXNVwOEGAYmnkh7Kv7TCnrwXvnTljQm2aEve2YX9TUec4hrRVnDw4qXY4IiPB98DoM9aDDVvyVMk2BsgoieiQznBmG8tIdG8gxS8o_agQDGHV_z_wo89C5ia4x7PXjOaCJHF0XD/s320/CVM.JPG" width="320" /></a></div>
The timing of orthodontic treatment is an interesting topic and really revolves around the
issue of whether we can ‘modify growth’ of the mandible or not. Based upon the available quality scientific evidence it seems we can temporarily
accelerate mandibular growth (<a href="http://aoj.aso.org.au/AOJ/AOJ_docs/Past_issues/Vol_14_No_3.htm#1434a" target="_blank">Lysle Johnston’s ‘mortgage on growth’</a>) but not achieve
a significant long-term change and so the final outcome is mostly dento-alveolar/tooth movement. Studies
supporting a change are retrospective in nature and/or use a historical control
which is ~60 years old and not valid for comparison as <a href="http://ejo.oxfordjournals.org/content/early/2016/04/29/ejo.cjw035" target="_blank">trials using historical controls show larger treatment effects</a>. In contrast the
prospective RCT’s (UK, UNC, Florida) show no difference between treating early or in adolescence and this is
supported by the <a href="http://www.cochrane.org/CD003452/ORAL_orthodontic-treatment-for-prominent-upper-front-teeth-in-children" target="_blank">Cochrane Review on the topic</a>. The long-term ‘amount’ of change is similar regardless of the timing of
treatment so it is more the ‘efficiency’ of the change/how quickly that is
achieved that is affected by timing. Therefore the importance of determining the
ideal timing of treatment with any method seems of minimal significance to the
final outcome.<br />
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Finally I would like to thank Maria and all my other instructors at the Univ of Pittsburgh. I was so incredibly fortunate to have such wonderful mentors and friends.<br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="background-color: white; color: #818181; font-family: arial, helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px; text-decoration: none;" target="_blank">Dr Peter</a><span style="background-color: white; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="background-color: white; color: #818181; font-family: arial, helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px; text-decoration: none;" target="_blank">Newwave Orthodontics</a><span style="background-color: white; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"> in Caloundra, Australia and was a part-time lecturer at the University of Queensland for 11 years and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" style="color: #818181; text-decoration: none;" target="_blank">Evidence-Based Clinical Orthodontics</a>'.</span></div>
Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-64210831609655693752016-03-07T19:24:00.003-08:002016-05-10T21:28:07.636-07:00PASSIVE SELF-LIGATING BRACKETS ARE BETTER - IT'S OBVIOUS?<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWiUh2c67b0L88ZsxnetivrQ6HzeFOT6mJSKsuRO9LYCSZgE5T-HVHkN1P5jNhP35bLuG412DfY14gfrKbEjoURXHD-JB7DwPspDlLmWM_-CszZbut114DpY7YFFLJloAX9OJbZ1HmOWw_/s1600/passive+self-ligating.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="PSL vs. ASL vs. Conventional brackets" border="0" height="111" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWiUh2c67b0L88ZsxnetivrQ6HzeFOT6mJSKsuRO9LYCSZgE5T-HVHkN1P5jNhP35bLuG412DfY14gfrKbEjoURXHD-JB7DwPspDlLmWM_-CszZbut114DpY7YFFLJloAX9OJbZ1HmOWw_/s200/passive+self-ligating.jpg" title="Passive versus Active and Conventional brackets" width="200" /></a>This Blog topic was prompted by comments in Kevin O'Brien's excellent Blog regarding '<a href="http://kevinobrienorthoblog.com/a-thinking-about-orthodontics-blog-post/" target="_blank">thinking about orthodontics</a>'. Kevin was discussing evidence-based care and what we know versus what we don't know and how to apply our knowledge, skill and experience as clinicians in the treatment of our patients. Many suggestions were made about what we do and don't know but two comments in particular claimed that Passive Self-ligating (PSL) brackets were superior to conventional brackets during initial alignment in non-extraction treatment. I have also seen other claims in Facebook study clubs where the clinician states that in their experience, PSL brackets are superior for space closure in extraction cases (a future Blog topic). So is this evidence or their opinion and what is the evidence if any?</div>
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In 2006 I conducted the first prospective study comparing PSL brackets with conventional brackets in the lower arch in non-extraction cases. This was published in <a href="http://www.angle.org/doi/pdf/10.1043/0003-3219(2006)076%5B0480%3AACTODV%5D2.0.CO%3B2" target="_blank">The Angle Orthodontist</a> and I found that the PSL bracket was
no better during initial alignment than a conventional bracket. Another non-extraction study published in the <a href="http://dx.doi.org/10.1016/j.ajodo.2009.08.019" target="_blank">American Journal of Orthodontics in 2010</a> found there was no difference between PSL or Active SL brackets. Based upon this evidence in clinical trials this refutes the claim that PSL brackets are more effective in non-extraction cases during initial alignment. If we then include the evidence from extraction cases as well, this was summarised very nicely in another article in the <a href="http://dx.doi.org/10.1016/j.ajodo.2013.12.016" target="_blank">American Journal of Orthodontics in 2014</a> where the data was plotted graphically (shown below) in a meta-analysis. The vertical line at zero ('0') represents no difference between brackets and the purple squares are the individual studies. What we are most interested in are the large green diamonds which represent the results combined together and as they overlap the zero line, this indicates there was no difference between any of the bracket types tested across the various studies during initial alignment. It seems the evidence is quite compelling that there is no advantage in PSL or ASL brackets over conventional brackets during initial alignment.<br />
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As the evidence clearly shows there is no difference between brackets, the choice of bracket then comes down to the personal preference of the clinician. BTW if you are interested in evidence-based orthodontics then I highly recommend subscribing to Kevin's Blog at http://kevinobrienorthoblog.com/<br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="background-color: white; color: #818181; font-family: arial, helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px; text-decoration: none;" target="_blank">Dr Peter</a><span style="background-color: white; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="background-color: white; color: #818181; font-family: arial, helvetica, sans-serif; font-size: 13.2px; line-height: 18.48px; text-decoration: none;" target="_blank">Newwave Orthodontics</a><span style="background-color: white; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 18.48px;"> in Caloundra, Australia and was a part-time lecturer at the University of Queensland for 11 years and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" style="color: #818181; text-decoration: none;" target="_blank">Evidence-Based Clinical Orthodontics</a>'.</span></div>
Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-11155200035474006752015-12-29T13:15:00.001-08:002015-12-29T13:15:43.011-08:00HIGHEST VIEWED BLOGS SO FAR!!<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFI84a7EaJuWfZo1YEwp-wvunIM2d5nZsYrMR4KQn0gwzcxFSdslB7cScslFFkLe80YCLWd60JFoCJASv16BeFEV_OQ_CotQYtLSz3DitD3cBt2-kzEak6DodY34WB3LqjiIalvQzHFFWh/s1600/Blog_myofunctional.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFI84a7EaJuWfZo1YEwp-wvunIM2d5nZsYrMR4KQn0gwzcxFSdslB7cScslFFkLe80YCLWd60JFoCJASv16BeFEV_OQ_CotQYtLSz3DitD3cBt2-kzEak6DodY34WB3LqjiIalvQzHFFWh/s200/Blog_myofunctional.jpg" width="200" /></a></div>
<span style="font-family: Arial, Helvetica, sans-serif;">For this Blog I thought I would recap the 5 most popular Blogs I have published so far and it is interesting to note that they are all related to early #orthodontic treatment. Although some of these involve the same topic I will rank them in order of the most viewed individual Blogs. Note the text in a different colour is a link to the original Blog or document so just click on it if you wish to know more.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">1) The most read and searched Blog and also one of the more recent was <a href="http://newwaveorthodontics.blogspot.com.au/2015/09/maxillary-expansion-unexpected-benefits.html" target="_blank">'Maxillary Expansion - Unexpected Benefits?'</a> in September this year. This Blog has interest for readers who are clinicians as well as the general public discussing #expansion and its possible effect upon bed-wetting, sleep #apnea and middle ear problems. Expansion is a common procedure in orthodontics but there is limited quality research on these specific areas. It is also an emerging topic with a lot of mis-information accessible on search-engines and deserves more well-designed research in the future.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">2) On a similarly related topic was this Blog back in January 2015 titled <a href="http://newwaveorthodontics.blogspot.com.au/2015/01/do-orthodontic-extractions-cause-sleep.html" target="_blank">'Do Orthodontic Extractions Cause Sleep Apnea?'</a>. Again it is a controversial and emerging subject with a lot of mis-information which is easy to disseminate when there is minimal research. I am glad these two topics have received such an enthusiastic response.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">3 - 5) The next three topics all related to #Myofunctional appliances. In order these Blogs were <a href="http://newwaveorthodontics.blogspot.com.au/2015/04/more-on-myofunctionals-2-clinical-trials.html" target="_blank">'More on Myofunctionals - 2 Clinical Trials'</a> followed by the first of the Blogs on this topic, <a href="http://newwaveorthodontics.blogspot.com.au/2014/11/myofunctional-appliances-whats-evidence.html" target="_blank">'Myofunctional Appliances - What's the Evidence?'</a>. The third and most recent of the Blogs on this topic was also the most recent Blog prior to this and reported the <a href="http://newwaveorthodontics.blogspot.com.au/2015/10/results-of-rct-of-prefabricated.html" target="_blank">'Results of a RCT of a Prefabricated Functional Appliance'</a>. This is an area dominated on search engines by companies and clinicians extolling the virtues of these appliances and treatment approach. The higher levels of evidence come from clinical trials which are discussed in these Blogs and although these trials are not ideal they currently are the best level of evidence we have and come to a similar conclusion. Although they find statistical differences, these differences were quite small and indicated that these appliances were less effective than more conventional treatments for bite correction. Despite being in an evidence-based era where we would like to see well-conducted clinical trials upon which to base our treatments, there is limited quality research and both clinicians and the general public need to be wary of the claims being made until well designed research is available.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMoOxTPbjiYdnTT9TFZH6Os6t66AhnKcC1DAVzRfuTgyJ3TYTtzb-UXDu1Nngj4VMUzr8892_pk9sinxKt0VJ9R1kR2GL08m1malKIy41ko2yerHwZZZr-G4XBNgA1OJU_d08thyW13Dzb/s1600/Blog_orthodontics.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="135" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjMoOxTPbjiYdnTT9TFZH6Os6t66AhnKcC1DAVzRfuTgyJ3TYTtzb-UXDu1Nngj4VMUzr8892_pk9sinxKt0VJ9R1kR2GL08m1malKIy41ko2yerHwZZZr-G4XBNgA1OJU_d08thyW13Dzb/s200/Blog_orthodontics.jpg" width="200" /></span></a><span style="font-family: Arial, Helvetica, sans-serif;">I would like to thank you the reader for your interest as my goal throughout is to provide quality information for clinicians and the general public on the more controversial topics in orthodontics. I would also like to point out that I have no financial interest in any appliance or technique I discuss in these Blogs so when gathering information, consider whether the source of information is potentially biased and associated with that particular appliance or technique.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br />Remember any of the Blogs can be found at</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><a href="http://newwaveorthodontics.blogspot.com.au/" style="font-family: Arial, Helvetica, sans-serif;">http://newwaveorthodontics.blogspot.com.au/</a><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">and scrolling down and older ones can be accessed at the bottom of the page by clicking 'older posts'. </span><span style="font-family: Arial, Helvetica, sans-serif;">Wishing all a happy, safe & prosperous 2016.</span><br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 18.4799995422363px; text-decoration: none;" target="_blank">Dr Peter</a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 18.4799995422363px;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 18.4799995422363px; text-decoration: none;" target="_blank">Newwave Orthodontics</a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 18.4799995422363px;"> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" style="color: #818181; text-decoration: none;" target="_blank">Evidence-Based Clinical Orthodontics</a>'.</span></div>
Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-5316922767044665062015-10-19T17:36:00.002-07:002016-08-02T20:30:27.523-07:00RESULTS OF A RCT OF A PREFABRICATED FUNCTIONAL APPLIANCE - MYOBRACE<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: "arial" , "helvetica" , sans-serif;">One of the most popular topics in my series of Blogs has been on prefabricated #Myofunctional appliances and so I thought I would share the results of <a href="http://wfo15.kenes.com/wfo15/CM.NET.WebUI/CM.NET.WEBUI.scpr/SCPRfunctiondetail.aspx?confID=05000000-0000-0000-0000-000000000106&sesID=05000000-0000-0000-0000-000000024367&absID=07000000-0000-0000-0000-000000094681" target="_blank">this randomized clinical trial</a> from Sweden which was presented at the recent 8th International Orthodontic Congress in London. The complete abstract is below and follows on from their paper reported at the 7th IOC in Sydney in 2010 which <a href="http://newwaveorthodontics.blogspot.com.au/2015/04/more-on-myofunctionals-2-clinical-trials.html" target="_blank">I reported here</a>.</span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The conclusions reinforce that the overjet/protrusion correction obtained with the prefabricated Myobrace was dental/tipping of teeth while the custom made #Activator appliance achieved a better molar correction, however compliance with both appliances was poor. This will affect the clinical choice of an appliance as in cases where simple tipping may be suitable then the cheaper prefabricated appliance may be appropriate. However if more molar bite correction is required then the custom-made appliance would be more suited.... as long as they wear it. The percentage of subjects in this study having unsuccessful treatment was very high at 70% with the Myobrace appliance and ~53% with the Activator which the authors attributed mainly to a lack of compliance. The patient and the family should therefore be involved in the appliance choice or alternatively appliances that do not require as much cooperation can be used (the subject of a future Blog). These authors are to be congratulated on a job well done in conducting this trial.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b><u><span style="color: blue;">Update: </span></u></b>The full paper is now available in the <a href="http://ejo.oxfordjournals.org/content/early/2015/11/04/ejo.cjv080" target="_blank">European Journal of Orthodontics</a>.</span></div>
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<b><span style="font-family: "arial" , sans-serif;">Authors</span></b><span style="font-family: "arial" , sans-serif;"><o:p></o:p></span></div>
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<u><span style="font-family: "arial" , sans-serif;">E. Cirgic</span></u><span style="font-family: "arial" , sans-serif;">, K.
Hansen, H. Kjellberg.<o:p></o:p></span></div>
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<b><span style="font-family: "arial" , sans-serif;">Abstract:</span></b><span style="font-family: "arial" , sans-serif;"><o:p></o:p></span></div>
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<i><span style="font-family: "arial" , sans-serif;">TREATMENT EFFICACY OF PREFABRICATED FUNCTIONAL APPLIANCES AND
ANDRESEN ACTIVATORS IN CLASS II, DIVISION1 CASES: A RANDOMIZED CLINICAL TRIAL</span></i><span style="font-family: "arial" , sans-serif;"><o:p></o:p></span></div>
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<b><span style="font-family: "arial" , sans-serif;">Aim:</span></b><span style="font-family: "arial" , sans-serif;"> The
purpose of this study was to compare the clinical effectiveness in reducing large
overjet between a prefabricated functional appliance (PFA) and a slightly
modified Andresen activator (AA).<o:p></o:p></span></div>
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<b><span style="font-family: "arial" , sans-serif;">Methods:</span></b><span style="font-family: "arial" , sans-serif;"> A
multicentre, prospective and randomized clinical trial was conducted in 12
general dental practices and an ethical committee approved the study. The
sample consisted of 97 subjects (44 girls, 53 boys) mean age 10.3 years with
a Class II, division 1 malocclusion and an overjet ≥ 6 mm. The study was
designed as intention to treat and the patients were randomly selected to
treatment with either a PFA or a AA. The PFA and AA group consisted of 57
subjects (28 girls, 29 boys) and 40 subjects (16 girls, 24 boys)
respectively. Overjet, overbite, lip seal and sagittal relation were recorded
before and at 3, 6 and 12 months after start of treatment. The endpoint of
treatment was set to overjet ≤ 3mm and after this a 6 months retention period
followed.<o:p></o:p></span></div>
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<b><span style="font-family: "arial" , sans-serif;">Results:</span></b><span style="font-family: "arial" , sans-serif;"> No
significant difference was found in overjet, overbite and lip seal between
the two groups. Significant difference was found in sagittal molar correction
between the two groups. The treatment of 40 patients with PFA and 21 with AA
were considered unsuccessful mainly due to poor compliance.<o:p></o:p></span></div>
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<b><span style="font-family: "arial" , sans-serif;">Conclusions: </span></b><span style="font-family: "arial" , sans-serif;">Prefabricated
functional appliances are as effective as Andresen activators in correcting
overjet, overbite and lip seal. Andresen activators seem to be more effective
in sagittal molar correction than PFA. The success rate in treatment with
both appliances is however, low.<o:p></o:p></span></div>
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.2px; line-height: 16.8px; text-decoration: none;" target="_blank">Dr Peter</a><span style="background-color: white; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 16.8px;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.2px; line-height: 16.8px; text-decoration: none;" target="_blank">Newwave Orthodontics</a><span style="background-color: white; font-family: "arial" , "helvetica" , sans-serif; font-size: 13.2px; line-height: 16.8px;"> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" style="color: #818181; text-decoration: none;" target="_blank">Evidence-Based Clinical Orthodontics</a>'.</span><br />
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-11577278301259833982015-09-01T15:06:00.000-07:002015-09-01T15:06:42.500-07:00MAXILLARY EXPANSION - UNEXPECTED BENEFITS?<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjasnUFfXQITLu-0r3oM6boWgvxkqN6nQ8RztChmV5DEBmQh2ZJCP6l3FIaG4tnJgPSqZEUAEQmPbPE8y3q9Gbdz_VfD4UKa5no69isq1Wij4BcrcfhpQvCMzhNzBCFFJ8jPe-oH7HL6uAp/s1600/bed-wetting.jpeg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="120" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjasnUFfXQITLu-0r3oM6boWgvxkqN6nQ8RztChmV5DEBmQh2ZJCP6l3FIaG4tnJgPSqZEUAEQmPbPE8y3q9Gbdz_VfD4UKa5no69isq1Wij4BcrcfhpQvCMzhNzBCFFJ8jPe-oH7HL6uAp/s200/bed-wetting.jpeg" width="200" /></a></div>
<span style="font-family: Arial, Helvetica, sans-serif;">Maxillary expansion is a relatively common procedure in orthodontic treatment for bite correction and I have Blogged previously about it for the <a href="http://newwaveorthodontics.blogspot.com.au/2014/12/expansion-for-cross-bites.html" target="_blank">correction of crossbite</a> as well as its use in <a href="http://newwaveorthodontics.blogspot.com.au/2014/10/can-expansion-prevent-extractions.html" target="_blank">creating space</a>. However, expansion has also been showing some unexpected benefits for some patients in other areas which I will discuss in this Blog.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Expansion of the upper jaw is most effective in pre-pubertal children when the midline suture is still responsive and the surrounding bones are more malleable. As the maxilla (upper jaw) forms the floor of the nasal airway and supports the soft tissues of the nose, this expansion has been suggested to improve a constricted or congested airway. Much of this was anecdotal as improvements can occur coincidentally or with time and not necessarily be related to the procedure. This is why research in the form of clinical trials is important to try to reduce the biases inherent in simply observing something. However there is a growing body of evidence of the potential beneficial effects of maxillary expansion beyond the correction of dental crossbites.</span><br />
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<span style="color: purple; font-family: Arial, Helvetica, sans-serif;"><b>Expansion and Nocturnal Enuresis/Bed-wetting:</b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">In the 1990's some <a href="http://www.angle.org/doi/abs/10.1043/0003-3219%281990%29060%3C0229%3ARMEITT%3E2.0.CO%3B2?=" target="_blank">research</a> suggested that <a href="http://www.angle.org/doi/abs/10.1043/0003-3219%281998%29068%3C0225%3AOMEAIE%3E2.3.CO%3B2?=" target="_blank">expansion</a> of the upper jaw may help reduce nocturnal enuresis or bed-wetting in children. More recent studies agreed with these findings showing <a href="http://www.angle.org/doi/abs/10.1043/0003-3219%282003%29073%3C0532%3AEORMEO%3E2.0.CO%3B2?=" target="_blank">significant reductions (~75%)</a> in the number of nights of bed-wetting following expansion with <a href="http://www.angle.org/doi/abs/10.2319/031014-172.1?=" target="_blank">~30% were completely dry</a> at night after expansion. This was even in the absence of a pre-existing crossbite. Suggested reasons for this improvement relate to an indirect effect on the pituitary gland or </span><span style="font-family: Arial, Helvetica, sans-serif;">an improvement in the airway with expansion which may help with</span><span style="font-family: Arial, Helvetica, sans-serif;"> a possible association between enuresis and sleep disordered breathing in children.</span><br />
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<span style="color: purple; font-family: Arial, Helvetica, sans-serif;"><b>Expansion, Congestion, Sleep Apnoea:</b></span><br />
<span style="background-color: white;"><span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://dx.doi.org/10.2319/031014-172.1" target="_blank">One of the above papers</a> also found that nasal airflow increased while nasal resistance to airflow decreased. Earlier <a href="http://deepblue.lib.umich.edu/bitstream/handle/2027.42/26523/0000062.pdf?sequence=1&isAllowed=y" target="_blank">research by Peter Vig</a> in the 1980's found that rapid maxillary expansion resulted in a significant reduction in nasal resistance but there was considerable variation and so the outcome was not predictable. <a href="http://www.ajodo.org/article/S0889-5406(08)00556-8/abstract" target="_blank">Other research</a> has shown this reduction remained a year later. <a href="http://www.ncbi.nlm.nih.gov/pubmed/2472491" target="_blank">Another paper</a> found those with the highest initial nasal resistance tended to obtain the greatest benefit from expansion with the greatest reduction in nasal resistance.</span></span><br />
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<span style="background-color: white;"><span style="font-family: Arial, Helvetica, sans-serif;">Maxillary expansion has also been suggested to improve obstructive sleep apnoea or apnea in children (</span></span><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;">where the child stops breathing several times per hour of sleep)</span><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;">. I have discussed </span><a href="http://newwaveorthodontics.blogspot.com.au/2015/01/do-orthodontic-extractions-cause-sleep.html" style="background-color: white; font-family: Arial, Helvetica, sans-serif;" target="_blank">extractions and sleep apnoea</a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> previously</span><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;">. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22455530" target="_blank">Studies</a> have found expansion can result in a <a href="http://www.ncbi.nlm.nih.gov/pubmed/15283012" target="_blank">significant reduction</a> in the numbers of episodes of apnea in children including those with <a href="http://www.ncbi.nlm.nih.gov/pubmed/17239661" target="_blank">enlarged tonsils and adenoids</a>. Although the </span><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;">response is unpredictable the </span><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;">results are promising enough to warrant more comprehensive clinical trials and to be considered as a treatment strategy especially when there are other reasons to consider maxillary expansion.</span><br />
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheDwND9vzOEVOZhHw_DtS2VwZI-CnpsZau4sacUaFseMgSfvBmcTkntFoeZsxE6dRE3SJXhuus-o1k5YlxXXPsdZcDucuCviG-jTCzspruv6M298w93Km8mY61mxnnJWzc3LxqyWr91X-g/s1600/ear-horn.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="192" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheDwND9vzOEVOZhHw_DtS2VwZI-CnpsZau4sacUaFseMgSfvBmcTkntFoeZsxE6dRE3SJXhuus-o1k5YlxXXPsdZcDucuCviG-jTCzspruv6M298w93Km8mY61mxnnJWzc3LxqyWr91X-g/s200/ear-horn.jpg" width="200" /></a><span style="background-color: cyan; font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="color: purple; font-family: Arial, Helvetica, sans-serif;"><b>Expansion and the Middle Ear:</b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">In studies on <a href="http://www.ncbi.nlm.nih.gov/pubmed/18416625" target="_blank">patients with narrow arches</a> and conductive hearing loss it has been found that rapid and <a href="http://www.ncbi.nlm.nih.gov/pubmed/18538248" target="_blank">semi-rapid</a> expansion of the maxilla resulted in an <a href="http://www.centrodeotorrino.med.br/media/doc/92cf5b45ebcce8266dafd52052e29c29.pdf" target="_blank">improvement in hearing</a> and eustachian tube function and these improvements held up for 3/4 of the subjects <a href="http://www.ncbi.nlm.nih.gov/pubmed/14719731" target="_blank">up to 2 years later</a>. However these are children with narrow jaws so the same may or may not hold for those with normal or wide arches.</span><br />
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<span style="color: purple; font-family: Arial, Helvetica, sans-serif;"><b>Summary</b></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;">So it seems that maxillary expansion may have benefits beyond correcting crossbites and creating some space. However it must be kept in mind these studies are not definitive and the outcomes are not guaranteed so more research in the form of randomised clinical trials is indicated. For this reason expansion may be suggested when it is indicated for other reasons or in consultation between your medical practitioner/sleep physician/Otolaryngologist (ENT) and your orthodontist.</span><br />
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I would like to thank Dr James Noble (Orthodontist - Toronto) for his feedback on this Blog topic.<br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 16.7999992370605px; text-decoration: none;" target="_blank">Dr Peter</a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 16.7999992370605px;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 16.7999992370605px; text-decoration: none;" target="_blank">Newwave Orthodontics</a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 16.7999992370605px;"> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" style="color: #818181; text-decoration: none;" target="_blank">Evidence-Based Clinical Orthodontics</a>'.</span></div>
Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-28037237291382768772015-07-01T00:52:00.002-07:002015-08-20T06:16:00.241-07:00VIBRATION & ACCELERATED ORTHODONTICS - CLAIMS VERSUS EVIDENCE<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: inherit;">Claims of faster treatment with 'special' quick or fast braces or appliances such as AcceleDent, OrthoPulse and others are appearing more and more in the market place and on Google. The companies hope their product can shorten treatment and heavily advertise so - but what is the evidence?</span><br />
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<span style="font-family: inherit;">When you are paying up to $1000 or even more for something you want to be sure or pretty sure it works... or not care about the $1000! Some clinicians and patients use the special brace or appliance and feel their treatment went faster and extol the virtues of the appliance while others do not see a difference, shrug their shoulders and move on. </span><span style="font-family: inherit;">When we are told something is better/faster we look for that difference - some remember the ones that worked (the Believers) while others remember the ones that didn't (the Naysayers) and so we now have two camps, both with a biased perspective! This happened with self-ligating brackets where initially it was felt by some that they shortened treatment (and appeared in the media saying so) but later research revealed that in fact they were not (see my previous Blog on </span><a href="http://newwaveorthodontics.blogspot.com.au/2014/11/fast-braces-do-they-exist.html" style="font-family: inherit;" target="_blank">Braces claiming to be Fast</a><span style="font-family: inherit;">)!</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1AXl7DCdtbNnbEc1VFmCGqRzYMp-Qh6UYYe1MyYCulo7ve8YcoCox1NM60xY65i5J8MVwzc7_KnwhrTZe0ibf1l4hT8YZtnYOaK97qZrGYxU2ybkpoqFhMkBhQpbXFoZoygv9dT9Q-Czh/s1600/davidgoliath.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: inherit;"><img border="0" height="131" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg1AXl7DCdtbNnbEc1VFmCGqRzYMp-Qh6UYYe1MyYCulo7ve8YcoCox1NM60xY65i5J8MVwzc7_KnwhrTZe0ibf1l4hT8YZtnYOaK97qZrGYxU2ybkpoqFhMkBhQpbXFoZoygv9dT9Q-Czh/s1600/davidgoliath.jpg" width="200" /></span></a><span style="font-family: inherit;">Currently some state that you can use #Invisalign clear aligners every week instead of every two weeks (as the manufacturers currently recommend) when using #vibration or other appliances. However many patients get away with weekly wear without these appliances anyway while others won't. There are <a href="http://www.slideshare.net/EdwardHAngle/the-effect-of-vibration-on-the-rate-of-leveling-and-alignment" target="_blank">current studies</a> that suggest vibration <a href="http://www.semortho.com/article/S1073-8746(15)00036-5/abstract" target="_blank">accelerates tooth movement</a> with braces while a better designed <a href="http://www.ncbi.nlm.nih.gov/pubmed/23304970" target="_blank">prospective trial</a> finds <a href="http://www.ncbi.nlm.nih.gov/pubmed/?term=woodhouse+acceledent" target="_blank">no difference</a>. I am currently running a randomized clinical trial on the vibration appliance, AcceleDent and the results of this will be available for publication later this year (2015) to further examine any effect of vibration during initial alignment and space closure so this will be discussed in a future Blog. Although the idea of vibration holds some merit, the evidence supporting it is currently of a lower quality while the higher level evidence from a prospective randomized trial finds no difference. More research is obviously required to clarify the debate and will be forthcoming over the next couple of years but it is the quality of the evidence that is important to answering this question.</span><br />
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<i style="background-color: white; font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; line-height: 18.4799995422363px;"><a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="color: #818181; text-decoration: none;" target="_blank">Dr Peter</a> Miles is the orthodontist at <a href="http://www.newwaveorthodontics.com.au/" style="color: #818181; text-decoration: none;" target="_blank">Newwave Orthodontics</a> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" style="color: #818181; text-decoration: none;" target="_blank">Evidence-Based Clinical Orthodontics</a>'. </i><span style="font-family: Arial, Helvetica, sans-serif;"><i>Importantly, he has no financial interest in any products discussed in these Blogs.</i></span><br />
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com1tag:blogger.com,1999:blog-3429483328496183956.post-87046474874479654332015-04-20T18:40:00.002-07:002015-08-04T20:16:01.692-07:00MORE ON MYOFUNCTIONALS - 2 CLINICAL TRIALS<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6rD9FC9eJtpdeA60SsQL7G18QXpcQ_eolIK-K_1DtqEEa2-Q0bF3YItbOooiDiEnjBVFdgEe7qU8wgYllLiM-LFVCFUeoudhnLQ09cikasbCVMomjjqCmiv1ILXCqh70BmFgHkI4vJwRe/s1600/Myofunctional2.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="154" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6rD9FC9eJtpdeA60SsQL7G18QXpcQ_eolIK-K_1DtqEEa2-Q0bF3YItbOooiDiEnjBVFdgEe7qU8wgYllLiM-LFVCFUeoudhnLQ09cikasbCVMomjjqCmiv1ILXCqh70BmFgHkI4vJwRe/s1600/Myofunctional2.jpg" width="200" /></a></div>
<span style="font-family: Arial, Helvetica, sans-serif;">Some manufacturers of myofunctional appliances claim that that they achieve better results by treating at a very young age (~5-8 years of age) but what is the evidence? I have <a href="http://newwaveorthodontics.blogspot.com.au/2014/11/myofunctional-appliances-whats-evidence.html" target="_blank">Blogged on this topic previously</a> but more recently I came across two unpublished randomised clinical trials (RCT's - which are considered the more robust way of testing a treatment) where they compared myofunctional appliances with conventional functional appliances - so what did they find? </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The first was presented at the Eu</span><span style="font-family: Arial, Helvetica, sans-serif;">ropean Orthodontic Congress in </span><span style="font-family: Arial, Helvetica, sans-serif; line-height: 18.3999996185303px;">Istanbul- Turkey </span><span style="font-family: Arial, Helvetica, sans-serif;">(Abstract book, scientific poster :361) and was a follow-on from their previous study evaluating comfort of myofunctional appliances where they found </span><span style="font-family: Arial, Helvetica, sans-serif;">the Activator caused less discomfort </span><span style="font-family: Arial, Helvetica, sans-serif;">and was more acceptable</span><span style="font-family: Arial, Helvetica, sans-serif;"> than the T4K™ myofunctional appliance </span><span style="font-family: Arial, Helvetica, sans-serif;"> (</span><span style="font-family: Arial, Helvetica, sans-serif;">Eur</span><span style="font-family: Arial, Helvetica, sans-serif;"> J </span><span style="font-family: Arial, Helvetica, sans-serif;">Paediatr</span><span style="font-family: Arial, Helvetica, sans-serif;"> Dent. 2012;13:219-24)</span><span style="font-family: Arial, Helvetica, sans-serif;">. The follow up study evaluated the effectiveness of the appliances and the abstract (<a href="http://www.researchgate.net/publication/267755513_SOFT_AND_HARD_TISSUE_CHANGES_FOLLOWING_TREATMENT_OF_CLASS_II_DIVISION_1_WITH_ACTIVATOR_VERSUS_TRAINER" target="_blank">found here</a>) presented the results of the 60 patients treated over the 14 months of the study. </span><span style="font-family: Arial, Helvetica, sans-serif;">The authors found that the Activator group showed better skeletal improvement than the myofunctional T4K® group. They also found that t</span><span style="font-family: Arial, Helvetica, sans-serif;">he facial convexity improved significantly with the Activator
and to a lesser extent with the T4K® while the s</span><span style="font-family: Arial, Helvetica, sans-serif;">oft tissue profile was improved only by the Activator. They concluded that t</span><span style="font-family: Arial, Helvetica, sans-serif;">he Activator is more effective than the T4K®
in treating patients with protrusive upper teeth (C</span><span style="font-family: Arial, Helvetica, sans-serif;">lass II division 1</span><span style="font-family: Arial, Helvetica, sans-serif;">).</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The second paper was presented at the </span><span style="font-family: Arial, Helvetica, sans-serif;">World Federation of Orthodontists meeting in Sydney (<a href="https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=7&ved=0CD4QFjAG&url=http%3A%2F%2Fwww.researchgate.net%2Fprofile%2FNarayan_Gandedkar%2Fpublication%2F251232607_A_Prospective_CBCT_Study_on_Opening_of_Circumaxillary_Sutures_by_Alternate_Rapid_Maxillary_Expansions_and_Constrictions%2Flinks%2F00b7d51ef5f74f3f7e000000.pdf&ei=IJc1VZKKFsS9mgXFhoGoCQ&usg=AFQjCNEpKqRlxSd2n9KSz0z6hzMBpoOXSQ&sig2=79N9UlHwhbXsgfsWo_Ax2A&bvm=bv.91071109,d.dGY&cad=rja" target="_blank">abstract #0335 of this PDF file</a>) and was a m</span><span style="font-family: Arial, Helvetica, sans-serif;">ulti-centre RCT of 74 subjects comparing another myofunctional appliance with an Activator. Although they found that the p</span><span style="font-family: Arial, Helvetica, sans-serif;">refabricated myofunctional appliances were as effective
as Activators in correcting overjet/protrusion, they were </span><span style="font-family: Arial, Helvetica, sans-serif;">less effective in correction of the Class II molar
relationship (bite on the back teeth). This implies that the main factor in correction of the overjet/protrusion was only due to tipping of the front teeth as discussed in the previous Blog on myofunctionals (study by Usumez. Angle Orthod 2004;74:605-60).</span><span style="font-family: Arial, Helvetica, sans-serif;"> However t</span><span style="font-family: Arial, Helvetica, sans-serif;">he advantage with the myofunctional appliance is that no impressions are needed
and the cost is less than that of the Activator.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><br />So it would seem that myofunctional appliances have 'some' effect but were less effective than the custom made Activator appliance, particularly in molar/bite correction and skeletal/growth change. This is consistent with the findings of studies discussed in my <a href="http://newwaveorthodontics.blogspot.com.au/2014/11/myofunctional-appliances-whats-evidence.html">previous Blog on Myofunctional appliances</a>.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-FboRnE7n6eWEV7t3YNOZQWul-BrbSkNLA_VKYssmj-87T3gNqrRvnoVFPHxksIwDf7I8LUS7aw0Ay2PxPtcHrdxKFUoWti-M6-iOnG5uKVKsZyZTylF61EI_lO8cvCOFb-pMVqMzaeoL/s1600/myofunctional_effectiveness.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="150" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-FboRnE7n6eWEV7t3YNOZQWul-BrbSkNLA_VKYssmj-87T3gNqrRvnoVFPHxksIwDf7I8LUS7aw0Ay2PxPtcHrdxKFUoWti-M6-iOnG5uKVKsZyZTylF61EI_lO8cvCOFb-pMVqMzaeoL/s1600/myofunctional_effectiveness.jpg" width="200" /></a><span style="font-family: Arial, Helvetica, sans-serif;">If we are then considering what is the most effective appliance then the custom-made appliances win out but a case could be made where in remote communities with limited or no access to laboratories for impressions or making a custom-made appliance, then perhaps a prefabricated myofunctional appliance can offer some improvement. Both of the main authors of these RCT's are currently PhD candidates and therefore extremely busy people but I also believe they are in the process of writing these papers up for publication which will allow a more thorough read of the trial design and findings.</span><br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="font-family: Arial, Helvetica, sans-serif;" target="_blank">Dr Peter</a><span style="font-family: Arial, Helvetica, sans-serif;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="font-family: Arial, Helvetica, sans-serif;" target="_blank">Newwave Orthodontics</a><span style="font-family: Arial, Helvetica, sans-serif;"> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" target="_blank">Evidence-Based Clinical Orthodontics</a>'. </span><span style="font-family: Arial, Helvetica, sans-serif;">Importantly, he has no financial interest in any products discussed in these Blogs.</span></div>
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com3tag:blogger.com,1999:blog-3429483328496183956.post-52869868635484423092015-03-12T18:00:00.000-07:002015-03-17T05:19:57.812-07:00WHAT AGE IS BEST FOR ORTHODONTIC TREATMENT TO ACHIEVE THE BEST JAW GROWTH?<div dir="ltr" style="text-align: left;" trbidi="on">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_FUWSwZqYKGZTrYocwTDVLXDghfhPZRDbMK6e_2zXWR2UOmVCMGSzSpo_40qxGTm9CF_7G6AmmgUq9G9GyFriQ7Fmc8XR88n7p6zFydujD_KJJCTeZsaEnUkyA_RqnxOXI9nLHubOjsTg/s1600/Bart-Simpson-01-icon.png" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img alt="myofunctional appliances" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_FUWSwZqYKGZTrYocwTDVLXDghfhPZRDbMK6e_2zXWR2UOmVCMGSzSpo_40qxGTm9CF_7G6AmmgUq9G9GyFriQ7Fmc8XR88n7p6zFydujD_KJJCTeZsaEnUkyA_RqnxOXI9nLHubOjsTg/s1600/Bart-Simpson-01-icon.png" height="200" title="timing of orthodontic treatment" width="200" /></a><span style="font-family: inherit;">Many orthodontic associations around the world recommend an orthodontic exam at age 7 but does this mean your child needs treatment then? There is much debate over what is the best time to treat protrusive upper teeth and/or a retrusive lower jaw (Class II bite like Bart)</span><span style="font-family: inherit;">. Some </span>suggest<span style="font-family: inherit;"> waiting until adolescence (when all adult </span>teeth<span style="font-family: inherit;"> have erupted), others earlier at age 9-10 with functional </span>appliances<span style="font-family: inherit;"> such as Twin Blocks, Activators or Bionators, while </span>others<span style="font-family: inherit;"> suggest even as early as age 5-6 with myofunctional appliances (covered in a <a href="http://newwaveorthodontics.blogspot.com.au/2014/11/myofunctional-appliances-whats-evidence.html" target="_blank">previous Blog</a>)!</span><br />
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<span style="font-family: inherit;">The evidence supporting very early treatment with myofunctional appliances at age 5-10 is of low quality and that research </span>demonstrates only small clinical changes of ~2mm which for most is not a significant change. Much higher level evidence from well-designed <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003452.pub3/abstract;jsessionid=A01ED1FF31FAFAACC8EBC85BF8A81BA9.f01t02" target="_blank">randomised clinical trials</a> have demonstrated that you can treat much worse bites with protrusions of 7mm and more at ages 9-10 but also just as effectively during adolescence when all the adult teeth have erupted (~ages 13-14). The only advantages of treating earlier are in the form of improved self-esteem earlier than if treated later, and a modest reduction in trauma discussed in a <a href="http://newwaveorthodontics.blogspot.com.au/2014/10/are-protrusive-teeth-more-prone-to.html" target="_blank">previous Blog</a>. Self-esteem can be an important issue for some and a valid reason to consider early treatment.<br />
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Some have suggested that you can predict the timing of treatment based upon x-ray markers of growth such as hand-wrist x-rays or more recently using cephalometric radiographs of the skull and identifying the developmental stages of the cervical spine (neck bones), called the CVM method. <span style="font-family: inherit;">The CVM method was based upon work by Dr Don Lamparksi from the University of Pittsburgh where I trained and was later revised by othe<span style="background-color: white;">rs. The </span>timing of peak growth varies widely from 8½-11</span>½<span style="font-family: inherit;"> in girls and 10-14 in boys.
<a href="http://www.ajodo.org/article/S0889-5406(11)00118-1/abstract" target="_blank">Research</a> has demonstrated a </span><span style="font-family: inherit;"><a href="http://www.ajodo.org/article/S0889-5406(09)00514-9/abstract" target="_blank">low agreement</a> in identifying the stages of these spine markers and that it cannot predict the onset of peak
mandibular growth. You would also likely need multiple radiographs to determine
when you are actually approaching peak growth and by the time you see
it you are already at the peak or past it. But let’s say you do achieve the perfect timing for treatment with an appliance such as a <a href="http://www.ajodo.org/article/S0889-5406(09)00222-4/abstract" target="_blank">Herbst</a></span><span style="background-color: white; font-family: inherit;">.</span><span style="font-family: inherit;"><span style="background-color: white;"> </span>In this study evaluating patients treated with a Herbst </span>appliance<span style="font-family: inherit;"> the authors found that with </span><i style="font-family: inherit;">ideal</i><span style="font-family: inherit;"> timing compared with a historical control they found 1.9mm
advancement of the chin (Pogonion). Firstly a historical control from </span>over<span style="font-family: inherit;"> 50 years ago <a href="http://ejo.oxfordjournals.org/content/37/1/60" target="_blank">does not allow a valid comparison</a> as the amount and timing of peak growth has changed over the past 50 years. </span><span style="font-family: inherit;">We will also overlook the stability issue in that functional </span>appliance<span style="font-family: inherit;"> studies always show some early growth effect but that long term the growth slows so there is no difference between those children treated earlier and those treated in adolescence. So now let's compare it to a </span><a href="http://www.ajodo.org/article/S0889-5406(04)00329-4/abstract" style="font-family: inherit;" target="_blank">study using a Herbst in ‘non’-growing adults</a><span style="font-family: inherit;">. They still
found a 1.3mm advancement of the chin (Pogonion) so with ideal timing vs. non-growers
there is only a 0.6mm advantage! You then have to ask yourself 'Does 0.6mm matter' and most would accept that this is not a clinically meaningful change. Now back to
the issue of timing and efficiency - if the treatment time is a little shorter
(as growth helps you out a bit more) at the ideal time, then you <i>possibly</i> (and this is unclear) save 2-3 months in overall treatment time compared to treating much earlier or much later This then comes down to </span>whether<span style="font-family: inherit;"> you consider this potential time saving a big enough benefit to try to determine this most ideal time. However I would not consider it a critical issue.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiW0qnZYSKq3OuuQeDBopOY2Iq53PzMe5Rd9Q-SE3SwkoJp6l03kpWMl4DQ9AZLu3dPETGEX5gOv5lTCGbhbIhT4vUsec6E3UjmDpjEMyefa-PXOMdRkqI3gOjCzrXHNu8vuc4eopjpxdr/s1600/roger-ramjet.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img alt="functional appliances" border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiW0qnZYSKq3OuuQeDBopOY2Iq53PzMe5Rd9Q-SE3SwkoJp6l03kpWMl4DQ9AZLu3dPETGEX5gOv5lTCGbhbIhT4vUsec6E3UjmDpjEMyefa-PXOMdRkqI3gOjCzrXHNu8vuc4eopjpxdr/s1600/roger-ramjet.jpg" height="200" title="Class II bite treatment" width="200" /></a><br />
<span style="font-family: inherit;">So why age 7 for a screening exam? </span>Most do not need treatment at this age but it is a good age to identify the small number that would benefit form an early intervention such as early loss of baby teeth that result in space loss, or crossbites of front teeth. Others could be left until age 9-10 e.g. to preserve space to reduce crowding or identify those developing impacting maxillary canine teeth (much easier to intervene at age 9-10 then try to treat a fully impacted canine at age 14-15), while the majority can quite happily wait until all adult teeth have erupted in early adolescence. However your orthodontist does not want to miss the small number that could greatly benefit from such early interventions so if you are unsure then seek a consultation with your orthodontist who can then inform you of the most appropriate treatment time as well as the pros and cons of any options.<br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 18.4799995422363px; text-decoration: none;" target="_blank">Dr Peter</a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 18.4799995422363px;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="background-color: white; color: #818181; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 18.4799995422363px; text-decoration: none;" target="_blank">Newwave Orthodontics</a><span style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: 13.1999998092651px; line-height: 18.4799995422363px;"> in Caloundra, Australia, editor and author of the textbook Evidence-Based Clinical Orthodontics, and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA.</span><br />
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0Newwave Orthodontics-26.803256698627067 153.12251537637405-26.803478198627065 153.12220037637405 -26.803035198627068 153.12283037637405tag:blogger.com,1999:blog-3429483328496183956.post-36182002912283038502015-01-27T22:26:00.000-08:002016-06-02T19:26:43.511-07:00DO ORTHODONTIC EXTRACTIONS CAUSE SLEEP APNEA?<div dir="ltr" style="text-align: left;" trbidi="on">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6NXRnQos-ykOhDwQzfi5kdOJL-mawhnaA67z3gBADGmHz_mA46qO-u75_4affY0SA5pXlXewqxwRykt_Bgsj4nPaEDsFlPVkhGrfyL7-Fsv9DxuAZ9Waa6vQ7CkUgGUAxP409T5ocd0K1/s1600/extractions-and-sleep-apnea-or-apnoea.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6NXRnQos-ykOhDwQzfi5kdOJL-mawhnaA67z3gBADGmHz_mA46qO-u75_4affY0SA5pXlXewqxwRykt_Bgsj4nPaEDsFlPVkhGrfyL7-Fsv9DxuAZ9Waa6vQ7CkUgGUAxP409T5ocd0K1/s1600/extractions-and-sleep-apnea-or-apnoea.jpg" /></a></div>
Sleep apnea (or #apnoea) is a serious condition resulting in excessive daytime sleepiness which can affect concentration and potentially increase accidents. It also increases the risk of high blood pressure, stroke and heart disease. More recently some proponents of myofunctional appliances (see <a href="http://newwaveorthodontics.blogspot.com.au/2014/11/myofunctional-appliances-whats-evidence.html" target="_blank">previous Blog</a>) have suggested that extractions can cause sleep #apnea. They state that extractions must reduce the jaw size and therefore the tongue space which in turn, forces the tongue back thereby compromising the airway. This sounds possible in theory but what is the evidence? I'm glad you asked!<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLWaU5Oi7C0sTlh8qqNK4JbeIP-vOv6cFuyReZDQudavGfUnXxywx2WJp8pLvSAC3v6QuybvixUAxGliwvgP3rdyYkZSnsa1geO3yhK-dmmeNzMK4rhUAf5v04fGh6VLiJmBUXpJgTZGOx/s1600/Archwidth_with_extractions.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLWaU5Oi7C0sTlh8qqNK4JbeIP-vOv6cFuyReZDQudavGfUnXxywx2WJp8pLvSAC3v6QuybvixUAxGliwvgP3rdyYkZSnsa1geO3yhK-dmmeNzMK4rhUAf5v04fGh6VLiJmBUXpJgTZGOx/s1600/Archwidth_with_extractions.png" width="145" /></a>It has been claimed that extractions narrow the jaws. Arch dimensions depend upon the points from which you measure them. If you measure the distance between the upper molars before and after closing premolar/bicuspid #extraction spaces then the distance between them does get smaller so it seems the jaw has become narrower. However if you measure between the canine teeth, the measured <a href="http://www.ajodo.org/article/S0889-5406(13)00966-9/abstract" target="_blank">distance gets larger</a> - what the? This paradox is due to the shape of the jaw being an arch which is wider in the molar region and tapers becoming narrower toward the canine teeth. As extraction spaces are closed, the molars move forward (into the narrower part of the arch) while the canines move back (into the wider part) but the actual arch itself has not necessarily narrowed, it can even have widened depending upon the mechanics and archform used by the treating orthodontist. Depending upon the reason for extractions (e.g. crowding vs. protrusive teeth) the front teeth may or may not move back. For example, if the extraction space is merely used to alleviate crowding, then the arch may not have reduced in size at all. However if the front teeth have been retracted back (to reduce protrusion) then there is potentially less space for the tongue.<br />
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Studies looking at patients with protrusive upper and lower teeth requiring extraction of four teeth (two upper and two lower first bicuspids) have varied in their findings. There are a number of limitations to these studies as some use imaging systems which only evaluate in 2-dimensions (x-rays), the subjects are upright and not lying down as we do when asleep (when apnea occurs), and none assess the dynamic changes in the airway with function even if in 3D (e.g. CT) so they only offer a limited appraisal of the subject's airway. Keeping this in mind let's examine their findings. <a href="http://www.ncbi.nlm.nih.gov/pubmed/20677956" target="_blank">Two studies</a> in American and Arab subjects found <a href="http://www.ncbi.nlm.nih.gov/pubmed/22369618" target="_blank">no change</a> in the upper airway as did a <a href="http://onlinelibrary.wiley.com/doi/10.1111/ocr.12009/abstract;jsessionid=B9661CA37BF0E4B779D7EA475626D009.f01t03" target="_blank">third study</a>. However <a href="http://www.ncbi.nlm.nih.gov/pubmed/24963245" target="_blank">three other</a> studies in Oriental and Indian subjects <a href="http://www.ncbi.nlm.nih.gov/pubmed/21793712" target="_blank">did find </a>a reduction in the <a href="http://www.ncbi.nlm.nih.gov/pubmed/22462464" target="_blank">airway size</a>. So why the difference in findings? Apart from random chance, there could be racial differences in the response of the airway to movement of the teeth, or how people in these countries are treated. It has been <a href="http://www.sciencedirect.com/science/article/pii/S095461110300372X" target="_blank">postulated</a> that craniofacial factors make a larger contribution to the severity of sleep disordered breathing in Chinese than in Caucasians. In addition, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/21118911" target="_blank">7th study</a> in Turkish subjects examined trying to retract the teeth a lot (maximum anchorage) vs. not much or none (minimum anchorage) found there was an <u>increase</u> in the airway in the minimum anchorage cases while the maximum anchorage cases where the goal was to retract the front teeth as they were too protrusive did result in a reduction in the airway dimensions. One of the studies found that the reduction in airway seemed to mostly be related to any <a href="http://www.ncbi.nlm.nih.gov/pubmed/21793712" target="_blank">retraction of the lower front teeth</a> potentially making less space for the tongue. Protrusion of the front teeth is more common in subjects with an Oriental heritage than in those of European ethnicity and so the goal in Oriental subjects undergoing extraction treatment tends to be aimed at greater retraction of the front teeth.<br />
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So perhaps extractions where the goal is to retract the front teeth as much as possible may reduce the airway size in some patients. Most orthodontic patients in Western countries are treated without extractions (only ~15-20% in the USA and Australia for example) and an even smaller number of these are treated with four premolars and a minority with maximum anchorage. Blockage of the airway in apnea is not always at the base of the tongue and many are behind the soft palate or velopharynx. What we must also consider is that a reduction in the airway size on an x-ray does NOT mean that you will develop sleep apnea as the airway will still be sufficiently patent for most if not all. Conversel<span style="background-color: white;">y <a href="http://www.ncbi.nlm.nih.gov/pubmed/16494093" target="_blank">studies using plates</a> </span>have found that despite advancing the lower jaw and potentially increasing the airway, ~13% of subjects actually got worse! Research has also demonstrated that measures of the <a href="http://thorax.bmj.com/content/65/8/726.full.pdf+html" target="_blank">airway volume or area</a> could not predict who would respond to treatment. Sleep apnea is a complex condition with those highest at risk being middle-aged, over-weight males and the use of alcohol and sedatives can also increase the risk.<br />
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What do humans and bull-dogs have in common? We both can suffer from snoring and sleep apnea (well, about 3% of humans do)! Bull dogs are the result of selective breeding (believed to be mastiffs and pugs) resulting in an altered facial and airway form. One theory for humans is that to evolve the ability of speech, this required our jaws to be shorter, the tongue positioned further back and our larynx to descend. Speech was a major advantage and the backward and downward positioning of our faces was not a disadvantage for an animal (that's us humans!) that on average only lived to about 50 years of age until about 100 years ago. However now with many living into their 80's and beyond a backward positioned tongue due to evolution's 'selective breeding' may be placing a small number of us at risk for obstructive sleep apnea (#OSA). Based upon current research we cannot with certainty totally discount that some may be at more risk with extractions, but if there is a risk it would be a small percentage of the subjects that meet the criteria of maximum anchorage and other risk factors so it would be a very small risk indeed if it does exist at all. A recent review article in the <a href="http://www.aasmnet.org/jcsm/ViewAbstract.aspx?pid=30357" target="_blank">Journal of Clinical Sleep Medicine</a> compared patients having had four premolars/bicuspids removed with those having none out and found the prevalence of sleep apnea was not significantly different between groups and concluded that past orthodontic extraction treatment is not supported as a significant risk factor in the cause of obstructive sleep apnea.<br />
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</span> <a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="font-family: inherit;" target="_blank">Dr Peter</a><span style="font-family: inherit;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="font-family: inherit;" target="_blank">Newwave Orthodontics</a><span style="font-family: inherit;"> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland. He is a visiting lecturer at Seton Hill University in the USA as well as lectures internationally. Peter is one of the editors and authors of the orthodontic textbook, '</span><a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" style="font-family: inherit;" target="_blank">Evidence-Based Clinical Orthodontics</a><span style="font-family: inherit;">'.</span></div>
Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-78615850954565383422014-12-15T16:02:00.001-08:002014-12-30T15:59:30.345-08:00EXPANSION FOR CROSS-BITES<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial, Helvetica, sans-serif;">Posterior crossbites where the top back teeth bite inside the lower teeth are relatively common affecting up to ~16% of children with their baby or milk teeth. Crossbites seldom self-correct and so some form of expansion of the top jaw is usually required. We have various options ranging from partial braces with elastics to plates and fixed expanders but </span><span style="font-family: Arial, Helvetica, sans-serif;">what is the most effective way to correct a crossbite?</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">For a single tooth crossbite your #orthodontist may elect to use buttons and elastics but for multiple teeth they are more likely to choose a removable plate or a fixed #expander such as a quad-helix appliance or a rapid-maxillary expander (RME), also known as a rapid-palatal expander (RPE). </span><span style="font-family: Arial, Helvetica, sans-serif;">Plates can be successful but rely on compliance from the patient with ~20-30% not cooperating - which makes the orthodontists job a bit harder :-/ . </span><a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000979.pub2/abstract" style="font-family: Arial, Helvetica, sans-serif;" target="_blank">Research has demonstrated</a><span style="font-family: Arial, Helvetica, sans-serif;"> that the fixed type of expanders (quad-helix, <a href="http://youtu.be/1j3CHtC5ScE" target="_blank">RME/RPE</a>) remove this compliance issue as they are cemented in place and so tend to be more successful and offer slightly more expansion (~1mm).</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">A posterior #crossbite (circled in green on the right) can result in a slide of the lower jaw to one side on closing creating a bite asymmetry and midline discrepancy (purple lines). Expansion to correct the bite interference can correct some asymmetries (as in this example) while others will have a persistent asymmetry that may require future treatment. Treatment of asymmetries will be the topic of a future Blog. Expansion can also be used to create space as covered in a <a href="http://newwaveorthodontics.blogspot.com.au/2014/10/can-expansion-prevent-extractions.html" target="_blank">previous Blog</a>. So if you have a posterior crossbite, visit your orthodontist for them to assess the most appropriate appliance that best suits your needs.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" target="_blank">Dr Peter</a> Miles is the orthodontist at <a href="http://www.newwaveorthodontics.com.au/" target="_blank">Newwave Orthodontics</a> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland. He is a visiting lecturer at Seton Hill University in the USA as well as lectures internationally. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" target="_blank">Evidence-Based Clinical Orthodontics</a>'.</span></div>
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-10047293756427830942014-11-23T14:31:00.001-08:002015-08-04T20:15:48.619-07:00MYOFUNCTIONAL APPLIANCES - WHAT'S THE EVIDENCE?<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial, Helvetica, sans-serif;">Myofunctional therapy is treatment aimed at changing muscle (Myo = muscle) function and possibly influencing jaw growth and the position of the teeth. Myofunctional appliances have been around in various forms for many years. These can include lip shields and screens, eruption guidance appliances and the T4K™. Although claims are made that they alter muscle function resulting in improved facial growth, better alignment, and more stable results, what evidence is there to support these claims?</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">There are a number of studies examining the clinical effects of the eruption guidance appliance and the T4K™ and they provide clinical evidence as to the compliance and effect of these appliances.1-5 These appliances are available in a small range of sizes where one is selected to suit an individual rather than being custom made from an impression/scan. Possibly due to this generic fit, one study found 31% of patients did not wear the appliance.1 A randomised trial of the T4K™ vs. a custom made Activator appliance found the Activator caused less discomfort than the T4K™ and was more acceptable.6 All five studies showed that treatment at age 5-9 was quite long (13-36 months) and protrusion of the top teeth was reduced by only a small amount (1.5-2.5mm).1-5 A study of the T4K™ appliance showed it had no growth effect.3 Another study on the eruption guidance appliance followed patients over time and found the small 2mm improvement in crowding relapsed to the initial state which shows it is not stable.4 A 2mm improvement in bite depth was also unstable and relapsed leaving only 0.5mm of change.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSVTHHEIZyiuahHSdu3kLy7X5dTLtpgkArcJvEABFKH2hV-IlIZfU-F2E1Sd7yQrSbA-ASPzpEzQd_CeggxSQjiwuS_0OryixhxHxTdm8jHCSS2ecMkYl5RmVJQmMXTIoqdySY1PuGsk0k/s1600/FacialGrowth.png" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiSVTHHEIZyiuahHSdu3kLy7X5dTLtpgkArcJvEABFKH2hV-IlIZfU-F2E1Sd7yQrSbA-ASPzpEzQd_CeggxSQjiwuS_0OryixhxHxTdm8jHCSS2ecMkYl5RmVJQmMXTIoqdySY1PuGsk0k/s1600/FacialGrowth.png" /></a><span style="font-family: Arial, Helvetica, sans-serif;">A 2mm change is considered a minor improvement and could be treated once all adult teeth have erupted (~age 12-13) in one phase of treatment. This results in a reduced overall treatment time as well as potentially less cost than doing two or more phases of treatment. Clinical trials in the both the USA and the United Kingdom where patients were randomly assigned to early or late treatment have shown that when patients were treated early for much more severe protrusions (7mm rather than 2mm) they could be treated equally as well by delaying treatment until all the baby teeth had been lost.7,8 The result of treating later (~ age 12-13 years of age) was a shorter overall treatment and less cost. However a case can be made for early treatment to reduce protrusive teeth when the appearance or function is concerning the patient or for a small reduction in the risk of trauma to the front teeth (<a href="http://newwaveorthodontics.blogspot.com.au/2014/10/are-protrusive-teeth-more-prone-to.html" target="_blank">see my previous post on trauma</a>).</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">So if you are unsure about whether early treatment is required for your child, consult your orthodontist. Some problems such as crossbites and impacted teeth can be detected and treated more effectively if found early. Your orthodontist is an expert in growth and development and can best determine if early treatment or simply monitoring your child is indicated to achieve the most efficient and cost-effective treatment at the most appropriate time.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">References:</span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">1.<span class="Apple-tab-span" style="white-space: pre;"> </span>Keski-Nisula. American Journal of Orthodontics & Dentofacial Orthopedics 2008;133:254-60</span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Methenitou. Journal of Pedodontics 1990;14:219-30</span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">3.<span class="Apple-tab-span" style="white-space: pre;"> </span>Usumez. Angle Orthodontist 2004;74:605-60</span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">4.<span class="Apple-tab-span" style="white-space: pre;"> </span>Janson. American Journal of Orthodontics & Dentofacial Orthopedics 2007;131:717-28</span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">5.<span class="Apple-tab-span" style="white-space: pre;"> </span>Myrland et al. European Journal of Orthodontics <a href="http://ejo.oxfordjournals.org/content/37/2/128">2015;37:128-134</a></span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">6.<span class="Apple-tab-span" style="white-space: pre;"> </span>Idris. European Journal of Paediatric Dentistry 2012;13:219-24</span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">7.<span class="Apple-tab-span" style="white-space: pre;"> </span>Tulloch. American Journal of Orthodontics & Dentofacial Orthopedics 2004;125:657-67</span><br />
<span style="font-family: Arial, Helvetica, sans-serif; font-size: x-small;">8.<span class="Apple-tab-span" style="white-space: pre;"> </span>O’Brien. American Journal of Orthodontics & Dentofacial Orthopedics 2009;135:573-9</span><br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="font-family: Arial, Helvetica, sans-serif;" target="_blank">Dr Peter</a><span style="font-family: Arial, Helvetica, sans-serif;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="font-family: Arial, Helvetica, sans-serif;" target="_blank">Newwave Orthodontics</a><span style="font-family: Arial, Helvetica, sans-serif;"> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" target="_blank">Evidence-Based Clinical Orthodontics</a>'. Importantly, he has no financial interest in any products discussed in these Blogs.</span></div>
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com1tag:blogger.com,1999:blog-3429483328496183956.post-23253583528725396992014-11-05T13:45:00.000-08:002015-08-13T17:41:34.702-07:00QUICK OR FAST BRACES - DO THEY EXIST?<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="font-family: Arial, Helvetica, sans-serif;">Claims of faster treatment are easy to make and we would all like this but is it realistic? In the 1960's and 70's Begg braces/brackets were very popular and were thought to provide faster treatment as they allowed very rapid tipping and alignment. However this was at the price of less control over the root position which took more time to recover later and so they are seldom used nowadays. Other bracket designs that allow tipping have <a href="http://www.angle.org/doi/abs/10.2319/011707-24.1" target="_blank">been shown</a> to actually be slower than conventional brackets when closing extraction spaces.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">More recently self-ligating brackets such as the Damon bracket, Smart-Clip, In-Ovation, Quick and more were introduced with claims of faster treatment. This was marketed well and became quite popular but with little evidence to support the claims. Dr Miles conducted the <a href="http://www.ncbi.nlm.nih.gov/pubmed/16429868" target="_blank">first prospective clinical trial</a> and found there was actually no difference during initial alignment which was later confirmed by other researchers. The <a href="http://ejo.oxfordjournals.org/content/36/3/350" target="_blank">most recent evidence</a> suggests that despite the claims of faster treatment, the self-ligating brackets may actually be slower than conventional #braces by about 2 months! Braces claiming to be fast are use brackets and wires just like conventional systems and so would not be expected to be any quicker. They claim lower friction but this allows the greater tipping and lack of control seen in earlier systems that proved to be slower. Let's look at an analogy - when you build a house the frame goes up quickly but then seems to slow when the smaller jobs are taking place such as the painting, tiling, etc. - but you don't want to move into your new home without this done do you? The same with braces - the initial alignment of teeth can be quite rapid but these are the simple tipping movements and the roots have not been moved into their correct and more stable positions. Your bite may need correction with elastics or other techniques and this is also a slower movement. These are the ‘detailing’ stages of #orthodontics and are slower and less obvious but very important for the most aesthetic and stable result possible.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9gDudXMuRr9CnBhnWxSBQWPZOk0lq1grhDsr7jgpcOebvlVYjfC6cYwqiQqIVmL3O3357fzk1tHKlkn8OH2YzWD9NLuW1IG5mCOrKls_pRagnpeOYh_nLMxhhRfk6evT_SYNzB-AXINxF/s1600/fast_braces2.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: Arial, Helvetica, sans-serif;"><img border="0" height="110" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9gDudXMuRr9CnBhnWxSBQWPZOk0lq1grhDsr7jgpcOebvlVYjfC6cYwqiQqIVmL3O3357fzk1tHKlkn8OH2YzWD9NLuW1IG5mCOrKls_pRagnpeOYh_nLMxhhRfk6evT_SYNzB-AXINxF/s1600/fast_braces2.jpg" width="320" /></span></a><span style="font-family: Arial, Helvetica, sans-serif;">The skill of the practitioner in placing the brackets as accurately as possible and using the correct wires, mechanics and appointment intervals affect your treatment duration. However treatment time is also affected by patient cooperation (e.g. are you wearing your elastics as directed?) and biological variation – everyone is different and their teeth move at different rates and respond in varying amounts. The same wire and adjustments will have differing responses in different people and your orthodontist will adjust your treatment based upon what they observe. Even extremely precise methods of bracket positioning using computer-aided design and manufacture, or robotic wire-bending are prone to the same problems of variation in response. Orthodontists are aiming for the best outcome possible for you and this variation is why your #orthodontist cannot give precise times to the eternal question; "When am I getting my braces off?".</span><br />
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<a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" style="font-family: Arial, Helvetica, sans-serif;" target="_blank">Dr Peter</a><span style="font-family: Arial, Helvetica, sans-serif;"> Miles is the orthodontist at </span><a href="http://www.newwaveorthodontics.com.au/" style="font-family: Arial, Helvetica, sans-serif;" target="_blank">Newwave Orthodontics</a><span style="font-family: Arial, Helvetica, sans-serif;"> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA. Peter is one of the editors and authors of the orthodontic textbook, '<a href="http://www.amazon.com/Evidence-Based-Clinical-Orthodontics-Daniel-Rinchuse/dp/0867155647/" target="_blank">Evidence-Based Clinical Orthodontics</a>'. Importantly, he has no financial interest in any products mentioned in these Blogs.</span></div>
Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-14672294637462752342014-10-30T16:28:00.001-07:002014-11-23T19:56:07.375-08:00WHAT TO DO ABOUT THUMB SUCKING AND TONGUE THRUST?<div class="separator" style="clear: both; text-align: center;">
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_JX-EOASZTnjNSJkro0b4n3EwurNgW1YVlLl5FtIDZyRQRp-NrD19dECA3f-qw-2cYfhINZUKnxFAY5L1UhaRM7IKYz1hjD0_jpszAz5NmZCVXsRspbHiUZGnDiARUCUD4A7Yrca8DacC/s1600/Openbite.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg_JX-EOASZTnjNSJkro0b4n3EwurNgW1YVlLl5FtIDZyRQRp-NrD19dECA3f-qw-2cYfhINZUKnxFAY5L1UhaRM7IKYz1hjD0_jpszAz5NmZCVXsRspbHiUZGnDiARUCUD4A7Yrca8DacC/s1600/Openbite.jpg" height="166" width="200" /></a></div>
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<span lang="EN-GB" style="font-family: Arial, Helvetica, sans-serif; font-size: 11.0pt; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 10.0pt;">Open bites or front teeth not overlapping can be caused by habits with
fingers, lips or the tongue placed between the teeth but how should we treat them? Habits can often be corrected early with minimal intervention. We prefer to see the habit reducing as the adult incisors erupt, about age 6, but even those at ages 9-10 stopping the habit results in improvement of the #openbite.
Many children stop themselves by age 6 as they interact with their peers and decide
it is not as socially acceptable.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmrYqS7NInR7k3x-1Y32YwMLGG36xQLeLIIwbmRJM1diQ-5zduyed-ZZ-p5LXs1MriNHdGvA1CsDIaXa6jaIjQXv5XPjcL257lDsQK41YKTA0Km5EkjsZgEMH_Usw2vOVADiKGvV5R-EbV/s1600/ThumbHabit.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><span style="font-family: Arial, Helvetica, sans-serif;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmrYqS7NInR7k3x-1Y32YwMLGG36xQLeLIIwbmRJM1diQ-5zduyed-ZZ-p5LXs1MriNHdGvA1CsDIaXa6jaIjQXv5XPjcL257lDsQK41YKTA0Km5EkjsZgEMH_Usw2vOVADiKGvV5R-EbV/s1600/ThumbHabit.jpg" height="132" width="400" /></span></a></div>
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<span lang="EN-GB" style="font-family: Arial, Helvetica, sans-serif; font-size: 11pt;">Those that persist beyond age 6 we suggest
initially trying reminder and reward strategies as in this case on the right. Remind the child in a
non-threatening manner and set a goal e.g. praise them when they have refrained
and perhaps have a small reward if they have stopped for a week (to involve the child in treatment). Reminders can
be physical such as a sock, mitten or hand puppet at night. An elastic
elbow support over the elbow to make it harder to bend the elbow to suck the
thumb could be considered. Thumb ‘paints’ work for some but others will simply suck it off. If
these attempts do not work, then a more intrusive reminder such as a thumb
crib/habit appliance can be fixed in place by an orthodontist. Some persist due
to emotional issues and the habit is a comforting device so when the child is
upset, they are more likely to suck and it is more difficult to correct as the
underlying cause is still present. Scolding them will simply make this worse.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgL1Ly9doEsL1Mp0Vn4gd3TU4AbsZPQhprACVwE0KEm2MyBxxX_ykiyEBFj6LfY-ojOmeSyYVvAerCuroWsu2aFOzSBh9UuVzS3Cyr4pwFiLjOhlxDZL8dMuQYE6W-d9gWSIpFMkwxr3WnF/s1600/TongueThrust.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><span style="font-family: Arial, Helvetica, sans-serif;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgL1Ly9doEsL1Mp0Vn4gd3TU4AbsZPQhprACVwE0KEm2MyBxxX_ykiyEBFj6LfY-ojOmeSyYVvAerCuroWsu2aFOzSBh9UuVzS3Cyr4pwFiLjOhlxDZL8dMuQYE6W-d9gWSIpFMkwxr3WnF/s1600/TongueThrust.jpg" height="194" width="200" /></span></a></div>
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<span style="font-family: Arial, Helvetica, sans-serif;"><span style="font-size: 11pt;">A long held concept is that a tongue
thrust swallow is the cause of open bites but it is actually an adaptation to an open bite (to swallow you need a seal at the front
and so the tongue is placed between the teeth). We swallow about 600-1000 times per day for 1 second each (~10-17 minutes per day) which is
not enough time to cause the open bite, it takes hours to move teeth not
minutes. However, </span><i style="font-size: 11pt;">‘habits’</i><span style="font-size: 11pt;"> such as
thumb sucking or forward resting posture of the tongue between the teeth can be
of sufficient duration to cause an open bite. Some may need help with exercises to retrain the tongue to position itself correctly and a Speech Pathologist can help with this. If these strategies are not working, then consult your
orthodontist to consider placing a thumb or tongue crib as a final resort.</span></span></div>
Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com2tag:blogger.com,1999:blog-3429483328496183956.post-39283593963670746202014-10-25T08:04:00.000-07:002014-10-27T06:29:23.280-07:00DOES EARLY TREATMENT OF PROTRUSIVE TEETH PREVENT TRAUMA?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgctxLPlyksfCMiYtqUcYzSXOr_cJgnH2biOdztsxxmn3A8plvLNTkOG6VM8HjeuljXB25Z1DJUOSj9-0kyYT5jtZqLkYIypL11w6GBpCiBLPxUkpfUiyU5NBh9RPU9aG9IpYgUW0fLfIt4/s1600/aaaGOOFY+PIC.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgctxLPlyksfCMiYtqUcYzSXOr_cJgnH2biOdztsxxmn3A8plvLNTkOG6VM8HjeuljXB25Z1DJUOSj9-0kyYT5jtZqLkYIypL11w6GBpCiBLPxUkpfUiyU5NBh9RPU9aG9IpYgUW0fLfIt4/s1600/aaaGOOFY+PIC.jpg" height="200" width="153" /> </a></div>
<span style="font-family: Arial, Helvetica, sans-serif;">Protrusive or bucked top teeth are at a higher risk of trauma but how much is this risk and should you seek early #orthodontic treatment to reduce the risk? Kids run around and can't be protected from all harm so it is no surprise that some trauma will occur. A recent <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003452.pub3/abstract;jsessionid=C57C965E1BBEA6DF7EEBEB4362C8110C.f01t02#.VEu2jQwq-iE.blogger" target="_blank">systematic review</a>, one of the highest levels of scientific evidence, found that the risk of trauma in children having orthodontic treatment at the ages of 9 - 10 was 19.8% while those receiving later treatment in adolescence (say ~13) it was 29.2% so there is a 9.4% additional
risk of trauma if delaying treatment.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">This sounds ominous to some but most are not at additional risk. The studies this review were based upon also concluded that early treatment led to more overall time and cost than later treatment. Some would therefore choose to
delay treatment but some of the more active/sporty patients or those not willing to
bear the risk will seek early treatment. However what type of trauma are we talking about? This is discussed in the textbook I helped edit and author titled, <a href="http://amzn.com/0867155647" target="_blank">Evidence-Based Clinical Orthodontics</a>.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiaAleV52X5WMusWggEqnkzUU9XGBMFjEYKUWXRn6UacthEk5j50twJLVEpKbL9BmwN1M1JSt81p2C3zH5yROipvLzQnlkRM68JgZ7Xu92JJUhK3HnJ-oSs5cv8LOUcYgT6cnZZPOhrSfoU/s1600/aaachip.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiaAleV52X5WMusWggEqnkzUU9XGBMFjEYKUWXRn6UacthEk5j50twJLVEpKbL9BmwN1M1JSt81p2C3zH5yROipvLzQnlkRM68JgZ7Xu92JJUhK3HnJ-oSs5cv8LOUcYgT6cnZZPOhrSfoU/s1600/aaachip.jpg" height="117" width="200" /></a><span style="font-family: Arial, Helvetica, sans-serif;">One of the <a href="http://www.ajodo.org/article/S0889-5406(11)00620-2/abstract" target="_blank">clinical trials</a> included in the review quantified the types of trauma seen in those receiving early or late treatment and they found that 80% of
the trauma was in the enamel only (small chips as pictured) while 19% were more involved and into dentine while only 1% had reached the nerve. If we then consider major trauma to be only the dentine and
nerve involvements (or any knocked out) this is only ~20% of all the additional trauma. This then gives 20% of 9.4% (or 0.2 x 9.4%) which is only a 1.9% higher risk of a major
trauma if delaying treatment until the age of ~13 rather than treating at age 9-10. This then allows you to make a more informed choice about the risk of trauma if choosing to delay treatment of protrusive upper teeth until all the adult teeth have erupted.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" target="_blank">Dr Peter</a> Miles is the orthodontist at <a href="http://www.newwaveorthodontics.com.au/" target="_blank">Newwave Orthodontics</a> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA.</span><br />
<br />Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com1tag:blogger.com,1999:blog-3429483328496183956.post-31549716700492820762014-10-22T20:12:00.001-07:002014-10-25T18:37:43.711-07:00CAN EXPANSION PREVENT EXTRACTIONS? <a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-FOptzXlJBZkJXGj3X3TJ8OPJTqStyyGyzujwN0aGvX6snGrl8LHqcwqp7uZPatRHc5RhP0y2nmIgUlMPJ15D2UsjIFXq5XagmN3ZvhU7nRzPNo2jduoojfITMzAYCQaapjyIPbTK9Ay7/s1600/Wallace.jpg" imageanchor="1" style="clear: left; display: inline !important; margin-bottom: 1em; margin-right: 1em; text-align: center;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj-FOptzXlJBZkJXGj3X3TJ8OPJTqStyyGyzujwN0aGvX6snGrl8LHqcwqp7uZPatRHc5RhP0y2nmIgUlMPJ15D2UsjIFXq5XagmN3ZvhU7nRzPNo2jduoojfITMzAYCQaapjyIPbTK9Ay7/s1600/Wallace.jpg" height="185" width="200" /></a><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Expansion is a strategy that can be used to create space but how much can we expand and how much space do we obtain? </span><span style="font-family: Arial, Helvetica, sans-serif;">When undergoing #orthodontic treatment, most patients and orthodontists would prefer to avoid #extractions. In most cases (~80%) extractions are avoided but some cases it is indicated to reduce crowding, to help improve the bite, reduce the risk of relapse, or to reduce the risk of the gums receding. Rapid palatal expanders are a common appliance used to correct crossbites (top teeth biting inside the lowers) and this correction tends to be very stable. Expansion also creates space but not as much as you may think.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLYipr6lbq5UkngarwAKx-bZCLS5EhHOrH3uO71_bGFGLIFR7DG0S_gSD-EfkJtFxsWKFJWiOK6ahlqmt6p3p4Nldf1OJLOqgWpphu1QYl6R6f-OIWxK-PJNPZYNHILIr2ys3M1br_B-u-/s1600/Miles_Cvr_F.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLYipr6lbq5UkngarwAKx-bZCLS5EhHOrH3uO71_bGFGLIFR7DG0S_gSD-EfkJtFxsWKFJWiOK6ahlqmt6p3p4Nldf1OJLOqgWpphu1QYl6R6f-OIWxK-PJNPZYNHILIr2ys3M1br_B-u-/s1600/Miles_Cvr_F.jpg" height="200" width="154" /></a><span style="font-family: Arial, Helvetica, sans-serif;">When assessing the amount of arch perimeter or space gained (to reduce crowding) with #expansion <a href="http://www.ncbi.nlm.nih.gov/pubmed/1815557" target="_blank">it was found</a> that only about 1mm of space is created for every 3mm of expansion of the back molar teeth. Research into expansion beyond correcting crossbites shows that although quite large expansion can be achieved, it invariably relapses back to within 2-3mm of the original dimensions. We therefore can only gain ~3mm of stable expansion which only creates about 1mm of space for reducing crowding - not much really! Fortunately this is not the only strategy orthodontists have for creating space as I discuss in the textbook, <a href="http://www.amazon.com/dp/0867155647/ref=cm_sw_su_dp" target="_blank">Evidence-Based Clinical Orthodontics</a>. We can treat more moderate crowding (5-6mm) by involving other techniques such as incisor proclination (up to ~2mm is stable and this creates ~2mm of space), interproximal reduction/thinning can be used if prudent and E-space maintenance (a future Blog) can contribute ~3-4mm of additional room.</span><br />
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Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0tag:blogger.com,1999:blog-3429483328496183956.post-25859448536725012682014-10-18T06:56:00.000-07:002014-11-05T18:34:06.934-08:00SHOULD YOU REMOVE YOUR WISDOM TEETH TO PREVENT CROWDING?<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiN95TIuetsioK213dkY-0u4-iwLORmRJNB8Ah-taqbNiYZpxZsp_05VcAAj-wqlxlagK-DijtH7A0TfF0KzsBiDmXA3Vw5sUvzX4eMwqW3hQB1KuLPcZaw_pUcIM_kNuQLb3k9Wl_CSeHh/s1600/wisdom_teeth.jpg" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiN95TIuetsioK213dkY-0u4-iwLORmRJNB8Ah-taqbNiYZpxZsp_05VcAAj-wqlxlagK-DijtH7A0TfF0KzsBiDmXA3Vw5sUvzX4eMwqW3hQB1KuLPcZaw_pUcIM_kNuQLb3k9Wl_CSeHh/s1600/wisdom_teeth.jpg" height="200" width="156" /></a></div>
<span style="background-color: white; color: #404040; font-family: Roboto, arial, sans-serif; font-size: 13px; line-height: 18.2000007629395px;">As adolescents get older their teeth can move in their late teens, about the same time as their #wisdom-teeth erupt - but is that the cause of any movement or just poor timing? Researchers have examined whether wisdom teeth can cause crowding and the following statements can be made:</span><br />
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<span style="background-color: white; color: #404040; font-family: Roboto, arial, sans-serif; font-size: 13px; line-height: 18.2000007629395px;">There is no difference in incisor #crowding between people who have third molars impacted, erupted normally, congenitally absent or extracted early (<a href="http://dx.doi.org/10.1016/0889-5406(90)70105-L" target="_blank">Ades et al, American Journal of Orthodontics 1990</a>).</span><br />
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<span style="background-color: white; color: #404040; font-family: Roboto, arial, sans-serif; font-size: 13px; line-height: 18.2000007629395px;">Direct measurement of the pressure before and after third molar extraction reveals no forward pressure from impacted third molars (<a href="http://dx.doi.org/10.1016/0889-5406(91)70004-G" target="_blank">Southard et al, American Journal of Orthodontics 1991</a>).</span><br />
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<span style="background-color: white; color: #404040; font-family: Roboto, arial, sans-serif; font-size: 13px; line-height: 18.2000007629395px;">Removal of third molars resulted in only 1.1mm difference so extraction to reduce or prevent late incisor crowding is not justified (<a href="http://www.ncbi.nlm.nih.gov/pubmed/9668994" target="_blank">Harradine et al, British Journal of Orthodontics 1998</a>).</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxcv-Wb_XE9xmspviL1I6KpokvPc-q1KlV5vWqxqhb_xQ0ULyLak4ZWa06SjM1_GclcIQ6lnA4yslH1BpyF0hivPLnc87f-GHORDC34fQhFp3SzhSO3PYDeEG1ELbEP9vJJRkW-Arf39dP/s1600/Bonded+3-3+Google.jpg" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgxcv-Wb_XE9xmspviL1I6KpokvPc-q1KlV5vWqxqhb_xQ0ULyLak4ZWa06SjM1_GclcIQ6lnA4yslH1BpyF0hivPLnc87f-GHORDC34fQhFp3SzhSO3PYDeEG1ELbEP9vJJRkW-Arf39dP/s1600/Bonded+3-3+Google.jpg" height="109" width="200" /></a><span style="background-color: white; color: #404040; font-family: Roboto, arial, sans-serif; font-size: 13px; line-height: 18.2000007629395px;">So there is minimal reason (1mm) to believe that extraction of third molars will alleviate or prevent crowding of incisors. So what are the causes of the crowding? The picture is not yet clear enough to say for sure, but the jaw narrows throughout adult life. This may be due to late jaw growth and ageing changes in the gums which compress the teeth.</span><br />
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<span style="background-color: white; color: #404040; font-family: Roboto, arial, sans-serif; font-size: 13px; line-height: 18.2000007629395px;">Unfortunately, a retainer is the only way to reliably prevent incisor crowding and #orthodontic tooth movement the only way to treat it.</span><br />
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<span style="color: #404040; font-family: Roboto, arial, sans-serif; font-size: x-small;"><span style="line-height: 18.2000007629395px;"><a href="http://www.newwaveorthodontics.com.au/dr-peter-miles/" target="_blank">Dr Peter</a> Miles is the orthodontist at <a href="http://www.newwaveorthodontics.com.au/" target="_blank">Newwave Orthodontics</a> in Caloundra, Australia and teaches orthodontics part-time at the University of Queensland and is a visiting lecturer at Seton Hill University in the USA.</span></span><br />
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<br />Dr Peter Mileshttp://www.blogger.com/profile/01593702083852650306noreply@blogger.com0