Speaker 1: 0:41

Welcome everyone to another Thursday Night Live. We are here with Dr Claudia Pinter. Thank you for being here with us today.

Speaker 2: 0:50

Thank you, it's such an honor, renata.

Speaker 1: 0:53

Thank you. I'm going to go ahead and introduce our speaker. Dr Claudia Pinter is a leading expert in the aligner technique. A graduate of the University of Vienna, she specializes in invisible orthodontics with clear aligners. She's internationally sought after as a speaker and is appreciated for her ability to break down complex information into easy principles that are applicable in everyday practice. Her excellence inspires doctors to learn more about aligner techniques and is known for openly sharing her protocols. Dr Claudia Pinter is passionate about aligner techniques and is known for openly sharing her protocols. Dr Claudia Pinter is passionate about engaging with colleagues and thrives in the mutual exchange of knowledge and ideas. I really don't think that the Zentro really expresses how incredible you are and how much you have done for all of us in the orthodontic world, in the airway world, in the malfunction world. So thank you, thank you, thank you for everything you do, and I cannot wait for Aerie Circle and all of our listeners to get to know you a little bit more.

Speaker 2: 2:00

Thank you, renata. First of all, I need to thank you for bringing us all together. I got in contact with a lot of great professionals through your podcast, through your videos, so thank you for what you're doing.

Speaker 1: 2:15

Of course. So let's start our topic today slow expansion, a new paradigm. So why did you pick this topic?

Speaker 2: 2:23

Well, you know, I love actually to follow your instagram page and I know that you're. You did once a a post about uh rpe's rapid maxillary expansion and you explained the slow expansion and fast expansion, and I also do a lot of posts on that on instagram and this is where I got the most requests, most questions, and while it can be a little bit confusing, it doesn't have to be. It's just that there have been incredible innovations in medicine and this is really shifting the paradigm. So it's now more comfortable for patients. The whole treatment experience is different. So I know, renata, that you had an expander and I would love to hear more about your experience and your treatment. So could you explain to us what kind of expander you had?

Speaker 1: 3:19

yes, well, actually, this is funny. I still have it. That's so cool, that's beautiful. Dr ilia, let me bring you home. That's my marpie in there you guys can see the screws. Let's see if I can show you how long these screws were.

Speaker 1: 3:35

I think that's something that freaked me out. Uh, whenever I was sitting there to get ready for them to install it, I looked over in the computer and you showed the size of the screws and one of them was 17 millimeters long and I was like, oh my god I know that means I'm a hygienist and I used to probe my patients all the time 17 is crazy. I think that for me, you know, whenever I was getting the, the appliance put in, it was more of a mental like I know exactly what's happening and that kind of freaks me out. However, my experience has been very, very positive in terms of barely any pain, in terms of the improvement of my breathing. But I love the conversation of slow versus rapid expansion. There are so many dentists and orthodontists out there saying, no, do not expand too fast. That's so detrimental to your body. Your body has to adjust. You can't just push something mechanically so quickly. And then other doctors are saying, well, if you move too slow, you're going to move just teeth. So I have no way to hear from you about exactly what's going on. What is the physiology of expansion? You know also ages of the patients. I know that everything is going to be different depending on what the patient presents with.

Speaker 1: 5:00

So in my case, I was 14 years old and I told my mom I want braces. I always had straight teeth, but I thought that it was cool to have braces or just an appliance that would make me talk funny, and it's because it's always the same way. So I made my mom take me to the orthodontist. I had straight, beautiful teeth, but I was super narrow. So she put a spander in my mouth and I didn't understand exactly what was happening, why I needed that, but it made me talk funny and I was sold. I was like yep, super cool, 14 year old with a lisp, you're a perfect patient. So I turned um, I don't remember how often, but I remember that they there used to be this candy that I liked in Brazil and it would not fit in my palate and all of a sudden it did. So I could remember that I was expanding. However, I moved to the United States and I forgot my expander at home.

Speaker 1: 6:04

I relapsed. I'm not sure how much I relapsed, and I also would love for you to touch a little bit on that later on. So as an adult, I still had tons of breathing issues. I was sleeping with my mouth open, I was snoring, I was drooling, exhausted during the day, not getting a very good quality of sleep. So then this world of airway fell on my lap and I'm recommending, you know, palatal expansion to my patients. But I'm not doing it, so I just had to. Last year I said, okay, 2023 is going to be my year. I'm going to, no matter what it takes, go through this, and I am so glad that I did. I feel so much better, I can breathe better, my tongue fits better. Has the a hundred percent fixed my sleep? We'll talk about that in a little bit.

Speaker 2: 6:56

I'm curious but first of all, renata, you said some orthodontists say you cannot expand slow because then you're only moving the teeth. You showed us your expander. I didn't see any connection to the teeth. Did you have a connection to the teeth?

Speaker 1: 7:14

yes, so the way that dr iller litkin does, um, he puts the appliance and he does have arms to the motors and usually we keep those arms about six weeks. I'm not sure if my case was different because I live so far away and I had to fly to go see him. So either you keep the arms in until you're done turning or you just keep it for six weeks. I'm not 100 percent sure if he may be, you know, removed mine earlier because it's hard for me to get up there. However, the arms made me have an open bite so I had probably, you know, a couple millimeters of no contact between upper and lower teeth, making it super hard to chew. I was hitting on one spot so, like salads and things like that, you would just go right through the teeth. So that was extremely challenging for that time.

Speaker 1: 8:11

However, whenever we got the MRP installed on the top, he went ahead and gave me aligners for the lower teeth so I had Invisalign on the bottom while I was going through the expansion on the top. That actually helped a lot cushion the metal on the molars that were around the teeth, because it was making it a little bit higher if I didn't have the aligner on the bottom to cushion it. It would have really damaged my lower teeth because I was putting a lot of pressure on the lower teeth. Um, what else happened after that? So six weeks he removed it and as soon as he removed it I remember feeling a lot of pressure kind of go away. So those arms were doing something. I could tell that they were really, really helping.

Speaker 2: 9:01

That's interesting and you know, when I talk to colleagues and ask them why they include the teeth when they have tats and I saw in your expander you had six tats the answer that I would usually get is for stability. You need to include the molars to have stability so that the expander can actually expand the jaws. So I use a different design. I don't include the teeth at all, it's just usually four tats. I don't use more than four tats, but I place them exactly where I have the best bone. It's less but better in a way that it's customized. So I think you also had a customized appliance, and Dr Ilya Lipkin is a great orthodontist. I had the pleasure to meet him at a conference. We're totally aligned and I admire his work.

Speaker 2: 10:01

But there are different expanders on the market and they have different advantages and weaknesses. And expanders on the market and they have different advantages and weaknesses. So, um, the interesting thing is so if you do not include the teeth as an anchor, you really need to rely on the bone and, um, so why do we need to go for slow expansion or rapid expansion? Or let's say, why are we going for rapid expansion? Usually because we don't want tooth remodeling, which happens, for example, when you wear your aligners in a lower jaw very minimal forces and just small increments so the bone can remodel and the tooth can move. However, if we big forces, strong forces and a rigid appliance where there's no time for remodeling but we're separating the maxillary huffs, this is the rationale behind the rapid expansion. So we want to go faster than bone remodeling to separate the maxillary huts. So, coming back to the rate of expansion, we were talking about rapid expansion. How often did you have to activate, turn your expander, renata?

Speaker 1: 11:22

So in my case and I know everybody is slightly different but for my case he recommended two turns until it's split. Body slightly different, but for my case he recommended two turns until it's split. I'm pretty sure that I split on day three because I had a light headache and I could start to almost start feeling air going in. Between eight and nine, my two front teeth. On day five I could clearly feel air going through those teeth. So I stopped at day five doing two turns a day and after that I did one turn a day for a few weeks, I think, and after that was three times a week.

Speaker 1: 11:52

And then I met Dr George Faber in Amsterdam and he looked at me and he goes you're going too fast. And I was like tell me everything, tell me everything I need to know. And he said there's new research coming out saying that slow is better when it comes to a dopalato extension because the screws are anchored in the bone. So there's no reason for you to go fast, fast. And he said that research is showing that the suture as it's regenerating in the middle, if it's too fast, if you're moving too fast, it's very unstable and more likely to relapse and very thin. So if you do it a little bit slower they're seeing better results.

Speaker 1: 12:45

So then I freaked out and I didn't turn for two weeks. I had a big diastema and since I stopped turning all my teeth went and then I had just crazy teeth moving. You saw me like that, crazy teeth moving everywhere. And then I called Dr Lipkin and I said is there any way I can go any slower than this? And he said let's do it to a week then. And I did it once or twice a week until I was done.

Speaker 2: 13:13

I see so the interesting thing is, before we had those tats, those mini screws, we could not go for slow expansion because we just had the teeth as anchor. But now that we have the screws as anchor we can go at any rate we want. And it's so interesting. So I went down the really to the really old literature on where they described distraction, osteogenesis, um, so what they did. They did experiments on dogs where they did limb elongation. So they had I mean that was in 1988, that was a long time ago they did not have those fancy cat cam designed expanders with orthodontic mini screws in a highly compliant patient like you. So they had dogs where they had nails and some crazy construction with wires.

Speaker 2: 14:14

So and they tried different, or he tried different expansion protocols and he saw that if he went faster than faster than one millimeter per day, it's too fast. Fast, okay, you're just ripping it apart and it won't heal. So that's why he came up with one millimeter per day is good, okay. Then with the literature it got a little bit slower and we're now down to maybe one millimeter or two millimeter a week.

Speaker 2: 14:45

However, what also what I'm seeing in my patients is that going even slower creates less complications. So there are a lot of complications that can come along with marpy, um, uh, mini implant, implant assisted rapid palatal expansion and I hardly see any complications because the process is very physiologic. So I have those screws anchored in solid bone, I'm expanding slowly, and I'm expanding extremely slowly, so slow that it's the same speed as tooth movement. So what is happening is I'm synchronizing the aligners with the expander to keep the front teeth aligned, because I wish I had as compliant patients who say oh, I'm so happy if I have a lisp or even, you know, a diastema, I don't mind. No, it's like I want expansion for better breathing and you know what those this diastema, no way. So either you find another solution or I'm out of here you know.

Speaker 1: 15:59

This is interesting that you say that, because I have started seeing some orthodontists start aligner therapy. As they are expanding, however, they're still moving fast, and I mean clothing.

Speaker 2: 16:14

Probably that's even possible. Possible because when you think we also move teeth into extract extraction sites. But I just like the idea of going slowly because I mean we're creating new bone, we're growing new bone. I mean that doesn't have to take place in two months. Okay, we can give it some time. That only seems logic to me.

Speaker 1: 16:41

Okay, I have so many questions right now. One. I'm going to go back a little bit. You mentioned that you usually use four tads. What is the difference of a custom appliance versus non-custom? Is that MSE1, MSE2, and Marpe?

Speaker 2: 17:00

That's a really good question. I look at CBCTs all the time and everybody is so different. So by having customized appliances we can place the screws where the patient has bone, and it's very different in each patient. So there's one insertion site for TADS that is described as the best insertion site, which is the anterior pallet. So in every case you should have two TADS here, and for the second two TADS you need to look where you have bone. So this could be between the roots here where you're in safe distance to the roots, or sometimes even here in the posterior. So along this line we can also find bone, but it's very narrow so it's hard to get the screws there. However, there are other expander designs that place the screws just where the appliance has the holes, and usually this is somewhere a little bit more lateral to this T-zone, little bit more lateral to this t-zone. So if you wrote the t on the palate, you have the t-zone, which is described as the best insertion site.

Speaker 2: 18:22

However, those screws go slightly lateral and usually here the bone is paper thin and this is why a lot of failure, even though they include the teeth, the molars, as anchor, because the bone is paper thin and if you look at 100 CBCTs, 97% of patients, I would guess, have absolutely narrow bone in that area and then it's up to the sutural maturation stage, up to the age of the patient, if it still works out or not. But what I see is having patients who are over the age of 50, 5-0, where the bones of the maxillary halves are so highly interdegutated, so fused, that you cannot even see a line. Degutated, so fused that you cannot even see a line. So probably 10 out of 10 orthodontists surgeons would say this is a case that needs surgery and I'm seeing sutural separation without surgery. There's a protocol to it and I will be very happy to touch on that at the Vienna Away Congress and, yeah, I think it's a breakthrough.

Speaker 1: 19:40

Tell us a little bit about the Vienna Airway Congress before we keep going.

Speaker 2: 19:47

Well, I should start how I came to toway in the first place. Actually, Renato, one of your interviews, I think it was with Dr Stanley Liu and Dr Audrey Yoon, it really inspired me that there's more to orthodontics than just a great smile and a healthy bite. And suddenly I started seeing that in my patients. So they would come back and say, hey, you know the expander, you're not only fixing my jaw, I can also breathe better. So that really caught my attention. Or patients would say, you know, since my jaw is wider stop snoring.

Speaker 2: 20:31

So I thought, wow, this is so incredible. Of course you know I learned about that in dental school, but it was not applicable back then. I was not taught about maxillary expansion, how it relates to breathing, and, yes, we, we know that in children, there are a lot of publications, but we were really lacking solutions for adults. Because even if I would tell my patients, hey, you have a narrow jaw, it needs to be wider, you need to go for surgery and we expand the jaw, they say, no, just align those front teeth and I'm fine. And now suddenly we have minimally or maybe even non-invasive solutions for adults. So this is a game changer in orthodontics solutions for adults. So this is a game changer in orthodontics and um, but then I would um go to conferences and and see that the breathing in orthodontics is not a topic yet. So, yeah, we talk about making the teeth fit together, but there's so much more to it and this is why I'm so passionate about it. And you know I have patients. I'm guilty, I need to tell you I have patients where I treat it according to the old paradigms where I just looked at make the teeth fit together. You know non-brain patients. Yes, okay, they have a retrognostic maxilla and a narrow jaw, but there's no crossbites. So I make the teeth fit together.

Speaker 2: 22:01

And then, when they came for the recall and I saw this high arched palate and tired eyes and patient forward posturing, and then I asked him well, well, can you breathe for your nose properly? No, never. Uh, how is your sleep? Well, I've been diagnosed with sleep apnea, but I cannot tolerate the c-pap because you know, air nose doesn't work. And I thought I was only looking at teeth. Well, I could have presented him with an option that would have improved his nasal breathing. Maybe he could then better wear his CPAP and his sleep would improve, he would feel more energy.

Speaker 2: 22:47

And I said, okay, we have to bring this information to the world and how cool the latest innovations in treatments are. We got to get the word out there. So we're super thrilled, renata, to have you as a keynote speaker. You're doing such an amazing job in bringing really the interdisciplinary approach. You're sending me a lot of patients. I'm sending a lot of patients to my functional therapy because we need to address this topic together. It's not enough if we try to solve a complex problem that has multiple factors going into alone. It needs to be addressed as a team 100%.

Speaker 1: 23:27

So who else is behind the Vienna Airway Congress?

Speaker 2: 23:32

I'm very fortunate to do that with a team. Dr Christian Leonhardt is one of the organizers as well and actually he brought me to this idea of keeping the teeth aligned while we expand. So he is full of great ideas and he's an expert clinician. On top of that, we also have dr florence six. He's the dentist in whose practice I I treat patients and we try to deliver this comprehensive care.

Speaker 2: 24:06

So, for example, there are many manifestations of sleep related breathing disorders in a patient that would see a doctor, a dentist, for a regular checkup. For example, heavy wear on the teeth, erosions you know where the teeth are half in size, because some acid washed away all the teeth and cavities, although the patient is breathing, brushing well and inflamed gingiva, breathing uh, brushing well and inflamed uh gingiva. So we need the dentist to recognize possible manifestations of a sleep apnea or sleep related breathing disorders. And yes, this patient had a high-rich palate and we can treat him accordingly. And I also want to mention dr clements paffenholz, who is in a practice together with Dr Christian Leonhard. He's taking care of the kids and very mindful about airway and kids. You know, the children are really the most important patients. This is where we can still have an impact on change, growth and development.

Speaker 1: 25:12

Isn't Dr Christian at COI Center right now? Oh?

Speaker 2: 25:15

yeah, he is. He's lecturing there, I think, together with dr stefan deca, who will also talk about children, orthodontic treatment for airway and breathing, and, of course, uh, our keynote speaker, dr stanley liu, who has inspired all of us.

Speaker 1: 25:33

He definitely has, and are you also going to be in Australia for a different meeting, correct?

Speaker 2: 25:45

Yes, dr Sharon Lim is organizing the event Inspiration by Integration, so it's also a multidisciplinary approach and I will be attending there. I will be cheering in the crowd for the speakers. But yeah, it's an incredible important topic and I'd love to learn more about it.

Speaker 1: 26:07

That is so exciting. I have so many questions about Marpey and expansion in general. I am going to throw this question here because even though it's not related, because I just want to get it out of the way I have so many patients that have a cleft palate. What do we do? Is there something that can still be done? Can they be expanded safely, the mucosal cleft?

Speaker 2: 26:39

I think that's a very challenging topic because usually we have a lot of scar tissue. Scar tissue is different than normal tissue. We are limited with expansion. However, I would still try to be as minimally invasive as possible, and the approach is the same have the expander anchored in good bone. Have a lean design that still allows patients to. You know, in the end, for me, the patient experience is incredibly important. It's not just about the outcome, it's also about the journey there. So this is why I'm using a design where the screw sits completely flat on the palate, so the patients can still put their tongue where it's supposed to be. Um, yeah, I've tried different designs so I've come a long, but I can definitely tell what are the advantages in terms of the doctor side and the patient side.

Speaker 1: 27:39

Perfect. Another thing what is the youngest age you have used a Marpy on and the oldest?

Speaker 2: 27:48

The youngest age is nine years, where there was a diagnosed sleep-related breathing disorder patient with an AHI of five, which is too high for a child, and we went to that, sorry.

Speaker 1: 28:06

I'm so glad you said that. I literally had a patient the other day come in from Mexico, this little girl who went to a sleep physician. They had the sleep study done and the mom said they said it's fine, so they sent me I sleep physician. They had the sleep study done and the mom said they said it's fine, so they sent me. I was like, let me see the study, send me a copy of the study AHR 5. And the sleep physician wrote within normal range. And I'm like it is not. It's within normal range for an adult, but not a child. Oh my gosh, I just said that, okay, go ahead.

Speaker 2: 28:36

Oh my, an adult but not a child. Oh my god. Sometimes I just said that, okay, go ahead. Oh my god, I'm so glad you requested to see the sleep study. So that is not, um, not normal for children. It should be closer to zero and um. So I did the same protocol. However, in children you only need two tats. That's absolutely not. The bone is still so, um, malleable so malleable that you can expand easily. And I did the same protocols aligners simultaneously to keep the gap closed and it worked seamlessly. So patients don't report any pain, they get a little anesthesia and usually you know they handled it well. So I'm pretty surprised actually and it's funny because I I think, because the bone is rather soft, there's a pain afterwards.

Speaker 1: 29:27

So I was pretty astonished uh, how well they managed it I was going to ask you about how are kids handling it?

Speaker 2: 29:34

Yeah. So one more important thing about that patient was she had a cross bite. That could absolutely be solved just with dental expansion. But because there was a nasal obstruction, we went for a dental expansion and adjusted the bite with liners.

Speaker 1: 29:55

You're answering all my questions before I ask them. So it was going to be. When do you choose to do a tooth-borne expander versus a bone-borne expander? So it's nasal obstruction that you're looking at Exactly.

Speaker 2: 30:09

So of course I mean we could do a skeletal expander in everybody because it's working so fine, but I still think we need to be as minimally invasive as possible. We need to use the appliance that does the job good without being invasive. And even if there is not a high complication rate, still you need to put in anesthesia. And I again want to have a great patient experience, not because, you know, I want to be the doctor with the most patients in my town, but rather because I want my patient to tell their friend, hey, it wasn't bad, it was a nice experience, so that other people have the courage to go for treatment as well.

Speaker 1: 30:58

Fantastic. What is the rate of turns of tooth-borne expansion versus bone-borne expansion for a child?

Speaker 2: 31:09

So for a child with a tooth-borne expander, we need to go for rapid expansion, so that could be, for example, one turn per day. It could also be two turns per day. I think most orthodontists go for one turn a day For the bone-borne expander. We could use the same. However, if we want to synchronize it with aligners, I recommend for a slower expansion protocol. So no faster than every other day. A turn every other day.

Speaker 1: 31:49

So whenever you are doing a little bit slower expansion with aligners the aligners plus the bone-borne expander what is the length of time of treatment? How much more does it increase?

Speaker 2: 32:06

So as a rule of thumb, expansion takes about four months, so significantly longer than with the rapid expansion. But again, the patients don't mind because the expander is comfortable and I'm also not risking any dental side effects of moving the teeth outside the bone or having the tats and the appliance fail because it's neatly placed in good bone.

Speaker 1: 32:34

If there's a significant crossbite, expansion can take longer, so up to eight months, for example how long, uh, do you keep the tooth bone or the bone borne expander in after the patient is done turning?

Speaker 2: 32:52

in children six months. I want to wait six months until there's um, until there the bone has mineralized. In adults I go for an even longer period, closer to nine months or even 12 months, if they don't mind, because I assume that all the processes, the mineralization process of the bone, is slower than in children. I want to make sure I don't lose any millimeter of the expansion that I gained. And again, patients don't mind If they do mind the expander. There's a great solution. So, since I'm using tats with interchangeable abutments, so basically it looks like that in a patient they have the tats and on top of that comes the expander, which is then fixed with fixing screws. So if they want to get rid of the expander and we're not done with the stabilization phase, no problem. I remove the expander and put a skeletal retainer. So this is just a little metal plate connecting those little screws and it holds the tats apart. That is so.

Speaker 1: 34:05

I have never heard of that. That is so interesting and I love it. Yes, 100%. It's difficult to eat while we have the expander in there because you know, there's a little bit of room between the roof of the mouth and the expander so stuff gets caught in there. It's challenging to clean at times. Um, so that's very interesting I did feel whenever he removed my marpie. I kind of felt a lot of pressure like, oh my gosh, it was my biggest fear, I having nightmares. I did not want to relapse. Yeah, with my daughter when she had her extension, the orthodontist wanted to remove the expander, which was a toothbone expander. He wanted to remove within four months and I was just too busy and I told him I couldn't come in until six months later. But it was on purpose. But what are some reasons why patients will relapse?

Speaker 2: 35:06

Well, first of all, we know from you know the very early studies if we use a tooth and bone borne expander, or let's say, if we use a tooth borne expander First, we do the rapid expansion and we get skeletal effects. But what showed is that over the period of time of a few months the dental side effects catch up. So what I see is, when we expand the bones, there is a lot of resistance. You know all the other craniofacial structures here. They have been bended and they exert pressure. So we really need to have something very rigid there. And teeth are not really rigid because they have a periodontal ligament that will do bone remodeling. That's how we move teeth. So that's what makes it even more logic for me to use bone-borne expanders.

Speaker 1: 36:15

I love that. So reasons for relapse. Let's talk about piezo, or piezo? People say it different ways. Do you use it in your practice? Do you feel the need? Is there a certain age where you decide to do that? And before we keep going, would you explain to people what that is?

Speaker 2: 36:42

to people what that is sure. So piezo is a little saw that oscillates. So it's a little bit different than what dentists or surgeons usually use. They use rotating instruments. Rotating instrument you cut. You cut everything, even bone tissue, a nerve, a blood. With piezo it's different. So it's a little bit like the ultrasound with which we remove the calculus from the teeth.

Speaker 2: 37:05

So we remove the calculus because it breaks, but we're not scratching the tooth or we're not hurting the tooth. So this is the same principle with piezo it's slower than a rotating burrr, but it's safer because it doesn't cut um the nerve, for example, or only if you're very, uh, um, hectic or whatever. So I don't use piezo for the reason. Well, I would have gotten one, but I feel like I don't need it anymore because there are some really cool studies that just came out about a protocol where we can activate the sutures. So basically, it is like you put some pressure on the sutures and you release it and you build it up again, release it and build it up, and that causes the body to realize, okay, I need to change here, and then the maxillary halves drift apart.

Speaker 1: 38:09

So that's my I'm going to put a t-shirt that says the way to win my heart.

Speaker 2: 38:19

So I mean, if you we're not that you had two children. I mean you brought some huge babies to life, so your bones had to be a little bit flexible.

Speaker 1: 38:29

Well, I had to see sections, but yeah, naturally it would have happened that way exactly.

Speaker 2: 38:37

So the body has capabilities to, to change, to stimulus. And the way I explained to myself is, if I wanted to do a split, I would try to go there down there the first day I would you know, go down pressure and release next day a little bit further and further in one day.

Speaker 2: 38:59

Okay, this constant stimulus makes my body react and produce more fibers, so they get longer. So one day I will touch the floor. Wow, and this is what I'm seeing in my patients. So those who were with completely fused sutures they will open. We have a little bit of patience and, with light forces, activate the sutures, because my biggest fear is that the bone breaks, but not in the mid-palatal suture, but somewhere up here. That's what I want to avoid in any case but somewhere up here.

Speaker 1: 39:41

That's what I want to avoid in any case. What are the troubles of the bone?

Speaker 2: 39:47

breaking where you don't want it to break. Well, in most of the cases we probably won't have any effect. It just breaks and will heal. There are some complications reported where patients then have some impairment of, for example, the auditory system, but there are also reports where there was a cerebral spinal fluid leakage and that patient then could not move his eyelid again. So this is something we want to avoid in any case. That's why my question is do we need to break the suture or can we open the suture?

Speaker 1: 40:32

Oh, I want to see research on that. That is incredible.

Speaker 2: 40:37

Yeah, on that, that is incredible yeah, you're just putting so many questions in my mind right now. Well, I think I think there. The research is out there, so there are publications on this polycyclic protocol that I just mentioned, and the success rate was 100% and they had patients up to the age of 27. And, of course, we need to go further down that road. We need to have studies with more patients, with older patients. Right now I'm applying that protocol and it works like a charm, and the colleagues that applied as well say the same, so it's so promising and you're going to be talking about this at the airway vienna airway congress yes, so I will make sure I highlight the most important aspects, but it's it's really a breakthrough because we could talk about maxillary expansion all day long.

Speaker 2: 41:34

Doctors, if colleagues cannot um communicate this uh treatment to their patients because patients or cannot sell it to their patients because the patient said I don't want heavy surgery or I don't want to diastema, whatever, it's not going to happen. So we need to focus on a patient experience. This needs to be a procedure for the masses. We need to make it safe and predictable.

Speaker 1: 42:00

I love it. Let's talk a little bit about asymmetrical expansion. Why so? I usually tell people well, you're already asymmetrical, so it's just going to. You know, the forces are pushing the same amount of force both ways. Is that true? Is there any way that you can fix a symmetry doing expansion, or is it always going to exacerbate that asymmetry?

Speaker 2: 42:25

um, I totally agree with you. I mean, we're not perfectly symmetric to begin with, how can we expect a perfect symmetric expansion? Um, I think this is really where orthodontic the value of orthodontics comes into place in this whole procedure. So, for example, I had a patient who was asymmetric to begin with. The asymmetry exacerbated during expansion. But fixing the asymmetry was part of the treatment plan anyway. So what I used is then use another bone bone appliance, which was cool because I didn't have to change the tats. I could use the same tats as for the marpie and just drag the teeth where they're supposed to be oh wow, that's fantastic.

Speaker 1: 43:12

Um, a lot of times, as my functional therapist will recommend, of course, working on the muscle as you're expanding, and working with a cranial osteopath who can do some adjustments. But it's interesting what these body professionals feel when you have the TADs in place. My cranial sacral therapist did some work on me before and after. My craniosacral therapist did some work on me before and after and it was interesting to hear from her. You know what she was feeling differently in my cranial bones that she felt with different patients. So again, multidisciplinary collaboration. Let's have different professionals. Look at the same patient. Before we go, can we talk a little bit about failure? And you were going to say something.

Speaker 2: 43:59

Oh yeah, that's one of my. You know, I always love to talk about failures because this is where we learn the most and I'm passionate about sharing. So I have seen it all. Um, yeah. So actually, this is what most um colleagues are afraid of afraid of failure, what most colleagues are afraid of, afraid of failure. I think that they don't have to be afraid because, due to the clever designs we have today, the risk for complication has been dramatically reduced.

Speaker 2: 44:32

But you need a bone-borne expander, or? Yeah, first of all, you need a bone born expander. It needs to be customized, it need to be customized to where we have bone in the patient. And then colleagues would say, yeah, but it's so expensive. Of course it will cost more, but you need to think of how much money will you save if you just have one complication less. So one complication will pay for 10 custom-made appliances, and I guarantee that there is a lot more complications if we just place the screws wherever and it's not going to work.

Speaker 2: 45:12

The problem is, renata when you have an expander with t tats and it failed, where are you going to place your new tats? Yes, because you have a hole in the bone from the original tat of the area of three millimeter circumferential is also not suited to place a tat because there is increased inflammatory response. So where are you now going to place the new t? Because there is increased inflammatory response, so where are you now going to place the new TADs? This is why it's really crucial to get it right the first time.

Speaker 1: 45:45

I have a couple of friends who got the MSE first, with four TADs and using the protocol of turning four times a day, or they do like six turns in the office before to activate the appliance before the patient even leaves the office and two of them failed. Okay yeah, who was dragging into the bone? Why did that happen?

Speaker 2: 46:16

This is when the tats don't have enough stability in the bone. So, as I told you, when you look at skulls or at CVCTs, the bone here in that area is paper thin, just for the one CVCT you will get confirmation. So you have then this 10 millimeter screw which is engaging with half a millimeter of cortical bone. That's usually not enough so you can turn up the expander. It will get bigger, but the tats are just dragging through the bone because the bone is not metal, I mean, it's hard tissue, but if the forces are too high they just drag through the bone.

Speaker 1: 46:59

One of them had. I'm not sure how long she waited, but she had another appliance put on and she was successful with that expansion. And my other friend had the new appliance put in and she said that her body rejected it. I don't know any details about it, but she wasn't able to do the expansion at all. Have you had any of those cases?

Speaker 2: 47:26

Rejection. It would be interesting what was involved here. So there can be psychological rejection. Another form of rejection is when the body tries to protect itself. So if the tats are a source of inflammation, if not cleaned properly, or if there is bacterial inflammation for some reason, the body tries to get rid of it. Okay, because it's a threat. So again, insertion sites for the TADs are really important.

Speaker 1: 48:02

So the difference of a custom expander, so a custom is a Marpie and the MSC1 and MSC2 already have the places for the TADs pre-made. Is that correct?

Speaker 2: 48:16

Yeah, so the MSC designs that I've seen? It's not a custom-made. Is that correct? Yeah, so the msc designs that I've seen, it's a. It's not a custom made appliance. People buy the expander and place the screws wherever the holes in their expanders are. Um, and this usually is right next. So the expansion hyrixx is located, seated between the first molars, and left and right to it are the holes for the screws. But this is not in the T-zone. Usually it's further lateral and this is where the bone is really thin. I see that there are new approaches to the mse. I'm not an expert on mse, but they're moving a little bit more into the anterior region, as I see it, and some also have screws between the roots of the sixes. So they also keep evolving, um, and I think we need to appreciate all the signs. They all teach us something. They all have advantages, like having a prefabricated design has the advantage of being super cheap.

Speaker 1: 49:33

However, we need to consider if failure is higher. If it's still cheap A hundred percent I love that. So if anybody wants to learn more, do you offer any courses?

Speaker 2: 49:48

Yeah, I'm super excited to offer this kind of expansion in the fellowship in aligner orthodontics the advanced course, where it's about breathing bite and beauty with bone-borne expanders, and it is evolving so rapidly. So people definitely should check out the Vienna Airway Congress where we present the newest, latest protocols and, yeah, just keep following me on Instagram, for example, that's drfordrclaudiapinta. I always announce new resources, new ways of doing that and, yeah, if somebody wants to do that on their patients and wants to make sure they get it right, I also offer treatment planning service for those expanders, where we go through how to make it custom made for your patient, where to place the screws, what the expander needs to look like, then decide on an expansion rate that is aligned with the patient's age and the patient's needs, and how to synchronize that with aligners. So the full package that you have. You don't have to worry.

Speaker 1: 50:51

You just do and you're guided by an expert, perfect, and they just reach out to you guided by an expert, perfect, and that they just reach out to you.

Speaker 2: 51:02

Uh, yes, so the website will come out soon. Uh, for this planning service, but for now, they just can contact me on instagram until the website is up and running perfect.

Speaker 1: 51:10

That sounds wonderful, thank you. Thank you so much for spending uh today with us and it's play tonight, but it's today, right now. So much incredible information. I know that many patients and professionals need more clarity when it comes to rate of expansion, types of appliances and all of this wonderful work you guys are doing with TEDS. Oh, my goodness, before we go, can you talk to us just a little bit about gummy smiles and how you can correct that with TADS?

Speaker 2: 51:45

So funny because actually I just have the model here where people in my course can learn how to do that. So here you can see how they need to exercise to remove the gums. So that's a really cool procedure because usually patients with a gummy smile were told that they need surgery. You know, cut off the maxilla and impact it. But some really cool colleagues came up with a protocol, how to do it with pads and aligners, and these are the most life transforming treatments that I do. It's amazing. So basically we're intruding, we're moving all teeth up to where they're supposed to be and then usually we do a gingival recontouring, you know, because the gingiva is part of the frame of the teeth and, um, yeah, to really get the smile that people want how early can we do this?

Speaker 1: 52:49

because we see so many kids with a gummy smile already that's. You know they were mouth breathers. It's already a problem. Now we're expanding these kids, but they still have a gummy smell. At what age is it safe to do something like this?

Speaker 2: 53:01

so, um, I think we need to think of the indication very clearly. Um, usually patients also present with a narrow maxilla. So it's really important to assess breathing and expand the maxilla if necessary. In children, it's really important to assess breathing and expand the max if necessary. In children, it's probably enough to do a gingivectomy. However, we need to consider that teeth might still be erupting. So I would say, to be safe after the age of 14 is probably good. Then we make sure. Okay, teeth fully erupted. This is how it's going to be. No changes.

Speaker 1: 53:41

Now we can modify the changeable margins, perfect. Well, thank you so much, dr Claudia. I cannot wait to see you in Australia and then Vienna this year. Anybody that's over here, I'm going to put Dr Claudia's information in the show notes. I'm going to add this to our Area Circle Professionals Facebook group. If you are a professional listening to this, go over to Facebook and search Area Circle Professionals. That's a private group for professionals only.

Speaker 1: 54:10

We have about 2,900 multidisciplinary professionals right now that we can collaborate, we can network, we can ask questions, share research and we also have, if you're a patient or a parent interested in learning more, you can go over to Facebook and search Area Circle Patients. There are many professionals there ready to help you, to answer your questions, to offer you guidance. So, anyways, thanks everybody for listening. If you're not an Area Circle member yet, please join us on wwwareacirclecom slash membership. And if you'd like to learn more about myofunctional therapy, we now have registered Myofunctional Therapy University. We have three courses foundations of our official myofunctional therapy, fully online, 15 weeks long, and it starts August 1stst. We only offer it once a year. We have myobiz, that's a business growth um course for myofunctional therapists, and we have myocircle uh every january, which is our advanced myofunctional therapy, the why behind the exercises. Anyways, thanks everybody, have a wonderful day and we'll see you next thursday.