Rethinking Mandible As Reference

SPEAKER_01 0:41

was one of the best orthodontic presentations we have ever had. I am in um how many to plan on right now. Wait till I'll be there this week and we won't be there.

SPEAKER_00 0:54

Yeah yeah thank you. Gosh I love how you measured uh and you compare the relationship of the mandible and the maxilla I feel like that makes a lot more sense to explain to people why some patients let me ask you this and this was this was my theory this is my hasn't been my theory on that and I want you to because you're you're probably more knowledgeable in the the myo space but like let's just say your tongue was completely tethered horrible tongue tie completely tethered to your mandible does it not make sense that the mandible would be as wide as it needs to be to accommodate the tongue because if if it's just like stuck it's true it's it's gotta be but your but your maxilla won't be and we and we're as orthodonists we're used to using the mandible as a reference point for the maxilla all the time like in CEPs when people were talking about extraction treatment it was always the lower incisor is your reference point it's always the lower arch because you can't change it. But I just don't think we've been taught on how to use CBCT. I anyway I'm hoping I'm hoping that if we can you if you can pop if we can popularize this measurement tool or this analysis more then then it really won't it'll it will make it a much easier conversation to have because you can get people to do expansion if they don't even want to think about it away which is silly but they'll get it once they start doing it I think that's my hope at least that's a um so anyways I'm glad to glad to hear you enjoyed it.

SPEAKER_01 2:25

I love that uh for the intermolar width I'm also not a huge fan of measuring um clinically as much so what

Making CBCT Measurements Useful

SPEAKER_01 2:33

I do I usually use a caliper and I tell all my patients whenever you put this in in in the in the palate don't touch the teeth I want you to close a little bit more go a little bit higher and touch the palate actually going to poke yourself with these on the palate because I want to see how much room the tongue has and not necessarily uh how wide the teeth are you know how far apart uh three and 14 are because yes you're gonna get skewed measurement so even on the CBCT I had a meeting with a TrueView and Beam Readers they're two companies that are actually designing protocols.

SPEAKER_00 3:08

I I actually just finished designing the protocols for airway uh airway circle so if you guys call these companies and say we want the airway circle protocol uh it's gonna be an option uh besides the basic things for the CBCT readings that they're doing they're gonna have all these extra uh images that we are we think we think that are very beneficial for anybody looking at airway um malofunctional therapy dentists and orthodontists um so anyways I was selling them whenever they were measuring you know they usually measure the CJ I was like can you go like a little tiny bit more on my to make sure that you're on the palate

Buccal Bone, Recession, And Limits

SPEAKER_00 3:43

um so the reason the reason I use the the buckle so originally that analysis I did I I took it out of the the lecture because I I didn't know if we'd have time but that analysis originally was talking about uh periodontal tissue so the rationale for using the buckle bone the buccal cortex yeah is that if you if you make the maxilla broader you can dentally expand the teeth further into the maxilla but if you if you try to use a let's just say you put on some braces of the heavy wire you can translate those teeth outside of the maxilla and it looks like you've done a good job making the you know well you've made the tongue space bigger stuff over time though those patients in their 2030s and 40s they start exhibiting tons and tons of buckle recession because those there was no bone there to begin with so what I want what I want to know in terms of just positioning teeth is do I have enough room on the buckle to tip teeth that way or not? And if you make the palate bigger the entire complex goes with it. And so that buckle bone is changing whatever you know wherever you want to measure it but the buckle aspect is more useful for me because I can then see where the teeth I can I can then see where I need to move. Exactly um is there any hope for an adult who has recession buckle recession uh yes there is I mean I think um you know I I think there is what causes recession a lot of the times is you know people always would just say toothbrushing or whatever but really it's function and occlusion. So those compensated discrepancies quite frankly when you look at those as adults they're almost always exhibiting buckle recession on the especially on the lower posterior teeth which are lingually inclined as they're occluding they're bending those teeth and they're that that buckle bone pulls away over time. It's like I think someone described like a fence post in the ground every time if you do this every night but the component there underneath all that is functioning. So if you have someone who doesn't grind their teeth at night at all there's no reason for the there's no reason for that bone to to resorb like that but someone who's functioning super heavily it's an issue. So for for those patients I mean you know grafting is one but grafting typically will just delay it's like a band it'll put a band aid on the problem. SFOT or PAO um the the basically the corticotomies in grafting but it doesn't build up new bone but what you're trying to do really is prevent future recession. So for someone who wants to be most super conservative I mean you can make a night guard and that sometimes is buys you some time but when I do you know that's where MARPs come into play and in the way you design the Marpees if you need to because if that's that's the problem those teeth are being inclined like this then you can build a Marpey and then once you secure in the palate you can cut all the appliance off the teeth and then you're expanding only the bone not even that you so there's no there's no dental effects and and the when I used to do SARBs when in residency and early in my career where it was just a surgical expansion typical you end up getting a lot more buckle recession because along with moving the the jaw you move the teeth out of the bone

MARPE To Expand Bone Safely

SPEAKER_00 6:53

and then you just kind of have to pretty much manage it. But I think the the Marpeys have definitely changed that equation. I think um and it depends on severity but I've also seen the other the scenario that I see more often honestly is is over constricted arches. So it's not just over expanded arch it's over constricted arches. And I've seen a lot of especially in extraction cases if they what I what I I went back after I did this analysis and I I I looked at a few of my older extraction cases that I did early in my career and what I found was the when you extract you move the posterior teeth they move forward a little bit and you actually end up resolving the transverse discrepancy by moving the teeth into a different part of the arch. If you go back and look at the CBCT

Overconstricted Arches And Extractions

SPEAKER_00 7:41

on a few of the uh patients that I had um I actually was extracting on maxillas that were a little too narrow and if I had expanded them I would have gotten the space that I needed to not do that. And I wouldn't say extractions are never indicated I mean that they're just very I I I just don't do them rarely if you get them on early enough quite frankly I don't see how you can't get there. I've had you know mesial space loss it's just the window is very small in my opinion it's not nearly as wide as we wanted it to be um and I think we're just I think we're treating a not that not treating the root cause I think we're just treating the teeth because that's what we see. But the tree the teeth just um the teeth are easy to treat if the bone's in the right spot you know can we put that on a billboard?

SPEAKER_01 8:28

What's that can we put that in a billboard somewhere? Yeah sure they got to um my goodness I have so many questions okay so an adult who has recession and a constricted maxilla there's still hope is it still safe for them to get maybe a MARP and then have braces or invisalign afterwards what could possibly happen to that recession do you usually recommend having grass then before or do you can you move the I'm I'm not an orthodontist can you move uh the teeth in the dental bone after they're expanded in the MARP and I mean the bone will never grow on the buccal again if there's right so so I would say you it depends on in terms of the graph so the answer is yes and it designed the way you would design your MARP is to not touch the teeth right so you I would do that in conjunction with a periodonist I have a few colleagues that I work with um if you need if you're worried about the recession worsening or if you have lingually inclined teeth with recession typically in terms of uprighting those teeth especially on the lower um you would do SFOT or PAO so basically corticotomies flaps bone grafting and uprighting and then what you do is it's not that you gain bone back but the cortical plate then is allowed to move with the teeth as opposed to the teeth moving through the cortical plate.

SPEAKER_00 9:50

You can do that the anterior the posterior so what I've seen most often is uh and uh Rick Robley's done a lot of this he's the surgical that does a lot of cool stuff a lot

Managing Adult Recession Risk

SPEAKER_00 10:01

of cool stuff um is is Marp beyond top with lower aligners and SFOT so he's he's and broadening the cortical plate base basically for your lower arch so the answer is yes I mean I think you always have to look out for that but what to really the reality of it is what I see most of it's not just I mean a little recession I hate to say little recession is not going to kill you the it what what causes teeth to fail is is severe progressive untreated occlusion recession. So like someone who's left a you know who's functioning really heavily on a tooth uh grinding a lot on these teeth and the bony base just dissolves away eventually you know I think periodonist I've seen periodonists keep very recessed teeth in the mouth without any problem but I guess for me as an orthodontist my my always concern is like if I if my because we don't get to see our patients really after a lot when they're like 15, 16, they leave. So I always wonder what my patients are going to look like when they're 30 or 40 because I see a lot of adults as well I do a lot of restorative treatment and I I uh if I my you know on expansion and stuff like that if I get the teeth upright at least I'm giving the best shot. I won't guarantee they never have recession but at least I'm giving a better shot that they won't and that they won't have as many dental issues down the road.

SPEAKER_01 11:18

So for what kind of a message can you send to dentists who are doing full cosmetic cases on patients who do not have a staple occlusion.

SPEAKER_00 11:30

Yeah so I think for for dentists who are doing like full cases full mouth cases and stuff um you know that's what we teach a lot at Spear is to have a diagnostic process. We have a what what originally was called the EFSB method is aesthetics function structure biology and then added to that was airway uh so it's now airway aesthetic structure function biology. So um in terms of comprehensive cases the aesthetics of what Frank Spear always taught was the aesthetics drives the plan. But underneath that you have the structure and the biology of the occlusion and you have to get that to work in your favor. Airway is the component which controls most of a lot of the function. So if you have patients who have bad airway they're the ones who you're gonna have to rehabilitate. But the problem is you know you do a full mouth rehab and not that I've done full mouth rehab but if you've done that and it breaks down on you, I mean that's a that's a bad day. So what Rouse's Jeff Rouse at at Spear brought into it was you know he's a prostodontist by trade. He's not you know he's not an orthodontist or a pediatric dentist or whatever he's a prostodontist and it's the you you see prostodonic failures or people who have these longstanding chronic problems of recession shipping you know it's it's oh it's recession uh wearing of the teeth and carries those are your three chronic long-term

Planning With Airway At The Top

SPEAKER_00 12:51

problems and maybe not as much carries but the other two are mostly just if someone's clinching and grinding their teeth or not because you you you use your teeth sparingly during the day unless you're eating or swallowing you do it a lot at night which you can't control. So if you have an unstable base, you know you you have to build from the ground up and airway is the base. I mean that's it that's where airway got moved to the top of that pyramid uh it's you know airway EFSB. So if the patient's airway is a mess if you don't control that you can do as much dentistry as you want uh and people do and then you can watch it you can watch it fail and and that's that's what people are missing a lot of times.

SPEAKER_01 13:34

So his course is great for restorative dentist I mean it's designed for restorative dentists uh because they see these problems and now that I'm in that world I see those problems um a lot amazing couple more questions before we go if you have time um a child who is a class two uh but they're bimaxillarily retruged all my orthodontist friends always ask me Bernara if I extend them and they move forward more what am I gonna do with the mandible? And I would say I don't know because I'm not an orthodontist but I see people do different types of treatments. I know that you know functional therapy mind to bring the mandible forward I need to make sure that I can bring the tongue forward up and forward so if they have a tongue tie if they just have low tongue posture um nasal obstruction I know that I can you know do what I what I do to make sure that the tongue can move up and forward but as an orthodontist what are your options?

SPEAKER_00 14:35

Well my thinking on class twos has changed a little bit I mean I first of all I have seen many patients with expansion and class twos self-correct

Class II, Expansion, And TMJ Links

SPEAKER_00 14:44

or improve their class two relationship a lot. And McNamara talked about that for years and when you start doing you start seeing more of it not everybody. The other part of it is there's also a world that I I'm not as deep into but in the TMJ world there's a lot of thinking about where those disks on those class two patients are being in the wrong spot. The reality of it is most class twos will get better with expansion and a lot of times the class twos are not as severely class two. If your arch is very narrow it pushes your front teeth out to a lot of overjet. When you expand it brings the front teeth back to less overjet and the molars will come forward. So if I can get someone from a full class two to a half step class two then I have a lot more options down the road for me. Now if someone is still a full class two then you're kind of hoping on a herbst to to bail you out of it. I had a herbst appliance when I was younger uh I have I'm a I snore a lot but I have a I have an oral appliance I wear every night to stop me from snoring and my sleep scores are great. So you know it's it's tough um but I I would say there's a a different take on that uh with the TMD people who would want to look at an MRI about where the joints are. What I have found and what McNamara talked about is if you expand those patients, it does unlock the mandible to a certain degree they come forward in your class two lessons over time. Also there's some thinking about you know if someone is mouth breathing where they put their tongue and how how that changes your mandibular position. I suspect just like most everything this is probably part and parcel of the same thing. I think many airway patients have related joint conditions as well. The discs are in the wrong spot. And I feel like a maxilla that's too narrow almost traps your mandible from being allowed to come forward. And if you don't resolve it early enough those patients can develop or I'm conjecturing mostly but can develop more TMD. A lot of patients I've seen with TMD issues have narrow maxillas and the airway problem is what exacerbates the function on all of that and makes it worse. So they're not easy to treat no one's eager to treat those patients but um but for kids at least um I do the same measurements that I did before um it's not a whole lot different and uh and I expand to where I need them to be and I've found a lot of good results with that early um how early do you treat what's the youngest the youngest patient I've treated for with expansion was probably four I believe four to four and a half and it was a uh face mask expansion case. Um so we you know class three patient with airway problems uh Maxilla was you know yay big and the reality of it I I think

Treating Early And Treating Late

SPEAKER_00 17:28

for me that's probably where just in terms of my practice where I uh where I set my bar I I just because of the appliances that I'm used to using that that are fixed traditional appliances and the patient age and tolerance of that um that's where I would that's where I would um stop myself I suppose but the reality of is I mean I see patients my youngest is four my oldest is the youngest patient is four my oldest is 87 so I I I treat patients of all shapes and sizes I mean mostly kids because of what I do but a ton of adults as well. And one is the youngest one even a Marpey and the oldest one even a Marpe on the youngest of then a Marpee was uh she was I think 12 and a half but she so she was one I expand so she was the third sibling both brothers relapsed on me during expansion and so she came in and she rallied relapsed again so I told mom I said look I don't normally do this because at 12 I feel like I can normally I was like I'm just tired of this working and I on uh on my cousin who's also 12 I'm doing just a two tad Marpey like a small little baby one and the oldest patient I had and a MARP is 65. 62 maybe 60 maybe something like that early early 60s full restorative case with it's on Spear Talk if anyone's on Spear but it's a a MARP with lots of restorative components SFOT MARPY uh veneers like it's a fun it was a fun case.

SPEAKER_01 19:00

Any other options for the herbs appliance I feel like most of my patients that get the herbs eventually end up with a very flat maxilla.

SPEAKER_00 19:08

Well that's where yeah that's where you have a uh you have a there's a headgear effect to the herbs appliance to all of class two correcters unfortunately I mean to be honest with you I mean my opinion on on well this is a little bit unorthodox but I'm not as I'm not as torn up by class two patients long term. I think the the question I would say that I'm starting to kind of work out is

Herbst Limits, MRI, And Surgery

SPEAKER_00 19:37

I would want to know where those patients' discs were in their joint. I'd be willing to bet and what I've seen from people and I don't I can't say I don't do this but if you do MRIs in those patients those joints are not in the right spot. And some patients with herpes work out great others don't so you you you the ones you that work out you look like a genius and what I'm thinking is happening is maybe we're recapturing those discs because we're posturing the man and then the in the mandible grows and we look good and then um the ones that aren't in place we never get them and then they look okay and then they click so I I don't have a great uh I don't have anything that's super different than that. But I do a lot I will also say this I do a lot of surgery I with this with an oral surgeon and if I have borderline herbs cases which are a bit of a stretch I don't I have no problem just saying look you'd better off either staying here or doing surgery. And airway is the kicker to get him over the hump. You know you if I had a larger mandible I'd probably Wouldn't have to wear my snoring appliance that I have at night.

SPEAKER_01 20:45

All right, last question.

SPEAKER_00 20:46

Yeah.

SPEAKER_01 20:47

At what point during your treatment do you recommend myofunctional therapy?

SPEAKER_00 20:52

Uh it is as soon as I can as soon as we need it. I mean, I think I a lot of times um it it kind of depends on the tongue tie, but most of the time, if I have a patient with uh a tongue tire, bad tongue posture, all those kind of things, uh, I'll refer them and then expand, and then they'll be seeing them during and after. That's what we've mostly worked out. And I've also had some adults who need it too. Um, I've had some patients who go through with it, I've had others who kind of balk at it. I will say if we change the relationship, it tends to be a lot more stable. But um, this is whenever we can. I've worked with some good people in the area

When To Add Myofunctional Therapy

SPEAKER_00 21:30

um that have that have been very kind to me.

SPEAKER_01 21:33

So awesome. All right. Well, thank you so much. I'm so sorry I kept you longer. I wanted to I have so many questions that we're actually gonna put all these questions in our uh podcast. It's called Beauty of Breathing. So if you guys are not following us on your favorite podcast platform, please do so. Thank you so much, Dr. Teller. This has been absolutely wonderful. You guys, I'm gonna put all his information in the Aerie Circle Professional stage if you'd like to follow him. Um, have a wonderful weekend. Thank you so much.

SPEAKER_00 22:01

So much, bye-bye.

SPEAKER_01 22:03

All right, bye bye.