1. The Myobrace System -A hammer for a houseSat-Sun, January 18-19, 2014 dr. barry raphael the raphael center for integrative education www.alignmine.com drbarry@alignmine.comDay 2 AM Sunday, January 19, 14

2. Airway-focused Orthodontics 1.Airway-focused Diagnostics 2.Prevention 3.Undo the Damage 4.Establish Good Habits 5.Interdisciplinary Treatment Nothing changes unless something changes. - R. PriceSunday, January 19, 14 3. 4. Ancillary Modalities 1.Education and Motivation 1.The Activity Center and Health Educators 2.Educational materials 1.Activities Book 2.Parent CD 3.Trainerkids.com 4.Myobrace.com 2.Prevention 3.Expansion mechanics 1.BWS/ALF 2.Palatal expanders 3.Biobloc 4.Myofunctional Therapy 5.Ortho-postural Training 6.Nutrition Sunday, January 19, 14 4. Its NOT about the Trainer Part 1Sunday, January 19, 14 5. You mean I have to pay $7 for this?Sunday, January 19, 14 6. Now thats a bowl of oatmeal! Yum!Sunday, January 19, 14 7. Its about the VALUE youre adding Habit Training Better Breathing Nutrition Trainer and straight teeth Overall health Sunday, January 19, 14 8. Its NOT about the Trainer Part 2Sunday, January 19, 14 9. The Process: The Chip ShotThe Goal: To get the ball as near to the cup as possibleSunday, January 19, 14 10. Sunday, January 19, 14 11. Which Hammer should I use?Sunday, January 19, 14 12. Which Trainer should I use?Sunday, January 19, 14 13. Its not the Trainer Its the TrainingSunday, January 19, 14 14. When should treatment begin?Sunday, January 19, 14 15. A tree brace This is a tree brace. It helps the tree grow straight in the face of environmental forces (ie: wind, waves, trucks, etc.) Sunday, January 19, 14 16. Here is a bent tree. If you had wanted it to grow up straight, when would you have applied the brace?A) Lets wait for all the branches and leaves to grow in rst. B) When the tree was young, before it started to bend C) Will you repeat the question? Sunday, January 19, 14 17. Airway-focused Orthodontics 1.Airway-focused Diagnostics 2.Prevention 3.Undo the Damage 4. Establish Good Habits 5.Interdisciplinary Treatment Our ultimate goal is to keep children from getting sick. By knowing the causes, we can prevent the disease.Sunday, January 19, 14 18. Pre-natal careSunday, January 19, 14 19. FrenectomyFrom Paula Fabbie, COM Sunday, January 19, 14 20. Internal FrenectomyFrom Paula Fabbie, COM Sunday, January 19, 14 21. MUST DO P.T.PRE- AND POST-operative Mobility Exercises Clucks Caves Palate Wipes Waggle Spots and Waggle FlapsFrom Paula Fabbie, COM Sunday, January 19, 14 22. Breast-feedingSunday, January 19, 14 23. ADHD/Breastfeeding/Malocclusion/ dental trauma/SDB Understanding the relationships between breastfeeding, malocclusion, ADHD, sleep-disordered breathing and traumatic dental injuries. Sabuncuoglu O., Med Hypotheses. 2013 Jan 7. pii: S0306-9877(12)00566-X. doi: 10.1016/j.mehy. 2012.12.017. [Epub ahead of print]Sunday, January 19, 14 24. Nutrition Soft Processed and Pre-cooked foods Limit muscular exercise and development Fail to stimulate osseous development Fail to develop muscular coordinationSugar over-feed bacteria in the mouth and gutSunday, January 19, 14 25. Hardening the Diet start with fiber crackers then fruits, fresh and dried then vegetables then small, cooked meat progressively over 4 to 12 months, depending on childSunday, January 19, 14 26. Baby Led Weaning Starting at 6mo Give baby real food Let them explore and choose Establish Chewing skills naturallySunday, January 19, 14 27. Oral Habits Thumb Sucking Paciers Nail Biting Tongue Sucking Object Mouthing Lip Biting Chin-Leaning Trichotillomania Sunday, January 19, 14 28. Thumb suckingFor pleasure and comfort...To prop open the airwayTo relieve a cranial strainEach type needs a different approach Sunday, January 19, 14 29. AdenectomySunday, January 19, 14 30. Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome -Clinical Guidelines-Technical Report-Carole L. Marcus, MBBCh, Lee J. Brooks, MD, Sally Davidson Ward, MD,Kari A. Draper, MD, David Gozal, MD, Ann C. Halbower, MD, Jacqueline Jones, MD, Christopher Lehmann, MD, Michael S. Schechter, MD, MPH,Stephen Sheldon, MD, Richard N. Shiffman, MD, MCIS, and Karen Spruyt, PhDAmerican Academy of Pediatrics SUBCOMMITTEE ON OBSTRUCTIVE SLEEP APNEA SYNDROMEhttp://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1672 Sunday, January 19, 14 31. Symptoms and Signs of OSAS History Frequent snoring (3 nights/wk) Labored breathing during sleep Gasps/snorting noises/observed episodes of apnea Sleep enuresis (especially secondary enuresis)a Sleeping in a seated position or with the neck hyperextended Cyanosis Headaches on awakening Daytime sleepiness Attention-decit/hyperactivity disorder Learning problems Sunday, January 19, 14Physical examination Underweight or overweight Tonsillar hypertrophy Adenoidal facies Micrognathia/retrognathia High-arched palate Failure to thrive Hypertension 32. The 8 KEY ACTION STATEMENTS 1.Screening for OSAS As part of routine health maintenance visits, clinicians should inquire whether the child or adolescent snores2. Referral and Testing Regular snoring or S&S should be referred for PSG, ENT eval, SM eval, or other tests (video, home study) sensitivity and specicity of the history and physical examination are poor 3. Tonsiloadenectomy Has OSAS AND hypertrophy, the T&A is rst line of treatment. 4.High Risk T&A Monitor Postoperatively 5.Revaluation Further treatment is necessary in approx 21% (in obese, 73%) 6.CPAP If T&A cant be done or didnt work Compliance is a problem 7.Weight Loss If needed, with everything else 8.Nasal Sprays intranasal corticosteroids for children with mild OSAS (pre- or post T&A) Sunday, January 19, 14 33. Protocol for Swollen Lymph Exam and History Shrink Tissue Medication YesBreathing Modication No T&ABreathing Modication Sunday, January 19, 14Nasal Breathing Reduced BreathingDiaphragmatic 34. Shut you mouth and save your life.Sunday, January 19, 14 35. Dear Barry, You should be at this point at about 9:15. Yours, RogerSunday, January 19, 14 36. Airway-focused Orthodontics 1.Airway-focused Diagnostics 2. Prevention 3.Undo the Damage 4. Establish Good Habits 5.Interdisciplinary Treatment As much as possible, reverse the condition TOWARD the genetically programmed ideal. Sunday, January 19, 14 37. Undoing the DamageThe appropriate treatment for a Collapsed Maxilla Moves/Grows the Maxilla (up and) forward AND the Mandible rotates and moves forward Sunday, January 19, 14 38. Treatment Goals Based on Upper Incisor (UI)Sunday, January 19, 14 39. Incisor Goals Type 1 Treatment: Place U1 in ideal positionBiobloc Orthotropics, Orthognathic Surgery, Distraction Osteogenesis Sunday, January 19, 14 40. Incisor Goals Type 2 Treatment: Expansion enough to uncrowdMyofunctional Ortho, Myofunctional Therapy, Crozat, ALF, Expansion Orthodontics Sunday, January 19, 14 41. Incisor Goals Type 3 Treatment: Maintain UIFunctional Orthodontics, Expansion Orthodontics, Distalization Ortho or No Treatment Sunday, January 19, 14 42. Incisor Goals Type 4 Treatment: Retract/Extrude UIExtraction Orthodontics, Retraction Ortho, Distalization Ortho Sunday, January 19, 14 43. Treatment for Bimaxillary Dysplasia1. Maxillary Expansion 2. Maxillary Advancement 3. Maxillary Impaction 4. Mandibular AdvancementBackB. Hockel 2012 Sunday, January 19, 14 44. Treatment for Bimaxillary Dysplasia 1. Maxillary ExpansionHyrax Haas Niti Exp Sunday, January 19, 14BioBloc SchwartzALF Crozat Bent Wire 45. The Farrell BENT WIRE SystemSunday, January 19, 14 46. Arch Development in conjunction with the TRAINER SystemRecommended Age Group: 10 - 15+ yrs Simultaneous arch development and myofunctional training.Sunday, January 19, 14 47. The Farrell BENT WIRE SystemArch Lengthening Sunday, January 19, 14 48. The Farrell BENT WIRE SystemArch Expansion Sunday, January 19, 14 49. The Farrell BENT WIRE SystemIncisor Advancement Sunday, January 19, 14 50. BIOBLOC and BWS System ARCH DEVELOPMENTTongue Position and Function Sunday, January 19, 14 51. BWS : FabricationBending the BWSSunday, January 19, 14 52. The BWS - Upper - FabricationSunday, January 19, 14 53. BWS : Placement Adapted WireSunday, January 19, 14Ideal Wire 54. BWS : Placement Advanced Lightwire FunctionalSunday, January 19, 14 55. BWS : Placement Adapted WireSunday, January 19, 14Ideal Wire 56. BWS: Adjustments Undo KinksSunday, January 19, 14 57. Treatment for Bimaxillary Dysplasia 1. Maxillary Expansion 2. Maxillary AdvancementBioBloc Sunday, January 19, 14 58. Effects of Maxillary Protraction and Fixed Appliance Therapy on the Pharyngeal Airway Emine Kaygsz et.al., Angel Orthodontist, Volume 79, Issue 4 (July 2009)25 x 11 year olds Reverse Pull HG, 350 g, 14h/d for 6 months Follow-up 4 years post-treatment 2D analysis only (cephs) ...the maxilla continued to grow forward after treatment, which was maintained in the long-term observation. improved the nasopharyngeal and oropharyngeal airway dimensions initially, . was maintained at long-term follow-up. Sunday, January 19, 14 59. Expansion and Protraction Biobloc Expander, RPHG, OMT over 24 monthsCourtesy: Dr. Kevin Boyd Sunday, January 19, 14 60. Expansion and ProtractionExpansion and Protraction, 2x4 over 24+ monthsCourtesy: Dr. Kevin BoydSunday, January 19, 14 61. Widen, Advance, Intrude, then1. Maxillary Expansion 2. Maxillary Advancement 3. Maxillary Impaction 1 3 42B. Hockel 2012 Sunday, January 19, 14 62. ...Extract or Equilibrate Primary Occlusal Stops1. Maxillary Expansion 2. Maxillary Advancement 3. Maxillary ImpactionB. Hockel 2012 Sunday, January 19, 14 63. And Autorotate the mandible closed1. Maxillary Expansion 2. Maxillary Advancement 3. Maxillary ImpactionB. Hockel 2012 Sunday, January 19, 14 64. Treatment for Bimaxillary Dysplasia 1. Maxillary Expansion 2. Maxillary Advancement 3. Maxillary Impaction 4. Mandibular DecompensationBioblocFixed Protrusion Sunday, January 19, 14IMDO 65. Dr. John Mew Sunday, January 19, 14 66. Once that happens we begin the last phase: Walking the lower jaw forward while the remaining adult teeth come in.B. Hockel 2012 Sunday, January 19, 14 67. And THAT is the beauty of Biobloc!B. Hockel 2012 Sunday, January 19, 14 68. And THAT is the beauty of Biobloc! There is currently no other technique in orthodontics except for facial surgery that can change the face in this way. Not only does the face look better, but the lips can close more easily, the tongue can rest on the palate, and the breathing space behind the mouth is more open. All good things! B. Hockel 2012 Sunday, January 19, 14 69. Principles of Biobloc 1.Treat Early (before deciduous molars lost) 2.Over-treat 3.Long Retention 4.Myotherapy to establish neutral postureSunday, January 19, 14 70. Myobrace or Biobloc? Severity Age and StageSkills AcceptanceGoals Commitment FeeMyobrace Sunday, January 19, 14Biobloc Myofunctional Therapy 71. Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome -Clinical Guidelines-Technical Report-Carole L. Marcus, MBBCh, Lee J. Brooks, MD, Sally Davidson Ward, MD,Kari A. Draper, MD, David Gozal, MD, Ann C. Halbower, MD, Jacqueline Jones, MD, Christopher Lehmann, MD, Michael S. Schechter, MD, MPH,Stephen Sheldon, MD, Richard N. Shiffman, MD, MCIS, and Karen Spruyt, PhDAmerican Academy of Pediatrics SUBCOMMITTEE ON OBSTRUCTIVE SLEEP APNEA SYNDROMEhttp://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1672 Sunday, January 19, 14 72. Rapid Maxillary Expansion Two case studies without controls (level IV) Study 1 31 patients 4 months after RME, all patients had normalized AHIPirelli P, Saponara M, Guilleminault C., Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27(4):761766 Study 2 14 eligible sleep center patients a signicant improvement in signs and symptoms of OSAS as well as polysomnographic parameters Villa MP, Malagola C, Pagani J, et al. Rapid maxillary expansion in children withobstructive sleep apnea syndrome: 12-month follow-up. Sleep Med. 2007;8(2):128 134Data were insufcient to recommend rapid maxillary expansion. Sunday, January 19, 14 73. Rapid Maxillary Expansion Conclusions an orthodontic technique that holds promise as an alternative treatment of OSAS in children maxillary expansion may be effective in specially selected patients data are insufcient to recommend its use at this time. Biobloc Orthotropics holds great promise for the treatment of OSA is Children - Stephen Sheldon, 2012 Sunday, January 19, 14 74. Dear Barry, It should now be 10:00. Lets take a break for 15 minutes. Thanks, TiffanieSunday, January 19, 14 75. Airway-focused Orthodontics 1.Airway-focused Diagnostics 2. Prevention 3.Undo the Damage 4. Establish Good Habits 5.Interdisciplinary Treatment Retraining Proper Oral-Rest Posture, Oral Function, and other good health habits for a lifetime of stabilitySunday, January 19, 14 76. Establish Good HabitsSTAGE 1HABIT CORRECTION4-6 MONTHS Sunday, January 19, 14STAGE 2ARCH EXPANSION4-6 MONTHSSTAGE 3FINAL ALIGNMENT & RETENTION4-6 MONTHS 77. Trainer Activities Purpose: To apply Myofunctional Therapy principles on a broad scale. Assumption: One-on-one MFT is impractical on a large scale. We can use Myobrace to do MFT and train new habits. Must be done in conjunction with Myobrace wear.Sunday, January 19, 14 78. Sunday, January 19, 14 79. Sunday, January 19, 14 80. Trainer Activities MRC Activities Workbook Groups 1,2,3, extrasSunday, January 19, 14 81. Activity Score SheetSunday, January 19, 14 82. COMBINING ORTHODONTICS WITH MYOFUNCTIONAL THERAPYLESS TIME CONSUMING BUT EDUCATION IS STILL NEEDED Sunday, January 19, 14 83. Trainer Activities MRC Activities Workbook Groups 1,2,3, extras www.trainerkids.comSunday, January 19, 14 84. NEW PATIENT EDUCATION CDMOST USEFUL FOR PARENTS AND DOCTORS Sunday, January 19, 14 85. NEW PATIENT EDUCATION CDMOST USEFUL FOR PARENTS AND DOCTORS Sunday, January 19, 14 86. Orofacial Myofunctional Therapy Oral Myology Myofunctional Therapy Tongue Thrust TherapySunday, January 19, 14 87. Myofunctional Therapy The study of normal function of the muscles of the mouth Tongue Masticatory muscles Facial musclesProtocols Group Therapy Individual Therapy Sunday, January 19, 14 88. Myofunctional Therapy Neutral Rest Posture Normalized function bite, chew, and swallow Eliminate noxious behaviors Planning: assessment, examination,diagnosis, treatment planning, implementation of a therapeutic process Evaluation of outcomes Sunday, January 19, 14 89. Neutral Rest Posture Tongue rests lightly on palate or slightly away Dental Freeway space is open Minimal masticatory muscular tension (contraction) Minimal pressure or tension within TMJs Facial muscles relaxedThe position from which all functional movement can beginSunday, January 19, 14 90. Myofunctional Therapy helps OSA Effects of Oropharyngeal Exercises on Patients with Moderate Obstructive Sleep Apnea Syndrome Katia C. Guimaraes, et. Al. AM J OF RESP AND CRITIC CARE MED VOL 179 2009, p962-966 RCT, n=16 adults 3 months of exercise training reducedthe severity of OSASby 39% (by AHI and lowest O2 sat) a reduction in snoring, daytime sleepiness, and quality of sleep score signicant reduction in neck circumference muscle training while awake will reduce upper airway collapsibility during sleep in patients with OSAS. improvements in several subjective sleep scalesSunday, January 19, 14 91. It is a sad state of affairs that for every 100 orthodontists in this country there is only one oral myologist when it should be the other way around - Dr. Bill Hang, 2013Sunday, January 19, 14 92. Dear Roger, It should be about OK, now its your turn. You have 45 minutes for your section, if you will be so kind. Sincerely, BarrySunday, January 19, 14 93. Ortho-Postural Training Better breathing Reduced rate and volume Restore diaphragmatic function Better posture Sitting, standing, sleeping Roger Better Nutrition Price Real food Harden the diet Better oral rest posture and function Better sleep habits and breathing Nothing will change if nothing changes. Sunday, January 19, 14 94. 90% OF PEOPLE WITH A SLEEP DISORDER REMAIN UNDIAGNOSEDUnaware that such things exist. Unaware that they have such a disorder In denial when theyre advised of it Fearful of doing anything about itWHAT IS REQUIRED IS A SYSTEM THAT IS:SIMPLE LOW COST EASY TO IMPLEMENTSCIENTIFIC CLEAR AND CONCISE IN THE INFORMATION PROVIDEDFREE FROM ANY MEDICAL OR INSURANCE REQUIREMENTINTEGRATIVE SLEEP HEALTH EDUCATION Sunday, January 19, 14 95. + The Facts SECOND ONLY TO HEARTBEAT WE BREATHE MORE TIMES A DAY THAN ANY OTHER FUNCTION IN THE BODY. The average person, living a Western lifestyle, breathes around28,000 to 30,000 breaths a day.If each breath is just a fraction out of balance the cumulative effect can have a signicant impact on health.Sunday, January 19, 14 96. + The Science Newton and Bohr NEWTONS THIRD LAW OF MOTION Sir Isaac Newton 1642 - 1727Every action has an equal and opposite reaction. THE BOHR EFFECTChristian Bohr 1855-1911As the pressure of CO2 in arterial blood drops so does the bond between O2 and hemoglobin strengthen. (the reality of this is that O2 ow to the brain and other cells is reduced causing hypoxia, apnea, disturbed sleep, chronic tiredness, memory and attention issues and many more complications.)Sunday, January 19, 14 97. + The Science - Hypocapnia Denition: Noun1.hypocapnia - a state in which the level of carbon dioxide in the blood is lower than normal; can result from deep or rapid breathing. Hypocapnia causes smooth muscle bands around hollow organs to constrict, resulting in multiple dysfunctions in the various smooth muscle systems in the human body. HypertensionBronchoconstriction, Asthma Anxiety/Panic attacks Sunday, January 19, 14 98. + Hypocapnia affects the entire bodySunday, January 19, 14 99. + How efficiently are you functioning? Efficient systems: last longer cost less to run seldom break down require less maintenance If you are able to get your patient to understand that if: sleep posture breathing are efficient, then the body is in balance and is running as smoothly as it can.Sunday, January 19, 14 100. + How to do this? SLEEP EFFICIENCY: Sleep Image SnoreLabBREATHING EFFICIENCY: Capnometer reading Comparison with standardPOSTURE EFFICIENCY: Photographs against grid Highlight anomaliesSunday, January 19, 14SleepBreathingPosture 101. +Sleep Efficiency CPC (Cardiopulmonary Coupling) Spectral Imaging will correlate: Time Breathing Movement Heart Rate REM Sleep Body Position Snoring (graphic) Sleep Spectrogram SQI - Sleep Quality Index HFC - Stable Non-REM Sleep LFC - Unstable Non-REM SleepSunday, January 19, 14 102. +Sleep Efficiency Breathing and Snoring Set relevant parameters such as: Alcohol Sedatives Stimulants Hot bath Dental appliance Report will indicate: Hours slept Snore score Time of snoring episodes Audio of breathing/snoring Can pinpoint restless movementSunday, January 19, 14 103. + Breathing Efficiency The Breathing Efficiency Check will highlight the following: Inefficient Breathing End tidal CO2 Breathing rate Breathing dynamics Breathing mechanics Oxygen release potential Response to external stimuli Effect of posture on breathingSunday, January 19, 14Efficient Breathing 104. + Posture Efficiency - daytime Posture photographs will show: Lateral balance Midline balance Shoulder position Mouth open or closed Forward head position Kyphosis and Lordosis Compensation mechanisms Foot mechanics pronation, supination or mixed ascendingSunday, January 19, 14 105. + Posture Efficiency night time Much night-time restlessness is as a consequence of daytime postural and physical dysfunction. The body is trying to nd a place where it is not in distress and that is why people often land up in quite weird positions. This again is manifestation of Newtons Third Law as often it is the action of the day that causes the reaction at night. Breathing is severely compromised during night-time acrobatics. Many allergies and night-time asthma attacks are as a consequence of people breathing into their pillows and bedding and inhaling dust, aked skin particles and other airborne allergy triggers.Sunday, January 19, 14 106. + The greatest amateur anatomist James Weldon Johnson, born 1871 and died 1938, composer and songwriter and creator of Dem Bones. Anybody who fails to recognize that the human body is an intricate complex of eleven independent yet interdependent systems will fail to achieve a stable and long-lasting outcome. It is simply inefficient to try to treat a comorbid condition by focusing on only one aspect.Sunday, January 19, 14 107. + The Western Medical System John Maynard Keynes, the noted British economist summarized it perfectly. It is more acceptable to fail conventionally than to succeed unconventionally The irony of it all is that what we teach IS conventional it is most of the other stuff that is unconventional.Sunday, January 19, 14 108. + Promote your status as a Doctor Patients need to be educated that their dentists are not simply skilled technicians but are also highly trained and experienced Oral Physicians. This can be achieved by setting up your practice to emphasize that you evaluate the entire person, not just the teeth.Sunday, January 19, 14 109. + Education is the key Until dentists realize, and can get their patients to understand, that the teeth are usually not the problem, and that there are numerous underlying factors that have either caused the problem or are getting in the way of correcting them, failures and relapse will continue to happen. This can be achieved by regular information sessions, talks and other community educational activities, for both the public as well as associated health practitioners.Sunday, January 19, 14 110. + Change how they view you For as long as the emphasis of your practice is on: Smile White Teeth Straight Teeth Pearly Whites Laser treatment Pain Free dentistry your patients will regard you as a skilled technician and not expect you to know anything about, or talk to them about anything other than TEETH.Sunday, January 19, 14 111. + Practice Integrative Dental Care By inserting a single word Integrative into the name of your practice, you and your team are then in a position to explain to your patients that yours is not just a General Dental Practice. You in fact not only look at the Teeth attached to the Patient but also closely look at the Patient attached to the TeethSunday, January 19, 14 112. + The information trap Thanks to the Internet most people have a vast amount of information on a wide range of topics especially pertaining to their health. What is often missing however, is the knowledge to make sense of all this information, and the reason we have developed the Berg Education program is to address this issue. By educating your patients you will be able to create an awareness of what they can do for themselves to make your treatment more effective and stable.Sunday, January 19, 14 113. +Berg Education Using the principle of the Iceberg, where only 10% is visible, and the danger lurks in the 90% that cant be seen, it becomes simple for your patients to understand that the Symptoms they are seeing and feeling are only the Tip of the Iceberg. When they see what is going on under the surface they will appreciate that there are other issues to be dealt with in addition to the physical and mechanical adjustments.Sunday, January 19, 14SYMPTOMSOther underlying issues causing or aggravating the initial problem 114. + The Toothberg People do not catch: Open bite Malocclusion Tongue thrust Crooked teeth Forward head positionThis is a consequence of what they are doing. Unless they change what they are doing they will not change what caused the problem in the rst place.Sunday, January 19, 14Other underlying issues causing or aggravating the initial problem 115. + The Sleepberg People do not catch: Apnea Snoring Grinding Clenching Malocclusion Tongue thrust Crooked teeth TMJ disorders Forward head positionThese are a consequence of what they are doing, and unless they change what they are doing they will be working against the treatment.Sunday, January 19, 14Other underlying issues causing or aggravating the initial problem 116. + The Jawberg TMJ disorders are a complex of multiple dysfunctional patterns in day to day life. Included in these can be: Consequences of previous dental and orthodontic treatment. Degradation of teeth and jaw integrity. Severe damage from bruxing and clenching. Damage done by reux and medications. Failure to address and treat these issues can seriously affect remedial treatment.Sunday, January 19, 14Other underlying issues causing or aggravating the initial problem 117. + The Stressberg That Stress is extremely harmful to our health is a well known fact, but Stress is usually regarded by most people as the emotional condition brought about by worries, problems and other life issues. The reality is however that Stress also has other causes, such as postural, dental, environmental, dietary and occupational dysfunction which aggravates the condition. Stress needs to be addressed across all fronts.Sunday, January 19, 14 118. +This is a Dental Team Program Because this is primarily an Educational Program and not Clinical Treatment or Therapy, it is designed to be run almost exclusively by the Dental Team. The dentists primary role is chair-side, and his or her only involvement in this program occurs when evaluating the results, doing the case presentation or providing an overview of progress.Sunday, January 19, 14 119. + Flow chart and involvement Patient at ReceptionExplaining Integrative Dental Care Breathing Efficiency CheckBrief greeting by Dentist ( 2-3 minutes)Issue Sleep Image and SnoreLabResult evaluated by Dentist in down timeNo Problem Dental TeamSunday, January 19, 14No ActionProblem DentistFurther Action 120. +Detailed procedure STEP 1 The purpose is to make a patient aware that this is an Integrative Dental Care practice and that it does things differently. STEP 2 Explain the Berg Education principle and make the patient aware that there is a low cost simple process available to check Sleep and Breathing Efficiency. STEP 3 Invite them to have a complimentary Breathing Efficiency Check while theyre waiting. You will need to get a consent form signed on the basis that this is condential information and subject to Privacy Laws. This will also cover you for taking photographs.Sunday, January 19, 14 121. +Detailed procedure STEP 4 Print out the graph and let them compare it with a functional breathing graph. Let them draw their own conclusions. STEP 5 Explain that the way they sit, stand, walk, talk and function can affect their breathing and offer them a quick Posture Photo session. This will immediately show them that they are out of balance. STEP 6 Explain that dysfunctional breathing and poor posture during the day can carry over to the night and could interfere with their Sleep Efficiency. Offer them the Sleep Image and SnoreLab package.Sunday, January 19, 14 122. +Detailed procedure STEP 7 Tell them that the Dentist will look at the various printouts and decide whether or not they have anything to do with their current symptoms. STEP 8 He/she will then discuss the options available, how they will affect the treatment protocol, when they should be done and will quote an allinclusive fee for the program. Any comment that a lower quotation has been obtained can quickly be countered by asking if that was from an Integrative Dental Care practice. STEP 9 The nal step is the Informed Consent and to get started.Sunday, January 19, 14 123. Ortho-Postural Training Home Education KitWorkbook Stopwatch Tongue Tip Tags TapeSunday, January 19, 14 124. Ortho-Postural Training Home Education Kit Workbook Stopwatch Tongue Tip Tags (cellulose) TapeSunday, January 19, 14 125. Ortho-Postural Training 4. Patient and Parent WorkshopDr. John Flutter Sunday, January 19, 14 126. First learn sit-up-straight and stand-up straight in the correct sized chair Sunday, January 19, 14 127. Identify the diaphragm and feel it move. Sunday, January 19, 14 128. When placed in the correct position the can should rock with every breathSunday, January 19, 14 129. Sunday, January 19, 14 130. CapnotrainerSunday, January 19, 14 131. Breathing Well AppSunday, January 19, 14 132. More Exercises...Additional Exercises From Alfred Rogers Jaw Stretches Neck StretchesSunday, January 19, 14 133. More Exercises...From Kondo Tongue Lift (with gum)Sunday, January 19, 14 134. More Exercises...If you show these to anyone, Ill kill you...From Flutter/Buteyko 3M Micropore tapeSunday, January 19, 14 135. More Exercises... Nasal rinsingSunday, January 19, 14 136. Game:FACE We teach:PowerUPs: things you do that make you Better Villians : things you do that make you worse Allies: people and things that help you Quests: Challenges to meet Epic Wins: All the Ways in which you get BETTER Sunday, January 19, 14 137. Game:FACE PowerUPs and Rewards Program Parent Worksheet1. Set Budget 2. Determine Point Values = (2000/3000/4000)/budget 3. Choose Rewards 4. Earning Points 5. Celebrating Epic Wins Points 100 250 500 1000 Sunday, January 19, 14$/pointPrize ValuePrize #1Prize #2 138. Airway-focused Orthodontics 1.Airway-focused Diagnostics 2.Prevention 3.Undo the Damage 4.Establish Good Habits 5. Interdisciplinary Treatment Only by working together will we get to the root of the problem. Sunday, January 19, 14 139. Context: Dentistry is Medicine Big-Picture Issues related to (Mal)OcclusionEarly Feeding, Nutrition and muscular development Tight Frena and Early Nutrition Posture, musculo-skeletal-cranial stress and facial growth Breathing, Airway and Apnea Soft Tissue Dysfunctions, Habits and malocclusion Sunday, January 19, 14 140. Context: Dentistry is Medicine Big-Picture Issues related to (Mal)Occlusion Multi-Disciplinary Effort: Various dental, medical, and supportspecialties will nd a common thread in preventing and treating airway issues. GPOral myologistOrthoPediatricianChiropractic/PTPedo(Pediatric) ENTHygienistOral SurgPain MedicineEducatorsProstho Sunday, January 19, 14AllergistSleep MedicineBreathing Therapy 141. Context: Dentistry is MedicineThe separation was political andeconomic, (for good reason) but is now coming to an end The dentist as oral physician Broaden your view.....Sunday, January 19, 14 142. My Next Dream Practice Full Time Staff Director/Orthodontist Myofunctional Orthopostural Therapist 2 Health Educators Admin Part Time Staff Chiropractor/Physical Therapist/Cranio-sacral/AK ENT with training in Sleep Allergist with training in nutrition Nutritionist with training beyond the Pyramid Referral Oral Surgeon with training in mid-tongue release Private practices of parttime staff Pediatrician with Integrative background Sunday, January 19, 14 143. Airway-focused Orthodontics 1.Airway-focused Diagnostics 2. Prevention 3.Undo the Damage 4. Establish Good Habits 5. Interdisciplinary Treatment When to start? When damage from poor breathing is noticed or when bad habits are discovered. Sunday, January 19, 14 144. The Goals of Airway Orthodontics 1. 2. 3. 4. 5. 6. 7. 8. Sunday, January 19, 14Breathing through the nose Lips together at rest Correct tongue position No facial muscles moving on swallowing Optimal FORWARD facial development Class I occlusion Straight teeth Better Stability long term 145. Putting it (us) all together Function Nasal clearing Muscle balance and tone Undoing Damage Breathing Dynamics Posture Cranial balance Nutrition Sleep ?Professional ENT, Pulm, OMT, Breathing OMT, Myofunctional Ortho GP, Pedo, Ortho, OMFS OPT, OMT, Breath Phsyio DC, OPT, PT, Osteo Osteopath RDH, Nutritionist, Dietitioan ENT, Sleep Med, Dent ?The Interdisciplinary Center Sunday, January 19, 14 146. Raphael Center for Integrative Education Bodywork Myobrace Activity CenterMyofunctional Therapy Ortho-Postural training Sunday, January 19, 14MedicalPublic and Professional Education 147. 5. Case presentations and patient demos 1. Case results 2. Clinical Case: Assessment 3. Clinical Case: Myobrace delivery and managementSunday, January 19, 14 148. Francesca (Cessa)Sunday, January 19, 14 149. Mixed DentitionSunday, January 19, 14 150. Sunday, January 19, 14 151. What to expect. The Dental Model : Getting Perfection The Medical Model: Getting Better iSunday, January 19, 14 152. Batting Average? Double: Good Trainer Wear. Braces 18mo, Easy Non-XTriple: Good Trainer Wear. Braces 12 mo or aligners to touchup Home Run: Great Trainer Wear. No Braces Needed Sunday, January 19, 14Single: OK Trainer Wear. Braces 24 mo. Crowding or OJ remain Walk: Tries Trainer. Cant/Wont do it. Do Conventional Tx. Strike out: Poor Wear. Case Drags On. Gets nowhere. Braces are a compromise 153. CasesSunday, January 19, 14 154. Case July 2010 9-10y F Class II div 1 Excess OJ/OB Narrow arches Lip Incompetence STD Mouth breathingSunday, January 19, 14 155. Soft Tissue Dysfunctions Lip Incompetence Lip Entrapment Hypermentalis MouthbreathingSunday, January 19, 14 156. Symptoms Deep Bite Excess Overjet Low Frenum Palatal Tissue Trauma Extruded incisorsSunday, January 19, 14 157. Symptoms Tapered upper arch Palatal Tissue Trauma Rotated rst molars Protrusive IncisorsSunday, January 19, 14 158. Symptoms Narrow arch Crowded IncisorsSunday, January 19, 14 159. After TreatmentArch expansion 6 months Muscle Training 12 monthsSunday, January 19, 14 160. 12 month progressSunday, January 19, 14 161. 8 month progressSunday, January 19, 14 162. 12 month progressSunday, January 19, 14 163. Case 1Class II w rotated U6s Narrow and mild crowding Lower midline to right Crowding at LR4 Tight labial musculatureSunday, January 19, 14 164. Case 1Upper BWS 4mos T4K Soft, then Hard 9 mos Lower BWS 2 mos Better arch width and form No crowding Molars still rotated Sunday, January 19, 14 165. Case 1Upper BWS 4mos T4K Soft, then Hard 9 mos Lower BWS 2 mos Better arch width and form No crowding Enough space for LR4 (with leeway and midline shift) Available space on left to correct midline Sunday, January 19, 14 166. Case 1Upper BWS 4mos T4K Soft, then Hard 9 mos Lower BWS 2 mosReduced overbiteNo crowding Enough space for LR4 (with leeway) Sunday, January 19, 14 167. C.F. 7-6F OJ=7mm, Lost c-space, Open Mouth PostureSunday, January 19, 14 168. What do you see?Sunday, January 19, 14 169. What do you see?Sunday, January 19, 14 170. What do you see?Sunday, January 19, 14 171. What do you see?Sunday, January 19, 14 172. Clinical Findings Severe Soft Tissue Dysfunction Anterior Tongue Thrust Open Mouth Posture Hyperactive Mentalis Lower lip entrapment Lip Incompetence Lips dry Large Tonsils Narrow Arches 7mm overjet Lost LR c-space Class II molar Mom had X4s and chin implantSunday, January 19, 14 173. C.F. 8-7yo U-BWS,T4K soft, L-BWSSunday, January 19, 14 174. Treatment Notes is trying to sleep with trainer will really try harder...will try tape doing great with trainer..has started to stay in at night positions tongue between anteriors...reviewed tongue spot still falls out at nightSunday, January 19, 14 175. C.F. 9.2yo Done w/ BWS, doing neck stretchesSunday, January 19, 14 176. Treatment Sequence Month6/10 U-BWS 9/10 T4K soft 12/10 T4K hard 2/11 OJ=8mm 4/11 d/c U-BWS, insert L-BWS 9/11 OJ=1mm 12/11 d/c BWS, cont T4K 10/12 d/c trainer 6/13 U/L Fixed (Goal 9/14) Sunday, January 19, 140 3 6 8 10 15 18 28 177. C.F. 10-1yoF Perm dentition. Still Class II RightSunday, January 19, 14 178. Developing the Arch7-6yo8-7yo9-2yo Sunday, January 19, 1410-1yo 179. Recover Lost c-space7-6yo8-7yo9-2yo Sunday, January 19, 1410-1yo 180. Recover Lost c-space10-1yo 7-6yoSunday, January 19, 14 181. Better Lip Competence7-6yo Sunday, January 19, 1410-1yo 182. C. R. 10-8yo FLate Mixed Dent Crowded incisors FaMu active swallow HypermentalisSunday, January 19, 14 183. Treatment Sequence Month9/11 U-BWS, T4K soft 12/11 Trainer Activities 3/12 Microbond U1-1 7/12 d/c BWS, T4K hard 1/13 Trainer 15min/day 11/13 MB4Sunday, January 19, 140 3 6 10 16 26 184. 10-8yo11-6yo12-0yoSunday, January 19, 1413-0yo 185. 10-8yo12-0yo Sunday, January 19, 1411-6yo13-0yo 186. .012 Niti Wire Microbond10-8yo12-0yo Sunday, January 19, 1411-6yoComposite Stops 13-0yo 187. Sunday, January 19, 14 188. J.S. 11-8yo F I want braces...Just try it for a coupla months... Sunday, January 19, 14 189. Deep Bite Corrected 11-6yo12-4yoSunday, January 19, 14 190. Class II Improved 11-6yo12-4yoSunday, January 19, 14 191. Treatment Sequence 1/12 Start MBS1 3/12 stays in all night 4/12 increases daytime wear 7/12 Occlusion settled. Decide to forgo bracesSunday, January 19, 14Month 0 2 3 6 192. Still want braces?Sunday, January 19, 14 193. C.G. 9-10yo MSunday, January 19, 14 194. Lots of cajoling with little success... 9/09 Initial Pix 10/10 DS 1/11 U-BWS 2/11 K1 (FOAN, 2 on coop) 7/11 Group 1 Exercise 8/11 BWS broken, made new 10/11 K2 (good daytime, poor nighttime wear 1/12 d/c U-BWS, place L-BWS 3/12 coop improves 6/12 d/c L-BWS 8/12 still FOAN 1/13 still Class II 3/13 mandibular stretching 9/13 still waiting for es Sunday, January 19, 14Month0 1912 14 17 24 195. Upper Narrow, CrowdedSunday, January 19, 14 196. Parents wait to see if Im right about crowdingSunday, January 19, 14 197. BWSSunday, January 19, 14 198. Crowding resolvingSunday, January 19, 14 199. Arch wideningSunday, January 19, 14 200. Crowded and narrowSunday, January 19, 14 201. Waiting to startSunday, January 19, 14 202. Before BWSSunday, January 19, 14 203. After BWSSunday, January 19, 14 204. Not bad after allSunday, January 19, 14 205. Still waiting for es to dropSunday, January 19, 14 206. Deep Bite9 monthsPerm Dentition Sunday, January 19, 14 207. Anterior CrossbiteSunday, January 19, 14 208. Patient Name: MYOBRACE K1/BWS - K2 - K3 DOB 20.08.92 RHYS WADE - COOPER 21/04/2010 30 August 2005Sunday, January 19, 1421/04/2010 30 August 2005 209. Patient Name: MYOBRACE K1/BWS - K2 - K3 DOB 20.08.92 RHYS WADE - COOPER 21/042010 30 August 2005Sunday, January 19, 1421/04/2010 30 August 2005 210. Patient Name: MYOBRACE K1/BWS - K2 - K3 DOB 20.08.92 RHYS WADE - COOPER 26/10/10 30 August 2005Sunday, January 19, 1426/10/10 30 August 2005 211. Patient Name: MYOBRACE K1/BWS - K2 - K3 DOB 20.08.92 RHYS WADE - COOPER 21/04/2010 30 August 2005Sunday, January 19, 1428/09/2011 30 August 2005 212. T4K - MYOBRACE K1 Patient Name: RHYS WADE - COOPER - DOB 20.08.92 10/11/2008 30 August 2005Sunday, January 19, 1410/11/2008 30 August 2005 213. T4K - MYOBRACE K1 Patient Name: RHYS WADE - COOPER - DOB 20.08.92 12/07/10 30 August 2005Sunday, January 19, 1412/07/10 30 August 2005 214. T4K - MYOBRACE K1 Patient Name: RHYS WADE - COOPER - DOB 20.08.92 10/11/2008 30 August 2005Sunday, January 19, 1412/07/10 30 August 2005 215. Infant WADE Patient Name: RHYSTrainer --I-3 - Myolay DOB 20.08.92 COOPER 02/04/09 30 August 2005Sunday, January 19, 1402/04/09 30 August 2005 216. Infant WADE Patient Name: RHYSTrainer --I-3 - Myolay DOB 20.08.92 COOPER 02/04/09 30 August 2005Sunday, January 19, 1402/04/09 30 August 2005 217. Infant WADE Patient Name: RHYSTrainer --I-3 - Myolay DOB 20.08.92 COOPER 10/01/12 30 August 2005Sunday, January 19, 1410/01/12 30 August 2005 218. Infant WADE Patient Name: RHYSTrainer --I-3 - Myolay DOB 20.08.92 COOPER 10/04/12 30 August 2005Sunday, January 19, 1410/04/12 30 August 2005 219. Infant WADE Patient Name: RHYSTrainer --I-3 - Myolay DOB 20.08.92 COOPER 02/04/09 30 August 2005Sunday, January 19, 1410/04/12 30 August 2005 220. MYOBRACE K1/BWS COOPER - DOB 20.08.92 Patient Name: RHYS WADE - - K2 - T2 - T3 02/09/09 30 August 2005Sunday, January 19, 1402/09/09 30 August 2005 221. MYOBRACE K1/BWS COOPER - DOB 20.08.92 Patient Name: RHYS WADE - - K2 - T2 - T3 02/09/09 30 August 2005Sunday, January 19, 1402/09/09 30 August 2005 222. MYOBRACE K1/BWS K2 - T2 Patient Name: RHYS WADE --COOPER--T3 DOB 20.08.92 25/05/2011 30 August 2005Sunday, January 19, 1425/05/2011 30 August 2005 223. MYOBRACE K1/BWS K2 - T2 Patient Name: RHYS WADE --COOPER--T3 DOB 20.08.92 31/08/11 30 August 2005Sunday, January 19, 1431/08/11 30 August 2005 224. MYOBRACE COOPER - DOB 20.08.92 Patient Name: RHYS WADE -K1-K2 09/11/09 30 August 2005Sunday, January 19, 1409/11/09 30 August 2005 225. MYOBRACE COOPER - DOB 20.08.92 Patient Name: RHYS WADE -K1-K2 09/11/09 30 August 2005Sunday, January 19, 1409/11/09 30 August 2005 226. MYOBRACE COOPER - DOB 20.08.92 Patient Name: RHYS WADE -K1-K2 09/01/12 30 August 2005Sunday, January 19, 1409/01/12 30 August 2005 227. MYOBRACE COOPER - DOB 20.08.92 Patient Name: RHYS WADE -K1-K2 09/01/12 30 August 2005Sunday, January 19, 1409/01/12 30 August 2005 228. MYOBRACE K1/BWS - K2 - T2- DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 26/08/09 30 August 2005Sunday, January 19, 1426/08/09 30 August 2005 229. MYOBRACE K1/BWS - K2 - T2- DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 26/08/09 30 August 2005Sunday, January 19, 1426/08/09 30 August 2005 230. MYOBRACE K1/BWS COOPER T3 Patient Name: RHYS WADE - - K2 - T2-- DOB 20.08.92 05/08/10 30 August 2005Sunday, January 19, 1405/08/10 30 August 2005 231. MYOBRACE K1/BWS COOPER T3 Patient Name: RHYS WADE - - K2 - T2-- DOB 20.08.92 26/08/09 30 August 2005Sunday, January 19, 1405/08/10 30 August 2005 232. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 08/12/09 30 August 2005Sunday, January 19, 1408/12/09 30 August 2005 233. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 08/12/09 30 August 2005Sunday, January 19, 1423/12/09 30 August 2005 234. K1/BWS - K2 COOPER Patient Name: RHYS WADE - - T2- T3 - DOB 20.08.92 08/12/09 30 August 2005Sunday, January 19, 1410/05/10 30 August 2005 235. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 23/12/09 30 August 2005Sunday, January 19, 1410/05/10 30 August 2005 236. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 10/05/10 30 August 2005Sunday, January 19, 1410/05/10 30 August 2005 237. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 10/05/10 30 August 2005Sunday, January 19, 1419/07/10 30 August 2005 238. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 10/05/10 30 August 2005Sunday, January 19, 1419/07/10 30 August 2005 239. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 08/12/09 30 August 2005Sunday, January 19, 1419/07/10 30 August 2005 240. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 08/12/09 30 August 2005Sunday, January 19, 1406/08/11 30 August 2005 241. BB1/T4K - MYOBRACE K2-T2-T3 07/04/09Sunday, January 19, 1407/04/09 242. BB1/T4K WADE - COOPER - DOB 20.08.92 Patient Name: RHYS - MYOBRACE K2-T2-T3 14/09/09 30 August 2005Sunday, January 19, 1414/09/09 30 August 2005 243. BB1/T4K WADE - COOPER - DOB 20.08.92 Patient Name: RHYS - MYOBRACE K2-T2-T3 07/04/09 30 August 2005Sunday, January 19, 1407/04/09 30 August 2005 244. BB1/T4K WADE - COOPER - DOB 20.08.92 Patient Name: RHYS - MYOBRACE K2-T2-T3 22/04/09 30 August 2005Sunday, January 19, 1422/04/09 30 August 2005 245. BB1/T4K WADE - COOPER - DOB 20.08.92 Patient Name: RHYS - MYOBRACE K2-T2-T3 20/07/09 30 August 2005Sunday, January 19, 1420/07/09 30 August 2005 246. BB1/T4K WADE - COOPER - DOB 20.08.92 Patient Name: RHYS - MYOBRACE K2-T2-T3 10/01/12 30 August 2005Sunday, January 19, 1410/01/12 30 August 2005 247. BB1/T4K MYOBRACE K2-T2-T3 Patient Name: RHYS-WADE - COOPER - DOB 20.08.92 07/04/09 30 August 2005Sunday, January 19, 1410/01/12 30 August 2005 248. BB1/T4K WADE - COOPER - DOB 20.08.92 Patient Name: RHYS - MYOBRACE K2-T2-T3 07/04/09 30 August 2005Sunday, January 19, 1410/01/12 30 August 2005 249. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 17/03/09 30 August 2005Sunday, January 19, 1417/03/09 30 August 2005 250. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 17/03/09 30 August 2005Sunday, January 19, 1417/03/09 30 August 2005 251. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 17/01/2010 30 August 2005Sunday, January 19, 1417/01/2010 30 August 2005 252. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 25/08/10 30 August 2005Sunday, January 19, 1425/08/10 30 August 2005 253. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 06/02/12 30 August 2005Sunday, January 19, 1406/02/12 30 August 2005 254. MYOBRACE K1/BWS - K2 - T2 - DOB 20.08.92 Patient Name: RHYS WADE - COOPER -T3 17/03/09 30 August 2005Sunday, January 19, 1406/02/12 30 August 2005 255. Demo: Assessment Roger Price: overview of Ortho-postural Training Medical and airway history Photos Posture photos and analysis Breathing efciency analysis Sleep efciency (Models, radiographs)Sunday, January 19, 14 256. Demo: Myobrace Delivery Welcome patient Choose color Describe use and importance Deliver Myobrace Instructions The two things Comfort check Daytime wearing schedule Score card What to expect at night Cleaning Next appointment Sunday, January 19, 14