Whatrsquos an RO to doA replay of the March 2014

IAFGG Annual SymposiumCalgary Alberta

dr barry raphaelthe raphael center for integrative orthodontics

the raphael center for integrative education

wwwalignminecombioblocnjcom

drbarryalignminecom

IAFGG 2014

SOFT TISSUE DYSFUNCTION

With Chronic Open Mouth Posture

Comparison of Unsupported vs Supported Growth

The End

The Beginning

Everyday in my practice

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

14 Instructors 14 Techniques

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

My Dream Office 2001

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

In the ROrsquos Mind

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

SOFT TISSUE DYSFUNCTION

With Chronic Open Mouth Posture

Comparison of Unsupported vs Supported Growth

The End

The Beginning

Everyday in my practice

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

14 Instructors 14 Techniques

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

My Dream Office 2001

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

In the ROrsquos Mind

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

The End

The Beginning

Everyday in my practice

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

14 Instructors 14 Techniques

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

My Dream Office 2001

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

In the ROrsquos Mind

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

The Beginning

Everyday in my practice

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

14 Instructors 14 Techniques

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

My Dream Office 2001

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

In the ROrsquos Mind

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Everyday in my practice

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

14 Instructors 14 Techniques

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

My Dream Office 2001

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

In the ROrsquos Mind

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

14 Instructors 14 Techniques

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

My Dream Office 2001

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

In the ROrsquos Mind

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

RO since1983 (30 yearsyikes)

Bucknell University 1974University of Pennsylvania 1978

(Three Years in General Practice)Fairleigh-Dickenson University 1983

My Dream Office 2001

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

In the ROrsquos Mind

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

My Dream Office 2001

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

In the ROrsquos Mind

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

In the ROrsquos Mind

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

1Crooked teeth are THE PROBLEM

2The lower incisor must be upright

3Patients donrsquot want to cooperate

4Straightened teeth arenrsquot stable

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

A Change of Mind

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

George Catlin

Are we developing the wayour genes program us to be

Westin Price

Kevin Boyd

Peter Gluckman

Neese and Williams

Scott Gilbert

Clark Spencer Larsen

Darwinian Dentistry

MeJames

Sim Wallace

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Obesity

Metabolic SyndromeCeliac

Intestinal PermeabilityType 2 Diabetes

Fatty Liver Disease Cardiovascular Disease

HypertensionSome Cancers

The Results of the MismatchBetween Genes and the Environment

Chronic Non-Communicable Diseases of CivilizationWestern Lifestyle Diseases

Asthma

Autism

Aspergerrsquos

Alzheimers

ADDADHDDepression

Chronic Back Pain

Osteoporosis

Caries

Malocclusion

Sleep Apnea

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

The Toothberg

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Airway-Related Craniofacial Dysfunctions

bullChronic Naso-pharyngeal Obstructionbull Tongue form aberrations (Frenum and tongue-tie)bullOpen Mouth Rest Posture bullMyofunctional disorders (Swallowing chewingetc)bullChronic Hyperventilation and Hypocapniabull Breathing Disordered Sleep (OSA UARS snoring)bull Bruxism and parafunctionsbull TMD and facial pain componentsbullCranial and postural issuesbull Malocclusion

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Airway Orthodontics

bullEarly Feeding and Nutrition

bullAllergies Asthma URT infections

bullPosture

bullAirway Breathing and Sleep Disorders

bullSoft Tissue Dysfunctions (Tongue Thrust Open Mouth)

Instead of crooked teeth being The ProblemThey are just a SYMPTOM of something larger

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Parentrsquos Private-eye Sheet

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Parentrsquos Private-eye Sheet

ldquoThere are many things about your childrsquos health that are important to know but that I often donrsquot get to see at the office Also there are signs to look for that you may not have known were connected to your childrsquos teeth or health By looking for and tracking these ldquosigns and symptomsrdquo we can get a better handle on the problem and watch for resolution

You donrsquot have to spend a lot of time with this but donrsquot rush either Watch for certain things at different times of day Try not to let your child know they are being watched You want to see the most natural behaviors

Check off what you see If yoursquore not sure check it anyway and wersquoll talk about it Make comments if you wantrdquo

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

While sitting around

While sitting around (watching TV in the car) does your child

put ldquothingsrdquo in the mouth alot (toys sleeves pencils fingernails etc) ______________________________

lick or suck on the lips have the lips apart even a little stick or dart the tongue out of the mouth have the tongue resting between the teeth lean the cheek on a hand breath with his mouth open even a little bit make noises when breathing have trouble sitting still

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

While talking

While talking does your child talk very fast talk very slowly gasp for air have a lisp take speech lessons

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

During a meal

During a meal does your child gasp for air while eating stick his tongue between his teeth when swallowing stick the tongue out to meet the drinking glass drink a lot while eating make noises when chewing eat sloppily take a breath before drinking puff the cheeks out when drinking make the lips purse when swallowing make the chin ldquocrinklerdquo when swallowing bob the head when swallowing have trouble sitting still

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

While sleeping

While sleeping does your child have the mouth open snore wet the bed toss and turn tilt the head back wake up frequently have frequent nightmares have abnormal sleep issues grind the teeth have trouble waking up wake with darker circles under eyes

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

S R 10-10yo M

bullMissing 3242bullImpacted 1323bullLate mixed 25 eruptedbullSoft tissue dysfunctionbullIL = 40bullNot compliant

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

S Reardon 10-7yo M

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Impacted 3s Missing 2s

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Medical history

bull Reactive Airway Diseasebull ldquoBronchial Constrictionrdquo bullCare of Pulmonologistbull Preventil

bull Dad OSA CPAP for 11 years diabetesbull Grandfather OSA untreatedbull ETCO2 = 361 at 10 bpm (acceptable)bull Posture number - 18 (lt10 ideal)bull Father refuses sleep screening

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Treatment Options1 Extract upper premolars Align2Open spaces for impacted canines Open spaces for lower lateral implants

Whatrsquos more importantEase of treatment

OrBreathing well at night

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Bolton Standards15yo

The Maxilla is Down and Back

The Mandible is Retrognathic

Nasal Cartilage Collapse

Insufficient Facial Support

Bi-maxillary Retrusion

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Bimaxillary Retrusion Forward Growth

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Mouthbreathers have significantly smaller airway space

(measurements PAS-OccL PAS-UP airway volume area and minimum axial area)

Mouth breather Nasal breather

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

Alves M etal Int J Ped ORL 75 (2011) 1195ndash1199

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

B Hockel 2012

This is the profile Biobloc children start with long and retrusive

This is the profile Biobloc children finish with Forward with lips

together

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

From the tip of the Central

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

To the Forwardmost Tip of the Nose

41mm

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Maxillary Heightbull Indicator Line (Mew)

bull Distance from most anterior point on nose to upper incisal edge

bull Age + 23bull A variable number but important to watch over time

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

B Hockel 2012

Herersquos the ldquoinsiderdquo look Notice how the upper front teeth are closer to the nose (yellow arrows)

Notice how the lower jaw rotates around the star so the chin comes up and forward (red arrow)How do we make this happen

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Using IndicatorCosmetic Line

bull To define a starting pointbull To set treatment goalsbull To track treatment progressbull To gauge the effectiveness of treatment

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Charting the InCos Line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Incisor pulled away from noseNot ldquoundertorquedrdquo or ldquogummy smilerdquo

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Hypothetical ClI OrthoMARA

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

OJ = 7mm

Starts Ortho

ldquoGreat Headgear

Effectrdquo

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Class II Elastics

50

40

30

20mm

y J F M A M J J A S O N

boys

Start Non-x

Expansion UncrowdingFinished

Start Cl II elastics

OK thatrsquos

enough

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Hypothetical Mouthbreather(Dr Mewrsquos Hamster Boy)

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Boy gets

hamster

MFT

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Hypothetical BBO 7yoM

50

40

30

20

5 6 7 8 9 10 11 12 13 14 15

girlsboys

Initial

StartBB1

BB3

Night

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

bullLR 11-9yFbullMissing all 5s6s8s and upper 4sbullHad ortho to close diastemahellipbullInL = 39bullGP objects to deX plan equil

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

LR Tx Plan

1Preparation Hang Expanser2deX 3Training BB3 to advance mandible4Myofunctional Therapy5Orthopostural Training6Myobrace to hold7 Reevaluate for dental detailing

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

LR Spotty progress

50

40

30

20mm

y 313 4 5 6 7 8 9 10 11 12114

2 3

Expanser

Parents dragging30 turnsStart Adv

Rx deXGP

objects

After delays

Equil ersquosBB3

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

bullLR 12-3 yF (6mo in tx)bullInL = 37 (+2)bull ersquos equilibratedbull OJ =10bull Appliance OJ = 5bull Still accommodating to BB3

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Is there a calculus for the Indicator Line

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Treatment GoalsBased on Indicator Line

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Incisor Goals

Type 1 Treatment Place U1 in ideal position

Biobloc Orthotropics Orthognathic Surgery Distraction Osteogenesis

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Type 1 Ideal InCos line

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

YZ 9yo M

bullLost upper d-spacebullInL = 36(+4)bullOJ = 9mmbullLip entrapmentbullLip Incompetence

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Y Z 9yo M

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Y Z 9yo M9mm OJ

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Y Z 9yo M

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Treatment Options

1 Type 1 Reduce InL open lost space BB3 to advance mandible

2 Type 2 Open lost space Align

3 Type 4 Extract four premolars

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

YZ 9yoM

50

40

30

20mm

yM A M J J A S O N D J F M A

boys

Hang Expanser

Upper and Lower

Brackets Hang Retainer

BB3

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Incisor Goals

Type 2 Treatment Develop arch just enough to uncrowd

Biobloc Myofunctional Ortho Myofunctional Therapy Crozat ALF Expansion Orthodontics

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Type 2 Uncrowding

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

bullLip incompetencebullLip entrapmentbullHypermentalisbullMouthbreathing

Type 2 Uncrowding

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

12 month progress

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

12 month progress

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

12 month progress

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

After Treatment

Bent-wire6 monthsMyobrace12 months

Hey RaphaelWhat about that

profile

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

ZP 9-5yoM

i

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

After Expansion Phase

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Incomplete profile improvement better breathing head posture and sleep

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Incisor Goals

Type 3 Treatment Maintain UI

Functional Orthodontics Expansion Orthodontics Distalization Ortho or No Treatment

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Type 3 Maintain

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Bimax retrusion

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Successful dental result

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Profile Unimproved

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Incisor Goals

Type 4 Treatment RetractExtrude UI

Extraction Orthodontics Retraction Ortho Distalization Ortho

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Type 4 Retraction

50

40

30

20mm

y 5 6 7 8 9 10 11 12 13 14 15

girlsboys

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Bimax retrusion

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Successful dental result

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Failed Profile Result

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Changes of pharyngeal airway size and hyoid bone position following orthodontic treatment of

Class I bimaxillary protrusion

Qingzhu Wanga Peizeng Jiab Nina K Andersonc Lin Wangd Jiuxiang Line

Angle Orthodontist Vol 00 No 0 0000 (pre-publication 2012)

ldquothe dimension of the velopharynx glossopharynx and hypopharynx were decreased after maximal retraction of anterior teeth with extraction of four premolarshelliprdquo ldquoAny factors that can influence the posture and position of tongue and soft palate may displace them backward andencroach upon the pharynxrdquo

ldquothe more the incisors were retracted the more the pharyngeal airway was reducedrdquo

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Backed into a corner

bull

Moving teeth faster more efficientlyhellipin the wrong direction

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Now that wersquove made smoking unacceptable

could we not do the same withbull Sugarbull Processed foodbull Cheap milk and meatbull Fast foodbull Pill popping for symptomatic reliefbull Looking for the cure instead of the causebull Surgery as a quick fixbull Thinking braces are a status symbol

Each industry thrives on the status quoConsumers must drive the change

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

NP 10yM

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

NP

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Sisterrsquos non-x ortho

Shersquos happyhellipbut Irsquom not so

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

I make my pitch for BBO

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

The dilemma of progress

(I forgot the progress pictureshellip)

Dad sells prosthetic parts to orthopedic surgeons

I selling the case against my previous work they loved

It takes me 3 hours to sell the case

They fret until the BB3 goes in

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Connecting the dots

bull Adult SDB and OSA

bull Narrow jaws and faces

bull Soft tissue dysfunction

bull Early parafunctional habits ie open mouth posture

bull Environmental stressors

bull CPAP MARAUPPP SurgWherersquos the best

place to start treatment here

or here

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

1 Prevention 2 Undo the damage already done3 Establish good habits

When to start When damage from poor breathing is noticed and when bad habits are discovered

The strategies of Airway Orthodontics

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Prevention

bull Remove ankyloglossiabull Promote breastfeedingbull Harden the dietbull Develop masticatory strengthbull Discourage oral habitsbull Promote whole-foods low sugar dietbull Reduce oropharyngeal obstructionbull Promote nasal breathing

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Breathing retraining

bull Nasal rinsingbull Nasal clearingbull Decongesting

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

The goals of Airway Orthodontics

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Optimal forward facial development6 Class I occlusion7 Straight teeth8 Better stability long term

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Myofunctional Trainers

Professors R Soulet and A Besombes

Dr Earl Bergeson

Dr Chris Farrell

The Multi ndash Family System

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

Orofacial MyofunctionalTherapy

Oral MyologyMyofunctional TherapyTongue Thrust Therapy

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

B Hockel 2012 Back

Undoing Bimaxillary Dysplasia

1 Maxillary deconstriction2 Maxillary advancement3 Maxillary impaction4 Mandibular advancement

1 Maxillary Expansion

Treatment for Bimaxillary Dysplasia

ALFCrozat

Bent Wire

HyraxHaas

Niti Exp BioBlocSchwartz

The Farrell BENT WIRE Systemtrade

Recommended Age Group 5-12 yrs

Arch Development in conjunction with the TRAINER Systemtrade

Dr John Mew

Establish Good Habits

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Stand and sit in balance6 Breath gently using the diaphragm7 Eat to nourish8 Sleep to rest

Ortho-Postural TrainingWorkshops

Breathing

Nutrition

Posture

Sleep

COPYRIGHTRoger L PriceOctober 2012

Posture Number

Forward head posturecan be a compensationfor a deficient airway

Sleep Screening and Hygiene

SQI = 10 SQI = 98

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

The Farrell BENT WIRE Systemtrade

Recommended Age Group 5-12 yrs

Arch Development in conjunction with the TRAINER Systemtrade

Dr John Mew

Establish Good Habits

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Stand and sit in balance6 Breath gently using the diaphragm7 Eat to nourish8 Sleep to rest

Ortho-Postural TrainingWorkshops

Breathing

Nutrition

Posture

Sleep

COPYRIGHTRoger L PriceOctober 2012

Posture Number

Forward head posturecan be a compensationfor a deficient airway

Sleep Screening and Hygiene

SQI = 10 SQI = 98

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Recommended Age Group 5-12 yrs

Arch Development in conjunction with the TRAINER Systemtrade

Dr John Mew

Establish Good Habits

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Stand and sit in balance6 Breath gently using the diaphragm7 Eat to nourish8 Sleep to rest

Ortho-Postural TrainingWorkshops

Breathing

Nutrition

Posture

Sleep

COPYRIGHTRoger L PriceOctober 2012

Posture Number

Forward head posturecan be a compensationfor a deficient airway

Sleep Screening and Hygiene

SQI = 10 SQI = 98

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Dr John Mew

Establish Good Habits

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Stand and sit in balance6 Breath gently using the diaphragm7 Eat to nourish8 Sleep to rest

Ortho-Postural TrainingWorkshops

Breathing

Nutrition

Posture

Sleep

COPYRIGHTRoger L PriceOctober 2012

Posture Number

Forward head posturecan be a compensationfor a deficient airway

Sleep Screening and Hygiene

SQI = 10 SQI = 98

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Establish Good Habits

1 Breathing through the nose2 Lips together at rest3 Correct tongue position4 No facial muscles moving on swallowing5 Stand and sit in balance6 Breath gently using the diaphragm7 Eat to nourish8 Sleep to rest

Ortho-Postural TrainingWorkshops

Breathing

Nutrition

Posture

Sleep

COPYRIGHTRoger L PriceOctober 2012

Posture Number

Forward head posturecan be a compensationfor a deficient airway

Sleep Screening and Hygiene

SQI = 10 SQI = 98

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Ortho-Postural TrainingWorkshops

Breathing

Nutrition

Posture

Sleep

COPYRIGHTRoger L PriceOctober 2012

Posture Number

Forward head posturecan be a compensationfor a deficient airway

Sleep Screening and Hygiene

SQI = 10 SQI = 98

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

COPYRIGHTRoger L PriceOctober 2012

Posture Number

Forward head posturecan be a compensationfor a deficient airway

Sleep Screening and Hygiene

SQI = 10 SQI = 98

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Posture Number

Forward head posturecan be a compensationfor a deficient airway

Sleep Screening and Hygiene

SQI = 10 SQI = 98

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Sleep Screening and Hygiene

SQI = 10 SQI = 98

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Integrative Healthcare

Function ProfessionalNasal clearing ENT Pulm MFT BreathingMuscle balance and tone MFT Myofunctional OrthoUndoing damage GP Pedo Ortho OMFSBreathing dynamics OPT MFT Breath PhysiologistPosture DC OPT PT OsteopathCranial balance OsteopathNutrition RDH Nutritionist Dietitian Sleep ENT Sleep Med DentNeurocognitive development Pedrsquon SLP Psych SpEd

The Interdisciplinary Center

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

1Crooked teeth are A SYMPTOM

2 The UPPER incisor directs treatment

3Patients donrsquot want to be exploited

4Teeth that grow straight are stable

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Now that I know

My personal missionTo create from what Irsquove

learned from the besta model for others to followhellipespecially the orthodontists

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Myofunctional Orthodontics

Chris Farrell

John Flutter

German Ramierez

Damien OrsquoBrien

Myofunctional Research CoRancho Cucamonga

2008-2012

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Oral Myology

Oral Myology Basic CourseJoy MoellerNYC 2011LA 2012

Oral Myology Levels 2 3Kim BenkertClifton 2012

Habit CessationShari GreenClifton 2013

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Biobloc Orthotropics

BBO Mini-residencyBill Hang

Agora Hills2012-13

BBO IntensiveDrs John and Mike

MewLSFO2013

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Breathing and Sleep

Buteyko MentorshipThe Breathing Center

Woodstock2010

Breathing Well ProgrammeJohn Flutter

2010 Ortho-Postural TrainingRoger Price

2013

Sleep DentistryMichael Gelb etal

NYU2012

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

ALF and Cranial

Jim Bronson2013 Tasha Turzo

Cranial Academy2014

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Bucket Listbull ALF and Crozat (Bronsonrsquos course)bullMore on Biobloc (Hangrsquos Advanced London School)bull More Cranial (The Farm)bullChirodontics (Bob Walker)bull Airway Dentistry with Marc Cruz Jeff Rousebull Sleep Dentistrybull Less-than-Six with Kevin Boydbull Intra-mandibular Distraction Osteogenesis (IMDO)

Off My ListAnything that moves the teeth faster in the wrong direction

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Whatrsquos an RO to do

To create from what Irsquove learned from the best

a model for others to followhellipespecially orthodontists

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Teaching

Mt Sinai Pedo ResidencyAli Attaie

2010-2012

Montefiore Ortho ResidencyTony Maganzini

2012

2009-Present

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Mt Sinai School of MedicinePedodontic Residency

Guest SpeakersJim BronsonMike MewKevin BoydSandra KahnJennifer TowRoger PricePaula Fabbie

Damien OrsquoBrien

First clinical program in myofunctional orthodontics

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

Airway and Facial DevelopmentCollaborative Webcast

Mark Cruz

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

AAPMD Symposium

wwwaapm

dorg

Annual MeetingApril 25-26 2014

Westin Chicago North Shore

the raphael center for integrative orthodontics

wwwalignminecomwwwbioblocnjcom

wwwmyobracenjcom

Integrative vs Conventional

Integrative vs Conventional

ldquoWith improvements in expansion orthodontics advances in myofunctional orthodontics and the growing recognition about sleep disordered breathing among children and adults it is time for orthodontics to expand its horizons There is now so much more we can oerrdquo

The Raphael name has been associated with high quality orthodontics in New Jersey for over 60 years Dr Barry Raphael has been a university trained orthodontic specialist and a member of the American Association of Orthodontists for 30 years

He has a wide range of techniques and services to offer He has studied oral myology applied kinesiology Buteyko breathing Biobloc Orthotropics and Myobrace as part of his integrative training He can offer Damon Invisalign Insignia and Incognito appliances designs as some of his many conventional orthodontic services too

Dr Raphael teaches his techniques at post-graduate residencies study clubs dental societies and for the Myofunctional Research Co He is available for presentations to any group interested in learning more about the benefits of integrative orthodontics

wwwalignminecomLearn about the choices you have in orthodontics

dr barry raphael Why its

too Early never

1425

bro

ad

str

ee

tc

lifto

n n

j 070

13

973-

778-

4222

fax

973-

778-

9625

nj s

pe

c

368

4

1425 broad street clifton nj 07013973-778-4222

wwwalignminecom

the raphael centerforintegrative orthodontics

the

raph

ael c

ente

r fo

rin

tegr

ativ

e or

thod

onti

cs

Learn about an important choice you need to make before starting braces

the raphael center for integrative education

the raphael center for integrative education

Ongoing Intro to Airway Orthodontics

April Biobloc Study Group

April Training Ortho-Postural Therapists w Roger Price

June MRC Myobrace Basic Series

August Airway Dentistry with Mark Cruz and company

October Advanced MFT with Sandy Coulson

October Less than Six with Kevin Boyd

(who else wants to play)

Mission to create a space for spreading the word about Airway and Orthotropic principles and practice

Orthodontics in the 21st Century

EstheticOrthodontics

AirwayOrthodontics

GeneticTooth-Focused

Dental PerfectionEsthetics Primary

Treating SymptomsAirway Ignorant

AdaptationMuscle-FocusedMedical Better

Esthetics SecondaryTreating Causes

Airway Conscious

The EndAnd

The Beginning

Integrative vs Conventional

ldquoWith improvements in expansion orthodontics advances in myofunctional orthodontics and the growing recognition about sleep disordered breathing among children and adults it is time for orthodontics to expand its horizons There is now so much more we can oerrdquo

The Raphael name has been associated with high quality orthodontics in New Jersey for over 60 years Dr Barry Raphael has been a university trained orthodontic specialist and a member of the American Association of Orthodontists for 30 years

He has a wide range of techniques and services to offer He has studied oral myology applied kinesiology Buteyko breathing Biobloc Orthotropics and Myobrace as part of his integrative training He can offer Damon Invisalign Insignia and Incognito appliances designs as some of his many conventional orthodontic services too

Dr Raphael teaches his techniques at post-graduate residencies study clubs dental societies and for the Myofunctional Research Co He is available for presentations to any group interested in learning more about the benefits of integrative orthodontics

wwwalignminecomLearn about the choices you have in orthodontics

dr barry raphael Why its

too Early never

1425

bro

ad

str

ee

tc

lifto

n n

j 070

13

973-

778-

4222

fax

973-

778-

9625

nj s

pe

c

368

4

1425 broad street clifton nj 07013973-778-4222

wwwalignminecom

the raphael centerforintegrative orthodontics

the

raph

ael c

ente

r fo

rin

tegr

ativ

e or

thod

onti

cs

Learn about an important choice you need to make before starting braces

the raphael center for integrative education

the raphael center for integrative education

Ongoing Intro to Airway Orthodontics

April Biobloc Study Group

April Training Ortho-Postural Therapists w Roger Price

June MRC Myobrace Basic Series

August Airway Dentistry with Mark Cruz and company

October Advanced MFT with Sandy Coulson

October Less than Six with Kevin Boyd

(who else wants to play)

Mission to create a space for spreading the word about Airway and Orthotropic principles and practice

Orthodontics in the 21st Century

EstheticOrthodontics

AirwayOrthodontics

GeneticTooth-Focused

Dental PerfectionEsthetics Primary

Treating SymptomsAirway Ignorant

AdaptationMuscle-FocusedMedical Better

Esthetics SecondaryTreating Causes

Airway Conscious

The EndAnd

The Beginning

ldquoWith improvements in expansion orthodontics advances in myofunctional orthodontics and the growing recognition about sleep disordered breathing among children and adults it is time for orthodontics to expand its horizons There is now so much more we can oerrdquo

The Raphael name has been associated with high quality orthodontics in New Jersey for over 60 years Dr Barry Raphael has been a university trained orthodontic specialist and a member of the American Association of Orthodontists for 30 years

He has a wide range of techniques and services to offer He has studied oral myology applied kinesiology Buteyko breathing Biobloc Orthotropics and Myobrace as part of his integrative training He can offer Damon Invisalign Insignia and Incognito appliances designs as some of his many conventional orthodontic services too

Dr Raphael teaches his techniques at post-graduate residencies study clubs dental societies and for the Myofunctional Research Co He is available for presentations to any group interested in learning more about the benefits of integrative orthodontics

wwwalignminecomLearn about the choices you have in orthodontics

dr barry raphael Why its

too Early never

1425

bro

ad

str

ee

tc

lifto

n n

j 070

13

973-

778-

4222

fax

973-

778-

9625

nj s

pe

c

368

4

1425 broad street clifton nj 07013973-778-4222

wwwalignminecom

the raphael centerforintegrative orthodontics

the

raph

ael c

ente

r fo

rin

tegr

ativ

e or

thod

onti

cs

Learn about an important choice you need to make before starting braces

the raphael center for integrative education

the raphael center for integrative education

Ongoing Intro to Airway Orthodontics

April Biobloc Study Group

April Training Ortho-Postural Therapists w Roger Price

June MRC Myobrace Basic Series

August Airway Dentistry with Mark Cruz and company

October Advanced MFT with Sandy Coulson

October Less than Six with Kevin Boyd

(who else wants to play)

Mission to create a space for spreading the word about Airway and Orthotropic principles and practice

Orthodontics in the 21st Century

EstheticOrthodontics

AirwayOrthodontics

GeneticTooth-Focused

Dental PerfectionEsthetics Primary

Treating SymptomsAirway Ignorant

AdaptationMuscle-FocusedMedical Better

Esthetics SecondaryTreating Causes

Airway Conscious

The EndAnd

The Beginning

the raphael center for integrative education

the raphael center for integrative education

Ongoing Intro to Airway Orthodontics

April Biobloc Study Group

April Training Ortho-Postural Therapists w Roger Price

June MRC Myobrace Basic Series

August Airway Dentistry with Mark Cruz and company

October Advanced MFT with Sandy Coulson

October Less than Six with Kevin Boyd

(who else wants to play)

Mission to create a space for spreading the word about Airway and Orthotropic principles and practice

Orthodontics in the 21st Century

EstheticOrthodontics

AirwayOrthodontics

GeneticTooth-Focused

Dental PerfectionEsthetics Primary

Treating SymptomsAirway Ignorant

AdaptationMuscle-FocusedMedical Better

Esthetics SecondaryTreating Causes

Airway Conscious

The EndAnd

The Beginning

the raphael center for integrative education

Ongoing Intro to Airway Orthodontics

April Biobloc Study Group

April Training Ortho-Postural Therapists w Roger Price

June MRC Myobrace Basic Series

August Airway Dentistry with Mark Cruz and company

October Advanced MFT with Sandy Coulson

October Less than Six with Kevin Boyd

(who else wants to play)

Mission to create a space for spreading the word about Airway and Orthotropic principles and practice

Orthodontics in the 21st Century

EstheticOrthodontics

AirwayOrthodontics

GeneticTooth-Focused

Dental PerfectionEsthetics Primary

Treating SymptomsAirway Ignorant

AdaptationMuscle-FocusedMedical Better

Esthetics SecondaryTreating Causes

Airway Conscious

The EndAnd

The Beginning

Orthodontics in the 21st Century

EstheticOrthodontics

AirwayOrthodontics

GeneticTooth-Focused

Dental PerfectionEsthetics Primary

Treating SymptomsAirway Ignorant

AdaptationMuscle-FocusedMedical Better

Esthetics SecondaryTreating Causes

Airway Conscious

The EndAnd

The Beginning

The EndAnd

The Beginning