Expand podcast: Are you a Class I driven orthodontist?

Expand is the brand new podcast from DSD in which DSD Ortho Clinical Mentor, Dr Daniel Ramos, interviews dentistry heavyweights on the most pertinent topics in the field of aligners and orthodontics right now.

To kick off the series, Daniel was joined by esteemed guests in the fields of aligner and airway dentistry, Dr Claudia Pinter and Dr Stanley Liu, to discuss Class I orthodontics. Among other topics, they covered:

• Whether Class II looks set to become the new normal.
  

• The importance of focusing on functional outcomes and facial esthetics as well as teeth alignment.
  

• Why we must consider all aspects of a patient's anatomy, health and functional needs in orthodontic planning.
  

Read on for some of the highlights from this episode or listen to the conversation in full on Spotify, Apple Podcasts or YouTube.

Is Class II the new normal?

Reflecting on the concept of Class I driven orthodontics and noting how many patients now present with class two alignments, Daniel got the conversation off to a start with a question: is Class II the new normal? Dr Pinter began with an explanation of how she had broadened her horizons on this issue:

“I have to admit that I was definitely a Class I driven orthodontist, because probably this is how I saw the world. It's right when it's Class I, and there's a place for that. However, thanks to the work of Dr Stanley Liu and Dr Audrey Yoon, I broadened my horizons, and I saw that there's more than just the teeth in the patient's mouth. They're actually here to serve a purpose. You know, the mouth is where the tongue is living. So we want to make it comfortable for the tongue.

We want to facilitate breathing for a patient, and there's so many things that we can improve for our patients and their quality of life that we miss when we're just looking at the teeth.”

Should Class I always be our goal?

With digital tools in our hands it’s easier for us to understand what needs to be done to achieve a Class I bite. But is this always our goal? Daniel asked Dr Pinter about her techniques.

“I think if we can achieve a Class I, that definitely makes our lives easier. Easier because the teeth simply fit together in that position. If we finish in like half a Class II, this is really difficult for the patient to feel comfortable in that position. It's not ideal. Finishing in full Class II is for sure also not ideal.

But at the end of the day, there's a person attached to the teeth. So we need to consider their limitations as well. Some are just not open for surgery.”

Dr Pinter went on to describe a successful case in which a young Class III patient opted against having surgery:

“She was in full Class III and she's now in Class I. So that is why I'm of the opinion that skeletal maxillary expansion, distraction osteogenesis, maxillary expansion is one of the most powerful tools we have in orthodontics. And she came in and said: ‘I suddenly can breathe so much better through my nose. I don't have to wake up during the night because I cannot breathe from my nose. And it immensely improved her quality of life. So I would like to see more of that’.”

How can surgery improve quality of life?

Moving on to surgery, Daniel posed the question: what can be done to improve quality of life for Class II patients that orthodontists can’t do? How much can surgery help these patients?

Dr Liu reflected: “The only way, really, for surgery to help is to have orthodontic support. Of course, when game day comes and we have to do surgery. But a bigger help from the dental orthodontic community is to address these patients before they even need to be considered for those considerations.”

“If we can manage the bite, breathing and beauty aspects for all of our patients, we can do less surgery. Because in the end, all that surgery does is recapitulate the milestones that are missed during growth and development. Any surgery, actually, outside of that, I consider less optimal. Because you're creating surgery. It's sort of like just creating surgery to fix a form, but it's not really directed functionally.”

Addressing claims in the research right now

Daniel moved on to address a common claim in current research that distalizing extracted premolars will not affect posterior airway that much, posing the imaginary case of a Class II patient for whom the angle between the upper lip and nose is good, the position of the maxilla is good, but they have a retrognathic mandible. If the patient doesn’t have any airway issues, is retracting the upper not a problem, or is it better to leave this patient in Class II without retracting with more space?

Dr Pinter described her own experience of critique when distalizing and her efforts to achieve expansion:

“It's not black and white. I'm not a fan of seeing things black and white: ‘Extractions and distalizations are always bad, they always harm the patient’ because that's not true. However, I do think that too often, maxillary transverse deficiency is under diagnosed, overlooked, and not treated. And too often, teeth are extracted where we do not look at the function of the patient. Is he breathing well through his nose? Where's the tongue?”

Dr Liu reflected on the issue with research and the importance of bringing the discussion back to the real world:

“The problem with papers is you can only share one point at a time. This is how papers work. You have one hypothesis and one conclusion and that's all you write because you don't write more than that. But the problem is: this is not the real world.

And having this patient, as you mentioned, the best of scenarios is we offer both types of options to the patient, because obviously, in that situation, if you have an adult patient, the lower jaw is going to be surgical. Lower surgical advancement of the jaws comes with many issues, whereas a well-thought-out orthodontic plan likely doesn't have as many side effects, but offer both options for the patient and also assess the symptoms.

One thing that's often missed is our goals, the doctor's goals of Class I occlusion, the perfect facial airway position. Again, that's according to us. The patient has to tell us what works best for them. So starting from the nose, there has to be a questionnaire that asks about breathing coming down to the maxilla. Then ask them about the smile. That smile arc is predicated on what you do with the upper jaw and, you know, coming down to the lower jaw with the occlusion and then TM joint pain and overall quality of life. And then finally, the financial aspect, all of these actually have to be in play before we even go out there and start designing what we want to do.”

Are we talking enough about airway?

Moving onto airway as one of the final topics, Daniel reflected on whether orthodontists are aware of the minimum knowledge needed in order to identify the need for help - as well as how to better diagnose and know when to refer.

Dr Liu discussed the evolution of this field over the last decade, the need for an established questionnaire as part of your patient intake and some of the important markers to look at when deciding whether to refer. He also spoke about the shift towards working together to figure out solutions and how it might look in the coming years:

“Look at people in your community. So you build a little pod, you have a little team, and that's my hope. In the coming ten years, I think that is the only way. And by the way, why are dentists doing this? The academics have this weird argument: first, why are the surgeons doing this? Why are the dentists doing it? Well, here's the thing right now, who's doing this then? Is your pediatrician looking at your child's adenoid and breathing pattern? They're too busy. At least in the US, there's incredible demand. The patient comes in and if the child is walking healthily they go out: they don't have the time, nor is it practical for them. But that child may see the dentist every six months or so.”

“Even from the surgical field - they don't say this in meeting symposiums, but in the cocktail hour after the symposium. They say that they firmly believe that dentists will be really the front line. Dentists will be the primary care people, taking care of airway concerns in the upcoming years.”