Expanding Orthodontics: Exploring MARPE with Dr. Claudia Pinter

WEBVTT

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Now I know.

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As long as I win As long as

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I win As long as

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before.

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I’ll be fine

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Thank you.

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Hello.

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Hello, everyone.

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Thanks so much for joining us.

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My name is Tom Wright.

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I am the VP and partner here at ODL.

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We’ve been in business for

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forty years and we are

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super excited to present

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this webinar today with an

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amazing guest that we have.

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But first,

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I just want to talk a little bit

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about ODL and who we are.

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And where we kind of come from.

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I’m going to just go through our history.

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We are a fifth generation

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orthodontic family,

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starting out with Frank Casto.

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He was in the second class

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of Edward Angle.

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Right there, that’s his diploma.

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Pretty cool.

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You know,

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so orthodontics runs in our blood.

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That’s Frank right there

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with my grandfather who was

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also an orthodontist.

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So you had Frank who then

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his grandson became an orthodontist

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And then my father is right there,

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Jim Wright,

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who did not become an orthodontist,

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but both of his brothers

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did become orthodontists.

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And unfortunately,

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we did not become orthodontists,

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but we ended up buying the

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lab from my father back in

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twenty seventeen,

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who started the lab back in

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nineteen eighty four.

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So it’s been quite the journey.

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It’s been amazing.

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This is where we are right now in Buffalo,

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New York, in a rehabilitated building.

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Absolutely beautiful.

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New York State did

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quite the knockup job here

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making our space completely renovated,

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brand new ceilings, brand new floors,

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everything.

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So state-of-the-art

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laboratory here in Buffalo, New York.

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And it’s just been an honor

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being in here for, you know,

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the past five years.

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So again, we have a,

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we’re still waiting for

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some people to come in, but we have over,

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you know,

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or hundred and fifty registrants.

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So if you weren’t able to make it,

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or if you have someone, you know,

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who was going to be joining,

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They will get an email with

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the recording of the webinar after this.

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So our mission here is to

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create solutions and

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products that inspire a

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lifetime of confidence.

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And that’s what we’re trying

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to accomplish today,

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creating confidence for you,

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for your patients,

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because we’re not always

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first to the game,

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but we do like to improve what we see.

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So a couple of housekeeping

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notes that I want to talk about here,

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and I’m just going to

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remove that from the screen here.

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So if you’re interested in

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setting up time with us if

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you would like to set up a

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discovery call with us I

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have the link in the uh in

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the comments here it’s

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pinned to the top and then

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I also have a link to I’ll

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actually show that real

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quick so that’s the link right there

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And then also a link to our

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airway landing page that if

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you want to learn more

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about what we offer at ODL,

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that’s the page right there for you.

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And so we’re going to be

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onboarding people in stages,

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making sure that we’re

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providing the best quality

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possible for you and your staff.

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So if it’s a couple of weeks out,

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bear with us.

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We just want to make sure

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that the doctors that we do

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have onboarding,

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utilizing our airway

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products are getting the utmost service.

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If you’re going, another housekeeping note,

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if you’re going to the AAO

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in Philadelphia, we will be there.

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If you want to talk more in depth,

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we’ll be at booth,

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so be sure to stop by there.

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Another housekeeping note,

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stay tuned in the next few months,

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we’re going to be, well,

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we currently are beta

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testing our patented class two product,

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rivaling Herbst and Mara appliances.

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So that’s really exciting,

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fully three D printed.

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So if you want to be part of that beta,

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send us an email and we

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will get you on board for that.

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But we’re only taking ten

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doctors right now.

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So keep that in mind.

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Lastly,

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we put your questions into the chat

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and we will try to get to

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as many as we can.

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If we can’t,

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we will make sure that we

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either put your email in

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there or contact us info at

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odlorso.com and we will get

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back to you with the answer

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to that question.

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So I would love to introduce

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right now TJ Wright,

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our Clinical Sales Director.

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TJ, it’s good to have you.

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TJ,

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why don’t you tell us a little bit

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about your role here in

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Airway and a little bit

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about your past experience?

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Thanks, Tom.

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Yeah, I’m TJ Wright.

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I’m ODL’s clinical sales director.

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My journey in orthodontics

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actually started when I was

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one month old and my dad

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started orthodontic residency.

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I was the baby getting

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brought into the clinic.

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I don’t remember any of it,

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but that’s what they tell me.

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Growing up,

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I had a lot of flipper

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retainers because I was

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missing a front tooth,

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multiple palatal expanders,

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and then my final retainers

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in ODL made all of that for me.

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So I started off as a

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uh, ODL patient.

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And then I ended up working

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in my dad’s practice as a child, uh,

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around twelve years old.

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I was working as

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sterilization after school, um,

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really got to see how the,

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the clinic ran and got to

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see patients and clean up chairs.

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And then after university,

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I ended up going back to

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his office and working full time there.

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Started off as a orthodontic assistant,

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worked my way into

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treatment coordinating with him.

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And then, um,

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helping to manage the office

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and ordering supplies and

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everything for the six

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location practice and

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bringing the team together there.

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After I helped him sell his practice,

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I moved to ODL and been there ever since.

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And we started in,

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I started in a role as the

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customer service manager.

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So you guys,

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some of the long time

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customers will remember me

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from when I managed

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customer service and logistics.

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I switched roles because my

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wife graduated dental

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school and my wonderful wife, Anna,

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she started orthodontic

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residency down here in

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Florida at Nova Southeastern.

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And at that time I moved to

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a sales rep role at ODL,

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still in the customer

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support communications side of the lab,

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just in a slightly different capacity.

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Now, as clinical director,

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I’m able to do all my favorite things,

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which is talking to our clients,

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our doctors,

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and collaborating with them

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to make sure their custom

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appliances are translated

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from their head into

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reality in our technicians’

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brains and printed exactly

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as they want it.

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And it’s just really fun

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being able to collaborate

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and work with so many

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amazing doctors across the

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world at this point to help

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them with all sorts of

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different appliances and

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especially Marpie nowadays.

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So we’re able to fully

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customize your patient’s

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Marpie experience, what we’re doing.

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Wonderful.

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Thanks so much, TJ.

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Really appreciate that.

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So I want to bring on

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our host today, or our guest, I should say,

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Dr. Claudia Pinter.

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She has a lot of experience here,

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but I’m just going to give

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a quick little intro about her.

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Dr. Claudia is

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internationally recognized

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for her experience in orthodontics,

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particularly in aligner

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therapy and TAD-assisted expansion.

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She’s based in Vienna and Wales, Austria,

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and she specializes in

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aesthetic orthodontic

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treatments and has

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dedicated her career to

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advancing clear aligner

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techniques and MARPI protocols.

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She’s not only a clinician,

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but also a sought-after educator,

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and we definitely know that,

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serving as a visiting

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faculty member at Nova

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Southeastern University and

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course director of the

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Fellowship in Aligner

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Orthodontics with Wright Global.

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Her ability to break down

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complex techniques into

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practical real-world

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applications has made her

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an invaluable resource for orthodontists

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worldwide and it’s been an

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honor to work with dr

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claudia honestly like she’s

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she’s so easy to work with

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so laid back but her

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knowledge is just it’s very

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vast so that’s why we

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wanted to work with her

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because it’s been it’s been

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quite enjoyable as well uh

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so what we’re going to

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cover today is we’re going

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to cover tad first tad last

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approach understanding the

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pros and cons of each work

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workflow um clinical case

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review we’re going to go

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through some cases

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real world applications and

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some success stories,

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some common pitfalls.

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This is important and how to avoid them.

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So key insights to refine

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your market protocol.

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And then we will try to get

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to a live Q&A to have your

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questions directly answered

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by Dr. Pinter.

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So, Dr. Pinter,

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it is an honor to have you here.

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Welcome.

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Thank you, Tom.

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And thank you, everybody who joined.

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It’s amazing to be here with you today.

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I appreciate

00:13:32.062 –> 00:13:33.883
that you give me all your time.

00:13:34.803 –> 00:13:37.544
It’s your most valuable resource.

00:13:37.644 –> 00:13:39.046
It’s also unrenewable.

00:13:39.686 –> 00:13:41.407
So I was thinking of three

00:13:41.466 –> 00:13:44.009
promises that I want to

00:13:44.048 –> 00:13:45.288
give to you for this webinar,

00:13:45.308 –> 00:13:46.610
what you’re going to get out of it.

00:13:47.610 –> 00:13:49.692
So first of all, you will have,

00:13:49.951 –> 00:13:51.552
with the knowledge you get today,

00:13:51.572 –> 00:13:52.732
you will have higher

00:13:52.793 –> 00:13:55.674
acceptance rate for patient

00:13:55.695 –> 00:13:57.395
cases that would have

00:13:58.277 –> 00:13:59.618
traditionally been

00:13:59.677 –> 00:14:01.477
considered as surgical cases.

00:14:01.999 –> 00:14:02.999
So this is what I hear in my

00:14:03.038 –> 00:14:03.919
practice all the time.

00:14:03.960 –> 00:14:05.559
Patients saying what this

00:14:05.580 –> 00:14:06.841
can be done without surgery.

00:14:07.020 –> 00:14:08.422
Oh my God, I’m so happy.

00:14:08.481 –> 00:14:09.081
Let’s do it.

00:14:09.942 –> 00:14:11.322
So I think this will be a big win,

00:14:12.043 –> 00:14:13.443
but also you will be able

00:14:13.484 –> 00:14:16.044
to serve your patients who

00:14:16.445 –> 00:14:18.105
seek those patients who

00:14:18.145 –> 00:14:20.407
seek to improve their breathing.

00:14:21.347 –> 00:14:22.207
And they’re becoming more

00:14:22.227 –> 00:14:23.048
and more nowadays.

00:14:24.349 –> 00:14:26.309
And we’re,

00:14:27.182 –> 00:14:28.562
We’re all set after this

00:14:29.003 –> 00:14:30.344
webinar that you

00:14:30.504 –> 00:14:34.525
confidently start your first Murphy case.

00:14:35.025 –> 00:14:36.386
So let’s start right into it.

00:14:36.807 –> 00:14:37.548
I would like to give you a

00:14:37.567 –> 00:14:38.768
little bit of my background.

00:14:39.109 –> 00:14:43.150
So, um, I studied dentistry in Wurzburg.

00:14:43.831 –> 00:14:45.131
This is in Germany.

00:14:45.652 –> 00:14:48.214
It’s the city hard to pronounce Wurzburg,

00:14:48.653 –> 00:14:49.995
but it’s beautiful to live in.

00:14:50.355 –> 00:14:51.315
It’s famous for its

00:14:51.554 –> 00:14:54.397
vineyards and they have incredible wine.

00:14:55.072 –> 00:14:56.192
you can imagine it was a lot

00:14:56.232 –> 00:14:57.333
of fun studying there

00:14:58.114 –> 00:15:00.495
however as an austrian my

00:15:00.875 –> 00:15:02.857
heart always belonged to

00:15:03.077 –> 00:15:04.938
vienna it’s actually also

00:15:04.979 –> 00:15:06.600
the city where I live and

00:15:06.679 –> 00:15:09.442
work well I I don’t have my

00:15:09.682 –> 00:15:11.283
own practice there because

00:15:11.563 –> 00:15:13.304
I honestly I’m so in love

00:15:13.325 –> 00:15:15.346
with orthodontists or with

00:15:15.726 –> 00:15:17.827
orthodontics not

00:15:17.908 –> 00:15:19.649
orthodontists I’m in love

00:15:19.668 –> 00:15:23.432
with orthodontics um so that

00:15:24.115 –> 00:15:26.197
I want to leave managing a

00:15:26.256 –> 00:15:28.778
practice and taking care of

00:15:28.839 –> 00:15:29.899
staff to someone else.

00:15:30.438 –> 00:15:31.299
So this is why I’m an

00:15:31.340 –> 00:15:32.580
associate in a practice.

00:15:34.520 –> 00:15:35.861
So it’s a practice with

00:15:35.922 –> 00:15:36.982
different specialists and

00:15:37.062 –> 00:15:38.903
I’m a specialist for orthodontics.

00:15:40.203 –> 00:15:42.946
And you can imagine when I started,

00:15:44.110 –> 00:15:46.312
You know, which way,

00:15:46.451 –> 00:15:49.153
I started from scratch and in the city,

00:15:49.214 –> 00:15:51.775
like Vienna, the market is saturated.

00:15:51.936 –> 00:15:53.756
So there are enough orthodontists.

00:15:54.018 –> 00:15:54.998
Nobody waited for me.

00:15:55.778 –> 00:15:57.080
And on top of that, you know,

00:15:57.600 –> 00:15:59.822
back then I looked even younger, uh,

00:16:00.162 –> 00:16:02.124
which was not an advantage back then,

00:16:02.163 –> 00:16:03.365
because when I walked into

00:16:03.384 –> 00:16:04.966
the operating room, you know,

00:16:05.145 –> 00:16:06.746
the patient would say, uh, you know,

00:16:06.767 –> 00:16:08.208
excuse me, I’m waiting for the doctor.

00:16:09.909 –> 00:16:10.509
I’m the doctor.

00:16:11.390 –> 00:16:13.913
Oh, so that was usually the case.

00:16:14.706 –> 00:16:17.107
However, I had one big advantage.

00:16:17.648 –> 00:16:19.847
So I was trained very well.

00:16:20.609 –> 00:16:21.908
I had a lot of knowledge in

00:16:22.028 –> 00:16:23.349
how to solve complex

00:16:23.589 –> 00:16:25.350
malocclusions with clear aligners.

00:16:25.909 –> 00:16:27.610
So I could often offer a

00:16:27.671 –> 00:16:28.971
patient a comfortable

00:16:29.451 –> 00:16:31.672
non-visible solution where

00:16:32.011 –> 00:16:34.552
they have been told all their life,

00:16:35.052 –> 00:16:36.753
it can only be done with braces.

00:16:37.552 –> 00:16:39.594
So this is not my,

00:16:41.914 –> 00:16:43.075
I’m standing on the shoulders

00:16:44.022 –> 00:16:45.582
of big giants of my mentors.

00:16:45.743 –> 00:16:48.344
And just to name a few, Dr. Ivan Malagon,

00:16:48.364 –> 00:16:49.404
Dr. Diego Pedro,

00:16:49.485 –> 00:16:50.424
who have really

00:16:50.504 –> 00:16:52.687
revolutionized aligner treatment.

00:16:53.246 –> 00:16:55.168
I learned from Dr. Barbara Kitzmantel,

00:16:55.187 –> 00:16:57.129
where I’m so grateful for

00:16:57.168 –> 00:16:58.909
everything I could learn from her.

00:16:59.485 –> 00:17:00.625
The lady in blonde next to

00:17:00.664 –> 00:17:01.725
me is my sister.

00:17:01.765 –> 00:17:03.586
She’s my mentor for life.

00:17:04.247 –> 00:17:05.708
But I’m also very grateful

00:17:05.768 –> 00:17:07.067
for what I could learn from

00:17:07.228 –> 00:17:08.388
Professor Benedict Wilmess.

00:17:09.028 –> 00:17:10.950
So he was one of the first

00:17:11.029 –> 00:17:14.691
who actually published on MARPI, you know,

00:17:14.770 –> 00:17:15.751
hybrid hybrids.

00:17:16.551 –> 00:17:18.232
And I’m also very thankful

00:17:18.292 –> 00:17:20.472
for my mentor in the States,

00:17:21.213 –> 00:17:22.213
Dr. Kibam Kim.

00:17:23.174 –> 00:17:26.056
And I, you probably noticed,

00:17:26.556 –> 00:17:29.257
I have a passion for teaching because

00:17:29.824 –> 00:17:31.284
The person who probably

00:17:31.364 –> 00:17:33.384
learns the most is the one

00:17:33.424 –> 00:17:34.365
who is teaching.

00:17:34.785 –> 00:17:36.086
This is why I’m very proud

00:17:36.125 –> 00:17:39.767
of also having a mentee, Dr. Theresa Meis,

00:17:39.946 –> 00:17:41.666
who is a big support for me.

00:17:42.946 –> 00:17:44.127
So when I’m not working,

00:17:44.188 –> 00:17:45.567
when I’m not moving teeth,

00:17:46.347 –> 00:17:47.769
I love being with my husband.

00:17:49.628 –> 00:17:53.670
He’s like part of the reason

00:17:53.710 –> 00:17:55.250
why I’m standing here today.

00:17:55.330 –> 00:17:56.871
He gave me so much confidence.

00:17:57.896 –> 00:18:00.238
And our free time we love to

00:18:00.278 –> 00:18:01.159
spend in Italy.

00:18:01.219 –> 00:18:03.000
He’s a big fan of Italy.

00:18:03.019 –> 00:18:04.480
He speaks fluently Italian.

00:18:04.941 –> 00:18:06.142
So whenever we get the chance,

00:18:06.541 –> 00:18:09.063
we escape to… Italy is

00:18:09.143 –> 00:18:10.003
actually a neighboring

00:18:10.044 –> 00:18:10.963
country of Austria.

00:18:11.865 –> 00:18:13.806
So I’m sure you’re all

00:18:13.846 –> 00:18:18.929
familiar of this Italian iconic building.

00:18:19.509 –> 00:18:21.849
It’s the Leaning Tower of Pisa.

00:18:22.851 –> 00:18:23.851
And you probably also know

00:18:23.891 –> 00:18:24.751
why it’s famous for.

00:18:25.369 –> 00:18:26.750
because it’s leaning.

00:18:27.131 –> 00:18:28.730
So if you don’t know the story,

00:18:28.932 –> 00:18:31.011
the reason is because the engineers,

00:18:31.732 –> 00:18:34.233
they had the vision of this

00:18:34.554 –> 00:18:35.734
tower and they just built it.

00:18:36.295 –> 00:18:39.415
They did not check the foundation.

00:18:40.356 –> 00:18:41.936
They did not notice that

00:18:42.057 –> 00:18:44.597
it’s built on sandy ground

00:18:44.637 –> 00:18:45.398
and the foundation is

00:18:45.578 –> 00:18:47.579
actually only three meters deep.

00:18:48.160 –> 00:18:50.421
So this is why during building,

00:18:51.500 –> 00:18:53.021
it started leaning because

00:18:53.082 –> 00:18:54.782
the foundation was not there.

00:18:56.201 –> 00:18:57.142
And I’m bringing this up

00:18:57.182 –> 00:18:58.502
because it’s reminding me

00:18:58.603 –> 00:19:00.144
one of my patients,

00:19:00.223 –> 00:19:01.945
one of the case that I

00:19:01.986 –> 00:19:03.626
treated that I want to share with you.

00:19:04.748 –> 00:19:06.949
So this is the patient, um,

00:19:08.269 –> 00:19:11.232
he was referred to me and, uh, you know,

00:19:11.333 –> 00:19:12.634
he had multiple orthodontic

00:19:12.673 –> 00:19:13.634
treatments before and

00:19:13.694 –> 00:19:14.595
nothing seemed to work.

00:19:14.674 –> 00:19:16.277
And this is how I presented

00:19:16.297 –> 00:19:17.877
with an anterior open bite,

00:19:18.218 –> 00:19:19.979
narrow maxilla.

00:19:19.999 –> 00:19:20.799
So you can see there’s a

00:19:20.900 –> 00:19:23.781
little bit of class two here also,

00:19:23.882 –> 00:19:25.784
and there’s an ectopic canine.

00:19:27.573 –> 00:19:28.513
Uh, everything.

00:19:28.653 –> 00:19:28.874
Okay.

00:19:28.894 –> 00:19:30.695
A little bit of everything, crowding,

00:19:30.796 –> 00:19:32.576
not enough space here.

00:19:33.017 –> 00:19:33.096
Um,

00:19:33.478 –> 00:19:35.078
this is the stuff I’m just going to go

00:19:35.199 –> 00:19:36.359
really quickly through that.

00:19:37.260 –> 00:19:39.261
So my treatment plan was to do, you know,

00:19:39.521 –> 00:19:41.844
dental expansion, do it with aligners,

00:19:41.963 –> 00:19:42.223
you know,

00:19:42.243 –> 00:19:44.006
because we’re not doing braces anymore.

00:19:44.066 –> 00:19:45.207
Aligners are cool and

00:19:45.846 –> 00:19:48.788
wonderful and intrude, uh,

00:19:48.848 –> 00:19:50.971
the posterior teeth because

00:19:50.990 –> 00:19:52.412
they have been over erupted

00:19:53.212 –> 00:19:54.894
and fix the malocclusion

00:19:54.913 –> 00:19:56.115
and get him a great smile.

00:19:57.000 –> 00:19:58.700
So this will still align a treatment plan,

00:19:58.720 –> 00:20:00.240
you know, dental expansion,

00:20:00.780 –> 00:20:02.661
making sure the teeth fit together.

00:20:03.381 –> 00:20:06.582
And actually it turned out really nicely.

00:20:06.741 –> 00:20:08.122
Patient was very compliant.

00:20:09.122 –> 00:20:11.083
I was extremely proud of the

00:20:11.323 –> 00:20:12.303
results back then.

00:20:12.323 –> 00:20:17.443
Occlusion I think is quite

00:20:17.983 –> 00:20:20.164
acceptable and the smile is

00:20:20.184 –> 00:20:20.904
just beautiful.

00:20:22.565 –> 00:20:26.506
However, when I did some further training,

00:20:27.651 –> 00:20:29.311
I realized that this result

00:20:29.392 –> 00:20:30.353
is actually like the

00:20:30.393 –> 00:20:33.515
Leaning Tower of Pisa

00:20:33.535 –> 00:20:36.757
because I didn’t address the root cause.

00:20:37.017 –> 00:20:38.257
I didn’t address the function.

00:20:39.038 –> 00:20:41.859
Why were the teeth like in the beginning?

00:20:42.480 –> 00:20:43.980
Why were the molars over erupted?

00:20:45.201 –> 00:20:46.762
So the reason is because the

00:20:46.782 –> 00:20:49.984
patient was now breathing at night.

00:20:50.045 –> 00:20:54.646
So later at the recall, I asked the mother,

00:20:55.587 –> 00:20:57.169
how is he breathing at night?

00:20:57.864 –> 00:20:58.845
with his mouth open.

00:21:00.605 –> 00:21:01.266
Then I asked, you know,

00:21:01.286 –> 00:21:02.507
when he’s doing his homework,

00:21:02.606 –> 00:21:04.028
is his mouth shut?

00:21:04.107 –> 00:21:05.148
Is he breathing through his nose?

00:21:05.328 –> 00:21:05.709
No,

00:21:05.769 –> 00:21:07.651
it’s always open because it’s just too

00:21:07.671 –> 00:21:08.711
difficult for him to

00:21:08.751 –> 00:21:09.632
breathe through his nose.

00:21:10.313 –> 00:21:11.113
And we did the nasal

00:21:11.133 –> 00:21:12.294
obstruction evaluation

00:21:12.334 –> 00:21:13.394
scale and it showed he had

00:21:13.615 –> 00:21:14.875
severe problems breathing

00:21:14.895 –> 00:21:15.496
through his nose.

00:21:16.576 –> 00:21:19.358
So I came to the realization

00:21:19.499 –> 00:21:21.319
there was a too narrow upper jaw.

00:21:21.840 –> 00:21:23.701
I could have done skeletal expansion.

00:21:23.721 –> 00:21:24.603
It would have been very

00:21:24.643 –> 00:21:26.203
straightforward in a child like this.

00:21:26.925 –> 00:21:29.127
But I missed the root cause.

00:21:29.248 –> 00:21:30.749
I only saw occlusion.

00:21:30.788 –> 00:21:32.671
I was only thinking about bite and beauty.

00:21:33.310 –> 00:21:34.392
But there is something even

00:21:34.451 –> 00:21:35.071
more important.

00:21:35.133 –> 00:21:35.813
It’s breathing.

00:21:36.574 –> 00:21:38.355
And the negative

00:21:38.394 –> 00:21:39.496
consequences of mouth

00:21:39.516 –> 00:21:41.396
breathing are malocclusion,

00:21:41.758 –> 00:21:42.698
either in the first place,

00:21:43.038 –> 00:21:44.920
or even if you treat a patient,

00:21:45.160 –> 00:21:46.602
it’s prone to relapse

00:21:46.781 –> 00:21:48.123
because the mouth is open,

00:21:48.682 –> 00:21:49.624
molars will over-erupt.

00:21:50.834 –> 00:21:52.595
If the patient is still in development,

00:21:54.175 –> 00:21:56.877
it can mean altered facial development.

00:21:57.999 –> 00:22:00.981
Later, it can cause snoring.

00:22:01.961 –> 00:22:03.583
But also if children mouth

00:22:03.603 –> 00:22:04.263
breathe at night,

00:22:04.544 –> 00:22:06.365
the tonsils tend to be

00:22:06.465 –> 00:22:08.186
enlarged and then they start snoring.

00:22:09.248 –> 00:22:11.788
And this then can result in poor sleep,

00:22:11.890 –> 00:22:12.569
leading to poor

00:22:12.609 –> 00:22:13.730
concentration during the day.

00:22:15.221 –> 00:22:17.503
So I was fascinated when I

00:22:17.544 –> 00:22:19.644
got introduced to the dome

00:22:19.684 –> 00:22:21.125
concept that has been

00:22:21.625 –> 00:22:22.926
described by Dr. Stanley

00:22:22.967 –> 00:22:25.669
Liu and Dr. Artie Yoon at Stanford.

00:22:26.148 –> 00:22:29.171
So it basically means it’s pretty simple,

00:22:29.191 –> 00:22:29.991
but brilliant.

00:22:30.491 –> 00:22:32.413
Turning a high arch pallet

00:22:32.633 –> 00:22:35.295
in a narrow jaw into a dome

00:22:35.355 –> 00:22:36.395
shaped pallet.

00:22:37.094 –> 00:22:37.775
wide jaw.

00:22:38.494 –> 00:22:40.236
And as you can see in this illustration,

00:22:40.757 –> 00:22:42.238
the roof of the mouth is

00:22:42.317 –> 00:22:43.959
also the floor of the nose.

00:22:44.579 –> 00:22:46.760
So if we expand the maxilla,

00:22:47.501 –> 00:22:49.623
we also expand the nasal cavity.

00:22:50.223 –> 00:22:52.204
That means reduced nasal

00:22:52.465 –> 00:22:53.665
airflow resistance.

00:22:54.126 –> 00:22:55.988
So this can improve nasal

00:22:56.008 –> 00:22:58.410
breathing and also improves

00:22:58.569 –> 00:23:00.330
pharyngeal airway stability

00:23:00.371 –> 00:23:01.372
so that the airway here

00:23:01.791 –> 00:23:02.813
stays open and doesn’t

00:23:02.853 –> 00:23:03.834
collapse and cause

00:23:04.755 –> 00:23:06.516
breathing issues or even sleep apnea.

00:23:07.474 –> 00:23:09.296
So in the QR codes,

00:23:09.375 –> 00:23:13.817
you always find scientific papers to it.

00:23:13.856 –> 00:23:16.458
So I was so fascinated with

00:23:16.498 –> 00:23:18.218
that because I mean,

00:23:18.278 –> 00:23:20.239
imagine if you cannot only

00:23:20.278 –> 00:23:21.259
provide your patients with

00:23:21.298 –> 00:23:23.119
a better bite and a beautiful smile,

00:23:23.480 –> 00:23:26.921
but also help them breathe better,

00:23:27.381 –> 00:23:28.781
which will have an impact

00:23:28.961 –> 00:23:30.261
on their overall health.

00:23:31.365 –> 00:23:33.226
So I wanted to work with Dr.

00:23:33.286 –> 00:23:34.226
Stanley Liu together.

00:23:34.445 –> 00:23:36.366
This is why I joined NOVA

00:23:36.446 –> 00:23:37.606
Southeastern University.

00:23:38.468 –> 00:23:40.667
And this topic is so

00:23:40.708 –> 00:23:41.689
important that a few

00:23:41.729 –> 00:23:43.970
colleagues of mine and me,

00:23:44.190 –> 00:23:46.631
we started the Vienna Airway Congress,

00:23:47.070 –> 00:23:48.391
where we bring specialists

00:23:48.431 –> 00:23:51.271
from all different fields together, ENPs,

00:23:51.451 –> 00:23:53.353
that means ear, nose, throat doctors,

00:23:53.961 –> 00:23:55.423
or maxillofacial surgeons,

00:23:55.482 –> 00:23:57.163
myofunctional therapists together,

00:23:57.564 –> 00:23:58.724
because breathing is a

00:23:58.785 –> 00:23:59.984
topic that needs to be

00:24:00.145 –> 00:24:00.846
addressed together.

00:24:01.226 –> 00:24:02.267
If you’re interested in that,

00:24:02.406 –> 00:24:04.448
the Vienna Aero Congress is

00:24:04.627 –> 00:24:06.909
going to be in October, in Vienna.

00:24:07.049 –> 00:24:11.791
And yeah, so joining NSU,

00:24:11.892 –> 00:24:12.633
Nova Southeastern

00:24:12.712 –> 00:24:14.314
University also brought

00:24:14.354 –> 00:24:16.414
another wonderful aspect to it.

00:24:16.755 –> 00:24:19.096
I get to know the residents, Anna,

00:24:19.317 –> 00:24:20.017
TJ’s wife,

00:24:20.595 –> 00:24:21.717
And this is how the

00:24:21.738 –> 00:24:24.102
collaboration with ODL started.

00:24:24.182 –> 00:24:26.385
And thanks to the generosity of ODL,

00:24:26.866 –> 00:24:29.451
we can have this webinar today.

00:24:29.471 –> 00:24:31.075
So here we were at Topgolf,

00:24:31.536 –> 00:24:32.337
which was a lot of fun.

00:24:33.358 –> 00:24:37.080
But coming back to maxilla and breathing.

00:24:37.701 –> 00:24:41.022
So here is a video of a

00:24:41.083 –> 00:24:42.042
superimposition of the

00:24:42.083 –> 00:24:44.344
CBCTs showing you what

00:24:44.423 –> 00:24:46.865
happens when we expand the maxilla.

00:24:47.346 –> 00:24:48.165
It’s amazing.

00:24:48.566 –> 00:24:49.567
We’re moving bones.

00:24:49.906 –> 00:24:50.186
Okay.

00:24:50.586 –> 00:24:53.008
So also look how the nasal

00:24:53.048 –> 00:24:56.569
cavity is embedded in the maxilla,

00:24:57.049 –> 00:24:58.330
in the maxillary bones.

00:24:58.971 –> 00:25:00.311
So if we expand,

00:25:01.198 –> 00:25:05.080
we increase the nasal cavity.

00:25:05.240 –> 00:25:06.321
And think of it,

00:25:07.102 –> 00:25:08.682
if somebody has problems

00:25:09.083 –> 00:25:10.084
with nasal breathing and

00:25:10.104 –> 00:25:11.404
they go to an ENT,

00:25:12.185 –> 00:25:15.448
the ENT can take out stuff, okay?

00:25:15.468 –> 00:25:16.489
He can do turbinate

00:25:16.528 –> 00:25:17.628
reduction straight in the

00:25:17.689 –> 00:25:19.971
septum or even remove the turbinates.

00:25:21.092 –> 00:25:23.213
So imagine like when you

00:25:23.233 –> 00:25:24.154
were a student and you

00:25:24.194 –> 00:25:25.635
lived in this small flat

00:25:25.875 –> 00:25:27.397
and it all was cramped and

00:25:27.458 –> 00:25:29.419
you had the desk on top of

00:25:29.499 –> 00:25:31.800
the bed and no place to move.

00:25:32.342 –> 00:25:34.182
So the ENT can take out

00:25:34.262 –> 00:25:36.204
stuff like remove your working desk,

00:25:36.685 –> 00:25:37.806
but you still need it.

00:25:40.067 –> 00:25:42.329
But what you can do as an orthodontist,

00:25:42.891 –> 00:25:44.632
you can make the house bigger.

00:25:45.874 –> 00:25:48.154
So dome is the only

00:25:48.214 –> 00:25:50.715
procedure that is expensive

00:25:51.356 –> 00:25:53.357
because it is expensive

00:25:54.278 –> 00:25:55.739
because maxillary expansion

00:25:56.259 –> 00:25:58.099
increases the volume in the nasal cavity.

00:25:58.599 –> 00:26:02.761
This reduces nasal airflow resistance.

00:26:02.781 –> 00:26:04.623
All right.

00:26:04.643 –> 00:26:05.763
So skeletal maxillary

00:26:05.804 –> 00:26:07.345
expansion is not only for

00:26:07.365 –> 00:26:09.526
breathing and beauty or not

00:26:09.586 –> 00:26:11.066
only for bite and beauty,

00:26:11.125 –> 00:26:12.186
but also for breathing.

00:26:14.133 –> 00:26:16.814
So you probably wonder if this is so great,

00:26:16.854 –> 00:26:17.993
why isn’t that everybody

00:26:18.233 –> 00:26:19.535
already doing it all the time?

00:26:20.375 –> 00:26:21.194
There are also some

00:26:21.434 –> 00:26:23.195
complications that I also

00:26:23.236 –> 00:26:24.736
want to emphasize to show

00:26:24.756 –> 00:26:26.317
you both sides of the coin.

00:26:27.817 –> 00:26:29.357
And this will take us into

00:26:29.478 –> 00:26:31.917
our next step where we talk

00:26:31.939 –> 00:26:33.358
about avoiding the complications.

00:26:34.358 –> 00:26:37.619
So common complications are

00:26:37.740 –> 00:26:38.921
soft tissue inflammation,

00:26:39.881 –> 00:26:43.102
soft tissue impingement if the screws

00:26:43.689 –> 00:26:45.210
don’t move the bone,

00:26:45.549 –> 00:26:47.569
but they move in the bone,

00:26:47.630 –> 00:26:49.371
like in a piece of butter,

00:26:50.030 –> 00:26:51.731
because they don’t have enough retention.

00:26:52.951 –> 00:26:56.973
Then the expanded some, some time, um,

00:26:57.054 –> 00:26:59.013
at some point will impinge

00:26:59.535 –> 00:27:03.096
into the gum or if the

00:27:03.135 –> 00:27:06.257
maxilla doesn’t expand, but you know,

00:27:06.297 –> 00:27:08.538
we keep, uh, turning the expander.

00:27:08.857 –> 00:27:09.018
We.

00:27:09.772 –> 00:27:11.054
do dental expansion of the

00:27:11.173 –> 00:27:12.515
anchor teeth and move them

00:27:12.775 –> 00:27:13.915
outside the bony housing.

00:27:14.415 –> 00:27:15.217
It’s not pretty.

00:27:16.557 –> 00:27:20.681
So how can we avoid those complications?

00:27:20.740 –> 00:27:20.961
Well,

00:27:22.882 –> 00:27:25.864
what we still cannot know is who will

00:27:25.943 –> 00:27:27.164
expand or not.

00:27:27.285 –> 00:27:29.165
Of course, with surgical assistance,

00:27:29.185 –> 00:27:30.707
if you cut the maxilline pieces,

00:27:30.727 –> 00:27:32.167
you can always expand it.

00:27:32.949 –> 00:27:34.049
But we want to be as

00:27:34.109 –> 00:27:35.530
minimally invasive as possible.

00:27:35.590 –> 00:27:37.332
And patients are usually not

00:27:38.196 –> 00:27:39.678
super excited to get surgery

00:27:40.818 –> 00:27:42.900
unless it’s absolutely necessary.

00:27:44.040 –> 00:27:47.202
So taking the bone quantity

00:27:47.702 –> 00:27:49.003
and quality into

00:27:49.104 –> 00:27:51.405
consideration will give you

00:27:51.746 –> 00:27:53.527
a higher chance for success.

00:27:54.228 –> 00:27:55.788
And it’s bone quality and

00:27:55.828 –> 00:27:57.750
quantity is very variable

00:27:57.910 –> 00:27:59.250
from individual to individual.

00:28:01.141 –> 00:28:02.601
So let’s talk about the

00:28:02.641 –> 00:28:04.422
different approaches and

00:28:04.481 –> 00:28:05.862
what’s the pros and cons.

00:28:06.482 –> 00:28:09.364
So if we have the TAD last approach,

00:28:09.683 –> 00:28:11.564
it’s basically appliance first.

00:28:11.703 –> 00:28:13.244
So you have the appliance

00:28:13.664 –> 00:28:17.945
and then you fix it with the screws.

00:28:18.806 –> 00:28:19.886
You would cement the

00:28:20.247 –> 00:28:22.347
appliance and then put the

00:28:22.387 –> 00:28:26.608
TADs through the eyelets, as I explained.

00:28:27.355 –> 00:28:30.497
Just to show you how this could look like,

00:28:30.557 –> 00:28:30.998
for example,

00:28:31.018 –> 00:28:32.759
this is a power expander by

00:28:32.798 –> 00:28:34.681
Dr. Juan Carlos Perez Morela,

00:28:35.161 –> 00:28:37.383
a Spanish orthodontist.

00:28:39.403 –> 00:28:40.105
Here you can see,

00:28:40.444 –> 00:28:42.906
first you see the appliance

00:28:43.106 –> 00:28:45.929
and then the screws fix the

00:28:45.989 –> 00:28:49.491
appliance to the skull, to the bone.

00:28:50.211 –> 00:28:52.213
So first appliance, then the TAD.

00:28:53.527 –> 00:28:54.768
This is how it would look

00:28:54.807 –> 00:28:56.429
like this is one of my

00:28:56.469 –> 00:28:59.030
cases here I did a purely

00:28:59.050 –> 00:29:00.291
bone borne expander sort of

00:29:00.531 –> 00:29:02.333
arms to the teeth or just to.

00:29:04.114 –> 00:29:06.355
Have a correct positioning

00:29:07.036 –> 00:29:09.218
of the appliance the blood

00:29:09.238 –> 00:29:10.259
here I’m sorry for that,

00:29:10.298 –> 00:29:11.599
but this is from cortical

00:29:11.640 –> 00:29:13.340
puncture and now.

00:29:13.922 –> 00:29:15.082
Now that the appliance is in place,

00:29:15.843 –> 00:29:17.022
I placed the tabs and

00:29:17.063 –> 00:29:18.884
removed the holding arms.

00:29:19.104 –> 00:29:21.164
Those were really just to

00:29:21.525 –> 00:29:23.105
seat the appliance in the

00:29:23.144 –> 00:29:28.027
card space until I put the tabs in there.

00:29:28.067 –> 00:29:30.307
So this can be done without

00:29:30.367 –> 00:29:32.648
insertion guides, as I show you here.

00:29:32.729 –> 00:29:34.109
I just put the screw here

00:29:34.289 –> 00:29:35.069
through the eyelets.

00:29:36.190 –> 00:29:39.311
Or because this is not really accurate,

00:29:39.332 –> 00:29:40.231
you can see, I mean,

00:29:41.038 –> 00:29:43.940
depending which angle you put the screw,

00:29:44.059 –> 00:29:45.079
there can be a little bit

00:29:45.140 –> 00:29:48.321
of distortion and like

00:29:49.462 –> 00:29:51.344
deviation from the plant position.

00:29:52.284 –> 00:29:53.164
So for example,

00:29:53.184 –> 00:29:55.185
the power expander has the

00:29:55.306 –> 00:29:57.747
insertion guide built into the appliance.

00:29:58.708 –> 00:29:59.228
However,

00:29:59.307 –> 00:30:01.169
this makes the appliance pretty

00:30:01.269 –> 00:30:03.049
bulky because the insertion

00:30:03.069 –> 00:30:05.592
guide is part of it.

00:30:07.053 –> 00:30:08.874
An example for without,

00:30:09.778 –> 00:30:12.239
Surgical guides would be the MSC.

00:30:12.578 –> 00:30:14.359
You just put it through the holes.

00:30:17.922 –> 00:30:20.083
So the TAD last approach,

00:30:20.542 –> 00:30:22.804
the pros of this treatment

00:30:22.864 –> 00:30:25.605
is you have one appointment delivery.

00:30:26.006 –> 00:30:29.007
So basically you order the appliance,

00:30:29.807 –> 00:30:30.428
you seed it,

00:30:31.769 –> 00:30:33.409
you cement it to the molars

00:30:33.710 –> 00:30:34.349
and put the TADs.

00:30:35.575 –> 00:30:35.894
However,

00:30:35.934 –> 00:30:38.517
the contra here is that you have

00:30:38.596 –> 00:30:42.098
less accuracy with tab placement.

00:30:42.719 –> 00:30:44.680
Or imagine if you need to re-drill,

00:30:45.119 –> 00:30:46.381
you need to re-drill

00:30:46.560 –> 00:30:48.241
through the holes and

00:30:48.481 –> 00:30:50.042
imagine you place the tabs

00:30:50.163 –> 00:30:51.503
between the roots of the

00:30:51.544 –> 00:30:52.285
five and the six.

00:30:53.085 –> 00:30:54.746
Here you don’t want to be

00:30:56.047 –> 00:30:58.307
inaccurate and maybe drill the root.

00:30:58.407 –> 00:31:00.009
So this could be really dangerous.

00:31:00.909 –> 00:31:02.109
Or if the insertion guides

00:31:02.150 –> 00:31:03.471
are part of the appliance,

00:31:03.631 –> 00:31:05.271
the appliance gets a little bulky.

00:31:06.909 –> 00:31:08.930
And I think the biggest

00:31:08.990 –> 00:31:11.070
contra point here is if

00:31:11.090 –> 00:31:12.531
there’s a problem and you

00:31:12.551 –> 00:31:13.971
need to remove the appliance,

00:31:14.472 –> 00:31:15.913
you also need to remove the task.

00:31:17.594 –> 00:31:18.755
And if you remove the task

00:31:18.815 –> 00:31:20.234
and you want to place

00:31:20.275 –> 00:31:21.915
another expander like you

00:31:21.976 –> 00:31:24.376
can’t really use to the

00:31:24.416 –> 00:31:26.018
places where the tasks have been before.

00:31:26.617 –> 00:31:28.117
And you also cannot use the

00:31:28.157 –> 00:31:29.338
free millimeters around it

00:31:29.358 –> 00:31:30.138
because the rapid

00:31:30.259 –> 00:31:31.278
accelerated phenomena

00:31:31.699 –> 00:31:33.700
causes there to be blood

00:31:33.740 –> 00:31:34.400
vessels and stuff.

00:31:34.440 –> 00:31:36.800
So it has decreased stability.

00:31:37.181 –> 00:31:39.442
So this is really an issue.

00:31:39.721 –> 00:31:41.142
This is why I really like

00:31:41.201 –> 00:31:43.442
the TAD first approach or

00:31:44.182 –> 00:31:46.044
also it’s called bone first

00:31:46.443 –> 00:31:49.545
approach because basically

00:31:49.924 –> 00:31:51.944
it means we place the TADs

00:31:52.204 –> 00:31:53.806
where we have the best bone.

00:31:54.965 –> 00:31:56.247
So not the appliance

00:31:56.307 –> 00:31:58.728
dictates where the tats go,

00:31:59.268 –> 00:32:00.268
but the bone does.

00:32:00.847 –> 00:32:02.288
So coming back to our

00:32:02.489 –> 00:32:04.650
analogy with building a foundation.

00:32:05.349 –> 00:32:08.632
So I’m sure you notice a tower.

00:32:08.872 –> 00:32:10.011
This is in Dubai.

00:32:10.372 –> 00:32:12.313
It’s the Burj Khalifa and

00:32:12.472 –> 00:32:14.673
it’s the biggest tower in the world.

00:32:15.394 –> 00:32:16.694
So you can imagine that the

00:32:16.815 –> 00:32:18.556
engineers could not afford

00:32:18.955 –> 00:32:21.257
not bothering about the foundation.

00:32:22.236 –> 00:32:22.756
In fact,

00:32:23.116 –> 00:32:26.038
before a single thing of this

00:32:26.098 –> 00:32:28.020
building has been built,

00:32:28.421 –> 00:32:30.602
the engineers spent months

00:32:30.623 –> 00:32:32.044
and years studying the

00:32:32.084 –> 00:32:33.505
ground because the ground there,

00:32:34.045 –> 00:32:34.726
it’s a desert.

00:32:35.105 –> 00:32:35.685
It’s sad.

00:32:36.267 –> 00:32:37.928
If you go there, there’s nothing in it.

00:32:37.948 –> 00:32:39.388
Out of nothing comes the city.

00:32:40.309 –> 00:32:41.891
So what they had to do is

00:32:42.412 –> 00:32:44.633
they had to drill a hundred

00:32:44.653 –> 00:32:46.375
and ninety two deep

00:32:46.454 –> 00:32:48.195
foundation pills really

00:32:48.236 –> 00:32:49.237
deep into the earth.

00:32:49.497 –> 00:32:51.898
And on this, the tower stands.

00:32:53.410 –> 00:32:55.451
So this reminds me really of

00:32:55.490 –> 00:32:57.491
the TAD first approach.

00:32:57.612 –> 00:32:58.333
We do the same.

00:32:58.633 –> 00:33:00.834
So we study our foundation,

00:33:01.013 –> 00:33:04.336
which is the bone of the maxillary bones,

00:33:05.896 –> 00:33:08.018
plan where we place the TADs,

00:33:09.057 –> 00:33:09.719
place the TADs,

00:33:09.778 –> 00:33:12.099
and then the appliance is

00:33:12.299 –> 00:33:13.681
fabricated depending on

00:33:13.701 –> 00:33:14.621
where the TADs go.

00:33:15.701 –> 00:33:16.582
So for example,

00:33:16.741 –> 00:33:18.823
we have the TADs here first.

00:33:19.364 –> 00:33:21.065
This can be done with insertion guides,

00:33:21.105 –> 00:33:21.664
for example.

00:33:22.853 –> 00:33:25.055
Then you scan the test,

00:33:25.355 –> 00:33:26.655
no scan bodies are needed,

00:33:27.395 –> 00:33:28.757
and you order the appliance.

00:33:28.896 –> 00:33:30.978
So ODL will provide you with

00:33:30.998 –> 00:33:32.940
a beautiful appliance like this.

00:33:34.080 –> 00:33:37.163
And then you insert it in

00:33:37.202 –> 00:33:39.044
the patient and mount it

00:33:39.163 –> 00:33:40.664
with little fixing screws.

00:33:41.894 –> 00:33:42.653
So this is,

00:33:43.015 –> 00:33:46.375
you need a special type of TAD for that.

00:33:46.636 –> 00:33:48.958
This is the PSM benefit screw.

00:33:49.538 –> 00:33:51.179
And it’s special because it

00:33:51.219 –> 00:33:52.839
has a bone part.

00:33:52.980 –> 00:33:55.221
So the bone screw and a

00:33:55.260 –> 00:33:57.122
fixing screw that allows

00:33:57.162 –> 00:33:59.343
you to fix an appliance

00:33:59.644 –> 00:34:03.164
onto the bone screws.

00:34:03.204 –> 00:34:04.546
And it has a couple of advantages.

00:34:05.567 –> 00:34:05.767
So.

00:34:07.557 –> 00:34:08.818
Let’s repeat the process.

00:34:09.057 –> 00:34:09.418
First,

00:34:09.599 –> 00:34:12.541
you insert the tats with guides or

00:34:12.581 –> 00:34:13.260
free-handed.

00:34:13.601 –> 00:34:14.101
For example,

00:34:14.141 –> 00:34:15.603
in a case where I have very

00:34:15.623 –> 00:34:16.623
little bone where I need to

00:34:16.643 –> 00:34:17.945
be absolutely accurate,

00:34:18.545 –> 00:34:20.967
I do surgical guides first.

00:34:21.847 –> 00:34:23.088
If there’s a case where I

00:34:23.108 –> 00:34:24.188
have plenty of bone,

00:34:24.309 –> 00:34:26.731
where I know I can get the best bone,

00:34:27.351 –> 00:34:28.371
placing them free-handed,

00:34:28.452 –> 00:34:30.052
or if you’re already experienced,

00:34:30.753 –> 00:34:32.255
you can also do it free-handed.

00:34:32.715 –> 00:34:35.036
Then, once you place the screws,

00:34:35.197 –> 00:34:36.398
you take an intraoral scan.

00:34:37.621 –> 00:34:38.742
You don’t need scan bodies.

00:34:40.123 –> 00:34:41.123
So this has another

00:34:41.143 –> 00:34:42.804
advantage because once you

00:34:42.844 –> 00:34:43.804
inserted the screws,

00:34:43.983 –> 00:34:45.423
you can check if they’re firm.

00:34:45.945 –> 00:34:46.605
So what you would do,

00:34:46.644 –> 00:34:48.706
you would knock on the tats

00:34:49.085 –> 00:34:49.885
like you would do on an

00:34:50.045 –> 00:34:51.947
implant to hear the sound.

00:34:53.007 –> 00:34:55.568
If it sounds like an implant, that’s good.

00:34:56.088 –> 00:34:59.768
If it sounds very dull,

00:35:00.369 –> 00:35:01.829
that’s not a good sign.

00:35:03.530 –> 00:35:05.271
Then you insert the appliance.

00:35:06.206 –> 00:35:08.186
And then you fix it with fixing sprues.

00:35:09.768 –> 00:35:12.469
So the appliance is always custom made.

00:35:13.188 –> 00:35:15.351
And if you want to go into the literature,

00:35:15.411 –> 00:35:16.731
you would find examples

00:35:16.811 –> 00:35:18.231
under quad expander.

00:35:19.813 –> 00:35:22.954
So the pros and cons of this

00:35:23.695 –> 00:35:28.516
approach is the contra is

00:35:29.317 –> 00:35:30.297
you have two appointments.

00:35:31.351 –> 00:35:33.351
In at least in adults above the age of.

00:35:34.273 –> 00:35:36.153
Because for in adults,

00:35:36.173 –> 00:35:37.173
the bone is so dense.

00:35:38.074 –> 00:35:41.677
And if you like,

00:35:42.996 –> 00:35:44.518
if there’s one phase approach,

00:35:44.737 –> 00:35:45.719
this is also possible.

00:35:45.759 –> 00:35:46.699
We’ll have a look at that.

00:35:47.039 –> 00:35:48.860
That means the lab would

00:35:49.360 –> 00:35:51.922
place the tats in a software crate,

00:35:52.061 –> 00:35:54.724
the surgical guides, and also, um,

00:35:54.864 –> 00:35:56.744
plan to the appliance

00:35:56.804 –> 00:35:58.666
according to this crew position.

00:35:59.769 –> 00:36:00.731
However, in adults,

00:36:00.751 –> 00:36:02.952
the bone is sometimes so dense,

00:36:04.134 –> 00:36:05.974
even if you place it with surgical guides,

00:36:05.994 –> 00:36:06.876
there is a little

00:36:06.956 –> 00:36:08.556
abbreviation or a little

00:36:09.137 –> 00:36:10.798
deviation of the plant

00:36:10.818 –> 00:36:11.599
position and then the

00:36:11.619 –> 00:36:12.521
appliance won’t fit.

00:36:12.940 –> 00:36:15.123
This is why I recommend in

00:36:15.262 –> 00:36:16.963
adults above twenty five,

00:36:17.804 –> 00:36:22.028
always first place a test, then scan,

00:36:22.668 –> 00:36:24.170
then insert the appliance.

00:36:24.590 –> 00:36:26.813
That means you have two appointments.

00:36:27.335 –> 00:36:28.255
This is for me,

00:36:28.275 –> 00:36:31.257
the only con contra point

00:36:31.277 –> 00:36:31.958
to this approach.

00:36:32.478 –> 00:36:35.000
However, there are a lot of pro aspects.

00:36:35.460 –> 00:36:38.161
So you have high accuracy of

00:36:38.262 –> 00:36:39.222
TAD placement.

00:36:39.963 –> 00:36:41.563
If you, if there’s little bone,

00:36:41.923 –> 00:36:43.204
you do it with surgical

00:36:43.244 –> 00:36:45.005
guides to have the most

00:36:45.065 –> 00:36:46.967
precise TAD placement.

00:36:48.007 –> 00:36:50.208
Also, if you need pre-drilling,

00:36:50.628 –> 00:36:52.971
which in adults, I highly recommend.

00:36:54.106 –> 00:36:56.228
You can safely do it and be

00:36:56.288 –> 00:36:57.108
precise with it.

00:36:57.987 –> 00:36:59.748
You can even redrill between

00:36:59.789 –> 00:37:01.449
the routes with the surgical guides.

00:37:02.750 –> 00:37:04.170
And if there’s a problem,

00:37:05.030 –> 00:37:05.931
you can remove the

00:37:06.231 –> 00:37:08.972
appliance without changing the task,

00:37:09.992 –> 00:37:11.932
or you can use the same

00:37:11.952 –> 00:37:13.753
task for multiple appliances.

00:37:15.233 –> 00:37:16.114
That’s a big win,

00:37:16.454 –> 00:37:18.916
especially in patients with

00:37:19.275 –> 00:37:20.195
arch asymmetry,

00:37:20.536 –> 00:37:22.036
where you can later have a slider,

00:37:22.077 –> 00:37:22.597
for example.

00:37:24.516 –> 00:37:26.277
And I think the most

00:37:26.318 –> 00:37:27.898
important aspect to

00:37:28.418 –> 00:37:29.958
understand here is that the

00:37:29.998 –> 00:37:32.398
design is according to the

00:37:32.478 –> 00:37:33.838
best phone available.

00:37:34.500 –> 00:37:38.521
So the bone dictates where the screws go,

00:37:38.780 –> 00:37:41.581
not the appliance.

00:37:41.601 –> 00:37:44.601
Because let’s have a look at this here.

00:37:44.722 –> 00:37:49.043
So this is actually a map of

00:37:49.543 –> 00:37:50.724
good insertion sites.

00:37:51.621 –> 00:37:53.782
So here in the green area,

00:37:53.802 –> 00:37:55.342
this is the anterior palate.

00:37:55.463 –> 00:37:57.483
This is the best insertion site.

00:37:59.364 –> 00:38:01.166
When you look at the upper picture,

00:38:01.606 –> 00:38:03.407
you can see there’s a lot of bone.

00:38:03.867 –> 00:38:05.708
We’re in safe distance to

00:38:05.728 –> 00:38:08.550
the roots and we have good bone quality.

00:38:08.771 –> 00:38:12.032
So let’s always place two tats there.

00:38:12.972 –> 00:38:14.454
And then in adults,

00:38:14.914 –> 00:38:17.976
I recommend to place four tats at least.

00:38:18.880 –> 00:38:20.521
Um, we need two more.

00:38:21.001 –> 00:38:23.983
So another area would be, for example,

00:38:24.023 –> 00:38:25.043
the poster pallet.

00:38:25.663 –> 00:38:29.664
And here we have either, uh, paramedia.

00:38:30.525 –> 00:38:34.327
We have tricortical or between the roots.

00:38:35.487 –> 00:38:37.188
So paramedia would be

00:38:37.389 –> 00:38:39.090
lateral to the mid pellet

00:38:39.110 –> 00:38:40.851
to suture tricortical,

00:38:40.871 –> 00:38:41.731
which is in a picture.

00:38:41.931 –> 00:38:43.032
Number two would be.

00:38:44.431 –> 00:38:46.132
Like you would try to aim

00:38:46.152 –> 00:38:47.974
for the cortical bone of the pallet.

00:38:48.369 –> 00:38:49.490
of the nasal cavity and the

00:38:49.530 –> 00:38:50.512
maxillary sinus.

00:38:50.692 –> 00:38:51.411
That’s why it’s called

00:38:51.452 –> 00:38:55.255
trichortical or between the roots.

00:38:55.275 –> 00:38:56.637
Let’s have a look at an example.

00:38:57.077 –> 00:38:59.858
So this patient wanted to

00:38:59.878 –> 00:39:01.199
have maxillary expansion.

00:39:01.420 –> 00:39:02.862
She already had nasal

00:39:02.902 –> 00:39:05.503
surgeries because her breathing was bad.

00:39:06.545 –> 00:39:08.505
However, the nasal surgeries,

00:39:08.525 –> 00:39:09.407
the septum correction

00:39:09.447 –> 00:39:12.148
didn’t resolve her impaired

00:39:12.309 –> 00:39:12.869
nasal breathing.

00:39:13.699 –> 00:39:15.000
So this is why she wants

00:39:15.320 –> 00:39:16.521
skeletal expansion.

00:39:16.740 –> 00:39:18.141
And then we’ll also advance

00:39:18.161 –> 00:39:19.621
the jaw because obviously

00:39:19.641 –> 00:39:20.541
there’s no cross by.

00:39:21.163 –> 00:39:23.402
So this is how I would approach this case.

00:39:23.543 –> 00:39:25.704
I will look at the CBCT and

00:39:25.744 –> 00:39:28.565
this is where TJ is helping you.

00:39:28.965 –> 00:39:30.405
He has a lot of experience.

00:39:30.545 –> 00:39:32.065
He’s doing it perfectly.

00:39:32.266 –> 00:39:33.666
I could not do it any better.

00:39:34.146 –> 00:39:36.007
So I’m glad you have his help.

00:39:36.668 –> 00:39:37.947
So here I’m looking at the

00:39:38.588 –> 00:39:39.768
anterior palate.

00:39:40.188 –> 00:39:40.489
Okay.

00:39:40.648 –> 00:39:43.349
Can you see this huge chunk of bone?

00:39:44.346 –> 00:39:45.867
We’re going to place a tat here.

00:39:46.987 –> 00:39:49.068
One on the left side of the suture,

00:39:49.230 –> 00:39:50.030
of the paramedian,

00:39:50.269 –> 00:39:51.391
of the mid-palate of the suture,

00:39:52.552 –> 00:39:53.532
and one on the other side

00:39:53.753 –> 00:39:55.673
of the mid-palate of the suture.

00:39:55.773 –> 00:39:56.094
All right.

00:39:56.375 –> 00:39:58.036
So we already have two tats.

00:39:59.257 –> 00:40:01.778
Now we need to look for two

00:40:02.099 –> 00:40:04.019
more insertion sites.

00:40:04.199 –> 00:40:05.181
Okay.

00:40:05.221 –> 00:40:07.282
So we go through the skull

00:40:07.443 –> 00:40:08.583
from the nose to the back.

00:40:09.983 –> 00:40:10.744
And now look at here.

00:40:12.161 –> 00:40:13.903
going through the nose we’re

00:40:13.923 –> 00:40:14.503
at the height of the

00:40:14.563 –> 00:40:18.628
premolars the molars okay

00:40:18.847 –> 00:40:20.550
where did you find good

00:40:20.590 –> 00:40:22.492
ball let’s have a look at

00:40:22.512 –> 00:40:24.713
it again where would you

00:40:24.733 –> 00:40:33.121
place this cruise all right so

00:40:34.588 –> 00:40:37.090
If we look at the posterior palate,

00:40:37.329 –> 00:40:38.851
now we can have them

00:40:38.911 –> 00:40:40.492
pointing towards the nasal cavity,

00:40:40.572 –> 00:40:42.393
towards the sinus, or between the roots.

00:40:43.255 –> 00:40:44.295
Now on the right side,

00:40:44.335 –> 00:40:45.836
there’s plenty of bone.

00:40:46.197 –> 00:40:46.777
Luxury.

00:40:47.777 –> 00:40:49.298
However, on the other side,

00:40:49.820 –> 00:40:51.641
there is little bone.

00:40:52.262 –> 00:40:53.382
Very, very little.

00:40:53.742 –> 00:40:54.943
It’s not even dense.

00:40:54.963 –> 00:40:58.166
It’s like hardly even gray.

00:40:58.246 –> 00:41:01.369
It’s, yeah, next to nothing.

00:41:02.101 –> 00:41:04.905
So you can imagine how much

00:41:05.184 –> 00:41:06.806
anchorage you will get from

00:41:06.826 –> 00:41:09.088
the left screw.

00:41:09.108 –> 00:41:09.409
Nothing.

00:41:09.648 –> 00:41:11.731
It’s like the Leaning Tower of Pisa.

00:41:12.652 –> 00:41:14.994
However, on the right side, wonderful.

00:41:15.094 –> 00:41:17.677
This is more the Burj Khalifa.

00:41:17.737 –> 00:41:18.036
All right.

00:41:21.550 –> 00:41:24.072
We need to find two more insertion sites.

00:41:24.331 –> 00:41:26.472
This is what I chose in her case.

00:41:27.034 –> 00:41:29.394
So I placed them paramedian

00:41:29.715 –> 00:41:31.496
in a little bit more posterior area.

00:41:32.556 –> 00:41:33.657
The tip of the screw can

00:41:33.777 –> 00:41:35.579
actually reach into the nasal cavity.

00:41:35.599 –> 00:41:36.500
It’s not a big issue.

00:41:38.001 –> 00:41:39.161
If it’s not all the way in

00:41:39.181 –> 00:41:39.981
the nasal cavity,

00:41:40.141 –> 00:41:41.322
it won’t cause problems.

00:41:41.862 –> 00:41:42.204
However,

00:41:42.264 –> 00:41:43.664
patients will feel it a little bit

00:41:44.125 –> 00:41:45.385
when you insert it.

00:41:45.585 –> 00:41:47.027
So what I would tell my patients,

00:41:47.126 –> 00:41:50.349
if I plan a screw like this, I would say,

00:41:51.068 –> 00:41:53.891
you know, you’re going to feel it,

00:41:54.431 –> 00:41:55.510
you’re going to feel a

00:41:55.550 –> 00:41:57.733
little tickling in your nose, or,

00:41:58.193 –> 00:41:58.373
you know,

00:41:58.413 –> 00:41:59.614
it can feel like if you jump

00:41:59.634 –> 00:42:01.875
into water and forgot to close your nose,

00:42:02.715 –> 00:42:04.835
but it’s gone after ten seconds.

00:42:05.876 –> 00:42:07.398
So this is how it would look like.

00:42:07.697 –> 00:42:10.760
So we have here the tats in

00:42:10.960 –> 00:42:14.001
the anterior palate.

00:42:14.260 –> 00:42:18.824
And here in the back, we would have

00:42:19.487 –> 00:42:21.369
So those are the posterior tests.

00:42:21.869 –> 00:42:22.188
OK,

00:42:22.809 –> 00:42:25.931
so it takes the time to get used to

00:42:26.092 –> 00:42:27.092
free the images.

00:42:27.731 –> 00:42:28.313
However,

00:42:28.512 –> 00:42:30.673
I’m sure you will be able to do

00:42:30.693 –> 00:42:33.635
that really quickly.

00:42:33.695 –> 00:42:34.096
All right.

00:42:35.076 –> 00:42:36.476
So then you scan,

00:42:37.177 –> 00:42:38.717
as you’ve seen in the last slide,

00:42:39.119 –> 00:42:42.039
and send the scan to the

00:42:42.079 –> 00:42:45.842
lab and order the appliance.

00:42:46.663 –> 00:42:48.923
So my tip is in adults,

00:42:49.365 –> 00:42:51.106
You have two appointment approach.

00:42:51.467 –> 00:42:52.547
First you place the TADs,

00:42:52.789 –> 00:42:53.628
then you scan for the

00:42:53.648 –> 00:42:57.391
appliance and then you see the appliance.

00:42:57.452 –> 00:42:59.454
So let’s have a look at if

00:42:59.494 –> 00:43:00.974
you need multiple appliances.

00:43:01.335 –> 00:43:01.855
For example,

00:43:01.914 –> 00:43:04.757
this patient had a circular cross bite.

00:43:06.438 –> 00:43:10.641
So we did an expander to expand maxilla.

00:43:11.293 –> 00:43:14.655
but she also had an arch asymmetry.

00:43:15.235 –> 00:43:16.576
So later I wanted to

00:43:16.755 –> 00:43:18.556
mesialize the second quadrant.

00:43:19.356 –> 00:43:22.039
So I used the same task for

00:43:22.239 –> 00:43:23.239
a mesial slider.

00:43:24.300 –> 00:43:26.099
So here you see again the mesial slider,

00:43:26.380 –> 00:43:27.460
and those are the same

00:43:27.501 –> 00:43:32.623
tasks as here for the

00:43:32.682 –> 00:43:34.503
expander that I used in the beginning.

00:43:35.525 –> 00:43:35.806
And yeah,

00:43:35.846 –> 00:43:37.887
you see aligners here at the

00:43:37.907 –> 00:43:39.226
beginning of expansion.

00:43:39.246 –> 00:43:40.307
This is because I’m using a

00:43:40.427 –> 00:43:41.688
no-diastema protocol,

00:43:42.847 –> 00:43:46.929
which is part of another session.

00:43:47.610 –> 00:43:49.471
It’s too much to cover it today,

00:43:49.610 –> 00:43:50.771
but I just want to give you

00:43:51.251 –> 00:43:53.072
like a little teaser of

00:43:53.092 –> 00:43:55.793
what’s possible today.

00:43:56.172 –> 00:43:56.932
Or for example,

00:43:57.112 –> 00:43:59.954
if you need multiple expanders to expand,

00:44:00.173 –> 00:44:01.755
actually in the patient you just saw,

00:44:02.135 –> 00:44:02.815
in that patient,

00:44:03.422 –> 00:44:05.543
I actually had multiple expanders.

00:44:05.702 –> 00:44:08.744
I had three expanders in her.

00:44:08.804 –> 00:44:14.226
So here also, I had the first expander,

00:44:14.827 –> 00:44:17.188
then this expander was fully extended.

00:44:17.568 –> 00:44:19.668
So I took it off, scanned,

00:44:20.148 –> 00:44:22.050
and then ordered a new

00:44:22.150 –> 00:44:24.309
expander to expand further.

00:44:26.570 –> 00:44:29.733
My tip for you is to use the power screw.

00:44:29.833 –> 00:44:30.932
So the power screw is the

00:44:31.012 –> 00:44:31.972
one you see in the right

00:44:32.034 –> 00:44:33.153
side on the picture.

00:44:33.646 –> 00:44:35.666
The left is the Leone or a

00:44:35.726 –> 00:44:36.746
Forrester Dent screw.

00:44:37.047 –> 00:44:39.047
The Forrester Dent screw has advantages.

00:44:39.307 –> 00:44:41.108
It sits nice and flat on the palate.

00:44:41.588 –> 00:44:43.289
It’s super in children.

00:44:44.090 –> 00:44:46.150
However, in adults where we need power,

00:44:46.630 –> 00:44:49.753
use the power screw.

00:44:49.793 –> 00:44:52.813
So another example where I

00:44:52.853 –> 00:44:54.213
want to give you a run

00:44:54.293 –> 00:44:56.996
through of the step-by-step procedure.

00:44:58.056 –> 00:45:00.396
So this patient,

00:45:01.775 –> 00:45:02.474
didn’t have,

00:45:02.755 –> 00:45:03.996
her chief complaint basically

00:45:04.036 –> 00:45:09.737
was her bite was not functional.

00:45:10.036 –> 00:45:11.777
She had too little space for

00:45:11.797 –> 00:45:12.998
her tongue and also

00:45:13.398 –> 00:45:14.619
impaired nasal breathing.

00:45:14.998 –> 00:45:17.039
She was a mouth breather at night.

00:45:17.059 –> 00:45:19.199
This is why her molars over erupted.

00:45:20.019 –> 00:45:22.221
And she also had a deviated septum.

00:45:22.820 –> 00:45:24.320
However, after expansion,

00:45:24.501 –> 00:45:26.342
she said her nasal breathing is so good.

00:45:26.891 –> 00:45:28.932
She doesn’t even want a nasal correction,

00:45:29.112 –> 00:45:32.474
like a septum correction anymore.

00:45:32.534 –> 00:45:35.996
So here I ordered this type of expander.

00:45:37.757 –> 00:45:38.157
Of course,

00:45:38.318 –> 00:45:39.958
the screw positions were first

00:45:40.199 –> 00:45:41.820
planned in the lab with a

00:45:41.880 –> 00:45:45.061
CBCT to get the best screw position.

00:45:45.081 –> 00:45:46.063
You can see they’re slightly

00:45:46.163 –> 00:45:48.164
asymmetric because they’re

00:45:48.224 –> 00:45:50.465
exactly where that was the

00:45:50.664 –> 00:45:51.806
best available.

00:45:53.288 –> 00:45:53.929
So as you can see,

00:45:53.949 –> 00:45:55.670
it sits nice and flat on the palate.

00:45:55.829 –> 00:45:58.873
Patients can speak very well with it.

00:45:59.653 –> 00:46:01.675
However, if you have an adult,

00:46:01.835 –> 00:46:02.856
there is a lot of

00:46:02.936 –> 00:46:04.858
resistance in the bone and

00:46:04.958 –> 00:46:06.500
the force of the screw

00:46:06.760 –> 00:46:10.182
tends to bend and then it’s stuck.

00:46:11.143 –> 00:46:12.125
So this is the problem.

00:46:12.164 –> 00:46:13.125
Okay.

00:46:13.505 –> 00:46:15.887
So you would anesthetize the patient,

00:46:16.088 –> 00:46:17.168
make the palate numb.

00:46:18.230 –> 00:46:20.452
You would check the insertion guides and

00:46:20.958 –> 00:46:23.360
I’m so glad that ODL offers

00:46:23.400 –> 00:46:24.581
those insertion guides

00:46:24.641 –> 00:46:27.543
because they’re wonderful to work with.

00:46:27.563 –> 00:46:31.447
So you have a drill def stop.

00:46:32.788 –> 00:46:34.489
You have a window for

00:46:34.568 –> 00:46:36.710
checking if the thing is turning.

00:46:37.690 –> 00:46:41.713
And you can check very well

00:46:41.893 –> 00:46:48.119
if the insertion guide is seated properly,

00:46:48.159 –> 00:46:48.579
like here.

00:46:51.635 –> 00:46:52.916
This here is also where you

00:46:52.956 –> 00:46:54.597
can see the screw.

00:46:54.637 –> 00:46:57.539
So it’s really well designed,

00:46:58.239 –> 00:46:59.260
designed in Germany.

00:46:59.860 –> 00:47:01.181
They know how to do those things.

00:47:02.820 –> 00:47:04.081
So here you can see this is

00:47:04.101 –> 00:47:05.362
the Breed Driller and it

00:47:05.422 –> 00:47:07.704
has a little lip or a lid

00:47:08.284 –> 00:47:10.184
and it cannot go further

00:47:10.204 –> 00:47:11.364
because there’s a safety

00:47:11.405 –> 00:47:13.927
stop in the guide.

00:47:13.947 –> 00:47:15.286
So Breed Drilling is done

00:47:15.487 –> 00:47:17.068
with nine hundred rounds

00:47:17.128 –> 00:47:18.548
per minute and water cooling.

00:47:18.947 –> 00:47:20.668
I recommend re-drilling in

00:47:20.748 –> 00:47:23.871
adults above the age of thirty.

00:47:23.911 –> 00:47:25.092
This is the re-drilling

00:47:25.132 –> 00:47:27.114
process and it runs per minute.

00:47:27.954 –> 00:47:31.657
And yes, you need an implant motor.

00:47:33.298 –> 00:47:35.420
Here you can see how the

00:47:35.440 –> 00:47:37.382
drill has a safety stop and

00:47:37.442 –> 00:47:40.324
it’s hitting the safety stop.

00:47:40.344 –> 00:47:42.045
So the TAD insertion here,

00:47:42.085 –> 00:47:43.606
you always need to check, OK,

00:47:44.027 –> 00:47:45.007
you need to switch the

00:47:45.088 –> 00:47:47.050
program to twenty rounds per minute.

00:47:47.561 –> 00:47:48.862
Not nine hundred rounds per minute.

00:47:48.902 –> 00:47:51.204
I was not good.

00:47:51.264 –> 00:47:52.744
So two hundred rounds per

00:47:52.804 –> 00:47:54.626
minute without water

00:47:54.666 –> 00:47:56.208
cooling and make sure the

00:47:56.248 –> 00:47:57.349
torque is not exceeding

00:47:57.829 –> 00:47:58.889
sixty Newton centimeter.

00:47:59.851 –> 00:48:00.931
So this is what it looks like.

00:48:01.552 –> 00:48:08.978
You insert the TAD and you just insert it.

00:48:09.338 –> 00:48:10.980
So this takes about twenty

00:48:11.039 –> 00:48:13.101
seconds and it’s good to

00:48:13.141 –> 00:48:15.884
count down so the patient knows how long

00:48:17.045 –> 00:48:18.847
they need to,

00:48:18.907 –> 00:48:20.188
how long it’s still going to take.

00:48:20.929 –> 00:48:22.431
So here now the TAD is

00:48:22.471 –> 00:48:24.092
completely inserted and now

00:48:24.172 –> 00:48:26.914
you remove the guide and

00:48:27.074 –> 00:48:29.777
the hand piece all together.

00:48:29.858 –> 00:48:30.498
And you removed it.

00:48:31.039 –> 00:48:32.059
This is how it’s looked like.

00:48:32.539 –> 00:48:34.822
You have the TADs in the gum.

00:48:36.264 –> 00:48:37.143
Here’s another picture.

00:48:38.264 –> 00:48:39.365
So there’s no bleeding.

00:48:40.547 –> 00:48:41.547
Only bleeding is here from

00:48:41.568 –> 00:48:43.170
where placed the anesthesia.

00:48:44.521 –> 00:48:46.983
And now you insert the expander.

00:48:48.324 –> 00:48:48.925
So here,

00:48:48.985 –> 00:48:53.487
this is where I did a one

00:48:53.586 –> 00:48:54.608
appointment approach.

00:48:55.128 –> 00:48:56.389
So it had everything planned

00:48:56.409 –> 00:48:58.590
in the lab and inserted in

00:48:58.670 –> 00:48:59.150
one appointment.

00:48:59.210 –> 00:49:00.170
However, in adults,

00:49:00.291 –> 00:49:03.132
I recommend to now scan and

00:49:03.213 –> 00:49:04.693
order the appliance because

00:49:04.733 –> 00:49:05.773
it can be that there’s a

00:49:05.853 –> 00:49:07.494
little bit of distortion

00:49:07.574 –> 00:49:08.896
and the appliance doesn’t fit.

00:49:10.315 –> 00:49:12.478
So here in the Leona screw,

00:49:12.498 –> 00:49:13.358
there’s the hole,

00:49:13.418 –> 00:49:16.201
the keyhole to activate the expander.

00:49:16.920 –> 00:49:18.302
And now the expander is

00:49:18.382 –> 00:49:22.726
fixated with those fixing screws.

00:49:22.806 –> 00:49:24.226
So because I briefly

00:49:24.266 –> 00:49:26.628
mentioned the Dome XD protocol,

00:49:27.309 –> 00:49:30.012
so the Dome XD protocol is

00:49:30.032 –> 00:49:32.554
basically based on the dome concept,

00:49:32.594 –> 00:49:34.094
turning a high arch pallet

00:49:34.436 –> 00:49:35.597
jaw that’s not breathing

00:49:35.956 –> 00:49:37.358
into a dome-shaped pallet.

00:49:37.762 –> 00:49:39.784
where we have good nasal breathing,

00:49:40.644 –> 00:49:42.646
tongue can rest in its proper position,

00:49:43.106 –> 00:49:45.588
and we have the function addressed.

00:49:46.329 –> 00:49:49.873
So here you can see the

00:49:49.913 –> 00:49:51.614
expander and aligners are

00:49:51.795 –> 00:49:53.235
used simultaneously.

00:49:53.456 –> 00:49:54.237
So the movements are

00:49:54.317 –> 00:49:57.460
coordinated and it’s a

00:49:57.539 –> 00:49:59.882
patient specific expansion rate.

00:50:00.362 –> 00:50:02.625
So it’s not rapid expansion.

00:50:03.242 –> 00:50:04.764
It’s tailored to the patient

00:50:04.923 –> 00:50:06.826
considering the age, the sex,

00:50:07.286 –> 00:50:08.746
and the line of treatment plan.

00:50:09.527 –> 00:50:10.027
And at the end,

00:50:10.047 –> 00:50:11.208
you can see the expander is

00:50:11.289 –> 00:50:12.710
fully extended and there’s

00:50:12.769 –> 00:50:15.512
still no diastema.

00:50:15.532 –> 00:50:16.713
And this is very well

00:50:16.773 –> 00:50:18.833
received in adult patients

00:50:18.893 –> 00:50:21.195
because the diastema is a

00:50:21.235 –> 00:50:24.637
problem with speaking and chewing.

00:50:25.219 –> 00:50:26.980
And yeah, you know, adults,

00:50:27.019 –> 00:50:28.300
they usually have demanding

00:50:28.340 –> 00:50:30.141
jobs and some of them can’t afford,

00:50:30.322 –> 00:50:30.922
have a big gap.

00:50:31.929 –> 00:50:33.751
So these are the progress pictures,

00:50:33.791 –> 00:50:35.512
and please note how the

00:50:35.652 –> 00:50:37.094
bite also changed.

00:50:37.974 –> 00:50:39.536
So this is what I would see

00:50:39.735 –> 00:50:41.918
very often in cases with crossbite.

00:50:43.340 –> 00:50:45.440
Once the maxilla is expanded,

00:50:46.001 –> 00:50:47.643
the lower jaw centers.

00:50:48.164 –> 00:50:50.106
Because if the upper jaw is too small,

00:50:50.746 –> 00:50:52.367
the lower jaw doesn’t fit in the middle.

00:50:52.728 –> 00:50:54.349
It needs to go either left or right,

00:50:54.550 –> 00:50:55.791
but it can’t fit in the middle.

00:50:57.304 –> 00:50:57.583
All right,

00:50:57.684 –> 00:50:59.025
I need to speed up a little bit

00:50:59.045 –> 00:51:00.184
because I want to leave

00:51:00.244 –> 00:51:01.646
some time for your questions.

00:51:01.965 –> 00:51:02.907
Common pitfalls.

00:51:04.527 –> 00:51:05.927
So I want to use this

00:51:07.088 –> 00:51:08.349
analogy with the leaning

00:51:08.588 –> 00:51:10.010
tower of Pisa again because

00:51:10.050 –> 00:51:11.891
it fits so well with the

00:51:11.990 –> 00:51:13.070
anchorage of our screws.

00:51:13.530 –> 00:51:16.092
So please compare those two CBCTs.

00:51:16.353 –> 00:51:18.253
Can you see how different

00:51:19.153 –> 00:51:20.594
the amount of bone is?

00:51:21.014 –> 00:51:23.275
In the left, the bone is paper thin.

00:51:23.715 –> 00:51:25.637
In the right, you have really nice, good,

00:51:25.657 –> 00:51:26.336
sufficient bones.

00:51:27.422 –> 00:51:30.304
So a mistake that is often

00:51:30.344 –> 00:51:32.126
made is that the tats are

00:51:32.226 –> 00:51:33.527
placed in areas where

00:51:33.547 –> 00:51:34.869
there’s very little bone.

00:51:35.590 –> 00:51:36.230
For example,

00:51:36.289 –> 00:51:39.172
the MSE expander has the tats

00:51:39.813 –> 00:51:41.614
to the left and right to

00:51:41.634 –> 00:51:42.635
the mid-palate suture,

00:51:43.056 –> 00:51:44.956
but sometimes the bone is

00:51:45.056 –> 00:51:46.637
paper thin as it is here.

00:51:47.159 –> 00:51:52.802
So there’s little anchorage of the screw.

00:51:53.443 –> 00:51:53.864
However,

00:51:54.224 –> 00:51:55.385
if it’s a patient like on the

00:51:55.445 –> 00:51:56.927
right where you have sufficient bone,

00:51:57.382 –> 00:51:57.702
You know,

00:51:57.742 –> 00:52:02.065
the MSC expander can actually

00:52:02.106 –> 00:52:03.027
perform the expansion

00:52:03.067 –> 00:52:04.527
because it’s inserted in

00:52:04.568 –> 00:52:05.389
good area of bone,

00:52:05.429 –> 00:52:07.849
but everybody is different.

00:52:08.351 –> 00:52:09.711
Or if the tads are only

00:52:09.771 –> 00:52:12.072
placed in soft tissue, like look at this.

00:52:12.434 –> 00:52:13.614
One of my cases, okay,

00:52:13.974 –> 00:52:15.835
high arch pallet patient.

00:52:16.416 –> 00:52:18.617
If you have a patient that is high arched,

00:52:19.639 –> 00:52:20.960
don’t touch it at the beginning.

00:52:21.139 –> 00:52:22.079
It’s really challenging

00:52:22.119 –> 00:52:23.701
because the soft tissue is so thick.

00:52:26.260 –> 00:52:28.963
Or too high insertion torque,

00:52:29.963 –> 00:52:32.045
exceeding eighty Newton centimeter.

00:52:32.865 –> 00:52:34.266
This is why I recommend to

00:52:34.447 –> 00:52:36.829
re-drill the bone in adults.

00:52:37.568 –> 00:52:39.831
Or another common pitfall is,

00:52:40.210 –> 00:52:40.992
in my opinion,

00:52:41.472 –> 00:52:44.014
a too high activation rate in adults.

00:52:44.454 –> 00:52:45.956
If we try to do rapid

00:52:46.036 –> 00:52:47.797
palatal expansion in adults, I mean,

00:52:48.416 –> 00:52:49.478
it’s not just the

00:52:49.518 –> 00:52:51.599
mid-palatal suture that needs to move.

00:52:52.148 –> 00:52:54.568
All the other craniofacial sutures,

00:52:54.748 –> 00:52:57.389
they also move.

00:52:57.909 –> 00:52:59.369
And this is why I really

00:52:59.409 –> 00:53:00.990
don’t like the word MARCP

00:53:01.030 –> 00:53:02.530
because I’m not doing MARCP.

00:53:02.630 –> 00:53:05.032
I’m not doing rapid expansion.

00:53:05.112 –> 00:53:07.032
I’m doing a patient specific

00:53:07.152 –> 00:53:07.813
expansion rate.

00:53:08.472 –> 00:53:10.152
So rapid expansion is not

00:53:10.193 –> 00:53:11.153
defined very clearly,

00:53:11.193 –> 00:53:12.514
but it’s usually one to two

00:53:12.594 –> 00:53:15.295
activations per day.

00:53:15.394 –> 00:53:17.115
And my question to you is,

00:53:18.135 –> 00:53:21.836
do we need rapid expansion?

00:53:22.614 –> 00:53:29.518
if we’re purely anchored in the bone.

00:53:29.539 –> 00:53:31.380
The reason why the rapid

00:53:31.440 –> 00:53:32.822
pelvic expansion protocol

00:53:33.061 –> 00:53:35.804
was defined is to minimize

00:53:36.244 –> 00:53:37.664
dental side effects and

00:53:37.764 –> 00:53:39.507
maximize skeletal effects.

00:53:39.987 –> 00:53:41.188
But with this appliance,

00:53:41.668 –> 00:53:42.889
there are no dental side

00:53:42.909 –> 00:53:44.990
effects and we maximize skeletal effects.

00:53:46.490 –> 00:53:49.271
And if you think back of the

00:53:49.711 –> 00:53:51.333
video that I showed you

00:53:51.373 –> 00:53:52.693
with the expanding jaw,

00:53:52.893 –> 00:53:55.893
you clearly saw how the cheekbones,

00:53:55.934 –> 00:53:57.675
how everything is moving as

00:53:57.695 –> 00:54:00.175
the maxillary expands.

00:54:00.235 –> 00:54:02.396
So I wouldn’t want to do too

00:54:02.436 –> 00:54:04.757
rapid and risk breaking a bone.

00:54:06.478 –> 00:54:09.018
So for your first MARPI case,

00:54:10.298 –> 00:54:11.759
choose a female patient.

00:54:11.818 –> 00:54:13.300
It’s easier in female patients.

00:54:13.972 –> 00:54:15.914
Between age twenty, twenty five,

00:54:16.034 –> 00:54:18.617
have a clear indication like a cross bite,

00:54:19.137 –> 00:54:20.177
because, you know,

00:54:20.217 –> 00:54:21.918
with breathing can also be

00:54:22.679 –> 00:54:24.240
allergies can be the reason

00:54:24.300 –> 00:54:25.501
for nasal breathing

00:54:25.541 –> 00:54:26.402
impairment or something.

00:54:26.422 –> 00:54:28.244
So clear indication like a cross bite.

00:54:28.384 –> 00:54:31.166
You submit the CBCT and the

00:54:31.246 –> 00:54:33.186
intraoral scans to ODL.

00:54:33.608 –> 00:54:35.889
They plan the TADS for you.

00:54:36.269 –> 00:54:38.692
You can also use my

00:54:38.751 –> 00:54:40.293
expertise for your MARPI case.

00:54:40.353 –> 00:54:41.653
I would be happy to assist you.

00:54:42.713 –> 00:54:45.635
Place four tats with guides.

00:54:45.775 –> 00:54:46.916
Okay, if you’re not experienced,

00:54:47.096 –> 00:54:48.217
I really recommend it.

00:54:48.257 –> 00:54:49.637
It makes it so easy.

00:54:50.677 –> 00:54:51.498
You saw the process,

00:54:51.518 –> 00:54:52.559
it’s really straightforward.

00:54:53.378 –> 00:54:54.360
Then scan again.

00:54:55.219 –> 00:54:57.181
Order the Marpie with a power screw.

00:54:57.681 –> 00:54:58.282
In adults,

00:54:59.141 –> 00:55:01.003
the power screw has so many advantages.

00:55:01.382 –> 00:55:03.023
It’s also so easy to activate,

00:55:03.043 –> 00:55:04.244
so it’s really a blessing.

00:55:05.485 –> 00:55:07.266
And insert the appliance and

00:55:07.326 –> 00:55:09.407
mount with the fixing screws.

00:55:09.806 –> 00:55:11.027
And then start turning.

00:55:11.865 –> 00:55:13.126
One turn a day, you know,

00:55:13.166 –> 00:55:14.686
that’s their conventional protocol.

00:55:15.068 –> 00:55:15.447
However,

00:55:15.668 –> 00:55:17.449
I would be very happy to assist

00:55:17.489 –> 00:55:19.130
you in the patient specific

00:55:19.190 –> 00:55:20.811
protocol that also allows

00:55:20.851 –> 00:55:24.172
you to do the no diastema protocol.

00:55:24.231 –> 00:55:27.253
So to summarize it, um,

00:55:27.673 –> 00:55:28.675
to build the firm

00:55:28.974 –> 00:55:31.036
foundation for your market cases,

00:55:31.436 –> 00:55:32.597
let’s first, okay,

00:55:32.637 –> 00:55:34.478
consider the function for

00:55:34.878 –> 00:55:36.378
stability of our result.

00:55:37.079 –> 00:55:38.360
Skeletal, I want to remind you,

00:55:38.420 –> 00:55:41.021
skeletal maxillary expansion can improve

00:55:41.536 –> 00:55:42.896
nasal breathing by reducing

00:55:43.056 –> 00:55:46.679
nasal air flow resistance.

00:55:46.800 –> 00:55:48.101
Anchorage in the bone.

00:55:48.601 –> 00:55:50.302
Choose insertion site

00:55:50.443 –> 00:55:52.425
according to best bone available.

00:55:52.824 –> 00:55:54.146
I think you saw a lot of

00:55:54.405 –> 00:55:56.688
pitfalls and why it doesn’t

00:55:56.708 –> 00:55:59.590
make sense to anchor the screws in tiny,

00:55:59.630 –> 00:56:01.532
tiny bone.

00:56:01.592 –> 00:56:03.594
Tad first or bone first

00:56:03.614 –> 00:56:04.855
approach allows us to

00:56:04.954 –> 00:56:07.137
harness the best available

00:56:07.157 –> 00:56:09.237
bone and gives us the best

00:56:10.239 –> 00:56:11.139
possible stability.

00:56:12.719 –> 00:56:13.920
I would be happy if you

00:56:13.960 –> 00:56:15.523
connect with me also on Instagram.

00:56:15.782 –> 00:56:17.043
I always share some

00:56:17.204 –> 00:56:21.028
educational content and I’m

00:56:21.068 –> 00:56:22.231
really looking forward to

00:56:22.291 –> 00:56:23.231
all your questions and I

00:56:23.251 –> 00:56:24.733
want to give the word back to Tom.

00:56:45.657 –> 00:56:48.358
um tom sorry I could not

00:56:48.398 –> 00:56:50.201
hear you thank you yes now

00:56:50.380 –> 00:56:51.442
now you can hear me thanks

00:56:51.481 –> 00:56:58.027
so much um so gotcha um

00:56:58.047 –> 00:56:59.047
that was wonderful thank

00:56:59.088 –> 00:57:01.110
you so much uh I have a lot

00:57:01.150 –> 00:57:02.510
of questions myself and we

00:57:02.530 –> 00:57:03.371
have a couple questions

00:57:03.431 –> 00:57:05.974
here um in the chat uh some

00:57:05.994 –> 00:57:08.215
things that you can sign up

00:57:08.235 –> 00:57:09.255
with dr pincher if you’d

00:57:09.295 –> 00:57:10.697
like to uh we have that

00:57:10.797 –> 00:57:11.697
link where you would sign

00:57:11.737 –> 00:57:13.599
up uh a session with yourself

00:57:13.900 –> 00:57:14.900
you’ve never done a Marpie,

00:57:15.280 –> 00:57:17.123
or if you just have a very difficult case,

00:57:18.143 –> 00:57:19.264
you can sign up a session

00:57:19.284 –> 00:57:21.827
with TJ and Dr. Pinter,

00:57:22.166 –> 00:57:23.168
and she’d be happy to set

00:57:23.208 –> 00:57:25.128
up a thirty minute session

00:57:25.168 –> 00:57:26.289
with you to work through that case.

00:57:26.309 –> 00:57:27.251
We’ve done a few with her

00:57:27.630 –> 00:57:28.952
and they’ve been really excellent.

00:57:30.072 –> 00:57:31.114
So make sure you do that.

00:57:31.634 –> 00:57:33.436
And those are places where

00:57:33.476 –> 00:57:34.297
she could actually cover

00:57:34.356 –> 00:57:36.318
things like Marpie versus

00:57:36.358 –> 00:57:38.079
Tad born expansion.

00:57:38.119 –> 00:57:39.000
Like it’s a little,

00:57:39.780 –> 00:57:40.400
Controversial.

00:57:40.440 –> 00:57:41.262
What’s the real name?

00:57:41.302 –> 00:57:42.322
What should we be calling this?

00:57:42.342 –> 00:57:43.043
Because some people don’t

00:57:43.063 –> 00:57:44.583
like the word Marpie, and I hear it,

00:57:45.923 –> 00:57:46.764
or even Airway.

00:57:47.324 –> 00:57:50.826
But six or eight idlets.

00:57:51.646 –> 00:57:53.646
Dr. Pinter talks about four here.

00:57:53.748 –> 00:57:54.807
What happens?

00:57:54.887 –> 00:57:56.369
I was told that I should do eight.

00:57:56.528 –> 00:57:58.329
I should have ten pads.

00:57:59.010 –> 00:58:00.911
Let’s talk about that before you do that.

00:58:01.351 –> 00:58:02.552
um because there’s a lot of

00:58:02.652 –> 00:58:03.632
options that you could do

00:58:03.672 –> 00:58:04.693
before you actually and a

00:58:04.713 –> 00:58:05.934
lot of it’s in the planning

00:58:06.375 –> 00:58:08.376
with the cbct uh and it’s

00:58:08.416 –> 00:58:08.936
probably a little more

00:58:08.976 –> 00:58:09.876
comfortable for the patient

00:58:09.916 –> 00:58:11.018
too and then if you’re

00:58:11.097 –> 00:58:12.298
using other aspects if

00:58:12.318 –> 00:58:14.079
you’re using fifteen or

00:58:14.119 –> 00:58:15.420
even seventeen millimeter

00:58:15.460 –> 00:58:16.722
tads just so you know in

00:58:16.742 –> 00:58:17.541
the united states those are

00:58:17.601 –> 00:58:19.684
not fda approved so make

00:58:19.724 –> 00:58:21.344
sure that you’re using the

00:58:21.385 –> 00:58:22.666
right tads and if you’re

00:58:22.846 –> 00:58:24.306
getting them yourself uh

00:58:24.327 –> 00:58:25.427
that they are from an fda

00:58:25.467 –> 00:58:27.789
approved laboratory or

00:58:27.849 –> 00:58:29.911
utilizing those from an fda lab vendor

00:58:30.391 –> 00:58:31.532
So we have a bunch of

00:58:31.572 –> 00:58:32.614
questions that just came in here.

00:58:33.795 –> 00:58:34.135
Right here,

00:58:34.155 –> 00:58:36.297
we will get to Dr. I believe

00:58:36.338 –> 00:58:37.358
it’s Dr. Emanuele.

00:58:39.039 –> 00:58:40.382
What is the auxiliary you

00:58:40.561 –> 00:58:41.762
use on the lingual of the

00:58:41.802 –> 00:58:43.565
maxillary central incisors

00:58:43.864 –> 00:58:47.228
to help with root tip?

00:58:47.268 –> 00:58:51.472
So those are surgical hooks, actually,

00:58:51.574 –> 00:58:52.554
from Dentaurum.

00:58:53.411 –> 00:58:55.972
And they have a bracket slot

00:58:56.032 –> 00:58:58.534
at the base and a little extended arm.

00:58:59.054 –> 00:59:00.175
So what I would do is,

00:59:00.295 –> 00:59:01.795
when I expand and I do the

00:59:01.894 –> 00:59:03.235
no-diastema protocol,

00:59:03.556 –> 00:59:06.036
the crowns move faster than the roots.

00:59:06.378 –> 00:59:08.398
So in order to get root parallelism,

00:59:08.778 –> 00:59:10.559
I bound those surgical hooks,

00:59:10.579 –> 00:59:11.820
or I call them power arms,

00:59:12.161 –> 00:59:13.501
and then put a wire through

00:59:13.701 –> 00:59:16.603
to help with parallelizing the roots.

00:59:17.657 –> 00:59:18.418
Awesome.

00:59:18.438 –> 00:59:19.798
Thank you.

00:59:19.898 –> 00:59:20.519
Okay.

00:59:20.599 –> 00:59:24.202
So let’s go on to Anitha here.

00:59:24.322 –> 00:59:25.463
What’s your turning protocol

00:59:25.503 –> 00:59:28.907
for adults and then for kids?

00:59:28.947 –> 00:59:31.329
So thank you, Anitha, for your question.

00:59:31.949 –> 00:59:32.851
In kids, I do…

00:59:34.092 –> 00:59:35.614
a turn every other day.

00:59:35.954 –> 00:59:39.514
So I’m slightly faster than an adult.

00:59:39.934 –> 00:59:41.655
An adult is highly individual.

00:59:41.996 –> 00:59:45.556
Usually it’s around two turns per week.

00:59:46.077 –> 00:59:46.677
However,

00:59:46.978 –> 00:59:49.639
I don’t just start with expansion

00:59:49.739 –> 00:59:50.378
right away.

00:59:50.798 –> 00:59:51.278
In adults,

00:59:51.338 –> 00:59:52.800
especially above the age of

00:59:52.860 –> 00:59:55.860
thirty and in men, male patients,

00:59:56.496 –> 00:59:57.878
I start with a suture

00:59:57.958 –> 00:59:59.400
stimulation protocol.

00:59:59.760 –> 01:00:01.440
So basically I’m preparing

01:00:01.521 –> 01:00:02.762
the bones to move.

01:00:03.382 –> 01:00:05.264
So I don’t know if, um,

01:00:06.186 –> 01:00:08.427
any one of you had a child, but I imagine,

01:00:08.447 –> 01:00:08.668
you know,

01:00:08.708 –> 01:00:11.170
the body has nine months to prepare.

01:00:11.550 –> 01:00:13.411
What does little baby to go

01:00:13.452 –> 01:00:15.072
through the birth canal.

01:00:15.393 –> 01:00:17.094
So why don’t we also give

01:00:17.135 –> 01:00:19.177
the bone some time to prepare?

01:00:20.114 –> 01:00:21.775
for the maxillary bones to move.

01:00:21.815 –> 01:00:23.418
So this is kind of how it

01:00:23.438 –> 01:00:24.318
makes sense to me.

01:00:24.778 –> 01:00:26.802
Adults were so different from children.

01:00:26.942 –> 01:00:29.103
The bones are rigid and we

01:00:29.143 –> 01:00:32.427
cannot just crank it open and maybe risk.

01:00:32.739 –> 01:00:35.860
breaking a bone,

01:00:36.161 –> 01:00:37.422
so I go slow at the beginning.

01:00:37.442 –> 01:00:37.641
Nice, nice.

01:00:37.661 –> 01:00:38.922
Does ODL do international shipping?

01:00:39.043 –> 01:00:39.782
We do,

01:00:39.943 –> 01:00:41.123
but there are a number of really

01:00:41.164 –> 01:00:42.204
good labs over in Europe.

01:00:42.224 –> 01:00:42.824
I know we have a lot of

01:00:42.905 –> 01:00:44.865
European viewers today,

01:00:44.925 –> 01:00:46.146
so we’re not looking to

01:00:46.166 –> 01:00:48.367
have a monopoly on Markey.

01:00:48.768 –> 01:00:51.269
So if you do have a lab, that’s great,

01:00:51.550 –> 01:00:53.030
but we do do international shipping,

01:00:53.070 –> 01:00:56.813
so contact us and we can work with you.

01:00:57.034 –> 01:00:58.434
Here’s one.

01:00:58.655 –> 01:01:00.235
How much expansion per turn

01:01:00.295 –> 01:01:02.217
for the Power Screw Expander?

01:01:03.097 –> 01:01:04.418
That’s a really good question.

01:01:04.518 –> 01:01:06.018
So always inform yourself

01:01:06.039 –> 01:01:07.739
about the expansion of the screw.

01:01:07.780 –> 01:01:08.780
For the power screw,

01:01:09.121 –> 01:01:11.242
that is zero point one

01:01:11.583 –> 01:01:14.304
seven millimeter per panel.

01:01:14.425 –> 01:01:20.248
So per panel of this hexagonal screw.

01:01:20.750 –> 01:01:21.090
However,

01:01:21.329 –> 01:01:23.791
you need to consider that you do

01:01:23.831 –> 01:01:25.193
not get one hundred percent

01:01:25.313 –> 01:01:27.434
a one to one translation of

01:01:27.574 –> 01:01:29.215
expansion of the power

01:01:29.235 –> 01:01:31.157
screw at the level of the bone.

01:01:31.516 –> 01:01:33.438
because also the screw will

01:01:33.498 –> 01:01:34.518
tilt a little bit,

01:01:34.998 –> 01:01:37.121
maybe the appliance bends a little bit,

01:01:37.400 –> 01:01:38.242
so you don’t get a

01:01:38.422 –> 01:01:39.583
one-to-one translation.

01:01:39.663 –> 01:01:42.324
You get maybe a third,

01:01:42.826 –> 01:01:44.467
maybe even a half if you’re

01:01:44.586 –> 01:01:45.867
using a Forrester-Dent

01:01:45.887 –> 01:01:47.009
screw or something like that,

01:01:47.289 –> 01:01:48.110
so you need to take that

01:01:48.170 –> 01:01:49.110
into consideration.

01:01:49.150 –> 01:01:50.251
This is also what I help

01:01:50.652 –> 01:01:51.773
people with when they do

01:01:52.054 –> 01:01:53.675
the no-diastema protocol,

01:01:53.715 –> 01:01:54.516
because then you need to

01:01:54.596 –> 01:01:56.237
synchronize the expansion

01:01:56.617 –> 01:01:57.818
of the screw with the

01:01:57.878 –> 01:01:59.179
expansion done by the aligners.

01:02:00.250 –> 01:02:00.710
Wonderful.

01:02:00.931 –> 01:02:02.831
I will go with one.

01:02:03.192 –> 01:02:07.456
I think this is a fun question here.

01:02:07.496 –> 01:02:09.918
Do you have any unsuccessful cases?

01:02:10.597 –> 01:02:11.239
What is the reason?

01:02:12.000 –> 01:02:13.221
I have lots of them.

01:02:13.260 –> 01:02:14.722
And this is also why I have

01:02:14.842 –> 01:02:16.782
this experience that I can

01:02:16.842 –> 01:02:17.603
share with you.

01:02:18.985 –> 01:02:20.306
Yeah, I have cases.

01:02:20.606 –> 01:02:23.108
I have patients that did not open yet.

01:02:24.510 –> 01:02:26.351
But I learned from every case.

01:02:26.391 –> 01:02:27.172
So I looked at them.

01:02:27.717 –> 01:02:29.036
Some patients I used,

01:02:29.197 –> 01:02:30.478
I didn’t harness everything

01:02:30.498 –> 01:02:31.237
with the bone.

01:02:31.617 –> 01:02:33.619
Like I used two short screws

01:02:34.478 –> 01:02:36.179
or I had too little of the

01:02:36.219 –> 01:02:37.519
screw anchored in the bone.

01:02:37.559 –> 01:02:38.659
So most of the screw is

01:02:38.739 –> 01:02:40.701
actually in a soft tissue.

01:02:41.601 –> 01:02:43.740
Or I had patients who were

01:02:43.800 –> 01:02:45.521
too ambitious with turning.

01:02:45.541 –> 01:02:45.722
You know,

01:02:45.742 –> 01:02:47.521
they were so excited to get the

01:02:47.561 –> 01:02:48.382
expansion and they were

01:02:48.483 –> 01:02:50.123
turning way too fast.

01:02:50.523 –> 01:02:51.664
So what they did is they

01:02:51.963 –> 01:02:53.083
overloaded the screws.

01:02:53.244 –> 01:02:54.704
The body was not ready.

01:02:54.724 –> 01:02:56.905
You need to give it a little bit of time.

01:02:57.614 –> 01:02:58.856
So there was a soft tissue

01:02:58.896 –> 01:03:00.557
inflammation around the screws.

01:03:01.199 –> 01:03:01.559
However,

01:03:01.599 –> 01:03:04.003
luckily I could take the expander off,

01:03:04.664 –> 01:03:05.784
let the tissue heal.

01:03:06.226 –> 01:03:07.907
And two weeks later I insert

01:03:08.228 –> 01:03:10.211
the expander back in and we start again.

01:03:11.943 –> 01:03:12.882
awesome awesome well there’s

01:03:12.902 –> 01:03:13.864
a lot of questions about

01:03:13.983 –> 01:03:15.204
aligners and the aligner

01:03:15.244 –> 01:03:16.664
protocol like that’s that’s

01:03:16.704 –> 01:03:18.985
another you know whole talk

01:03:19.005 –> 01:03:20.764
in itself so um but you can

01:03:20.804 –> 01:03:21.945
set up a time with dr

01:03:21.985 –> 01:03:23.565
pinter and we can discuss

01:03:23.605 –> 01:03:24.965
that and tj and there’s a

01:03:24.985 –> 01:03:25.965
lot of amazing other

01:03:26.025 –> 01:03:27.126
questions here I’m sorry we

01:03:27.146 –> 01:03:28.106
weren’t able to get to them

01:03:28.186 –> 01:03:29.507
but please do set up a time

01:03:29.527 –> 01:03:30.907
with us it’s been an honor

01:03:30.927 –> 01:03:32.467
to have you dr pinter thank

01:03:32.487 –> 01:03:33.987
you so much thank you tom

01:03:34.027 –> 01:03:36.248
thank you so much everybody for joining