IAFGG 2014 What's an RO to Do?

What’s an RO to do?
March 15, 2014
IAFGG Annual Symposium
Calgary, Alberta
dr. barry raphael
the raphael center for integrative orthodontics
the raphael center for integrative education
www.alignmine.com
bioblocnj.com
drbarry@alignmine.com
Monday, March 17, 14

SOFT TISSUE DYSFUNCTION
With Chronic Open Mouth Posture
Comparison of Unsupported vs Supported Growth

The EndThe Beginning

Everyday in my practice...

RO since1983 (30 years...yikes)
Bucknell University 1974
University of Pennsylvania 1978
(ThreeYears in General Practice)
Fairleigh-Dickenson University 1983
14 Instructors: 14 Techniques

RO since1983 (30 years...yikes)
Bucknell University 1974
University of Pennsylvania 1978
(ThreeYears in General Practice)
Fairleigh-Dickenson University 1983

My Dream Ofﬁce, 2001
Clifton, NJ
Clifton
Empire
State
Building

My Dream Ofﬁce, 2001

1.Crooked teeth are THE PROBLEM.
2.The lower incisor must be upright.
3.Patients don’t want to cooperate.
4.Straightened teeth aren’t stable.

1.Orthotropics is the string theory of most
malocclusion
2. Biobloc is the gold standard
3. Biobloc cannot cover all cases or needs
4. I need other solutions
The Beginner’s Mind

1.Crooked teeth are THE PROBLEM.
2.The lower incisor must be upright.
3.Patients don’t want to cooperate.
4.Straightened teeth aren’t stable.
1.Crooked teeth are A SYMPTOM.
2. The UPPER incisor directs treatment.
3.Patients don’t want to be exploited.
4.Teeth that grow straight are stable.
A Change of Mind

1.Crooked teeth are A SYMPTOM.
2. The UPPER incisor directs treatment.
3.Patients don’t want to be exploited.
4.Teeth that grow straight are stable.

The Toothberg

Airway-Related Oral Dysfunctions (AROD)
• Chronic Naso-pharyngeal Obstruction
• Tongue form aberrations (Frenum and tongue-tie)
• Open Mouth Rest Posture
• Myofunctional disorders (Swallowing, chewing,etc.)
• Chronic Hyperventilation and Hypocapnia
• Breathing Disordered Sleep (OSA, UARS, snoring)
• Bruxism and parafunctions
• TMD and facial pain components
• Cranial and postural issues
• Malocclusion

Airway Orthodontics
•Early Feeding and Nutrition
•Allergies,Asthma, URT infections
•Posture
•Airway, Breathing, and Sleep Disorders
•Soft Tissue Dysfunctions (Tongue Thrust, Open Mouth)
Instead of crooked teeth being The Problem,
They are just a SYMPTOM of something larger

•K.K 6-11y F
•Post XX with shift
• InL = 35 (+7)
•Tx plan: Expand for XX
correctiion, then reeval for BBO

•K.K. 8-2y F
•Upper 2’s delayed, just bonded
•InL = 30 (+1)
•Dad opposes deX , until...
•SleepQualIndex = 1.3

S. R. , 10-10yo M
•Missing 32,42
•Impacted 13,23
•Late mixed, 25 erupted
•Soft tissue dysfunction
•IL = 40
•Not compliant

S. Reardon, 10-7yo M

Impacted 3s, Missing 2s

Medical history
• Reactive Airway Disease
•“Bronchial Constriction”
•Care of Pulmonologist
• Preventil
• Dad : OSA, CPAP for 11 years, diabetes
• Grandfather: OSA untreated
• ETCO2 = 36.1 at 10 bpm (acceptable)
• Posture number - 18 (<10 ideal)
• Father refuses sleep screening

Treatment Options
1.Open spaces for impacted canines. Open spaces for
lower lateral implants.
2. Extract upper premolars. MFT. Align.
Patient chooses option 2. Goes elsewhere...

Using Indicator/
Cosmetic Line
•To deﬁne a starting point
•To set treatment goals
•To track treatment progress
•To gauge the effectiveness of treatment

Charting the In/Cos Line
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

Incisor pulled away from nose.
Not “undertorqued” or “gummy smile”

Hypothetical ClI Ortho/MARA
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys
OJ =
7mm
Starts
Ortho
“Great
Headgear
Effect”

Guiding Type2 Tx
50
40
30
20
mm
y J F M A M J J A S O N
boys
Start
Non-x
Expansion
Uncrowding
Finished
Start Cl II
elastics
OK,
that’s
enough...

Hypothetical Mouthbreather
(Dr. Mew’s Hamster Boy)
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys
Boy
gets
hamster
MFT

Hypothetical BBO, 7yoM
50
40
30
20
5 6 7 8 9 10 11 12 13 14 15
girls
boys
Initial
Start
BB1
BB3
Night

•L.R. 11-9yF
•Missing all 5s,6s,8s and upper 4s
•Had ortho to close diastema…
•InL = 39
•GP objects to deX, plan equil

L.R.Tx Plan
1.Preparation: Hang Expanser
2.deX
3.Training: BB3 to advance mandible
4.Myofunctional Therapy
5.Orthopostural Training
6.Myobrace to hold
7. Reevaluate for dental detailing

L.R. : Spotty progress
50
40
30
20
mm
y 3/13 4 5 6 7 8 9 10 11 12
1/
14
2 3
Expanser
Parents
dragging.
30 turns.
Start Adv.
Rx deX.
GP
objects
After
delays,
Equil e’s,
BB3

•L.R. 12-3 yF (6mo in tx)
•InL = 37 (+2)
• e’s equilibrated
• OJ =10
•Appliance OJ = 5
• Still accommodating to BB3

Is there a calculus for the Indicator Line?

Treatment Goals
Based on Indicator Line

Incisor Goals
Type 1 Treatment:
Place U1 in ideal position
Biobloc Orthotropics, Orthognathic Surgery, Distraction Osteogenesis

Type 1: Ideal In/Cos line
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

Y.Z., 9yo M
•Lost upper d-space
•InL = 36(+4)
•OJ = 9mm
•Lip entrapment
•Lip Incompetence

Y. Z., 9yo M

Y. Z., 9yo M
9mm OJ

Treatment Options
1. Type 1: Reduce InL, open lost space, BB3 to advance
mandible.
2. Type 2: Open lost space.Align.
3.Type 4: Extract four premolars.

Y.Z. 9yoM
50
40
30
20
m
m
y
M A M J J A S O N D J F M A
boys
Hang
Expanser
Upper and
Lower
Brackets Hang
Retainer
BB3

Incisor Goals
Type 2 Treatment:
Develop arch just enough to uncrowd
Biobloc, Myofunctional Ortho, Myofunctional Therapy, Crozat,ALF, Expansion Orthodontics

Type 2: Uncrowding
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

50
40
30
20
mm
y S O N D J F M A M J J
Lower
Sweep
H.G. 9yo F
Expanser
Brackets
Hang Ret

H. G. progress

H.G. progress
Next: Bond lowers to level and align
Revisit deX to decrease vertical.Also reduce InL to ideal.

Z.P., 9-5yoM
i

After Expansion Phase

Incomplete proﬁle improvement...
better breathing, head posture and sleep.

Incisor Goals
Type 3 Treatment:
Maintain UI
Functional Orthodontics, Expansion Orthodontics, Distalization Ortho
or No Treatment

Type 3: Maintain
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

Bimax
retrusion

Successful
dental result

Failed Proﬁle Result

Incisor Goals
Type 4 Treatment:
Retract/Extrude UI
Extraction Orthodontics, Retraction Ortho, Distalization Ortho

Type 4 : Retraction
50
40
30
20
mm
y 5 6 7 8 9 10 11 12 13 14 15
girls
boys

Changes of pharyngeal airway size and hyoid bone
position following orthodontic treatment of
Class I bimaxillary protrusion
Qingzhu Wanga; Peizeng Jiab; Nina K. Andersonc; Lin Wangd; Jiuxiang Line
Angle Orthodontist, Vol 00, No 0, 0000 (pre-publication 2012)
“the dimension of the velopharynx, glossopharynx, and
hypopharynx were decreased after maximal retraction of
anterior teeth with extraction of four premolars…”
“Any factors that can inﬂuence the posture and position of
tongue and soft palate may displace them backward and
encroach upon {the pharynx}.”
“the more the incisors were retracted, the more the
pharyngeal airway was reduced.”

Backed into a corner...
•
Moving teeth faster, more efﬁciently…
...in the wrong direction

Now that we’ve made
smoking unacceptable,
could we not do the same with...
• Sugar?
• Processed food?
• Cheap milk and meat?
• Fast food?
• Pill popping for symptomatic relief?
• Looking for the cure instead of the cause?
• Surgery as a quick ﬁx?
•Thinking braces are a status symbol?
Each industry thrives on the status quo.
Consumers must drive the change.

Nicholas Plaskon 10yM

Sister’s non-x ortho
She’s happy….
but I’m not, so...

I make my pitch for BBO

The dilemma of progress.
(I forgot the progress pictures….)
Dad sells prosthetic parts to orthopedic surgeons.
I selling the case against my previous work they loved...
It takes me 3 hours to sell the case.
They fret until the BB3 goes in...

Connecting the dots...
• Adult SDB and OSA
• Narrow jaws and faces
• Soft tissue dysfunction
• Early parafunctional habits, ie. open mouth posture
• Environmental stressors
• CPAP, MARA,UPPP, Surg
Where’s the best
place to start
treatment? here?
orhere?

1. Prevention
2. Undo the damage already done
3. Establish good habits
When to start?
When damage from poor breathing is noticed and
when bad habits are discovered.
The strategies of
Airway Orthodontics

Prevention
• Remove ankyloglossia
• Promote breastfeeding
• Harden the diet
• Discourage oral habits
• Promote whole-foods, low sugar diet
• Reduce oropharyngeal obstruction
• Promote nasal breathing

Breathing retraining
• Nasal rinsing
• Nasal clearing
• Decongesting

The goals of
Airway Orthodontics
1. Breathing through the nose
2. Lips together at rest
3. Correct tongue position
4. No facial muscles moving on swallowing
5. Optimal forward facial development
6. Class I occlusion
7. Straight teeth
8. Better stability long term

Myofunctional Trainers
Professors R. Soulet
and A. Besombes
Dr. Earl Bergeson
Dr. Chris Farrell
The Multi – Family System

Soft Tissue Dysfunctions
•Lip incompetence
•Lip entrapment
•Hypermentalis
•Mouthbreathing

12 month progress

After Treatment
Bent-wire
6 months
Myobrace
12 months
Hey,
Raphael...What
about that
proﬁle?

Orofacial Myofunctional
Therapy
Oral Myology
Myofunctional Therapy
Tongue Thrust Therapy

B. Hockel 2012
Back
Undoing Bimaxillary Dysplasia
1. Maxillary deconstriction
2. Maxillary advancement
3. Maxillary impaction
4. Mandibular advancement

1. Maxillary Expansion
Treatment for Bimaxillary Dysplasia
ALF
Crozat
Bent Wire
Hyrax
Haas
Niti Exp BioBloc
Schwartz

The Farrell BENT WIRE System™

Recommended Age Group:
5-12 yrs
Arch Development in
conjunction with the
TRAINER System™

At age 16
Twin Study

Four years earlier...
One of them has crooked teeth.

3 August 2003 3 August 2003
RHYS - 10Y 11MHow did these teeth get this way?
Different genes than his brother?

1 March 2007 1 March 2007
RHYS - 14Y 5M
Four years later, after successful MFO
Text
(Treatment by Dr. Chris Farrell)

RHYS - 16 AUGUST 2007 KYLE - 16 AUGUST 2007
TRAINER BWS MYOBRACE MINIMAL SWA
RHYS & KYLE - 13Y 8M
Did genetics make the teeth straight again?
Did genetics make the teeth crooked?

Dr. John Mew

Establish Good Habits
1. Breathing through the nose
2. Lips together at rest
3. Correct tongue position
4. No facial muscles moving on swallowing
5. Stand and sit in balance
6. Breath gently using the diaphragm
7. Eat to nourish
8. Sleep to rest

Ortho-Postural Training
Workshops
Breathing
Nutrition
Posture
Sleep

COPYRIGHT
Roger L Price
October 2012

Posture Number
Forward head posture
can be a compensation
for a deﬁcient airway

Sleep Screening and Hygiene
SQI = 10 SQI = .98

Integrative Healthcare
Function Professional
Nasal clearing ENT, Pulm, MFT, Breathing
Muscle balance and tone MFT, Myofunctional Ortho
Undoing damage GP, Pedo, Ortho, OMFS
Breathing dynamics OPT, MFT, Breath Physiologist
Posture DC, OPT, PT, Osteopath
Cranial balance Osteopath
Nutrition RDH, Nutritionist, Dietitian
Sleep ENT, Sleep Med, Dent
Neurocognitive development Ped’n, SLP, Psych, Sp.Ed.
The Interdisciplinary Center

Now that I know...
My personal mission:
To create, from what I’ve
learned from the best,
a model for others to follow….
...especially the orthodontists.

Myofunctional Orthodontics
Chris Farrell
John Flutter
German Ramierez
Damien O’Brien
Myofunctional Research Co.
Rancho Cucamonga
2008-2012

Oral Myology
Oral Myology Basic Course
Joy Moeller
NYC 2011
LA 2012
Oral Myology: Levels 2, 3
Kim Benkert
Clifton 2012
Habit Cessation
Shari Green
Clifton, 2013

Biobloc Orthotropics
BBO Mini-residency
Bill Hang
Agora Hills
2012-13
BBO Intensive
Drs. John and Mike
Mew
LSFO
2013

Breathing and Sleep
Buteyko Mentorship
The Breathing Center
Woodstock
2010
Breathing Well Programme
John Flutter
2010
Ortho-Postural Training
Roger Price
2013
Sleep Dentistry
Michael Gelb, et.al
NYU
2012

ALF and Cranial
Jim Bronson
2013 Tasha Turzo
Cranial Academy
2014

Bucket List
•ALF and Crozat (Bronson’s course)
•More on Biobloc (Hang’s Advanced, London School)
• More Cranial and Chirodontics (The Farm)
•Airway Dentistry with Marc Cruz, Jeff Rouse
• Sleep Dentistry
• Less-than-Six with Kevin Boyd
• Intra-mandibular Distraction Osteogenesis
Off My List
Anything that moves the teeth faster in the wrong direction...

What’s an RO to do?
To create, from what I’ve
learned from the best,
a model for others to follow….
...especially orthodontists.

Teaching
Mt. Sinai Pedo Residency
Ali Attaie
2010-2012
Monteﬁore Ortho Residency
Tony Maganzini
2012
2009-Present

Mt. Sinai School of Medicine
Pedodontic Residency
Guest Speakers
Jim Bronson
Mike Mew
Kevin Boyd
Sandra Kahn
Jennifer Tow
Roger Price
Paula Fabbie
Damien O’Brien
First clinical program in myofunctional orthodontics

Airway and Facial Development
Collaborative Webcast
Mark Cruz

AAPMD Symposium
www.aapmd.org
Annual Meeting
April 25-26, 2014
Westin Chicago North Shore

the raphael center for integrative orthodontics
www.alignmine.com
www.bioblocnj.com
www.myobracenj.com

Integrative vs Conventional

“With improvements in
expansion orthodontics,
advances in myofunctional
orthodontics, and the growing
recognition about sleep
disordered breathing among
children and adults, it is time for
orthodontics to expand its
horizons. There is now so
much more we can offer.”
The Raphael name has been associated with high
quality orthodontics in New Jersey for over 60 years.
Dr. Barry Raphael has been a university trained
orthodontic specialist and a member of the
American Association of Orthodontists for 30 years.
He has a wide range of techniques and services to
offer. He has studied oral myology, applied
kinesiology, Buteyko breathing, Biobloc Orthotropics
and Myobrace as part of his integrative training. He
can offer Damon, Invisalign, Insignia and Incognito
appliances designs as some of his many
conventional orthodontic services, too.
Dr. Raphael teaches his techniques at
post-graduate residencies, study clubs, dental
societies, and for the Myofunctional Research Co.
He is available for presentations to any group
interested in learning more about the benefits of
integrative orthodontics.
www.alignmine.com
Learn about the choices you have in orthodontics
dr barry raphael
Why it's
too Early...
never
1425broadstreet
clifton,nj07013
973-778-4222
fax973-778-9625
njspec#3684
1425 broad street, clifton, nj 07013
973-778-4222
www.alignmine.com
the
raphael center
for
integrative
orthodontics
theraphaelcenterfor
integrativeorthodontics
Learn about an important
choice you need to make
before starting braces.

Ongoing Intro to Airway Orthodontics
April Biobloc Study Group
April Training Ortho-Postural Therapists w Roger Price
June MRC Myobrace Basic Series
August Airway Dentistry with Mark Cruz and company
October Advanced MFT with Sandy Coulson
October Less than Six with Kevin Boyd
(who else wants to play?)
Mission: to create a space for spreading the word about
Airway and Orthotropic principles and practice.

Orthodontics in the
21st Century
Esthetic
Orthodontics
Airway
Orthodontics
Genetic
Tooth-Focused
Dental: Perfection
Esthetics Primary
Treating Symptoms
Airway Ignorant
Adaptation
Muscle-Focused
Medical: Better
Esthetics Secondary
Treating Causes
Airway Conscious

The End
And
The Beginning

IAFGG 2014 What's an RO to Do?

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IAFGG 2014 What's an RO to Do?