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Advances in Orthodontics

Dec 20 | 2:30 PM

In dentistry, malocclusion is one of the most commonly occurring conditions in the human population. A misalignment of the bite leads to both functional and aesthetic complications for the individual. So how do doctors fix this? Orthodontics is a field that has made incredible strides in the development of more effective dental appliances, brackets, and bonding agents to address this problem. Join Dr. Jayesh Rahalkar, a very well-known orthodontist, as he takes you through the advances in diagnostic, communication, and therapeutic procedures in the field of orthodontics.

[Music] so i welcome you all for yet another amazing session on interdisciplinary or aspect of orthodontics management and advances today we have with us dr jayesh rahalkar who is the professor in department of orthodontics at diy patel dental hospital pune is also the honorary consultant at dinanath dinana hospital pune he also has his exclusive orthodontic practice in pune after pursuing his graduation he completed his mds in orthodontics and then went on to complete his m ortho conducted by the royal college of surgeons edinburgh he has a rich experience of almost three decades and we are pleased to welcome such an experienced faculty on our platform so now i would like to hand it over to sir dr rahalpin you can please start your presentation thank you very much for your kind words of interaction dr brishali i would like to thank team netflix for giving me an opportunity to have this particular presentation in front of such a fantastic audience i also would like to thank my student dr samadia for introducing me with the medflix team and when i was asked sir what do you like to present i said uh if the target audience are the clinicians and who are you know they want to give excellent treatment to their patient then i would like to share what my specialty that is orthodontics can do uh wonders with interdisciplinary aspect and how we can manage those interdisciplinary cases and what are the current advances in this particular field so i thought of this particular topic as interdisciplinary aspect of orthodontics the management of cases and advances in this particular field so let's understand what are disciplinary dc when we say when we work only in one discipline it's called as intra-disciplinary when we view one discipline from the perspective of another it's called as cross-disciplinary then we have been taught as multi-disciplinary treatment where people from different disciplines work together and each draws their disciplinary knowledge but what we actually need to do in clinical condition is the interdisciplinary where we integrate the knowledge and the methods from various disciplines using a synthesis of approaches and in future we will be going to a concept of transdisciplinary where we create a unity of intellectual framework beyond the disciplinary perspective so this is the concept of interdisciplinary in uh from intra-disciplinary to multi-disciplinary to cross-disciplinary to interdisciplinary and trans discipline so let's understand what is interdisciplinary orthodontics you know when we do effective and efficient utilization of the skills of various disciplines of dentistry and the key is the combination of diagnosis treatment planning and the therapeutic procedures with extensive communication along the team members you know in orthodontics in the past was only associated with creating beautiful smiles just by aligning the teeth orthodontics was just considered that they just aligned the team but what is the current concept today it has become a fully integrated partner in the interdisciplinary development of the smile and why do we require interdisciplinary see when uh in say 30 40 years back we used to get orthodontic patients which were young and this younger generation usually has a non-born non-restored non-periodontally involved complete dentition and hence the result were very predictable so the treatment was predictable now today orthodontics is just not for younger patients the orthodontic practices all over the world treat around 25 to 50 percent of the adult patient okay so i'm going to show some cases i would like to tell you that these are the cases which are treated in my private clinic see i'm attached to two big institutions uh doctor dywa patil dental college in pimbre and uh hospital in pune so people feel that whatever cases i show are treated in those institutes only no what i do is that i don't show any of the cases treated in those institute i show the cases which are treated in my private clinic to give you confidence that if i can do these type of cases in my clinic you all with the help of your orthodontist coming to your clinic and your knowledge of restorative dentistry and other branches can give the same result so this is a small disclaimer before that so whenever a patient like this comes to us initially we were only trained to look at this particular case from the orthodontic point of view we used to align the teeth and forget everything rest about it but if you carefully see this particular patient this particular patient is an adult patient apart from male occlusion there are uh periodontal tissue issues then there are uh restorative dentistry related issues the anatomy uh the micro aesthetic of the dentition is affected so what has happened actually uh the problems in the idols what we see as the representative problems in this particular cases what we see in adults is that we have uneven gingival levels the crown length discrepancies are there the anterior teeth are abraded because of attrition abrasion and erosion whatever are the reasons restorations are there sometimes they are good or sometimes they are failing because of the metabolism issues or trauma from occlusion there is a parental bone loss which we see the soft tissue recession is also associated many times and there are other dental problems resulting in the altered tooth positions so we have to do something called as a solution driven orthodontics in these type of cases along with the help of restorative dentistry from your point of view so what we do is that we do alignment and leveling of the dentition then we level the anterior gingival margins then we eliminate excessive gingival display we obliterate the open gingival embrasures or what we call it as the black triangles and if there are missing teeth then we create appropriate anterior or as well as posterior restorative spaces i'll be showing cases where we have done pre orthotic treatment to give an excellent result to the patients so uh then also we correct the uneven anterior crown lengths we develop implant sites uh crystal bone improvement can also be done dental mid lines that is matching the upper dental midline with the facial midline to give excellent aesthetics and we eliminate the incisal plane discrepancies now current scene is that you see there are some cases which require adjective treatment of this sort either before during or after the orthodontic correction of a better finish now these cases are usually seen by the orthodontists first and it is the intelligence and clinical acumen of the orthodontist to know that these particular case requires support from the other specialities so it is what we need is that his expertise in proper treatment planning and involving specialists of other branches and the general dentist but see for example this particular patient reported with an orthodontic problem of deep bind and other things but if you see the maxillary right lateral incisor was traumatized and there was no crown structure this was a non-extraction case patient had a lot of retrusion so we said that just orthodontic correction is not sufficient here so after orthonormatic correction during the orthodontic treatment we got some temporary restoration done of this particular lateral incisor and this is how the patient is just at the end of the orthodontic treatment now this particular patient will go ahead and will get the proper crown and other restoration and whatever necessary restorative work is there so i was in discussion with the restorative dentist of this particular patient and we had kept the space sufficient enough to match with the lateral incisor of the other side so it will have a nice smile line now if you see the smile line is nice we have to just change the shade and the other things for this particular patient and she will be done so these are the cases which are seen by the orthodontist first and the orthodontist should know that this particular case requires support from other specialities i am not the only person who will be doing this particular patient but there are some cases which require orthotic treatment before the final restorative prosthetic or aesthetic treatment of that particular patient for better outcome and these cases are not seen by the orthodontist these cases are usually seen first by the other specialist than the orthodontist and we need your expertise to plan the comprehensive treatment so for example this particular case was sent to me by my prosthodontic friend dr mohit if you see the patient had an implant in the region of maxillary lateral insider the same tooth which the previous patient had an issue now this particular superstructure the crown of this was continuously failing because in the lateral excursion movement there was no guidance on the left side because the left maxillary canine of the patient was in crossbite and that is where we convinced the patient uh in spite of she being an adult patient like this this was the smile aesthetic we corrected we went in for a comprehensive treatment of orthodontics for this patient and look at the condition here the patient has a uh implant for one two as well as three six uh implant was planned for four six as well and uh this is how the patient was and if you see this is how the patient is at the end of the treatment the patient uh didn't wear the retainers properly so mild midline diastema has opened up but if you see the canine which was in crossband got corrected the leveling of crown margins happened after that the prosthodontist could go ahead and give a nice crown for the maxillary right lateral incisor and this is how the patient smile is and for comparison you see on the left hand side you have the pre and on the right hand side you can see the post treatment okay and this is a nice occlusion which was created this is the occlusal view on the left hand side the pre treatment and on the right hand side you can see the post treatment so there has to be a good synergy and a communication between the orthodontist and the other branches of dentistry and the general dentist sometime now this particular adult treatment or what we call as the interdisciplinary treatment is of two types one is called as an adjunctive treatment and another called as a comprehensive treatment the adjunctive treatment is where the tooth movement carried out to facilitate the other dental procedures necessary to control the disease restore the function or enhance the appearance and it usually involves only a part of the dentition it doesn't involve the whole condition uh it is of a shorter duration and retention is usually by restoration and prosthesis and orthodontist is one of the member of this particular team now here the only issue is that if the particular patient has malocclusion related issues in the other areas it doesn't get corrected in this particular treatment because it's a section and treatment now look at this particular exam this patient you can make out this patient uh this is the left side uh panorex of the patient where uh the tooth number three seven is uh extruded uh because the patient uh had a long history of missing uh two seven the three eight is also impacted the implantologist wanted to because the uh 2 6 also was having failing restoration there was a vertical crown vertical root fracture so uh the prosthodontist wanted to give up implant for tooth number two six and two seven but he wanted me to include that three seven so that there will be sufficient space uh to give the pontic so what we did is that we did a sectional orthodontic treatment and with the help of implant orthodontic implant and the uh [Music] band on the truth number three six uh what we did is that we included the three seven now here this is a adjunctive treatment sectional treatment the remaining male efficient of the patient remains the same but there is something called as comprehensive treatment it is the same treatment like what we do for young or adolescent patients either with the help of ceramic appliances so that the other patients are there so they can see things less then even with the current uh aligners you must have heard about the invisalign uh and other things so this particular comprehensive treatment is to is given to produce the best combination of dental and facial appearances dental occlusion and stability of the results the comprehensive treatment is a longer duration of the treatment but it gives the excellent result and it we can use aesthetically enhanced appliances so for example like you know i will just share you two cases this particular patient is reported with a meteor dense you know you all know what's a museo dance it's a supernumerator between the central incisors the lateral incisors were erupting so the patient was looking like a dracula with three teeth jutting out so what we did we the patient also had a missing lower central incisor so we extracted the mesio dents uh we discussed the case with the pediatric dentist and the restorative dentist the restorative dentist said that the tooth size is so the tooth area where the tooth is missing is so small that if you just close the space it will be great i said fine uh the space can be close but my upper midline will not have a congruent lower midline because as there are lower three incisors it will be on the middle portion of the lower incisor but that was okay uh because the maxillary midline was occluding with the facial midline so we extracted the mesodens and completed the case like this now i will show you a case where the patient reported with the midline dystema and said that i need cosmetic treatment and when i saw carefully there was a denture tooth fitted between the dye steamer of two central incisors and it was fixed to the dentition with the help of self-cure acrylic the patient said masala even the same situation was there in the lower arch now if you see the same situation was in the previous case where the patient had midline diastema lower incisor was missing we closed the dye stemmer and we gave an excellent aesthetic to the patient by closing the lower spaces also same thing could have been done here if this particular doctor would have discussed the case with the orthodontist the patient said that i went to this particular dentist he said he's a cosmetic dentist and he gave this so i call this as an ayatogenic music so this is a treatment for me or mesoderms and this is a creation of an iatrogenic mesoderm so this is like shooting your own mouth so remember that in these type of cases uh your remember the management lesson that never start a project unless all resources are available you know this if you have seen delhi believe you will be remembering the funny incidents so this is the diagnostic jargon which we all should do but i will just go in a quick nutshell see here the team should be such that you know it should not happen like this particular team there's one team coming from one side building the tracks and the other team coming and actually there is a mismanagement and so this is what we don't want so the treatment planning should be good so what is the most important thing apart from the diagnostic records i feel is that work backstroke setup the diagnostic setup is a very essential thing you know it a fully waxed management of the patient dentition gives us prescribed orthodontic treatment what we need to do which rest need what type of restoration and how the replacement of the missing teeth should be done it gives a 3d visual of patient's dentition on completion of the treatment and it is actually a blueprint for the proposed plan of treatment it's an excellent communication within the team members uh it's an educational and counseling tool for the patients so when we plan the treatment goals in interdisciplinary cases what we need to do is that we need to have two types of goals one is the idealistic treatment goals where we look at a nice static occlusion functional occlusion and excellent facial aesthetic but let's say as these are interdisciplinary cases sometimes some of the tissues are compromised so let's go for the realistic treatment goals so let's have the best possible aesthetic efficient occlusion and stability of the masticatory system and the treatment objective should be planned in such a way that it is always what the patient wants but at the same time we have to understand what the patient wants may not be scientifically correct so we have to have a proper interaction of what the patient wants that is the cheap complaint of the patient and the what the science says if there is a patient who comes to me with highly proclaimed teeth and tells me that doctor rather than putting braces extract my all six teeth and give me a artificial teeth that is what the patient wants but that is not my what my science says i will do what is scientifically correct and i will ask myself a question whether i will do this particular treatment on my own child if my answer is yes then only i will do it if my answer is no i will convince the patient this is not what is wrong this is not what is correct for you this is wrong so please don't go ahead so keep a balance between patients cheap components and what the patient wants and what is scientifically correct then explain nicely the duration of the treatment to the patient then the fee ah also work about the cost benefit or the risk benefit analysis and also consider the psychology of the patient that how patient is cooperative what is the cooperation level uh whether they understand the benefit of the import how how is the understanding of the patient about the importance and benefits of the treatment so that is what you need to understand then how do we time these interdisciplinary cases remember first is control of any active dental disease should be done i will not start my work of corrective orthodontic treatment unless all active carries and the pulpal pathologies are taken care of so first control any active dental disease which include active carries pulpal pathologies then uh going for restorations or temporary prosthesis or endodontic treatment or extraction if the tooth is not having a good prognosis prognosis go for extraction then we can come into picture and do the further work then control the periodontal disease by scaling puritans and flap grafting uh to be decided judiciously we recommend that the grafting should be done only at the end of the orthodontic treatment and uh later on and then correction of the occlusion by orthodontic treatment and periodontal surgeries such as surgical pocket elimination and osha surgery are preferred after orthodontic treatment the restorations prosthesis required requiring detailed anatomy should be done after the orthodontic treatment is completed and what you have to emphasize on the patient is the maintenance okay okay so let's start with the seek you know case series uh of interdisciplinary cases where we have used the latest advances in orthodontics and other specialities to give excellent treatment to the patients so this particular patient reported with proclamation as well as a history of aversion of the maxillary left central incisor so this was the intraoral view of the patient we can see tooth number two one has been advanced and there is a history of exfoliation you can see there is a constriction of the alveolus which has happened the patient also has a proclamation so when we evaluated the case there was a proclamation now you can see there was a residual gutta-percha also which was there on the average truth because the patient actually had got the transplant you know replantation done but there was a resolution now people will uh have a discussion about this particular case uh the choice was to go in for all four extraction because the patient requires retraction of the teeth so extract all four first premolars retract the teeth and then go in for the prosthesis by doing an implant but there are a lot of issues of having an implant in the anterior aesthetic zone okay so what we decided is that we decided that instead of extracting four premolars we will extract three premolars and we will utilize the space of the average maxillary left central incisor and what we will do is that now when you are deciding this what points do you you need to ponder upon type of male equation like for example this particular type of case should require space uh for correction of the malignant if this particular type of male occlusion comes for a non-extraction case i won't be able to close the space i have to maintain the space for the pointing and let my restorative dentist come into play and go in for an external prosthesis so what you need to check is type of mild occlusion how is the space condition then also you need to think about how is the size shape and the shield of the canines size of the crown and the root length of the lateral incisor and you to understand that there are disadvantages of the uh anterior implants in the younger adults so how do you plan the occlusion the sequence of the teeth will change the lateral incisor in that particular side will become central incisor canine will become the lateral incisor first premolar will become the canine so you need to alter the brackets reshape the teeth plant the gingival contouring with gingivectomy and gingivoplasty and built up the tooth material either with direct composite or crowns and veneers so you will land up in a situation where the patient will have three missing premolars lateralization of the central centralized sorry centralization of the lateral incisor lateralization of the canine so you will have a lateral incisor in place of central incisor with a crown of a central incisor so there has to be a proper position of the gingival margins you need to include them so i will and the distribution of the space should be such that there has to be one third on the measles side space should be left and two third on the distance side so this is how you can make out we started closing the space we have changed the brackets we are keeping sufficient space on either side for the tooth to be built up these are the occlusal views then we went ahead and got a temporary built up of the uh tooth done matching the mesio distal width of the contralateral central incisor because this particular lateral incisor has to look like a central incisor so the measured distal bits should match so this is how the patient with the temporary process is the patient's age was 16. so my prosthodontist said that okay what we will do this is how the patient is at the end of the treatment smiling photo he said that what we will do is that we will hold it at this particular stage when the patient completes 18 years of age we will go for the gingival contouring where the gingival lines will be matched between the centers and both the centers the laterals are already matching and the canine will be a little bit of ginger tommy will be done so this is how the patient and then the lingual cusp of the premolar will be grinded off a little bit so that uh [Music] you know the it will not interfere with the lateral excursion movements so this is how the opg you can make out the central incisor is missing and the lateral inside has taken up the place there and there is a temporary built up which is there this is the comparison of the external photographs before and after treatment see carefully the smiling photo uh these are the comparison of the intra-oral photographs before and after treatment this is the occlusal view before and after treatment this is the cephalogram before and after treatment and this is the comparative opg you can see nicely uh treated case and this is how the patient extraoral view comparison before and after treatment now i would like to show a similar case where a contralateral central incisor is missing and where we went ahead and got the prosthesis done so this is how the patient was so the rest of the things were same only thing instead of upper left central incisor this patient's upper right central in size that was missing so we went ahead with the similar extraction three premolars and one central incisor we went ahead and you can see that there is a space closure which is happening then uh as the patient was an adult we went ahead and did a little bit of gingival contouring you can see the canine is in place of lateral and the premolar is in place of canine but we adjusted the torque and tip in such a way that the premolar is actually looking like a canine and this is how the patient immediately at the tree and the end of the treatment this is the occlusal view this is the comparison between the pre-treatment and end of orthodontic treatment this is the occlusal view comparison and you can make out here here what we have done this is the introvert photograph before treatment and after treatment and you can make out here that we have got the gingival margins match we have got an excellent occlusion midlines are matching and with the gingivic tummy and a proper ceramic laminate both the insiders are looking like central incisor even though one is a lateral incisor now this particular patient has to just take care of that laminate throughout the life rather than any plant it's a natural tooth with a little bigger crown so this is the way if you plan the interdisciplinary approaches properly with the restorative dentist it will give you an excellent result now i will show you another case where we have used the interdisciplinary method to a little more extended way this particular patient reported with the trauma and a severe fracture of i mean fracture at the cervical level of the central incisors so this is how the patient was and uh the patient went ahead with the temporary root canal treatment basically because the patient was having a lot of pain so uh we temporarily uh got the things done but when that then the root canal was done it was found that there was a vertical fracture also in the root so this is how the patient was so what we did is that we went ahead and thought of two treatment plan extract one four two four three four and four four uh but then we have to go for prosthesis of 1 1 and 2 1 and the prognosis is poor then at a later stage she will have to go in for replacement so we thought that will be little adventurous and we will extract the central incisors one by one and move the dentition there and let's centralize the lateral incisor lateralize the cuspid cuspidized the biker speed and everything will be in class one so this is how the patient was we decided to extract upper incisors lower right second premolar because there was a class two molar relationship on that side so i wanted to correct into a class one and this is how the extractions we did the patient was on ceramic appliance you can see there is alteration of the brackets is done and you can see here the space closure is starting and this is how uh we found out that how the mesodigital width of the maxillary inside that has to be done see when there was a unilateral missing tooth you always have a adjacent or the contralateral central line sensor which will tell you what should be your visual distillate but when you have both the central incentives missing how to know what should be the measured distal width of the central incisor so there is a formula which says which is given by a pound that the width of your central incisor should be the bizagomatic width of the patient's face divided by 16 so this is by zygomatic width uh that is number two divided by 16 will give you the measured distal width of the central incisor so this is how we went ahead and we built up temporarily then the patient uh there was some second molar cross bites we which we corrected with modified transparent largest and this is how the patient is slowly nearing the completion of the treatment okay this is how the patient on the day of the bonding after that the patient went ahead see this is how the patient was after that the patient went ahead and got the crown preparations done and this is how the patient was pre-treatment this is how the patient was progress this is how it is mid treatment mid treatment post treatment and this is how the patient is at the end of the treatment now here you can make out the patient was convinced by my prosthodontist to go in for the uh laminate for all 14 because he told her that your lad your canines are little yellowish so they will not look like lateral incisor so she was ready to go for four laminates and those laminates were so nicely done that this is how the patient is yes see this is the post treatment result this is how the patient was at the end of the treatment excellent class 1 molar relation nice intercuspation and excellent anterior aesthetics so this is how the occlusal view of the patient is and this is how the patient is at the end of the treatment you can make out the lateral incisor laminates are put up on the canine tooth so this looks like a proper central and a lateral incisor which is actually a lateral incisor in place of central and a canine in place of lateral incisor so now the patient doesn't have to worry about two missing teeth he has to just take care of these four laminates nicely she'll be happy for a long time so this is the comparison and this is the comparison here you can make out intraoral photographs before treatment and at the end of the treatment so this is the comparison before treatment and at the end of the treatment see this is the patient before treatment in in extraordinary and at the end of the treatment okay so i think here my first section is over so i'll just go to the second part now many times we have you will be facing in your clinical situation that you get lot of pec shaped lateral incisors so rather than the theory let's directly go and see the case we have to understand that we need to have this particular proper golden proportion to have a excellent smile aesthetics for the patient so this was a patient who reported to us with procline teeth and spacing so on a clinical examination we could see that the patient had peg shaped lateral incisors procession deciduous canines in the maxillary arch were over retained because the patient had impacted maxillary canines so we went ahead uh extracted the deciduous canine surgically exposed them maxillary canines got them down aligned the pectin lateral incisors and calculated the mesio-distal width of the lateral incisor based on various formulae and we maintained that particular space between the distal margin of the maxillary central incisor to the measles margin of the maxillary canine so that we know that that particular space has to be divided in such a way that on the mesial side it is one third and on the distal side it is two third that means if my maxillary lateral incisor is four millimeter and it has to be built to seven millimeters and on the mesial side i must have one millimeter and on the distal side i must have two millimeters so this is how the build up will be done so this is how the patient is at the end of the treatment i apologize for the photographs because they're very old photographs they are not digital portorahs they are print photographs which were scanned so they are looking little exposed okay so this is how the patient is at the end of the treatment look at the smile aesthetics see this is how the patient is intra-hourly before treatment and on the right-hand side intraoral post treatment and as i mentioned that we also do lot of pre-implant orthodontics why we do orthodontics in implant is that you know we adjust the pontic space we correct the measles and distal drips of the adjacent teeth we level the antagonist tooth in case of extrusion and we coordinate the arches for better static and functional occlusion so that your prosthesis doesn't get affected and we generate the implant side by extrusion of the teeth or by mesio distal movement or by bone generation by orthodontic movement so i will show you a case series where we have used orthodontics to assist in the implant prosthesis so uh okay i will go to a case this is a case where maxillary lateral and canines were missing so the patient had 14 missing in the upper jaw and lower incisor was missing so now here when i have to maintain a space the prosthodontist also is at a little uh you know difficult situation how much space has to be kept so we have developed a concept of riding pointing what do you mean by riding pointing we take a denture tooth which is supposed to be the measured distance width of the lateral incisor for this particular patient so based on calculation of the central incisor width we decided what should be the measured distal width of that particular lateral incisor then i chose one denture tooth from the set then i bonded my brackets to that then i put those brackets onto the wire so these became contacts which are riding with the help of the brackets onto the wire so these are called as the riding contacts now when i place this particular wire in the patient's mouth okay i know exactly that i need to close a space which is from the distal of this lateral incisor pontic to the measles of the premolar okay then only the sufficient space will be maintained so this riding pontic helps me as an index to close the space so this is how the space closure is happening you can see the space closure happening you can see the space closure has happened and this is how the patient so the lower incisor was missing so lower mid line is also on the midpoint of the central incisor so from here to here now here you can make out the same point it can be given into the retention plate as well okay now this was in case of uh you know how much space to be closed now this particular patient uh we in pune i get a lot of korean patients because yundai has a plan so before the lockdown i used to get a lot of uh on patients with you know korean background so this patient reported with us and told that they need uh midline correction i mean the smile is deviated so when we analyze we found that the patient had a missing maxillary right lateral incisor so the patient had missing one two so we explained to the patient that we need to create space so now here as the tooth is missing you know that whenever there is a genesis of a tooth the alveolar process doesn't form but if there is a drifting of the adjacent teeth which has happened it helps to grow the bone now here if you see the central and the canine are very close to each other sorry and uh distal to canine there is lot of space the patient's mid line is also skewed so when i match the mid line i can get the central incisor close to the central incisor of the opposite side i can push the canine distally to touch the premolar so that the canines will come in class one and as these two teeth will leave away from each other they will leave healthy bone for the lateral incisor implant so what we did is that yeah this is you can make out here there is a lot of drifting which has happened now you can make out here when i shifted the dentition the midline started matching okay the canine came into a good classroom and those two teeth left an excellent healthy bone where implants can be put up so you can make out here there is an implant put up there is a temporary prosthesis and this is how demanding the final processes will be done by my prosthodontist soon so this is how the patient before treatment you can make out there is a complete skewing of the midline it is completely gone on one side and here the implant is placed and now here you can make out look at the smile aesthetic on the left hand side in the pre-treatment the maxillary midline maxillary dental midline upper dental midline is not matching with the facial mid line that is the reason the aesthetic is not looking good now here in the post treatment photograph the maxillary midline the upward little midline is matching with the facial mid line and because of which the aesthetic is looking excellent okay this is how the occlusal view before and after now what we can do is that we can create a space for the roots as well like look at this particular patient reported to us and was not having much issues with the occlusion but there is something called as a column angle we feel that the long axis of the crown and the long axis of the root should be the same there is nothing called as a long axis of a tooth there is separate long axis of the crown and there is a separate long axis of the root and it can vary in the meso distal direction or it can vary in the labio-lingual direction that means the long axis of the crown and the long axis of the root may have an angle mesodistelli or the long axis of the crown and the long axis of the root may have a angle labiolingually also it is called as column angle now in this particular patient and what we have found that whenever there is a genesis of the lateral incisor the column angle for the central incisor is very high so the crown looks straight but the roots look as if they are going into the space of lateral incisor area so look at this so the patient's uh orthodontic of the my prosthodontist said that i can't put an implant here so what we did is that we change the root angulation intentionally between the canine and the central incisor the central incisor crown we tipped distally so that the crowns the roots came easily and there was a big gap created between the roots of the canines and the central incisor so this is how the patient was you can make out here and because of that what happened is that those two teeth those two roots went away from each other and then the patient's prosthetist put the implant there the after the implants are put up then we align the teeth now people will ask me what if this particular root comes close to the implant the literature says that if there is a bone thickness of 1.5 millimeters between the natural tooth and the implant still there is no much better implant that is which is seen so we have to take care that because while inserting the implant sometimes the clinician may have a little bit of leeway of error but after the implants are put up if we are uprighting and if we keep around 1.5 mm of bone between the implant and the tooth there should not be any issue so this is how we separated the roots the implant was inserted this is how the implant was inserted then we align the teeth again temporaries given this is the patient before treatment and with the temporaries this is the patient with the uh before treatment and after the temporaries were given and this is where we assisted the implantologist to get the things done the same thing this particular patient if you see the patient has a deep bite at the same time the patient has a chief complaint of missing tooth number one to five that is maxillary left second premolar okay so this is the occlusal view and when we saw the case if you very very carefully can see that near the palatal and the sinus area you can see an horizontal tooth which is not so clearly seen in this particular x-ray but we had to take a cbct and the maxillary left second premolar was impacted here completely unfavorable so what we did we went ahead uh we aligned the teeth created space for the implant see here we align the teeth created space for the implant got the midline corrected got an excellent molar relationship and this is how the implant was placed and this is how the implant was loaded so this is how the patient is exactly at the end of the treatment so not every time we can close the implant space we have to create implant space also so this is the patient at the post implant situation see here this is the implant so upper left is a pre-treatment upper right photograph is immediately after the implant is placed and the bottom photograph is where we have placed the prosthesis is given to the patient this is the occlusal view upper left before treatment upper right after implant placement and the bottom photograph is where prosthesis is placed so sometimes if there is a long standing extraction you can make out here in the bottom left photograph that the tooth number 2 6 that is maxillary first molar is extruded because the patient has a long standing extracted area in the third quadrant so it is very difficult for the prosthodontist to place an implant here so this is the occlusal photograph of the patient lot of implants required so what we did is that we went ahead with our comprehensive orthodontic treatment we gave an orthodontic implant you must have heard about temporary skeletal anchorage devices these are called as temporary skeletal anchorage devices one implant given on the palatal area one implant on the buccal a alveolus and like a slingshot okay like a slingshot we intruded you can make out the molar is getting included and you can see here progressively especially in the bottom left photograph that tooth number 2 6 is nicely included and it's in level with the second premolar where it was in the pre-treatment it was highly extruded too so you can compare here see the green line is the marginal ridge of the second premolar and before treatment it was somewhere way down and when we included there is sufficient space for the pointy created between the alveolus of the lower ridge and the occlusal surface of the upper six and this is how the implant was placed and the temper i mean the temporary crowns were given so this is how the patient is before and after the treatment left side is before treatment right side is after treatment with the help of orthodontic treatment what we can do is that we can extrude we can do something called as uh orthodontic tooth extraction like this particular uh maxillary right central incisor had a root fracture and there was insufficient one so my prosthodontist suggested that slowly let's extrude it so we started extruding the tooth you can make out i am putting a line on the margin of the left central incisor to uh for you to understand the improvement in the uh attached gingiva see this is before treatment you can see slowly there is a extrusion of the central insides are happening we are getting good ginger there still there is good gingiva you can make out here look at the increase in the width of attach in java there and look here the extraction on the day of extraction you can see with the williams probe the tooth was the root there was sufficient bone there there was an immediate implant and a temporary which was given and later on this temperature will be changed so for the patient also it is good then this particular patient had a history of bruxing and this is most commonly you will find in your practice that the patients have para function because of which there is lot of attrition which leads to sensitivity especially in the lower arch the occlusal surface gets untreated now in this particular patient what is necessary number one opening the bite for creating sufficient space for the built up of the prosthesis for the lower as well as the upper incisor number two having a good occlusion and number three correcting the para function so what we did is that so this is the occlusal view you can make out look at the lower incisor inside the ledges that completely are treated okay so we opened the bite with the help of orthodontic treatment you can make out we got it to almost h2h so that two millimeters of overjet and overbite can be established by the prosthesis so this is immediately after the orthodontic treatment before giving the prosthesis and this is immediately after the process you can make out the central all the anteriors canine to canine upper and lower are given modified on lace okay you can see in the lower arch there's a onlays which are covering the occlusal surface as well as the labial surface same thing in the upper so now this is a rehabilitation now this particular patient has to be given a para functional habit corrector night guard so that the patient doesn't grind off the remaining teeth which have been given to the patient so this is how the patient is on the left hand side before treatment and on the right hand side after the orthodontic treatment as well as the prosthetic correction done so this is the occlusal view okay now coming to the last part of my lecture i will be completing in three to four minutes see this is the uh occlusal view of an adult patient crowding spacing we went ahead with the latest concepts of aligners you can make out there is an aligner the patient is wearing and this is the aligner in place when you take the photograph because of the watermelon effect you can see the aligner but when the patient smiles it is not seen much and this is the end result lower right six also has to go for an implant so this is before and after treatment this is the occlusal view upper on the left hand side pretreatment on the right hand side post treatment okay now i would like to also tell you that with the aligners we can also treat cases with extraction like here you can see that the upper left photograph is before treatment upper right photograph is where first premolar extractions are done lower left photograph is where the patient is wearing an aligner and the aligner has an area of something called as an artificial context so there is an area in the aligner which looks like a tooth where you just feel some composite so that those blank gaps are not seen so aesthetically also the patient is happy this particular patient was a uh actor so for her i need to she was an actress so i need to have something which is continuously there otherwise for close up it would have looked bad and this is how she's in the space closure mode uh and the miner finishing you know with aligners uh posterior settling and deep bite is the most common with the extraction cases which i'll be solving it in the finishing and detailing refinement alignments so what i wanted to show you is that with the aligners if a proper planning is done with the orthodontist even extraction cases can be done but it has to work in the best hands of the expert in that particular speciality so for a closer look again the same case upper left before treatment upper right after extraction lower left with the aligner on you can make out there is a pointed space and the lower right where space closure has happened and this is on a closer look you can see there is a pointing and there is a composite which is given to mask the extraction space so even in a very uh high adult i mean adult of around for 58 year old adult we can close the spaces your upper left is three treatment upper right is with the aligner lower left is in the finishing stage and lower right is where complete alignment has happened now this is with only with aligners so with aligners even we can do surgeries but it has to be planned well see remember aligner is a modality of treatment what is at the heart of it is a proper diagnosis treatment planning and understanding of biomechanics by the specialist of that particular field so you along with your orthodontic friend can sit down and give these type of excellent results so this is before and after so i showed you a cartoon before that this is how it can happen but on the internet i found a photo where they have shown that it actually happened in one particular place so if we don't plan the treatment this is going to happen but remember if we plan properly then we can have outcome like this it will be so fantastic and it will be giving excellent result so i always say that rather than being fighting into individuals like i'm an orthodontist i'm a prostitute i'm a paradise i'm an endodontist we have to understand there is a common thread that we have to be a fighting team together i know that this particular team loses sometimes but this particular team has won the 2020 has won the world cup so i i saw one uh on the internet that the uh board saying that between hinduism jainism buddhism sikhism islam and christianity there is a common thread of being indian so in all our orthodontists periodic period understand everything we have to know that there is a common thread of being a dentist which has to be there and if we do that then all our cases with our collective wisdom will give excellent results to the patient so thank you very much for your kind attention i again thank team netflix and the team members of netflix for giving me an opportunity and giving me a platform to interact with you people these are my communication details and if there are any questions talk to shali if you can go ahead yes sir so we have a question from dr miraj but how is ginger will hyperplasia treated okay ginger hyperplasia uh is of two types ginger hyperplesia because of pseudopockets uh can be treated with uh gingivectomy and gingivoplasty we recommend that it should be done in the orthodontic treatment at the time of finishing and detailing before the debonding is done because after the ginger ectomy is done if you find any particular tooth is having a torque or a tip related issue you can correct it gingiva hyperplesia because of excessively faster space closure requires epileptomy it has to be done with a little bit of caution okay so next question is by dr niranjan if phrynectomy is required should it be done before the ortho treatment or after completing the entire see the literature says that the phrenectomy should be done at the end of the ortho treatment where the space is completely closed because after the phrenectomy is done whether you do a phrenectomy or a phrenotomy or vy plasti or a z plastic there is little bit of scarring of tissue which happens and this particular scarring of tissue actually helps in holding the diastema so it should be done before the only but it has to be uh retained with a permanently bonded retainer for all diastema cases with a hyphenal attachment uh there is a classification of freedom you know papillary mucosal like that so accordingly it has to be done but only a case where flying ectomy might be required to be done before the space closure is a highly muscular thick freedom where the freedom itself is preventing the space closure that's the only option where you do it before the space closure rest in all cases it has to be done after the space closure okay next question by dr niranjan again how many weeks should we wait after patient undergoes a flap surgery usually uh we recommend the flap surgery uh of a non-grafted type to be done before ortho treatment drafting should be done after the ortho treatment but after the flap surgery is done the periodontist is recommend to wait us for six to eight weeks same thing with the disimpacted like for example if you have a impacted tooth very close to the roots which is not salvageable and you have extracted before the orthodontic treatment it is usually 8 to 12 weeks okay all right there's a question by dr chet nagar for how much time do we keep the fixed retainers uh there are some cases where we advise the fixed retainers lifelong as i just now mentioned midline diastemas with pharynx high fresnel attachments then uh midline the dystemias with tongue thrust cases should be kept as long as possible as a protocol in our clinic we give upper canine to canine and lower canine to connect bonded retainers till the age of 25 at the age of 25 by the time the third molars are erupted i inform the patient that you have to take a informed decision because we know that there is a continuous flux which goes on so some amount of movement will be there but when you are giving a bonded retainer you have to always inform the patient the side effects of that that is the decalcification accumulation of blood if they don't report so in my clinic i monitor the patient till they are 25 every once in a year and if i feel they are not maintaining it i recommend that you go ahead with the removal be happy with a little bit of implications of teeth oh thank you so much sir there are very positive comments dr prakash says super work uh dr vimla sony says it was a very informative and uh it's commendable the way these smiles have been designed thank you very much yeah there are dr pinata has asked while correcting the alignment what special care do we take to maintain the occlusal scheme if the class 1 molars are there and class 1 canines are there then only you need to maintain otherwise if the patient is to start with a class two or a class three you have to in fact correct after alignment so when you are doing the alignment uh there is going to be some special moment which is going to happen so after the alignment is done whatever is the sagittal relation based on that you have to either correct with some class two characters or class three settling elastics okay uh so just one thing our doctor chetna who had asked that how much time do we keep the fixed retainers unfortunately she lost the connection so she was just requesting if you could yeah sure fix retainers as i said in some special cases for example midline dysthema because of either a high freedom or a peckship lateral incisor or a missing lateral incisor then midline diastema with tongue thrust habit we keep it lifelong we recommend the patient to go in for lifelong bonded retainers and other cases i keep it till the age of 25 for all the patient at the age of 25 i tell them that you take an informed decision whether you want to keep it or you want to remove it but i monitor them once in a year and if there is ill effect on the periodontium or the tooth decalcification if they are not maintaining the hygiene i explain that to them and still they don't do it then i report okay one more thing to add to that uh the holly's plate the retainer plate has to be kept lifelong for all cleft patients where we have done expansion so for all cleft patients the maxillary hollis retailer for one year is 24 hour wear and after one year i recommend them to use it night time lifelong because we have developed the arch but because of palatal scarring there is a relapse which happens right oh yes dr chaitna says thank you so much sir my pleasure thank you there's so one more question by dr siddhisha are aligners giving competition to orthodontics uh very difficult question to answer i think i compete with myself i see to it that i'm better than yesterday is myself so when i take out my treated cases which are treated 20 years back i curse myself how bad clinician i was now today if i that those kids come to me i will treat them more better so it is i think that every clinician should compete with himself and try to make a better delivery system in your thing appliances will come and go fixed appliances are doing by many people so you know if it's a good orthodontist and a good clinical hand i don't think there should be any problem yes rightly said ultimately the doctor skills matters how you use the airplanes and when do you use it absolutely very true so dr pinak has one more question that occlusal schemes are in group function are canine guided do we consider that at time of diagnosis and do we maintain uh no no i i i didn't get the question uh uh occlusal skin schemes okay okay okay got it uh see uh in the beginning of the treatment whatever is the situation uh you should always go in for the canine guided if your canines are healthy if the canines are not healthy or if canine is not in place of canine like for example i showed some cases where canine is in place of lateral incisor in that case it has to go for group function if the canine has a periodontal problem or a morphological issue that if the cusp tip or anything is upgraded then you go for group function but at the end of the treatment if the canines are healthy it should be always tried to be given as a canine okay all right so dr sanjari vijayan asked how is the pontic fixed see the pontic is fixed in such a way that we take the tooth from the denture set to that we apply some conditioner you can either bond it with the help of the bonding adhesive or you can fix it with the regular cyanoacrylate okay and the bracket and that bracket is ligated to the wire so it rides onto the wire and when the wire goes in it automatically goes in place okay all right so dr ibrahim is asking he would like to know more about the s6 retainer yeah a6 retainer are good only problem is a6 retainer should not be given in cases where you have developed the arch transversely because s6 retainers don't maintain the transverse width of the connected arch in that case go for a holley's retainer a6 retainers in all other cases is good all our cases where we have done intrusion i mean i didn't have sufficient time but sometime i will come back and show you cases where orthognathic surgery is advised and we have done orthodontic treatment with the help of the temporary anchorage devices where we have included in cases where leapfrog when osteotomy was required so all my intrusion cases uh we always give essex retainer because it has got an occlusal byte platform but i will recommend that you should go for a6 in the upper arch and hollies in the lower arch because if you go for a6 in both the arches then as there is a disocclusion because of the occlusal interferences sometimes the settling of the occlusion goes away so i whenever i have to go for six i go for upper a6 and lower uh removable rated the acrylic plate okay that was great i hope dr ibrahim uh sir has answered your question so there are many positive comments dr sanjay is saying thank you sir for a super lecture dr darshan is saying excellent lectures are as always and yes i agree with all of them so excellent lecture especially with the photographs the lecture felt like a theoretical uh boost as well as a practical because just hearing about the theoretical it doesn't give much idea as much as when you see the photograph so so excellent uh i would like to thank you on behalf of all the audience as well as on behalf of netflix and like you said we are looking forward to have you next time as well for the orthognathic treatments thank you so much thank you very much wish you all a very happy new year in advance all of you please stay safe and let's pray that our world comes out of this pandemic very quickly thank you very much

BEING ATTENDED BY

Dr. Murtuza Zozwala & 538 others

SPEAKERS

dr. Jayesh Rahalkar

Dr. Jayesh Rahalkar

Professor, Dr D.Y.Patil Dental College, Pune

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dr. Roma Kumar

Dr. Roma Kumar

Senior Consultant, Max Super Specialty Hospital Gurgaon & Institute of Child Health at Sir Ganga Ram Hospital, New Delhi

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dr. Jayesh Rahalkar

Dr. Jayesh Rahalkar

Professor, Dr D.Y.Patil Dental College, Pune

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dr. Roma Kumar

Dr. Roma Kumar

Senior Consultant, Max Super Specialty Hospit...

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