Speaker 1: 1:11

All right. So welcome to Airway Answers, expanding your breadth of knowledge, and we have Dr Mariana Evans here. I'm so excited to have you on this show today. Dr Evans, I'll read your bio and I'm sure everybody already knows who you are.

Speaker 1: 1:27

Dr Evans received her DMD in specialty training at the University of Pennsylvania. To serve her patients better, she joined the University of Pennsylvania Sleep Surgery Department as adjunct professor. She is the founder of OrthoPerio Institute, an interdisciplinary study club with extensive emphasis on prevention of oral and systemic diseases. She recently developed 4D morphotropic orthodontics, an innovative jaw expansion protocol with the focus on airway and periodontal health. Dr Evans divides her time between her busy practice teaching and conducting research on the relationship between oral and systemic health, and I gathered your bio from an upcoming course that you're having, which I'd love to hear a little bit about that course, and today one of our focuses is going to be on expansion for the under six-year-old population, which is extremely, extremely important. So thank you so much for being here, dr Evans. So could you talk a little bit about the 4D morphotropic orthodontics and then the upcoming course that you're having, that is, I see it's April 12th through the 13th and it's called Innovations in Early Orthodontic Treatment. Revisiting Treating Children Younger than the Age of Six.

Speaker 2: 2:54

So thank you so much for your invitation to be part of this discussion and I think talking about expansion for young children is really a very important step in facial development and facial assessment that we should all take do, but it has been very minimally researched and the research in this area is very limited because for a hundred years we were looking on how to align the teeth, how to make them stable and how to make them stable and how to treat crowding. We didn't look at the jaw development from a very young age in terms of doing skeletal development for patients with airway issues, and we completely, completely underestimated the value of early treatment for periodontal reasons. All the research that we have, for example, in periodontology, shows that children in the primary dentition have much wider band of attached keratinized tissue around primary teeth as compared to children around permanent teeth, and we never asked the question why there is a big jump in deficiency in the gum tissue from primary to the permanent dentition. Well, it turns out now that we have CBCT imaging to evaluate some of these skeletal problems, because I believe, based on my experience as a periodontist and an orthodontist, that gingiva, just like alignment of the teeth if the teeth are crooked, it's just a symptom of a bigger problem. So the same thing goes with gingiva If a patient doesn't have enough gingiva, it's just a symptom of a bigger problem. So the same thing goes with gingiva. If patient doesn't have enough gingiva, it's a symptom. It's not a disease. It's a symptom of a much bigger problem.

Speaker 2: 5:05

And after looking at so many children, so many adults that have deficient jaws, I see a strong correlation between soft tissue or gum or periodontal deficiency and the poor skeletal jaw development type of characteristics in these patients. So my course was developed over the past 12 years when I realized that we cannot use conventional tools to evaluate whether little children need to be expanded and even if we agree that little children need to have GI expansion earlier, how much to expand them. We have very limited research in this area and I started to document a lot of cases and utilizing different tools to measure who needs expansion, who doesn't need expansion, and once I determined that they need expansion, how much to expand them. So I came up with the 4D morphotropic orthodontics, which is focusing mainly on jaw development and once the jaw is fully developed skeletally, with the orthopedic tools that we use, we position teeth axially in the bone and then we engage those teeth in axial loading so they can be loaded axially rather than off axis, as teeth are loaded when the jaw doesn't grow correctly. And once they receive that axial loading, what we notice actually very interesting we notice that the bone around teeth gets stronger and is more visible on the x-ray, which every single study shows that there is less bone around the teeth after conventional orthodontic treatment with braces, for example.

Speaker 2: 7:04

So we actually see the opposite that patients, when we do this treatment in the right time, will have a thicker bone around the teeth when you combine skeletal development together with loading the teeth that are positioned axially in the bone.

Speaker 2: 7:20

So it's very exciting and I opened this course primarily for the orthodontists and pediatric dentists because I think that the majority of these patients that will be treated under age six will be treated by a pediatric dentist because they have the experience, they have the education to manage these children in the chair, utilizing all the new technologies that we have today and being able, in the best way, to deliver very high quality treatment for these young children. And I hope that orthodontists also will do it younger rather than waiting until age 8 or 7 or after age 6. And maybe even some general dentists that like to see children and do already some very basic early treatment for children also will engage and do a service for these young patients and help their jaws grow in a younger age. So by the time they have permanent teeth erupting in the oral cavity, those teeth will have space and they will not erupt in compromising the periodontal tissues around them.

Speaker 1: 8:38

That's amazing. I never really thought about that. So that's the thing that traditional orthodontic techniques because maybe they're aligning teeth without attending to the skeletal components, so we're kind of teeth are compensated, is that's what's causing the periodontal components? So we're kind of calm, teeth are compensated, is that's what's causing the periodontal issues is because there's not enough bone supporting the teeth when they're not lined up straight in the bone. Is that correct?

Speaker 2: 9:08

So the interesting thing about development of the teeth is the transition. So a very big component of my course will be focusing on the transition of the patient, of a child, from the primary to the permanent dentition. There is very little attention that was given to this transition in the research, in pediatric dentistry, orthodontic research, when it comes to eruption of the teeth. So the way when you look at the size of the permanent teeth and the size of the primary teeth there is a very dramatic difference in size. So the nature designed of a JAS so you don't transition from the primary dentition to the permanent dentition all at once. There are special sequence of eruption that is pre-programmed to happen in each child and a certain number of teeth will erupt at a certain age and then there will be a little kind of resting period and then more permanent teeth erupt. So that resting period is accommodating for the growth of the jaw and the growth of the follicle of the tooth that is happening inside the jaw to allow those teeth to erupt safely in the oral cavity and safely in my eyes means that the tooth erupts with enough gingiva and enough bones supporting it from all around it. What is happening to children today? We know that the faces of children are not growing properly. They are not growing forward enough, they are not growing wide enough, so there is a traffic jam inside the bone Before those teeth are up. It's like everything is all the follicles of the permanent teeth that push back and in inside the bone and they start changing their orientation inside the bone before they wrap and in some children, when the jaws are so small, those follicles will basically perforate the bone, make a hole in the bone like moth eating the bone on the outside, on the inside of the jaw, that by the time those teeth erupt into the oral cavity they will not only not have enough gingiva but they will not have even enough bone around them by the time they reach the position in oral cavity. So that all can be diagnosed early. And, believe it or not, I am a strong believer that you don't need all this fancy 3D imaging to diagnose it. There is a more simple way to diagnose the problem in a younger age, using very simple clinical indicators. But the CBCT is excellent to use for educational purposes. So we have some CBCTs already of children that have very severe deficiency. We can learn a lot from those CBCTs. So CBCTs show that if you have severe crowding, that the buccal and lingual bone around the tooth that is so, so important because that's the bone that is going to support the root of the tooth for the rest of the patient's life is already eaten away before the tooth even makes it into the oral cavity because of the crown bone. So if you can address it in a younger age you can avoid all of these complications. So this is what I would like to teach orthodontists and especially pediatric dentists and also periodontists that are developing all these fancy bone and soft tissue grafting techniques to regenerate the bone that is not even there by the time the tooth erupts.

Speaker 2: 13:22

Because we are missing the window of treating in young kids it's not only the airway. The airway is a big component too. The airway in the younger child is more of a cause of the poor jaw development and then when jaw fails to grow right, it's a vicious cycle that kind of closes that it compounds on the compromised breathing through the nose. But so you have to break that vicious cycle as soon as possible. You have to optimize that nasal breathing, lip closure, tongue to the palate posture, and that has to happen in a young age. Even between age four and six is to some extent some of these problems already laid to fix. We are not fixing, preventing anything. We are fixing the problem that already is there. But when it comes to eruption of the teeth and development of the follicles of the teeth and preventing gum issues, periodontal problems later in life, I think under age six you can still make a difference. Okay.

Speaker 1: 14:36

Rachel, I think under age six you can still make a difference. Okay, do you think this is something most periodontists aren't even aware of?

Speaker 2: 15:01

Well, the periodontists are trained to has everything to do with already existing periodontal disease. So you are not preventing periodontal disease unless you are a restorative or general dentist when you see the patients regularly every six months before they develop the disease. Every six months before they develop the disease, the periodontist sees patients that already lost the teeth, are about to lose their teeth because of bone loss and gum infection and periodontal attachment loss, or they are there to treat those periodontal defects when they already need treatment.

Speaker 1: 15:33

Yeah, I wonder if periodontists would even be okay. Yeah, the one.

Speaker 2: 15:40

It's too late to prevent the recession from progressing when recession is already there or when the patient doesn't have any attached periodontal tissue. We have to do it earlier. The question becomes how early? What is the right age? Well, the minimum that we can do is actually treat a child in the primary diagnose crowding diagnose, small jaw problem in a younger age. Make room for those follicles of the permanent teeth to allow those teeth to erupt with sufficient gingiva and bone around them.

Speaker 2: 16:18

And that is totally possible and I will show cases in my course that will reflect what we are talking about that you can improve periodontal support with proper, healthy improving and facilitating healthy eruption of the permanent teeth.

Speaker 1: 16:37

And it makes perfect sense Like that's so clear, it's so logical.

Speaker 2: 16:45

How did we not think about it 50 years ago?

Speaker 1: 16:49

Exactly it's same with like the whole airway and our jaws are shrinking. It's just so logical, it makes perfect sense. Our teeth are crowded, our jaws are not large enough to house our teeth and we're choking on our tongues, like. All of this is so logical, but it's so surprising that it's really taken so long to get to where we are and there are many people who still doubt or are treating with traditional methods or not working to prevent right. I have a question about you said CBCT might not be needed to diagnose these issues. There are some clinical indicators. Are you able to talk about what some of those clinical indicators might be?

Speaker 2: 17:31

Well, one of the very simple clinical indicators is looking at the face of a child from the side. If the upper and lower jaw are recessed and not ahead of the forehead, automatically that child doesn't have space for the teeth, because in order for the teeth to have space in the jaw, the jaw has to be certain size and certain distance to the rest of the cranial. And if that jaw is recessed I will show you case after case I have not seen a patient. In other words, I have not seen a patient, when I look at the face and the face is recessed, that had normal development of the face. Yeah, so this is like. In other words, like we as dentists are used to look in the mouth before looking at the face, this is thinking the opposite way. Let's look at the face first and estimate what is happening inside the mouth, if the face is growing this way or that way. And once you start looking for these things, you will be surprised, because there is. If the upper and lower jaw are too short and not growing forward enough, you will rarely.

Speaker 2: 19:01

I have not seen one patient that has no crowding if the jaws are recessed, they could be in a cross bite, they could still crowding doesn't mean that no, crowding is not equal to have spacing between the teeth, because the patient could have spacing between the teeth and still have crowding, not not enough room if the teeth are severely flat. So, for example, if the patient has low tongue posture, has huge obstructive tonsils and the only way for them to be able to breathe and to be able to function properly is to hold the tongue forward and on the lower jaw you may have spacing between the lower teeth, but those teeth will be flat. So you have to position them virtually on the basal bone axially in order to diagnose if you have enough room for them or not. So just because clinically you see, spacing doesn't mean somebody is not proud. That's a good point, because without teeth could be flat and flat teeth are not. This is not healthy either. It's not the normal physiologic position in the bone.

Speaker 1: 20:41

And a lot of the adult expansion techniques involve not just expanding the bone but then uprighting the teeth because due to all that compensation right. So decompensating the teeth in order to provide you can't go back and like fix the periodontal problems, but it'll help prevent future periodontal problems when the teeth are decompensated.

Speaker 2: 21:03

Yes, so the teeth are decompensated yes, so we are talking decompensate when you do the expansion at any age and obviously we cannot do like appliance type of expansion in infants. You can theoretically but it's not going to be a common practice, let's say, Because in infants we have to do more breastfeeding, more physiologic type of feeding, to grow that upper jaw. But if you talk about expansion with appliances, if you determine that the patient needs jaw expansion and you are going to use teeth or implants for that expansion, you already determined that the jaw is deficient. So if those patients already have any kind of teeth in the mouth, those teeth grew to compensate for that deficiency. So sometimes the upper teeth will be flat, buckly, and the lower teeth will be lingually, excessively lingually inclined. Sometimes the upper teeth will be upright but in a cross bite and crowded and the bottom teeth will be pushed out of the basal bone because the tongue is resting on the back of the mandible. Pushing those teeth out of the bone is resting on the back of the mandible, pushing those teeth out of the bone. So any type of expansion therapy, orthopedic expansion, where we widen the jaw, has to involve the compensation of the teeth. And the compensation of the teeth means if you expand the bone enough, you will be putting the teeth back into the axial position to function axially in the bone.

Speaker 2: 22:48

There is now a very huge, I would say, problem in the orthodontic profession because we don't have good consensus on how much to expand the patient, on how much to expand the patient. You could talk to 10 different orthodontists and they may have a different way to measure how much they expand and what they consider sufficient expansion. That shouldn't be like that. Right, we should have more consensus. There is a reason why it's happening, but I don't want to discuss and create any friction here. But how much to expand right now is an open question, because if you don't use a CBCT to expand, which I think is a very common practice today practice today you may not see in adult patients in particular, and in adult patients I always use the CBCT by expense because we are dealing with a compromised situation.

Speaker 2: 23:57

Without CBCT it's very difficult to know where the bone is and where the tooth is in relationship to the bone, so that research is very clear. With CBCT we can more accurately diagnose how much to expand. But even if we use the CBCT to look at the teeth, we don't have a consensus. What do we use for measurement? Do we look at the teeth to measure how much to expand? What do we use for measurement? Do we look at the teeth to measure how much we've spent? If we look at the bone, how much we've spent? Which points or references we use to expand? There is no consensus. So 10 different orthodontists may expand one patient, different amounts. Right, that's a problem. This type of expansion should involve dental decompensation.

Speaker 1: 24:46

Okay, so does it seem like you should expand enough to where you can decompensate the teeth and line them up correctly? How do they come up with a consensus? What's the right amount to expand? Is that ever going to be a question answered? What's?

Speaker 2: 25:03

the right amount to expand. Is that ever going to be a question answered? So one of the problems that we have in imagining how much to expand is that traditionally we look at the back of the jaw. Is it narrow enough and needs expansion or not? At the level of the first mors. When you look at the average population, the majority of the patients have the problem in the front of the mouth, not always in the back. If it's in the back it's already a big problem, at least in my observation and experience. But if it's not in the back, you can miss it and not expand the patient. That really needs expansion for the front Today, the jaw.

Speaker 2: 25:49

If you are familiar with myofunctional therapy, the function of the tongue there is a variation how people rest their tongue. When the jaw is deficient, the tongue can expand the back of the maxilla and the mandible. If the tongue has a lot of strength in the back, it also depends on the attachment of the tongue to the base of the floor of the mouth and sometimes it's just the tip of the tongue that is not functional. Sometimes it is the whole tongue is just very lazy and like just laying and putting a lot of pressure on the lower jaw and sometimes the tongue actually is extremely strong, you know, and it's very strong, it's very difficult to manipulate and it will expand even in adult very common in patients with sleep ap. Maybe they have more restriction in the posterior portion of the tongue but that tongue will broaden the back of the mandible even in adults. But the front of the maxilla and the mandible is very narrow.

Speaker 2: 26:56

So luckily today we have the tools that we can differentiate expansion. We can say that this patient needs more parallel expansion from the front to the back of the jaw and that patient needs more expansion in the front and we can customize the appliance and the position of the screw for that particular patient based on their knee. Who needs more expansion in the front? We can expand them more in the front. More expansion in the front we can expand them more in the front. Well, like in the front, who needs more expansion in the back usually also need expansion in the front. So you can expand them more parallel or program your device for more parallel expansion. So we are practicing in our dream time where we have the technology. We just need to use it to the full expression.

Speaker 1: 27:48

Yes, well, I'd love to talk a lot about the under the six-year-old population, because that is so important that we get to these children early, because clearly we can prevent not only airway problems but periodontal problems and a whole array of other health issues. So how did you get interested in expanding children at such a young age? When did you realize this is so important? And what's the youngest age you expand on? What techniques? I want to hear it all. Tell me all about it, young ones so for me.

Speaker 2: 28:23

I have a brain and the eyes of the periodontist. My hands are the hands of the orthodontist, but this part and this part is the periodontist, so I think my brain is set to think like a periodontist. So when I started my practice, which is now 13 years ago, I saw a lot of patients that were adults with periodontal issues like gum recessions, periodontal disease, fractured teeth that need implants, and was treating them for these periodontal problems that they had. And because we had this new practice, a lot of these parents started to bring their children for evaluation and then I had an opportunity to see a child and also know what is happening in the parent moms and that was extremely eye-opening and very helpful for me to be where I am today because I could see a little boy that looks just like his dad in the primary dentition before or like early mixed dentition, before they even developed the same problems.

Speaker 2: 29:42

But I saw the pattern, the trajectory of the jaw growth, the pattern of facial development, similar symptoms in terms of breathing, airway and periodontal issues. So you could tell that I don't know if it is like fully genetic. I think there is a very big environmental influence here, but I was always curious about. What can we do about preventing things, especially in periodontal field? And it was very logical back then for me to assume that treating somebody younger and allowing the teeth to erupt into a healthy periodontal position in the mouth was better than treating children with lack of keratinized and attached gingiva once those teeth already wrapped, crowded.

Speaker 1: 30:45

Yeah, what techniques do you use for the young children for expansion under the age of six, and what's the youngest child you've ever expanded?

Speaker 2: 30:53

So the youngest child I ever expanded is two and a half, okay, and that is a child with sleep apnea. And that is a child with sleep apnea. And an average child that I would expand under age six would be age four. Not every four-year-old, not every five-year-old, not every three-year-old is ready for this treatment treatment. But we have a team and we kind of test the child step by step to see if they will be able to do it. Okay, not everyone needs to be treated that young, but I think we have to at least screen them that young, if not younger, and evaluate the medical history, evaluate the facial development pattern and try to at least at the minimum educate parents on what are potential risks and how we can treat them and avoid complications.

Speaker 2: 31:59

So I don't use any removable appliances in young children. I use everything customized. I use a lot of 3D printed type of devices. Now, with intraoral scanning, we don't have to take an impression on the child. We can just take a magic wand and do a digital impression. That is a big advancement in the field. That allows us to very accurately capture the oral anatomy of a child and fabricate a very, very precisely fitting expander. And I like to use baby teeth, I think again as a periodontist. There are many reasons to use a primary tooth for anchorage versus to use a permanent tooth for anchorage, a permanent tooth with immature periodontium, that's, a child between age six and eight. Traditionally, the orthodontists like to wait for the sexes or the first permanent molars to erupt to start expansion. That's wrong and I can even speak very loud.

Speaker 1: 33:12

That's one of my.

Speaker 2: 33:14

Yes, that is one of my questions for you and we'll get to that in a little bit, but I it's unacceptable because if you wait for the permanent mol molar to erupt and you put that orthopedic expander that puts a lot of force on that permanent tooth, you're compromising the tooth periodontally.

Speaker 2: 33:35

And what if, on top of that, the patient has severe clenching, parafunctional activity, poor sleep, if that patient has poor occlusion, you're putting that tooth with immature periodontal support in occlusal trauma. That's a recipe for problem. So I will use the permanent molars as anchorage, but in conjunction with primary teeth. And if you want to use a primary tooth for your expanders and the child is eight, you missed your train because the primary molar, especially E, which is the second primary molar, very strong anchor, by the time the child is eight, especially female patients, that tooth is already too weak to apply proper orthopedic forces to it. So there is so much happening in the face of a little child between age of two, when you have eruption of the primaries, to the age of 10, that every stage, every day, there is a change. You have to know and I think our education today is not focusing enough on that early development and transition from the primary to permanent addition. I'm going to do it because we have to finish, we need more of you.

Speaker 2: 35:07

I mean, I guess this is I'm excited how many pediatric dentists contacted me because I was told before the pediatric dentists are not interested in orthodontics. That's wrong. There is so much they can do and so many of them got so excited they contacted me and we have an amazing group already formed that are going to take the pediatric dentistry to the next level. So you're very excited.

Speaker 1: 35:35

I'm so happy, like it's so good to say this, because we get so many referrals for myofunctional therapy and the orthodontist is referring and we're happy because they're aware of oral soft tissue dysfunction. It's great they're referring. But we see these kids with extremely narrow palates, clear sleep, disorder, breathing and we ask, in our own perspective of myofunctional way, can you please expand to allow more tongue space? Right, because we don't want to tell them what to do. But I list all the signs of the sleep disorder breathing characteristics, you know paroxysm, snoring, mouth breathing. You know, I see the roof of the mouth is narrow. We would love for you to widen so we can allow more tongue space. And I have so many orthodontists who come back and say nope, the child's too young, we don't want to do any attachments on primary teeth, we want to wait until the adult molars are in. And then they have a reason and what is their rationale that they want to wait? And they say there's something wrong with putting attachments on the baby teeth. What is the thought or the false thought?

Speaker 2: 36:46

What is the thought or the false thought Conventionally? I think I don't have the answer for you because I think it's really there is no answer to your question. But there is a habit that we have in any type of specialty, that we develop a habit, a routine of doing things and then we transfer that habit to the next generation training, to the next generation orthodontist. So the orthodontist that is in training today is not even questioning, they are given the information what appliance to use. And the most common orthodontic appliance is called a hyrax. Are you familiar with the hyrax expander? So basically it's the expander where you have bands on the first molars with a screw in the middle and the wire connecting those bands.

Speaker 2: 37:45

So some orthodontists that are more kind of have engineering mind added the premolar bands to redistribute forces to more teeth than just two teeth in the mouth. So here you have the most common appliance using two teeth in the mouth with the screw. When you look at the literature it's the least effective because it expands very little the bone, especially in kids older than eight, and it tips the teeth a lot. And in the kids younger than eight we don't have much research to know what it does. But I guess, looking at some of these cases that I see for second opinion, it does the same, because under age eight you have immature molars and older than eight you have a little bit more mature bones. So you still put a lot of pressure on the single tooth on each side, even with MSE. I know you're familiar with MSE, right?

Speaker 2: 38:43

Everyone now knows about skeletal expansion for adults. The same with MSE. The design of the appliance includes just the bands on the sexes. In adult patient do you know that it tips the teeth before the bone splits? In adult patient those molars are going to be already tipped buckly because the wires connecting the screw to the molars are flexible. Luckily we have now 3D printed technology where the arms connecting the screw to the teeth are rigid and you have less taping, but only if you connect the teeth and splint the teeth in the device and not just put force on a single tooth on each side, or you can use more implants. So the reason why the orthodontists are doing it, waiting, is because it's a habit and it's from generation to generation taught that the hyrax has to be on the first permanent molars. So if you look at it on my kids, Go ahead.

Speaker 1: 39:50

I was just going to say that. So it sounds like it's an appliance issue, so maybe these orthodontists.

Speaker 2: 39:56

So the decision, so the way I explain it and this is my opinion it's not based on science. My opinion is that it's the decision that is being made when to start expansion is based on what appliance you use.

Speaker 1: 40:14

Yeah, that's what I was just saying.

Speaker 2: 40:16

And it's wrong. It should be patient-based. What is the best time to expand that particular patient and some patients, maybe it is better to wait until eight. Luckily, I tell my patients and I tell my parents that I have technology today. I have tools in my hands in my practice to expand a patient at any age. Even at age 75 is the oldest patient I have expanded in my practice, skeletally opening the sutures. But that is not the best age to expand a patient, right. The best time to expand the patient when you can diagnose this problem early and also to allow not just for the patient to breathe better but also for the teeth to grow in a healthier type of environment.

Speaker 1: 41:10

Yeah, and that's a really good point. So I think it's probably the client's driven. Yeah, that's a really good point. And now I get it. The orthodontist who might have this mindset is maybe a little narrow-minded thinking. We can use a hyrax and that's the only type of expander we use and it's. It's going to cause too much dental tipping and problems if it's um affixed to a primary tooth. So we need to wait till the adult tooth is in, but they're just focused on the appliance. Meanwhile you would expand a child younger because you have different types of appliances where you could do that.

Speaker 2: 41:46

Where you wouldn't be, you can design the appliance in so many different ways based on the patients. And even some children have some teeth that are weaker, like have weak enamel, so you can design the appliance to accommodate that patient's needs. So you can design the appliance to accommodate that patient's needs.

Speaker 1: 42:06

Yeah, well, it's interesting because this one recent case that we got was a six-year-old with a lot of sleep disorder, breathing issues, very narrow palate, and the orthodontist said that there's negative implications for expanding on children that young and she thinks it's absolutely crazy that people are trying to expand four-year-olds and said, fine, I agree, I will try to do an expansion on this six-year-old, only for a little bit, for one month, to open things up. That's all she would do. So that just happened recently, so I'm curious what's going to happen. But I don't know if that's a good thing or a bad thing, like maybe we open the orthodontist mind up or what. But what would you recommend?

Speaker 2: 42:50

you are raising from this is how much do you expand a four-year-old and this is a six-year-old? How much do you expand a six-year-old? How much do you expand a 12 year old? What are you using to measure? And the answer is not the same. You cannot use the same tools to measure how much to expand a 4 year old that you use to measure how much to expand a 12 year old, and that mindset has to. You have to reset your brain, because you are already programmed to think in the wrong way.

Speaker 2: 43:31

Not only we measure in the back when the patient needs to be measured, how much to expand in the front. So that's one mistake we can easily make. And another mistake is how am I going to expand a four-year-old? You cannot use the same tools that you use to expand an older kid if the child is only four. So you have to use other tools. And I agree you should not expand a four-year-old to a 12-year-old size.

Speaker 1: 44:02

Right. How do you know, like for the patients you treat? How do you know how much expansion they need? Is it going by symptoms and relief of symptoms, or is it a certain number?

Speaker 2: 44:23

thing, and only one thing, is the jaw deficiency. It makes the jaw a little bit longer and a little bit wider. Or, if you want to talk about permanent indentation, you basically make it the width and the length that it should be right. So if you have a four-year-old, there is a formula that you have to use. You can't expand a four-year-old to a 12-year-old. There is a formula that you have to use. You can't expand a four-year-old to a very old size, because there is a growth that is going to happen from the moment you finish expansion until the adulthood.

Speaker 1: 44:59

So you have to. Is it like the Bogue index? So you?

Speaker 2: 45:05

have to expand. So the problem of orthodontists' mind is like we don't want to expand them too early. One of the problems is because we are afraid what we will do to the nose that may cause nasal deformity. Valid point nasal deformity, violet form. So you need to know how to apply forces and how fast you are going to turn that expanded to make sure you minimize the nasal changes If those changes are unfavorable. But in some patients those changes may be favorable. So you have to look.

Speaker 2: 45:42

You cannot look at the upper jaw without looking at the nose, whenever you do any type of expansion, even in adults. So the nose is part of the upper jaw and you have to put it into equation. So on one end you have the nose, on the other end you have to decide what protocol of turning the expander and how much space you need for the teeth to do those turns to achieve that expansion. So in the orthodontist's mind they think that if the child is going to get expansion at age four and then they need more expansion later, then it's not worth expanding at age four. That's better to wait and just expand all at age eight or later. Right, yeah? And in the parents' eyes they may think oh, if I do this early expansion will I need more treatment later, or this is all that I need. Expansion will I need more treatment later, or this is all that I need. And we have to understand if we have a growing child that needs expansion at age four, that child probably is not growing right. So we can expand them a little bit at age four to help them, to give them a little jump and little push in growth. But unless they continue to grow well, they probably will need additional treatment.

Speaker 2: 47:10

So just because you are doing it h4, there are benefits of it, but it doesn't mean that that four-year-old treatment replaces additional treatment that that child may need later.

Speaker 2: 47:22

What you're actually doing, you are probably simulating the growth of the jaw in a more physiologic way where you don't do a big jump in expansion and increase the risk of root resorption, for example. Yeah, you do it gradually to simulate the way, to some extent, the way the face is growing, to allow that upper jaw to grow a little bit, support the teeth that are growing, support the base of the nose and then reassess and hopefully, with that myofunctional therapy that you can offer, after that expansion the patient will change the habits and will improve the posture and will continue to grow better at the minimum, if not fully normal, and will continue to grow better at the minimum if not fully normal. But I think there are going to be still a lot of patients that don't grow well. Even if you expand, it doesn't mean it relapsed, but it may mean that the growth is still not optimal and they need more help later on.

Speaker 1: 48:20

It looks like it froze it froze, I think you froze, I froze. Now we're back. Okay, good, good, good. So you said there's some patients who won't, even with maybe myofunctional therapy or good habits, they might still need some more expansion as they get a little bit older. And I think that's actually, and it's so important for parents to know that, because you can only expand a certain amount based on the age, the size of the face. You can't, you have to expand, like you're saying, take into account the nose.

Speaker 1: 48:57

And I think I also didn't realize that for my son who he had an alpha appliance when he was four, like almost five, had an alpha appliance when he was four, like almost five, and the molars got really tipped out. So when he was eight he couldn't do RPE. He got MSC, which was pretty young to do that, and the orthodontist said he might need more expansion when he's a little bit older. And I felt a little shocked, like what we're doing MSC. But he said there's only so much we can expand at every age, because the face is growing and you can't expand out of the face.

Speaker 1: 49:28

And it made me really think, wow, that's important for parents to know and that's not a bad thing, and I think Kevin Boyd explains it well too. It's like glasses your prescription might change as you get older. You don't deprive a child of glasses when they're young, because they're going to need different ones when they're older or something more. So that's really interesting. I'm wondering for these younger ages, like four or five, six year olds, how long is the actual expansion process? Is it a month, six months, like? How long is that going on for About six months, where they're actively turning?

Speaker 2: 50:08

month? Were they actively turning? No, they actively turned, probably like for about two months, and then you have to hold the expansion additional four months as you apply the lower teeth.

Speaker 1: 50:19

Okay, so what do you recommend? We respond to orthodontists who may say that they can't expand that young, even though we see signs and symptoms of jaw deficiency and sleep disorder breathing. What do we say to the orthodontists?

Speaker 2: 50:37

I think in the end of the day, it's going to be mom that is going to be making the decision what they want their child to expand at a younger age. And there is some European literature that shows very clearly that the primary teas are good anchors as well. And I think the answer you always have to back up with some kind of research and the answer is that primary teas can be used for anchorage. We already have literature utilizing traditional bands in the expanders. Now, with the 3D printed technology, it becomes even easier to use primary teeth and also you get less tipping because you have more rigid connection between the bands and the expanded screw and if the orthodontist's mind is so set on the hyrax and they're not thinking of other appliances, then it's probably not a good match.

Speaker 1: 51:37

Anyways, we're not going to convince them to like learn about a new appliance or different techniques, so, yeah, it's probably just talking to the parents.

Speaker 2: 51:45

This is another valid point that the need for orthodontic treatment today is so high and right now our profession is in a major transition where we are realizing that that we need to expand these services more to children. So now, for example, looking only at my practice alone today we have more adult patients seeking treatment and we also have more young patients seeking treatment, right? So somebody we don't have enough providers where the orthodontist we will have enough orthodontists treating both. The demand is going to be higher than the supply and it's going to be higher than the supply very soon. So the orthodontists today are probably overwhelmed treating adolescent patients, treating adult patients. They can only see so many patients a day and if you want and demand to expand their practice to younger children, sometimes you have to actually modify your practice to see those younger patients because those younger patients require more time, they require a little bit different setup than when we see adult patients.

Speaker 2: 53:05

It becomes challenging and the orthodontic practice that is busy, established, it's very quick, short appointments and it may be a big transition for already established practice. For pediatric dentists it may be different, especially new pediatric practice where you can focus more on prevention, more on the facial development, maybe a little bit less on restorative and I think that the little kids are going to be, or should be, even treated by pediatric dentists because they have the experience treating younger children. Now we have the technology that they can learn some very simple appliances that they can use in a very predictable way for those younger children. But if there is an airway indication or periodontal indication to treat younger, I think those patients probably will be treated by pediatric dentists.

Speaker 1: 54:09

That's an interesting point.

Speaker 2: 54:11

Think about a mind of a four-year-old or a three-year-old where they see they already are familiar with the pediatric practice that they go to every six months, maybe more than every six months, and now you are sending them to another provider that they haven't met before. That is a big fear for a lot of children of the unknown, and if they have a good, established experience with the pediatric dentist that they see for regular care, they will be better patients, their behavior will be more positive and they'll have much better experience getting the care by the primary care pediatric dentist than seeing somebody new. That's my observation.

Speaker 1: 54:57

That makes sense. And when you get a young pediatric patient, what makes you determine whether they need expansion? Is it based on specific measurements or based on symptoms that the patient presents with?

Speaker 2: 55:11

You have to entail both. So we look at the symptoms, existing symptoms of crowding, poor facial development and poor sleep and poor nasal congestion. They don't have to have sleep apnea, but if they can breathe through the nose that upper jaw is not growing properly. So medical history and the symptoms are very important and then, of course, clinical indicators If the face is not growing forward, if the upper jaw is too narrow, if they are crowded.

Speaker 1: 55:46

That's enough information for me to to justify treatment okay, and you said you use like measurements to know the measurements differ for each age of when the expansion is done. Is that based off of like the bogue index or is there a specific formula that you use?

Speaker 2: 56:04

yes, I, I use the specific formula and it's not necessarily very easy to use but not very difficult to use and it's part of the course for the pediatric dentist to learn. But I use to some extent development of the jaw and to some extent development of the teeth as the measurement, measuring indicator. Okay, okay.

Speaker 1: 56:29

And that's true in your case. So if someone takes your course, they'll be able to learn how to specifically measure at each age.

Speaker 2: 56:38

At each age. Yes, at each dental and chronologic age. Okay, dental and chronologic age, okay. So we are basically going back to some extent to the dental age. Dental age has nothing to do with expansion today, but we are going back a little bit to utilizing dental age and utilizing the size of the teeth to determine and customize expansion for each child.

Speaker 1: 57:09

And that makes sense to go off of the dental age and it's very customized per each patient. Where do they land it?

Speaker 2: 57:17

allows you to not overdo it. It's just as important to do it when you it's bad not to do it. And it's bad not to do it and it's also not good to overdo it.

Speaker 1: 57:30

Yeah everything in life.

Speaker 2: 57:32

Moderation, yeah, so I mean just try and I will share what I figured out in my practice utilizing CBCT what works and what didn't work for me. I realized early on as a periodontist that that expansion in the 10-year-old is too late. When I need to graft the lower incisors before they get braces. I miss the window. That's the problem. That's missed diagnosis in younger age. So I think I realized back then that you have to do something before those low incisors not even before the low incisors and then.

Speaker 2: 58:27

But I didn't have the right way to measure, so how do I measure? So it took me a long time to realize and I think it's working, so I'm very excited.

Speaker 1: 58:38

Okay, I'm non-orthodontist, I'm myofunctional therapist, speech therapist, but I want to know the secret. I want to take your course. So I know the numbers, the measurements, because it's so interesting. What about um? Do you have a protocol for tonsils? Um, whether you recommend tonsillectomy before expansion or vice versa.

Speaker 2: 58:58

Well, I am very orthodontist. I cannot recommend tonsillectomy. I can refer the patient to the ENT to decide on tonsillectomy. But I always tell the patients I look for the tonsils if they are obstructive or not clinically and also if I have a CBCT or the CBCT and we do a PSQ question to see the symptoms and of course look at the age because there is a shrinkage of some of these lymphoid tissue with age. So if the patient doesn't have symptoms, even if they have bagotonsils, you have to think twice to recommend removal.

Speaker 2: 59:41

And I think today ear, nose, throat specialists are very cautious on deciding doing this surgery on younger children. So I don't recommend on tonsillectomy prior or after expansion. I work in a team with ent and we decide together I I can recommend expansion and how much to expand at a certain age. But when it comes to the surgery, this is something between the patient and the ent to decide if they want to do it prior to expansion and after. I think there are indications for do it prior to expansion or after. I think there are indications for doing it prior to expansion and there are situations when you can wait and do it later. But I cannot give that recommendation.

Speaker 1: 1:00:29

Okay, yep, that makes sense and we know there are studies showing that expansion can reduce the size of tonsils and adenoids. So in certain cases you can try the expansion first or vice versa. It's all child dependent, right, patient dependent, given the situation, probably how narrow they are, how large the tonsils and adenoids are, it's all very specific.

Speaker 2: 1:00:51

They are in the AP, right From the front to the back, mm-hmm.

Speaker 1: 1:00:58

I have a few more questions, because I know we're almost at the hour mark, but I have a couple adult questions. So I know you do a lot of customized Marpys and I'm wondering do you do the Invisalign at the same time you're doing the expansion part of the Marpy, or do you wait until the expansion part's done and then use Invisalign to decompensate the teeth?

Speaker 2: 1:01:19

Yes, so I think some of the providers. Basically the answer to your question. We are limited now by our imagination. You can totally do both. Not every person is a candidate for doing Invisalign the same time as you do the expansion, but you can. There is a big population of patient that is coming with straight teeth but narrow jaw and I think those patients are the best candidates for aligners done in conjunction with expansion. And I have to decide, based on what exactly you are doing to the upper and lower teeth, if it's worse to put the patient through aligners and expansion the same time.

Speaker 2: 1:02:03

Sometimes you are not sure, like if it is also if it is a female or a male. If the female, it's like every female should split. If you do the right mechanics, the right appliance, the female patient should split without any corticotomy or piezoatom, 100%. So if you design the appliance right, then you can probably use aligners from the very beginning. You just have to program the split into the aligner. You just have to program the split into the aligner. But if you have the male patient and there is still a small chance that they may not split even with the best technology we have today, especially like the ones that have very thin bone that have compromised anatomy for the implant anchorage, then why would you order aligners if you don't know if they split?

Speaker 2: 1:03:00

So you have to use the logic.

Speaker 1: 1:03:04

The reason I ask is because I've had a handful of patients who have started Invisalign while they're doing the expansion part of their MARPI and they've had not good experiences. It's really painful and some have actually had to drop out of their orthodontic treatment because of that. My Invisalign started after the expansion was done and I was just wondering if there's a specific protocol or maybe negatives to using Invisalign while you're still expanding. It's caused, like a couple of the patients I've worked with, a lot of facial pain and a lot of symptoms where they couldn't tolerate both and I was like, why do they do it at the same time? I wasn't sure why.

Speaker 2: 1:03:42

In our practice. We have a very busy practice and I would say that my practice is based on very complicated cases and I like the result that I deliver is more important than the appliance is the most important and some cases I think I can give a better result with braces than with aligners. The problem with aligners is that it's very difficult If you need a lot of expansion, it's very difficult to apply the roots of those central incisors in diastema. You can totally use the expansion protocol that you almost don't open diastema anymore, like Dr Casey Lee is doing with his procedure, so you don't have to open diastema. In other words you won't have space as you're expanding very slowly. But you take a CBCT and the crowns are tipped measly and the roots are far apart. And because it takes such a long time, that new bone that fills that diastema space is very cortical and it's not going to be easy to bring those roots into the right position into the bone. So some patients may have the teeth that visually look more or less straight but they have this black triangle near the base of the papilla that they hate because the teeth are not fully upright. So that is a disadvantage of aligners, because you can't easily upright those teeth. In some patients it's going to be more difficult than others, especially in patients that have very triangular teeth. That's susceptible to the black space between the gum and the teeth.

Speaker 2: 1:05:29

But in general, I know that some of my colleagues are doing it at the same time and I think it probably is not a bad idea for younger patients that when the bone is sore and they can tolerate a little bit of pressure better. But in adults that have very flat teeth, barkley it may be too much pressure on the teeth as you are trying to expand and especially if it is an airway patient where they may feel some constriction. So I can see that some people have these symptoms. So that's why maybe it is better to finish your expansion and use the aligners, because today we can expand with a little bit slower protocol without opening the diastema more than half a millimeter. So a millimeter diastema, maybe a little bit of bonding will make some people that don't want a space between the teeth Okay. Aligners during expansion are not for everyone and even aligners after expansion should not be for everyone.

Speaker 1: 1:06:30

Yeah, and to be honest, I feel like I don't sleep as well with the aligners because I feel like it takes up so much space even though it's such a thin amount of acrylic. It increases a vertical dimension and I feel my lower jaw goes back almost like a night guard or something where the like the lower jaw needs to be affixed to the upper jaw and I really feel like I don't sleep as well and I might wake up with like I was clenching, trying to hold my lower jaw forward. So I can see, sometimes the aligners might not be the best option for patients.

Speaker 2: 1:07:04

It wasn't what I do of the teeth, and I think that the teeth are designed to function in propriocept, to utilize proprioception during function. So the teeth, when you touch tooth against the tooth is not the same as you touch plastic against plastic. If the patient doesn't have a long treatment plan, I think aligners are great, but if it is a case that needs 200 aligners, you have to think twice More than 400 aligners. You have to think twice More than quarter aligners. I always like to get the teeth settled with rubber bands and with braces after expansion so I can get a solid bite. I mean, aligners are amazing, they work, but I don't think they should be for everyone and you have to think twice when you want to use them on patients that need a lot of expansion and also patients who might be traveling to the orthodontist.

Speaker 1: 1:08:04

it's better, right, if they got their pack of aligners versus driving to get braces adjusted. You know who don't have the distance. Last couple of things how is your MARPI expansion going and can you tell us a little bit about that and why you decided to do marpy for yourself?

Speaker 2: 1:08:23

expansion was. The goal of my expansion was to address what my minimal maxillary deficiency that was compromising my bite and I had a little bit of narrow smile issue and also my nasal congestion. There was a time in my life before expansion and there is now my life after expansion. The life before expansion was that I had runny nose all the time. I could not travel or go anywhere without Kleenex in my bag because I had to blow my nose all the time. I never was tested for allergies. This was me from a young age and after expansion it all changed. I don't need to carry Kleenex on me anymore. So expansion helped my nasal breathing significantly. I was told before by ENT that I need septoplasty turbinate reduction and I was told by an orthodontist that I need a surgically assisted palatal expansion. So I'm glad I waited. My expansion journey started three years ago.

Speaker 2: 1:09:40

Right before COVID I had two MSEs. They didn't work. With one MSE I had like developed some pain and I didn't finish it completely. I maxed out the screw so I took it out. I couldn't take it and then the second MSE got me in the end three millimeters of expansion. So I was like one to two millimeters short of the goal that I wanted to achieve. I accepted it. But then I got busy after COVID removed my expander and I didn't put back the braces on the teeth. So anyway, I waited. Well, now I'm finishing my expansion joint. It was the custom market and who did Expansion in the fall. I'm very happy, but I'm just doing a little bit more to fine tune. I expanded, I split, with my first expander on day three and with my third expander I opened on day one. As soon as I turned, I felt like oh, how many screws do you have?

Speaker 1: 1:10:44

Do you have six? I have four. You have four towels, and who installed your Marpie?

Speaker 2: 1:10:52

My associate, dr Juliana Zoga. Okay, she installed my third one. One of my dear friends, dr Meryl Bowermash from New Jersey she's practicing right outside of New York, so she installed my first one. My friend and colleague, dr George Bandelak, the periodontist that we work with, installed my second one.

Speaker 1: 1:11:20

You're like everybody. Help me out here. Well, it's so great. You got to experience and that sounds amazing too how you felt that change with the runny nose and now your nose feels clear, and that's great.

Speaker 2: 1:11:33

Like I, do not travel and sleep in the hotel without being severely congested. I think it's something I have probably allergy to dust, yeah, yeah.

Speaker 1: 1:11:48

I remember when my before my suture even split, it felt like Afrin in the nose, like I felt so clear. I'm like that's weird, am I making this up Because it hadn't even split yet, but I felt that really way better nasal breathing. So I think we want to wrap up allowing you to talk about your course, but I know Renata also had a question. She was going to pop in. So whenever, renata, whenever you're ready to come in to ask your question, there she is Ta-da, yes, ta-da, okay. So I wanted you, dr Evans, just to talk about your course and could you also explain why it says 4D? What?

Speaker 2: 1:12:29

does a 4D stand for? The fourth dimension is the time. The fourth dimension is the age. Okay, the expansion that we are doing is a three-dimensional expansion, because we are changing the jaw in three planes. We are helping the jaw grow horizontally, grow forward, and we are controlling the vertical dimension. So that's three planes, and the fourth dimension is the age of the patient.

Speaker 1: 1:12:55

Okay, because at this age you have to think differently patient because at a different age you have to think differently. Okay, that's perfect, that's, that's great. I was like, what is this fourth dimension? I don't know about. Um, so do you want to just summarize, like, talk about where your course is, the dates and everything again, what's covered?

Speaker 2: 1:13:11

yes, so this is the course that we will be. This is the first course because a lot of people contacted us and I will do it again and they're going to be an online version in a few months, but it's going to be in my office so we can have a nice hands-on part on the appliances and make everyone comfortable going home and being able to use those appliances in their practices. So in my practice right outside of Philadelphia, in Glen Mills area, it's March, april 12th and 13th and there will be more dates that I will be posting soon.

Speaker 1: 1:13:52

Okay, so this one will be in person, there'll also be a virtual, and then you'll have more course dates as well. Oh great, that's wonderful. Well, this sounds extremely important and amazing, and I hope you've got a lot of people who register who are going to change the lives of children under the age of six, because that is the most important age group to get these issues treated and get them on a correct growth path. So I thank you so much for your time. I really appreciate it. I know you're so busy.