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Orthodontics for the mixed dentition is not well taught at Dental School – for which malocclusions should you intervene and by what age? Dr. Amanda Wilson will show you how to identify whether early or interceptive orthodontics is right for your young patients as part of their antero-posterior, vertical and transverse development.
The Protrusive Dental Pearl: Prevent misdiagnosing ectopic canines by palpating the permanent canine early (from age 10 onwards). Put your index fingers a little bit apical and a little bit distal to the lateral incisors and you should be able to feel a 5-10 millimeter bulge
Need to Read it? Check out the Full Episode Transcript below!
Highlights of this episode:
- 1:58 Prevent misdiagnosing ectopic canines
- 8:55 Difference between Interceptive and Phase one
- 16:15 Phase 1 Interceptive Treatment Guidelines
- 20:20 Arch Expander Guidelines
- 24:07 Crossbite Tendency
- 24:57 Rapid versus Slow Expansion
- 27:42 Guidelines using functional appliances
- 28:21 Invisalign Mandibular Advancement
- 31:10 Deep Bite Guidelines
- 34:08 Q: Percentage of patients that would undergo Phase 2
- 36:43 Patient(Parent) Communication
- 39:51 Retention Protocol
- 43:36 My Phase One Smile PDF
Get this My Phase One Step-By-Step PDF Checklist by Dr. Amanda to get started and help you diagnose malocclusions
Check out Straight Smile Solutions for more Orthodontic Consulting and StraightSmile Solutions Orthodontic Coach for GPs for Orthodontic Educational Videos
If you enjoyed this episode, you should also check out General Dentists Doing Orthodontics
Click below for full episode transcript:
Opening Snippet: If you have six millimeters, no vertical issues, no trans issues, no AP issues. Your child may not ever need braces. So that's incredible, right? So what we're aiming for? obviously, the part of the reason why kids have crowding it's actually a first world problem. Believe it or not, it's partially genetic, but it's also for the most part environmental.Jaz’s Introduction:
Welcome back Protruserati, I’m Jaz Gulati to your favorite dental podcast and today we’re covering INTERCEPTIVE ORTHODONTICS. Why this topic? Well, actually, I’ve been a super busy boy. And I’ve got so many episodes recorded, a whole range of awesome topics. And so nowadays, I’m pitching it to you guys, which one do you want next? And on the Facebook group, gosh, it was extremely tight. But you guys just about voted for interceptive orthodontics. And this episode, what it serves to do is to help you the discerning GDP to gain some clarity on what you’re looking for in our young patients. When you’re thinking, would this patient benefit from EARLY ORTHODONTICS or for INTERCEPTIVE ORTHODONTICS ie to intervene in their mixed dentition so that they can benefit and have straighter teeth or a better occlusion for their later years and teenage years. Now, it’s important to mention that this episode, it’s not been made with any countries or systems in mind, per se, ie what I mean is, for example, if you’re a dentist in the UK listening to this, you might be thinking, ‘Okay, this is great knowledge. But how can I implement that in the system where I work in the country that I’m in with the political system and the public funding that I’m in, etc?’ Well, that is irrelevant, because what I want to pass on to you from this episode is really good knowledge and fundamental orthodontic diagnoses. And then you can have a conversation with an orthodontist, or know when you should refer for a second opinion. That’s what this is about. So if you’re in the US, and you’re worried about insurance, and whatnot, it’s all about finding out all these issues. And really, I love the way that our guest Dr. Amanda Wilson breaks it down. If you really think about it, the main things we’re looking for are any errors in development or any problems malocclusions that affect the anterior posterior, the vertical and the transverse. If you just look at your growing patient, and those three planes, and you identify all the things that could be not normal, then you have a basis on which to know when you might consider a referral and when you might not. So this episode is going to open your mind to these things and you will see your growing patients differently from now on, I hope.
The Protrusive Dental Pearl:
The Protrusive Dental Pearl is very relevant to interceptive orthodontics. It’s all about impacted canines. Now, we know impacted canines can affect one to 3% on average 2% of all people, which is a lot of young people affected by this and what I would encourage you to do as my Pearl and this is stuff that we should already know but let me expand on it is to palpate for the adult canine for the permanent canine from age 10 onwards. So you put your index fingers, you try and find the upper laterals which have erupted by age eight, obviously, and then you go a little bit apical and little bit distort and you should be able to feel a bulge 5-10 millimeter bulge above those lateral incisors and distal to them, you should be able to feel that buccally and if you can, great write that in your notes. But if you can’t, descend warrants, some investigation. For example, an OPG and OPD radiograph is usually the first nine investigation. And this is all to help us to make sure that we don’t miss these cases of ectopic canines, which can go surgical and be more complicated in the future. So in terms of our diagnosis, as a general dentist, we all need to be hot and as part of our checklist. So my advice to you is make sure that your notes template for when you’re treating a young person, when you’re examining a young person, make sure your notes system has something that along the lines of canines palpated. And if so were they buccal or they’re palatal, for example, if they’re palatal and you’re really worried about an impaction, obviously, but you need to be able to systematically do that for every young patients from age 10. Are you palpating the canines? And if so, are you recording that in your notes? That’s a good way to stay out of trouble medical legally going forward because 2% of a large number is a lot of young people. So let’s not forget these really good practices of palpating for canines, so that we can better diagnose and intervene with potentially ectopic canines. I will join in the outro guys, but let’s join our guest Dr. Amanda Wilson, on the topic of interceptive orthodontics. This episode is eligible for CPD or a CE certificate by answering the questions of this episode. If you’ve got the app if you’ve got the app on iOS or Android, just answer the questions of this episode. And my team will email you the certificate if you’ve got the questions right, so that you get proof that you listen to this episode and you get a certificate that will count towards your educational quota. So what are you waiting for? Download the app on iOS or Android by searching for protrusive and as you’re already listening to the episodes, you might as well gain the CPD.
Main Episode:
Dr. Amanda Wilson. Welcome to Protrusive Dental Podcast. How are you?
Thank you so much. It’s an honor Jaz. I’ve been listening to your podcasts all weekend. I’m super psyched to meet some of your audience and I’m doing well. [Jaz]
Amazing. And you got to tell the people listening right now the Protruserati, the most beautiful place in the world that you are speaking from today. And how you ended up there because we had a little chat before there. So you’re obviously from Hawaii. Tell us more about that. [Amanda]
Sure. I think a lot of us go to dental school and I went to University of California, San Francisco for dental school. And I met, I was sitting next to a guy with a last name Huang and my last name is obviously Wilson. And that’s we sat alphabetically so it was me Long, Wang Yang, all in one row. And I ended up marrying him. So he brought me back to Hawaii. And it’s a really wonderful place to raise children. I have two teenagers now and very family oriented, very Asian population. I’m obviously not interesting on video, but I love it here so much. It’s Honolulu, Hawaii. It’s fabulous. If I had, if it wasn’t 9pm, it’s 8am in UK right now, but it’s 9pm here in Hawaii behind me. I have an incredible view of waterfalls and mountains. But I can’t show you but I did pick some flowers from our garden. [Jaz]
You’re making us all so, so jealous. Honestly, like, you know, I’ve got people in like places of the UK, like Stoke, and all these places, you know, driving in the miserable weather on the car right now listening to this, and they ‘Gosh, I wish I was in Hawaii right now.’ But that’s great. Thanks so much for making time for this. Amanda, just tell us a little bit about yourself. What is your mission statement? What is it that you do? Because I think what you do is very empowering. But I just want to share that with those listening today. [Amanda]
Absolutely. So we all have a different journey, right? And now all of us think we’re going to start we’re going to be dentists. And we’re going to have this practice until we retire. And that’s what I thought and that’s what my husband thought he was going to do. And I listened to a really great podcast about families. It’s a few podcasts back this weekend. And I really felt inspired by that. And it was a very similar story as what I went through. Since I married my classmate. And we both had practices. It got really tricky, especially when we had kids. Every time one was sick, it was like, oh, no, which is all the time right? When you I think you believe you, you said you have a three year old. [Jaz]
Big time, all the time. [Amanda]
Somebody has to be flexible. And we’d always be like pulling up the schedule. Oh, I have 10,000 production, I have 8000 production, whoever had less had to close their schedule, right? And it was often me so at one point we said you know what this is you know, not working. So let’s do something a little different. He said, ‘Why don’t you take a couple years off?’ And I had started kind of a side hustle, teaching first with him and then his friends how his general dentist, how to do orthodontics. Mostly aligners Invisalign, which a lot of people are doing now. And it started to grow from there. And so I went full time and I started a company called Straight Smile Solutions, six years ago, actually this week, incredible. And full time I help doctors with any ortho cases, not just Invisalign, aligners, phase one interceptive, braces, if it’s ortho airway, I help them. [Jaz]
And your orthodontic training. So, from speaking to lots of guests on the US, I know you do your undergrad. Well, this is traditionally what I’ve learned and then dentistry in the US is like a postgrad degree that you would do. And then for orthodontics, was that involved in terms of further training? [Amanda]
Another three years and another degree, and it’s incredibly expensive. I think you guys are very blessed. I’d say the average dentist gets out with a half million dollars US in loans close to me because I’m close to 800,000. So it’s such an expensive journey, I went to University of Connecticut for my orthodontic residency. And if you go straight, straight, straight, you finish at age 29. So it’s pretty, it’s pretty crazy. [Jaz]
And just because we talked a bit about families and stuff, and it’s great to extrapolate journey. So when you were in Connecticut, hope I said that correctly. And then where was your husband, does he relocate with you to your training or how does that work? [Amanda]
He went to Hawaii to start his practice. Yeah, he went back to Hawaii. So when we, you know, commute, it was a very long distance relationship for three years and part of the time we were married, but we made it through. So if anyone is listening to this podcast, doing something like that it is doable, where there’s a will there’s a way. [Jaz]
It’s a reality for young aspiring dentists who want to specialize and do further training, whether it’s a masters or speciality, that these things are going to happen whereby you’re going to have to be a time apart, kind of because of the training pathways will take you to different locations around the world. So just it’s nice to share people’s experiences in that. So today, we’re talking about what we call in the UK, interceptive orthodontics and what you have referred in our conversations as phase one, so just break that down. Is there a difference between interceptive and phase one? And just define those terms for us. [Amanda]
You know, I’ve always called a phase one interceptive. I use the term synonymously. So either one works for me. I think in the US it’s getting more popular. Unfortunately, our insurance only covers one phase of something you never get both covered. So you have to pick and choose, right? So it is still difficult for our doctors sometimes to convince as my families have not a problem, right? But for the average family, they are, it’s hard to explain the why behind phase one interceptive treatment. [Jaz]
So if in the US, the average family if they had that phase one orthodontics, interceptive orthodontics to improve their malocclusion at that young age. Therefore, later on in life, should they require phase two? And we can discuss later on in terms of what percentage would then benefit and end up having phase two, they would not be able to get that covered from the insurance. That’s how it works, right? [Amanda]
Unfortunately, yes, that is generally how it works. But I’m gonna get you guys so excited and so pumped about it because here’s the truth of the matter. First of all, if you are a primary care dentist, there’s no reason you can not do phase one interceptive treatment, it’s actually so easy. And I would work on a six to nine year old any day over a teenager and I personally have teenagers, six to nine year olds are so compliant, so lovely to work with, you know. As long as you get along with the parent, the kid is usually so excited. For those who have video, you might be able to see some of the fun things I have on my desk here, I have glow in the dark expanders, you can get decals and glitter in them, they just have so much fun. You can even have entirely removable appliances if you wanted to. And in the US just to add to it. In most states and all of our states are slightly different in terms of what you can do and what dentists can do, or what dental nurses can do, or dental assistants can do, hygienist can do. But in most states, everything can be done by the team, the dentist doesn’t have to do anything but the treatment plan and supervise obviously, you can’t just like you know, leave the building, you could be working on a crown prep or placing an implant and your team is just right next to you working on the Phase One patient. So even if you don’t like it, who cares? You’re only the brain behind it. And I know for my husband one of the reasons he wanted to learn a lot of ortho and not just invisalign. Well, twofold. Number one, he’s a little older than me a lot older than me. And actually, I was the youngest people in the class. And he was the oldest, second oldest. But in any case, he goes, ‘You know, I don’t want to be 70 years old still doing drill and fill, I want to do all specialty work, I want to learn how to do high quality specialty work so that I’m just using my brain, you know, I don’t have to use my back and my arms and my fingers.’ And he loves it, you know, so. But the cool thing about phase one, like I mentioned, first of all, like, your team can do it, you don’t have to do it, you just have to understand it because you’re the brains you make the treatment plan. But also very often when you do phase one treatment, if people aren’t familiar with what it is, phase one basically is defined and this is my definition as fixing malocclusion the bite. So we’re basically fixing things like transverse, so like narrow jaws, we’re widening jaws with expanders to be fixed or removable. If someone had like a small lower jaw, we’re going to grow that jaw. Lots of ways you can do that. And now with Invisalign MA, it’s a fantastic appliance, you can use invisalign first with MA that works really well. You can do if someone has a slightly lower, slightly bigger lower jaw than the upper jaw, most of the time that when it presents in phase one, it’s because they’re maxillary rretrognathic, it’s very easy to jump that bite with a little appliance with elastics. It’s super, super easy, all different ways you can do things. So transfers, AP, and vertical. It’s basically those are the three major things we’re going to fix, you know in terms of bite, the bites and open bites, habits, airway, and then lastly, just watching out for impacted canines. If you start to see those in the OPG, or the panoramic X ray, you can do some expansion, a little two by four or like a, phase one liner really, really, really easy. And get those kids out of trouble. And the added benefit and I can tell you just from personal experience, I started noticing the more phase one I did in my practice, the less phase two I had in my practice, or the less hard phase two. So it took something that was just a big mess. And you break it into two pieces and tackle the harder stuff when the kids are young, compliant and excited and willing to wear fun stuff like this. And then maybe, maybe not if worse comes the worst. Usually all you have is a super easy like go aligner treatment later. I mean, you rarely even need to do the full thing. And it’s definitely something when you could tackle both parts and both could be done by a GP. And that’s the cool part. Now I’m going to tell you, I might really upset a couple orthodontist if they’re listening and I don’t know how many orthodontist listen, but part of the reason I started teaching phase one and pivoting to really wanting to educate as many dentists as possible about phase one is I was at this ail American Association of orthodontics, which is our big orthodontic conference. And I was in this meeting room and I was listening to orthodontics and orthodontist for the most part has always been kind of an old boys network, you know, really single colored, single sex that I always felt a little bit excluded from the whole crew, but they were telling me you should never do phase one. Because if you do phase one, the general dentists will keep the phase two because it’s too easy. So they say when general dentists refer to phase one, and I’ve heard this more than once, I just say no, that they don’t need it, even though they do. Because that’s only a two to $3,000 treatment plan. And if they wait two years, I know it’s gonna get significantly worse. And now it’s a $6,000 treatment plan that they won’t take. And I’ve heard that- [Jaz]
That is shocking. [Amanda]
It literally blew my mind, because I don’t think like that, and I was so disgusted, to be honest. And you guys, I’m speaking just for myself, in this, maybe it’s only a few dentists. But you know, orthodontics has changed a lot in the last 20 years, especially with direct to consumer aligners, and invisalign, and everything. And it’s become much easier, and many, many more general dentists are doing it because it’s easier and it’s fun. So I mean, listen, us orthodontist, especially those of us who were in the previous generation, when I graduated, really invisalign had just started, it wasn’t really a thing. So we were still getting all these referrals, you know, it wasn’t a problem. But I mean, we’re watching our profession basically, change, you know, a lot. So we’re grabbing at straws trying to keep those patients but it just wasn’t something I could do. I can’t do that. I don’t feel right doing that. So I said, You know what, this isn’t right. How can I educate as many general dentists as possible? I don’t care if they don’t want to do it, not do it, I just want them to understand it. So that way they can, they can educate their patients and say ‘you need this because’, because too often as general dentists will just say to the patient, you need this because you’re seven, you should just go for a consult. If you say it like that the patients don’t and the parents aren’t like they’re busy, right? They don’t want to go unless there’s a reason they need to go. So you guys need to build explain the reason you know whether you take the case, or you refer the case, and then you need to find orthodontist if you’re not going to take the case, who will actually do the Phase One when it’s needed, because that is my biggest pet peeve. [Jaz]
I think it all starts Amanda with the diagnosis. I know you gave the subgroups where it’s affected. But let’s talk about, one from each scenario, perhaps. So you see a someone between six and nine, what are the kind of things we’re looking out for? So for example, you mentioned transverse, and you mentioned a narrow arch, how narrow does it need to be for you to then think, ‘Okay, this patient will benefit from expander.’ Do you need to be completely in like a full crossbite? Or do they need to be a crossbite tendency? What are the guidelines that you can look at to decide? And also what age is a cutoff point? And then also, just follow on from that you mentioned about communicating to the parent. Is it because it’s time sensitive and growth related? Is that the main message you want to send to the patient or to the parent? [Amanda]
Wow, you hit a bunch of amazing points. So, let me start backwards and go with that last point. So every patient, every child has three different ages, believe it or not. So you know, obviously their chronological age, I mean, my daughter, she’s 13 years, five months, okay, that’s her birthday. But we’ll go back, when she was eight, she only had a few permanent teeth in. So her dental age was much younger than her actual chronological age. They were girls in her class in third grade, who had all their permanent teeth in. There were boys are a class that had no permanent teeth. So we all have a dental age, we all have a chronological age. And then we all have a skeletal age. And this is the most critical part. And I know you have a three year old, I have teenagers, you’ve probably seen, probably have lots of cousins and nieces and nephews. Kids are maturing way faster than they ever were. No one really knows what it is. The milk is chicken. I don’t know what it is, you know, conspiracy theory. But I mean, it’s one generation before me, I mean, girls matured at 14-15, boys matured at 17. Now, you know, my generation, it was 13 and 16. And my daughter’s generation, it’s 10, for girls, on average. It’s crazy, crazy early. So there’s 10 year olds who may only have a few permanent teeth, but they’re skeletally done growing. And this really changes things because we really, really have to do phase one, while they’re skeletally still growing. And it’s a very sensitive topic. It’s less much less sensitive with boys, I have no problems bringing that up. But you really need to understand all those type of growth and how to treatment time. And too often in my practice, when I was practicing full time, I would get these teenagers coming especially these girls who were 12, 13, 14 and they were done, done, done growing. And they needed orthodontic treatment, and we weren’t able to utilize any of the fun stuff that I could do to grow things. You know, we just basically had a compromised outcome. It looks bad, Mom’s not happy, kids not happy. And I’m like, I’m so sorry, you should have come for phase one. And they’re like, ‘My dentists never told me.’ And that really, really bothered me. And then we had to take out bicuspids and I would love love, love for there to be a completely extraction free if at all possible. Generation of orthodontics. It’s slowly moving in that direction, but I’m so opposed to extractions, if we can avoid them. [Jaz]
I mean, the most common thing that I see is a narrow maxilla. And what I was taught was I deal ages between 8 and 10. And please, you know, let me know what you are using it but that’s what I was taught by one orthodontic consultant, but it can vary. And then it’s so important to get that you know, rapid and maximum expansion or any sort of expansion. You can talk about in a slow and rapid and when we might consider that. Once I referred these cases and it’s a shame because it just highlights some of the issues we have in the UK because of the funding more orthodontics. The fact that we have this National Health Service, which pretty much covers orthodontics, where there is a need. And most of the specialists, unfortunately, wi’ll wait, just like you mentioned earlier for a different reason, until all the permanent teeth erupted. And then they’ll just, you know, take out bicuspids. So this is a real issue in the UK. And I’m a big fan of the mantra of treat adults realistically and treat children idealistic. Children are not getting the ideal treatment. So tell us about what what age are we looking at in terms of either doing the treatment yourself phase one or referring for a narrow maxilla? And how narrow does it need to be? [Amanda]
Yeah, I need to answer your question about that narrow maxilla. So I’ll go ahead and use this as a demo for those of you who have visuals, but I’ll talk you guys through it. So there’s a lot of things I look at when I’m deciding whether or not we need to do arch expansion. And that is just so simple, you guys, if you don’t want to deal with bands, and spacers, that’s fine, you can do removable, we’ve got this really fun one like I had here, it’s got glitter, it actually glows in the dark. So if they lose it at night, you know, you can turn off the light and they will glow, but basically many things I’m looking at I’m just measuring the crowding, you know, first of all, obviously they might only have two to two in on top. But you can kind of visualize and see if you have crowding already on two to two there’s definitely crowding. And just to let you guys know, I will still answer the question but fun party trick for like, say a two, three or four year old? Let’s see if you know the answer to this how much spacing is ideal in your son per arch? What would you like to see? What would you want to see in all baby teeth. You know the answer? [Jaz]
Well, firstly, the way I’ve been taught is that I like to see some spacing, because it’s a predictor of less likely to get crowding in the future. If I see there’s no space or definitely if there’s any tendency to crowding that I know my child will be screwed, and more likely in the second condition because there will be crowding. So I don’t know the exact answer. But I do like to see spacing. And when I see my son’s teeth, I like the fact that he’s got some spacing in his lower anteriors. And between the canine and the first deciduous molar. I like that, but I don’t have a numerical answer. Please, please, enlighten us. [Amanda]
Six millimeters. [Jaz]
Six millimeters, wow. [Amanda]
Six millimeters, you should, if you have six millimeters, no vertical issues, no trans issues, no AP issues. Your child may not ever need braces. So that’s incredible. Right? So what’s we’re aiming for? Obviously, the part of the reason why kids have crowding is actually a first world problem, believe it or not, and it’s partially genetic. But it’s also for the most part environmental. It’s you know, we are eating were meant to exclusively breastfeed the age 2. Obviously not many people do that they’re feeding them baby foods and stuff like that. And then to go straight into eating hard root vegetables, meat off bones, very primitive, you know, Paleo diet. And obviously, most people aren’t doing that. Well, some people in California are, you know, when you’re not using your jaw and you’re eating soft foods and you’re feeding your child on a spoon, they’re not using their muscles of mastication, which doesn’t develop their bone structure correctly. And of course, also a lot of there’s tongue tie and tongue knot going up on the roof of the mouth and tongue position and habits, a lot of these things can affect the growth of the jaw not only transversely, like you talked about, but also you know, AP direction growing the lower jaw. So we talked about looking for evidence of crowding, we want to see, you know, spacing ideally is what we want to see in that kind of two to two stage when they were like that, I also like to look at the OPG or the X ray and see if there’s impacted canines or tipped canines. That’s a sign that I know we need it. I’d like to look at the anatomy of the palate and see if it’s vaulted. I don’t want to see a vaulted steep palate, I want to see a nice, you know, broad, shallow palate. And one of the fun party tricks I learned also is you can measure, it’s just one of the additional things I do. I measure from the esio-palatal cusp tip of the sixes, okay. From mesio-palatal cusp tip to medial Palom cusp tip of the sixes, and you want it to be at least 40 millimeters. Now of course, on a child with tiny little teeth, it might be a little bit less than a child with gigantic teeth is going to be a little bit bigger. So that’s a rough estimate. But if we’re seeing 37, 36, 35, 34,that’s a guess you definitely need expansion. We’re seeing 43, 44, probably no not needed. Of course, if the molars are rolled in, it’s a little bit different. But I mean, all you take into account all these different things and then you know, if I hit, you know, one, two or three of those indicators, we’re probably going to go ahead and benefit. I mean, obviously you’re looking at the crossbite in the back tooth, if you see a crossbite you know, that’s another reason. If I see any crossbite remember that- [Jaz]
What about if it’s a crossbite tendency? So instead of the lower molar buccal cusps being in the fossa of the upper, what if it’s like a tendency so that the way that occluding is not cusp to fossa is almost cusp to cus? But how much of a degree should we accept that, okay, this is going to be okay. And things will bear in or what’s the threshold? [Amanda]
So I probably look at all these other indicators I talked about. And if I hadn’t one of those other indicators, then I’d probably do it. If not, I feel pretty confident I could just get it with some braces, some wires or some aligners. But I mean, there’s also airway benefits. And we got the whole other thing there. You know, I’d like to do an airway screening, looking for evidence of snoring, mouth breathing, things like that. So that would be another indication that I might want to do it. So you can’t do anything wrong by expanding, you can always just expand a little. There will have to fall and expand. And to answer your question about rapid versus slow, I learned rapid in school. But when I started teaching my GPs, I switched to slow only because I’ve seen some very scary things with rapid expansion. One story, I had one patient that in California, I worked with a more lower middle class population in the valley, a lot of farm workers, lot of migrant workers that would pick strawberries and things. And sometimes the kids would disappear and go to Mexico or go to South America for a few months. So we had put a expander in a patient. And we told them, you know, do X amount of turns, I’ll see you in two weeks. Well, they disappeared, and we never, we couldn’t get a hold of them. Well, they kept turning, they kept turning, they kept turning. And basically this child had a full on scissor bite on both sides. I mean, like the whole mouth basically collapsed. And it was like, I mean, we ended up getting it back. But it was so scary, you know. [Jaz]
And a huge diastema as well, because that’s one things that maybe GPs I need to appreciate is when you do the maxillary expansion so rapidly, you’re expecting see a diastem, correct me if I’m wrong. [Amanda]
Correct. Correct. And that’s one of the benefits of slow is that you actually won’t see that because they’ll slowly start to fill in. And they don’t freak out as much. But you can totally do rapid. Obviously, that works better with fixed than removable. You can do slow to me, they both work exactly the same. Slow is a little less discomfort, a little less risk happens a little more gradually, you don’t get that really ugly, big gap. But it tends does take a little more time. But you know, I do have, I want to let your your listeners know that I made fun fact, especially during COVID, I made over 6,500 How To videos on basically every topic that’s out there for ortho and I tried to explain it as- [Jaz]
6500?! You’re the most productive woman on earth. [Amanda]
That is not how many I have there. And literally I’ve created playlists. So there’s a phase one playlist last I checked I had 166 videos. So there’s literally something on average, that type of appliance, basically. Only thing I don’t really get into is like jaw surgeries, because I don’t think GPs should be doing that. TADs, I don’t think GPS should be doing. And you know, that’s not the fun stuff. That’s the yucky stuff. So I try to make ortho clean and fun and blood less and shot less. But yeah, people are welcome to take a look at my YouTube channel, which is Straight Smile Solutions. It’s free and everything’s on it’s just like completely free orthodontic education. So the more I can get out there, I think the healthier bite kids are going to be. And that’s my ultimate goal. [Jaz]
It’s sounding like Netflix for orthodontics. So we’ll definitely be able to share that in the show notes. Because it sounds very, very comprehensive. That’s amazing. The other common scenario, which I think the UK dentists do get more of or get more done is, you know, the expansion issue can be tough. But the whole functional appliance I feel as though in the UK, we are more for thinking when it comes to the use of functional appliances. Where does that lie in terms of your preference for treatment? And what ages are we looking for with someone who’s got a large overjet to bring their mandible forward? So what kind of guidelines we’re looking for in that scenario? [Amanda]
Pretty much same age as I mean, I want to get started as early as possible, you’re also gonna get more compliance thoroughly as possible. So according to some of the literature, it says to wait till pubertal growth spurt, but I’ve had just as much luck doing it earlier, you know, at six, seven and eight. And now with invisalign with MA it’s makes it so easy actually have one of those liners here, just a little ramp that’s built on me- [Jaz]
Just to really break it down for those listening and watching for those who haven’t heard of it. So Invisalign MA stands for mandibular advancement. [Amanda]
Yes. [Jaz]
And so what age can you use Invisalign MA? [Amanda]
Well, in the US, we have it built in baked into two different systems. One is called Invisalign first, you can start that as young. They require you to have the sixes in and they require you to have for the most part two to two in at least six anterior teeth, I think is the rule. And then you have to have, you have to be in kind of that intermediate transition where you haven’t lost the back teeth yet because it needs retention. So you know, kind of in that six to eight incisors and six is in is when you can do Invisalign first and the left is not that on that. So to be honest, you can get the same outcome with just a twin block or a bionator which is a functional appliance like you reference and the lab fee on that is only going to be like $100 US as opposed to $1,200 US. So I’m all for that you know and then they can have fun and they can bling it out with colors and glitter. [Jaz]
Very good. And in terms of what do you do when you’re too late in terms of you see a child and they’ve missed the growth in terms of you know, the news you give their parents as you just have to wait to a phase, well what would have been phase two, but now it’s going to be their phase one. And essentially, they’re more likely to then need extractions. And that’s generally the the main theme of this conversation is that the benefits of phase one is that it may make a simpler treatment plan later on, and also one that can prevent extractions, right? [Amanda]
That is totally true. And I mean, I’m just going to tell you my own opinion, and there’s almost no research on this. But I do follow two of your really good bloggers or podcast hosts. One of them is John Mue, who’s in the UK. He’s pretty incredible. I know he’s a little controversial, but he’s fabulous. I think he’s fabulous. I’d love to meet him someday. The other one is Kevin O’Brien. He’s incredible at breaking down research. And I believe he has some blogs just on that topic. But I do know, there’s a lot of really anti-extraction people that are out there, and I’m definitely one of them. Listen, I’m telling you from my experience, and this is just my personal opinion from what I’ve seen. I feel like the orthodontic community is afraid to do research on this because we’re afraid to get the answer. But I definitely think there’s a correlation between extractions and OSA. I’ve seen it, I see it with my own eyes, my husband sees it with his own eyes. We believe that. So anything we can do, and not to mention, they look terrible, they look sunken in and they get older, you know, adult patients come in and cry that they had four bites taken out or two bites taken out. And they felt like they were never given a choice. They were never given an option. And they feel like it’s ruining their lives and their health. So if there’s anything I can do to stop that, in a new generation of kids, I want to do it. [Jaz]
Very good. And then that’s a very noble sort of mission. I think the more we educate ourselves, the better equipped we are to have those conversations with parents either treating it ourselves, getting the training that’s required, or referring it to someone local specialists have a good relationship with them. It’s a really important thing. So let’s just summarize some of these diagnoses that we can make as a GDP. So you mentioned about the crossbites so they’ll narrow maxilla, watch out for a narrow maxilla, watch out for the increased overjet, what about deep bites? Is that a role for phase one therapy for deep bites? And if so, what does that look like? [Amanda]
Definitely, definitely. And I have all my toys here. There’s a couple different ways you can fix it. And anytime you have a deep bite you need to find out is my deep bite due to over eruption of the incisors, be it the uppers or the lowers and you’ve been I mean, the ceph is the gold standard for this diagnosis. Obviously, I don’t want you guys to be afraid of cephalometric or lateral cephalometric x-rays are actually really really easy to understand. If you can get one and then I’d be glad to give any of your listeners a free handout, I’m trying to understand them. But in any case, things you can do just without taking that stuff because I know that, that’s a lot to do is just get the child a smile look at obviously you might see a deep bite and a deep bite obviously as when ideal for vertical is when the child bites down we want to see at least half of their lower incisors. You know the the upper incisors should not completely encompass the lower incisors. And definitely they shouldn’t be hitting up on the roof of their mouth and causing trauma. Real quick, fun story. Other people may have heard, I had strict teeth, but a deep bite that was the only malocclusion I had. And my parents, you know, really couldn’t afford treatment at the time. And no one ever told them I needed treatment because my teeth are straight. I just had a deep bite, right. So you know, I went on through high school and then later one of our dentists finally said, ‘She has a really deep bite, she’s causing trauma on the roof of her mouth.’ Well, my top front permanent teeth were all damaged from fremitus, I had no roots left, I had completely busted up those teeth and permanently I have literally have no roots on my front teeth. They’re just crowns. And they’re still there. I was told I was gonna lose them when I was 12. But I just can’t eat, I can’t bite into apples or corn on the cob or bagels. So it’s like terrible, right. But if I had been treated properly in phase one, I would not have what I have now, which is a really big life changing, you know, you have to really alter things in your life. So yeah, so you have to see if there’s, check the smile line. If you see a really gummy smile, you probably give me an absolute intrusion of the incisors, which isn’t hard, you can do some braces, you can do it with you know, just some aligners to push them up, there’s lots of things you can do. Or if sometimes it’s relative just having a very low jaw angle, we call that brachiocephalic. And you can do something called a fixed bite plate. Or it can even be baked into the aligners and it’s basically just a thick thing that they bite on. And again, you can make colors and glitter and glow in the dark. And it’s just you know, to bands, almost like a space maintainer. Lab makes it you just put it in and they wear it for about four to eight months, and it prompts the bite open in the back. So the back teeth can’t touch and you know, teeth always want to touch. So if they’re not touching, they’re gonna super erupt a little bit. And then that helps to open the bite in the back. And usually it’s a combination of both that you do, but it’s really not that hard. And it really does need to be fixed. And it’s much easier to fix in kids than in adults. [Jaz]
And what percentage of these patients that have phase one therapy go on to need or want because they’re two different things, I suppose need or want phase two. [Amanda]
So I usually end my phase one and that’s a great question. For me, everyone’s a little bit different, phase one is defined ended for me once the bite is fixed. And if we needed to throw some braces or do some, you know, express aligners on the front teeth to for either cosmetic reasons or for functional reasons, like if there were impacted canines, and we wanted to consolidate the space to give them more of a chance to erupt more, if we had anterior crossbite, then we would do some type of braces on that. Otherwise, it’s just fixing the bite. So I’m done with phase one, when two to two are straight, you know, if needed, and the bite is fixed. So we have, you know, perfect bite, no overjet, no, negative overjet, no vertical issues, no open bite, no deep bite, and no transverse issues. So we’re gonna hit it all in all planes of space. So if you do phase one properly, and you’ve done all that, and you know, we basically waiting for the 16 more teeth to come in, right? We’re waiting for threes, fours, fives, three fours, fives and all four quadrants and sevens, not going to count eight, because they’re not that important. Which is 16 more teeth. So usually, if you give the teeth room to come in, and you get rid of all the vertical issues and transverse issues, usually they come in pretty darn straight, you know, can always I mean, with my two kids, I did phase one on both of them. My older son, he didn’t need phase two at all literally, he looks like he had braces, never had any braces, never had any aligners. I think upper left two is rotated like three degrees, like I can see it with my eyes, you know, he goes, ‘Mom, no one sees but you.’ But I mean, let’s just do some invisaligneExpress. Let me make it perfect. You know, the girls are gonna like it. He’s not interested, too busy. So, but I just did phase one. And if you you people think, ‘Oh, well, maybe he didn’t need it, dude.’ He had 100% deep bite and five millimeters overjet, he needed it. So, you know, we took care of it at a young age, and he’s good. Whereas my daughter, you know, couldn’t control it, she ended up with an impacted canine still. But I kind of knew that, that might happen. It was really bad when I took the OPG at age eight. So we did have to do ligation and exposure and phase two, which she’s not too thrilled about. But, you know, it would have been so much worse if we hadn’t done phase one. So at least we didn’t have to do two. So, you know, trying to be positive. But you know, that’s worst case scenario, what happened to her best case scenario? What happened to him? And you know, he can’t predict but all you can do is have the odds more in your favor. [Jaz]
What do you tell the parents? So like did you give them a percentage chance? I think impacted canines can be quite tricky. But when it comes to, you know, deep bites, crowding, large overjet. What do you say to parents in terms of because they might ask, okay, if I have phase one, now, I may be paying a lot more in the future, if my child needs a phase two. So how do you pitch it to the parents? [Amanda]
Yeah, I mean, well, we tell them that we’re taking something that’s very long and hard. That’s about two years, which, you know, your traditional comprehension is comprehensive treatment is when the child is really, really busy. I mean, 13, 14, 15, 16 year olds are busy, busy, busy and busier than ever, they’re doing sports, they have their studies, then they don’t want to wear things. It’s an awkward time. It’s a terrible time to have braces. I mean, we all went through it. And it was, I did later. Finally, later in high school, when I got my braces, it’s a rite of passage, but it doesn’t have to be why. I mean, I look at my daughter with Invisalign now and she’s gorgeous, to be honest. It’s a 13 year old, and then she looks at the picture of me when I was 13. And she’s like, ‘Ew, she was so awkward.’ But why not take away that, you know, and let them be more have more self confidence. And, you know, and plus, it’s less busy for the parents. They’re already so busy anyways, why have to go to the dentist every month? It’s a hassle. But yeah, to answer your question, I can’t promise all I can do is promise you that it’s gonna be easier and shorter. That’s all I can promise you. And occasionally, it’s not needed. It is an air quotes. Because I mean, like I said, my son still has a rotated number upper left two. Well, is it needed? No, not at all. It’s completely cosmetic. So, certain percentage, definitely, we’d have more of an idea after Phase One was finished. But I mean, think about transverses. If you correct it, it doesn’t relapse a vertical if you correct it, it doesn’t relapse. AP, if you correct it, the only thing that could possibly get worse and overjet will get worse, but a negative overjet could get worse. So if you were class three, you can have a late jaw growth. So that is one thing I can’t control growth. I mean, you might get that in a boy, if they were class three, it’s possible. But hey, if I can stop you from having job surgery, you know, like 50,000-100,000 US dollars, you know, no one wants to put their kid to surgery. So I think I feel pretty confident you will have to do this jaw surgery most likely. [Jaz]
Well, before I share with you a sad story. Actually, I’m just completely off script. I just thought of something I want to show you get your opinion very interesting. While I’m finding the photos, essentially, I’m gonna show you a photo of an eight year old child that I referred to a specialist because I thought this kid definitely needs intervention phase one ASAP, and what happened and I said, ‘Mom, look, I really think there’s an issue here. I think it’d be wonderful. You can get some expansion here. And then the orthodontist had a completely different opinion. And the orthodontist belittled me as a lowly GDP and said that, ‘You know I’m a specialist, he don’t know what hes’ talking about. We’re going to wait until this kid is 13, 14, and then we’ll do it.’ Now I’ll show you this photos and maybe you’ll think, ‘You know what Jaz, maybe he had a point.’ And you know, I’d love to get your opinion. But while I’m finding this photo, I’m gonna switch gears and while I’m finding this photo, I just want answer a very good question that I think will help the GDPs listening is that, once you finish phase one, what kind of retention protocols are we looking for that young patient? So what kind of retention will they be having? Is it always gonna be a holy? Because the acrylic allows you to maintain that expansion? Or can Essex style retainers work well to prevent relapse of expansion? I’d love to hear that while I find the photos. [Amanda]
Sure, sure, sure, I’ll be glad to talk about while you look for your photo. So, think really depends on what you did. So after I expand, I do transverse expansion, I leave that expander in for a good three to six months, so it doesn’t relapse. So I’m not worried about that. Same thing I said overjet correction doesn’t relapse. So the only thing that you really have to retain would be if you decided to retain like two to two alignment. If you did end up doing some braces or aligners, that’s a good idea to retain that. I do want to, well, mostly one of two different things. One would be a bonded retainer that you can just slap on, it’s not going to be on forever, it’s only gonna be on for a few years, it doesn’t have to be pretty and you probably don’t even have to send it out. Just use like, you know, braided wire or one of those flat braided wires and put a couple of drops of composite on and it’s really easy to floss technique. But if you don’t like to do that kind of stuff. You can also order it from any orthodontic lab and it usually comes in a jig or a matrix and then you just drop it on, you know, etch prime bond, drop it in so easy. You can do that. Or you can with the essix appliance, obviously you can’t do a regular essix because the teeth we’ve got like we said we’ve got 12 to 16 more teeth coming in, right. So that’s not going to fit because you can’t, really have to remake it. But you can make something called a Theroux. And a theroux is a modified essix where they basically scoop out some of the areas so that they can still come in so you can look it up T-H-E-R-O-U-X, I think. Tricky to make in house but there’s plenty of labs that will make them but now you can do that. Some people also do like some of these myofunctional functional trainers they use these for retention. They work pretty well too because I mean if they’re usually already straight they usually don’t relapse that much so but yeah. That’s pretty obviously you can do Nance, you can do lingual arch on the lower just to maintain molars if you want to work on that. But for the most part, it’s not usually a huge- [Jaz]
And compliance is good compliance usually with these kids, do you see much relapse? Yeah. [Amanda]
No, no. I mean, these kids that are, you know, 6 to 10 they want to be there. They’re, they’re excited to be there. They’re stoked to be there. I mean, with a few exceptions, you know, it really is the parent, that I picked the parent department with, if I have a good parent that’s excited to be there and a kid that psyched to be there. And, you know, it’s all in how you talk. It’s not like, ‘Oh no, you need braces.’ It’s like, ‘You’re gonna get braces what color you’re gonna get? Or you know, we’re gonna do an expander and we’re gonna do removal one, want to see my color chart? You want to see, you can put your favorite team on there and decals, like so excited.’ So, another fun story. When I was in third grade, I wanted a retainer so badly that I actually made one out of candies, toffee candies, hard toffee candies, we call nine liters and paperclips. And I wore it to school and I said did such a good job that the teacher mentioned to my mom at conference. ‘Oh wow, Amanda doing such a good job with her retainer.’ And then mom’s like, ‘Huh, she didn’t have a retainer.’ So that, that was the sign that I was probably meant to be an orthodontist, but I never got one. [Jaz]
Definitely. [Amanda]
I wanted one. [Jaz]
It was your it was your calling? [Amanda]
It was. That was the coolest kids were the ones that had head gears and retainers. Very cool. [Jaz]
Excellent. [Amanda]
Do you want me to tell your readers about, what little gift we have for them? [Jaz]
Yes. If you tell them about the handout, the purpose of the handout and how it’s going to help them to get these diagnoses and points as a checklist. Because I’m a huge fan of checklists, please tell them, I will to link it in the show notes. And I when our intro and outro are given a URL to go to, so they can get that PDF downloaded. [Amanda]
Great. Yes. And I’m gonna give everyone who’s listening, a copy of a form called, that I created called ‘My Phase One Smile.’ And I’m actually holding it up right now. It’s a two pager, but it’s actually an interactive PDF. So you can, it’s going to ask you questions and you’re going to check them and points are going to be assigned and you know, different questions about malocclusion and habits, overjet. And you know, you’ll need like a little either a boley gauge or a perio of probe to do the measurements because obviously my eyeballs can measure things very quickly without a gauge, but you’re going to need that. But that’s pretty much all you need. And you will need an OPG or pano x-ray, because there are some questions about canine impactions and angles and things like that, but it’s really not that hard. And it’s going to spit out a score for you somewhere between 0 and 80. If the lower the score, if they’re less than 20 points, they probably don’t need phase one treatment. I recommend that you keep them on six month eval. If they’re 20 to 40 points, it’s strongly recommended that either you do it in house or you refer and find an orthodontist to do it. And if it’s more than 40 points, it’s an emergency. So it’s really, really bad. And the reason why I love it because it actually gives, quantifies and qualifies, and gives us actual score. And it’s something tangible that can be either taken to the orthodontist, you know, now, the orthodontist can’t say anything if you refer because they obviously see that the patient’s, the parents know what the issues are. Or- [Jaz]
I wish I had that when I refer that patient, I’m gonna find the photos for if I wish I had that. [Amanda]
And we could even fill this out for your patient, if we wanted to, and give them a score, that would probably be the best thing. Well, you may not have the OPG. So we probably won’t be able to do it. But well- [Jaz]
I do. I found the OPG actually. [Amanda]
Let’s do it. Okay, [Jaz]
I will show you that as well. [Amanda]
I’m trying to deal with my eyeballs the best I can. It’s easier when the patient is in the chair, because then you can actually measure them. But yeah, it’ll spit out a score. And I feel like sometimes also, you know, the mom comes in, but the dad doesn’t then the dad says, ‘Well, do they really need it?’ And the mom’s like, ‘I forgot what the orthodontist said.’ So now they have this handout, and they can come home and literally shut look, they got this score, that’s a bad score that we got to do it, you know. So it took me years to develop this. But it’s basically I mean, as you’re one of the more things when you do, the more you understand it, but initially, it’s like, ‘Oh, my goodness, there’s so many things I have to look at, what did I forget anything?’ This way, you just go step by step. And you’ll make sure you hit all the main points, you know, and you’ll feel very confident with your Phase One screening, and it’s so easy, literally, you’re done. A nurse can do it, your front desk can do it. It’s really, really easy. So anyone in your team, I want your whole team to be screening every kiddo in the practice, you know, so we’re not missing anyone. [Jaz]
Amazing. Okay, so I’m gonna share my screen. Okay. I mean, look at this. [Amanda]
Let’s do it. Let’s walk through, it’s gonna take me five minutes to go through this. Is that okay? If we go through this? [Jaz]
Yeah, of course, of course, of course. And we can go through it. And I know mom’s really cool. And she will give consent for it retrospectively, and we won’t publish it. Obviously, if she doesn’t. But, have a look at this. I’ve only got these two photos that was different patient these two photos, and then I’ve got the OPG as well. So let me know what you want to see. [Amanda]
We’ll just estimate but you probably remember stuff. So I might, I’m gonna ask you some questions, but let me know when we’re ready to go. [Jaz]
Sure. [Amanda]
All right, guys. So we’re gonna go over when a doctor Jaz’s patients that he mentioned. And we’re actually going to run through this my phase one smile index, I’m going to take you through point by point and we’re going to give this patient a score. Now normally, when you do this, it’s an interactive PDF. So it’s going to calculate the score for you. I’m gonna print out so I’m gonna make sure my math is good at 10 o’clock at night. Okay, so first of all, how old is your patient? [Jaz]
At this point, he was eight and a half. [Amanda]
Okay, good to know. There’s no points for that. But just the questions, so have an idea of what to expect. Okay. So the first question is, is either the child or the parent embarrassed about their teeth, the psychosocial part? [Jaz]
I think the mom was very forward thinking saying that, ‘I don’t want my child to have the same issues that I have on my teeth.’ And then the child also was interested as well. [Amanda]
Okay, great. So that’s two points. Is the child having trouble closing his lips over his teeth? Or are there any oral habits that you know of like thumb sucking, paci sucking anything like that? [Jaz]
No. [Amanda]
That’s a zero. If the child is an all primary dentition please answer this question. Otherwise, skip this question. Okay. If the childhood mixed dentition, in which we are pleased to answer this question. Does the child have crowding present? I would say yes, definitely. [Jaz]
Yes. [Amanda]
Definitely on permanent teeth. So that’s two. Okay. Is there a presence of a constricted maxilla and that’s where we’re gonna go to your maxillary arch picture that I saw real quick. I mean, obviously, I’m sure there’s but yes, that’s definitely a constricted maxilla. And we talked about the, the trick from six to six, although it’s pretty funny because on this construction, it’s a V-shaped maxilla. Sometimes you have U-shaped constricted as V-shaped constricted, so the molars might measure it 40 millimeters. It’s possible, but it’s clearly constricted and vaulted 100%, especially towards the front. So yes, I would call that restricted maxilla. So that’s going to get two points. Is there overjet? There is not overjet, but we have negative overjet, which gets points. But the other question is, is there open by sorry, is there overbite and that would be no, it’s almost edge to edge. So that’s a zero. Is there anterior crossbite or negative overjet? The answer is yes. And so we go from the furthest most deflected one, which should be upper left two, and it says how many millimeters of negative overjet? So if you had to estimate from, you know the cusp tip of lower left two. Incisal edge of lower left two to the facial aspect of upper left to what do you think the distance is in millimeters? [Jaz]
I’m gonna say three. [Amanda]
It’s exactly what I was gonna say. Okay, good. All right, first page. We are already at seven. Okay. All right. Let’s go ahead and put up that OPG. [Jaz]
Yeah, sure. Let’s see. [Amanda]
Perfect. Okay, this one’s gonna be a little tricky because I usually use a protractor to do this one, ruler, but basically we’re talking about the, if there’s any angled canines, which there clearly are. I definitely would say upper right three is angled. And they have you kind of bisect it and run a line parallel to the occlusal plane, it’s all explained. And they, we talked about how tip does that. So I’m going to put this at about maybe 60 degree angle, between 60 and 40. So we’re going to go ahead and give the six points because there is an angled one. Oh, and you have to do it for both sides and add them. So that would be the right the left one is just a tiny bit angled. So we’re going to give that one point. So that’s seven points right there. Okay. So we’re already up to 14. So we’re getting there. And then there’s a couple more. This one, we’re gonna look at the tip, the cusp tip of both threes, and by the way, yeah, so we’re just doing uppers. But the cusp tip of both threes and is it crossing over the two’s at all? And actually, we’re not on the right side and the left a little bit. So we’re gonna go ahead and give this four. So we’re at 20. Now, I think, right? And then do you think that either of these canines, especially the right one possibly could be palatally placed or buccally placed? Because it’s definitely one or the other? Because it’s taped? [Jaz]
Yeah. So I will, I can just check my notes, probably. But I’m ganno say- [Amanda]
Like ligation and exposure? Chain and exposure later or no? [Jaz]
No, no, he’s too young at the moment, but we extracted, I extracted his deciduous canine as per the orthodontist advice in terms of to allow a better path for the eruption of the permanent canine. [Amanda]
Okay, so that’s questionable, so we probably won’t get it. But at the any case, we’re a little over 20 points, which basically says consider orthodontic referral. And I probably didn’t give justice to the severity of that crossbite in the back, but it definitely would say consider orthodontic referral. So yes, you fell in the, let’s do it. And if and if that was indeed if you’d taken a CBCT. And you noticed it was slightly paddle that would give it five more points. [Jaz]
Okay. Hey, guys, if you want download that document, the Straight Smile Solutions, My Phase One Smile Index, then either go to link protrusive.co.uk/phaseone, that’s P-H-A-S-E and the number one, so phase one all one word. Or if you’re on the protrusive premium, and you’ve got a membership on the app, so iOS or Android, you can download it in your infographics section straightaway. Once again, that’s protrusive.co.uk/phaseone, or via the protrusive app on iOS, or Android, this is the same PDF that we were talking about in the episode. And it’s really useful to go through with your growing patient. So that’s either for slash phase one, or from the iOS or Android app, just such protrusive on the App Store or iOS store. [Jaz]
Fine. [Amanda]
So you did the right thing. [Jaz]
Yeah, but I mean, in your experience, and whatnot, and what you teach seeing a child like this, do not feel that there’ll be some benefit to doing some expansion? [Amanda]
100% And then we didn’t even we don’t even have the whole airway thing factored in here. You know, I probably would have said recommended doing us a Stevie are asleep for him. And I have kids, one of everyone for Papi. I’m glad to give it to you just screening all different things about snoring and how they breathe. And certainly there was- [Jaz]
So he is a mouth breather that can tell you that right now he is mouth breather. [Amanda]
Boom. And that’s a 100% do not pass go collect $200. Yes, you get started if you have any airway issues, or a mouth breathing, because it’s gonna make the face grow long, you know, and we didn’t even get into the whole face thing or anything like that. So obviously, there’s a couple of things I noticed here that concern me. This is a boy you said, right? [Jaz]
Yes. And I think he’s about nine and a half, I think. Yeah. Okay. So [Amanda]
Yeah. Okay. So- [Jaz]
He was just slightly delayed. [Amanda]
It’s a boy so less urgent for me and unless I started to see him developing a beard or something like that. And he’s six foot tall. You know, I’m not as worried about the skeletal issue on a girl I’d be flipping, but boy, I’m not as worried about that. So yes, in theory, you could wait till age 12 because it will still be fixable at age 12. But the airway is something that’s critical, 2 years of not having an ideal airway and growing in the wrong direction is gonna get worse. Also, I’m worried about the ones you know, the front teeth, that you know, they basically almost one on top of another, you know, negative overjet and you’re gonna have wear. They’re probably going to chip him. This kid is active, this kid’s gonna go bike riding or you know, put ride a skateboard he’s gonna totally chip it, you know, upper ones I know it’s gonna happen. [Jaz]
Yeah, so he has already and it hasn’t happened already. We’ve restored with composite, the upper centrals, so that’s happened already. [Amanda]
Yeah. So we got that, you know, and like I said, you could theoretically fix it when he’s 12. And he hit it right before he grew. But you know, we’ve got the wear that’s gonna get worse. We have the growth that is going to get worse so and then that canine if we don’t do something now the chance of it being impacted is exponentially higher. And you know, taking up the seats is great. But that’s still not giving that canine enough space to come down. It’s not going to come down unless expand. [Jaz]
No, I was only doing what the official advice from the orthodontist came to be. But yeah, I was a little bit disheartened that the orthodontist had zero interest. And this is purely in my opinion, just the way that UK orthodontics is set up in terms of funding and preference. And I’m happy to be shut down on that from any UK orthodontist listening, but I don’t feel that this, clinically, if you put money and funding aside clinically, I think there was a need for treatment. So the mother was upset, I was upset that this wouldn’t be able to be done. And they are now considering going the private route to get done rather than relying on the National Health Service, which rejected this case, basically. So having that kind of having the kind of a checklist like you presented, it’s great that we went through it can be really, really helpful. And I think in hindsight, if I had a checklist like that, to give to the orthodontist, so that they can see my working out, they probably wouldn’t have been as flippant as they were towards me, in terms of how the referral came to be [Amanda]
They would’ve said you have 20 something points, you need to have and like I said that for me, airway is always a yes. So you know, should be another score. But that’s so hard to quantify. But what you told me it’s definitely a yes. So what ended up happening then? So are they still looking, they’re still looking for- [Jaz]
Yes. So it’s still a patient, I still do provide his routine care, I extracted the canine and a deciduous molar as per the orthodontist advice. And so now, the next step is okay, ‘Mum, do you want to take next door to the private orthodontist? Or do you want to wait until age 12? Plus when all the teeth through to have some treatment then?’ So that’s kind of where he’s at the moment? [Amanda]
Yeah, but most likely, he’s going to need canine exposure surgery, possible pre-molars out, there’s a lot of things just going to be so much more painful and complicated if they wait. [Jaz]
I agree. I agree now. So Amanda, thanks so much for spending some time with us to guide us through these things. These things are very scary for GDPs. You know, when you’re looking at treating children, it can be outside the comfort zone for a lot of GDPs. But I think listening today, the most important thing we got from today was just knowing which diagnoses would benefit from phase one, and being able to diagnose and be aware and have that conversation. Now, some dentists may feel that they can, ‘Hey, I know maybe I can help my patients out.’ And that’s where I can get further training. I know you do lots of training and stuff. So I’ll put the link so they can reach out to you make sure you download, the download, which I’ll put the link source so you can actually get that PDF. So next time you’re referring, if you’re referring or treating. So whether you’re justifying to yourself, ‘Hey, am I right in thinking that this patient may benefit from interceptive orthodontics and you can go through a checklist?’ But even if you’re referring for your peace of mind, it’s good to show the working out to the orthodontist, you’re referring to potentially, to show them your thought process and how you follow something logical in terms of diagnoses. So I think that handout will have incredible value for those listening and watching. Please tell us some other channels that we can reach out to you Amanda? [Amanda]
Sure, no problem. My website is straightsmilesolutions.com. So Straight Smile Solutions, plural, and you can Google it, it’ll pop up. And on my channel, I also have that access or that link to that 6500 ortho educational videos that are totally free and might occasionally see a Google pop up ad. Basically pays for my Starbucks occasionally, but that’s about it. But um, there’s just I, my goal, like I told you guys is to help to make kids happier and healthier and have to pull out less teeth, you know, and prevent surgery. So if I can give away information, then I think I’ve done a good thing in life. So you guys, it’s out there. It’s free. Enjoy it. [Jaz]
Amazing. Thank you so much, Amanda, it’s been it’s been great to have you as a really passionate guest, and then someone who’s empowering to dentists, who’s going to help us treat children at the right time to get better care, and better growth, better airways, and less need hopefully, for phase two and extraction. So thanks so much. [Amanda]
You got it. Aloha guys.
Jaz’s Outro:
Well, there we have it guys. That was Dr. Amanda Warson. She’s so energetic and enthusiastic about the development of these young people, and how with the relevant phase one, you could really help these patients avoid a phase two or less complicated phase two. Now, wherever you are in the world, remember that the system that you’re in, it can be difficult to implement these things and also depends on medical legally, where you stand in being able to implement phase one therapy to have the right training and mentorship behind you. But I think we’d all appreciate that all the things that Dr. Amanda Wilson talked about. These are things that we should be looking out for in growing children. And it makes sense when we’re looking at the development of facial and occlusal development of our young growing patients that we look out for these things and refer when appropriate. So have you found that episode useful, and I join you same time, same place, next week.