国際学会から最新情報

　　　　　　14時 - 21時の診療　　“女性の成人矯正”専門　　新宿駅近

　学会講演の要約ではなく、Dr.井上が興味を持った部分だけをピックアップしています。Dr,井上の勘違いもありますから、原著を確認してください。

Accerelated orthodontics　(スピード矯正 )　
Airway　(気道)　
Aligner　(アライナー)　
Alveolar bone　(歯槽骨)　
Ankylosis　(アンキローシス)　
Apical periodontitis　(根尖病巣)　
Archform　(歯列弓の形態)　
Asymmetry　(非対称)　
Autotransplantation　(歯の自家移植)　
Botox　(ボトックス)　
Bruxism　(歯ぎしり)　
Children, Orthodntics for children　(小児矯正)　
Deepbite　（過蓋咬合）
Emergency　（緊急事態）
Extraction　（抜歯と非抜歯）
Genetics　（遺伝）
Gingival recessions　(歯肉退縮)　
Gummy smile　（ガミー・スマイル）
Herbst appliance　（ハーブスト装置）
Impacted teeth　(埋伏歯)　
Management　(マネージメント)　
Medication　（薬の影響）　
Missing tooth　（欠損歯）　
Molar distalization　（大臼歯の遠心移動）　
Myofunctional therapy (MFT)　（口腔筋機能療法）　
Non-extraction treatment　(非抜歯治療)　
OSAS(obstructive sleep apnea syndrome)　（睡眠時無呼吸症候群）　
Occlusion　(咬合)　
Open bite　(開咬)　
Palatal expansion, MARPE　(上顎側方拡大)　
Periodontitis　(歯周病)　
Retention & Relapse　（保定と再発）
Risk Management　（リスク・マネジメント）
Root resorption　(歯根吸収)　
Smile　（スマイル）　
Surgery first　（サージェリー・ファースト）　
Surgical orthodontics （外科矯正）　
TADs （TAD、スクリュー、矯正インプラント）　
TMD　（顎関節症）
Tooth movement　（歯の移動）
Transverse discrepancy 　(側方の不調和)　
Trauma　(外傷)　
Whitespot　(ホワイトスポット)　
Wisdom teeth　(親知らず、第三大臼歯)　
Miscellaneous　（その他）　

☆以下はヨーロッパ矯正学会 (EOS June 2024) のレクチャー

Do we need to sandblast or just pumice the enamel surface before our lower retainers? A single-operator 2-arm 18-month 88-patient randomized controlled trial. (Estelle Phonchareun. EOS 2024)

Orthodontics and periodontrogy: two disciplines, one goal. James Deschner. EOS 2024

Long-term impact of orthodontic treatment on gingival recession in adults with compromized anterior teeth: a retropspective study. Ghazal Hasanzadah. EOS 2024

Study on the impact of maxillary and mandibular anterior crowding on periodontal health in middle-aged and older adults. (Junichi Watahiki, EOS 2024)

Discussion
1. In Adult patients, anterior crowding in the Lower, specifically crowding of over 4mm, may pose a risk for gingival recession.
2. In the maxilla, anterior crowding wasn't a high risk of gingival recession.
3. PD, CAL, and BOP have no significant correlation with crowding. However further research is necessaryu due the small sample size.

Why
Probably Due to Anatomical Difference Maxillary Anterior Phenotype is Signigicantly Thicker than Mandible. (Am J Orthod Dentofacial Orthop.2018 Sep;154(3):356-364)

Conclusion
Recently, the risk of adult orthodontic gingival recession has been known. Especially the lower anterior is high risk for gingival recession. This study suggests that over 4mm lower anterior crowding may strongly significantly induce a risk for gingival recession.

Take-Home Message
Orthodontic treatment at a young age may contribute to preventing gingival recession. The 4mm Lower anterior Crowding May Be threshod for orthodontic extraction.

Timing of soft tissue augmentation in orthodontic patients, Before or after treatment? (Dimitris Kloukos, EOS 2024)

Second molar eruption disturbances in borderline-extraction orthodontic cases, comparing extraction vs. non-extraction treatment outcomes. Kelly Mitchell, EOS 2024

Orthodontics, upper airways and sleep apnea: Linking anatomy, diagnosis and management with 3D technology. (Alexandra Papadopoulou, EOS 2024)

OSA
Male: 49%, Female: 30% in 40-65 years old (Arnardottlr 2016, Iceland)
Male: 24%, Female: 9% in 30-60 years old (Young 1993, USA)
Male: 26%, Female 28% in 30-70 years old (Duran 2001, Spain)
Male: 19,7%, Female 7.4% in 30-60 years old (sharma 2006, India)

Risk Management in Orthodontics (Dr,Athanastios E.Athanasiou, EOS 2024)

1. ROOT RESORPTION, Exteral Apical Root Resorption (EARR)

・it is probably an inevitable consequence of tx
・Typically amounts to 1-2mm during tx
・Affects almost all teeth
・Has no cliicalconsequences

Severe Generalized Resorption
・We do not know why it occures, but it is rare
・It happens in the absence of orthodontic tx but also in treated patients
・Perhaps it is related to some type of auto-immune respose
・If it happens to our patients, almot surely it is not the fault of the orthodontist

Severe Localized Resorption
・Loss of more than 1/4 of the root length of some teeth, usually maxillary incisors
・Is observed in 2-3% of orthodotnic patients
・It is related to orthodontic tx
・One identifiable cause is movement of the root apices against the lingual cortical plate

HISTORY
・Hereditary factors (outcome of any orthodontic tx received by parents, siblings, other relatives)
・Systemic factors (diabetes, allergic reactions, other systemic diseases)
・Local factores (nail biting, other oral habits)
・Trauma (earlier trauma, type and follow-up)
＊Tooth agenesis is a feature of many genetic syndromes. There is a high risk of EARR during othodontic tx in patients with multiple aplasia (4 or more teeth), in particular in teeth with an abnormal root form and lengthy tx.

During Treatment
・It has been suggested that once tx with fixed appliance has begun, an initial follow-up is recommended at 6-9 months and should include periapical radiographs of all maxillary teeth and mandibular incisors, since these are the teeth most susceptible to root resorption.
However, the amount and directoiin of tooth movement or presence of excessive tooth movility should be considered before requesting a new radograph.

Post-treatment
A radiograph examination is mandatory, and the patient and referring dentist should be informed if EARR has occurred.
If it is mild or moderate, no further action is indicated.
If it is severe, there is risk of tooth mobility. In such a case,farther follow-up and instructions to the patient are necessary.

Medication
Studies on humans are inconclusive regarding EARR and medication administration.
Increase EARR was noted in patients with allergies. Good practice would suggest that it is important to identify patients with allergy and consider the possible implications.

The average tooth color becomes darker and shifts into more red and especially yellow color range after orthodontic tx.

Orthodontic debonding and cleaning procedures were found to have statistically significant effects on the CIE color prameters of treated teeth, during the first retention year.

The tooth color changes may be caused by
・Enamel structure alterations resulted from the irreversible penetration of resin tags
・Enamel surface modifications associated with bonding, debonding and cleaning procedures
・Extrinsic and intrinsic discoloration of the remaining adhesive material

Bleaching was associated with an increase of the L value (lightness) and decrease of b and a values (red/green & yellow/blue axes) in both treated and untreated teeth.
Parameters ΔE,L, and b exhibited statistically significant differences between the Bleaching-Untreated and Bleaching Retention subgroups.
Previous exposure to fixed orthodontic appliance infuluenced the efficacy of external tooth bleaching.
The effect of bleaching was higher after orthodontic treatment and with longr period in retention.

After orthodontic tx, almost all examined teeth had decreased in volume. The mean decrease was 1.03 mm cubic per tooth (p<0.001). Tx duration over 30 months was an important factor in the development of occlusal eat (p<0.001). Further studies are needed.

The bracket removing plier produces the most consistent separation at the bracket-adhesive interface.
The force applied must not exceed 13MPa to prevent enamelcracks.
Care must be exercised when debonding attachments from compromised teeth.

4. ADVERSE EFFECTS DURING ORTHODONTIC TRACTION OF IMPACTED CANINES

5. EXTRA-ORAL DAMAGE

Relapse is defined as the return of features of the original malocclusion following orthodontic correction and its extend is highly variable and difficult to predict.
Retention is a method to retain the teeth in their correceted position. It is now accepted that without retention there is a significant risk the teeth will move.
Continuous changes of the dental arches occur until the adult period, with individual variations. This change is a biological migration of the dentition, resulting in anterior crowding especially in the mandible, even in subjects with congenitally missing 3rd molars.
This natural development has to be considered in orthodontic tx planning as well as in assessing post-tx stability.

IS THE RETENTION RISK-FREE?
The FSW canine-to-canine lingual retainer is very effctive in maintaining the alignment of the mandibular anterior region. However, regular checkups are necessary to determine bonding failures, post-treatment changes, and complications as early as possible.
In 3% of the patients, unexpected post-treatment complications (torque differences of the incisors, increased buccal canine inclination) were observed.
Although fixed orthodotnic retainers have been used for yaers in clinical practice, the selection of the best retention still remains a subjective issue.

7. ORTHODONTIC MALPRACTICE

The efficacy of maxillary protraction using skeletal anchorage - a systematic review and meta-analysisi Dr.Sarah Joda Kathem (EOS 2024)

WHAT IS THE IMPACT OF MARPE ON THE MIDFACIAL SOFT TISSUE? A PROSPECTIVE 3D STEREOPHOTOGRAMMETRY STUDY Dr.Aldin Kapetanovic (EOS 2024)

Results
IMMEDIATE EFFECTS
・Anterior displacement <1.0mm
・All 5 regions except for philtrum p<0.05
・Alar width +1.59mm p>0.05
OVERALL EFFECTS
・Relapse, p>0.05
・Effects are stable
・Effects 0.3-0.71mm
・Alar width +1.51mm p>0.05
DENTAL EFFECTS
・Inter-premolar width

Discussion

☆以下は世界矯正インプラント学会 (WIOC October 2023) のレクチャー

Exploring Bone Screw Placement in the Digital Era : Lessons from the past and embracing innovation (Sunanda Roychoudhury, WIOC 2023)150810744

内容

Accerelated orthodontics (スピード矯正 )

Should We Use External Aids to Accelerate Orthodontic Tooth Movement? (M.Ali Darendeliter,AAO 2022)

vibration, soft laser, photobiomodulation, piezocision, micro-osteoperforations は、臨床的に役に立たない。micro-osteoperforationsでは、12週間で16%速く犬歯が動いた（統計学的に有為の差）(Alikhani et al.AJODO 2013)　-　すなわち、一か月に0.15ミリ速く犬歯が動いた。こんなに僅かな歯の移動のスピードアップでは、臨床的に役に立たない。

Why does the Treatment take longer?

More is Better: A Revisonist Story of Accelerated Tooth Movemewt(Peter Buchang, AAO,2022)

systematic review (Dimitrios Mavreas et al.European J Orthodontis,2008)によれば、Class I症例よりもlass II症例、可撤式装置よりも固定式装置、子供よりも大人、非抜歯症例よりも抜歯症例のほうが治療期間が長い。

治療期間が長くなると、歯根吸収やホワイトスポットや歯周組織の問題が起こりやすく、治療費も高くなる。

スピード矯正でない場合の犬歯の後方移動では、平均1.4㎜/月（0.5-2.4mm/月の範囲）移動量

コルティコトミーをすると2.1倍、ピエゾシジョンをすると1.6倍の速度で歯が移動した。(Abbas et al 2016)

micro-osteoperforationでは、歯の移動速度は変化しなかった。(Amal Alkebai et al AJODO 2018)

骨修復の3段階：①inflammatory phaseは1-2週間、reparative phaseは1-4か月、remodeling phaseは数か月から数年。

歯の移動速度に影響する因子 (Sarandeep Huja. IOC,2020)

スピード矯正のbiomechanics (Carialberta Verna. IOC,2020)

振動や光や外科処置(Corticotomyを除く)は、歯の移動速度に影響するか? (All Darendellfer. IOC,2020)

歯根周囲の骨吸収の最大スピードは 3mm/month (Eugene Roberts et al.,1981)

	歯根吸収 micro-CT	歯の移動速度	歯根損傷	その他
Acceledent-30Hz	有意差なし	有意差なし
Hummingbird-50Hz	1/3の減少	15%速かった		15%は臨床的に意味がある?
Soft Laser	24%の減少	有意差なし
Photobiomodulation	有意差なし	有意差なし
Micro-OsteoPerforation	42%多い	16%速かった		16%は臨床的に意味がある?
Pezocision	44%多い	有意差なし	14症例中5症例に歯根損傷
Corticotomy				外科的侵襲が大きすぎる?

矯正治療が長引く理由

スピード矯正 (P.H.Busschang, AAO, 2019)

スピード矯正

corticotomy:　動物実験では、コルチコトミー側の歯の移動速度はコントロール側の約2倍で、歯の移動速度のピークは、コルチコトミー側では21日目、コントロール側では27日目であった。42日後にはコルチコトミー側とコントロール側で歯の移動速度に差はなかった。(Payam et al., EJO, 2010)

a full-thickness mucoperiosteal flap: 動物実験で、center of resistanceの移動を計測すると歯の移動速度は31%速かった。　(Kelly M. et al., AJODO, 2017)

RAP: 動物実験では、抜歯側では1.7mm移動し、抜歯＋フラップ側では2.9mm移動した。つまり、損傷の量が多いほど歯の移動速度は速い。 (Cohen et al.,2010) （Dr.井上の意見：意訳しすぎ？）

MOP: 動物実験では、歯の移動速度に差はなかった。組織学的に、皮質骨には変化はあったが、歯根の周りにはあまり変化はなかった。(Swapp et al.,AJODO,2015)（Dr.井上の意見：組織学的に皮質骨に変化があったということは、狭窄している歯槽骨のある症例では歯の移動が容易になる可能性があるのだろうか？）

MOP: 動物実験で、最初の3週間において歯の移動速度は速くなったが有意差はなかった。　(Cramer et al.,AJODO, in press)

MOP: 動物実験で、MOPからat least 4mmの範囲でdemineralizationがおこるが、その効果は短期間であった。(Gemert et al.., AJODO, in press)（出典が違う？）

バイブレーションの効果

・今までの研究結果からバイブレーションは、骨密度、歯の移動速度、治療期間、来院回数、治療後の咬合、疼痛、口腔内の健康、アライナーの装着期間、歯根吸収、アラインメントにおいて、ヒトに影響しない。

骨損傷の効果

バイブレーションの効果　

	手術	薬物注入	レーザー	PEMF（パルス電磁場）	振動
ヒトに対する効果	治療期間33%-50%短縮	動物実験では歯の移動速度は42%-73%増加	治療期間は50%-67%減少	歯の移動速度は42%増加	治療期間は約38%-50%減少
生物学的メカニズム	炎症メディエイターと治癒反応により骨代謝が活性化される	骨吸収ファクターの注入で骨代謝が活性化される	不明。仮説としては、フリー電子が活性化される	不明。PEMF刺激が破骨細胞を増殖し分化させる	RANKLEを活性化させ破骨細胞を増殖させる
利点	・治療期間の大きな減少・外科矯正が必要な患者に有益	None	・非侵襲性・歯の移動速度の増加が証明されている	効果的	非侵襲性
欠点	・侵襲性・術中と術後の不快感	・エビデンスがない・ヒトで研究できない	副作用が不明	・バイオ・セイフティの心配・副作用が不明	患者の協力が必要

alveolar corticotomy は、治療期間の短縮のためにおこなうのではなく、アンカレッジを最小にするためにおこなうのである。alveolar corticonomyは治療期間短縮の予測ができない。alveolar corticotomy で治療期間が短縮されれば、それはボーナスである。一方、TAD は、アンカレッジを最大にするためにおこなうのである。 alveolar corticotomy の適応症はimpacted teeth, transpositions, molar distalization, molar mesialization molar intrusion, complex spce closures, labial expansion, (Raffaele Spena, MOIP2016>)

元記事

に外部リンク

Airway (気道)

Maxillary Palatal Expansion for Airway: Myth vs Fact (Dr.Audrey Yoon AAO 2023)

Does Head and Neck Posture Affect Cone-Beam Computed Tomography Assessment of the Upper Airway (Coppelson et al.J Oral Maxillofac Surg 2023)

Protocol for CBCT scans
・Natural head position
・Horizontal visual axis
・Close mouth, breathe through nose, place teeth together
・Swallow once, the rest your tongue where it naturally goes
・Avoid bite-registration and avoid reaching for chin rest

Conclusions

Aligner (アライナー)

EJO Open Session: The EJO aligner battle - evidene, clinical considerations and individual perspectives

20230614_074903450

Keeping Things Straight - How Alignrs have changed our Practice of Orthodontics (Dr Kau Chung How, AOSC Feb.2023)　（Dr井上の意見："アライナー矯正は劣っている"ではなく、適用症例の選択が大切なのでしょう）

アライナー矯正が適している症例

アライナー矯正が適していない症例

治療の有効性 evaluation of ABO-OGS score (Djeu G et al.AJODO 2005, Papageorgiou SN et al.EJO 2020)

アライナー矯正の現実　(Nuel D et al.AJODO 2022)

Predictability of orthodontic tooth movement with aligners: effect of treatment design (Castroflorio et al. Progress in Orthodontics 2022)

Seccess and pitfalls in clear aligner therapy, using the clear correct system (Dr.Hironobu Fumino,AOSC 2023)

マウスピース矯正の利点（Dr井上の意見：これらの利点は表面的な利点で、欠点も多いです）

日本でマウスピース矯正が流行らない理由

矯正治療のゴールは

1.歯の位置　ー　かみ合わせを良くする
2.顔面の形態　－　顔面骨格のバランス
3.軟組織　ー　審美的な調和
4.機能的なマトリックスの標準化(Neutralize functional matrix: ①Posture, ②Breathing, ③Swallowing, ④Muscle Balance, ⑤Habits)
5.予後の安定

デコボコの歯ならびを揃える方法は

歯ならびを悪くする癖

いつも次のようなことをしている。肘をついて顎を支えている、睡眠中の姿勢、指しゃぶり、低位舌、良くない嚥下動作、食いしばり、上下の歯がいつも接触している、唇をしゃぶる、右側or左側の歯だけで食べている。

マウスピース矯正では、計画した歯の移動量の約60%ぐらいが実際の治療で移動する (Justin R,Chisari JODO 2014)

Clear Aligners for Phase I: A Treatment Choice for Your Practice (Dr. Adriana Da Silveira, AAO 2022)

Objectives of phase 1 with clear aligners

When should you use clear aligners for phase 1?

clear aligner and fixed appliance

"Fixed appliances": ・Able to make precise wire adjustments within 0.5mm to intrude or extrude teeth, as necessary.; ・Placed a force coronal and buccal to the center of resistance of teeth, resulting in tipping and proclination during alignment.; ・Treatment time for the braces group is significantly longer than that for the nvisalign group.; ・More effective in creating adequate occlusal contacts and controlling posterior buccolingual inclination.

"Clear aligners": ・Effective in controlling anterior intrusion.; ・Preferable alternative to fixed appliances for the treatment of anterior open bites because the double thickness of the aligners, in combination with the patient's biting force, intrudes the posterior teeth and thus aids in bite closure.; ・Extrusion and rotation are the most difficult movements.; ・Highest predictability movement: upper molar distalization.; ・Good control of keeping teeth inclination during alignment in nonextraction cases.; ・Align teeth individually with one aligner moving one to several teeth, minimizing tooth proinclination (ideal for patients with thin gingival biotype).; ・High cost.; ・Less root resorption; ・Treatment time was shorter in mild-to-moderate case.; ・More relapse than fixed appliances.

Trim height of the aligner (Brent Bankhead,AOSC 2021)

ポイント
・Software design: ソフトウェア・デザインの段階であれば、上顎側切歯を動かす前に、捻転した又は舌側転位した上顎側切歯の近心と遠心に隣接歯と密な接触がないようするように技工士に指示せよ。
・Clinical Execution: 上顎側切歯の移動スペースを確保するために上顎側切歯の近心と遠心の隣接歯と接する部分を軽くサンドペーパーする。たとえ、IPRがクリンチェックになくても。
・Troubleshooting: 圧下してしまった上顎側切歯を挺出させるために、上顎側切歯の頬側と舌側にクリアボタンを接着しエラスティックスを使用する。

ポイント
・アライナー治療に入る前に重度の捻転は、ボタンとパワーチェインでなおしておく。歯の2点にクリアボタンを接着すれば、回転の中心が歯の中心と一致する。
・捻転歯の移動スペースを確保するために捻転歯の近心と遠心の隣接歯と接触している部分を軽くサンドペーパーする。たとえ、IPRがクリンチェックになくても。
・アライナーと歯の移動が一致していない場合には、捻転歯の頬側と舌側にボタンを接着しパワーチェインを使用する。

解決策
・セトリングしやすいように、保定治療においては夜間だけの装着にする
・後方歯が挺出しやすいように、犬歯より後方または小臼歯より後方にあるアライナーの一部を切り取る

アライナーを装着する前に説明

治療を終了するまでに、通常、2シリーズのアライナーが必要であることを患者に説明

Clearbite aligners

に外部リンク

Asoaligner

に外部リンク

・Most of the studies presented with methodological problems: small sample size, bias and confounding variables, lack of method error analysis, blinding in measurements, and deficient or missing statistical methods. The quality level of the studies was not sufficient to draw any evidence-based conclusions.
・CAT is an effective procedure that is able to align and level the arches in non-growing subjects.
・The anterior intrusion movement achievable with CAT is comparable to that reported for the straight wire technique.
・CAT is not effective in controlling anterior extrusion movement. Contrasting results have been reported in relation to the posterior vertical control, and definite conclusion cannot be drawn.
・CAT is not effective in controlling rotaions, especially of rounded teeth.
・CAT is effective in controlling upper molar bodiily movement when a destalization of 1.5 mm has been prescribed.
・CAT is not based on aligners alone. It requires the use of auxiliaries (attachments, intorarch elastics, IPR, altered alaigner geomotties) to improve the predictability of orthodontc movement.“アライナー矯正は、アライナーだけではうまくいかない。歯の移動の予知性を高めるために、アタッチメント、顎間ゴム、IPR、altered aligner geometrics などの使用が必須である。”

オルソ・コム

に外部リンク

Alveolar bone（歯槽骨）

differential alveolar bone modeling

Determination of labial protuberance (LP): ・LP (diameter > 1mm); ・Present at intraoral photograph and dental cast; ・Agreement of two examiner

Results: Incidence: ・Male 5.0% vs Female 2.4%, p=0.039; ・Age
　　10-19: 2/434 patients
　　20-29: 19/292 patients
　　30-39: 5/79 patients
　　40-49: 2/27 patients
　　>50s: 0/12 patients; ・Non-extraction 0.6% vs Extraction 6.6%, p <0.0001

Conclusion: ・The overall incidence rate of differential alveolar bone modeling following orthodontic treatment is 3.21%.; ・Differential alveolar bone modeling is noted especially at lateral incisal area.; ・Differential alveolar bone modeling occures more frequently in male adults as age increases, and treaed with extraction.

bone borne expander のほうが tooth borne expander よりもbone lossが少なかった。(? 2015)

High angle cases have a risk of violating the alveolar borders (Hoang et al. Prog Orthod. July 2016; 17: 22)

上顎前歯の抜歯後におこる歯槽骨稜幅の減少：　最初の6ヵ月で23%減少、次の5年間で11%減少。（Carlson G. Acta Odont Scand 1967;16:84-95）

萎縮性歯槽骨における歯の移動(Adilson Luiz Ramos,IOC,2020)

- How much bone can we expect to be formed in such movement? → vertically=about 3mm, transversely=about 3.5mm
- How much root resorption (apical and lateral) can we expect? → lateral (1 to 2mm)=in about 50% of the teeth, apically=traditional Tx (0.5 to 1mm)
- How much bone loss ( and dehiscences) may occur during such movement? → around 0.5 to 1 mm (mesial, distal, lingual), attention to the buccal plates (median 2.2mm)
- Is ther a correlation between root resorption to the bone atrophy level? → Moderate correlation between transverse atrophy to the lateral root resorption
- How stable is this new bone with time? → Up to 5 years with reasonable stability

Ankylosis （アンキローシス）

Navigating into the Dental Ankylosis World (Jose A.Bosio,AAO 2022)　骨性癒着歯の治療方法

Decoronation / Coronectomy

乳歯の骨性癒着の発生率

乳歯が骨性癒着しているかどうかの判定方法

乳歯が骨性癒着している場合の問題点：

Most ankyosed teeth , if not remved, will promote impaction and/or displacemet of permanent teeth,（DR.井上の意見：たぶん、乳臼歯の話でしょう）

Kennedy DB,Eur Arch Paediat Dent 2009 - Suggested to "building up the primary tooth with composite or place a metal crown to prevent tipping of adjacent teeth and to prevent opposing arch supra-eruption." He does contra-indecate when growth remains. Bpsop,AAO 2022 - propose not to teach this method anymore, since alveolar growth contoinues throughout life, and eventually it will compromise the occlusion.（DR.井上の意見：たぶん、乳臼歯の話でしょう）

Conclusion for 95%+ of dental ankylosis cases? Extraction for ankyosed teeth is, almost every thime, the best option.

Central Incisor Ankylosis in Children & Adolescents: Extraction, Distraction or Autotransplantation? (Ivo Marek, AAO 2022) 小児のの上顎中切歯の骨性癒着：抜歯、distraction、歯の移植？

Apicotomy: Surgical managema ent of maxillary dolacerate or ankylosed canines. Eustaquino A. Araujo et al. AJODO

Apicotomy: a root apical fracture for surgical treatment of impacted upper canines. Puricelli E. Head Face Med. 2007;3:33

Apical periodontisitis （根尖病巣）

Archform （歯列弓の形態）

Asymmetry （非対称）

Autotransplantation （歯の自家移植）

Dental Autotransplantation: A changing Perspective on Treatment of Children with Missing Teeth (Dr.J.R.Christensen,AAO 2023)

Current options for replacing a missing tooth

Endodontic treatment of the donor tooth is suggested beyond stage 6 development.

Complication such as inflammatory root resorption, ankylosis, pulp necrosis, and compromised periodonal healing can occur.

Indications

（Dr.井上の意見：下顎前歯を上顎側切歯の位置に移植して下顎前歯が3本になっていた症例が紹介されていた）

Treatment of impacted teeth with autotransplantation　埋伏歯の自家移植 (Seung-Cheol Song, Sun-Hyung Park, APOC 2022)

1.Open Apex? Closed Apex? →　Not big difference

2.Is endodontic Tx mandatory?　→　Not likely
3.Timing of endodontic Tx　→　Within 14 days

4.Type of splint?　→　After 1 month

5.When can we apply orthodontic force?　→　After 1 month

	No. of teeth	Success rate	Survival rate	Follow up ( years)
Andrease n et al. 1990	33	88%	98%	1-13
Kristerson & Langerstrom 1991	23	87%	96%	4-17
KKugelburg et al. 1994	31	87%	90%	1-4
Plakwicz et al. 2013	23	100%	100%	9-17
Leeds 2010	90	87.5%	94%	0.5-9

歯の銀行（外部リンク）

Botox （ボトックス）

Interdisciplinary Treatment for Deep Bite and Bruxism - is Botox the Answer? (Sr.Nan E.Hatch,AAO 2023)　（Dr.井上の解説：噛む力が強すぎる人にはボトックスを注入）

chemical Denervation of the Masseter:

Potential Adverse Effects:

Minimizing Adverse Effects:

Chemical Denervation (botox) for myofacial pain and migranes (Dr.sharon Ron Aronovich)

^nd

Bruxism （歯ぎしり）

Interdisciplinary Treatment for Deep bite and Bruxism - is Botox the Answer? (Dr Nan E. Hatch, AAO 2023)

外科手術後の問題点（Dr井上の解説：ローアングル、ディープバイト、クレンティングのある33歳の男性患者を外科手術により下顎骨を前方に移動させた症例報告）

Masseter Muscle Hypertrophy:

・Injection of neurotoxins into muscle

Chemical Denervation of the Masseter:

Wu Y et al.Aesthet Surg J Open Forum 2023

Potential Adverse effects (Dr井上の解説；botoxの副作用）

MInimizing Adverse Effects:

Chemical Denervation (botox) for myofacial pain and migraines (Dr.sharon (Ron) Aronovich)

Children, Orthodontics for children （小児矯正）

Evidence-Based Orthodontics: Same old questions - are there new answers? Dr Martyn Coboume (EOS 2023) （Dr.井上の意見：Class IIの小児患者において、1期治療と2期治療をした患者と1期治療をしないで2期治療だけした患者を比較して、1期治療をすべきかどうかを論じている）

・Early class II treatment will take longer overall

・Early class II treatment may be associated with some burnout

治療前後のoverjetの変化：early class II treatment group では、10.77 → 4.33mm。late groupでは、10.30 → 3.37mm。

・Early class II treatment: Functional,HG

If you provide a functional appliance to a child with an overjet at age 9: Early or late treatment produces essentially the same outcome

Conclusion:

dental trauma:

All class II children do not benefit from routine early treatment.But some may benefit from a reduced trauma risk. And there is data to support this.

2021 Jacob A. Salzmann Award Lecture; Effecient and Effective Growth Modification: A 30-year Perspective (Dr. Lorenzo Franchi, AAO 2021)

Class II
・Functional appliances are effective in altering short- and long-term mandibular growth and mandibular sagittal position if active treatment is performed AT PUBURTY
・Mandibular morphology should be evaluated AT PUBERTY to assess patient responsiveness: good responders have a small mandibular angle

Class III
・RME/FN is effective if performed BEFORE PUBERTY
・The long-term unsuccess rate for RME/FM is 30%. Unsuccessful cases are chracterized by a large CondAx-Mand.Pl.angle.

元記事

に外部リンク

Deebite （過蓋咬合）

Interdisciplinary Treatment for Deep bite and Bruxism - is Botox the Answer? (Dr Nan E. Hatch, AAO 2023)

Masseter Muscle Hypertrophy:

・Injection of neurotoxins into muscle

Chemical Denervation of the Masseter:

Wu Y et al.Aesthet Surg J Open Forum 2023

Potential Adverse effects (Dr井上の解説；botoxの副作用）

MInimizing Adverse Effects:

Chemical Denervation (botox) for myofacial pain and migraines (Dr.sharon (Ron) Aronovich)

Clinical Applications of TADs in Challenging Deep Overbite Cases (Dr.Jae Hyun Park,AAO 2023)

スマイル時に見える歯茎の適切な量は 2.5 (1.5-4) mm (Simone Parrini et al.AJODO 2016)

Force Vectors for the Intrusion of Six Segments:

Midline Bony Cleft (Huang WJ et al.Pediatr Dent 1995)

Mandibular symphaseal distraction osteogenesis → None of our patients experienced TMJ dysfunction symptoms during the entire follow-up period.(Alkan et al.IJPMS 2007)

Mandibular distraction osteogeneis: a systematic review of stability and the effects on hard and soft tissues (Rossini et al. IJOMS 2016)

Three-dimensional evaluation of mandibular midline distraction: A systematic review (Arilla et al, J Craniomaxillofac Surg 2018)

Summary

Deep Bite Treatment: Looking Beneath the Surface (Dr.Flavia Arthese,AAO 2023)

DEEP BITE: Overbite>5mm, Overlap>1/3 on the crown,

Handbook of Orthdontics (Robert E. Moyers,1973)

Wide variations in depth of the bite may be seen, however, with no danger to the occlusion or health of the supporting structures.

Occlusal Vertical Dimension: Best Evidence Consensus Paper (Goldstein G. et al. J of Prosthod 2021)

deepbiteの学生さんのほうがopen biteの学生さんよりも噛む力が大きかった(Abu Alhalja ES et al., Eur J Orthod.2010)

	Mx/Md	bite force (N)
deep bite	≦22	679.60±117.46
normal	<27±5	593.08±99.69
open bite	≧32	453.57±98.30

Emergency （緊急事態）

Survivng Medical Emergenccies in the Orthodontic Office by Being Prepared (Rovert D.Elliott,AAO 2022)

2021 Medical Emergencies Reported By Dentists (Source: Malamed)

Fainting (syncopy)＊ 30.1%

Mild Allergic Reactions＊ 18.7%

Seizures＊ 4.6%

Asthma Attack (bronchospasm)＊ 2.8%

Teenager patient scheduled for an afternoon orthodontic appointment and is coming from practice or athletic event

4つの "HYPOS"

ASPIRATION:

In the orthodontic office, this includes: molar bands, brackets, elastics and loose primary teeth.

患者の意識がなくなったら、4つの"HYPO" を考える

用意しておく器材

Rovert D. Elliott, AAO 2022 の翻訳。2022年のアメリカ矯正学会での口演ですから、歯科矯正クリニックに特化した話でしょう。ですから、麻酔注射の話が出てきません。訳者の勘違いがあるかもしれませんから、原著で確認してください。

以下をプリントアウトして、スタッフルームの壁に貼ってください

Rovert D. Elliott, AAO 2022

意識消失　→　低血糖症、低血圧症、低酸素血症、血液量減少症を疑う

低血糖症：

低血圧症：

低酸素血症：

血液量減少症：

失神

アレルギー反応

朝のミーティングで確認

けいれん

喘息発作（気管支痙攣）

十代の子供の矯正治療の予約を午後にしていると、学校での実習や運動部活動のあとに来院する

誤嚥

異物が咽頭に入る。矯正クリニックでは、大臼歯バンド、ブラケット、エラスティックス、動揺している乳歯

用意しておく器材と薬剤

以上をプリントアウトして、スタッフルームの壁に貼ってください

歯科クリニックでの医療事故

Extraction （抜歯と非抜歯）

Neither 4 PM-extraction nor nonextraction treatment has a predictable effect on smile aesthetics (Moser L et al. South Eur J Orthod dentofac Res 2020, Akyalcin S.et al.Korean J.Orthod 2017, Meyer AH. et al.AJODO 2014, Burrow SJ.Semin Orthod 2012, Ioi H.et al.AJODO 2012, Janson G.et al.Angle Orthod 2011, これら以外にも、2007, 2007, 2006, 2006, 2005, 2003 に論文あり)

In a well-managed orthodontic case, with or without extractins, the soft-tissue and facial aesthetic changes are generally favourable or clinically insignificant (Hodgkinson D et al.J Orthod 2019)

Cl II long-term profiles more esthetic in patients with 2 max extractions (Mendes LM et al.AJODO 2019)

SAP (Smile Arc Protection) bracket placement gingival to facial axis point (Pitts TR. JCO 2017)

Extraction of maxillary canines (Badri et al.AJODO 2017)

小臼歯抜歯抜歯症例の歯列弓幅径 (Akyalcin S.et al. Korean J Orthod 2017)

年	%
1953	10.0%
1958	15.0%
1963	52.0%
1968	46.0%
1973	42.0%
1978	33.0%
1988	17.0%
1993	10.0%

抜歯症例と非抜歯症例に差がなかったテクニック

抜歯症例と非抜歯症例に差があったテクニック

Temporary Anchorage (TADs) (Odds Ratio = 2.45)

Genetics （遺伝）

Exploring Genetic Factors in Class II div 2 (Malocclusion James Hartsfield, AAO 2022)

Class II div 2の特徴：

一卵性双生児の両方がCIID2になる確率は100％、二卵性双生児の両方がCIID2になる確率は10.7% (Markovic, Eur J Orthod 1992)。一卵性双生児がCllD2 & CllD1になる確率は0% (Ruf, Pancherz, Angle Orthod 1999)

Gingival recessions （歯肉退縮）

Plaque, Gingival Inflamation, and the Oral Microbiome

Conclusion/Clinical Application

Patients are better able to maintain periodontal health with CAs than FAs: ・Greater plaque accumulation and gingival inflammtion in the FA group; ・Absence of bands, brackets, and wires facilitate better oral hygiene
The bacterial communities in anterior and posterior teeth were very similar: ・Indicates that the microbial population is very stable in plaque; ・There was only a significant increase in the potentially pathogenic genus, Leptotrichia in the FA group
The plaque in the CA tray harbored a unique and less diverse community than tooth associated communities: ・The tray can act as a reservoir and retentive site for pathogenic bacteria
The study revealed that CAs have a better clinical outcome than FAs

ColorVue predicted Biotype	Frequencies	Predicted periodontal probe measurement
thin type	18%	0.40 - 0.52 mm
medium type	67%	0.53 - 0.59 mm
thick type	10.5%	0.77 - 0.89 mm
very thick type	4.5%	0.80 - 1.01 mm

Gummy smile （ガミー・スマイル）

A stepwise approach to the correction of excessive gingival display　ガミースマイル　(Eddie Hsiang-Hua Lai,APOC 2022)

LIPG checklist

Lip length measurement

Incisal line determination

Proportion of teeth

Gummy smile

Treatment considerations (Rule of CPR)

Treat Your Patients as You Would Your Own Family (David M. Sarver, AAO 2022)

ガミースマイルの原因：

ガミースマイル

ドクター向けYouTube

上顎骨が上下的に過成長　→　歯列矯正治療（スクリュー使用）による上の前歯の上方への移動＋CLP（歯冠長延長手術）＋スマイルトレーニング。上顎骨の手術

Herbst appliance (ハーブスト装置)

Class II Back or forth? (Dr.Mauro Cozzani,AAO 2023)（Dr.井上の解説：ハーブスト装置とアンカースクリューを同時に使用）

Herbst appliance anchored to miniscrews in the upper and lower arches vs standard Herbst: A pilot study (Antonio Manni et al.AJODO 2019)

Impacted teeth (埋伏歯)

Study on the impact of maxillary and mandibular anterior crowding on periodontal health in middle-aged and older adults. (Junichi Watahiki, EOS 2024)

Why
Probably Due to Anatomical Difference Maxillary Anterior Phenotype is Signigicantly Thicker than Mandible. (Am J Orthod Dentofacial Orthop.2018 Sep;154(3):356-364)

Take-Home Message
Orthodontic treatment at a young age may contribute to preventing gingival recession. The 4mm Lower anterior Crowding May Be threshod for orthodontic extraction.

Second molar eruption disturbances in borderline-extraction orthodontic cases, comparing extraction vs. non-extraction treatment outcomes. Kelly Mitchell, EOS 2024

Tips, Tricks, Decisions and troubles when Treating Impacted Maxillary Central Incisors (Dr.Miguel Hirschhaut; Dr.Carol Weinstein AAO 2023)

Impacted maxillary incisors occurs in 0.2-1% of the population (Chiara P. et nnali di Stomatologia 2012)

Forty-one patients with unerupted incisors: 30 males and 11 females (Bartolo et al.Euro J Orthod 2009)

The causes of the impacted maxillary incisors: Trauma, Supernumeraries, Odontoma, crowding/Narrow Premaxilla，Syndromic Cases

Space opening and elimination of the cause
Spontaneous resolution in 54% to 78% of patients
Delay treatment up to 3 years
(Shaushu et al AJODO 2015)

Closed Eruption

Open Exposure

Closed-eruption technique for impacted maxillary incisors: A postorthodonic periodontal evaluation (Becker A.et al.AJODO 2002)

5 to 6% less bone in impacted incisor. 1/3 of the cases abnormal gingival contour. Statisticallu significant but not clinically significant.

Root Development of Imapcted Incisors

Contact with cortical bone can stop root development generation a shorter root (Aburto et al.)

Impacted incisors present a reduction of 25% their root length (Mattiello et al.AJODO )

Ankylosis

When it comes to Severe Impactions, Timing is Everything (Dr.Stella Chushu,AAO 2023)

Impacted canines' root length was shorter by -1,2mm, but volume was unaffected ... this means a change in the root shpe

Chushu s.et al.Sem Orthod 2023

Prognosis of tx of impacted canines in the adult is uncertain and reduces with age (41% success rate in adults over 30) (Becker and Chaushu,2003)

Third Molars in Orthodontics: To retain, or not retain, that is the question. 矯正治療において第三大臼歯はどうする（Kyung-Ho Kim,APOC 2022)

親知らず（第三大臼歯）の発達

Meta-analysis of 49 studies (Carter et al.J Dent Res 2016)

親知らずの埋伏に関係する要因

下顎大臼歯の埋伏では

親知らず埋伏による障害　Review of 1001 cases (Van der Linden et al.1995)

親知らずの抜歯が推奨されるケース

4本の小臼歯抜歯して矯正治療すると親知らず埋伏の発生率が低くなる (Kim et al. AJODO 2003)

young adults の抜歯矯正治療によって親知らず埋の発生率が低くなる (Turkoz et al.Angle Orthod.2013)

親知らず埋伏に対処するための第二大臼歯抜歯

上顎第三大臼歯を抜歯すると上顎第二大臼歯は自然萌出するのか?

下顎第二大臼歯を抜歯すると下顎第三大臼歯は自然萌出するか? (Yoonjeong Noh, Master's thesis,2017)

The Management of Impacted Mandibular Second Molars　埋伏下顎第二大臼歯の対処法 (Patrick Turley, 2019)

Recommendation

Main causes of MM2 impaction

Climbing the Mountain of Severe Impaction (Stella chaushu, AAO 2022)　重度の埋伏歯の解決方法

Dekal, et al.AJODO 2021)

Stewart et al.,2001, Becker et al.,2003, Amuk et al.,2021

Becker et al.,2005

埋伏歯の牽引開始時期：

切歯が埋伏していると、同側の犬歯の41.3％が位置異常（頬側30.2%、口蓋側9.5%、transposed 1.6%)。(Becker et al.,AJODO 2003)

埋伏切歯の治療 (Chaushu et al.,2015)(Sun et al.,2016)

埋伏上顎犬歯

・Different procedures-different periodontal concerns

・On the buccal: 2-3mm of keratinized tissue or apically repositioned flap ・On the palatal side: Seems to lengthen the treatment time (Pearson et al., 1996: Ferguson and Parvizi, 1997)

・On the palatal side: Better hygiene, shorter treatment time.

埋伏歯

・口蓋側の犬歯：口腔衛生状態が良好で、治療期間が短い。

唇側にある埋伏犬歯が高位にある場合には、apically repositioned flap は可能ではないので、ツー・ステージにわける必要がある。犬歯を遠心側方向と咬合側方向に移動させ、そして、apically repositioned flap

Management (マネージメント)

Orthodontic Referral Marketing Success: Powerful Stragegies to Increase Referrals & Referral Sources (Dr. Roger P. Levin, AAO 2022)

The Data

Why I Partnered with a DSO at the Age of 36 (Dr. Ben Fishbein, AAO 2022)

We're not always perfect...　Message:

Leading the Life You Wnat (Dr.Anil J.Idiculia,AAO 2022)

First Follower: Leadership Lessons from Dancing Guy　（Dr.井上の意見："リーダーとは" の話になると、よく紹介されるユーチューブ動画です）

Discover the Custom Digital Solution for All Your Metal And Clear Fixed Appliance Patients (Dr.Brandon Owen,AAO 2022)

Dr.Jpseph ConiglioのクリニックでのBraces/Aligners(%) の割合は

Now is the tTime for Lower Overhead & Higher Production (Ms.Edwina Wood,AAO 2022)

Overhead Key Indicators

New Patient Referral Sources for Orthodontic Practices

Orthodontic Industry Trends; Sponsored in part by AAOF (Chris Bentson, AAO 2022)

アメリカにおけるアライナ矯正の割合は、1996年には1%、2020年には25%であった。2030年には50%になるだろう。Digital Bracesの割合は、1996年には0%、2020年には1％であった。2030年には25%になるだろう。

Team Up! The Doctor's & Team's Role in Practice Success (Ms.Nancy Hyman,AAO 2022)

Identify Your Targets

Treatment Options

How to Convert Leads into New Patients BEFORE the Consultation (Dr.Leon klmpner & Ms.Amy Epstein,AAO 2202)

矯正治療の市場の拡大は続いている！

アライナ矯正は少ない来院回数で高VPV $450 per visit　→　その理由は：

Interpersonal Communication & Neuroergonomics to Increase Happiness & Performance (Ms Nathalie Rumiz,AAO 2022)< /p>

Why do we need to motivate patients?

It's All About Timing: How to Keep Your Clinic on Time (Ms.Andrea Cook,AAO 2022)　

予想治療期間と実際の治療期間

来院回数

AAOIC Risk Mangement for the Orthodotnic Team (Ms.Elizabeth Franklin,AAO 2022)

Screen Potential Patients for Problems. Easier to decline to treat than handle a claim!

Medical Insurance Guidlines

Approval rates: Provider: 100%; BCBS: 94％; AETNA: 90％; HUMANA: 88％; CIGNA: 88%; UHC: 14%

Reason for denial: No significant deformity: 8%; No health impairment: 29%; Etiology of deformity not covered: 63%

Conclusions: ・This study shows that the orthognathic surgery guidlines used by the major American medical insurance plans need revision.; ・The most consequential flaw was considering etiology in judging medical necessity.; ・Fortunately, only one company (UHC) made this grave mistake.; ・Moreover, all guidlines have omissions and erros in the way jaw deformity is determined and how health impairment is determined.

Medication (薬の影響)

Category	Substance
Vitamines	1,25(OH)3D3
Thyroid hormones	L-thyroxine Thyroxine

Category	Substance
ACE inhibitors	Losartan
Antihistamines	Ceririzine
Antihyperlipidemics	Simvastatin
Minerals	Strontim Ranelate Lithomamnlu,/CaCO3 Calcium Gluconate
Proton pump inhibitors	Famotidine

Category	Substance
Anticonvulsants	Phenytoin

Category	Substance
Antidepressants	Diazepam Fluoxetine
Adrenal cortical steroids	Hydrocortizone Prednisolone Methylprednisolone Triamcinolone acetonide
Beta-blockers	Propanolol
Vitamine C

Missing tooth (欠損歯)

Jose Nelson Mucha Memorial Lecture; Agenesis and Ankylosis, Practice and Evidence (Dr.Roberto B.Brandao,AAO 2023)

C.L.Hvaring et al.Eur.J.Orthd.2019 （Dr.井上の意見：後継永久歯がない乳歯は何年ぐらい維持されるのかを論じています）

Prosthetic replacement vs space closure for maxillary lateral incisor agenesis: A systematic review (G.S.Silveira et al.AJODO 2016)

（Dr.井上の意見：右下5を右上2の部位に移植し、アンカースックリューで右下6と右下7を近心移動させて右下5のスペースを閉鎖した症例が紹介されていた）

Tooth Agenesis Conclusions

Dentoalveolar Ankylosis Conclusions

To Open or To Close Spaces in the interdiciplinary Patient? (Dr.Ute Schneider-Moser,AAO 2023)

Pasukdee P et al.AJODO 2021

There is little scientific evidence regarding long-term survival of deciduous teeth into adulthood, but the lower second primary molar, followed by the upper primary canine, seems to have the best prognosis. (Nordquist I et al.Swed Dent J 2005)

IPR treatment and attachments design in clear aligner therapy and risk of open gingival embrasures in adults (Zhang et al.Progress Orthodontics 2023)

上唇の長さは、19歳から60歳になると男性は2.25mm、女性は0.49mm長くなる。(Drummond S.et al.Angle Orthod 2013)

Constant compensatory torque due to lingual tilting of the mandibular canine crowns and unwanted narrowing of the intercanine width. (Faerovig E.et al.AJODO 1999)

RBFDP (Resin Bonded Fixed Dental Prostheses); 15-year survival rate > 95% (Kern M et al.Eur J Dent 2021)

The Aesthitic Problem of Multiagenesis of the Teeth in adolescents and Possible Solutions (Dr.Ivo Marek,AAO 2023)

Deciduous teeth, when no root resorption is present at age 14 resp. 16 and above, are only subject to minimal resorption (Bjerklin et al.Eur.J.Orthod 2000, Kurol et al.Angle Orthod 1984)

Deciduous teeth and ectodermal dysplasia (Mehmet-Sinan et al.Med Oral Patol Oral Cir Bucal 2015)

インプラントの成功率

年数	1-3年	5年	10-15年	20年
文献	Ioannidis et al.2015 Bechera et al.2016 Joda et al.2016	Galluci et al.2016 Pappaspyridakos et al.2012 Pjetursson et al.2014	Wittneben et al.2014 De Angelis et al.2017	Chappuis et al.2013
成功率	96% - 100%	93% - 97%	71% - 86%	76% - 86%

Management of complex situations due to missing teeth in the smile area 前歯欠損症例の矯正治療　(Dr.Ute Schneider-Moser AOSC 2023)

前歯の欠損部位の隣の歯に1つの人工歯を接着剤で付けた場合、15年後にも維持できていた症例は95%で、2つの人工歯では85%の成功率だった。(Mendez JM et al.Eur J Dent 2021)

5 requisites for a predictable esthetic result

It is of interest to note that no or only a minor degree of infraocclusion was observed in patients with good inter-incisor stability, while missing anterior tooth contacts were associated with a more obvious degree of infraocclusion, (Thiander B.Eur J Orthod 31,2009)

Developmental tooth malformation

Solitary Median Maxillary Central Incisor (SMMCI)（Dr井上の意見：左右の上顎中切歯が癒合することもあるらしい。私は見たことないです。このレクチャーでは、癒合歯を抜歯して左右の上顎側切歯を上顎中切歯の位置に移動させていた）

Avulsion 歯の脱落

歯の欠損がある症例では、どうする?

Common & Uncommon Solusions for Missing Teeth in the Anterior & Posterior Zone (Ute Schnelder-Moser,AAO 2022)　前歯部と臼歯部に欠損歯ある症例の治療方法

　25% exposure of lower teeth is most attractive, and a sightly flatter smile arc is preferred (Pasukdee et al.,AJODO 2021)　スマイル時に下の前歯が25%ぐらい見えているのが最も魅力的だと思われている

　下顎切歯1本欠損症例でスペースを閉鎖すると、52%の症例でブラックトライアングルが生じる。(Uribe et al.,AJODO 2011)

　ブラックトライアングルのリスクファクター (Taemow et al.,J Periodonto; 1992), (Burke,AJODO 1994), Foerovig et al.,AJODO 1999), Kokich,AJODO 2000), Kurth et al.,AJODO 2001), Ikeda et al.,Aust Orthod J.2004), Chow et al.,J Clin Periodontol 2010), An et al.,Angle Orthod 2018)

　下顎4切歯がある症例で下顎切歯1本抜歯する場合には、抜歯する予定の切歯が舌側に45 degrees 傾斜し抜歯予定歯の2本の隣接歯がコンタクトしてから抜歯すると、ブラックトライアングルはできにくい。20歳以下では0%、20-40歳では11%。40歳以上では100%の確率でブラックトライアングルが生じた。　(Vilhjalmsson G.et al.,AJODO 2019)

　イタリアでの欠損歯がある割合は9%。(Gracco et al.,Prog Orthod 2017)

　イタリアの12歳の子供の40%に虫歯があった。(Campus G et al.,Caries Res 2007)(Napoli C et al.,J Dent Sci 2012)

　イタリア人の18％にMIH (Molar-Incisor-Hypomineralization)　があった

Esthetic Guide for Canine-lateral Substitutions (Neal D.Kravitz,AAO 2022)　上顎側切歯の位置に上顎犬歯をもってきた場合の審美的なガイド

　上顎側切歯が欠如している症例では、上顎側切歯の位置に上顎犬歯をもってくることもある：　①下顎は2本の小臼歯抜歯　②下顎は非抜歯　③下顎は非抜歯で上顎4と上顎5の間にスペースをつくりインプラントにする

　上顎犬歯に接着するブラケットは、①UR1のブラケット(+17torque,+4angulation) ②UR2のブラケット(+10torque, +8angulation) ①②ではブラケットの接着面をenameloplastyする。③LL5のブラケット(+17torque, +2angulation)を上下逆に接着する。UR3のブラケット(+7torque, +8angulation)は使わない。

上顎犬歯の位置に上顎4がくるので、上顎4のブラケットを少し遠心寄りに接着する。

1.L7 on U67s for camouflage cases　2.Switch sides (LR7 to UL67)
REASON: A)Lower tubes have 0 degree offset　B)L7 has -10 degree torque

上顎犬歯の切端、舌側、隣接面をストリッピングする。上顎4の舌側咬頭のストリッピング。

上顎犬歯の近心隅角部にレジンを盛る

上顎4-4の6本にボンデッドリテーナ

歯数不足

212人の小児矯正治療患者のうち11.3%であった。1歯不足が29%、2歯不足が58.5%、3歯不足はほとんどなかった。

Molar distalization (大臼歯の遠心移動）

Molar Distalization using TADs: Postential, Limitation, and Precautions (Dr. Sung-Hoon Lim, AAO 2023)

Take home message 1
Evaluate the third molar

Take home message 2
Observe the distal tipping and gingival recession of second molars

・Preexisting distal tipping requires more root distal movement than the crown. ・Extraction treatment can be better.

Take home message 3
Intrusive and lingual distalizaiton can reduce the collisio with anatomic obstacle. → Applicable to open bite cases and Class III surgery cases.

Conclusion
・Distalization is unpredictable and risky when the alveolar ridge lacks sufficient width and height. ・Prepare an alternative plan from the start and monitor the second molar respose.

Myofunctional therapy (MFT)（口腔筋機能療法）

Continuous positive airway pressure, mandibular advancement splint or both: a randomized controlled trial (Mona Hamoda,AAO 2022)　OSA患者のCPAPとスプリントの使用：ランダマイズにコントロールされた研究

・約50％のOSA患者が6か月後も1日4時間以上CPAPを使用し、5年後に1日4時間以上CPAPを使用したOSA患者は17%であった。(Bartlett et al.,Sleep 2013)(Weaver et al.,Oral Maxillofac Surg Clin North Am 2009)
・20年以上の臨床結果から、6か月間以下の期間に1日4.5時間CPAPを使用したOSA患者のCPAP使用中止率は35.5%で、6ヶ月以上の期間に1日4.6時間CPAPを使用したSA患者のCPAP使用中止率は34.2%であった。CPAP使用中止率の高さは、CPAPをOSA患者の主たる治療方法であるとの考えを再考する必要があるかもしれない。(Rotenberg et al.,J Otolaryngology 2016)
・It si not sufficient simply to prescribe a PAP machine and consider the patient to be treated (Cistulli et al.,Sleep Medicine 2019)
・
・治療方法の選択にあたってはpateint-centeredであるべきだ。：

研究の結論：

前歯部開咬と口腔筋機能療法 (David Covell, 2020 Winter AAO)

IAOM (International Association of Orofacial Myology)

・American Speech-Language-Hearing Association (ASHA) と協力
・会員は歯科医、歯科衛生士、Speech and Language Patholgists に限る
・4日間コース
- ・筆記試験：Certified Orofacial Myologist
- ・Mandatory CE hours to maintain certification
・IOAMの認定医として名簿にのる

Reviews

dyskinesiaのある患者群では、矯正治療とOMT (Oral Myofunctional therapy)の併用治療のほうがOMTだけの治療よりも効果的だった。

Non-extraction treatment) (非抜歯治療)

New Strategies to Break the Limitations of Non-extraction Treatment Dr.Yoon-Ah Kook (AAO,2023)

1. Is 1st molar distalization feasible for patients with unerupted 2nd or 3rd molars?

The findings suggest that clinicians do not need to extract developing third molars before first molar distalization in adolescents.

2. How much first molar distlization is possible?

3. Is it possible to distalize 1st molar in the case of sinus pneumatization?

There was no significant difference in the amount of distal movement and intrusion of the maxillary first molars between groups 1 and 2. (Kim S.et al. AJODO 2021)

4. Dose molar distalization cause airway problems?

The airway space in the MCPP group had no significant changes after distalization and the postretention period. In addition, there was no difference between the MCPP and contol groups. (Chou AHK et al. AJODO 2021, Park JH et al. Angle Orthod 2018)

Our approach for crowding casses

New Strategies to Break the Limitations of Non-extraction Treatment Dr.Yoon-Ah Kook,AAO 2023)

Non-extraction orthodontics for clinicians FAQ

^st

^nd

^rd

^st

OSAS(obstructive sleep apnea syndrome) (睡眠時無呼吸症候群)

Orthodontics, upper airways and sleep apnea: Linking anatomy, diagnosis and management with 3D technology. (Alexandra Papadopoulou, EOS 2024)

Multidisciplinary treatment of Obstructive Sleep Apnea: Keys to Precision Therapy (Dr.Shaun Loh,AOSC 2023)　(Dr井上の意見：ほんの一部だけをピックアップしています)

Mandibular advancement device　下顎を前方に位置付けるマウスピース (Hui Chen et al.Sleep Medicine Review, www.elsevier.com/locate/smrv)

Paediatric OSA (Obstructive Sleep Apnea) - The ENT (Ear Nose Throat) Perspective (Dr.Dawn Teo,AOSC 2023)　(Dr井上の意見：ほんの一部だけをピックアップしています)

Paediatric sleep disordered breathing (SDB)

小児の睡眠時無呼吸症候群(OSA)

Sites of obstruction

Using Technology for Risk Assesment, Imaging & Management of OSA J.Martin Palomo,AAO 2022)　睡眠時無呼吸症候群　（Dr.井上の意見：治療方法ではなくリスクアセスメントを述べている）

発生率　(Young 1993, Young 2004, Marshall 2008, CDC 2008, Young 2008)

矯正治療を希望している303人の思春期の患者のうち、7.3%にOSAのハイリスクがあった。(Ashok et al.,AJODO 2018)

オーボエやバスーンを演奏するとOSAのリスクが減る(Ward CP,JCSM 2012)。ディジェリドゥを演奏すると、眠気とAHIが減った (Puhan MA,BMJ 2006)

研究の結論：

発現率：　男性は4人に1人、女性は10人に1人。

原因：　肥満、骨格の不調和、鼻閉塞、軟組織の不調和。

唾液分泌過多、不快、下顎の位置の変化、咀嚼筋や顎関節の痛み（咀嚼筋や顎関節の痛みに対しては、3－7日ほど装置の使用を止める、1日に2回アイス治療、NSAID投与（etodolac 300g, 2-3 times a day)、下顎の前方偏位の量を減らす、下顎の前方偏位の量を少しずつ大きくする）

歯の移動、

Occlusion (咬合)

Occlusal Vertical Dimension(Goldstein G. et al, J Prosthod 2021)

What is the range for IOD: Mean IOD = 3mm. Reported range from 1 to 9.5mm
(DR井上の意見：IODとは、interocclusal distance ?)
Does the RVD change during life?: Very little evidence
Aging causes a decrease in muscle tone that might affect RVD
(Dr井上の意見：RVDとは、resting vertical dimension ?)
Will restorative alteration in OVD cause harm?: Clinical evidence that restoring OVD is successful
Depends on muscular adaptation
(Dr井上の意見：OVDとは、occlusal vertical dimension ?)

Open bite (開咬)

Troubleshooting for Treating the Open Bite Using TADs: Learning from the Failure and Sharing 20 Clinical Tips (Dr.Tae-Woo Kim, AAO 2023)

Factors related with the increase of failure rate （Dr井上の解説：埋入したTADが脱離しやすい要因）

How to decrease the failure rate in open bite cases?

How to retain the result after debonding?

Three-dimensional Management in Open Bite Treatment　開咬　(Doan Quoc Huy,APOC 2022)

1. Muscle dysfuntion

The loss of muscle mass in Muscular dystrophy lets the lower jaw open a lot and increases the lower face height →　The posterior teeth' overeruption and facial muscle pressed in can create a narrow maxillary arch and open bite.

2. Hormone disorders

3. Respiratory diseases

4. Thumb sucking

5. Tongue thrusting

6. Large tongue

A large tongue constantly presses on the chewing surface of the upper and lower teeth causing an open bite condition.

7. Tongue-tie (ankyloglossia)

Tongue-tie (ankyloglossia) sets the tongue low and forward, which easily develops an anterior open bite and widens the lower arch but narrows the upper arch.

8. Third molars

Clear Aligners to Close Skeletal Open Bites & its Stability 1-5 Years Post-treatment (Dr. Bella Shen Garnett, AAO 2022)

前歯部開咬の治療メカニックス (Greenlee et al.AJODO 2011)

Previous Studies

What About Clear Alingers?

Clear aligners could successfully control the vertical and close opn bite without the needs of extraction or TADs.

Discussion

Myofunctional Therapy

Retention

Game Changers in Open Bite Treatment (Flavia Artese, AAO 2022)

前歯部開咬の治療方法：

後戻り：

歯に作用する異常な力：　指しゃぶり、口呼吸、舌の位置

アメリカにおける前歯部開咬の成人患者の治療方法は、①aligners, ②fixed appliances, ③TADs, ④orthognathic surgery (Huang GJ et al. AJODO 2019)

4 types of Anterior Open Bite (Chris Chang, AOSC 2021)

Possible symptoms & signs for AOB (Chris Chang, AOSC 2021)

deepbiteの学生さんのほうがdeepbiteの学生さんよりも噛む力が多きかった(Abu Alhalja ES et al., Eur J Orthod.2010)

	Mx/Md	bite force (N)
deep bite	≦22	679.60±117.46
normal	<27±5	593.08±99.69
open bite	≧32	453.57±98.30

前歯部開咬と口腔筋機能療法 (David Covell, 2020 Winter AAO)

IAOM (International Association of Orofacial Myology)

・American Speech-Language-Hearing Association (ASHA) と協力
・会員は歯科医、歯科衛生士、Speech and Language Patholgists に限る
・4日間コース
- ・筆記試験：Certified Orofacial Myologist
- ・Mandatory CE hours to maintain certification
・IOAMの認定医として名簿にのる

Reviews

dyskinesiaのある患者群では、矯正治療とOMT (Oral Myofunctional therapy)の併用治療のほうがOMTだけの治療よりも効果的だった。

開咬症例における非抜歯治療と抜歯治療の差 (Guilerm Janson, 2020 Winter AAO)

・治療内容：

・No overcorrection
・No uprighting of the posterior teeth
・No active retention
・No tongue spurs
・Speech or myofunctional therapy not evaluated

下顎骨の回転

molars（?) が1mm垂直的に移動すると下顎骨の回転によってgnathionは3mm移動する。Robert J. Kuhn et al. Angle Orthodontist. 1968;38(4):340-9

Wedge effect

Differential Mechanics Plan

治療方法	利点	欠点
習癖治療	・単純なメカニックス	・少しだけバイトが閉鎖する・治療期間が長い
アーチワイヤーで前歯の挺出	・笑うと上顎切歯が見えてくる・ネガティブなスマイル・アークが改善される	・Differential moments/side-effects on U6's
臼歯の圧下	より安定しているだろう	・下あごの反時計回りの回転・笑ったときに上顎切歯が見えにくく審美性に欠ける・TPA if TAD-based
小臼歯4本抜歯	Improves ST convexity	・切歯の後方傾斜・Non-conservative

Palatal expansion MARPE(上顎側方拡大）

WHAT IS THE IMPACT OF MARPE ON THE MIDFACIAL SOFT TISSUE? A PROSPECTIVE 3D STEREOPHOTOGRAMMETRY STUDY Dr.Aldin Kapetanovic (EOS 2024)

Discussion

Tooth Bone Borne MSE: Could This be the Total Solution? (Dr.Seong-Hun Kim,AAO 2023)

Lee JA,et al. AJODO 2021
・Preferred MIS Position: 7-8mm from CEJ
・Interradicular Space: 5-6 > 6-7 > 3-4 > 4-5

3D Guided Maxillary Skeletal Expansion (MARPE/SARPE) in Adults and Young Adult Patients (Dr.Juan Carlos Perez Varela, AAO 2023)

（Dr.井上の意見：演者は、下顎歯にだけブラケットを接着して下顎歯列のレベリングが終わってから、MARPE/SARPE をして、その後に上顎歯にブラケットを接着して治療していた。理由①骨性の側方拡大量と歯性の側方拡大量の比率を考えると、MARPE/SARPE 後に上顎歯列のレベリングをしたほうが、上顎歯列のレベリング後に MARPE/SARPE するよりも骨の拡大量の比率が高いのでしょうね。レベリングをすると歯根の周りの歯槽骨の吸収添加が始まっており歯が移動しやすい。理由②下顎歯列のレベリングが終わっていると必要な上顎の側方拡大量を計算しやすい。これは私の推測ですから、間違ってたら正解を教えてください）

（Dr.井上の意見：演者は、成人患者において、上顎頬側臼歯部と下顎唇側前歯部にスクリューを埋入し、これらのスクリュー間にClass III エラステックスを使っていた。この方法は、成人と子供で効果に差があるのでしょうか?）

（Dr.井上の意見：演者は、患者さまがドイツに引っ越したので、患者さまがスマホ(?)で歯列をスキャンしたSTLファイルを矯正科に送り、アライナーを製作して治療をしていた。もう矯正専門医は必要ない???）

Maxillary Expansion with Microimplant Assisted RPE Appliances (Dr.Peter Ngan,AAO 2023)

Five Dimensions in Treatment of Skeletal Malocclusions

Advantages of early Treatment

Why do we start Maxillary Orthopedic treatment in the Mixed Dentition?

Orthodontic Correction of Transverse problem with MARPE appliance (Carlson C. et al. AJODO 2016)

Use of RPE at West Virginia University

RPE: Age 5-13, CVM 1-3
MARPE: Age 14-20
SARPE: Age 20+

3D Treatment of Transversal & sagittal Maxillary Hypoplalsia in Adults & Young Adult Patients: Is There Only One way?　　(Juan Carlos Perez Varela,AAO 2022)

ADULTS (marpe): it cannot be predicted correctly, because pterygopalatine suture main site of resistance. So minimally invasive surgically assisted rapid palatal expansion. 成人ではMARPEの効果を正確に予測できないので、外科的に骨に切れ目を入れてMARPEをする。（Dr.井上の意見：切れ目を入れる部位がよくわからない。SARPE プラス MARPE？）

Early Treatment of Maxillary transverse Deficiency with TADs (Peter Ngan,AAO 2022)　TMDのある上顎狭窄症例の早期治療

若年者患者のMPRPE使用

West Virginia 大学でのRPEの適用：　①transverse discrepancyの量、②differential max/mand index (5mm)、③periodontal biotype、④年齢と骨の成熟度を考慮する

34症例において、Gp 1 - bone anchored RPE (13.8yrs)とGp 2 - bone and tooth anchored (14.9yrs)を比較すると、Gp 1 のほうが骨性拡大量が大きく、歯の頬側傾斜が少なく、頬側の骨のロスも少なかった。(Mohamad Sarraj et al.,APOS 2020)

MARPEによる側方拡大では、41%が骨性、12％がalveolar bone bending、48%が歯性であった。(Peter Ngan et al.,APOS)

MARPE (Celenk-Koca et al.,Angle Orthod 2018)

MARPE治療後の安定性(Chi et al.,Angle Orthod 2016)

子供に対するMSE治療(He H et al.,Sem in Orthod 2019)

25名の成長期の患者群と成長後の患者群にMARPEを使用(Graig MacMullen et al.,AJODO 2021)

MARPE治療の気道に対する影響(Peter Ngan et al.,APOS )

TADsを使用しない拡大装置の気道に対する影響(Gordon C.Cheung et al.,Euro J Orthod 2020)

MARPE治療の上気道に対する影響(Fang UYi et al.,J Xray Sci Tehnol 2020)

外科手術による上下顎骨の前方移動(Ghaddy AlSaty et al.,AJODO )

MMA手術による気道容量の変化(Parsi GK et al.,Int Oral & Mxillofac Surgery 2019)

Don't Make the Same Mistake I Did: MARPE Complication (Audrey Yoon, AAO,2022)

Is Success Predictable When Expanding with TADs? (Sercan Akyalcin, AAO, 2022)

従来の上顎側方拡大装置では、49% dental tipping, 13% alveolar bending, 38% skeletal expansion (Garrett et al. 2008)

Midpalatal Suture Maturation Stage (MPSM)

CBCTを使って測定したMidpalatal Suture Density Ratio (MPSD)は、拡大の安定性と統計学的に相関はなかった。(Titus et al.2020)

成功率は、15-19歳で83.3%、20-29歳で81.8%、30-17歳で20％であった。(Oliveira et al.2021)

complicationは年齢とともに多くなった。(Winsauer et al.2021)

Facts about Maxillary Expansion in Adults: Fracture or Remodeling? Dee-Joon Lee, AAO, 2022)　成人のMARPE：破折かリモデリングか？

　MARPEの成功率は、男性61,05%、女性94.17%、全体で79.53%であった。(Ji Yoon Jeon et al., Clinical Oral Investigations 2022)

　上下の前歯が傾斜移動した症例群（27例）と歯体移動した症例群（26例）における根尖の前後的な移動量、A点、B点、soft tissue A点、soft tissue B点の前後的な移動量を調べた。(Wonkyeong Baik et al., Korean J Orthod 2022)

Miniscrew Assisted Rapid Platal Expansin

Conclusion: ・Of the 19 cases treated with MARPE, 16 were successful in opening the palatine suture, representing 84.2% of total maxillary expansion success.; ・There was a significant reduction in the buccal bone thickness of the first molars and, in general, an increase in the palatal bone thickness of all evaluted teeth.; ・The transverse increase was statistically significant for all interdental distances, as well as nasal base and jugula widths.; ・Buccal inclination was statistically significant of the first molars.; ・The midpalatal suture was opened in a triangular shape, with the smallest increase observed in the nasal base (2.82mm) and the largest increase observed in the intermolar distance (6.37mm). The skeletal expansion, measured in the maxillary width represented 48% of the total transversal gain measured at the molar level.; ・Expansion with this type of MARPE appliance showed to be an effective method for the correction of maxillary atresia in young adult patients combining skeletal and dental effects.

Cortoiopuncture

This clinical case showed:: ・A case of failure in expansion with a device supported by 4 mini-implants on the plate; ・A second successful approach in which the corticopuncture technique was applied using a mini-implant.; ・The coticopuncture performed along the midpalatal suture can help to decrease sutural resistance in rapid maxillary expansion in adult patients, as the mechanical stimulus of perforation attracts a greater amount of inflammatin mediators that act in bone resorption and neoformation (proven in scientific research)

Conclusion / Clinical Application: ・MARPE's success was related to age and a greater bone thickness.; ・In failure cases the subsequent performance of corticopuncture provided the success of the maxillary disjunction.

MARPE (Mini screw Assisted Rapid Palaral Expansion)の作用

MSE の利点

上顎側方拡大

成人患者の上顎側方拡大

Periodontitis (歯周病）

Orthodontics and periodontrogy: two disciplines, one goal. James Deschner. EOS 2024

Long-term impact of orthodontic treatment on gingival recession in adults with compromized anterior teeth: a retropspective study. Ghazal Hasanzadah. EOS 2024

Timing of soft tissue augmentation in orthodontic patients, Before or after treatment? (Dimitris Kloukos, EOS 2024)

Development of gingival recession in orthodontically treated patients in comparison to untreated individuals. (MALMO UNIVERSITY EOS 2023) (092107511)

Gingival Recession Development in Orthodontic Patients (D.Kloukos et al.EOS 2023) 091737818

Periodontium and Orthodontics - in Health and Disease: Managing Periodontitis stage IV patuents with Pathological Tooth Migration, Integration of Periodontal and Orthodontic Therapies

IMG_20230614_083450980

Good results

Guidline for Ortho-Perio Integrated Approach　歯周病患者の矯正治療　(Chung Ju Hwang,APOC 2022)

歯周病の発現率

Alveolar bone levels

Patients at high perio risk during Orthod Tx

Retention & Relapse (保定と再発)

Do we need to sandblast or just pumice the enamel surface before our lower retainers? A single-operator 2-arm 18-month 88-patient randomized controlled trial. (Estelle Phonchareun. EOS 2024)

Pre-fabrecated bonded retainers: A randomized controlled trial (Sara Waldenstrom EOS 2023) (23155)

Comparison of Effectiveness of Coaxial versus Linked Bonded Retainers: A Randomised controlled Trial E. Versluysen et al. EOS 2023 IMG_20230614_090627061_HDR

・ No caries and no unwanted tooth movements were reported after 1 year in retention

Orthodontic retention: where are we now? Marie Cornelis. EOS 2023

Factors for relapse
・Gingival & periodontal tissues
・Function
・Occlusion
・Posttreatmet facial growth & development

Biological mechanisms of relapse
・PDL reorganization: 3-4 months
・Gingival colageneous fivers reorganization: 4-5 months
・Gingival elastic supracrestal fibers remodeling: >7-8 months

Retention protocols are stil largely contoversial!
・France: 84% orthodontists prefer fixed permanent retention (Renkema et al 2009)
・Swiss: 87% orthodontists prefer fixed permanent retention (Lai et al 2014)
・America: Removable retention preferred
・Australia: Maxilla: 7.6% fixed - 39% removable, Mandible: 39% fixed - 22% removable (Meade & Dreyer 2019)

Fixed vs removable? Maxilla
Stability of maxillary anterior teeth: removable retainer alone equally efficient as combination of removable & fixed retainer (Bjering et al 2015)

Fixed vs removable? Mandible
Fixed retainers: Improved preservation of mandibular alignment compared to removable retainers 4 years postteatment (Dalya et al 2018)

Dual retention = Fixed retainers in addition to removable retainers overnight
If the fixed retainer fails: teeth can be held in position by removable retainer until fixed retiner can be repaired (Johnston & Littlewood 2015)

Fixed retainers: how?
1.When, where, how do fixed retainers fail?
2.Canine-to-canine or canine-and-canine?
3.Which type of wire?
4.How to avoid side effects?

Bond failures:
Wide variation in risk of bond failure: 3.5% to 53% (Iliadi et al 2015)

Types of bond failures
・Most debondings: composite-enamel interface (Bovalietal 2014)
・Retainer wire-composite interface = detachments happening at a later stage: "secondary mechanism of failures" (Ardshna 2011)

Timing of failures:
Most failures:
・within first month (Bovali et al 2014)
・withi first 3 to 6 months (Dahl et al 1991, Lie Sam Goek 2008)
thus when tooth movility is highest

First year of retention: 5 times more failures compared to 2nd year - probably of failure significantly drops after a year (Cornelis et al 2022)

Repeated failures ・Repeated failures of the same tooth: 21% (Bovali et al 2014) - 28% (Taner & Aksu 2012) in vito: bond strength of rebonded multistranded wires to enamel: signigicantly lower than initial bond strength (Cooke and Sherriff 2010)
・Rebonding to previously bonded enamel: unpredictable. due to difficulties in removing the adhesive remnants under the wire?

Regular retention visits; necessary mainly during the first year. BUT even after 1 year, failures continue to occur!

Advantage of canines only?

Failure rate after 2 years:
・canine-and-canine lingual retainers: 18%
・canine-to-canine　0.0215-in multistranded: 53%
Stormann & Ehmer 2002

Failure rate after 3 years:
・canine-and-canine lingual retainers: 9%
・canine-to-canine: 27%
Artun et al 1997

Advantage of canines only?

Disadvantage of canines only?

Design for lower fixed retainers. Cleo Wouters et al 2019

Clinical advice: Q2: Canine-to-canine or canine-and-canine?

Which type of wire?

Round multistranded fixed retainer

Rectangular wires?

Heat-treated or not?

Dead-soft wires?
0.016x0.022-in dead-soft 8-braided flattened wire

Dead-soft wires? Development fo a clinical practice guidline for orthodontic retention. Cleo Wouters et al 2019

Which wire dimension? Multistranded stainless steel wire

CAD/CAM fixed retainers?

2-year follow-up: No difference in failure rate

Unexpected tooth movements

Indirect vs direct bonding of mandibular fixed retainers 2023 AJO-DO)

Clinical advice - Q3: How to avoid side effects?

Risk decreases considerably after 1 year

The Future of Orthodontic Retention & How to Get Your Patients to Wear Retainers (Dr Simon J Littlewood,AOSC 2023)

If bonded retainers are going to fail, this happens early　→　Review bonded retainers, face to face within a month of debond

How to get your patients to wear retainers
Simon's Top 10 Tips

Do the videos work? (Parker,Bharmal et al.2020)

Bonded Retainers - Everything You Wanted to Know But Were Too Afraid to Ask (Dr.Simon Littlewood, AOSC 2023)

・What's the best type of bonded retainer?
・Technical tips for placing bonded retaines
・What problems can occur with bonded retainers?
・CADCAM bonded retaines - are they superior?

・Bonded retaners or Removable retainers?

Essential use of bonded retainers

Bonded or Clear Plastic Retainers (Eur J Orthod 2018)

Oral Health
・No difference in caries
・More plaque with bonded retainers
・More calculus with bonded retaines
・More gigival inflammation with bonded retainers
・No evidence of periodontal attachment loss

Patient satisfaction
Overall patients preferred bonded retainers
・More comfortable
・Needed less compliance
・Less effect on speech
...but bonded harder to clean

Stability
・No difference in itercanine or intermolar width
・No difference in overjet or overbite
・No diffence in PAR score (quality)
・There was a difference in irregularity

Cost-Effectiveness
・Looked at material & labour costs
・Bonded retainers more expensive overall

Al-Moghrabi et al.AJO-DO 2018 (4-year follow-up)
・Less relapse in lower with bonded
・67% no longer wear vacuum-formed retainers

What's does this high quality evidence tell us?
・Upper arch - both equally good
・Lower arch - bonded slightly better retention
・Bonded more potential for health issues
・Removable more cost-effective in upper
・Bonded more expensive in lower
・Compliance is a big issue for removable
・Most bonded fail early - so review after 1 month

Which type of bonded retainer should I use?

Common Types of Bonded Retainers
・Multi-strand
・Canine-and-canine
・Polyethylene ribbon retainer
・Dead-soft wire
・Ortho Flex-Tech
・Nickel-Titanium

Polyethylene ribbon retainer
(Nagani et al.2020, Sobouti et al.2016, Torkan et al.2014, Salehi et al.2013, Bolla,2012, Rose et al.2002)

Canine and canine retainer
(Ferreira et al.2019, Al-Nlmn et al.2009)

Dead-soft Co-axial Wire
(Gunay et al.2018)

Ortho-Flex Tech

Clinical Tips
・Etch & primer first
・Place minimal composite as "undercoat"
・Lay chain onto this adhesive undercoat and take up slack in chain
・Place "overcoat" of composite
・Now light-cure
・Ensure composite covers almost entire wire across tooth width

Warning: when NOT to use Ortho-Flex Tech
To keep spaces closed

Nickel-Titanium CAD-CAM retainer - "Memotain" Retainer
・Made of nickel titanium - shape memory & flexible
・Precision made - excellent fit, easier to place
・Laser cut from sheet of Nitinol so no work hardening

Jowett et al.J Orthodontics 2022

・There is no perfect bonded retainer
・Understand advantages & disadvantages of each
・Recognize problems & how to minimise these

Problems
1.Bonded Retainer Failure (12-50%)(Kucera et al.BDJ 2021)

Avoiding bond failure

Where is the failure? (Kucera et al.BDJ 2021) ・Enamelcomposite interface
・Wire fracture
・Between wire and composite

General top tips
1.Plan for the fixed retainer from the begining

Problems
1.Bonded Retainer Failure (12-50%)
2.Effect on periodontal health

Retainers

Problems
1.Bonded Retainer Failure (12-50%)
2.Effect on periodontal health
3.Unwanted tooth movement

Conclusions

dental crowding relapse

T1: pretreatment
T2: posttreatment
T3: long term postretention

	T1	T2	T3	P
Maxillary dental casts measurements
Little's Irregularity Index	6.84±2.97	0.36±0.67	1.55±1.95	0.000
3-3 width	34.20±2.50	34.85±1.87	33.85±2.75	0.183
5-5 width	44.79±2.66	43.40±1.68	41.90±2.48	0.000
6-6 width	49.19±2.59	48.18±1.42	47.53±2.48	0.057
Arch lengtn	27.89±2.71	22.71±3.50	20.10±2.31	0.000
Arch perimeter	70.66±5.98	61.91±3.06	58.86±3.72	0.000
Mandibular dental casts measurements
Little's Irregularity Index	3.31±2.10	0.58±0.97	3.66±2.11	0.000
3-3 width	26.53±0.50	26.73±1.32	24.22±2.69	0.008
5-5 width	39.07±2.64	35.40±1.92	34.48±2.47	0.000
6-6 width	44.05±2.01	40.74±1.42	41.78±2.91	0.000
Arch lengtn	23.11±1.87	17.86±1.93	15.57±1.75	0.000
Arch perimeter	62.20±5.53	52.75±3.02	49.94±3.10	0.000

	T1	T2	T3	P
Maxillary dental casts measurements
Little's Irregularity Index	8.40±4.10	0.11±0.41	2.71±2.38	0.000
3-3 width	34.57±2.25	35.25±1.64	34.23±2.14	0.032
5-5 width	43.81±2.18	42.85±1.89	41.70±2.23	0.000
6-6 width	49.33±1.96	47.89±2.49	47.54±2.80	0.000
Arch lengtn	28.08±2.64	22.08±2.90	21.17±1.62	0.000
Arch perimeter	72.16±5.29	62.96±2.67	60.46±3.49	0.000
Mandibular dental casts measurements
Little's Irregularity Index	9.94±2.65	0.48±0.81	4.60±3.05	0.000
3-3 width	25.73±2.24	27.15±1.38	25.36±2.31	0.000
5-5 width	37.17±2.20	35.46±1.74	34.05±2.08	0.000
6-6 width	42.89±2.24	40.39±2.30	40.65±2.60	0.000
Arch lengtn	22.72±2.52	18.23±2.33	16.93±1.98	0.000
Arch perimeter	63.76±3.11	53.60±2.27	50.46±3.35	0.000

Conclusions

After 37 years ...

The transversal and longitudinal dimensions of the dental arches decreased while the crowding increased;

The mandibular dental alignment obtained with the treatment with extraction of 4 premolars was not stable in the long term.

orthodontic extraction spaces

矯正装置撤去時　T1
矯正装置撤去後1年　T2
矯正装置撤去後5年　T3

T2で残存抜歯空隙が出現した割合は(perentages of quadrants)、6.3% from the total, 9.7% from the closed ones。

T3で残存抜歯空隙が出現した割合は(perentages of quadrants)、2.2% from the total, 3.3% from the closed ones。

T2で残存抜歯空隙が閉鎖した割合は(perentages of quadrants)、17.5% from the total, 50.2% from the open ones。

T3で残存抜歯空隙が閉鎖した割合は(perentages of quadrants)、7.5% from the total, 21.4% from the open ones。

T1, T2, T3で残存抜歯空隙がある割合は(perentages of quadrants)、9.9% from the total, 28.4% from the open ones。

T1, T2, T3で残存抜歯空隙がない割合は(perentages of quadrants)、56.6% from the total, 87% from the closed ones。

残存抜歯空隙は徐々に閉鎖する傾向にある
　　T1の残存抜歯空隙：0.29±0,45mm
　　T2の残存抜歯空隙：0.21±0.43mm
　　T3の残存抜歯空隙：0.14±0.37mm

Conclusions: ・The percentage of patients with residual spaces at the end of treatment was 56.4%;
・space reopening and late closure take place mainly in the first year after treatment, but they still occur more discreetly in the longterm;
・From the quadrants which were closed at the end of treatment, 87% remained stable;
・There was significant reduction in orthodontic extraction space dimension in the short- and long- term stages, with significantly greater reduction in the mandibular arch

skeletal stability (Peter Buschang, AAO 2021)

Orthodontic Relapse vs Instability
・Relapse

・Instability

- relates to posttreatment changes that are not due to relapse

More stable occlusion であった症例は、①Greater ACNC ②Greater occlusal suport ③Higher bite forces ④More and denser bone であった。

Take-home Mwssage #1

Take-home Message #2

・Posttreatment overjet is less stable than posttreatment molar relations

Take-home Message #3

Bonded retainer

Unexpected Complicated Bonded Retainer (UCBR)

5%(Katsaros et al.,2007)、2.7%(Renkema et al.,2001)、1.1%(Kucera & Marek,2016)。50%が再治療を要した。

I. ボンダブル・リンガル・リテーナーがパッシブに接着されなかった。

・dentoalveolar compensation

・咬合力のanterior vector

III. 機械的外傷　－　ワイヤーの金属疲労、接着剤の脱離

デッド・ソフト・ワイヤーは切れやすく歯間にスペースが生じやすい。

ワン・ストランデッド・ワイヤーがいいかもしれない。

マルチ・ストランデッド・ワイヤーは不安定だ。Zachrisson, JCO 1995. Katsaros et al. AJODO 2007. Kucera et al. AJODO 2016.

前歯6本にボンダブル・リンガル・リテーナーを接着していても、200症例のうち6症例（2.7%）で予想外の歯の移動があった。（Renkema et al. Am J Orthod Dentofacial Orthop 2011,139:614-621）

Risk Management （リスク・マネジメント）

Risk Management in Orthodontics (Dr,Athanastios E.Athanasiou, EOS 2024)

1. ROOT RESORPTION, Exteral Apical Root Resorption (EARR)

・it is probably an inevitable consequence of tx
・Typically amounts to 1-2mm during tx
・Affects almost all teeth
・Has no cliicalconsequences

The average tooth color becomes darker and shifts into more red and especially yellow color range after orthodontic tx.

Orthodontic debonding and cleaning procedures were found to have statistically significant effects on the CIE color prameters of treated teeth, during the first retention year.

4. ADVERSE EFFECTS DURING ORTHODONTIC TRACTION OF IMPACTED CANINES

5. EXTRA-ORAL DAMAGE

7. ORTHODONTIC MALPRACTICE

Root resorption （歯根吸収）

Diagnosis and Treatment of Maxillary Central Incisors with Compromised Prognosis (Dr.F.A.Uribe,AAO 2023)

Compromised Maxillary Central Incisor

Short Root Anomaly

Results; (23 SRA patients and 25 control patients) (A.Cutrera et al.WILE,2018)

Clinical Management of Orthodontic Root Resorption 歯根吸収 (Glenn Sameshima,APOC 2022)

retraction	resorption
0-1,5mm	1.04mm
1.5-3.0mm	1.46mm
3.0-4.5mm	1.57mm
4.5mm+	1.67mm

If you move a tooth with an immature apex　→　Orthodontic treatment had no significant negative impact on the continued root development of incomplete roots with two-thirds root formation. (Wan J.et al.AJODO in press)

Root-filled teeth　→　endodontically treated lateral inisors significantly less EARR than ccontralateral side (Yun Ju Lee,AJODO 2016)

What if i have a patient with higher risk?

What should I do if I see root resorption at progress?

Management of EARR post-treatment

When does root resorption cease?

Long-tre, EARR outcome: Literature

Predisposing/diagnostic risk factors

Treatment risk factors

Management

root resorption degree

Evaluation of the degree of root resorption: ・The scoring system proposed by Malmgren et al was used to quantify root resorption degree.; ・Initial and final periapical radiographs were scanned using the Sprint Scan 35 Plus Scanner, with a resolution of 675 dpi at a scale of 1:1. The initial radiographs were used as a parameter of the resorption severity durin evaluation.; ・The images were analyzed with Phtoshop software at 300% enlargement, without quality loss.; ・Blind evaluation.

variable	Group 1 　・Class I malocclusion 　・57 patients 　・Mean age=13.89 years 　・Treatment time=29.09 months			Group 2 　・Class II malocclusion 　・53 patients 　・Mean age=13.49 years 　・Treatment time=30.81 months
	mean	median	SD	mean	median	SD	P
Mx2R
Mx1R
Mx1L
Mx2L
Mean superior resorption	2.03	2.00	0.68	2.27	2.00	0.83	0.193

Md2R
Md1R
Md1L
Md2L
Mean inferior resorption	1.91	2.00	0.59	1.92	2.00	0.62	0.825

EARR (Glenn Sameshima. IOC,2020)

The root resorption occurs every time a toorh is moved orthodontically but is reversible unless it occurs at the root apex (Jimenez-Pellegrin C, Arana-Chavez VE. AJODO,2004)

Generally for a normal length, non-periodontally involved tooth:

EARRの発生率	2-4mm	>4mm
上顎中切歯	22.0%	4.2%
上顎側切歯	25.3%	6.1%
上顎犬歯	24.1%	5.4%

Risk factor (Hartsfield J. AA 2010): Genetic 65%, Mechanical 15%, Unknown 20%

Diagnostic Risk factors (Sameshima & Sinclair 2001 AJODO)

Idiopathic root resorption: Familial expansible osteolysis, Multiple Idiopathic EARR

Treatment risk factors ?

Teeth with immature apices have less risk

Endodontic treatment may have a protective effect (but do not recommended to stop EARR)

Management

歯根吸収 (Anne Marie Kujipers Jagtman. IOC,2020)

矯正治療のマイナス面

Grade	Definition
0	No evidence for resorption
1	Irregular root contour
2	Apical root resorption less than 2mm
3	Apical root resorption > 2mm and < 1/3 of original root length
4	Root resorption exceeding 1/3 of original root length

Apical root resorption と Slanting surface resorption

Lund et al. 2012 が、152名の患者で275本の歯根をCBCTで調べたところ、上顎中切歯で15.1%、上顎側切歯で11.5%の Slanting surface resorptionがあった。

#2 What factors increase the risk of developing EARR during orthodontic treatment?

Treatment related factors	GRADE	Patient related factors	GRADE
Duration of active treatment (not)	low	Gender & age (not)	Moderate
Duration in rectangular wire (not)*	low	Previous trauma (not)	low
Horizontal apical displacement (yes)	very low	Endodontic treatment (preventive)	very low
Vertical apical desplacement (unclear)	very low	Root / tooth morphology (not)*	low
Overjet reduction (unclear)	very low	Root length (not)*	very low
Extraction vs non-extraction (yes)	low	Lip/tongue dysfunction/habits (unclear)	very low
Elastics Class II (unclear)	very low	Agenesisi (not)	low
Elastics anterior (not)	low	Previous treatment (preventive)	low
Wire sequence (not)	low	Overjet & overbite	very low
Distance to palatal bone (unclear)	very low	Angle Clasiffication (not)	very low

#1 What types of radiographs enable the diagnosis/detection of orthodontically induced EARR?

#3 What treatment protocol should be followed when EARR has been detected during treatment?

#4 What is the follow-up protocol for patients with EARR?

The clinical message .......

クリア・アライナーの100症例において20%以上の歯根吸収があったのは6%の切歯であった　（Krieger E et al. Head Face Med 2013 Aug）

エビデンスがない

No OIRR	44%
Mild OIRR	36%
Moderate OIRR	17%
Severe OIRR	3%

Etiology　は、Genotype 80% と　Other risk factors 20% (?, APOC2016)

Artun 2005	1 - Take periapical Rx(s) 6 months after initial brkt placement
Levander 1994	2 - Alternate archwire activations
Justus 2015	3 - Use tx strategies that minimize dental movements (root sparing strategies)

	治療前	ディボンディング時	治療5年後
Fixed lingual retainers 有	10%	19%	38%
Fixed lingual retaines なし	6%	10%	33%
治療しなかったグループ		10%	21%

flexible wire retainesを接着した患者の3-5%　において、治療後に予想外の歯の動きがあった。(Katsaros et al. 2007, Renkema et al. 2001)　(?, MOIP2016)（Dr. 井上の解説：　右上2が下顎前歯と接触していないにもかかわらず、著しく唇側傾斜しているスライドがあった）

Smile （スマイル）

2022 Jacob A.Salzman Award Lecture; Weird Tales About Teeth or Orthodontics in Daily Practice (Steven J.Bouman, AAO 2022)

　Appropriately applied extraction treatment does not produce a routine adverse effect on profile (fullness) or smiles (corriors), tmd, or airways. （Dr,井上の意見：抜歯治療は、側貌をフラットにし、バッカルコリダーを大きくし、顎関節に悪影響があり、気道を狭くするという意見もあるが、これらは事実でないという発表です）

　Mini-screw anchorage should finally eliminate concerns for adverse facial changes form extraction as spaces can ba closed predictability while maintaining or enchancing specific incisor position.

Striving for Ideal White & Pink Esthetics (Liwia E Minch,AAO 2022) 白色(歯)とピンク色(歯肉)の審美の達成

Smile Ethetic index (Rotundo R.et al.,Eur J Oral Implantol 2015)

Surgery first （サージェリー・ファースト）

	S.First	S.Early	S.Late	S,Last	S.Only	S.Never
Esthetic Motivation	+++	+++	++	+++	+++	-
Occlusal Motivation	+	++	+++	-	-	+++
Respiratory Motivation(OSA)	+++	+++	-	+++	+++	-
3D Virtual Orthodontic Setup	+++	+++	+	-	-	+
Patient Decides Timing	+++	++	+	+++	+++	NA
Preop Orthodontics	-	+	++	+++	-	NA
Use of TADs	+++	+++	-	+++	+++	-
Corticotomie	+++	+++	-	-	-	+
Orthodontic Complexity	+++	+++	+	NA	NA	+++
Surgical Comlexity	++	++	+	+++	+++	NA

Sendai (Japan)	Passive wire bonded to the teeth or contoured/ 1-2 monthes of PreSx ortho
Taipei (Taiwan)	No wire, only brackets
Seoul (Korea)	Passive wire bonded to the teeth or contoured/ 1-2 months of PreSx ortho
Barcelona ( Spain)	No wire Or "Soft wire" day before Interdental Miniscrews (4-8)
UConn-USA	Niti wires, Preferable 16x22 on Maxilla. 16x22 NiTi in mandible or Coaxal 16x16

Sendai (Japan)	Splint worn 4 weeks post surgery
Taipei (Taiwan)	splint worn post surgery 1-4weeks
Seoul (Korea)	Splint worn post surgery 4 weeks
Barcelona (Spain)	No splint after surgery unless maxillary segmentation (2 weeks)
UConn-USA	Niti wires, No splint after Sx. Only if Sx expnasion

手術による下顎の後退量が10mmぐらいまでであれば、気道の狭窄による問題は生じない（？, JAO2016）

新しい治療方法は魅力的だが、科学的な裏づけが得られないこともしばしばある。たとえば、Surgery without orthodontics, Resorbable fixation, Distraction osteogenesis, TMJ Arthroscopy, Rotation of the MMC　などが紹介された当初は注目を集めたが、しだいに振り返られなくなった。Surgery first は、どのような運命をたどるのだろうか。(Johan Reyneke, MOIP2016)

Surgical orthodontics （外科矯正）

Surgery and Orthodontics: In Adequate Planning Leading to Cpmplications (Kathrine P.Klein,AAO 2022)

外科矯正チーム：　Oral and Maxillofacial Surgeons, Orthodontists, Psyhologists, Speech and Language Specialists, Plastic Surgeons, Dieticians, Nurses, Dentists 　

TADs (スクリュー、矯正インプラント)

The efficacy of maxillary protraction using skeletal anchorage - a systematic review and meta-analysisi Dr.Sarah Joda Kathem (EOS 2024)

Troubleshooting for Treating the Open Bite Using TADs: Learning from the Failure and Sharing 20 Clinical Tips (Dr.Tae-Woo Kim, AAO 2023)

Factors related with the increase of failure rate （Dr井上の解説：埋入したTADが脱離しやすい要因）

How to decrease the failure rate in open bite cases?

How to retain the result after debonding?

Molar Distalization using TADs: Postential, Limitation, and Precautions (Dr. Sung-Hoon Lim, AAO 2023)

Take home message 1
Evaluate the third molar

Take home message 2
Observe the distal tipping and gingival recession of second molars

・Preexisting distal tipping requires more root distal movement than the crown. ・Extraction treatment can be better.

Take home message 3
Intrusive and lingual distalizaiton can reduce the collisio with anatomic obstacle. → Applicable to open bite cases and Class III surgery cases.

Conclusion
・Distalization is unpredictable and risky when the alveolar ridge lacks sufficient width and height. ・Prepare an alternative plan from the start and monitor the second molar respose.

Clinical Applications of TADs in Challenging Deep Overbite Cases (Dr.Jae Hyun Park,AAO 2023)

スマイル時に見える歯茎の適切な量は 2.5 (1.5-4) mm (Simone Parrini et al.AJODO 2016)

Force Vectors for the Intrusion of Six Segments:

Midline Bony Cleft (Huang WJ et al.Pediatr Dent 1995)

Mandibular symphaseal distraction osteogenesis → None of our patients experienced TMJ dysfunction symptoms during the entire follow-up period.(Alkan et al.IJPMS 2007)

Mandibular distraction osteogeneis: a systematic review of stability and the effects on hard and soft tissues (Rossini et al. IJOMS 2016)

Three-dimensional evaluation of mandibular midline distraction: A systematic review (Arilla et al, J Craniomaxillofac Surg 2018)

Summary

Management of Complex Orthodontic Problems with TADs (Ravindra Nanda AOSC 2023)

Incisors Extrusion

Radiographic Evaluation of Installation Site for Mini-implant　アンカー・スクリューの脱落　(il-Hyung Yang,APOC 2022)

Primary Stability & Secondary Stability

Success rate of OMI reported

No difference (Spyridon N. et al.AJODO 2012 ?)

Statistical difference in (Spyridon N. et al.AJODO 2012 ?)

No Difference (Fahad A. et al.Euro J Orthod 2018 ?)

Statistical difference in (Fahad A. et al.Euro J Orthod 2018 ?)

Long-term Evalusatin of Class III Orthopedics Using Skeletal Anchorage (Tung Nguyen,AAO 2022)　（Dr.井上の意見：Bone-Anchored Maxillary Protraction (BAMP): 頬骨につけたプレートと下顎前歯頬側骨につけたプレートの間にエラスティックスをつけて骨格性反対咬合を治療）

Retention Protocol
・Wear elastics (250 grams) to anchors at nighttime until completion of growth
・See patients every 6 months　　・If OJ is decreasing, increase elastic wear　　・If OJ is increasing, lower force level to 150 grams or have wear elastics every other night
・Anchors can be removed at the same time as 3rd molar extractions （Dr.井上の意見：このアンカーはプレート）

After 16 years experiance with BAMP, what have we learned? ・Most effective for maxillary deficient Class III
・More effective with mild to moderate Class III
・More effective when initiated at a younger age when Zygomatico-maxillary sutures are immature
・Primarly restrain/redirects mandibular growth after 15 years of age
・More effective with mild to moderate Class III
（Dr.井上の意見：以下は外科矯正の問題点）
・Expected some surgical failure of maxillary bone plate (UNC -15%)
・Need to retain until completion of growth
　- Mandibular prognathic and asynmetric Class III have the worse long-term success rate

Orthodontic Microimplant: The Last Two Decades of Evolusion in How & What Happened (Hee-Moon Kyung,AAO 2022)

上顎歯列のEn Mass retraction

Class II Correction with Maxillary Distalization & TADs (Jae Hyun Park,AAO 2022) Class II 患者のTADによる上顎歯列の遠心移動

Fudalej P et al.,AJODO 2011

大臼歯の遠心移動（Oh et al.,AJODO 2011）

上顎第一大臼歯の平均の遠心移動量は、歯冠レベルで3.78 mm、歯根レベルで3.20 mm　(Sugawara et al.,AJODO 2006)

IZC（頬骨下稜）スクリューの利点欠点　(Santos et al.,J Orthod 2017), (Jia et al.AJODO 2018) (Baumgaertel et al.,Clin Oral Impl Res 2009) (Liou et al.AJODO 2007)

口蓋側では、T-Zone (rugaeの後方部分とその後方の口蓋正中部分）にスクリューを埋入する　(Wilmes et al.,JCO 2016)

MCPP（口蓋にスクリュー）では、第一大臼歯が4.2㎜遠心移動、1.6㎜圧下、2.0degrees遠心傾斜、上顎中切歯が0.8㎜挺出。頬側歯肉にスクリュー埋入では、第一大臼歯が2.0㎜遠心移動、0，1㎜圧下、7.2degrees遠心傾斜、上顎中切歯が0.3㎜挺出。(Le et al.,Angle Orthod 2018)

adolescents では、上顎大臼歯の遠心移動の前に第三大臼歯を抜歯する必要はないようだ。(Jou Hee Park et al.,AJODO 2021)

大臼歯の遠心移動と第二第三大臼歯の萌出ステージの関係 - systematic review (Flores-Nir et al.,Angle Ortho 2013)

Distalize and Class II Treatments with Skeletal Anchorage: When and How? (AEEDC 2022)

Factors deciding the prognoses and stability of the screws are:: 1) Optimal hygiene and brushing around the screws; 2) Soft tissue quality and quantity; 3) Bone quality and quantiry; 4) Biomechanics

Buccal Shelf TADs (AEEDC 2022)

Anatomy: ・The evalustion of the buccolingual dimension showed that the mandibular canal was located either in contact with or close to the lingual cortical plate (less than 2mm) in the molar region of the majority of the cades and at 15-17 mm to the alveolar crest. As it proceeds anteriorly it moves toward the buccal aspect of the mandible, where it finally emerges through the mental foramen. Three emerging patterns of mandibular canal were observed: sharp turn (53.2%) soft curved exit (28.8%), and straight path (17.4%) (Eclzrcio et al. 2020); ・Anatomic limites for orthodontic tooth movement can be divided into 2 types according to level: corown and root level. At crown level, the only anatomic structure that can be encountered during orthodontic tooth movement is the mandibular ramus. When a crown of a tooth is forced against the cortical bone, enamel makes direct contact with the bone, leading to pressure necrosis. (Sung-lin et al. 2014); ・the root level, the cortical layer of the alveolar bone limits tooth movement. When the root makes contact with the inner cortex, tooth movement slows, and the risk of root resorption is dramaricalluy increase. If the tooth moves farther to the outer cortes, it can cause alveolar bone loss, gingival recession and root esxposure, compromising periontal support. (Tae-Hyun et al. 2014); ・The mean distances between the root and the inner and outer lingual cortexes at a level of 10 mm from the cementoenamel junction is 2.87 and 6.73 mm, respectively.; ・In most patients skeletal, the posterior anatomic limit for molar distalization is the lingual cortex of the mandibular body. Lateral cephalograms provide limited but valuable information for predictin the posterior available space and the presence of root contact with the inner lingual cortexs. (Sung-Jin et al. 2014); ・CT evalustion is recommened in patients requiring significant molar distalization, when the lateral cephalograms show posterior available space less the 3.9 mm. A reasonabe amount of molar distlization is approximately 3mm. Extraction of 38 and 48 required. (Young-Lin 2011)

Insertion protocol: ・No pilot drill is needed, screw heads, at the insertion point, are at least 5mm above the soft tissue. On average, there is 5mm of bone engagement. The optimal position for the TAD is lateral to the contact of the lower first and second molars. Approximately 5-7mm below the alveolar crest. And inserted at an orentation of about 30 degrees to the bone surface. (Chang et al. 2014)

Failure Rate: ・The overall failure rae of buccal shelf screw placement is 7.2%. (Chang et al. 2014)

Distalize and Class II Treatments with Skeletal Anchorage: When and How?

Factors deciding the prognoses and stability of the screws are:: 1) Optimal hygiene and brushing around the screws; 2) Soft tissue quality and quantity; 3) Bone quality and quantiry; 4) Biomechanics

An Overview on Mini-screws in Orthodontic Practice Part I (Olivier Quinty, AEEDC 2022)

Are TADs 100% Stable ?: ・Orthodontic miniscrews can remain clinically stable but not absolutely stationary under orthodontic loading. Unlike an endosseous dental implant that osseointegrates, orthodontic miniscrews achieve stability primarily through mechnical retention. (Liou et al. 2004)

Are We supposed to load them immediately ?: - Loading protocols for screw involve immediate loading or a waiting period of 2 weeks to apply orthodontic forces. (Ohasfu et al. 2006)

Flap or flapless placement ?: - no significant association between the placement technique and the success rates of the miniscrews. (Ayawaki et al. 2003)

What are the risks and complication ?: 1) Root trauma and root proximity
No pulpal involvement and if the affected area is not more than 4 mm square the outer root and periodontium may demonstrate complete repair in three to four months, (Asdkekricks et al. 2005) (Feaiinafly et al. 2008); 2) Staionary anchorage failure
TADs may become loose, tip and extrude under orthodontic load. Miniscrews that become mobile will not regain stablility and may need to be removed and reinserted. (Liou et al. 2004); 3) Soft-tissue irritation and miniscrew slippage
TADs placed in loose alveolar mucosa may result in sot-tissue irritation, tissue overgrowth and minor aphthous ulceration. (Myowoki et al. 2003); 4) Nerve infury
The greater palatine nerve (Finks at al. 2007)
The inferior alveolar nerve (Auks et al. 2007); 5) Nasal and mazillary sinus perforation
Small (less than 2mm) perforations of the maxillary sinus heal by themselves without complicaions. (Brangenre et al. 1984) (Atdekian et al. 2006); 6) Relapse
Extrusion of intruded molars may occur. The average relapse rate for first and second molar intrusion is approximately 30%. (Sugawara et al. 2002); 7) Miniscrew bending, fracture, and torsional stress (Kuroda et al. 2014)

What are the risk factors for stability ?: - Material length diameter: Differences in the findings, not to be assciated with the miniscrew implant failure rates. (Papagcorgio et al. 2017); - Good oral hygiene around the implant site is very important because it parevents soft tussue infammation, which is associated with higher TAD failiure rates. (Dalssandra et al. ); - Age, sex, side of insertion: no association of miniscrew implant failure rates. Papogcorplow et al. 2012); - Cortical bone thickness, quality and quantity of the alveolar bone considered as important influential factors affecting the success rate of orthodontic mini-implants as it related to the primary sability, (Marquran et al. 2014); - Maxilla or Mandible: There was a significantly higher success rate for miniscrews placed in the maxilla compared with those in the mandible. (Hyun Park et al. 2021)

Where are the safe zone ?

Upper molar distalization: - The first molar distalization is 2.75 mm when buccal interradicular TADs were used, but 4.07 and 4.17 mm with palatal and infrazygomatic TADs. Palatal bone-anchored pendulum-like appliance are associated with a large amount of distal tiping of the first molars (11.17 degrees). While the infrazygomatic and buccal interradicular TADs showed 3.99 and 1.70 degrees, respectively. The three subgroups of TADs-supported distalization produce in a small amount of first molar intrusion (0.06-0.69 mm). (Mohamed et al. 2021); - Analysis of the data showed significant distalization of the maxillry first molars produced by the FCA (mean: 4.00 mm) when compared with the untreated group (mean: 0.95 mm). The rate of molar movement was 1.00 mm per monthe, which, however, was associated with distal tipping of the first molars (8.56 degrees). (Monhas et al. 2010)

Maxillary expansion: - The TBB RPE induced significantly higher nasal airway flow annd lower nasal resistance values than TB RMA. It might be wiser to use TBB RME in cases with constricted maxilla and upper airway obstruction. (Farhan et al. 2021); - MARPE enable more predictable and greater expansion, as well as less buccal tippingand alveolar height loss on anchorage teeth. Thus MARPE is a better alternative for patients with skeletal maxillary deficiency during the post-pubertal growth spurt stage. ( 2021); - Both TB RPE and BBRPE improved on a short-term bases dimensions of the airway through the differece was not significant. MARPE did not lead to a significant change in the airway volume in young children and adolescents between 10- and 17-year-old; There was short-term significant change in the function, in the muscle strength, nasal resistance and airflow favoring MARPE over conventional RPE. (Sarah et al. 2021)

Upper molars intrusion: - The mean molar intrusion was 2-3 mm. The mean decrease in anterior face hihgt was 1.6 mm. (Scheffer et al. 2014); - The maxillary molars were intruded by approximately 2.0 mm, and 1.0 mm of intrusion was also achieved in the mandibular molars, resulting in about a 3.0 degrees counterclockwise rotation of the mandible. (Deguchi et al. 2011); - Maxillary molars after 1 year of followup, showing a rate of relapse around 12%, with a tendency to increase in the second year post treatment, with values ranging between 13 and 21 %. After 3 years, post treatment values were 18% for relapse, with 80% of these changes occurring during the first year post treatment. Overall, these relapse values give a success rate of 77%. (Amanda et al. 2020)

Lower teeth mesialisation

Palatal mini impllant: - Palatal mini-implant have gained popularity in the last decade. The palatal implant are usually placed either median (in the suture area) or para-median. Success of median palatal mini-implants has been shown to be approximatly 90%. Palatal mini-implant are usualy preferred because they do not interfere with the desired orthodontic tooth movement, the placement site is easily accessible, and no major blood vessels and nerves are present (Karagkiolidou e al. 2013)

An Overview on Mini-screws in Orthodontic Practice Part II (Olivier Quinty, AEEDC 2022)

What are the risks and complication ?: 1) Root trauma and root proximity; 2) Stationary achorage failure; 3) Soft-tissue irritaion and Miniscrew slippage; 4) Nasal and maxillary sinus perforation; 5) Nerve injury; 6) Miniscrew bending, fracture, adn torsional stress; 7) Relapse

Infrazygomatic Crest TADs

Anatomy: ・Anatomically, the IZC, or infrazygomatic crest, is a reinforced bone area, with greater thickening of the cortical layer, which extendes along the maxilla from the zygoma towards the molars.; ・Clinically, it is a palpable bony ridge running along the curvature between the alveolar and zygomatic processes of the maxilla.; ・The TAD is placed buccal to the second molar because there is a thicker buccal plate bone and less divergence of the mollar roots. (Lin et al. 2014); ・In younger subjects, it is between the maxillary second premolar and the first molar, Whearas it is between the maxillary first molar and second molar in adults. (Marqueran et al., 2014); ・Maxillary and mandibular cortical bones at commomly used miniscrew implant placemant sites are thicker in adults than n adolescents. (Farrsworth, et al. 2011); ・Cortical bone tends to be thicker in hypodivergent than in hyperdivergent subjects. (Posner et al 2012); ・There is a positive association between Mini-implants primary stability and Cortical Thickness of the receptor site. The average cortical thickness of the infrazygomatic creast is 1.44 to 1.58 mm. Corticlal bone thickness of more than 1 mm is required for good stability and a high success rate with orthodontic mini-implants. (Marqueson et al. 2014); ・Bone thickness of the IZ crest above the maxillary first molar is 5 to 9 mm, when it is measured at 40" to 75" to the maxillary occlusal plane and 13 to 17 mm above the maxillary occlusal plane. The clinical implication for miniscrew insertion in the IZ crest of adults is 14 to 16 mm above the maxillary occlusal plane and the maxillary first molar, and at an angle of 55" to 70" to the maxillary occlusal plane (Liou et al 2007); ・Soft tissue is penetrated by the screw tip and oriented perpendicular to the buccal plate, and the screwdriver is turned clokwise to penetrate the approximately 1.44-1.58 mm to thick cortical plate, As the screw penetrates the corticl plate, the screwdriver is gradually rotated inferiorly about 60-70 degrees to achieve a final insertion position buccal to the roots of the molars. (Chris et al 2019); ・The final position of the screw head is about 5 mm superioer to the soft tissue, which is at about the level of the gingival crest or hooks of the buccla tubes.

Failure rate: ・Both SS and TIA are clinically acceptable materials for IAC BSs because whe overall success rate was 93.7%. Compared with TIA, SS IZC BSs have an insignificanty higher failure rare of (Chang 2019); ・Higher failure rates when miniscrews inserted in the mandible than the maxilla. (Fapangoargioe et al. 2012)

Indication: IZC mini-screws are recommeded in ccase of:
・En masse anterior teeth retraction,
・Anchorage for retraction of an anterior dental block in cases of superior extraction,
・En masse retraction of the dentoalveolar arch of the maxilla,
・Intrusin of the posterior teeth.; ・Mx arch distalization ＆Molar intrusion → 2x12 SS TAD
・Molar mesialization & Impaction or transpositon → 2x14 H SS TAD

Upper molar distalization: ・Upper molar distalization is approximately 4 mm with infrazygomatic TADs, Tipping 4 degrees, Intrusion 0.6-0.7 mm, Need of extraction 18, 28 when erupted or on the way to eruption. (Mchamed et al. 2021); ・The rate of molar movement was 1.00 mm per month, which, however, was associated with distal tipping of the first molars (8.56 degrees) (Moschos 2010)

Buccal Shelf TADs

Anatomy: ・The evalustion of the buccolingual dimension showed that the mandibular canal was located either in contact with or close to the lingual cortical plate (less than 2mm) in the molar region of the majority of the cades and at 15-17 mm to the alveolar crest. As it proceeds anteriorly it moves toward the buccal aspect of the mandible, where it finally emerges through the mental foramen. Three emerging patterns of mandibular canal were observed: sharp turn (53.2%) soft curved exit (28.8%), and straight path (17.4%) (Eclzrcio et al. 2020); ・Anatomic limites for orthodontic tooth movement can be divided into 2 types according to level: corown and root level. At crown level, the only anatomic structure that can be encountered during orthodontic tooth movement is the mandibular ramus. When a crown of a tooth is forced against the cortical bone, enamel makes direct contact with the bone, leading to pressure necrosis. (Sung-lin et al. 2014); ・the root level, the cortical layer of the alveolar bone limits tooth movement. When the root makes contact with the inner cortex, tooth movement slows, and the risk of root resorption is dramaricalluy increase. If the tooth moves farther to the outer cortes, it can cause alveolar bone loss, gingival recession and root esxposure, compromising periontal support. (Tae-Hyun et al. 2014); ・The mean distances between the root and the inner and outer lingual cortexes at a level of 10 mm from the cementoenamel junction is 2.87 and 6.73 mm, respectively.; ・In most patients skeletal, the posterior anatomic limit for molar distalization is the lingual cortex of the mandibular body. Lateral cephalograms provide limited but valuable information for predictin the posterior available space and the presence of root contact with the inner lingual cortexs. (Sung-Jin et al. 2014); ・CT evalustion is recommened in patients requiring significant molar distalization, when the lateral cephalograms show posterior available space less the 3.9 mm. A reasonabe amount of molar distlization is approximately 3mm. Extraction of 38 and 48 required. (Young-Lin 2011)

Insertion protocol: ・No pilot drill is needed, screw heads, at the insertion point, are at least 5mm above the soft tissue. On average, there is 5mm of bone engagement. The optimal position for the TAD is lateral to the contact of the lower first and second molars. Approximately 5-7mm below the alveolar crest. And inserted at an orentation of about 30 degrees to the bone surface. (Chang et al. 2014)

Failure Rate: ・The overall failure rae of buccal shelf screw placement is 7.2%. (Chang et al. 2014)

mid-palatal screwsの埋入方法(Motsuru Motoyoshi. IOC,2020)

	Extra-radicular	Inter-radicular
Maximal Anchorage	same	same
Major Types	IZC, Bucal shelf	between the roots
Size	2.0 mm	1.2 mm - 1.5 mm
Fracture	almost none	easier
Root Damage	almost zero	higher chance
Whole Arch Distalization	easy	not as easy

	MARPE(T0-T1)	SARPE(T0-T1)	RPE(T0-T1)
Maxillary width (mm)	2.11	2.45	2.22
Inter molar width (mm)	8.32	7.81	7.38

	MARPE(T2-T3)	SARPE(T2-T3)	RPE(T2-T3)
Maxillary width (mm)	-0.07	-1.35	-1.19
Inter molar width (mm)	-0.42	-2.23	-2.79

TMD (顎関節症)

Managing the Templomandibular Joint: Pathology, Treatment and Future Innovation (Dr.Kau Chung How,AOSC 2023)

TMJ Diagnostic Categories

Juvenile Idiopathic Arthritis (JIA)

Idiopathic Condylar Resorption (ICR)

Background
・ICR is a progressive degenerative disease of the TMJ
・Most commonly seen in females (female:male ratio is 9:1)
・10-40 years old (predominant in teenagers during pubertal growth phase). (Wollord et al.2001)

Etiology (David M Sarver et al.2013)
・Local factors: Osteoarthritis, Traumatic injuries and infection
・Systemic factors: Rheumatoid arthritis, Systemic lupus erythromatosus, Connective tissue disease, Sjogren's syndrome
・Past operaticve factors: 3rd molar extraction, Previous orthodontic treatment, Orthognathic surgery

Wolford and Cardenas in 1999 and 2001
Hormone mediates biological changes in TMJ
↓
Hyperplasia of synovial tissue causes break down of ligamentous structure
↓
Anterior displacement of articular disc
↓
Condylar resorption

Clinical Features:
・Skeletal and occlusal instability (mostly Class II malocclusion)
・Dentofacial deformities: Anterior open bite, High mandibular plane angle, Shortening of ramus, Midline discrepancy, Cross bite and posterior occlusal prematurity
・Unilateral or bilateral condylar resorption
・TMJ dysfunction and pain (Wolford et al. 1999: no TNJ pain in 25% of patients)

Mamagement Strategies
・Medication
・Splint therapy
・Orthodontics and Orthognathic Surgery (after remission for 6-12 months)
・Mitek Anchor (Posterior head of the condyle and posterior band of the articular disc)
・Condylar replacement

Occlusion & Temporomandibular Disorders: A Paradigm Shift (Ambra Michelotti, AAO 2022)

下顎の位置異常でTMDを説明できない。下顎のリポジショニングは、TMD患者の治療方法として適切ではない。(Greene,2015; Rankasamy,2018)

今あるエビデンスでは、咬合とTMDの関係性は低い (Turp & Schindler,2021)

顎関節のクリッキングは、思春期において臼歯部反対咬合や異常なオーバージェット/オーバーバイトとは関係なかった。矯正治療の受診歴と顎関節のクリッキングは関係なかった。(Olliver et al.,Research Reports 2020)

TMDの原因がcondylar function, occlusal disharmonies, occlusal interferencesでないなら、occulsal perception, neuroplasticity, occlusal hypervigilance を考える必要がある

Higher anxiety is axxociated with pain, discomfort and frequency of tooth clenching. (Chow et al.,2022)

TMD患者は、TMDの原因は歯の噛み合わせであると考え、歯の噛み合わせを過度に気にするようになり、facilitate stimulus detection with tactile exploration.

REMINDER
・No evidence that (mal)occlusion is associated with TMD　(Temporo Mandibular Dysorder)
・No evidence that Orthodontic treatment prevent, cure or provoke TMD
・No evidence rhat an ideal condylar position can prevent or cure TMD
・CNS (Central Nervous System) is continuously adapting: neuroplasticity
・CNS modulates perception with a top-down mechanism: vigilance
・Occulsal hypervigilance and occlusal perception are mediated by CNS

Occusaion & Temporomandibular Disorders: A Paradigm Shift (Ambra Michelotti,AAO 2022)

TMDに関する3つの論点：　①Condylar function、②Occlusal disharmonies、③Occlusal interferences。

思春期の患者において、TMJクリッキングと臼歯部反対咬合や異常なオーバージェット/オーバーバイトの関係はなかった。過去の矯正治療の有無も関係なかった。(S.J.Olliver et al.,Research Reports; Clinical,2020)

reminder

Progressive/Idiopathic Condyler Resorption

・矯正治療プラス TADs

The American Academy of Orofacial Pain（アメリカ口腔顔面痛学会）が2013年に発行した"Orofacial Pain" の164ページには、次のように書かれています。

Management of TMDs

1. Patient education and self-management

2. Biobehavioral therapy

3. Pharmacologic management

4. Physical therapy

5. Orthopedic appliance therapy

6. Occlusal therapy

The topic occlusion continues to remain an enigma to those interested in studying the pathophysiology of TMDs and therapeutic concepts related to occlusal discrepancies......

a. Occlusal adjustment

Occlusal adjustment was at one time considered beneficial for TMDs, and occlusal interferences were implicated in the etilolgy of TMDs......

b. Restrrative therapy

Restrative dental care should never be a primary treatment option for TMDs (ref. 474)......

c. Orthodontic-orthognathic therapy

Orthodontic treatment is often the treatment of choice when major occlusal alterations are considered to be dentally advantageous. Fixed, removable, functional, and extraoral orthodontic appliances are all capable of improving occlusal and mandibular stability (ref.493). Orthodontics has been suggested to anterior positioning appliance therapy to correct a TMJ disc displacement. This has not proven to be as successful on a longitudinal basis as anterior positioning applinace therapy alone (ref. 494, 495). Orthodontic therapy does present some risk of destabilizing the masticatory system during treatment (ref. 496). Therefore, the orthodontic diagnosis and treatment plan must consider possible influences of resulting occlusal instability on preexisting TMDs during treatment (ref. 497, 498).

Many retrospective clinical studies has examined the relationship between orthodontic treatment and TMDs and have found no significanat correlation on a population basis (ref. 499-512). Additonally, several recent prospective longterm studies also confirm no correlation between orthodontic treatment in childhood and increased risk of developing TMDs later in life (ref. 436, 513-516). Orthodontic treatment with premolar extraction has been specifically implicated in the developmennt of TMDs through incisor retraction and subsequent destalization of the mandible (ref. 517). However, studies compareing orthodontic treatments with and without premolar extraction have found no difference in postreatment condylar position (ref. 518-521)., overbite (ref. 520), discrepancy between intercuspal position and retruded contact position (ref. 522), or symptoms of TMDs (ref. 510, 523, 524).

A prospective study of posttreatment changes in the TMJ found no statistically singnificant correlation between chages in the condyle-fossa relationship based on age, sex, skeletal or denatl variables, signs or symptoms of TMDs, headgear use, type of elastics, or nonextraction versus extraction treatment (ref. 525). Additionally, there are some longitudinal studies that suggest that a history of orthodntics tends to be associated with a lower prevalence of TMD signs and symptoms than no history of orthodntic treatment (ref. 436, 502, 526). A recent review of the literature concluded that, based on the available evidence, orthodontic treatment "neither causes nor cures" TMDs (ref. 527).

Althogh there is little evidence that orthodontically treated patients as a group have a greater prevalence of TMD symtoms, the individual patient response to the dental instabilities associated with orthodontic treatment may be quite different (ref. 528). Thus, the orthodontist must be alert for and prepared to deal with the onset or exacerbration of signs and symptoms that may occur during orthodontic tooth movement. The potential for problems clearly mandates a pretreatment TMD screening examination for all orthodontic patients (ref. 528, 529).

Orthognathic surgery may be consideered in conjunction with orthodntic or restorative treatment for correction of skeletal malocclusions. However, when orthognathic surgery is considered in TMD patients, it should always follow careful evaluation to confirm reasonable symptom resolutin and stability of the maxillomandibular relationship. Surgical treatment for skeletal asymmetries and growth anomalies with the specific intent of alleviating pain associated with TMDs is rarely indicated and should only follow careful evaluation and management of any other contributing factors. However, in those TMD patients with severe skkeletal malocclusion who desire greater occlusal stability or improved esthetics, orthognathic treatment is often the method of choice (ref. 506,530-532). Two retrospective studies showed no increase in TMD signs and symptoms in patients with anterior open bites (ref. 534) who underwent orthognathic surgery. One other study showed that in patients who underwent orthognathic surgery with rigid fixation, symptoms of clicking and muscle pain improved, whereas these symptoms increased in patients with nonrigid fixation (ref. 535). A systemic review pointed out that the studies to date generally have small groups, no controls, and other methodologic flaws (ref. 536). While prospective studies and systematic reviews are lacking, the available literature indicates that orthognathic surgery in patients with TMDs does not generally exacebrate or improve the condition and, hence, is feasible option for those who desire it.

7. Surgery

Tooth movement　（歯の移動）

Upper Central Incisor Across the Midline

歯の移動速度に関係する要因　(Stavros Kiliaridis. IOC,2020)

歯の移動速度の速い個体と遅い個体があった。(Catherine Giannopoulou et al. EJO 2016)

対合歯と接触している歯よりも、対合歯と接触していない歯のほうが歯の移動量が大きかった。(Alexander Dudic et al. AJODO,2013)

・If an interarch obstacle is present, the amount of tooth movement is less (Dudic et al.2013)
・Thus, with smaller forces, and less resulting masticatory loading, it is easier to shift the occlusion

・Mandibular alveolar bone is less dense in individuals with weaker masticatory force (Jonasson and Kiliaridis,2004)
・Faster orthodontic tooth movement has been shown to take place in individuals with less dense bone (Bridges et al. 1988, Hoshimoto et al.,2013)

・In the animal experimental model used, the botox injection enhanced the amount of tooth movement (Arizono et al.2020). However, it may have created changes in bone density, which ha to be tested.

Transeverse discrepancy （側方の不調和）

The Transverse Dimension: Why it Matters, and How to Diagnose Discrepancies (Dr.Leslie Will, AAO 2023)

The nasal cavity is only a portion of the airway

Complex association between OSA and Maxillary dental and skeletal (Markkanen et al.EJO 2019, Smith et al.J Clin Sleep Med 2016, Fernandez-Barriales et al.Sleep Med Rev 2022, Pirelli P et al.Sleep Medicine 2015)

R.Matthews Miner et al.AJODO 2012

In summary
・The transverse relationship between the maxilla and mandible and the dental arches is important for optimal occlusion, function, and health
・Dental compensations often mask a skeletal discrepancy, but compensations are often accompanied by problems in occlusion, stability, and health
・CBCT analysis should be used to detemine whether a skeletal discrepancy exists if crossbite or compensations are apparent

Trauma (外傷)

Dental Trauma: Revisiting Protocols & Long-tem Follow-ups (Eustaquio A.Araujo,AAO 2022)　外傷による歯の損傷：治療方法と長期のフォローアップ

Andreasen et al.,2007

David R.Steiner et al.Seminars in Orthodontics,1997

来院プロトコールと長期フォローアップ

1. 事故原因を調べる　how? where? when?
2. 検査
3. 麻酔
4. 歯をつかんで元の位置に戻す
5. .016X.022 NiTi or .17X.025 TMAを装着
6. speed bumps or similarを使って外傷歯の早期接触をなくす
7. 柔らかくて熱くない食べ物を食べる　for a few days
8. 2週間後にリコール

予後が良好な患者の割合は、事故発生から1時間以内では74%、1-24時間では25%、24時間以上では6％（Dr.井上の意見：グラフから％を読み取りましたので％の数字は不正確です）

脱落歯を再植した後に骨性癒着がおこりやすい。骨性癒着は歯槽骨の発達を阻害する。歯槽骨の発達阻害の程度は、年齢や顔面の成長度に影響される。

骨性癒着歯は、space maintenersや esthetic preserversとして役に立つが、いつもそうなるとは限らない。成長期に骨性癒着歯があると、ridge defectがおこることもある。今のところ、歯槽骨の保全のために歯冠除去が推奨される。ridge defectは思春期の急激な成長期におこる。

再植後に骨性癒着をおこした前歯を除去する最適な時期はの見極めは困難である。最適な時期は、bone defectの量と治療プランによる。

Unexpected Complication in Retention (保定中の予想外の歯の移動)

Bonded retainer

Unexpected Complicated Bonded Retainer (UCBR)

5%(Katsaros et al.,2007)、2.7%(Renkema et al.,2001)、1.1%(Kucera & Marek,2016)。50%が再治療を要した。

I. ボンダブル・リンガル・リテーナーがパッシブに接着されなかった。

・dentoalveolar compensation

・咬合力のanterior vector

III. 機械的外傷　－　ワイヤーの金属疲労、接着剤の脱離

デッド・ソフト・ワイヤーは切れやすく歯間にスペースが生じやすい。

ワン・ストランデッド・ワイヤーがいいかもしれない。

マルチ・ストランデッド・ワイヤーは不安定だ。Zachrisson, JCO 1995. Katsaros et al. AJODO 2007. Kucera et al. AJODO 2016.

Trauma (外傷)

Management of bone loss, ankylosed teeth and facial asymmetries due to trauma (Dr.Ali Darendeliler,AOSC 2023)

出っ歯の子供は、顔面打撲時に上の前歯の外傷がおこりやすい

12歳以下の子供において、オーバージェット9㎜以上だと45%、9㎜以下だと23%の確率で上の前歯の外傷がおこっていた (Todd JE et al.,Office of Population Censuses and Surveys 1985)

歯の欠損部位に、いつインプラントを埋入するのか?　歯槽骨は何歳まで上下的に成長するのか?

in some casesにおいて18歳から23歳になる間に3㎜の上下的な歯槽骨の成長があった。Vertical Position of Maxillary Incisors in Girls from 9 to 25 Studied by Implant Method (Bjork's Material)　→　In some cases 3mm of vertical alveolar bone growth was detected between 18 and 23 years old. (Iseri H et al.,EUR J Orthod 1996)

Alveolar Ridge Width Loss following Extraction Maxilla Anterior

歯根吸収の発現率

上顎犬歯が骨内に埋伏していると、

・107症例のうち、上顎側切歯に歯根吸収があったのは38例で、上顎中切歯に歯根吸収があったのは9例だった　(Ericson et al.,2000)
・210症例のうち、上顎側切歯に歯根吸収があったのは27例で、上顎中切歯に歯根吸収があったのは23例だった　(Liu et al.,2008)

Black triangle / Papilla

Distance	Presence
5 mm	98%
6 mm	56%
7 mm	27%

解決方法

Ankylosis

Trauma to Condyles

White spot (ホワイトスポット)

Treatment of white spt lesions with MI paste plus, with and without microabration: a splitmouth, randamized clinical trial (Steven LeRoy,AAO 2022)

・1か以上のホワイトスポットがある患者は23% (Julien et al.2013)
・40% of adolescents have at least mild flourosis (NHANES,1999-2004)

虫歯の前段階でないホワイトスポット

矯正治療によるホワイトスポット

ホワイトスポットの治療方法

Takeaway messages:
#1 After braces removal, allow3-6 months for narural remineralizaion

Deproteinization of Tooth enamel Surface to Prevent White Spot Lesions & Bracket Bond Failure: A revolusion in Orthodontic Bonding Roberto Justus,AAO 2022)

矯正治療によってホワイトスポットが生じる確率は：

唇側のホワイトスポットの発生を少なくする方法：

エナメル質の表面にaquired pellicle（厚さは約3ミクロン）があり、その上にbiofilmがある。
acquired pellicleは：

3 enamel etch-pattern Types: Type 1;Prism head, Tpe 2;Interprismatic substance Type 3;Superficial (poor micro-mechanical ret.)

Clinical example ブラケット接着の前処理

clincal recommendation:

natural remineralization process. ホワイトスポットは徐々に消失することもあるので1年ほど様子を見る

New carious tooth destruction (Hanif A, et al. J Res Dent 015)

・Abration: wearing by mechanical process
・Abfraction: wedge shaped defect at the CEJ
・Attrition: wearing by tooth to tooth contact: ・Contact betwee opposing teeth with well defined wear facets
・Parafunctional habits, porcelain restraurations against natural teeth, Class III with incisal relationship and lack of posterior support
・Stress related, sleep disorders, increased screen time (blue light)
・Erosion: chemical etching without bacgterial involvement: ・Extrinsic: dietary carbonated drinks, acidic diet
・Intrinsic: gastric reflux, vomiting due to anorexia and bulemia
Specific localization →　perimolysis

White Spot Lesion (WSL) (W. Eugene Roberts, AAO 2021)

Wisdom teeth (親知らず、第三大臼歯)

Third Molars in Orthodontics: To retain, or not retain, that is the question. 矯正治療において第三大臼歯はどうする（Kyung-Ho Kim,APOC 2022)

親知らず（第三大臼歯）の発達

Meta-analysis of 49 studies (Carter et al.J Dent Res 2016)

親知らずの埋伏に関係する要因

下顎大臼歯の埋伏では

親知らず埋伏による障害　Review of 1001 cases (Van der Linden et al.1995)

親知らずの抜歯が推奨されるケース

4本の小臼歯抜歯して矯正治療すると親知らず埋伏の発生率が低くなる (Kim et al. AJODO 2003)

young adults の抜歯矯正治療によって親知らず埋の発生率が低くなる (Turkoz et al.Angle Orthod.2013)

親知らず埋伏に対処するための第二大臼歯抜歯

上顎第三大臼歯を抜歯すると上顎第二大臼歯は自然萌出するのか?

下顎第二大臼歯を抜歯すると下顎第三大臼歯は自然萌出するか? (Yoonjeong Noh, Master's thesis,2017)

Miscellaneous (その他)

Three-Dimensional Analysis of Tooth Movement in Class I Bimaxillary Protrusion Treatment En-Masse or Two-Step Space Closure: A Randomized Clinical Trial

IMG_20230613_144923709

Heo Wet et al. Angle Orthod 2007, Xu TM et al. AJODO 2010, Schneider PP et al. Angle Orthod 2019

En masse and two step space closure techniques are similar in relation to anterior tooth movement and anchorage loss of posterior teeth. Anchorage loss is greater in the upper arech and may demand reinforcement

Prove it to me and I still won't believe it: separating truth from bias and wishful thinking in orthodontics Spyros Papageorgiou. EOS 2023

Topic #1: Prefabricated myofunctional appliances　→　No

Topic #2: Class II correction after maxillary expansion　→　No

Topic #3: Aligners instead fixed braces　→　No

Topic #4: Definite (long-term) effects from early Class II correction　→　Yes

Topic #5: Effect of Orthodontics on Airway & Breathing　→　No

Topic #1: Orthodontic management of Adults with Obstructive Sleep Apnes　→　

Topic #2: Orthodontic contribution in treating Adults with severe (stage IV) periodontitis　→　

Topic #3: Orthodontic contribution for Adults in need of Prosthetic Rehabiltation　→　

Direct Printed Orthodntic Appliances: Where are We Now? (Dr.Simon Graf)

The MDD applies to a great variety of more than 400,000 different medical devices. Therefore, a classification system is necessary. This classification into four classes is based on the intended application of the products and the risk potential associated with each individual product.Essentially, all devices fall into four basic catetories: (http://dx.doi.org/10.5272/jimab.2015211.705)

Orthodontic learnig journey(J.Kuruger et al.J Pers Soc Peych 1999) （Dr.井上の意見：歯科矯正専門医の学習曲線です。まさに、このとおりです。私はlast stageですが、このlast stageに達するまでに数十年かかりました。今でも、毎年、国際学会に出席して勉強してますが、終わりが見えない）

botulinum toxin

Effect of BTX in masseter: ・were in the facial dimension; ・skeletal & dental dimensions → unaffected
Clinical applications: ・Combine BTX injections with orthodontics; ・Slim the lower facial profile; ・↓ bruxism, myofacial pain & bite force w/out skeletal and dental changes

Conclusions: Althogh our results concur with clinically adequet values, we found enamel loss in 6.66%, whick should not have drastic clinical consequences in the formation of lesions or erosion, since it is clear that, during the removal of brackets, enamel loss is almost ineviatble, in addition to the fact that there is no association between SBS and the presence of enamel. (Dr井上の意見：SBSとは、Shear Bond Strength Test); In most of the samples we found less than 50% of adhesive remaining on the enamel.

Untreated root fracture

Every Visit Repacement of Working Archwire

Group 1: the same 0.019X0.025-inch SS archwire on the allocated side was kept througout all the visits during space closure.
Group 2: the 0.019X0.025-inch SS archwire was replace with a new archwire each visit using joining hook.

- The 0,019X0.025-inch SS archwire in the upper arch was split 2 halves in the midline and each one half was connected to the other by a wide joining hook.
- Elastomeric power chain from first molar to first molar was used to close extraction spaces.
- All patients were reviwed within a 4-week interval.

Conclusion
The rate of upper premolar space closure was similar when the same 0.019X0.025-inch SS working archwire was used each visit or when it was replaced with a new wire monthly.

Anterior Tooth Crack

A total 764 teeth from 68 subjects were included in the present study, 247, 267, and 250 teeth for young (18≦age≦34, N=22), middle (35≦age≦50, N=23), and elderly (age≧51, N=23) groups, respectively. After all the tooth evaluation, a totally of 291 cracks were detected from 764 teeth.

No crack on the tooth
　　221 teeth in the young group (N=247)
　　208 teeth in ghe middle group (N=267)
　　145 teeth in th elderly group (N=250)

Conclusion
The prevalence of cracked teeth increased significantly with age in the young and middle age, and increased more rapidly with age after 50 years old. The length of crack tended to increase with age, but not statistically significant.

Upper Central Incisor Across the Midline

How to develop and validate a questionare of orthodontic research (Elbe Peteret al.)（DR井上の意見：矯正治療の臨床医として、患者さまが何を期待して矯正治療を開始しようと考えているのかを知ることも重要でしょう）

心理的な要素: □ １．歯ならびに満足していない
□ ２．歯ならびに劣等感がある
□ ３．歯ならびに対する異性の視線が気になる
□ ４．歯ならびを友達がからかう
□ ５．矯正治療をしたいと思う
□ ６．整った歯ならびを持つ友達を見ると羨ましくなる
社会経済的な要素: □ ７．歯ならびの問題を解決してくれる歯科医を知っている
□ ８．家庭の経済事情により矯正治療を受けれない
矯正治療によって得られるもの: □ ９．自分の歯ならびに自信が持てる
□ １０．歯ならびにに満足する
□ １１．スマイル時の歯ならびに満足する
□ １２．鏡を見た時に自分の歯ならびに満足する
□ １３．自分の歯ならびが他の人に魅力的に見える
社会的な要素: □ １４．歯ならびに劣等感があるので、他人と接したくない
□ １５．話す時に手で歯を隠す
□ １６．笑う時に手で歯を隠す
機能的な要素: □ １７．話す時に発音しにくい
□ １８．食べにくい
□ １９．食べにくいので、食べない食べ物がある
□ ２０．顎関節がおかしい

Psychological impact: 1.Not satisfied with teeth position
2.Inferiority feeling
3.Bothered about what members of opposite sex thinks about my teeth
4.Friends have made fun
5.Felt like getting brace treatment
6.Distressed when I see nice teeth others/dd>
Socio economic: 7.Opportunity to meet a dentist would have reduced my problem
8.Family income affects my treatment options
Orthodontic self confidence: 9.Proud of my theeth
10.Satisfied with teeth position
11.Satisfied with teeth position during smile
12.Satisfied with teeth position when I see in mirror
13.My teeth are attractive to others
Social impact: 14.Kept away from public functions
15.Covers the teeth with hand while talking
16.Covers the teeth with hands while laughing
Functional impact: 17.Difficulty in pronouncing words
18.Difficulty in chewing foods
19.Avoid eating some foods
20.Had problems with jaw joints

可撤式矯正装置のcomplianceについてのreview and meta-analysis (Dalya Al-Moghrabd et al. AJODO 2017)

clear aligner のcompliance (James M.Crouse. J Clin Orthod 2018)

顎間ゴムのcompliance (Helen J.Veeroo et al. AJODO 2014)

Average use of elastics was 49.5% of ideal (range: 16-76%) (without the motivating intervention)

エビデンスに基づいたテクノロジー

セルフ・ライゲーティング・ブラケットは　①摩擦を少なくする　②治療期間短縮　③痛みや不快感が少ない　④抜歯を少なくできる　⑤ヘッド・ギアは必要ない　⑥上顎拡大装置は必要ない　⑦骨を成長させる　⑧舌位置をwake upする　といわれているが、実際には、①蓋を開け閉めするだけなのでチェアー・タイムの減少　②ワイヤーがスロットにきっちりとキープされる　③後方牽引のときに犬歯の捻転が少ないだけだ。

Suresmileは、①マーケティングの勝利であり、②診療システムの確立、治療計画、治療のビジュアル化、治療期間と治療結果、新しい矯正治療テクニックに興味のある先生には理想的だ。

バイブレーションは、①歯の移動速度を速くする　②破骨細胞を増加する　③繊維芽細胞と破骨細胞にRANKLが作用しやすくする　④セルフ・ライゲーション・ブラケットにおいて摩擦を減少させる　と言われているが、エビデンスがなく、$1000 - Daily Use - 0.37mm at best - No real benefit

従来の固定式装置の治療期間は18－24ヶ月であるが、一方、CBCT + Self Ligation（治療期間25%減少） + SURESMILE（治療期間40%減少） + ACCELEDENT（治療期間50%減少）なら治療期間1-3ヶ月だな。

各国の不正咬合の発現率

	Class I	Class II	Class III
USA	54%	40%	3-5%
Europe	54%	40%	6%
China	50%	25%	25%
Japan	50%	37%	13%
APAC	58%	29%	13%

抜歯率の変遷

1902	Angle	0.2%
1913	Case	6.5%
1931	Friel	8.0%
1953	Proffit	30.0%
1963	Proffit	70.0%
1966	Tweed	80.0%
1979	Peck	42.0%
1993	Proffit	28.0%
2000	Damom	＜5.0%
2010	Greenfield	＜1.5%

The "Decision Tree" for Full Orthodontic Tx

	Peck & Savusalo Practice, Boston 2015	Typical "NonExtraction" Practice, 2015
Tx recommended　①	＞85%	～100%
①のうちNonSurgical　②	＞90%	＞99%
②のうちNonEx	＞75%	＞98.5%
Fixed retention	＜5%	＞95%
Removable retention	＞95%	＜5%

more stable ↑
	Maxilla up Mandibule forward* Chin, any directin	VERY STABLE (*w/short or normal face height, & not more than 10 mm advancement)
	Maxilla forward Maxilla, asymmetry	STABLE
	Mx up + Mn forward Mx forward + Mn back Mandible, asymmetry	STABLE (w/rigid fixation)
	Mandibular set-back Maxilla down Maxilla wider	PROBLEMATIC!
less stable ↓

目次

内容

Accerelated orthodontics (スピード矯正 )

Airway (気道)

Aligner (アライナー)

Alveolar bone（歯槽骨）

Ankylosis （アンキローシス）

Apical periodontisitis （根尖病巣）

Archform （歯列弓の形態）

Asymmetry （非対称）

Autotransplantation （歯の自家移植）

Botox （ボトックス）

Bruxism （歯ぎしり）

Children, Orthodontics for children （小児矯正）

Deebite （過蓋咬合）

Emergency （緊急事態）

Extraction （抜歯と非抜歯）

Genetics （遺伝）

Gingival recessions （歯肉退縮）

Gummy smile （ガミー・スマイル）

Herbst appliance (ハーブスト装置)

Impacted teeth (埋伏歯)

Management (マネージメント)

Medication (薬の影響)

Missing tooth (欠損歯)

Molar distalization (大臼歯の遠心移動）

Myofunctional therapy (MFT)（口腔筋機能療法）

Non-extraction treatment) (非抜歯治療)

OSAS(obstructive sleep apnea syndrome) (睡眠時無呼吸症候群)

Occlusion (咬合)

Open bite (開咬)

Palatal expansion MARPE(上顎側方拡大）

Periodontitis (歯周病）

Retention & Relapse (保定と再発)

Risk Management （リスク・マネジメント）

Root resorption （歯根吸収）

Smile （スマイル）

Surgery first （サージェリー・ファースト）

Surgical orthodontics （外科矯正）

TADs (スクリュー、矯正インプラント)

TMD (顎関節症)

Tooth movement （歯の移動）

Transeverse discrepancy （側方の不調和）

Trauma (外傷)

Unexpected Complication in Retention (保定中の予想外の歯の移動)

Trauma (外傷)

White spot (ホワイトスポット)

Wisdom teeth (親知らず、第三大臼歯)

Miscellaneous (その他)

Tooth movement　（歯の移動）