WEBVTT 1 00:00:00.120 --> 00:00:02.560 You know, usually when we talk about a medical diagnosis, 2 00:00:02.560 --> 00:00:07.839 there's this expectation of clinical precision. It feels very much 3 00:00:07.919 --> 00:00:10.039 like engineering, right, Like if. 4 00:00:09.919 --> 00:00:12.720 You break your arm, the X ray shows that jagged 5 00:00:12.759 --> 00:00:14.800 white line, the doctor points to it and says, there 6 00:00:14.880 --> 00:00:16.199 is the problem exactly. 7 00:00:16.320 --> 00:00:19.960 It's beautifully binary broken or not broken. You just fixed it. 8 00:00:20.199 --> 00:00:24.199 But it's a static snapshot, which makes the treatment plan 9 00:00:24.679 --> 00:00:27.320 fairly straightforward. I mean, you cast it, you stabilize it, 10 00:00:27.800 --> 00:00:28.600 and then you just wait. 11 00:00:28.760 --> 00:00:31.199 But then you look closely at the world of orthodonics, 12 00:00:31.239 --> 00:00:35.159 and suddenly that static X ray machine feels completely inadequate. 13 00:00:35.240 --> 00:00:36.799 Oh, completely, because we aren't. 14 00:00:36.600 --> 00:00:38.439 Just looking at a still image, right, we are looking 15 00:00:38.479 --> 00:00:43.320 at a living, moving dynamics system of bone, muscle and 16 00:00:43.439 --> 00:00:46.920 soft tissue that honestly never actually stops changing. 17 00:00:46.960 --> 00:00:50.960 It is the absolute definition of a dynamic biological environment. 18 00:00:51.240 --> 00:00:54.159 And for those of you listening, whether you're studying dental nursing, 19 00:00:54.280 --> 00:00:57.399 stepping into the clinic as a young professional, or just 20 00:00:57.520 --> 00:00:59.840 fascinated by the mechanics of the human face. 21 00:00:59.640 --> 00:01:00.920 Which is super fascinating. 22 00:01:00.960 --> 00:01:04.120 By the way, we are drawing from Fiona Grist's textbook 23 00:01:04.480 --> 00:01:08.680 Basic Guide to Orthodontic Dental nursing. We're going straight to 24 00:01:08.719 --> 00:01:11.200 the coal face of orthodonic delivery today. 25 00:01:11.480 --> 00:01:15.640 Yes, we are unpacking the biomechanics, the hardware, and the 26 00:01:15.680 --> 00:01:19.400 psychological strategy is used to physically remodel the lower half 27 00:01:19.439 --> 00:01:22.000 of the skull, which is wild to think about it 28 00:01:22.239 --> 00:01:22.560 really is. 29 00:01:22.599 --> 00:01:24.159 It's structural engineering in the mouse. 30 00:01:24.280 --> 00:01:27.400 Yeah, But before a single bracket gets glued to a tooth, 31 00:01:27.959 --> 00:01:31.040 there has to be a master plan, right. A patient 32 00:01:31.120 --> 00:01:34.400 usually starts this journey with a referral from their general 33 00:01:34.599 --> 00:01:37.000 dental practitioner their GDT, right, and. 34 00:01:37.000 --> 00:01:39.560 They get sent over to a specialist, maybe a community 35 00:01:39.680 --> 00:01:43.040 orthodontist or a dentist with special interest also known as 36 00:01:43.040 --> 00:01:44.040 a DPWSI. 37 00:01:44.439 --> 00:01:47.640 And looking at the textbook, that very first appointment isn't 38 00:01:47.680 --> 00:01:51.799 just a quick look around. It's a massive data gathering. 39 00:01:51.400 --> 00:01:54.760 Exercise, far more massive than people realize. It goes way 40 00:01:54.879 --> 00:01:58.640 beyond opening the mouth and just you know, looking for cricketete. 41 00:01:58.760 --> 00:01:59.599 What's the first step? 42 00:01:59.640 --> 00:02:02.599 Then? The clinical team has to take a comprehensive medical 43 00:02:02.680 --> 00:02:04.640 history first, think about what we. 44 00:02:04.599 --> 00:02:07.680 Are doing here putting metal in people's mouths exactly. 45 00:02:07.959 --> 00:02:11.039 We are introducing foreign metals and materials into a wet 46 00:02:11.120 --> 00:02:14.800 mucosal environment for years at a time. If a patient 47 00:02:14.840 --> 00:02:17.759 has an allergy to nickel or latex. 48 00:02:17.520 --> 00:02:21.680 Oh wow, that would alter the entire treatment plan completely. Yeah. 49 00:02:21.719 --> 00:02:26.159 The classic stainless steel brackets and archwires contain nickel, chromium, 50 00:02:26.240 --> 00:02:29.759 and cobalt, so the immune system has to be accounted 51 00:02:29.759 --> 00:02:31.080 for before anything else. 52 00:02:31.439 --> 00:02:34.439 That makes total sense. You definitely don't want a localized 53 00:02:34.439 --> 00:02:36.479 allergic reaction happening inside the mouth. 54 00:02:36.680 --> 00:02:39.159 No, you don't. And then the assessment moves to the 55 00:02:39.240 --> 00:02:40.599 underlying skeletal pattern. 56 00:02:40.719 --> 00:02:43.840 I was actually looking at the section on cephalometric tracings. Ah. 57 00:02:43.919 --> 00:02:44.280 Yes. 58 00:02:44.360 --> 00:02:47.439 They take these specialized lateral X rays of the skull, right, 59 00:02:47.919 --> 00:02:51.479 and then use computer software to analyze the exact geometric 60 00:02:51.520 --> 00:02:54.560 relationship between the maxilla the upper jaw, and the mandible 61 00:02:54.599 --> 00:02:55.560 the lower jaw. 62 00:02:55.520 --> 00:02:58.840 Because those tracings tell the clinician what is happening beneath 63 00:02:58.879 --> 00:03:02.360 the gums. A patient might look like they have severely 64 00:03:02.400 --> 00:03:03.400 protruding upper. 65 00:03:03.199 --> 00:03:05.919 Teeth, like an extreme overbite. 66 00:03:05.439 --> 00:03:08.479 Right, but the cephalomentric tracing might reveal that their upper 67 00:03:08.599 --> 00:03:12.639 jaw is actually perfectly normal. It's their lower jaw that 68 00:03:12.759 --> 00:03:15.560 is severely underdeveloped and sitting too far back. Oh so, 69 00:03:15.599 --> 00:03:19.199 it's an illusion exactly. Yeah, and that completely changes how 70 00:03:19.199 --> 00:03:20.319 you approach the intervention. 71 00:03:20.719 --> 00:03:24.319 Okay, so beyond the bone, they measure the teeth themselves, 72 00:03:24.439 --> 00:03:27.719 the overjet, which is the horizontal distance between the upper 73 00:03:27.719 --> 00:03:30.159 and lower front teeth, and the overbite, which is the 74 00:03:30.240 --> 00:03:34.319 vertical overlap. Right. But the part of the assessment that 75 00:03:34.560 --> 00:03:37.919 absolutely blew my mind was the focus on the soft 76 00:03:37.919 --> 00:03:40.560 tissues like the tongue, the lips, the cheeks. The textbook 77 00:03:40.560 --> 00:03:42.199 calls it the soft tissue envelope. 78 00:03:42.240 --> 00:03:45.280 It is fundamentally important to the final outcome. The teeth 79 00:03:45.319 --> 00:03:48.560 do not just float in space, you know. They are 80 00:03:48.639 --> 00:03:50.960 caught in a constant tug of war between muscles. 81 00:03:51.120 --> 00:03:54.039 Yeah. I kept picturing it as this invisible mold. 82 00:03:54.199 --> 00:03:55.199 That's a good way look it. 83 00:03:55.240 --> 00:03:59.319 You have this massive, incredibly strong muscle tom constantly pushing 84 00:03:59.319 --> 00:04:01.639 outward from the side every time you swallow or speak, 85 00:04:02.280 --> 00:04:04.759 and then you have the lips and cheeks pushing inward 86 00:04:04.800 --> 00:04:08.439 from the outside. So that balance of muscular forces creates 87 00:04:08.479 --> 00:04:09.879 a neutral zone. 88 00:04:09.639 --> 00:04:13.479 Right, and that invisible mold dictates exactly where the teeth 89 00:04:13.759 --> 00:04:16.639 will naturally want to sit to form the dental arches. 90 00:04:16.800 --> 00:04:18.759 It's like a physical equilibrium that. 91 00:04:18.839 --> 00:04:21.720 Is a perfect way to visualize the mechanics, because if 92 00:04:21.759 --> 00:04:26.000 a clinician artificially moves teeth outside of that neutral zone 93 00:04:26.519 --> 00:04:30.720 without correcting the underlying soft tissue behavior, the intervention will fail. 94 00:04:30.839 --> 00:04:32.040 Teeth will just move back. 95 00:04:32.120 --> 00:04:35.319 Inevitably, they will relapse and migrate right back to where 96 00:04:35.319 --> 00:04:37.199 the dominant muscular forces push them. 97 00:04:37.319 --> 00:04:40.519 Okay, So, once the team gathers all this data, the 98 00:04:40.680 --> 00:04:44.240 X rays, the measurements, the soft tissue analysis, how do 99 00:04:44.279 --> 00:04:46.879 they actually decide who gets treatment? Because I assume you 100 00:04:46.920 --> 00:04:49.399 can't just slap braces on everyone who walks through the 101 00:04:49.399 --> 00:04:50.600 door based on vibes. 102 00:04:50.839 --> 00:04:54.040 No, definitely not based on vibes. The sources detail a 103 00:04:54.079 --> 00:04:58.560 metric called the IOTN, the Index of Orthodontic Treatment Need. Right. 104 00:04:58.680 --> 00:05:00.800 The IOTN how the National. 105 00:05:00.600 --> 00:05:04.360 Health Service and various insurance bodies quantify a patient's need 106 00:05:04.399 --> 00:05:06.920 for treatment, providing a standardized baseline. 107 00:05:06.959 --> 00:05:09.279 And it's broken into two parts, right, Yes. 108 00:05:10.040 --> 00:05:13.920 The first is the Dental Health Component or DHC. This 109 00:05:14.000 --> 00:05:16.720 grades the clinical severity on a scale from one to five. 110 00:05:17.519 --> 00:05:21.160 Grade one means minor or no need for treatment. Grade 111 00:05:21.160 --> 00:05:23.439 five represents a severe immediate need. 112 00:05:23.680 --> 00:05:26.560 So grade five would be the major functional issues like 113 00:05:26.839 --> 00:05:31.040 impacted teeth that can't erupt, or extensive hypodontia where multiple 114 00:05:31.040 --> 00:05:32.839 teeth are just completely missing. 115 00:05:32.639 --> 00:05:36.240 Or craniofacial anomalies like a cleft lip and palette. Those 116 00:05:36.279 --> 00:05:39.319 are objective clinical criteria where the health of the mouth 117 00:05:39.439 --> 00:05:40.920 is genuinely at risk. 118 00:05:41.000 --> 00:05:41.920 Okay, that makes sense. 119 00:05:41.959 --> 00:05:44.319 But the second part of the index is the esthetic component, 120 00:05:44.399 --> 00:05:47.519 the AC This uses a sliding scale of one to 121 00:05:47.560 --> 00:05:51.360 ten based on a series of reference photographs. Right, photograph 122 00:05:51.439 --> 00:05:54.639 one shows a highly acceptable occlusion and photograph ten shows 123 00:05:54.680 --> 00:05:58.480 a severe esthetic irregularity. During the assessment, the patient is 124 00:05:58.519 --> 00:06:00.959 often asked to look at these photos and point out 125 00:06:00.959 --> 00:06:03.040 which one they feel most resembles their own teeth. 126 00:06:03.040 --> 00:06:05.319 Okay, wait, I have to pause on this because it 127 00:06:05.319 --> 00:06:08.319 feels like a glaring contradiction. Oh so, well, if you 128 00:06:08.399 --> 00:06:11.560 are asking a patient, especially like a self conscious teenager, 129 00:06:12.040 --> 00:06:14.199 to look at a book of photos and rate their 130 00:06:14.240 --> 00:06:17.399 own smile, isn't that inherently subjective? Oh? 131 00:06:17.399 --> 00:06:18.600 Absolutely, How does a. 132 00:06:18.519 --> 00:06:23.160 Feeling of self consciousness qualify as a rigorous, objective clinical tool. 133 00:06:23.639 --> 00:06:27.240 It is a highly subjective moment, and honestly, you are 134 00:06:27.279 --> 00:06:30.079 hitting on a major debate in the field right there. 135 00:06:30.439 --> 00:06:33.480 It absolutely relies on patient perception, yeah. 136 00:06:33.360 --> 00:06:34.680 Which fluctuates wildly. 137 00:06:34.839 --> 00:06:38.319 It does. However, the IOTN as a whole isn't just 138 00:06:38.360 --> 00:06:43.279 about validating feelings. It provides a standardized medico legal justification 139 00:06:43.360 --> 00:06:46.800 for treatment a paper trail exactly. Moving teeth through boone 140 00:06:46.879 --> 00:06:50.759 carries inherent biological risks like root resorption, where the ends 141 00:06:50.800 --> 00:06:54.120 of the tooth roots literally dissolve or decalcification of the 142 00:06:54.199 --> 00:06:57.560 enamel around the brackets. The IOTN helps the clinician weigh 143 00:06:57.639 --> 00:07:01.160 those concrete clinical risks against both the functional improvements and 144 00:07:01.199 --> 00:07:04.720 the psychosocial benefits for the patient. It proves the intervention 145 00:07:04.879 --> 00:07:05.600 is justified. 146 00:07:05.680 --> 00:07:08.040 It's a balancing act between the risk of the hardware 147 00:07:08.079 --> 00:07:10.600 and the benefit to the human. Perfectly said and speaking 148 00:07:10.639 --> 00:07:13.360 of the hardware. Once the need is established, the clinical 149 00:07:13.399 --> 00:07:16.759 team has to choose their tools. The textbook transitions into 150 00:07:16.759 --> 00:07:19.879 the actual biomechanics of how we move teeth, starting with 151 00:07:20.000 --> 00:07:21.199 removable appliances. 152 00:07:21.639 --> 00:07:25.839 Removable appliances are incredibly versatile, but they have very specific 153 00:07:25.920 --> 00:07:31.360 mechanical limitations. To understand how they function, dental professionals use 154 00:07:31.399 --> 00:07:36.120 a core acronym ARB, aarab. 155 00:07:35.639 --> 00:07:40.519 Oh anchorage retention active and base plate let's break. 156 00:07:40.279 --> 00:07:43.680 Down why each of those matters. For the listeners, anchorage 157 00:07:43.959 --> 00:07:46.959 is the resistance to unwanted tooth movement. If you want 158 00:07:46.959 --> 00:07:49.399 to push a front tooth backward, you have to push 159 00:07:49.439 --> 00:07:50.600 off of something else. 160 00:07:50.519 --> 00:07:52.920 Newton's third law, right, for every action there is an 161 00:07:52.959 --> 00:07:54.240 equal and opposite reaction. 162 00:07:54.399 --> 00:07:57.240 Precisely, if you don't have proper anchorage, pushing that front 163 00:07:57.240 --> 00:07:59.800 tioth back will just shove your back teeth forward. 164 00:08:00.079 --> 00:08:02.560 You need a solid foundation so the appliance doesn't just 165 00:08:02.600 --> 00:08:05.040 push itself right out of the mouth right, which leads 166 00:08:05.040 --> 00:08:07.959 into retention, which is how the appliance physically grips the 167 00:08:08.000 --> 00:08:11.600 teeth to stay in place. The text mentions using specialized 168 00:08:11.639 --> 00:08:15.120 metal components for this, like atoms clasps which tightly grip 169 00:08:15.160 --> 00:08:16.160 the molars. 170 00:08:16.240 --> 00:08:19.759 Or south end clasps which hook neatly over the front incisors. 171 00:08:20.000 --> 00:08:22.839 Okay, so once the appliance is anchored and retained, we 172 00:08:22.920 --> 00:08:24.399 look at the active components. 173 00:08:24.480 --> 00:08:26.600 These are the pieces actually doing the heavy lifting to 174 00:08:26.639 --> 00:08:30.240 move the bone. We are talking about intricate wire springs, 175 00:08:30.720 --> 00:08:34.799 Z springs, T springs or labial bows that sweep across 176 00:08:34.840 --> 00:08:35.840 the front teeth. 177 00:08:35.759 --> 00:08:36.919 And they apply force. 178 00:08:37.279 --> 00:08:40.960 Yes, they apply a light continuous pressure. That pressure triggers 179 00:08:40.960 --> 00:08:43.720 osteoclasts to break down bone in front of the moving 180 00:08:43.759 --> 00:08:46.759 tooth and osteoblast to build new bone behind it. 181 00:08:46.799 --> 00:08:50.559 Biology is amazing. And finally, the base plate, which is 182 00:08:50.600 --> 00:08:53.360 the pink acrylic body molded to the roof of the 183 00:08:53.440 --> 00:08:56.679 mouth that holds all these metal springs and clasps together. 184 00:08:56.840 --> 00:08:59.799 That's right. But the crucial takeaway here is that removable 185 00:08:59.759 --> 00:09:02.120 alliances are primarily used to tip. 186 00:09:01.919 --> 00:09:04.639 Teeth, tip them like leaning them over exactly. 187 00:09:05.000 --> 00:09:07.360 They apply force to the crown of the tooth, which 188 00:09:07.360 --> 00:09:10.080 acts as a fulcrum. The root moves in the opposite direction. 189 00:09:10.360 --> 00:09:13.360 So if a removable appliance is like steering a boat, 190 00:09:13.639 --> 00:09:15.600 you know, you're basically just tipping it and nudging it 191 00:09:15.639 --> 00:09:18.960 in a general direction across the surface. A fixed appliance 192 00:09:19.039 --> 00:09:21.720 is like putting a high speed train on a meticulously 193 00:09:21.799 --> 00:09:22.960 engineered track. 194 00:09:23.159 --> 00:09:27.480 That's a great analogy. Fixed appliances, colloquially known as train tracks, 195 00:09:27.799 --> 00:09:31.360 offer a completely different universe of biomechanical control. 196 00:09:31.080 --> 00:09:32.519 Because they're glued down right. 197 00:09:32.879 --> 00:09:35.440 Because they are glued to the teeth, they give you 198 00:09:35.519 --> 00:09:39.159 precise three dimensional control over both the crown of the 199 00:09:39.200 --> 00:09:42.200 tooth and the root buried deep in the jawbone. 200 00:09:42.240 --> 00:09:44.960 I was looking at the textbooks photograph of a fixed 201 00:09:44.960 --> 00:09:49.679 appliance tray, and the sheer volume of highly specialized tools 202 00:09:49.720 --> 00:09:52.480 required just to put these things on is staggering. A 203 00:09:52.559 --> 00:09:54.720 curious learner would look at that tray and think it 204 00:09:54.759 --> 00:09:56.039 was meant for neurosurgery. 205 00:09:56.159 --> 00:09:57.200 It does look intense. 206 00:09:57.279 --> 00:10:00.480 You've got ligature directors Mitchell Trimmer's to sc rape off 207 00:10:00.559 --> 00:10:04.480 excess glue, a few hemostats replacing those tiny rubber O rings, 208 00:10:04.799 --> 00:10:07.799 and these intense blue led curing lights. 209 00:10:08.159 --> 00:10:11.519 The complexity of that tray exists because attaching these brackets 210 00:10:11.559 --> 00:10:15.600 is a high stakes race against moisture. The chair side 211 00:10:15.600 --> 00:10:18.799 procedure for direct bonding, which is gluing the brackets on 212 00:10:18.799 --> 00:10:21.639 one by one, is a meticulous chemical. 213 00:10:21.240 --> 00:10:23.159 Process, and the nurse is doing a lot of this. 214 00:10:23.399 --> 00:10:26.399 The nurse's role here is absolutely critical. It starts with 215 00:10:26.440 --> 00:10:31.120 an acid etch, usually a viscous phosphoric acid gel. This 216 00:10:31.159 --> 00:10:34.200 is placed on the tooth to create microscopic pores in 217 00:10:34.240 --> 00:10:35.480 the smooth enamel. 218 00:10:35.279 --> 00:10:37.679 So it roughs up the surface on a microscopic level, 219 00:10:37.720 --> 00:10:39.320 so the glue has something to grab onto. 220 00:10:39.559 --> 00:10:42.039 After the etch is washed off and the tooth is dried, 221 00:10:42.279 --> 00:10:45.519 a liquid primer is applied, followed by the composite adhesive 222 00:10:45.559 --> 00:10:46.919 on the back of the bracket itself. 223 00:10:47.000 --> 00:10:47.240 Okay. 224 00:10:47.519 --> 00:10:51.440 Throughout this entire sequence, the nurse must maintain absolute isolation 225 00:10:51.879 --> 00:10:55.159 using dry field systems, cheek retractors, and cotton. 226 00:10:54.919 --> 00:10:56.440 Rolls absolute isolation. 227 00:10:56.519 --> 00:10:58.799 If a single drop of saliva or a breath of 228 00:10:58.840 --> 00:11:02.440 condensation touches that etched enamel before the bracket is cured 229 00:11:02.480 --> 00:11:06.080 with the LED light, the micromechanical bond is ruined. The 230 00:11:06.120 --> 00:11:08.360 bracket will inavily fall off weeks later. 231 00:11:08.720 --> 00:11:09.039 Wow. 232 00:11:09.080 --> 00:11:12.960 So it is an intense, high focus procedure and that's 233 00:11:13.080 --> 00:11:16.679 just gluing them on one by one. The textbook also 234 00:11:16.759 --> 00:11:21.240 mentions indirect bonding, which seems like a massive technological leap. 235 00:11:21.440 --> 00:11:24.600 Indirect bonding is a game changer for the patient experience. 236 00:11:25.000 --> 00:11:27.440 Instead of the patient sitting with their mouth wedged open 237 00:11:27.480 --> 00:11:30.519 for an hour while the dentist places twenty individual brackets, 238 00:11:30.960 --> 00:11:32.879 the heavy lifting is done in the laboratory. 239 00:11:33.080 --> 00:11:34.200 Oh, how does that work. 240 00:11:34.600 --> 00:11:38.879 The clinician takes highly accurate rubber impressions and plaster models 241 00:11:38.879 --> 00:11:40.519 of the patient's teeth are cast. 242 00:11:40.679 --> 00:11:44.200 Right then the lab technician calculates the exact ideal placement 243 00:11:44.240 --> 00:11:47.480 for every single bracket and temporarily glues them to the 244 00:11:47.519 --> 00:11:51.039 plaster model. Right. Yes, and they pressure form a flexible 245 00:11:51.080 --> 00:11:54.600 thermoplastic tray over the whole arch. So when the patient 246 00:11:54.639 --> 00:11:57.279 comes in, the dentist does the etching and priming, but 247 00:11:57.360 --> 00:12:00.480 instead of placing individual brackets, they fill that cust try 248 00:12:00.519 --> 00:12:03.639 with adhesive, seat the entire tray over the teeth, cure 249 00:12:03.679 --> 00:12:05.960 it with the light, and peel the flexible tray away 250 00:12:06.080 --> 00:12:07.320 m boom. 251 00:12:07.559 --> 00:12:09.840 All the brackets are perfectly positioned on the teeth in 252 00:12:09.879 --> 00:12:12.919 a fraction of the time. It vastly reduces chair time 253 00:12:12.960 --> 00:12:14.559 and moisture contamination risks. 254 00:12:14.720 --> 00:12:15.519 That's incredible. 255 00:12:15.799 --> 00:12:18.960 And once those brackets are on the choice of archwire 256 00:12:19.159 --> 00:12:22.120 dictates the movement. You don't just use one type of metal. 257 00:12:22.480 --> 00:12:26.840 We start with nickel, titanium or nitty wires. Nitty is 258 00:12:26.840 --> 00:12:27.960 a shape memory alloy. 259 00:12:28.200 --> 00:12:31.200 Wait explain how the memory wire actually works in the mouth, 260 00:12:31.279 --> 00:12:32.759 like how does metal have a memory? 261 00:12:32.919 --> 00:12:35.080 The nitty wire is manufactured in the shape of a 262 00:12:35.080 --> 00:12:38.840 perfect dental arch. When the clinician forces that wire into 263 00:12:38.879 --> 00:12:42.799 the jagged, misaligned brackets of trickid teeth, the wire bend. 264 00:12:42.720 --> 00:12:45.120 Right, it conforms to the croked teeth, but because of 265 00:12:45.159 --> 00:12:48.120 its thermal memory properties, which are activated by the heat 266 00:12:48.159 --> 00:12:51.320 of the patient's mouth, the wire constantly tries to return 267 00:12:51.360 --> 00:12:53.559 to its original perfect U shape. 268 00:12:53.879 --> 00:12:57.440 As it slowly springs back over weeks, it drags the 269 00:12:57.480 --> 00:12:58.080 teeth with it. 270 00:12:58.240 --> 00:13:01.440 That is fascinating, so the nitre does the initial aligning, 271 00:13:01.519 --> 00:13:04.600 and then later in treatment they switch to heavy stainless 272 00:13:04.600 --> 00:13:07.399 steel wires which are totally rigid exact to hold the 273 00:13:07.440 --> 00:13:10.559 shape and allow the orthodontis to apply specific three D 274 00:13:10.720 --> 00:13:13.679 movements like extruding a tooth to pull it further out 275 00:13:13.720 --> 00:13:16.399 of the gum, or applying root torque to twist the 276 00:13:16.480 --> 00:13:18.919 root into the perfect angle within the bone. 277 00:13:19.039 --> 00:13:23.039 That's how we achieve a perfectly balanced occlusion. But fixed 278 00:13:23.080 --> 00:13:27.559 appliances have a major limitation. They only move teeth through bone. 279 00:13:27.600 --> 00:13:32.000 If the patient's actual jawbone is fundamentally misaligned, no amount 280 00:13:32.039 --> 00:13:32.960 of memory wire. 281 00:13:32.759 --> 00:13:36.320 Will fix it, which brings us to the heavier orthopedic interventions, 282 00:13:36.879 --> 00:13:40.799 moving beyond the teeth and addressing the actual skeletal structure 283 00:13:40.919 --> 00:13:42.360 of the maxilla and manible. 284 00:13:42.799 --> 00:13:46.000 If a patient is still growing, usually in their early teens, 285 00:13:46.480 --> 00:13:49.919 we can actually harness and redirect their natural growth spurts 286 00:13:50.240 --> 00:13:53.600 using functional appliances. Think of appliance as like the twin 287 00:13:53.679 --> 00:13:54.759 block or the andrsin. 288 00:13:54.919 --> 00:13:57.679 I've seen pictures of these, and they are incredibly bulky. 289 00:13:57.720 --> 00:14:01.000 They have these large thick acrylic blocks that between the teeth. 290 00:14:01.159 --> 00:14:04.240 They are bulky by design. The acrylic blocks are angled 291 00:14:04.240 --> 00:14:06.519 in such a way that the patient literally cannot bite 292 00:14:06.600 --> 00:14:10.159 down in their normal retruded position to close their mouth. 293 00:14:10.480 --> 00:14:13.320 They are forced to posture their lower jaw forward, so they. 294 00:14:13.200 --> 00:14:15.879 Are walking around with their jaw permanently jutted out. 295 00:14:16.120 --> 00:14:21.000 Yes, and that active, continuous posturing places tension on the 296 00:14:21.080 --> 00:14:26.120 muscles and ligaments around the tempomandibular joint the TMJ. Over 297 00:14:26.200 --> 00:14:29.879 a period of several months, that tension actually stimulates bone 298 00:14:29.919 --> 00:14:33.399 growth at the condyle of the jaw, permanently remodeling the 299 00:14:33.480 --> 00:14:37.399 joint and lengthening the mandible. To correct the severe overbite. 300 00:14:36.960 --> 00:14:40.480 Wow, and to build an appliance that fits that precisely, 301 00:14:40.960 --> 00:14:44.120 the nurse has to take a postured wax bite registration 302 00:14:44.399 --> 00:14:47.840 in the clinic. Yes, they have the patient intentionally bite 303 00:14:47.879 --> 00:14:51.000 forward into a thick block of warm wax, capturing that 304 00:14:51.080 --> 00:14:53.919 exact advanced position, so the lab knows how to angle 305 00:14:53.960 --> 00:14:55.720 those acrylic blocks correct. 306 00:14:56.159 --> 00:14:58.240 And conversely, if we need to restrict the growth of 307 00:14:58.279 --> 00:15:02.000 the upper jaw, we use extra traction, commonly known as headgear. 308 00:15:02.240 --> 00:15:04.360 It uses a heavy metal faceboat that connects to the 309 00:15:04.360 --> 00:15:08.000 appliances inside the mouth and extends outside to a headcap, 310 00:15:08.120 --> 00:15:10.919 applying a backward and downward orthopedic poll on maxilla. 311 00:15:11.039 --> 00:15:14.320 But what if you just need like absolute unyielding anchorage 312 00:15:14.399 --> 00:15:16.720 inside the mouth to pull a really stubborn tooth, and 313 00:15:16.759 --> 00:15:19.679 you don't want to use external headgear. The textbook dedicates 314 00:15:19.720 --> 00:15:23.120 an entire section to Tee's temporary anchorage devices. 315 00:15:23.440 --> 00:15:28.440 Tads have completely revolutionized modern biomechanics. These are tiny titanium 316 00:15:28.480 --> 00:15:32.559 mini screws. The clinician applies a little topical anesthetic and 317 00:15:32.840 --> 00:15:36.200 screws the tad directly through the gum and into the jawbone. 318 00:15:36.240 --> 00:15:40.039 They literally screw a titanium post into the bone between 319 00:15:40.080 --> 00:15:40.840 the tooth roots. 320 00:15:41.039 --> 00:15:44.080 Think back to Newton's third law and our anchorage problem 321 00:15:44.080 --> 00:15:46.960 from earlier. Right, If you use a molar to pull 322 00:15:47.000 --> 00:15:50.519 a front tooth back, the molar will inevitably get pulled 323 00:15:50.519 --> 00:15:54.480 forward a little bit. A tad provides absolute anchorage, the 324 00:15:54.519 --> 00:15:57.679 bone doesn't move. You can attach a heavy coil sprain 325 00:15:57.759 --> 00:16:00.519 from the mini screwed to the target tooth, and only 326 00:16:00.559 --> 00:16:01.639 the target tooth moves. 327 00:16:01.759 --> 00:16:04.879 And the craziest part is that when they've outlived their usefulness, 328 00:16:05.200 --> 00:16:09.480 the clinician just unscrews them. They heal incredibly fast and 329 00:16:09.559 --> 00:16:11.519 leave no lasting damage to the bone. 330 00:16:11.559 --> 00:16:14.440 It's remarkable now for adult patients whose jaw growth is 331 00:16:14.480 --> 00:16:17.559 completely finished, functional appliances and heagear are. 332 00:16:17.480 --> 00:16:19.120 Useless because they aren't growing anymore. 333 00:16:19.240 --> 00:16:23.440 Right For severe skeletal discrepancies in adults, orthodontics must be 334 00:16:23.480 --> 00:16:27.399 combined with maxilla facial surgery. This is called orthoanatic surgery. 335 00:16:27.679 --> 00:16:30.720 So the orthodonis spends a year aligning the teeth so 336 00:16:30.759 --> 00:16:33.440 that they will fit together perfectly. After the surgeon goes 337 00:16:33.480 --> 00:16:37.559 into the operating room, surgically fractures the jawbones and physically 338 00:16:37.559 --> 00:16:40.720 moves them into a new position. Yes, the dental nurse 339 00:16:40.799 --> 00:16:44.759 manages the preop records, taking precise impressions for surgical wafers, 340 00:16:45.159 --> 00:16:47.559 which act as a physical guide for the surgeon to 341 00:16:47.600 --> 00:16:50.200 know exactly where to position the jaws during the operation. 342 00:16:50.759 --> 00:16:54.480 The post operative care is highly delicate. The patient comes 343 00:16:54.519 --> 00:16:57.320 back to the orthodonic clinic about ten days after surgery. 344 00:16:57.840 --> 00:17:01.399 They're often heavily swollen. Naturally, the team checks the heavy 345 00:17:01.399 --> 00:17:05.720 intermaxillary elastics holding the jaws shut, and they meticulously check 346 00:17:05.799 --> 00:17:08.839 for normal sensation in the lips and cheeks. Moving the 347 00:17:08.880 --> 00:17:13.160 lower jaw stretches the inferior alveolar nerve and nerve bruising 348 00:17:13.240 --> 00:17:15.920 is a common surgical risk that can cause temporary or 349 00:17:15.960 --> 00:17:17.319 even permanent numbness. 350 00:17:17.519 --> 00:17:21.200 It is a profound medical intervention. But there's another jaw 351 00:17:21.200 --> 00:17:23.960 application mentioned in the sources that is int frastraightened teeth 352 00:17:23.960 --> 00:17:28.599 at all mandibular advancement devices for adults. These are plastic 353 00:17:28.640 --> 00:17:32.319 splints used specifically to treat sleep apnua and snoring. 354 00:17:32.759 --> 00:17:36.880 This is a rapidly growing frontier for dental professionals. Sleep 355 00:17:36.880 --> 00:17:40.960 APNOI is a dangerous disruption of breathing. When a person sleeps, 356 00:17:41.279 --> 00:17:44.799 their airway muscles relax. In some patients, the lower jaw 357 00:17:44.880 --> 00:17:47.839 drops back and the tongue in soft tissues collapse backward, 358 00:17:47.920 --> 00:17:50.119 physically blocking the airway in the throat. 359 00:17:50.400 --> 00:17:54.359 Okay, so how does a dental splint fix a breathing problem? 360 00:17:54.519 --> 00:17:58.480 It relies on airway mechanics. A mandibular dxancement device locks 361 00:17:58.480 --> 00:18:01.680 the upper and lower teeth together, physically posturing the lower 362 00:18:01.759 --> 00:18:04.559 jaw forward, much like a functional appliance. Oh I see, 363 00:18:04.599 --> 00:18:06.519 because the base of the tongue is attached to the 364 00:18:06.519 --> 00:18:09.839 lower jaw, Pulling the jaw forward mechanically pulls the tongue 365 00:18:09.839 --> 00:18:11.680 in soft tissues away from the back of the throat, 366 00:18:11.960 --> 00:18:13.640 holding the airway open all night. 367 00:18:13.839 --> 00:18:17.200 It's a brilliant anatomical life hack. But here is the 368 00:18:17.240 --> 00:18:19.839 massive caveat to everything we've discussed today. All of this 369 00:18:19.920 --> 00:18:24.799 sophisticated hardware, the needy memory wires, the titanium tads, the 370 00:18:24.839 --> 00:18:28.519 sleep apnuess splints, the bulky functional appliances. None of it 371 00:18:28.599 --> 00:18:30.079 works if the patient doesn't comply. 372 00:18:30.519 --> 00:18:34.759 The biomechanics are entirely dependent on the human element. The 373 00:18:34.799 --> 00:18:38.960 psychology of treatment and the evolving role of the dental 374 00:18:39.000 --> 00:18:41.799 professional are vital for treatment success. 375 00:18:41.960 --> 00:18:46.319 The textbook is incredibly explicit about this. Excellent oral hygiene 376 00:18:46.319 --> 00:18:49.559 requires immense daily effort with all those brackets in the way, 377 00:18:50.319 --> 00:18:54.519 Wearing a functional appliance requires immense willpower. The dental nurse 378 00:18:54.599 --> 00:18:58.599 is effectively the primary monitor and psychological motivator for the patient. 379 00:18:58.880 --> 00:19:02.480 It requires a very del ritz psychological strategy. Teenagers in 380 00:19:02.519 --> 00:19:05.759 particular can suffer from serious burnout during a two year 381 00:19:05.839 --> 00:19:06.799 orthodonic treatment. 382 00:19:06.920 --> 00:19:08.359 Yeah, that's a long time for a kid. 383 00:19:08.480 --> 00:19:10.880 It is. If they show up and their brushing is terrible, 384 00:19:10.920 --> 00:19:14.160 the instinct might be to sternly scold them. The text 385 00:19:14.279 --> 00:19:18.519 specifically warns against this. If a patient hears only negative feedback, 386 00:19:18.960 --> 00:19:22.480 even if it is completely clinically accurate, they will shut down. 387 00:19:23.079 --> 00:19:24.519 It is profoundly demotivating. 388 00:19:24.599 --> 00:19:26.559 They just tune you out, so the nurse has to 389 00:19:26.559 --> 00:19:28.480 find something the patient is doing well to keep those 390 00:19:28.519 --> 00:19:31.680 lines of communication open. If their hygiene is struggling but 391 00:19:31.720 --> 00:19:34.480 they haven't broken any brackets, you praise them for being 392 00:19:34.480 --> 00:19:37.160 careful with their diet and protecting the hardware before you 393 00:19:37.240 --> 00:19:38.960 gently tackle the plaque issue. 394 00:19:39.039 --> 00:19:43.240 And education is relentless. The team is constantly demonstrating how 395 00:19:43.240 --> 00:19:46.359 to thread interdental brushes under the arch wire. Yeah, giving 396 00:19:46.440 --> 00:19:50.039 strict dietary advice to avoid hard or sticky foods that 397 00:19:50.079 --> 00:19:53.759 pop brackets off, toffee, and dispensing medical grade relief wax 398 00:19:53.799 --> 00:19:56.599 so the patient can cover a bracket that is ulcerating 399 00:19:56.640 --> 00:19:57.960 their cheek even. 400 00:19:57.759 --> 00:20:00.960 When the braces come off, the education can take. They 401 00:20:00.960 --> 00:20:03.200