What do kids with overbites really need?

Hello to my friends with the International Dental Implant Association and thank you for allowing me to present to you all at your online conference for June 2021. My name is Paul Kociancic. My good friend, your organiser Arun Garg has asked me to talk to you on what I do for a real job. Arun has recently written an extraordinary book published through Quintessence and which you can buy and also hopefully read. It's all about facial fillers and things that we as dentists can provide our patients today easily and I really recommend it. It's really beautifully written and illustrated and the print quality is wonderful and you can literally do it now. So a little bit about me. I am in Sydney, Australia and like Arun Garg I practice as an oral and maxillofacial surgeon and like Arun, but not nearly as handsome or as famous as him, I too have written a book which I've called Six Ways to Design a Face. It's really all about how to see a face and to see it holistically and therapeutically and to see the face how surgeons see the face. I practice not very far from here. This is my garden. It's late autumn, a sunny day, but it's really cold. I hope you don't mind the tour. I'm lucky that my real work is entirely dedicated to dual correction surgery which we also call orthonatic surgery. You see, I'm not just a dentist. I'm also a medical doctor, a specialist surgeon. What I really have dedicated myself to doing is apply myself to the treatment and fundamental cure of a medical disease I call obstructive sleep apnea and whilst OSA is considered a medical problem, curiously it has a strong link to dentistry as well and if you allow me, I will try to change your mind on how dentists can practice too and potentially a new way for dentists to see their everyday patients like a facial surgeon does like me. This link between the medicine of OSA and the smiles we treat in dentistry at first glance are not that obvious and I suppose that's why I'm talking to you today. Like Arun and like all oral and maxillofacial surgeons, our specialty serves as a bridge between the world of dentistry and the world of medicine. Arun talks about how dentists can make beautiful smiles and beautiful faces and I talk about how we can make beautiful smiles and beautiful faces too but I also talk about surgery and how as medical surgeons we can also work with dentists and orthodontists as well as medical doctors like medical GPs and sleep specialists and ear nose and throat surgeons and how all of us can work together. Now if you want to find out more about what I'm talking about and if you as a dentist want to start working with us as specialist jaw surgeons and want to incorporate these new ideas and new treatments into your own practices then please. I'd be honored if you would read my book. It explains how surgeons like me can work with dentists and how dentists can perform the dental procedures that in combination with specialist surgery can make and match beautiful smiles with beautiful and healthy faces. My book begins with my beliefs that the origin of dental crowding, impacted wisdom teeth, malocclusion, sleep apnea, of clear nasal health and of a disproportionate facial profile are in my belief all linked. They are linked by a universally small lower jaw. Whilst my illustrations appear to orient to a Caucasian face the evidence for the of a commonality that extends across all races is clear. These ideas of high frequency for the small jaw and universality is one which I believe translates equally to Asian, Black, Hispanic or Caucasian faces and jaws and that to see this perspective my personal view from a jaw surgeon's eye a holistic look as opposed to a sleep medicine perspective or only a teeth perspective or even a narrow orthodontic perspective is what I believe to be a collective point for reorientation. The next thing I do in my book is that I propose a new method to categorize the face and profile in a holistic way a total way to be able to categorize the face from a combined surgical and medical and dental classification and to see the whole face first and to see the whole face whole and to see the teeth as a part rather than as well just as teeth. When I look at everything when I see all the patterns of facial growth I see how the dominoes all line up and I see what domino fell and when what came first then next and next and then I see it all in everything in everyone I see it in everyone who comes to me these adolescents who come to me after orthodontics because the orthodontist asks me to remove their impacted wisdom teeth and that's when I really get to see it first for the first time it's after the orthodontics I see the diminished jawline and there I see other dominoes I see that they have a big nose and big ears but I also know though no one else can see it because it is inside them but I'm a trained surgeon so I can see it because they have a small jaw and crowded teeth that are now straight and because they still have impacted wisdom teeth I see that they have a collapsed tongue and I call this glossoptosis and I know there is another domino a big back of tongue pushing into the airway behind it at the level of the upper epiglottis what I call the c3 erpo column serpo this is a hard thing to explain but I'm seeing other dominoes now too the medical dominoes instead of seeing them awake I'm trying to imagine how they are asleep and how that glossoptosis is collapsing how the back of their tongue is collapsing how their tongue is falling backwards when they are asleep and I can see how glossoptosis becomes obstructive sleep apnea and now I'm linking all the dominoes and I can see them as an old person I can see how they will age and how they will become old and I can see that they are doing something when they will become old which they're now doing as a child when they are asleep why they now are snoring and why they sleep with their mouths open and why osa eventually develops at all so now I look at the adolescent again with his braces now off and I see his originally crowded teeth his original malocclusion the bad teeth that made him see the orthodontist in the first place and now his impacted wisdom teeth making him see me and I'm the last one all of it though started with his small lower jaw so what though so what if he has an open mouth breathing pattern but for me another domino falls and suddenly I see why they have small cheekbones and there's no nasal airflow and because of their small lower jaw some children also have an under-expanded upper jaw and that there is a secondary pneumatic smallness of maxilla an upper jaw smallness that may be almost nothing but which can also extend to severe extremity and so my new orthognathic classification sees all of these dominoes lined up it sees the common lower jaw smallness and it sees a secondary upper jaw smallness and then all the patterns of dental crowding and malocclusion that form because of that that these airway and tongue and postural patterns produce my book proposes that there is an anatomical disease and I call it am hypo or anterior mandibular hypoplasia this is a smallness of the front of the lower jaw of the forward tooth bearing portion of the lower jaw and it is really common but there is another type of small jaw which is really much rarer and it belongs to a bunch of conditions that only affect the back of the jaw of the size of the posterior rami and the jaw condyles and which leads to the various forms of posterior mandibular hypoplasia or pm hypo they include all the rare facial syndromes like treacher colon syndrome and the jaw joint diseases that affect children like juvenile rheumatoid arthritis and developmental conditions that you get in the womb like hemifacial microsomia but I'm not talking about pm hypo these things are really rare these patients don't visit routine orthodontic practices my discussion is about something which is so common that we really don't see it at all it's the small anterior jaw called am hypo it's the cute little kid with a big overbite and big brown eyes I call it am hypo so I can study it and look at everything that is associated with it and so I look on the dental facial profile and retroglossal airway changes of am hypo and then I look at the secondary upper airway changes that occur in the nasal air passages basically 98% of all the patterns of how faces grow and how bites develop and how teeth crowd and arrange can be explained using this premise of these three basic things am hypo first with glossoptosis and nasal airflow which stops because they stop breathing through their nose and then there is a secondary smallness of the upper jaw and this leads to everything we see with dental crowding patterns the new classification I have given is to divide the a through to f with class a being ideal and perfect with 32 teeth and a classic class one bite and b c d and f all having am hypo which is common and c d e and f having various stages of upper jaw smallness b has a normal upper jaw f has a condition of anterior open bite for 2021 I am proposing class a b c d and f what Edward Angle gave us in 1895 over 125 years ago we still use it it's a system all dentists still use an idea that malocclusion is somehow a disease that we have class one two or three no explanations behind it and no treatments except dental extractions and braces but I think that system is just completely outdated and simply wrong to keep using it because it forces us as dentists to still just think about teeth in my new way I still try and keep a link to orthodontics and our love of the angle classifications of malocclusion I still incorporate it within my new orthonatic system but the occlusion states and what is primary is not the teeth or the bite or an AHI score given by a sleep specialist who doesn't care about teeth at all the sleep specialist doesn't really understand dentistry either so to try to get us to all of us work together to see the whole face inside and out from nasal bones down and of the inner airway and jaws and of course finally the bite and right after that in my classification and it seems almost an afterthought I consider the chin either it is there or it is not do we have one or not the chin is strange it's a strange little object that in my view is wonderfully misunderstood that either a person has it or does not have it that it can look odd or it can look really good but in my view the chin is enormously critical to the therapy of airway collapse because it holds a critical tongue muscle which we need to contract and pull to open an airway and the chin is also important to how lips meet and seal and kiss and of how oral continence is achieved and how we sustain nighttime closed mouth breathing when we are unconscious and asleep and how smiles and lower facial proportions mingle and combine to provide what we all think of in terms of total beauty the thing that we look at every day and use every day and growl and grimace and laugh with every day our personal facial identity the combination of the lower jaw and of the anterior tongue forms together it comes from the first gill of the first fish that walked onto land over 400 million years ago this fish eventually evolved into an amphibian and then a mammal and finally a simian and then to us a human the genetics that make at least three million years of homo evolution has made our jaws normally sized and able to fit in 32 teeth in a normal class one occlusion that's just logical but increasingly for some reason something is making the small lower jaw which can fit far fewer teeth almost universal and everywhere affecting all races in all countries around the world my view is that the genetics is being manipulated by modern human breeding which compared to the 300,000 years that modern homo sapiens has been on this planet the knowledge of breeding is really recent human breeding rose with the development of agriculture and plant and animal husbandry all of which in western europe anyway is only around 6 000 to 8 000 years old in modern paleoanthropological terms this idea of culture and beauty and westernization which has reduced our physical jaw size everywhere is called neoteny in females it gives an appearance of big eyes of a western idea a idea of femininity and female beauty but the breeding effect is seen in males as well and so the effects of small jaws are seen in both sexes and importantly western ideals of female beauty are spreading everywhere so it is affecting all people males and females everywhere as western culture as western ideals of female beauty spread and as the prevalence of small jaws is increasing through something called the cliff edge model of health care which really means the more we treat and camouflage the effects of small jaws which is mainly crowding and impacted and crooked teeth the more the genetics spread and spread and like many areas of surgical intervention we survive our children survive and the genes simply become more common and the operations we use to fix our genetic breeding mistakes become more and more common what cliff edge medicine in dentistry and orthodontics has led to is that we now see an almost 100 prevalence of dental crowding in all adolescents and we see wisdom teeth impactions and various patterns of malocclusion that which all of it defines modern 21st century orthodontic and dental practice malocclusion and impacted wisdom teeth and cosmetics and aesthetics now replaces traditional drill and fill and decay based dentistry and we wonder why it is all happening but unless we see all the dominoes it's a difficult pattern of human existence to explain what we do know is that as dentists we start to really see the dental effects of small jaws in adolescence around the age of 10 when we first start seeing those big front teeth and all the other crowding teeth coming into the cute little face we see neoteny but that small lower jaw a proportionally small anterior lower jaw that used to fit in all the teeny tiny baby teeth that proportionally small lower jaw that just never seems to catch up was there since they were a baby it has always been smaller than everything else and if it was always small it will always be small when they become an old man or woman it neonates the most severe form when the fundamental suffocation that causes the blue baby is seen by pediatricians we call it pierre robin syndrome in middle-aged adulthood another craft group the sleep physician now sees the expression of the small jaw not for what it is but rather through the medical lens of hypertension of irreversible obesity as diabetes and as something very fundamentally and extremely life-threatening what we now see as the worldwide phenomenon of obstructive sleep apnea and these extremes of life the baby without teeth and the old man who doesn't care what he looks like they are both not seeing an orthodontist for their crooked teeth it is only in adolescence that there are the impacted wisdom teeth surgeries and adolescent camouflage orthodontic treatments and big tonsils that are the cardinal features of small jaws and glossoptosis for the child who is just losing their baby teeth and the old man who has long forgotten his orthodontic adventures he just lives on his c-pad unable to connect the logical dots of a long life that began in the womb a long time ago as a jaw suit i am using jaw distraction to correct for the severe apnea effects seen with the small jaw other surgeons like me use jaw distraction in pierre robin babies who don't yet have any teeth where we are trying to save their life the pediatrician sees the blue baby and the small jaw and the obstructing tongue when we accidentally laid them on their back and sent them to us and we operate using jaw distraction to save their life because the condition was life-threatening when they were very young at the start of life but for the rest of us who got through those early years but where we still have the same small lower jaw and the same glossoptosis it is in adolescence that i have introduced indo surgery to correct the very same condition there are lots of birds about here after the adult teeth have erupted the same proportionally small lower jaw that wasn't recognized as a baby but which is now noticed as big front teeth as dental crowding as impacted wisdom teeth as a bad bite so in effect i'm a dentist working for an orthodontist helping them in treating a malocclusion but as a doctor i'm also treating a medical problem i'm treating the fundamental reason why they have a bad bite which is their small lower jaw and with it i'm also treating their glossoptosis and their airway the glossoptosis that will lead to them snoring the glossoptosis that will lead to their osa the glossoptosis that will lead to their c-pap as an old man or woman this glossoptosis is always there it's the glossoptosis that made the neonate have life intervening jaw distraction or the child whose glossoptosis was seen as big tonsils needing a tonsillectomy or the teenager whose glossoptosis was completely ignored by the orthodontist and who is simply seen as someone with severely crowded teeth needing braces but is there another better way the indo protocol is revolutionary because it reimagines the interplay of orthodontist and oral surgeon i argue that orthodontists shouldn't just look at teeth i argue there is no such thing as an 1895 classification of malocclusion that malocclusion is not a disease i argue that malocclusion is not real it is not an entity whole and complete that exists only for itself i argue that dental crowding is a medical sign of a very fundamental medical condition a deadly medical condition called glossoptosis and which goes hand in hand with jaw smallness and that extracting excessive teeth that extracting teeth in small jaws is a band-aid it's a band-aid on a bullet hole our view of the routine inevitability of impacted wisdom teeth surgery our view of committing our children to classical camouflage orthodontics our view that adolescent orthodontics alone without any other medical perspective alone and as seen as it's benign and easy and without consequence without association to anything should be something that we critically re-examine nothing belonging to braces to orthopedic jaw splints to classical orthodontics can grow a small jaw or removes glossoptosis as an oral surgeon i see the 19 year old patient after they have had camouflage braces as the expert on how faces grow as the expert on the medicine and science and surgery of small jaws well i come last and all i am asked to do is remove the impacted wisdom teeth after all the band-aid cures for all the ideas of whatever have all of them come before me but i should have come first i should have come before the nose and throat surgeon before the orthodontist before the sleep physician instead of asking me to remove wisdom teeth at the end i have a far simpler surgical intervention that i could have done in the beginning and that avoids camouflage orthodontics and avoids wisdom teeth surgery too and it avoids ear nose and throat surgery and will help avoid the sleep position as well i use imdo surgery and the imdo protocol it's this new way that rearranges the relationship the classical order of all the players the medical gp the pediatrician the ear nose and throat surgeon the sleep physician the family dentist the orthodontist the oral surgeon i'm trying to introduce a new player in effect it's the imdo search and the imdo protocol is now there for a new modern world where we have a new way of assessing medical health and anatomical abnormality and where we are looking to both cure and prevent the effects of an obstructing tongue from ever developing into adult sleep apnea this is imdo it's the vaccine before the disease but what if we already have had braces and and acquired the artificial class one occlusion already and yet we still need massive movement of jaws to overcome glossoptosis and get rid of osa in this way we now have custom titanium and custom digitally designed by maxillary orthodontic surgery the custom bimax i call it the remedial bimax but i'm not using it to get a better bite for the orthodontist camouflage orthodontics has been and gone the bite is already there and the patient doesn't want a repeat of their adolescent orthodontics it's without surgical splints without braces that we can digitally design the face and maximize the airway and delete the os risk osa risk or even the osa if it has already developed and we can do this with digital design and digital titanium milling and printing and general dentists can easily straighten the teeth after surgery there is no need for expensive years of camouflage orthodontics custom titanium revolutionizes how orthonathic surgery can be practiced custom titanium returns the patient back to the care of where it belongs the general dentist the whole and the true where it truly belongs custom titanium is expensive but it's predictable and most importantly it is life-changing for someone who is already on a c-pap for which there is no future of deleting c-pap is the scourge of modern medicine it is the band-aid treatment for a disease that is incurable and we are all of us vulnerable to it but we do have a cure it is called us dentistry through maxillofacial surgery using orthonathic surgery and remedial bimax with custom titanium and with general dentists and orthodontists using invisalign to help us past the bimax we have super bimax where we need overwhelming forward distances that can't be acquired by even the most ambitious bsso or classical orthonathic procedure where we can first grow the jaw with imdo and then use bimax surgery with custom titanium to produce exceptional and radical and amazing and permanent and predictable change where we can combine new forms of laforte surgery to also interact with imdo where we can correct the secondary maxillary hypoplasia and where we can maximize imdo lengthening to truly overcome both glossoptosis and nasal airway congestion and maximize the opportunities that surgery now gives to us to manage the whole lower face bite and airway we have new ways to expand the maxilla in late adolescence it's called MAMI if growth has ceased and sutures have fused if we've missed the boat then we can advance to more formally surgically assisted surgeries like SAMI where we surgically expand the upper jaw and get all the upper teeth to fit and mix as a proper dental arch and finally when all is said and done when the custom bimax or imdo genio pauli or imdo laforte has healed and when the plates have been removed when bone grafting to defects has been completed there's the residual asymmetry that bimax just cannot fix it comes with small cheekbones with cheekbone and orbital asymmetry or with a residual jawline asymmetry that comes from condylar disease and all the forms of posterior mandibular hypoplasia what i'm talking about is custom peak implants this incredible technology and incredible material polyethyl ethyl keto allows us to gain control over the complete symmetry of the face this new technology is really an enormous advance on dental implants and they are used in almost the same way as dental implants where implantologists create smiles and functional eating our facial implants create faces and functional living my book describes these six new and wonderful ways we can design faces to make them function and to make them work and to make them healthier and to make them more beautiful and naturally beautiful i want to treat the face the airway and the bite to combine those narratives and to give new options and new credentials to our armamentarium of primary surgical care i call them imdo genio custom bimax sami super bimax and finally custom jawline peak implants so thank you for letting me speak to you all to all the people from the international dental implant association you are all my new friends and i am grateful to arun garg for introducing me to you all and hopefully with our books you can all see a new way to help practice dentistry with us and with surgeons like us welcome to our brave new world