Bill Klaproth (Host): This is OMS Voices, an AAOMS podcast. I'm Bill Klaproth. And with me is Dr. David Cummings, who is here to discuss the OMS's role in orthodontics-related

procedures. Dr. Cummings, thanks for being here.

Dr. David Cummings: Well, thanks for having me, Bill. I'm glad to share my information.

Host: Well, that's what we're looking for. We're looking for the great information you have for us, Dr. Cummings. So, how do Oral and Maxillofacial surgeons collaborate with orthodontists in patient care and what are some common procedures that are collaboratively performed by these specialists?

Dr. David Cummings: Well, Oral and Maxillofacial surgeons, also known as OMSs, work closely with orthodontists to enhance patients' oral functionality and aesthetics. Orthodontists often refer patients to the OMS for specialized procedures that contribute to the alignment, proper functioning of the jaws, essential for breathing, chewing, and speaking effectively. working together involving the OMS performing various procedures includes tooth extraction, uncovering impacted teeth, or participating in orthognathic surgery, which involves correcting the jaw alignment. These surgical interventions can be an integral part of orthodontic plans, occurring both before braces and after braces are removed.

Some of the procedures that the OMS and the orthodontist work together on include TADs, which stands for temporary anchorage device; exposing and bonding, this is for teeth that are trapped sometimes in the upper and lower jaw. Sometimes it's just for extracting teeth for crowding from an orthodontic standpoint. We also work with them doing surgical uprighting. We also work closely with the orthodontists for dental implants and also for orthognathic surgery, which is reconstructive jaw surgery.

Host: Yeah, that's really interesting. So, let's talk more about the temporary anchorage devices or TADs as you call them. So, what is the exact function then of the TADs in orthodontic treatments?

Dr. David Cummings: Again, TAD, T-A-D, stands for temporary anchorage device. And these are small little titanium screws that the orthodontists use to help reposition teeth. There's a lot of times when you do orthodontics, it's a very kind of mechanical thing. And so, they need anchorage to move certain teeth around in certain areas, whether they're missing teeth or have the teeth in certain areas. It's challenging them, for the orthodontist, to complete the braces and the orthodontic treatment without having these TADs. So, typically, this is something that we insert in the patient's either upper or lower kind of gum area and bone tissue. And then, once the treatment's complete, these are removed. These procedures are very simple to do, very easy to remove. So, it's a really nice adjunct for the orthothontist when they're treating cases that need extra anchorage.

Host: So, Dr. Cummings, these are obviously temporary. They're right in the name, temporary anchorage devices. So, what factors influence the duration of the TAD placement procedure? How long do they usually stay in there?

Dr. David Cummings: The TADs, again, temporary anchorage device, are a wonderful tool for the orthodontist. So, the treatment duration of once the TADs put in can vary. So if there's very little tooth movement that's needed and not a lot of anchorage needed, then the TAD can be, you know, just there for a few months. In cases where there's much more tooth movement needed from the orthodontist and therefore more anchorage, then the TADs might need to stay in there a lot longer. So, that could be six or nine months.

But the great thing about these TADs is that most of the time, these can be done with local anesthesia. And I'm talking about age ranges from 9 to 10 year old, young, healthy children up to adults in their 40s, 50s, 60s to any age. So, the procedure is not necessarily one that you need to go to sleep to have completed. But as oral and maxillofacial surgeons, we can offer any of those things. So if some patients have anxiety and they're concerned about the procedure, they can be done with general anesthetic. They can be done with a twilight. They can be done with just local anesthesia and a little bit of laughing gas, which does not put them to sleep, but just relaxes them enough to get the procedure done. Or the procedure also can be done with just local anesthesia by itself.

And so, the nice thing too is that once these TADs, the treatment, is completed, the orthodontist sends the patient back to the Oral and Maxillofacial surgeon to have the TADs removed. When the TAD's removed, it's very simple to do, and not much is needed. A lot of times just topical anesthesia and no shots and no local anesthesia are needed to remove the TADs. So, it's really a wonderful device where the OMS or the Oral and Maxillofacial surgeon can work with the orthodontist to help in these specific situations.

Host: Absolutely. So, thank you for that great education on what TADs are. Really important. So for someone listening to this, wondering about orthodontics-related procedures, they may hear the phrase expose and bond. Can you explain what that is, that procedure, and how it's used in orthodontic treatments?

Dr. David Cummings: Actually, that's a great question, Bill. Really good. So, expose and bond, as we term, is usually used for teeth that are impacted, or as I tell my patients, the teeth are trapped, meaning for some reason, it's most commonly the canine tooth, probably more in the upper jaw, but we also see it a lot in the lower jaw, where the canine tooth is coming in at an angle that's not the normal position. So, it might be a little off angle or a little off direction and needs a little help.

So typically, the orthodontist a lot of times will try to widen the jaw or take out baby teeth to allow to create a path of least resistance for these canine teeth to drop in on their own. But a lot of times, the teeth are in such an unusual position that neither one of those techniques work. So, the tooth is still trapped up there. The age range is usually anywhere from probably 9 to 10 up to 14 years of age where we see this. And typically, what an expose and bond does, the expose part refers to exposure. So, we go in there and we expose the gum tissue. So, we move the gum tissue back, and then we can see that the eye tooth or whichever tooth is trapped up there needing help to come into

so when this happens, what happens is we move the gum tissue back. And we put a little orthodontic bracket. So, it's just like any other orthodontic bracket that an orthodontist use on their braces, except this one has a chain. So, that chain comes down through the opening that we've created in the gum tissue, and attaches to the orthodontic wire. So, the wire that connects all the braces going across is called the arch wire. So, our chain is usually connected with a small little string to the arch wire, and then we see the patient back a week later, and then they follow back up with the orthodontist. At this point in time, the orthodontist will remove the little string, and then they put on a rubber band. So when that rubber band is applied, there's tension that slowly pulls that tooth down into position and gets it back into the correct alignment for the tooth to come into position.

So, this typically takes anywhere from three to six months. And again, usually around nine to 11 months is usually where some of the more challenging cases take to get back in, because sometimes these canine teeth are really high up, and some of them are down lower. So, the ones that are down lower are going to naturally find that path of least resistance and drop into their correct position sooner rather than the one that's higher up. But it's a really nice adjunct for the orthodontist, because sometimes these teeth, for some reason, just don't want to come in the right direction.

Host: So, you're basically untrapping the trapped tooth to expose it.

Dr. David Cummings: Wonderful way to put it, yeah. You're exactly right.

Host: Okay.

Dr. David Cummings: We do a lot. It's a very, very common procedure. When the patients come in, a lot of times the parents are concerned that it's very unique, but this is a very, very common procedure that's done by all Oral and Maxillofacial surgeons.

Host: So, let's talk about another procedure that someone might want to know about, and that is the significance of tooth extractions done by an OMS. Can you talk to us about that in the case of an orthodontic treatment?

Dr. David Cummings: Sure, Bill, I'd love to talk to you about that too. When a patient requires a tooth extraction, it can be due to a variety of different factors, like tooth decay, injury, or a necessary step in their orthodontic treatment. In these instances, patients are generally referred to the oral and maxillofacial surgeon.

The OMS will then conduct the tooth extraction in their clinic, applying an anesthetic that is best suited for the nature. So, some patients are very fearful at young ages, and they need some sedation, twilight, or general anesthesia. And some of them are not, don't have as much high as anxiety, and they're very comfortable having the procedure done with just local anesthesia or along maybe just with local anesthesia and laughing gas. So, the OMS is trained in all these things and allows them to offer a variety of different choices from an anesthesia standpoint. The extraction is often a vital part of the orthodontic process, helping to manage space and align the patient's mouth for the optimal outcomes.

Host: And then, let's cover another term. Can you tell us what surgical uprighting entails?

Dr. David Cummings: Yes, I'd be happy to discuss that also too. This is more commonly seen for lower second molars. So, the second molar is the molar in front of the wisdom tooth. And for some reason, they don't know exactly why. There's lots of different theories, but that second molar tooth comes in more sideways or like on a 45-degree angle and not coming up in a vertical direction like most second molars do.

So, there's lots of things that can be done by this. But an uprighting procedure is done when the tooth is like at about 45 degrees. And then, we rotate. We literally kind of slide the tooth into its new position and hold it there with orthodontics. And you will wait about six weeks for the bone to kind of fill in around the tooth in that location. And then, the orthodontist can continue to do final movements. So, this is, again, more commonly seen around the age of 14 also. And a lot of times, this is when orthodontic treatment is complete. And so sometimes this is a step along the way, that the orthotist is done with everything, but they're waiting for this one last tooth to come in. So as teeth develop at that age, this is like one of the last teeth to come in. So, sometimes this comes up because the braces are ready to come off, but they haven't directly addressed this issue of a second molar coming in. So, the surgical uprighting is a very predictable adjunctive procedure to use for a tooth that again has not come in in the ideal position.

Host: So, when it comes to dental implants, we've all heard of those. Can you explain to us the role of the OMS, and the role the OMS has with the orthodontist concerning dental implants?

Dr. David Cummings: Yes. So, I'm happy to discuss that also. So, dental implants have been around for a while now. Very great way to replace missing teeth, there's no question about it. In general, implants are not completed or implants are not placed until somebody is completed with orthodontics. So as oral and maxillofacial surgeons, we have a lot of patients that are referred to us to check and evaluate spaces.

For an example, some people, some children are congenitally missing teeth. So, the most common probably be in the upper front teeth on the side, which we call the lateral incisors. So, an orthodontist might be treating a patient that's congenitally missing these teeth and they're doing the braces. So when the braces are almost done, they'll send them to the Oral and Maxillofacial surgeon to evaluate the spaces. So, we, as surgeons placing dental implants, need to make sure there's adequate space to put dental implants into these patients. So, the orthodontist refers us patients to evaluate this space. So when it does come time to put the implants in, that the spacing is correct. So, it's a very important interaction for dental implants with the orthodontist.

Host: And then when it comes to reconstructive surgery, say there's an accident or a sporting incident, you know, baseball to the line drive to the base, if you will. How do OMSs interact with the orthodontist then for reconstructive surgery?

Dr. David Cummings: Yeah. This is another big, huge interaction between the orthodontist and the oral and maxillofacial surgeon. And so, whether it's from trauma or anything, we also see a lot of patients that congenitally have like a strong underbite. So if you think of famous people like Jay Leno where his bottom jaw is kind of strong, there are a lot of kids that are born this way, and they have reconstructive surgery to correct their jaws. And this is called orthognathic surgery. So, just like orthopedics, ortho- refers to straighten, -pedics refers to limbs. So, an orthopedist doctor, is somebody who straightens limbs. orthognathic is straightening of the jaws. So, gnothology is the study of jaws. So, orthognathic surgery is to straighten the jaws.

So, this is something we work in combination with the orthodontist. The orthodontist traditionally has braces put on. Then, there's reconstructive surgeries completed. The braces stay on during the surgery and the braces stay on after the surgery until the kind of fine finishing touches are completed. But up to that time, getting ready for reconstructive surgery, there's lots of interaction between the oral and maxillofacial surgeon and the orthodontist. And that being that, if there's crowding or if there's trauma or sometimes there's additional teeth that need to be taken out to set up the case, the procedure to be done in a correct fashion.

So, when we're doing reconstructive surgery, the orthodontists tend to move the teeth in the opposite direction that they would do if they were having a non-surgical procedure, meaning if the child is just going to have braces put in, the teeth are moved in a normal fashion. But if the patient needs reconstructive surgery, whether it's a child and adult, the teeth are kind of moved in a different direction. So, that communication and interaction between Oral and Maxillofacial surgery and orthodontist is critical to the outcome for reconstructive surgery.

Host: Then, at what age should a child see an orthodontist to begin care?

Dr. David Cummings: That's a wonderful question, Bill. It's really good. It's advisable for children to have an orthodontic evaluation usually by the age of seven. At this stage, the orthodontist is capable of identifying early signs of jaw misalignment or misaligned teeth, like we talked about with the exposed and bond. They can start seeing if the teeth are trapped and they're not going to come into their normal position. Even while the baby teeth are still present, some people might think the age of seven is young, but it's absolutely not. It's definitely a good age to do that. Early intervention can be beneficial in correcting for the proper jaw alignment, reducing the chance of damage to protruding teeth, correcting detrimental oral habits, and ensuring the proper permanent teeth emerge into optimal positions.

Now, not every child requires orthodontic intervention or a need to consult with an OMS. But an orthodontic assessment at the age of seven really makes it a good baseline to start with, not to necessarily say that they need to have orthodontics started at seven, but just to have a baseline so you have a good plan.

So, this approach is centered on proactive healthcare, focusing and detecting and addressing potential oral health issues early on to prevent them from escalating into more complex problems. So again, really good idea to get it seven years of age. Again, it's just kind of a baseline thing. You know, most people, patients, most things line up good. But a lot of times, you just don't know until you've had a professional take a look at it. So, that interaction between the oral and maxillofacial surgeon and the orthodontist is really critical.

Host: So, that orthodontic evaluation by the age of seven is really a good idea, because the sooner you catch or see things, the easier it is to correct. Is that right?

Dr. David Cummings: That is absolutely correct. That is, yes.

Host: Yeah. That seems like it really makes sense. And if someone listening to this podcast has never heard that, you might think, "Oh, that might be a little young." But as you just said, Dr. Cummings, really, it's not. Age of seven seems like the good place to get in there very early on. Is that right?

Dr. David Cummings: You're absolutely 100% correct.

Host: Well, Dr. Cummings, thank you. This has been a pleasure talking to you and very informative for any parent listening to this for sure. As we wrap up, is there anything you'd like to add when we're talking about the OMS's role in orthodontics-related procedures?

Dr. David Cummings: Yeah. I think, again, it's critical to get an evaluation at the age of seven and just understand when you see the orthodontist, there's a very good likely chance that you'll probably end up needing an Oral and Maxillofacial surgeon for your children at some point, whether it's removing teeth or placing a TAD or doing a surgical uprighting or exposing and bonding, or if it's just for routine wisdom teeth removal, most likely you'll have some interaction with an Oral and Maxillofacial surgeon for your children at some point in their life.

Host: You know, that really makes sense. I know with my own kids, having an early relationship with an OMS really helps, because eventually those wisdom teeth are going to have to come out in other things as well. So, that just really makes sense. And Dr. Cummings, thank you so much again. This has really been informative and educational. Pleasure speaking with you. Thanks again.

Dr. David Cummings: It's been my pleasure.

Host: Once again, that is Dr. David Cummings. And for more information in the full podcast library, please visit myoms.org. And if you found this podcast helpful, please share it on your social media, and don't forget to subscribe. Thanks for listening.