IAADent Orthodontic course

 Just finished the course 3 of 8 of the IAADent comprehensive orthodontics and orthopedics course. I've been quite busy lately and haven't really had much free time to jot things down in this blog. I'll put own a few thoughts about the course here. The first two sessions was a lot of revision for me having attended the first couple of EODO ortho sessions about diagnostics. The philosophy taught by IAADent and Derek Mahony run pretty parallel with a focus on a triad of airway, TMD and sleep and considering facial aesthetics. From what I gathered at EODO, Kenneth Lee has more of a focus on TMD and incorporating this into diagnosis and management prior to commencing any orthopedic or orthodontic changes. I could be wrong but although TMD isn't absent in EODO, it isn't as deeply ingrained into the philosophy they teach which is more heavily airway and sleep focussed. However, knowing a bit more about the subject now, I guess you can't really separate the three from each other and by aiming to address one aspect, you're pretty much heading in the right direction to address the other two.

To compare this to other ortho courses, I have a colleague who is attending Geoffrey Hall's Ortho ED course. He said he was going to do IAADent with me and then changed his mind after I had decided to attend. He does have a background with ortho and EODO philosophy so probably would have benefited more from the OrthoED course from his perspective. They seem to be less airway and TMD focused, more "semi traditional" orthodontics i.e still incorporate extractions but more judiciously than "traditional orthodontics" who solely do so based on crowding. There seems to be much more of a focus on orthodontics i.e alignment of teeth rather than orthopedics i.e development of bones. For my interest in prosthodontics, this course may have been more useful though I after this last course I don't really regret the choice I've made. This was the first course that actually addressed treatment phases and it was a step past what I've been exposed to in the past which has pretty much been diagnostics. I am not discounting the importance of diagnostics, but to actually get to the interventional side of things is more exciting and motivational for learning.

The IAAdent philosophy is essentially a reflection on  what I would call "contemporary orthodontics". That is contemporary in the sense of the progression of "traditional" or "old school" orthodontics. There is a lot of mud slinging in the orthodontic profession from both sides and I will be careful not to get myself too involved in this, and to keep an open mind about things. I do know that I am being exposed to one side of the story by attending this course and for all the exasperation about traditional orthodontics, both sides have their own "evidence base" which seems to completely oppose each other. Standing apart from the battle, I suppose I will see what works in my hands and what results I can attain before making any final judgements. However, having attended a few classes on the subject, I do see the appeal, rationality and logic in the contemporary philosophy.

My understanding of traditional orthodontics is based on the biased reports of teachers of the contemporary philosophy, so my interpretation may be flawed. My thinking is that there is a sole focus on teeth. In the name, orthodontics, there is straight+teeth. The reference point for alignment is in the mandible as it is considered the "correct" position and is the template for treatment. Considering the more common of malocclusions i.e Class 2, the direction of correction would be for retraction of the maxilla to achieve a class 1 molar relationship. Again, this "correction" of the dental relationship centres the whole mechanics and purpose of the treatment around achieving a tooth relationship and ignores the effect on the TMJ, airway and face. For most common malocclusions, when considering the jaws, independant of the teeth, the jaws are retracted and require protraction. However, by only considering teeth, most malocclusions employ retraction mechanics which worsens the problem. Retraction entraps the mandible causing distalisation and TMD risk, narrows the airway and flattens the mid face. The contention that traditional orthodontic practitioners would hold is that retraction mechanics doesn't have any relationship with TMD or airway. I haven't considered the evidence or opinion from that side yet but again, I do see the appeal and logic behind the airway centred philosophy.

Coming from a prosthodontic standpoint, I certainly can see the hesitancy of some of the TMD concepts that they have covered. My previous instruction was that centric relation was the goal for oral rehabilitation and this is a protected position where the muscles will be in harmony. The concepts they raise of moving the TMJ down and forwards down the eminance and restoring the patient in that position feels like trekking into uncharted waters. The concepts they use to back this is that distalisation of the mandible will cause dysfunction and remodelling of the bones of the TMJ and skull in of a pathologic nature and this can be reversed by decompressing the assembly and holding the mandible in a position for long enough to allow remodelling of the tissues to reverse pathology. This requires 24 hours splint wear for true TMD patients. Traversing the minefield of TMD is to open a can of worms in a can of worms and it seems like I will need to wait until later sessions to explore this topic further. 

The contemporary orthodontic philosophy that they teach aims to address sleep, airway, TMD issues and develop the face by protracting the maxilla and mandible "to the patient's full genetic potential". They teach that the aetiology of the retracted jaw position is functional deficits. i.e  The "modern" soft diet, abberations of nasal breathing due to allergies, mouth breathing posture, muscle abberations e.g lip tie, tongue tie, thumbsucking, tongue thrust etc. The list goes on, essentially anything that departs from normal function. Having the back story of malocclusion certainly clears up the mystery of just assuming it is genetic and all the mechanisms they suggest certainly have a certain logic to them. 

From here on out, I'll need to learn more and more about this subject. The problem is, once you tiptoe into the rabbit hole you can't escape the way that you now see the world. I had a similar feeling after my brief encounter with the EODO philosophy. I am interested to see how this can be incorporated with my current understanding of prosthodontics. I can forsee that there may be trouble incorporating the theory into practice at my current position but will also try my best to do so.