StraightSmile Solutions®

Open Mouth Posture in Cephs – Numbers Invalid? Turning CBCT into Cephs with Extension Arms
I. Introduction

Dr. Amanda explains how open mouth posture during cephalometric imaging leads to invalid or distorted measurements, particularly when converting CBCT scans to 2D cephs. As more clinicians adopt CBCT extension arms or outsource ceph conversions, understanding proper mouth closure protocols becomes critical for diagnostic accuracy. She emphasizes establishing a consistent workflow and verifying patient posture before image capture.

1. Ceph Workflow and Equipment Setup
2. Clinicians may use CBCT machines with extension arms or services like Beam Readers and 3DX to extract ceph images.
   B. Dr. Amanda stresses the need to practice image acquisition before complex cases arise.
   C. Each CBCT system differs in setup; clinicians should consult manufacturers for proper bite positioning tools and calibration settings.

III. Importance of Mouth Closure

1. The mouth must be fully shut for accurate skeletal and dental relationships.
   B. If “daylight” (visible space) is seen between both anterior and posterior teeth, the ceph is invalid.
   C. Open-mouth posture skews mandibular readings, causing diagnostic errors in Class II or III evaluation.
2. Impact on Cephalometric Measurements
3. Accurate values: SNA angle, upper incisor to NA, and maxillary metrics remain reliable.
   B. Distorted values: SNB, ANB, mandibular position, and vertical skeletal dimensions.
   C. An open mouth alters the hinge position of the mandible, lengthening facial height artificially.
4. Case Example and Clinical Insight
5. In a Phase I case showing a possible Class III profile, ceph readings were misleading due to an open-mouth posture.
   B. True diagnosis revealed a retrognathic maxilla (small SNA) rather than a prognathic mandible.
   C. This highlights the importance of reviewing ceph posture before interpretation.
6. Clinical Recommendations
7. Always confirm bite closure prior to scanning.
   B. Request retakes if an imaging center returns open-mouth cephs; no patient should be recharged.
   C. Develop internal standard protocols for CEPH imaging and posture verification.

VII. Conclusion

Open mouth posture compromises cephalometric reliability by distorting mandibular and interjaw measurements. While some maxillary readings remain usable, skeletal analysis becomes invalid for treatment planning. Clinicians must ensure proper bite closure, equipment calibration, and staff training to produce accurate cephs. Maintaining image quality protects diagnostic confidence, prevents re-radiation, and enhances orthodontic outcomes.

Risks of Using a Haas Expander Instead of IPE, RME, or RPE
I. Introduction
Dr. Amanda introduces the Haas expander, a traditional orthodontic device similar to a Hyrax expander but with an added layer of acrylic over the palate. While some clinicians consider it for improved retention and skeletal movement, Dr. Amanda explains why she generally does not recommend Haas expanders in modern orthodontics. She emphasizes that IPEs (Invisalign Palatal Expanders) and 3D-printed RPE/RME designs now offer better precision, comfort, and hygiene with fewer complications.
How Haas Expander Works
• Acrylic plate sits along palate → increases stability and adaptation
• Can improve force distribution
• Less buccal segment tipping compared to standard Hyrax
• Reduces posterior wedge effect (posterior opening more than anterior)
Why Some Clinicians Still Use It
• Historically used to achieve more predictable skeletal expansion
• Some clinicians believe it gives a stronger orthopedic effect vs. RPE/RME
• Occasionally chosen when doctors want maximum anchorage and force control
Modern Perspective: Is It Necessary?
• With current Interproximal Expansion (IPE) systems, Haas is often not required
• Many orthodontists prefer non-acrylic expanders for cleanliness and comfort
• Dr. Amanda rarely uses Haas today → considers it older-generation tech
Clinical Risks & Complications
• Acrylic can compress the palate, creating ischemia and soft-tissue trauma
• Improper seating → palatal blanching
• Potential outcomes if blanching is ignored:
o Painful ulcers
o Tissue necrosis
o Fistulas extending toward the sinus (severe but documented)
• Hygiene challenge: must be able to floss beneath the acrylic
• Without access, food/debris trap → inflammation and infection
Best Practices for Using Haas
• Use clear or light-pink acrylic to monitor tissue
• Ensure no blanching when seating before cementation
• Confirm floss access beneath the appliance
• Monitor tissue throughout activation period
V. Conclusion
While the Haas expander can achieve good skeletal movement, it carries significant risks of soft tissue trauma and hygiene complications due to its acrylic design. Modern 3D-printed and digital expansion systems provide comparable or better results with fewer side effects. Dr. Amanda concludes that the Haas expander is largely outdated, and clinicians should prioritize patient safety, tissue health, and predictable biomechanics over tradition.

Which Makes the Worst POB (Posterior Open Bite) at the End of Expansion? RPE, IPE, or 3D Printed RME?

Dr. Amanda with Straight Smile Solutions addresses clinicians’ concerns about POBs post-expansion and reassures that this is often a normal, temporary occurrence.

Understanding Why POBs Occur

• Common Cause:
  • Teeth become slightly intruded due to constant occlusal contact against thick expansion material.
  • Bands, screws, or plastic components add vertical thickness → bite propped open.
• Material Thickness:
  • 3D-printed RMEs and soldered band expanders are thicker than traditional banded devices.
  • Repeated occlusal contact (“slam, slam, slam”) over months leads to minor intrusion of posterior teeth.
• Cuspal Interference:
  • Hanging or misaligned cusps after expansion can create temporary posterior separation, appearing as open bites.

Clinical Management & Misconceptions

• Do not panic or overcorrect. POBs are typically self-resolving.
• Avoid forced eruption:
  • Let gravity, occlusal settling, and muscle balance gradually close the bite.
  • Forcing an eruption can cause unwanted vertical discrepancies or instability.
• Natural adaptation:
  • Posterior teeth re-erupt and occlusion normalizes once the appliance is removed and function resumes.
• Reference to traditional orthodontics:
  • In braces-era expansion with posterior acrylic blocks, similar POBs were common and resolved naturally during finishing.

Recommended Approach

• Allow natural settling post-expansion; avoid unnecessary mechanical intervention.
• Reassess occlusion during the retention or finishing stage, not immediately after appliance removal.
• Use deprogramming techniques (as covered in Dr. Amanda’s related content) if minor functional imbalance persists.

Key Takeaway

• All expansion types, RPE, IPE, and 3D-printed RME, can cause temporary POBs.
• The “worst” is usually linked to thicker expanders, not the expansion method itself.
• Patience > force: Nature and time resolve most posterior open bites.

Introduction

• Dr. Amanda explains how to determine the right time to stop expansion using RPE, RME, Hyrax, or Invisalign IPE.
• Many clinicians struggle to know when enough is enough during expansion.
• Expansion goals vary, such as airway improvement, better tongue posture, or creating arch space.
• She emphasizes understanding the original purpose before continuing with more turns.

Reassess the Treatment Goal

• Always start by reviewing why expansion began.
• If the airway is improved, the tongue can now rest on the palate, and the arch width meets the function expansion, which can stop.
• If the tongue is still restricted, consider myofunctional therapy or frenectomy instead of more expansion.

Evaluate Arch Width and Retention Stability

• Ideal alignment: Upper arch ½ tooth wider than the lower.
• Slight overexpansion is acceptable to offset natural relapse.
• Overexpanding is safer than under-expanding; extra space can later be corrected.
• Proper retention (at least 3 months full-time) is key to maintaining results.
• Poor compliance with removable retainers leads to relapse.

Confirm Space for Developing Teeth

• In mixed dentition, use panoramic x-rays to ensure enough room for eruption.
• Teeth should be upright with clear eruption paths.
• Rapid expansion needs longer retention than slow, gradual turns.

Conclusion

• Stop expansion once the chief complaint is resolved, arches are proportionate, and eruption space is confirmed.
• Avoid unnecessary turns; stability matters more than extra widening.
• Proper retention and observation will preserve the final result.

Introduction

• Amanda addresses the challenge of identifying ankylosed or impacted canines before orthodontic treatment.
• Clarifies that Straight Smile Solutions doesn’t handle surgical cases but provides educational support.
• Emphasizes that recognizing ankylosis early prevents financial, ethical, and clinical issues for providers.

Ankylosis Definition & Causes

• Ankylosis = the root surface fuses to bone, losing periodontal ligament (PDL) flexibility.
• The tooth becomes “glued” in place, behaving like an implant.
• Often caused by trauma, abnormal root structure, or developmental issues.

Commonly Affected Teeth

• Most often: canines, premolars, and sometimes upper incisors.
• Rare in growing children but more likely in adults (20s–30s).

Diagnosis Tools & Methods

• CBCT (3D imaging): Best for full root visualization in 360°.
• 2D PA X-rays: Limited view; consider taking angled shifts for more perspective.
• True confirmation often comes only when traction is applied and the tooth fails to move.

Clinical Red Flags & Risk Factors

• Stalled tooth movement despite traction.
• Root resorption (external or internal).
• History of trauma, palatal crown position, tapered or oddly angled root.
• Mature, non-growing root apex (no apexogenesis).

Patient Communication & Documentation

• Always disclose ankylosis risk in informed consent forms.
• Get written acknowledgment if risk factors exist.
• Be realistic—prepare patients for the possibility that a tooth might not move.

Conclusion

• Ankylosis can’t always be predicted, but CBCT improves detection chances.
• Be cautious, particularly with adult or complex cases—if ankylosis occurs, the provider may bear financial responsibility.
• Amanda advises erring on the side of caution, managing expectations, and avoiding risky adult ankylosed cases when possible.

Gen X and Boomer Dentists — Is Culture or Neurodivergence Killing Your Happiness in the Office?
Introduction
• Dr. Amanda opens by addressing a growing issue among Gen X and Boomer dentists: a deep sense of unhappiness and burnout within their practices.
• She observes this daily through online dental forums, Facebook groups, and professional communities where doctors vent frustration about their teams, patients, and careers.
• Dentistry has shifted culturally, with fewer conventions, more isolation, and less real collaboration.
• Dr. Amanda believes the problem runs deeper: it’s not just business stress, it’s about mismatched culture and unrecognized neurodivergence within the dental profession.
The Cultural Disconnect
• Many older dentists (Gen X, Boomers) were raised in a “work hard, keep quiet” mindset, but younger generations (Millennials, Gen Z, Alphas) crave collaboration, feedback, and shared decision-making.
• Today’s staff want culture, not just a paycheck. They want to contribute to office dynamics, incentive systems, and overall mission.
• When older doctors ignore this, toxicity grows. Offices lose good employees because the culture doesn’t match modern expectations.
• Dr. Amanda warns: you can’t fight culture, it’s evolving, and ignoring it will destroy your practice faster than you realize.
Personality and Team Fit
• Understanding personality types is crucial. Dr. Amanda recommends tools like the Enneagram to assess how team members communicate and collaborate.
• When each staff member works in alignment with their strengths, productivity and morale improve.
• She urges dentists to invest in culture-building, even if it feels “too millennial,” because happy teams create thriving practices.
Neurodivergence Awareness
• Dr. Amanda candidly shares her own journey, discovering she’s neurodivergent, her brain processes faster and differently than others.
• Many Gen X and Boomer professionals may also be undiagnosed, having learned to mask and adapt since childhood.
• This long-term masking often manifests as irritability, burnout, or unhappiness at work.
• Recognizing and understanding neurodivergence can dramatically improve self-awareness and relationships within dental teams.
Conclusion
• The unhappiness many older dentists feel isn’t purely from stress; it’s a mix of cultural mismatch and unacknowledged neurodivergence.
• To restore joy in practice:
o Acknowledge the changing workplace culture.
o Invest in personality and communication training.
o Learn about neurodiversity and support differences rather than resist them.
• Dr. Amanda’s takeaway: modern success in dentistry isn’t just clinical, it’s cultural and emotional. Understanding yourself and your team may be the real cure for burnout.

Tongue and Lip Ties in Kids and Adults: When to Trim the Frenum (Frenectomy)

Dr. Amanda with Straight Smile Solutions

• Focus: tongue and lip ties in children and adults.
• Builds on prior content about maxillary labial frenectomies (timing with braces/Invisalign/Phase 1).
• Offers an orthodontist’s perspective on when trimming is necessary vs. avoidable.

Why/When Frenectomy is Indicated

• Upper lip ties:
  • If a gap (diastema) between teeth exists, pulling the lip shows blanching and a visible tissue tag.
  • Must close the space first with orthodontics before trimming → prevents scar tissue from blocking closure.
  • Procedure timed after Phase 1, Phase 2, or comprehensive treatment and retention.
• Lower ties:
  • Usually less of a concern unless affecting orthodontic closure/retention.
  • Signs to trim:
    • Space reopens quickly (within 12 hours) after removing the power chain/aligners.
    • Persistent relapses despite retention.
  • Requires bonded (permanent) retainer after trimming.

Testing Before Deciding on Surgery

• With braces:
  • Remove power chain near the end of treatment → monitor if spaces pop open.
  • If reopening occurs → frenectomy + bonded retainer.
  • If not → surgery is often unnecessary.
• With Invisalign/aligners:
  • “Day off” test → patient skips aligner wear during the day (under orthodontist’s supervision).
  • If spacing reappears, → frenectomy may be indicated.
  • Orthodontist verifies results in person, not just the patient’s word.

Clinical Decision Making

• Avoid trimming too early (can complicate closure).
• Base decision on relapse behavior rather than routine trimming.
• Collaboration with an OMT (orofacial myofunctional therapist) may guide lower tie management.

Key Takeaway

• Frenectomy should be timed strategically after space closure and retention testing.
• Not every tie requires trimming; only pursue it when relapse or spacing proves persistent.

Thrush, Tongue Scraping, and How to Tell if Your Tongue Has a Yeast Infection

Dr. Amanda with Straight Smile Solutions discusses tongue health, tongue scraping, and signs of thrush (oral yeast infection).

She shares perspective from both professional experience and family traditions (grandmother checking tongue for illness).

Healthy Tongue Basics

• Tongue surface covered in papillae (taste buds) with sensory and functional roles.
• Grooved texture allows food, plaque, and bacteria to accumulate.
• Historically: brushing the tongue. Modern recommendation: scraping instead.

Tongue Cleaning Practices

• Scraping removes plaque, food, and debris more effectively than brushing.
• Tools: firmer scraper (more effective, harsher) vs. softer scraper (gentler).
• Best practice: scrape tongue twice daily along with brushing.

Normal vs. Abnormal Tongue Coating

• Normal: White coating that wipes/scrapes away easily = plaque or food residue.
• Thrush (oral yeast infection):
  • Thick, creamy, cottage cheese-like patches.
  • Cannot be fully removed by scraping.
  • Red, raw, or bleeding tissue underneath.
• Other possible causes of white lesions: leukoplakia or lichen planus (non-fungal conditions).

Oral Microbiology & Thrush

• The mouth hosts good and bad bacteria plus fungi.
• Good bacteria → maintain balance.
• Bad bacteria → cavities, gum disease.
• Fungal imbalance (Candida) → thrush.
• Some individuals are prone to recurrent thrush, like recurring strep.

Transmission & Risk

• Thrush can spread through kissing or close contact.
• Choosing partners with poor oral or gut health increases risk.
• Links to earlier discussions on transmission of bad gut bacteria.

Management & Care

• If thrush is suspected: visit the dentist for a biopsy and diagnosis.
• Treated with antifungal medications.
• Important to distinguish from other white oral conditions.

Key Takeaway

• Practice daily tongue scraping.
• Learn to identify thrush vs. harmless debris.
• Oral health and partner health both influence long-term microbiome balance.

Context & Position

• Dr. Amanda clarifies her stance on early pediatric expansion (ages 2–5, before first molars erupt).
• Emphasizes standard, predictable orthodontics backed by literature and time, not “fringy” methods with higher risks.
• Holds insurance/liability coverage, chooses not to support unpredictable or legally risky cases.

Professional Responsibility

• As an educator, she may decline cases that she believes are unsafe, unpredictable, or outside scope.
• More clinicians are showing interest in early expansion, but risks remain significant.

AAPD Statement & Legal Concerns

• Refers to the AAPD’s official statement on early expansion (recommends collaboration with a physician).
• Like general dentists in sleep dentistry: must work with MDs (ENT, pulmonologist, etc.).
• If attempted solo and complications arise, legal/insurance risks are high.
• For this reason, Dr. Amanda opts out of supporting these cases directly.

Alternative Approaches & Safer Options

• She suggests non-expansion therapies:
  • Tooth pillows, myofunctional trainers, habit correctors, U-concepts.
  • ENT referrals for nasal breathing & posture correction.
• Endorses Dr. Simon Wong’s approach (no expansion on very young kids). Notes: Kevin Boyd teaches courses in this area.

Finishing & Practical Considerations

• Every early expansion case requires finishing with braces or Invisalign.
• Without the ability to deliver finishing, clinicians risk poor outcomes.
• Advises starting only once first molars + incisors are in (age ~7–8).
• Notes: lab fees are high and often not covered by insurance → financially messy.
• Personal reflection: even her husband, considering holistic dentistry, plans to avoid this route.

Context & Background
• Builds on her prior video about early expansion (ages 2–5) requiring physician involvement.
• Refers viewers to the AAPD’s policy (linked on her site under “Get Started → Help with RPE”).
Key Principle: Stay Within Standard Orthodontics
• To avoid needing MD oversight, avoid very young or very old cases.
• Stick to normal orthodontic expansion cases routinely done by orthodontists.
• Expansion must have an orthodontic indication, not purely medical/airway reasons.
Orthodontic vs. Medical Distinction
• Expansion for orthodontic problems = dentist/orthodontist scope.
• Expansion only for sleep/airway = classified as medical → requires physician collaboration.
• The difference is largely semantic but critical for liability and compliance.
Requirements for Safe Practice
• First permanent molars (all four) must be erupted before expansion.
• She will help with:
o Ortho-driven expansion (vaulted palate, tongue space issues).
o Case support via multiple service models (a la carte, premium, concierge, hourly).
• Will not assist with:
o Pre-molar eruption expansion.
o Adult expansion (too risky, not her scope).
Adult Expansion Risks & ADA/FDA Alerts
• ADA (April 3, 2023) urged dentists/public to report adverse effects in adults with expanders.
• FDA is also monitoring concerns → highlights increased scrutiny.
• Yes, adult expansion can be done, but it carries high risks and requires medical collaboration.
Closing Message
• Dentists should:
o Keep cases within orthodontic indications.
o Avoid pediatric “itty bitty” and adult-only airway cases unless working with MDs.
o Protect themselves legally and clinically by staying in the orthodontic lane.