D2 ◊Page D1 real answer. Bringing costs down is not the way to solve fear. An exam- ple is CBCT. When I got into it, almost 12 years ago, it was very expensive and there was no education avail- able—it was like diving off a cliff. My first CBCT machine cost over US$200,000 and that was a lot of money! You can now get a machine for much less; so yes, the cost will always come down as technology advances, but seeing something that offers so many new possibilities, that insight, as happened for me when I first saw what CBCT could do, meant I could not go back; I had to have it. The value overcame the cost; I could not practise consciously and not have that because I knew it was out there and how it could improve the treatments and care I was giving my patients. Aligners are not suitable for every- one. Can you tell me when you do not see them as a treatment pos- sibility, and if you use them as part of a hybrid treatment plan? My practice treats children exclu- sively—a conscious decision I took four years ago when I decided to commit to what I was really good at and really loved, which is build- ing faces and young bites that are healthy and will last a lifetime. I do a lot of developmental treat- ments, a lot of two-phase treatments. Therefore, I have very small inter- ventions, often in children aged 7 to 10, in which we develop facial bones, correct jaw width and allow the den- tition to erupt quite straight. Clean- ing that up with conventional fixed ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 6/2019 I T D © appliances to get a perfect occlusion is what we do in our second phase, which usually happens around 12 years old. Conceptually, you can do that with any appliances, so it does not matter if one uses lingual or la- bial appliances or aligners; it is just about knowing what your goal is and how to get there, and making sure to evaluate your results to get to a result that is good and stable. Therefore, as long as you are paying attention, you can use anything. Personally, I do not use aligner therapy a lot simply because what works well in my prac- tice is conventional labial appliances, which are on for very short periods. For my practice model, it is very ef- ficient and the only reason I do it that way. I think someone can have a practice exactly like mine and do it with aligners completely; it is just not what I developed. If I wanted to switch my practice to aligners, thought that it is that much better than what I am doing, I would push through the pain we talked about before and do it. But I don’t yet see someone getting results that are re- markably disruptive to what I am do- ing, results that I cannot achieve with the way I work. Okay, but do you use them in par- ticular cases or in combination with conventional fixed applianc- es? Do you see that one day they will replace conventional appli- ances? Much depends on the area where you live and the demand for it. In my area, a very wealthy community with a lot of discretionary income and high education, and because I treat children, the demand for aligners is not as high. Will conventional fixed appliances ever go away completely? Maybe, but I think that because there are still certain challenges with align- AD ers conventional brackets are slightly better at certain things. I just don’t think it is going to be an all or noth- ing game; it just depends on the type of practice you have. In your presentation, you spoke about a 91 per cent decrease in the apnoea–hypopnoea index with maxillary expansion and removal of adenoids and tonsils. Is it a pos- sible solution to snoring for both children and adults? If you identify and can remove those tissues, it is beneficial. I think that, at least in the US, adenoids and tonsils are largely overlooked now com- pared with the 1970s. I believe in the late 1970s or early 1980s, a study had come out stating that recurrent in- fection was not a reason to remove adenoids and tonsils, so doctors de- cided not to do it anymore and insur- ance didn’t cover it so readily. What they did not know at the time was that all these breathing issues were also related to obstruction in the adenoid and tonsil areas. They prob- ably overlooked the fact that many of these children were suffering from sleep-disordered breathing be- cause of their tonsils and adenoids. If you can identify this problem, it is a life changer for these children, and I think that, if you don’t look at that, you could be missing a massive health benefit for your patients, and I therefore believe all of us should consider this. Does expansion or adenoid and tonsil removal cure sleep apnoea? No, it is a very complex disease. We do a lot of early expansion in my practice, called rapid palatal expan- sion, which is sutural distraction of the maxilla, to improve the width of the maxillary bones, and this is now also done more commonly on adults, using temporary anchorage devices to produce larger maxillae. There are many studies in the lit- erature that show an increase in up- per airway volume with maxillary expansion, so physically, you create a larger airway space. That does not necessarily correlate with curing sleep apnoea. For some patients with a structural issue, it improves their sleeping quality tremendously and sometimes you can eliminate intra- oral appliances. If you can benefit many patients and understand that you won’t cure or benefit all patients, then I think it is an important thing to do. I think what is happening, at least in the US, is that people are trying to make it an all or nothing argument. They either want to know that it definitely works and cures everybody, or it definitely does not work. The problem is that, it is never that easy. Biology, health- care and medicine are never that easy. Getting a study to tell you one way or another is not how research works; you are never going to get the answer from one study, but people want black and white. Editorial note: This article was originally published in ortho-international magazine of orthodontics, Issue 1/2019. Dr Sean K. Carlson ORTHOSCIENCE 163 Miller Avenue, Suite 4 Mill Valley, CA 94941 +1 888 673 2827 info@orthoscience.com