Beyond braces: CBCT expands orthodontists’ capabilities

Editor’s intro: In this article, Dr. Robert “Tito” Norris shows that orthodontists who adopt the latest knowledge and technology are helping patients breathe, sleep, and focus better.

Dr. Robert “Tito” Norris discusses Carestream Dental’s 3D modules and systems

Everyone knows what orthodontists do: braces. From a patient’s perspective, orthodontists simply straighten teeth, and that’s it. But if they only knew what orthodontists could do for them thanks to advancements in digital technology such as cone beam computed tomography. While admittedly clear aligners are making the image of brackets slowly fade in patients’ minds, straightening teeth in general is just the tip of the iceberg of what CBCT allows orthodontists to do for their patients.

Airway visualization

Figure 1: Patients with a posterior crossbite often have nasal constriction, leading to mouth breathing, a low tongue posture, and lack of maxillary support by the tongue, resulting in narrowing of the maxilla. These patients will usually have well-developed mandibular arches with minimal crowding
Figure 2: Many patients with anterior open bites have narrow pharyngeal airway space, often exacerbated by enlarged tonsils. The anterior tongue posture is the frequently the body’s natural effort to open the pharyngeal airway

I’ve been looking at airways for about the past 15 years, trying to educate and elicit the support of local ENTs to assist in opening airways constricted by tonsils, adenoids, polyps, swollen turbinates, deviated septa, and enlarged tongues. We’ve known since the 1960s that expanding the maxilla can increase nasal air volume significantly. Airway has gained national attention in orthodontics over the past 5 years as a movement of “airway-friendly” orthodontics has emerged. In fact, the entire 2019 AAO Winter Conference lecture series revolved around the topic.

Though these concepts are still relatively new within the specialty, orthodontists play a critical role in recognizing signs of airway problems, and patients are frequently surprised when an orthodontist recognizes an airway issue that has been missed by multiple physicians over the patient’s lifetime, often with significant sequelae. In addition to large tonsils, narrow palates, open bites, tethered tongues, anterior spacing, dento-alveolar extrusion, high mandibular plane angles, short upper lips, anterior tooth wear, and narrow nares — just to name a few — orthodontists now have the ability to send patients off with a home sleep study and utilize important visualization tools such as the CS Airway module (Carestream Dental) to quantify the minimum axial airway area (Figure 3B).

These two tools have been critical in getting patients to actually go to the ENT specialist for evaluation. The CS Airway module alone is used in my practice multiple times a day to quickly analyze the airway in 3D. The color coding of the pharyngeal region highlights constrictions, so I can effectively communicate concerns with patients. As a specialty, orthodontists must continue to take the lead in this area because constricted airways are simply not on the radar for most physicians, and patients are suffering because of it.

Figure 3A: This patient with an anterior and posterior crossbite also had a constricted pharyngeal airway. A skeletally anchored expander with protraction headgear allowed transverse and anterior correction of the maxilla while improving the airway


Micro-implant assisted rapid palatal expansion (MARPE)

Though this technique has a history of inconsistent results and significant morbidity, in the past couple of years, these issues have been resolved, and it has now become an effective and predictable method to get true parallel (not trapezoidal) skeletal expansion in all teens and even most adult females. We’ve been using the MARPE technique that was developed at UCLA for over a year now with amazing success.

Having a CBCT in-house (CS 9300 system, Carestream Dental) is critical to the success of the technique because the micro-implant placement must be extremely accurate, and bicortical engagement of the micro-implants must be verified via CBCT before the patient can begin expansion (Figure 4). Using MARPE, we have been able to increase nasal airway volumes; increase oral cavity volumes to improve tongue posture; and develop maxillae not only laterally, but also anteriorly via a facemask therapy or mandiublar Bollard plates applied to a skeletally anchored maxillary expansion appliance, which has just loosened all five maxillary sutures.

As more orthodontists adopt in-house CBCT systems, the MARPE technique will spread in orthodontics, giving clinicians the ability to solve a number of complaints for their patients

TMJ discomfort

Most orthodontists have some basic understanding of TMJ but many are simply too busy straightening teeth to deal with it. Imaging of the joint with a CBCT system plays an important role in properly managing these patients. With a large FOV CBCT system like the CS 9300, orthodontists are able to offer an interdisciplinary solution for patients in TMJ discomfort.

Dentofacial orthopedics

Figure 3B

It’s time that we started living up to our name as specialists in orthodontics and dentofacial orthopedics. By using the latest knowledge and technology, we have the ability to help patients breathe, sleep, and focus better. We can help alleviate the suffering of most TMJ patients as well. Spread the word — let your patients know you invested in them by investing in advanced technology. Let referrals know that they can send their patients to you for 3D scans rather than an imaging center (especially helpful for doctors practicing in rural areas). Let everyone know that orthodontics is so much more than straight teeth; it’s life changing.


Figure 4

For more about the latest knowledge and technology for orthodontists, check out “Carestream Dental and the Orthodontic Solution” here.

Dr. Robert “Tito” Norris completed dental school at the University of Texas Health Science Center, San Antonio, and did a general practice residency at the Washington DC VA Medical Center, followed by an orthodontic residency at Howard University. He then served 3 years in the Air Force as an orthodontist in Misawa, Japan, before opening his practice in 1998 in San Antonio. Dr. Norris was board certified in 2003 and has served as a clinical consultant for numerous technology companies along the way.

Dr. Norris can be reached through

Disclosure: Dr. Norris is a key opinion leader for Carestream Dental.

  1. Kumar SA, Gurunathan D, Muruganandam E, Sharma S. Rapid Maxillary Expansion: A Unique Treatment Modality in Dentistry. Journal of Clinical and Diagnostic Research. 2011;5(4) 906-911.

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