IMPACTOLOGIST OR A FUNCTIONING 'TEAM'
"Impactologist" or Team work
All literature about impacted canines emphasize the importance of a collaboration between dentist/ orthodontist/ radiologist/ oral surgeon/ endodontist/ implantologist.
A multidisciplinary approach, atraumatic surgery, and judicious use of orthodontic forces can ensure an
excellent result in form, function, and esthetics in cases with delayed canine eruption.(1)
Do you get a sense that the different clinicians communicate with each other, that they have a well functioning network?
Actually, it seems like a funny kind of situation. Your orthodontist, is the one in charge of treatment and final result, but the oral surgeon is extremely important and is the one who actual gets a more physical sense of the problem teeth if the orthodontist is not present at surgery.
You wish you could have the orthodontist and surgeon merge in the same person, and then you need to add the radiologist too for the CBCT. My solution, is the 'impactologist', but if you can't have it all in one person, you need the orthodontist, surgeon, and radiologist are as intimate as can be, sharing thoughts about how to pull, what needs to me rotated, tilted, pulled, and how. You want a team.
In his work on the "Orthodontic Treatment of Impacted Teeth" Dr. Becker writes how the ideal situation a an 'expose & bond' procedure would have the orthodontist present, which seems quite logical, but I don't think most patients have the luxury of such care in the US.
Below is a beautiful piece of writing by Dr. Becker in his 'Orthodontic Treatment of Impacted Teeth', both language wise and by sentiment. He understands, what a parent feels: it is very important to
strive to optimal care when dealing with a situation where the result is something that will affect the rest of a young person's oral health.
From the above account, it will be appreciated that, that the presence of the orthodontist at the
surgical intervention has much to commend it. In the first place, the orthodontist is able to see
the exact position of the crown, the direction of the long axis and the deduced location of the
root apex. The height of the tooth and its relation to the adjacent roots may all be noted and the
orthodontist may plan the strategy of its resolution by direct visualization. The orthodontist will
be in a position to decide exactly where he/she would like to see the attachment placed from the
mechano-therapeutic point of view and will bond it there. The orthodontist is also the best
person to fabricate and place a suitable and efficient auxiliary to apply a directional force of
optimal magnitude and a wide range of movement and to place it at the time of surgery.
It is not fair to expect the oral surgeon to be aware of how different attachment positions may
affect the orthodontic or periodontic prognosis; nor should it be expected of him/her to be
sufficiently experienced with the bonding technique to do this. For most oral surgeons, bonding
is not a procedure that they will routinely carry out. The presence of the orthodontist allows for
bonding to be performed efficiently, with the surgeon and the nurse maintaining hemeostais,
and the necessary dry field. So, if a surgeon were to take exception to the present
recommendation that the orthodontist be present at the exposure, with the words 'even the
lowliest oral surgeon can place a bracket' or that it is 'a waste of time', that the oral surgeon
would be sorely missing the point and the wider context of ensuring quality care and overall
treatment success.
The ultimate responsibility for success of the case, from the initiation of orthodontic treatment
up to the point where the impacted tooth is brought into full alignement, rests firmly on the
shoulders of the orthodontist. It would seem irresponsible to abrogate this crucial stage of the
treatment, where a force is to be applied to the newly exposed impacted tooth and where so
much is at stake that affects the future of the case, to another party. Absenting himself from
the procedure, as has been advocated by many orthodontists and surgeons alike, leaves the
surgeon to make orthodontic decisions for which he is not equipped, thereby endangering the
outcome and inviting legal proceedings, from which the orthodontist will not be immune. (1)
Googling around looking at surgery and orthodontics in the US on impacted canines, I see the same copied information for parents that 'impacted' means that the tooth is 'stuck' et cetera, the same talk of the 'team', but nowhere does this seem to extend to the orthodontist and surgeon actually working together in the operating room. It is really sad if the team work is represented by a referral slip for 'expose & bond, thank you'. Dr. Becker is way ahead of conventional thinking. He is concerned with getting the best results. Sadly medicine is sometimes hampered with conventions and it takes very long for evidence based research to change them.
Emerging 'impactologists'
Googling, I found Dr. Vu (drhungvu.com) in Los Angeles. He is a dentist/orthodontist /professor in
mechanical and aerospace engineering who is also a CBCT afficionado. This is what I'm talking about!
Dr. Vu will be speaking at the 2014 AAO meeting in New Orleans on the subject of: "CBCT, Surgical Exposure, and Orthodontic Treatment of Impacted Canines".( He is also very nice to talk to.)
Dr Vu has a page on 'impacted canines' with case stories explained. He uses laser for surgery of soft tissue.
Who is doing what with with teeth?
All literature about impacted canines emphasize the importance of a collaboration between dentist/ orthodontist/ radiologist/ oral surgeon/ endodontist/ implantologist.
A multidisciplinary approach, atraumatic surgery, and judicious use of orthodontic forces can ensure an
excellent result in form, function, and esthetics in cases with delayed canine eruption.(1)
Do you get a sense that the different clinicians communicate with each other, that they have a well functioning network?
Actually, it seems like a funny kind of situation. Your orthodontist, is the one in charge of treatment and final result, but the oral surgeon is extremely important and is the one who actual gets a more physical sense of the problem teeth if the orthodontist is not present at surgery.
You wish you could have the orthodontist and surgeon merge in the same person, and then you need to add the radiologist too for the CBCT. My solution, is the 'impactologist', but if you can't have it all in one person, you need the orthodontist, surgeon, and radiologist are as intimate as can be, sharing thoughts about how to pull, what needs to me rotated, tilted, pulled, and how. You want a team.
In his work on the "Orthodontic Treatment of Impacted Teeth" Dr. Becker writes how the ideal situation a an 'expose & bond' procedure would have the orthodontist present, which seems quite logical, but I don't think most patients have the luxury of such care in the US.
Below is a beautiful piece of writing by Dr. Becker in his 'Orthodontic Treatment of Impacted Teeth', both language wise and by sentiment. He understands, what a parent feels: it is very important to
strive to optimal care when dealing with a situation where the result is something that will affect the rest of a young person's oral health.
From the above account, it will be appreciated that, that the presence of the orthodontist at the
surgical intervention has much to commend it. In the first place, the orthodontist is able to see
the exact position of the crown, the direction of the long axis and the deduced location of the
root apex. The height of the tooth and its relation to the adjacent roots may all be noted and the
orthodontist may plan the strategy of its resolution by direct visualization. The orthodontist will
be in a position to decide exactly where he/she would like to see the attachment placed from the
mechano-therapeutic point of view and will bond it there. The orthodontist is also the best
person to fabricate and place a suitable and efficient auxiliary to apply a directional force of
optimal magnitude and a wide range of movement and to place it at the time of surgery.
It is not fair to expect the oral surgeon to be aware of how different attachment positions may
affect the orthodontic or periodontic prognosis; nor should it be expected of him/her to be
sufficiently experienced with the bonding technique to do this. For most oral surgeons, bonding
is not a procedure that they will routinely carry out. The presence of the orthodontist allows for
bonding to be performed efficiently, with the surgeon and the nurse maintaining hemeostais,
and the necessary dry field. So, if a surgeon were to take exception to the present
recommendation that the orthodontist be present at the exposure, with the words 'even the
lowliest oral surgeon can place a bracket' or that it is 'a waste of time', that the oral surgeon
would be sorely missing the point and the wider context of ensuring quality care and overall
treatment success.
The ultimate responsibility for success of the case, from the initiation of orthodontic treatment
up to the point where the impacted tooth is brought into full alignement, rests firmly on the
shoulders of the orthodontist. It would seem irresponsible to abrogate this crucial stage of the
treatment, where a force is to be applied to the newly exposed impacted tooth and where so
much is at stake that affects the future of the case, to another party. Absenting himself from
the procedure, as has been advocated by many orthodontists and surgeons alike, leaves the
surgeon to make orthodontic decisions for which he is not equipped, thereby endangering the
outcome and inviting legal proceedings, from which the orthodontist will not be immune. (1)
Googling around looking at surgery and orthodontics in the US on impacted canines, I see the same copied information for parents that 'impacted' means that the tooth is 'stuck' et cetera, the same talk of the 'team', but nowhere does this seem to extend to the orthodontist and surgeon actually working together in the operating room. It is really sad if the team work is represented by a referral slip for 'expose & bond, thank you'. Dr. Becker is way ahead of conventional thinking. He is concerned with getting the best results. Sadly medicine is sometimes hampered with conventions and it takes very long for evidence based research to change them.
Emerging 'impactologists'
Googling, I found Dr. Vu (drhungvu.com) in Los Angeles. He is a dentist/orthodontist /professor in
mechanical and aerospace engineering who is also a CBCT afficionado. This is what I'm talking about!
Dr. Vu will be speaking at the 2014 AAO meeting in New Orleans on the subject of: "CBCT, Surgical Exposure, and Orthodontic Treatment of Impacted Canines".( He is also very nice to talk to.)
Dr Vu has a page on 'impacted canines' with case stories explained. He uses laser for surgery of soft tissue.
Who is doing what with with teeth?
With braces and implants the divisions between what belongs in which speciality seems to get ever fuzzier. Orthodontists are about to loose a lot of their clientele as dentists are taking up Six Month Smiles® and Invisalign®. Here'a a website with the heading: Short-Term Orthodontics - a Gold Mine for General Dentists (from dentaleconomics.com) It talks of how easy it is, most of the work can be delegated to assistants, and it is short enough that you don't have to worry about the liability of root resorption, so short-term orthodontics is a 'huge profit center available...that dentists from the U.S, Canada and U.K. are discovering in droves...it's exploding right before our eyes'. Absolutly horrible from the viewpoint of being a 'patient'. This isn't healthcare. This is purely business, and not the kind of caring professional anybody knowingly wants anything to do with. |
Here's a totally online version of braces: 'Smile Direct Club' (smiledirectclub.com). For $ 1850 and a $99 retainer.
They send you an at-home impression kit or you go to a 'Smile-Shop' to have your teeth scanned, then a 'dental professional' will make a treatment plan and send you the invisible aligners.
So they take on the low-hanging fruit that everybody want. If the 'hard-wire' orthodontist loose this market, maybe they'll have more time for the impacted canines and difficult cases.
They send you an at-home impression kit or you go to a 'Smile-Shop' to have your teeth scanned, then a 'dental professional' will make a treatment plan and send you the invisible aligners.
So they take on the low-hanging fruit that everybody want. If the 'hard-wire' orthodontist loose this market, maybe they'll have more time for the impacted canines and difficult cases.
What goes for teeth alignement goes for dental implants. Dentists are in the implant business, as well as periodontists, oral surgeons and prostodontists. I don't know it is for better or worse, but maybe it can be a good motivator for orthodontist to specialize further and get better at treating impacted canines, and maybe there is the speciality of 'impactologist' on the horizon.
(1) Nilesh V. Joshi. Periodontal Status Following Treatment of Impacted Maxillary Canines by Closed Eruption
Technique: An Overview and Case REport. J Orthod 2014 Mar;41(1): 13-8.
Technique: An Overview and Case REport. J Orthod 2014 Mar;41(1): 13-8.