RISKS WITH TREATMENT
Ending up at a University Clinic...not a guarantee for state-of-the-art
Without some kind of diploma and training that certifies an orthodontist as qualified in the art of 'impacted teeth' and CBCT, what do you do? After our orthodontist gave us a referral for extraction saying there was no other possible alternative, our family turned to the University Clinic. As a parent you have no idea who is 'good at' impacted teeth, and a university clinic seems the safest bet. It's the natural setting for team work, and you expect a genuine interest in the subject and cutting edge science. Caveat, don't presume this. Don't think things are taken care of just because your child is now under the auspices of a University and Professors.
Dr. Becker's May 2014 Newsletter (1) relates a complicated impaction case. An experienced orthodontist realizes he is in over his head, refers the case to the university, where the child ends up with a 'young and inexperienced
student'. His supervising professor could not solve the case either, so they write to Dr. Becker for advice.
(This is what happened in my son's case. A second opinion case isn't identified as deserving the most experienced professor with an interest in impaction - presuming there is such a person. You end up with someone young enough not to have much experience, who asks around for advice among his professors when he is out of his depth, but evidently none of the professors feel actually responsible in this case, so the result is not optimal).
At the Hadassah University they have a clinic for impacted canines.
Complicated cases needs to be matched with someone competent! In orthodontia, time is important, and after going through often a year or more of failed traction, you don't want to end up with someone else, 'giving it a go' even if it is a university setting. You need careful, experienced orthodontist from the start, working in close collaboration with an oral surgeon, periodontist, etc.
Without some kind of diploma and training that certifies an orthodontist as qualified in the art of 'impacted teeth' and CBCT, what do you do? After our orthodontist gave us a referral for extraction saying there was no other possible alternative, our family turned to the University Clinic. As a parent you have no idea who is 'good at' impacted teeth, and a university clinic seems the safest bet. It's the natural setting for team work, and you expect a genuine interest in the subject and cutting edge science. Caveat, don't presume this. Don't think things are taken care of just because your child is now under the auspices of a University and Professors.
Dr. Becker's May 2014 Newsletter (1) relates a complicated impaction case. An experienced orthodontist realizes he is in over his head, refers the case to the university, where the child ends up with a 'young and inexperienced
student'. His supervising professor could not solve the case either, so they write to Dr. Becker for advice.
(This is what happened in my son's case. A second opinion case isn't identified as deserving the most experienced professor with an interest in impaction - presuming there is such a person. You end up with someone young enough not to have much experience, who asks around for advice among his professors when he is out of his depth, but evidently none of the professors feel actually responsible in this case, so the result is not optimal).
At the Hadassah University they have a clinic for impacted canines.
Complicated cases needs to be matched with someone competent! In orthodontia, time is important, and after going through often a year or more of failed traction, you don't want to end up with someone else, 'giving it a go' even if it is a university setting. You need careful, experienced orthodontist from the start, working in close collaboration with an oral surgeon, periodontist, etc.
IATROGEN PROBLEMS= treatments that are destructive
Dr. Becker explains two ways how surgeons might cause the impaction (2):
...overzealous and wide exposure of the tooth, down to the CEI and beyond, will cause tearing of the fibres
of the periodontal ligament and exposure of the surface of the cementum...an aggressive resorption process
may be initiated in the exposed cervical area of the root due to chronic inflammation in the granulation tissue
which is in contact with the dentine, which may prevent the marginal gingival epithelium from forming
protective cervical cell layer in an angular defect.
Pushing elevators down the side of the tooth aimed at ensuring a good degree of mobility causes damage to
the cementum which may then heal with an ankylotic union.(p 55)
Dr Stella Chu:
a critical evaluation of the reasons for failure showed that the main reasons were poor biomechanical
planning of anchorage and an incorrect diagnosis of location and resorption. Ankylosis was only the third
factor for failure. In this particular sample of failed cases, the extremely high incidence of ankylosis could
have been caused by iatrogenic factors, such as trauma, radical surgery, instrumentation or etchant spillage
on exposed root surfaces, or excessive orthodontic force.(3)
Dr Puricelli:
In our experience, the ankylosis process affecting the apical region of the root masy, also, be particularly
related to luxations performed in previous surgical interventions. (4)
Also, if the orthodontist doesn't stop to analyse the problem, but just pulls harder, he/she might cause ankylosis:
Subsequent attempts with ever increasing traction forces may provoke periradicular trauma, aggravating the
underlying conditions and leading to ankylosis. Optimal orthodontic force to erupt the impacted teeth might
be as subtle as 50 grams, and preferably not over 150 grams5-7,9,11,15.(5)
You've taken your child for months trying to have a canine emerge. You reach the point where there is a need for expose & bond. You have to wait weeks for the appointment, your child is put under general anesthesia, you pay $ 2000, then an arrogant, careless surgeon ruins everything with faulty technique. No orthodontist present to advocate for your child and supervise. A couple of months later the tooth is declared ankylosed, back to the surgeon for extraction. Another general anesthesia and $$$... so it goes, as Vonnnegut would have put it. Ankylosis is the Catch-22 of orthodontics.
The risks associated with traction
Orthodontic traction involves risks such as ankylosis, discoloration, loss of vitality, and root resorption of
retained tooth and adjacent teeth, gingival regression, and loss of keratinized mucosa.(6)
Periodontal aspects
When extruding a tooth, there are more things to consider than just the forcible pulling on a tooth.
You don't want to harm the neighboring teeth. You want to imitate the normal eruption and have bone layed down as the tooth moves, you want to be careful with the gum.
"Periodontal Status Following Treatment of Impacted Maxillary Canine by Closed Eruption Technique: An Overview and Case Report (3) outlines some of the concerns:
Limit epithelial tissue removal: Epithelial tissue removal should be as limited as possible to enable bracket
bonding in the absence of blood and saliva; otherwise, apical migration of the junctionalepithelium could
occur. Dental follicle remnants can help in creating functional epithelial attachment.
Protect the cemento-enamel junction: No procedure - either mechanical (during removal of epithelial tissues)
or chemical (during bracket bonding) - should affect the area of the cemento-enamel junction. Injury to this
area has been shown to relate to gingival recession. That is the reason for using small brackets with rounded
ends. Moreover, the bracket should be placed near the incisal edge and any resin residues that may irritate
periodontal tissues should be removed
Consider magnitude of orthodontic forces: The magnitude of orthodontic forces should be minimal -
preferably no more than 60 grams - so tooth movement is accompanied by the migration of the periodontal
tissues.
When extruding a tooth, there are more things to consider than just the forcible pulling on a tooth.
You don't want to harm the neighboring teeth. You want to imitate the normal eruption and have bone layed down as the tooth moves, you want to be careful with the gum.
"Periodontal Status Following Treatment of Impacted Maxillary Canine by Closed Eruption Technique: An Overview and Case Report (3) outlines some of the concerns:
Limit epithelial tissue removal: Epithelial tissue removal should be as limited as possible to enable bracket
bonding in the absence of blood and saliva; otherwise, apical migration of the junctionalepithelium could
occur. Dental follicle remnants can help in creating functional epithelial attachment.
Protect the cemento-enamel junction: No procedure - either mechanical (during removal of epithelial tissues)
or chemical (during bracket bonding) - should affect the area of the cemento-enamel junction. Injury to this
area has been shown to relate to gingival recession. That is the reason for using small brackets with rounded
ends. Moreover, the bracket should be placed near the incisal edge and any resin residues that may irritate
periodontal tissues should be removed
Consider magnitude of orthodontic forces: The magnitude of orthodontic forces should be minimal -
preferably no more than 60 grams - so tooth movement is accompanied by the migration of the periodontal
tissues.
Oral surgeons
Then enters the oral surgeon. When Sam comes to Dr Bohannan and I ask what is the best choice for Sam where we are at, what would he do if it was his son, the answer was 'I wouldn't do so many surgeries'. He, as an oral surgeon is concerned with vascularisation and scar tissue.
Along the way, you think 'implants' are always a solution. Nobody mentions 'dehiscence' as an obstacle to getting
an implant, even though, apparently, 20 % of teeth have it.
When we entered the scene with Sam as a 12-year-old with two impacted canines, there was no team of specialist to give us a holistic view of the problem, to give us the best solution...we get piecemeal points of view,
after 8 years there still is no 'good' solution. Instead of being guided by a team caring for the end result, a swift and good resolution, every step of the way has been full of anguish.
Along the way, you think 'implants' are always a solution. Nobody mentions 'dehiscence' as an obstacle to getting
an implant, even though, apparently, 20 % of teeth have it.
When we entered the scene with Sam as a 12-year-old with two impacted canines, there was no team of specialist to give us a holistic view of the problem, to give us the best solution...we get piecemeal points of view,
after 8 years there still is no 'good' solution. Instead of being guided by a team caring for the end result, a swift and good resolution, every step of the way has been full of anguish.
(1) dr-adrianbecker.com: May 2014 Newsletter
(2) Becker A, Chaushu G, Chaushu S. Analysis of failure in the treatment of impacted
canines, Am J Orthod Dentofacial Orthop. 2010 Jun; 137(6): 743-54.
(3) Chaushu S, Chaushu G. Skeletal Implant Anchorage in the Treatment of Impacted Teeth - A Review of the
State of the Art. Seminars in Orthodontics, Vol 16, No 3 (September), 2010: pp 234-241.
(4) Edela Puricelli. Apicotomy: a root apical fracture for surgical treatment of impacted upper canines. Head
Face Med. 2007; 3:33.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2045087/?tool=pubmed
(5) Edela Puricelli. Apicotomy: a root apical fracture for surgical treatment of impacted upper canines. Head
Face Med. 2007; 3:33.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2045087/?tool=pubmed
(6) Vilharinho M, Sa de Lira. Palatally impacted canines: diagnosis and treatment options. Braz J Oral Sci.
April/June 2010 - Volume 9, Number 2.
(2) Becker A, Chaushu G, Chaushu S. Analysis of failure in the treatment of impacted
canines, Am J Orthod Dentofacial Orthop. 2010 Jun; 137(6): 743-54.
(3) Chaushu S, Chaushu G. Skeletal Implant Anchorage in the Treatment of Impacted Teeth - A Review of the
State of the Art. Seminars in Orthodontics, Vol 16, No 3 (September), 2010: pp 234-241.
(4) Edela Puricelli. Apicotomy: a root apical fracture for surgical treatment of impacted upper canines. Head
Face Med. 2007; 3:33.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2045087/?tool=pubmed
(5) Edela Puricelli. Apicotomy: a root apical fracture for surgical treatment of impacted upper canines. Head
Face Med. 2007; 3:33.http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2045087/?tool=pubmed
(6) Vilharinho M, Sa de Lira. Palatally impacted canines: diagnosis and treatment options. Braz J Oral Sci.
April/June 2010 - Volume 9, Number 2.