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 alignment,
rests firmly on the shoulders of the orthodontist.
It would seem irresponsible to abrogate this crucial stage of the treatment [= surgery as in 'expose and bond'], 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.
(Dr Becker in 'Orthodontic Treatment of Impacted Teeth')
If the orthodontist lives up to this credo, and then collaborates closely with an oral surgeon, both conversant in 3D and CBCT, the more complicated impacted canines has a chance of survival; if not, the outcome is up to chance.
The orthodontist is responsible for the final outcome, in extension, also the surgical part of the treatment. Few orthodontists fully grasp all the aspects of surgery, and vice versa, few oral surgeons are totally conscious of what needs to happen after surgery to make the surgery actually successful.
Surgery is not an isolated event, it is part of a longer endeavor.
Surgery is not an isolated event, it is part of a longer endeavor.
Dr Becker writes that every surgery is trauma, and with impacted canines it is consequently essential you make every time count and not just 'give it a go' without careful, thoughtful analysis first. Dr Becker's main message to his fellow orthodontists, as I understand it, is that they should care enough about their patients and final outcomes to be present and actively participating at the expose & bond surgeries. This is from Dr Becker's November 2014 Newsletter describing a case of non-eruption of a developing first permanent molar in an 8-year-old:
It is important to point out and to emphasize that surgical exposure of an impacted tooth should be a 4-
handed procedure involving both orthodontist and oral surgeon, which is critical for the success of the entire
treatment. Optimal conditions must be achieved to ensure a securely bonded attachment. Neither the
orthodontist nor the surgeon and certainly not the patient are interested in failure and the need for a repeat
performance! In many cases , an oral and maxillofacial surgeon (OMFS) working only with chairside assistance
will fail achieve a good exposure with reliably bonded attachment for one or more many reasons. The OMFS is
not as skillfull, adroit, or precise as the orthodontist at bonding attachments, since it is not a procedure he/she
executes more than once or twice a month, while the orthodontist performs it on hundreds of teeth each
week. The orthodontist knows exactly where the attachment needs to be placed with what connector and in
which direction to draw the it through the exterior. Furthermore, even the most practised chairside assistant
cannot hold back surgical flaps nor control bleeding points with the same degree of expertise as the OMFS,
who is often able to manipulate freshly cut and bleeding tissues in almost inaccessible locations, to permit
successful bonding. If this cri-de-coeur is heard and the present procedure for the exposure procedure is
universally adopted, fewer impacted teeth will be sacrificed and the failure rate of those that are attempted
will plummet.
It is important to point out and to emphasize that surgical exposure of an impacted tooth should be a 4-
handed procedure involving both orthodontist and oral surgeon, which is critical for the success of the entire
treatment. Optimal conditions must be achieved to ensure a securely bonded attachment. Neither the
orthodontist nor the surgeon and certainly not the patient are interested in failure and the need for a repeat
performance! In many cases , an oral and maxillofacial surgeon (OMFS) working only with chairside assistance
will fail achieve a good exposure with reliably bonded attachment for one or more many reasons. The OMFS is
not as skillfull, adroit, or precise as the orthodontist at bonding attachments, since it is not a procedure he/she
executes more than once or twice a month, while the orthodontist performs it on hundreds of teeth each
week. The orthodontist knows exactly where the attachment needs to be placed with what connector and in
which direction to draw the it through the exterior. Furthermore, even the most practised chairside assistant
cannot hold back surgical flaps nor control bleeding points with the same degree of expertise as the OMFS,
who is often able to manipulate freshly cut and bleeding tissues in almost inaccessible locations, to permit
successful bonding. If this cri-de-coeur is heard and the present procedure for the exposure procedure is
universally adopted, fewer impacted teeth will be sacrificed and the failure rate of those that are attempted
will plummet.
In the chapter on impacted canines (8) the authors describes the orthodontist as an active team member when it comes to planning how to expose the impacted canine, even if he/she is not present.
The orthodontist should guide the surgeon properly to select an appropriate technique [gingivectomy/apically
positioned flap/closed eruption technique]. If the correct uncovering technique is chosen, the eruption process
can be simplified, resulting in a predictably stable and esthetic result. Four criteria should be evaluated by the
orthodontist in order to determine the appropriate method for uncovering the tooth before referring a patient
for surgical exposure. First, the labiolingual position of the impacted canine crown should be determined...The
second criterion to evaluate is the vertical position of the tooth relative to the mucogingival junction...The third
criterion to evaluate is the amount of attached gingiva in the area of the impacted canine...The final criterion to
evaluate is the mesiodistal position of the canine crown...
The orthodontist should guide the surgeon properly to select an appropriate technique [gingivectomy/apically
positioned flap/closed eruption technique]. If the correct uncovering technique is chosen, the eruption process
can be simplified, resulting in a predictably stable and esthetic result. Four criteria should be evaluated by the
orthodontist in order to determine the appropriate method for uncovering the tooth before referring a patient
for surgical exposure. First, the labiolingual position of the impacted canine crown should be determined...The
second criterion to evaluate is the vertical position of the tooth relative to the mucogingival junction...The third
criterion to evaluate is the amount of attached gingiva in the area of the impacted canine...The final criterion to
evaluate is the mesiodistal position of the canine crown...
"Expose & Bond, please."
If this is the extent of collaboration between your orthodontist and treating surgeon, you are in trouble. Impacted canines need team work in the fullest sense:
Maxillary canine impaction usually needs multidisciplinary care, which involves oral surgery and periodontics
along with orthodontic treatment. It is essential thatt the various clinicians working on the case have good
communication to provide optimal care for the patient. The management of impacted canines can be divided
into 2 treatment categories: interceptive treatment and corrective treatment.(1)
Experts on impacted canines know better than to have the surgery side of the treatment be at the discretion of
the surgeon.
See 'Surgical and orthodontic management of impacted maxillary canines' (2) by the late Dr. Vincent Kokich*.
Although the mechanical management of impacted teeth is a routine task for most orthodontists, certain
impactions can be frustrating, and the esthetic outcome can be unpredictable if the surgeon uncovers the
impacted tooth improperly. When referrring a patient to have an impacted tooth uncovered, the orthodontist
might assume incorrectly that the surgeon knows which surgical procedure to use. However, if not instructed
properly, the surgeon could select an inappropriate technique, leaving the orthodontist with the difficult if not
sometimes lengthy and challenging task of erupting the impacted tooth into the dental arch. On the other
hand, if the correct uncovering technique is chosen, the eruption process can be be simplified, resulting in a
predictably stable and esthetic result. This is especially true for impacted canines.
Dr. Becker draws the logical conclusion of the importance of the surgical phase in treating impacted canines, he
is there. 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', (3) 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.
A Brazilian article (6) doesn't go as far as saying the orthodontist should do the bonding but remarks:
With the purpose of individualizing the mechanics in terms of the direction of traction forces, it was, and still
is, adequate that orthodontists be invited to watch the surgery in order to view the exact position of the
unerupted canine. As a result, traction would be planned and and all such details in the patient's records.
When the orthodontist was not present during surgery, it was requested that information was described in an
official referral to enable safer traction. Maintaining this hypothesis, the surgeon must have enough
orthodontic knowledge to guide the orthodontist on how best to perform the movement.
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 or sitting down to discuss a CBCT. It is really sad if the team work is represented by a referral slip for 'expose & bond, thank you'.
Dr. Becker cares enough to draw the logical consequence, whether or not the orthodontist considers it an inconvenience. He is concerned with getting the best results.
Besides actually being present at the time of operation, Dr. Becker is also in favor of using eyelets, which bond better, compared to the normal brackets, until the tooth is erupted, and recommends that orthodontist takes
photos during surgery to record 'the exact position of the exposed canine".(4)
There are different approaches and techniques for approaching the impacted canine. Oral surgeons mainly deal with extraction of wisdom teeth or do implants, so same as with orthodontists, an impacted canine is the odd duck. (It's hard to find a better illustration of this than the title 'Surgical Treatment of Impacted Teeth Other than Third Molars' (3), a canine doesn't deserve it's own title and chapter!)
Actually, I have the sense that orthodontists want to avoid oral surgeons if possible and go with the more delicate touches of periodontists if they can. 'Efficient Management of Unerupted Teeth: A Time-Tested Treatment Modality' describes:
increasingly frequent complications observed with unerupted teeth, especially canines. This phenomenon
of more frequent harmful sequelae may be attributed to the surgical technique used to uncover the
teeth. (p 212)(5)
The combined efforts of the orthodontist, oral surgeon and endodontist must be thought through carefully for a good result in the more than simplest cases. This is the essential springing point.
I could only wish that all orthodontists approached impacted teeth the way Dr. Becker does. This IS rocket science! It evidently is too hard for the average orthodontist, but is that an excuse for sacrificing 'impacted canines' when there are ways to deal with them. It is puzzling and very sad to realize that something that afflicts our children and teens, and will affect them their whole lives, is not taken seriously, even at Universities!
I found an interview of an orthodontist in the Journal of Clinical Orthodontics discussing impacted canines. On the question of being able to estimate treatment times, Dr Mulick answers "Prior to my being present in the surgeon's office, to band the tooth at the time of uncovering, my "track record" on impaction treatment time was poor. Since then [1968!], with few exceptions, it has been very good."(7)
Yes, the article is from 1979! It seems like it could have been established decades ago that standard of practice would have the orthodontist as part of the surgical team! Dr Mulick goes on to describe his MO:
It has been our practice since 1968 to band the impactions at the time of uncovering. This means being
present in the oral surgeon's office to do this procedure. It, of course, takes office time away from our
office, but because the appointment is scheduled as the first appointment in the morning, and one-half hour
earlier than we usually see patients, it really has not had an adverse effect on starting our day time as
usual, but has had a definite effect in terms of controlling impactions from the day of uncovering. Therefore,
after the crown is uncovered by the oral surgeon, we fit and cement an orthodontic band on the impaction
with the appropriate attachment. The appropriate attachment is determined by availability of space on the
crown of that cuspid. As mentioned above, many times the crown of the cuspid is directly up against the
lingual surfaces of either the lateral and central incisors, or both. Therefore, frequently the attachment must
be placed on the distal-lingual angle of the cuspid. I try to position that attachment in line with the direction
in which I want to start initial tooth movement. In most cases, it can be likened to taking a small boat that
has run aground on a sandbar, off the sandbar, back into the proper sailing channel. We back the cuspid off
the incisors, and then move it laterally into the arch.
If this is the extent of collaboration between your orthodontist and treating surgeon, you are in trouble. Impacted canines need team work in the fullest sense:
Maxillary canine impaction usually needs multidisciplinary care, which involves oral surgery and periodontics
along with orthodontic treatment. It is essential thatt the various clinicians working on the case have good
communication to provide optimal care for the patient. The management of impacted canines can be divided
into 2 treatment categories: interceptive treatment and corrective treatment.(1)
Experts on impacted canines know better than to have the surgery side of the treatment be at the discretion of
the surgeon.
See 'Surgical and orthodontic management of impacted maxillary canines' (2) by the late Dr. Vincent Kokich*.
Although the mechanical management of impacted teeth is a routine task for most orthodontists, certain
impactions can be frustrating, and the esthetic outcome can be unpredictable if the surgeon uncovers the
impacted tooth improperly. When referrring a patient to have an impacted tooth uncovered, the orthodontist
might assume incorrectly that the surgeon knows which surgical procedure to use. However, if not instructed
properly, the surgeon could select an inappropriate technique, leaving the orthodontist with the difficult if not
sometimes lengthy and challenging task of erupting the impacted tooth into the dental arch. On the other
hand, if the correct uncovering technique is chosen, the eruption process can be be simplified, resulting in a
predictably stable and esthetic result. This is especially true for impacted canines.
Dr. Becker draws the logical conclusion of the importance of the surgical phase in treating impacted canines, he
is there. 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', (3) 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.
A Brazilian article (6) doesn't go as far as saying the orthodontist should do the bonding but remarks:
With the purpose of individualizing the mechanics in terms of the direction of traction forces, it was, and still
is, adequate that orthodontists be invited to watch the surgery in order to view the exact position of the
unerupted canine. As a result, traction would be planned and and all such details in the patient's records.
When the orthodontist was not present during surgery, it was requested that information was described in an
official referral to enable safer traction. Maintaining this hypothesis, the surgeon must have enough
orthodontic knowledge to guide the orthodontist on how best to perform the movement.
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 or sitting down to discuss a CBCT. It is really sad if the team work is represented by a referral slip for 'expose & bond, thank you'.
Dr. Becker cares enough to draw the logical consequence, whether or not the orthodontist considers it an inconvenience. He is concerned with getting the best results.
Besides actually being present at the time of operation, Dr. Becker is also in favor of using eyelets, which bond better, compared to the normal brackets, until the tooth is erupted, and recommends that orthodontist takes
photos during surgery to record 'the exact position of the exposed canine".(4)
There are different approaches and techniques for approaching the impacted canine. Oral surgeons mainly deal with extraction of wisdom teeth or do implants, so same as with orthodontists, an impacted canine is the odd duck. (It's hard to find a better illustration of this than the title 'Surgical Treatment of Impacted Teeth Other than Third Molars' (3), a canine doesn't deserve it's own title and chapter!)
Actually, I have the sense that orthodontists want to avoid oral surgeons if possible and go with the more delicate touches of periodontists if they can. 'Efficient Management of Unerupted Teeth: A Time-Tested Treatment Modality' describes:
increasingly frequent complications observed with unerupted teeth, especially canines. This phenomenon
of more frequent harmful sequelae may be attributed to the surgical technique used to uncover the
teeth. (p 212)(5)
The combined efforts of the orthodontist, oral surgeon and endodontist must be thought through carefully for a good result in the more than simplest cases. This is the essential springing point.
I could only wish that all orthodontists approached impacted teeth the way Dr. Becker does. This IS rocket science! It evidently is too hard for the average orthodontist, but is that an excuse for sacrificing 'impacted canines' when there are ways to deal with them. It is puzzling and very sad to realize that something that afflicts our children and teens, and will affect them their whole lives, is not taken seriously, even at Universities!
I found an interview of an orthodontist in the Journal of Clinical Orthodontics discussing impacted canines. On the question of being able to estimate treatment times, Dr Mulick answers "Prior to my being present in the surgeon's office, to band the tooth at the time of uncovering, my "track record" on impaction treatment time was poor. Since then [1968!], with few exceptions, it has been very good."(7)
Yes, the article is from 1979! It seems like it could have been established decades ago that standard of practice would have the orthodontist as part of the surgical team! Dr Mulick goes on to describe his MO:
It has been our practice since 1968 to band the impactions at the time of uncovering. This means being
present in the oral surgeon's office to do this procedure. It, of course, takes office time away from our
office, but because the appointment is scheduled as the first appointment in the morning, and one-half hour
earlier than we usually see patients, it really has not had an adverse effect on starting our day time as
usual, but has had a definite effect in terms of controlling impactions from the day of uncovering. Therefore,
after the crown is uncovered by the oral surgeon, we fit and cement an orthodontic band on the impaction
with the appropriate attachment. The appropriate attachment is determined by availability of space on the
crown of that cuspid. As mentioned above, many times the crown of the cuspid is directly up against the
lingual surfaces of either the lateral and central incisors, or both. Therefore, frequently the attachment must
be placed on the distal-lingual angle of the cuspid. I try to position that attachment in line with the direction
in which I want to start initial tooth movement. In most cases, it can be likened to taking a small boat that
has run aground on a sandbar, off the sandbar, back into the proper sailing channel. We back the cuspid off
the incisors, and then move it laterally into the arch.
"Surgical Treatment of Impacted Canines: What the Orthodontist Would Like the Surgeon to Know"
This is the title of an article by Dr Adrian Becker and and Stella Chaushu from 'Oral and maxillofacial surgery clinics of North America' (9). Dr Becker also refers to this article in his Bulletin #70, October 2017 (10).
Dr Becker has long argued for the orthodontist being present at 'expose & bond'. In 1998 he wrote "The Orthodontis't Presence at Surgical Exposure of Impacted Teeth - That's Quality Care!".
The orthodontist is the one who is responsible for getting an impacted tooth down, and has to refer to the surgeon for the service of getting to it. The surgeon with a more shortsighted view of the problem, he/she only sees the patient for a one-time surgery, and does his/her thing, but if it is not done in a way that helps traction, it is all for naught. _.Drs Becker and Chaushu explains where it can go wrong.
In the bulletin Dr Becker relates the reasoning of a New York orthodontist and attorney, Dr Laurence Jerrold,editor for Litigation, Legislation, and Ethics of AJODO. In 1996 Dr Jerrold argued that it was the orthodontist should not be involved in the surgery part in order to limit their liability.
So why isn't there a close collaboration between orthodontist & surgeon? The reaons why, need to be seen against the background that failure with a kid of 12 or so might lead into years and years of trying to find a solution.
- It is inconvenient for the orthodontist, time consuming.
- Orthodontist and surgeon don't get along. Medicine in the US (I can compare with medicine in Sweden) is highly
hierarchtical, a surgeon will not 'take orders' from an orthodontist. (OK, that is prejudical, and there are
different individuals in different specialities, however, as a prosthodontist said, there are personality reasons why
people end up in different specialities, this in explaining the nature of a surgeon who instead of answering a
very reasonable question, proclaimed he was much too important to waste his time answering a question from a
patient that was the wrong kind. Sam had just turned 17, and the question was about putting an implant in at
that age.)
The only solution, is 'impaction center' where there are teams working togetherto get the best possible outcome for the patient.
PAYING THE PRICE: WHEN ORTHODONTIST AND ORAL SURGEON DO NOT COLLABORATE
Sam's 3 Bay Area surgeries are examples of this (for details see 'Sam's story'):
Orthodontist 1 never remarked on the irregular contour (=resorption) of the canines. Oral surgeon 1 saw it on the pano and mentioned it presurgery. He didn't explain it, it just sounded like it was curious, but it happens. He did not mention it in the surgical report or when I asked for info that would help surgeon 2. He did not relate it to orthodontist 1, which seems that it would have been a good idea, since he wasn't surprised at the idea that the resorption would progress after surgery: Anytime surgery is performed, the local blood supply is compromised and any number of responses to that trauma can rarely occur, including resorption or arrested development. The orthodontist never thought of checking on the progress of resorption, since he was unaware of it even though he had the x-rays. Orthodontist 1 put traction on for 6 months after surgery, he then wrote a referral for extraction without discussing it with the oral surgeon or analyzing reasons for failure of traction.
Oral surgeon 2 ordered a CBCT she never looked at. Nor did she look at the panos available enough to be aware of anything wrong with the canines. At surgery, 5 months after the CBCT, she was surprised by her findings and the extent of crown damage. She first blamed surgeon 1 and thought he had drilled into the tooth. She writes that 'the original incision was a small horizontal incision in the non attached tissue', the gold chain 'appeared loose' and there was 'only a very small buccal window' when looking at surgeon #1's work. After made aware that the contour of the tooth predated surgery 1 (as shown by panos that she had, but evidently didn't look at properly either), she instead blamed the dentist for leaving root fragments after extracting the baby teeth. The dentist in question tried contacting her, but got no call back. Orthodontist 2 never looked enough at the CBCT to identify the progress of resorption and said the CBCT was done for the surgeon so he didn't look at it much himself. Neither oral surgeon, nor orthodontist bothered looking into the nature of resorption, and must have been unaware about conditions such as ICRR and PEIR, which is surprising for a university,(PEIR is on the schedule at the dental school in Jordan!). Oral surgeon 2 never responded to orthodontist 2 when he sought advice after failure of traction.
Orthodontist 3 and oral surgeon 3 never had any communication besides a note asking for apicotomy and osteotomy. (The surgical notes take several weeks until they are available). Orthodontist 3 wanted to apply traction on the canine immediately, as in, day after surgery. When he poked in the dental pack, the blue of the power chain from a week before was visible and orthodontist 3 was satisfied to leave it at that. When the oral pack was removed 10 days post surgery, the oral surgeon declared that there had been no traction since the power chain was totally embedded in the dental pack. The request was fr a new attachment on the lower canine. The surgeon instead exposed the whole tooth, removed all glass ionomer.
I am of course heartbroken that 4 years later and thousands of dollars, thousands of miles,
hours of heartache sitting in waiting rooms while Sam undergoes general anesthesia, these efforts have failed in retrieving his upper canine. For Sam, dealing with this as a 12-year-old, as a 17-year-old, a 20-year-old, it is hopelessly frustrating. He's had 5 surgeries, swells up, misses school, deals with wires, rubber bands and lengthy cleaning procedures every day.
I have no doubt that if the first surgeon/orthodontist 'team' had indeed been a competent Team, we would not be at this point seven years later, even the second 'team' could have saved the upper canine, but did not look at the CBCT they ordered, nor give resorption a second thought. This last effort lacked coordination between orthodontist and oral surgeon about when and how to apply traction to #6
If Dr Becker's main argument, to have the orthodontist present and participating at surgery, had been the gold standard, I don't think we as a family would have been going through 7+ years of heartache, tens of thousands of dollars and hundreds of hours traveling to appointments and going through surgeries and Sam's teenage years becoming a frustrating story of orthodontia.
The implant solution, I've always thought of as a last resort, because it does not seem to be the simple solution it is often made out to be to patients. At least not when the patients are children, who actually are too young to get implants, and have to wait until the maxilla and mandibel are fully developed. Implants are brought up by a lot of US dental professionals as a panacea and easy solution without mentioning any negative aspects. Other solutions
such as autotransplantation and apicotomy are not considered.
If in the end you do need an implant, just like management of impacted teeth, you are dependent on your dental professionals skill and careful consideration to be a success, or in the words of the late Dr Kokich:
Implants have become an important part of restorative dentistry for patients who are congenitally missing
teeth as well as those patients where teeth were extracted due to extensive caries, trauma, or periodontal
diseases. If all members of the team participate correctly, the result can be outstanding. However,
if the team of surgeon, orthodontists, and restorative dentists do not coordinate their efforts
properly, the result could be disastrous.
Sam's 3 Bay Area surgeries are examples of this (for details see 'Sam's story'):
Orthodontist 1 never remarked on the irregular contour (=resorption) of the canines. Oral surgeon 1 saw it on the pano and mentioned it presurgery. He didn't explain it, it just sounded like it was curious, but it happens. He did not mention it in the surgical report or when I asked for info that would help surgeon 2. He did not relate it to orthodontist 1, which seems that it would have been a good idea, since he wasn't surprised at the idea that the resorption would progress after surgery: Anytime surgery is performed, the local blood supply is compromised and any number of responses to that trauma can rarely occur, including resorption or arrested development. The orthodontist never thought of checking on the progress of resorption, since he was unaware of it even though he had the x-rays. Orthodontist 1 put traction on for 6 months after surgery, he then wrote a referral for extraction without discussing it with the oral surgeon or analyzing reasons for failure of traction.
Oral surgeon 2 ordered a CBCT she never looked at. Nor did she look at the panos available enough to be aware of anything wrong with the canines. At surgery, 5 months after the CBCT, she was surprised by her findings and the extent of crown damage. She first blamed surgeon 1 and thought he had drilled into the tooth. She writes that 'the original incision was a small horizontal incision in the non attached tissue', the gold chain 'appeared loose' and there was 'only a very small buccal window' when looking at surgeon #1's work. After made aware that the contour of the tooth predated surgery 1 (as shown by panos that she had, but evidently didn't look at properly either), she instead blamed the dentist for leaving root fragments after extracting the baby teeth. The dentist in question tried contacting her, but got no call back. Orthodontist 2 never looked enough at the CBCT to identify the progress of resorption and said the CBCT was done for the surgeon so he didn't look at it much himself. Neither oral surgeon, nor orthodontist bothered looking into the nature of resorption, and must have been unaware about conditions such as ICRR and PEIR, which is surprising for a university,(PEIR is on the schedule at the dental school in Jordan!). Oral surgeon 2 never responded to orthodontist 2 when he sought advice after failure of traction.
Orthodontist 3 and oral surgeon 3 never had any communication besides a note asking for apicotomy and osteotomy. (The surgical notes take several weeks until they are available). Orthodontist 3 wanted to apply traction on the canine immediately, as in, day after surgery. When he poked in the dental pack, the blue of the power chain from a week before was visible and orthodontist 3 was satisfied to leave it at that. When the oral pack was removed 10 days post surgery, the oral surgeon declared that there had been no traction since the power chain was totally embedded in the dental pack. The request was fr a new attachment on the lower canine. The surgeon instead exposed the whole tooth, removed all glass ionomer.
I am of course heartbroken that 4 years later and thousands of dollars, thousands of miles,
hours of heartache sitting in waiting rooms while Sam undergoes general anesthesia, these efforts have failed in retrieving his upper canine. For Sam, dealing with this as a 12-year-old, as a 17-year-old, a 20-year-old, it is hopelessly frustrating. He's had 5 surgeries, swells up, misses school, deals with wires, rubber bands and lengthy cleaning procedures every day.
I have no doubt that if the first surgeon/orthodontist 'team' had indeed been a competent Team, we would not be at this point seven years later, even the second 'team' could have saved the upper canine, but did not look at the CBCT they ordered, nor give resorption a second thought. This last effort lacked coordination between orthodontist and oral surgeon about when and how to apply traction to #6
If Dr Becker's main argument, to have the orthodontist present and participating at surgery, had been the gold standard, I don't think we as a family would have been going through 7+ years of heartache, tens of thousands of dollars and hundreds of hours traveling to appointments and going through surgeries and Sam's teenage years becoming a frustrating story of orthodontia.
The implant solution, I've always thought of as a last resort, because it does not seem to be the simple solution it is often made out to be to patients. At least not when the patients are children, who actually are too young to get implants, and have to wait until the maxilla and mandibel are fully developed. Implants are brought up by a lot of US dental professionals as a panacea and easy solution without mentioning any negative aspects. Other solutions
such as autotransplantation and apicotomy are not considered.
If in the end you do need an implant, just like management of impacted teeth, you are dependent on your dental professionals skill and careful consideration to be a success, or in the words of the late Dr Kokich:
Implants have become an important part of restorative dentistry for patients who are congenitally missing
teeth as well as those patients where teeth were extracted due to extensive caries, trauma, or periodontal
diseases. If all members of the team participate correctly, the result can be outstanding. However,
if the team of surgeon, orthodontists, and restorative dentists do not coordinate their efforts
properly, the result could be disastrous.
(1) Park JH, Srisurapol T, Kiyoshi T. Impacted maxillary Canines: Diagnosis and
Management.dentalcetoday.com, sep 2012.
(2) Kokich V. Surgical and orthodontic management of impacted maxillary canines. American Journal of
Orthodontics and Dentofacial Orthopedics. Volume 126, Number 3. September, 2004.
(3) Dr. Mehran Hossaini in 'Surgical Treatment of Impacted Teeth Other than Third Molars' in 'Oral and
Maxillofacial Surgery', 2010.
(4) Becker et al. Attachment bonding to impacted teeth at the timer of surgical exposure. European Journal off
Orthodontics 18 (1996) 457-463.
(5) Robert L., Vanarsdall Jr., Efficient Management of Unerupted Teeth: A Time-Tested
Treatment Modality, Seminars in Orthodontics, Vol 16, No 3 (September), 2010:pp
2122-221.
(6) Filho L, Consolaro A, Almeida Cardoso, Siqueira D. Enamel drilling for canine traction: advantages,
disadvantages, description of surgical technique and biomechanics.Dental Press Journalk of Orthodontics.
vol 16 no 5 Maringá Sept./Oct. 2011.
(7) http://www.jco-online.com/archive/article-view.aspx?year=1979&month=12&articlenum=824
(8) Emerging Trends in Oral Health Sciences and Dentistry. Chapter 21: Clinical Consideration and Management
of Impacted Maxillary Teeth. Edited by Belma Isak Aslan and Neslihan Üçüncü at the Gazi University, Faculty
of Dentistry, Department of orthodontics, Ankara, Turkey. Published: March 11, 2015. DOI: 10.5772/59324.
This book is published with open access online! Intech -open science, open minds! The authors are in
different parts of the world Brazil, Morocco, Finland, Australia, Japan, China...It's very exciting with a
collaboration like this with open access!
Belma Işık Aslan and Neslihan Üçüncü (2015). Clinical Consideration and Management of Impacted
Maxillary Canine Teeth, Emerging Trends in Oral Health Sciences and Dentistry, Prof. Mandeep Virdi (Ed.),
ISBN: 978-953-51-2024-7, InTech, DOI: 10.5772/59324. Available from: http://www.intechopen.com
/books/emerging-trends-in-oral-health-sciences-and-dentistry/clinical-consideration-and-management-
of-impacted-maxillary-canine-teeth
(9) Becker A, Chauchu S. Surgical Treatment of Impacted Canines: What the Orthodontist Would Like the
Surgeon to Know. Oral and Maxillofacial Surgery Clinics of North America. August 2015, pp 449-458.
DOI:10.1016/j.coms.22015.04.007
(10) Dr Becker Bulletin #70, October 2017, dr-adrianbecker.com.