THE ORTHODONTIST v. ORAL SURGEON
"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.
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.
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 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.
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, so same as with orthodontists, an impacted canine is the odd duck. It's hard to find a better example of this than the title 'Surgical Treatment of Impacted Teeth Other than Third Molars' (3).
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.
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.
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 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.
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, so same as with orthodontists, an impacted canine is the odd duck. It's hard to find a better example of this than the title 'Surgical Treatment of Impacted Teeth Other than Third Molars' (3).
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.
Funny with the animal analogies. I've called Sam a unicorn because some practitioners (or especially the endodontist at UCSF who has never heard of PEIR, never seen it, never read of it; ergo it doesn't exist) are PEIR deniers. One orthodontist recently called Sam a zebra, as in the parable mostly told in med school: "when you hear hooves...expect horses...not zebras". Dr Mulick talks of sheep and goats:
the sheep representing routine malocclusions; and the goats, representing those few cases with an extremely high degree of difficulty, and how important it is to be able to differentiate sheep from goats not only in the pasture, but in the orthodontic practice as well! Whether we like it or not, impacted canine cases are goats! (7) (By the way, Sam, a now extremely frustrated 17-year-old, is not happy about being either zebra, goat, or even a unicorn. Being unique in this tooth aspect is not something a teenager revels in.) Black swan might be the best allegory, something that does exist, but that most people haven't encountered and dont believe in. |
Who's the boss? Ego and politics
The orthodontist has "the ultimate responsibility for success" as stated above. He/she spends months and years with the patient, while, hopefully, the patient only needs the surgeon for the actual surgery (usually with a visit before and after). In the case of impacted canines, the surgery is however the game changer.
In the American medical hierarchy, it seems very likely that in some cases the orthodontist is 'intimidated' by the surgeon, but hopefully he/she does have some choice and can pick whoever is expected to do the best job. I don't know what you can do about all this as a patient, but it is something to be aware of. You don't want ego and politics coming in the way of patient care. 'Expose & bond' is nothing to be trifled with, it's a big investment for success. You would not want your orthodontist to be timidly bowing down to the surgeon, but being present and looking after the best interest of the teeth and his/her patient.
Advancing orthodontics
One of my conclusions is that to advance orthodontics, improving treatment and furthering science in general, there needs to be a stimulating teamwork between at least one orthodontist and one surgeon/endodontist/periodontist (preferably it would be interdepartmental). Only then can you get the optimal treatment for patients and optimal climate for advancing the science of orthodontics. Judging from where you can find new methods around the world, this circumstance is quite rare.
One of my conclusions is that to advance orthodontics, improving treatment and furthering science in general, there needs to be a stimulating teamwork between at least one orthodontist and one surgeon/endodontist/periodontist (preferably it would be interdepartmental). Only then can you get the optimal treatment for patients and optimal climate for advancing the science of orthodontics. Judging from where you can find new methods around the world, this circumstance is quite rare.
Private practice vs. University setting
In my experience now with oral surgeons, as limited as it might be, there is, from the private side, a certain disdain as concerns the 'academic side'. Take the golden standard of a cephalogram series for determining if jaw growth is compleated before implant, the 'private' side seems to rely on gut and experience rather than xrays, and might bother so far as to as about height and shoe sizes changes during the last year.
Also, with limited proof, but what seems reasonable after chatting with a private orthodontist, you are not guaranteed quality just because you seek a University setting thinking you have the latest knowledge or the most experienced and curious minded professors. A private practitioner has so much more to loose in reputation if you give bad reviews. A university affiliated clinician is very protected by the university from lawsuits. Also my source said that some clinicians would stay on at the university to practice there if they haven't really fulfilled courses or lacked competence to graduate out to start a practice.
In my experience now with oral surgeons, as limited as it might be, there is, from the private side, a certain disdain as concerns the 'academic side'. Take the golden standard of a cephalogram series for determining if jaw growth is compleated before implant, the 'private' side seems to rely on gut and experience rather than xrays, and might bother so far as to as about height and shoe sizes changes during the last year.
Also, with limited proof, but what seems reasonable after chatting with a private orthodontist, you are not guaranteed quality just because you seek a University setting thinking you have the latest knowledge or the most experienced and curious minded professors. A private practitioner has so much more to loose in reputation if you give bad reviews. A university affiliated clinician is very protected by the university from lawsuits. Also my source said that some clinicians would stay on at the university to practice there if they haven't really fulfilled courses or lacked competence to graduate out to start a practice.
(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
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