Ortho Tip for December 3 2015

Here is an interesting article from the AJODO that talks about intrusion of maxillary incisors in a periodontally compromised case.

It has application to middle age and senior patients where extruded teeth are causing esthetic and functional issues.

If a maxillary incisor is orthodontically intruded back to its original position, the base of the gingival sulcus will migrate up and deepen the gingival sulcus. This may also resorb the buccal and lingual plates of bone. So generally in these cases orthodontic intrusion is contraindicated.

However, in this article the researchers did a supracrestal fiberotomy at each orthodontic appointment to free the gingival attachment during the intrusion to prevent buccal and lingual bone loss from the intrusion. At the end of the intrusion they performed guided tissue generation with bone grafting to repair the angular bone defect that intruding the tooth caused.

The result was that the angular vertical bone defect was repaired and the intruded incisors had a normal gingival attachment at the appropriate level for function and esthetics. No buccal or lingual bone loss occurred.

Very interesting!

Stan

Please feel free to share this with friends. If you have a friend who would like to be on the “Ortho tips” list please let me know.

p.s. If you prefer not to get these OrthoTips please return this email with a “No Tips Please” comment.

Orthodontic Tips October 13, 2015

When a second molar has been removed, can the wisdom tooth replace it?

If the wisdom tooth is of proper shape and size it can replace the second molar.

In this case the second molar needed to be removed. Fortunately the wisdom tooth was a reasonable shape and size to replace it.

I am using an Essex appliance to hold the first molar in position. I bonded braces on the first molar and wisdom tooth. There is a copper Niti wire and a light elastic ligature guiding the wisdom tooth into position. The forces are very light so the first molar will stay in place.

Stan

Please feel free to share this with friends. If you have a friend who would like to be on the “Ortho tips” list please let me know.

Orthodontic Tips October 6, 2015

Untitled

How can we intrude an over-erupted second molar?

Bond both the buccal and lingual to avoid rolling the tooth buccally and exposing the palatal root.

This patient lost the 46 and the 17 over-erupted. There was insufficient space to place an implant to replace the 46.

I bonded the quadrant on the buccal and lingual to provide an equal vertical force on the 17 to intrude it. Otherwise the tooth would roll towards the side where the force was applied. I am holding the maxillary arch form with a thick Essex appliance worn at night time. The Essex appliance is adjusted like a maxillary splint on the occlusal surface. Also, it is relieved on the buccal and lingual to accommodate the braces.

I am expecting success and adequate space available for the dentist to place the 47 implant.

Stan

Please feel free to share this with friends.  If you have a friend who would like to be on the “Ortho tips” list please let me know.

Orthodontic Tips September 26, 2015

Untitled

How can we place a permanent lingual wire that is less likely to break and lets us floss between the teeth?

Use a looped lingual wire.

This adult case originally presented with upper and lower anterior spacing because of a strong tongue thrust.

Her braces closed the spacing and then double retainers were placed. First, straight lingual wires were bonded behind the anterior teeth in both the maxilla and mandible. Second, for night time, upper and lower full coverage open bite TMJ splints were made to hold the teeth in place and provide space for the tongue to come forward for breathing.

Unfortunately, during the day, the tongue habit was so strong that the upper lingual wire broke.

I replaced the straight lingual wire with this looped one. The advantages are as follows:

  • The loops provide some flexibility for the teeth to do micro-movements during eating without causing the metal or plastic to fatigue which results in failure.
  • This wire can be placed closer to the gingiva without interfering with the gums. That is particularly good in deep bite situations (which this is not).
  • The patient can floss her teeth.

The disadvantages are that is takes a lot more effort to make and place. That makes it more expensive.

Stan

Please feel free to share this with friends.  If you have a friend who would like to be on the “Ortho tips” list please let me know.

p.s. If you prefer not to get these OrthoTips please return this email with a “No Tips Please” comment.

Orthodontic Tips August 28, 2015

Do people need occlusal stop distal to the first molars?

Yes they do!

I have been creating bites and adjusting occlusion for 43 years and my opinion is that occlusal stops are necessary in the region of the 2nd molars.

Today I say a patient for her annual recall visit. At night time she wears a maxillary Hawley retainer with bite blocks distal to the first molars to replace the missing 2nd molars. She also wears a mandibular primary TMJ splint. This set up serves her well since I completed her orthodontic treatment 8 years ago and there are no TMJ symptoms even though she still bruxes her teeth. I know that she is still bruxing because her Masseter muscles are as hard as the table I working at.

Another situation to illustrate the need of an occlusal stop distal to the first molars is a patient I saw with a unilateral TMJ problem. There was clicking and jaw pain only on the left side. The lower left second molar was missing. I inserted an upper and lower TMJ splint system with a bite block in the lower splint in the region of the missing second molar. Of course the problem went away immediately.

Although these two stories are anecdotal and not evidence based with statistical data, I feel that this perspective has served me and my patients well over the past decades.

Stan

Please feel free to share this with friends. If you have a friend who would like to be on the “Ortho tips” list please email us at waeseorthodontics@rogers.com.

Orthodontic Tips April 27, 2015

Are there dental indicators of a Skeletal Class III malocclusion that requires Orthognathic Surgery?

Yes!

Here is a short list that you can use.

image003

If the lower incisors are tipped lingually, that is a sign of “dental compensation” and Orthognathic Surgery will probably be the best choice for care.

If the lower dental midline is off to one side, that is a sign of asymmetry and Orthognathic Surgery will again be the best choice for care. Notice in this picture, not only is the lower dental midline 5mm to the left but the lower incisors are tipped to the right.

This case requires braces and Orthognathic Surgery for a stable result.

Braces will be placed on the upper and lower teeth to “decompensate” them. This will initially make the occlusion appear worse. Then the lower jaw will have a bilateral sagittal split osteotomy to move it back. The movement will be larger on the right side to match the dental midlines. The entire orthodontic/surgical care should be completed in 18 months.

Stan

Please feel free to share this with friends. If you have a friend who would like to be on the “Ortho tips” list please let me know.

p.s. If you prefer not to get these OrthoTips please return this email with a “No Tips Please” comment.

Orthodontic Tips – Should these baby teeth be extracted?

Should these baby teeth be extracted?

Check for overlapping of adult crowns on top of baby teeth roots.

image003

Notice the overlapping of the crowns of the un-erupted maxillary laterals and mandibular cuspid teeth on top of the roots of baby teeth.

In the mouth, these baby teeth are not loose at all!

This is a case of “lack of resorption” of these baby teeth. The result is certainly very slow change-over of the teeth. Sometimes the result is impaction of the permanent cuspid teeth in the maxilla or mandible.

In this case the 52, 53, 62, 63, 73 and 83 should be extracted immediately to prevent possible impaction of the adult cuspid and lateral teeth.

Orthodontic Tips December 9, 2014

Should it be crown lengthening or orthodontic intrusion?

Compare the gingival margin, the incisal edges and the length of the crown of adjacent teeth to decide.

image003

This patient had a long standing malocclusion with crowding and a deep bite. Also, he was a bruxer. If you check the before picture you will see that the tooth 11 not only has lost 1.5mm off the incisal edge; but also, the tooth has over-erupted.

The over-eruption of tooth 11 is diagnosed by the fact that the gingival margin of tooth 11 is more incisal than the gingival margin of tooth 21.
This case is currently in treatment. In the progress picture you can see that the gingival margin of both incisors is level from one tooth to the other. If you look closely you will also see that 1.5mm of tooth coloured acrylic has been added to the incisal edge of the 11 to replace the dental material that was lost from the bruxing habit.

After orthodontic care is completed, this patient’s dentist will restore the 11 properly to the correct dental proportions.

Crown lengthening will not be necessary in this case.

On another topic, my buddy Dr. Jim Hyland is giving a periodontal webinar on December 18, called “Stop The Bleeding”. I’ve attended one of his live presentations and fount it enlightening. Here is the link for more information:

http://practiceperfection.com/webcasts/2014_ADM_webcast_December.html

Stan

PS: I have moved my office to join a group practice at Sheppard Yorkland Dental across the road from Fairview Mall. The phone number is the same so please continue to call me! Please feel free to share this with friends. If you have a friend who would like to be on the “Ortho tips” list please let me know.

Orthodontic Tips December 4, 2014

Why can’t everyone’s ideal occlusion be the same.

Because everyone has a different skeletal structure.

I saw a patient last month for a retainer recall. He came with his father for his appointment.

I checked the lingual bonded wires; I checked his upper and lower night time retainers; I checked his Masseter muscles for tonicity; I checked his jaw joints for clicking. There were no problems. I congratulated them for everything being OK and said “See you next year”.

Then the dad said “My wife wants to know why my son’s teeth are sticking forward!”

(Of course, it’s always the parent who is not there who needs to know.)

This was an opportunity for me to explain about dental compensation for skeletal disharmony.

This patient has a prognathic mandible and a concave midface. In an extreme situation the teeth would be in an anterior crossbite and would have required Orthognathic surgical assistance to get a Class I occlusion. However, this was not an extreme situation and I felt that if I tipped the upper incisors forward and the lower incisors back, I could achieve an acceptable and stable occlusion without jaw surgery.

You can see in the photos that there is dental compensation to accommodate the large mandible and small maxilla. It is not an ideal Class I occlusion. It has a tendency to Class III and there is also a tendency to posterior crossbite as well.
I feel that this was a good choice in this case. Many of my other cases do require Orthognathic surgery when the skeletal disharmony is too large.

Stan

PS: I have moved my office to join a group practice at Sheppard Yorkland Dental across the road from Fairview Mall. The phone number is the same so please continue to call me!

Please feel free to share this with friends. If you have a friend who would like to be on the “Ortho tips” list please let me know.

p.s. If you prefer not to get these OrthoTips please return this email with a “No Tips Please” comment.

Orthodontic Tips November 4 2014

Orthodontic Tips November 4 2014

How do I know which TMJ splint to use?

Experience helps.

This morning I saw a patient with a chief complain of sore jaw muscles and a history of morning headaches.

The patient’s age was 32 years old. When I placed my hands on the Masseter muscles they were as hard as a table top. When I placed my fingers over the jaw joints and asked her to open a close there Continue reading