Questions and answers

Facial asymmetry Generally, if you perceive that your face is asymmetric, a "quite pronounced asymmetry" as you say, the masseter muscles are not the only asymmetric structures. The problem is more accurately skeletal and you possibly suffer from hemimandibular hyperplasia causing a facial asymmetry and deviation of the chin. In this example, we can indeed pretend that the right masseter muscle is bigger than the one on the left side and it is true. However, notice how the chin deviates to the left (green arrow). This patient, whom I treated when he was 14 years old and who showed a perfect symmetry at that time, came back to see me at 29 years of age. He believed that his teeth had moved. In fact, hypergrowth of the right temporomandibular joint occurred, which caused the visible asymmetry. The analysis of X-rays confirmed the presence of a bigger right condyle compared to the left one. The patient was referred to an oral surgeon and he underwent a bone scan (scintigraphy) to determine if growth was still occurring. The result came back negative, the patient was reassured and did not start any treatment. He could very well live with his condition.

Thumb grid to break a thumb sucking habit. I recommend that you consult an orthodontist to evaluate the probable consequences of a prolonged thumb sucking habit. Indeed, the orthodontist is the most qualified to evaluate the problems associated with a bad finger sucking habit. He will be able to make the best diagnosis on the state of your child’s occlusion or malocclusion and propose good solutions to you. To know more, I recommend that you read the page "Nonnutritive sucking behavior". The enumerated consequences consist of: 1- Increased overjet (the upper teeth are positioned more anteriorly than the lower teeth). 2- Anterior open bite. 3- Elongated arch depth. This is related to the fact that the teeth are positioned more anteriorly (point 1). 4- Narrower upper maxilla. Case #1 Thumb grid with Hyrax The intervention that is most indicated is a rapid palatal expansion to correct the insufficient palatal width. At the same time, I take this opportunity to install a small "crib" anteriorly so it is uncomfortable for the patient to place the thumb against the palate. Since the appliance must stay in the mouth permanently for a period of 7 months (about 1 month of enlargement and 6 months of retention), it is enough to break this habit. Moreover, at 7 years of age, the child knows about his problem and is quite happy to see that this appliance helps him get rid of his habit. The example illustrated above is of a young girl who is 8 years and 4 months of age and who presented consequences of palatal constriction (narrow palate) with a right posterior crossbite and an anterior open bite associated with her bad thumb sucking habit. The picture in the middle shows the expander once it is enlarged and the anterior grid. The picture on the right shows that the relationship in width between the upper teeth and the lower teeth is normal. The crossbite is gone. The upper teeth have erupted (come down) and the open bite has improved compared to the initial picture on the left. The expander was put in the mouth on 4 December 2014. The picture on the right was taken on 11 February 2012, that is a little more than 2 months later. The young girl stopped sucking her thumb as soon as the first week after the appliance was installed. Case #2 Passive thumb grid Here is the case of a young boy who had a bad thumb sucking habit and who had undergone a treatment with a palatal expander at 6 years of age. The young boy had not been able to overcome his bad sucking habit despite the successful correction of his palatal width problem. I had not put a little crib at that time. Whether this was the cause or the young boy was not mature enough, I do not know. He came back in 2011 and he was determined to break his bad habit. He was then 9 years old and was fully aware of his problem. He did not show any maxillary constriction since it had been corrected 3 years beforehand. A thumb grid was then made and installed on an archwire and molar bands. Three or four weeks after the thumb grid was installed, I saw the patient again and I noted in his file that he had completely stopped his bad habit. The picture taken in May 2012 (7 months after the appliance was installed) shows the closing of the spaces between the teeth and the covering of the upper teeth over the lower ones, which indicates an increased overbite (closing of the open bite). The appliance was removed in November 2012, that is 12 months after it was installed. I saw the patient again in April 2015 and he had not restarted his bad habit.  

Dental mutilation Mutilation of tooth #46 (X). Mesial tipping of teeth #47 and #48. Hypereruption of tooth #16. Adjacent periodontal problem indicated by the arrows. Inevitably, when a tooth is lost, a lower right molar (#46) in the example above, tipping of the posterior teeth occurs toward where the missing tooth was located. The upper tooth #16, which no longer has its opposing tooth and has no vertical support, starts to erupt and goes down in the lower toothless space. Food traps are thus created and accumulation of dental tartar and bone loss occur. The white arrows indicate the areas where bone loss is starting to occur. The tipped teeth must be uprighted and the missing tooth must be replaced or the teeth must be uprighted and the space must be closed by protracting the posterior teeth. The surface of the teeth must also be cleaned and all the tartar removed to avoid the progression of the bone loss. Implant Implant of tooth #36. Uprighting of tooth #38 and intrusion of tooth #26. This example shows a similar case where the upper left tooth has collapsed in the opposing toothless space. The lower molar (#38) is tipped toward the toothless space (missing teeth #36 and #37). The treatment consisted of intruding the upper tooth to obtain a straight plane. The lower molar was uprighted and protracted forward to reduce the width of the toothless space. A molar on implant of an optimal width and height was placed afterward. Piece of advice I recommend you to consult your dentist so he can evaluate your situation and propose solutions. You will possibly need treatments in orthodontics, periodontics and prosthodontics.

Posterior vertical excess and anterior open bite Your question is short, but the answer is complex. First, let's define the term skeletal open bite. I assume that you want to designate an anterior open bite where the upper teeth do not cover the lower teeth. The above picture presents 2 cases of anterior dental open bite, but with different skeletal problems. The MJBE patient on the left suffers from a dental open bite and vertical maxillary excess, whereas the PABI patient on the right suffers from an anterior dental open bite, without vertical maxillary excess. Extraction of the second premolars The MJBE patient on the left underwent the extraction of the upper and lower second premolars to reduce dental prominence and fix the problem of not having enough space. The above pictures show the result of the orthodontic preparation with the extraction of MJBE’s second premolars. Although the occlusion is excellent, the patient wanted to correct the vertical maxillary excess that persisted. Thus, she underwent a bimaxillary orthognathic surgery and genioplasty. The picture on the right shows the case 2 years after the fixed appliances were removed. We can conclude that the extraction of premolars and the retraction of the anterior teeth can help close an anterior open bite, but will not change the skeletal vertical dimension. The PABI patient, not having undergone extraction and not suffering from vertical maxillary excess, had to undergo an orthognathic surgery to lengthen the premaxilla in addition to Le Fort I maxillary advancement to correct the Class III relationship. Extraction of the first molars With the previous examples, we saw that it is possible to close an anterior open bite, without necessarily changing the skeletal vertical relationship. The reason is that if premolars are extracted, the skeletal vertical dimension is maintained by the occlusion of the first and second molars. If we want to reduce the skeletal vertical dimension, we have to proceed with the extraction of the first molars when they are the only ones supporting the vertical dimension. This means right before the second molars erupt and before the premolars touch.   In my career, I proceeded with the extraction of the four first molars in only 4 patients. One might say that it is not a lot, but it gives a good idea of what needs to be done and when it needs to be done to succeed. Each of these cases is well documented. I present only one to you; the one illustrated above. On the left, I indicated the first molars that need to be extracted. Notice that they are the only teeth to touch. The second molars and the premolars have not finished erupting and have not reached the occlusal plane. The anterior open bite is indicated by the red arrow. The picture in the middle, taken one month after the extraction of the first molars, shows that the second molars support the vertical dimension and the upper anterior teeth cover the lower teeth vertically (positive overbite). The vertical dimension has closed by about 4 mm. The blue Xs show the site of the extracted first molars. The picture on the right shows the finished case and an optimal Class I occlusion. I would like to specify that the maxilla no longer showed skeletal vertical excess due to the extraction of the upper first molars. However, a small vertical excess was present where the symphysis is. A genioplasty to shorten the chin vertically and to advance it was performed. Conclusion The extraction of premolars may reduce, even close an anterior dental open bite, but will have a small or no effect at all on the skeletal vertical relationship. The extraction of the first molars will have an effect on the closing of the open bite only if they are the only teeth to touch. In adults, this will most likely have a small vertical effect if any at all. In the young patient, it is possible to reduce the skeletal vertical dimension if the extraction is performed before the second molars and the premolars are in occlusion. Nowadays, with the technique that uses anchoring miniscrews, it is possible to intrude the posterior teeth and close an anterior open bite while reducing the skeletal vertical dimension. The example above shows a case with 2 tomas®-pin EP miniscrews in the palate and a tomas®-pin EP miniscrew between the first and second left and right molars. The posterior teeth are intruded (the upper and lower teeth go into the bone respectively), which allows the closing of the anterior open bite. Here is another case using a combination of tomas®-pin and Vector TAS miniscrews.

Good Sunday morning Mister Lacasse, It is true to say that the situation is quite bothering and that damage to the permanent teeth is present. You daughter is 12 years old and you say that the treatment started "several years" ago. This confuses me. I think that there is a strong iatrogenic cause to the resorption of your daughter's incisors. The problem should have been handled way before and differently. It would have been better to de-impact the canines first (exposure surgery, traction metal ligature and removable appliance with a cantilever spring) WITHOUT using fixed appliances. When traction was performed on the canines, it would have been simple to make the decision to undergo a major orthodontic treatment and to proceed with the removal of premolars to solve the problem of the lack of space. All of this assumes that the canines were accessible by the palate. But the damage is done. The same option can be considered. I would certainly remove the fixed appliances to free up the lateral incisors during the traction of the canines. As soon as the crown of the canines will be moved away from the root of the lateral incisors, the root resorption will stop, healing will follow and the treatment with fixed appliances will be able to start again. What now? The option to extract both canines is a good choice. It is probably what is simplest mechanically and as soon as the canines are gone, resorption will stop. The first premolars (#14, #24) can fill out the role of the canines with or without coronary modifications. I am thus in favor. Note that the removal of the lateral incisors would not be a bad choice, but the duration of treatment will be longer, because the canines need to be brought into the mouth and this can take one year or even more. By seeing how the canines were managed up to now by the orthodontist, I would be careful... What calls to my mind is that nobody talked to you about the definitive relationship between the upper and lower teeth. Indeed, there will be 2 fewer teeth in the maxilla and a complete dentition in the mandible. A treatment with the extraction of 2 teeth in the maxillary arch is valid if the molar relationship is in Class II. If the molar relationship is in Class I, we have to consider the removal of 2 lower premolars to obtain an acceptable functional occlusion. I introduce you to a case of a patient who comes to my office and who has 2 impacted canines that cause resorption of the incisors. Any traction attempt on the canines would have meant a more important damage to the incisors. The patient had a Class II malocclusion. I thus proposed a treatment including the removal of 2 permanent maxillary canines, but without any removal in the mandible. Notice that the treatment was initiated in the mandibular arch while waiting for the upper canines to be extracted. The treatment in the maxillary arch started in March a few weeks after the extraction surgery. Notice the resorption of teeth #21 and a little bit of teeth #22. Teeth #12 and #11 are less damaged.  

I must admit that the description provided is rather confusing. I understand that the treatment started in March 2013, that there are impacted canines, that a palatal expansion occurred but did not go as planned, that extracting a premolar was suggested to you, that another orthodontist suggested to remove the appliances and start all over again, that a surgery is recommended toward 16 years of age. It is rather rare, even exceptional, that a palatal disjunctor does not work on a 13-year-old boy and it appears to me that it is rather normal to see a disjunctor push the teeth outward. However, your words may not express well what your orthodontist intended to tell you. The suggestion to extract a tooth is not impossible, but I question the fact that only one extraction is recommended, although I acknowledge having conducted a few treatments where the extraction of only one premolar was indicated. If an orthodontist suggests a surgery toward 16 years of age, I imagine that there is a discrepancy between both jaws. It is probably the reason why wearing elastics was suggested. It is hard for me to tell you what to do or what could be done for your son. I wish that you will meet an orthodontist who will take the time to perform a good analysis and sit down with you to talk about the best solution, the best treatment. Either the explanations that were provided to you were bad, either they were provided to you, but you did not understand at all, or the treatment is forever changing, like the weather. I hope that you will find an orthodontist that will know how to reassure you. I cannot tell you more on what should be done and I find that the situation is already confusing enough with 2 orthodontists without my two cents thrown in remotely, even if I knew what to do if I saw him in consultation. Good luck with the rest.

My best advice would be to extract your baby tooth, get the impacted canine exposed and pulled into the arch with an appliance. Read the page on mechanotherapy of impacted canines (mechanotherapy). You should visit an orthodontist and ask for a treatment.

Miss, We have to take into account the facts to take an informed decision. First, you have received a treatment with Invisalign® aligner trays which ended up being a total failure with regard to your occlusion. If this kind of appliance did not work once, why should it work better the second time? Of course, chances of success may have been different if it had been administered by an orthodontist, but I doubt it. The difference, however, is that the orthodontist had possibly more chances of identifying your other problem, the pain in the cervical vertebrae, jaws and ears. Let's compare the situation with antibiotics. If you take a prescription of antibiotic for an infection X and that after the treatment, this infection X comes back, is it possible that the spectrum of action of this antibiotic might not be the right one? Shouldn't the antibiotic be changed? Could the Invisalign® treatment that you received be the least suited treatment with regard to the occlusal condition that you had at first? Personally, if a patient consulted me for a malocclusion and on top of that, he had pain in cervical vertebrae, joints and ears, I would not start the treatment with Invisalign®, that’s for sure. I would begin by searching for the cause of this pain and propose a specific treatment to this problem. Then, I would take care of the occlusion. You should know that the pain that you feel is probably not related to the state of your occlusion. Neuromuscular dentistry IS NOT a specialty of dentistry. It is a school of thought based on concepts which are little or not supported by scientific literature. It is a little like a religion. A limited group of supporters believe in it, but the scientific community does not adhere to it. The Ordre des dentistes du Québec published a public press release on the problem of temporomandibular disorders (TMD link) (in French). Thus, I do not believe that neuromuscular dentistry could be of any help to you. I believe that you need an orthodontist who has in-depth knowledge in temporomandibular disorders and who could propose a treatment which could be different from Invisalign®, without necessarily excluding it. Good luck Dr Sylvain Chamberland

Good evening Julie, You are clever and your question is pertinent. You are right to pretend that someone should have the same number of teeth on each side, but it is not always the case and conditions (of malocclusions) exist where the extraction of 3 teeth is indicated (1 premolar on each side in the maxilla and 1 premolar on only one side in the mandible). When there is asymmetry in the molar and canine relationships between the right and left sides, the extraction of 3 teeth is often the best option. This makes it possible to cover the asymmetry. There are conditions where the extraction of only one premolar on only one side in the maxilla can be suited although it is less frequent. I do not want to get into the details to confuse you. Let's get back to your case. The removal of an upper premolar and a lower one on the side where there had not been any extraction is likely to be necessary. I admit that it puzzles me to have to reopen a space on the lower left side, unless you have an asymmetry to the left and that the addition of a premolar will make it possible to recenter the mandibular midline. In that case and since you do not want any surgery, would it be possible to extract an upper right premolar, not to extract any lower right premolar and reopen a space on the lower left side? This is the same as a covering treatment of a Class II with the extraction of only 2 upper premolars. I do not know. I would have to examine you clinically. Here is an example where I extracted 3 premolars to cover a mandibular asymmetry to the left. I took these pictures 8 years after the end of the orthodontic treatment. Notice the excellent occlusal stability.

The cost of an orthodontic treatment is distributed in the following way. The cost of the complete examination, an initial payment when the appliances are installed in the mouth, followed by an X number of consecutive monthly payments. The number of monthly payments is approximately the same as the estimated duration of the orthodontic treatment. For payments, we accept cash, checks, or bank transfers. No interests are charged since invoicing is done monthly as the treatment evolves. I hope that this information is what you are looking for. For more details, consult the Financing and Medical expenses and tax return pages. Do not hesitate to contact my secretary to make an appointment. Good night Jessie.