Questions and answers

Mister, Thank you for providing me with a nice example of odontoma which was an obstacle to the eruption of a permanent canine. I have numerous cases of odontoma in the lower canines or upper incisors. I do not believe having seen one in the upper canines. Thank you, I add your case to my collection. I would like to answer your question: are there chances that your impacted canine will appear in the mouth? The answer is YES. But you will have to be patient, because it can take 24 to 48 months without any orthodontic treatment. I guess that you are an adult (> 20 years). The tooth will move and go down. This will take time. Will the tooth be rotated when it will appear in the mouth. Answer: Yes. Solution You can speed up the eruption of this tooth by an orthodontic traction of the canine. We then need to proceed with a surgery to expose the canine and bond a traction wire to it. A removable appliance will be very efficient. However, fixed appliances will be necessary to de-rotate the tooth. The necessary force system is relatively complex. Good luck  

Hi Al, You may print the webpages and show to your staff or patients, but you cannot copy the content into your website. However you may redirect, via an hyperlink, your patients to the English or French version of my website. If questions are asked, I will likely answer them like I do for the French speaking people. My goal is to provide good and reliable information. Best regards Dr Sylvain Chamberland

Right mandibular laterodeviation and facial asymmetry. Someone recently asked me a similar question (see this link) (in French). If growth of the faulty condyle has stopped, the situation should not worsen. I explained this concept in the above link. A facial asymmetry, when it is as visible as you describe, cannot be hidden orthodontically. The best solution would definitely be to consider an orthognathic surgery. Note that there is most likely an underlying malocclusion with dental compensations associated with your mandibular laterodeviation. I recommend that you consult an orthodontist in order for him to plan a treatment combining orthodontics and a surgery. It is the best way to obtain an optimal result and to have a functional occlusion and symmetrical face. The following image shows the smile of a 47-year-old woman with a facial asymmetry to the right and a Class III malocclusion. An orthodontic treatment made it possible to correct the dental compensations. The orthognathic surgery consisted in a Le Fort I advancement osteotomy and a genioplasty of laterodeviation to the left. Performing a mandibular osteotomy was not necessary in her case. Facial asymmetry to the right and mandibular Class III.

Damon® Clear2™ The Damon® Clear™ system is a passive self-ligating system and it is one of the reasons among many others why I do not use this system.   A visit on the Ormco manufacturer’s site reveals that this bracket is available in the upper maxilla from one second premolar to another (UR5 to UL5) and in the mandible from canine to canine (LR3 to LL3). The Damon® Clear2™ bracket is made of polycrystalline alumina. The company performed in vitro tests to verify wear of the polycrystalline material by comparing it to Damon® 3 and In-Ovation® C brackets. Results show that after 300 000 cycles of simulated chewing, the Damon® 3 bracket shows significant wear. The Damon® Clear2™ and In-Ovation® C brackets do not show any signs of wear and their structural integrity was comparable after 1 year in an artificial oral environment. What does that mean? This means that a Damon® or In-Ovation® polycrystalline bracket is so hard that it will not wear out. Is it a benefit or a disadvantage? If the bracket is placed on the upper teeth, this does not cause any major problems, except when the brackets are removed. If the bracket breaks under the force applied with debonding pliers, and believe me it happens, a diamond bur needs to be used to remove the residues instead of a carbide bur. The diamond bur can remove enamel whereas it is less probable with a carbide bur. But if the brackets are placed on the mandibular incisors and canines, they can get in contact with the tip of the upper teeth. Wear tests show that the brackets are perfectly hard. Nevertheless, tooth enamel is made of hydroxyapatite that is a lot softer than polycrystalline alumina. If one rubs on the other, the hardest will wear out the softest. Thus the ceramic brackets will wear out the opposing upper teeth. Do you really want to take the risk of having the Damon® Clear™ brackets bonded to the lower teeth wear out the tip of your upper incisors? Having already seen this problem at the beginning of my career, I thus banned any ceramic bracket in the mandible.  

Class III You are describing what seems to be a Class III malocclusion. Fixed appliances will be necessary in both upper and lower dental arches. I almost exclusively work with the self-ligating SPEED™ system. Most of Class III malocclusions will necessitate an orthognathic surgery that could include a Le Fort I osteotomy to move the maxilla forward and a bilateral sagittal split osteotomy to move the mandible backward. However, there are some cases where the shift is not significant and may be hidden without surgery. It is impossible to tell you how much this can cost without having seen the nature of your malocclusion.  

You report your problem, but you refuse the solution. We have to determine what causes the crowding of these 2 teeth and see if it is an isolated problem or if other problems are associated with it. When problems are identified, and there can be either only 1 of them or several, we can propose solutions. These solutions will include appliances, either conventional ones worn on the mouth side or appliances such as Invisalign® aligners. Usually, when there is a will, there is a way.

Usually, the shedding of primary teeth in both jaws is coordinated. Generally, the order in which primary teeth exfoliate or in which permanent teeth erupt is the following: 1- Lower central incisors 2- Upper central incisors 3- Lower lateral incisors 4- Upper lateral incisors 5- Lower canines 6- Lower first premolars 7- Upper first premolars 8- Upper second premolars 9- Upper canines 10- Lower second premolars The order in which teeth erupt is however more variable from item 6 to 10 and not all individuals are similar. Consult the dental age page. You will find a more detailed Keynote. At 9 years of age, girls sometimes show a more advanced dental age and only the exfoliation of primary canines remains. I cannot make any recommendation regarding extraction without having seen any X-ray beforehand and without having seen your daughter in consultation. I recommend that you consult an orthodontist.

Miss Di Cesare, Your question includes 2 parts that I will summarize as follows: 1- Can a chin stop growing following a hit on the lower jaw? My answer will be according to the following interpretation: Can a hit, an impact on the lower jaw, affect the forward growth of this jaw? 2- Can an early treatment (7-10 years of age) in 2 phases (1 phase with a functional appliance (Bionator, Frankell, orthopaedic devices) followed by a second phase with fixed appliances) can stimulate lower jaw growth and be beneficial compared to a similar treatment performed later in only one phase (12-14 years of age)? 1- Hit on the lower jaw A single hit on the jaw will have little effect on mandibular growth and your son's Class II malocclusion can be explained in a totally different way than an impact. The apple never falling very far away from the tree that bore it, heredity (from the father or mother) is the explanation that must come first. Indeed, physical characteristics of an individual are hereditary and a malocclusion, whether it be Class II or Class III, is a physical characteristic, so, consequently, hereditary. With that being said, a young child can hit his chin when falling and fracture one or both mandibular condyles. This will have an effect on the forthcoming mandibular growth. For more details, consult the page Child with hypoplasia of the processus condylaris and caput mandibulae on the left. If there are no fractures, contusion (compression) could cause damages to the articular surface. If the effect of a fracture can be seen quite quickly after the event (impact), the effect of contusion can be seen later. The figure on the opposite side shows a slower mandibular growth curve (green line) than normal growth which occurs in the absence of trauma and internal derangement. I point out that I do not believe that it is your son's case.     2- Early treatment in 2 phases versus late treatment in 1 single phase In the 1990s, 2 major research projects using a randomized clinical trial method were conducted by the University of North Carolina (Dr Camila Tulloch and Dr William R Proffit) and by the University of Florida (Dr Greg King and Dr Tim Wheeler). More recently, an important similar research project was conducted at the University Manchester in the United Kingdom (Dr Kevin O’Brian and Dr. J. Wright). These projects provide us with the best data available to understand the response obtained by treatment of growth modification in Class II malocclusions. The trial conducted at UNC on a 10-year period compared 2 treatment strategies. 1- Treatment in 2 phases: an early treatment in mixed dentition, before adolescence, followed by a second phase of treatment in permanent dentition. 2- Treatment in 1 phase: a treatment during full growth of adolescence at the beginning of permanent dentition. During phase 1, patients were assigned randomly (randomization) either in an observation-only group (no treatment), either in a group with treatment using a functional appliance (bionator), either in a group with treatment using a headgear. They were followed for 15 months. During phase 2, all patients were reassigned randomly to 4 treating orthodontists. Those who were in the control group and whom had not received any treatment started theirs. Groups who had received a treatment were compared to the group who had not received any at the end of phase 1. At the end of phase 2, the research project emphasized on the comparison of results of those who had already received an early treatment to those who had not received any treatment in phase 1 and who were treated only during adolescence. . Results of a 2-phase treatment versus a 1-phase treatment Data from these research projects make it possible to conclude that: 1- In average, a child treated with a headgear or a functional appliance before adolescence will obtain a small but significant correction of the Class II intermaxillary relationship compared to a control group of untreated children. About 75% of treated children before their puberty growth had a favorable response. 2- Change in the skeletal relationship obtained during the early treatment phase is partially lost and is not maintained during subsequent mandibular growth, whether it be for the headgear group or the bionator group. Indeed, an early treatment has little or no effect on subsequent skeletal changes, alignment of teeth, occlusion, duration or complexity of treatment. 3- At the end of the major treatment (phase 2) performed during adolescence, there are no differences between patients having received a phase 1 and those who had not. This means that a 2-phase treatment initiated before adolescence in mixed dentition is not more efficient than a treatment initiated during adolescence in permanent dentition. An early treatment is thus not efficient since it does not shorten the duration of treatment with fixed appliances during phase 2, does not decrease the complexity of such phase 2 treatment whether it be in terms of extractions or orthognathic surgery. The figure on the opposite side shows the effect of a "so called" acceleration of growth during the phase of treatment with functional appliance and return to normal once the use of functional appliance is stopped. This shows that there was no "stimulation" of mandibular growth, but only acceleration, because if stimulation had occurred, the growth curve would not have returned towards a normal growth curve. Conclusion Consult an orthodontist when your child will be 7 years old. Do not rely on European sites concerning early treatments, they are a little behind on this kind of news... It is not impossible that your child could benefit from some interceptive treatment, but it is not likely that it could be beneficial to receive a treatment to stimulate growth of his jaw before he is 12-13 years old (depending on his physical maturity level at that moment). The systematic review (meta-analysis) of Drs J.E. Harrison, K.D. O’brien and H.V. Worthington, Orthodontic treatment for prominent upper front teeth in children, published in 2008 in the Cochrane database concludes that: The evidence suggests that providing orthodontic treatment, for children with prominent upper front teeth, in two stages does not have any advantages over providing treatment in one stage, when the children are in early adolescence. References: Harrison JE, O’Brien KD, Worthington HV. Orthodontic treatment for prominent upper front teeth in children. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003452. DOI: 10.1002/14651858.CD003452.pub2. Gregory J. King, et al, Comparison of peer assessment ratings (PAR) from 1-phase and 2-phase treatment protocols for Class II malocclusions, AJODO 2003;123:489-96. Proffit WR, and Tulloch J. Preadolescent Class II problems: Treat now or wait? American Journal of Orthodontics and Dentofacial Orthopedics. 2002, Jun;121(6):560-562. Tulloch JF, Proffit WR, and Phillips C. Outcomes in a 2-phase randomized clinical trial of early Class II treatment. Am J Orthod Dentofacial Orthop. 2004, Jun;125(6):657-67. Tulloch JF, Proffit WR, and Phillips C. Influences on the outcome of early treatment for Class II malocclusion. Am J Orthod Dentofacial Orthop. 1997, May;111(5):533-42. Tulloch JF, Phillips C, and Proffit WR. Benefit of early Class II treatment: progress report of a two-phase randomized clinical trial. Am J Orthod Dentofacial Orthop. 1998, Jan;113(1):62-72, quiz 73-4.  

Your situation is thus the following. You lost 2 lower molars at around 17 years of age. 6 years later, you started replacing these teeth by osteointegrated implants. These implants were recently installed. The opposing upper molars have erupted (egressed) in the toothless space in the lower arch and negatively affect the future restoration on the lower implants. The consequences of mutilating lower first molars are described in the Collapse of the vertical dimension page and admirably well illustrated by Case 1: dental mutilation of #36 and #46. In summary, if you do not replace your missing teeth now, all your teeth will move and spaces could be created between the upper teeth even if you do not lose any teeth in the upper maxilla. This would be quite bad, mostly for someone like you who underwent an orthodontic treatment at an earlier age. I see on the X-ray that you published that large cavities on the upper second molars, which are very visible, are now repaired since we can see large amalgam fillings on your intraoral pictures. I do not think that grinding your molars is a good solution, because we would have to grind down close to 2 mm of teeth. It is almost as thick as the enamel. Let's continue analyzing your problem. Similar case Your situation can thus be compared to the situation on the figure below. The upper molar hypererupted or egressed (green arrow) in the toothless space in the lower arch and goes beyond the upper occlusal plane (white line). The lower molar probably tilted forward (red curve arrow) and its axis is tilted or in mesioversion (blue bar). You question the fate of your 2 egressed teeth whereas you already have 2 osteointegrated implants where teeth #36 and #46 used to be located. I think that your dentist did not plan this well. He should have requested the ingression of the upper first molars at best before installing the implants, or at worst simultaneously with the osseointegration period. Moreover, as the second molars are free to continue tilting until you are ready to have the crowns installed, it compromises the making of the crowns that have an ideal width. For your case, my recommendation is to ingress the upper teeth and, at a minimum, insert stabilizing segments to avoid seeing your second molars tilt even more. Ideally, they should even be straightened. Example of treatment Let's continue describing the treatment of the above example. 8-mm Vector TAS anchorage miniscrews.   Anchorage miniscrews. The miniscrews are inserted between teeth and must not be in contact with the roots. Two 8-mm Vector TAS anchorage miniscrews were inserted, one on the palatal side and the other one on the buccal side. Special care must be taken to position the miniscrews between the roots. Elastomeric chains attach the tooth to the miniscrews and apply an ingression vertical force. The following picture presents the final restorations on an implant of the aforementioned example. Notice that the leveling of the occlusal plane obtained with the intrusion (ingression) of the upper first molar and the uprighting of the lower molar. The toothless spaces were planned in a way to obtain an ideal width and height for the restorations (crowns). This whole work will make it possible to maintain an optimal oral health and hygiene.

I have never had any patient whose hemimaxillas were moving of 5 mm vertically while talking after undergoing a SARPE. This is definitely not normal. I recommend that you consult your surgeon as soon as possible.