Questions and answers

Miss, I went to see the site that you make a reference to. We have to know how to read between the lines to decode their message. Thus, I quote their text: Accelerated orthodontic treatment aims to enhance the aesthetic appearance of your smile by quickly and efficiently straightening the most visible teeth. The major advantage of this option is the shortened duration of treatment, (usually an astounding 6 months or less!) The compromised treatment does not aim to correct any underlying malocclusion or functional problems. If you want to have straight and white teeth quickly, but do not want a complete treatment, accelerated treatment is your best choice.   You will understand that an accelerated treatment does not mean that teeth will move faster, but instead, you WILL NOT HAVE a complete treatment. This is why it is accelerated. In other words, it is finished prematurely. He clearly says that he only aligns the 6 front teeth...   Forget stability, improvement of dental function and quality occlusion. It seems like quick and cheap is his motto. Less treatment time, just the 6 front teeth (the "six social ones"), it is easy to say that it costs less.   My father always used to tell me: "If you do not pay much, but it is not good, it is still too expensive." My father would have been 92 years old this month. He was a very wise man.   Moreover, I bring to your attention that this dentist is not an orthodontist who followed a known specialty program. He took courses during weekends over a 2 to 3-year period. This has nothing to do with a real specialist in orthodontics who must follow a 3-year second-cycle program.

Thank you, Hadrien, for sending me your pictures and X-rays so I can offer you a better response. I thus performed a cephalometric tracing and I evaluated both scenarios. First, I would like to point out that you suffer more from retrognathia than you believe so. Your X-ray shows a shift of 8° between both jaws whereas the normal is 2°. There is a shift on the occlusal plane of 10 mm. The normal is 0 mm. The distance between the upper and lower teeth is from 5 to 7 mm (green circle on simulation #1). Simulation #1 shows an advancement genioplasty of 6.8 mm to bring the profile back to normal. The distance between the upper and lower teeth does not change. The lower teeth are still too far back or the upper ones are too advanced. Simulation #2 shows a mandibular advancement osteotomy of 3.5 mm and an advancement genioplasty of 4.5 mm. This will have the benefit of obtaining a normal gap between the upper and lower teeth. You can show these tracings to the surgeon and orthodontist that you have met. If you lived in Quebec, I would probably recommend simulation #2. I always aim for an optimal treatment. I offer you the simulations on morph pictures. There is little difference visually. The bulk of the difference will be in your occlusion. Like I have already said, "a skeletal malformation is rarely isolated" and in your case, you seem to suffer from mandibular retrognathia and underlying Class II division 1 malocclusion that you should not underestimate.   PS: Orthosurgery simulation of treatment with the QuickCeph Studio™ software.    

Dear Dr P., I want to thank you for you question as it permits me to address an underestimated cause of facial asymmetry in young growing children. I commend you for the quality of the case analysis and the quality of the picture you sent me. The most likely diagnosis for the facial asymmetry of this young girl is an undiagnosed condylar fracture that most likely happen when she falled on a metal crossbar bar ladder 2 or 3 years ago while she was 4 - 5 years old or so. The condylar stump has healed and a new condylar head has formed, but the losted substance of the condyle is gone. Therfore, the height of the ramus has shortened. On the xray picture, # 1 indicates the right condylar head, #2 the right articular eminence, #3 the left articular eminence and #4 the left condylar head. It is obvious that the left ramus and condylar neck are shorter and the left eminence has no slope if any. Healing and normal growth had reshaped both condyle and eminence. When looking to the condyle from an anterior view, one can see the familiar oblong shape of a condyle but the left condyle is smaller. You mentionned that beside a deviation to the left when opening (see above pict) there is no limitiation of the amplitude (it is obvious when looking at the picture) and there is no discomfort for the patient. This remind me the caveat of Dr Bill Proffit: "If it can move, it can grow. If it don't move, it will not grow." This young girl was fortunate to not experienced any limitation of jaw opening movement and prolonged discomfort, except when the accident has occured. There is one minor thing I disagree with your diagnosis. The midline are not coincident. I traced the upper and lower midline on the right picture. Note that the lower midline is toward right like the occlusal plane canting to the right. This can be explained by the lack of heigh of the left ramus and as normal growth occur, there is a wagon wheel effect and the midline deviate toward the normal side, the occlusal plane is moving up on the affected side. What should we do now? It is sad that such event occur in children. I think the best attitude would be to wait and see. Monitor her dental and facial development until age 13-14. Chances are that she will have a class II molar relationship in the left side and a class I (may be a class III) molar relationship in the right side. A decision will have to be made regarding her occlusion and her facial asymmetry. Treatment may involve an asymmetric extraction pattern (no extraction in the lower left quadrant). It is hard to tell so long time in advance. Chances are that an orthognathic surgery might be indicated if this pretty young girl wish to have a symmetric face during adulthood. But chances are also that she might be ok with some asymmetry. I am aware of one publication of Dr Birte Melsen who reports 3 cases where hybrid functional appliance was used to correct the asymmetry. In this case, if i would have to try something, I would use an hybrid of bionator in the right side and Frankell II in the left side. The goal would be to disctract the left condyle from the fossa, create an open bite in the left side to allow vertical dentoalveolar growth while restricting to some extent the dentoalveolar growth with the bite plane in the left side. I would not garanty if it would work, but it is the only think I can think of at this age if the parents insist of doing something I would not recommend osseous disctraction at this age neither would I recommend it at the adolescence. The fibrocartilage of the condylar surface has been damage and she is lucky to have a regenerated condyle even if it is smaller. Doing osseous disctraction would generate significant pressure on the newly formed fibrocartilage and resorption is likely to occur. This would be drammatic. I would prefer an hybrid Bionator-Frankell rather than osseous distraction. Conventional orthodontic treatment and, if necessary, an orthognatic surgery, are much more predictable than osseous distraction of a ramus with a reshape fractured condyle. Finally, I want to share with the case of a 5 years 10 months girl who falled on her chin and suffer bilateral condylar fracture. It was in september 2006. Please look at the panoramic radiograph and note that both condylar head are displaced anteriorly. The right side seem more damaged thant the left side. Seven year later she was ready for the orthodontic treatment. Note her facial asymmetry to the right, cant of the occlusal plane to the left, deviation of the lower midline toward the side that is longer vertically. Orthodontic treatment is going well. I delayed the orthodontic treatment as much as I could. The radiograph taken in july 2013 show a small reshaped condyle in the right side while the left condyle has a more normal form despite its previous fracture. I wish all those information will help. Note that the analysis of the case you submitted is only an opinion on the data you sent and should be interpreted with caution because i did not do a clinical exam. For more information on facial asymmetry, I recommend this Keynote: Hemimandibular Hyperplasia and Facial Asymmetry. Slide from 89 to 98 describe talks about condylar fracture. Bibliography Proffit WR, Vig KW, and Turvey TA. Early fracture of the mandibular condyles: frequently an unsuspected cause of growth disturbances. Am J Orthod. 1980, Jul;78(1):1-24. Melsen B, Bjerregaard J, Bundgaard M. The effect of treatment with functional appliance on a pathologic growth pattern of the condyle. AJODO. 1986;90503-512.