The comments
Dr Jules E. Lemay III, orthodontiste says:
If a homeopath can move these impacted canines and position them in the dental arch, we invite him to the Quebec Association of Orthodontists to allow him to teach us how to do it, I will be all ears!Dr Sylvain Chamberland says:
Wow!A homeopath? Why not walk on Compostela road? Or eat bananas?
Or ask Santa Claus? A shaman maybe?I have a colleague who made this recommendation on his site about someone who was looking for a miracle method to close an interincisal diastema. He thinks that it could work for impacted canines as well... Maybe homeo banana pills would kill 2 birds with one stone.
I believe that you do not understand how severe the situation is. You daughter’s condition which seems to have been managed so-so up to this date (rather poorly than well), what on earth will a homeopath, who has no dental training, no knowledge of the evolution of dentition, do better with imposition of hands and a banana pill?
In your daughter's case, it takes a cone beam computed tomography to determine the extent of the damages and the real position of the canines. In the above example, you can see the root resorption of the upper incisor and how close the crown of the canine is to the root of the incisors. It is another example where the therapeutic decision included the extraction of 3 premolars (#14, #34, #44) and the impacted canine (#23). With this being said, do not believe that I only do that, extract impacted canines. I show you exception cases, because the rule is rather to spare the canines.
I told you so. It is not necessarily impossible to apply traction to your daughter’s canines. However, it will take space in the dental arch to put them and it is not simple. Extractions will likely be necessary. It could be #14 and #24, it could be #13 and #23, it could be #12 and #22. I told you that a treatment will need to be done in the mandibular arch and as there will be extractions in the maxillary arch, extractions will likely be required in the mandibular arch unless a Class II relationship exists.
I wish that you would consult a certified orthodontist who will present to you a comprehensive treatment, without compromise rather than a partial solution. The stomato only does surgery, he does not know orthodontics much if at all.
I spent a lot of time answering you the best I could.
But a homeopath... I cannot believe it.
Eric says:
Hello Doctor Chamberland,Thank you again for your response and your interest in our case. To be honest, my spouse and I are confused...
We do not "feel" the extraction of canines at all - surgical procedure that will probably be quite traumatizing to our daughter who has just already worn an appliance for 3 years...
I talked to a friend about it and she advised me to make an appointment with a homeopath, which I did.
Regards,
Eric
Dr Sylvain Chamberland says:
The permanent wire that you were told about is a wire bonded to the lingual side of teeth. I put this kind of wire routinely in the majority of patients when I remove their fixed orthodontic appliances. No need to have root resorption. The goal of this bonded retention wire is to preserve alignment of teeth. Of course, if one or more teeth are weakened by exaggerated resorption (50% or +), this can be useful to solidify the tooth.Thank you for keeping me in the loop
Eric says:
Hello Dr Chamberland,Thank you so much for your response which is clear and understandable. I forwarded it to our orthodontist to see her reaction...
It is possible that when we contacted her the first time, I do not quite remember when it was, it was maybe already too late to apply traction to the canines in the palate... but anyway, the appliance she wore to make room was frankly useless... as you say, the damage is done.
We were also told about a very thin permanent wire to fix behind the incisors to consolidate them (I do not remember the exact term). What do you think about the use of this appliance?
Thank you in advance,
Regards,
Eric Lacasse
Dr Sylvain Chamberland says:
Thank you for your comments about the photos.I humbly admit that most pictures receives some photoshop editing before publication like cropping, adjusting the angle of view, and some sharpening. But to get those nice edited photos, i need good raw materials.
I will list the armamentarium.
First and foremost, you need a good camera set-up. I use a Nikon D3200. The lens is an AF-S VR Micro-Nikkor 105 f2,8G IE-ED. The flash is a R1C1 Wireless Close-Up Speedlight System.
Secondo, you need a good set of retractors and mirrors. You can find buy it from Ortho-Pli Corporation.
You will need:
1-Double ended cheek retractor #0118-D.
2- Lip retractor #0118-LRH with handle (the one indicated by the black arrow).
3- An intra-oral side view and occlusal view angled mirror #PM3R-3. This one will fit for most patients. For very young patients there are smaller mirrors.The field of view is 65 to 70 mm for frontal, left and right view. For occlusal view a field of 80 mm or so is necessary.
Prise de photo intrabuccale
If you click on the videoclip link above you will see me in action. Note that i did not took intra-oral mirrors for this patient, but this is an exception. Normally, there is an intraoral mirror and I shoot the picture in the mirror. The flash is rotated and adjusted. For frontal intra-oral view, the flash is at 12h00. For left intra-oral view, the flash is facing the mirror at 15h00; for right intraoral, the flash is placed at 09h00. For upper occlusal view, the mirror is looking up and the flash is at 06h00. For lower occlusal view, the mirror is looking down and the flash is at 12h00.
I hope this will help you to obtain good pictures.
Best regards
Dr Sylvain Chamberland.
Margarida Leal says:
Dear Dr Sylvain,I am a brazilian orthodontist. I was in Internet looking for some data about traction of impacted teeth when I found your site.
I really like the mechanics, but I am very surprised with the quality of photos. I am trying to make my intra-oral photos always in the same pattern in but I think it is very, very dificult. How can you achieve the exactely same position in lateral intra-oral photos that are made in different moments of time? There are something to help? Is it only with eyes?
Thank you a lot.
Margarida
Dr Sylvain Chamberland says:
Thank dr McCannI think case #2 "radicular resorption of permanent incisors" and case #3 "ankylosed canine" are exemple where surgical exposure and traction is NOT an option.
Best regards
Dr Sylvain Chamberland says:
Thank you Dr Ohlenforst for your comments.Kevin J. McCann says:
The risk of developing pathological conditions as a result of retention of an impacted tooth is low, with the exception of decay/resorption of the roots of adjacent teeth. It is often said that an impacted tooth may be asymptomatic, but that does not mean that they will remain that way!As an Oral and Maxillofacial Surgeon who routinely removes impacted teeth, I do suggest removal of impacted cuspids. Tiis advice is always tempered with a recognition of the risks that may be associated with the removal of the tooth/teeth. Impacted cuspids can be some of the most difficult teeth to remove and can give riise to issues such as oro-nasal or oro-antral fistula. Surgical exposure and application of orthodontic traction is not always an option and will depend on the location of the tooth in the alveolar bone. It is always best to discuss all risks, complications and benefits with an Oral and Maxillofacial Surgeon before making a final decision over management of an impacted tooth, cuspid or otherwise.
Pat Ohlenforst says:
Excellent description of the choices in your example cases and the problems of NOT identifying and correcting impactions. The correct final statement!Pat Ohlenforst
Irving, TX
Dr Sylvain Chamberland says:
Yes, there is a way to get your canine into dental arch alignment.
This case show an impacted canine (23) at baseline in March 2013. The primary canine (63) was retained and there was a periapical lesion (granuloma) depicted by the dashed line.
The canine was surgically exposed and a button was bonded on the crown like show in the surgical techinique above. A force was applied through a cantilever spring soldered on the Adams clasp of the removable appliance. The picture of march 2013 show the evolution at 1 year. I saw this patient yesterday and the button is exposed through the gingiva. In 2 weks or so, I will bond the brackets on every teeth and continue the treatment until the canine is aligned. I expect one more year of treatment to finish the case and debond.
.
karl jerome s. Zapanta says:
i have impacted canine behind my two incisor teeth and it is slanted by 45 degrees.. are there any way to positioned my canine tooth...Dr Sylvain Chamberland says:
I think we should differentiate Hormone Replacement Therapy (HRT) from the use of Oral Contraceptive Pill (OCP). You said that resorption started at age 19 and you are now 27. Chances are that you were taking OCP during that period which is different than HRT for a menopause women. Like I said before, i am not a gynecologist but HRT might be useful for a 50 years or so women to prevent osteoporosis if she have sign of such problem.The diagram on the left (from monography #46, CranioFacial growth Series, page 115) depict the patterns of estradiol and progesterone across a prototypical menstrual cycle. Circulating levels of estradiol in women on HRT correspond to those of the early follicular phase of the cycle(arrow). Naturally secreted 17β-estradiol has been shown to decrease inflammation and reduce bone loss in women. Ethinyl Estradiol (the hormone use in HRT) on the other hand, has beeen shown to increased inflammation and periodontal bone loss. This pattern of inflammatory bone loss could be responsible for agressive condylar resorption in some women.
But you are 27.
The mecanism of bone regulation by 17 β-estradiol
How does 17b-estradiol affect the OsteroProteGerin / Receptor Activator for Nuclear Factor k B Ligand (OPG/RANKL) balance?
17b-estradiol has been shown to be a potentiator of osteoprotegerin (OPG) release, thus protecting bone in the face of local and systemic inflammatory factors. Conversely, when 17β-estradiol is deficient, OPG is not promoted, allowing local and systemic inflammatory factors to inhibit new bone formation or promote resorption of bone mass. Liang et al showed OPG up-regulation
in human periodontal cells when exposed to 17β-estradiol.
In addition to the OPG/RANKL effect, women with consistently low circulating 17β-estradiol levels have increased inflammatory cytokines and resultant increases in arthritic symptoms and decreases in bone mineral density. (AJODO. 2009, Dec;136(6):772-9)
I recommended you some test to do (blood test, Tc99 bone scan) You should have those information in hand to validate or invalidate possible diagnostic and support further treatment.
I wish you will accept to send me your xray for further comments and recommendations. Your case is very interesting.
Best regards
Dr Sylvain Chamberland
Gunson MJ, Arnett GW, Formby B, Falzone C, Mathur R, and Alexander C. Oral contraceptive pill use and abnormal menstrual cycles in women with severe condylar resorption: a case for low serum 17beta-estradiol as a major factor in progressive condylar resorption. Am J Orthod Dentofacial Orthop. 2009, Dec;136(6):772-9.
Gunson MJ, Arnett GW, and Milam SB. Pathophysiology and Pharmacologic Control of Osseous Mandibular Condylar Resorption. J Oral Maxillofac Surg. 2011, Oct 17;70(8):1918-34.
emm says:
Thank you for your advice. You mention HRT makes condylar reorption worse. If lack of 17 beta estradiol causes bone resoprtion, then shouldn't taking extra 17 beta estradiol help with bone resorption as it is helping to increase levels of estrogen in the body? I was reading the journal article 'condylar resorption Matrix Metalloproteinases,and Tetracyclines' Michael J. Gunson, DDS, MD and it mentions there is promising research with HRT and the cessation of condylar resorption.It would be interestignt o get your thoughts on this and if in theory this would work?
If the resorption started when I was 19 (i am now 27) - went into remission and is now worsening does this mean the six year period has started over again before it will stop?
Many Thanks
Dr Sylvain Chamberland says:
Thank for for you questions.I wish I can help in some manner.
Estrogen (17β-estradiol) help to reduce bone loss in women. It reduces the cytokynes and inflammatory markers and matrix matalloproteinase transcription (MMPs). Therefore, low estrogen levels will inhibit the fibrocartilage synthesis, promote cytokine production (promote MMPs) and bone loss may occur at the condyle which lead to progressive mandibular retrusion. It is not unbalanced estrogen and progesterone that cause condylar resorption. Non susceptible patient to arthrosis can have low estrogen and not have condylar resorption.
Contraceptive pills (Ethynil estradiol) suppress the production of naturally occuring 17β-estradiol. Hence, it mimic low estrogen status. I am not an endocrinologist, nor an obtetrician. I can not tell if estradiol valerate is different than ethynil estradiol. But hormone replacement therapy (HRT) is more likely to make condylar resorption worse than better. Pain is associated with the level of estrogen and progesterone. In pregnancy, lower level of TMJ pain is associated with higher level of progesterone and estradiol.
Thus, the pregnancy and menstrual cycle studies suggest that in women who have TMD, pain is associated with low levels of estradiol. The initial hormone replacement study, however, found that the use of exogenous estradiol was associated with increased risk of experiencing TMJ pain. (monography #46, CFGS page 114).
You said you underwent a bimaxillary surgery (Le Fort 1 and BSSO) in 2010. SInce then you overjet that was 2 mm increase to 6 mm which is closed the the 8 mm overjet you had initially. You have an open bite that is widening. Those are typical signs of postoperative condylar resorption (POCR).
We can't not tell if it will stop, changes may occurs up to 6 years after the initial changes. It is often self limiting, but it may cause a significant disfunctionnal deformity (the open bite and the mandibular retrusion). The patient of the left photo will undergo bilateral condylar replacement (costochondral graft). Her resorption was not associated with any systemic inflammatory disease (like rheumatoid arthritis).A scintigraphy will help to asses the bone remodeling activity wheter it is resorbing or proliferating. You need 2 consecutives Tc99 bone scan at 6 months intervals to be sure there is no resorptive activity.
I recommend that you have blood exam, dosage of estrogen and 17β-estradiol at debut and midcycle, FSH, LH, Vit D, level of rheumatoid factor, antinuclear anbodies, anti CCP, inflammatory status.
You may need an occlusal splint to help reduce parafunction and get some rest of your masticatory muscle. You can take Calcium Carbonante 500mg/day and up to 1000iu of vit D. Your doctor could prescribe you NSAI.
I wish those information can help.
Best regards
Dr Sylvain Chamberland
Emm says:
Hi,I am really struggling after being given the diagnosis of idiopathic condylar resorption. I would really like to email you to ask some advice and explain my case to you to see if you can help me.
I underwent bimax (saggital split and le fot 1 ) surgery in 2010 and my bite and appearance has relapsed. I found your slides very interesting and i am very worried that my surgery was for nothing and that my jaw may totally receed. I have full case notes and x rays that I can show you if that helps. I just feel a bit let down by my UK surgeon as he just says i have to wait and see as my bite gets worse and worse. It would be great to hear from you as you seem to be an expert in this field.
Please can you explain if it is unbalanced estrogen and progesterone that causes condylar resorption or just low estrogen. What is the effect of PCOS on condylar resorption also?
I had one more question: I noticed you mentioned about low Estrogen causing condylar resorption and the pill containing ethinestridiol making it worse as it reduces the amount of 17 beta estrogen in the body.
I am taking a contraceptive pill called Qlaria which contains Estradiol Valerete and dienogest ( I think this is the same type of estrogen that is in HRT) - As this is mean't to mimic the natural estrogen in a womans body will this stop condylar resorption or make it worse in your opinion.
I was also wondering is progesterone made it worse and testosterone in females?
I am 27 years old so really want a stable outcome. I constantly find myself looking at my jaw and it has relapsed from an overjet of 2mm to 6mm 2 years post operatively. I had an 8mm overjet to start off with before surgery so i feel i look the same as when i started. I also have an open bite which seems to be widening.
Do you know anything i could do to halt this condylar resoption ?
I was also wondering at what age condylar resorption is likely to stop as you refer to it as self limiting - is this only when the whole condyle is absorbed?
Can anything else cause relapse other than condylar resorption i.e muscle memory etc?
Any advice would be really appreciated.
Many Thanks
Emm
Dr Sylvain Chamberland says:
Thank you Dre Chhay for your comments.It takes indeed a lot of time to set this blog and website and to continue to add pages. The english translation is lagging behing the french version, but I can assure you there is more to come.
I know Baylor College for its reputation, but also because a very good friend of mine was the chairman of the orthodontic departement, Dr Emile Rossouw, for about 10 years before being recruited by University of North Carolina. Dr Rossouw was an examiner at the RCDC when he was chairman at University of Toronto. I know also Dr Peter Bushang who do tremendous research in growth and development, TADs, tooth movement, etch. Before going to Baylor, he was a teacher at University of Montreal. Unfortunately for me, he was recruited at Baylor the year before I begun my speciality training.
Dr. Sue Chhay says:
Great information Dr. Chamberland!I'm sure all your time and effort in doing research regarding tongue piercing are much appreciated from ones who read this blog.
Its most certaintly very impressive to me since I belong to the Faculty Team at Baylor College of Dentistry.
We are a huge advocate for doing research and promoting healthy oral health for the public.
Thanks for posting the much needed, educational information.
Dre Chhay