I need your help on an interesting case.

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Permalink Reply by Ted Anibal on April 17, 2008 at 1:57pm

I have never seen a "relapse" like this one, so there has to be more to this case. I'm only speculating, but perhaps her ortho treatment did not involve brackets and arch wires, but rather active retainers of the kind I used to fabricate for minor tooth movements. Using that approach here would have been ill advised (but inexpensive), highly subject to patient noncompliance, and seems most unlikely that a dentist would attempt to treat this case with active retainers unless it was "the best he could do" given her or her family's financial situation.

Even if Invisalign could treat this case, compliance may still be an issue, so brackets and wires seem the only alternative for treatment, using fixed retainers at completion.

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Permalink Reply by Dr. Joe Blaes on April 17, 2008 at 2:13pm

If this case were treated orthodontically, you would first need to split the palatal suture with an expansion screw. If the expansion screw were mounted in a removable appliance and the patient had the key and instructions to move the screw so much every day, then she obviously was not doing that. If she had been my patient during the ortho treatment phase, I would have cemented the expansion screw and moved it myself. I do not think this is a relapse case. But it could have been a case of the best the dentist could do. Perhaps the dentist did not know what he did not know.

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Permalink Reply by Ted Anibal on April 17, 2008 at 2:52pm

Perhaps, but it seems even a weekend ortho seminar graduate might have figured that out. We always used fixed palatal expanders, which is another item I routinely fabricated in the ortho lab at the Naval Academy. The Midshipman could get into serious trouble for noncompliance, so we didn't give them the opportunity. I, too, found it hard to believe that Patti ever completed treatment (and thus no relapse), but it's equally incredible and unlikely that she could have removed any cemented-on appliances -- twice! Could it be that her dentist removed them early on for some reason -- nonpayment, perhaps? I rather doubt it, but there's something very fishy about this case, including facts she hasn't yet divulged. A talk with her former dentist could prove revealing.

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Permalink Reply by Dr. Joe Blaes on April 17, 2008 at 3:06pm

But all of that does not solve the problem since she has ruled out ortho as a solution. Knowing that, how do you treat the case as it is now and finish with a nice smile which is what she says she wants?

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Permalink Reply by Ted Anibal on April 17, 2008 at 5:05pm

After I give my last two cents on this, I'm going to be very quiet and pray that your colleagues will chime in with the answers you seek. The way I see it, there are some significant challenges to overcome before any treatment begins. First, Patti needs OHI, patient education, and obviously all necessary perio and restorative work for any chance of long-term oral health.
From the photos, it's clear that her oral hygiene is inadequate and there is at least one visible carious lesion on the cervical of #21. Without ortho, the extreme position of #9 could not even be crowned and look good, so it would have to be extracted and replaced with a bridge, implant, or removable "flipper." But even suggesting that is anathema to me; it's already starting to get expensive, and she'd still have an open bite. Perhaps some veneers could be used on the lower anteriors to straighten them out, but the maxillary anteriors would need crowns -- long ones if you wanted to close the bite. If not, at least her smile would be improved.
At that point, the cost would certainly be as much as full ortho treatment and the result would be far from esthetically or functionally ideal. I would try once again to change her mind about ortho. Failing that, I would do the crowns and veneers if she could afford them, but it would be an unsatisfying compromise. And now, I will defer to others.

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Permalink Reply by Dr. Joe Blaes on April 27, 2008 at 1:45pm

From Dr. Al Ousborne Joe, Do the case gratis or at cost to start giving her the smile back. Try Endo and root elongation on #8, remove #9, add appropriate bone graft with an implant. Then crown and or veneer as appropriate for a great smile. Ask her to be a missionary for the practice and use the slides of the work for promotion. You really need more info for an appropriate tx plan. Digital x-rays would really help.

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Permalink Reply by Ronald A. Pomykala on April 27, 2008 at 1:52pm

A tough decision!
Patti's oral hygiene seems OK to me. It looks like she has an over retained upper right cuspid and her center line deviated to the right. with a very narrow arch form adding complexity to a treatment plan.
Anyhow, I would tell Patti that there is a lot dentistry could do for her, depending on her ability to sacrifice for those goals.
After verification of her dental history, her treatment would be contingent on, at a minimum, the following considerations,,,,
1, Money.
How much could she pay to achieve towards her goal over time, five years for example. Costs could escalate
to $35,000 or more
Would he be willing to seek treatment at a Dental School trading time for fees?
2. Her tolerance for extended treatment (deferred satisfaction)., up to 18 months.
3. Her tolerance to discomfort, like post surgical recovery etc.
Given the above considerations, treatment could very from orthognathic surgery, consisting of repositioning of the right and left maxilla and mandible repositioning for the expansion. plus crown and bridge restoration; to removal of teeth and replacement with a removable partial denture.
The critical end point would match her desires with her willingness and ability to make that trade.
This is all we can do as we go through life, IE face reality, look at all our options, and make a decision.

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Permalink Reply by Charlie Vogel on April 28, 2008 at 5:38am

What is the habit that caused this ? tounge or finger or what? What teeth are in occlusion? The photos make this look like a open bite?

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Permalink Reply by Christina Licona on May 6, 2008 at 4:02pm

This is the thought that comes to my mind. Does she have some sort of habit that would prohibit the osteoblast and osteoclasts to do their job? (that is if it's truly a relapse) If she does then almost anything you do would end up in frustration for both you and your patient.. It's difficult to tell from the photo, but I don't see a lot of excessive wear on her occlusal surfaces althought it seems to me that everything is a bit lingually inclined. Is it feasable to use a memory wire to tilt the incisal/occlusal surfaces buccally which would allow more space for #9 to come down in it's position?
Considering she's not up for ortho, you could attempt veneers or crowns to even the apprearance, however, it would seem that regardless, it would have to be gratis or she'd have to get creative for the finances. I can't imagine it to be an easy fix regardless.

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Permalink Reply by Susan Fredericks, RDH on April 28, 2008 at 7:47am

The concern I have is the edema around #8 and 9. Is there any pocketing? The patient has to realize that her gums are the foundation of her teeth. Hopefully, with education, she will become more compliant. Does she qualify for Care Credit or the like so that proper care can begin?

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