orthodontics overkill treatment?

[rewtedesco]

Not sure if anyone will read this on a science forum, but there is simply no other forum where one could ask a question on orthodontics without being presented with the standard answer: as many braces as you can possibly fit in your mouth and pay for.

 

My 15 year old son has a tooth with delayed eruption. This is the second premolar right (number 12). The root is completely developed and the tooth is just below the gum line but is hindered by the two neighboring teeth which are beginning to migrate to fill that gap. We went to an orthodontist for consultation, after this was pointed out by a dentist. A dental model was made and a bunch of complete x-rays to see the exact conditions. I expected that next would be a simple design of a small device similar to a retainer that would be inserted to slowly bring the two neighbour teeth sufficiently apart so there was enough space for the new tooth. I asked the orthodontist how likely it would be that that tooth would actually succeed to erupt assuming proper treatment. The answer was quite vague. I didn't expect a sure answer, but expected a somewhat more reassuring answer and got the impression that there wasn't much of a chance at all. The orthodontist proposed a complete brace system that would cover all teeth, both lower and upper teeth, starting with the upper teeth. The argument for that was that the upper teeth needed to provide a little more space for the lower teeth to go further apart, and so first the upper teeth would have to be equipped with braces to create later even enough space for braces on the lower teeth. If all that should fail, the specialist explained that there there was another additional treatment possible, namely wrapping a sling around the none erupted tooth to slowly pull it up.

I was not exactly convinced and explained to the orthodontist that I actually had expected a more local treatment rather then an entire braces system that involves the entire mouth, which would certainly not to my son's liking. Another circumstance is the relatively high total cost of the proposed treatment, which would be about $5-6000 just for the braces, plus a hard to predict additional cost for an alternative treatment, namely a small orthodontic surgery, and additional lab costs, should the braces alone not help. This is not small cash for me but I would be happy to pay this if there was just a little more likelihood of success, and the confidence that the method proposed by the orthodontist is indeed the only possible treatment.

 

Other than for this one delayed tooth, my son has no other health problems and no other problems with his teeth, no other misalignments, and he also takes well care of his teeth, no cavities. No one would expect him to have to wear braces because everything else in his mouth is fine, straight teeth without deformation and without overcrowding except for this one place. Another consideration is my speculation on possible genetic factors here: I had a very similar condition. In my mid-thirties I lost the lower right canine (number 10), and it turned out that it was still my last baby tooth. The second tooth had never erupted, and much later I found out that it is embedded horizontally in my mandible below the incisors. This is mainly why I'm suspicious if my son's tooth will ever erupt, with or without braces.

 

Nevertheless, I think some kind of treatment should be tried. So I proposed that there should be a simple device with a small spring load inserted between the two neighbour teeth which exerts a small force on them, pushing them apart. It would have to be carefully monitored to see if the orientation of the device has to be adjusted to avoid "derailing" of these neighbours. Even though the orthodontist began to entertain this idea and considered asking a lab if they could provide such a device, his final decision was to not take on something like that. He stated frankly and with honesty that it would be unusual given this common practice and he would not be sure if he could take the risk of providing a care that may result in other problems he could not foresee, and possibly be blamed for it. I understand this concern completely, but still didn't give up the idea.

 

I believe (and hope) the orthodontist didn't think that I'm a complete cook. However, in the friendly discussion we disagreed over something that he considered as completely in the assertive, almost fundamental, for the entire business of making braces for teens and adults. The central argument was that without the complete support of an overall braces system, there was no control over what would happen to the teeth. And I said there is no need for complete control. I argued that complete control over how all teeth adjust would only be necessary if the system was pretty much out of balance already, which is very unlikely in the case of my son's teeth. I don't understand how a natural proper arrangement of the growing teeth would be possible if there weren't plenty of self regulating biomechanical and physiological processes going on already. The orthodontist's central argument appears to me too close to a an idea that almost everyone needs braces, which of course he wouldn't say and didn't say.

 

Hence my question. What is the state of the art really? Does a method like I tried to outline actually exist? It could be even a simple retainer device that is only used overnight. In this case my son would simply insert with a gentle pressure a special device that is held in place by the two neighbouring teeth and exerts a small pressure of, say, 0.3 N (one ounce) on the two teeth, pressing them apart. This device would have to be, of course, tailored to the specific case. If I look at the dental model which I kept for the time being I believe to have a very clear intuition of how this device would be oriented and how it exerts forces (including a small extension by a very small brace that may be necessary to also keep the canine tooth in check to not be pressed out as an unwanted side effect).

 

Should I be so utterly wrong in my intuition?

[Cap'n Refsmmat]

My thoughts (as a non-orthodontist) are that if you simply pressed the two teeth apart, you'd have no guarantee that they'd remain in relative alignment. They may end up rotating out of the way rather than simply moving sideways, or they might push the teeth behind them in a way that causes them to rotate and become crooked.

 

Now, I think the idea of full braces may be overkill, though as a non-orthodontist I may be totally wrong. Before I got full braces, I had four brackets on my front upper teeth and a bracket on each rear top molar, which were used to correct an overbite. They didn't have to place brackets on all the other teeth, and they left the bottom teeth alone until that was done. So certainly corrections can be done without an entire set of braces.

 

I think your best option would be to get copies of the X-rays and head to a different orthodontist for a second opinion. Orthodontists often have different approaches and techniques for dealing with problems, and perhaps a second opinion will shed some light on the issue.

[rewtedesco]

Oh I agree that I will need a second opinion and find another orthodontist. I am concerned that my ideas may be total baloney, and I absolutely don't want to mess up my little boy's teeth (wait, didn't he already measure taller than me?). There is the little problem though that orthodontists usually also run a business, and are usually highly specialized to be efficient. The one I visited with my kid is definitely specialized in terms of what types of braces they use. So it's a little bit like asking a Honda only dealer to sell me a Ford or Toyota after they have tried so hard to convince me that Honda is the only real car and only consider their trade-ins for other models. So I want to figure out what possibilities actually exist and then find an orthodontist who can do it. I'm hoping a little bit that a more impartial specialist comes across this thread. For example, someone who teaches this stuff at a dental school.

 

Regarding the 'dreamed up' teeth-pressing-apart device: You're right that without any additional measures one can't simply press the teeth apart without taking their rotational degrees of freedom into account. The device would have to be stuck on and between both teeth, and in addition the rotation needs to constrained by further stabilising it using the next teeth. So it would be a device that is attached to four teeth with the gap in the centre. The two molar teeth behind the gap and the first premolar and the canine in front of the gap would all be in connection with the device (or may be I should call it a partial brace). So it wouldn't be quite as "local" as it may appear from my description in the original post above. I could find that typically one can move a tooth at about a rate of 1mm per month. The amount of additional space needed is about 6 mm. The gap at the closest distance is about 3.5 mm wide, and the new tooth will need about 8-10 mm, judging from the completely emerged symmetric tooth. I know that this business is technically complicated but I'm not convinced it's rocket science. Any ways, I shall check out some books on orthodontics. I may actually really learn something.

[mahtab partovi]

Hello, My daughter had narrow upper jaw, class III malocclusion, crowding, and posterior open bite. After two years of braces all the problems seem fixed. My daughter is happy with the way she bites. The only problem left before removing the braces is a midline discrepancy, about 2 mm. The upper jaw is aligned with the middle of the nose but the lower jaw is not. The Orthodontist In Los Angels who did her surgery asked my daughter to wear the elastics in a certain position and warned her to stop if the jaws shift the other way. After a few nights she couldn't bite properly so she stopped using the elastics. She went back to the office and notified the orthodontist about the problem. After 30 sec he said that her bite and smile are beautiful and she should not wear any elastics until next week when he plans to remove the braces. He did not address the midline discrepancy. Is this reasonable after two years of treatment?

Thank you very much,

Edited July 29, 2015 by swansont
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