Cosmetic Dentistry: How Would You Treat This Case?

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Fullosseousflap

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Look at the photo located here.

And Let me know:

How would you treat this patient?
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First off, is #6 actually #6 or is it a retained #C?? That would really effect my decision greatly if it was a retained primary tooth.

Also need to be careful with the rotated #5 and her rather wide smile line. If she's really as esthetically concerned.

Lastly depending on her occlusion and the above issues, I've got a raher dramatic/yet "conservative" treatment plan in mind that I'll chime in on later. Since I'm a "pro" I'll let some of DIT "dentists in training" respond first. :D
 
DrJeff said:
First off, is #6 actually #6 or is it a retained #C?? That would really effect my decision greatly if it was a retained primary tooth.

Also need to be careful with the rotated #5 and her rather wide smile line. If she's really as esthetically concerned.

Lastly depending on her occlusion and the above issues, I've got a raher dramatic/yet "conservative" treatment plan in mind that I'll chime in on later. Since I'm a "pro" I'll let some of DIT "dentists in training" respond first. :D
Click to expand...

Fair Enough!
 
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P.S. I'l try and void out my wife's opinions about how to tackle this case(she's an orthodontist) and was jumping up and down when teh picture came up on the screen :D
 
I would say to have her get those hairs on her nose removed first because i notice those way more than the slightly crooked tooth.
 
I would treat it with a #150 forceps....but I'm biased.
 
Fullosseousflap said:
Look at the photo located here.

And Let me know:

How would you treat this patient?
Click to expand...


primarily i would go with orthodontics to gather the teeth, shallow the anterior guidance and extrude 6 to provide canine guidance then ct graft on 6. and bleach the teeth. But the pt rejects ortho you say.

at first glance even though the teeth are not in occlusion a few things strike me.
1.there looks like there will be a steep anterior guidance due to the increased overbite.
2. does this overjet allow immediate disclusion in protrusion to provide a mutually protected occlusion
3. how will i attain canine guidance on 6
4. this is a class 2 patient and is therfore at risk of a dual plane of occlusion on the lower. i will think of including a horizontal guide table on the lingual of the maxillary anetriors and provide light contact in CR gto prevent this.
5. rotated #5 mesial furcation opening up, especially if this pt has trauma from occlusion being in a group function occlusla scheme.

IT WOULD PAIN ME TO GO THE NON ORTHO ROUTE and i would probably refer her instead of doing something i feel is not in the pts interests - but hers is the option i would give them.
.....i would not have veneers. this is due to the occlusion. pascal magne showed in photo elastic tests that if you prep on to the lingual you increase fracture risk. to alter the guidance prepping of the lingual is required.


.....tx - i would go for 6 crowns with shallow anterior guidance but enough to allow immediate disclusion and a horizontal guide table giving light contact in CR. lastly a night guard.
 
If she rejects the orthodontic treatment, I would crown #c,#7, #10 and veneers on #8 and #9. Reappoint her few years later, remove #6, #5 and root of #c and place some implants in.
 
Great treatment options!

More?

Different approaches?
 
Impact the pre-maxilla, rip out C and put in an implant. Next question.
 
Patient will not do ortho!

How Would You Treat this Case?
 
crazy_sherm said:
I would say to have her get those hairs on her nose removed first because i notice those way more than the slightly crooked tooth.
Click to expand...

If she wants to improve her self image, that is THE BEST advice, you go sherm! :D
 
The patient declines orthodontic treatment.

Would you consider 6 Porcelain Veneers for this case?

How about 8 or 10?
 
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This is what I would do, maybe!
1. Evaluate occlusion, diagnostic casts, tx plan....
2. Extract #C and impacted K9
Then
1. Immediate loading or regular implant K9
2. In office full mouth teeth whitening
3. 5 veneers, #7 through #11. I wouldn't touch #5 and #12 because they seem to be rotated, especially #5. Full coverage crowns for #5, #12 if the patient wants to change their appearances.
4. A nose wax

since the patient doesn't seem to have CL I, also with rotated teeth (tooth) my main concern is her occlusion, esthetic second. I would warn her that she might need to have her occlusion equilibrated by an experienced prosthodontic after restorations are finished. If she goes for the ortho route then she should definely needs to see prostho afterwards.
 
The patient changes her mind and says no to ortho, extraction and an implant.

How do you treat the case?

Here is the photo again here.
 
You're a nut case! Your patient is a nut case! You both should start treating each other! :scared:
 
Well, I'll start my answer in various parts.

Part 1(given her lack of desire for a more "ideal" treatment (i.e. ortho/implant) After LISTENING to her desired expectations, I'd pick up a lab slip and along with photos I'd get a diagnostic wax up made of what I can REALISTICALLY accomplish. Then in the week or so it takes my lab tech to get the wax up back to me, I'd make sure that as she was heading out to my front desk to schedule a follow up consult to review the wax up and finalize her treatment plan that I would not only give her one of my patient brochures (the ADA puts them out) about veneers, but also about bleaching, and then subtly add in the brochures about orthodontics and implants for her to hopefully look over before she comes back in a week or so.

Part 2 to follow after a few more replies :D
 
Okay...I'll bite. With the stipulations you/your patient have set, besides veneers, maybe you could do some esthetic recontouring. Using soft-flex discs etc, you could recontour those teeth to look more esthetic.

1. The facial line angle of #7 could be moved to make the tooth appear to not be jetting out as much, in addition to evening out that incisal of #7 to match the incisal of #10.

2. She's female, so her teeth should be more ovoid...her incisors are rather squared. It would help to smooth out the distoincisal tips of them to make them more rounded and feminine.

3. Why not do some composite additions to #7 and the primary tooth next to it. Adding to #7 to can lengthen it a little and get rid of the point, to match #10. Resin could be added to that primary to build it up to esthetically resemble an adult canine. All of this should be done post bleaching for best esthetic result.

A lot depends on her anterior guideance. IF she does not rely heavily on 7-10 for the ant guideance, these composite esthetic additions are a good tx option IMO. However, I would definitely not do them if she will be in quideance on those additions. They will not last for long if she is.

A case such as hers can definitely get a pleasant result with recontouring as I suggested. It's much less invasive as well. If I were you, I would tell her this: Veneers are a good option, but they are invasive. How about we try to reshape your teeth, add some composite to increase symmetry, and see what you think. If you are not happy with the results, then we can head in the direction of veneers. Of course, a diagnostic waxup of what I think I can do would be completed to give her an idea of what we are talking about.

I have a similar case myself, I can post it soon.
 
Keep them coming!

And yes I look forward to more cases beig posted.

Any dental students presenting this case in school?
 
i want to know WHY she rejected the ortho option. too expensive? doesn't want wires to be showing? etc. maybe if we can address her concerns on this topic, she may give in to ortho in the end...(how old is she btw?...)
 
cusp of carabelli said:
i want to know WHY she rejected the ortho option. too expensive? doesn't want wires to be showing etc. maybe if we can address her concerns on this topic, she may give in to ortho in the end...
Click to expand...

Does not want to wait 2-3 years.

Wants a quicker smile makeover.
 
cusp of carabelli said:
i want to know WHY she rejected the ortho option. too expensive? doesn't want wires to be showing? etc. maybe if we can address her concerns on this topic, she may give in to ortho in the end...(how old is she btw?...)
Click to expand...


ortho will be a lot cheaper than the prostho.
 
Fullosseousflap said:
Keep them coming!

And yes I look forward to more cases beig posted.

Any dental students presenting this case in school?
Click to expand...

Any PBL students out there ready to present or discuss this case? Regular dental students?

The patient is in her mid-30's.
 
Well, sir, omfsres and I have a joint solution.
1) Bleach teeth
2) Composite veneer #C to bulk the tooth up and match contralateral canine
3) Porcelain veneer #5,7-12 to provide color match and correct alignment--don't prep the lingual contrary to an earlier post
4) When C loosens/falls out--implant with or without ext #6 depending on x-ray

Need to mount the casts and study the occlusion and do a diagnostic wax-up first, though. We don't feel the pt needs esthetic crown lengthening secondary to the fact that she doesn't show her ant gingiva in this picture, which we assume to be a smile attempt. No crowns. Lee press-on teeth are conservative and simple.

For the love of god, don't muck with her occlusion! Fix the smile if she wants it but leave the occlusion alone (assuming she is asymptomatic).
 
tx oms said:
Well, sir, omfsres and I have a joint solution.
1) Bleach teeth
2) Composite veneer #C to bulk the tooth up and match contralateral canine
3) Porcelain veneer #5,7-12 to provide color match and correct alignment--don't prep the lingual contrary to an earlier post
4) When C loosens/falls out--implant with or without ext #6 depending on x-ray

Need to mount the casts and study the occlusion and do a diagnostic wax-up first, though. We don't feel the pt needs esthetic crown lengthening secondary to the fact that she doesn't show her ant gingiva in this picture, which we assume to be a smile attempt. No crowns. Lee press-on teeth are conservative and simple.

For the love of god, don't muck with her occlusion! Fix the smile if she wants it but leave the occlusion alone (assuming she is asymptomatic).
Click to expand...

Why not do a porcelain veneer on C?

Why only 6 veneers? Why not 10? For the entire smile line?
 
Depends on what the patient wants. Because she rejected ortho I am assuming she is not looking for a Hollywood smile, but is mainly concerned about a quick fix for the snaggle-tooth #C. If this is the case my treatment plan would be pretty conservative.

I would bleach and go for a crown or veneer on C... leaning towards the crown just because I don't like the prospects for a porcelain veneer being responsible for so much guidance. Probably a crown on #5. I would explain to the patient that a "run of the mill" crown is probably not going to match; so to avoid touching the other anteriors we are going to need to send this to a top notch lab and it is going to cost more. (There are lab techs out there who can match that dead on -- you just have to give them the needed information and be willing to pay for it.) Even with the fee for the premium crown, this is still a cheaper and more conservative option than your classic 10 veneer "makeover". Also, as someone else suggested, I would recontour the incisal of #7; it's too pointy.

And I would definitely push for crown lengthening. It isn't totally necessary in this case, but I do think it would make a significant difference in her overall smile to have more clinical crown exposed - especially on #8 and #9. I'm also guessing that this is her "photo" smile which tends to be a lot more closed than a truly spontaneous grin.


But if she's looking for some sort of extreme smile makeover she gets bleaching, a crown on #C, a crown on #5, and 6 - 8 porcelain veneers. Just out of curiosity, have any of you ever placed a veneer on a molar? This patient's first molars are extremely visible in her smile line (as much as her second premolars), though I'm sure a good bleaching will be enough for an acceptable match. Oh yeah, if she's going for the whole shebang with 10 crowns and veneers, she is definitely getting crown lengthening too.
 
Let's see if she's in her 30's and wants this done quick, would see be expecting to re-enter the dating scene soon (likely with less jewelry on her left ring finger :eek: ;) ) or would she be coming up on big reunion soon?? Or maybe she's just overdosed on Extreme Makeover episodes recently??

I've learned over the years, especially with female patients that folks who are looking for a rather quick/dramatic cosmetic change to their teeth typically have some type of major life change and/or social change occuring, and the psychological issues need to be taken into account or else you might end up with a REALLY unhappy patient down the road demanding that you fix her smile again because it wasn't done "how you said it would" :eek: :mad:

I'd probably treat this case, given her parameters/ demands as follows:

1) after she approves of the diagnostic wax up (and it might take more than 1 wax up to accomplish this), I'd bleach her teeth (whatever system you prefer)

2) 10 lumineer veneers (these are made by Den Mat and are approximately 0.2mm thick and you quite often won't even need to prep the teeth) from #4 through #13. The only tooth that I'd likely do some prep work on is #5 to allow for a more "classical" appearance of the buccal surfaces of her maxiallary right posterior sextant

I've done about 20 cases now with this type of veneer and have been very satisfied with the esthetics (more importantly so have my patients), and I'll admit that I was quite skeptical of a "no prep" veneer before I tried them (1st case was one of my assistants, and as she put it, "Dr J, if they end up looking like Cr$%, I'll drive you crazy by smiling at you all day long and you'll redo them with traditional veneers in about 2 seconds!" - they've been in place for about 10 months now and she loves them!)

The other great thing about this option is that since you likely wouldn't have to prep 9 of the 10 teeth, this long term is a very, very conservative option with respect to tooth structure :thumbup:

The other thing to consider, is if you hit a "homerun" with this case, you can almost bet that a few of her friends will be referred to you asking that you make their smiles look as great as hers!"
 
Dr. Jeff, I can see a veneer on #5, but would you really trust a couple tenths of a millimeter of porcelain for anterior guidance on #c? (I'm assuming this tooth is going to be involved in canine guidance once appropriate form is established.) I'm not disagreeing with your treatment plan; I'm still in school and just trying to see why you're doing what you're doing. :)
 
DrJeff said:
Let's see if she's in her 30's and wants this done quick, would see be expecting to re-enter the dating scene soon (likely with less jewelry on her left ring finger :eek: ;) ) or would she be coming up on big reunion soon?? Or maybe she's just overdosed on Extreme Makeover episodes recently??

I've learned over the years, especially with female patients that folks who are looking for a rather quick/dramatic cosmetic change to their teeth typically have some type of major life change and/or social change occuring, and the psychological issues need to be taken into account or else you might end up with a REALLY unhappy patient down the road demanding that you fix her smile again because it wasn't done "how you said it would" :eek: :mad:

I'd probably treat this case, given her parameters/ demands as follows:

1) after she approves of the diagnostic wax up (and it might take more than 1 wax up to accomplish this), I'd bleach her teeth (whatever system you prefer)

2) 10 lumineer veneers (these are made by Den Mat and are approximately 0.2mm thick and you quite often won't even need to prep the teeth) from #4 through #13. The only tooth that I'd likely do some prep work on is #5 to allow for a more "classical" appearance of the buccal surfaces of her maxiallary right posterior sextant

I've done about 20 cases now with this type of veneer and have been very satisfied with the esthetics (more importantly so have my patients), and I'll admit that I was quite skeptical of a "no prep" veneer before I tried them (1st case was one of my assistants, and as she put it, "Dr J, if they end up looking like Cr$%, I'll drive you crazy by smiling at you all day long and you'll redo them with traditional veneers in about 2 seconds!" - they've been in place for about 10 months now and she loves them!)

The other great thing about this option is that since you likely wouldn't have to prep 9 of the 10 teeth, this long term is a very, very conservative option with respect to tooth structure :thumbup:

The other thing to consider, is if you hit a "homerun" with this case, you can almost bet that a few of her friends will be referred to you asking that you make their smiles look as great as hers!"
Click to expand...

Would you not be concerned about her occlusion and hence the ability to retain no prep veneers? Also, would they not look bulky on her laterals which already protrude?

Let's look at her photo again: Click here.

I'll be away for some of the day today - going to look at a practice in San Diego and play some cards with some dental school buddies.

But, hope you guys have some other great suggestions by the time I return.

Later,

Flap
 
Fullosseousflap said:
Would you not be concerned about her occlusion and hence the ability to retain no prep veneers? Also, would they not look bulky on her laterals which already protrude?

Let's look at her photo again: Click here.

I'll be away for some of the day today - going to look at a practice in San Diego and play some cards with some dental school buddies.

But, hope you guys have some other great suggestions by the time I return.

Later,

Flap
Click to expand...

sorry i am late but here is what i'd do. since she wants instant results, i'd extract all of her teeth, and as my lab tech to make her dentures with the brightest teeth. it will take about 2 weeks to complete and she will have the whitest and straightest teeth. on top of all of that, it will be the esiest work for you as well. :laugh: :laugh:

but before you take my suggestion, would it be easier for you to just have one of us do the treatment? :laugh: :laugh: :laugh: :laugh:

i'd also like to know if you have any ideas on how to approach this.

any other patients you need help with?
 
Flap, you seem to have the "right" answer, so what is it? BTW, #C won't last her lifetime; therefore, no permanent/porcelain restorations at this time.
 
Fullosseousflap said:
Would you not be concerned about her occlusion and hence the ability to retain no prep veneers? Also, would they not look bulky on her laterals which already protrude?

Let's look at her photo again: Click here.

I'll be away for some of the day today - going to look at a practice in San Diego and play some cards with some dental school buddies.

But, hope you guys have some other great suggestions by the time I return.

Later,

Flap
Click to expand...

I used to be very concerned about the retention factor with the lumineers, however the way that Den Mat fabricates these, you're not extending the restoration onto the lingual surface, and hence not "playing" with her occlusion. As for the laterals, this is where the wax up comes into play, I *moght* have to prep the buccals of the laterals, but much of that would be upto the patient's perception.

If this was an "ideal" treatment plan, I'd likely not go this route, but based on your parameters of quick, esthetic and conservative, this is the hand that I'd play
 
tx oms said:
Flap, you seem to have the "right" answer, so what is it? BTW, #C won't last her lifetime; therefore, no permanent/porcelain restorations at this time.
Click to expand...

If the patient declines orthodontics and decides to leave #6 impacted and C in place..

How many of you out there will prep the other teeth for either crowns or veneers? :rolleyes:

How many would just bleach and cosmetically reshape? :idea:

How many would just bleach and decline treating the case? :eek:

BTW just back from San Diego --- looking at another million dollar practice for sale!
 
Dr. Jeff,

Out of curiousity how would your wife treat her? In particular, would she extract #C and go after #6, or (given the pt's age) refer her back to the gp to crown or veneer #C after ortho?
 
DDSSlave said:
Dr. Jeff,

Out of curiousity how would your wife treat her? In particular, would she extract #C and go after #6, or (given the pt's age) refer her back to the gp to crown or veneer #C after ortho?
Click to expand...
Wouldnt you need to do ortho in order to retrieve the canine? How can she go with just c for the rest of her life? Couldnt #6 cause a cyst if left for a long time?
 
Good question. Certainly there are times when it is best to leave impacted teeth. You have to balance the risk of potential pathology with how easy it is to retrieve such a tooth. Certainly an impacted 3rd in the coronoid process of a 50yo with no current pathology is probably best left alone. I would guess a young teenager with an impacted canine would have the surgery. However, this woman is in her 30's, prob with denser bone. How easy is it going to be to retrieve the tooth orthodontically? Anyway, I'm far from being an orthodontist or oral surgeon, so I was curious.
 
DDSSlave said:
Good question. Certainly there are times when it is best to leave impacted teeth. You have to balance the risk of potential pathology with how easy it is to retrieve such a tooth. Certainly an impacted 3rd in the coronoid process of a 50yo with no current pathology is probably best left alone. I would guess a young teenager with an impacted canine would have the surgery. However, this woman is in her 30's, prob with denser bone. How easy is it going to be to retrieve the tooth orthodontically? Anyway, I'm far from being an orthodontist or oral surgeon, so I was curious.
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Simple, wait till she's in her 50's. Bone density won't be a problem anymore. ;)
 
It would nice to hear from an orthodontist on how they would treat/approach this case.

The photo again is here.
 
Fullosseousflap said:
It would nice to hear from an orthodontist on how they would treat/approach this case.

The photo again is here.
Click to expand...

Any ortho residents out there with an opinion on the case?
 
You guys are super dentists if you can tx plan from one photo. Since I'm not as good as you, I would need at least another 11 photos, xrays and casts. I would also like to know the patient's motives. I don't know if I can draw up an ideal tx plan from this one photo, but I think I can see some of the mistakes of others' tx plans:

Just bleaching the teeth will do nothing about the hypocalcified areas. Will this bug the patient?

If you are doing vital bleaching and then prepping the teeth for veneers, you have just wasted the pt's money. Her teeth are not very discolored (without color tabs handy, I'd guess A2) so prepping the teeth and picking an appropriate opaque will sufficiently remove the discoloration.

She'd probably knock a composite veneer off of #'s c and 7 (Since I don't have all the information I'll go with how you've numbered the teeth, but I'm not so sure).

#s 5 and c are so malpositioned, veneers might be contraindicated. How big is c's pulp chamber? A crown may also be contraindicated for it.

If #c is ankylosed, yes it can last a lifetime.

How can 12 year old kid say that she definitely needs crown lengthening? How about some bone sounding and xrays first? Besides, she's not showing gums in the anterior region and because the teeth are not severly discolored nor decayed we can keep the prep margins supragingival.

From this view it's hard to tell, but if the maxillary incisors are labioversed I don't think you will be using lumineers.

It's a shame to cut on healthy enamel, but if we're codiagnosing this case I guess I'd have to. This said, I'll take a stab at tx planning this case on such a dearth of information. After presenting an ortho option and the pt rejects it and she is of sound mind, here would be my conservative alternative:

Vital bleaching
Crown #5
Extract #c, GTR, place implant and restore with crown.
CT grafts of #5 and 12
Recontour anteriors
Class 5 composites for hypocalcifications

By the way a good quick reference for tx planning veneers are the flow charts on p200 and 202 of "Tylman's theory and practice of fixed prosthodontics".
 
Fullosseousflap said:
It would nice to hear from an orthodontist on how they would treat/approach this case.

The photo again is here.
Click to expand...

I'll try again.

I would like to hear from some Orthodontic and OMS Residents or Professors on a treatment rationale for the impacted cuspid and of course the evidence.

Thanks!
 
Fullosseousflap said:
I'll try again.

I would like to hear from some Orthodontic and OMS Residents or Professors on a treatment rationale for the impacted cuspid and of course the evidence.

Thanks!
Click to expand...

Flap, you lost us! First you don't want an ortho solution, now you're looking for one. If she doesn't want ortho and the impacted tooth hasn't caused her any problems, just leave it.
 
From an orthodontic perspective it is MUCH easier to predictably retrieve impacted canines from children/adolescents than it is in adults (anectodally and experimentally). Becker and Chaushu published an article in AJODO, November 2003 titled "Success rate and duration of orthodontic treatment for adult patients with palatally impacted maxillary canines" that discussed this issue.

The study was a retrospective study examining records of an "experimental" group (adults age 20 and over) matched to an adolescent control of unilateral, and bilateral impacted canines. In the control group the mean age was 13.7 years and retrieval sucess was 100%, while in the experimental group the mean age was 29.8 years and a sucess rate of 69.5%. Additionally, the number of appointments dedicated to "canine tx" was 15.3 in the adult group, and 6.8 in the control group (which would mean a longer overall treatment duration in the adult group). It was interesting to note that when the experimental group was subgrouped into adults over 30 the sucess rate was 41%, while the 20-29 year subgroup had 100% success.

The results of the study are subject to scrutiny due to the relatively small sample size (n=23), but I refer to the results often when discussing treatment options with adult patients. The biggest determining factors for me when deciding whether or not to go after an impacted canine in an adult is the radiographic proximity of the canine to the adjacent teeth (most often lateral incisor) as well as the age of the patient.

Hope this helps....as far as an orthodontic diagnosis and treatment plan I would need to see a complete set of records before I said anything except "braces" :) If it was decided to have an implant at that site I would just stress the importance of developing group function on that side to mitigate lateral forces directed on the implant.

Regards,

Ben White, DDS, MSD
Orthodontist
 
DrJeff said:
P.S. I'l try and void out my wife's opinions about how to tackle this case(she's an orthodontist) and was jumping up and down when teh picture came up on the screen :D
Click to expand...



wow she sounds like a real keeper then.... :laugh: :laugh: :laugh:


I would prefer to have a stupid stripper wife myself!

I aint goin to dental school to be married to another boring dentist!

Give me a porno wife!
 
drben said:
From an orthodontic perspective it is MUCH easier to predictably retrieve impacted canines from children/adolescents than it is in adults (anectodally and experimentally). Becker and Chaushu published an article in AJODO, November 2003 titled "Success rate and duration of orthodontic treatment for adult patients with palatally impacted maxillary canines" that discussed this issue.

The study was a retrospective study examining records of an "experimental" group (adults age 20 and over) matched to an adolescent control of unilateral, and bilateral impacted canines. In the control group the mean age was 13.7 years and retrieval sucess was 100%, while in the experimental group the mean age was 29.8 years and a sucess rate of 69.5%. Additionally, the number of appointments dedicated to "canine tx" was 15.3 in the adult group, and 6.8 in the control group (which would mean a longer overall treatment duration in the adult group). It was interesting to note that when the experimental group was subgrouped into adults over 30 the sucess rate was 41%, while the 20-29 year subgroup had 100% success.

The results of the study are subject to scrutiny due to the relatively small sample size (n=23), but I refer to the results often when discussing treatment options with adult patients. The biggest determining factors for me when deciding whether or not to go after an impacted canine in an adult is the radiographic proximity of the canine to the adjacent teeth (most often lateral incisor) as well as the age of the patient.

Hope this helps....as far as an orthodontic diagnosis and treatment plan I would need to see a complete set of records before I said anything except "braces" :) If it was decided to have an implant at that site I would just stress the importance of developing group function on that side to mitigate lateral forces directed on the implant.

Regards,

Ben White, DDS, MSD
Orthodontist
Click to expand...



Dr White, amazingly you typed all that and basically said so little in so many words. I am very disappointed... :sleep:
 
Hello all,

This is very interesting; I've look over the case study and everyone's responses and I'm learning quite a bit! :D

I was wondering if it would be at all possible to post other case studies? I think this is an awesome learning tool for those interested in Dentistry and those trying to get into Dental School, like me ;). Thanks!
 
drben said:
From an orthodontic perspective it is MUCH easier to predictably retrieve impacted canines from children/adolescents than it is in adults (anectodally and experimentally). Becker and Chaushu published an article in AJODO, November 2003 titled "Success rate and duration of orthodontic treatment for adult patients with palatally impacted maxillary canines" that discussed this issue.

The study was a retrospective study examining records of an "experimental" group (adults age 20 and over) matched to an adolescent control of unilateral, and bilateral impacted canines. In the control group the mean age was 13.7 years and retrieval sucess was 100%, while in the experimental group the mean age was 29.8 years and a sucess rate of 69.5%. Additionally, the number of appointments dedicated to "canine tx" was 15.3 in the adult group, and 6.8 in the control group (which would mean a longer overall treatment duration in the adult group). It was interesting to note that when the experimental group was subgrouped into adults over 30 the sucess rate was 41%, while the 20-29 year subgroup had 100% success.

The results of the study are subject to scrutiny due to the relatively small sample size (n=23), but I refer to the results often when discussing treatment options with adult patients. The biggest determining factors for me when deciding whether or not to go after an impacted canine in an adult is the radiographic proximity of the canine to the adjacent teeth (most often lateral incisor) as well as the age of the patient.

Hope this helps....as far as an orthodontic diagnosis and treatment plan I would need to see a complete set of records before I said anything except "braces" :) If it was decided to have an implant at that site I would just stress the importance of developing group function on that side to mitigate lateral forces directed on the implant.

Regards,

Ben White, DDS, MSD
Orthodontist
Click to expand...

Thanks Dr. White!

I do not like to commit the patient to a surely expensive restorative option and leave the cuspid impacted. I have seen them necrosis and require surgical removal after many years of observation.

This leaves one open to questions as to whether appropriate informed consent was given and/or understood.

Any OMS residents out there with evidence as to what is appropriate care for that cuspid?
 
vertical bite said:
Dr White, amazingly you typed all that and basically said so little in so many words. I am very disappointed... :sleep:
Click to expand...

I guess I could have just said "in my hands" followed by some BS about how I am 100% sucessful in retreiving EVERY canine...but in this day and age of "evidenced based dentistry" I thought YOU deserved more :idea:
 
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