Questions and answers

It is possible to bond brackets to porcelain crown. A special etch technique (porcelain etch and porcelain surface conditioner, rely-a-bond primer and paste from Reliance co.) is necessary, but it work fine and it will hold during your treatment. See these exemple: If the crown are on your front upper teeth, they may need to be redone after the orthodontic treatment. Generally speaking, bimax protrusion requires 4 dental unit extraction, although this can be reassess after closer upper spaces. Keep in mind that if you have deep bite, it will need to be address before retraction of the upper teeth. Gummy smile often need orthognathic surgery (Le Fort 1 superior repositioning along with mandibular surgical accommodation.) I hope that help.    

I cannot pass judgement on the treatment that you received. A 2-year treatment with Invisalign® aligners is already a long treatment, because about 50 aligners are necessary. You received a revision with 15 new aligners, which means 30 additional weeks. This indicates me that your treatment was rather difficult at first. This indicates me that the Invisalign® aligners may not have been the method of treatment that best suited your situation. I also question your dental health care provider. Was she a certified orthodontist? Had the objectives of the treatment been clearly defined? I recommend you to talk again to the one who treated you and if you are not satisfied with her answer, you can consult a certified orthodontist.

Dear Cary, Thank you for having chosen my website to ask your question. You sent me your picture and gave me the authorization to publish it. Your frontal photo confirms mandibular asymmetry to the right. The chin is to the right of the facial midline. The profile view shows a fairly normal relationship of your lips to the esthetic plane (tangent nose-chin). Prominence of the lower incisors relative to the plane A-Pg The 3D reconstruction confirm asymmetric molar relationship (Class II on the right, Class I on the left and lower midline deviated to the right). The ceph shows a moderate prominence of the dentition as one can see the tip of the lower incisors is in front of the plane A-Pg. The panogram that you sent me, as well as the condylar view, suggest a left elongated condylar neck which explains why your left mandibular border is lower than the right mandibular border in frontal view. Chances are that you have this kind of asymmetry since a while because it is unlikely that full cusp Class II would have developed because of a recent condylar hyperplasia. However, I would recommend a bone scan to confirm that there is no condylar growth activity. The right condylar clicking can be explained by some torsion of the condyle in the glenoid fossa. You may have some slight medial disk displacement. As you open, the disk returns over the condylar head and you hear the click. The important thing is that you have no pain and no limitation of jaw movements. Your occlusion seems fairly good despite the asymmetric molar relationship and midline deviation. My recommendation would be to do a bone scan to assess condylar growth. If it is negative, you may consider an orthodontic treatment plan. The treatment plan would involve extraction of 2 maxillary premolars (1 left, 1 right) and one mandibular premolar (1 left). This would help to camouflage the skeletal asymmetry and obtain a symmetric Class I canine relationship. A sliding genioplasty to the left would help to achieve frontal facial symmetry, assuming that there is no growth activity. I would not recommend any neuromuscular dentistry. You may consider an occlusal splint for 3-4 months prior to treatment, but I am not sure this would be that much important. I hope that helps. Best regards.    

I think that you case illustrates the limitation of what can be done orthodontically in the case of a severe anterior open bite. Having an anterior open bite indicated that you suffered from a vertical maxillary excess problem or a vertical deficiency of the ramus of the mandible. Anterior open bite Indeed, an anterior open bite can develop if the upper maxilla excessively grows vertically or if the vertical growth of the condyle is deficient in a way that the ramus of the mandible is too short, resulting in an anterior opening. I could continue elaborating on other fine details, but I would lose you in the explanations. Camouflage and vertical dimension You are right when you say that your problem was camouflaged. Indeed, the issue regarding the excessive vertical dimension was never addressed. Your teeth were retracted and extruded. Your lisping (sigmatism) problem was present before your treatment. I do not believe that your treatment caused the problem. The cracking problem could indicate an internal derangement problem and a problem in the alteration of the shape of the condyles. An orthodontic camouflage treatment means that the teeth were placed to compensate the skeletal problem. Therefore, dental compensations are made to match the skeletal relationship. If you envision a surgical treatment, you will benefit from undergoing an orthodontic treatment to undo these dental compensations and make it possible to correct the skeletal discrepancies optimally. If decompensation of the dentition is not done, a surgical treatment can be performed, but the skeletal correction may not be optimal. I say that carefully since I have not seen your case.

Edema or swelling of the face after an orthognathic surgery is normal and this swelling progressively goes down. 11 days post-surgery, nearly 50% of edema should have subsided. A recent study using a 3D stereophotogrammetric technique on postoperative swelling (JOMS2014) confirms that in average, 50% of the initial swelling has subsided after the third week post-surgery and that after 3 months, only 20% of the initial swelling remains. This study has made a correlation between the body mass index (BMI) and edema. Indeed, patients with a high BMI have more post-operative edema, but their edema has the highest reduction rate during the first week. Comparatively, patients with a lower BMI have less postoperative edema, but it takes more time for this edema to resorb. They have not found a different between men and women on the initial edema or the resorption of the edema. It is normal for you to feel the plates on each side of your nose. This sensation should decrease with time. From what I can remember, I have had one or two patients whose plates were too prominent and they had to have them removed 6 months after the surgery. The sensitivity in the chin can take from 2 to 3 months before going back to normal. Sometimes, it can take 3 to 6 months. Beyond 6 months, chances are that the loss of sensitivity is permanent. van der Vlis M, Dentino KM, Vervloet B, Padwa BL., Postoperative swelling after orthognathic surgery: a prospective volumetric analysis. J Oral Maxillofac Surg. 2014 Nov;72(11):2241-7. doi: 10.1016/j.joms.2014.04.026. Epub 2014 May 2.

Masseter muscle hypertrophy is often associated with bruxism. Therefore, the chewing muscles are hyperactive, which leads to muscular enlargement in the same way the volume of your biceps will increase if you lift weights. Injecting botulinum toxin type A in the masseter muscles is a recent medical application in the treatment of bruxism and the reduction of the volume of the masseter muscles. Dr James Mah presented an interesting webinar on this subject to the members of the Canadian Association of Orthodontists on November 18. The title was Neuromodulators in the management of bruxism. He quoted several studies, such as the one conducted by Chikhani L. and Dichamp J., that confirms the efficiency of Botox® in the treatment of bruxism in the ⅔ (two thirds) of patients. The study included 1150 patients. There were no side effects of diffusion to the superficial facial muscles, which means that the smile did not seem stiff. Usually, 3 to 4 treatments are necessary. The possible complications are pain or discomfort to the injection sites. This is a little understandable, it is never pleasant to get an injection. There are possibly surgical solutions, but the type of your face would have to be determined. I suspect that you have a rather short and square-shaped face. If this is the case, an orthosurgery treatment to lengthen the maxilla could be considered. I recommend you to consult a certified orthodontist. Chikhani L1, Dichamp J. . Ann Readapt Med Phys. 2003 Jul;46(6):333-7.  

Dental Age 7 Your question relates to the eruption sequence and timing of eruption. Therefore, one need to understand what is considered normal at age 7 in term of the evolution of the dentition. At age 7, the four lower incisors and the maxillary central incisors (1.1, 2.1) are erupted. Root formation of the maxillary lateral incisors (1.2, 2.2) are well advanced but it is still about 1 year from eruption while the canines (1.3, 2.3) and the premolars are still in the stage of crown completion or just at the beginning of root formation. So we can not pretend that the canines of your 7 years old daugther are impacted whil it is normal that they are very high and near the nose at this age. For more information, I recommend that you visit the page "dental age". The keynote is in french, but most picture are self explanatory. I hope that help. Bibliographie: Contemporary Orthodontics 5th edition, Proffit WR, Fields HW, Sarvers DM, Elsevier 2013, Chapter 3.    

Corticotomy-induced accelerated tooth movement To answer your question well, I will present a summary of an article about corticotomies and rapid orthodontics or accelerated tooth movement published in the American Journal of Orthodontics and Dentofacial Orthopedics in July 2013 in point and counterpoint form. The authors who are in favor are Drs William and Thomas Wilcko and the authors who present the counterpoints, those who are not in favor, are the respected Drs Vincent G Kokich and Dave Mathews. Effect of a local trauma Since remodeling of the alveolar bone is a significant element of any orthodontic tooth movement and since bone remodeling is accelerated during the healing of injuries, the idea of making the teeth move faster if the alveolar bone is "injured" locally came early in the history of orthodontics. In the late 1950s, a German surgeon called Köle rekindled the idea that cuts into the alveolar bone between the teeth would accelerate their movement. More recently, corticotomy-facilitated accelerated tooth movement was analyzed under the angle of a demineralization-remineralization process that produces a regional acceleration of bone remodeling called regional acceleratory phenomenon. To perform corticotomies, the gingiva and the periosteum need to be elevated to expose the bone. The osteotomy cuts are made between the teeth and the bone surface will also be perforated between the osteotomy cuts (figures B and D). The decorticated bone surfaces will be covered with a mixture of demineralized freeze dried bovine bone and plasma rich in blood platelets (figures C and E). The surgical flap is closed and sutured. This new volume of bone facilitates a greater scope of tooth movement toward the areas where bone was absent beforehand. It is recommended to start the orthodontic treatment within one week after the surgery. This kind of procedure is called Periodontally Accelerated Osteogenic Orthodontics therapy or PAOO. The corticotomy surgery accelerates tooth movement in areas aimed by the surgery because of the demineralization. Facilitated tooth movements will occur only close to the corticotomized teeth. According to the Wilcko brothers, treatment time could be reduced from ⅓ or ¼ of the treatment time that is typically required. Result of Periodontally Accelerated Osteogenic Orthodontics treatments No one asks better questions than Dr William Proffit. Therefore, he asks the question from the point of view of the benefit versus the cost and risk of treatment. I will summarize a few points highlighted in the Contemporary Orthodontics volume put in reference. The first benefit claimed by PAOO is to reduce the treatment time, the second benefit would be arch expansion. Treatment time The length of the rapid bone remodeling obtained after decortication is between 2 and 4 months. Tooth alignment, even for the cases showing severe crowding, rarely requires more than 5 months with superelastic shape memory alloy wires. If corticotomy reduces this time to 1 month, the 4-month reduction represents only 20% out of a treatment time of 18-21 months in average. Risk and cost of treatment Cost estimate includes all disadvantages of a treatment. Beyond the financial cost, morbidity and complications must be considered. According to Wilcko, teenagers do not suffer from vertical bone loss, but adults can be affected by a vertical loss of alveolar bone. A corticotomy surgery/PAOO is a rather extensive surgery, which led to the modification of the technique where it is no longer necessary to elevate the whole mucoperiosteal flap. Instead, vertical incisions are made to the gingiva between the teeth and bone graft material is inserted under the parts of the undermined flaps. The financial cost associated with a corticotomy surgery and bone grafting would be almost as high as the cost of the orthodontic treatment itself. Drs Dave Mathews and Vince Kokich's counterpoint is even more devastating concerning the efficiency and efficacy of this kind of treatment. They question the demineralization/remineralization process, because studies were performed in rats, which cannot necessarily be translated to humans. Studies in dogs and cats have not reported the demineralization effect seen in rats. Moreover, a tooth is not moving through the bone; it is the whole alveolus, the ligament and the tooth that are moving. When an alveolar corticotomy is performed near a moving tooth, the cellular response is to increase the number of macrophages which allow earlier resorption of the compressed bone (hyaline) near the ligament. A more rapid tooth movement is possible since the compressed areas are cleaned faster. How long does the regional acceleratory phenomenon last after a corticotomy? A study performed in foxhounds shows that the rate of tooth movement peaked between 22 and 25 days after the corticotomy and decelerated afterward. During this 3-week period, the rate was twice as fast. Similar findings were reported in 13 human adults whose maxillary canines were being retracted after first premolar extractions. Corticotomy was performed on one side only, and the other side was not operated, acting as a control side. During the first 2 months, the rate of tooth movement was twice as fast, reduced to 1.6 times during the third months and the rates of tooth movement were no different in the fourth month. Therefore, we can conclude that the regional acceleratory phenomenon of the rate of movement is about 4 months. Does demineralized bone graft incorporate into the cortical plate? Tomographies seem to demonstrate that a fibro-osseous encapsulation occurs on the outside of the cortical plate rather than an incorporation and augmentation in the cortical plate thickness. Conclusion Drs Mathews and Kokich conclude that it is not possible to determine whether periodontally accelerated osteogenic orthodontics / corticotomy is efficacious and efficient. Yes, alveolar corticotomy accelerates the rate of tooth movement. However, one cannot conclude that this accelerated movement invariably translates into reduced orthodontic treatment times. They believe in: 1- A limited duration of the regional acceleratory phenomenon of the rate of tooth movement. 2- A significant additional financial expense ($$$). 3- Lack of scientific evidence of a significant reduction in orthodontic treatment time. Now, to answer your questions, Is it a safe technique? Yes, it seems like it is a safe technique. It can be compared to another periodontal surgery with flap opening, but cuts are made into the bone that add to the periosteal release of the flap and therefore, the technique leads to further inflammation, swelling and discomfort compared to a normal periodontal surgery. Is remission good and does the bone become completely normal and viable again? The remission will be good, but with additional swelling and discomfort. The bone graft material will not necessarily transform into natural bone and a vertical bone loss of 1 mm may occur. Is durability of teeth compromised? Not necessarily. In short, are there any risks? There are risks, as for any surgery. It is up to you to decide if you are ready to pay 3000$ to 5000$ in addition to the cost of your orthodontic treatment to get it done a few months faster. Bibliographic references: 1- Contemporary Orthodontics, 5th ed.  chapter 8. Proffit WR Fields HW, Sarver DM, Elsevier, 2013. 2- Köle H. Surgical operations of the alveolar ridge to correct occlusal abnormalities. Oral Surg Oral Med Oral Pathol 12:515-529, 1959 3- Mathews D.P., Kokich V.G., Accelerating tooth movement: The case against corticotomy-induced orthodontics, AJODO, Vol. 144, Issue 1, p5, Published in issue: July, 2013 4- Wilcko W., Wilcko T., Accelerating tooth movement: The case for corticotomy-induced orthodontics AJODO, Vol. 144, Issue 1, p4.Published in issue: July, 2013

I answered a similar question on November 9, 2013 (in French) and on June 17, 2014 (in French). It is normal to see this tooth becoming hypersensitive and harder to anesthetize. I can understand your dentist's suggestion regarding the extraction of this tooth. However, I would consult an orthodontist beforehand to find out what kind of orthodontic treatment will be required for your daughter and more particularly, how he will manage the extraction of the molar and prevent the deviations and asymmetries that could result from this procedure. I present you a case on the image on the left where an orthodontic treatment with dental extraction was required. I modified the extraction plan and instead of the four second premolars, I extracted the upper left first molar instead of the second premolar in the maxilla (teeth marked with an X) and the lower second premolars. I cannot tell you exactly what to do. It is reasonable to think about extracting the hypocalcified tooth. I recently recommended, to 2 different patients, the extraction of their four first molars. It was the best thing to do for these young patients.   Patient 1 Young boy of 7 years and 6 months of age. The four first molars are affected by hypomineralization and 3 teeth show significant destruction of their crown. This means that numerous repairs are to come during his life. I came to an agreement, with Dr Bruno Ouellet, specialist in pedodontics, that extracting the four first molars had to be done as soon as possible, which was done. Patient 2 Young girl of 10 years and 5 months of age whose four first molars are affected by hypomineralization. Extensive restorations are present on four molars. The lower left molar, that shows a grey amalgam filling, shows a periapical lesion. Therefore, a root canal treatment will have to be performed if we want to save the tooth. This represents significant costs for this tooth and for the other teeth throughout the patient's life. The decision, always in agreement with the pedodontist Dr Bruno Ouellet, was to extract the 4 first molars.  

Facial asymmetry Generally, if you perceive that your face is asymmetric, a "quite pronounced asymmetry" as you say, the masseter muscles are not the only asymmetric structures. The problem is more accurately skeletal and you possibly suffer from hemimandibular hyperplasia causing a facial asymmetry and deviation of the chin. In this example, we can indeed pretend that the right masseter muscle is bigger than the one on the left side and it is true. However, notice how the chin deviates to the left (green arrow). This patient, whom I treated when he was 14 years old and who showed a perfect symmetry at that time, came back to see me at 29 years of age. He believed that his teeth had moved. In fact, hypergrowth of the right temporomandibular joint occurred, which caused the visible asymmetry. The analysis of X-rays confirmed the presence of a bigger right condyle compared to the left one. The patient was referred to an oral surgeon and he underwent a bone scan (scintigraphy) to determine if growth was still occurring. The result came back negative, the patient was reassured and did not start any treatment. He could very well live with his condition.