Today I observed an orthodontic braces consult with a teenage tv celebrity. He had orthodontic treatment previously but #10 had relapsed to its original position because of failure to wear his retainer. The patient had also developed a crossbite in both canine areas.

Normally, for a patient who has not complied with previous treatment an orthodontist would opt for fixed braces, however this patient presented a unique case. Being a singer and celebrity, the patient needed something that would be esthetic for performances and television time. In dental school we are taught about creating an “ideal” treatment plan, and then alternatives if the patient cannot choose the ideal plan for whatever reason (cost, esthetic issues, etc). The ideal treatment plan is generally created on scientific foundations. However this case shows us that this plan cannot be created just on science alone.

If we don’t have compliance, science can be thrown out the window. Fixed appliances are definitely the best scientifically, and best for the orthodontist because they can be assured of usage. But it would not allow this patient to continue his life normally, since he is a celebrity. The dentist has to treat the person, not just the teeth! In this case, the challenge was not moving #10 back, but doing so without affecting the patient’s career activities.

Clearly with this patient it would not be possible to put anything fixed onto the buccal surfaces of his maxillary teeth. That really left two options, a spring aligner or Triple Star trays. Once the treatment objective was attained, a bonded lingual retainer would be placed from #7-10.

How to treat the mandibular teeth, in particular the anterior crowding, became a topic of debate. When on stage, the patient’s mandibular teeth would not really be seen, usually only the incisal thirds of the teeth, so a wire could be placed without being seen during singing or other activities. The patient was apprehensive, but made the decision with his father to go through with it, because he understood realistically he would need a fixed appliance for the mandible. He was informed that it was better to do it now, rather than when he would be older, and the teeth could have move even further from ideal positioning.

Also Dr. Dorfman explained to him that at any point in his treatment he could opt for one of the alternative treatments. Nothing was irreversible, appliances could be taken off, and this went a long way to reassuring him that his singing and acting activities would be able to go ahead as planned. Also Dr. Dorfman examined his bite once again and found that the lower anteriors would need to be sculpted in order to place the lingual retainer from #7-10.

So the final treatment planned that both father and son agreed to was:

Maxillary arch- a spring aligner or Triple Star trays to align #10 followed by fixed bonded lingual retainer (#7-10)

Mandibular arch- fixed appliance to align lower anteriors with sculpting followed by bonded retainer

It is important to note that the treatment plan was signed by the father today. The patient often comes here without his father, and usually with someone else, such as an assistant. So it was very important to get the father’s consent before starting any of the work. Finally at the end of the visit, alginate impressions were taken, and the patient was told he would need to return to have some sealants placed and begin the orthodontic treatment.

Interestingly at the end of the appointment, when the patient was about to leave, he mentioned that he had problems with his jaw locking on opening. There are many possible causes to his locking. Being young and still growing can contribute to jaw locking by abnormal growth patterns. Chewing gum can definitely cause TMJ issues, and of course being a singer extra care must be taken with his TMJ health. So on his next visit, he will get an oral surgery consult in addition to having sealants placed and a PAN taken.

R.A., Columbia University School of Dental Medicine

Today I saw a couple of orthodontics cases and practiced taking photos with the digital dental camera. I have wanted to learn how to take pictures for a long time, so I am glad that I finally got the chance to do it. I like that our technology is becoming more and more digital, it helps the patient and the dentist communicate better as well as making things easier to keep track of. Both orthodontic cases that I saw today involved bracket placement. The first patient was receiving orthodontic treatment in part to correct her TMJ pain. I learned about how to place the brackets, what the correct angulations may be, and that it’s a very precise slow process.

A.L., New York University College of Dentistry, Observation 2

Today a treatment plan was discussed with the patient. The patient presented with braces of 2.5 years that were placed in another practice. The ortho had failed and had caused much damage to the patient’s teeth. There are perio, operative, endo, and cosmetic issues. The patient has opted out of correcting the issue with further orthodontic treatment. The treatment plan that we present to her should allow for orthodontic treatment in the future should the patient want it. Limited budget is another obstacle in this case.

On her first visit the patient is having her brackets removed under nitrous. On her second visit she will have a hygiene visit. We will allow a few weeks for the gums to heal. In the meanwhile after 4 bitewings are retaken we will start restorative work on her. We will do any cosmetic work in the anterior region after we see improvement in the gingiva. After all work is done patient will have her wisdom teeth extracted, have a lingual fixed retainer placed on the mandibular teeth and a bite guard will be made in order to increase the half life of all procedures.   

H.A., New York University College of Dentistry, Patient 8