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

This afternoon I observed an orthognathic surgery consult in a high end practice. I was familiar with orthognathic surgery from Columbia’s emphasis on medicine and high reputation in oral and maxillofacial surgery. However this was the first time I had really witnessed a consultation for orthognathic surgery in a very practical setting.

A 28 year old female patient presented to the clinic because she was unhappy with her facial proportions. She had orthodontic treatment for 2 years prior, but was unhappy with her prominent upper lip, retruded lower lip, and also mentioned that she was unhappy with her nose being too wide (despite having a previous rhinoplasty).

Seeing this patient reinforced how important it is to take a good history of the patient. This patient in particular had a history of plastic surgery, included the rhinoplasty, so right away one has to be aware that she is going to be very particular about the results. Often patients like these change their minds, so even if the surgery gives her what she wants, she may be unhappy with it at a later point in time. It is important for the surgeon not to make guarantees, and to thoroughly advise the patient on their options.

The consulting surgeon was simply brilliant in the manner he conducted his consult. This oral surgeon is an attending at Columbia and I have met him before. However this was the first time I got to see the wealth of his knowledge in full action. He is a very powerful presence but he listened to the patient and all her needs and concerns. He then advised her on the possible options, however the patient was still adamant that she wanted to have her maxilla retruded. The oral surgeon was very honest with her and explained that women pay thousands of dollars to have her full look. He pointed out that if you retract the maxilla, the soft tissues will fall back as well, and she would lose that youthful look that she naturally has.

One of the most impressive parts of his consultation was that he was still very knowledgeable about general dentistry. He took two sets of impressions and was very proficient at taking them for an oral surgeon!

He found two issues from his exam and consult:

1. Deficient mandible/class II skeletal discrepancy

2. Wide alar base

His best treatment plan at this point was mandibular advancement via BSSO (bilateral saggital split osteotomy) along with an alar cinch to address the patient’s issue with the width of her nose. The alar cinch procedure was an intriguing option and gave the patient an alternative to getting another rhinoplasty. He  explained to the patient that an oral surgeon can go intra-orally with the alar cinch procedure which is more effective and does not produce the scarring that is possible from a rhinoplasty performed by a plastic surgeon. He explained that plastic surgeons are limited in what they can do because they cannot work intra-orally.

The patient finally became convinced that it was not a good idea to touch the maxilla, and mandibular advancement was the best solution. The oral surgeon didn’t shoot her down right away, and he advised her to choose between the given choices. However he took it step by step, until the patient saw the benefits of a less invasive approach.

The patient would also have a consult with the orthodontist because she would probably need brief orthodontic treatment after the surgery to adjust the bite so it is properly aligned.

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