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 in the dental office there was a case that was very complex not only because of the dental work that was involved but because there was also issues of finance and patient management involved. The patients was chief financial officer of his company and had a lot of dental work that needed to be done. This patient was overweight as an adolescent and suffered from anorexia and bulimia. These two disorders ruined his upper teeth and neglect over many years worsened the situation. When he presented to the office the patient had almost no coronal tooth structure left on any of the maxillary teeth.

It was charted that 6-11 and 14 and 15 were restorable with guarded prognosis and any other root tips in the mouth were to be extracted. 6-11 and 14 and 15 were all to be treated with RCT in one visit and to be restored a few days later also in one visit with temporaries.

One of the main concerns with this patient was the loss of vertical dimension. After many years of going with the wrong vertical we were concerned that opening the bite again would cause stress to the TMJ. After endo and OS consults however it was deemed that restoration of the occlusion could be done immediately. It was also noted that this patient was very phobic and was pre-medicated prior to any treatment for the phobia.

The treatment time was about 4 hours in which 8 root canals, post space preparations, and impressions were done. The lab tech was on hand to observe the case so that he could process temps for the patient within 4 days when the post/cores are inserted. This is a case that would normally have taken months and a lot of patient visits but is going to be taken care of in a short span of time with specialist attention.

H.A., New York University College of Dentistry, Patient 10

Female patient presents to the dental office for an oral surgery consult for right mandibular pain and swelling. The patient filled out a TMJ pain form asking where her pain was. Oral surgeon performed a head and neck exam and specifically palpated the area of tenderness. Upon examination of the panoramic film, it was evident that there were two teeth present below the inferior alveolar nerve in the area of the angle of the ramus, which is probably causing the pain.

Patient informed she should have the teeth extracted by an oral surgeon, which should reduce the facial pain. Also noted was a loss of vertical dimension and deviation of the jaw upon closing.

N.S., New York University College of Dentistry, Patient 1 – part 2