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Orthodontics/Dilemnna about type of treatment

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Question
Dear Doctor,

I had a broken first molar on the right side that couldn't be restored after a root canal with a crown for a year as I was out of my home country and it was too expensive to get it in Europe. It caused the upper molar to supraerupt. I don't have a good bite with very limited anterior guidance and mild crowding. (The ortho treatment years ago with metallic braces had failed after I developed an allergy to the brackets) The situation started causing my jaw some trauma which was manifesting in TMJ pain episodes. On return to my country, I met an oral surgeon who recommended an orthodontic treatment to intrude the upper molar, followed by restoration of the lower one at a proper height. He recommended that I get full braces to get a good bite and ease the stress on my jaw.

I met the orthodontist who placed two titanium mini-screws connected with an elastic and said that the tooth should intrude in 3-5 months. Since I had developed an allergy to metallic braces in childhood, we had to decide to get clear aligners for the remaining orthodontic work. ClearPath is what is available in my country. I paid the first installment for the aligner treatment as well. Unfortunately the miniscrew on the palate side became loose in a month and had to be removed. My orthodontist tried three more places but it didn't work as 'the bone was giving way' he said.

Now I am stuck with a crucial decision. He has given me three options:

1. Get traditional braces that have been introduced recently that have nickel free wires and brackets and are less likely to cause allergic reactions. He said it would enable him to intrude the supraerupted molar with just one screw that is still in my mouth on the lip side. He agreed to put two test brackets for a week to see if there was a bad reaction.

2. Get a root canal on the supra erupted tooth with a crown, They can shave the tooth by 3 mm and put the crown on both upper and lower molars to stabilize the bite. The height of both the teeth will be compromised but I can go through aligner treatment after that. This way I don't stand to lose a part of my installment that I have paid for clear aligners. I must add that the supraerupted molar does have a big filling already.

3. Get the lower root canaled molar restored at a compromised height, leave the supraerupted tooth alone. He said its not considered an emergency if the upper tooth is extruded by 2 mm as is my case. Then also, I can go ahead with aligner treatment and not get an unnecessary root canal.

I would like to know what would be your suggestion for my case. I am a little disheartened by the failure of TAD screw treatment and its been a financial dent too. But finances aside, what would be your advice for a long term prognosis.

Answer
Dear Lily,

Thank you for your three part question, and I will address the Orthodontic aspects of the first one. I am going to also provide you with a link to another root canal specialist here on this website and you can submit the same question to him for his insights and guidance. There are often many ways to address a problem and which treatment plan is best really depends on the patient and often many other factors.

Before I go much further, let me again say what I write here are only my opinions based on very limited information. My comments should not be viewed as any form of diagnosis, definitive or otherwise, or any form of treatment recommendation.  Indeed, in the ultimate analysis all final decisions, particularly clinical ones, should only be made by qualified doctors who have had a chance to see you in person Lily, and who have had an opportunity to take and analyze proper diagnostic records.

I appreciate the concerns about allergies, and apparently the all titanium implants which you had placed by the orthodontist are biocompatible and do not cause you any concerns. I believe this fact will open up several options for you.

You wrote:
“I met the orthodontist who placed two titanium mini-screws connected with an elastic and said that the tooth should intrude in 3-5 months. “


You may wish to ask your orthodontist to consider all ceramic braces which obviously have no metal at all.  Note that “ some ceramic” braces have a metal slot where the wire goes so they in a sense are not all ceramic, so bear this in mind,. If you and your Orthodontist should decide to go for ceramic braces, then make sure they do not have a metal slot.
A second “braces” option is for you to use brackets made of pure titanium. There is a German company which manufactures such brackets. I believe their name is Dentaurum.  I have used thee in the past and had great success.

Here is the link:
http://www.dentaurum.de/eng/equilibrium-ti-12650.aspx

I am in no way connected with Dentaurum, and there may indeed be other manufacturers of titanium Orthodontic brackets who may offer a similar or even better product. I am offering this as a reference to a type of titanium bracket, and it should not be viewed as any form of an endorsement or recommendation per se.

The question comes up about the “metal wires” used in orthodontics and whether they can contribute to an allergic reaction.  While one cannot rule out this possibility completely, as it turns out these wires bind the various metals including certain  nickel and copper containing components  into a more or less inert alloy. Reactions therefore are ever so rare. Lily, it seems that if you do go with braces then the all titanium or all ceramic brackets would be the ones to consider.

Okay the next thing I would like to discuss is another possible option, namely the use of clear aligners.  

You wrote:
“ClearPath is what is available in my country. I paid the first installment for the aligner treatment as well. Unfortunately the miniscrew on the palate side became loose in a month and had to be removed. My orthodontist tried three more places but it didn't work as 'the bone was giving way' he said.”  


I am not familiar with the ClearPath product you mention. However, the concept of using a clear aligner, especially in concert with titanium TADS dental implants appears to be an imminently reasonable option. I think your Orthodontist chose a good approach, and it is unfortunate that the TADS implants were unsuccessful.  Your orthodontist might be able to still use the clear aligners and bond all ceramic or all titanium “buttons” onto the molar and intrude it that way. Generally one button goes on the inside “palatal” aspect of a molar, and a second button on the outside “buccal “ aspect. The aligner obviously will have an opening in the area of the intruded tooth in order to relieve and pressure from the retainer and to permit the elastics to be attached and to move/intrude the tooth.  

A lack of any photos and the fact that I obviously have never performed an in depth clinical examination of your teeth makes such comments very theoretical. Nevertheless, do discuss this possible option with your Orthodontist.

It would seem to me that your approach, if Orthodontics is indeed the treatment pathway chosen, should consider:

1)   Traditional Orthodontics using braces made of all pure titanium
2)   Traditional Orthodontics using braces made of all ceramics
3)   Using clear aligners and elastics attached to a ceramic or titanium button on the tooth to be intruded.

The other options you asked about Lily involved tooth canal treatment, that is Endodontics. This is a separate specialty and I would refer you to a Board Certified  Endodontic Specialist here on allexperts.com . Here is a link to a doctor who I think will be able to provide you with some insights regarding the Endodontic  options you asked about.

http://www.allexperts.com/ep/966-129503/Dentistry/robert-block.htm

I hope my comments have been helpful Lily. I am told the website here encourages readers like you to rate the answers and to resubmit with follow up questions. Good luck with your upcoming Doctor visits, and thank you for writing.

Paul Supan, DDS, MA, MPH
Board Certified Orthodontist

Specialist in Orthodontics
Specialist in Dental Public Health
http://www.braces.com  
http://www.leesburgbraces.com

Please allow a full week for a reply; my replies are generally fairly extensive and researched. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. I sometimes consult with other doctors on complex interdisciplinary questions. This of course takes time.  Your understanding is appreciated.

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Paul Supan, DDS, MA, MPH

Expertise

First may I say please set your questions to Public so other readers can benefit from the response. Also, if you look at my comprehensive answers, they are not short 1 or 2 paragraph quickie replies that anyone can type out in < 5 minutes. Instead I often will ask other colleagues in other specialties for their advice in order to provide you the questioner with a more interdisciplinary perspective. This all takes time. I ask for readers to therefore allow 5-7 days. You will be rewarded with a very detailed response.

Because of the nature of Orthodontic questions, any pictures of the teeth and X-ray images would be very helpful. If you write to me and explain that you have crooked overlapping front teeth can be interpreted in many many ways, and my goal is to provide a specific response that meets your needs.

I hold double specialty credentials. I am Board Certified in Orthodontics and Board Eligible in Dental Public Health. I welcome questions regarding Braces, Invisible Braces, & Invisalign, as well as issues involving combination Cosmetic Dentistry and Orthodontic treatment. Orthodontics alone sometimes is not enough to achieve that perfect smile. Gingival (gum) re-contouring, tooth reshaping, bonding and other services are sometimes needed. I also have substantial experience in the areas of Infection Control and Sterilization in the Dental Environment. My personal websites braces.com and Leesburgbraces.com are non-commercial for information purposes only and may provide you with some background to more precisely frame your question for allexperts.com.

Please allow a week for a reply. I am in full time Private Practice, lecture on occasion, and am involved in many volunteer activities. I am therefore not always able to respond to questions straight away. Your understanding is appreciated.

Experience

Board Certified Orthodontist (ABO Diplomate) with over 25 years of Private Practice experience. Second Specialty Certificate in Dental Public Health with research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control (CDC) in Atlanta. Postgraduate Masters degree from the Harvard School of Public Health, as well as a Master of Arts Degree in Education.

Organizations
American Dental Association, American Association of Orthodontists, Academy of General Dentistry, College of Diplomates of the ABO, OSAP - Office Sterilization & Asepsis Procedures Organization, Others

Publications
Available upon Request.

Education/Credentials
BS College of William & Mary, DDS Medical College of Virginia, Masters of Public Health (MPH) Degree Harvard School of Public Health. Dental Public Health Specialty Certificate from NIH. Orthodontic Specialty Certificate from University of Rochester Eastman Dental Center. USPHS clinical research experience at NIH, and Epidemiology Training & Research at Harvard, NIH, and the Centers for Disease Control. Fellow of the Academy of General Dentistry (FAGD), and Fully Board Certified Diplomate of the American Board of Orthodontics. Board Eligible in Dental Public Health. Visiting Adjunct Associate Professor at the Meharry Medical College School of Dentistry, Nashville, Tennessee.

Awards and Honors
Available upon Request Please see my personal websites braces.com and Leesburgbraces.com for further personal background.

Past/Present Clients
Available upon Request

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