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Orthodontics/Head Gear In Adults

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QUESTION: Hi Dr. Supan,
I have a question about headgear in adults. I need about 4ml of advancement in my upper arch with some widening of my arches. The problem is that I have tooth resorption in some of my teeth. My orthodontist will use Tads, and headgear. I have been trying to reversed the damage done that teeth extraction and braces caused to my face years ago. I have a retracted profile with no support in my soft tissue. Should I do surgery? to move my jaws forward, or does headgear really works? please help! any suggestions will be really appreciated,
Thanks. (sorry for my English)

ANSWER:
Hi Milenia,

I have studied your question and there are too many unknowns and variables for me to give you a definitive answer.  However, I am not going to leave it at that.  Let me share with you some general background information, and then you can decide if it applies to your case. Here are some important considerations:

1.   Age:  

I am assuming you are an adult, but it would be helpful to know how old you are.  In general it is held that growth sutures slowly fuse as one enters adulthood. Growth sutures are those little fissures that form the growth plates that allow bones to grow. Imagine for example a classic leaf table that one can pull apart revealing a gap in the middle. One then adds a center section and one now has a slightly longer and larger table. Likewise there is both growth at the growth suture and this is how bones get larger. There are a number of sutures in the upper jaw, as well as the rest of the human cranium (skull) which permits growth to take place. In any case, for very young adults sometimes there is still some elasticity in these sutures and they have not yet full fused shut.  Transverse expansion for example can sometimes still occur, albeit probably to a lesser extent than in adolescents. I mention this because you  said:  
” I need about 4ml of advancement in my upper arch with some widening of my arches. “

The widening may or may not be possible.

2.  Headgear:  

There are various types of “ headgear”. You mention the need for upper jaw advancement and some additional transverse widening.  Regular cervical pull headgear pulls backwards and utilizes a classic bow which often attaches to the molar teeth.  In other words the “headgear” can be used to provide a backwards pull and well as a “sideways and outward” force on the left and right sides that can potentially be used for transverse widening. Headgear can be used, with age appropriate patients to achieve orthopedic changes (changes to the bone such as the jaw). Headgear can also be used to achieve a dental impact, such as movement or anchoring of a tooth. A head gear could be used to help move a tooth backwards by providing anchorage to a main tooth which can then serve as an anchor point to allow another tooth to be moved. Imagine a Jeep pulling itself out of a ditch by using a winch and cable attached to a sturdy oak tree.  Headgear can create a” sturdy oak tree” by providing anchorage to a molar tooth for example. Another tooth, such as a premolar is the analog of the Jeep.  The premolar can be orthodontically pulled towards the anchored molar tooth, much like the anchored oak tree helps to pull the Jeep. Headgear can be used to provide anchorage.

There is also a second type of head gears called “reverse headgear”.  This is also known as a face mask, and resembles the face mask used by a baseball catcher. It is worn on the front of the face and allows the orthodontist to attach elastics from the mask to the teeth or TADS in the mouth. This can potentially provide a forward force.

The question I have is which type of “headgear” are you asking about (Cervical headgear or Reverse headgear ?)  Which effect is trying to be achieved (transverse change to widen the jaw, and/or an anterior-posterior change to help move the upper jaw forwards?) You wrote that:
“My orthodontist will use Tads, and headgear.”

I am not sure which type of head gear, and are the TADS (Temporary Anchorage Devices) being used for transverse or anterior –posterior changes?

3.  Surgery

You have mentioned that you have a 4mm discrepancy which you would like to have corrected. You noted:
“I have a retracted profile with no support in my soft tissue.”

For profile enhancement, sometimes a combination of soft tissue augmentation as well as skeletal corrective surgery is called for. Again, one would need a cephalometric radiograph to be able to assess the breakdown, and this is not available.  The fact that you have serious root shortening, which may or may not be related to previous orthodontic treatment, does limit your options. Also please be aware that some root shortening can occur with normal orthodontics and its presence does not necessarily reflect on the quality of the orthodontic care. Recent research at the University of Kentucky suggests that root shortening may in fact have a genetic component, with certain individuals predisposed to this phenomenon.

4.  Your final question:  

You asked:  “Should I do surgery? to move my jaws forward, or does headgear really works? please help! any suggestions will be really appreciated. “

As I said in the beginning, I can not answer your question  specifically. I do not have the needed records to diagnose this.  It is also not clear which type of headgear is being used for what intended purposes.

My advice is for you to check with several orthodontists and get a number of opinions. Realize also that if you get an opinion from a surgeon, there may be a bias, unintended or otherwise, recommending surgery. Finally, the root blunting and shortening needs to be thoroughly examined and documented before you undertake any form of treatment.

This is a very complex clinical case Milenia, and you have a number of limitations including poor soft tissue profile and pre-existing root shortening. Check with several different doctors and proceed with caution.

Thank you for writing Milenia.

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




---------- FOLLOW-UP ----------

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QUESTION: Hi Dr. Thank you for answering my question.
I'm 37 years old. My orthodontist is using the reverse head gear,(face mask)and TADS.
He also, he is going to open a space on my lower arch to move it forward, and have an implAnt there.
I will have 3 TADS total. Two on top and 1 on my lower arch close to my cuspids.
I have attached my X-Rays. If you can give me your opinion I will appreciate it.
Thanks again!
Milenia,

Answer


Hi Milenia,

Thank you for the additional information.  As I  noted in the earlier response, the reverse headgear often is employed for its facial orthopedic effects, but in your case it is being employed to help provide a forward force to help effect a dental (tooth movement) rather than skeletal (orthopaedic growth) change.

You wrote in a follow up question:

“I will have 3 TADS total. Two on top and 1 on my lower arch close to my cuspids.
I have attached my X-Rays. If you can give me your opinion I will appreciate it.


Orthodontic treatment plans can vary greatly, and orthodontists depending on their training and treatment philosophies may take different approaches to achieving the same thing, namely a beautiful smile and profile. I have looked at your radiograph and it looks like TADS would be helpful in better moving the into the correct positions whilst maintaining/improving the facial profile and bite.  A TAD (Temporary Anchorage Device) often allows the teeth to be more effectively positioned, without having to worry about detrimental reactive movements in other teeth.

As an example of this, imagine a frog jumping off a lillipad. The frog goes forwards, while the lillipad moves backwards in the opposite direction. This is basically an action-reaction principle. Likewise in orthodontics, when one has a series of teeth and one tooth is being pushed forwards, sometimes the other teeth will move slightly backwards, unless some form of “anchorage” is employed. This can be an external device like a headgear appliance or in an internal  device like a TAD which is temporarily anchored into the bone of the jaws.

Again, I do not have the full clinical records for you Milenia, and this website is not intended to ever give definitive diagnoses or treatment plans, but the use of TADS and Reverse Headgear demonstrates that your doctor has a very sophisticated understanding of orthodontics. I suspect that the TADS and Reverse Head Gear, if integrated into an effective treatment plan based on a proper diagnostic work-up, will produce a very satisfying final treatment result.

One note of caution is that I would keep the doctor apprised of any medications or other medical conditions you may have. Tobacco use, if any should be discouraged, especially when TADS are employed. Certain medications known as bisphosphonates have been associated with osteonecrosis in the jaws. I will not go into detail on this,  as it would be too  lengthy a discussion, but here are two helpful links:

http://www.dentistryiq.com/articles/rdh/2006/08/dental-side-effects-of-bisphosph

http://www.mayoclinic.org/diseases-conditions/osteoporosis/expert-answers/fosama

Any orthodontic treatment plan should include reviewing the planned procedures with the patient and having the patient review and sign an Informed Consent document. The American Association of Orthodontists has such a form and it includes information on the bisphosphonates  and TADS.

In summary, it looks like you are in good hands, and that with good cooperation, steady appointments, and good dental hygiene, you will end up with a beautiful smile. Thank you for writing Milenia, and for submitting the follow up question including the radiograph.

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

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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

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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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