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The Best Laid Plans

Published: November 2015

Bulletin #49 November 2015

The Best Laid Plans

The title of this month’s bulletin follows the spirit of a book by Sidney Sheldon and another by Terry Fallis, each with the identical title “The Best Laid Plans”. In the same vein, John Steinbeck wrote his novel “Of Mice and Men”. Each of these titles was borrowed from a line in a poem by the famous Scots poet, Robert Burns, and paraphrased from the original Scots as the best laid plans of mice and men often go awry” (Wiktionary). It is a proverbial expression used to signify the futility of making detailed plans when the ability to fully or even partially execute them is uncertain (Wikipedia).

While the outcome of orthodontic treatment in general is highly predictable, most of us will agree that for the orthodontic treatment of cases with impacted teeth, this is an appropriate and pertinent proverb. The multitude of factors that potentially stand in the way of the successful execution of a plan to reduce the impaction and bring about the alignment of the teeth are legion. Adverse factors may be divided into those which are orthodontist-dependent, those which are surgeon-dependent and those which are patient-dependent.1 The patient-dependent factors may be further sub-divided into those over which the patient has no control, which include such features as abnormal tooth morphology, pathology of the impacted tooth, gross ectopia, resorption of the root of an adjacent teeth and the patient’s age.

Then there are those factors where the patient does have control and where that control needs to be exercised in an affirmative manner. Most of these come under the general heading of compliance and include care of the appliances, maintaining a high level of oral hygiene, cooperation with the placement of auxiliary aids, such as rubber bands, headgears etc. and regular attendance for appliance adjustment.

The case report that is presented in this bulletin is an example of failure to generate an adequate response to compliance needs in the patient and how high hopes may be dashed because of a lack of projection of the operator’s enthusiasm and confidence in achieving success to an indifferent or apathetic patient.

ggg._Fig._1

Fig. 1. An oblique occlusal view of the affected left side of the plaster casts of the patient, showing the deciduous teeth (in red) and the permanent teeth (in yellow). The teeth are identified according to the Federation Dentaire Internationale (FDI) tooth numbering system. Note the erupting mesial tip of the lateral incisorlingual to the deciduous first molar.

Case Report

Examination:

The patient was a 10.4 year old female in the mixed dentition stage, with no specific complaint, but considerable apprehension regarding the prospect of treatment. Her mother had responded to the advice of an orthodontic colleague who had noted that the left mandibular lateral incisor was erupting in an ectopic location, lingual to the deciduous first molar on the same side (Fig. 1). A subsequent panoramic scan was performed, followed by a cone beam CT series. The patient was then referred to me for further advice and treatment.


At examination, the teeth were not clean even though the mother and child asserted that she cleaned her teeth regularly. A thin and diffuse layer of plaque was present on all the teeth and the gingival soft tissues exhibited a mild degree of inflammation with redness and swelling. The patient was given a hand mirror and these features were demonstrated to mother and child. The dental hygienist then spent some time teaching them how and when to perform her oral hygiene procedures and the patient was discharged and reappointed a month later to check on her compliance – as would be recognizable by improvement in the gingival picture.

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Fig. 2. The initial panoramic radiograph. Note the overall late developing dentition and the transposition of MnI2C and maxillary MxCPm1 of the left side.

The malocclusion was diagnosed as class 1 with slight bimaxillary dental retroclination, mild anterior crowding and a deepened incisor overbite. In addition to the deciduous canines and molars, the left maxillary and mandibular deciduous lateral incisors were present and, from the radiographs, both had almost complete and unresorbed roots (Fig. 2). The maxillary permanent lateral incisors were seen on the radiographs to each have a palatal dens in dente, although only the right incisor was erupted. The left deciduous first mandibular molar was almost totally resorbed from within, apparently due to the acute angle of the lingually-erupting lateral incisor.

ggg._Fig._3a ggg._Fig._3b

Fig. 3. The graduated CBCT panoramic view in the maxilla (Fig. 3a) with the red broken line indicating the location of the cross-sectional slice (Fig. 3b).

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Fig. 4. The graduated CBCT panoramic view in the maxilla (Fig. 4a) with the red broken line indicating the location of the cross-sectional slice (Fig. 4b).

The radiographs showed other anomalies of the teeth on the left side of both jaws, namely a distinct transposition of the unerupted left maxillary canine and first premolar4 (Fig. 3a, b) and of the mandibular canine and lateral incisor5 (Fig. 4a, b). The child’s overall dental age was judged to be 7-8 years, i.e. 2-3 years retarded in relation to her chronologic age, according to root development of the permanent teeth.

Treatment plan:

A phase 1 orthodontic treatment was proposed and commenced a month later, in September 2014, with the following aims:-

1. Extraction of the deciduous left mandibular lateral incisor, first molar and both canines.

2. Alignment and minimal proclination of the maxillary and mandibular incisors, including the grossly ectopic mandibular left lateral incisor

3. Surgical exposure of the ectopic permanent left canine

4. Appliance-driven eruption and alignment of the ectopic mandibular canine

5. Extraction of the maxillary deciduous canines, first molars and left deciduous lateral incisor.

6. Monitoring the future development of the left maxillary canine and premolar and phase 2 treatment at dental age 12 years (14-15 years chronologic age for the patient).

Treatment progress:

Because of her apprehension, simple removable “trainer” appliances2 were placed in September 2014, largely to help her overcome her initial fears and exaggerated gag reflex, and for her to learn to tolerate foreign objects in her mouth. We recommend this in particular for Special Needs patients who often suffer extreme forms of apprehension and anxiety and in whom we have experienced a very high degree of acceptance and subsequent improvement in management.3

In the first 3 months of treatment in the present case, the patient damaged both appliances, one of which had to be replaced!

In January 2015, the removable appliances were discarded, due to continued damage and replaced with a mandibular fixed lingual arch soldered to molar bands, with brackets placed on the deciduous and erupted permanent teeth. In February and March, 5 posterior brackets needed to be rebonded! In May 2015, all the brackets had been removed by the patient and needed to be rebonded, but only after a long discussion with mother and child. Following alignment and leveling in the mandible, a heavy 0.020mm stainless steel main arch was placed and the patient referred for the mandibular extractions. At the same visit, maxillary fixed molar bands with soldered transpalatal arch were placed and brackets bonded to all the uper teeth. In June 2015, the solder joint on one side of the lingual arch became detached.

During these months, compliance in oral hygiene was steadily dropping to an unacceptable level, despite efforts on the part of the practice hygienist and my own admonishments, to the contrary. A fairly widespread superficial decalcification was beginning to appear around the brackets.

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Fig. 5. Intraoral views of the dentition after extraction of the deciduous canines and the left deciduous lateral incisor and deciduous first molar and following anterior orthodontic alignment.

Thus, in July 2015, when the lateral incisors on the left side of both jaws had been brought into alignment, the midlines adjusted and some space gained in the left mandibular canine/first premolar area (Fig. 5), a new panoramic radiograph was taken, to consider the future of orthodontic treatment.

Re-evaluation of treatment:

Removable maxillary appliance present 6 months, fixed maxillary appliance present 4 months, mandibular fixed appliance present 7 months.

Summary of appliance damage:-

1. November 2014 - Broken upper removable appliance. Replacement appliance made

2. February 2015 - 3 loose brackets

3. March 2015 – 2 loose brackets

4. May 2015 – all brackets loose

5. June 2015 – lingual arch soldered joint loose


The new panoramic film, taken 13 months after the initial one, showed much root development of the unerupted premolars and canines and a minimal degree of improvement of the maxillary left lateral incisor/canine transposition. Whereas the mandibular canine had originally exhibited a strong mesial intrabony tip, the new film showed it to be more horizontal and having migrated beyond the mandibular symphysis and heading over to the left side of the jaw, deep down and palpable in the labial depression of the labial side of the alveolar ridge, above the chin (Fig. 6a, b).

ggg._Fig._6a

Fig. 6a. The same panoramic view of the dentition before treatment identifying the permanent (in yellow) and deciduous (in red) teeth and defining the long axes of the transposed teeth.

ggg._Fig._6b

Fig. 6b. At the prematurely aborted phase 1 treatment, the panoramic view shows the considerable migration of the unerupted left permanent canine (about 7-8mm) across the midline and a worsening of its inclination. The teeth to be extracted, which include the aberrant mandibular permanent canine, are marked x.

Given all the overt characteristics of the child’s lack of compliance and the record of damage, it was decided to abort the active orthodontic mechanotherapy and to extract the maxillary deciduous canines and first molars, in the hope that the first premolars would erupt rapidly and offer some space distal to the unerupted canines that would encourage their eruption. The prospective efficacy of this procedure in solving the incipient impaction of the transposed teeth on the left side is undoubtedly questionable. However, given the several facets of the child’s lack of cooperation, it was considered that greater damage would be inflicted on her dentition by continuing treatment than by leaving the situation in its present state of incompletion. In more favorable circumstances, an attempt at rescuing the mandibular canine might have been made, although its prognosis would been uncertain.5 There can be little doubt that, with the passage of many more months, this tooth may be expected to continue to migrate further distally on the right side. Certainly, the big surprise in this case was to see the degree of movement over the midline and its speed in just 13 months. Could this have been predicted?

Accordingly, the aberrant canine was scheduled for extraction together with the above mentioned deciduous teeth and simple removable retainers were prescribed for nocturnal wear only in September 2015, to hold the achieved alignment and gained space.

The patient will be followed up over the next few years until a phase 2 procedure may be considered. In view of her tardy dental development, this is unlikely to be recommended much before her 15th birthday, with much depending on the patient’s future attitude to treatment.

References

1. Becker A, Chaushu G, Chaushu A. An analysis of failure in the treatment of impacted maxillary canines. American Journal of Orthodontics & Dentofacial Orthopedics 2010;137:743-54

2. Becker A, Shapira, J.
Orthodontics for the Handicapped Child. (European Journal of Orthodontics , 1996,18:55-67

3. Chaushu S, Becker A. Behavior management needs for the orthodontic treatment of children with disabilities. European Journal of Orthodontics, 2000, 22:143-149.

4. Bulletin #45 June 2015. Treatment planning bilaterally impacted and transposed labial canines. http://dr-adrianbecker.com/page.php?pageId=281&nlid=135

5. Bulletin #44 May 2015. The impacted mandibular canine. http://dr-adrianbecker.com/page.php?pageId=281&nlid=131