It was with considerable interest that I read the Case Presentation in the December 2006 issue of Oral Health. Being a practicing orthodontist, one of the messages we are constantly trying to relay to our general dental colleagues is the benefit of a multidisciplinary team approach to handling complex restorative patients. It appeared on initial perusal that this patient fell into that category, and that the approach taken to treat her was in keeping with that general philosophy, for which I applaud the author. However, upon closer scrutiny, several flaws in both the treatment planning and orthodontic portions of the treatment became evident, as well as with the preparation/presentation of this case for publishing.
Quality orthodontic treatment begins with quality records. The cephalometric radiograph shown in Fig. 6 shows the patient with her teeth not in occlusion, which would flaw many of the measurements obtained from the radiograph. Secondly, the mounted models shown in Figs. 5 & 7 appear to be of the right buccal segment, while the occlusal photos show the opposite; it appears that the photos are reversed. Thirdly, the text states that the maxillary right second premolar was extracted when it was actually the first premolar. Fourthly, the diagnostic setups show interdental spaces present between the premolars and the canines in both arches. This in itself would certainly not be a universally condoned treatment objective, but this setup also illustrates that there will be deviation of the maxillary dental midline towards the right with the unilateral extraction of the right first premolar. The pre-treatment facial photograph appears to show deviation of that midline to the right, and therefore it would seem that a comprehensive treatment plan should have taken this into account and had one of the objectives of treatment to correct the deviation if possible.
The concept of placing cast restorations as provisionals to facilitate bite opening in this patient can only be labelled “a make work (read: make money) project.” For a patient such as this, bite opening can easily be accomplished through the orthodontic treatment. Placing bands rather than bonded attachments on some or all of the molars would have eliminated the concern about further fractures occurring during the orthodontic treatment. It is much more “efficient” (in all aspects for the patient) to complete the orthodontic treatment, then place final restorations, constructed to the now idealized occlusion.
The orthodontic treatment plan itself is where the most serious flaw in the treatment shows up, and demonstrates a lack of understanding of what goals are to be accomplished by the orthodontics. The author states that maximal maxillary anchorage was achieved through the use of a “transpalatal arch with headgear tubes.” It is not clear whether or not this patient actually wore a headgear, but I would contend that maximal anchorage is NOT indicated, nor desired with this patient. Although it is difficult to formulate a treatment plan from the records included with this article, it appears that a more ideal approach would have been to extract a premolar from the maxillary left side (most likely the second premolar due to the large pre-existing restoration) and from the mandibular left side, as well as the periodontally compromised maxillary right first premolar. This would have allowed for correction of the right Class II canine relationship to Class I, with SLIPPAGE of anchorage, while the midlines were brought into harmony with themselves and the facial midline. The final occlusal scheme would then have had a Class II molar relationship with the Class I canine relationship on the right, with a Class I canine and molar relationship on the left. This plan could have been accomplished in the same two years which was required for the treatment shown here, with a superior result, and without requiring the patient to wear a headgear.
The other concerns with the orthodontic treatment detailed here is that a significant space was left between the maxillary right canine and second premolar after the orthodontics was completed, requiring overly large restorations to be placed on those two teeth. This will result in periodontal compromise due to the overhanging restorations, which is contraindicated, especially at at site where there was a tooth with a previous eight millimetre periodontal defect. That space could have been closed with the orthodontics. The two plus millimetre midline deviation upon completion of the orthodontics is also suboptimal.
So, while I agree with the author’s statement that “orthodontic treatment to assist in the restoration of a compromised dentition can be the optimal treatment,” it is incumbent upon the practioner(s) to provide that optimal treatment, and to not undertake suboptimal treatment which then compromises the final result! Perhaps consultation with an orthodontic specialist prior to embarking upon treatment was indicated in this case.
Dr. P.G. Barer
Vancouver, BC
Philip Barer [pbarer@shaw.ca]
