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Early Orthodontic Treatment: Defining Goals and Establishing a Viable Treatment Plan in Early Trauma by David A. Balhoff, DDS

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Introduction

"Does Johnny really need two sets of braces?" and "What will happen if we don't treat Johnny now?" are two of the more commonly posed questions by parents of young patients considering two phases of orthodontic treatment. The answer given by the orthodontist should obviously be based solely on the individual patient. If indicated, early interceptive, or Phase 1 orthodontic treatment is often beneficial for both short-term and long-term goals for patients.

Early interceptive treatment has many potential positive outcomes. It can positively alter facial growth, lessen the severity of Phase 2 orthodontic treatment, reduce the likelihood of trauma to maxillary and mandibular anterior teeth, decrease further attrition and recession involved with specific teeth, provide spacing that is necessary for the permanent dentition (or the opposite in serial extraction cases), reduce or eliminate specific habits, and improve the overall self-esteem for many patients. These benefits must be weighed versus the cost, time, patient maturity and compliance relative to treating the patient only comprehensively in the future.

The aforementioned outcomes of early treatment are only successfully attained if specific treatment goals are established for patients. Proper dental aesthetics, an ideal functional occlusion with seated condyles, stability, periodontal health and a patent airway are necessary goals. Additionally, and most importantly, goals and treatment plans must take into account the patient's overall facial aesthetics. In the September 2004 issue of American Journal of Orthodontics, Dr. Bill Arnett, an oral maxillofacial surgeon in Santa Barbara, stated, "The bite indicates a problem. The face indicates how to treat the bite." Many orthodontic treatment plans are still dictated initially and predominantly by the patient's dentition. Such plans sometimes fail to produce the best aesthetic outcome for the patient. For example, Dr. Doug Knight, an orthodontist in Louisville, Kentucky, stated "in Class II malocclusions, the overjet should not be reduced by over-retraction of the upper incisors relative to a true vertical line from anterior nasal spine. Such orthodontic retraction will lead to facial decline and an unsupported upper lip." Additionally, extractions do not always imply retraction of the incisors or retrusion of the profile. Extractions often help to control the vertical dimension and can even allow for autorotation of the mandible. Therefore, extractions can achieve both proper overbite and overjet and a more balanced facial appearance.

The patient presented below provides another scenario in which early orthodontic treatment can help to obtain a more favorable long-term orthodontic result.

Case Presentation

Examination and Diagnosis

An eight-year-old female was referred as a result of a bicycle accident whereby she completely avulsed #9 and partially avulsed #8. The general dentist also previously referred the patient to an endodontist to evaluate the vitality and long-term prognosis of #8. A periapical radiograph (Fig. 1) revealed an apparent horizontal root fracture in the apical third of #8. Slight mobility was noted with #'s 7, 8, and 10. Dentally, there existed a mild Class II Division 1 malocclusion with mild upper crowding and moderate lower crowding (Figs 2-11).

The maxilla was slightly constricted and alow maxillary frenum was noted. Cephalometrically, the mandibular plane angle was steep, the lower-third facial height was long, and the upper and lower incisors were relatively upright. A slightly constricted airway inferiorly was noted. Facially, mild lip incompetency, lower lip eversion, and mild mentalis strain were all present. The zygomatic areas were slightly deficient due in part to the overall constricted development of the maxilla. Articulated models were taken of the patient.



Treatment Plan

Several treatment options were considered, including salvaging #8. The endodontist recommended endodontic instrumentation to the level of the fracture but not beyond, then CaOH placement for one month. Mineral trioxide aggregate (MTA) would be used to fill the coronal two-thirds of the root leaving the apical portion alone. The patient would then be placed on recall appointments at six months, one year, two year, etc. If the apical portion underwent necrosis at any time, an apicoectomy would be subsequently performed.

The patient's parents decided not to undergo endodontic treatment due to the possibility of losing #8 long-term. Instead, they requested that the general dentist monitor #8 and leave the tooth as is. The general dentist recommended this was not the best option for the patient. The parents also wanted to avoid the possibility of placing implants in the future. After consultations with the general dentist, a compromised, yet viable, early treatment option was established for the patient. Tooth #8 would be extracted with substitution of #s 7 and 10 for #s 8 and 9, respectively. Towards the end of early treatment, #s 7 and 10 would be restored with composite bonding (to simulate #s 8 and 9) and #s 6 and 11 would be restored with composite bonding (to simulate #s 7 and 10) until later Phase 2 orthodontic treatment. Growth and tooth eruption would then be monitored to determine whether or not the lower second bicuspids would need to be extracted in the future to accomplish our goals. The extraction of lower second bicuspids would potentially help to decrease the excessive lower-third facial height, allow for auto-rotation of the mandible, and alleviate crowding and mentalis strain. An RPE was considered. However, it was not used as part of early treatment due to the distance that the upper lateral incisors would need to already be mesialized. Our primary goal was to provide for an ideal, long-term dental result, while enhancing the patient's facial aesthetics.

Treatment

Seven months after the treatment plan was established, the general dentist surgically extracted #8 and its apical root tip. Two weeks later, GAC Ovation .022" brackets were placed on the upper 6s, Cs, and 2s. NiTi open coil springs were activated between the upper Cs and 2s to mesialize the upper 2s into the space of the central incisors. Archwires included 14NiTi, 18x18NiTi, 20x20NiTi, and 18x25SS. The upper Cs became mobile and were removed by the patient and NiTi open coil springs were subsequently activated bilaterally between the upper 6s and 2s to continue mesializing the upper 2s into the ideal space. Ormco power chain was also used to help close the spaces between the upper 2s. A progress Panorex was taken 7 months into treatment (Fig. 12). The upper 3s and 4s were eventually bonded and open coil springs were placed to mesialize the upper 3s into the spaces previously maintained by the upper laterals. After 13 months of tooth movements, the patient was referred back to the general dentist to evaluate spacing to restore #s 6, 7, 10, and 11. Two months later, all fixed appliances were removed and the general dentist restored #s 6, 7, 10, and 11 with composite bonding material. An upper Essix retainer was made after the restorations were completed. The lower arch was never orthodontically treated. Final photographic records (Figs. 13-20) were taken.



Results and Long-term Prognosis

The total treatment time was 15 months. Due to the patient's compliance with appointments, the overall immaturity of the patient's alveolar bone, and the young age at which the incident occurred, the early treatment's coordinated goals and plan produced a positive outcome. The parents were very satisfied with the final result. The patient displayed less lip incompetence, yet the lower lip eversion and the deficient maxilla and zygomatic areas are still present. Despite missing her upper central incisors and the remodeling of the maxilla and A Point, the patient's facial and dental esthetics appear acceptable, though not yet ideal. The low maxillary frenum, the non-ideal positioning of #s 7 and 10, and the lower incisor positioning/crowding complicated the general dentist's ability to provide ideal width and length to the composite restorations. The root of #10 appears to have shortened as a result of treatment and possibly from the bicycle accident. The most recent Panorex (Fig. 21) showed cervical burnout in addition to a slight overhang around the distal of #10. In hindsight, a lower lingual arch would have helped in maintaining the lower E space in the event that non-extraction treatment in the lower arch was the preferred treatment in the future. The patient has been seen once since the completion of treatment one year ago and records were recently taken (Figs. 22-29). An upper 1mm diastema is now present. The endodontist and the general dentist will be monitoring the long-term health of #s 6, 7, 10, and 11 due to past trauma and the distance that the teeth were moved mesially.

If future Phase 2 orthodontic treatment is undergone, the two most viable treatment plans to be considered are the following:
  • An RPE and a palatal TAD with a TOMAS T-bar would be placed in order to maintain the A/P positioning of the upper incisors and therefore maintain the upper lip in its position. The anchorage from the T-bar would be utilized to mesialize the upper posterior segments. The lower second bicuspids would not be extracted and lower interproximal reduction would instead alleviate the crowding. Final cosmetic restorations would be done in the upper arch.
  • An RPE would be used and lower second bicuspids would be extracted. Minimum anchorage would be employed. Final cosmetic restorations would be done in the upper arch. Phase 2 orthodontic treatment is currently pending.




Conclusion

Early orthodontic treatment can be very beneficial in helping to provide ideal long-term results. Timing of treatment and well-defined goals undeniably play a vital role in the overall outcome. It is important to be mindful, however, that patients or their parents may make choices that can affect ideal treatment planning which influences the mechanics used during treatment. As a consequence, out-of-the-box treatment approaches are sometimes necessary to produce an acceptable facial and dental aesthetic result.

Dr. Balhoff would like to thank Dr. Stephen L. Sherman, Dr. Robert Ory, Dr. Ben Ory and Dr. Blair Gremillion for their coordination with the presented case. He also thanks the LSU Orthodontics department and faculty, Dr. Doug Knight and the Full FACE course faculty, and Smiles Change Lives for helping to contribute to the orthodontic profession.


Dr. David A. Balhoff is in private practice with Dr. Stephen L. Sherman in Baton Rouge, Louisiana. Dr. Balhoff graduated from the LSU School of Dentistry Orthodontics Residency program in New Orleans in 2008. He completed the Full FACE USA course under the guidance of Dr. L. Douglas Knight in 2012. Dr. Balhoff received the New Dentist Award for the state of Louisiana in March 2014 and is also a member of the American Cleft Palate Craniofacial Association (ACPA). Dr. Balhoff was the first orthodontist to start treating patients through Smiles Change Lives in the state of Louisiana. He is married to Leah Blaize Balhoff and they have two sons, Thomas and Andrew. Dr. Balhoff can be contacted at david@shermanbalhoff.com or at 225-769-1276.

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