Teeth Gone Wild: The Impacted Tooth Story, Part II

Snow day! Well not for us at TDR but for all of the lucky kids in the area. Check out the snow outside of our back door! Hopefully all of you in southeast Michigan are digging out safely and get to enjoy the beautiful, snowy, sunshine today.

The view out our back door!

Getting to more interesting I know that most of you have been waiting for the sequel to Teeth Gone Wild – The Impacted Tooth Story, Part I. I am thrilled to announce that the wait is over!   As you may recall, Part I included some mean old “wisdom” teeth who decided to go off the beaten path and do damage. Part II will star the ever popular CANINES! I know, you probably predicted this, but we had to keep it a secret for as long as possible. Canines are the most commonly impacted teeth and, much like a puppy, they can be unpredictable. Let’s talk about the different types of canine impactions, how we can try to avoid them, and what happens when nothing seems to go our way and we must go chasing them down.

Typical presentation of potentially impacted canines around age 10

An impacted canine occurs when the tooth does not get the instructions on where to go. The tooth then goes off exploring on its own and can cause problems if it is not re-directed. Impacted canines are very common so if you have one you are NOT alone! There are two types of canine impactions: buccal (pronounced: buck-al, and meaning on the cheek/lip side of the mouth) and lingual (towards the tongue). Many times when we identify them early enough we can take action to prevent an impaction. Research has shown that removal of the baby tooth along with a palate expander can increase the likelihood of re-directing a potentially impacted canine up to 60%. The case below is very interesting because one baby tooth was removed and the other was not. Coincidently, the side where the baby tooth was left in was left with an impacted canine while the other side looks beautiful!

Right baby canine extracted while the left was not. The left canine became impacted.

Now, even in the face of our best efforts during a first phase of treatment some canines go down the bad road. When this happens we must give them a little help. Once the braces are placed and the space for the tooth is prepared the oral surgeon will place an attachment with a small gold chain that we use to gently guide the tooth into place. This process can take anywhere from a couple of months to almost a year depending on how deeply impacted the tooth is. In addition, care must be taken while directing an impacted canine into place because if it is not done carefully damage to the roots other teeth can happen (see below).  In most cases the damage does not have any effect over the long term prognosis of the tooth but on occasion it can be so extensive as to requiring the extraction of the tooth.

Pre-treatment radiograph depicting two impacted canines

The canines made it into the mouth but there is damage to the roots of the laterals incisors.

You can’t save them all! Rarely a case will come by that the tooth is so off track that we risk the health of several teeth to bring it in. With these types of cases the best course of action is to remove the impacted tooth and plan for an implant replacement in the future.

This tooth truly lost it’s way! We have no chance of bringing this tooth into the mouth.

There you have it. This has been conclusion of the impacted tooth story. It has been quite a journey and hopefully you have found this helpful.

Thanks for reading!

Dr. Groth

Hire Me!

Hire Me!

While the next post was planned to be part 2 of the Impacted Tooth Story (Canines and Premolars, OH MY) I have decided to delay that post because of some interesting new research that just came across my desk. In the latest issue of the American Journal of Orthodontics and Dentofacial Orthopedics (AJO-DO, for short) the cover story reads “Do dental esthetics have any influence on finding a job?”

We have known for a very long time that there is a close relationship between physical and social attractiveness. The face, and smile in particular, play a pivotal role in this relationship. People that are deemed “attractive” are seen as being more intelligent, capable, and responsible. Those same people have been shown to be happier and more successful than those who have been rated as “less attractive.” Now, does any of this cross over to our professional careers? Unfortunately, it does.

This study took 10 people (shown in the photo) with a variety of orthodontic treatment needs. Each person’s teeth were digitally corrected (so the patient had two photos: one with bad teeth and another with perfect teeth). These photos were shown to 100 people that are responsible for hiring for commercial companies. Each person was rated on their likelihood of being hired, honesty, intelligence, and work efficiency.

The results of the study are as follows: the photos of the perfect smiles were rated as having a greater likelihood of being hired and as more intelligent than the non-ideal photos. However, the smiles had no effect on the honesty and work efficiency rating, thankfully.

There is further scientific proof that a great smile opens doors that may be closed otherwise!

Thanks for reading,

Dr. Groth

Teeth Gone Wild – The Impacted Tooth Story, Part I

Heck it has been a long time! Hopefully everyone survived the summer. In Michigan, we had a cooler than normal summer which was great for those of us who like to do physical activity outside but not great for anybody who spends time on one of our amazing lakes. Here are a couple of pictures, including an obligatory family photo, of where my family vacations during the summer in Northern Michigan (we call it “Up north”). When I first told my wife about going “up north” she said: “You mean Michigan isn’t north enough!?” She had no idea how amazing northern Michigan can be.

Enough about my summer, let’s talk about impacted teeth. An impaction basically means that a tooth is surrounded by bone and is unable, or unwilling, to erupt into the mouth. Most people are familiar with impacted wisdom teeth, because most jaws do not have enough space to accommodate wisdom teeth so they simply hang out in the bone waiting for two things to happen: 1) they get removed, or 2) they become unruly and begin to misbehave potentially causing damage to perfectly healthy teeth.  The photos below show impacted wisdom teeth that were not removed in time causing significant damage to the tooth on the lower right of the picture.

While we are on the subject of wisdom teeth let’s clear up a common misconception. Eruption wisdom teeth do not cause shifting of the lower front teeth. This has been a heated debate in the dental field for many years and nobody has been able to prove it to be true (despite some very good efforts). The shifting that occurs is generally due to the fact that as we age our lower teeth tend to drift forward more than our upper teeth. Our lower jaw is on an angle, towards the ground, compared to our upper jaw so gravity and chewing forces tend to push lower teeth forward. As they drift forward and begin to contact the upper front teeth they have no choice but to become crowded. For patients who have been treated, the eruption of the wisdom teeth around the age of 16-18 is generally the time when people think that retainers are no longer necessary. So this is truly a case of correlation and NOT causation.

Moral of this story is: get your wisdom teeth removed because an impacted wisdom tooth is NOT harmless, and WEAR YOUR RETAINERS!

Stay tuned for Part II of the Impacted Tooth Story where we will discuss teeth that truly have gone off of the beaten path.

Thanks for reading,

Dr. Groth

Retention and Retainer Fatigue

Retention

Ask any orthodontist what the hardest part of their job is and there is no doubt, in my mind, that a very popular response will be retention.  There are several possible “phases” to orthodontic treatment. Some patients may go through two-phase treatment in which there is a phase I, where we are very focused on fixing a specific problem before all of the adult teeth are in, and a phase II treatment for comprehensive bite correction. I believe we should consider retainer wear as phase III of orthodontics, because it is just as important as any other phase of treatment. I am sure many of you are reading this and thinking, “When I went through braces I was told to wear my retainer for a certain amount of time and then it was no longer necessary.” Let me tell you why this is a bad idea!

Clear Retainers with Typodont

In many regards preventing teeth from moving is the hardest facet of orthodontic treatment. Your teeth are not unlike anything else in your body, they are set in bone and surrounded by tissue and ligaments. Bone is not like cement. Bone can, and will, change and if you don’t actively maintain the final position of your teeth, they will move. What I cannot tell you is how much they will move. A great example of this (many of you may have already heard this from me while in the office) is the difference between my wife, Kelly, and me. Kelly was treated with upper only braces and rarely wore her retainer for the better part of 10 years and her teeth barely moved. I have gone through initial treatment and two rounds of Invisalign because if I don’t wear my retainers I can feel my teeth move throughout the day! My teeth want to move whereas Kelly’s do not. She is lucky! The major problem is that I have no way of identifying who will experience relapse and who will not, but I can say if you are wearing your retainers, you will have less relapse than someone who does not.

Retainer Fatigue

I also want to touch on the importance of replacing your retainers. Clear retainers are our retainer of choice for several reasons: they look better (and hopefully are worn better), and hold the teeth in their position better than the traditional Hawley retainer. However, there is one downside to these retainers – the plastic fatigues. Every time you remove your retainer you are stretching the plastic just a tiny bit. Over time the plastic stretches enough to allow micromovement of your teeth and as these movements get larger and larger the retainer stretches more and more. This is the reason why some people come in after wearing their retainer faithfully still have experienced some minor relapse of their teeth. Believe it or not your teeth are stronger than a thin layer of plastic. Crazy, I know! If you were to take a person who had been wearing their retainers faithfully for a year and gave them a brand new retainer made off of their original models, that new retainer would be much tighter than the old retainer due to plastic fatigue.

Lost Retainers

I can’t tell you how often to replace your retainer because there has never been a long term study on what happens to the retainer plastic over time. Our suggestion at TDR is to replace your retainer every 18-24 months (or sooner if they are getting the funk). If I had the ability to give someone a pill that would eliminate tooth movement (and retainer wear) I would do it in an instant. There is a substance that has been shown to reduce tooth movement when injected around the teeth; however, it has only been used on lab rats and will not reach consumers anytime soon.

The moral of the story? Wear your retainers and replace them regularly for the best chance of keeping your teeth as straight and beautiful as the day your braces were removed.

Thanks for reading!

Dr. Groth

The Importance of Losing Baby Teeth

Few things bug us more at TDR than double parking.  No, not the double-parking that you are thinking of (although that is very annoying as well).  The double-parking that I am talking about is when you have a baby tooth and its adult twin occupying the same space.  Not only does this make you look like a character out of a sci-fi movie but it also can have long-term consequences.  So why do we want you to get baby teeth out as quickly as you can after they get loose?  Read on and you can find out!

Double Parking

Source: http://www.mouthhealthy.org

First let’s talk briefly about what ages you can expect the baby teeth to exfoliate (our fancy scientific term for the loss of a baby tooth).  The first wave of baby teeth is generally lost around 7-8 years of age.  These are the 8 upper and lower incisors.  After this first wave there is a quiet period where no teeth will be lost.  The second wave begins normally around 10 years old and can last 1-2 years.  In the second wave the final 12 baby teeth are lost.  The last baby teeth to be lost, in general, are the upper canines or lower second primary molars.

There are two main things that we worry about when baby teeth are not lost in time.  The first is the redirection of the adult tooth that is supposed to replace it.  If an adult tooth does not “hit the runway” perfectly it can head in the wrong direction and begin to erupt ectopically (another of those fancy terms which means that it is erupting in the wrong spot).  Ectopic eruption often causes treatment to be prolonged because we need to work harder in order to get the tooth to the correct position.  The worst type of ectopic eruption is when a tooth becomes impacted (has gone off track so far that it will not erupt into the mouth without intervention).  The upper canines are the most common teeth to become impacted (see the x-ray for an example of an impacted canine).  Often if we suspect that this will be an issue we will ask for the baby canines to be removed to help give the permanent canine a better “runway” to land on.  If they do not hit the runway we have to go in after them, but that is another subject all together.

Impacted Canine

The second issue with retained baby teeth is that food can get trapped underneath the loose baby tooth and cause problems with the adult tooth that it is covering.  It is not unheard of to have a cavity on an adult tooth that has recently erupted because of this.  While this does not have any effect on our orthodontic treatment, we never want to have our patients risk cavities due to baby teeth that don’t want to come out.

Why are baby teeth so darn stubborn sometimes?  There are a couple of reasons.  First, the back baby teeth have several roots on them and if an adult tooth does not dissolve all of the roots that baby tooth will hang on for dear life.  Often these require the help of your dentist to kick them out of the party.  Second, gum tissue can be very strong.  The majority of retained baby teeth are simply being held in the mouth by the tough gum tissue surrounding it.  All it takes to remove these is some persistence and willingness to wiggle that thing out of there!

So when you are in the office and we ask you to wiggle out those baby teeth, please do it!  We never ask our patients to do things without a reason.

Thanks for reading and go wiggle out those loose teeth!

Dr. Groth

New Year’s Resolutions

Happy New Year! Hopefully everyone has enjoyed a bit of rest and relaxation during the holiday break. 2013 was a great year at TDR and we are thankful to all of our great patients and parents who continue to make our offices the premiere orthodontic practice in metro Detroit.

Looking back, a few of the 2013 highlights would have to include the arrival of two new members of the TDR family (babies Reese Groth and Beckett Majors), the acquisition of three iTero scanners allowing us to deliver the most technologically-advanced treatment possible, and Buddy the Elf making his debut at TDR.
One of the greatest achievements from 2013 happened late in the year and that was our recognition as one of the top 1% of Invisalign providers in the country! At TDR we pride ourselves in providing a variety of treatment options for both children and adults, and Invisalign continues to be one of our favorite ways to give people the smile that they deserve. While Invisalign may not be the best treatment for everyone, we do everything we can to offer it to anybody who wants it.

If you have been considering orthodontic treatment why not make it one of your New Year’s resolutions? There have been debates over the long term benefits of orthodontic treatment when it comes to the health of the teeth, prevention of gum disease, and the health of the jaw joint; however, there is no question that orthodontic treatment has a profound positive effect on a person’s quality of life. Many research studies have examined this and here are a few of the results that you should know:

• The vast majority of people (94%) notice a person’s smile first and it is a key component to their first impression of that person.
• People with straight teeth are perceived as more successful, smarter, and even get more dates!
• Crowding in the front of the mouth and having excess overjet were shown to have a negative impact on quality of life.
• A space between the two front teeth and crowding of the front teeth were rated as less beautiful compared to ideal alignment.
• Women with crowded teeth were rated as less capable than those with ideal alignment!

So there you have it! A beautiful smile not only can improve your self-esteem but potentially can land a date with your future spouse, or get you your dream job. For everyone who has just started or is in the middle of treatment use this as motivation when you think it will never end, and for those contemplating orthodontic treatment just imagine the doors that may open!

Thanks for reading!

Dr. Groth

Thanksgiving Smiles

It is Thanksgiving week which brings up a few things that we always take for granted. The first two are a couple of traditional football games that always occur this time of year: the Detroit Lions playing on Thanksgiving Day and the Michigan/Ohio State matchup, and Florida/Florida State (my wife’s favorite pick). While football has become a four letter word in our household because of how poorly our favorite teams are playing (my Wolverines and Kelly’s Florida Gators have failed to live up to expectations in a big way, Michigan State and Ohio State are on fire and the Detroit Lions seem to be on a slippery slope out of playoff contention), these games will be played and watched by everyone in the house (even Reese).

After watching the Lions, hopefully, win against Green Bay we will all eat too much turkey, stuffing, mashed potatoes and pumpkin pie and let the tryptophan lull us into a post-prandial nap for the ages. It happens every year, I tell myself that I won’t eat too much but the delicious southern spread that is put in front of me is too much to turn down. For those of you who have never tasted deep fried turkey, smoked turkey, or a true pecan pie I will tell you that you are missing out!

Let’s not forget the meaning of this holiday though. It is a time to reflect and give thanks for everything that we have in our lives; even something as simple and fulfilling as a smile. With this in mind, I will end my thoughts with this recent press release from Dr. Reyes and our hope to bring just that, a smile at this time of year, to those who are in great need of something to smile about.

Local Orthodontist Hopes to Send Smiles Across the Miles with Relief Funds for the Philippines

Dr. Brian Reyes

Rochester Hills, Mich., November 26, 2013 — You can read about it over and over, “4 million Philippine children in need of food and water” as the country struggles to get aid to the survivors. No dollar goes unnoticed and no effort is too small when the devastation is this widespread.

Dr. Brian Reyes, of Tyler | Dumas | Reyes Specialists in Orthodontics, knows very well the landscape and the destruction that is possible when a typhoon hits this archipelago. Born and raised in Michigan, he has been back “home” many times over the years, where his extended family resides. “My parents and I have been in touch with the family, and all are safe but the grief and the horrors of this storm are heavy on their hearts. This is far from over. It’s going to take a long time to reach out and start to rebuild/reconnect the country.”

Tyler | Dumas | Reyes has decided to try and send some “some smiles across the miles” and now through the end of the year will donate 50% of all Lasting Impression retainer fees to the relief efforts for Typhoon Haiyan. This along with hygiene supplies from the office will be going out in November and December.

“I hope our patients can really help us get behind this initiative and try to make any impact we can to bring the slightest relief. We are asking that if you need to replace your retainers, you might not want to wait,” says Dr. Reyes. “We would like to send our first donations by the end of next week and then continue through the end of 2013.”

“This feels like a drop in the bucket compared to the multi-million dollar campaigns of larger corporations but being mindful of our local responsibility to the schools and charities we support, we would like to stretch just a bit further and if we can bring a smile to even one hungry child in the Philippines,” continues Reyes, “then I believe any effort is a worthy endeavor.”

Thanks for reading and don’t be like me and eat too much food on Thursday!

Happy Thanksgiving – Dr. Groth

Fall

Fall is probably my favorite season.  Kelly and I love just about everything about fall.  We love that you can shut off the air conditioning and open up the house to let in the crisp mornings.  College football kicks into high gear with conference play.  The Big Ten conference may not impress many people this year but the rivalries that fall brings never disappoints!

Cider mills open for business after 9 months of down time.  I have learned that everyone has their favorite cider mill.  Most of these are the ones that we spent time at as a kid (personally, nothing will beat a cup of cider and a hot donut from the Franklin Cider Mill).  There is something about apple cider and a donut that brings us back to being a kid!

Fall also brings Halloween displays out of the attic. Anybody who has been by our house has seen our ever-growing Halloween display (this year we added a “monster in a box” and a motion-activated scarecrow).  Kelly grew up in Jacksonville, Florida on a dead end street where Halloween was not a big deal, so very few kids ever came to her house for candy.  This is completely different from our current neighborhood where kids run between houses to maximize their candy collecting potential.  I am sure some of them keep mental notes from previous years as to what houses give out good candy so they can map out an ideal route to hit all of the great homes.

Probably the best part of fall in Michigan is the amazing change of colors that we get to witness.  We often take the awesome display of color for granted because we have the pleasure of seeing it every year; however, it only takes one out of town guest who does not get to see this every year to knock us back into appreciating the beauty around us.  As we are coming closer to peak color I urge everyone to spend time outside, enjoy the awesome fall weather that we have been having, and most of all eat lots of delicious cider and donuts!

Stay tuned because Dr. Tyler will be guest blogging soon and will be choosing the topic from those submitted on Facebook!

Thanks for reading!

Dr. Groth

Founding Fathers

It’s the 4^th of July, one of our favorite holidays in the United States.  Today we celebrate our nation’s birthday with patriotic outfits, fireworks, eating too much food, and hopefully spending time on a lake (if you live in Michigan).  I am sitting on a dock in northern Michigan enjoying a beautiful day with my wife and my family as I write this post.  The 4^th of July is about more than bombs bursting in air, hot dog eating contests, and yelling “U-S-A, U-S-A” at any chance you get.  The 4^th of July is a time to remember the founding fathers of our country, and in the spirit of the founding fathers, I am going to give a short history lesson of orthodontics.

           

            People have been moving, or attempting to move, teeth dating back to the time of the ancient Egyptians.  Skulls have been found that have evidence of attempted tooth movement with catgut and crude metal bands wrapped around teeth.  Ancient Greek Roman remains were found with appliances that were used to maintain spaces between the teeth, and gold wires to keep teeth bound together.  We don’t know much about their mechanisms other than that they were crude and probably very ineffective. 

 

It was not until Pierre Fauchard, a French dentist, published a book titled The Surgeon Dentist in 1778 that an orthodontic appliance was well documented.  Fauchard devoted an entire chapter of his book to an appliance known as the “Bandeau,” which was essentially a horseshoe made of gold that went around the teeth and was used to expand the arch.   Although very crude, a modification of the Bandeau is still used today.

 

Several men deserve the title of “Father of Modern Orthodontics.”  Norman Kingsley and J. N. Farrar wrote important texts outlining how teeth should fit together and how they can be fixed.  However, there is one man who is the true founding father of modern orthodontics.  In the early 1900s, Edward H. Angle came out with the classification system that we use today to describe how teeth fit together (the Angle Classification), and designed the orthodontic bracket that set the foundation for the orthodontic brackets that we use today.  Edward Angle also founded the first school of orthodontics, founded the American Society of Orthodontics (which eventually because the American Associations of Orthodontics), and also created the first orthodontic journal.  Because of Edward Angle’s achievements, orthodontics became the first recognized specialty of dentistry. 

 

Without Edward Angle who knows what orthodontics would be like today.  Maybe we would not have the amazing technologies that were built upon his inventions and maybe everyone would be walking around with crooked teeth and not so beautiful smiles!  So while everyone takes a moment today to thank the founding fathers of the USA, also take a moment to thank (or curse him if your teeth are sore) Edward Hartley Angle.  Without Dr. Angle you could possibly be enjoying corn on the cob, popcorn, and all sorts of hard candy on our nation’s birthday, but you would also not be on your way to a life with an amazing smile.

 

Thanks for reading!

 

Dr. Groth

 

 

Rubber Bands: Not Just Orthodontic Torture by Dr. Christian Groth

One of most unpopular aspects of orthodontic treatment is the rubber band. This tiny, innocent piece of rubber causes more headaches for patients, parents, assistants, and doctors than just about anything else we use. So what is the deal with rubber bands? What are they doing? Why do we ask some of you to wear them at night only, others for 18 hours per day, and some full time? Your questions will hopefully be answered below.

There are two basic types of rubber bands: those that move your teeth in a front to back direction, and those that move them up and down. If you have read the “Beginner’s Guide To Orthodontic Language” you should know that a Class II bite is one where the lower teeth are behind the upper teeth. The “Class II elastics” aim to bring the bottom teeth forward and upper teeth backward. Since the Class III bite is just the opposite, Class III elastics aim to bring the upper teeth forward and lower teeth backward. Check out the photos below for a visual representation of how the teeth are moving.

Class II Elastics move upper teeth back, lower teeth forward

Class III Elastics move upper teeth forward and lower teeth back

These are both front-to-back corrections. What about the up and down types of elastics?

Once the teeth are close to their correct position, we want to make sure that they fit together really well. In order to help this happen we will have patients wear “triangle” or “box” elastics. The typical triangle elastic hooks to one tooth on the top and two on the bottom in a – you guessed it – triangle fashion.

Aiding vertical tooth movement with Triangle Elastics

On the other hand, box elastics hook up to two teeth up top and two teeth on the bottom.

Aiding vertical tooth movement with Box Elastics

To be efficient we can have patients use “Class II triangle” elastics that help bring the lower teeth forward and the teeth together at the same time.

Now comes the time dilemma. Very often we ask people to wear their elastics full time or for 18 hours per day. When they take the liberty of wearing them a bit less, that patient is shocked their braces are taking longer than we anticipated! In general, when we ask a patient for full time elastic wear, we are looking for a sizable amount of bite correction. Wearing elastics is similar to pushing a big ball up a hill. If you push that ball consistently all day you will get to the top sooner than if you stop and let go of that ball for a while and let it roll back down the hill. When we need a small amount of correction, or have completed a large amount of correction and want to back off slightly, we will ask patients to wear their elastics for 18 hours (generally that is all the time except for school hours). If we want to hold the teeth where they are we will often simply ask for nighttime wear.

When we ask for a certain amount of rubber band wear we are doing so for a reason. We all understand that rubber bands are a pain in the rear, but they are a necessary evil for almost every orthodontic patient. Studies have shown that poor rubber band wear can extend treatment significantly. PLEASE wear your rubber bands as we ask because although we LOVE seeing our patients we would rather be checking your retainers (we will address that issue in another post), and not begging you to wear your rubber bands.

Thanks for reading,
~Christian Groth