Metal Mouth Message Board

Dr J--I hope you can clue me in here. My ortho says that the use of a device such as a W-Arch as you describe (Quad Helix) can't be used on adults (male, 33) because in a number of years down the road, their will be substantial gum recession and movement of teeth lingually after being shifted through this method.

I found an article (I am a research hound when it comes to something I am passionate about--and my mouth has lately become a passion of mine) that I am attaching here

http://www.angle.org/anglonline/?reques ... 02-0129-b1

After reading it, it seems that it was tolerated well in the test subjects. My question for you is:

What is your opinion on this subject? I have a posterior crossbite of about 50%, and have had 4 extractions (2 upper 2nd bicuspids, 2 lower 1st bicuspids--both to be used for space for crowded front teeth). I would really like to be rid of the the crossbite without SARPE.

Thanks for any insite you can provide.

I have been wearing a palatal expander for 14 months now (no surgery). If the results are not stable, I will sue the ortho for sure.

ShinyAM--are you using one with a key (Haas type) or a quad helix (W-Arch)? What was your diagnosis? How old are you if I can ask?

I'm using one with a key to expand the arch. I had severe overcrowding in the front. The doc told me two to two and a half years.

I was 29 when I got them on, 30 right now.

I am really going to push my ortho for a reason that he doesn't want to use an arch expander. Is your ortho younger (less than 40) or older?

thanks....

The bottom line is that a W-arch or quad helix - or even an RPE on a mature adult - results in dental expansion through the tipping of the teeth out. This means that the teeth will be in a position to accept the forces of mastication along a slant rather than their long axis. They will relapse back to a vertical, more healthy position.

A crossbite with good vertical interdigitation is much more healthy - dentally and periodontally- than a corrected crossbite by lateral tipping. The lingual cusps of the upper molars will become intereferences to excursions of the mandible when teeth are tipped.

Regarding the age, or comfort level of the orthodontist.. believe what you want. There are docs out there that just want you in treatment and will pick up the pieces later. Yes, there are success stories. But NOTHING IN THE LITERATURE SUPPORTS NON-SURGICAL ADULT EXPANSION WITH SEVERE CROSSBITES AND HAS A HIGH RATE OF STABILITY. There is always a study someone can Google that the layperson thinks fits a certain orthodontic side of a contraversy - but just know that non-surgical correction of skeletal crossbite by tipping is tantamount to complete relapse.

Dr.J

I read the article that was sited by Haas -ie. the Haas expander. This is required reading as a resident and very compelling. One problem: few folks are able to get this to occur on their own patients. His 47 folks that expanded - not fully if you read it xloely - are not typical.

Good literature citing however. I live for this stuff - perhaps that why I am such a dork!

dr.J

If I do have a relapase, what are my chances of winning a verdict against my dentist? He never gave me any options.

Jodster wrote:I am really going to push my ortho for a reason that he doesn't want to use an arch expander. Is your ortho younger (less than 40) or older?

thanks....

Yes, he is probably 35-40.

As a fellow dentist I would hope it would not come to that. Relapse occurs on many levels. One of the reasons that healthcare costs are out of control is b/c the price of malpracitce insurance is spiralling to oblivion -thus medical/dental services are more expensive. Hopefully tort reform will come about in the future before we have a huge national crisis. Touchy subject. I would really not jump to the thought of suing a dentist and possibly ruining their professional life (or just life) because of relapse of the upper arch width.

I would address this to the orthodontist and try not to let things get adversarial. Just explain your expecations. But that's just my point of view as an orthodontist.... ...definitely a subject of heated debate.
Esp. if your a lawyer.

Dr.J

Dr. J--thank you for your candidness and professional response. I guess I will need to thoroughly rely on his (my ortho) professional opinion. I just don't like the crossbite and SARPE is not a possibility in my mind. It isn't bad, I just wish that it was correctable with something besides surgery, or at least made a bit better.

The advances in orthodontics has been amazing, but I guess nothing beats mother nature.

I agree that society has become too litigious and unless there was gross negligence on a medical professional's part, I would never think of litigation as an avenue for something that happened to a family member or myself.

Thank you once again, you are truly a scholar and I think that being a dork is a great thing if it means that someone is continually educating themselves and trying to do what is best for their patients.

by this do you mean the fitting of the cusps together (top and bottom)? If I were to provide pictures prior to treatment would you be able to comment even more intelligently than you already have?

I agree that Dr. J's response was great. As a fellow medical professional I have only recently started responding to such "I'm going to sue" comments by shaking my head and keeping comments to myself.

A hijack and a question.

shinyam wrote:I have been wearing a palatal expander for 14 months now (no surgery). If the results are not stable, I will sue the ortho for sure.

Sorry folks, I just can't ignore this one.

First off, shinyam, you’re commenting about your own situation in someone else's thread, which in bulletin board world is inconsiderate. But ya did it anyway and you didn't even say sorry.

Second, you throw out "sue" quite flippantly, in the Ask the Doc section no less.

shinyam, if you are an adult, then you should understand the concepts of second opinions, weighing options, asking questions, making decisions based upon what you think is right in your situation, and then ultimately living with those results.

There is a HUGE difference between negligence on a physician’s part and you getting pissy over a tooth in 10yrs. Relapses happen. Physicians (hopefully) do the best they can, with the current tools and knowledge, and the unique medical situations they are presented with. BUT biology sometimes has a mind of its own. There is NO WAY a doctor can guarantee the results will last until your dieing day. Add the fact that you probably sighed something to this effect in your ortho's office before treatment. Read the paperwork.

If I have come across a bit harsh, it’s just that the way you threw out that comment came off as quite immature and ignorant.

/end of my hijack (again sorry)

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Jodster, even though I am not in your situation, I found your question and the doc's answer quite educating. I hope things work out for the best.

dr.j, interesting answer. A bit eye crossing to get through the jargon, but I am more the wiser, AND you've expanded my vocabulary.

Last I recall, there is no literature that definitively proves taking vitamins in pill form does anything for us either, but heck, I take one daily anyway.

Finally, a question on your below statement:

They will relapse back to a vertical, more healthy position.

Do the tipped teeth relapse because of natural forces occuring in the mouth, the pressure of the retainer, or just due to the fact that it is not the "natural" position they should be in?

Teeth tend to "want" to be positioned "upright". Meaning: the crown of a tooth (the enamel part) seeks to place itself over the root in the vertical plane.

Here is an example on a patient I am treating:

He had an upper left lateral incisor in a crossbite behind his lower teeth. Well, with braces I "jumped" this tooth out of crossbite by having the archwire carry the tooth forward via the bracket: flaring if you will.
Physics 101 says that if I have a force acting at a distance from the center of mass of an object i.e. the middle of the tooth root, the object/tooth will not move bodily but will tip. This is called a MOMENT. I created a tipping moment on the lateral. Well, now the root apex is still in the same place it started, it needs an incredible amount of root movement to come forward and join its buddies: the apices of the other normally positioned teeth in the arch. If I were to remove his braces now, the lateral incisor - seeking to be positioned normally in the vertical plane - would relapse 100% back to where it started. TEETH WANT TO BE UPRIGHT.

Furthermore: if we flare molars to get them out of crossbite - and I'm not saying I don't do this ever - we are challenged to torque the roots of these teeth outward to make them upright. Tough task! Teeth in crossbite are often already flared in a mechanism called dental compensation. Also, bringing the roots of molars out over the crowns of the teeth may put them in contact witht the cortical bone plate which is a no no.

This is not to say that good orthodontists do not expand the arches orthodontically (wires and w-arches,etc.). I do. But my patient has been informed of the risks of relapse and their unending marriage to a retainer.

Many folks say that they are fine with wearing a retainer everyday forever. How many folks do you know lose a ton of weight on Atkins and say they will just diet forever - easier said than done! Indefinite retention is tough to accept and tough to enforce.

Great subject. We have a Divinci Code type contraversy here!

Dr.J