Sessions Ortho Blog

Invisalign Case with Supernumerary Tooth & Ectopic Tooth

2011-10-11T20:55:00.000-07:00

I had a 20 yr old patient who presented for cosmetic correction with Invisalign treatment. He had a supernumerary tooth that caused tooth #27 to become ectopic and impacted. He declined exposure and positioning of #27 for a variety of reasons. With this in mind, our plan was then to remove the super and impacted #27. We would deliver Invisalign trays to align his teeth and to open space over retained deciduous tooth #R for a future implant.

To the right is the Invisalign "Clin Check" or set-up that shows the original malocclusion of the lower arch. As a side, it is one of the first Invisialign set-ups in the United States produced by our laser scanner. When measured, deciduous tooth #R is approx. 5.5mm wide.

To the right is the final Invisalign Clin Check that shows the resultant space that will be opened mesiodistal to #R. I asked Invisalign to open the space over #R to approx. 7.6mm. This is a little less than the width of the opposite tooth #22 but the occlusion and cosmetics worked out best to have this tooth this size. 7.6mm allows our Oral Surgeon plenty of space to place the implant following treatment.

Orthodontic Bonded Retainer for the Maxillary Arch

2011-09-25T19:39:00.000-07:00

Several years ago I came up with a style of lingual bonded retainer that allows easier flossing. This scalloped design also can be placed quite low. The very gingival positioning really helps keep it out of occlusion with the lower incisors. I use a stiff enough wire that it very nicely holds the alignment to prevent relapse. Quite a few hygienists have called me and said that they really like how much this improves oral hygiene. This design however doesn't work well in the lower arch. Because the teeth are so close together, the scalloping is so tight, it collects plaque and food.

Jeff

New Invisalign Digital Scanning for Patients

2011-07-18T22:02:00.000-07:00

Invisalign recently began allowing orthodontists & dentists to submit digital laser scans instead of PVS intra-oral impressions. We are the only office in the State of Oregon using laser technology imaging. We use the same iTero scanner that we use for our digital models. Alginate impressions are the common method for diagnosis or off-site scanning.

The iTero scanner is a huge breakthrough with Invisalign and a relief for our patients. It's like night and day when it comes to patient comfort; no longer does a patient have to endure multiple upper and lower impressions. The scanner also quickens turn-around time at Invisalign by at least 7-10 days. From a practice management standpoint, not only is this technology more comfortable for the patient, but this machine saves time and money. Having said this, many orthodontist may take years to implement digital scanning since the "tried and true" is still comfortable and familiar to the majority. Jeff

Supernumerary Tooth Impeding Eruption

2011-06-07T22:17:00.000-07:00

I received a second opinion exam where an orthodontist wished to extract tooth #14 (on the pano to the right) for "non-eruption." He had been monitoring it for some time and it was not erupting. The patient asked their pediatric dentist and he felt that there were other options available that did not involve extraction - exposure and/or exposure and luxation ( assuming ankylosis ) to see if the tooth would respond and erupt.

We found a pleasant surprise with our iCAT 3D imaging. On the coronal cross-section to the left, you can see a hint of the supernumerary tooth impeding the eruption of #14.

On the sagittal cross-section to the right you can see that due to the palatal orientation of #14 that the supernumerary tooth is blocking the eruption of #14. The 2D pano above doesn't show the supernumerary tooth and doesn't show the palatal angulation of #14.

With this information. We recommended removal of the supernumerary tooth. This should allow the eruption of #14 now. The million dollar question is: would the surgeon without 3D have taken out #14 and discovered the supernumerary tooth?

Ectopic Bicuspids Found from Cone Beam iCAT imaging

2011-04-09T19:56:00.000-07:00

The first radiograph is the iCAT Tru Pan that looks fairly routine. You get a hint that the maxillary second bicuspids might be intersesting. Normally most of us would probably monitor the maxillary deciduous second molars and underlying second bicuspids.

When you see the next radiograph you can see that both bicupids are quite ectopic towards the palate with the maxillary left one also considerably rotated.

With this information it would probably be beneficial to have the maxillary deciduous second molars removed now to see if the bicuspids might erupt better or erupt at all. Palatally ectopic bicuspids are often markedly delayed in eruption and often do not resorb the roots of the deciduous second molars.

3D Laser Scanning to Replace Alginate/Plaster in Orthodontics

2011-01-15T13:24:00.000-08:00

Our orthodontic office has been using 3D digital models for almost 10 years now. Just recently however, we have taken the next step. iTero through OrthoCad just developed the first intraoral laser digital scanner. Our office was the first in the state of Oregon to start using one of these machines and to date I believe we are still the only office in Oregon using this technology.

The hugh advantage of this scanner is that a new patient doesn't have to have a set of alginate impressions taken. This is especially nice for some of our young Phase 1 patients. Also, the models are more accurate than alginate and plaster. They are so accurate that you can see hairline cracks, chips and even plaque accumulation on the enamel surface. The digital bite capture is also more accurate than the wax bite registration that orthodontists routinely employ. Other advantages are that you can make measurements to the nearest 1/10 of a millimeter. This is very handy for tooth size analyses and tooth size discrepancies.

For those of you that are green friendly, laser scanning eliminates alginate from the records process, reduces sterilization costs, eliminates plaster, eliminates plaster models storage costs and boxing materials, eliminates laboratory procedures and costs to produce plaster models,

3D Cone Beam Tomography Continuing Ed

2010-10-31T00:10:00.000-07:00

Imaging Sciences ( iCAT manufacturer ) put on a great C.E. course in Las Vegas. It gave Melanie and I an excuse to enjoy the town after my classes. Most of you will recognize these statues from Caesars Place.

I was the only Orthodontist in the course. Most of the attendees were dentists/specialists who are doing implants on their patients. The C.E. was in regards to normal anatomy vs. patology as seen in 3D tomography. The instructor was a radiology instructor from Columbia University who has specialized in cone beam tomography for the last 6 years. The image that follows is an axial image at the level of the floor of the palate. The instructor spent most of his time going through axial images starting a the level of C4 vertebra and slowly working his way up through the head to just above the level of the pituitary gland. Fortunately most of the pathology is found in 40+ year old patients who only make up a small part of my orthodontic practice.

This 10 yr old has a supernumerary tooth impacted in his palate as you can see. Previous and traditional x-rays : panos, bite wings and PAs did not show this "surprise."

Hidden Teeth Found from iCat 3D Cone Beam Imaging in Orthodontics

2010-08-30T23:13:00.000-07:00

This is an orthodontic patient that I recently finished with a very nice result. We have been monitoring the upper left 12yr molar (#15) that has not erupted yet as seen on the Tru Pan rendered by our new 3D iCat Cone Beam machine (upper right xray). Our previous 2D digital panos (not shown) showed this unerupted molar essentially as it is now except higher in the bone. When we took an iCat 3D film, I evaluated the molar in question with the cross sectioning tool and found a "wisdom" tooth (upper left xray). This tooth was so perfectly hidden or positioned palatal to #15 that it didn't show on my previous 2D panos and did not show on the 3D Tru Pan that our iCat renders for quick viewing. It only presented when I cross sectioned (click on upper left xray) the Tru Pan and looked at the 3D representation (gold image in the lower left). The serial cross-sections (lower right images) also show this hidden tooth.

Prior to this new imaging that we now routinely use for our patients, I would have continued to monitor this tooth thinking that it might be ankylosed or be experiencing "primary failure of eruption." After enough time to see if eruption would occur, I would have presented leaving this tooth "as is," surgical luxation and/or removal. Now that I know that the wisdom tooth is essentially attached to #15 and appears to be within the same follicle as #15, I will ask the surgeon to remove the wisdom tooth and check for ankylosis of #15. Hopefully this tooth will start to erupt once the attached wisdom tooth has been removed.

In Blogs to come, I'll show other cases that only 3D would effectively show. Obviously I made the best decisions I could prior to 3D, but in just one month of using the iCat, I have not only found several "hidden" teeth, but I have changed my treatment plans several times over with the new information that 3D reveals.

Jeff

3D Cone Beam iCat X-rays

2010-07-17T08:15:00.000-07:00

For several years now, I have been waiting for 3 dimensional x-rays to come to orthodontics. This year, iCat improved their software to make it orthodontist friendly and created several options to scan a patient with very acceptable radiation amounts.

Our standard "3D pano" that we take on orthodontic patients is a 9 sec. scan with radiation essentially the same as my previous Sirona digital pan/ceph unit which was still lower than conventional film based units that many doctors still have. We also can take much higher resolution scans with longer scan times. These scans will be used when I need to see something that is not "routine" ( eg. root fracture or pathology) or if doctors send us a patient where they want us to take a 3D CB for an implant, etc.

The extremely beneficial feature of having 3D in orthodontics is that I no longer have to guess at a tooth's position base on a "flat" 2 dimensional image. Day in day out, I have new patient exams were I see ectopic cuspids, unerupted and "over-lapping" lateral incisors, twisted and ectopic 2nd bicuspids, etc. Now in 3D, I can look at the ectopic tooth position from several cross-sectional views and know exactly were the tooth is, it's path of eruption and how close it is to adjacent teeth.

Even though I have only had this machine for 2 weeks, patients are finding it very informational and are finding the technology very impressive. Another user friendly feature is that iCat makes if very easy for us to send or print a "JPG" file of any of the views to a doctor or patient. We can also "burn" a CD on any given patient that has the entire 3D file of the patient. The CD caries the complete software to view and manipulate the patient file on any PC computer.

If any one wishes get a quick 10 min lesson on how the use the software, please let me know. It is very fun and is definitely going to be the "standard of care" in Orthodontics and Oral surgery.

Jeff

2010-05-09T19:22:00.000-07:00

I was in Washington D.C. last weekend for the national American Association of Orthodontists meeting. There was only a small handful of Oregon orthodontists there as compared to last year. The scientific lectures were excellent and I learned about some new research on TMD, sleep apnea, and Invisalign.

I also purchased two new items in the technology department that will become standard of care in our profession in the next decade. I bought the iTero scanner for scanning patient's dentition with a laser wand and the iCat 3D cone beam machine.

The iTero has been available for general dentists to scan single teeth or bridge preps for a few years now. It was just introduced for the first time at this meeting to orthodontists. We will be able to scan a patients mouth with a laser for our initial and final records models. The really neat thing is that our child patients or our "gaggers" will not be subjected to a mouth full of alginate as one of their first steps into braces.

The iCat was upgraded since I first looked at it last year and it now has pertinent features that are more suited to an orthodontist than an oral surgeon. I truly believe 3-Dimensional images will revolutionize diagnosis for orthodontists, oral surgeons and other areas of dentistry. The really cool thing is that I will be able to send any dentist or patient the entire 3D scan with attached software that allows you to fully manipulate or "slice" any area of the head to see the area of interest.

I really wanted to be at the forefront of both of these technologies. 3D will be the standard of care quite quickly and the laser scanner is more of a tool to add additional comfort to patients. When both of these pieces of equipment are delivered in late June I'll give you an update about each.

Jeff Sessions, DMD

Invisalign Appointment

2010-04-05T20:23:00.000-07:00

I’m delivering a set of Invisalign trays to Gina. You can see our laptop computer that shows the patient their “Clin Check.” This 3D software package shows incremental stages of tooth movement that is used for developing the patient’s treatment plan.

Initially, the patient’s PVS impressions are sent to Invisalign and an online prescription is filled out. The Rx indicates which teeth are to be moved, how they should be moved and where they should be moved. The patients PVS impressions are scanned by an MRI and 3D files are generated. Several weeks later, the 3D Clinical Check is ready. It is essentially Invisalign’s best representation on how the patient’s teeth will be moved and straightened. After several emails to and from the lab tech at Invisalign, we attain a plan that will give us the best result, the trays are sent to us.

Invisalign: Before and After

2010-03-03T22:09:00.000-08:00

This is an example of an orthodontic patient treated solely by the Invisalign technique. Linda turned out great and she is thrilled with the results and experience. This is a typical example of what kind of case walks through my door. What is not typical is that a case that has such narrow arches and marked rotations ususally requires fixed appliances to finish nicely. What helped make this case an Invisalign only case was that Linda had a great attitude and her compliance with wearing the trays was phenomenal.

I haven't shown all the photos, but Linda's lower arch turned out equally well and her occlusion was also finished nicely. Following treatment, patients have to choose some type of retention plan. In my practice, we offer lingual bonded retainers or clear removable retainers. Linda chose to wear clear polyvinyl trays/retainers to hold her teeth in place.

Laser Exposure Procedure

2010-02-01T21:55:00.000-08:00

The picture at the right is a typical application of how I use my soft tissue diode laser. It is common in early treatment to open space for blocked out teeth. The tissue in these areas is often thick, fibrous gingival tissue. Often, lateral incisors or cuspids erupt to this thick surface tissue and stall out for many months, delaying orthodontic progression. In this particular case at the right, I opened up space for tooth #7 and we waited several months for this tooth to erupt. To avoid further wasted time, I opened a small widow with the laser allowing bracket placement so as to expedite treatment.

The procedure is very simple. We "numb" up the area with a topical gel anesthetic. After about 2-3 minutes of topical gel, we dry the area and the laser "vaporizes" the tissue over the tooth. The laser vaporizes the tissue with no bleeding or pain. All of the patients that have gone through the procedure have said it is simple, quick and pain free.

Following exposure, I bond a bracket to the exposed enamel and engage it to the archwire to begin moving the tooth into place.

Parents and patients have been very happy and impressed with how easy the procedure is and how much it expedites their treatment progress.

2010-01-10T20:21:00.000-08:00

Many of the dentists that I work with already know that I bought a soft tissue laser early in 2009. The nice feature of the model that I bought is that it is cordless and has disposable tips. These are phenomenal features when it comes to ease of use and sterilization.

I've been using it for shallow soft-tissue cuspid and lateral incisor exposures. I use the laser when we have waiting several months for a tooth that is extremely slow to erupt. Any tooth with overlying bone is still sent to the oral surgeon or periodontist.

The actual exposure takes about 5 - 10 mins with the entire procedure taking 20 - 30 mins. It requires a topical anesthetic over the exposure site. Once about 2 mm of the tooth is available, we bond a bracket and engage it to the nickle titanum archwire.

The parents have been thrilled with the ease and are blown away with how quick the tooth moves into place once we attach to the newly available tooth.

Also to date, I have had no patients complain of any pain during the procedure or post operatively :)

Orthodontic Splinting for Avulsed or Luxated Teeth

2009-12-16T21:12:00.000-08:00

This is the result after I positioned #8 and especially #9 back into their sockets. Brackets and a wire work very well for semi rigid fixation. This minimizes the chance for the teeth to ankylose. Braces have another advantage: about a month after splinting with braces, it is often necessary to adjust the positions of the teeth. In fact, more often than not, one or more of the teeth are often slightly "longer" and/or lingually tipped.

I usually find that the appliances can be removed within 2-3 months. Another nice feature to having braces on instead of a bonded wire or bonded fiberglass splinting is that you can remove the archwire to test for mobility. Once the teeth are back to Class I mobility, the patient is often ready to go into a nighttime clear retainer (very similar to an Invisalign tray).

I have described this procedure at some of my "lunch and learns," especially when a dentist has had a recent trauma experience.

Basketball Trauma

2009-12-16T21:02:00.000-08:00

This is the first of two entries today. I'm going to show a before and after. Sorry about how bloody it is. For some reason, Orthodontists get a fair amount of trauma. Mostly it involves patients with braces on. This was a patient who had been out of treatment for about 6ms. He was playing basketball in P.E. and someone going up for a ball came down with an elbow into his mouth. The patient ended up at his dentist who thought to send this patient back to me to reposition the teeth and splint them back together with brackets and a wire. The next entry will show you the result.

2009-12-01T23:02:00.000-08:00

Every year in my office, I put the U of O duck ( I have no idea what the ducks name is since I'm an Oregon State grad) in one corner of my waiting room and the Oregon State Beaver ( Benny ) in the other starting the week before the Civil War game. We have a bulletin board in our hallway where people post their Civil War picks. Even though people know I'm a beaver, I still seem to have more duck patients who are willing to cast their U of O votes.

Everyone seems to like the blow up figures. Melanie refuses to let me carry this to the next step: to get a blow up Santa or Snowman.

Early Evaluation

2009-11-12T20:00:00.000-08:00

We just placed a new ad in the LO review that is very fresh and fun. We used Gina, one our orthodontic assistants and her daughter. Both are shown in our clinic area. It is nice to use real people instead of "canned" photos of actors. The message that we are attempting to deliver is that orthodontists would like to evaluate kids as young as age 7 years. Even though it seems early to seek an orthodontic evaluation at this age, it is great for planning purposes, getting kids comfortable in a dental environment, and on the rare occasions kids might need some form of limited treatment. Thanks Gina for letting us use you and Karsyn.