Editor’s intro: Dr. Donald J. Rinchuse shows two patients who benefitted from insights from orthodontic literature. See their progress here.
An 11-year 7-month old female presented for an orthodontic consultation with a Class II malocclusion and all four second bicuspids extracted as well as the mandibular right first molar (Figures 1A-1E). The extraction spaces for these teeth were open and particularly large for the mandibular right second bicuspid/first molar area. The patient’s mother said that a pediatric dentist removed these teeth some time ago, and she did not know the reason (possibly to mitigate crowding and/or tooth decay).
On evaluation of the initial panoramic radiograph (Figure 2), it was observed that the area of the large extraction space of the missing mandibular right second bicuspid/right first molar was very radiolucent, indicating a bony defect. Further, from a clinical examination of this region (as well as a consideration of the panoramic radiographic findings), it was noted that there was little alveolar ridge in this region. The most logical explanation for the bony defect in this area was that on extraction of the mandibular right second bicuspid and right first molar, the buccal and lingual cortical plates were fractured. Parenthetically, the most distal molar in the mandibular right quadrant was by all accounts a third molar.
The issue for space closure into the bony defect left from the extractions of the mandibular right second bicuspid and right first molar was whether or not this was possible without jeopardizing the teeth being moved into the defect. That is, would the teeth being moved into the bony defect now be surrounded by defective bone and then be fraught by periodontal and endodontic problems leading to tooth loss? Or, on an optimistic note and based on the literature,1-6 would bringing the so-called good bone of the adjacent teeth into the bony defect augment the bone in this area?
Orthodontic treatment included the use of a .022 inch slot, pre-adjusted, fixed edgewise appliance; light Class II inter-arch elastics; intra-arch power chain elastics; and .016 x .025 inch and .018 x .025 inch stainless steel maxillary and mandibular “working” archwires.
At the end of orthodontic treatment, all the extraction spaces were closed in all four quadrants, including the large one in the mandibular right quadrant. Orthodontic treatment took 23 months and 17 appointments. From an examination of the progress and final panoramic radiographs (Figures 3 and 4), it was evident that orthodontic space closure caused bone augmentation of the mandibular right second bicuspid/first molar region, consistent with reports in the dental literature.1-6 Incidentally, the third molar in the mandibular right quadrant was nicely aligned.
Reading and knowing the dental and orthodontic literature, particularly the evidence-based literature, are clearly an important part of modern-day orthodontic clinical practice and can improve patient care. And as gleaned from this case report, it served to guide the treatment of this patient.
Editor’s call to action
We have orthodontic literature to help your practice grow! Dr. Rinchuse discusses marketing orthodontic practices in “The secret sauce” — more than the golden rule: part 1.