I took my 9 year old son to the orthodontist because some of his teeth didn’t seem to be coming through. He did an X-ray which showed he had some extra teeth stuck up in his gums that we couldn’t see yet, so he decided to get a specialist surgeon to remove them.   

It was really traumatic to take my young son to have the operation but it is so important to have a nice set of teeth. To make matters worse, the operation took much longer than we expected. When it was over I was told to wait a few months and the teeth would come through naturally.   

Four months later when we went back and there was still no sign of his new teeth. The dentist told me that he needed a brace and yet another operation to make room for the teeth to come through. He couldn’t even guarantee that this would work and said that he may need implants or even bone grafting. They warned me that it would take years, cost a fortune and even then there were no certainties.   

I wanted a second opinion so I took him to see another specialist.This time I was told that we could delay the surgery until he was fourteen years old. Now I was really confused, with two specialists and two conflicting views. I had heard about Medical Opinion (www.m-opinion.com) from a friend so I sent them all of my sons files so that a real specialist could look at it all, not just some guy from our area. The information was sent to one of the world best orthodontists and within a short time I had a detailed answer.

The first thing he pointed out was that the models made of Bens teeth did not match the X-rays that had been taken and these would have to be taken all again. To make matters worse the X-rays that were taken weren’t even of a good quality. He also said that some of the teeth were coming through too EARLY and this may have been happening BECAUSE OF THE OPERATION!!!!  

Thankfully he advised that with the right treatment the teeth would eventually be fine. He just needs the right orthodontist and ,for the moment, there is no need for surgery, just braces. It turns out that I’d been going to the wrong type of specialist all along and there had never been any need for a surgeon. He then advised me on how to find the best orthodontist in my area.

Now I’m much more relaxed. I don’t have to put my son through any more operations and I know that he will end up with a nice set of teeth and a good smile. If I hadn’t sent the files to Medical Opinion who knows what could have happened.

Clinical information

This 9 year old patient had an orthodontic visit and orthopantomography (panoramic x-ray) as a result of delayed eruption of his permanent upper premolars, while the 4 lower incisors had been replaced with permanent teeth as normal at the age of 6 years.

The x-ray showed the presence of supernumerary tooth germs.

Following the consultation with an experienced orthodontist and a maxillofacial surgeon, it was decided that the patient should undergo surgical avulsion of these elements.

Surgery turned out to be more complex than anticipated, but it allowed the removal of the two supernumerary teeth at spaces 11 and 21, as well as a third fractured supernumerary tooth.

At the time, the surgeon felt that it was not necessary to hook the permanent teeth that were still very high, as he was certain that within 3-4 months they would have erupted spontaneously.

Contrary to expectations, during a subsequent follow-up, the physicians excluded the possibility that the teeth would be able to erupt spontaneously due to a lack of space, irregularity of their position, partial root formation, and an unusual delay in bone tissue growth in the middle part of the jaw.

At this point, the physicians proposed that therapy should be started as a matter of urgency, using a mobile prosthetic on the upper arch in order to increase space, and to plan further surgery for disinclusion of the incisors and connecting them to a fixed prosthetic so as to guide their descent.

The problem at this point appeared to be associated with the presence of the underdeveloped roots of the delayed teeth and, consequently, the surgeons were unable to guarantee a positive outcome of therapy. In the meantime, in the event of an unsuccessful outcome, various therapies were suggested (implants, bone grafts, etc.) that could be considered in future to achieve an acceptable situation.

The treatment proposed by the surgeons would have lasted at least 5 years, would be painful and costly, wth no guarantee of success.

Meanwhile, the patient continues to replace his other teeth precociously and an another specialist was consulted who advised against the surgical procedure while the patient continues to lose his teeth. This specialist thought that there was no urgency in performing any treatment until bone growth is completed, at around 14 years old.

The patient’s mother decided to wait until the other permanent teeth erupted in order to assess whether a fixed prosthesis should be used to hook on more effectively to the unerupted teeth. This was partly due to the child’s poor compliance.

The patient’s mother would like to know:

1. Given the two opposing views, which do you feel would be the most appropriate route to take?

2. What kind of therapy will the patient be facing in the next few years?

3. What is the success rate of the various options?     

The expert opinion

Thank you for the referral and the copy of the medical records for this patient.

I had the opportunity to review his medical records and his study models:

This is a second opinion based on the attached clinical information. I have not performed a clinical examination of the patient. This second opinion has been requested on behalf of the patient by medical-opinion Ltd.

This is a 9 years old male boy with a diagnosis of complex orthodontic case. His history includes a diagnosis of late eruption of teeth, supernumerary teeth germs and surgical avulsion of those germs. According to the report, surgery was not simple, two germs were removed and a third germ was partially removed.

The concern is whether the non erupting teeth in the anterior region would have the force to erupt to their position in the mouth. The suggestion was to intervene surgically and even to extract and put implants in the future. Another opinion was to, wait stressing there is enough time.

I received for my evaluation his study models, panoramic and cephalometric x-rays.

The x-rays do not resemble the status in the study models. I would strongly recommend to take a new panoramic x-ray and periapical status of the mouth in the long cone technique so that we can rely on the best possible evidence.

I would definitely wait for the teeth to complete the eruption process.

The current process is taking place in an abnormal sequence.

The boy will need a long term orthodontic treatment with several stages as serial extraction treatment is not a possible due to the age of the patient.

The x ray and the photographic slides are not of good quality but according to the report, his lower incisors are crowded, his first molars, and first premolars in both jaws are already in the arch, though the latter are earlier than expected. The four permanent pre – molar teeth which are in the mouth and the two permanent right canine teeth erupted earlier than expected. (The boy is not yet 9 years old).This might be the result of the previous surgery which was performed.

If the upper central teeth do not erupt independently, orthodontic forces, such as mini implants will be needed to enhance the process. The whole treatment and follow up should be performed by a skilled orthodontist, who is a graduate of an organized program in a known university. This case should not be conduct or guided by a maxillo-facial surgeon, as it is not his filed of expertise.

I do not see a reason to perform any surgical procedure however an action to bond an anchoring bracket on the centrals may be needed if they do not erupt.

The length of the treatment is several years due to the crowding of both jaws. The growth and development of the child will assist the treatment process so there is no need to rush towards any treatment.

There is a question regarding whether the roots of the upper central incisors could be more accurately assessed with peri-apical and panoramic x-rays of the upper and the lower jaw using the long cone technique and I would like to see such x-rays. In any case, my opinion will most probably stay unchanged whatever there results.

My opinion is to delay any surgery other than a procedure to enhance the eruption.

There is enough time for all possible treatments, but I would recommend starting with conventional orthodontic non surgical treatment. With this approach the prognosis is good.

Thank you for allowing me to participate in the care of your patient.   I wish the boy the best.

Sincerely,

Dr. -------

Specialist in Orthodontics