PAOO Question

[Archives_Admin]

I was referred a healthy 15 year old patient for 2nd opinion who has significant root resorption 7-10. 10 is the worst because of previous canine exposure and eruption of impacted #11.

The primary question I was asked to evaluate was whether she should go ahead with extraction of 7-10 over Christmas vacation and have them replaced with implants and crowns as recommended by her orthodontist, oral surgeon and prosthodontist.

The answer to that question is clearly ABSOLUTELY NOT.

But the next question is given the awful orthodontic result, what can ortho retreatment offer, considering the amount of resorption that already occurred? Is there any reason to believe that PAOO (maybe after bicuspid extractions) would produce less root resorption and also provide an opportunity to increase thickness of the buccal bone? Other ideas?

Jeff

[photographs redacted]

————————————————————————————

First a question: What does the distal of #10 probe? In other words, where is the PDL on the distal of #10?

Karl

[photograph redacted]

————————————————————————————

Hi Jeff,

I totally agree with your decision not to extract though #10 is on it’s way.
I think the rest could be maintained for years to come and no rush is justified.
on my way back from Miami to the holyland..

Ziv

[photograph redacted]

————————————————————————————

Jeff

How well do you know this Orthodontist?

————————————————————————————

Tony and Chuck;

1. Distal #10 does not probe and if you enlarge the radiograph, there appears to be a thin lamina dura on the distal of the root.

2. The orthodontist is known to be a high volume mediocre practice. The patient was referred to me by her plaintiff’s malpractice attorney. That said, I am not in the least bit interested or inclined to create a legal issue for the orthodontist because that tends to backfire on us dentists. Even though I don’t like the orthodontist, I still think that it is “us against them” and we need to stick together unless the treatment is so offensive and egregious that the dentist deserves the punishment.

3. If someone went through with the proposed treatment and actually extracted her teeth and replaced them with implants and then came to me for an opinion, then that would qualify as offensive enough for me to weigh in against a dentist.

Jeff

————————————————————————————

Clearly the teeth stay as long as possible, and now knowing an attorney is involved, it seems PAOO wouldn’t be a good idea on this case.
I still question the concept of PAOO actually increasing buccal bone beyond the confines of the alveolar process. The follow up documentation on cases I have seen to date are weak.
Knowing how well you document your cases, It would have been nice to see what you could achieve (or not),
Maybe next case, This case needs to treated ultra conservative.

Chuck

————————————————————————————

Disagree. This case needs to be treated appropriately and documented, not fearfully or “conservatively”. I hate the terms conservative and aggressive. In my mind, the most appropriate and predictable procedures that achieve the best result is also the most conservative. If that means PAOO, then that is the right answer.

Not picking up a blade does not equal conservative. It’s just like the discussion that preceded the AAP on this site about visualizing calculus for perio treatment. Is doing a closed procedure (perioscope not included) that may leave subgingival calculus but doesn’t require a suture, conservative? Is raising a flap to visualize removing the last remnant of calculus aggressive? I think it is just the opposite. One leads to a predictable stable result and the other doesn’t necessarily. I think we need to revisit our semantics.

I’m not worried about the attorney. What’s done is done. Besides, it appears the root resorption may have started prior to orthodontic treatment. The question for the group is now what leads to the best, most stable, most predictable result?

Jeff

————————————————————————————

Once again, what does the distal of #10 probe. It’s long term prognosis depends on that answer.

Stabilize all and watch for changes in the radiographs. TxPing may change with those changes.

Karl

————————————————————————————

2mm, no inflammation, no clinical attachment loss.

Jeff

————————————————————————————

Jeff,
One big plus you have going for you (given the circumstances) is that the anterior teeth have already been written off , so no harm no foul.
How do you plan on establishing your baseline measurement of the alveolar process.
In addition, how can you differentiate between the effect of PAOO and skeletal growth.
Maybe the Orthodontist has another case like this one to use as a control. Just kidding.
Good luck with this one.

Chuck

————————————————————————————

That’s a key point. Stabilize the teeth, make sure the occlusion isn’t traumatic to the incisors and assess over time.

Karl

————————————————————————————

Jeff

One question I have is if skeletal growth is complete ?? If it is, then models and proposed wax up and consult with the restorative and ortho if PAOO is or is not a viable option?
Will the patient accept additional ortho(with limited tx time)? If not then a compromised result will be the final result. May be a wax up too if PAOO is not a consideration, this way both the best esthetic case and the unnesthetic can be presented to the parent and child thus lessening the burden.

Gail

————————————————————————————

I doubt growth is complete. She will probably accept more treatment if she has a reason to believe it will have a positive and beneficial outcome.

I am really concerned about her complete lack of anterior guidance and proclination of the maxillary anterior teeth. I can’t see leaving them alone, but also am not sure how they can be safely moved.

Jeff

————————————————————————————

As a side note: What about the Orthodontist’s liability regarding oversight of his/her patient’s progress in ortho therapy?

I have seen many problems like this one in patients (young and old) undergoing orthodontic therapy; and in not one of these cases has the orthodontist made routine (during treatment) radiographs to inspect for resorption.

Nor did they warn the patient of the potential for this problem when they (pre-treatment) consulted with the patient (their parents) about the issue of root resorption.

Similarly, I have determined that hardly any orthodontists discuss the need for life-long retention of the achieved tooth positions. Thus, orthodontically created tooth positions rarely endure over time.

Over the years I challenged my grad-students to produce literature (that can’t be refuted) which shows that orthodontic treatment results in longer tooth retention and less tooth disease. I never was provided any such (irrefutable) studies.

In my opinion, Ortho is all about Maslow’s 3rd level need. It has very little to do with dental health. It’s mainly used to satisfy Mom and Dad’s desire to have their child be popular and desirable.

Go ahead, Orthodontists, blast me.

Karl

————————————————————————————

Jeff,

On the topic of laser vs. surgery. I had an interesting new patient consult this morning.
The patient presented post S/RP with 5-7 PD in posteriors and I-6mm gingival recession 23-26.
I recommended osseous surgery in posteriors. Her response was “how about a laser instead , I am afraid of surgery. Isn’t a laser better?”
My response: ” At best the results will equal. However, if your afraid of surgery, I’ll use the laser, but I have to let you know it will cost twice as much, because it takes twice as long.”
They scheduled for osseous surgery without hesitation.
Food for thought.

Chuck

————————————————————————————

It’s all in the presentation. If you had a patient friendly version of the AAP position paper on lasers, you would have also convinced her on the merits of the procedures, not just the economics.

Jeff

————————————————————————————

Jeff,

The last position paper that I see was written in 1999. There is also a Q and A with Dr. Charles Cobb which is undated.

Is there anything more recent than that?

Lee

————————————————————————————

Tony,
Many good points. Unscientifically, I have noticed over the years an unusually high percentage of my ” garden variety” periodontal disease patients previously had orthodontic treatment. If you include gingival recession cases the percentage is much higher.
Many possible explanations for this correlation between orthodontics and periodontal disease.
My first thought was sub gingival deposits formed during treatment were left behind for years post treatment. Thus “garden variety ” periodontitis.
Orthodontist routinely position teeth beyond the confines of the alveolus and /or gingival tissues (especially in the mandibular anterior region
Then I thought maybe people who seek orthodontics in earlier life, place a higher value on their teeth, therefore seek periodontal treatment in later life.
Anyone else notice a high percentage of your patients went thru orthodontics?

[photograph redacted]

————————————————————————————

I thought don clem said there was a new one. Also see the 2006 AAP review.

Jeff

[document redacted]

————————————————————————————

Jeff,

You are correct. It’s like “shooting fish in a barrel”.

Chuck

————————————————————————————

Actually, Tony,

I have an interesting pair of cases in light of what you’re saying. I now have my second Straumann implant (each in a lower molar site, loaded 4 years in vital bone) that was removed by Invisalign. Who is responsible – the company for putting force on an immovable object when they designed the invisalign, or the orthodontist who supposedly viewed the images showing the forces to be applied and the directions in which they would be operating on the company’s software? Who is going to pay for the removal, bone graft, implant and restoration?
As the B52’s sang – who’s to blame? And who reimburses me and the restorative dentists for the costs to put her back together?

Bob

————————————————————————————

Jeff;

Tough situation. My 2 cents, and what I would not do;

1. I agree. No way extract these incisors now.
2. Do NOT extract bicuspids. Would require too much movement causing more resorption.
3. No way PAOO (sorry Colin) in this case. Rapid forces of any kind and a flap would worsen situation in my opinion.

What I would do;

1. Retract incisors and gather them utilizing light forces and IPR as needed to couple incisors and gain effective overjet-overbite relationship.
2. Stop ortho, remove brackets and provide lingual bonded retention from canine to canine.
3. Make certain no fremitus on incisors in CO and that occlusion is balanced with proper canine guidance and all incisors sharing in incisal guidance.
4. Long term re-evaluation over 12 months.

Regards and good luck

Maurice

————————————————————————————

Ditto.

Tony

————————————————————————————

I suspect that my previous email did not transmit because the file might have been too large with images. I am resubmitting with images in a PDF attachment .,
Questions:

What is the vitality status of #10? (We do not want to develop a perio-endo lesion on this tooth). I would continue to monitor the vitality status of #10.

(Perhaps I missed it), but what is the mobility status of 6-11, and all the maxillary anterior teeth?

What do the remaining root apices of the rest of her dentition look like?

What would be the objectives of additional orthodontics? If for anterior guidance – ????

Suggestions:

· Complete meticulous scaling and root planing as needed.

· Her anterior esthetics, from the gingival and dental perspective seems excellent, so long term meticulous maintenance of gingival health is essential.

· I agree with Mo. I would splint the maxillary anterior segment with a bonded lingual fixed retainer. However, if you want to enhance the esthetics by eliminating the anterior diastema, I would complete a deliberate maxillary anterior frenectomy, (which should probably have been completed prior to initiating orthodontic therapy), and then use a very simple Hawley appliance to gently retract the anterior segment, followed by a lingual retainer.

This is a perfect example of “who dropped the ball, gp or orthodontist by not taking timely and routine radiographs?

Vince Kokich (Sr.) recently presented on the long-term success of maxillary anterior teeth demonstrating severe root resorption. His evidence shows long term functional success, with common sense treatment, including debridement, non traumatic occlusion, splinting mobile teeth etc).

This image is one of our patients about 12 years in maintenance, no changes so far. Her maintenance and

gingival health is superb. (See first image attached)

Philosophy

The difference between PAOO induced tooth movement and conventional tooth movement is profound – PAOO is associated with physiologic wound healing changes in the periodontium and surrounding alveolar process for each teeth with the induction of a reversible osteopenic state, enabling teeth to move in a much gentler manner. Conventional tooth movement is associated with hyaline necrosis (necrosis with a capital NECROSIS), a much more destructive tooth movement process, with the development of numerous root surface lacunae. In the susceptible patient, these lacunae coalesce, and ‘cut of the apex of the tooth, resulting in root blunting, and as this condition progresses, irreversible apical root resorption.

PAOO can certainly be provided for patients with root resorption if orthodontic re-treatment is indicated. I currently have one such case in progress and one successfully treated case – as long as there is a substantial amount of time (>6 months), between appliance removal (following conventional treatment), and initiation of orthodontic therapy with PAOO allowing the hyaline necrosis to heal.

Relative to Chuck’s comment on adjunctive new bone formation, I have both histology and clinical observation. On rare occasions, where re-entry is needed – for a supplemental gingival augmentation, or implant placement, I have obtained biopsies. These demonstrate new vital buccal bone formation. I have also viewed new bone formation where previous bone did not exist. The attached image demonstrates my only complication of severe root resorption on #25 + 26. Both teeth demonstrated severe mobility at time of PAOO surgery. I placed a wire and composite splint (not a good thing to do, but had no choice), in order not to avulse the teeth whilst working or during immediate post-surgical healing. 2-3 years later #25/26 demonstrated severe root resorption. (My only patient so far with this type of complication, probably as a result of the immobilization at the time of surgery). I extracted, augmented the sockets only, a distinct intact facial bony plate was present on both teeth at the time of extraction, and then placed an implant subsequently. Note the facial bone status on the pre-and post PAOO treatment images. In general we might not achieve predictable vertical (coronal) re-growth of bone on dehisced or fenestrated teeth, but we absolutely obtain substantial horizontal facial or lingual bone – many CT and CBCT scans to demonstrate this situation.

Above: Pre-treatment; middle at time of PAOO surgery; below at implant placement demonstrating new facial bony structure on #23 and #24.

See images in attachment.
Image 2 is pre-treatment.
Image 3 is a gingival graft prior to PAOO in order to obtain a thicker zone of AG
Image 3 is at time of PAOO surgery – note severe dehiscences and fenestrations
Image 4 is re-entry, demonstrating new facial bone on # 23/24

Finally, with all new therapies, we have the ‘art and then the science’. The art is based on observation, clinical trials and case reports. Then the science follows with controlled trials. Implant dentistry is a good example – we continue to learn, but our implant dentistry pioneers tried, perfected and then studied, based on observations and clinical experiences. Finally, Tom and Bill Wilcko ‘s publications demonstrate that PAOO patients have less root resorption, less recession (I presented on this at the AAP – and recently published on the topic), less orthodontic relapse, and greater post-orthodontic stability. Also, marginal orthognathic cases can be treated using PAOO as an alternative to orthognathics. These are my experiences as well, with over 100 treated case. PAOO is the most satisfying procedure that I perform in my office – it even surpasses esthetic dentistry/periodontics!! It is the ultimate of Periodontal Regeneration. For the patient, they love it because high quality orthodontic treatment, provided in a timely manner, rather than compromised removable appliance treatment provided by an inexperienced clinician (read between the lines).

Hope that this helps

Colin

[document redacted]

————————————————————————————

Resending of same message with a compressed attachment.

I am currently working on a small presentation that I shall be presenting at the next Wilckodontics program in Eerie. II would like to share some of the images with the group.
Patient had extremely constricted arches; requests esthetics, function and speed.
Treatment time to date is 8 months; including removal of hopeless #3 at time of PAOO surgery, placement of a bone anchor 3 months later, and movement of #2 into #3 position in approximately 5 months.
Occlusion is currently being refined. Note extent of both arch expansions, with no associated facial gingival recession. Also note the comments of the orthodontist, sent to me at four months. These might be valuable to share with your reluctant orthodontic colleagues.
Looking forward to your thoughts.

Colin.

[document redacted]

————————————————————————————

Beautiful job, Colin.

Personally, I would want to see a little bit more information on what you did in the PA 00 surgery. I would also want to see when the P A O O surgery was done in conjunction with the orthodontic treatment.I personally know when it was done but there is nothing in t he slides is to say that.

Excellent work!

Lee Sheldon

————————————————————————————

When will you be in Erie?

Chuck

————————————————————————————

Today, tomorrow and Saturday

Colin

[Author]

Posts