Chapter 21
Jane and Simon were waiting in the rather pleasant waiting room of the second orthodontist. Jane hadn't been over happy with the first ortho that they had been to see an hour or so ago, and she was hoping this one would be a bit nicer. So far she was impressed: the receptionist had been very pleasant, and the decor of the waiting room felt quite relaxing. There had been another patient there when they arrived, but she had been called through a couple of minutes ago.
"Miss Jane Smith?" asked a smiling young lady with perfect teeth.
"Yes, that's me.." Jane replied
"Hi there, I'm Jan, Mr Sampson's assistant: would you like to come with me please?" she asked. Jane and Simon got up from their chairs, and followed Jan through to the treatment room.
"Good afternoon, I'm John Sampson, you must be Jane Smith: would you prefer that I call you Jane or Ms Smith?"
"Jane would be fine.."
"Ok, well would you both like to come over with me and have a sit down. And who is this that you've brought with you today?". John was leading them to a set of 3 chairs... (I'm not talking lounge type chairs, more high-quality office chairs, but nicer than office chairs!).
"Oh, this is Simon, my...." Jane paused, then looked at Simon. "Are we boyfriend and girlfriend yet?"
"I'm not sure" replied Simon. "I guess we probably are by now...."
"This is my boyfriend, Simon, he's here to be my second pair of ears, as well as to help me stay calm!"
"Hello there, Simon, take a seat. I always like it when a new patient brings someone along, as you say, it's another pair of ears: I'm sure you won't remember everything we talk about today. So, Jane, before I take a look at your teeth, I'd like to find out a bit about you. Yes, you already filled in our form, so I know you live reasonably locally, and that you are 26, and work in IT, but what I'm interested in is why you are here today. What do you feel is your problem. And what are you looking to achieve out of any treatment?".
Jane was quickly warming to John: it was very clear that he was looking beyond just her possible treatment, apparently wanting to understand her desires, rather than just her needs.
"Well, to be honest, I'm rather embarrassed by my teeth, I call them 'my war zone'. I know my actual teeth are all in pretty good condition, but it's clear that they aren't positioned where they should be!"
"So, what's your 'endgame'? What sort of result are you looking for?"
"Well, I'd like them to be straight, I guess"
"What do you mean by 'straight'? The perfect Hollywood smile? Or maybe something a bit more natural, but 'mechanically' sound"
"What do you mean by 'mechanically sound'?" asked Jane.
"Well, sometimes, when teeth are moved, they end up in the 'perfect looking' position, but that position is often not stable: without constant retention, the teeth will tend to move. However, it may be that you can end up with a 'very adequate' look, but with the teeth in a more stable position."
"Ah, ok... yes, 'very adequate' would probably do for me"
"What's the main thing that troubles you about how your teeth look at the moment?"
"Two things really... first of all, these top two at the front, I'd like them to be, like, out front with the others. Then I'd like my canines to line up with my other teeth too"
"Ok, that sounds good. Now, reading your medical history, I'm not seeing anything about previous orthodontic treatment - you never had any treatment as a teen?"
"No, I didn't.... a bit of a story there...."
"Yes? I'd like to hear it, if you're willing to share..."
"Well, as a kid, I was a bit of a loner, not too many friends at school. Definitely picked on. When I was about 12, I needed glasses, and mum, being mum, chose a pair for me. Not at all flattering, and I got called all the normal things, 'four-eyes' and that sort of thing. So when it came up that I would probably need braces, I refused. I was just about coping as a four-eyes with crooked teeth, but as a four-eyes with braces? No way! I had big arguments with my mum, and my brother backed me up, and I ended up telling her I'd not comply with anything that got done to me... and I won, so no braces. Oh yeah, I was reminded last week about the bad dreams too, with some very extreme treatment, and a not very nice orthodontist."
John smiled when Jane mentioned the extreme treatment. "How extreme was the treatment that you dreamed of, do you remember?"
"Oh, I do, I had the dream again last week: big expander screw things top and bottom, huge metal brackets, and then two of those headgear things - ah yes, non-removable headgear things at that!"
"Well", said John, still smiling "some of that is still used, but the things we use are quite small these days, and the 'fixed-in headgear' - I think was probably more of a scare-tactic than a reality. Oh, and I hope I'm not too scary! But yes, I can understand what you're saying, I know I wasn't the most popular kid at school either. Ok, well I've got a good feeling about what you're looking for, so why don't you come over into the treatment chair, and I can take a look at your teeth, then we can discuss what options there are for making your teeth look the way you want. Simon, there's a spare stool over there if you'd like to join us".
Jane was feeling very positive as she went over to the chair: John was clearly trying to find out what she wanted, rather than just 'what needed to be done'. She sat in the chair, and Jan, John's assistant, passed her some dark glasses.
"You'll probably want to wear these, the light is rather bright!" explained Jan. With the glasses on, John reclined the chair slightly, and pointed the light at her mouth.
"So, let me have a look like this, then I'll put in some 'lip spreaders' to hold your lips out the way, so I can have a better look. Then I'll scan your teeth. And along the way, I'll take some pictures"
"Scan?"
"Oh, yes, I have a lovely bit of tech that lets me do a 3D scan of inside your mouth, then we can have a look on the computer screen, and better see what to do.... So, can you start by just relaxing your mouth, so I can see how your lips sit...". Jane relaxed her mouth, and John took a couple of pictures. "Ah, that's good, you don't seem to have any problems fully closing your lips: that can be a problem for some people. Ok, how about giving me your most natural smile....". Jane smiled, letting John see how her lips lined up with her teeth.
Again, John took pictures. "Ok, now trying to keep yout teeth together, give me a big wide smile.... Lovely!". Of course, he could now clearly see how Jane's top central incisors sat inside of her lower incisors.
Jan passed John the lip spreaders. "I recognise those" said Jane.
"Sounds like you've already had a consultation somewhere else: a good idea, I'd always recommend getting 2 or 3 opinions. To be honest, getting a good result from treatment is as much about having a good relationship between the orthodontist and the patient, as it is the actual treatment itself." Jane opened her mouth, allowing John to fit the lip spreaders. John took a good look inside Jane's mouth, and took several pictures, some using a mirror, so the pictures could show the full upper or lower arch.
"Ok, so next I'll be using the tech to scan your teeth... if you look at the screen up there, you can see what I'm doing too...". John picked up what could best be described as a long thick pen on the end of a piece of cable, and put it into Jane's mouth. As he moved the 'pen' around, Jane and Simon could see a 3D image of her teeth, her jaws and her palate appearing on the screen. John paused for a moment, as he looked at the image, and rotated it in 3D. "Ok, almost done, there's a couple of bits that need a little more scanning..." Once again, he put the 'pen' into her mouth, and scanned: as he did so, Jane could see some extra detail being added to the image.
"Ok, that's all done, thank you, you've been very patient with me. Would you go with Jan back to where we were before. I need to do a couple of things here, then I'll be over with you."
Jane and Simon went back to the more comfortable chairs, and were joined by John a few minutes later. In his hand he had a large tablet.
"Something tells me that you're not going to be telling me that you can fix my teeth with those invisible braces?" said Jane, smiling.
"Yes, Jane, I think you would be quite correct there! Invisilign can do quite a lot now, but I think your teeth are a couple of steps beyond that!" explained John, smiling back. "Ok, so let me try and explain to you what the actual issues with your teeth are, and suggest a couple of ways we can go about making things better. By the way, do ask questions at any time... So, the fundamental issue is that you have too many teeth for the space in your mouth" he explained, showing them both the scan of her mouth. "That's why your canine teeth can't come down - or go up - to fit with the others. It's also why your lower teeth are crooked, and why your upper front teeth have been either rotated or pushed out of the way."
"I'm guessing my wisdom teeth are to blame? My dentist says I should have them taken out"
"Actually, no. It's a popular myth that wisdom teeth cause your front teeth to get crowded, but research has shown that's not the case. And in your case, I believe your issues started well before your wisdom teeth came into the picture. But I can say that, to achieve any sort of result, you will need some teeth removing, just to create some space in your mouth. So, one common thing we do to make space in a person's mouth is to remove the front pre-molars... they are the small molars that are normally just behind the canines... so here's what your mouth would look like with all 4 of your front premolars removed".
John pressed a couple of buttons on the tablet, and the image changed to show Jane's mouth without the pre-molars. "So, with those four premolars out of the way, we could use fixed braces to...." he continued, and using his tablet pen to move things on the screen, he roughtly dragged the canines into position. "... bring your canines down in their right position. You can see that there's still some space left, so now we can move the lateral incisors back a bit - we'd probably use a small spring on the archwire to help with that - and make enough space to allow your top cental incisors to be moved out, and into a more normal position."
"How do you move them out? Will I need some sort of appliance to push them forwards?"
"Not necessarily. The incisors only have one root, and compared to molars, are relatively easy to move, so the archwire, maybe with some help of some tiny wires, will pull them out just fine. Of course, when we do that bit, we'll need to hold your jaws open a little, to allow the top incisors to 'hop over' your lowers: there's several ways to do that, one of which would use a removable appliance, and we could then add a spring to help push the two teeth forwards. But there are other ways to do that too. Personally, I'd like to leave the decision on that till we get to that part of the treatment, as it will depend on the relative positions of your other teeth at the time."
"Ah, ok..."
"Now, down the bottom, like at the top, there's plenty of space to move your lower canines into position, and straighten your lower incisors." The image on the screen wasn't perfect, but it nicely explained how Jane's teeth would fit together, and what needed to be done to get to that state.
"And my wisdom teeth?"
"They stay where they are: in your case, they have all errupted, they are straight and have just enough space, and they are all in great condition". He paused a moment. "There is another treatment option, which would require removing your widom teeth, but I'll come onto that in a moment. I need to explain about your molars: what I just described would give you a good simple cosmetic fix for your front teeth, but I don't think that what you are looking for, is it, I think you're looking to get your molars sorted out as well?"
"Yes, I guess I do..."
"So, your upper arch really needs to be a tiny bit wider, and three of your upper molars are tipped inwards, causing what we call a 'cross-bite' with your lower molars: left untreated that cold give you jaw pain in the future, and perhaps uneven tooth wear. Specifically the issue is with these two main molars here" he said, pointing at the screen, "as well as this rear premolar. So I would need to use some form of expander to push those three teeth out, as well as widen your arch"
"Ah, so an expander like in my dream then?" asked Jane
"It depends. Do you remember anything about it?"
"Well, it was very large, and very much glued in!"
"So what I'm proposing is a bit similar, but nowhere near as big. It would be a 'Quad Helix' device: Jan, can you....". Before he'd actually finished his sentence, Jan had brought over a tooth model, with a lightweight appliance on the teeth. "So, this is a Quad Helix appliance...". The appliance had 2 bands, on the front full molars, with heavy wires pushing against the other molars to the front. Between the bands was another wire, in a sort of 'box' shape, with curly springs at the 4 corners. In terms of bulk, it is a lot less bulky than the common screw-expander. "In your case we would fit the two bands to the second molars - that's one further back compared to this model - as this second molar is needing to be straightened too."
"OK. And you said there was a second option?"
"Actually, there's two and a half options. Staying with what we've just looked at, a tiny change to what I just described would be to remove this REAR premolar, the one that's tipped inwards, rather than the front one. Whilst that would mean we would need to pull the front premolar back, it would mean that there's then just two molars that need their crossbite fixing."
"Wouldn't that take longer though? I mean having to move that front premolar?" asked Simon.
"Not really, not overall... we're just trading moving a front premolar backwards versus tipping the rear premolar up straight, so the time is pretty much the same" explained John. "So the OTHER other option.... rather than removing your premolars, we would take out your wisdom teeth - that in itself is slightly more complex. We would then need to move all of your molars and pre-molars back into the space vacated by your wisdom teeth, and tipping the 3 molars back straight again as we do it. It's a lot easier to do with children, but it can be done in adults, especially someone of your sort of age. But that would require that you wore headgear at night, and a lip bumper, along with several elastics. So it could be done, but it would mean your treatment would be more complicated, and a LOT longer"
"What do you mean by 'a LOT longer'?" asked Jane
"Well, my guess is that if we extract your pre-molars, and go that route, then the treatment would take something like 18 months, maybe a bit longer. If you go with the second option, I think you could probably add a year or more onto the treatment time. The only reason I suggested it was to show that there WAS another option if you were dead set against having your pre-molars removed. Look, why don't I show you some of the hardware that I've been talking about....". John got up, walked over to some shelves, and picked up several orthodontic models.
"I'll start with a couple of appliances that you WON'T be getting, so you can see that the Quad Helix appliance actually isn't too bad. This one shows a typical removable expander - the problem with this is that, with your teeth tipped inwards, you wouldn't be able to get it easily into the top of your mouth."
"Ah, yes, my sister had a big removable appliance, gave her quite a lisp..." said Simon.
"Yes, unfortunately they do, although the speech does improve with practice. Now this is an RPE... a Rapid Palatal Expander. It expands the palate, but can't tip the teeth into position quite so easily: we use a lot of these with teenagers, to make their upper jaw wider. By comparison, the Quad Helix is a lot less obtrusive than either of these, but a bit slower.... and we have to go slow with adults anyway. Now, as far as brackets go, there's several available, these ones are quite small, and are probably what I'd use for you" explained John, passing the model to Jane. Jane was pleased to see that the brackets really were quite small, so not as obvious as what some of the others kids had when she was at school.
"Aren't there options for less-visible, white, braces?"
"Yes, there are, but in your case I'd not really suggest them, simply because of what we need to mechanically do to your teeth, which would slightly extend your treatment time, and maybe give us a few problems. Besides, while people think they are 'invisible', they aren't really as invisible as they think - I've had several people comment along the lines of 'I don't really know whay I bothered'!"
"Ah, ok...."
"Now for the horror from your dreams: this is a facebow - removable I hasten to add! - and this..." said John, picking up a second model, ".. this is a lip-bumper. So the facebow uses external straps to pull your upper teeth back, and the lip bumper uses the pressure from your lower lip to push your lower teeth back... obviously only needed if you went for the wisdom teeth extraction option."
As Jane looked at the models, and the facebow and the lip bumper, her tongue was going around her mouth.
"Earlier on, you were talking about 'a good mechanical result'.... that my teeth would probably fit together better..."
"Yes, and I can't really make any comment on that until I've had a more detailed look with the computer simulation, to see how your teeth will 'mesh' together."
"So, I'm guessing you'd recommend the first treatment, just removing Jane's pre-molars?" asked Simon
"Yes, it is the more normal treatment, and it would be a lot simpler for Jane. At the end of the day, we have to remove some teeth from Jane's mouth, to make space for the other teeth. And removing the premolars is usually much simpler than removing wisdom teeth"
"And no need to remove BOTH the pre-molars AND the wisdom teeth?"
"From what I've seen so far, no. Now, one thing I've not mentioned yet is that, whatever treatment you opt for, you will need to wear retainers. Typically I would fit a bonded retainer to your bottom teeth - that's a wire glued to the back of your teeth - and for the top you would have a removable retianer. For the first six month that will need to be full-time wear, then after that, just at night. There's two types of retainers, the clear plastic ones... they look like the invisible braces, and then there's the Hawley Retainer, which looks like this". John picked up a model that had a hawley retainer on it.
"The plastic is very thin, and you might have a lisp for a few days, but most people get used to them within the week. But the Hawley is more 'forgiving' - by which I mean if you don't wear it for a few days, and your teeth move a little, the springs will tend to move the teeth back into place more gently. Also, Hawleys tend to last longer than the clear retainers"
"When would you decide which type of retainer I'd get?" asked Jane.
"There's no need to decide until just before you need it, and if you have a particular preference for any reason, you can tell me. And, in principle, you could have both - wear the clear one during the day, and the Hawley at night."
"Ah, yes that sounds like a good idea" said Jane
Now, before I would start any treatment, I would need to take a full set of x-rays, so I can see the state of the roots of Jane's teeth, and if there's a problem there, then we would need to re-consider the treatment options, but I hasten to add that that doesn't happen very often. The liklihood is that we would proceed the way we've been talking about."
"And will I get a 'Hollywood smile', or just the 'pretty good smile', not that I'm really worried which I get?"
"That's actually a very good question. From what I can see of the shape of your teeth, and from what I've seen on the computer, I think you will be very pleased with the result: as well as sending you printouts of the pictures I've taken, for your reference, I'll include a computer prediction of what yout teeth might look like"
"Oh, that will be interesting to see. So what happens next then?" asked Jane
"Well, I will look at the photos and play with the computer scans again, and double check that everything I've said to you is correct, plus check how well all your teeth will fit together. If it's all ok, and I think it will be, then I'll put together all three treatment plans, and costs for each, and get it sent off to you."
"And if Jane decides to come to you for her treatment, what then?"
"So, two initial visits. At the first, we would need to extract Jane's premolars - assuming that's the way she wants to go - and take X-rays, neither of which should take long. Then we would insert the spacers, to make space for the molar bands..."
"Ah yes," commented Simon, "I remember those..."
"Yes, I'm afraid they can be a bit sore. So the spacers would stay in for about a week, by which time we would have your appliance, and we could fit everything at the second visit."
Ten minutes later, they were back in Simon's car. "So, what did you think then?" he asked Jane.
"I thought he was ten times better and nicer, than the guy we saw earlier. He treated me as a person, asking what *I* wanted. And then he explained everything very well, I understood everything - more than I can say for the first guy - and he had no problems when we asked questions"
"Yes, I got a good feeling too. So, do you want to get a third opinion, and maybe a fourth?"
"Well, the actual treatment he suggested wasn't THAT much different from the first guy, so would a third opinion be any different? To be honest, I'm feeling pretty good about this guy."
