Orthodontics Expert Witness Advises on TMJ Post Procedure

This case takes place in Delaware and involves a teenage patient who suffers from Temporomandibular Joint Disorder following an orthodontic procedure. In February 2007, the patient began treatment with the defending orthodontist. In early 2011, the patient had a left canine tooth impaction (tooth #11) and underwent treatment to attempt to foster the eruption and descent of tooth #11. The patient was referred to the defending oral surgeon for surgical exposure of tooth #11 to attempt to promote the descent of that tooth on the left side. Orthodontic structures were then placed to apply tension on the tooth in an attempt to get the tooth to descend. On July 2, 2012, the orthodontist ordered the oral surgeon to perform another surgical procedure to attempt to descend tooth #11, to be followed by additional orthodontic pressure and tension on the left side of the patient’s mouth by the orthodontist. There has been no follow-up by the defendant following the procedure, and the patient suffered significant bone loss and severe angulations and deformity of his bite and jaw alignment. The patient had to undergo multiple dental procedures to graft bone to replace the bone lost and it is reported that the patient’s bite and jaw disfigurements cannot be repaired such that he is destined to suffer from worsening TMJ and its sequella for the rest of his life.

Question(s) For Expert Witness

1. Have you ever had a patient develop the outcome described in the case?

2. Is it such that orthodontic tension to cause the descent of an impacted canine tooth shouldbe accomplished in only 6-10 months?

3. What kind of follow-up would have been appropriate?

4. Do you believe this patient may have had a better outcome if the care rendered had been different?

Expert Witness Response E-009224

I routinely treat patients similar to the one described but I have not had a patient develop the outcome described. The outcome, if I understand, sounds like a cant off the occlusal plane, a slant from the force of bringing the tooth into occlusion. I avoid that problem by using a vertical component of force in the form of vertical rubber bands to minimize the intrusive force that would occur to the adjacent teeth particularly if the eruptive force is applied by a continuous wire as opposed to a segment. The fact that it had to be exposed twice implies the tooth could have been ankylosed( frozen to the bone) or was trapped by one of the roots to the adjacent teeth and unable to erupt. This, of course, would disrupt the occlusion, the way the teeth come together. It is difficult to know why bone was lost, the surgical uncovering of the tooth does require the removal of bone which normally reforms as the tooth erupts. When one notices the cant or slant of the adjacent teeth it is time to stop trying to erupt the tooth and consider removing the tooth if it is not going to erupt. The slant of the adjacent can then be corrected with appropriate orthodontic forces. The patient may have had a better outcome if care was rendered differently. The length of time to erupt an un-erupted tooth varies greatly depending how high into the maxilla it was. It can some time take several years to bring it into occlusion. I have treated over 35,000 patients in my career of 38 years and have treated thousands of patients with impacted canines.