Hey all,

Yesterday, me and my bride celebrated our 15th wedding anniversary. She is the best thing that ever happened to me.
I love her more every day.

I am so happy that the Lord blessed me with a friend/partner/wife/hot body like her. She loves me in spite of me and it has been a great 15 years and I can't wait for the next 15. I know it sounds corny but "she completes me".

We are celebrating tonight. There is a place on Disney property called The California Grill. It is on the 15th floor of the Contemporary Hotel. The restaurant is all windows and every night at 9:30 pm they drop the lights so you can see the Disney fireworks right outside. Then it is back home for some more fireworks (if you know what I mean).

Now that you are done puking a little in your mouth, lets talk teeth shall we.

I have this case that is killing me. I want to talk to you about it.
Here goes....
I have known this family before our kids were born.
They had their daughter one day before my first son. Hanna is now 11 years old.
She was born with a cleft palate. Not a cleft lip but a cleft palate.
She is a pretty little girl but her teeth are kind of messed up because of the original surgery. She has a tiny mouth.

I originally sent her to an orthodontist at the age of 6. She had big teeth and a small mouth and I saw the writing on the wall. She was going to have major crowding issues and I wanted to see if we could alleviate a lot of her later issues if we did some early teeth movement.
Here is the other thing: The parents are great. They do whatever I say and they trust me.

Now she is getting older and she has straight teeth. But is having severe crowding issues still. She is going to be a four bi case, as they say in the biz. To all you non-dental people, this means that we are going to have to remove teeth in the middle of her mouth (premolars or what they use to call them is bicuspids....bi=two and cusp=tips of teeth. So the teeth that have two tips).
So she was going to need her four 1st premolars removed (again to the non-dental people, we have two sets of premolars, 1st premolars and 2nd premolars).
This would have been no big deal except she is missing #10, her upper left lateral incisor.

So then it was the big discussion.
Do we just take out #7 (the other lateral incisor) and move the canines forward and leave the upper premolars alone?
Personally, I don't like this method of doing ortho. I don't think the look is ever very good and I am looking for very good. I would want very good on my daughter and I would want it on Hanna too.
So I said no to the above. I don't want to take out the other central and move the canines into the lateral space.
The alternative is pulling the premolars, doing the ortho, and leaving a space for #10 (to do an implant later).

Easy right?
Well, there is more to the story.
In taking the panoramic x-ray we found that #11 (upper left canine) was coming really nicely because she didn't have teeth there resisting. I was just coming into place really nicely.
#6 on the other hand was ectopicly erupting. It was horizontal. Still this is not a big deal right?
Do a little oral surgery and put a band and a chain on this tooth and pull it into place.
No problem.
Well, as it turns out after the pan I wanted a better look at #6. So I took a couple PA's of this tooth.
And here are the PA's.



Can you see the problem?
#6 is moving horizontally and eating the roots of #7 AND #8.
Are you f!@#$%king kidding me?
Like this girl has not been through enough. Cleft palate, ortho, lower premolar extractions. She has been missing front teeth since she was a kid. Now this. Come on...

So at this point, I have a periodontist friend that has one of those iCat machines. I asked if we could get one, for free, so we can really see what was going on.
He said, no problem.
We made an appointment and had this x-ray done.
Well, indeed the roots of #7 and #8 were compromised.
Son of a !@#$%.
After much discussion with the orthodontist we decided that she still could keep #7 and #8 and they probably would be fine for a long time.
So our plan was still intact. Do oral surgery and pull #6 into place. Do ortho and leave a space for #10.

We send her to the oral surgeon for a consult.
He then proceeds to tell us that there is significant blood supply issues in this area.
See, what appears to have happened is that after her cleft palate surgery as a baby, scar tissue has built up in this area (probably causing the canine to more horizontally in the first place). This scar tissue has a very poor blood supply. He is concerned about a couple of things. One is that if everything goes well and we can get a band on the canine that moving the tooth is still going to be too difficult—because without blood you're SOL. You are not giving this tooth the right cells to make the moving process possible.
Now the second issue is without a blood supply, even if you take out #6 you might not have enough blood supply for her to heal properly just from the extraction.
You are kidding me, right?

So now this is where we are at. The surgeon scheduled the surgery on a day that I am off, so I can be there. He wants me to be there so if there are any forks in the road we can try to make the best decision together.
Is this case crazy, or what?

Any thoughts?
The parents are both, "You know, Dr. John, we are with you. Whatever you decide."
But I had to tell them that whatever we do to the canine is one thing but you have to know that the front two teeth have been compromised and we will just deal with it the best we can and hope they will last.

Tough one huh?
Have a great weekend.
Next week is Thanksgiving week. I might blog on Monday and do a Thanksgiving blog on Wednesday but it is looking like a crazy week.