Category Archives: Topics of Interest

AESTHETIC RESHAPING

Brooklyn Orthodontist Dr Ted Rothstein Esthetic reshaping of front teeth

When I finish straightening my patient’s teeth I always ask them to go home and look carefully at them every day for three more weeks. I ask them to this because I want them to be sure that every tooth they can see is dazzling straight. Only when they are absolutely sure their teeth are perfectly straight do I remove their braces. The appearance of straight teeth begins at the very first visit when I first bond their braces on to their teeth. Even before that I use my sanding instruments to make the edges of their teeth straight and that often includes making pointy eye teeth more curved (less pointy:Bef/Aft 2). This approach makes it easier for me to accomplish making the teeth super-straight looking.

Nowadays I offer this service to those patients who refuse to have any kind of braces at all, but who have some snaggly-looking front teeth and would submit to having them sanded straight.  Are you one of those? if you are let me know I’ll show you what I can do for you.

Look carefully at the edges of the teeth. You can see how irregular the edges are in the before and how much straighter they are in the after. These photos demonstrate how much straighter the teeth can appear with light, painless reshaping of the edges of the teeth (no anesthesia required). These patients were pleased with the result and opted to have no braces.  The patient in before/after 2 was particularly happy with having her pointy canines reshaped.

 

Before 1

After 1

Before 2

After 2

Before 3

After 3

DENTOFACIAL ORTHOPEDICS

You may have noticed that I specialize in “Orthodontics and Dentofacial Orthopedics.” While most people have heard of orthodontics, many are confused by the “dentofacial orthopedics” part of the title. Let me explain!

Every orthodontist starts out in dental school. Upon completion of dental school, some graduates immediately go into practice as dentists. Others choose to pursue a dental specialty, which requires additional schooling during a two- to three- year residency program. There are nine specialties sanctioned by the American Dental Association. Some you are likely familiar with are Pediatric Dentistry (dentistry for children), Periodontics (dentistry focusing on the gums), and Oral Surgery.

One of the nine specialties is “Orthodontics and Dentofacial Orthopedics.” You probably know that an orthodontist straightens teeth, and indeed: “ortho” comes from the Greek for “straight” or “correct,” and “dontic” from the Greek for “teeth.” But what about dentofacial orthopedics? “Dentofacial” is “teeth” plus “face” while “ortho” again means “straight” and “pedic” is from the Greek for “child.”

Essentially, while orthodontics entails the management of tooth movement, dentofacial orthopedics involves the guidance of facial growth and development, which occurs largely during childhood. In both cases, appliances are frequently used – the more familiar braces for orthodontics, and other specialized appliances like headgear and expanders depending on what facial abnormalities are present. Sometimes orthopedic treatment may precede conventional braces, but often the two are accomplished at the same time. So if your child gets braces and headgear, he’s undergoing orthodontics and dentofacial orthopedics!

Because I am skilled in both areas, I am able to diagnose any misalignments in the teeth and jaw as well as the facial structure, and can devise a treatment plan that integrates both orthodontic and dentofacial orthopedic treatments. In  fact, distinguishing normal from abnormal growth was the subject of my Doctoral Dissertation which was published in the American Journal or Orthodontics and DentoFacial Orthopedics.

JAW SURGERY

Maxillofacial Surgery
by Henry Hatfield

THE SURGICAL CORRECTION OF OPEN BITE: SEE HENRY’S PRESURGICAL PHOTOS

     My name is Henry Hatfield and I am forty years old. I have known I needed surgery most of my life to correct my bite. I did have braces when I was in my teens, but since I did not not finish the treatment with the necessary surgery my teeth almost completed relapsed to their previous maloccluded state. In my twenties and thirties I had seen different dentists for normal oral care. Since I was getting older, and I did not want braces on the front of my teeth. I asked each one of them if they knew of lingual braces. (braces behind your teeth) Each time the answer was they the same, no you do not have enough space in your mouth for lingual braces or some other negative response.

    The truth of the matter was THEY DID NOT KNOW! Their ignorance and their need to give me a definitive answer left me with crooked teeth for many years.

     I will admit that I was not actively seeking to get my teeth corrected until my upper thirties.  If  one of the dentists had given me hope that there was an orthodontist out there that would have taken my case, I would have pursued it much much  earlier.  Finally, and thorough the advent of the internet I was not accepting “NO” for an answer any more.  My rear molars had started to ache if I chewed a tough steak or any other chewy food.  I knew I would eventually start losing my teeth in the back if I did not do something about my situation.

    After searching the internet, and finding many sites on the surgery and some on lingual braces, I saw light at the end of the tunnel.  I made an appointment at Doctor Ted’s in August of 2001.  To my pleasant surprise, I was a prime candidate for lingual braces!  This  really elevated my skepticism for doctor’s opinions.  Dr  Ted did excellent job explaining my correction before we started. Since I was going to have jaw surgery he did a full skeletal make-up and explained my maxilla (upper jaw ) needed to be moved.  I had always thought that my lower jaw protruded to far and it would be the lower jaw being moved not the upper.  He explained that surgically moving the maxilla leads to very stable result  i.e. the jaw holds its new position very well. To alter my chin would only require a minor surgical procedure called a “genioplasty”  NOT A WHOLE JAW SURGERY to correct my  protruding chin.

Mentally I was not really ready for this new information. Cutting my whole upper jaw loose and sliding it forward AND lifting it up upward a bit (to correct a “gummy” smile sounded more serious than making 2 cuts on my lower jaw  (WHICH IS VERY SERIOUS JAW SURGERY) and adjusting my bite.  Again, after doing my homework on the internet I found that Dr. Ted was right.  The upper jaw was a more stable move and was a less serious operation.

During the course of my orthodontic correction with Dr. Ted  he urged me to visit several oral surgeons for their diagnosis.  My skepticism for doctors grows!  Two out of the three doctors that I consulted say that I was a a two jaw  surgery case. Dr Beiber (Fishkill, Ny ) agreed with Dr. Ted that only upper jaw surgery was  necessary  to correct my bite. If it was not for Dr. Ted vehemently suggesting that I was only a upper jaw case, and another orthodontist left it up to the oral surgeon to decide my fate, I could have had very easily been led to have both jaws cut.  Advice, get several opinions!

Before I talked about the surgery, I will say a few things about Dr. Ted and lingual braces. Lingual braces do take about 2 weeks to get used to.  Nobody knows you are wearing them except you.  I have been wearing the braces for about 13 months now and they are barely a bother.

Dr. Ted’s treatment and service has been excellent and I would highly recommend him to anybody desiring lingual braces.  Now on to the surgery!

Dr. Beiber, after doing  some research, has the the most accomplished reputation in my area in New York.  Again, Dr. Beiber was the only surgeon to agree that only upper jaw surgery was necessary. My ultimate diagnosis was three fold.  1. I needed my deviated septum fixed, 2. the maxilla moved to correct my bite, and 3. the genioplasty to reduce my pronounced chin.   This was my first visit ever to the hospital so my fears and apprehensions were peaked.  Dr. Beiber was very good at explaining as much as possible about every detail of the operation.  He gave me references to call which were helpful in reducing my concern.

I spoke with maybe a dozen or more people who had the operation and the only averse comment I found was one girl had numbness in her upper lip for about one year.  I was as ready as I was to get going.

The day before the surgery Dr. Beiber informed me that since I was going to be in the operating room for many hours  I would need a catheter (a tube inserted in to my urethra to allow urine to pass).  Ouch!  That was one of the last surprises.  I had asked him to put it in after I was asleep and take it out before I woke up. In the pre-op room (the room in which you are placed just before being wheeled into the surgical suite).

I had been given my preoperative meds in the morning and I was feeling very solemn. I knew my moments were numbered until I would wake up in pain.

Dr. Bieber’s final words to me were, “It will be what it will be.”

When my eyes snapped open sometime that afternoon it was like someone slammed all 88 keys on the piano!  The nurse was there right away and she immediately put the morphine button in my hand.  The pain was excruciating (9/10). She said:  “press the button as you need it to reduce your pain”.  I immediately started pressing the button. She had said that I  could press the button up to 5 times to increase my dosage. I found that 2 to 3 times was sufficient to take the edge off the pain.

Now it was time to take out the catheter, another surprise.  I thought they were going to take this out before I woke up.  The first evening and night was by far the worst of the pain. My wife came to visit me around 7:00 pm and I saw her for a few minutes and then told her to leave me alone.  The best thing for me at this time was peace and quiet and most important my morphine button.

The morphine dosage was only good for 6 minutes at a time, so I can’t say how often I was pressing the button, but it was often for the first night.  I did not sleep the entire night.  In the morning I had stopped pressing the button and was able to deal with swollen aching pain.  The morphine was still hooked up giving me a minimum dosage.   My face felt like someone had inflated a basketball inside my head.  I felt like I was going to burst around my mouth and nasal area.

In the morning, the nurse asked me if I had urinated yet. I had not.  I was about to find out another reason you get a catheter is because morphine inhibits the urge to urinate.  She checked my bladder with a sonogram machine, and informed me that my bladder was very full and if I could not go to the bathroom she would have to catheterize me AGAIN!  Needless to say, I was able to force myself to go but it was not easy for the first day.  I failed to mention that the whole time you are in the hospital you are getting an I.V. of fluids.  This does make you drain your bladder about every hour once you are regular again.

Dr. Beiber came in about 10:00 am for a check up visit.  I this point I still had not looked at myself in the mirror.  He asked me how felt and requested room change because I had a loud obnoxious patient next to me. Around 10:30 I decided to look in the mirror.  I did not recognize myself.  Aside from the swelling I had blood oozing from both nostrils, and my mouth. This did not really bother me. I was trying to guess what I was going to look like after the swelling went down, but I gave up.

Pain management was far more important at this time.  Besides the morphine, good old ice was very good at keeping the pain at bay.  Although I could have very easily used more morphine in the first day, I was anxious to get off the stuff so I could get out of there.  By noontime I was coherent enough to activate my TV and make a few phone calls.  That night my wife and my good friend Andre came by for a visit. Although I did not say anything at the time, I was glad they left when they did because I was starting to get sore from talking and moving my mouth.  Dr. Beiber had told me that provided everything was ok; I was ready to leave in the morning of the third day.

This was the case. He was in early at 8:00 am and I was packing my bag.  Perfect timing.  He looked at me and said I was good to go.  The minimum drip of morphine (1mg per hour) that I was still getting up until the time I left the hospital turned out to be more than insignificant.  Five hours after I got home I realized I missed that morphine drip.

Dr. Beiber had anticipated this and gave me a prescription for hydromorphone.  These might have well been tic tacs compared to the morphine drip in the hospital.  They did take the edge off but the morphine in the hospital was better.  Even though the pain had elevated slightly I was still glad I was home.

It wasn’t until the third day that I stopped taking the pills and was completely off pain meds.  On the third day, I was finally at a pain level I could deal with. I still kept icing my face because this did feel good and it was bringing down the swelling. The last surprise.  Since I was not eating solid food for four days, I did not have a bowel movement, nor did I have the urge to go. On the fourth day I started eating pancakes and other soft foods.  Now there was a need to defecate.  This was the most constipated I had ever been in my life.  (Morphine suppresses bowel motility.)

Do drink plenty of prune juice while you are on morphine. Do not forget this advice.  One small but very important detail had been forgotten, the need for laxatives while on morphine.

Now I will recap the pain levels on a scale of one to ten.   Upon waking up, I put the pain at a nine,  after pressing the button a few times you can maintain between a seven to a five,  after 8 hours the pain levels off and I was around a five to a six.  I maintained around a five for the next 24 hours.

When I went home on Friday and I was off the hospital morphine the pain went back up to a 7 (I call a seven very uncomfortable) and the pills brought it back down to a five (bearable).  It wasn’t until Sunday that I would say that the pain was down to a three or four without medication.

I did go back to work the following Monday afternoon and I was not at full speed until the following week.  I did not do any exercise for the first 12 days and at that point I felt well enough to do a light workout.  Now it has been 17 days since my surgery and I any trying to get my level of fitness back where it was before the operation.  After the fifth day the pain is actually minimal and you experience only numbness and tightness. Yes this is uncomfortable, but I give it a two on the pain scale. Would I do this again? No, once was enough!  Am I happy with the results? Yes, very much. Would I recommend this surgery to someone considering bite correction? Yes, but in the words of Dr. Beiber, “It will be what it will be.”

My closing statement,  it has been 40 days since the operation and I still feel total numbness in my upper jaw and chin button where the major surgery was performed. Dr. Beiber had said that usually in younger patients ages 18-25 yrs.  total feeling comes back after 8 weeks.  Since you are older,  it may take a little longer for your feeling to return.  He also had said that I may return to a totally normal diet after 42 days but I still am not ready to bite into a ear of corn or chew rigorously  on a piece of steak.  At the rate of my healing I think this will be about another 30 days.  At the rate my feeling is returning, (very slowly) I am guessing it could be 6 months before I feel totally normal again.  The feeling of numbness at this point is not very uncomfortable at all.  There are points in the day when I think about it and let it bother me a little, otherwise it really is not distracting.

Both Dr. Ted and Dr. Beiber are outstanding doctors in their fields.  I would
highly recommend their services to anybody needing orthodontic work or oral surgery.
I do have pictures at both doctors upon request.

 

Post script from Dr. Ted:

The surgeon had moved Henry’s upper jaw exactly as planned. I had warned Henry that some patients experience a post-operative depression which sometimes lasts for weeks and months. Henry told me that had I not mentioned it prior to surgery he would not have noticed it. Since I had mentioned it he was able to hearken back to my works when it emerged.

I think this depression emerges and  hangs on until you actually can see the benefit of your election to have the procedure done. You tend to feel miserable and have doubts about your choice. Only gradually do you become accustomed to seeing to the new you in the mirror.

On 3/16 I began the final phase of Henry’s orthodontic treatment.  You see no matter how excellent the surgeon does his work the teeth need to be positioned even more precisely.  In Henry’s case I think the remaining treatment will take about 6 more months.

LASER GUM RESHAPING

Sometimes gums overgrow the crowns of the teeth making them look too short at the end of treatment. We sculpt them to look normal

I am pleased to announce the addition of a new instrument/service in the office called the “Sapphire Diode Soft-tissue laser” and have completed the Advanced Diode online soft tissue laser training course granting an Associate Fellowship Certificate in the WCLI (World Clinical Laser Institute)* See below. This laser instrument will permit my office to offer an array of services to treat conditions that commonly arise at the start of orthodontic treatment or occur during and at the end of orthodontic treatment. One of the most common problems at the start of treatment is to expose the surfaces of teeth that are covered with gums to allow braces to be attached to them, and at the end of treatment is the need to resculpture/reshape the gums of patients whose gums have become bulbous/ overgrown/ uneven or misshapen. The Sapphire can accomplish this in most cases painlessly, without swelling and without surgery/bleeding and without the need for stitches. It has a variety of other useful applications. See Video

Below: list of YouTube videos demonstrating a variety of treatment applications using the soft-tissue diode laser for common problem seen before during and after orthodontic treatment as well as for use in treatment of some common gum diseases

The operations the 810 soft tissue diode laser can perform

  • Excision and incision biopsies
  • Hemostatic/Hemostasis assistance
  • Treatment of apthous ulcers
  • Gingival incision and excision
  • Gingivectomy
  • Gingivoplasty (reshaping)
  • Gingival troughing
  • Gingival recontouring
  • Tissue retractions for impressions
  • Oral papillectomy
  • Sulcular debridement
  • Sulcular tissue removal
  • Removal of granulation tissue
  • Frenectomy
  • Frenotomy
  • Abscess incision and draining excision
  • Operculectomy
  • Removal of fibromas
  • Soft tissue crown lengthening
  • Vestibuloplasty

 

The 810 Diode Soft Tissue Laser

Case Study: Photos of a gingivectomy on RitaS. 113012 with her critique

 

Informed Consent for Procedures in Which the Soft Tissue Laser is Used

 

Literature References (*Articles Available to  Read)

  1.  Am J Orthod Dentofacial Orthop. 2005 Feb;127(2):262-4.
    HERE AT AAO
    * Principles of cosmetic dentistry in orthodontics: Part 3. Laser treatments for tooth eruption and soft tissue problems.
    Sarver DM, Yanosky M.
    sarverd@aol.com
    PMID: 15750548  [PubMed - indexed for MEDLINE]
  2. Dent Clin North Am. 2007 Apr;51(2):525-45, xi.
    HERE AT AAO
    * Laser use for esthetic soft tissue modification.
    Magid KS, Strauss RA.
    Department of Cariology and Comprehensive Care, New York University College of Dentistry, 345 East 24th Street, New York, NY 10010, USA. drmagid@adfow.com In esthetic dentistry, expanding the evaluation beyond the teeth is necessary to achieve a truly desirable result. The lips, attached and unattached mucosa, free gingival margin, and osseous position and contours must be considered and changed if necessary. Although many treatment modalities are available to accomplish these modifications, the use of lasers of varying wavelengths provides advantages not possible by other means. Lasers are often thought of as generic instruments, but different laser wavelengths function differently, and each has its place in the esthetic continuum. Diode, neodymium:YAG, CO(2) and erbium lasers each have advantages that can be exploited to maximum effect and disadvantages that must be taken into consideration. A thorough understanding of their mechanism of action, their tissue effects, and laser safety is vital to obtaining excellent results.
    PMID: 17532926  [PubMed - indexed for MEDLINE]

TEETH WHITENING

With teeth whitening, the results are always stunning whether you choose the 50-minute method or the take-home kit, or both.

"Experience and reputation really count when it comes to providing quality patient care."