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.

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.

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?

Location: IN B.S. Ball State University M.S., Zoology, Ball State University M.S.D., Orthodontics, Indiana University School of Dentistry D.D.S., Indiana University School of Dentistry Clinical Instructor, Dental Hygiene Program lecturing on Orthodontics and Temporal Mandibular Joint Dysfunction at Indiana School of Dentistry Honor, Diplomate with International College of Dentists Honor, Diplomate with American Board of Orthodontics Member, American Dental Association Member, American Association of Orthodontists Member, Angle Society of Orthodontists Member, Indiana Dental Association, Council for Dental Education Member, Past-President, North Central Dental Society Member, Past-President, St. Joseph County Dental Society Member, Past-President, Mishawaka Dental Society Member, Indiana Association of Orthodontists Member, Great Lakes Society of Orthodontists Member, American Board of Orthodontics Present, Attending Orthodontist at private practice

Northeast

Delaware

This highly qualified orthodontist received his M.S.D. in Orthodontics and D.D.S. at the Indian School of Dentistry where he graduated with distinction. This expert has been honored as a Diplomate with the International College of Dentists and Diplomate with the American Board of Orthodontics. He is a member of several professional organizations including the American Dental Association, American Association of Orthodontics, American Dental Association, American Association of Orthodontists, Angle Society of Orthodontist, Indiana Dental Association, North Central Dental Society, Mishawaka Dental Society, Indiana Association of Orthodontists, Great Lakes Society of Orthodontists, and American Board of Orthodontics. He has taught as a Clinical Instructor in the Dental Hygiene Program at the Indiana School of Dentistry focusing on Orthodontics and Temporal Mandibular Joint Dysfunction. This expert has authored 5+ publications in the field and is frequent invited guest speaker at major conferences related to Orthodontic and TM joint disorder. At his private practice, this expert is an Elite Provider of Invisalign which is a distinction reserved for the top 1% of providers of Invisalign in the country. Currently, he is an attending orthodontist at a private practice. He currently practices in three locations and has treated over 35,000 patients.

Orthodontics Expert Witness Advises on TMJ Post Procedure

This case involves a female patient who was seen by a periodontist for removal of a molar. The molar was etracted over the course of hours, and was noted to be a difficult extraction. After the extraction, she saw another doctor as an emergency patient with complaints of severe pain in the area of the extracted tooth. Doctors noted that the area around the empty socket was severely inflamed, and that the patient noted extreme pain when the socket was probed. The patient was diagnosed with dry socket, and it was also noted that a section of bone had been exposed. Some time later, the patient again presented to the hospital with extreme pain. During this visit, it was noted that the patient had developed an abscess in the empty socket. Despite numerous treatments since then, the patient continued to suffer from pain, limiting her diet severely.

I routinely treat patients with complications post wisdom tooth extraction, including muscle spasm, myalgia, TMJ arthralgia, lingual mucosal dehiscence, but rarely would you see a patient with all of the symptoms/findings occurring at the same time. It would seem from the brief history given, and without thoroughly reviewing the case, that an extremely difficult extraction, was attempted, and given the time frame for removal, was either unusually complicated, or the Doctor's skill set was not sufficient for the procedure. Being in active practice as an OMS for 20+ years, and after removing a considerable number of extremely difficult molars, I can tell you that even the most difficult of surgeries is typically less than 30-40 minutes for one tooth, so the time frame alone is enough to indicate a procedure that was either exceptionally complicated inherently, or became exceptionally complicated due to the lack of expertise on the part of the treating Doctor.

1. Do you routinely treat patients like the one described above?

Location: NJ BS, Biology, Fairleigh Dickinson University DMD, University of Medicine & Dentistry of NJ Residency, Oral & Maxillofacial Surgery, Kings County Hospital/Downstate Medical Center Board Certified, Oral & Maxillofacial Surgery Member, American Association of Oral & Maxillofacial Surgeons Member, American Dental Society of Anesthesiology Former A******** T*** O*** S****** Former D******* o* O*** & M************ S****** a N** J***** M****** C***** Current D***** S****** P****** P*******

This expert studied at Fairleigh S Dickinson Jr College of Dental Medicine, and finished his DMD at the University of Medicine & Dentistry of NJ. He completed his Residency in Oral and Maxillofacial Surgery at Kings County Hospital. For a decade, he served as the Director of Oral and Maxillofacial Surgery at Southern Ocean Medical Center in New Jersey. Currently, he is an active member of multiple professional societies and a dental surgeon in private practice.

Maxillofacial Surgery Expert Opines on Botched Molar Extraction

This case involves an elderly, non-verbal man with Alzheimer’s who went to a dentist’s office for a cleaning. The cleaning was performed by a hygienist under the supervision of a dentist. A bite block was placed during the procedure. After the procedure, the patient could not close his mouth. This persisted and the next day, the patient went to an urgent care facility. The patient was then referred to the hospital emergency room where a stroke was ruled out. An X-ray revealed that the patient’s mandible was dislocated. The patient required a corrective procedure and a stay in the hospital.

I served as the attending dentist for two nursing homes and treated hundreds of patients, many with serious levels of dementia. Our dental hygienist performs nearly all of our routine dental cleanings as well as most root planning and scaling treatments. This is customary for most dental practices. Use of a mouth prop/bite block in a patient with some form of dementia may be essential in order to be able to make a proper diagnosis and safely provide treatment. It is also more comfortable for some patients to rely on this artificial form of support than to voluntarily hold their mouth open for the duration of treatment. Proper use of a bite block should not cause a TMJ dislocation. Following the dental procedure, I would have been concerned that the patient could not close their mouth properly. Before dismissing the patient, I would have certainly tried to determine if the problem seemed like a muscular problem, a TMJ dislocation or even a possible fracture of the jaw. Dislocations can be successfully managed by either a primary care dentist with some experience or an oral and maxillofacial surgeon. Management of a case like this starts with a proper diagnosis. A routine 2D panoramic radiograph or 3D Conebeam (available in many dental offices) would likely show the dislocation. If a diagnosis could not be made, then referral would be indicated.

1. How often in your practice does a hygienist assist in dental cleanings? 2. In general, what aspects of the placement of a bite block and subsequent management can help prevent a dislocated jaw? 3. What is the management, in general, of a dislocated jaw after a procedure?

Dental Patient’s Jaw Becomes Dislocated During Cleaning

Location: ON BS, Pure and Applied Science, York University MS, Neuroscience, University of Toronto DDS, University of Toronto Faculty of Dentistry Member, International Congress of Oral Implantation Member, International College of Dentists Member, Ontario Dental Association Member, Canadian Dental Association Former, Staff Dental Surgeon, Baycrest Hospital for Geriatric Care Current, Staff Dentist, an ON private practice clinic Current, Assistant Professor, a major ON dental school

This expert has reviewed 150 cases, been deposed 15 times and has testified at trial 15 times.

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Orthodontics Expert Witness Advises on TMJ Post Procedure

Maxillofacial Surgery Expert Opines on Botched Molar Extraction

Dental Patient’s Jaw Becomes Dislocated During Cleaning

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