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Your dental practice needs to be independent of the threats to its (and your) freedom.

Too often, dental practice earnings are eroded or eliminated by diminishing and delayed insurance reimbursements and increasing restrictions. But there is a way to become independent.
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There are some important "blocks" to use when you build the foundations of both your dental practice and your life. The quality of those building blocks will determine the quality of what's built upon them.
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The problems of missing and ectopic second bicuspids

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Severely ectopic LR5 had to be removed. © 2018

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3 Facts for your consideration:
  • The “5’s”, or second bicuspids are statistically the third most-commonly congenitally anomalous teeth, misshapen, ectopic eruptive positions, and missing.  (The first two are wisdom teeth and upper laterals.)
  • The predecessor primary/baby tooth,  the “e” tooth, is typically 2-3 or more mm wider mesio-distally than the 5’s.  
This provides extra space in the arch between the 6 year molar which erupts distal to the “e”, and the lateral incisor, so that the 3’s, 4’s, and 5’s (permanent canine and first and second bicuspids) have space for eruption.
5 Things that can throw the system off:
  1. Missing permanent 5’s.
  2. One or more bicuspids in poor developmental/eruptive position
  3. Eruption sequence out of order, so space is lost early, OR held too long by a primary tooth, most often the “e”.
  4. Ectopic position after eruption, often rotations, sometimes as much as 90∘
  5. There is no space for lower 12-year molar eruption, and 5’s are crowded out.
  6. Profile is protrusive, and if all teeth remain in the arch, the protrusion is unesthetic.
For 5-eruptions to work well, the following 3 are necessary:
  1. All permanent teeth are present.
  2. All permanent teeth must be in relatively good eruptive position.
  3. The sequence of primary tooth exfoliation is ideally... 
    Upper: the “d” exfoliates and the 4 erupts the “e” exfoliates and the 5 erupts right away before the 6 year molar has a chance to mesialize the “c” exfoliates and the 3 erupts last
    Lower: the “c” exfoliates and the 3 erupts the “d” and “e” exfoliate about the same time and the 4 and 5 erupt without the 6-year molar having time to mesialize.

5 Things you do to reduce the risk of FIVEs not jiving. (Which will help provide better chance of the necessary factors above.)
  1. Clear the path (extract primary teeth that are in the path)... as early as the panoramic demonstrates an ectopic trajectory is obvious... ascertain LLA (lower lingual arch, Nance or upper lingual arch)... is in place to avoid any mesialization of the 6 year molars  (save the precious “e” space)
  2. Use a UAW (Utility Arch Wire) to create space
  3. If severely ectopic trajectory, removal may be needed at some point
  4. Utilize various orthodontic techniques to derotate a rotated bicuspid as soon as it erupts, before the interosseous and interdental fibers develop
  5. Include in a comprehensive orthodontic treatment plan, the removal of a bicuspid that will facilitate successful eruption and successful occlusion of other teeth, including the 12 year molars, or removal of bicuspids when it will facilitate the most beautiful profile.
You can reduce treatment time, reduce frustration for you and for your patient, and improve your finished results by utilizing the above treatments in your orthodontics.
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No space for 7’s and protrusive profile: plan to extract L5’s. © 2018 Dr Chris Baker.

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UAW’s to create arch length for 3,4,5’s. © 2018 Dr Chris Baker. All rights reserved.

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Unerupted L5; parents don’t want to remove now; hope for eruption. Completed ortho, removed braces… 5 is holding bone for implant. © 2018 Dr Chris Baker

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Relationships are transformational for your dental practice. Deal with your patients with absolute love in your heart.  

"If words come out of the heart, they will enter the heart. If they come from the tongue, they will not pass beyond the ears." - Suhrawardi
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Missing upper 2's, missing lower 5's, ectopic canines. © 2018 Dr Chris Baker

The Panoramic radiograph.  You may be surprised to discover the amazing information you can find about a child patient in that x-ray.  Can you name five really important findings in a panoramic on an early mixed dentition patient?

Can you name six?  Seven?  Let’s go for double that figure! (And we won’t include decay, as it’s not the best diagnostic tool of decay.  Well, on second thought, maybe we will include some  possible decay-related findings at the end of our discussion.)

The panoramic should be taken when any permanent teeth are erupting.  Often those first eruptions are the lower incisors, or the six-year molars, but no matter what teeth, take the pano then.  (You may find opportunity to change the child’s life because of the secrets that x-ray holds.)

Start by counting/identifying all teeth (Sounds pretty tame and familiar so far!) :
  1. Missing teeth.  Count ‘em.  Every single one.  Be sure.  Most often upper lateral incisors, and bicuspids, but maybe any incisor, any tooth actually.  While severe “anodontia” is typically related to Ectodermal Dysplasia, and other developmental disorders, any permanent tooth can be missing even without identifiable developmental disorders "with names.”
  2. Extra teeth.  Supernumerary teeth can be anywhere.  One of my patients had one that looked like a canine, but about the size of a primary canine, in the floor of the nose, over the bicuspid root area. 
  3. Malformed  and unusual teeth.   While ectopic and unusual trajectories of eruptive paths can cause dilacerations, there may be malformed crowns as well.  Note any taurodontic primary molars that may hinder exfoliation, dilacerated roots that may hinder eruption, or if the dilacerated root is next to a missing tooth space, it could prevent implant later.  Notice now.  Notice incisors with talon lingual cusps/dens evaginates, and shovel-shaped incisors with scooped out lingual surfaces which may be more at risk of decay at the cuspal interfaces, and may create occlusal issues in contact with the lower incisors.  
  4. Variations in sizes of teeth. Notice particularly large lateral incisors as well as peg or small laterals which may also interfere with occlusal harmony.
  5. Fused or possibly fused teeth; or geminated teeth.
  6. Ectopic teeth positions, which can portend huge difficulties in getting the teeth into the arch later, or even contribute to transpositions of teeth, and certainly to extended orthodontic treatment.  If normal eruption does not occur, ectopic teeth may need to be orthodontically moved over larger than normal distances, and past other tooth roots.  This predisposes both the ectopic teeth as well as the teeth in the path of the movement to potential damage, including root resorption, loss of vitality, alveolar bone loss and gingival and per problems, and some ankylose,
  7. Stage of exfoliation and eruption
  8. Poorly resorbing roots on primary teeth - is it due to ectopic position of succedaneous permanent tooth?  Is the permanent successor missing?
  9. Submerged primary molars - actually probably due to an ankylosis or other failure of the tooth to undergo normal eruptive growth with the adjacent teeth.
  10. Crowding.  Eruption issues to come.  Opportunity to clear the path of eruption and prevent more complex problems and need for extended treatments.  
  11. Third molar positions.  While not usually evident in the earliest mixed dentition panoramic x-ray, often are notable within a year or two.  Horizontal and severe ectopic positions may affect the eruption of the twelve year molars, and should be monitored for need for early removal to allow eruption of the twelve year molars.
  12. Twelve year molars that do not have the space to erupt in the mandible.  As human jaws get smaller, and teeth do not, we are seeing more 12 year molars that will never be able to clear the mandibular ramus, like many third molars.  Not frequent, but more and more so.
  13. Class II or III occlusion (at least as screening, to be evaluated further.)
  14. Atypical incisive papilla alveolar bone area.  Again, screening, to be confirmed with diastema, low and deep pull frenum, etc.
There you have some great secrets the pano may hold.  Nice not to be surprised later when it is later, and things have gotten way complex.  Think about what you can do for your patient when you take panos at the time of eruption of permanent teeth. 

Here’s an important opportunity to do outstanding diagnosis for your patient, and be paid for your care.  You’re in dentistry to care for people, and in business to make a living.  
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Missing LL5, and severely ectopic LR 5, which had to be removed. © 2018 Dr Chris Baker

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In our heart of hearts (for the most part) we pediatric dentists want to help our patients more through prevention than through restorative procedures. Unfortunately, pediatric dentistry has, partially by necessity, become way too focused on restoring a child's mouth. 
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Dr Chris Baker

America's most-trusted teacher of orthodontic continuing education, Dr. Chris Baker has practiced and taught for more than 30 years, and is a current or former faculty member of three U.S. dental schools.  She is a pediatric dentist, author, blogger, dental practice consultant, and mentor.  Dr. Chris is also Past President and Senior Instructor of the American Orthodontic Society.  She is based in Texas, USA, but lectures around the world.

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