It was July of 1972 in Minneapolis, just weeks into my orthodontic residency. Something happened in my life that started me thinking. That thinking led to a research project. The results of that research project started a process that may well help other orthodontists prevent impaction of cuspid teeth.
By 1975, I had figured out how to do it. With rear view mirror sight being 20/20, we can now comfortably say that.
Given the fact that various studies estimate 2 to 3 percent of the population suffers from impacted cuspids, and that failure to recognize this condition can have disastrous consequences, this issue is not inconsequential. Prevention of a problem is always better than treating collateral damage.
Weed abatement for Southern California residents is cheaper and better than replacing your home after it burns to the ground in a wildfire. I lived in Southern California for 27 years and learned that lesson early.
A beautiful nineteen year old girl, Julie K., sat in my chair in the clinic with her retainers in her mouth for me to check them. She had been treated for impacted cuspids at the University of Minnesota and was assigned to me as a “retention patient.”
The instructor on her case described her treatment as “successful.” As a new resident, I was really just learning how to check a retainer, which was fine. Her smile was beautiful. Ideally proportioned, gloriously white, perfectly shaped teeth aligned in textbook fashion. There was not a molecule of plaque in sight.
But something wasn’t right.
Her upper four incisors and cuspids were moderately mobile as I removed and reinserted her retainer. That didn’t make sense in such a healthy looking mouth. I reached for a periodontal probe and thought I struck oil when I inserted it around the cuspids.
She had 10 millimeter periodontal pockets on her upper cuspids.
How could that be when her oral hygiene was so good?
I reviewed her chart and examined the original radiographs taken before orthodontic treatment. The four upper incisor roots were more than 50 percent resorbed, with the cuspids headed directly toward them on each side.
Post treatment x-rays showed alarmingly short incisor roots, but no pocketing and appropriate bone levels around those teeth. The cuspids, however, showed severe bone loss, consistent with the 10 millimeter pockets.
I asked the instructor what had been done.
This case was treated long before bonding orthodontic attachments was common. Surgeons had uncovered the cuspids from the palate and placed orthodontic bands high in the palate. That alone required substantial bone removal.
Unfortunately, to make tooth movement easier, the surgeons had channeled out all the bone so the cuspids could move freely into position. What happened was predictable in hindsight. When the cuspids arrived at their destination, there was essentially no supporting bone left.
The reward for making treatment easier was severe periodontal damage.
I lost sleep over this case.
As an addicted runner, I do a lot of thinking while running. I kept thinking about Julie’s future.
Would she lose some or all of these teeth? How would you restore her smile if she did?
Dental implants had not been invented in 1972.
What kind of restoration would you even attempt if she lost all six anterior teeth?
I could not get her out of my mind.
Two years later, I completed my orthodontic certificate and M.S.D. degree. I was invited to join the faculty at the University of Minnesota straight out of residency, which had never happened before. I was flattered and accepted.
Julie K.’s case stayed with me. I knew there had to be a better way.
Over weeks and months, I studied every impacted cuspid case treated at Minnesota that still had records, going back many years. I thought a lot about what I saw on x-rays – especially when I was running.
Patterns began to emerge.
I started to believe that cuspid impaction could be predicted and prevented if patients were seen early enough.
In my mind, I developed a list of risk factors associated with impacted cuspids. Eventually, I decided private practice would suit me better than teaching and moved to Vermont to open my own practice.
There, I began applying what I had learned.
Within a few years, I expanded the list of risk factors and discovered that I could sometimes predict cuspid impaction in children as young as five or six years old, nearly seven years before eruption would normally occur.
When I identified a likely impaction, I intervened early and followed those children closely.
The results were unmistakable.
I was preventing the problem.
In cases where families chose not to follow my recommendations, my predictions unfortunately came true. Impacted cuspids developed exactly as expected.
I knew I was onto something.
I compiled records from dozens of patients and developed a lecture. I compiled records from dozens of patients and developed a lecture. I presented it at University of California San Francisco, where my former department head from Minnesota was now the department head.
He was impressed.
After moving to Virginia Commonwealth University, he invited me to present again. During that time, Stephen Lindauer, a newly graduated orthodontist from UCONN, was on faculty at VCU.
My work motivated him to conduct a retrospective study evaluating whether cuspid impaction could be accurately predicted. His research confirmed the validity of these concepts and was published in the March 1990 issue of the Journal of the American Dental Association.
By that time, I had essentially eliminated cuspid impaction in any patient I saw early enough and monitored consistently.
I later presented this work at a table clinic during an American Association of Orthodontists meeting. Orthodontists from around the world attended, including a European doctor who had independently researched impacted cuspids.
Today, I receive alerts from ResearchGate whenever new studies cite Dr. Lindauer’s article. It has been cited hundreds of times over the years.
And yet, cuspid impaction still occurs.
If these concepts were truly common knowledge, it would be rare to nonexistent.
It all began with Julie K. in the summer of 1972, when my curiosity told me there had to be a better way.
The only question that remains in my mind is this:
What ever happened to Julie K?
