Strange Case of Removal of upper lateral incisors implants: Thoughts?

This is not a primary case for a dentist or an OMFS. This is a case for psychology/psychiatry first.

Probably, the patient needs to be evaluated by a psychiatrist, but the size and the quality of the X-ray doesn't allow us to assess the situation around the implants.

Thank you for your answers. Yes the images are not so good, i'll try to ask him for better ones (is there any way to post new images through a comment?). The patient has already attended to a psycchology, because of recommendation by other specialists, and he seems to be in totally good mental health. He insists on the idea that he never had any problem with his teeth until they moved backwards his canines at 18 years old, from near the central incisors to their normal place. He says since then he feels an important compression and tension in the zone of the movements and in the entire head, specially in the back part of the skull. PD: Sorry for my bad english.

One more thing, the drawings show the change on the shape of his head due to the pulling back of his canine teeth, based in some photos he sent that were not published to protect his identity. The thing that concerns me most is the diagnostic of the ostheopatist, who said he has compression (lack of movement) and bad insertion of the bones of his head.

You can post new images using the Post Case Link, just be sure to use the same email address you used when you first posted the case, and be sure to reference this case in your new post. Also, please note that we cannot post actual facial photos or other easily identifiable personal photos. CBCT images and other dental-type images are fine. Thanks.

I would not toudh this patient, he is not rational!

oh and the osteopath is crazy too

You are dealing with a nut job. Refer him out and never think of him again. You can absolutely not win in a case like this. Don't even think about treating him

The world is really full of weirdos..

I wouldn't even refer him out to anyone. I would just say "I can't help you" and move on.

If anything refer him to a good ENT or psychologist... Absolutely work with a team....and have you gotten his records from ALL his other doctors? It is best to go VERY slow in this type of case ,,,,if you get involved at all. How did the patient come to you?...Good luck to both of you.

Run!, don't walk away from this case. I agree, referral to Psychiatrist is the best option

There is no or any kind of anatomical structer that could be damage during the implants placement in the maxile.The images are not so good but everything seems to be ok.I agree and don´t even thing to treat him because,then you will be the problem to his madness.

We are learning everyday. Occlusion and malocclusion can have deleterious and positive affects on systems we have yet to fully understand. I do full mouth reconstruction with an emphasis on biometrics and I have witnessed patient testimonies that both thrilled me and scared me. I recently wrote a paper called The Simple Theory of Dental Relativity emphasizing the possible role Bioesthetics/Biomimetics could play in our general health and well being. Start with a muscle deprogrammer rolling into a centric relation mounted model. Observe this and determine if there are problems with the occlusion. During this time while the muscle deprogrammer is in place do the cranial osteopathy and possibly rolfing.

I agree that treating him would be dangerous but a centric relation splint would be a start and is non-invasive. Perhaps his occlusion does cause tension in his facial/ cranial muscles which results in his problems. If this helps then tell him just to wear this every night or when convenient. I would definitely avoid any other form of treatment.

I applaud Dr. Charlton's open-minded response. As for all of the other posters, my only comment is that all of your words reflect a total unwillingness to (1)actually liste to this individual and (2) treat the WHOLE person rather than just his mouth.

The general palatial plate change in the mechanics shown is Expansion of the pre maxillary sutures and opening of the anterior portion of the mid palatine suture. Compression would not open up the lateral spaces. Spaces open between the cuspids and lateral incisors. No pre or post op ceph x-ray is shown, so opening, closing, translation, etc. are not possible to estimate. Most photos are not good diagnostic tools - too many possible variables. While there may be psychological skewing of what he feels happened to him, a good Orthodontic Ceph comparison and maybe a conservative TMJ evaluation would rely on concrete data to ascertain whether any documented changes could be related to his complaint. I think he deserves an unbiased, expert evaluation of his condition even though to do as he requests does not seem advisable. John

Also, the patient needs to understand that the cuspids and lateral are on different bones, like being on different continental plates. One can never move a tooth across a maxillary suture, whether the laterals are removed or not. Also, the recent pano x-ray shows balancing side contact facet profiles on the wisdom teeth. A trial relief of pathological contacts in this posterior area may give him some relief. The removal of the wisdom teeth may be indicated to free up the jaw movement. John

Dr. Manuel: would you kindly elaborate on how removal of the wisdom teeth is going to free up mandibular movement. Thank you. DrT

Dr T, you are correct in that I probably should have said that removal of contacts which are interfering with the proper joint/occlusion/ jaw relationship may reduce his symptoms. e.g. , balancing contacts can stretch ligaments and contribute joint problems while the muscular action to avoid them can lead to muscle problems. John

John, that is what I suspected you meant. I just wanted to check if you had some more specific rationale in actually removing the wisdom teeth. DrT

To simplify: 1 - Pano shows square jaw with over grown muscle attachments. Indicative of massive, heavy clenching. 2- The lateral profile of the DB cusps on #1 & 16 look like mated to DB cusps # 17 & 32. They did not get to match by accident. 3- You are likely to find occlusal markings on the distal corners of the lower wisdom teeth, demonstrating interference with the normal TMJ function. 4- Relieving these interferences is a temporary fix. The upper wisdom teeth are not wearing on the Distal half and the "wrapping around" of the lower third molars will continue as the contacting teeth wear over the years. 5- Pano x-ray shows a very long, basically flat occlusal plane, no Curve of Spee, and in fact shows a small reversed curve in the third molar area. 6- Analyzing these long, flat plane cases with an archial system shows a distalized stress axis which can be improved by shortening that long flat occlusal plane, allowing more freedom of jaw movement without overloading the joint ligament. I.e., the occlusion can function more like a normal Curve of Spee. 7- Some clinical examination of the attached tissue vs. mucosal tissue around the wisdom teeth is needed. 8- Some reduction in the heavy clenching action can come about by removing these far distal interferences. From the limited information here, I am thinking actions to free up and balance the occlusion are indicated, and consideration should be given to removing wisdom teeth as a portion of an overall comprehensive exam, referral, and treatment plan. John

Many Dental Schools have "Special Patient Clinics" where complex cases are evaluated by a panel of experts. Perhaps your patient would benefit from something like that. There are a number of reliable evaluation systems that may be able to confirm or refute any pathological conditions and I would think the professors would like to take on such an interesting challenge.

First of all, ask the patient to get a written request from the "osteopathologist" that is saying that his skull bones are 'compressed'. Then wait and see if that written diagnosis materialises. I doubt it.

The first thing i thought of was medieval trephination and bloodletting, no joke. Then i trailed off into csf pathways and drainage. Ortho caused slight craniofacial movement, doesn't matter if it's compression or expansion, changing the csf pressure (very slightly). He needs a shunt. Or trephination if he'd let you. Think about it. It's not the cranium. He's got pressure inside the cranium.

This is the case for Psychiatrist. Dentists do canine retraction in few cases without the changes in the skull. It is strange as to how in this case patients is claiming that the skull was also affected for shape change, whether extraoral anchorage was applied when canine was retracted!? Even then now patient need counselling that even the removal of this implant is not going to bring the skull back in original shape. Thus he/she should try to understand that it appears to be his/her feeling only that the shape of the skull is changed however only minor ( and insignificant arch changes were done during canine retraction, for affecting intelligence etc.), and thus he/she should try to forget that point and enjoy his/her new more esthetic look.

Your comment Dr.Rosen demonstrates a complete lack of empathy for this patient's situation. If you do not have anything constructive, I would request that you not interject your "sarcastic wisdom" in this case as it is most uninformative, and borders on unprofessionalism. DrT

Living on the west coast with numerous granola crunchers, we have seen similar patients with incredible diagnosis from pseudo professionals, ie naturopaths, osteopaths,faith healers and pychics. Usually there is an overriding mental problem interfering with their treatment and as many have said he needs REAL professional help including a competent prosthodontist. Some of his issues may indeed be real, as they are to him, but it needs to be separated from the fluff. I can't tell you how many times we have to deprogram patients coming from Naturopaths with all kinds of disorders that have been caused by their dental treatment. I had a guy in last week that wanted quartz crowns because they were recommended by their Naturopath, I explained I've never heard of them and wouldn't be using anything without long term support in the literature. We did gold after much discussion.

If a person suffering mental illness has a broken arm, he/she is clearly owed the respectful attention of the appropriate medical personnel, even if he/she believes the break was due to the sky falling. Of course, the actual facts and findings are to be considered per the standard of care of the practitioner's expertise, separately from the patient's psychiatric condition, in arriving at a diagnosis, However, the treatment plan and consent must consider the patient's other situational factors such as the ability to understand the diagnosis, the various plans of action possible, the action of choice, and what path is best for the well being of the patient. As such, one should decline to treat those who will not or can not understand and cooperate adequately, but one is also obligated to help each patient to find the best care environment possible for their unique situation. John

Csf pressure and lack of proper drainage is a proper diagnosis, and in fact makes relative sense. It is not unprofessional, but logical. He is complaining of a feeling of compression within the confines of his skull, which he has atributed to a misshapen skull. Change of the midface, and its alignment, may have blocked his natural shunting. He may not be mentally ill. Compression of the dura and its contents can cause all if his symptoms. Just because you have failed to look beyond your myopic field of vision at, what may be, a much larger diagnostic picture. He complains of problems in his brain after a traumatic occlusal event. Look at his brain then. Could the orthodontia and its consequence have caused it, probably not, but it may have been the final nail in this anatomic coffin. What if he had lived for many years with a compromised csf pathway, like a garden hose with a slight kink. Now the garden hose has been folded over and there is even less flow. The proper treatment for this condition in an emergency situation is trephination, in a non emergency situation it is establishing a new shunt to the abdomen.

Dr John Manuel is spot on, correct all abnormal contacts and review every 2 weeks, soft diet, muscle relaxants, and lot of encouragement ,

Great point, Seth. Usually, when a patient comes to our office and complains of a problem, there is a problem. Excellent point you post.

Hard part is making certain it's a dental problem before diving in to treatment.

I apologize Seth for misunderstanding your first post. I guess it was the way you started out by making what felt like a sarcastic reference to medieval blood letting. I did find your subsequent posting most informative...thank you. DrT

gregory charlton dds, Dr .T, John Manuel DDS: Thank you very much for your answers. They are very useful for me. I thought of the deprogrammer. I think i'll start with that, and i'll tell him to continue with the osteopathy. I will ask the osteopatist to give me a written diagnosis and i will post it here. I like the idea of the special patient clinic, I will search for one here in argentina. If you know any that could be specially interested in helping in this case through internet from another country please tell me. Arun Kumar JAIN: Thank you for your comment. Just to clarify, he doesn't think that the removal of implant will change his skull shape, what he wants to do is to move the canine teeth forward, back to the place where they always were untill they moved them backwards and he started feeling all those symptoms. Maybe not correct but he is not a dentist, he is just aplying elementary common sense logic.

Seth rosen thank you also very much!

Try cranial sacral therapy !

perhaps this patient should be evaluated and treated at the university hospital/teaching environemnt where multidisciplinary approach can be applied. we had a similar case at the Proshodontic/TMJ university clinic when a patient was reporting that his cranial bones were "rolling over" ever since his new bridge was seated. TMJ disorder specialist was treating him through numerous sessions.

I'm always dubious of opinions from alternative medicine types among whom I include osteopaths and chiropractors. If the osteopath can supply you with even the most remote evidence to support his rather implausible diagnosis.Then send him to some neurologist for further investigation.

This scenario has little to do with implants or dentistry. This is coming from a guy that has done cranial/facial surgery and still operates in this area, in the rare case of the frontal sinus fracture. The coincidental fact, that he has implants and had the canines moved to their appropriate position, is interesting at best. Any treatment rendered by any of us, would be foolish. An explanation of the lack of scientific correlative and an appropriate transfer is the "universal standard of care". Unfortunately too many dentist attempt to treat these patients. Muscle deprogramming, centric relation splints. What next; occlusal equillibration, night guards,NTI, tens. This is a neurologic/psychiatric or neurosurgical issue. No one is showing a lack of empathy for the patient. Psychiatric disease is real and can be debilitating. Recieving treatment from an unqualified doctor, is dangerous. Bv

Entertaining the possible causes of the patient's feeling of intracranial pressure, here are some possibilities: 1 - the brain, it's inclusions, or it's linings. 2 - the various sinus cavities within the skull. 3 - the internal musculature of head, neck and jaw 4 - the superficial musculature, e.g., temporal, parietal,occipital,etc. 5 - the wide, thin ligamentous layers surrounding the skull Asking the patient about any past head/neck trauma, including participation in football, soccer, rugby, etc. may bring to light a course of past concussion, injuries and especially scar tissue on the skull soft tissue components, particularly those near skull entry points. As one ages, the cicatrix shrinks and can result in nerves, vessels, and/or muscles trapped in limited volumes, or constricted passages. I once had a patient suffering from exotic head pain episodes which became so severe he would drop to the floor writhing in pain if he bent over just right or his blood pressure jumped. Following this through referrals, we discovered he had been a Rugby player for years and had suffered superficial cuts and bruises in the frontal, temporal and parietal skull areas. Over time, some nerves and vessels became entrapped within the shrinking scar tissue to the point that an increase in blood pressure would impinge upon the nerve. His symptoms had begun as somewhat mild, episodic headaches, but progressed over the years to such a severe state that he could not function normally due to the unpredictable, severe pain episodes. Fortunately some surgeons were later experimenting with various means of relieving nerve pressure in this type of captive situation. In some cases, the nerve and artery could be freed from the scar tissue, but in his situation some sort of protective pad was inserted between the nerve and artery while barring further impingement by shrinkage. This solved his problem, but the cure was not found until years after he'd lost his very successful career and major assets. As it may relate to this case, please note that this previously extremely successful businessman found himself being sent from one doctor to another, trying every possible avenue of relief, while they all saw him as a person with mental problems and most just wrote him off as a nut. Imagine how that would feel to you... to be suddenly seen as a crazy person and ignored for years while suffering from a genuine problem. So, ask carefully about sports and activities in this young man's history!

The patient has asked to remove the implants which he is very uncomfortable with. The quality and size of the X-ray presented to us does not allow us to evaluate the implants and determine if the patient's complaint is justified. I am surprised that instead of asking the author of the post to provide a better X-ray, those who left comments focused on discussing the patient's mental health condition.

Removing them is not the problem. Removing them with the proper informed consent and legal safeguards for the dentist is the issue. A round table discussion with the patient and relevant professionals may be in order. Sounds like a case of obsessive compulsive behaviour. I had a similar case years ago in which I finally subcumbed to the patient's pleas. Before I removed the implants, I exhausted every persuasive ploy that I could deploy and some..... Then I got the patient to sign a carefully worded informed consent that would exonerate me of all responsibility for the patient's free choice to have them removed.....and I removed them!..

The patient has his mind made up. The ceph tracings reveal that there have been changes to the skull. I think the dental school in Arizona is associated with an osteopathic school. Perhaps the patient should visit the Osteopathic school in Philidiaphia PA. It has a great reputation.

Moreover, I bet, if the implants had been installed correctly, the dentist would have definitely taken the best quality X-ray to prove it. Just because the patient signed the informed consent form, it doesn’t relieve the dentist of his responsibility to make things right. There is no way for a patient to tell, while he/she is in the office, that he/she would have this problem. So, the informed consent form does not work if the treatment was harmful.

Perception is reality. Even though I personally would not be able to help this individual, still I can show compassion for someone who is very clearly experiencing distress. It is not up to any individual, especially those of us who are health care practitioners, to pass judgment on those who come to us seeking some relief. Even though I would not be able to offer this patient any solutions, I would make every effort to aid him in finding someone who could. There is more than one way to help someone. DrT

I wasn't going to comment further, but should point out that the tracings do not appear to be the usual cephalometric type, but rather appear like silhouette tracings of a head in different positions, or tracings from a photographic series. None of them show the nasion nor infra orbital pointers , nor the ear stabilizers, so there there is a good question regarding the necessary standardization to allow unbiased serial comparison. Similar to before and after weight loss photos where the skull seems larger in the upright, straight on lateral view of the first tracing, and smaller in the second, chin down, dorsal neck extended, and rotated skull in the second. Did I miss the representation of these tracings? They are for certain NOT calibrated, standardized views

That's right John. Sorry if i was not clear about this. The drawings are not a ceph scientific analysis. I thought i was clear in one of my comments but it seems not. They just try to show a kind of change that can be observed in the photos and that was pointed out by the patient, as the photos can't be published. There is no material from before the teeth movements, only some photos that were not taken thinking about a future comparisson and that are not appropiate material to compare. The only use that can be given to the drawings is to understand the kind of change the patient says he suffered.

Munchausens syndrome.

The patient has been using a deprogrammer since August 2012. He has also continued with ostheopaty and RPG. He said that, at first, the deprogrammer did not do much. However, afterwards, he asked the deprogrammer to be opened, so as to expand the maxilar, and this did well to him, although he does not feel yet totally recovered. He says that he noticed that when the canine were moved backwards, the bones of his face compacted and the maxillary streched, and this provoke a compression in the whole skull. He still wants to remove the implants and move forward the canines, to the original place. I will send new images to be added to this post. Thank you all again for your help. gregory charlton: I am very interested in your point of view. I searched in the web for your paper on dental relativity and biometrics but I could not find it. Please if you are there, I would like to contact you. Thank you again.