Case Study #2

This patient underwent orthodontic treatment twice as a teenager. She presented requesting esthetic enhancement, an improved bite, and concern about multiple site of gingival recession.

The upper six images depict her pre-treatment status. Total treatment time was eight months following comprehensive PAOO™ treatment. The lower five images depict her post treatment status four years later. Note the robust muco-gingival complexes.

 

 

Of particular note:

• The extent of maxillary right arch expansion;
• Improved muco-gingival stability at all sites;
• Triangular spaces due to tooth shapes with coronal contact points;
• Residual minor resection 3 years post-treatment remains unchanged and is being monitored closely;
• Miller Class 3 recession lesions;
• Patient is extremely happy and faithful with maintenance care.

A New Syndrome for Dentistry: Dental Space Deficiency Syndrome (DSDS)

The following paper may provide an answer to the frequently encountered problems of tooth crowding, recession, and impaction.

Why Recession?, Why Crowding? and Why Impacted Teeth (especially wisdom teeth)? Why Apnea?

Colin Richman DMD

Periodontics and Implant Dentistry

www.drcolinrichman.com

Asst. Clinical Prof., Department of Periodontics

MCG – Georgia Regents University.

The three conditions of gingival recession, tooth crowding and impacted teeth are prevalent in the USA with more than half the population demonstrating one or more of these conditions. Recently Richman1, 2 defined a new syndrome for these dental conditions, entitled the Dental Space Deficiency Syndrome (DSDS). A syndrome is defined as a number of conditions or signs associated with a common causative agent. Relative to the causative agent for dental tooth crowding, and/or gingival recession and/or impacted teeth, we need to review texts on dental and human head and neck anthropology3-5. 

Data regarding the evolution of modern man suggests that our jaws are slowly decreasing in size. This is due to the fact that we changed from prehistoric hunters and gatherers to farmers, and then purveyors of industrialized food production as well as users of micro-wave ovens and other ultra-soft food substances. Consequently our jaws are slowly decreasing in size due to less and less use. However, on the good side, our brains are increasing in size at the expense of our faces. (See Fig 1a and 1b). Alternatively, tooth size is genetically predetermined6, with the resulting net effect that our normal sized, genetically predetermined teeth are being ‘forced’ into smaller jaw bones as they erupt into the mouth.

The consequences of these features are:

1. Oral surgeons will remove impacted third molar (wisdom) teeth, if there is a deficiency of alveolar jaw bone space, able to accommodate the impacted teeth comfortably without potential disease.
2. Orthodontists are able to effectively expand the tooth arch perimeter, and establish a healthy bite, with teeth well aligned both for function, esthetics and overall body health. 
3. Periodontists treat gum recession by means of grafting tissues (self or donor) into sites where gum tissue is either thin, or has already receded. The host then converts the grafted material to normal healthy tissues, to compensate for the deficiency of gum and underlying socket bone, due to the DSDS syndrome. 

Other conditions associated with DSDS may include:

1. Sleep disorders, due to constricted lower jaws and consequently, insufficient tongue space, frequently pushing the tongue towards the throat with resultant impingement of the pushed back tongue into the airway space7.
2. Rapid bone loss, if teeth are extracted, and the sockets not appropriately grafted. 
3. Esthetic aberrations when the larger teeth ‘appear’ disproportional to the smaller face. 
4. Pediatric developmental aberrations associated with compromised airways.

Fig 1a: Skull of prehistoric man

Fig 1b: Skull of modern man

The following two cases illustrate features of DSDS:

Case 1. 8 years old. (kur_i)

Fig 2: Ultra thin gingival (gum) tissue with early recession of lower teeth.

Fig 3: Crowded permanent teeth in 8 year old patient. Insufficient jaw bone space to accommodate the permanent teeth. 

Fig 4: Crowded front (deciduous) teeth.

Fig 5: Panoramic radiograph showing crowded teeth with insufficient space for permanent teeth.

Case 2. Permanent dentition. (hud_m)

Fig 6: Adult patient, thin gingival tissue, gum recession of lower front teeth and upper canine.

Fig 7: Same patient CT scan demonstrating ultra-thin bone covering the roots of the lower jaw teeth, rendering these teeth at future risk for gum recession.

Fig 8: Crowded lower front teeth (DSDS).

Fig 9: Panoramic radiograph demonstrating impacted third molars (wisdom teeth) due to inadequate jaw bone space available to accommodate these teeth.

1. Richman C. Is gingival recession a consequence of an orthodontic tooth size and/or tooth position discrepancy? A paradigm shift. Compendium of Continuing Education in Dentistry. Jan-Feb 2011;32(1):62-69. 
2. Richman C. American Academy of Periodontology Presentation. 2013. 
3. Hirshfeld I. A study of skulls in the American Museum of Natural History in relation to periodontal disease. J Dental Research. 1923;5:241-265.
4. Corruciccini R. How Anthropology Informs the Orthodontic Diagnosis of Malocclusion's Causes. The Edwin Mellen Press. 1999.
5. Lieberman D. The Evolution of the Human Head. 2011. 
6. Dempsey PJ, Townsend GC. Genetic and environmental contributions to variation in human tooth size. Heredity. Jun 2001;86(Pt 6):685-693. 
7. Lida-Kondo Cea. Comparison of Tongue Volume/Oral Cavity Volume Ration Between Obstrctive Sleep Apnea Syndrome Patients and Normal Adults Using Magnetic Resonance Imaging. J Med Dent Sci 2006;53:119-126.