One of my best referring general dentists once asked me to evaluate his 34-year-old receptionist. She did not have a complicated malocclusion, just a few malaligned teeth and a slightly deeper than normal anterior overbite. I examined her and explained that the orthodontic correction of her minor problems in tooth position would not take more than about 6 to 9 months and would not require the extraction of any teeth. Although she was not keen about wearing orthodontic brackets, she acquiesced and decided to proceed with the next step, gathering orthodontic records.
Today, this patient could be treated easily with aligners in probably about the same length of time. She certainly would have appreciated a nonbracketed approach to her treatment, but aligners were not possible at that time. So, if you were designing treatment for this woman with a minor tooth malposition, and your plan was to use aligners, what pretreatment records would you take?
Do you need pretreatment dental casts? In the past, polyvinylsiloxane impressions were required to produce accurate aligners. Today, however, an intraoral scanner can be used to create digital images of the teeth, so dental casts are simply an unnecessary expense.
Would you take any photographs? Digital facial and intraoral photographs would certainly be appropriate.
What about pretreatment radiographs? A panoramic radiograph would probably suffice for her relatively minor malocclusion. Would you take a lateral cephalometric radiograph? Why? Her facial profile is normal, and the changes in tooth position will not affect her profile. Why create the added expense and radiation of an additional radiograph, when there is no clear-cut need for a headfilm? Makes sense.
However, I have always taken complete pretreatment records on all of my patients, so I obtained a lateral headfilm of this woman. It has always been my tradition to trace all of my own cephalometric radiographs. Let me be clear. I do not measure the angles and planes. I simply trace the original and final cephalometric radiographs. In that way, I can accurately superimpose these films to determine the skeletal and dental changes that occurred during treatment. So, as I was tracing this woman’s pretreatment headfilm and trying to identify sella turcica, I noticed that it seemed enlarged. In fact, I discovered that it was 3 times larger than normal. I had never seen this before. I suspected a pituitary tumor, but, when I reviewed her health history, it was uneventful. What should I do?
Puzzled by her lack of symptoms, I decided to take the film to our local hospital and obtain a consultation from the head neuroradiologist. When I showed him the film and the area of concern, he said 2 words to me—“nice find.” He knew immediately that this was a benign but expansive tumor of the anterior lobe of the pituitary gland. He said to refer the patient to an endocrinologist.
Obviously, the patient was shocked to hear that an orthodontist had found a brain tumor on a routine radiograph. She did see an endocrinologist, who confirmed that the pituitary adenoma was a benign tumor and recommended surgical removal. Why didn’t she have any symptoms? She did. During the previous 8 years, she had stopped having regular menstrual cycles because of the hormone imbalance produced by the tumor. She had desperately wanted to have children but could not get pregnant.
This story does have a happy ending. She had the surgery to remove the tumor, completely recovered, and subsequently had 2 pregnancies and delivered 2 healthy children. Did she ever have orthodontic treatment? Yes, after delivering her second child. What did I learn from this experience? I still trace all of my own headfilms, and I scour all panoramic radiographs for abnormalities. I have found a few more anomalies, but fortunately none were life-threatening.
Do you look carefully at all of your patients’ radiographs? If not, you might miss something obvious.
