hey it's dr amanda with straight smile solutions straight smile solutions.com and today we're going
to be talking about panoramic x-rays pathology impacted canines root resorption supernumerary
teeth wow lots of things you can find in a panel right so i just took four kind of wacky panos
that i um had access to just to talk about what i see and i personally think this is absolutely
fascinating it's one of my favorite things to do in dentistry and if i had a do-over i might have
considered going into dental radiology instead of ortho i think it's definitely a huge growing
field i think that being an expert in reading x-rays especially dental x-rays is something that
people need to do and a lot of dentists want to outsource you know the the readings you know and
you can also read airways and all kind of things it's really fascinating so if you are getting this
um you know this video and you're a dental student or thinking about dental school think about this
because it's a really clean special to go into you're probably not even necessarily dealing with
patients you can probably do it from your home office um you know i know a lot of people that
do and or i know some that actually have their own center with the cbct and maybe in itero and other
things and they just do a lot of digital stuff um you know and it's convenient because not all
dentists want to purchase all this expensive equipment especially if you're in a big city
or something someplace convenient but anyways let's talk about what i see and what it means
and i realize that these videos are often watched by not only doctors and industry professionals but
also consumers so i might switch my language back and forth depending on who i'm talking to
because i know patients like to know about x-rays too and they want to know what they have and what
that means and what they saw so let's talk about all that all right so first of all
hi real super high level you know there's different types of x-rays out there this is a
panoramic x-ray panoramic x-ray it's kind of like a little spaceship that goes around your head
and it's meant to just get a bird's eye view of the dentition
um i like to take one on every patient starting at seven or eight because you find lots of surprises
often um i can tell you the story i mean i've taken thousands of x-rays on little kids for sure
over my career and i always find funky things that you're not expecting and it's so good to
have advanced knowledge on what to expect and not be surprised later so you can plan
in advance i can tell you a personal story as a mom you know you know i like to practice what i
preach so my daughter was maybe seven or eight we did our everything looked fine you know just
from what was coming in i had no concerns um i just kind of figured it was just a formality
um like everyone else does we took it as a screening and surprise all kind of crazy stuff
pathology transpositions oh big hot mess happening under the bone that you would never know so
um yeah but you know it's really really important so if you have kids and if they're seven eight and
you haven't had a panel yet you maybe have and you don't know you should ask your dentist if you can
have one it is covered by insurance usually every five years so um and often orthodontists will
do it gratis you know just at their screening appointments because they need to know what's
going on so you can always ask for a copy but really really important to be taking panos
now there's two different types of x-rays there's digital x-rays and then there's
analog x-rays um either way is fine um digital x-rays is probably this one um usually well there
could be any of these but this one's definitely not but um usually you can it's nice because you
can play with the colors and the contour and you can see things better um so and they usually have
less radiation so it's nice if you can do that and that's a really great question to ask before
you go to the orthodontist or before you go to the dentist you know do you have digital x-rays
it's okay if they don't but for me it's a it's a great sign that they're progressive if they do so
um okay what else also you know sometimes with um panos it kind of depends on if the patient moved
you can't wear earrings there's a lot of things you can't do you'll get um ghost images
so sometimes you know you have to verify what you see it's just a screen x-ray like you can't
necessarily see small decay or anything like that it's not meant really to see decay it
would have to be a gigantic decay in order to see it it's really meant to see
a bird's eye view of how you know permanent teeth are developing third molars trauma
pathology so pathology could be cancer yes it can be but it can also just be cysts and other weird
things that happen um science people have extra teeth sometimes people are missing teeth that's
all pathology um anyways so yeah don't freak out you know i've had weird things in my panel and
they turn out to be nothing so okay so let's talk about what we're seeing here just high level just
this is all these are really four really fun panoramic x-rays so this first one here if i
had to guess i know nothing about these patients by the way these are not my patients these are
just images that i have the rights to talk about so i don't really know i can tell you what i think
just based on what i see so this is probably an adult here um adult has an impacted wisdom
tooth right there only one sometimes people don't have four wisdom teeth sometimes you have one two
three or four i think i only had two i think one of my kids has none one of my kids has three so
we're all weird but yeah this is probably an adult um but this patient is cool because this patient
has some extra bonus teeth going on i like to call them extra bonus teeth so sometimes people are
missing teeth congenitally they just didn't form and so as people have extra teeth fun so you can
see if you know where they are there's one two three this one they had a tooth that was extracted
here and that's why that tooth is leaning over so this one was extracted but they have a bonus tooth
there i don't think that's gonna come in but it's not fully developed um it's just kind of a nubbin
one two three and there might be one there too it looks like there might be so they might have four
extra teeth right here that's what's cool the other interesting thing about this x-ray that
i wanted to talk about and i'm not entirely sure again i'd probably verify it with a single x-ray
or like a pa or a cbct to verify it but i kind of wanted to talk a little bit also about short
routes i was looking for a good i actually would if i wanted to take a panel i could take a pen out
myself and i'm a perfect example but i'll do that next time but this is also an example potentially
of short roots or root resorption so we're going to talk about that okay in a second this x-ray
we're going to talk a little bit more about impacted canines as you can see down here they're
a little blurry but there's one right there a little out of the focal plane one right there okay
um these ones are okay we just don't have enough space for them to come in this patient is probably
okay maybe seven and a half eight eight and a half if i had to guess so i'm really enjoy predicting
age and patience i mean this is just an estimate um 12-year-old lords are not in yet six year old
molars are in so somewhere between 6 and 12. i had to guess around 8. um with some impacted canines
and some no space for these canines to come in so this patient is probably very crowded this
patient would probably benefit from expansion of the arches and it would give these teeth
more of a likelihood of not becoming impacted if you did expansion it might decrease the likelihood
of needing a surgery an exposure surgery to get these it might decrease the likelihood of needing
premolars extracted so this is definitely a really interesting case here in this kid
here we have another impacted canine there's still a baby tooth present that just never fell out this
is an adult as well 12 year old molars are in no lower wisdom teeth has upper wisdom teeth that are
impacted baby tooth impacted canine so for this patient not enough space for this to come in um
luckily it didn't damage this route which is good news you probably want to pull that baby tooth you
probably want them depending on the age and make some space you'd have to find out where this tooth
is is it buckle or is it paddle you know which where is it impacted what in what plane of space
that's where a cbct would come in or you could do a series of pa x-rays with a shift the slob rule
um in order to localize it if it's so low that if it was buckle you'd be able to feel to see
the bump either way you'd probably see the bump on the pallet or you'd see the bump under the lip so
if it was under the lip i would give a really high likelihood a really good prognosis here it was on
the palette a little less so maybe under the lip 90 chance we can save it if it's on the palette
maybe 50 depending on the age of the patient um 50 60 70 chance we can get it in if we pull the
baby tooth you got to realize if you're going to pull this baby tooth and you're going to do braces
or aligners hoping it's going to come in if you need to do the exposure surgery most likely you're
going to want to do that in braces although i've done it in aligners but it's tricky um
that's going to be an additional fee with the oral surgeon or the periodontist so it's important to
you know add that all in if somehow it doesn't come in it could be something called ankylosed
which means that it's kind of glued to the bone nothing you can do then so then you have
to extract it and put in an implant so sometimes people don't want to pull that baby tooth because
it's a risk they're gonna have a big old space in there and they're gonna have to pay for an implant
later yeah it's a risk it happens nothing we can do you know so it's a little bit of roll the dice
so obviously if you've got something like this you want to treat all impacted canines as young
as possible 10 9 8 11. something like that and you don't want to wait til you're an adult the
longer you wait the more likely it's not going to come down and lastly you have some super funky
impacted canines here which probably the patient had no idea because the baby teeth
are still in there um you wouldn't know unless you took the pano these things are practically
sleeping they're horizontal this is a no-go this is not coming down no way not even worth it um
you don't want to necessarily leave them in there either you can take up cbct and see how close they
are to the roots of the other teeth but they will likely damage the other teeth and they'll probably
lose these teeth so it's best to get them out um it's a pretty brutal surgery to get these suckers
out so it's a big big surgery they're probably going to have to peel the pallet down drill in
there pluck them out it is not going to be fun and if you've ever had that surgery done before and i
have to myself it is not fun at all so sorry but that's pretty much what's going on here so pretty
much talked about these let's go back to this a little bit more supernumeraries leave them keep
them um i'm usually a big fan of taking them out but sometimes they won't take them out because of
their proximity to nerves if you leave them where they are they'll likely over time cause damage
to the nice teeth that are in there and certainly just my personal philosophy i do not do braces or
aligners on patients that have impacted teeth like this because i'm liable if i run the roots into
these teeth and i don't have x-ray vision i don't know if i'm running the roots into the teeth as
i'm straightening them so i that's just my policy i realize that sometimes people will do it and
it's it's it's your risk you know as the doctor um you know it might come back to haunt you later so
you know and and for the patient you know why just get them out there this is a very small surgery to
get this out these are super teeny tiny you know just go in have them removed let it heal up and
get your get your ortho done so um but let's talk a little bit more about root resorption
if that was it's hard for me to tell obviously i'd want to verify it these things happen too
resorption can be genetic it can be due to trauma it can just be due to generalized inflammatory
conditions that people have um it could be due to your bite it can be you do be do i can say
this it can be due to people having too much ortho too heavy forces too often if you've had
ortho so many people have had braces over and over and over you treatments um and they used
either two heavy other forces or they just had it too many times and every time you have braces your
roots can get shorter and shorter and shorter if you're prone to it so there's a point where
you know sometimes you're going to not want to do any more ortho treatment it's just too risky
to lose your teeth if they're getting shorter so in any case hopefully this video was helpful
there was a lot of information here but the moral of the story is take panels take screening panels
on kids you know at seven or eight making make sure you're taking panel on your ortho cases
um or at least having someone review the panel ahead of time and if you have a long-term ortho
case over a year you should be taking a standard of care a progress panel every year and you should
take a panel at the end just to verify resorption um root position sorry um if you're doing a liners
or invisalign i always like to take panels and i like even though they don't require it you're
going to get a better setup if you submit the panel because they they can see you know otherwise
they're just going with what's above the bone if they can see that a tooth is tipped they're going
to give you a much more accurate setup so all liner companies will accept x-rays so you should
definitely upload that x-ray um super important to have a good outcome so hopefully this is helpful
all right if you guys like more of this please leave feedback in the comments section
and feel free as always to reach out to us at straightsmilesolutions.com if you
are a doctor and would be glad to help you with your cases all right thanks so much