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Orthodontic Repositioning of Lateral Incisors Into Central Incisors

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Orthodontic Repositioning of Lateral Incisors Into Central Incisors 2 ‘2’ 1: Orthodontic IN BRIEF • Raises awareness of an integrated treatment approach to replace missing PRACTICE repositioning of lateral maxillary central incisors with lateral incisors. • Presents the indications, advantages and disadvantages for this treatment incisors into central incisors approach. • Discusses important orthodontic R. J. McDowall,1 R. Yar2 and D. T. Waring3 and restorative considerations when camouflaging lateral incisors to mimic central incisors. VERIFIABLE CPD PAPER The clinical problem of how best to manage an anterior space resulting from a missing central incisor will only be encoun- tered rarely. The goal should be to deliver treatment results that are indistinguishable from normal appearance. This article describes one treatment approach – orthodontic space closure with substitution of the maxillary central incisor by the lateral incisor. Treatment indications, orthodontic and restorative considerations, advantages and disadvantages, as well as the evidence base relating to this treatment modality will be presented and supported by two clinical case examples. INTRODUCTION by restorative modification to simulate a Table 1 General treatment planning considerations for the management of a A central incisor may be missing follow- central incisor.2 The last treatment option missing maxillary central incisor ing traumatic avulsion, developmental consists of total orthodontic space clo- Treatment planning considerations absence or an enforced extraction due to sure with substitution of the lateral inci- being malformed, grossly displaced, anky- sor for the central incisor in the final Patient wishes losed, severely fractured or as a result of occlusal scheme.3 Each of these treatment Need for orthodontic treatment in general local pathology. The clinical management approaches has its advantages and disad- Patient age of the resultant anterior edentulous space, vantages, but the choice of the appropriate to produce both a functional and aesthetic solution very much depends on the specific Number of missing teeth result, can be a significant challenge. characteristics of each individual situation. Type of malocclusion This is particularly the case for young Important treatment planning considera- Space considerations patients, where there is a need to preserve tions when deciding how best to manage a Soft tissue profile alveolar bone and gingival architecture missing maxillary central incisor are listed during the continuous growth of the in Table 1. Lateral incisor width and root length dentofacial complex. Canine shape and colour Essentially, there are three treatment TOTAL ORTHODONTIC SPACE CLOSURE Likely success rate approaches for a young person with a Relative cost:risk/benefit ratio missing maxillary central incisor and This article will specifically focus on concomitant malocclusion.1 The first orthodontic space closure with substitu- involves reopening and/or maintaining tion of the maxillary central incisor by the Table 2 Clinical indications for choosing orthodontic space closure and substitution the space throughout childhood allowing lateral incisor. The clinical indications for of the missing maxillary central incisor by for a definitive prosthetic replacement in choosing this treatment approach are listed the lateral incisor adulthood. The second approach includes in Table 2. This method is particularly Clinical indications for space closure premolar autotransplantation followed favoured when there is concomitant dental General need and desire for orthodontic treatment crowding or an increased overjet, whereby the anterior edentulous space can be use- Young person Absence of gingival show on smiling 1FTTA in Orthodontics, Dorset County Hospital, Wil- fully utilised to correct the malocclusion liams Avenue, Dorchester, DT1 2JY; 2Specialist Registrar avoiding the need to extract an additional Crowded maxillary arch in Restorative Dentistry, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester, tooth within the affected quadrant. Increased overjet M15 6FH; 3*Consultant Orthodontist, University Dental Undertaking orthodontic space closure Hospital of Manchester, Higher Cambridge Street, Full profile Manchester, M15 6FH in the management of a missing maxil- *Correspondence to: Mr David Waring lary central incisor dictates that the lateral Large lateral incisor with good root length Email: [email protected] incisor takes over the aesthetic and func- Small white canine Refereed Paper tional role of the central incisor, the canine Healthy adjacent teeth Accepted 10 January 2012 assumes the role of the lateral incisor and DOI: 10.1038/sj.bdj.2012.368 Access to restorative support ©British Dental Journal 2012; 212: 417-423 the first premolar the role of the canine. BRITISH DENTAL JOURNAL VOLUME 212 NO. 9 MAY 12 2012 417 © 2012 Macmillan Publishers Limited. All rights reserved. PRACTICE Labio-palatal tooth positioning RESTORATIVE CONSIDERATIONS Such positional alterations will necessitate specific orthodontic and restorative inter- The type of restoration to be placed on Crown proportions ventions to facilitate camouflaging the the lateral incisor will ultimately deter- involved teeth. Camouflaging canines and mine its labio-palatal position. If a direct The substituted lateral incisor needs to be premolars to resemble lateral incisors and composite restoration or porcelain veneer built up to the correct crown size and shape canines respectively has widely been dis- is to be utilised the lateral incisor should to mimic a central incisor. Guidance on the cussed in the literature.4 Therefore, we will be positioned palatally, close to contact- exact dimensions required can be gauged concentrate on the orthodontic and restor- ing the mandibular incisors. If a porcelain from the adjacent intact central incisor. ative camouflage considerations relating crown is chosen the tooth should be posi- However, if both central incisors are miss- to lateral incisors and their substitution for tioned on the centre of the ridge, leaving ing the use of the golden proportion, with missing maxillary central incisors. 0.5‑0.75 mm of overjet and allowing for a relative width ratio of 1.616:1.0:0.618 minimal tooth preparation on the palatal for the central incisor, lateral incisor and ORTHODONTIC CONSIDERATIONS aspect.8 It has also been proposed that the canine respectively,10 and the 80% rule, Diagnostic wax setup substituted lateral incisor should not actu- whereby the ideal maxillary central inci- ally contact the mandibular incisors, there- sor should be approximately 80% width A diagnostic wax setup of the proposed fore theoretically reducing the functional compared with height,11 can be helpful. tooth movements and the necessary modi- load on the tooth and avoiding unwanted However, many smiles exhibit dispropor- fications to camouflage the teeth is a use- jiggling forces.9 tionality, so these measurements should ful adjunct to facilitate treatment planning, not be taken as an absolute rule. patient consent and construction of a vacu- Tooth angulation formed matrix to aid restorative treatment.1,5 The substituted lateral incisor should Type of restoration ideally be positioned more parallel than Porcelain restorations, in particular ultra- Vertical tooth positioning normal or even slightly upright. This will thin enamel-bonded porcelain veneers, The orthodontist should disregard the improve the mesial emergence profile and have proved to be both aesthetic and incisal edge of the substituted lateral inci- ensure that a favourable contact point can extremely durable restorations and rep- sor as a guide for final tooth positioning be created with the adjacent central inci- resent the preferred treatment option for and concentrate on correctly positioning sor. Too much mesial crown angulation adults when camouflaging lateral incisors the gingival margin. As such, the lateral can result in a large gingival embrasure as centrals.12 An ultra-thin porcelain veneer incisor must be intruded significantly and a black negative space that compro- can also be placed directly onto a lateral so that its gingival margin matches the mises optimum aesthetics.5,9 incisor of a young patient, as the risks of adjacent central incisor and the ipsilat- pulp perforation and exposure of gingi- eral first premolar, camouflaging as the Appliance individualisation val crown margins during tooth eruption canine.1 Intrusion also provides further It is recommended that the central inci- are not contra-indications for a minimally intra-occlusal space to build up the tooth sor bracket, in the pre-adjusted edgewise invasive preparation with enamel-bonded to the correct vertical height and contour appliance, is placed on the substituted porcelain.4 However, composite resin to mimic a central incisor.6 lateral incisor. The wide central incisor build-up of the substituted lateral incisor bracket will more efficiently maintain the is still considered the treatment of choice Mesio-distal tooth positioning desired mesio-distal angulation of the lat- in young patients; because it is reversible, The cervical portion of the lateral incisor eral incisor and will also ensure that the non-destructive in nature, relatively inex- is narrower mesio-distally than the cen- inclination of this tooth matches the adja- pensive and allows for future incremental tral. The mesial and distal margins must cent central incisor. addition and removal of material as the therefore be over contoured otherwise the patient continues to mature.5,7,13
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