Revue de la littérature | Literature review Orthodontie/

HOW ORTHODONTICS CAN FACILITATE RESTORATIVE

Chimène Chalala*

Abstract Résumé Full comprehensive orthodontic treatment is often a requisite Le traitement orthodontique est souvent une phase néces- in the rehabilitation of oral form and function specifically when saire pour la réhabilitation complète de la forme et de la fonc- anterior restoration(s) is (are) needed. Patients with missing, tion, surtout en cas de restauration des dents antérieures. Les abraded or fractured teeth, peg-shaped lateral incisors, or patients dont les dents sont absentes, abrasées ou fracturées, other restorative needs may require tooth movement for optimal avec des incisives latérales riziformes, ou autres impératifs de treatment outcomes. Such treatment necessitate collaboration restaurations, nécessiteraient un traitement orthodontique pour between the orthodontist and others specialties, such as the res- optimiser les résultats. Un tel traitement exige la collabora- torative and / or the periodontist. tion orthodontiste/dentiste sur différents niveaux. L’indication The major indication for adjunctive orthodontic treatment is to majeure de ce traitement est au niveau de l’arcade (créer l’es- facilitate and improve the dental restorative conditions at the pace), des racines (pour un meilleur parallélisme des piliers) et level of the arch (space management), roots (parallel abutments) de l’os (considérations parodontales) pour le bon placement des and bone height (periodontal considerations) for the placement implants et la confection de couronnes bien adaptées. of well-adapted and contoured restorations, crowns or implants. Les objectifs majeurs du traitement sont donc la fonction, l’es- This interdisciplinary management will be illustrated through thétique et la santé parodontale. specific dental treatment phases, in addition to the assessment L’approche multidisciplinaire est illustrée par des cas cliniques of guidelines for general , specialists, and orthodontists où sont développées les étapes de traitement dentaire, en plus to establish a comprehensive treatment plan and execute it in an de l’élaboration d’un référentiel à l’intention des dentistes, des orderly way toward successful results. spécialistes, et des orthodontistes pour établir un plan de traite- ment global et pouvoir le réaliser dans les meilleures conditions Keywords: Orthodontics – - periodontics. de succès.

Mots-clés : orthodontie – restauration dentaire – parodontie.

* DESS Orthodontics Clinical Associate, Faculty of Dentistry, American University of Beirut Instructor, Faculty of Dentistry, Lebanese University [email protected] 67

Orthodontie/Orthodontics

Fig. 1: Orthodontic uprighting of mandibular right 1st molar.

Fig 2: Orthodontic crown lengthening for periodontal (biological width) and esthetic considerations (gingival margins).

Introduction Periodontal management Orthodontics crown lengthening Tooth fracture is a very common pro- With patients’ increasing esthetics and Optimization of restorative blem and the level of fracture is an functional demands, orthodontists conditions important factor that dictates the pro- are solicited to manage and create Uncompensated old extractions gnosis of the tooth [3]. If the fracture an optimal restorative environment. alter adjacent and antagonist teeth is cervical or more sub-crestal, an opti- In fact, various dental specialties are position as well as their bone level: mal restoration cannot be achieved available now to assure the ultimate the contiguous teeth will tilt toward without impinging on the biological dental condition of the most critical the vacant space creating an angular width. In such situation 2 options of cases. Thus the interdisciplinary mana- bony defect in addition to the loss of treatment are available: gement is essential for the attainment the available space. a. Surgical crown lengthening to of the best dental treatment outcome. In order to address these cited pro- recreate the proper biological width. The purpose of this paper is not to blems, an orthodontic treatment is It may compromise the esthetic out- criticize or support orthodontic ver- needed to eliminate the bony defect come, especially in the anterior region sus non orthodontic approaches, but by uprighting the tipped tooth [1]. creating uneven gingival margins rela- to emphasize the criteria by which Therefore, an amelioration of the tooth tive to the adjacent teeth and long cli- we assess the multiple and available axis is often mandatory for a better nical crowns [4, 5]. treatment options. realization of the prosthetic crown b. Orthodontic crown lengthening Orthodontics can support restora- and a better distribution of occlusal (extrusion) which provides sufficient tive dentistry for periodontal, occlusal forces [2]. Orthodontics is essential to supra-gingival tissue to restore appro- and dental considerations. recreate the adequate space for mis- priately the tooth with pleasing esthe- sing teeth replacement with optimal tic outcome [6] (Fig. 2). dimensions (Fig. 1). 68 IAJD Vol. 3 – Issue 2 Revue delalittérature/Literaturereview extrusion ofteeth: tors shouldbeconsideredinplanning an optimalcrowntorootratio. support apostcrownandtofinishwith root isacrucialparametermainlyto (divergent roots)correctedorthodontically. Fig. 4:Blacktrianglebetweenmaxillarycentralincisors fracture ofmaxillarycentralincisor. Fig. 3:Orthodonticrootextrusionofasubcrestal method oforthodonticcrown lengthe- - - - -Relativeimportanceofthetooth. -Levelofdefectorfracture. - tal crownlengtheningas: ding contra-indicationofperiodon- Periodontal considerations,inclu lesions) ment orapicectomy(endodontic endodontic treatment,retreat Endodontic considerations:good visible gingivauponsmiling. Esthetic Forced eruptiontechnique is a • Unevengingivalmargins[7]. • • In summary, thesubsequentfac - In both options, the length of the non-tapered. Root lengthandform:thick, Lossoftheinterdentalpapillae. flap design. Adjacent rootexposuredueto considerations: amount of - - gingival embrasures. associated withpost-treatment open rotation andoverlaparenot directly pretreatment maxillarycentral incisor Although accordingtoKokish [9], maxillary and mandibular incisors. disease. periodontal surgeryorto and summarizedasfollows: unaesthetic situationarenumerous the proximalcontactpoints[8]. from adeficitofgingivalpapillabelow vical regionbetweentheteethresult triangles (Fig.4)observedinthecer esthetics I periodontium basicallythebone(Fig.3). achieved withoutthepursuingof ning wheretoothextrusionispromptly mprovement ofgingival 3- Severecrowdingspeciallyof 2- Attachmentlosssubsequentto 1- Age. The contributingfactorstothis Open gingivalembrasuresorblack I nterdental papilla - after orthodontictreatment[15]. triangles between mandibular incisors ters involvedintheoccurence of black crown morphologywerethe parame- duration ofactivetreatment andthe around 40%[13,14].Theage,the of adultpatientsisestimatedtobe incisors afterorthodontictreatment embrasure between maxillary central periodontist andtheorthodontist. ration betweenthegeneraldentist, is primordialwithanultimatecollabo- disciplinary managementofthecases best outcome. Emphasize on the inter of theetiologyinordertoinsure depends firstonathoroughevaluation proximal contacts[11]. from moreincisallypositionedinter contact resultingfromabonelossor alveolar bonetotheinterproximal without boneresorption[10]. The prevalenceofopengingival Treatment ofblacktriangles 6- Divergentroots[12]. 5- Anincreaseddistancefromthe 4- Triangular-shaped crownwithor - - 69

Orthodontie/Orthodontics

Fig. 5: Uneven gingival margins due to abrasion of incisal edge of the tooth #11 orthodontically corrected.

Fig. 6: Retraction of canines in old extraction site had enhanced the bucco-lingual width of alveolar bone.

Fig. 7: Intrusion of maxillary 1st molar creating the needed space for the restoration of the mandibular opposite site. Orthodontic treatment was initiated to correct the crowding and manage the optimal space vertically and sagittally for proper restoration of mandibular edentulous space.

Gingival margins should be slightly more occlusal then et al. [20] revealed that bone created Uneven gingival margins are a the canines and the central incisors. by orthodontic separation of two teeth major aesthetic problem especially in The contour of the gingival margin is much less resorptive over time com- patients with gummy smile. They can should mimic the cemento-enamel pared to the amount of resorption fol- result from inflammatory periodontal junction (CEJ) of the teeth. lowing tooth extraction. deseases or from variable amount of tooth wear and abrasion on different Horizontal bone regeneration Vertical bone regeneration adjacent teeth (Fig. 5). Orthodontic sagittal movement can Orthodontic extraction of an unres- In some cases, orthodontic intru- be a substitute for guided bone rege- torable tooth is an advantageous and sion and restoration of incisal edge are neration, surgical bone augmentation an effective way to enhance the perio- required. or bone grafting (Fig. 6). Atrophic bone dontal conditions for the replacing The determining factors to correct in sites of tooth agenesis or previous implant [21, 22]. Such orthodontic the gingival margins include the sulcus extraction of permanent teeth prevents extrusion will improve the alveolar depth, the location of the cemento- the placement of implant in these areas bone and the gingival characteristics enamel junction relative to the bone without requiring a bone augmen- of the recipient site prior to the pla- level, the amount of existing tooth tation surgical procedure. However, cement of an implant. Furthermore, it structure, the root-to-crown ratio and moving orthodontically a tooth in such is considered as a viable alternative to the shape of the root [16]. atrophic areas can resolve the pro- the conventional surgical augmenta- The gingival margin of the central blem by developing alveolar bone on tive procedures of bone in height [23, incisors must be at the same level the tension side enhancing the width 24] and the lateral incisors gingival level of the crestal bone [17, 18, 19]. Spears 70 IAJD Vol. 3 – Issue 2 Revue delalittérature/Literaturereview central incisorthatwassubstitutedbythelateralincisor. Fig. 8:Reopeningofanadequatespaceforthemaxillaryright adequate papillae[26]. adjacent teeth is required for creating the crest, 1mm between implant and case ofunilateralmissingteeth. Along contralateral willbethereferencein [25]. Alongthecrown,widthof the properspaceforapleasantresult be consideredinordertomanage of teethrelativetoeachothersshould aesthetics (Fig.8).Proportionalwidth important impactonperceivedsmile anterior andpremolarareashasan tooth especiallyinthe a missing lengthening orextraction(Fig.7). substitute forcoronoplastyandcrown an adequateprostheticspacecanbea I I D between allanteriorteeththatwillberestoredwithnewcrowns. Fig. 9:Closureofmaxillarymidlinediastemaanddistributionspace ntra-arch spacemanagement nter-arch spacemanagement ental Opening anoptimalspacefor Orthodontic intrusiontorecreate M anagement than theefficiencyofretainer. term stabilityoftheresultmuch more forces must be considered for long- and the vertical effects of occlusal ling thedivergenceofincisal axis [33, 34,35]andsurgery. dontics [31,32],restorativedentistry approach [30](Fig.9)involvingortho- is facilitatedbyamultidisciplinary etiological factorscausingadiastema. (supernumerary teeth,cysts…)areall patients, andvariousdentalanomalies arch structureincleftlipandpalate mal displasia,abnormalmaxillary pathological conditions as ectoder imbalances, tooth-sizediscrepancies, [27, 28,29].Oralhabits,muscular should resolveitsetiologyandcause Management ofmaxillarydiastema sons ratherthantofunctionalones. to aestheticandpsychologicalrea- According toMulligan[36],control- The closureofmaxillarydiastemas Diastema closureisattributed - as porcelaincrowns,supplement conservative aesthetic therapies,such aesthetic height.Inmostinstances, for thereestablishmentof optimal create theneededoverjetandoverbite treatment isnecessaryinorderto relationship (Fig.10),anorthodontic addition toanedgeanterior ment ofthefinalrestorations. positive impact on the esthetic assess- (83%) [37,38].Thesedimensionsgivea the intermediateoneisforcanines the maxillarylateralincisors(79%)and (85%) whilethesmallestratioisfor maxillary centralincisorsisthelargest and length.Thewidth/lengthratioof are differentandvariableinwidth ratio. The measurements of these teeth size theimportanceofwidth/length maxillary anteriorteethshouldempha- R estoring toothproportions To restoreanabradeddentitionin The aestheticrehabilitationof 71

Orthodontie/Orthodontics

Fig. 10: Abraded anterior teeth in edge to edge relationship. Notice that the maxillary anterior teeth are not visible upon smiling.

Fig. 11: Orthodontic treatment recreates the appropriate overjet for full mouth restoration with ceramic crowns.

orthodontic therapy to create a final Furthermore, the impact of the An appropriate referral of patients result are possible only with singular media raising the slogan of Hollywood and fine considerations of the avai- approach (Fig. 11). smile has lift up the challenge toward lable orthodontic treatment possibi- a very high level of aesthetic accep- lities, limitations and risks are preva- Discussion tance and execution which define new lent factors for general practitioners criteria of a “beautiful smile”. This to admit any needed adjunctive dental General dentists are the first to motto led to introduce the porcelain treatment [40]. The orthodontic- pros- refer patients for a needed orthodontic restorations and lumineers to thodontics - periodontic collaboration intervention in order to correct a maloc- the dental practice and to execute a was conducted a long time ago [41] clusion or to improve the status of the beautiful smile without implementing to assist dentists in their practice. supporting structures. Optimizing a any orthodontic treatment. Such alter- Patients should be informed about the healthy environment for dental resto- native has some limitations regarding ideal treatment option before conside- rations is crucial for the longevity and the correction of gingival margins and ring the compromised approaches that stability of the outcomes. papilla [39] and in some cases is less should be discussed thoroughly wei- conservative. 72 IAJD Vol. 3 – Issue 2 Revue delalittérature/Literaturereview Table 1:Comparisonoforthodonticandnontreatments. table1. tion isneededcanbesummarizedin tion, especiallywhenanteriorrestora- rehabilitation oforalformandfunc- approaches inthecomprehensive orthodontic versusnon the advantagesanddisadvantagesof ghting theirrisksandbenefits.Finally, o rhdnis-Less timeinvolvement Non orthodontics Orthodontics T reatment - - Fewer restorations - L  surgery No rootcanalsorperiodontal ess cost A dvantages - Periodontal surgeryneeded - AggressivetoothPreparation - Morerestorations - Increasedcost - Needforretention - Longer treatment D isadvantages 6. 2. 1. R anaka OM,Furquim BD, Pascotto BósioJA, RC,Ribeiro GL, 13. 12. 11. 10. 9. 8. 5. 4. 3. 7.

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