Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2018-02-22, 14:08:19 | version 1.38.0
Dental Tribune Middle East & Africa Edition | 5/2016 11 mCME ◊Page10 multiple disciplines of dentistry, it is important to address the patient’s main concern, whether the patient is seeking treatment for functional or aesthetic improvement or both. Finding a solution to each individual problem leads to the formulation of a definitive treatment plan (5). A well-structured and organized list of problems makes sure that all areas have been evaluated in the diagnos- tic phase, and also serves as a valu- able reference tool during the course of treatment. All specialists involved in formulating the treatment plan for the patients should provide pos- sible solutions to individual prob- lems based on their own areas of expertise, and no problem should be treatedaslessimportant.Provisional treatment plans are then compared with respect to their overall effects, and the plan that enhances the treatment and provides maximum benefit to the patient, considering the patient’s chief complaint, is then regardedasfinalanddefinitivetreat- mentplan. The treatment planning process almost always follows the same events; however, the treatment se- quence varies significantly from patient to patient due to large vari- ations in morphological configura- tions and treatment priority. Here, it is critical to organize the sequence of various treatment procedures in such a way that each treatment procedure performed by one of the specialistsfromtheinterdisciplinary team facilitates the next in order (Fig.3). Figure 4 illustrates 11-point treatment protocol for interdiscipli- narycases. 3) Recognize ‘minor dental arch crowding’ as a ‘major’ periodontalconcern Dental arch crowding presents nar- row interproximal spaces, which may result in a constriction of the interproximal bone due to reduced interradicular distance (Fig. 5). This compromisedboneasaresultofsep- talconstrictioncanbeachallengefor both periodontists and prosthodon- tists. Decrowding of the dentition by orthodontictoothalignmentwidens the interproximal bone, which can significantly enhance local host re- sistance and improve the prognosis of compromised or infected teeth (Fig.6). Other than the aesthetic reasons, the resolution of interproximal tis- sue constriction and faulty contact points and embrasures is the pre- dominant periodontal reason to eliminatedentalarchcrowding(6). This integrated orthodontic and periodontic approach as an alveolar development exercise, should be considered as the most compelling periodontal rationale for orthodon- tic therapy. Hence, it is important to recognize orthodontics to be much more than simply an esthetic do- main. 4) Use orthodontic treatment in correction of ‘Biologic width’ violations Restorative therapies essentially re- quire a healthy and stable periodon- tium for long-term success. A den- togingival unit exhibits a constant interplay of gingival tissues with crowncontours,restorativematerial, its texture and its margins. Biologic width is defined as the dimension of space that the healthy gingival tis- sue occupies coronal to the alveolar bone(7). It is further elaborated as a total of supracrestal fibers, junctional epi- thelium and sulcus (8). This concept of existence of a specific width was first published by Gargiulo et al. in 1961 through cadaveric experiments whichreveledameanmeasurement of a total of epithelial attachment plusconnectivetissueattachmentto be2.04mm(Fig.7)(9). D. Walter Cohen was credited to first coin the term “Biologic width”. The significance of this width lies in the fact that it prevents penetration of microbesintoperiodontium.In1977, Ingber recommended a distance of 3mm minimum to be kept between restorativemarginandalveolarcrest for adequate gingival health main- tenance (10). This 3mm consists of 1mmofsupraalveolarconnectivetis- sue, 1mm of junctional epithelium and1mmofsulculardepth.Violation of this natural seal disrupts dentog- ingivalapparatusmakingitsuscepti- bletoingressoforalmicroorganisms and consequently causing gingival disturbances such as inflammation, recession and alveolar bone loss (11 and12). Thus it is imperative to minimize ir- ritationtothiszone. Thismeasureof 3mm allows for optimum conserva- tion of the mean value of 2.04mm and provides clinical comfort even whenthemarginsareplaced0.5mm withinthesulcus. 5) Improve implant site with orthodontics There are several orthodontic proce- duresemployedtoimproveimplant siteforpredictablerestorations. Determinethetimingof implant placement Facial growth is the determinant of the age for implant placement in adolescent patients. The osseoin- tegrated implant’s lack of eruptive potential makes it to behave like an ankylosed tooth, often causing a dis- crepancyintheocclusalplanedueto continuous eruption of the adjacent teeth.Therefore,earlyimplantplace- ment poses a greater risk of com- promised esthetics in the long term. Several studies on young adults who were treated with implant-support- ed restorations to replace missing teeth have observed discrepancy be- tween implants and adjacent teeth. In a study that followed the vertical changes of maxillary incisors adja- centtoimplantsinagroupofadoles- centsbetween15-20yearsofageand adults between 40-55 years dem- onstrated infraocclusion of the im- plant–supported restorations, with a vertical step of 0.1 -1.65 mm and 0.12 – 1.86 mm in adolescents and adults respectively(13). Therefore, lack of proper occlusion and unesthetic situations in the an- teriorregionmaybecommonobser- vationsduetojawgrowthinpatients with implant – supported restora- tions even if the implants are suc- cessfully integrated. The best meth- od to determine the status of facial growth is to superimpose sequential lateral cephalometric radiographs taken at an interval of six months (Fig8).Generally,theimplantshould be placed after completion of facial growth (around 17 years in females and21yearsinmales.) Establishoptimal implant space Adequate space gained for the resto- ration of the normal width of miss- ing lateral incisor based on esthetics and occlusion will determine the appropriate size of the implant to be placed.Whenselectingthesizeofthe implant, it is important to have 1.5 to 2.0mm space between the coro- nal diameter of the implant and the adjacent teeth for the development andmaintenanceofthepapillae(14). Aftertheevaluationofcoronalspace, it is important to radiographically evaluate the interradicular space. The roots of the adjacent teeth should be parallel to slightly diver- gent with adequate space between the roots for implant placement (Fig.9AandB). Once the optimal space has been gained with appropriate treatment mechanics, acrylic tooth of proper size and color shade can be brack- eted and attached to the archwire for esthetic purpose (Fig.10). If the space gained for the lateral incisor is in excess, the bracketed acrylic tooth can be used as a template, which will help determining the residual space closure. Clinical evaluation of the edentulous space and radiographic evaluationoftherootpositionofthe adjacent teeth should precede appli- anceremoval. The final implant restoration is significantly influenced by the po- sition and angulation of implant placement. For proper placement of an implant, the minimum space between the adjacent teeth roots is usually 5mm; providing enough room for small diameter implant placement,leavingabout0.75mmof space for the bone between the im- plantandtheadjacentroots(15). Position adjacent teeth to fa- cilitaterestorativetreatment It is a common observation that when an orthodontist is opening up the space for missing lateral incisor; as the force is applied on the crowns of the central and canine teeth, the roots get tipped into the lateral inci- sor region. This leads to an adequate crown space but the space between the adjacent roots gets reduced, makingitimpossibleforthesurgeon toplaceanimplant(Fig.11). It is equally important to take suffi- Figure10:Optimalspacegainedwithappropriateortho- dontic mechanics for the restoration, provisional tooth bracketedandattached to thearchwire Figure 16: (A) Pre-treatment intro-oral photographs showing malformed maxillary lateral incisors and inter- proximalspacing. Figure 16: (B) Pre-treatment photographs demonstrating impairedsmileestheticsanddeepoverbite Figure 17: Orthodontic treatment to redistribute inter- proximal spaces, correct deep bite and retract maxillary incisors Figure18:(A)Pre-treatment intra-oralphotographs. (B) Post-treatment: integrated orthodontic and restora- tive treatment to establish normal tooth proportions and smileesthetics Figure 19: (A) Pre-treatment smile. (B) Im- provedpost-treatment smile Figure 20: (A) Pre-treatment vertical gin- gival discrepancy between 11 and 21 causedmainlybysupra-eruptionof21. (B) Mid-treatment photograph demon- strating resolution of this discrepancy by differential vertical orthodontic tooth movements Figure 11: Orthodontic mechanics to open the space (A), adequate intra-coronal space (B), inadequate space between the roots of central incisor and canine as seen radiographically(C). Figure12:Assessment ofspaceacross threelevels ÿPage 12 A A A B B C Figure 13: (A) Pre-treatment model showing deep over- bite and cervical part of the lateral incisor. (B) Intraoral periapical radiograph shows the presence of maxillary left lateral incisor root piece with good interproximal bonelevels.(C)Pocket depthof6mmin thelateralincisor regionindicatingfacialboneloss. Figure 14: (A) Orthodontic treatment to gain adequate space for implant placement (≠22), implant site devel- opment and to improve deep overbite with orthodontic bracket attached to temporary crown on lateral incisor. (B)Controlledverticaleruptionofmaxillaryleftlateralin- cisor root at completion. (C) Lateral incisor root piece ex- tracted,notethepresenceofadequatebonysocketwalls. Figure 15: (A) Maxillary left lateral incisor implant resto- ration. (B) Intraoral periapical x-ray after implant place- ment,andafterabutment loading B Dental Tribune Middle East & Africa Edition | 5/201611