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Dental Tribune Middle East & Africa Edition | 5/2016 12 CME cient care to make sure that there is adequate interocclusal space for the implant restoration. It is, therefore, critical to establish optimal intra- coronal and interradicular spaces; evaluated clinically and radiographi- cally (Fig.12) respectively, for proper implant placement and long-term predictablerestoration. It is best to place an implant during the finishing stage of orthodontic treatment which allows finer ma- nipulation of space, maintenance of space and sufficient time for os- seointegration by the time appli- ances are removed. However, if the implant placement procedure is planned after the removal of ortho- dontic appliances, the gained space should be maintained during the re- tentionphase. Considerbiologic augmentation One of the prerequisites for placing an implant and subsequent good soft-tissue integration for more esthetic implant restoration is to have an excellent alveolar ridge. It is a common clinical observation that unrestored edentulous areas typically exhibit compromised bone levels due to alveolar bone atrophy. Research studies have shown that if maxillary anterior teeth are extract- ed,thealveolarridgewillnarrow34% overperiodof5years(16). However, these findings related to the alveolar resorptive change do not hold true in cases where the edentulous span has been created by orthodontic tooth movement. Another study which evaluated the long-termwidthofthealveolarridge after the required space was created for missing maxillary lateral incisors in adolescent orthodontic patients revealed that the amount of bone loss as result of resorptive changes was less than 1% over a period of 4 years(17). Orthodontic implant site develop- ment is a process involving the root movement that creates adequate alveolarridgewidththroughstretch- ing of the periodontal ligament fib- ers prior to the implant placement. This can be accomplished in any part of the alveolar ridge. In addi- tion to the compromised alveolar ridge width, vertical bony defect at the site of implant placement can be influenced by controlled vertical root movement to generate osteo- blastic activity before implant place- ment (Fig.13 - 15). The goal is to create an ideal implant site by establishing adequate alveolar ridge width and heightforapredictableandmorees- theticimplantrestoration. 6) Optimize pre-restorative orthodontics Oftenmanagementofadultpatients necessitates modification from usu- al treatment approach due to ana- tomical disfigurements displayed commonly in their dentition caused by previous pathological episodes. Interdisciplinary treatment required fortheholisticrehabilitationofthese individuals may involve manage- ment with periodontal, endodontic, restorative, orthodontic, surgical, etc., specialties. Orthodontic therapy mayplayavitalroleinrepositioning of teeth for subsequently planned restorative procedures. Such move- ments may either include elaborate alteration of teeth positions to re- orient occlusal forces, coordination of upper and lower arch forms, ap- propriate distribution of interdental spaces or simplified movements as guided by localized restorative requirements such as to improve crown-root ratio, achievement of parallelismofabutmentteeth,etc. Size of the teeth play an important role in anterior dental esthetics, and the clinicians are often faced with disproportionate widths of anterior teethinaday-to-dayclinicalpractice. This tooth size discrepancy is com- monly found in patients with peg- shaped lateral incisors. In such situ- ations, in spite of getting the teeth perfectly aligned and the occlusal discrepancies completely resolved with orthodontic treatment, the ab- normal shape and smaller size of lat- eral incisor pose esthetic problems. This requires planned tooth move- ments for proper space distribution with orthodontics to restore the nor- mal width of lateral incisor. If a later- alincisorisofnormalshapebutonly slightly narrower than normal, and the discrepancy is bilateral, it may not require any intervention. How- ever,incaseoftoothsizediscrepancy that is unilateral or quite significant, it is imperative to restore the size of the malformed lateral incisors after the completion of orthodontic treat- ment for overall good treatment re- sult(Fig.16-19). Pre-restorative orthodontic move- ments are primarily determined by the type of restoration planned for execution. The main objective of tooth repositioning is to assist in ac- complishment of predictable resto- rations. A classical case constitutes a mutilated dentition (often with parafunctional dental lesions such as attrition or abfraction) usually along with presence of old restora- tions which may frequently be func- tionally and/or esthetically compro- mised possibly resulting in partial or complete collapse of maxillary and mandibular arches in vertical, saggital and/or transverse planes. Presence of either upright or retro- clined anterior teeth cause improper anterior guidance without definitive vertical stop, which gradually lead to supra-eruption and subsequent creation of deep bite. Pathological migration disrupts interproximal contacts leading to possibility of production of multiple interdental caries. Consequently, in absence of timely dental intervention, deterio- ration of the dentition advances sig- nificantly. Adjacent teeth drift into carious spaces to seal off the broken continuity and decrease the arch width, produce saggital discrepancy and loss of vertical dimension. Such teeth typically present with tipped roots, which are not parallel to each other and have non-uniform inter- radicular spaces. Rehabilitation of such a dental architecture involves intense interdisciplinary planning with the restorative dentist. Treat- ment thus planned should involve strategic sequencing of procedures adhering to the holistic final result objectives ensuring predictability at every stage. Establishment of ap- propriate inter-incisal relationship with suitable anterior guidance, par- allelism of roots and evenly spaced inter-radicular architecture along with well-coordinated upper and lowerarches,formstheforemostob- jective of pre-restorative orthodon- tic treatment. This creates a reliable foundation for predictable distribu- tion of occlusal forces. Restorations can thereafter be fabricated for long- term functional and esthetic stabil- ity. Fine- tuning of tooth positions during the finishing stage of ortho- dontic treatment can be completed with valuable inputs from the re- storative dentist in accordance with the proposed restoration. Likewise, removal of orthodontic appliances can be timed along with restorative interventions so as to ensure avoid- ance of any untoward tooth move- ments. Proficient synchronization betweenorthodonticandrestorative strategies is the fundamental aspect for interdisciplinary treatment suc- cess. 7) Use customized orthodon- tic tooth movements to max- imizeaesthetics Contrary to traditional orthodontics that is focused solely on improve- ment of static and dynamic occlusal relationships, contemporary ortho- dontics encompasses treatment mo- dalities which aim at achieving good occlusal results in-conjunction with enhancement of the entire dento- gingival apparatus including prime emphasisonitsaestheticoutcome. In a cosmetically concerned society, aesthetics forms an integral part of patient expectations. This directly mandates orthodontic profession- als to systemically explore various factors that promote optimal aes- thetics. Adhering to principles of structural balance and functional ef- ficiency, treatment planning should diligently incorporate distinctly defined and customized aesthetic objectives. Various procedures from other disciplines of dentistry can be amalgamated with orthodontic treatment to refine aesthetic poten- tial. Whiteandpinkharmony Well-finished orthodontic realign- ment of teeth constitutes perfection of white esthetics within a smile. However, an ideal esthetic smile demands a harmonious balance of both, white and pink components. Color, contour and health of gingi- val architecture constitute the pink components, which provide the background framework within a smile. Completed orthodontic treat- ment with appropriately reposi- tioned teeth but neglected gingival discrepancies such as loss of papilla or asymmetrical gingival pattern causes white-pink disharmony lead- ing to an unaesthetic smile (18). Two significant factors related to gingival architecture which need to be con- sideredare: 1.Gingivallevels 2. Gingival marginal contour or gin- givalzenith Amount of gingival levels seen de- pend upon the upper lip line in an active smile. In certain individuals, the upper lip does not display any gingiva on smiling while in certain individuals gingival display is evi- dent. For optimum biological health, functional perfection of treatment is inevitable while gingival refine- ments subjectively elected are pure- ly cosmetic procedures, which may not augment towards health. Thus cases with no gingival display in ac- tive smile do not require corrective treatment. Alternatively, cases with noticeable gingival display require corrective measures for achieving white and pink balance within the smile. According to ideal esthetic param- eters, the free gingival margins of the maxillary central incisors and canines are at the same level and those of the lateral incisors are placed slightly coronal. These mar- gins should have contours, which resemble the cement-enamel junc- tions. Gingival zenith is termed as the most apical point of the labial gingival contour. For the maxillary central incisor and canine it is lo- cated just distal to the long axis of the tooth and for the lateral incisor its location coincideswith long axis of the tooth (19). Papillary tip of the gingiva should extend halfway be- tween the incisal edge and the labial gingival height of contour over the center of each anterior tooth. Thus the height of contour of the gingi- val levels should be centered on the lateral incisors and placed in the distal one-third for the central inci- sors and canines. Such arrangement of gingiva provides a semicircular appearance for the lateral incisors and an elliptical appearance for the canines and central incisors. Peri- odontal assembly is carried along with the erupting tooth. Presence of asymmetric tooth eruption will alter the underlying crestal bone levels, whichprovidesupporttotheoverly- inggingivalpattern.Thereforeasym- metries in gingival levels will result. Orthodontically, these clinical situa- tionscanbemodifiedbyintrusionor extrusionofteeth(Fig.20). Conclusion An interdisciplinary orthodontic treatment presents the philosophy and treatment strategy that also involves a group of professionals from other disciplines of dentistry as a cohesive team. This approach to manage complex clinical situations is highly sophisticated treatment modality and requires excellent communication and coordination among the team members. The goal is to simplify and idealize the treat- ment plan by providing solutions to a variety of clinical situations, which improves overall treatment progno- sisandenhancestreatmentresults. Initially, this approach may seem to beoutofreachofmostpractitioners, however when implemented regu- larly, this collaborative approach re- sults in very efficient protocols and execution that patients appreciate andbenefitfrom. The author has, since the initial days of orthodontic practice, enjoyed the professional collaboration with specialists from other disciplines of dentistry in a fruitful career and continues to maintain professional enthusiasmwiththem. This unique approach to manage complex clinical problems will cer- tainly inspire readers to engage in their own interdisciplinary collabo- ration, and advance the practice of dentistry for the benefit of the pa- tientandcommunityatlarge. Acknowledgements The author would like to acknowl- edge Dr Ratnadeep Patil for provid- ing restorative treatment for the patients, and Dr Aditi Jagdale for her assistance in preparation of this manuscript. References (1) Levitt HL. Modification of appli- ance design for the adult mutilated dentition. Int J Adult Orthod Orthog- nathSurg1988;3:9–21. (2) Alexander RG, Sinclair PM, Goates LJ. Differential diagnosis and treat- ment planning for the adult non- surgical orthodontic patient. Am J Orthod1986;89:95–112. (3) Lindauer SJ, Rebellato J. Biome- chanical considerations for ortho- dontic treatment of adults. DCNA Adult Orthodon I 1996; 40(4): 811– 836. (4) Karad AK, Patil RC. Interdiscipli- nary orthodontics. In: Ashok Karad, ed. Clinical Orthodontics: Current concepts, goals and mechanics, Reed Elsevier India Pvt Ltd, New Delhi, 2015;325-345. (5) Roblee RD. Treatment planning: Phase II of IDT. In: Roblee RD, ed. In- terdisciplinary Dentofacial therapy – a comprehensive approach to optimal patient care. Quintessence publishing: Printed in Singapore; 1994:77–99. (6) Mihran WL, Murphy NC. The orthodontist’s role in 21st century Periodontic- prosthodontic therapy. SeminOrthod2008;14:272-289. (7) Tylman et. al.1965) (Tylman SD: Theory and Practice of Crown and Bridge Prosthodontics, ed 5. St Louis, Mosby,1965. (8)NevinsM,SkurowHM.Theintrac- revicular restorative margin, the bio- logic width, and the maintenance of the gingival margin. Int J Periodon- ticsRestorativeDent1984;4(3):30-49. (9) Gargiulo et al. 1961) Gargiulo A,Wentz F, Orban B. Dimensions and relations of the dentogingival junction in humans. J Periodontol. 1961;32:261-267. (10) Ingber JS, Rose LF, Coslet JG. The “biologic width”—a concept in peri- odontics and restorative dentistry. AlphaOmegan.1977;70:62-65. (11) Kois J. Altering gingival levels: Therestorativeconnection,Part1:Bi- ologic Variables. J Esthet Dent. 1994; 6:3-9. (12) Kois JC. The restorative-perio- dontal interface: biological param- eters. Periodontol 2000. 1996; 11:29- 38. (13) Bernard J. P., et al. Long-term ver- tical changes of the anterior maxil- laryteethadjacenttosingleimplants in young and mature adults. A ret- rospective study. J Clin Periodontol 200;31:1024-1028. (14) Saadun AP, LeGall M, Touati B. Current trends in implantology: Part II – treatment planning and tissue regeneration. Pract Periodontics Aes- thetDent2004;16:707-714. (15) Greggory A. Kinzer, Vincent O. Kokich.Managingcongenitallymiss- ing lateral incisors. Part III: Single- tooth implants. J Esthet Restor Dent 2005;17:202-210. (16) Carlsson GE, Bergman B, Hede- gardB.Changesincontourintheup- per alveolar process under immedi- ate dentures: A longitudinal clinical and x-ray cephalometric study cov- ering5years.ActaOdontScand1967; 25(1):45–75. (17) Spear F, Mathews D, Kokich VG. Interdisciplinary management of single toothimplants.SeminOrthod 1997;3:45-72. (18) Karad A. Excellence in finish- ing: current concepts, goals and mechanics. J Ind Orthod Soc 2006; 39:126–138. (19) Rufenacht CR. Fundamentals of esthetic. Chicago: Quintessence pub- lishing;1990:124–127. Dr.AshokKarad isaDirectorofSmileCare, India.HeisaDiplomate andPast-Chairmanof the IndianBoardofOrthodon- tics,andFormerEditor-in- Chiefof"TheJournalofIn- dianOrthodonticSociety". Dr.Karadhasbeenactively ◊Page11 involvedinclinicalresearch,continuingeduca- tion,publicationsandclinicalphotography, andhasauthoredabook titled“Clinical Orthodontics:Current concepts,goalsand mechanics”. Contact info: SmileCare 1/C3-3,2,SujataNiwas,S.V.Road,Bandra (West),Mumbai–400050,India Tel:+91-22-26400188,+91-22-26400183 Email:drashokkarad@gmail.com Website:www.smilecareindia.com