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ePaper created 2017-03-17, 11:08:54 | version 1.38.0
I m p l a n t a n d o r t h o d o n t i c t r e a t m e n t The diagnosis and treatment of growing children with missing lateral incisors can be a problem for many clinicians. If the patient and his or her parents plan on him or her undergoing implant treatment in the future, it is important that the majority of vertical facial growth and tooth erup- tion be completed before implant placement.7 After completion of growth in body height, se- quential cephalometric or hand–wrist radio- graphs verify the cessation of facial growth over a time frame of approximately six months to one year. The sequence of treatment in cases of agenesis of anterior teeth must be carefully ex- plained to both the patient and his or her parents. They must realize that the orthodontic treat- ment is the beginning of the process, which is to be followed by the scheduling of periodontal therapy and final restorations. It is crucial that all of the treatment options be discussed with the interdisciplinary team, just as all of the options are explained in the orthodontic treat- ment phase. Space closure is recommended for missing lateral incisors in subjects with long faces, as it is the preferred treatment for preserving arch anchorage and avoiding clockwise rotation of the lower jaw. In addition, it is the treatment of choice in subjects with bimaxillary dental pro- trusion in order to avoid worsening of the profile or in cases of early treatment in adolescents. Space closure can also be considered with two types of malocclusions: a mandibular anterior with severe dental crowding and a Class I mal- occlusion, for which the first premolars and canines are extracted to achieve mesialization (thus obtaining a molar and canine Class I), as well as a Class II malocclusion without crowding and mandibular protrusion. Furthermore, space closure may benefit patients with a specific an- terior relationship, specifically those with an increased overjet and reduced overbite. Lastly, the presence of third molars is an additional factor that would be supported by space closure mechanics. The color of the natural canine should be approximately that of the central in- cisor. It is not uncommon for the canine to be more saturated with color, resulting in a tooth that is one to two shades darker than the central incisor. Space opening (between the canine and cen- tral incisor) is the second therapeutic option in the treatment of missing lateral incisors. Space opening and prosthodontic intervention are in- dicated in low-angle subjects and those with retruded profiles in order to improve the labial sagittal relationship. It is also the treatment of choice in patients with molar Class I or III ten- dency in order to preserve an ideal occlusal an- terior and posterior relationship. Space opening is also of benefit in cases with a reduced overjet and increased overbite. As mentioned previously, an important factor that clinicians should con- sider when deciding on treatment is the patient’s age. Space opening is not recommended before the age of 13 years in order to prevent the relapse and progression of bone atrophy.11 In the case of unilateral tooth agenesis, space opening is often recommended in order to improve the esthetics and preserve smile symmetry.12 According to Magne and Belser, there are various subjective and objective criteria for the assessment of an ideal smile.13 The midline is an imaginary line located at the center of the face, perpendicular to the interpupillary line. In a to- tally symmetrical face, the dental midline and the facial midline should coincide, but this is often not the case.14 According to Spear et al., a midline deviation greater than 4 mm can be detected by the general public,15 whereas a mid- line deviation of 2 mm remains undetectable by laypersons.14 Given these considerations, the choice of opening space for the implant in our patient was especially influenced by the presence of micro- dontia of the maxillary left lateral incisor and the midline deviation of over 3 mm. When examining the esthetics of the ante- rior teeth and overall smile, the clinician should be aware of the morphology of the gingival con- tours, tooth contacts, tooth morphology and tooth size problems. In order to obtain ideal es- thetic results, worn incisal edges, tooth shape, incisal contact, the contours of the gingival mar- gins, and black triangles should be considered before starting orthodontic treatment. The de- cision to reshape or add tooth structure should be evaluated in light of the width-to-length ratios of the golden proportion.16 It appears clini- cally that long, tapered triangular maxillary inci- sors have thin, arched gingival tissue with a longer, delicate papilla and thin bone with a smaller incisal contact point. In contrast, rect- angular-shaped incisors tend to have thicker gingiva with a flatter, wider free gingival margin. Furthermore, these latter teeth have broad con- tacts. Generally speaking, the more rectangular the teeth, the thicker the alveolus and the gingiva that house them.17 Present-day demands and expectations of esthetic dentistry are growing. In order to pro- Journal of Oral Science & Rehabilitation Volume 3 | Issue 1/2017 15