Ortho endo-prostho relationship /certified fixed orthodontic courses by Indian dental academy

Good
Morning

www.indiandentalacademy.com

1

Interdisciplinary
Orthodontics
INDIAN DENTAL ACADEMY
Leader in continuing dental education

2

CONTENTS
•
•
•
•
•
•
•
•
•
•

Concept of complete dentistry
Ortho Endo Relationship
Effect of Orthodontics on the Tooth Being Moved
Effect of orthodontics on vital and non vital teeth
Orthodontics as the etiologic agent for endodontics
Orthodontic factors associated with non vitality of teeth
Resorptive defects
Endo treatment after orthodontic treatment
Endo treatment during orthodontic treatment
Boltons Ratio

3

• Orthodontic Endodontic - Combined Therapy
oBasic periodontal principles for forces eruption
oBasic endodontic principles for forced eruption
oBasic orthodontic principles for tooth movement
oForced eruption


4

Ortho prostho relationship
• Introduction
• Why replace a missing back tooth ?
• Introduction to fixed partial dentures
Combined ortho prostho therapy
• Treatment planning: A multi disciplinary approach
• Missing tooth : Space closure or prosthetic replacement ?
• Management of a single tooth edentulous space
• Lateral incisors
• Forced eruption
• Alignment of anterior teeth


5

• How to upright inclined molar in preparation for
restorative treatment ?
• Orthodontic prosthodontic implant interaction
• Prosthodontic consideration when using implants for
orthodontic anchorage
• Clinical cases
• Conclusion
• Reference


6

THE CONCEPT OF COMPLETE DENTISTRY
•

The establishment of definitive goals is the foundation for
complete dentistry. If a goal is clear enough, it can be
visualized and in fact must be visualized.

•

Clearly defined goals give purpose to treatment planning and
make it possible to be highly objective.


7

Complete dentistry has four comprehensive goals :
1) Optimum oral health
2) Anatomic harmony
3) Functional harmony
4) Occlusal stability
If each of these goals is achieved, treatment success is assured.


8

Indications for orthodontic treatment in a adult patient
can be broadly classified into four categories :
1. Prosthodontic
2. Periodontal
3. Temporomandibular joint (TMJ)
4. Esthetic

9

Orthodontics is a central player in this multidisciplinary
dental team and has allowed for better management of these
challenging dentofacial problems especially presented by the
adult population.


10

A multidisciplinary approach to dental treatment is most
desirable and may dramatically improve the treatment outcome
as well as the long-term prognosis.


11

The increasing number of adult patients seeking
orthodontic therapy has resulted in a progressive modification of
treatment modalities.


12

ORTHODONTIC- ENDODONTIC
RELATIONSHIP


13

INTRODUCTION


14

•

Endodontic treatment can simply be defined as the
precautions taken to maintain the health of the vital pulp in
a tooth, or the treatment of a damaged or necrotic pulp in a
tooth to allow the tooth to remain functional in the dental
arch.


15

The pulp can become inflammed and
necrosed by the following reasons….
I.

Bacterial
A.

Coronal ingress
1.
2.

B.

Radicular ingress
1.
2.
3.

II.

Caries
Fracture
Caries
Retrogenic infection
Periodontal pocket or abscess

Traumatic
A.

Acute
1.
2.

B.

Coronal or radicular fracture
Luxation and avulsion

Chronic
1.
2.
3.

Adult female bruxism
Attrition and abrasion
Erosion


16

III. Itral
A.

Cavity Preparation
1.
2.

B.

Heat of preparation
Depth of preparation

Restoration
1.
2.

Insertion
Fracture

C.

Intentional extirpation

D.

Orthodontic movement

E.
F.
G.
H.

Periodontal curettage
Electrosurgery
Laser burn
Periradicular curettage

17

IV. Chemical
A.

Restorative materials
1.
2.
3.
4.

Cements
Etching agents
Cavity liners
Dentin bonding agents


18

B.

Disinfectants
1.

B.

Dessicants
1.

V.

Silver nitrate and Phenol
Alcohol and ether

Idiopathic
A.
B.
C.
D.
E.

Aging
Internal resorption
External resorption
Sickle cell anemia
Herpes Zoster infection


19

The expanding role of orthodontics into more phases of
dental treatment is illustrated by the awareness of relationships
with endodontics.
There are two major areas where endodontics and
orthodontics share common ground.


20

•

One is etiologic, because orthodontic treatment affects the
tooth being moved ,and some of the response may be noted in
the pulp tissue.

•

The second one is combined therapy, where orthodontic
treatment is necessary to gain a desirable endodontic result.


21

EFFECT OF ORTHODONTICS ON THE
TOOTH BEING MOVED


22

Orthodontic treatment is used
to gain a much more esthetic
appearance for the patient and is
often further utilized to improve the
occlusion. In the course of such
therapy, certain changes may occur to
the tooth being moved.
The most common side effect
of orthodontics is to blunt the root of
the moved tooth, due to apical and
sometimes lateral resorption.


23

Effect of orthodontics on vital
and
non vital teeth


24

A COMPARISON OF APICAL ROOT RESORPTION
DURING ORTHODONTIC TREATMENT IN
ENDODONTICALLY TREATED AND VITAL TEETH
STEVEN W. AJO DO 1990
•

The purpose of this study was to determine whether vital and
endodontically treated incisors exhibit a similar severity of
apical root resorption in response to orthodontic treatment.

•

The sample comprised of 20 male and 20 female patients under
going ortho treatment.

25

•

This study found a statistically greater degree and frequency
of mean apical root resorption in the vital control incisors
when these teeth were compared with the contralateral
endodontically treated incisors.

•

The results of this study indicate that there is very little
clinical difference in the amount or severity of apical root
resorption between vital and nonvital teeth.

26

CONCLUSION :
•

Endodontically treated incisors resorb with less frequency
and severity than vital control teeth.

•

No significant difference in root resorption between male and
female patients was detected in endodontically treated
incisors.

•

Control teeth exhibited significantly more resorption in male
patients than in female patents.

•

Even though statistical significance was noted, clinical
differences are minimal when endodontically treated and
vital incisors are compared.

27

Orthodontics as the Etiologic
Agent for Endodontics


28

Some teeth require endodontic
treatment

as

a

result

of

previous

orthodontics. Because the action of the
blunting of root tips usually occurs in the
area where the apical blood vessels and
nerves emerge, it can be seen that injury
at this susceptible site could affect pulp
vitality.


29

ORTHODONTIC FACTORS ASSOCIATED WITH
NON VITALITY OF TEETH


30

TYPE OF MALOCCLUSION :
•

Among different malocclusions, based on Angle’s
classification system, studies have observed a statistically
significant difference between class I and class II div 1
malocclusion, with the latter exhibiting more resorption.


31

•

Janson et al reported a higher resorption potential for class
II div 2 cases in comparison with class I , class II div I and
class III patients.

•

The rationale was that excessive intrusion mechanics were
necessary to correct the deep overbite in these cases and
also the torque required to correct the palatal inclination of
the incisors was high.

32

EXTRACTION VS NON EXTRACTION :
•

The analysis of literature reveals that both the extraction and
the non extraction treatment have the potential to produce
damage, with the extraction therapy being potentially more
detrimental.

•

Among all the extraction patterns, extraction of all the first
premolars showed the greatest resorption potential.

33

Mechanotherapy Begg Vs edgewise :
•

Although previous studies could not find any significant
resorption rate between Begg light wire mechanics and
edgewise ( Tweed ) techniques, a recent study by McNab et al
has reported a higher incidence of resorption, as well as
amount of root resorption in patients treated with the Begg
appliance.

34

•

They concluded that the incidence rate of root resorption
was 3.72 times higher when extractions were performed as
part of Begg appliance therapy.

•

Root resorption was also observed in all three stages of
Begg treatment, with the second stage exhibiting the least
severity.

35

TYPE OF TOOTH MOVEMENT :
•

Intrusion and torque movements are found to be most
commonly associated with the resorption process.

•

This is evident when studying class II div 2 correction as well
as Begg mechanics.


36

•

The intrusion performed in the first stage and the torquing in
the third stage make the Begg technique more vulnerable to
resorption.

•

The highest root resorption is reported to occur when 3 to 4.5
mm of torquing movement was performed.


37

Length of treatment time
•

The length of treatment time and root resorption have been
positively correlated by almost all studies.

•

These studies have shown that increased treatment time
makes tooth roots more prone to iatrogenic response.


38

Type of force applied (Continuous vs interrupted )
•

Interrupted forces were shown according to studies to cause
less severe apical blunting and smaller resorption affected
areas.

•

The authors of these studies emphasize the use of less
detrimental forces ( in the form of elastic usage, instead of
elastomeric

chains

)

during

space-closure

stages

of

orthodontic mechanotherapy.

39

Tooth specificity:
•

Evaluation of the vulnerability of specific teeth to the
resorption process in the literature has resulted in common
agreement among authors that the maxillary incisors are the
teeth that are the most susceptible to the process.

•

However, Controversy still exists regarding which incisors
resorb the most: the centrals or the laterals.

40

•

The majority of the studies published reported that the
central incisors were more susceptible to the process.

•

Following the incisors in susceptibility to resorption in the
maxillary arch are the molars, followed by the canines.

•

In the mandibular arch the most resorption vulnerable tooth
is the canine, followed by the lateral and central incisors.

41

•

Among the posterior teeth, the most resorbed are the
mandibular molars (with the distal root exhibiting more
resorption), followed by maxillary molars, mandibular
premolars, maxillary first premolars, and maxillary second
premolars.


42

•

Beck and Harris(AJO1942) in their classic article, described
the relationship of mechanotherapy to root resorption in the
distal roots of molars. According to them anchorage
archwire bends at the mesial of molars for bite opening
cause the distal roots to be compressed in the tooth sockets,
thereby initiating root resorption.


43

Root shape :
•

Various authors have evaluated abnormalities in root shape
and its association to the resorptive process.

•

Among differently shaped root ends (normal, blunted,
dilacerated, pipette shaped, pointed, and incomplete), the
least resorption was observed in blunted root ends and the
greatest was seen in pointed or tapered root ends.

44

•

This phenomena is explained by the fact that the pressure
from the axial component of orthodontic forces is felt most
at the root apex regions which are abnormal in shape. This
results in localized ischemic necrosis, which denudes the
pericementum and cementoblasts, permitting colonization
of dentinoclasts.


45

•

In comparison to the normal root shape, dilacerated roots
show the most resorption followed by pipette- shaped and the
incomplete roots.

•

Hence, any abnormal root shapes observed in the pretreatment diagnostic records should be observed with caution
and should be monitored throughout the treatment period for
any iatrogenic damage.

46

Root length:
•

A positive correlation is found between the root length and
root resorption. The studies in this regard report that longer
roots are more prone than shorter ones to resorption.

•

This may be due to the greater displacement required to
produce an equal amount of torque, versus shorter roots.


47

History of trauma:
•

Previous history of trauma and the presence of pretreatment
root resorption have been positively correlated with root
resorption seen after orthodontic treatment.

•

Also studies have found a relationship between cortical plate
proximity and increased root resorption. All these findings
point towards the importance of obtaining pretreatment
diagnostic records and proper evaluation. So that any risk
elements can be identified and described.

48

Overjet or overbite:
•

Studies to date have agreed with a positive correlation between
an increase in overjet and root resorption.

•

The main reasons attributed to this phenomenon are the
greater amount of torque and greater root displacements
required to correct excessive overjet.


49

Age, Gender and ethnicity: are they contributing factors?
•

Biologic factors such as age at the start of treatment and
gender, have long been associated with risk factors for the
initiation of root resoption.

•

Age at the start of the orthodontic treatment and incidence of
root resorption have been poorly correlated in almost all
recent studies.

50

•

Conflicting results have been seen when gender is considered.
Various studies supported that females are more prone to root
resorption whereas various others stated that men were more
prone.

•

The majority of the studies support a lack of correlation
between gender and resorption.

•

The relationship between ethnicity and root resorption was
evaluated recently. The results showed less severity among
Asians in comparison to Caucasians and Hispanics.

51

RESORPTIVE DEFECTS


52

Whether it was the orthodontic
therapy or some other pathology that
caused the resorption is questionable
under any circumstances.
However, just as some pulpal
changes include deposition of reparative
dentin, resorption can also occur from
pulpal injury that might have been
initiated by orthodontic movement.

53

So it is strongly recommended that following
orthodontic treatment a full set of radiographs be taken. These
films should be scrutinized carefully by both the orthodontist
and the general dentist for any incipient periapical lesions and
any unusual changes in pulp canal shape.


54

Furthermore, all teeth that have been moved, particularly
those that were pulled into occlusion, should be monitored at least
on a once-a-year basis via radiograph and careful clinical
examination to verify normalcy of the pulp.
If the pulp canal space does begin to diminish or get
larger, endodontic therapy should not be delayed.


55

ROOT RESORPTION IN MAXILLARY CENTRAL
INCISORS FOLLOWING ACTIVE ORTHODONTIC
TREATMENT
Copeland S. AJO DO 1986
•

The purpose of this study was to determine if apical root
resorption associated with orthodontic treatment continues after
the termination of active treatment.

•

A sample of 45 subjects who had experienced root resorption
during treatment was selected from the orthodontic clinic at the
state university of New York at Buffalo.

56

The data from this radiograph study support the hypothesis
that root resorption associated with orthodontic treatment ceases
with the termination of active treatment. There was also evidence
to suggest that when posttreatment root resorption does occur, it is
not necessarily associated with large amounts of root resorption
during the active treatment period. It is more likely associated with
other factors, such as traumatic occlusion and active forcedelivering retainers. (Am J Orthod 89:51-55, 1986).
The results of this study indicate that the termination of
active treatment will essentially stop further apical root resorption.

57

BOLTONS RATIO


58

• One of the basic fundamentals with which the orthodontist
has to deal in reconstructing the denture is tooth size,
specifically the mesiodistal width of the teeth.
• Tooth size is an important factor to be taken into
consideration in orthodontic diagnosis and treatment
planning.
• According to Bolton there exists a ratio between the
mesiodistal widths of maxillary and mandibular teeth.
Many malocclusion occur as a result of abnormalities in
tooth size.

59

•

Bolton Ratio may be helpful in cases in which

•

Teeth may be logically extracted if such a procedure deemed
necessary.

•

Extraction of teeth not confined to case in which shortened
arch length exists.


60

•

Gross disharmonies in tooth size may indicate removal of
dental unit or units, even when there is adequate arch
length.

•

Tooth size discrepancies may be corrected by placing over
contoured restorations when indicated.


61

ENDODONTIC –ORTHODONTIC COMBINED THERAPY :
Endodontic-orthodontic cotreatment may become necessary
to save teeth with advanced caries, traumatic destruction of the
clinical crown, lateral root perforation, external or internal resorption
near the alveolar crest, or overzealous tooth preparation. Without
such treatment, these teeth may not offer sound tooth structure on
which to place a restoration.

62

An additional

combined therapy

involves isolated

infrabony periodontal defects which also may be amenable to
forced eruption.
Orthodontic therapy will improve the existing periodontal
environment

by

modifying

the

osseous

topography

and

minimizing the need to remove supporting bone on adjacent teeth.


63

Endodontic therapy in conjunction with eruption permits
placement of a restoration that fulfills the periodontal and
occlusal requirements of the tooth.
Forced orthodontic
endodontic,

periodontal,

eruption, in conjunction with
and

restorative

therapy,

is

an

alternative. This multidisciplinary approach offers benefits not
available with periodontal surgery alone.


64

BASIC PERIODONTAL PRINCIPLES FOR
FORCED ERUPTION


65

Orthodontically erupting the tooth with its attachment
apparatus and gingiva may eliminate the need for periodontal
surgery to expose sound tooth structure and reduce alveolar
support on adjacent teeth.
Surgery may be necessary to level angular interdental alveolar
crests created by tooth movement and reposition the overlying
soft tissue to its proper coronal level.

66

A. Resorptive lesion at the
alveolar crest causing an
infrabony pocket. Patient had
history of orthodontic treatment.
B,
Endodontic
treatment
completed and initial post room
prepared
for
orthodontic
movement. If only surgical
treatment were employed to
eliminate the pocket and expose
the resorptive lesion, a crown-toroot ratio of 2:1 would result. By
forced eruption and surgical
exposure, a more acceptable
ratio of 1:1 is obtained.

A


B

67

C

D

E

F

C. The tooth is erupted, and the
alveolar bone and resorptive
lesion are moved to a position
more amenable to surgical
exposure.
D, An uprighting spring is
placed to align the tooth for
parallelism to adjacent teeth.
E. Final tooth position.
F. Final restoration


68

Exposing adequate sound tooth structure by periodontal
surgery alone will lead to a shortened clinical root and a larger
clinical crown as the tissues are positioned apically. The crown-toroot ratio of the tooth following surgery alone will exceed the
crown-to-root ratio of the tooth that is first orthodontically erupted.


69

There is thus a relative improvement in the crown-to-root
ratio of the tooth undergoing orthodontic eruption followed by
periodontal therapy that does not occur after a surgical procedure.


70

BASIC ENDODONTIC PRINCIPLES FOR
FORCED ERUPTION


71

Teeth that are certain to require endodontic therapy
should have such treatment completed prior to the initiation of
tooth movement. In the case of an isolated periodontal defect,
endodontic therapy should be completed before tooth
movement if it appears that intentional extirpation will be
required to restore the tooth after eruption.


72

This decision is based on the morphology of the
periodontal lesion and the amount of tooth movement required
to modify it. Early endodontic treatment eliminates the
problem of constantly changing working lengths as the tooth is
erupted and the crown is adjusted to the opposing articulation.


73

Teeth that have no pulpal problem and are undergoing
eruption may have endodontic therapy completed in one sitting.
Teeth that present with caries, resorptive or iatrogenic
perforation, or post-traumatic destruction of the clinical crown
should receive a multisitting regimen.


74

At times endodontic therapy may become necessary after the
initiation of tooth movement. In this case the pulpal tissue should be
extirpated as completely as possible, the canal sealed, and the
treatment completed as soon after tooth movement as possible.
There is no contra-indication to completing the endodontic therapy
while the tooth is undergoing orthodontic movement.


75

The problems of treating a tooth in this situation are the
presence of the orthodontic appliance and the changing working
length.
Teeth with loss or destruction of the clinical crown must have
endodontic therapy completed prior to tooth movement. Post
preparation room of adequate width and length must be provided. A
post may then be cemented into the tooth to allow for movement.


76

BASIC ORTHODONTIC PRINCIPLES
FOR
TOOTH MOVEMENT


77

The patient must understand the indication for tooth
movement and that endodontic therapy is essential or highly
likely. The patient also must be aware that restorative
procedures will follow the endodontic orthodontic cotherapy.


78

•

Prior to the initiation of treatment, an estimate of the
amount

of

attachment

apparatus

remaining

at

the

completion of tooth movement must be made. The tooth
must have sufficient radicular attachment to assist in the
support of a multiunit restoration or maintain its individual
integrity while contributing to esthetics, phonetics and
function.


79

Single-rooted

teeth

generally

narrow

from

the

cementoenamel junction to the apex. Eruption of teeth with
single roots generally brings a narrower portion of the root to
the level of the cementoenamel junction of adjacent teeth. This
improves the interdental environment if root proximity is
present.


80

Posterior teeth, with their greater osseous support, root
surface area, flatter interdental form, and lesser esthetic
requirements, are more amenable to osseous surgery than to
forced eruption. Forced eruption risks bringing furcations closer
to the level of the cementoenamel junction of adjacent teeth.
This may result in furcation exposure.

81

Infection and inflammation must be controlled before
tooth movement. Control of the inflammatory lesion by curettage
of the soft tissue pocket wall and removal of any granulomatous
tissue and gingival fibers to the alveolar crest must precede tooth
movement. No tooth movement should be started unless the
retention and stabilization phases have been fully planned.


82

•

Unless very light force is used to extrude the tooth, a lag
period occurs between movement of the tooth and
movement of its attachment apparatus and surrounding
gingiva. The attachment apparatus and gingival unit follow
the tooth after it begins to erupt from the alveolus.


83

The amount of force used and the speed of eruption
determine the lag time, because the faster the tooth is forcibly
extruded the greater will be the lag between the movement of
tooth and attachment apparatus.


84

A, Preoperative view of a mandibular cuspid
with

advanced

caries

extending

A

to

attachment apparatus.
B, Elastic ligature is tied from existing
bridge to wire cemented into tooth.

B

C, With rapid eruption, tooth is extruded
from

alveolus,

exposing

sound

tooth

structure. Movement of attachment apparatus
and gingival tissue did occur, as indicated by

C

position of the soft tissue relative to the
adjacent crowns.

85

Forced Eruption


86

• With the advent of orthodontic direct bonding brackets,
adjunctive tooth movement such as forced eruption can be
practiced efficiently and economically.
• With the clinical situation previously described, the
technique of forced eruption takes on one of the two
clinical protocols…


87

Tooth lacking a clinical crown : Endodontic therapy is
completed immediately. Post room of adequate width and length is
provided. Control of gingival inflammation by curettage is
completed prior to tooth movement.
If necessary, a customized post may be fabricated by
adding cold-cure acrylic resin around a prefit post for maximum
adaptation to the canal walls.

88

Tooth having an intact clinical crown :
•

A direct bond bracket or orthodontic band is placed as far
apical as is permissible.


89

•

The greater the force placed on the tooth, the more rapid the tooth
erupt from the alveolus. With slow, constant, light pressure, the
alveolus and soft tissue will move with the tooth.

•

Do not be fooled into thinking that the tooth is not erupting if you
do not see it extruding from the soft tissue. If properly managed,
the soft tissue will move with the tooth.

90

ORTHO PROSTHO - RELATIONSHIP


91

INTRODUCTION


92

Prosthodontics is that discipline of dentistry pertaining to the
restoration of oral function, comfort, appearances, and health
by restoring natural teeth and replacing missing teeth and
contiguous oral and maxillofacial tissues with artificial
substitutes. There are three main branches of prosthodontics :
•

Fixed

•

Removable

•

Maxillofacial

93

Fixed prosthodontics pertains to the restoration or
replacement of teeth with artificial substitutes that are
attached to natural teeth, or implants and that are not readily
removable.


94

Removable prosthodontics pertains to the replacement of
missing teeth and contiguous oral structures with artificial
substitutes that are readily removable.


95

Maxillofacial prosthetics pertains to the restoration of
developmental or acquired defects of the stomatognathic
system and associated facial structures with artificial
substitutes.


Fitzgibbon(1923)

96

WHY REPLACE A MISSING BACK
TOOTH?


97

If we fail to replace an extracted back tooth with a false
tooth, we could lose all of our teeth..


98

Losing Teeth “Two-For-One”
Recent extraction of a lower
molar has created space X.
Upper tooth 6 is now
useless because it no longer
has a tooth to chew against.
•

Therefore, losing one tooth
can result in the loss of the
use of two. Losing two teeth
can result in the loss of the
use of four, and so on.

99

A SERIES OF PROBLEMS
BEGINS


100

Overeruption :
•

Back teeth have a lifetime tendency to erupt (move farther into
the mouth). Only the presence of a tooth to chew against keeps a
back tooth from overerupting.

•

This patient had a tooth extracted from space X. Upper tooth 6
has overerupted.


101

• The resulting unevenness among the upper back teeth has
created areas between these teeth that trap debris. It is very
difficult to keep spaces between uneven teeth clean, despite your
best efforts at brushing and flossing.
• Unclean teeth usually cause inflammation of the surrounding
gums. They decay more readily too.
102

•

Lower molar 7 is jamming food in between overerupted 6 and 7
during eating (arrow).

•

This pressure between upper 6 and 7 has caused upper 7 to move
backward and separate slightly from upper 6. It has created a
103
space between these teeth (arrow).

•

Food can pack into this space with great force during chewing.
This creates a serious inflammation of the gum.

•

Note that overeruption of upper 6 has caused some of its root
to become exposed. Exposed root decays faster than the crown
104
of a tooth, as we will see later.

Tilt and drift :
Back teeth have a lifetime tendency to tilt (lean over) toward
the front of the mouth. They also have the potential to drift (move)
toward the front of the mouth.

105

•

Now that a tooth has been extracted from position X, a space
is left. This allows lower molar 7 to tilt and drift forward.

•

Lower 7 will tilt farther and farther over as you chew on it.

106

Gum pocket formation :
A tooth tilted over will develop a gum pocket along its forward
root, as shown here.
Gum pockets are narrow, abnormal spaces or clefts that
develop between the gums and the tooth root. These pockets trap food
107
debris and bacteria.

•

A gum pocket is a problem, you can almost never keep it clean,
even with the best brushing and flossing.

•

The debris and bacteria that collect in pocket lead to everworsening inflammation of the gums adjacent to the pocket.

108

Loss of bone supporting the tooth :
•

When an area of the gums is constantly inflamed, as you see in
this gum pocket, the bone immediately adjacent to it can
become inflamed too. Inflamed bone softens, and slowly begins
109
to disappear.

Destruction spreads :
Lower molar 7 has drifted and tilted so far forward that
upper 7 no longer bites on it. This allows upper 7 to overerupt
too. Arrows (↑) show advancing gum pockets, gum inflammation,
and bone loss.


110

•

Decay has begun on upper teeth 6 and 7, particularly on the
exposed portions of the roots of 6 and 7. Exposed roots are
especially prone to decay.

111

•

Both upper molars are deeply decayed. Decay has also started on
lower 7.

•

Periodontal disease – gum pockets, gum inflammation, and loss of
bone – continues to worsen.

112

•

Deep decay has allowed bacteria to enter and infect the pulps
(“nerves”) of upper 6 and 7. These two teeth have abscessed
(become seriously infected). They are so badly damaged by decay
that they must be extracted.

113

•

Because of inflammation from the gum pocket of lower 7, bone
loss (outlined by arrows) has spread around the front root of this
tooth and extended to part of the back root too. This tooth has lost
so much bone support www.indiandentalacademy.com and must be extracted. 114
that it is now loose

•

Because all the molars on this side of the mouth have been
removed, the upper and lower 5s have no support behind them
and are forced backward by the action of chewing.

115

•

Food jams between the separated teeth (arrows). Gum
inflammation has begun. Gum pockets will follow, along with
bone loss and decay.www.indiandentalacademy.comwill have to be extracted
Eventually the 5s
116

•

After the loss of the upper and lower 5s, the destructive process
can move farther forward. The front teeth will start to spread
apart, gum pockets will form, decay begin.

•

Now you may lose your front teeth too.

117

SUMMARY
•

So failure to replace a single molar tooth may start a chain of
events : overeruption, tilt, gum pockets, decay, bone loss.

•

Over the years this chain of events can lead to the loss of all
your teeth.

•

Inserting a false tooth today will avoid grief and much greater
expense tomorrow.


118

INTRODUCTION
TO
FIXED PARTIAL DENTURES


119

•

A fixed partial denture is defined as “A partial denture that is
cemented to natural teeth or roots which furnish the primary
support to the prosthesis”

•

A fixed prosthesis is defined as ‘A restoration or replacement
which is attached by a cementing medium to natural teeth,
roots or implants’.


120

INDICATIONS FOR FPD :
A fixed partial denture is preferred for the following situations :
• Short span edentulous arches
• Presence of sound teeth that can offer sufficient support adjacent
to the edentulous space.
• Cases with ridge resorption where a removable partial denture
cannot be stable or retentive.
• Patient’s preference
• Mentally compromised and physically handicapped patients who
cannot maintain the removable prosthesis.

121

Contraindications for FPD :
Fixed partial dentures are generally avoided in the
following conditions :
• Large amount of bone loss as in trauma.
• Very young patients where teeth have large pulp chambers.
• Presence of periodontally compromised abutments.
• Long span edentulous spaces.
• Bilateral edentulous spaces, which require cross arch
stabilization.


122

• Congenitally malformed teeth, which do not have adequate
tooth structure to offer support.
• Mentally sensitive patients who cannot cooperate with
invasive treatment procedures.
• Medically compromised patients (e.g. leukemia, hypertension).
• Very old patients.


123

Type of veneers :

VENEERS

Ceramic :
•

It is the most ideal veneering material when used with metal
substructure or in all ceramic restorations.

Acrylic :
•

Tooth colored acrylic can be used with metallic restorations as
a veneer. They are not considered as a permanent material due
to poor wear resistance. Recent advances include use of
indirect composite resins as veneer materials.

124

Indications
• Retainers of fixed partial dentures for abutments with
sufficient enamel to etch for retention.
• Splinting of periodontally compromised teeth
• Stabilizing dentitions after orthodontics.
• Medically compromised patients, who can not cooperate
with long sessions of therapy.


125

Contra Indications
• Patients with sensitivity to base metal alloys (Nickel).
• Inadequate enamel surface to bond.
• Deep vertical overbite.
• Incisors with extremely thin faciolingual dimensions.


126

COMBINED ORTHO PROSTHO
THERAPY


127

Treatment planning : A multidisciplinary approach
•

Treatment planning of the adult patient differs from
conventional treatment planning of the growing patient in a
number of ways.

•

First, the compromised malocclusions encountered in many
adult patients are often associated with various degrees of
edentulousness and with various stages of periodontal
pathology.

128

•

These observations clearly demonstrate that the dental
needs of adult patients are challenging and unique.

•

The ideal goals of orthodontic treatment, which include
good esthetics (facial as well as dental), function, and
stability, may not always be necessary or realistic to
achieve in all adult patients.

129

•

Although one should always aim to achieve these ideal
treatment goals with acceptable degrees of compromise
which can be developed and may be more appropriate to
obtain optimal multidisciplinary treatment results.

•

The multidisciplinary need that these patients present often
includes ortho, operative, periodontal and prosthetic therapy
as well as implants and surgery.


130

•

Another important difference in approaching orthodontic
therapy in adult patients involves the careful selection of an
appropriate mechanotherapy.

•

Orthodontic tooth movement in adult patients with
compromised dentition must be done carefully because of the
possible reduction of bone support.


131

• When designing a treatment plan, it is important to decide
exactly where the teeth will be moved, which type of tooth
movement they will undergo (uncontrolled tipping, controlled
tipping, translation, or root movement), and the required
moment-to-force ratio for optimal tooth movement.

Space closure


Molar Uprighting

132

•

Treatment planning of the adult patient includes a thorough
extraoral and intraoral clinical examination and collection of
adequate diagnostic records.

•

During the extraoral examination, the patient’s face is
assessed in the frontal plane to check for symmetry, in the
sagittal plane to check the convexity of the profile, and in the
vertical plane to evaluate the vertical proportion of the face.

•

Particular attention is given to measuring the upper incisor
display at rest and the amount of gingival tissue showing at
rest and on smiling.

•

The intraoral examination includes a detailed periodontal
evaluation with a recording of the areas of lost attached
gingiva, dehiscences, abnormal frenum attachment, pockets,
areas of inflammation, and gingival recession.
133

•

The presence of dental pathologies is recorded, and the teeth
are checked for the adequacy of existing restorations and the
presence of caries.

•

The next step is to assess the dental occlusion in the sagittal,
frontal and vertical planes.

•

Overjet and overbite relationship are noted along with the
Angle classification.

134

•

The presence of a centric relation-centric occlusion (Cr-Co)
discrepancy is carefully recorded, and crossbites are
evaluated in Cr and Co. Prematurities are also evaluated in
relationship to the presence of a Cr-Co shift.

•

Lateral excursive movements are checked, and any balancing
side interference is recorded.

•

Specific attention should be directed toward potential
temporomandibular problems.

135

MISSING TEETH : SPACE CLOSURE VS.
PROSTHETIC REPLACEMENT

Space closure


Molar Uprighting

136

Following are the factors we should keep in mind….
Old Extraction Sites :
•

In adults, closing an old extraction site is likely to be
difficult.

•

The problem arises because of resorption and remodeling of
alveolar bone.


137

•

After several years, resorption results
in a decrease in the vertical height of
the bone, but more importantly,
remodeling produces a buccolingual
narrowing of the alveolar process as
well.

•

When this has happened, closing the
extraction space requires a reshaping of
the cortical bone that comprises the
buccal and lingual plates of the
alveolar process.

138

Tooth Loss Due to Periodontal Disease :
•

A space closure problem is also posed by the loss of a tooth due
to periodontal disease.

•

As a general rule, it is unwise to move a tooth into an area
where bone has been destroyed by periodontal disease, because
of the risk that normal bone formation will not occur as the tooth
moves into the defect.

•

It is better to move teeth away from such an area, in preparation
for prosthetic replacement.

139

Space regaining – Molar uprighting :
•

In clinical situations in which space closure is not a
treatment option to address the loss of a permanent first
molar, the presence of an edentulous space causes a number
of occlusal problems that are challenging to correct
orthodontically and restore prosthetically.


140

•

The success of treatment depends
entirely on a well-selected clinical
situation.

•

Indications for molar uprighting
include …

•

Mesially tipped teeth with enough
vertical space to accommodate any
extrusion of the teeth during its
correction.

•

Mesially tipped teeth with mesial
bony defects.

141

•

The pocket depth reduction has been shown to
average 3.5 mm on the mesial of the tipped molar
as it is uprighted.

•

Teeth presenting periodontal involvement of the
furcation are not good candidates for molar
uprighting.

Before

any

orthodontic

tooth

movement, thorough evaluation and treatment of
the periodontal condition is a must.

142

•

The potential for impaction of
the tooth distal to the tooth to be
uprighted

should

also

be

carefully evaluated.
•

In cases in which both second
and third molars have tipped
into a first molar extraction site,
a decision as to whether to
maintain or remove the third
molar must be made.www.indiandentalacademy.com

143

•

The third molar may be maintained if there is adequate space
available for its uprighting while maintaining its function
against the opposing arch.

•

If the second molar is compromised, it is desirable to keep the
third molar.


144

•

But if the second molar needs to be distalized as
it is uprighted to reopen adequate restorative
space for prosthetics, it may be advantageous to
remove the third molar.

•

The decision to extract or maintain the third
molar should be made after consultation among
the orthodontist, periodontist, restorative dentist,
and patient.


145

•

Clinical records may include a set of orthodontic models and
radiographs necessary to evaluate the root angulation and bone
distribution and therefore assist in deciding what type of tooth
movement is desirable for adequate correction.

•

Models are helpful in evaluating the amount of vertical space
available between the arches to accommodate the corrected
position of the tooth to be uprighted.


146

•

In every case in which it may be possible to avoid the
placement of a bridge, orthodontic therapy should be
considered to achieve adequate space closure.

•

The prognosis of such a correction primarily depends on the
basic malocclusion and the anticipated corrected occlusion.


147

•

The presence of any radicular shape anomalies, root
resorption, ridge atrophy, or periodontal disease would
compromise the outcome of such a challenging treatment plan.

•

When we are planning for the patient who presents with
edentulous spaces, the use of visualized treatment objectives is
essential if excellent orthodontic and prosthetic results are to
be achieved. Diagnostic wax up may prove helpful.


148

LATERAL INCISORS


149

•

The occurrence of congenitally missing maxillary lateral
incisors or abnormally shaped maxillary lateral incisors (Peg
laterals) brings patients to consult for orthodontic therapy as
part of the restoration of such occlusal problems.

•

Congenitally missing lateral incisors account for 11% of
patients presenting with midline spacing.

Missing lateral


Peg shaped lateral

150

•

Clinically, the absence of maxillary lateral incisors is reflected
by the presence of anterior spacings, including a diastema
between the central incisors and a mesial drifting of the
cuspids.

•

When maxillary lateral incisors are small, midline
discrepancy may also be observed according to the size of the
teeth.


151

Treatment options include :
1) The opening of the space to replace the missing lateral incisors
with bridges or implants when indicated. This treatment strategy
is favored when the posterior occlusion is class I.


152

2. The space corresponding to the missing lateral incisors may
be closed by protraction of the cuspids and the buccal
segments of teeth leading to a molar class II final occlusion.
The cuspids can be reshaped into lateral incisors, bonded
with composite, veneered, or crowned.


153

Contraindications :
• Contraindications in reshaping the cuspids into lateral incisors
include situations in which the cuspids are oversized
mesiodistally or buccolingually.
• The presence of a prominent cusp tip or cingulum is also a
contraindication to this treatment approach.

154

•

In some instances, space closure is the optimum treatment
option when maxillary lateral incisors are missing because
it avoids the need for prosthetic replacement of the lateral
incisors.

•

A number of factors should be considered during treatment
planning. The buccal occlusion and the amount of overjet
usually indicate if retraction of the anterior teeth and
protraction of the posterior teeth are desirable.

155

FORCED ERUPTION


156

Indications :
•

Teeth with defects in the cervical
third of the root or isolated teeth with
one or two walled vertical periodontal
defects pose a complex dental
problem.

•

These problems can arise after
horizontal or oblique fracture, internal
or external resorption, decay,
pathologic perforation or periodontal
disease.

Crown Fracture at alveolar crest

Internal root resorption


157
Vertical periodontal defect

•

To obtain good access for endodontic and restorative
procedures or to reduce pocket depth, it would be necessary
to perform extensive crown lengthening that would produce
poor esthetics and adverse changes in the crown-to-rootratio.


158

•

Controlled extrusion is an excellent alternative.

•

Forced eruption also allows crown margins to be placed on
sound tooth structure while maintaining a uniform gingival
contour that provides improved esthetics.


159

•

In addition, the alveolar bone height is not compromised, the
apparent crown length is maintained, and the bony support
of adjacent teeth is not compromised. As the tooth is
extruded,

the

attached

gingiva

should

follow

the

cementoenamel junction.

160

A: This central incisor had a crown placed after A
being chipped previously, but now showed
gingival inflammation and elongation.
B: Apical radiograph revealed internal root
resorption below the crown margin. The
treatment plan was:

B

C: Endodontic treatment, than elongation of the
root so that the new crown margin could be
placed on sound root structure.
C
D: Initally elastomeric tie was used from an
arch wire segment to an attachment on the post D
cemented in the root canal

161

TREATMENT PLANNING


162

•

Before beginning treatment, it is essential to
have good periapical radiographs to examine
the vertical extent of the defect, the
periodontal support, the root morphology
and position. The ideal morphology is a
single tapering root.

•

Flared or divergent roots will result in
increasing root proximity with extrusion and
the possibility of exposing the root furcation
area.

163

•

As a general rule, endodontic therapy should be completed
before extrusion of the root begins.

•

For some patients, however, the orthodontic movement must be
completed before definitive endodontic procedures, because one
purpose of extrusion may be to provide better access for
endodontic and restorative procedures.


164

The distance the tooth should be extruded is determined
by three factors :
•

The location of the defect (fracture line, root perforation, etc.)

•

Space to place the margin of the restoration so that is not at
the base of the gingival sulcus (typically, 1 mm is needed).

•

An allowance for the biological width of the gingival
attachment.

165

Orthodontic technique :
•

Since extrusion is the tooth movement that occurs most readily
and intrusion that occurs least readily, ample anchorage is
usually available for adjacent teeth.

•

The appliance need to be quite rigid over the anchor teeth, and
flexible where it attaches to the tooth that is being extruded.


166

• This contraindicates the use of a continuous flexible
archwire, which would produce the desired extrusion but
also tip the adjacent teeth toward the tooth being extruded,
reducing the space for subsequent restorations and
disturbing the interproximal contacts within the arch.


167

•

The alternative is to bond brackets to the anchor teeth, bond
or band the tooth to be extruded, and use a modification of
the T-loop appliance.


168

HOW TO UPRIGHT INCLINED MOLAR
IN PREPARATION FOR RESTORATIVE
TREATMENT?


169

•

One of the most complicated problem a clinician faces is
when mandibular first molar is missing.

•

Perhaps the most complex aspect of the above sequelae is the
mesially inclined second molar.


170

•

Considerations associated with the malposed mandibular molar
include inadequate parallelism, poor occlusal plane, lack of
interproximal space, adverse root proximity, faulty occlusal
landmarks, excessive tooth preparation with potential pulpal
involvement, inadequate pontic space, prominent roots exhibited
by rotated molars, as well as other periodontal soft and hard
tissue deformities of the periodontal structures.

171

•

The patients most likely to benefit from tooth movement are
those that exhibit periodontal breakdown.

•

When the decision has been made to replace a strategic tooth
(for example : lower first molar) to establish or preserve
occlusal stability, the goal is to create a therapeutic occlusion.


172

•

It is therefore not always necessary to correct to the
orthodontic normal or Class I molar relationship. The
objective is to develop an occlusal scheme in which the
posterior teeth function to support the vertical dimension in
maximum intercuspation and the anterior teeth function to
disarticulate the posterior teeth during mandibular excursions.


173

DIAGNOSTIC CONSIDERATIONS IN CASE SELECTION

•

When the clinician selects a case for uprighting the mesially
inclined molar, the patient that exhibits an acceptable
occlusion is the best candidate.

•

The acceptable occlusion, basically, is one in which there is a
local dental malposition without a significant skeletal
dysplasia.


174

It is defined as having the following characteristics
•

A normal to mild Class II skeletal pattern in the
sagittal dimension with no evidence of transverse or
vertical dysplasia.

•

Posterior teeth present to support the vertical
dimension.

•

Anterior teeth which provide incisal guidance.

175

A. Orthodontic Classification :
Orthodontic

classification

involves

a

systematic

description of the interrelationships of the patient’s
a) Skeletal pattern,
b) Musculature, and
c) Dental arches and the tooth in the dental arch.

176

Analysis of the Skeletal Pattern :
•

Both arches are evaluated for symmetry of the basal support.
Arch forms must be similar for them to occlude properly.

1) Assessment of the Sagittal Dimension :
•

In the sagittal (anteroposterior) dimension, it is critical to
evaluate for the existence of a centric occlusion-centric
relation discrepancy.

177

2) Assessment of the Vertical Dimension : Examination of
the facial form should also be made in the vertical dimension.
An estimate is made of the open bite or deep bite skeletal
pattern by looking clinically or cephalometrically.
3) Assessment of the Transverse Dimension : There should
be no basal bone discrepancy in the bucco-lingual
relationship of the posterior teeth. It is imperative that this
evaluation be made in the retruded position (centric relation).

178

B. Analysis of the Musculature :
•

A clinical assessment should be made of the muscles of
mastication. In the presence of tight or strong musculature, as
determined by visual and tactile examination, there is
potential for trauma to the tooth that is being uprighted and
possibly less tendency for developing an open bite during
mechanotherapy.

179

•

In the presence of flaccid or weak musculature, during
uprighting, there is the danger of extrusion that may be
difficult to reverse. This is particularly true when there is both
a superimposed skeletal open bite tendency and a weak
musculature.

180

3. Analysis of the Dental Arch and the Tooth in the Dental
Arch :
First the maxillary and mandibular arches should be evaluated
for dental arch symmetry. Then, an assessment is made of the
alignment and axial position of the lower molar and premolars
relative to their basal support and the occlusal plane.

181

a) Assessment of the Anteroposterior Dimension :
In the anteroposterior dimension, the molar should be only
mesially inclined. Preferably, the tooth could be repositioned
properly by distal tipping. If bodily movement forward is
desired, an alteration in appliance design would be necessary.

182

b) Assessment of the Occlusogingival Dimension :
In the occlusogingival dimension, the molar with a normal
attachment apparatus might exhibit minimal extrusion. Intrusion
of lower molars is extremely difficult to accomplish and requires
gentle force over a prolonged period of time.

183

c) Assessment of the Buccolingual Dimension :
In the buccolingual dimension, the molar that has severe
lingual or buccal axial inclination should be avoided because of
the amount of torque that would be necessary to properly
reposition the tooth for restorative treatment.

184

PERIODONTAL MANAGEMENT


185

•

If inflammation is not controlled, then tooth movement
accomplished for a periodontally susceptible patient can
result in irreversible crestal bone loss probably causing more
harm than benefit to the patient.

•

Therefore before orthodontics is begun, thorough root planing
and curettage must be done to eliminate all inflammation.

186

APPLIANCE DESIGN


187

A. Moderately mesially inclined molar with no distal
drifting of premolars :
1. Initial arch wire
The molar is tipped back into position.


188

2. Finishing arch wire
Rectangular arch wire for buccolingual control.


189

B. Moderately mesially inclined molar with distal drifting of
premolars :
1. Initial arch wire


190

2. Second arch wire
•

Once mild uprighting has been achieved, rectangular wire
(0.018 by 0.25 in.) and an open coil spring should be inserted.

•

This is not recommended unless the patient has distal tipping
and spacing of the premolars.


191

C. Severely mesially inclined second molar :
•

Initial arch wire may be a “T” loop in 0.016 in round wire.

•

Now the first appliance can be utilized for finishing as
necessary.


192

D. Mesially inclined second and third molars :
The third molar should always receive the buccal tube.
1. When using this appliance, it may be necessary to utilize several
light, multilooped, round arches to achieve the bracket alignment
necessary for rectangular arch engagement.


193

ORTHODONIC PROSTHODONTIC
IMPLANT INTERACTION


194

Definition :
An implant can be defined as, “A graft or insert set firmly
or deeply into or onto the alveolar process that may be prepared
for its insertion”.
A dental implant is defined as, “A substance that is placed
into the jaw to support a crown or fixed or removable denture.

195

Indications for implants :
• Othodontic Anchorage
• For completely edentulous patients with advanced residual
ridge resorption, where it is difficult to obtain adequate
retention.
• For partially edentulous arches where removable partial
dentures may weaken the abutment teeth and also provide
reduced masticatory efficiency.
• For single tooth replacements where fixed partial dentures
cannot be placed.
• Patient’s desire.


196

Advantages of using implants :
• Preservation of bone : The implant stimulates the bone like a
natural tooth thereby preventing the progress of residual ridge
resorption.
• Improved function : Implants can be designed such that the
effect of harmful forces can be minimized. The chewing
efficiency is greater than other prosthetic replacements.

197

•

Aesthetics : Implants provide a natural emergence profile
(appearance of the tooth as if it emerges directly from the soft
tissues).

•

Stability and retention : Implants are more stable and retentive
due to osseo-integration.


198

Disadvantages of implants :
• It is very expensive. Patient affordability is the primary
concern in the use of implants.
• Cannot be used in medically compromised patients who
cannot undergo surgery.
• Many patients do not accept longer duration of treatment and
tedious fabrication procedures.

199

•

It requires a lot of patient cooperation because repeated
recall visits for after care is essential.

•

It cannot be universally placed due to the presence of
anatomical limitations.


200

•

Adults presenting for comprehensive orthodontic treatment often
have dental problems that require restorative as well as
orthodontic treatment.

•

Such problems include loss of tooth structure from wear and
abrasion or trauma, gingival esthetic problems, and missing teeth
that require replacement with either conventional prosthodontics
or implants.

201

Problems Related to Loss of Tooth Structure :
The positioning of damaged, worn or abraded teeth during
comprehensive orthodontics must be done with the eventual
restorative plan in mind. Early consultation with the restorative
dentist obviously becomes important.


202

•

There are three particularly important considerations in deciding
where the orthodontist should position teeth that are to be
restored :
• The total amount of space that should be created
• The mesio-distal positioning of the tooth within the space
• The bucco-lingual positioning.

203

•

The orthodontic positioning obviously should provide
adequate space for the appropriate addition of the restorative
material.

•

The ideal position may or may not be in the center of the space
mesio-distally. This would depend on whether the most
esthetic restoration would be produced by symmetric addition
on each side of the tooth, or whether a larger build-up on one
side would be be better.


204


205

•

Similarly, the ideal bucco-lingual position of a worn or damaged
tooth would be influenced by how the restoration was planned.

•

If a crown or composite build-ups are planned, the tooth should
be in the center of the dental arch.

•

But if a facial veneer is to be used, the orthodontist should place
the tooth more lingually than otherwise would be the case, to
allow for the thickness of the veneer on the facial surface.


206

•

Finally, better restorations can be done if the orthodontist
provides slightly more space than is required, so there is
room for the restorative dentist to finish and polish
proximal surfaces.

•

The slight excess space can than be closed with a retainer.


207

Gingival Esthetic Problems :
•

Gingival esthetic problems fall into
two categories : those created by
excessive or uneven display of gingiva
and those created by gingival recession
after periodontal bone loss.

•

This can be an important consideration
when one lateral incisor is missingsubstituting a canine on one side
almost always results in uneven
gingival margins, even if the crown of
the substituted canine is recontoured.

208

•

If several teeth have been worn or fractured, elongating them
can create an unesthetic “gummy smile” even if the gingival
margins are kept at the same level across all the teeth.

•

In that circumstance, it would be better to intrude the incisors to
obtain a proper gingival exposure, and then restore the lost
crown height. Dental esthetics is not just the teeth-the gingiva
play an important role as well.

209

•

A particularly distressing problem is created by gingival
recession after periodontal bone loss, which creates “black
holes” between the maxillary incisor teeth.

•

Even if periodontal therapy succeeds in obtaining some
regeneration of the lost bony support, there is no way to
regenerate the missing soft tissue.


210

•

One approach to this problem is to remove some
interproximal enamel so that the incisors can be brought
close together. This moves the contact points more
gingivally, minimizing the open space between the teeth.


211

COMPREHENSIVE ORTHODONTICS
IN
PATIENTS PLANNED FOR IMPLANTS


212

•

Major concerns when implants are to be placed are adequate
bone in the edentulous area to support the implant, especially
when the implant is to replace a congenitally missing tooth,
and for single-tooth implants, adequate space between the
roots as well as the crowns of the adjacent teeth.


213

•

A successful implant requires adequate bone to support it. If
there is no tooth to erupt into an area of the dental arch, little or
no alveolar bone ever forms.

•

The result is a large defect in the alveolar process that can make
implant placement almost impossible.

214

•

Alveolar bone will form in a 2-4 mm area adjacent to an
erupting tooth.

•

For this reason, when an implant is planned as the eventual
replacement for a missing maxillary lateral incisor or
mandibular second premolar (the most frequent congenitally
missing teeth,) it is important for a tooth to erupt in the
eventual implant area.


215

•

The orthodontic plan would be to open the edentulous space
and position the adjacent teeth after the permanent tooth has
erupted and to place an implant to support the prosthetic
crown after the vertical growth has completed.


216

• The timing of implant placement is particularly critical for
adolescents and young patients.
• Implants to support the restorations should not be placed
untill all vertical growth has completed.
• Once the implant has been placed, no further eruption of this
tooth will occur, even though the adjacent teeth continue to
erupt in response to increase in the patient’s vertical facial
height.
• The implant is analogous to an ankylosed tooth.


217

PROSTHODONTIC
CONSIDERATIONS WHEN USING
IMPLANTS FOR ORTHODONTIC
ANCHORAGE


218

• Orthodontic treatment has been a valuable adjunct to
prosthodontics for decades.
• Indeed, certain prosthodontic treatments are not possible or
would

be

severely

compromised

without

preprosthetic

orthodontic therapy.
• This mutually beneficial orthodontic prosthodontic relationship
has been significantly enhanced through advancements in adult
orthodontic treatment.

219

•

The use of implants for orthodontic anchorage can produce
superior preprosthetic tooth alignments.

•

However the prosthodontic advantages of using implants for
orthodontic anchorage are only fully realized when the location
and angulation of the implants are carefully planned so that
they are optimally located for prosthesis that will be placed
after orthodontic therapy.

220

• A. Patient has extensive vertical
overlap

of

anterior

teeth.

Mandibular incisors are contacting
palatal soft tissue to create gingival
trauma.
• B. Six remaining mandibular teeth
are

proclined

facially

and

malaligned. Because of lack of
posterior
anchorage,

teeth

for

orthodontic

retraction

and

realignment of these teeth cannot be
effectively accomplished.

221

• C. Mandibular cast shows location of 4 endosseous root
form implants that have been placed to provide posterior
anchorage for retraction and realignment of anterior teeth.
Implants are thereby located in position where they can be
used to support definitive posterior prosthesis after
completion of orthodontic therapy.


222

• D. Cast showing one of the
orthodontic implant prosthesis that
provided orthodontic anchorage.
Anteriorly cantilevered pontic was
veneered with resin and orthodontic
bracket bonded into resin veneer.
• E. Orthodontic treatment is nearing
completion.
Retraction of both
maxillary and mandibular anterior
teeth has improved their relationship,
eliminated palatal soft tissue trauma
and improved facial esthetics through
changing lip contours.

223

• Without use of mandibular posterior implants, these
improvements would not have been possible. Patient will
soon be ready for definitive prosthodontic treatment that
includes replacement of single incisor crowns and fabrication
of maxillary fixed partial dentures from canines to first
molars.
• Mandibular posterior implants will be used to support and
retain posterior prosthesis.

224

CONCLUSION

It would do well for all of us to keep in mind that orthodontics
cannot stand alone. We are after all dentists by profession.
Thus it is our moral obligation to assess not just the teeth but
also the surrounding structures . In this manner we elevate the
standards of not just orthodontics ,but of dentistry within and
outside our community.

225

References:

• Maxillofacial prosthesis: William R. Laney
• Contemporary fixed prosthodontics: Second edition
Stephen F. Rosenstiel
• Tylman theory and practice of fixed prosthodontics: 8th
edition: W.F.P. Malone
• Fundamentals of fixed prosthodontic: 3rd edition, Herbert T.
Shillingberg
• Fixed prosthodontics: Keith E. Thayer.
• Implants in dentistry: Michael S.Block
• William R. Profit 3rd edition Text book of orthodontics


226

• Text book of orthodontics : Sameer E. Bishara
• T. M. Graber 3rd edition Text book of orthodontics
• Endodontic therapy 6th edition Franklin S. Weine
• Endodontics 2nd edition John Ide Ingle
• Pathways of Pulp 5th edition Steephan Cohen & Richard C.
Burns
• Endodontics 3rd edition E. Nicholls
• Dental clinics of North America : Adult orthodontics Part I
and Part II

227

Thank You

228

Ortho endo-prostho relationship /certified fixed orthodontic courses by Indian dental academy

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