Journal of Orthodontics, Vol. 32, No. 3, 182-184, September 2005 doi:10.1179/146531205225021069
© 2005 British Orthodontic Society
Clinical pearl In-treatment replacement of missing incisors
T. M. Hodge
Eastman Dental Institute, London, UK
Address for correspondence: T. M. Hodge, Eastman Dental Institute, 256 Gray’s Inn Road, London WC1X 8LD, UK., Email: trevorhodge{at}eggconnect.net
Received February 28, 2005;
accepted April 29, 2005
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Abstract
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Four methods of in-treatment replacement of missing incisors are described.
Key words: Orthodontics, clinical pearl, in-treatment, missing incisors
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Introduction
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Missing incisors can have a major impact on dental and facial aesthetics. Prior to achieving the goals of orthodontic treatment, patients are frequently left with embarrassing, unaesthetic spaces. The aim of this article is simply to highlight the practical management of missing incisors with temporary in-treatment replacement.
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Methods
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Prosthetic tooth and labial bracket
A bracket sited on an acrylic tooth often makes a suitable single unit replacement. Initially, when an archwire of round or reduced dimension is in place, an additional palatally-bonded retaining wire will prevent unwanted movement of the prosthetic tooth. To increase retention the area of the acrylic beneath the bracket can be roughened and coated with a plastic bracket primer, or an undercut on the labial surface of the acrylic can provide mechanical retention at the composite-tooth interface. A prosthetic tooth of appropriate shape and size can aid space closure to the desired amount as it acts simply as a space maintainer.
Prosthetic tooth and acrylic flange cantilever
If sufficient space is present prior to tooth alignment, or forces are to be applied to teeth adjacent to the space, a more substantial means of in-treatment placement may be required. An acrylic tooth incorporating an acrylic flange strengthened with a fibre reinforced composite (Figure 1
) can provide this interim measure. Perforations to the cantilever facilitate a mechanical bond.
Patient 1 (Figure 2) had anterior spacing due to congenitally absent upper lateral incisors and an unerupted, dilacerated UR1. Following the extraction of UR1 the resulting space meant it was both desirable and possible to place an immediate prosthetic tooth. Initial archwire dimension and the need to apply a force to the mesial of UL1 to create space indicated the use of such a tooth- borne prosthesis.
Prosthetic tooth attached directly to the archwire
An acrylic tooth reduced buccolingually can be used where space is required in this dimension and sufficient mesio-distal space is available. Additional space can be gained by fixing the tooth directly to the archwire avoiding the depth of a bracket base.
Patient 2 was referred following loss of a cast post and crown when the buccal wall of the root of UL1 fractured below the gingiva to the level of the alveolar crest. In order to expose the fracture margin and allow for reconstruction, root extrusion was planned. Brackets were placed using a rigid rectangular steel archwire as a guide plane, which allowed a tractional force to be applied immediately. In order to maintain both the space and smile aesthetics a veneer was made by reducing the labio-lingual thickness of the acrylic tooth. The incisor was bonded directly to the archwire so as not to encroach on the root being extruded or the labial mucosa, as could have occurred had a bracket and a labial offset in the archwire been placed (Figure 3). Vertical offsets were placed in the archwire to ensure space maintenance and allow sufficient tractional force to be applied (Figure 4). The presence of the prosthetic tooth also avoided a potentially large, irritant span of archwire.
Extracted tooth
When extraction of a tooth is enforced, and the coronal tissue remains intact and not discoloured, use of the tooth itself can be an ideal choice of in-treatment replacement.
Patient 3 had previously avulsed UR1 and sustained an intrusive injury to UL1. Although UR1 was promptly re-implanted it subsequently became ankylosed and despite repeated application of calcium hydroxide replacement root resorption occurred (Figure 5). Once in treatment, UR1 was extracted, the root remnant was removed, the coronal defects were restored with composite and a bracket was then bonded to the tooth and added to the appliance (Figure 6). Additional support was provided by a palatally bonded retainer.
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Conclusions
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The in-treatment replacement of missing incisor teeth can be beneficial in achieving the desired orthodontic goals and improving the patient experience.
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Acknowledgments
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With thanks to Steve Jones, Melissa Chen and Samantha Hodges, who supervised the above cases, and Ed Payne, for technical support provided.
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Abstract
Introduction
