part 12 combined orthodontic treatment

BRITISH DENTAL JOURNAL VOLUME 196 NO. 8 APRIL 24 2004 449

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Orthodontics. Part 12: Combined orthodontictreatmentD. Roberts-Harry1 and J. Sandy2

Dentistry is becoming more sophisticated and capable of providing much higher treatment standards than ever before.Treatments previously considered impossible can now be achieved as a direct consequence of these advances. However, thisincreased complexity of treatment also means that the different branches of dentistry have, as a necessity, become more andmore specialised. It is important that the specialities collaborate in a systematic focused way to ensure the optimal treatmentoutcome with the minimum burden of care for the patient.

1*Consultant Orthodontist, OrthodonticDepartment, Leeds Dental Institute,Clarendon Way, Leeds LS2 9LU; 2Professorin Orthodontics, Division of Child DentalHealth, University of Bristol Dental School,Lower Maudlin Street, Bristol BS1 2LY*Correspondence to: D. Roberts-HarryE-mail: [email protected]

Refereed Paperdoi:10.1038/sj.bdj.4811174© British Dental Journal 2004; 196:449–455

● The dental specialities can collaborate with the treatment of complex cases● Joint treatment planning is essential● A clear treatment plan must be agreed by all parties prior to treatment starting● Responsibility for each treatment stage must be agreed in advance● Combined treatment can produce high quality treatment outcomes in complex cases

I N B R I E F

Recent advances in dentistry, coupled withpatients’ increased expectations and demands,means that some areas of clinical practice havebecome more specialised. An individual dentistis unlikely to have the necessary skills andexpertise to undertake all aspects of treatment.In the management of complex cases joint plan-ning between the orthodontist and the otherdental specialities is important if a satisfactorytreatment outcome is to be obtained. The dentalspecialities cannot work in isolation, and joint-working relationships should be fostered. Whilstorthodontists may be highly skilled in movingteeth, they are heavily dependent on other dentaldisciplines if optimal treatment outcomes are tobe achieved in complex cases.

There are many areas in which orthodontictreatment may be of help to other dental special-ities. Some of these are as follows:

• Missing teeth• Traumatised teeth• Periodontal problems• Occlusal problems• Surgical problems

MISSING TEETHThe choice in these cases is usually to recreatespace for the prosthetic replacement of missingteeth, or to close the space instead.

If an upper central incisor is missing then theusual choice is to open up the space and put insome form of prosthesis. If the space is closedand the lateral incisor is placed in the centralincisor site, then camouflage is difficult because

of the small width of the lateral that results in anunsightly emergence angle of the crown. Incases where an upper incisor is missing, thespace may need to be re-distributed. The patientin Figure 1 had a partial upper denture, and itwas difficult to restore the site with a bridgebecause of the inclination of the upper lateralincisor and the generalised spacing in the upperlabial segment. Fixed appliances were thereforeused to re-distribute the space in the upper arch.In order to maintain the appearance, a bracketwas fitted to a denture tooth. At the completionof treatment the patient was fitted with an upperremovable retainer carrying a denture tooth.Note the proximal metal stops on the upper rightcentral and upper left lateral incisor, to prevent a space re-opening during retention. Finally a bonded bridge restored the site.

When lateral incisors are missing the choice isnot so clear-cut, and often depends on theamount of spacing the patient has, the buccalocclusion and the shape and colour of thecanines. Opening the space for prostheticreplacement produces optimal aesthetics but hasthe disadvantage of the maintenance involvedwith this type of restorative treatment. Closingthe space obviates the need for false teeth butthis may produce a less satisfactory appearance.

Where there is considerable space, the buc-cal occlusion is well inter-cuspated and thecanine has a pointed cusp tip then the usualtreatment is to open the spaces. Closing spaceswill affect the buccal occlusion, and if it is awell interdigitated Class I then this may not bethe best option. The shape of the canines is

12

ORTHODONTICS1. Who needs

orthodontics?2. Patient assessment and

examination I3. Patient assessment and

examination II4. Treatment planning5. Appliance choices6. Risks in orthodontic

treatment7. Fact and fantasy in

orthodontics8. Extractions in

orthodontics9. Anchorage control and

distal movement10. Impacted teeth11. Orthodontic tooth

movement12. Combined orthodontic

treatment

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450 BRITISH DENTAL JOURNAL VOLUME 196 NO. 8 APRIL 24 2004

important because if they are pointed they willlook unsightly adjacent to the central incisor.Although the tips of the teeth can be trimmedto improve their appearance, this is not alwaysthe best choice. Figure 2 shows a case withspacing in the upper arch due to developmen-tally absent upper lateral incisors. The uppercanines have very pointed tips and it would bedifficult to modify the shape of these teeth tomake them resemble lateral incisors. In addi-tion, the buccal occlusion would make spaceclosure very difficult. Therefore, space in theupper arch was recreated to allow prostheticreplacement. An upper fixed appliance withcoil springs at the upper lateral incisor sitesaccomplished this task. At the completion oftreatment, an upper retainer with denture teeth

was used to restore the missing sites. Thisretainer was worn for a year prior to definitiverestoration with adhesive bridgework.

If the canine teeth are more amenable tomasking, and the buccal occlusion is not wellinter-cuspated with less spacing in the upperarch, then consideration can be given to spaceclosure. Figure 3 shows a case where this wasaccomplished, again using a fixed appliance andthe tips of the canines subsequently trimmed. Agood aesthetic appearance was achieved, but itis worth noting the slightly different colour ofthe canines in relation to the central incisors. Ifnecessary, this can then be masked with veneers.Before the decision to open or close spaces ismade, consultation with a restorative dentist orthe patient's GDP is a pre-requisite.

Fig.1a,b A patient with a missing upper left central incisor,which has been replaced with an inadequate denture

Fig. 1c A fixed appliance with a denture tooth to mask the space

Fig. 1e A retainer with a denture tooth. Note the proximalmetal stops. If these are not used there is a risk of the teethsliding past the denture tooth.

Fig. 1f A bonded bridge was placed 1 year after the removal ofthe fixed appliance

Fig. 1d The space has been redistributed

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TRAUMATISED TEETHTraumatised, fractured, intruded or avulsedteeth may sometimes benefit from an orthodon-tic input. Teeth, which are fractured or intruded,may need extrusion, and this can be accom-plished by using a number of different appli-ances and techniques. Figure 4 is an example ofan upper appliance being used to extrude twounerupted upper incisors as an interceptive formof treatment. The upper permanent lateral inci-sors had already erupted; a clear sign that some-thing was wrong. A supernumerary tooth, pre-venting the eruption of the central incisors, wasfirst removed and brackets bonded to the centralincisors. A modified palatal arch was then fittedand attached to the central incisor brackets withwire ligatures. The ligatures were gently activatedto extrude the teeth. Once the teeth had eruptedthe remaining dentition was then allowed todevelop prior to definitive orthodontic treat-ment. A similar technique can also be used toextrude fractured roots so that post-crowns canbe placed on the teeth.

If upper incisors are traumatised and have apoor prognosis it is occasionally possible totransplant teeth to restore these sites. The mainprinciples of transplantation have been welldocumented by Andreasen1 and provided theseare followed, success rates in excess of 90% canbe expected. Premolars are good teeth to replaceupper central incisors because they often havethe same width at the gingival margin as theteeth they are replacing. Figure 5 shows an

Fig. 2a A patient with missing upper lateral incisors andspacing

Fig. 2c Following removal of the fixed appliance Fig. 2d A retainer with denture teeth was fitted and worn forone year prior to definitive restorative treatment

Fig.2b A fixed appliance with coil springs to re-open thespaces for the lateral incisors

Fig. 3a Another case with missing upper lateral incisors

Fig. 3b Because the spaces were small these were closed up using afixed appliance

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example of a case where the upper incisors had apoor prognosis and were extracted. The lowerfirst premolars were then transplanted into theextraction sites. Veneers were then placed on thepremolars to produce a satisfactory treatmentoutcome. The advantage of transplantation overimplants is that transplantation can be under-taken at an early age and will grow as the patientgrows. If an implant were placed at this stage itwould, as the child grows, become graduallysubmerged. There is also a risk of ridge resorp-tion by waiting until the patient is old enough tohave an implant placed. In addition the cost oftransplantation is also considerably less than forimplants.

PERIODONTAL PROBLEMSWith advanced periodontal disease, teeth areprone to drift producing an unsightly appear-ance. The teeth can be realigned orthodontically,but prior to this it is essential that all pre-exist-ing periodontal disease is eliminated and thepatient can maintain a meticulous standard oforal hygiene. If treatment is undertaken in the

presence of active disease, very rapid bone losscan result.

Figure 6 shows a patient who had substantialvertical and horizontal bone loss, and as a con-sequence, drifting of the upper teeth hadoccurred, in particular the upper lateral incisor.Alignment of the teeth was achieved using fixedappliances. Near the completion of treatment aresidual black triangle was left between theupper incisors. This is quite a common problemin adults and is caused by the inability of thegingival tissue to regenerate and re-form aninter-dental papilla. In order to reduce the size ofthe black triangle, some inter-proximal reduc-tion was undertaken to reshape the mesial con-tact points of the incisors allowing the teeth tobe brought more closely together. Permanentretention is needed in situations like this becausethe tooth will drift as soon as the appliances areremoved.

OCCLUSAL PROBLEMSOrthodontics can be used to try and produce anoptimal occlusion, and there are many situa-tions in which this can be used.2 The occlusioncan be adjusted to provide canine guidance,and eliminate non-working side interferences.In situations where anterior open bites exist, itis occasionally possible to close these downwithout the need to resort to surgery.3

Sometimes the occlusion can damage theteeth and supporting tissues. Figure 8 is anexample of a patient with a unilateral cross biteextending from the upper central incisor to theterminal molar on the right hand side. Thistraumatic occlusion had produced substantialtooth wear. Treatment was carried out using anupper fixed appliance in conjunction with aquad helix to expand the upper arch, correctthe cross-bite and align the teeth. At the com-pletion of treatment the incisal tips wererestored with composite.

SURGERYThere is a limit to how much tooth movementcan be achieved, and in cases with severe skele-tal discrepancies, orthodontics alone is notcapable of correcting the incisor relationship,or improving facial aesthetics. In these circum-stances close liaison with an oral and maxillo-facial surgeon will be required. An outline ofthe processes involved and the orthodontistsrole in orthognathic surgery has recently beenreviewed.4

Figure 7 shows an example of a patient with aClass III skeletal pattern. There has been somedento-alveolar compensation with the lowerincisors retroclined and the upper incisors pro-clined in an attempt to make incisal contact.There is no scope for correcting the incisor rela-tionship further with orthodontics alone. A com-bined orthodontic/surgical protocol was estab-lished and the patient started treatment withfixed appliances, in order to decompensate theincisors. This made the incisor relationship andthe facial profile worse. Clearly, patients need to

Fig. 4a Thepresence of asupernumerarytooth preventedthe eruption of theupper centralincisors

Fig. 4b Thesupernumerary wassurgically removedand brackets bondedto the upperincisors. A modifiedtrans-palatal barwith wire ligatureswas used to extrudethe teeth

Fig. 4c Once theteeth weresuccessfullyextruded thedentition wasallowed to developprior tocomprehensivetreatment in thepermanentdentition

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Fig. 6a The patient complained that her teeth had moved andwere getting worse. She had extensive periodontal diseasethat needed addressing prior to any orthodontic treatment

Fig. 6c A dark triangle between the anterior teeth is acommon complication of treatment in adults. This is becausethe inter-dental papilla fails to regenerate

Fig. 6d Inter-proximal reduction (slenderizarition) of thecontact points helped to substantially reduce the gap andimprove the aesthetics

Fig. 6b Fixed appliances were then used to realign the teeth

Fig. 5a Both the upper central incisors had been badlydamaged after a fall

Fig. 5c The teeth were extracted and two lower premolarstransplanted into the extraction sites. The teeth were thenaligned with fixed appliances

Fig. 5d At the completion of fixed appliance treatmentveneers were placed on the transplanted teeth

Fig. 5b A peri-apicalradiograph indicatedthat the teeth had ahopeless prognosis

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Fig. 7a-d Pre-treatmentphotographs of a patient with aClass III incisor relationship andskeletal pattern. The problem isbeyond the scope oforthodontics alone because ofthe skeletal discrepancy

Fig. 7f-i The completed case

Fig. 7e Fixed appliances were used to decompensate theincisors and co-ordinate the arches prior to bi-maxillaryorthognathic surgery

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be advised of this prior to the commencement oftreatment. Once the incisors are decompensatedand the arches co-ordinated the patient is readyfor surgery. The maxilla was advanced 7 mmand the mandible set back by 6 mm, producingan overall change of 13 mm in the skeletal rela-tionship. In addition, because the patient had afacial asymmetry, the mandible was rotated inorder to correct this.

As dentistry becomes increasingly sophisti-cated with more treatment options availablethan ever before, no single specialty in dentistrycan work alone to provide the full range of treat-ment options. Some of the most interestingaspects of orthodontic treatment come from

working in a combined approach with one’s col-leagues and it is important to recognize andrespect the skills of other disciplines. Work ofthis nature can be amongst the most satisfyingboth for the clinician and the patient.

The authors thank Paul Cook for the use of figures 5(a-d)

1. Andreasen J O, Andreasen F. Textbook and color atlas oftraumatic injuries to the teeth. 3rd ed. pp671-690.Munksgaard, Copenhagen: Mosby, 1994.

2. Davies S J, Gray R M J, Sandler P J, O'Brien K D O.Orthodontics and occlusion. Br Dent J 2001; 191: 539-549.

3. Kim Y H. Anterior openbite and its treatment with multiloopedgewise archwire. Angle Orthod 1987; 57: 290-321.

4. Sandy J R, Irvine G H, Leach A. Update on orthognathicsurgery. Dent Update 2001; 28: 337-345.

Fig. 8a,b A right-sided cross bite has produced substantialocclusal wear. This would be impossible to correctrestoratively with this occlusion

Fig. 8c An upper fixed appliance with a quad helix was usedto expand the upper arch, correct the incisor relationship andalign the teeth

Fig. 8d At the completion of orthodontic treatmentthe teeth were restored with composite

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part 12 combined orthodontic treatment

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