|Year : 2022 | Volume
| Issue : 1 | Page : 26-31
Interdisciplinary orthodontic and prosthodontic approach for esthetic rehabilitation in an adult patient
Akshai Kannan1, Vaibhav Jain2, Merekha Raghavan3
1 Department of Orthodontics and Dentofacial Orthopaedics, INDC, Danteshwari, Mumbai, Maharashtra, India
2 Department of Prosthodontics and Crown & Bridge, INDC, Danteshwari, Mumbai, Maharashtra, India
3 Private Clinic, Mumbai, Maharashtra, India
|Date of Submission||25-Apr-2021|
|Date of Acceptance||13-Sep-2021|
|Date of Web Publication||30-Apr-2022|
Dr. Vaibhav Jain
INDC Danteshwari, RC Church Road, Mumbai - 400 005, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A 38-year-old female patient reported with a chief complaint of spacing between anterior teeth, and she desire to improve her facial esthetics. The patient was diagnosed with chronic generalized periodontitis with generalized horizontal bone loss on the basis of clinical and radiographic findings. On orthodontic evaluation, she has proclined upper and lower anterior with Class I molar relationship bilaterally and a canine Class I relationship bilaterally. She was treated with an interdisciplinary therapeutic protocol that included nonsurgical periodontal therapy, endodontic treatment, orthodontic therapy, and prosthetic rehabilitation. The orthodontic therapy was performed in generalized horizontal bone loss having loss of bone support in mandibular anterior region. Space closure was done using prosthetic rehabilitation in a healthy periodontium. The interdisciplinary treatment protocol was the key factor in achieving significant improvement in facial and dental esthetics, masticatory function, and quality of life of the patient.
Keywords: Adult orthodontics, esthetic rehabilitation, interdisciplinary orthodontics, interdisciplinary prosthodontics diastema closure, periodontitis
|How to cite this article:|
Kannan A, Jain V, Raghavan M. Interdisciplinary orthodontic and prosthodontic approach for esthetic rehabilitation in an adult patient. J Interdiscip Dentistry 2022;12:26-31
|How to cite this URL:|
Kannan A, Jain V, Raghavan M. Interdisciplinary orthodontic and prosthodontic approach for esthetic rehabilitation in an adult patient. J Interdiscip Dentistry [serial online] 2022 [cited 2022 Jul 3];12:26-31. Available from: https://www.jidonline.com/text.asp?2022/12/1/26/344461
| Clinical Relevance to Interdisciplinary Dentistry|| |
- Esthetic rehabilitation of the patient using interdisciplinary approach is need to get the acceptable outcome and good prognosis
- Adult patients are more prone to periodontal problems, hence before interdisciplinary approach for orthodontic and prosthodontic rehabilitation its mandatory for the patient to be periodontally stable
- On completion of the prosthetic rehabilitation and orthodontic treatment, the patient should undergo periodontal review every 6 months to prevent reinfection and recurrence and to maintain the successful results obtained through the multidisciplinary approach.
| Introduction|| |
Esthetic rehabilitation is a challenging option in adult patients due to the interdisciplinary dependence. Such patients must be identified before starting treatment and informed regarding the duration and periodontal risks of the orthodontic and prosthodontic therapy., The risk factors commonly associated with periodontal disease and gingival lesions include smoking, poor oral hygiene, stress, hormonal changes, systemic diseases, familial history of periodontal disease, allergic reactions, and occlusal trauma. Periodontitis is usually asymptomatic and if it is not treated will eventually lead to tooth loss.,
| Case Report|| |
Diagnosis and etiology
A female patient, aged 38 years, was referred to the orthodontic department by the treating periodontist. Her chief complaint was spacing between the upper and lower front teeth and she wanted to improve her facial esthetics [Figure 1].
The treating periodontist had diagnosed the patient with chronic generalized periodontitis with generalized horizontal bone loss on the basis of clinical and radiographic findings. Grade III mobility with 31, 41. Generalized moderate periodontal pockets, bleeding on probing, and Grade I mobility with the upper anteriors 21, 11, 22, and 12 were also reported.
The extraoral photographs showed excessive protrusion of the lower lip. Intraoral photographs showed pathological migration of mandibular and maxillary anterior teeth with large gaps between the upper and lower incisors resulting from poor periodontal support. She had proclined upper and lower anterior with Class I molar relationship bilaterally and a canine Class I relationship bilaterally with an overjet of 6.0 mm and an open bite of 3.0 mm [Figure 1]. The radiographs [Figure 2] showed generalized horizontal bone loss with bone loss in the mandibular central incisors extending up to the apical third. The cephalogram showed increased proclination of upper and lower anteriors.
Treatment objectives and plan
Eliminate periodontal pockets and to prevent subsequent bone loss, the teeth with bone loss till middle 3rd (teeth 32 and 42) of the root was retained as to use as a abutment and prevent further bone loss after extraction of these teeth to undergo further orthodontic treatment.
Endodontic rehabilitation of 32, 33, 42, and 43 which will serve as abutments to replace missing 31 and 41.
First, the teeth need to be aligned and leveled, followed by the closure of the spaces and the protrusion of the maxillary and mandibular anterior teeth is to be reduced. Thereafter, we achieve a Class I canine and molar relationship along with an ideal overjet and overbite.
Extraction of 31, 41 having poor periodontal prognosis followed by prosthetic rehabilitation of 31, 41 through a fixed partial denture spanning from 33 to 43 including 42 and 32 also as abutments. The treatment of implant-supported prosthesis was eliminated as it can be seen clinically and radiographically that there is a Seibert's Class III defect which requires further surgical protocol to rehabilitate using implant-supported prosthesis.
At the onset of treatment, the patient was referred for endodontic procedures in 32, 42, 33, and 43. The patient also had to undergo a 3-month periodontal recall schedule during the course of orthodontic therapy to maintain periodontal disease control and emphasize oral hygiene instructions.
Treatment was initiated with a standard edgewise appliance with a 0.018 × 0.025 in the slot. Light forces and good control of tooth movement to limit stress on reduced periodontal support in the maxillary and mandibular anteriors were applied. A sequence of archwires was used in the maxillary and mandibular arch to perform alignment and leveling. First, 0.016 in and 0.014 in NiTi, respectively [Figure 3], thereafter 0.016 × 0.22 in NiTi was used. Space closure in the maxillary anterior teeth was performed with a 0.016 × 0.022 in TMA with open vertical loops in maxilla and modified omega loop in lower to close the lower anterior space [Figure 4]. The force was verified, and adjustments of the archwire were performed to maintain torque control and bodily movement of the maxillary and mandibular anterior teeth. Anterior retraction was performed over 8 months. The same sequence of archwires was also used in the mandibular arch [Figure 5].
|Figure 5: Treatment progress (spaces consolidated 20 months since start)|
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After retraction was achieved, the extraction of both 31, 41 was carried out and the space was maintained by 0.17 × 0.25 SS wire with passive open coil spring [Figure 6]. Healing of the extraction site was reviewed after 4 weeks and the patient was referred to prosthodontist for further management. After prosthetic rehabilitation, the appliance was removed and a removable Essix retainer was placed in the maxillary and mandibular arch. Periodontal recall schedule was maintained every 3 − 6 months.
|Figure 6: Treatment progress (extraction of 31, 41, and space maintenance)|
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After the orthodontic phase, the patient was assessed for prosthetic rehabilitation of the mandibular anterior region. Intraoral examination reveals missing 31, 41 and reduced amount of diastema in the maxillary and mandibular anterior region. On local examination of 31, 41 area, both horizontal and vertical amount of bone loss was found which and denotes Seibert's Class III defect [Figure 7]. The treatment plan was formulated to rehabilitate using full coverage PFM fixed dental prosthesis using 32, 42, 33, and 43 as abutment for replacing 31, 41 as pontic, to restore the alveolar ridge defect gingival porcelain was used. First, teeth preparation was done for full coverage PFM crown for 32, 33, 42, and 43, and impression was made using double-phase putty-wash impression technique (3M ESPE). Shade selection was done and provisional crown with 31, 41 as pontic was luted using noneugenol temporary luting cement. The impression was poured using Type III dental stone and full-coverage PFM-fixed dental prosthesis was fabricated involving gingival porcelain over 31, 41 to close the alveolar ridge defect. After fabrication of fibrin degradation product (FDP), the patient was recalled and FDP was luted using permanent luting cement (GC FUJI I), after completion of treatment postinsertion instruction was given and occlusion was checked. After prosthetic rehabilitation, the patient was referred to the orthodontist for review and further management.
|Figure 7: Treatment progress (orthodontic phase completion and evaluation for prosthetic rehabilitation)|
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| Treatment Results|| |
The profile of the patient had significantly improved with reduced dental protrusion and competent lips. The maxillary and mandibular anterior teeth which had pathologically migrated were intruded and uprighted. A normal overjet and overbite were achieved. A Class I canine relationship bilaterally and a Class I molar relationship bilaterally were obtained [Figure 8],[Figure 9],[Figure 10],[Figure 11]. The patient was observed for 10 months, and the results were found to be stable. The total duration of treatment is around 15 months which includes interdisciplinary approach and regular follow-up was done after the completion of treatment. Periodontal status was also stable according to the treating periodontist.
| Discussion|| |
Adult patients are more prone to periodontal problems; hence, risk factors must be identified before starting interdisciplinary approach for orthodontic and prosthodontic rehabilitation. The American Board of Orthodontics recommends at least one of the following procedures before beginning orthodontic treatment in these patients: (1) full mouth periodontal probing to detect gingival bleeding during probing, (2) written documentation certifying the periodontal treatment of the patient, (3) pretreatment panoramic with bitewings and periapical radiographs, and (4) full mouth periapical and bitewings radiographs.,,
Apart from the improvement in dentofacial esthetics, interdisciplinary approach also provides several benefits such as improvement of osteogenic formation (this sometimes improves bony defects), and reestablishment of the occlusal plane, which eliminates occlusal trauma that together with periodontal disease leads to rapid destruction of periodontal tissues. Crowding may be a predisposing factor for periodontal disease as it is difficult to maintain oral hygiene. Orthodontic alignment would facilitate oral hygiene, but studies correlating malocclusion to periodontal disease are minimal.,,,
The benefits of interdisciplinary approach for periodontal patients are questioned as it can instead exacerbate the condition., In the present case report as a result of the orthodontic treatment, the patient improved her dentofacial esthetics, periodontal health, and masticatory functions. The spaces from missing teeth 31, 41 were properly distributed for adequate prosthetic rehabilitation.
At the beginning due to pathologic migration, the patient had flared incisors and diastemas palatal pockets are often present in pathologically flared incisors, so the retraction of these teeth must have an intrusion component to improve insertion. In this case, open vertical loops in maxilla and modified omega loop in mandible were inserted in the archwire to obtain closure of spaces as retraction movements have an extrusive tendency. Buccolingual movements were avoided as it is riskier and potentially harmful and undesirable in periodontally compromised cases., Hence, activation was performed every month to enable bodily tooth movement.
In periodontally stable cases, controlled orthodontic treatment does not appear to increase or activate the disease; although this requires patient co-operation and commitment. In the above discussed case, the patient regularly maintained her periodontal treatment appointments before scheduling the orthodontic treatment and prosthetic rehabilitation. She also went for the 3 monthly follow-up according to the schedule.
Continuous light forces were used to move the teeth because the center of resistance is located more apically due to bone loss as a result of compromised periodontal status. This would enable more physiological frontal bone resorption, and therefore, to a quicker tooth movement. High forces potentially interfere with the remodeling process., This must be specially recalled because the aplastic cortical bone of adults normally shows delayed bone formation and regeneration. A sequence of wires was followed, and TMA wire was used for space closure followed by stainless-steel wires that were initially placed passively and slowly rectified at each appointment. Thus, providing better control and avoiding the release of high-intensity forces.
Permanent retention is advisable; however, after removing the appliance, essix retainers were used on the insistence of the patient, the patient was advised oral hygiene measures and the maintenance of the retainer.
Interdisciplinary orthodontic and prosthodontic treatment of a periodontal patient with pathologic tooth migration is effective if there is multidisciplinary cooperation which deters aggravation of periodontitis and occlusal trauma. The improvement of facial esthetics contributed to the self-confidence of an adult periodontal patient with pathologic tooth migration.
It is mandatory to have periodontal disease control before, during, and after orthodontic treatment and prosthetic rehabilitation of adult patients with periodontal disease/condition. On completion of the prosthetic rehabilitation and orthodontic treatment, the patient should undergo periodontal review every 6 months to prevent reinfection and recurrence and to maintain the successful results obtained through the multidisciplinary approach.
| Conclusion|| |
This case report highlights the fact that in an adult patient, interdisciplinary treatment approach is possible with reduced bone support and pathological tooth migration provided adequate periodontal disease control is achieved and maintained throughout the treatment period and thereafter. A holistic multidisciplinary approach is a key to improve the restoration of function, esthetics, and quality of life in adult patients. Thus, happy patients result in happy smile.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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