LINGUAL ORTHODONTICS IN A MULTIDISCIPLINARY PRACTICE - GINGIVAL MARGIN LEVELING

Laura Frost, D.D.S

 www.lingualnews.com Vol 4 No 2 September 2006

 Abstract

Multidisciplinary practices are involved mainly with adult patients that are looking for aesthetic solution to their smile.
As discussed by many authors, adults patients may present with various different aspects in their malocclusion that can make treatment troublesome such as abraded anterior teeth, failing restorations, crown-length discrepancies, uneven gingival levels, bone loss, tissue recession, bone loss (1).

Adults will generally accept orthodontic treatment when they are presented with the option of hidden braces. That is why lingual orthodontics came as a perfect partner in the interdisciplinary treatment of adults.

Levelling of gingival margins, up righting of molars and creating adequate space for implant placement are among the most required items when it comes to treatment plan in our practice.

This article will present two cases of how levelling of the gingival line helps in creating an aesthetic and natural looking smile prior to the placement of definitive crowns.

Case 1

A 37 year-old patient came to us complaining that her right central incisor crown appeared longer than the adjacent upper left central incisor (fig1). Looking at the gingival level of that tooth we can see an excess of cement in the apical region, as well as the uneven gingival margins.

Fig 1: Case 1, upper right central incisor longer the the left one, excess of cement in the gingival margin

Fig. 2: Evaluation of the gingival margins after placement of a well fitted temporary crown.

Fig. 3: Special instructions to the laboratory for bracket placement

Multidisciplinary treatment plan consisted in orthodontic extrusion of upper right central incisor (UR1)of 1,5mm to level the gum line followed by preparation and placement of new ceramic crown.

After placement of a well-fitted temporary crown we can evaluate the difference in the level of the gingival margins between UR1 and UL1 (fig2)

Lingual orthodontics was the choice of treatment in this case. As we knew how much we wanted to extrude the UR1, special instructions were sent to the laboratory to place the UR1 bracket 1,5 mm lower than UL1 in order to make it still possible to work with a straight wire in the anterior area (fig3).

Fig 4: Initial wire was a 012 Niti archwire followed by 014 Niti and finishing with 016 Niti

Fig 5: Gingival margin leveling, 3 months into treatment

It took three months of treatment to get the gingival margin aligned and at the same time achieve a better alignment in the front area (fig 5, 6).
Fixed rention with Ribbond was planned for 3 months prior to the final restoration. A new temporary crown was fitted during that time. (Fig7)

Fig 6: Alignment , 3 months into treatment

Fig 7:Retention for 3 months prior to restoration

Case 2

A 58 year-old patient presented with uneven marginal levels after temporization of all 6 front teeth (fig 8). She had implants positioned in UR1 and UL2 (fig 9).

Muldisciplinary treatment plan consisted of orthodontic extrusion of UL1, UL3, UR 3 and intrusion of UL2 to level gingival margins (fig10) followed by final restorations with porcelain crowns. 

Fig 8: Case 2, uneven gingival margins after temporization of the six front teeth

Fig 9: Case 2, Implants positioned in UR1 and UL2

Fig 10:Treatment plan included extrusion of UL1, UL3, UR 3 and intrusion of UL2 to level gingival margins

As gingival margin follows a selective extruded tooth to about 80% of the distance it is moved (2), brackets were positioned in a planned way to allow good result and at the same time, allow the use of straight wire segment in the front area. The brackets were prepared for indirect bonding on the cast in a in-office simplified approach as described by Scusso and Takemoto.

We started treatment using 012 Niti (fig 11) followed by 014 and 016 Niti.
Recontouring of the temporary crown was necessary during treatment to maintain aesthetics. After 7 months final result was achieved (fig12, 13) and the gingival margins now show a more harmonious line. Patient was ready to move on to definitive crowns (fig14).

Fig 11: Initial archnwire was 012 Niti, followed by 014 and 016 Niti

Fig 12: Frontal view after 7 months, at the end of orthodontic phase

Fig 13: Frontal view after 7 months, at the end of orthodontic phase

Fig 14: Retention of orthodontic results, patient was ready to move on to definitive crowns

Conclusions

In multidiscilpinary treatment, gingival margin levelling with Lingual Orthodontics can help in achieving a more natural looking smile, specially in cases that require either single or multiple crown work.

References

1. Kokich,Vincent G. Adult orthodontics in the 21st century: guidelines for achieving successful results. World Journal of Orthodontics: 2005, vol 6:14-23.

2. Kajiyama K, Murakami T, Yokota S. Gingival reactions after experimentally induced extrusion of the upper incisors in monkeys. Am J Orthod Dentofacial Orhtop 1993;104:36-47.

3. Zachrisson B., Toreskog S., Missing Maxillary Central Incisors: Interdisciplinary Approach with Orthodontic Space Closure, Autotransplantation of Premolars, and Single-Tooth Implants. in: Romano R. The art of the smile, 2005 Quintessence Publications Data. 2006

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Adult and Lingual Orthodontics
EDITORS:
Dr. Silvia Geron D.M.D., M.Sc
Dr. Rafi Romano D.M.D., M.Sc
Dr. Pablo Echarri D.M.D., M.Sc