Good

Morning

Ortho-Endo-Prostho
Relationship

DR. ASHISH DABAS

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
Golden proportion
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

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
Maxillofacial prosthesis
Clinical cases
Conclusion
Reference

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.

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.

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

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

 Orthodontics (AAO) is defined as the area of dentistry

concerned with supervision, guidance and correction of the
growing and mature dentofacial structures, including those
conditions that require movement of teeth or corrections of
malrelationships and malformations of related structures
by the adjustment of relationships between and among
teeth and facial bones by the application of forces and / or
the stimulation and the redirection of the fundamental
forces within the craniofacial complex.

15

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.

16

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

17

III. Itral
A.

Cavity Preparation
1.
2.

B.

Restoration
1.
2.

C.
D.
E.
F.
G.
H.

Heat of preparation
Depth of preparation
Insertion
Fracture

Intentional extirpation
Orthodontic movement
Periodontal curettage
Electrosurgery
Laser burn
Periradicular curettage
18

IV. Chemical
A.

Restorative materials
1.
2.
3.
4.

Cements
Etching agents
Cavity liners
Dentin bonding agents

19

B.

Disinfectants
1.

C.

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

20

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.

21

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.

22

EFFECT OF ORTHODONTICS ON THE

TOOTH BEING MOVED

23

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.

24

Effect of orthodontics on vital

and
non vital teeth

25

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.
26

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.

27

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.

28

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.

29

Orthodontics as the Etiologic

Agent for Endodontics

30

Some teeth require endodontic

treatment

as

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.

31

ORTHODONTIC FACTORS ASSOCIATED WITH

NON VITALITY OF TEETH

32

TYPE OF MALOCCLUSION :

Among different malocclusions, based on Angles

classification system, studies have observed a statistically
significant difference between class I and class II div 1
malocclusion, with the latter exhibiting more resorption.

33

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.

34

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.

35

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.

36

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.

37

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.

38

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.

39

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.

40

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.

41

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.

42

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.

43

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.

44

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.

45

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.

46

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.

47

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.
48

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.

49

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.
50

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.

51

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.

52

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.
53

RESORPTIVE DEFECTS

54

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.
55

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.

56

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.

57

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.

58

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.
59

ENDO TREATMENT
AFTER
ORTHODONTICS

60

One observation can be made in

teeth needing endodontic therapy that had
previously received orthodontic movement
that there is a high percentage of overfills.
The cause of these overextensions
can be related to the orthodontic treatment
because the root end has been blunted by
resorption.
61

Therefore working length should

be shortened when such teeth are
being treated, and the customized
master cone technique should be
employed wherever possible.

62

ENDO TREATMENT
DURING
ORTHODONTICS

63

Problem can be faced here because of the conduction

potential of the bands and archwires, electric pulp testing is
impossible.
Test cavity preparation is available,but it is difficult to
drill into these teeth, which generally are noncarious and
unrestored yet have large pulps without absolute certainty that a
necrotic pulp is present.

64

Apical and lateral radiolucencies and root resorption,

which are common findings when endodontic therapy is
needed, are found in these cases incident to orthodontics and
do not necessarily indicate pulp damage. Evaluation of these
is most complicated and confusing.

65

Even when a correct decision is made in determination

of therapy, some postoperative films may indicate the opposite.
It is extremely important to keep these patients under close
supervision until complete healing is verified or further
treatment is indicated.

66

BOLTONS RATIO

67

 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.
68

Sum of mandibular 12
The mesiodistal width of all teeth mesial to mandibular
second permanent molar is measured and summed up.
Sum of maxillary 12
The mesiodistal width of all teeth mesial to maxillary second
permanent molar is measured and summed up.
Sum of mandibular 6
The mesiodistal width of all teeth mesial to mandibular first
premolar is measured and summed up.
Sum of maxillary 6
The mesiodistal width of all teeth mesial to maxillary first
premolar is measured and summed up.
69

Over all ratio =

Sum of mandibular 12 x 100

Sum of maxillary 12

If overall ratio is less than 91.3%, it indicates maxillary tooth

material excess.
If overall ratio is more than 91.3%, it indicates mandibular
tooth material excess.

70

Anterior ratio =

Sum of mandibular 6 x 100

Sum of maxillary 6

If anterior ratio is less than 77.2%, it indicates maxillary

anterior excess.
If anterior ratio is more than 77.2%, it indicates mandibular
anterior excess.

71

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.

72

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.

73

Sowmya G.S.

17 years

Female

74

All 5 Extraction Begg

75

Sowmya G.S.

Post Treatment

76

Begg Retainer

77

After 1 year

After Buildup

78

GOLDEN PROPORTION

79

Philosophers and mathematicians have always been

fascinated by the relationship between mathematics and nature.
The Ancient Greek philosopher Pythagorus defined Golden
Proportion, which explain beauty in nature as it relates to the
science of numbers.

80

GOLDEN RATIO
A

B
B

AB

AC

= 1.618
81

This ratio is called Golden ratio.

The concept of golden ratio is of historical importance in

aesthetics, art, and architecture.

It has often been thought that a form, including the human

form ,is most pleasing when its parts are divided in golden
sections.

82

Golden proportion in Dentistry :

The application of golden
proportion to dental esthetics was
first written about in 1978. Those
humble beginnings have sown the
seeds of a proliferation of Golden
Proportion studies undertaken in
four main directions.
Prosthodontic
Surgical
Orthodontic
Restorative dentistry.

83

Winston Senior, an
eminent
orthodontist
in
Manchester, UK was the first
orthodontist to appreciate the
application of the Golden
Proportion to orthodontics. It
is with thanks to his
enthusiastic lectures and case
reports
that
so
many
orthodontists have taken a
strong interest in the
application of the Golden
Proportion.
84

Dr. Mc. Arthur 1985 wrote an

article maxillary and mandibular teeth
widths in which he explained the
average ratio of upper central incisor to
lower central incisor is 1.62.
Dr.

Stephen

Marquardt,

an

eminent Oral surgeon in California,

discovered that, The Height of the
central incisor is in Golden Proportion
to the width of two central incisors.
85

The Golden Proportion is considered a starting point

in designing the relative width of teeth in a beautiful smile.

86

Typically the presence or absence of the Golden Proportion

within a smile is evaluated by measuring the anterior teeth
from the frontal aspect.

So when viewed from front ,if the tooth arrangement has to be

in golden proportion ,the ratio between the perceived width of
the maxillary anterior teeth would be

87

Nataraj

27 Years

Male

88

Space distribution according to Golden Proportion

89

Golden Proportion done with Photoshop software

90

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.

91

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.

92

Endodontic therapy in conjunction with eruption permits

placement of a restoration that fulfills the periodontal and
occlusal requirements of the tooth.
Forced orthodontic

eruption, in conjunction with

endodontic, periodontal, and restorative therapy, is an alternative.

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

93

BASIC PERIODONTAL PRINCIPLES FOR

FORCED ERUPTION

94

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.

95

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.

96

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

97

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.

98

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.

99

BASIC ENDODONTIC PRINCIPLES FOR

FORCED ERUPTION

100

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.

101

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.

102

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.

103

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.

104

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.

105

A, Before orthodontics, maxillary first A

bicuspid has a deep distal infrabony
pocket.

B, After 4 weeks of orthodontic

movement. Pulp was extirpated, and a C
temporary filling placed.

C, Continued eruption with contiguous

occlusal adjustment.
D. Final view
E, Five years after original treatment,
normal bone appearance has been
maintained.

106

BASIC ORTHODONTIC PRINCIPLES

FOR
TOOTH MOVEMENT

107

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.

108

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.

109

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.

110

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.

111

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.

112

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.

113

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.

114

A, Preoperative view of a mandibular cuspid

with

advanced

caries

extending

to

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

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

position of the soft tissue relative to the

adjacent crowns.

115

Forced Eruption

116

 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

117

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.

118

Tooth having an intact clinical crown :

A direct bond bracket or orthodontic band is placed as far

apical as is permissible.

119

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.

120

ORTHO PROSTHO - RELATIONSHIP

121

INTRODUCTION

122

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
123

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.

124

Removable prosthodontics pertains to the replacement of

missing teeth and contiguous oral structures with artificial
substitutes that are readily removable.

125

Maxillofacial prosthetics pertains to the restoration of

developmental or acquired defects of the stomatognathic
system and associated facial structures with artificial
substitutes.

Fitzgibbon(1923)

126

WHY REPLACE A MISSING BACK

TOOTH?

127

If you fail to replace an extracted back tooth with a false

tooth, you could lose all of your teeth..

128

Each tooth consists of two parts : the crown and the root (s).

Only the crown is visible in the mouth. The roots are in the
bone, under the gums.
129

The gums are a protective type of skin that clings to the necks
of the teeth and covers the bone holding the teeth.

Molars are back teeth. They have two or three roots. Most
other teeth have one root.
130

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.
131

A SERIES OF PROBLEMS
BEGINS

132

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.

133

 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.
134

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
space between these teeth (arrow).
135

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
of a tooth, as we will see later.
136

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.
137

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.
138

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
debris and bacteria.
139

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.

140

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
to disappear.
141

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.

142

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.
143

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.

144

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.

145

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 that it is now loose and must be extracted.146

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.
147

Food jams between the separated teeth (arrows). Gum

inflammation has begun. Gum pockets will follow, along with
bone loss and decay. Eventually the 5s will have to be extracted
148

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.

149

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.

150

INTRODUCTION
TO
FIXED PARTIAL DENTURES

151

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.

152

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.
Patients preference
Mentally compromised and physically handicapped patients who
cannot maintain the removable prosthesis.

153

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.
154

 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.

155

PARTS OF A FIXED PARTIAL DENTURE

156

RETAINER :
Retainer in a fixed partial denture is defined as, the part of
a fixed partial denture which unites the abutment(s) to the
remainder of the restoration.

157

TYPES OF RETAINERS :
Retainers in fixed partial dentures can be broadly
classified as :
Based on tooth coverage :
Full veneer crowns
Partial veneer crowns
Conservative (minimal preparation) retainers

158

Based on the material being used :

All metal retainers

Metal ceramic retainers

All ceramic retainers

All acrylic retainers

159

Pontic :
An artificial tooth on a fixed partial denture that replaces
a missing tooth, restores its functions and usually fills the space
previously filled by a natural crown.

160

IDEAL REQUIREMENTS OF A PONTIC :

A pontic should fulfill the following ideal requirements.
It should restore the function of the tooth it replaces
It should provide good aesthetics
It should be comfortable to the patient
It should be biocompatible. It should not impinge on the
tissues or produce any kind of tissue reaction.
It should permit effective oral hygiene. It should be easy to
clean and easy to maintain.
It should preserve underlying mucosa and bone. It should not
produce any ulceration in the mucosa. It should not produce
resorption of the residual alveolar ridge.
161

FACTORS AFFECTING THE DESIGN OF A PONTIC :

The major factors that determine the design of a pontic are :
Space available for the placement of the pontic.
The contour of the residual alveolar ridge.
Amount of occlusal load that is anticipated for that patient.

162

CONNECTOR :
Connector in a fixed partial denture can be defined as, The
portion of a fixed partial denture that unites the retainer and
pontic.
C

163

Connectors can be broadly classified as :

Rigid connectors

Non-rigid connectors

Rigid connectors are immovable attachments between the

pontic and retainer. Example : Solder joints.
Non-rigid connectors are movable attachments with a keykeyway mechanism. Example : Precision attachments (stress
breakers).
164

ABUTMENT :
An abutment can be defined as A tooth, a portion of a
tooth or that portion of an implant used for the support of a fixed or
removable prosthesis.

165

Healthy / Ideal abutments :

An unrestored vital tooth in its normal anatomic position is

considered as an ideal abutment.

Adequate tooth structure should be present to develop retention

and resistance forms.

166

An ideal abutment should have the following characteristics :

Ideal crown root ratio.

Adequate thickness of enamel and dentin.

Adequate bone support

Absence of periodontal disease

Proper gingival contour

167

TYPES OF ABUTMENT

168

Cantilever abutments :

The selection of a cantilever abutment is more critical because

this prosthesis is going to face / withstand more than normal
forces.

169

Pier abutments :
A pier abutment is a single tooth with two adjacent
edentulous spaces on either side. In this case, the single tooth
will have to act as an abutment for both the edentulous spaces.

170

Since a single abutment supports two edentulous spaces, it

will be subjected to unbalanced forces, which can lead to
trauma of the periodontium.

171

Tilted abutments :
When

tilted

tooth

is

chosen as an abutment, obtaining a

single path of insertion is difficult.
Certain

biomechanical

considerations like path of insertion

and stress distribution play an
important role in the construction of
the prosthesis.
Tilted
generally

abutments

avoided

due

are
to

the

complex design involved in the

fabrication of the prosthesis.

172

TYPES OF FIXED PARTIAL DENTURE

173

CONVENTIONAL FIXED PARTIAL DENTURES :

They are the most commonly used type of fixed partial
dentures. The design involves fabrication of a fixed partial
denture, which takes support from abutments on either side of
the edentulous space. The design may vary according to the
condition of the abutments but the abutments on either side
should be able to support the fixed partial denture.

174

CANTILEVER FIXED PARTIAL DENTURES :

A cantilever fixed partial denture is used when support can
be obtained only from one side of the edentulous space. The
abutment teeth on the supporting side should be strong enough to
withstand the additional torsional forces. Support can be obtained
from more than one tooth on the same side of the edentulous space.

175

Advantages :
Very conservative design especially when a single abutment
is involved.
When secondary abutments are used, parallel preparation can
be easily obtained because the abutments are adjacent to one
another.
Easy to fabricate.

176

Disadvantages :
Produces torquing forces on the abutment
Cannot be used to restore long span edentulous spaces
Minor design errors can affect the abutments in a large scale.

177

SPRING CANTILEVER FIXED PARTIAL DENTURES :

This is a special cantilever bridge exclusively designed
for replacing maxillary incisors but these dentures can support
only a single pontic.
A long resilient bar connector is used to connect the
posterior retainer to the anterior pontic.

178

Advantages :
Can be used for diastema cases.
Metal crown retainers that require minimal tooth preparation,
can be used in posterior teeth to replace missing incisors.

179

Disadvantages :

The connector bar may interfere with speech and mastication.

Deformation of the connector bar may produce coronal

displacement of the pontic.

There may be food entrapment under the connector bar, which

may lead to tissue hyperplasia.

180

FIXED FIXED PARTIAL DENTURES :

The term denotes fixed partial dentures with rigid
connectors. The design of these dentures is more conventional.
Since the connectors are rigid, there can be no movement
between the connected components. These are the most
commonly used fixed partial denture designs.

181

Advantages :
The major advantages of these partial dentures include :
Easy to fabricate
Economical design
Strong
Easy to maintain
Robust design provides maximum retention and strength
Helps to splint mobile abutments
Can be used for long bridges along with periodontally weak
abutments.
182

Disadvantages :
Since the connectors are rigid, unwanted stress and lever
forces are directly transferred to the abutment producing
considerable damage.
Requires excessive tooth preparation to achieve a single path
of placement.
Difficult to cement on multiple abutments.
Contraindicated for pier abutments.

183

VENEERS :

Veneer is a layer of restoration placed over the labial surface of

a tooth. They are primarily used as aesthetic adjuncts to
discolored or fractured teeth.

184

Type of 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.
185

SHORT SPAN BRIDGES :

These are simple fixed partial dentures, which replace one or

two teeth, and the teeth on either side are ideal abutments.
These dentures are considered ideal because they have
minimal

torquing

forces.

For

example

first

molar

replacement.

A short span 3- unit FPD

186

LONG SPAN BRIDGES :

Long span bridge denotes a condition where two or more teeth

have to be replaced and more than one abutment has to be
taken for support on either side.

Long span bridges have the potential for producing more

torquing forces on the bridge and the weaker abutment
(especially weak abutments are adversely affected).

Long span FPD replacing more than one tooth

187

RESIN-BONDED FIXED PARTIAL DENTURES :

As the name implies, these are fixed partial dentures,

which are cemented onto the abutments using special
resins.

188

Types of resin bonded Fixed Partial Denture :

Based on the technique used to finish the tissue surface of the
retainer, resin bonded fixed partial dentures can be classified as

Rochette bridge

Maryland bridge

Cast mesh FPD

189

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.

190

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

191

to be continued

192

193

Ortho-Endo-Prostho
Relationship

DR. ASHISH DABAS

194

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 ?
Lateral incisors
Forced eruption
Alignment of anterior teeth
195

 How to upright inclined molar in preparation for

restorative treatment ?
Orthodontic prosthodontic implant interaction
Prosthodontic consideration when using implants for
orthodontic anchorage
Maxillofacial prosthesis
Clinical cases
Conclusion
Reference
196

COMBINED ORTHO PROSTHO

THERAPY

197

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.
198

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.

199

Although one should always aim to achieve these ideal

goals,treatment goals with acceptable degrees of compromise
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.

200

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.

201

 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 202

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 patients 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.

203

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.

204

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.

205

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.
206

MISSING TEETH : SPACE CLOSURE VS.

PROSTHETIC REPLACEMENT

Space closure

Molar Uprighting 207

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.

208

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.
209

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.
210

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.

211

The mesial tipping of the second molar into the edentulous

space may contribute to the periodontal involvement on the
mesial aspect of this tooth, the adjacent gingival tissue
becomes folded and distorted, forming a plaque-harboring
pseudopocket that may be virtually impossible for the patient
to clean.

212

This may result in the supraeruption of the antagonist teeth

partway into the edentulous space and needs to be addressed
during treatment to ensure an optimal long-term prognosis of
any proposed correction.

213

Simultaneously, distal drifting associated with tipping and

rotation of the premolars may be observed along with a
midline displacement toward the side of the missing molar.

Careful evaluation of the clinical situation should be done

to decide on space regaining or space closure.

214

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.
215

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.
216

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.
217

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.

218

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.
219

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.

220

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.

221

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.

222

LATERAL INCISORS

223

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 224

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.

225

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.

226

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.

227

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.
228

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.
229

FORCED ERUPTION

230

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

Vertical periodontal defect

231

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.

232

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.

233

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.
234

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:

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

235

TREATMENT PLANNING

236

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.
237

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.

238

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.
239

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.

240

 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.

241

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.

242

Rumanna B.

18 years

Female

243

Pre Treatment

244

Surgically Exposed and forced eruption

245

Space distribution

246

Immediate post Treatment

247

Immediate Post Treatment

248

Post treatment after prosthesis

249

After prosthesis

250

Pre

Post

251

ALIGNMENT OF ANTERIOR TEETH

252

Indications :
The major indications for adjunctive orthodontic treatment
to correct malaligned anterior teeth are :
1.

To improve access and permit placement of well-adapted and

contoured restorations (e.g., when composite resin build-ups to
recontour incisors are planned, or when periodontallycompromised incisors must be splinted)

2. To permit placement of crowns and pontics without

overcontoured crowns that would produce poor embrasure
form.
253

To reposition closely approximated roots, to improve the

embrasure form and increase the amount of interradicular
bone, which in turn increases the chance that periodontal
disease can be controlled.

To position teeth so implants can be placed to support

restorations.

Rotations, crowding, spacing, tipped teeth, and crossbites all

pose problems for restorative and periodontal procedures.

254

TREATMENT PLANNING

255

Anterior

teeth

that

require

alignment should be brought into

their

proper

position

before

definitive restorative procedures.

A diagnostic setup is very helpful

in planning treatment for alignment
problems, particularly if crowding
or spacing must be corrected.
256

While slenderization of anterior teeth may be an excellent way

of gaining a small amount of space, such treatment should be
undertaken with caution since it may have an undesirable effect
on the esthetics, overbites, overjet, and posterior intercuspation.

Treatment of this type should never be undertaken without a

diagnostic setup to be sure that the teeth will fit satisfactorily.

257

Kousar Jan

17 years

Female

258

Pre Treatment

259

All 4 extraction PEA

260

Space distribution for FPD

261

Post Treatment

262

Post Treatment

263

Pre

Post

264

Pre

Post

265

HOW TO UPRIGHT INCLINED MOLAR

IN PREPARATION FOR RESTORATIVE
TREATMENT?

266

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.

267

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.
268

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.

269

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.

270

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.
271

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.

272

A. Orthodontic Classification :
Orthodontic

classification

involves

systematic

description of the interrelationships of the patients

a) Skeletal pattern,
b) Musculature, and
c) Dental arches and the tooth in the dental arch.
273

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.
274

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).
275

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.
276

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.

277

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.
278

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.
279

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.
280

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.

281

PERIODONTAL MANAGEMENT

282

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.
283

APPLIANCE DESIGN

284

A. Moderately mesially inclined molar with no distal

drifting of premolars :
1. Initial arch wire
The molar is tipped back into position.

285

2. Finishing arch wire

Rectangular arch wire for buccolingual control.

286

B. Moderately mesially inclined molar with distal drifting of

premolars :
1. Initial arch wire

287

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.

288

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.

289

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.

290

Manjula

18 years

Female

291

Pre Treatment

292

Marcotte Molar uprighting spring (0.017 x 0.025 TMA)

293

After molar uprightning

294

Post Treatment

295

Immediate Post Treatment

296

After Prosthesis

297

After prosthesis

298

ORTHODONIC PROSTHODONTIC
IMPLANT INTERACTION

299

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.

300

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.
Patients desire.
301

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.
302

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.

303

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.
304

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.

305

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.
306

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.

307

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.

308

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.

309

310

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.

311

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.

312

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.
313

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.

314

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.

315

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.

316

COMPREHENSIVE ORTHODONTICS
IN
PATIENTS PLANNED FOR IMPLANTS

317

If the decision for an individual patients is to replace missing

teeth rather than close spaces, the second important question
is how this is to be done.

The success of implants has rapidly made them a preferred

way to replace missing teeth.

For the orthodontist, the implant vs. bridge decision makes a

difference in how the teeth are positioned and in the
sequencing of treatment..

318

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.

319

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.

320

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.

321

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.

322

 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 patients vertical facial
height.
The implant is analogous to an ankylosed tooth.

323

PROSTHODONTIC
CONSIDERATIONS WHEN USING
IMPLANTS FOR ORTHODONTIC
ANCHORAGE

324

 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.
325

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.
326

 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.
327

 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.

328

 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.

329

 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.
330

MAXILLOFACIAL PROSTHESIS

331

Obturators :

An obturator can be defined as, A prosthesis used to close a

congenital or acquired tissue opening, primarily of the hard
palate and/or contiguous alveolar structures.

Prosthetic restoration of the defect often includes use of

surgical

obturator,

interim

obturator,

and

definitive

obturator.

332

Types of obturators :
Obturators can be classified :
Based on the phase of treatment
Based on the material used
Based on the area of restoration

333

BASED ON THE PHASE OF TREATMENT :

Surgical obturators :

It is defined as, A temporary prosthesis used to restore the

continuity of the hard plate immediately after surgery or
traumatic loss of a portion or all of the hard palate and/or
contiguous alveolar structures (ie., gingival tissue, teeth).

334

Interim obturators :

It is defined as, A prosthesis that is made several weeks or

months following the surgical resection of a portion of one or
both maxillae.

It frequently includes replacement of teeth in the defect area.

This prosthesis, when used, replaces the surgical obturator that

is placed immediately following the resection and may be
subsequently replaced with a definitive obturator.
335

Definitive obturators :

It is defined as, A prosthesis that artificially replaces part or

all of the maxilla and the associated teeth lost due to surgery
or trauma.

336

Based on the material used :

Based on the material used, obturators can be classified into :
Metal obturators
Resin obturators
Silicone obturators
Based on the area of restoration :
Palatal obturator
Meatal obturator
337

Palatal lift prosthesis :

It is a special type of obturator, which is a definitive prosthesis

with a posterior extension.

It is helpful in restoring palato-pharyngeal incompetence

where the soft palate musculature is compromised. It can be
clubbed with an obturator if needed.

338

Advantages :
Minimised gag response
Tongue physiology, swallowing, mastication and speech are
not compromised
Access to the nasopharynx for the obturator is facilitated
The palatal lift portion can be added later as desired

339

Contraindications :

If adequate retention is not available for the basic prosthesis

If the palate is not displaceable

Un-cooperative patients

340

A velo-pharyngeal
defect requiring palatal
lift prosthesis

Palatal lift prosthesis

used to restore a
physiological velopharyngeal
insufficiency

Palatal lift prosthesis

with an obturator to
restore an anatomical
velo-pharyngeal
insufficiency

341

Extra Oral Prosthesis

Ocular prosthesis

Nasal prosthesis

Auricular prosthesis
342

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.
343

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

344

 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
345

Thank You
346