Incisivi Laterali Maxilari Lipsă, PROCEDURI SI INDICATII OPTIME PENTRU INCHIDEREA SPATIULUI CU LUCRSTE PROTETICA PTIN TRATAMENT ORTODONTIC

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CHAPTER 25
c00025 Missing Maxillary Lateral Incisors: New
Procedures and Indications for Optimal
Space Closure
Marco Rosa and Bjørn U. Zachrisson
T
he maxillary lateral incisor is the second most Another drawback of the space reopening alternative for p0025
common congenitally absent tooth. There are three a teenage patient is that several years must elapse between
p0010 treatment options to replace missing lateral incisors: completion of orthodontic treatment and implant place-
canine substitution,1–8 a single-tooth implant,9–11 or a tooth- ment. After successful orthodontic opening of the implant
supported restoration.12 space, the central incisor and canine roots may reapproxi-
p0015 Available evidence indicates that proper orthodontic mate during retention and prevent implant placement. Olsen
space closure is well accepted by patients, does not produce and Kokich32 have reported that retreatment and orthodon-
a major risk for temporomandibular joint disorder (TMD) tic space reopening was needed in 11% of their patients. At
problems, and from a periodontal standpoint is safer than this stage of treatment, related problems and questions arise,
prosthetic replacements.13–15 such as:
p0020 The advent of osseointegrated implants decreased the • What is the optimal retention device? u0010
popularity of the space closure alternative among many • Will a temporary resin-bonded bridge be esthetically u0015
orthodontists and referring dentists and the implant substi- acceptable?
tution became their first option. Although it may appear • How long must we wait to place the implants? u0020
preferable from an esthetic and functional point of view to • Will the newly regenerated alveolar bone undergo u0025
create space to replace the missing lateral incisor with a atrophy?
single-tooth implant crown, recent studies have demon- • Will a second orthodontic finishing phase be needed? u0030
strated that frequent biological complications may occur in In contrast, the canine substitution option has the indis- p0055
the long-term.16–28 Such problems may include blue coloring putable advantage that the entire treatment is accomplished
of the marginal gingiva following labial bone resorption,19 in one phase and the result is permanent and independent
peri-implantitis,18 bone loss around neighboring teeth,20 of residual maxillary growth.2–8 This point is particularly
abutment exposure due to retraction of the labial gingiva,28 important since the majority of patients with missing maxil-
and progressive infraocclusion.20 Infraposition of the clinical lary lateral incisors are diagnosed at an early age.
crown may occur even when the implant has been placed in It has to be stated, however, that even if space closure p0060
a mature adult, due to continuous eruption of the adjacent treatment results are well accepted by the patient and parents
teeth (Fig. 25-1).21,23–26,29–31 The cessation and degree of verti- and acceptable from a functional standpoint,13,14 the simple
cal growth is unpredictable.21,23–27,30,31 Even if some evidence substitution of the missing lateral incisor with the canine is
exists to help define the “end of growth” period, at present not sufficient for today’s high esthetic standards. The reasons
the individual variation is high and it is not possible to for this are several:
predict when unforeseen changes will appear.29 This could • The gingival margins frequently became unnatural. The u0035
itself contraindicate the single-tooth implant restoration in borders are too high apically on canines moved to replace
the esthetic zone of patients who show the gingival margins the lateral incisors and too short on the first premolars
K when smiling. moved in the place of the canines (Fig. 25-2).
528
ISBN: 978-1-4557-5085-6; PII: B978-1-4557-5085-6.00025-4; Author: Nanda; 00025
Nanda_0856_Chapter 25_main.indd 528 1/24/2014 7:17:20 PM

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Age 19.4 Age 20.6

A B
Age 20 Age 20 Age 24
C D E
f0010
Age 20
F
Age 21
G
Age 27
I
Figure 25-1 Infraocclusion of an implant crown placed at the “end of growth.” A and B, An adequate implant site was orthodontically opened in a 19-year-
old woman. C and D, The osseointegrated implant was inserted during orthodontic treatment and a temporary resin restoration was cemented 1 month after
the end of orthodontic treatment when the patient was 20 years old. F, The periodontal tissues were leveled similarly to the contralateral natural tooth. Due
to continued eruption of adjacent teeth, (G) the gingival margin of the porcelain crown was already 2- to 3-mm higher than the implant restoration after 1
year and (E) uneven bone peaks were evident after 4 years. H and I, After 7 years the clinical situation was even worse. There is no reason to believe that this
situation will remain stable. (The treatment was performed by the same team of professionals, in the same years and using similar procedures and implants, as
the case shown in Fig. 25-18. It is impossible to explain why in this case an evident amount of infraocclusion occurred while in the case shown in Fig. 25-18 it did
not.) (Periodontist: Dr. Francesca Manfrini; Prosthodontist: Dr. Giovanni Manfrini, Riva del Garda, Italy; Ceramist: Antonio Bertoni, Brescia, Italy.)

530 PART 8 Interdisciplinary Management
A B
f0015
Figure 25-2 Long-term appearance after space closure. A, Twenty-five years after orthodontic space closure the result is stable and the periodontal tissues
are healthy, although the esthetic result is not ideal and the smile is not natural. B, The gingival margins are not natural. They are too high on the canines,
which were moved in place of the lateral incisors, and too short on the first premolar, which was moved to replace the canines.
u0040 • Canines are generally more yellow than lateral incisors. • Class I or Class II molar occlusal relationship (depend- u0095
u0045 • The canine is sometimes too large. This may make it ing on the need for extractions in the lower arch) (see
impossible to grind it to the proper size of a lateral incisor Figs. 25-3 and 25-4; Figs. 25-5 to 25-7).
and achieve good balance with the adjacent teeth. • On anterior teeth: u0100
u0050 • The closed spaces may reopen in some patients. • Alignment of the incisal edges of the central incisors u0105
p0085 Over the last decade, new clinical procedures have been with the cusps of the canines and the buccal cusps of
proposed to improve the esthetic and occlusal outcome for the restored first premolars (“new” canines) (see Fig.
canine substitution treatment by combining carefully 25-7, N; Figs. 25-8 and 25-9).
detailed orthodontic finishing with techniques used in • Ideal frontal exposure. Compared to the lateral incisor u0110
esthetic dentistry.5–8 Together, these procedures are able to width, the central incisors should be about 160% and
provide the improvements needed to approach the appear- the canines 70%.33
ance of a natural intact dentition, both functionally and • Leveling with torque control of the upper six front u0115
esthetically, and provide predictable final results that are teeth to achieve natural “high-low-high” gingival
stable in the long-term (Figs. 25-3 and 25-4). It is the authors’ margins. The new canines (i.e., the first premolars) are
opinion that this will make orthodontic space closure a more at the same level as the central incisors and the new
attractive treatment alternative than before. lateral incisors (i.e., the canines) are at a lower level
p0090 The goal of this chapter is to: (see Fig. 23-6). Such adjustments can be made using
o0055 1. Describe the method for optimal space closure. archwire bends or, more easily, by bonding the canine
o0060 2. Define priorities in treatment planning. brackets higher than normal and the first premolar
o0065 3. Suggest new indications and contraindications for the brackets in an incisal position.5–8 The gingival leveling
space closure alternative. is particularly important in patients who show much
o0070 4. Recognize and address the most frequent hidden gingiva when smiling.
problems.
o0075 5. Suggest possible treatment alternatives. Restorations s0020
o0080 6. Suggest what needs to be improved further in the future. The goals of the restoration phase for canines and first pre- p0175
molars (and possibly central incisors) are:
s0010 CLINICAL METHOD FOR OPTIMAL • Temporary hybrid-composite direct restorations made u0120
SPACE CLOSURE just after the orthodontic treatment.
• Final restorations as porcelain veneers, which should be u0125
p0125 When the goal is the appearance of a naturally intact denti- made after an adequate stabilization period.
tion, both functionally and esthetically, the patient needs a
long, sometimes difficult two-phase interdisciplinary treat- Six-Step Clinical Procedure (Box 25-1) s0025
ment approach. Step 1: Space Closure and Correction s0030
of the Malocclusion
s0015 Orthodontic Treatment The extraction of two premolars in the mandibular arch is p0190
p0130 The overall goal of orthodontic treatment is not only space sometimes necessary, depending on the extent of lower arch
closure while correcting the malocclusion, but also proper crowding, incisor protrusion, lip posture, and expected
finishing in the esthetic zone to create a well-balanced expo- growth pattern. Typically, a normal mandibular arch form
sure of the upper front teeth, allowing the restorative dentist should not be expanded and should maintain the pre-
to perform minimally invasive, ideal restorations. treatment shape. The maxillary archwires should be coordi-
p0135 The specific goals of the orthodontic finishing phase are: nated with the lower ones.
u0085 • On posterior teeth: The space closure in the upper arch may be performed p0245
u0090 • Stable occlusion with no prematurities and no centric without major problems in crowded cases and in Class II
K occlusion–centric relation (CO-CR) discrepancy. malocclusions. If the diagnosis is made in the early mixed

CHAPTER 25 Missing Maxillary Lateral Incisors: New Procedures and Indications for Optimal Space Closure 531
dentition, a serial extraction strategy may sometimes be

b0010 BOX 25-1 Six-Step Clinical Procedure to Properly
effective to shorten the treatment time stage with fixed appli-
Achieve Optimal Space Closure ances (see Fig. 25-3).
p0195 1. Space closure and correction of the malocclusion. The problems become more relevant when treatment p0250
o0135 2. Orthodontic finishing in the maxillary front area. must be achieved with maximum anterior anchorage. In
o0140 a. Alignment and overjet (taking into consideration such cases, conventional biomechanics (Fig. 25-10, A and B)
size and morphology, function, and long-term are usually sufficient to close the spaces.3 However, moving
stability). each tooth individually is time consuming and the patient’s
o0145 b. Leveling of the gingival margins by extrusion and compliance with intermaxillary elastics is essential to achieve
grinding of the canines and intrusion of the first the treatment goal in a reasonable time span. Usually space
premolars. closure is made with a heat-treated 0.016-inch × 0.022-inch
o0150 c. Torque control of the canines and first premolars stainless steel archwire, using brackets of different slot sizes:
to prevent periodontal tissue complications and to 0.018-inch on the central incisors and canines and 0.022-
allow optimal restorations. inch on the premolars and molars.
o0155 3. Local gingivectomies in selected cases. With recent technical advances, including absolute p0255
o0160 4. Resin buildups for esthetic, functional, and stability skeletal anchorage with two connected palatally inserted
reasons. mini-screws,34–38 maximum anchorage problems can be
o0165 5. Vital bleaching of yellowish teeth. overcome and all posterior teeth can be moved simultane-
o0170 6. Occlusal finishing, final porcelain restorations, and ously forward without compliance problems. This system
long-term stability. Text continued on p. 537
1993
A B C
72
71
1
105
8
36
0
128
0
4
44
91
1993
D E F
G H I
f0020
Figure 25-3 Long-term stability of space closure and gingival remodeling. A–F, An 8-year-old girl with hyperdivergent Class III malocclusion, narrow maxilla,
lower crowding, and unilateral missing upper right lateral incisor in the early mixed dentition. Early orthopedic treatment included (G) rapid maxillary
expansion (RME) and (H) maxillary protraction using deciduous teeth as anchors. Continued K

1997 1997
J K L
1999
M N O
1993
1997
Q 1999
P
2012
R S T
2012
U V
W
Figure 25-3, cont’d Following (I) serial extraction of the upper left peg-shaped lateral incisor and the lower first premolar, (J–L) the upper left canine
erupted in the lateral incisor’s site and simplified the second phase of treatment with fixed appliances. The fixed appliance stage lasted 11 months and effectively
closed the spaces with a good occlusion (M–P). On the same day that debonding occurred, the upper canines were ground and restored with composite resin
to close the “black triangles” and the first premolars were built up to resemble and function as canines. Q, The patient showed gingival margins when smiling
and the overall exposure of teeth and periodontal tissues was in good balance. Twelve years after the end of treatment the patient was 27 years old. R–V, The
occlusion is stable and (W) the overall esthetics remains satisfactory. Minimal maintenance of the composite buildups was needed, although substitution with
porcelain veneers would increase the esthetic outcome and improve the long-term prognosis. (Composite buildups: Dr. Patrizia Lucchi, Trento, Italy.)

A B C
D E
f0025
F G H
I K
J
Figure 25-4 Space closure and facial surgery after unsatisfactory space reopening. A–H, In a previous treatment performed elsewhere, spaces were reopened
for implant substitution in a 17-year-old female. The occlusion appears normal and maxillary lateral incisor spaces were prepared bilaterally for implants.
Because of the Class III tendency with retruded maxilla, the upper incisors were protruded in an attempt to correct the overjet and improve the profile. The
lateral incisors were temporarily replaced with a removable plate. I–K, The revised treatment plan included closure of all spaces in the maxilla. Uprighting of
the maxillary incisors produced an anterior crossbite. J, Note that the soft tissue profile after the 7 mm incisor retraction didn’t change significantly when
compared to the initial profile. The overjet was corrected surgically together with the skeletal discrepancy. Continued
K

L M
N O P
Q R
S T
Figure 25-4, cont’d L, The first premolars were intruded to achieve ideal levels of the gingival margins. L and M, On the day that debonding occurred,
temporary composite direct restorations were made on the six front teeth. M–Q, Five years postop, the direct composite build-ups were substituted with resin
veneers. M, The incisor display while smiling is ideal for a young adult woman. N–P, Final results show maxillary molars in Class II relationship. R, Retention
consisted of one bonded six-unit retainer in the lower arch. The profile (S) improved significantly due to (T) the surgical vertical/sagittal maxillary reposition-
ing and the concomitant mandibular rotation. T, Surgery involved just the maxilla, which was moved forward and down to increase the overall vertical
dimension. The superimposition in T also shows that the upper lip did not move forward. (Surgeon: Dr. Mirco Raffaini, Parma, Italy; Composite restorations
and veneers: Dr. Patrizia Lucchi, Trento, Italy.)

A B
C D
E F
G H
I J
f0030
Figure 25-5 Space closure with lower premolar extractions. A, A 13-year-old boy with unilateral agenesis. Peg-shaped left lateral incisor and lower first
premolars were extracted. C–F, Treatment lasted 22 months and (B and E–I) included gingival leveling by extrusion of the canines and intrusion of the first
premolars. J, Composite resin buildups on six teeth included elongation of the central incisors to produce a nice smile arc. (Composite restorations: Dr. Patrizia
Lucchi, Trento, Italy.)

1999
A B C
2000
D E F
2001
G H I
12 years postop
J K L M
12 years postop
N O P
f0035
Figure 25-6 Long-term stability of space closure and gingival remodeling. A–C, An 11-year-old girl presented with Class II, subdivision and a missing
maxillary lateral incisor. The small left lateral incisor was extracted. The lower arch was treated with minor stripping to flatten the curve of Spee and solve the
2-mm crowding. D–F, Upper space closure was performed with maximum anchorage on the upper central incisors, extrusion of the canines, and intrusion
of the first premolars to create a natural-looking gingival profile. At the end of active treatment (25 months), the patient was 14 years old. G–I, The result was
satisfactory: good intercuspation with Class II molar relationship and natural-looking front teeth, mainly due to the “big” canines. Resin buildups were made
directly on the canines and first premolars. J–M, Twelve years after treatment, cone beam computed tomography (CBCT) shows the adequate tissues were
achieved by the palatal root torque of the canines during their extrusion and the labial root torque/palatal crown tip of the premolars during their intrusion.
K The occlusion is stable and the periodontal tissues are healthy. N–P, Twelve years after treatment, there is no bleeding on probing and probing depth (PD) is
within the normal range.

Q R
S T
Figure 25-6, cont’d Q and S, Ten years postop and despite the satisfactory occlusal result and periodontal stability, the overall esthetics of the smile was
not ideal due to the small teeth, especially the central incisors. R and T, After buildups on the central incisors and canines, the macroesthetic elements of the
smile were improved. (Buildups: Dr. Patrizia Lucchi, Trento, Italy.)
allows mesial movement of molars and premolars with no Mesiodistal enamel reduction of the canines may be nec- p0280
extra anchorage and/or Class III elastics39 (Fig. 25-10, C-H). essary to make them more similar in width to a lateral
p0260 The mesial movement of the first premolar may be com- incisor. Minor diastemas may be left mesially and/or distally
plicated in the presence of two divergent roots. It may be to the first premolars and restored to proper canine shape
indicated to slightly rotate such premolars to prevent the later. The zenith (most apical point of the gingival tissue)
buccal root from moving into the cortical plate, which would should be distal to the long axis of the central incisors and
slow down the movement and potentially produce a risk for canines but should coincide with the long axis of the lateral
periodontal tissue breakdown. incisors.33
p0265 Furthermore, the curve of Spee should be flattened to The overjet relationship is usually ideal on the “new” p0285
allow proper orthodontic finishing. Fixed appliances are nec- lateral incisors (i.e., canines ground on the palatal surface),
essary in the mandibular arch, at least in the final stages of while it may be 1- to 3-mm on well-aligned central incisors7
treatment. A correct cusp to fossa relationship should be (see Fig. 25-9, M).
achieved on the upper second premolars, together with a
solid stable occlusion with no notable CO-CR discrepancy. Extrusion of the Canines and Intrusion of the First s0045
Sometimes slight selective grindings are necessary. Premolars to Achieve Ideal Levels of the Gingival
p0270 Another possible alternative treatment plan for agenesis Margins. Canines that replace lateral incisors must be p0290
patients who show much gingiva when smiling is to close the extruded to move the gingival margins 1- to 2-mm below
spaces anteriorly and open up space for a third premolar in those of the central incisors (see Fig. 25-5, F). During extru-
the posterior areas (see Fig. 25-9; Fig. 25-11). sion the canine needs to be ground not only on the cusp but
also on the palatal surface in order to provide a good occlu-
s0035 Step 2: Orthodontic Finishing in the Maxillary sion. To avoid abrasion of the lower lateral incisors due to
Anterior Region contact with the thick palatal surface of the canines, the
s0040 Alignment of the Six Maxillary Front Teeth. To canine’s palatal surface can be reduced or an artificial “canine
p0275 achieve an optimal alignment, some adjustment bends must protection” can be developed through a composite buildup
be made on the maxillary archwires. An offset bend is neces- on the first premolar.
sary between the central incisors and the mesially moved The gingival contours also must be considered in cases of p0295
canine, while inset bends may be needed mesially and dis- canine substitution. First premolars should be intruded until
tally to the first premolars (see arrows on Fig. 25-14). the cementoenamel junction (CEJ) is close to the level of the K

A B C
84
84
0 67
36
115 7
14
11
29 4
1
27
98
D E F G
H I J
f0040
Figure 25-7 Space closure in Class III malocclusion with narrow maxilla and spaced upper arch. A–G and M, A 12-year-old girl presented with bilateral
maxillary lateral incisor agenesis, Class III malocclusion, narrow maxillary arch, and pronounced spacing. Because of optimal motivation of and cooperation
by the patient, the treatment plan was to close all spaces. H–J, After rapid maxillary expansion (RME), fixed appliances were used for space closure to obtain
good intercuspation of the second premolars with Class II molar occlusion. Canine extrusion and first premolar intrusion, as well as torque control of anterior
and posterior teeth, was achieved by archwire bending.
central incisor but at a higher level than the “new” lateral It is important to prevent central incisor intrusion as a p0305
incisors (see Fig. 25-5, F). Extrusion and intrusion will move side effect in the leveling stage and to maintain a good verti-
the periodontal supporting tissues together with the tooth. cal exposure. The vertical position of the central incisor
Intrusion will move the gingival margin about 70% to 80% brackets is decided on, with the goal of having 4- to 5-mm
of the tooth movement and a small pseudopocket may incisal show with relaxed lips in young patients, and having
appear.40 Extrusion may move the gingival margin down 2- to 3-mm of gingiva exposed on full smiling at the end of
80% of the tooth movement.41 The vertical movements not treatment (see Figs. 25-4, L, and 25-5, I). The brackets on the
only produce changes in the soft tissues but may also produce canine and first premolars should be positioned intentionally
uneven bone peaks (Figs. 25-12 and 25-13). These are not high and low, respectively, at the beginning of treatment in
true vertical defects and the patient can brush and floss effec- order to achieve optimal gingival levels in the first months
tively. During retention often the alveolar bone and the bone of treatment (see Fig. 25-12, B).
peaks remodel while the gingival margins remain unchanged
(see Fig. 25-12). Torque Control of Extruded Canine and Intruded s0050
p0300 The starting point in planning the amount of extrusion First Premolar to Prevent Periodontal Complica-
and intrusion is the position of the maxillary central incisor tions and Enable Correct Restorations. The root of p0310
edge relative to the upper lip at rest and when smiling.42 The the canine is bigger than the root of the lateral incisor and it
position of the maxillary incisal edge with resting lips cor- is critical to consider the thickness of the alveolar ridge and
relates with their display and can be acceptable or unaccept- soft periodontal tissues. The risk for development of labial
K able, depending on age (see discussion in Chapter 3). gingival recession is obvious, particularly in patients with a

K L
M N O
P Q
Figure 25-7, cont’d As shown in K and L, the maxillary anterior teeth may need further elongation to improve their relationship to the lips. N, Note the
detailed alignment on rectangular stainless steel archwires, with mesial and distal offset bends for the canines in lateral incisor position and distal offsets for
the first premolars in canine position. At the end of treatment (R–T) the occlusion was good and (O) a fixed retainer was bonded on four teeth. The (V) profile
and (W and X) frontal facial appearance improved significantly due to the mandibular posterior rotation, which increased the vertical dimension. The selective
extrusion and intrusion of the canines and first premolars, respectively, leveled the gingival margins to (R–T) a natural high-low-high relationship. The com-
posite resin buildups were made on the day of debonding for esthetic reasons and to stabilize the occlusion. The canines in lateral incisor position were not
ground and shortened. P and Q, The clinical crown length of the central incisors was increased with the buildups to an improved proportion compared to
the new lateral incisors and (Q and X) to provide a good smile arc. Continued
thin periodontal biotype. In addition, when the canine is restorative dentist who is trying to restore the premolar to
extruded with labial appliances the root tends to move buc- canine shape (see Fig. 25-14, D). To avoid the buccal tip of
cally. For this reason, palatal root torque should be applied the premolar during intrusion, the upper stainless steel
at the start of the extrusion. Application of lingual root (0.016-inch × 0.022-inch) archwire must be shaped straight
torque results in less enamel grinding near the labial CEJ, in this segment and sometimes an inset bend is needed
where the enamel layer is sometimes thin.2 This can be mesial to the second premolar and distal to the canine (see
accomplished by using a bracket with a higher torque pre- Fig. 25-14, E; Fig. 25-15, B).
scription or by placing third-order bends in the archwire To check the proper torque and angulation of the roots a p0320
prior to extrusion (Fig. 25-14). cone beam computed tomography (CBCT) examination is
p0315 During intrusion of the first premolars with labial appli- useful after the space closure in the finishing stages of the
ances and preformed nickel-titanium (Ni-Ti) archwires, treatment (see Figs. 25-13 and 25-14).
their crowns tend to tip buccally. This is not a problem for
the roots, which will move toward the palate, but the labial Step 3: Gingivectomy s0055
crown tip may impair the smile esthetics and produce In select cases, localized gingivectomies are required to level p0325
an excessive overjet, which will create problems for the the gingival margins (see Fig. 25-15).5 While rare in adult K

R S T
84
82
2 68
26
18 127 4
16
25 4
3
30
93
U V W X
Figure 25-7, cont’d Q and X, After the cosmetic phase with composite resin buildups on all six front teeth and whitening (vital bleaching) of the canines,
a balanced and naturally looking appearance was achieved. The smile is pleasant not because of the new lateral incisors but because of the restored first pre-
molars in canine position and central incisors. (Composite resin buildups: Dr. Patrizia Lucchi, Trento, Italy.)
patients, surgery is sometimes necessary in growing patients premolar intrusion. At this point, since the final goal is to
to modify hypertrophic gingivae due to poor oral hygiene or achieve an optimally esthetic incisor exposure, restorations
allergies and/or to correct negative aspects of altered passive are necessary on the canines and the first premolars for
eruption.43,44 A gingivectomy involving the marginal gingiva esthetic and functional reasons.6–8
should be done post-treatment and after repeated sessions of The extruded canine, even if properly ground, often p0345
professional oral hygiene instruction. The excision must be requires restoration to correct a “black triangle” and embra-
wide since up to half of the excised tissue will regenerate.45 sures47,48 (see Figs. 25-5 and 25-13, A).
Even if the excision is extended into the alveolar mucosa, The intruded first premolars must be suitably restored to p0350
the coronal part of the regenerated gingiva will still be resemble natural canines. A wide restoration is necessary to
keratinized.46 build up the cusp, lingual surface, and contact points. The
p0330 When the gingiva is swollen or hypertrophic during orth- lingual surface of the buildup may provide canine guidance
odontic treatment, it may be difficult to probe the CEJ and but more often participates in group function. The palatal
plan the amount of intrusion and extrusion needed for indi- cusp of the first premolar does not need to be ground and is
vidual teeth. It may be even more problematic if the teeth are sometimes covered by the restoration (see Fig. 25-13).
abraded and have lost their anatomic integrity. If there is The final goal is to achieve a balanced and attractive expo- p0355
altered active eruption in growing patients (i.e., persistence sure of the upper front teeth (see Figs. 25-3 to 25-5, 25-9,
of alveolar bone and periodontal attachment coronally to the and 25-15):
CEJ), a gingivectomy is not enough. In such instances open • Transversally: 70% for the canines and 160% for the u0175
flap surgery is needed during the orthodontic treatment to central incisors33
remodel the levels of the alveolar bone and the gingival • Vertically: correct periodontal levels and smile arc47 u0180
margins (see Fig. 25-15). For a truly satisfactory result, not only do the restorations p0370
p0335 In all cases, it is very important to motivate and educate need to be intraorally ideal, but the overall result needs to
patients regarding proper oral hygiene measures before, incorporate macroesthetic elements, such as the relationship
during, and after the orthodontic treatment, to maintain between teeth, lips, and face.49 A consonant smile arc is
normal healthy tissues. important to consider and the parallelism between the arc
formed by the maxillary teeth and the inner contour of the
s0060 Step 4: Esthetic Restorations lower lip when the patient is smiling needs to be harmoni-
p0340 At the end of the orthodontic treatment, the malocclusion ous.47 In some cases the central incisors may need to be made
should be corrected, the spaces closed, and the gingival longer and wider to achieve an optimal smile arc6–8 (see Fig.
K margins optimally leveled due to canine extrusion and first 25-6).

A May B
C November D
E F
f0045
G H
I J
Figure 25-8 Porcelain laminate veneers (PLV) and long-term stability. A–D, At least 10 months before the PLV are made, the upper bonded retainer must
be removed, which will allow small spaces to reopen. During this time the patient should not use any removable retainer in the upper arch. Selective grinding
may become necessary to stabilize the occlusion. E and F, When the occlusion and the small spaces are stable, the PLV are made and will close the spaces.
G–J, Two years after the porcelain restorations, the result was stable and no spaces were noticeable among the upper front teeth. The porcelain veneers will
also optimize the functional occlusion. In the absence of a lingually bonded retainer, group function may be better than a cuspid protected occlusion to ensure
long-term stability. G to J show simultaneous contacts on the second, third, and fourth tooth (blue marks in H and I). (Prosthodontist: Dr. G. Manfrini, Riva
d G, Italy. Ceramist: A. Berto.)

A B C
D E
R L
F G
R L
H I
f0050
Figure 25-9 A–G, A 37-year-old female patient with bilateral agenesis of the maxillary lateral incisors and severe asymmetry of the upper small-sized front
teeth. A 5-unit bridge restoration replacing the upper left first molar and a small canine (cantilever) is evident in the upper left arch. The treatment plan was
to close the spaces in the smile area and correct the upper midline while reopening a space (implant site) between the upper left premolars. During treatment,
adequate diastemas were opened mesially and distally on the central incisors to allow resin buildups on those teeth. I, An implant was inserted into the
orthodontically regenerated alveolar bone during orthodontic treatment.
p0375 Recent studies have demonstrated that subjects with uni- Generally, buildup restorations should be made directly p0380
lateral or bilateral agenesis of maxillary lateral incisors may with hybrid composite material immediately after the
have smaller teeth than those with normal dentition.50–52 debonding (on the same day, if possible). The hybrid com-
Therefore if the goal is to obtain a balanced, ideal smile, posite allows for easy finishing and adjustments until ideal
restorations should also be considered on the central incisors esthetics are achieved. The restorations should be whiter
in many patients with agenesis. This is also valid for patients than the yellowish enamel of the canines and the color
K in whom space opening is planned. should be chosen with consideration given to the subsequent

J K L
M N
O P Q
R S
Figure 25-9, cont’d J–L, The canines were extruded and the first premolars in canine position were intruded. D and H, The maxillary arch form was cor-
rected and the symmetry was reestablished. M, A 3-mm overjet was left intentionally after the orthodontic treatment, to be filled by restorations of the small
central incisors: (N) two different porcelain veneers in the palatal and buccal side. O–Q, Four years post-treatment, with porcelain restorations on the implant
and on the six upper front teeth, the result was stable. Continued
bleaching procedure (see step 5). It is easier and more con- Step 6: Occlusal Finishing, Final Restorations, s0070
venient to adapt the bleaching to the color of the composite and Long-Term Stability
resin than vice versa. Proper occlusal finishing is important for long-term success p0395
and stability. It is accomplished in the last months of treat-
s0065 Step 5: Vital Bleaching ment and during the first year after removal of the orthodon-
p0385 Relocated canines may be more yellow than intact central tic appliances. Fundamental points are as follows:
and lateral incisors. This problem can be solved relatively • Do not expand the lower arch and keep normal pre- u0185
easily and predictably with either at-home or in-office vital treatment arch forms.
bleaching procedures.53,54 Nocturnal use of 10% hydrogen • A long-term bonded retainer should be placed on the u0190
peroxide gel in an Essix-type retainer is a preferred way of lower front teeth.
bleaching teeth in young patients, when the risk of develop- • Lip competence should be achieved at the end of orth- u0195
ing increased sensitivity is significant. odontic treatment (consider lower premolar extractions,
p0390 The thermoplastic tray is applied after the composite res- maxillofacial surgery to correct skeletal discrepancies,
torations have been made. The whitening procedure starts and/or speech therapy).
on the canines with the bleaching gel injected only in the • There should be secure stable occlusion in the posterior u0200
canine reservoirs (see Fig. 25-15). Once the enamel of the areas with no CO-CR discrepancy.
canine is sufficiently whitened, the same procedure can start • Group function occlusion anteriorly without balancing u0205
on the adjacent teeth. In-office bleaching may be preferable interferences (see Figs. 25-8 and 25-9) may be preferable
for adult patients. to pure cuspid protected occlusion.55 K

T U
V W
X
Figure 25-9, cont’d T–W, The anterior occlusal guidance is a group function and was ideal after the restoration of upper central incisors. O–W, With no
retention in the upper arch, the upper space closure remained stable with no reopening of the spaces. X, The overall smile is better than what could have been
possible with two restorations replacing the missing laterals because of the ideal size of the central incisors, which are in good balance with the face. The
long-term prognosis is more predictable because of the presence of natural roots instead of foreign bodies. (Prosthodontist: Giovanni Manfrini, Riva del Garda,
Italy; Ceramist: Antonio Bertoni; Brescia, Italy.)
p0425 Since it is common that spaces may reopen after debond- The long-term stability of composite resin buildups is p0455
ing, long-term retention is mandatory in the maxillary arch. inadequate and, because of large individual variation, the
The thermoplastic retainers used for vital bleaching are not restorations must be maintained regularly throughout the
adequate for retention. A fixed bonded retainer on the maxil- patient’s life. Smokers and patients with parafunctional
lary six front teeth is presumably the best option, as it needs habits show small breakages and unesthetic shadowing of the
no patient compliance and allows the first premolars to bear buildups. This is the main reason why definitive porcelain
some weight in function.56 The optimal retention time is still restorations should be proposed to patients before treatment
to be documented. The authors’ clinical experience indicates (see Fig. 25-8).
that spaces may reopen after retainer removal as much as 5 For porcelain veneers the following procedure is p0460
to 6 years after the end of treatment. advisable:
p0430 Spaces may reopen especially: • Carefully check the occlusion and perform selective u0230
u0210 • After excessive upper incisor compensation (i.e., exces- grinding when indicated.
sive palatal tip) in hyperdivergent skeletal Class II patients • Remove the upper fixed retainer. u0235
u0215 • In lateral agenesis patients with small teeth • Allow 8 to 12 months for stabilization, during which time u0240
u0220 • In the presence of parafunctions or dysfunctional habits small diastemas may reopen between the front teeth in
u0225 • In cases where the occlusal finishing was not sufficiently some patients (see Fig. 25-8). During this period the resin
K detailed buildups can be adjusted further.

A B C
D E F
G H
f0055
Figure 25-10 Noncompliance space closure. A, A 15-year-old boy presented with missing maxillary lateral incisors. The lower arch was not crowded and
the lower incisors were well positioned on the A-Pogonion line. B, The upper space closure was difficult due to poor cooperation in wearing Class III elastics.
Two mini-screws were inserted in the palatal vault at the level of the first premolars. C, Appliances were removed in the lower arch and (D–F) a sliding
structure, which acted as absolute anchorage in supporting the mesial movement of the premolars and molars with pulling springs for 14 months, was tied to
the mini-screws. G and H, It was possible to move the whole posterior dentition in the upper arch mesially while maintaining a good interincisal angle and
lip posture and profile.
p0480 The porcelain veneers will match the resin restorations At the end of treatment the use of a bonded or removable p0490
and will optimize function and esthetics. The porcelain res- retainer or a biteplate (to be worn at night) is advisable in
torations should provide group function on the mesially patients who are seeking long-term excellence and those
moved upper canines and first and second premolars (see who show parafunctions.
Figs. 25-8 and 25-9, T-W) as well as provide new embrasures
and closure of small spaces that have reopened in the months
after the retainer removal. Supragingival preparations secure PRIORITIES IN TREATMENT PLANNING s0075
long-term periodontal health (see Fig. 25-8).
p0485 Even when porcelain veneers are planned, it may be Before starting a long, complicated, and expensive interdis- p0495
advisable to use direct hybrid resin restorations to determine ciplinary orthodontic and restorative treatment, it is impor-
the optimal size and morphology of the new lateral incisors tant to define the priorities of the treatment plan. This
and cuspids. They can be reevaluated and adjusted at subse- includes an understanding of what the patient expects from
quent visits and the porcelain veneers can be placed when the treatment and an evaluation of his or her motivation and
the patient is well out of treatment with a settled occlusion. potential cooperation. K

A 1999 B 2000
1999 2000 2001
C D E
1999 2000
F G
H 2001 I 2006
f0060
Figure 25-11 Atrophy of the orthodontically regenerated alveolar bone in the interim between orthodontic treatment and the implant, after unilateral space
closure and space reopening in the back. A, C, F, and N, A 13-year-old girl presented with a gummy smile and unilaterally missing upper right lateral incisor.
B, D, E, and G, She was treated with space closure while a space was reopened between the premolars. At the end of the orthodontic treatment, the implant
site was adequate in (E) width, (G) height, and (B and H) thickness. Since the patient was then 15 years old, the final restoration was delayed until the “end
of growth” and a lingual retainer was bonded on the six upper front teeth. Placement of an osseointegrated implant was planned for when the patient was 21
years old. I, During the 6-year interim the thickness of the alveolar crest decreased due to bone atrophy (arrow).

2006 2012
J K
L 2012 M
1999 2012
N O
Figure 25-11, cont’d J, The implant was placed at age 21 years. K, L, M, and O, Six years after the implant restoration, further bone loss and bluish gingival
discoloration was evident. The composite buildups on the right premolar and canine were substituted with porcelain restorations. L and O, The upper right
lateral incisor (the canine) looked healthy, with the gingival margin at the same level as the left lateral incisor. L, The loss of periodontal tissue thickness was
evident in the buccal side of the implant area and created a severe esthetic impairment in this “gummy smile” woman, who was not satisfied with the final
result after a very long and expensive treatment. The long-term prognosis is uncertain and it is not possible to exclude the necessity of maintenance, adjust-
ments, periodontal procedures, or possible remaking of the implant crown. (Periodontist: Dr. Francesca Manfrini, Riva del Garda, Italy; Prosthodontist: Dr.
Giovanni Manfrini, Riva del Garda, Italy; Ceramist: Mr. Antonio Bertoni, Brescia, Italy.)
s0080 Predictability zone were the least tolerated aspects of the smiles in patients
p0500 The first priority is the predictability in achieving the desired with agenesis of the maxillary lateral incisors, as judged
treatment objectives and the long-term stability of the by different categories of observers (specialists in orthodon-
outcome. From a biological and periodontal point of view, tics, adult orthodontic patients, general practitioners, and
clinical experience and scientific evidence have demon- laypersons).58
strated that the long-term results with all types of prosthetic Symmetry is another critical esthetic goal. For this reason, p0515
replacement of missing laterals are unpredictable in terms of unilateral agenesis of a lateral incisor can often be treated
periodontal health and less satisfactory when compared to more successfully with extraction of the contralateral lateral
the natural root substitution.13,14,16–26 incisor, especially when it is peg-shaped (see Figs. 25-3, 25-5,
and 25-6).
s0085 Overall Esthetics When examining the possibility of changing facial esthet- p0520
p0505 In cases with missing maxillary lateral incisors, esthetics is ics and profile by opening or closing the spaces for absent
naturally the main focus for the patient and expectations of maxillary lateral incisors, some myths and biases need to be
achieving an attractive tooth display and smile have increased discussed.
in recent years. Therefore the goals cannot simply be replace- In hypodivergent Class III cases with a narrow maxilla, p0525
ment of the missing tooth and correction of the malocclu- concave profile, and congenitally absent lateral incisors, the
sion. The goal, especially in young patients, is overall esthetics. assumption that orthodontic maxillary sagittal expansion
Overall esthetics is the ideal alignment of beautiful teeth, can improve the facial profile is not supported by the litera-
surrounded by intact gingiva, displayed attractively in the ture and is probably not true. As shown in Figure 25-4,
face during conversation and when smiling.5–8,57 protrusion of maxillary incisors will not improve a concave
p0510 In a recent study, tipping of incisors, interdental gingival profile and the overall face esthetics. Increasing the vertical
recessions (“black spaces”), and diastemas in the esthetic dimension by clockwise rotation of the mandibular and K

A B C
D E F
G H I
f0065
Figure 25-12 Long-term stability of gingival margins and alveolar bone remodeling. A and B, A 15-year-old girl with Class I malocclusion and agenesis of
the upper right lateral incisor was treated for 23 months to close spaces. C, Simultaneous intrusion of the first premolars and extrusion of the canines with
torque control remodeled the periodontal tissues to natural leveling of the gingival margins. D–F, The intrusions and extrusions moved the entire periodontal
apparatus, not only the soft tissues, but also the bone peaks (yellow circles). D, F, G, and I, Six years after the orthodontic treatment, the gingival margins are
stable (H) and the alveolar bone has remodeled (yellow circles). The front teeth were restored with porcelain veneers. (Prosthodontist: Dr. Giovanni Manfrini,
Riva del Garda, Italy; Ceramist: Antonio Bertoni, Brescia, Italy.)
occlusal planes is much more effective (see Fig. 25-7). malocclusions has no contraindications should be regarded
On the other hand, it is possible to close spaces for the with caution, as we are entering into the era of “overall
missing lateral incisors without collapsing the maxilla esthetics.” In some patients (as described in Fig. 25-9) it may
and, in doing so, worsen the profile6 (see Figs. 25-7 and be preferable to finish the treatment and leave some overjet,
25-10). In this type of malocclusion, the only way to really which will be filled by restorations. Such inclination of the
improve the profile and smile is to use a surgical approach7 upper central incisors is also more stable.
(see Fig. 25-4).
p0530 In contrast, in the case of a hyperdivergent patient, sagit- Patient’s Age s0090
tal changes of the upper incisors can affect the position of Most patients with congenitally absent maxillary lateral inci- p0535
the lips. As a consequence, space reopening can produce lip sors are younger than 20 years. The first obligation when
incompetence. In Class II, Division 1 malocclusions, correc- dealing with adolescent patients is to provide them with an
tion of the overjet by space closure could worsen the posture attractive tooth display at a young age. These patients not
of the upper lip, causing a “dished-in” profile, and should be only need a smile, but need it as soon as possible. Adolescent
avoided, especially in females. Thus the common opinion patients are entering the most critical part of their lives,
K that the space closure alternative in Class II, Division 1 when a balanced smile is fundamental to creating the

A B C D
E F
f0070
Figure 25-13 Premolar buildup to resemble a canine. After (A and B) intrusion, the premolar (B–D) needs to be built up for esthetic and functional reasons
in order to participate in (E and F) proper group protection during lateral movements of the mandible. C and D, The palatal cusp of the premolar remains
untouched and not ground.
B C
D E
f0075
Figure 25-14 During extrusion of canines with labial appliances, the root may tip labially and reduce the thickness of the periodontal tissues. This can lead
to a predisposition to gingival recession in the years after treatment. A–C, It is important to maintain the root of the canine inside the periodontal envelope,
with proper palatal root torque on the finishing archwire. D, During their intrusion the premolars tend to tip labially, with resulting excessive overjet, and
during premolar intrusion with straight-wire technique, buccal tip of the crown is a common side effect. E, To prevent this, the maxillary stainless steel archwire
must be shaped straight in this segment (green lines); sometimes an inset bend is necessary mesial to the second premolar (yellow arrows). The red arrows in
E indicate the offset bends for proper alignment of the canines.

A B C
D E F
G H I
J K
f0080
Figure 25-15 Gingivectomy and resective surgery during orthodontic treatment. A, G, and J, A 14-year-old girl presented with Class II malocclusion and
a unilaterally missing upper right lateral incisor. B and C, She was treated with space closure after the extraction of the contralateral lateral incisor. D, During
the orthodontic finishing phase, it was difficult to identify the cementoenamel junction (CEJ) and plan the amount of intrusion and extrusion because of the
swollen marginal soft tissues and the altered active eruption. The removal of the brackets and professional oral hygiene maintenance was not successful.
E, After a check of the alveolar bone crest (with the patient under local anesthesia), the periodontist diagnosed the presence of alveolar bone coronally to the
CEJ and performed surgical remodeling of the bone crest and gingival margins. F, Three months after surgery the brackets were rebonded and the orthodontic
treatment was finished more effectively. C, After treatment, on the same day as debonding occurred, a bonded retainer was made for the upper four front
teeth and direct resin buildups were made on the upper left central incisor, which was smaller than the upper right one. H and I, Vital bleaching was performed
at home with an Essix removable plate. K, The smile is well balanced and the result was stable 2 years after the end of treatment. (Periodontist: Dr. Francesca
Manfrini, Riva del Garda, Italy; Direct resin buildups: Dr. Patrizia Lucchi, Trento, Italy.)
self-esteem they need to approach many crucial life deci- restorations to replace missing lateral incisors may break,
sions. Psychosocial pressures are also of concern for parents, debond, and otherwise need maintenance. Adolescents and
who want an early resolution of their children’s esthetic young adults often travel for their education and problems
problems. These adolescents should not have to wait until with a temporary tooth may create discomfort in several
K the “end of growth” to achieve the finished result. Temporary ways and for many years.

mandibular incisors or, better, thickening of maxillary resto-

s0095 INDICATIONS AND CONTRAINDICATIONS rations may need to be executed to achieve ideal esthetic and
functional results7 (see Fig. 25-9).
p0540 Due to recent improvements in clinical procedures, the tra-
ditional indications and contraindications for the space Class III Cases with Retrognathic Profile s0110
closure alternative in patients with missing maxillary lateral In hypodivergent Class III patients, some improvement of p0600
incisors should be reviewed.5–8,39 the profile can be achieved by increasing the vertical dimen-
sion through occlusal plane and mandibular clockwise rota-
s0100 Indications for Space Closure tion (see Fig. 25-7), while the inclination of the upper incisors
p0545 The optimal canine substitution patient is one who has small may be irrelevant to obtaining improved changes in lip
canines with crowns that match the shade of the central inci- posture6,7 (see Fig. 15-4).
sors as well as:
u0245 • Crowding, normally inclined anterior teeth, and a well- Contraindications for Space Closure s0115
balanced profile The detailed orthodontic and restorative interdisciplinary p0605
u0250 • Dentoalveolar protrusion treatment is contraindicated in:
u0255 • Canines and premolars of similar size • Elderly patients who have no gingival exposure when u0280
u0260 • Class II dental relationship smiling
p0570 In the authors’ opinion, space closure interdisciplinary • Patients who have low esthetic expectations u0285
treatment should be proposed as the best treatment option • Patients who indicate lack of cooperation and u0290
in three categories of patients: motivation
o0265 1. Adolescents and young adults In such instances the alternative is space reopening or
o0270 2. Patients who show the gingival margin when smiling patient-oriented, limited treatment (see “Alternatives to
o0275 3. Patients who will also undergo maxillofacial surgical Space Closure” below).
procedures
p0590 In light of recent clinical research findings, some tradi- MOST FREQUENT PROBLEMS s0120
tional contraindications for space closure should be reevalu-
ated and can be considered obsolete. This may be valid for The interdisciplinary space closure treatment is sometimes p0625
cases with pronounced spacing in the maxillary arch, no difficult due to several problems, which can come as a sur-
malocclusion, and normal intercuspation of posterior teeth. prise or be overlooked during treatment. The most frequent
In such cases, the space closure is more difficult than reopen- problems are discussed here.
ing and it takes longer but it can be done without the risk of
causing “dished-in” profiles. Patient cooperation with Class Excessive Buccal Tip of the Intruded s0125
III elastics is generally sufficient to close the spaces without First Premolar Crowns
losing anchorage in the front areas. Even more relevant are Excessive buccal tip of the intruded first premolar crowns p0630
the findings that skeletal anchorage, provided by two con- may occur and result in excessive overjet in the canine area
nected mini-screws inserted in the palatal vault (see Fig. (see Fig. 25-14, D). This is one of the most common mistakes
25-10), will allow for compliance-free space closure in a and will make it difficult for the restorative dentist to achieve
shorter time than tooth-by-tooth movement.39 correct esthetics and functional occlusion. To diagnose the
problem clinically, the patient must be examined while
s0105 Large Difference in Size Between Canines standing in an eye-to-eye position.42 To correct this problem
and First Premolars when it occurs, the stainless steel finishing archwire must be
p0595 A large canine cannot be ground to resemble a small lateral shaped straight in the segment of the intruded premolar (see
incisor in good balance with the adjacent teeth. Since patients Fig. 25-14, E). Sometimes an inset bend is needed mesially
with unilateral or bilateral agenesis of lateral incisors gener- to the second premolar (see Figs. 25-14 and 25-15).
ally have smaller teeth than patients without any dental
anomalies,50–52 the correct question often is not “How do we Uncontrolled Buccal Root Torque of the s0130
make the canine smaller?” but rather “Do the central incisors Canines During Extrusion
need widening and/or elongation?” If the goal is to create a Uncontrolled buccal root torque of the canines during extru- p0635
well-balanced, attractive smile and optimal incisor display at sion will decrease the width and volume of the periodontal
rest and during speech, restorations may be necessary on the tissues and produce a risk for gingival recession several years
central incisors and the large canines can become excellent after treatment in patients with a thin periodontium. A
lateral incisors (see Figs. 25-4 to 25-7 and 25-9). Widening bracket with a minimum 20-degree palatal torque prescrip-
of the central incisors may result in a tooth-size discrepancy tion together with rectangular superelastic archwires during
(with maxillary excess) and increased overjet, as the tooth extrusion in the first months of treatment, as well as proper
widths are generally reduced in both the maxillary and third-order bends on a stainless steel rectangular archwire
the mandibular teeth in patients with agenesis of the lateral during the finishing phase, should be used to prevent this
incisors. Therefore procedures such as enlargement of the problem. K

• Adolescents who can be treated better or more efficiently u0320

s0135 Undefined Marginal Periodontal Tissue at the “end of growth”:
in Young Patients • Space reopening cases. The interim between the orth- u0325
p0640 Undefined marginal periodontal tissue in young patients odontic treatment and the restoration will be shorter
(altered passive or active eruption and poor hygiene) can (Fig. 25-18).
make it difficult to properly locate the CEJs. A strict hygiene • Surgical discrepancies. The surgical option should be u0330
protocol must be applied from the beginning of orthodontic discussed with the patient after growth and psycho-
treatment. Careful bracket positioning and regular checks of logical maturity (see Figs. 25-4 and 25-17).
anatomic details during treatment are necessary to level the • Adolescents with little motivation who will not coop- u0335
front teeth properly. erate during treatment.
• Patients who cannot afford a long and invasive treatment u0340
s0140 Unilateral Space Closure for financial or biological reasons (e.g., external root
p0645 Unilateral space closure can also create problems and is often resorption, periodontal problems, high caries activity).
a dilemma for the orthodontist. In unilaterally missing • Patients with low expectations and little motivation to u0345
incisor patients, the upper midline is often asymmetrical and achieve an ideal result.
deflected relative to the midline of the face and necessitates • Patients with Class III deep bites with a “hidden smile” u0350
extraction of one tooth on the contralateral side. A generally not showing the gingival margins when smiling (usually
safe decision is to extract the other lateral incisor, particu- associated with vertical skeletal maxillary hypoplasia) and
larly if it is narrow or peg-shaped (see Figs. 25-3, 25-5, 25-6, who do not want to undergo surgical correction to make
and 25-15). In cases where the lateral incisor and the canines the upper dentition more visible.
are of similar size, the first premolar can be extracted as an The primary goal of limited treatment is to correct the p0735
alternative.5–8,57 essential problems related to esthetics and function. The
p0650 An orthodontist may decide to close the space unilaterally goals can sometimes be achieved with direct composite res-
because this treatment appears easier and is more acceptable torations but a short orthodontic treatment is usually neces-
to the patient and/or the patient’s parents. However, bilateral sary first to reduce spaces and correct incisor angulations.
space closure should require similar treatment time com- A retention strategy is necessary to ensure stability. Fixed p0740
pared to the unilateral approximation and the final result bonded retainers and/or a removable biteplate will stabilize
may be more symmetrical and easier to finish with the the temporomandibular joint (TMJ) and prevent extrusion
restorations. and abrasion of the mandibular front teeth.
p0655 The main indication for unilateral space closure is a Class After limited treatment in adolescents, the treatment plan p0745
II subdivision case on the agenesis side, with a symmetrical should be reevaluated and discussed with the patient again
upper midline in a patient who does not show the gingival at the “end of growth.” For adult and elderly patients, limited
margins when smiling (Fig. 25-16). treatment may represent the best option.
Limited treatment is not a compromise. It is a precise p0750
s0145 ALTERNATIVES TO SPACE CLOSURE treatment option with clear and predictable goals. It is not
necessarily easy. When only a few teeth have to be moved, it
s0150 Limited Treatment is sometimes difficult to prevent undesired movements of the
p0660 Limited treatment refers to treatment solutions in which the anchor teeth and temporary anchorage devices may be
result is not the ideal occlusion but ones that can be achieved needed.
in a shorter time and in an easier way with both space closure
and space reopening with prosthetic replacement. It is Space Reopening and Autotransplantation s0160
usually an interdisciplinary treatment involving orthodon- A tooth with a single, partially developed root is suitable for p0755
tics and cosmetic restorative dentistry (Fig. 25-17). autotransplantation in anterior or posterior regions that have
p0665 The prerequisites for limited treatment include the been developed by orthodontic space reopening. Ideally, the
following: root to be transplanted should fit the alveolar ridge and its
u0295 • It takes a short time. root development should range from one-half to two-thirds.
u0300 • It is not invasive for teeth and periodontal tissues. Teeth that may fit are lower premolars, upper second premo-
u0305 • It is efficient (optimal cost to benefit ratio). lars, and sometimes diminutive upper third molars or a con-
u0310 • It effectively solves the main complaints of the patient. tralateral supernumerary incisor. The predictability and
u0315 • It leaves other treatment alternatives to be reconsidered long-term stability of this procedure are supported by scien-
at a later date. tific evidence to a greater extent than exists for implants.59,60
s0155 Indications Space Closure in the Front and Space s0165

p0695 Limited treatment is indicated in situations where there is Opening Posteriorly
no reason to propose a long, difficult, sometimes invasive, In selected patients, when the goal is to shorten the treat- p0760
and expensive interdisciplinary treatment. Examples of such ment time or simplify the biomechanics, while also keeping
K situations are: a natural root in the smile area, the treatment plan can be to

A B C
D E F
G H
I J
K L
f0085
Figure 25-16 Unilateral space closure. A–C, A 14-year-old girl presented with ideal conditions for unilateral space closure: hypodivergent Class II subdivi-
sion (molar Class II only on the right side) with a solid occlusion in the posterior segments and the upper midline deflected a few millimeters to the right rela-
tive to the facial midline. K, On smiling, the patient did not show the gingival margins. D–F, After orthodontic treatment the occlusion was still Class II
subdivision, a subdivision with coincident midlines. The upper right canine was ground during orthodontic treatment. Composite buildups were done on the
upper right first premolar, canine, peg-shaped upper left lateral incisor, and small central incisors. L, Two years later the smile arc was correct, with incisal
margins tangent to the lower lip. E, K, and L, The asymmetry of the gingival margins does not impair the overall smile esthetics because of the low smile line.
Lateral movements of the mandible are guided by (H [blue mark] and J) a canine protected occlusion in the left side, while (G and I [blue marks on the canine
and first premolar]) group function is evident on the mutilated right side. (Composite buildups: Dr. Patrizia Lucchi, Trento, Italy.)

80
85
5
5 119
25
141
5
3
0
30
75
A B
C D E
F G H
f0090
I J
K L
Figure 25-17 Limited treatment. A and B, A 12-year-old girl presented with congenitally missing lateral incisors, skeletal Class III, and maxillary sagittal
and vertical deficiency. C–E, I, and K, The occlusal relationship was a Class II subdivision with the upper midline well positioned when smiling. No centric
occlusion–centric relation (CO-CR) discrepancy was noticed and the occlusion was stable with acceptable group function. D, I, and K, Since the chief com-
plaint was the presence of black spaces when smiling and the treatment goals to correct the malocclusion (space closure, space opening, surgery) would be
better focused at the “end of growth,” a phase of noninvasive, inexpensive, limited treatment was chosen to solve the patient’s complaints in a short time, while
leaving all possible treatment alternatives open later. F and G, The spaces between upper anterior teeth were reduced in 3 months with fixed appliances and
(H, J, and L) the residual black spaces were filled with composite restorations. At the end of the limited treatment, the result was satisfactory from an esthetic
and functional point of view. The treatment goals will be reevaluated at the “end of growth.” (Composite restorations: Dr. Patrizia Lucchi, Trento, Italy.)

close anterior spaces and reopen space in the premolar area when compared to a natural root substitution.13,14,16 The total
for an implant crown. Usually an implant site is created treatment time for frontal space opening in children is
between the premolars. The orthodontic treatment involves extended because the final restoration generally can be done
developing an effective implant site, one that is adequate in only at the “end of growth.” When the orthodontic reopening
volume and does not need any further surgical improve- is done during adolescence, the interim may last many years
ment7 (see Figs. 25-9 and 25-11). In the years after space and the temporary restorations could create many problems
reopening in the maxillary posterior areas, the regenerated and discomfort for the patient (as discussed earlier in the
bone seems to undergo atrophy (see Fig. 25-11) to a greater chapter). Therefore orthodontic treatment should be delayed
extent than in spaces opened up for implants in the lateral with the specific goal of shortening the interim as much as
incisor area.61,62 This can be explained by differences in possible. If the appearance at a young age is not acceptable
embryological origin. For this reason, osseointegrated and some treatment is necessary during adolescence, it is
implants should be inserted as soon as possible after poste- preferable to choose a limited treatment to solve only the
rior space reopening and, when possible, during the orth- esthetic problems (black spaces, diastemas, and evident
odontic treatment7 (see Fig. 15-9). asymmetries). The long, difficult, and expensive procedures,
p0765 For the very demanding patient, this alternative could including space opening, can then take place at the “end of
require the highest number of restorations: four or six por- growth.”
celain veneers on front teeth and implant restoration in the After orthodontic space reopening, the lateral incisor can p0775
posterior segments. The esthetic effectiveness, biological be replaced with a removable plate, an implant-supported
health, and long-term stability are predictable but the finan- restoration, or a tooth-supported restoration.63
cial cost of such a solution is high.
Removable Plate s0175
s0170 Space Reopening and Prosthetic Replacement The removable plate can be esthetically satisfactory and is p0780
of the Congenitally Missing Lateral Incisor the most conservative solution, although it is the solution
p0770 The available scientific evidence concludes that, in the long- least accepted by patients. It is usually the first option in the
term, any type of restoration is less favorable and less pre- interim immediately after debonding. It can also be used as
dictable in terms of periodontal health and patient satisfaction a retainer while waiting for a fixed restoration. A removable
A B
Age 12 Age 22
C D
f0095
Figure 25-18 Ideal timing for space reopening for an implant-supported porcelain restoration. A, C, A 12-year-old girl presented with a unilaterally missing
right lateral incisor and persistent primary canine. Since space reopening and implant restoration were planned for later and she did not complain about her
esthetic appearance (no noticeable spaces), orthodontic treatment was delayed until toward the “end of growth.” B, D, and E, Orthodontic treatment began
when the patient was 22 years old and lasted 20 months. Continued K

Age 22 Age 24
E F G
H Age 24 I J
Age 25 Age 37
K L M N
O
Figure 25-18, cont’d G, H, and I, An adequate implant site was developed by orthodontic movement. F, The implant was inserted during the orthodontic
treatment. J–L, A temporary resin crown was cemented on the implant 8 weeks after the end of orthodontic treatment. M–O, Twelve years after the implant
insertion, the stability was good, the alveolar bone was healthy (although the papilla is shorter on the implant site), and there was no infraocclusion. (The
treatment was performed by the same team of professionals, in the same years and using similar procedures and implants, as the case shown in Fig. 25-1. It is
impossible to explain why evident infraocclusion happened in the case shown in Fig. 25-1 but did not occur in this one.) (Surgeon: Dr. Francesca Manfrini;
Prosthodontist: Dr. Giovanni Manfrini, Riva del Garda, Italy; Ceramist: Antonio Bertoni, Brescia, Italy.)
plate cannot provide stability of the root position32 and The cases that can be restored with a resin-bonded FPD p0790
therefore should be substituted quickly with a fixed bonded are those with a shallow overbite and no mobility of the
retainer in cases where an implant restoration is planned. adjacent teeth. Contraindications for this restoration are the
presence of parafunctions, deep overbite, and proclined
s0180 Tooth-Supported Restoration abutment teeth.
s0185 Resin-Bonded Fixed Partial Denture. The resin-
p0785 bonded fixed partial denture (FPD) is the most conservative Cantilevered Fixed Partial Denture. The cantilevered s0190
tooth-supported restoration because it is possible to leave the FPD is less conservative than the resin-bonded 3-unit bridge p0795
adjacent teeth almost untouched. This type of restoration because it needs full or partial coverage of the canine. It is
must fulfill stringent criteria to provide an esthetic and stable more secure in use than a resin-bonded FPD. The key factor
result. For this reason the long-term predictability is poor, for long-term success is careful removal of all eccentric con-
with debonding the most common cause of failure.64 The tacts from the pontic.67
zirconia resin-bonded FPDs provide a better esthetic result
than what was possible with the metal-supported resin- Conventional Full-Coverage Fixed Partial Denture. s0195
K bonded FPDs (Fig. 25-19).65,66 The conventional full-coverage FPD is the least conservative p0800

A B
C
f0100
Figure 25-19 Zirconia resin-bonded fixed partial denture (FPDs) can provide a better esthetic result than what was possible with the metal-supported resin-
bonded FPDs. (Prosthodontist: Dr. Giovanni Manfrini, Riva del Garda, Italy; Ceramist: Antonio Bertoni, Brescia, Italy).
procedure. Its indication is limited to patients who need able in the long-term. Such treatment can be completed
full-coverage crown restoration on the central incisors during adolescence and the result can be considered
and canines for other reasons than merely lateral incisor permanent.
prosthesis. The restorations, which can be done directly at the end of p0820
orthodontic treatment, provide ideal esthetics and function
s0200 Implant-Supported Restoration in a conservative way. The tooth preparation is minimal, with
p0805 The most commonly used treatment alternative is the single- supragingival restoration margins that do not intrude into
tooth implant porcelain crown. This solution is the most the gingival sulcus.
conservative since the adjacent teeth may remain untouched. On the other hand, space reopening always requires p0825
The orthodontic treatment should not only provide ideal root and tooth replacement and restorations, which are
position of the adjacent crowns and roots, but also develop more invasive and less predictable in the long-term. The
the implant site (see Fig. 25-9). This is most predictable when total treatment time can be frustrating for young patients
the canine is close to the central incisor before the orthodon- who must wait several years until the difficult-to-define
tic treatment (see Fig. 25-18). It has been reported that the “end of growth” period before final restorations can be
bone created through orthodontic tooth movement is largely implemented.
stable in both horizontal and vertical directions.62,63 However, Even though the introduction of osseointegrated implants p0830
other authors have found a significant decrease in alveolar has decreased the popularity of the space closure alternative
ridge width and height during and immediately after the among dentists, the natural root is the best solution in the
space opening.68,69 As discussed earlier in the chapter, the esthetic zone, as discussed in this chapter. In the future, it is
preferred procedure when an implant-supported restoration expected that the canine substitution, supplemented with
is planned is to delay the orthodontic space opening treat- proper interdisciplinary restorative treatment, will experi-
ment so it is as close as possible to the time of implant inser- ence a renaissance among clinicians.
tion (see Fig. 25-18), to try to avoid the central incisor
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Age 19.4 Age 20.6

Age 20 Age 20 Age 24

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dentition, a serial extraction strategy may sometimes be

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1999 2000 2001

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mandibular incisors or, better, thickening of maxillary resto-

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• Adolescents who can be treated better or more efficiently u0320