Case ReportExtraction of Maxillary Central IncisorsAn Orthodontic-Restorative Treatment
Zohreh Hedayati Maryam Zare and Fateme Bahramnia
Orthodontic Research Center School of Dentistry Shiraz University of Medical Sciences Ghom Abad GhasrodashtShiraz 71866-77764 Iran
Correspondence should be addressed to Zohreh Hedayati hedayatzyahoocom
Received 31 May 2014 Accepted 18 September 2014 Published 16 October 2014
Academic Editor Carla Evans
Copyright copy 2014 Zohreh Hedayati et al This is an open access article distributed under the Creative Commons AttributionLicense which permits unrestricted use distribution and reproduction in any medium provided the original work is properlycited
Malformed central incisors with poor prognosis could be candidates for extraction especially in crowded dental arches This casereport refers to a 12-year-old boy who suffered from malformed upper central incisors associated with severe attrition Upperlateral incisors were positioned palatally and canines were rotated and positioned in the high buccal area The patient had classII malocclusion and space deficiency in both dental arches Due to incisal wear and malformed short maxillary central incisorsand the need for root canal therapy with a major crown build-up these teeth were extracted The maxillary lateral incisors weresubstituted Thus the maxillary canines were substituted for lateral incisors and the first premolars were substituted for canines Inthe lower dental arch the first bicuspids were extracted Composite resin build-up was performed on the maxillary lateral incisorsand canines This allowed for the crowding and the malocclusion to be corrected Subsequent gingivectomy improved the patientrsquosgingival margins and smile esthetics one month after orthodontic therapy
1 Introduction
There aremany acquired and inherited developmental abnor-malities that alter the size shape and number of teeth Mal-formed teeth are derived from a developmental disturbanceduring odontogenesis [1]
Extraction of upper central incisors is not commonin orthodontics However malformed central incisors withpoor prognosis could be candidates for extraction [2] Thetype of occlusion space requirements shape size and rootheight of lateral incisors and canines play important rolein making decision between orthodontic and prosthodontictreatments after extraction of central incisors [3ndash8] Theprincipal approach to resolution of such problems especiallyin crowded dental arches would be orthodontic treatmentand closure of anterior space by substitution of the maxillarylateral incisors When orthodontic treatment is the choiceextraction ofmaxillary central incisorsmay provide the spaceto correct crowding or an increased overjet without a need forextraction of other posterior teeth [3]
In the orthodontic approach there are some challengeslateral incisors usually have short and tapered crown emer-gence profile Periodontal deteriorationmay result fromover-contoured mesial and distal margins of final restoration andfinally there are height discrepancies between the gingivalmargins of lateral incisors and canines [3]
Care should be taken to
(i) parallel the roots of lateral incisors(ii) reduce the prominence of canine root by creating a
lingual torque(iii) rotate the first premolars slightly in mesiopalatal
direction(iv) reduce palatal cusp to resemble canine [3 4]
The presented case is a description of a class I maloc-clusion complicated by malformed maxillary central incisorswith severe attrition and crowded dentition treated with acombined orthodontic-restorative approach
Hindawi Publishing CorporationCase Reports in DentistryVolume 2014 Article ID 268590 6 pageshttpdxdoiorg1011552014268590
2 Case Reports in Dentistry
Figure 1 Pretreatment facial photography
Figure 2 Pretreatment lateral cephalometry and panoramic radiographs
2 Case Report
The patient was a twelve-year-old boy with good physicalhealth He had a symmetric face with a convex soft tis-sue profile His chief complaint concerned malaligned andmalformed anterior teeth The patient also had a history ofmeningitis in his childhood
Extraoral examination showed increased vertical skeletalproportions increased lower facial third leptoprosopic facialtype and nonconsonant smile (Figure 1)
Cephalometric analysis revealed an anteroposterior classI skeletal relationship (Figure 2) The Sum-of-Bjork andFrankfurtmandibular plane angleswere both high indicatinga vertical growth pattern Inclination of themaxillary incisorswas within the normal range (102 degrees) and themandibu-lar incisors were proclined (96 degrees)
The patient presented with a class I malocclusion in earlypermanent dentition 0mm overjet (edge to edge bite oncentral incisors) and incomplete overbite in the centric occlu-sion super class I molar relationship in the right side andclass I molar relationship in the left side malformed uppercentral incisors with incisal attrition palatally positionedupper lateral incisors and high buccal and rotated caninesThere were 84mm and 3mm space deficiency in his upper
and lower dental arches respectively His periodontal statuswas good While his upper left primary canine was retainedall of the permanent teeth were erupted with the exception ofthe second and third molars
Lateral maxillary incisors were placed palatally withlarge clinical crowns and long roots Both maxillary centralincisors were malformed with short roots (Figure 3) androot canal therapy was needed due to severe attrition Hencefrom endodontic and restorative points of view the presenceof severe incisal attrition (which had led to shortening ofclinical crowns) and the need for root canal therapy with amajor crownbuild-up central incisorswere chosen as a betterchoice for extraction in this case
3 Treatment Objectives
The objectives of the orthodontic treatment were(i) producing satisfactory esthetic results by eliminating
(ii) correcting crossbite(iii) preserving class I molar relationships
Case Reports in Dentistry 3
Figure 3 Pretreatment intraoral photography
(iv) establishing a stable occlusion with normal overbiteand overjet and esthetic smile
4 Treatment Concept
Because of the above-mentioned clinical and radiographicfindings together with poor prognosis of upper centralincisors and the appropriate size of lateral incisors with longroots extraction of the upper central incisors plus substi-tution of the lateral incisors was determined as a suitabletreatment This involved extraction of upper central incisorsto disperse the crowding in the maxilla and extraction oflower first premolars to achieve normal incisors inclinationand normal overjet
5 Treatment Progress
After extraction of permanent maxillary central incisors andmandibular first premolars a preadjusted edgewise 001910158401015840by 002210158401015840 slot fix appliance was placed in the maxillaryand mandibular dental arches Conventional aligning andleveling were performed Initially a 0014 inch round nickel-titanium (Ni-Ti) archwire was ligated followed by a 0016
inch round nickel-titaniumThe correction of palatally lateralincisors was started by using bite raisers in order to facilitatecrossing the teeth
Once the maxillary lateral incisors had been situated inthe central incisor and the maxillary canines in the lateralincisor positions rectangular stainless steel arch wires wereligated in place to correct the torque in both arches anduprighting of the incisors roots
The active orthodontic treatment was completed in 16visits over the course of 19 months At the completion oforthodontic treatment the smile was consonant and thepalatally lateral incisors were corrected Further aims of treat-ment including preservation of class Imolar relationships andcreation of normal overjet and overbite were also achieved(Figures 4 and 5) By the completion of orthodontic treatmentbrackets were removed and the patient was referred forprosthodontic alteration of the shape of teeth The maxillarylateral incisors were built upwith Z100-3M resin composite toresemble central incisors The cusps of canines were grindedThe distal and labial surfaces were flattened and reshapedto mimic lateral incisors and also meet the patientrsquos estheticrequirements The palatal cusps of the first bicuspids weregrinded as well to make these teeth ready to serve as canines
4 Case Reports in Dentistry
Figure 4 Posttreatment facial photography
Figure 5 Posttreatment intraoral photographs
Case Reports in Dentistry 5
Figure 6 Gingival appearance after gingivectomy
Figure 7 Posttreatment lateral cephalometry and panoramic radiographs
However an inflamed and enlarged gingival contour waspresent at the end of orthodontic and restorative period(Figure 5)
Amaxillary fixed retainer was placed following treatmentto prevent any tendency for posttreatment space openingOne month later a limited gingivectomy was performed inorder to eliminate hyperplastic gingival tissues and improvegingival margins Three months later a normal gingivalcontour was established However in spite of extrusion ofcanines higher levels of their gingival margin were stillpresent (Figure 6) Normal relationship of jaw bases anddentition was present at the end of treatment (Figure 7)
6 Discussion
The treatment of children with poor prognosis or avulsedupper central incisors is a great challenge in dentistry Therearemany approaches available to solve this problem includingosseointegrated implants [4 5] fixed or removable partialdentures autotransplantation of other growing permanentteeth or buds [6] and orthodontic space closure Orthodonticmanagement by substitution of the lateral incisors for the lostor extracted central incisor teeth has been performed inmanyclinical experiments [3 7ndash9]
The illustrated case essentially had a class I malocclusioncomplicated by palatally upper lateral incisors and mal-formed upper central incisors with severe attrition
Clinical and radiographic assessment of upper centralincisors revealed poor long-term prognosis Therefore theybecame candidate for extraction in this patient Long rootsand large crowns of the lateral incisors made these teethappropriate substitutes for the central incisors
Consequently by removal of the maxillary centralincisors crowding of the upper arch was dispersed Extrac-tion of the lower first premolars was undertaken to create anormal overjet
Dental esthetics was enhanced by selective incisal reduc-tion of the maxillary canines remodeling was performedsequentially and under cooling to avoid short-term sensitivityand long-term complications including sclerosis [10 11]
Mandibular excursions were also smoothed without non-working side interferences The prevalence of nonwork-ing side interferences and overall temporomandibular jointhealth is almost identical in subjects treated with orthodonticspace closure or prosthetic replacement with absent lateralincisors [12 13] Therefore central incisor substitution is alsounlikely to have a prolonged influence on temporomandibu-lar integrity [14]
Utilizing the above approach is ideal when a patient isyoung and without gingival display in smiling Crowding inupper dental arch or large overjet requiring extraction lateralincisors with large clinical crowns and long roots and smallsize of canines are other conditions required for this kind ofapproach [3]
Fortunately this young patient had the required condi-tions including suitable size of lateral incisors and caninesenough long roots of lateral incisors and crowding in his bothupper and lower arches
When a lateral incisor is substituted for a missing max-illary central incisor several important steps will ensure anesthetic result First the gingival margins of the maxillaryanterior teeth must be positioned properly [15ndash19] Whena lateral incisor is substituted for a central one the canineis substituted for the lateral incisor In this situation the
6 Case Reports in Dentistry
orthodontist must disregard the incisal edges of these teethas guides for final tooth positioning [2]
During orthodontic treatment the maxillary caninesmust be extruded to move their gingival margins incisallyto resemble the usual gingival margin position of lateralincisorsThe lateral incisors must be intruded significantly sothat their gingival margins match the adjacent canines andcreate the illusion of normal anterior gingival levels [2] Anadditional benefit of intruding the lateral incisor is to facilitaterestoration of this tooth into the shape of a central incisor [15]In this case this was done from the first stage of orthodontictreatment by altering the bracket positioning
However addition intrusion of the incisors could haveimproved the gingival margin relationships even further
In order to enhance the gingival architecture excessivemesial angulation of the maxillary lateral incisors (which isunwanted during space closure) should be prevented Thiswas avoided for the patient by placing central incisor bracketson the lateral incisors and preserving appropriate angulationThe reduced mesial angulation allowed the propensity forenhanced torque delivery Consequently proceeding slowlywith space closure to achieve ideal root positioning andusing selective second-order archwire adjustments promotedmesial positioning of the lateral incisor roots
Finally the young patient was treated successfully Asatisfactory occlusion with coincident midlines and estheticresults was achieved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] B W Neville D D Damm C M Allen and J Bouquot Oraland Maxillofacial Pathology Saunders St Louis Mo USA 3rdedition 2009
[2] V G Kokich and K E Crabill ldquoManaging the patient withmissing or malformed maxillary central incisorsrdquo AmericanJournal of Orthodontics and Dentofacial Orthopedics vol 129no 4 pp S55ndashS63 2006
[3] S Chaushu A Becker and M Zalkind ldquoProsthetic consider-ations in the restoration of orthodontically treated maxillarylateral incisors to replace missing central incisors a clinicalreportrdquo The Journal of Prosthetic Dentistry vol 85 no 4 pp335ndash341 2001
[4] M Ferrari and M C Cagidiaco ldquoTraumatic injuries to perma-nent incisors a case reportrdquo Quintessence International vol 25no 10 pp 717ndash721 1994
[5] C W Wang S Koo D Kim and E E Machtei ldquoNegotiatingthe severely resorbed extraction site a clinical case report withhistologic samplerdquoQuintessence International vol 45 no 3 pp203ndash208 2014
[6] B U Zachrisson ldquoPlanning esthetic treatment after avulsion ofmaxillary incisorsrdquo Journal of the American Dental Associationvol 139 no 11 pp 1484ndash1490 2008
[7] MKawakami KOkamoto R Fujii andTKirita ldquoOrthodonticrehabilitation for anterior teeth lost due to trauma with crowd-ing malocclusionrdquo Dental Traumatology vol 26 no 4 pp 357ndash359 2010
[8] S Drummond L S V Pessica A B L Monnerat A F Mon-nerat and M A de Oliveira Almeida ldquoMultidisciplinary solu-tion for an avulsed upper central incisor case reportrdquo DentalTraumatology vol 27 no 3 pp 241ndash246 2011
[9] K Sayinsu and D Nalbantgil ldquoOrthodontic treatment of apatient with traumatic loss of maxillary incisorsrdquoWorld Journalof Orthodontics vol 9 no 1 pp 43ndash47 2008
[10] B U Zachrisson and I A Mjor ldquoRemodeling of teeth bygrindingrdquoThe American Journal of Orthodontics vol 68 no 5pp 545ndash553 1975
[11] A Thordarson B U Zachrisson and I A Mjor ldquoRemodelingof canines to the shape of lateral incisors by grinding a long-term clinical and radiographic evaluationrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 100 no 2 pp123ndash132 1991
[12] S Robertsson and B Mohlin ldquoThe congenitally missing upperlateral incisor A retrospective study of orthodontic spaceclosure versus restorative treatmentrdquo European Journal ofOrthodontics vol 22 no 6 pp 697ndash710 2000
[13] G G Nordquist and RWMcNeill ldquoOrthodontic vs restorativetreatment of the congenitally absent lateral incisormdashlong termperiodontal and occlusal evaluationrdquo Journal of Periodontologyvol 46 no 3 pp 139ndash143 1975
[14] P S Fleming J Seehra and A T Dibiase ldquoCombinedorthodontic-restorative management of maxillary centralincisors lost following traumatic injury a case reportrdquoOrthodontics vol 12 no 3 pp 242ndash251 2011
[15] V G Kokich D L Nappen and P A Shapiro ldquoGingival contourand clinical crown length their effect on the esthetic appearanceof maxillary anterior teethrdquo American Journal of Orthodonticsvol 86 no 2 pp 89ndash94 1984
[16] V G Kokich and V O Kokich ldquoInterrelationship of orthodon-tics with periodontics and restorative dentistryrdquo in Biomechan-ics and Esthetic Strategies in Clinical Orthodontics R NandaEd Elsevier St Louis Mo USA 2005
[17] V Kovich ldquoEsthetics and anterior tooth position an orthodon-tic perspective Part I crown lengthrdquo Journal of Esthetic andRestorative Dentistry vol 5 no 1 pp 19ndash23 1993
[18] V G Kokich and F M Spear ldquoGuidelines for managing theorthodontic-restorative patientrdquo Seminars in Orthodontics vol3 no 1 pp 3ndash20 1997
[19] VG Kokich ldquoEsthetics and vertical tooth position orthodonticpossibilitiesrdquo Compendium of Continuing Education in Den-tistry vol 18 no 12 pp 1225ndash1231 1997
Figure 2 Pretreatment lateral cephalometry and panoramic radiographs
2 Case Report
The patient was a twelve-year-old boy with good physicalhealth He had a symmetric face with a convex soft tis-sue profile His chief complaint concerned malaligned andmalformed anterior teeth The patient also had a history ofmeningitis in his childhood
Extraoral examination showed increased vertical skeletalproportions increased lower facial third leptoprosopic facialtype and nonconsonant smile (Figure 1)
Cephalometric analysis revealed an anteroposterior classI skeletal relationship (Figure 2) The Sum-of-Bjork andFrankfurtmandibular plane angleswere both high indicatinga vertical growth pattern Inclination of themaxillary incisorswas within the normal range (102 degrees) and themandibu-lar incisors were proclined (96 degrees)
The patient presented with a class I malocclusion in earlypermanent dentition 0mm overjet (edge to edge bite oncentral incisors) and incomplete overbite in the centric occlu-sion super class I molar relationship in the right side andclass I molar relationship in the left side malformed uppercentral incisors with incisal attrition palatally positionedupper lateral incisors and high buccal and rotated caninesThere were 84mm and 3mm space deficiency in his upper
and lower dental arches respectively His periodontal statuswas good While his upper left primary canine was retainedall of the permanent teeth were erupted with the exception ofthe second and third molars
Lateral maxillary incisors were placed palatally withlarge clinical crowns and long roots Both maxillary centralincisors were malformed with short roots (Figure 3) androot canal therapy was needed due to severe attrition Hencefrom endodontic and restorative points of view the presenceof severe incisal attrition (which had led to shortening ofclinical crowns) and the need for root canal therapy with amajor crownbuild-up central incisorswere chosen as a betterchoice for extraction in this case
3 Treatment Objectives
The objectives of the orthodontic treatment were(i) producing satisfactory esthetic results by eliminating
(ii) correcting crossbite(iii) preserving class I molar relationships
Case Reports in Dentistry 3
Figure 3 Pretreatment intraoral photography
(iv) establishing a stable occlusion with normal overbiteand overjet and esthetic smile
4 Treatment Concept
Because of the above-mentioned clinical and radiographicfindings together with poor prognosis of upper centralincisors and the appropriate size of lateral incisors with longroots extraction of the upper central incisors plus substi-tution of the lateral incisors was determined as a suitabletreatment This involved extraction of upper central incisorsto disperse the crowding in the maxilla and extraction oflower first premolars to achieve normal incisors inclinationand normal overjet
5 Treatment Progress
After extraction of permanent maxillary central incisors andmandibular first premolars a preadjusted edgewise 001910158401015840by 002210158401015840 slot fix appliance was placed in the maxillaryand mandibular dental arches Conventional aligning andleveling were performed Initially a 0014 inch round nickel-titanium (Ni-Ti) archwire was ligated followed by a 0016
inch round nickel-titaniumThe correction of palatally lateralincisors was started by using bite raisers in order to facilitatecrossing the teeth
Once the maxillary lateral incisors had been situated inthe central incisor and the maxillary canines in the lateralincisor positions rectangular stainless steel arch wires wereligated in place to correct the torque in both arches anduprighting of the incisors roots
The active orthodontic treatment was completed in 16visits over the course of 19 months At the completion oforthodontic treatment the smile was consonant and thepalatally lateral incisors were corrected Further aims of treat-ment including preservation of class Imolar relationships andcreation of normal overjet and overbite were also achieved(Figures 4 and 5) By the completion of orthodontic treatmentbrackets were removed and the patient was referred forprosthodontic alteration of the shape of teeth The maxillarylateral incisors were built upwith Z100-3M resin composite toresemble central incisors The cusps of canines were grindedThe distal and labial surfaces were flattened and reshapedto mimic lateral incisors and also meet the patientrsquos estheticrequirements The palatal cusps of the first bicuspids weregrinded as well to make these teeth ready to serve as canines
4 Case Reports in Dentistry
Figure 4 Posttreatment facial photography
Figure 5 Posttreatment intraoral photographs
Case Reports in Dentistry 5
Figure 6 Gingival appearance after gingivectomy
Figure 7 Posttreatment lateral cephalometry and panoramic radiographs
However an inflamed and enlarged gingival contour waspresent at the end of orthodontic and restorative period(Figure 5)
Amaxillary fixed retainer was placed following treatmentto prevent any tendency for posttreatment space openingOne month later a limited gingivectomy was performed inorder to eliminate hyperplastic gingival tissues and improvegingival margins Three months later a normal gingivalcontour was established However in spite of extrusion ofcanines higher levels of their gingival margin were stillpresent (Figure 6) Normal relationship of jaw bases anddentition was present at the end of treatment (Figure 7)
6 Discussion
The treatment of children with poor prognosis or avulsedupper central incisors is a great challenge in dentistry Therearemany approaches available to solve this problem includingosseointegrated implants [4 5] fixed or removable partialdentures autotransplantation of other growing permanentteeth or buds [6] and orthodontic space closure Orthodonticmanagement by substitution of the lateral incisors for the lostor extracted central incisor teeth has been performed inmanyclinical experiments [3 7ndash9]
The illustrated case essentially had a class I malocclusioncomplicated by palatally upper lateral incisors and mal-formed upper central incisors with severe attrition
Clinical and radiographic assessment of upper centralincisors revealed poor long-term prognosis Therefore theybecame candidate for extraction in this patient Long rootsand large crowns of the lateral incisors made these teethappropriate substitutes for the central incisors
Consequently by removal of the maxillary centralincisors crowding of the upper arch was dispersed Extrac-tion of the lower first premolars was undertaken to create anormal overjet
Dental esthetics was enhanced by selective incisal reduc-tion of the maxillary canines remodeling was performedsequentially and under cooling to avoid short-term sensitivityand long-term complications including sclerosis [10 11]
Mandibular excursions were also smoothed without non-working side interferences The prevalence of nonwork-ing side interferences and overall temporomandibular jointhealth is almost identical in subjects treated with orthodonticspace closure or prosthetic replacement with absent lateralincisors [12 13] Therefore central incisor substitution is alsounlikely to have a prolonged influence on temporomandibu-lar integrity [14]
Utilizing the above approach is ideal when a patient isyoung and without gingival display in smiling Crowding inupper dental arch or large overjet requiring extraction lateralincisors with large clinical crowns and long roots and smallsize of canines are other conditions required for this kind ofapproach [3]
Fortunately this young patient had the required condi-tions including suitable size of lateral incisors and caninesenough long roots of lateral incisors and crowding in his bothupper and lower arches
When a lateral incisor is substituted for a missing max-illary central incisor several important steps will ensure anesthetic result First the gingival margins of the maxillaryanterior teeth must be positioned properly [15ndash19] Whena lateral incisor is substituted for a central one the canineis substituted for the lateral incisor In this situation the
6 Case Reports in Dentistry
orthodontist must disregard the incisal edges of these teethas guides for final tooth positioning [2]
During orthodontic treatment the maxillary caninesmust be extruded to move their gingival margins incisallyto resemble the usual gingival margin position of lateralincisorsThe lateral incisors must be intruded significantly sothat their gingival margins match the adjacent canines andcreate the illusion of normal anterior gingival levels [2] Anadditional benefit of intruding the lateral incisor is to facilitaterestoration of this tooth into the shape of a central incisor [15]In this case this was done from the first stage of orthodontictreatment by altering the bracket positioning
However addition intrusion of the incisors could haveimproved the gingival margin relationships even further
In order to enhance the gingival architecture excessivemesial angulation of the maxillary lateral incisors (which isunwanted during space closure) should be prevented Thiswas avoided for the patient by placing central incisor bracketson the lateral incisors and preserving appropriate angulationThe reduced mesial angulation allowed the propensity forenhanced torque delivery Consequently proceeding slowlywith space closure to achieve ideal root positioning andusing selective second-order archwire adjustments promotedmesial positioning of the lateral incisor roots
Finally the young patient was treated successfully Asatisfactory occlusion with coincident midlines and estheticresults was achieved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] B W Neville D D Damm C M Allen and J Bouquot Oraland Maxillofacial Pathology Saunders St Louis Mo USA 3rdedition 2009
[2] V G Kokich and K E Crabill ldquoManaging the patient withmissing or malformed maxillary central incisorsrdquo AmericanJournal of Orthodontics and Dentofacial Orthopedics vol 129no 4 pp S55ndashS63 2006
[3] S Chaushu A Becker and M Zalkind ldquoProsthetic consider-ations in the restoration of orthodontically treated maxillarylateral incisors to replace missing central incisors a clinicalreportrdquo The Journal of Prosthetic Dentistry vol 85 no 4 pp335ndash341 2001
[4] M Ferrari and M C Cagidiaco ldquoTraumatic injuries to perma-nent incisors a case reportrdquo Quintessence International vol 25no 10 pp 717ndash721 1994
[5] C W Wang S Koo D Kim and E E Machtei ldquoNegotiatingthe severely resorbed extraction site a clinical case report withhistologic samplerdquoQuintessence International vol 45 no 3 pp203ndash208 2014
[6] B U Zachrisson ldquoPlanning esthetic treatment after avulsion ofmaxillary incisorsrdquo Journal of the American Dental Associationvol 139 no 11 pp 1484ndash1490 2008
[7] MKawakami KOkamoto R Fujii andTKirita ldquoOrthodonticrehabilitation for anterior teeth lost due to trauma with crowd-ing malocclusionrdquo Dental Traumatology vol 26 no 4 pp 357ndash359 2010
[8] S Drummond L S V Pessica A B L Monnerat A F Mon-nerat and M A de Oliveira Almeida ldquoMultidisciplinary solu-tion for an avulsed upper central incisor case reportrdquo DentalTraumatology vol 27 no 3 pp 241ndash246 2011
[9] K Sayinsu and D Nalbantgil ldquoOrthodontic treatment of apatient with traumatic loss of maxillary incisorsrdquoWorld Journalof Orthodontics vol 9 no 1 pp 43ndash47 2008
[10] B U Zachrisson and I A Mjor ldquoRemodeling of teeth bygrindingrdquoThe American Journal of Orthodontics vol 68 no 5pp 545ndash553 1975
[11] A Thordarson B U Zachrisson and I A Mjor ldquoRemodelingof canines to the shape of lateral incisors by grinding a long-term clinical and radiographic evaluationrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 100 no 2 pp123ndash132 1991
[12] S Robertsson and B Mohlin ldquoThe congenitally missing upperlateral incisor A retrospective study of orthodontic spaceclosure versus restorative treatmentrdquo European Journal ofOrthodontics vol 22 no 6 pp 697ndash710 2000
[13] G G Nordquist and RWMcNeill ldquoOrthodontic vs restorativetreatment of the congenitally absent lateral incisormdashlong termperiodontal and occlusal evaluationrdquo Journal of Periodontologyvol 46 no 3 pp 139ndash143 1975
[14] P S Fleming J Seehra and A T Dibiase ldquoCombinedorthodontic-restorative management of maxillary centralincisors lost following traumatic injury a case reportrdquoOrthodontics vol 12 no 3 pp 242ndash251 2011
[15] V G Kokich D L Nappen and P A Shapiro ldquoGingival contourand clinical crown length their effect on the esthetic appearanceof maxillary anterior teethrdquo American Journal of Orthodonticsvol 86 no 2 pp 89ndash94 1984
[16] V G Kokich and V O Kokich ldquoInterrelationship of orthodon-tics with periodontics and restorative dentistryrdquo in Biomechan-ics and Esthetic Strategies in Clinical Orthodontics R NandaEd Elsevier St Louis Mo USA 2005
[17] V Kovich ldquoEsthetics and anterior tooth position an orthodon-tic perspective Part I crown lengthrdquo Journal of Esthetic andRestorative Dentistry vol 5 no 1 pp 19ndash23 1993
[18] V G Kokich and F M Spear ldquoGuidelines for managing theorthodontic-restorative patientrdquo Seminars in Orthodontics vol3 no 1 pp 3ndash20 1997
[19] VG Kokich ldquoEsthetics and vertical tooth position orthodonticpossibilitiesrdquo Compendium of Continuing Education in Den-tistry vol 18 no 12 pp 1225ndash1231 1997
(iv) establishing a stable occlusion with normal overbiteand overjet and esthetic smile
4 Treatment Concept
Because of the above-mentioned clinical and radiographicfindings together with poor prognosis of upper centralincisors and the appropriate size of lateral incisors with longroots extraction of the upper central incisors plus substi-tution of the lateral incisors was determined as a suitabletreatment This involved extraction of upper central incisorsto disperse the crowding in the maxilla and extraction oflower first premolars to achieve normal incisors inclinationand normal overjet
5 Treatment Progress
After extraction of permanent maxillary central incisors andmandibular first premolars a preadjusted edgewise 001910158401015840by 002210158401015840 slot fix appliance was placed in the maxillaryand mandibular dental arches Conventional aligning andleveling were performed Initially a 0014 inch round nickel-titanium (Ni-Ti) archwire was ligated followed by a 0016
inch round nickel-titaniumThe correction of palatally lateralincisors was started by using bite raisers in order to facilitatecrossing the teeth
Once the maxillary lateral incisors had been situated inthe central incisor and the maxillary canines in the lateralincisor positions rectangular stainless steel arch wires wereligated in place to correct the torque in both arches anduprighting of the incisors roots
The active orthodontic treatment was completed in 16visits over the course of 19 months At the completion oforthodontic treatment the smile was consonant and thepalatally lateral incisors were corrected Further aims of treat-ment including preservation of class Imolar relationships andcreation of normal overjet and overbite were also achieved(Figures 4 and 5) By the completion of orthodontic treatmentbrackets were removed and the patient was referred forprosthodontic alteration of the shape of teeth The maxillarylateral incisors were built upwith Z100-3M resin composite toresemble central incisors The cusps of canines were grindedThe distal and labial surfaces were flattened and reshapedto mimic lateral incisors and also meet the patientrsquos estheticrequirements The palatal cusps of the first bicuspids weregrinded as well to make these teeth ready to serve as canines
4 Case Reports in Dentistry
Figure 4 Posttreatment facial photography
Figure 5 Posttreatment intraoral photographs
Case Reports in Dentistry 5
Figure 6 Gingival appearance after gingivectomy
Figure 7 Posttreatment lateral cephalometry and panoramic radiographs
However an inflamed and enlarged gingival contour waspresent at the end of orthodontic and restorative period(Figure 5)
Amaxillary fixed retainer was placed following treatmentto prevent any tendency for posttreatment space openingOne month later a limited gingivectomy was performed inorder to eliminate hyperplastic gingival tissues and improvegingival margins Three months later a normal gingivalcontour was established However in spite of extrusion ofcanines higher levels of their gingival margin were stillpresent (Figure 6) Normal relationship of jaw bases anddentition was present at the end of treatment (Figure 7)
6 Discussion
The treatment of children with poor prognosis or avulsedupper central incisors is a great challenge in dentistry Therearemany approaches available to solve this problem includingosseointegrated implants [4 5] fixed or removable partialdentures autotransplantation of other growing permanentteeth or buds [6] and orthodontic space closure Orthodonticmanagement by substitution of the lateral incisors for the lostor extracted central incisor teeth has been performed inmanyclinical experiments [3 7ndash9]
The illustrated case essentially had a class I malocclusioncomplicated by palatally upper lateral incisors and mal-formed upper central incisors with severe attrition
Clinical and radiographic assessment of upper centralincisors revealed poor long-term prognosis Therefore theybecame candidate for extraction in this patient Long rootsand large crowns of the lateral incisors made these teethappropriate substitutes for the central incisors
Consequently by removal of the maxillary centralincisors crowding of the upper arch was dispersed Extrac-tion of the lower first premolars was undertaken to create anormal overjet
Dental esthetics was enhanced by selective incisal reduc-tion of the maxillary canines remodeling was performedsequentially and under cooling to avoid short-term sensitivityand long-term complications including sclerosis [10 11]
Mandibular excursions were also smoothed without non-working side interferences The prevalence of nonwork-ing side interferences and overall temporomandibular jointhealth is almost identical in subjects treated with orthodonticspace closure or prosthetic replacement with absent lateralincisors [12 13] Therefore central incisor substitution is alsounlikely to have a prolonged influence on temporomandibu-lar integrity [14]
Utilizing the above approach is ideal when a patient isyoung and without gingival display in smiling Crowding inupper dental arch or large overjet requiring extraction lateralincisors with large clinical crowns and long roots and smallsize of canines are other conditions required for this kind ofapproach [3]
Fortunately this young patient had the required condi-tions including suitable size of lateral incisors and caninesenough long roots of lateral incisors and crowding in his bothupper and lower arches
When a lateral incisor is substituted for a missing max-illary central incisor several important steps will ensure anesthetic result First the gingival margins of the maxillaryanterior teeth must be positioned properly [15ndash19] Whena lateral incisor is substituted for a central one the canineis substituted for the lateral incisor In this situation the
6 Case Reports in Dentistry
orthodontist must disregard the incisal edges of these teethas guides for final tooth positioning [2]
During orthodontic treatment the maxillary caninesmust be extruded to move their gingival margins incisallyto resemble the usual gingival margin position of lateralincisorsThe lateral incisors must be intruded significantly sothat their gingival margins match the adjacent canines andcreate the illusion of normal anterior gingival levels [2] Anadditional benefit of intruding the lateral incisor is to facilitaterestoration of this tooth into the shape of a central incisor [15]In this case this was done from the first stage of orthodontictreatment by altering the bracket positioning
However addition intrusion of the incisors could haveimproved the gingival margin relationships even further
In order to enhance the gingival architecture excessivemesial angulation of the maxillary lateral incisors (which isunwanted during space closure) should be prevented Thiswas avoided for the patient by placing central incisor bracketson the lateral incisors and preserving appropriate angulationThe reduced mesial angulation allowed the propensity forenhanced torque delivery Consequently proceeding slowlywith space closure to achieve ideal root positioning andusing selective second-order archwire adjustments promotedmesial positioning of the lateral incisor roots
Finally the young patient was treated successfully Asatisfactory occlusion with coincident midlines and estheticresults was achieved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] B W Neville D D Damm C M Allen and J Bouquot Oraland Maxillofacial Pathology Saunders St Louis Mo USA 3rdedition 2009
[2] V G Kokich and K E Crabill ldquoManaging the patient withmissing or malformed maxillary central incisorsrdquo AmericanJournal of Orthodontics and Dentofacial Orthopedics vol 129no 4 pp S55ndashS63 2006
[3] S Chaushu A Becker and M Zalkind ldquoProsthetic consider-ations in the restoration of orthodontically treated maxillarylateral incisors to replace missing central incisors a clinicalreportrdquo The Journal of Prosthetic Dentistry vol 85 no 4 pp335ndash341 2001
[4] M Ferrari and M C Cagidiaco ldquoTraumatic injuries to perma-nent incisors a case reportrdquo Quintessence International vol 25no 10 pp 717ndash721 1994
[5] C W Wang S Koo D Kim and E E Machtei ldquoNegotiatingthe severely resorbed extraction site a clinical case report withhistologic samplerdquoQuintessence International vol 45 no 3 pp203ndash208 2014
[6] B U Zachrisson ldquoPlanning esthetic treatment after avulsion ofmaxillary incisorsrdquo Journal of the American Dental Associationvol 139 no 11 pp 1484ndash1490 2008
[7] MKawakami KOkamoto R Fujii andTKirita ldquoOrthodonticrehabilitation for anterior teeth lost due to trauma with crowd-ing malocclusionrdquo Dental Traumatology vol 26 no 4 pp 357ndash359 2010
[8] S Drummond L S V Pessica A B L Monnerat A F Mon-nerat and M A de Oliveira Almeida ldquoMultidisciplinary solu-tion for an avulsed upper central incisor case reportrdquo DentalTraumatology vol 27 no 3 pp 241ndash246 2011
[9] K Sayinsu and D Nalbantgil ldquoOrthodontic treatment of apatient with traumatic loss of maxillary incisorsrdquoWorld Journalof Orthodontics vol 9 no 1 pp 43ndash47 2008
[10] B U Zachrisson and I A Mjor ldquoRemodeling of teeth bygrindingrdquoThe American Journal of Orthodontics vol 68 no 5pp 545ndash553 1975
[11] A Thordarson B U Zachrisson and I A Mjor ldquoRemodelingof canines to the shape of lateral incisors by grinding a long-term clinical and radiographic evaluationrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 100 no 2 pp123ndash132 1991
[12] S Robertsson and B Mohlin ldquoThe congenitally missing upperlateral incisor A retrospective study of orthodontic spaceclosure versus restorative treatmentrdquo European Journal ofOrthodontics vol 22 no 6 pp 697ndash710 2000
[13] G G Nordquist and RWMcNeill ldquoOrthodontic vs restorativetreatment of the congenitally absent lateral incisormdashlong termperiodontal and occlusal evaluationrdquo Journal of Periodontologyvol 46 no 3 pp 139ndash143 1975
[14] P S Fleming J Seehra and A T Dibiase ldquoCombinedorthodontic-restorative management of maxillary centralincisors lost following traumatic injury a case reportrdquoOrthodontics vol 12 no 3 pp 242ndash251 2011
[15] V G Kokich D L Nappen and P A Shapiro ldquoGingival contourand clinical crown length their effect on the esthetic appearanceof maxillary anterior teethrdquo American Journal of Orthodonticsvol 86 no 2 pp 89ndash94 1984
[16] V G Kokich and V O Kokich ldquoInterrelationship of orthodon-tics with periodontics and restorative dentistryrdquo in Biomechan-ics and Esthetic Strategies in Clinical Orthodontics R NandaEd Elsevier St Louis Mo USA 2005
[17] V Kovich ldquoEsthetics and anterior tooth position an orthodon-tic perspective Part I crown lengthrdquo Journal of Esthetic andRestorative Dentistry vol 5 no 1 pp 19ndash23 1993
[18] V G Kokich and F M Spear ldquoGuidelines for managing theorthodontic-restorative patientrdquo Seminars in Orthodontics vol3 no 1 pp 3ndash20 1997
[19] VG Kokich ldquoEsthetics and vertical tooth position orthodonticpossibilitiesrdquo Compendium of Continuing Education in Den-tistry vol 18 no 12 pp 1225ndash1231 1997
Figure 7 Posttreatment lateral cephalometry and panoramic radiographs
However an inflamed and enlarged gingival contour waspresent at the end of orthodontic and restorative period(Figure 5)
Amaxillary fixed retainer was placed following treatmentto prevent any tendency for posttreatment space openingOne month later a limited gingivectomy was performed inorder to eliminate hyperplastic gingival tissues and improvegingival margins Three months later a normal gingivalcontour was established However in spite of extrusion ofcanines higher levels of their gingival margin were stillpresent (Figure 6) Normal relationship of jaw bases anddentition was present at the end of treatment (Figure 7)
6 Discussion
The treatment of children with poor prognosis or avulsedupper central incisors is a great challenge in dentistry Therearemany approaches available to solve this problem includingosseointegrated implants [4 5] fixed or removable partialdentures autotransplantation of other growing permanentteeth or buds [6] and orthodontic space closure Orthodonticmanagement by substitution of the lateral incisors for the lostor extracted central incisor teeth has been performed inmanyclinical experiments [3 7ndash9]
The illustrated case essentially had a class I malocclusioncomplicated by palatally upper lateral incisors and mal-formed upper central incisors with severe attrition
Clinical and radiographic assessment of upper centralincisors revealed poor long-term prognosis Therefore theybecame candidate for extraction in this patient Long rootsand large crowns of the lateral incisors made these teethappropriate substitutes for the central incisors
Consequently by removal of the maxillary centralincisors crowding of the upper arch was dispersed Extrac-tion of the lower first premolars was undertaken to create anormal overjet
Dental esthetics was enhanced by selective incisal reduc-tion of the maxillary canines remodeling was performedsequentially and under cooling to avoid short-term sensitivityand long-term complications including sclerosis [10 11]
Mandibular excursions were also smoothed without non-working side interferences The prevalence of nonwork-ing side interferences and overall temporomandibular jointhealth is almost identical in subjects treated with orthodonticspace closure or prosthetic replacement with absent lateralincisors [12 13] Therefore central incisor substitution is alsounlikely to have a prolonged influence on temporomandibu-lar integrity [14]
Utilizing the above approach is ideal when a patient isyoung and without gingival display in smiling Crowding inupper dental arch or large overjet requiring extraction lateralincisors with large clinical crowns and long roots and smallsize of canines are other conditions required for this kind ofapproach [3]
Fortunately this young patient had the required condi-tions including suitable size of lateral incisors and caninesenough long roots of lateral incisors and crowding in his bothupper and lower arches
When a lateral incisor is substituted for a missing max-illary central incisor several important steps will ensure anesthetic result First the gingival margins of the maxillaryanterior teeth must be positioned properly [15ndash19] Whena lateral incisor is substituted for a central one the canineis substituted for the lateral incisor In this situation the
6 Case Reports in Dentistry
orthodontist must disregard the incisal edges of these teethas guides for final tooth positioning [2]
During orthodontic treatment the maxillary caninesmust be extruded to move their gingival margins incisallyto resemble the usual gingival margin position of lateralincisorsThe lateral incisors must be intruded significantly sothat their gingival margins match the adjacent canines andcreate the illusion of normal anterior gingival levels [2] Anadditional benefit of intruding the lateral incisor is to facilitaterestoration of this tooth into the shape of a central incisor [15]In this case this was done from the first stage of orthodontictreatment by altering the bracket positioning
However addition intrusion of the incisors could haveimproved the gingival margin relationships even further
In order to enhance the gingival architecture excessivemesial angulation of the maxillary lateral incisors (which isunwanted during space closure) should be prevented Thiswas avoided for the patient by placing central incisor bracketson the lateral incisors and preserving appropriate angulationThe reduced mesial angulation allowed the propensity forenhanced torque delivery Consequently proceeding slowlywith space closure to achieve ideal root positioning andusing selective second-order archwire adjustments promotedmesial positioning of the lateral incisor roots
Finally the young patient was treated successfully Asatisfactory occlusion with coincident midlines and estheticresults was achieved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] B W Neville D D Damm C M Allen and J Bouquot Oraland Maxillofacial Pathology Saunders St Louis Mo USA 3rdedition 2009
[2] V G Kokich and K E Crabill ldquoManaging the patient withmissing or malformed maxillary central incisorsrdquo AmericanJournal of Orthodontics and Dentofacial Orthopedics vol 129no 4 pp S55ndashS63 2006
[3] S Chaushu A Becker and M Zalkind ldquoProsthetic consider-ations in the restoration of orthodontically treated maxillarylateral incisors to replace missing central incisors a clinicalreportrdquo The Journal of Prosthetic Dentistry vol 85 no 4 pp335ndash341 2001
[4] M Ferrari and M C Cagidiaco ldquoTraumatic injuries to perma-nent incisors a case reportrdquo Quintessence International vol 25no 10 pp 717ndash721 1994
[5] C W Wang S Koo D Kim and E E Machtei ldquoNegotiatingthe severely resorbed extraction site a clinical case report withhistologic samplerdquoQuintessence International vol 45 no 3 pp203ndash208 2014
[6] B U Zachrisson ldquoPlanning esthetic treatment after avulsion ofmaxillary incisorsrdquo Journal of the American Dental Associationvol 139 no 11 pp 1484ndash1490 2008
[7] MKawakami KOkamoto R Fujii andTKirita ldquoOrthodonticrehabilitation for anterior teeth lost due to trauma with crowd-ing malocclusionrdquo Dental Traumatology vol 26 no 4 pp 357ndash359 2010
[8] S Drummond L S V Pessica A B L Monnerat A F Mon-nerat and M A de Oliveira Almeida ldquoMultidisciplinary solu-tion for an avulsed upper central incisor case reportrdquo DentalTraumatology vol 27 no 3 pp 241ndash246 2011
[9] K Sayinsu and D Nalbantgil ldquoOrthodontic treatment of apatient with traumatic loss of maxillary incisorsrdquoWorld Journalof Orthodontics vol 9 no 1 pp 43ndash47 2008
[10] B U Zachrisson and I A Mjor ldquoRemodeling of teeth bygrindingrdquoThe American Journal of Orthodontics vol 68 no 5pp 545ndash553 1975
[11] A Thordarson B U Zachrisson and I A Mjor ldquoRemodelingof canines to the shape of lateral incisors by grinding a long-term clinical and radiographic evaluationrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 100 no 2 pp123ndash132 1991
[12] S Robertsson and B Mohlin ldquoThe congenitally missing upperlateral incisor A retrospective study of orthodontic spaceclosure versus restorative treatmentrdquo European Journal ofOrthodontics vol 22 no 6 pp 697ndash710 2000
[13] G G Nordquist and RWMcNeill ldquoOrthodontic vs restorativetreatment of the congenitally absent lateral incisormdashlong termperiodontal and occlusal evaluationrdquo Journal of Periodontologyvol 46 no 3 pp 139ndash143 1975
[14] P S Fleming J Seehra and A T Dibiase ldquoCombinedorthodontic-restorative management of maxillary centralincisors lost following traumatic injury a case reportrdquoOrthodontics vol 12 no 3 pp 242ndash251 2011
[15] V G Kokich D L Nappen and P A Shapiro ldquoGingival contourand clinical crown length their effect on the esthetic appearanceof maxillary anterior teethrdquo American Journal of Orthodonticsvol 86 no 2 pp 89ndash94 1984
[16] V G Kokich and V O Kokich ldquoInterrelationship of orthodon-tics with periodontics and restorative dentistryrdquo in Biomechan-ics and Esthetic Strategies in Clinical Orthodontics R NandaEd Elsevier St Louis Mo USA 2005
[17] V Kovich ldquoEsthetics and anterior tooth position an orthodon-tic perspective Part I crown lengthrdquo Journal of Esthetic andRestorative Dentistry vol 5 no 1 pp 19ndash23 1993
[18] V G Kokich and F M Spear ldquoGuidelines for managing theorthodontic-restorative patientrdquo Seminars in Orthodontics vol3 no 1 pp 3ndash20 1997
[19] VG Kokich ldquoEsthetics and vertical tooth position orthodonticpossibilitiesrdquo Compendium of Continuing Education in Den-tistry vol 18 no 12 pp 1225ndash1231 1997
Figure 7 Posttreatment lateral cephalometry and panoramic radiographs
However an inflamed and enlarged gingival contour waspresent at the end of orthodontic and restorative period(Figure 5)
Amaxillary fixed retainer was placed following treatmentto prevent any tendency for posttreatment space openingOne month later a limited gingivectomy was performed inorder to eliminate hyperplastic gingival tissues and improvegingival margins Three months later a normal gingivalcontour was established However in spite of extrusion ofcanines higher levels of their gingival margin were stillpresent (Figure 6) Normal relationship of jaw bases anddentition was present at the end of treatment (Figure 7)
6 Discussion
The treatment of children with poor prognosis or avulsedupper central incisors is a great challenge in dentistry Therearemany approaches available to solve this problem includingosseointegrated implants [4 5] fixed or removable partialdentures autotransplantation of other growing permanentteeth or buds [6] and orthodontic space closure Orthodonticmanagement by substitution of the lateral incisors for the lostor extracted central incisor teeth has been performed inmanyclinical experiments [3 7ndash9]
The illustrated case essentially had a class I malocclusioncomplicated by palatally upper lateral incisors and mal-formed upper central incisors with severe attrition
Clinical and radiographic assessment of upper centralincisors revealed poor long-term prognosis Therefore theybecame candidate for extraction in this patient Long rootsand large crowns of the lateral incisors made these teethappropriate substitutes for the central incisors
Consequently by removal of the maxillary centralincisors crowding of the upper arch was dispersed Extrac-tion of the lower first premolars was undertaken to create anormal overjet
Dental esthetics was enhanced by selective incisal reduc-tion of the maxillary canines remodeling was performedsequentially and under cooling to avoid short-term sensitivityand long-term complications including sclerosis [10 11]
Mandibular excursions were also smoothed without non-working side interferences The prevalence of nonwork-ing side interferences and overall temporomandibular jointhealth is almost identical in subjects treated with orthodonticspace closure or prosthetic replacement with absent lateralincisors [12 13] Therefore central incisor substitution is alsounlikely to have a prolonged influence on temporomandibu-lar integrity [14]
Utilizing the above approach is ideal when a patient isyoung and without gingival display in smiling Crowding inupper dental arch or large overjet requiring extraction lateralincisors with large clinical crowns and long roots and smallsize of canines are other conditions required for this kind ofapproach [3]
Fortunately this young patient had the required condi-tions including suitable size of lateral incisors and caninesenough long roots of lateral incisors and crowding in his bothupper and lower arches
When a lateral incisor is substituted for a missing max-illary central incisor several important steps will ensure anesthetic result First the gingival margins of the maxillaryanterior teeth must be positioned properly [15ndash19] Whena lateral incisor is substituted for a central one the canineis substituted for the lateral incisor In this situation the
6 Case Reports in Dentistry
orthodontist must disregard the incisal edges of these teethas guides for final tooth positioning [2]
During orthodontic treatment the maxillary caninesmust be extruded to move their gingival margins incisallyto resemble the usual gingival margin position of lateralincisorsThe lateral incisors must be intruded significantly sothat their gingival margins match the adjacent canines andcreate the illusion of normal anterior gingival levels [2] Anadditional benefit of intruding the lateral incisor is to facilitaterestoration of this tooth into the shape of a central incisor [15]In this case this was done from the first stage of orthodontictreatment by altering the bracket positioning
However addition intrusion of the incisors could haveimproved the gingival margin relationships even further
In order to enhance the gingival architecture excessivemesial angulation of the maxillary lateral incisors (which isunwanted during space closure) should be prevented Thiswas avoided for the patient by placing central incisor bracketson the lateral incisors and preserving appropriate angulationThe reduced mesial angulation allowed the propensity forenhanced torque delivery Consequently proceeding slowlywith space closure to achieve ideal root positioning andusing selective second-order archwire adjustments promotedmesial positioning of the lateral incisor roots
Finally the young patient was treated successfully Asatisfactory occlusion with coincident midlines and estheticresults was achieved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] B W Neville D D Damm C M Allen and J Bouquot Oraland Maxillofacial Pathology Saunders St Louis Mo USA 3rdedition 2009
[2] V G Kokich and K E Crabill ldquoManaging the patient withmissing or malformed maxillary central incisorsrdquo AmericanJournal of Orthodontics and Dentofacial Orthopedics vol 129no 4 pp S55ndashS63 2006
[3] S Chaushu A Becker and M Zalkind ldquoProsthetic consider-ations in the restoration of orthodontically treated maxillarylateral incisors to replace missing central incisors a clinicalreportrdquo The Journal of Prosthetic Dentistry vol 85 no 4 pp335ndash341 2001
[4] M Ferrari and M C Cagidiaco ldquoTraumatic injuries to perma-nent incisors a case reportrdquo Quintessence International vol 25no 10 pp 717ndash721 1994
[5] C W Wang S Koo D Kim and E E Machtei ldquoNegotiatingthe severely resorbed extraction site a clinical case report withhistologic samplerdquoQuintessence International vol 45 no 3 pp203ndash208 2014
[6] B U Zachrisson ldquoPlanning esthetic treatment after avulsion ofmaxillary incisorsrdquo Journal of the American Dental Associationvol 139 no 11 pp 1484ndash1490 2008
[7] MKawakami KOkamoto R Fujii andTKirita ldquoOrthodonticrehabilitation for anterior teeth lost due to trauma with crowd-ing malocclusionrdquo Dental Traumatology vol 26 no 4 pp 357ndash359 2010
[8] S Drummond L S V Pessica A B L Monnerat A F Mon-nerat and M A de Oliveira Almeida ldquoMultidisciplinary solu-tion for an avulsed upper central incisor case reportrdquo DentalTraumatology vol 27 no 3 pp 241ndash246 2011
[9] K Sayinsu and D Nalbantgil ldquoOrthodontic treatment of apatient with traumatic loss of maxillary incisorsrdquoWorld Journalof Orthodontics vol 9 no 1 pp 43ndash47 2008
[10] B U Zachrisson and I A Mjor ldquoRemodeling of teeth bygrindingrdquoThe American Journal of Orthodontics vol 68 no 5pp 545ndash553 1975
[11] A Thordarson B U Zachrisson and I A Mjor ldquoRemodelingof canines to the shape of lateral incisors by grinding a long-term clinical and radiographic evaluationrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 100 no 2 pp123ndash132 1991
[12] S Robertsson and B Mohlin ldquoThe congenitally missing upperlateral incisor A retrospective study of orthodontic spaceclosure versus restorative treatmentrdquo European Journal ofOrthodontics vol 22 no 6 pp 697ndash710 2000
[13] G G Nordquist and RWMcNeill ldquoOrthodontic vs restorativetreatment of the congenitally absent lateral incisormdashlong termperiodontal and occlusal evaluationrdquo Journal of Periodontologyvol 46 no 3 pp 139ndash143 1975
[14] P S Fleming J Seehra and A T Dibiase ldquoCombinedorthodontic-restorative management of maxillary centralincisors lost following traumatic injury a case reportrdquoOrthodontics vol 12 no 3 pp 242ndash251 2011
[15] V G Kokich D L Nappen and P A Shapiro ldquoGingival contourand clinical crown length their effect on the esthetic appearanceof maxillary anterior teethrdquo American Journal of Orthodonticsvol 86 no 2 pp 89ndash94 1984
[16] V G Kokich and V O Kokich ldquoInterrelationship of orthodon-tics with periodontics and restorative dentistryrdquo in Biomechan-ics and Esthetic Strategies in Clinical Orthodontics R NandaEd Elsevier St Louis Mo USA 2005
[17] V Kovich ldquoEsthetics and anterior tooth position an orthodon-tic perspective Part I crown lengthrdquo Journal of Esthetic andRestorative Dentistry vol 5 no 1 pp 19ndash23 1993
[18] V G Kokich and F M Spear ldquoGuidelines for managing theorthodontic-restorative patientrdquo Seminars in Orthodontics vol3 no 1 pp 3ndash20 1997
[19] VG Kokich ldquoEsthetics and vertical tooth position orthodonticpossibilitiesrdquo Compendium of Continuing Education in Den-tistry vol 18 no 12 pp 1225ndash1231 1997
orthodontist must disregard the incisal edges of these teethas guides for final tooth positioning [2]
During orthodontic treatment the maxillary caninesmust be extruded to move their gingival margins incisallyto resemble the usual gingival margin position of lateralincisorsThe lateral incisors must be intruded significantly sothat their gingival margins match the adjacent canines andcreate the illusion of normal anterior gingival levels [2] Anadditional benefit of intruding the lateral incisor is to facilitaterestoration of this tooth into the shape of a central incisor [15]In this case this was done from the first stage of orthodontictreatment by altering the bracket positioning
However addition intrusion of the incisors could haveimproved the gingival margin relationships even further
In order to enhance the gingival architecture excessivemesial angulation of the maxillary lateral incisors (which isunwanted during space closure) should be prevented Thiswas avoided for the patient by placing central incisor bracketson the lateral incisors and preserving appropriate angulationThe reduced mesial angulation allowed the propensity forenhanced torque delivery Consequently proceeding slowlywith space closure to achieve ideal root positioning andusing selective second-order archwire adjustments promotedmesial positioning of the lateral incisor roots
Finally the young patient was treated successfully Asatisfactory occlusion with coincident midlines and estheticresults was achieved
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] B W Neville D D Damm C M Allen and J Bouquot Oraland Maxillofacial Pathology Saunders St Louis Mo USA 3rdedition 2009
[2] V G Kokich and K E Crabill ldquoManaging the patient withmissing or malformed maxillary central incisorsrdquo AmericanJournal of Orthodontics and Dentofacial Orthopedics vol 129no 4 pp S55ndashS63 2006
[3] S Chaushu A Becker and M Zalkind ldquoProsthetic consider-ations in the restoration of orthodontically treated maxillarylateral incisors to replace missing central incisors a clinicalreportrdquo The Journal of Prosthetic Dentistry vol 85 no 4 pp335ndash341 2001
[4] M Ferrari and M C Cagidiaco ldquoTraumatic injuries to perma-nent incisors a case reportrdquo Quintessence International vol 25no 10 pp 717ndash721 1994
[5] C W Wang S Koo D Kim and E E Machtei ldquoNegotiatingthe severely resorbed extraction site a clinical case report withhistologic samplerdquoQuintessence International vol 45 no 3 pp203ndash208 2014
[6] B U Zachrisson ldquoPlanning esthetic treatment after avulsion ofmaxillary incisorsrdquo Journal of the American Dental Associationvol 139 no 11 pp 1484ndash1490 2008
[7] MKawakami KOkamoto R Fujii andTKirita ldquoOrthodonticrehabilitation for anterior teeth lost due to trauma with crowd-ing malocclusionrdquo Dental Traumatology vol 26 no 4 pp 357ndash359 2010
[8] S Drummond L S V Pessica A B L Monnerat A F Mon-nerat and M A de Oliveira Almeida ldquoMultidisciplinary solu-tion for an avulsed upper central incisor case reportrdquo DentalTraumatology vol 27 no 3 pp 241ndash246 2011
[9] K Sayinsu and D Nalbantgil ldquoOrthodontic treatment of apatient with traumatic loss of maxillary incisorsrdquoWorld Journalof Orthodontics vol 9 no 1 pp 43ndash47 2008
[10] B U Zachrisson and I A Mjor ldquoRemodeling of teeth bygrindingrdquoThe American Journal of Orthodontics vol 68 no 5pp 545ndash553 1975
[11] A Thordarson B U Zachrisson and I A Mjor ldquoRemodelingof canines to the shape of lateral incisors by grinding a long-term clinical and radiographic evaluationrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 100 no 2 pp123ndash132 1991
[12] S Robertsson and B Mohlin ldquoThe congenitally missing upperlateral incisor A retrospective study of orthodontic spaceclosure versus restorative treatmentrdquo European Journal ofOrthodontics vol 22 no 6 pp 697ndash710 2000
[13] G G Nordquist and RWMcNeill ldquoOrthodontic vs restorativetreatment of the congenitally absent lateral incisormdashlong termperiodontal and occlusal evaluationrdquo Journal of Periodontologyvol 46 no 3 pp 139ndash143 1975
[14] P S Fleming J Seehra and A T Dibiase ldquoCombinedorthodontic-restorative management of maxillary centralincisors lost following traumatic injury a case reportrdquoOrthodontics vol 12 no 3 pp 242ndash251 2011
[15] V G Kokich D L Nappen and P A Shapiro ldquoGingival contourand clinical crown length their effect on the esthetic appearanceof maxillary anterior teethrdquo American Journal of Orthodonticsvol 86 no 2 pp 89ndash94 1984
[16] V G Kokich and V O Kokich ldquoInterrelationship of orthodon-tics with periodontics and restorative dentistryrdquo in Biomechan-ics and Esthetic Strategies in Clinical Orthodontics R NandaEd Elsevier St Louis Mo USA 2005
[17] V Kovich ldquoEsthetics and anterior tooth position an orthodon-tic perspective Part I crown lengthrdquo Journal of Esthetic andRestorative Dentistry vol 5 no 1 pp 19ndash23 1993
[18] V G Kokich and F M Spear ldquoGuidelines for managing theorthodontic-restorative patientrdquo Seminars in Orthodontics vol3 no 1 pp 3ndash20 1997
[19] VG Kokich ldquoEsthetics and vertical tooth position orthodonticpossibilitiesrdquo Compendium of Continuing Education in Den-tistry vol 18 no 12 pp 1225ndash1231 1997
![Passive Eruption Patterns in Central Incisors[1]](https://static.documents.pub/doc/80x56/55029cb74a7959362a8b4a9a/passive-eruption-patterns-in-central-incisors1.jpg)
