Ortho endo-prostho relationship /certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call

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Ortho endo-prostho relationship /certified fixed orthodontic courses by Indian dental academy

  1. 1. Good Morning www.indiandentalacademy.com 1
  2. 2. Interdisciplinary Orthodontics INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com 2
  3. 3. CONTENTS • • • • • • • • • • Concept of complete dentistry Ortho Endo Relationship Effect of Orthodontics on the Tooth Being Moved Effect of orthodontics on vital and non vital teeth Orthodontics as the etiologic agent for endodontics Orthodontic factors associated with non vitality of teeth Resorptive defects Endo treatment after orthodontic treatment Endo treatment during orthodontic treatment Boltons Ratio www.indiandentalacademy.com 3
  4. 4. • Orthodontic Endodontic - Combined Therapy oBasic periodontal principles for forces eruption oBasic endodontic principles for forced eruption oBasic orthodontic principles for tooth movement oForced eruption www.indiandentalacademy.com 4
  5. 5. Ortho prostho relationship • Introduction • Why replace a missing back tooth ? • Introduction to fixed partial dentures Combined ortho prostho therapy • Treatment planning: A multi disciplinary approach • Missing tooth : Space closure or prosthetic replacement ? • Management of a single tooth edentulous space • Lateral incisors • Forced eruption • Alignment of anterior teeth www.indiandentalacademy.com 5
  6. 6. • How to upright inclined molar in preparation for restorative treatment ? • Orthodontic prosthodontic implant interaction • Prosthodontic consideration when using implants for orthodontic anchorage • Clinical cases • Conclusion • Reference www.indiandentalacademy.com 6
  7. 7. THE CONCEPT OF COMPLETE DENTISTRY • The establishment of definitive goals is the foundation for complete dentistry. If a goal is clear enough, it can be visualized and in fact must be visualized. • Clearly defined goals give purpose to treatment planning and make it possible to be highly objective. www.indiandentalacademy.com 7
  8. 8. Complete dentistry has four comprehensive goals : 1) Optimum oral health 2) Anatomic harmony 3) Functional harmony 4) Occlusal stability If each of these goals is achieved, treatment success is assured. www.indiandentalacademy.com 8
  9. 9. Indications for orthodontic treatment in a adult patient can be broadly classified into four categories : 1. Prosthodontic 2. Periodontal 3. Temporomandibular joint (TMJ) 4. Esthetic www.indiandentalacademy.com 9
  10. 10. Orthodontics is a central player in this multidisciplinary dental team and has allowed for better management of these challenging dentofacial problems especially presented by the adult population. www.indiandentalacademy.com 10
  11. 11. A multidisciplinary approach to dental treatment is most desirable and may dramatically improve the treatment outcome as well as the long-term prognosis. www.indiandentalacademy.com 11
  12. 12. The increasing number of adult patients seeking orthodontic therapy has resulted in a progressive modification of treatment modalities. www.indiandentalacademy.com 12
  13. 13. ORTHODONTIC- ENDODONTIC RELATIONSHIP www.indiandentalacademy.com 13
  14. 14. INTRODUCTION www.indiandentalacademy.com 14
  15. 15. • Endodontic treatment can simply be defined as the precautions taken to maintain the health of the vital pulp in a tooth, or the treatment of a damaged or necrotic pulp in a tooth to allow the tooth to remain functional in the dental arch. www.indiandentalacademy.com 15
  16. 16. The pulp can become inflammed and necrosed by the following reasons…. I. Bacterial A. Coronal ingress 1. 2. B. Radicular ingress 1. 2. 3. II. Caries Fracture Caries Retrogenic infection Periodontal pocket or abscess Traumatic A. Acute 1. 2. B. Coronal or radicular fracture Luxation and avulsion Chronic 1. 2. 3. Adult female bruxism Attrition and abrasion Erosion www.indiandentalacademy.com 16
  17. 17. III. Itral A. Cavity Preparation 1. 2. B. Heat of preparation Depth of preparation Restoration 1. 2. Insertion Fracture C. Intentional extirpation D. Orthodontic movement E. F. G. H. Periodontal curettage Electrosurgery Laser burn Periradicular curettage www.indiandentalacademy.com 17
  18. 18. IV. Chemical A. Restorative materials 1. 2. 3. 4. Cements Etching agents Cavity liners Dentin bonding agents www.indiandentalacademy.com 18
  19. 19. B. Disinfectants 1. B. Dessicants 1. V. Silver nitrate and Phenol Alcohol and ether Idiopathic A. B. C. D. E. Aging Internal resorption External resorption Sickle cell anemia Herpes Zoster infection www.indiandentalacademy.com 19
  20. 20. The expanding role of orthodontics into more phases of dental treatment is illustrated by the awareness of relationships with endodontics. There are two major areas where endodontics and orthodontics share common ground. www.indiandentalacademy.com 20
  21. 21. • One is etiologic, because orthodontic treatment affects the tooth being moved ,and some of the response may be noted in the pulp tissue. • The second one is combined therapy, where orthodontic treatment is necessary to gain a desirable endodontic result. www.indiandentalacademy.com 21
  22. 22. EFFECT OF ORTHODONTICS ON THE TOOTH BEING MOVED www.indiandentalacademy.com 22
  23. 23. Orthodontic treatment is used to gain a much more esthetic appearance for the patient and is often further utilized to improve the occlusion. In the course of such therapy, certain changes may occur to the tooth being moved. The most common side effect of orthodontics is to blunt the root of the moved tooth, due to apical and sometimes lateral resorption. www.indiandentalacademy.com 23
  24. 24. Effect of orthodontics on vital and non vital teeth www.indiandentalacademy.com 24
  25. 25. A COMPARISON OF APICAL ROOT RESORPTION DURING ORTHODONTIC TREATMENT IN ENDODONTICALLY TREATED AND VITAL TEETH STEVEN W. AJO DO 1990 • The purpose of this study was to determine whether vital and endodontically treated incisors exhibit a similar severity of apical root resorption in response to orthodontic treatment. • The sample comprised of 20 male and 20 female patients under going ortho treatment. www.indiandentalacademy.com 25
  26. 26. • This study found a statistically greater degree and frequency of mean apical root resorption in the vital control incisors when these teeth were compared with the contralateral endodontically treated incisors. • The results of this study indicate that there is very little clinical difference in the amount or severity of apical root resorption between vital and nonvital teeth. www.indiandentalacademy.com 26
  27. 27. CONCLUSION : • Endodontically treated incisors resorb with less frequency and severity than vital control teeth. • No significant difference in root resorption between male and female patients was detected in endodontically treated incisors. • Control teeth exhibited significantly more resorption in male patients than in female patents. • Even though statistical significance was noted, clinical differences are minimal when endodontically treated and vital incisors are compared. www.indiandentalacademy.com 27
  28. 28. Orthodontics as the Etiologic Agent for Endodontics www.indiandentalacademy.com 28
  29. 29. Some teeth require endodontic treatment as a result of previous orthodontics. Because the action of the blunting of root tips usually occurs in the area where the apical blood vessels and nerves emerge, it can be seen that injury at this susceptible site could affect pulp vitality. www.indiandentalacademy.com 29
  31. 31. TYPE OF MALOCCLUSION : • Among different malocclusions, based on Angle’s classification system, studies have observed a statistically significant difference between class I and class II div 1 malocclusion, with the latter exhibiting more resorption. www.indiandentalacademy.com 31
  32. 32. • Janson et al reported a higher resorption potential for class II div 2 cases in comparison with class I , class II div I and class III patients. • The rationale was that excessive intrusion mechanics were necessary to correct the deep overbite in these cases and also the torque required to correct the palatal inclination of the incisors was high. www.indiandentalacademy.com 32
  33. 33. EXTRACTION VS NON EXTRACTION : • The analysis of literature reveals that both the extraction and the non extraction treatment have the potential to produce damage, with the extraction therapy being potentially more detrimental. • Among all the extraction patterns, extraction of all the first premolars showed the greatest resorption potential. www.indiandentalacademy.com 33
  34. 34. Mechanotherapy Begg Vs edgewise : • Although previous studies could not find any significant resorption rate between Begg light wire mechanics and edgewise ( Tweed ) techniques, a recent study by McNab et al has reported a higher incidence of resorption, as well as amount of root resorption in patients treated with the Begg appliance. www.indiandentalacademy.com 34
  35. 35. • They concluded that the incidence rate of root resorption was 3.72 times higher when extractions were performed as part of Begg appliance therapy. • Root resorption was also observed in all three stages of Begg treatment, with the second stage exhibiting the least severity. www.indiandentalacademy.com 35
  36. 36. TYPE OF TOOTH MOVEMENT : • Intrusion and torque movements are found to be most commonly associated with the resorption process. • This is evident when studying class II div 2 correction as well as Begg mechanics. www.indiandentalacademy.com 36
  37. 37. • The intrusion performed in the first stage and the torquing in the third stage make the Begg technique more vulnerable to resorption. • The highest root resorption is reported to occur when 3 to 4.5 mm of torquing movement was performed. www.indiandentalacademy.com 37
  38. 38. Length of treatment time • The length of treatment time and root resorption have been positively correlated by almost all studies. • These studies have shown that increased treatment time makes tooth roots more prone to iatrogenic response. www.indiandentalacademy.com 38
  39. 39. Type of force applied (Continuous vs interrupted ) • Interrupted forces were shown according to studies to cause less severe apical blunting and smaller resorption affected areas. • The authors of these studies emphasize the use of less detrimental forces ( in the form of elastic usage, instead of elastomeric chains ) during space-closure stages of orthodontic mechanotherapy. www.indiandentalacademy.com 39
  40. 40. Tooth specificity: • Evaluation of the vulnerability of specific teeth to the resorption process in the literature has resulted in common agreement among authors that the maxillary incisors are the teeth that are the most susceptible to the process. • However, Controversy still exists regarding which incisors resorb the most: the centrals or the laterals. www.indiandentalacademy.com 40
  41. 41. • The majority of the studies published reported that the central incisors were more susceptible to the process. • Following the incisors in susceptibility to resorption in the maxillary arch are the molars, followed by the canines. • In the mandibular arch the most resorption vulnerable tooth is the canine, followed by the lateral and central incisors. www.indiandentalacademy.com 41
  42. 42. • Among the posterior teeth, the most resorbed are the mandibular molars (with the distal root exhibiting more resorption), followed by maxillary molars, mandibular premolars, maxillary first premolars, and maxillary second premolars. www.indiandentalacademy.com 42
  43. 43. • Beck and Harris(AJO1942) in their classic article, described the relationship of mechanotherapy to root resorption in the distal roots of molars. According to them anchorage archwire bends at the mesial of molars for bite opening cause the distal roots to be compressed in the tooth sockets, thereby initiating root resorption. www.indiandentalacademy.com 43
  44. 44. Root shape : • Various authors have evaluated abnormalities in root shape and its association to the resorptive process. • Among differently shaped root ends (normal, blunted, dilacerated, pipette shaped, pointed, and incomplete), the least resorption was observed in blunted root ends and the greatest was seen in pointed or tapered root ends. www.indiandentalacademy.com 44
  45. 45. • This phenomena is explained by the fact that the pressure from the axial component of orthodontic forces is felt most at the root apex regions which are abnormal in shape. This results in localized ischemic necrosis, which denudes the pericementum and cementoblasts, permitting colonization of dentinoclasts. www.indiandentalacademy.com 45
  46. 46. • In comparison to the normal root shape, dilacerated roots show the most resorption followed by pipette- shaped and the incomplete roots. • Hence, any abnormal root shapes observed in the pretreatment diagnostic records should be observed with caution and should be monitored throughout the treatment period for any iatrogenic damage. www.indiandentalacademy.com 46
  47. 47. Root length: • A positive correlation is found between the root length and root resorption. The studies in this regard report that longer roots are more prone than shorter ones to resorption. • This may be due to the greater displacement required to produce an equal amount of torque, versus shorter roots. www.indiandentalacademy.com 47
  48. 48. History of trauma: • Previous history of trauma and the presence of pretreatment root resorption have been positively correlated with root resorption seen after orthodontic treatment. • Also studies have found a relationship between cortical plate proximity and increased root resorption. All these findings point towards the importance of obtaining pretreatment diagnostic records and proper evaluation. So that any risk elements can be identified and described. www.indiandentalacademy.com 48
  49. 49. Overjet or overbite: • Studies to date have agreed with a positive correlation between an increase in overjet and root resorption. • The main reasons attributed to this phenomenon are the greater amount of torque and greater root displacements required to correct excessive overjet. www.indiandentalacademy.com 49
  50. 50. Age, Gender and ethnicity: are they contributing factors? • Biologic factors such as age at the start of treatment and gender, have long been associated with risk factors for the initiation of root resoption. • Age at the start of the orthodontic treatment and incidence of root resorption have been poorly correlated in almost all recent studies. www.indiandentalacademy.com 50
  51. 51. • Conflicting results have been seen when gender is considered. Various studies supported that females are more prone to root resorption whereas various others stated that men were more prone. • The majority of the studies support a lack of correlation between gender and resorption. • The relationship between ethnicity and root resorption was evaluated recently. The results showed less severity among Asians in comparison to Caucasians and Hispanics. www.indiandentalacademy.com 51
  52. 52. RESORPTIVE DEFECTS www.indiandentalacademy.com 52
  53. 53. Whether it was the orthodontic therapy or some other pathology that caused the resorption is questionable under any circumstances. However, just as some pulpal changes include deposition of reparative dentin, resorption can also occur from pulpal injury that might have been initiated by orthodontic movement. www.indiandentalacademy.com 53
  54. 54. So it is strongly recommended that following orthodontic treatment a full set of radiographs be taken. These films should be scrutinized carefully by both the orthodontist and the general dentist for any incipient periapical lesions and any unusual changes in pulp canal shape. www.indiandentalacademy.com 54
  55. 55. Furthermore, all teeth that have been moved, particularly those that were pulled into occlusion, should be monitored at least on a once-a-year basis via radiograph and careful clinical examination to verify normalcy of the pulp. If the pulp canal space does begin to diminish or get larger, endodontic therapy should not be delayed. www.indiandentalacademy.com 55
  56. 56. ROOT RESORPTION IN MAXILLARY CENTRAL INCISORS FOLLOWING ACTIVE ORTHODONTIC TREATMENT Copeland S. AJO DO 1986 • The purpose of this study was to determine if apical root resorption associated with orthodontic treatment continues after the termination of active treatment. • A sample of 45 subjects who had experienced root resorption during treatment was selected from the orthodontic clinic at the state university of New York at Buffalo. www.indiandentalacademy.com 56
  57. 57. The data from this radiograph study support the hypothesis that root resorption associated with orthodontic treatment ceases with the termination of active treatment. There was also evidence to suggest that when posttreatment root resorption does occur, it is not necessarily associated with large amounts of root resorption during the active treatment period. It is more likely associated with other factors, such as traumatic occlusion and active forcedelivering retainers. (Am J Orthod 89:51-55, 1986). The results of this study indicate that the termination of active treatment will essentially stop further apical root resorption. www.indiandentalacademy.com 57
  58. 58. BOLTONS RATIO www.indiandentalacademy.com 58
  59. 59. • One of the basic fundamentals with which the orthodontist has to deal in reconstructing the denture is tooth size, specifically the mesiodistal width of the teeth. • Tooth size is an important factor to be taken into consideration in orthodontic diagnosis and treatment planning. • According to Bolton there exists a ratio between the mesiodistal widths of maxillary and mandibular teeth. Many malocclusion occur as a result of abnormalities in tooth size. www.indiandentalacademy.com 59
  60. 60. • Bolton Ratio may be helpful in cases in which • Teeth may be logically extracted if such a procedure deemed necessary. • Extraction of teeth not confined to case in which shortened arch length exists. www.indiandentalacademy.com 60
  61. 61. • Gross disharmonies in tooth size may indicate removal of dental unit or units, even when there is adequate arch length. • Tooth size discrepancies may be corrected by placing over contoured restorations when indicated. www.indiandentalacademy.com 61
  62. 62. ENDODONTIC –ORTHODONTIC COMBINED THERAPY : Endodontic-orthodontic cotreatment may become necessary to save teeth with advanced caries, traumatic destruction of the clinical crown, lateral root perforation, external or internal resorption near the alveolar crest, or overzealous tooth preparation. Without such treatment, these teeth may not offer sound tooth structure on which to place a restoration. www.indiandentalacademy.com 62
  63. 63. An additional combined therapy involves isolated infrabony periodontal defects which also may be amenable to forced eruption. Orthodontic therapy will improve the existing periodontal environment by modifying the osseous topography and minimizing the need to remove supporting bone on adjacent teeth. www.indiandentalacademy.com 63
  64. 64. Endodontic therapy in conjunction with eruption permits placement of a restoration that fulfills the periodontal and occlusal requirements of the tooth. Forced orthodontic endodontic, periodontal, eruption, in conjunction with and restorative therapy, is an alternative. This multidisciplinary approach offers benefits not available with periodontal surgery alone. www.indiandentalacademy.com 64
  65. 65. BASIC PERIODONTAL PRINCIPLES FOR FORCED ERUPTION www.indiandentalacademy.com 65
  66. 66. Orthodontically erupting the tooth with its attachment apparatus and gingiva may eliminate the need for periodontal surgery to expose sound tooth structure and reduce alveolar support on adjacent teeth. Surgery may be necessary to level angular interdental alveolar crests created by tooth movement and reposition the overlying soft tissue to its proper coronal level. www.indiandentalacademy.com 66
  67. 67. A. Resorptive lesion at the alveolar crest causing an infrabony pocket. Patient had history of orthodontic treatment. B, Endodontic treatment completed and initial post room prepared for orthodontic movement. If only surgical treatment were employed to eliminate the pocket and expose the resorptive lesion, a crown-toroot ratio of 2:1 would result. By forced eruption and surgical exposure, a more acceptable ratio of 1:1 is obtained. A www.indiandentalacademy.com B 67
  68. 68. C D E F C. The tooth is erupted, and the alveolar bone and resorptive lesion are moved to a position more amenable to surgical exposure. D, An uprighting spring is placed to align the tooth for parallelism to adjacent teeth. E. Final tooth position. F. Final restoration www.indiandentalacademy.com 68
  69. 69. Exposing adequate sound tooth structure by periodontal surgery alone will lead to a shortened clinical root and a larger clinical crown as the tissues are positioned apically. The crown-toroot ratio of the tooth following surgery alone will exceed the crown-to-root ratio of the tooth that is first orthodontically erupted. www.indiandentalacademy.com 69
  70. 70. There is thus a relative improvement in the crown-to-root ratio of the tooth undergoing orthodontic eruption followed by periodontal therapy that does not occur after a surgical procedure. www.indiandentalacademy.com 70
  71. 71. BASIC ENDODONTIC PRINCIPLES FOR FORCED ERUPTION www.indiandentalacademy.com 71
  72. 72. Teeth that are certain to require endodontic therapy should have such treatment completed prior to the initiation of tooth movement. In the case of an isolated periodontal defect, endodontic therapy should be completed before tooth movement if it appears that intentional extirpation will be required to restore the tooth after eruption. www.indiandentalacademy.com 72
  73. 73. This decision is based on the morphology of the periodontal lesion and the amount of tooth movement required to modify it. Early endodontic treatment eliminates the problem of constantly changing working lengths as the tooth is erupted and the crown is adjusted to the opposing articulation. www.indiandentalacademy.com 73
  74. 74. Teeth that have no pulpal problem and are undergoing eruption may have endodontic therapy completed in one sitting. Teeth that present with caries, resorptive or iatrogenic perforation, or post-traumatic destruction of the clinical crown should receive a multisitting regimen. www.indiandentalacademy.com 74
  75. 75. At times endodontic therapy may become necessary after the initiation of tooth movement. In this case the pulpal tissue should be extirpated as completely as possible, the canal sealed, and the treatment completed as soon after tooth movement as possible. There is no contra-indication to completing the endodontic therapy while the tooth is undergoing orthodontic movement. www.indiandentalacademy.com 75
  76. 76. The problems of treating a tooth in this situation are the presence of the orthodontic appliance and the changing working length. Teeth with loss or destruction of the clinical crown must have endodontic therapy completed prior to tooth movement. Post preparation room of adequate width and length must be provided. A post may then be cemented into the tooth to allow for movement. www.indiandentalacademy.com 76
  77. 77. BASIC ORTHODONTIC PRINCIPLES FOR TOOTH MOVEMENT www.indiandentalacademy.com 77
  78. 78. The patient must understand the indication for tooth movement and that endodontic therapy is essential or highly likely. The patient also must be aware that restorative procedures will follow the endodontic orthodontic cotherapy. www.indiandentalacademy.com 78
  79. 79. • Prior to the initiation of treatment, an estimate of the amount of attachment apparatus remaining at the completion of tooth movement must be made. The tooth must have sufficient radicular attachment to assist in the support of a multiunit restoration or maintain its individual integrity while contributing to esthetics, phonetics and function. www.indiandentalacademy.com 79
  80. 80. Single-rooted teeth generally narrow from the cementoenamel junction to the apex. Eruption of teeth with single roots generally brings a narrower portion of the root to the level of the cementoenamel junction of adjacent teeth. This improves the interdental environment if root proximity is present. www.indiandentalacademy.com 80
  81. 81. Posterior teeth, with their greater osseous support, root surface area, flatter interdental form, and lesser esthetic requirements, are more amenable to osseous surgery than to forced eruption. Forced eruption risks bringing furcations closer to the level of the cementoenamel junction of adjacent teeth. This may result in furcation exposure. www.indiandentalacademy.com 81
  82. 82. Infection and inflammation must be controlled before tooth movement. Control of the inflammatory lesion by curettage of the soft tissue pocket wall and removal of any granulomatous tissue and gingival fibers to the alveolar crest must precede tooth movement. No tooth movement should be started unless the retention and stabilization phases have been fully planned. www.indiandentalacademy.com 82
  83. 83. • Unless very light force is used to extrude the tooth, a lag period occurs between movement of the tooth and movement of its attachment apparatus and surrounding gingiva. The attachment apparatus and gingival unit follow the tooth after it begins to erupt from the alveolus. www.indiandentalacademy.com 83
  84. 84. The amount of force used and the speed of eruption determine the lag time, because the faster the tooth is forcibly extruded the greater will be the lag between the movement of tooth and attachment apparatus. www.indiandentalacademy.com 84
  85. 85. A, Preoperative view of a mandibular cuspid with advanced caries extending A to attachment apparatus. B, Elastic ligature is tied from existing bridge to wire cemented into tooth. B C, With rapid eruption, tooth is extruded from alveolus, exposing sound tooth structure. Movement of attachment apparatus and gingival tissue did occur, as indicated by C position of the soft tissue relative to the adjacent crowns. www.indiandentalacademy.com 85
  86. 86. Forced Eruption www.indiandentalacademy.com 86
  87. 87. • With the advent of orthodontic direct bonding brackets, adjunctive tooth movement such as forced eruption can be practiced efficiently and economically. • With the clinical situation previously described, the technique of forced eruption takes on one of the two clinical protocols… www.indiandentalacademy.com 87
  88. 88. Tooth lacking a clinical crown : Endodontic therapy is completed immediately. Post room of adequate width and length is provided. Control of gingival inflammation by curettage is completed prior to tooth movement. If necessary, a customized post may be fabricated by adding cold-cure acrylic resin around a prefit post for maximum adaptation to the canal walls. www.indiandentalacademy.com 88
  89. 89. Tooth having an intact clinical crown : • A direct bond bracket or orthodontic band is placed as far apical as is permissible. www.indiandentalacademy.com 89
  90. 90. • The greater the force placed on the tooth, the more rapid the tooth erupt from the alveolus. With slow, constant, light pressure, the alveolus and soft tissue will move with the tooth. • Do not be fooled into thinking that the tooth is not erupting if you do not see it extruding from the soft tissue. If properly managed, the soft tissue will move with the tooth. www.indiandentalacademy.com 90
  91. 91. ORTHO PROSTHO - RELATIONSHIP www.indiandentalacademy.com 91
  92. 92. INTRODUCTION www.indiandentalacademy.com 92
  93. 93. Prosthodontics is that discipline of dentistry pertaining to the restoration of oral function, comfort, appearances, and health by restoring natural teeth and replacing missing teeth and contiguous oral and maxillofacial tissues with artificial substitutes. There are three main branches of prosthodontics : • Fixed • Removable • Maxillofacial www.indiandentalacademy.com 93
  94. 94. Fixed prosthodontics pertains to the restoration or replacement of teeth with artificial substitutes that are attached to natural teeth, or implants and that are not readily removable. www.indiandentalacademy.com 94
  95. 95. Removable prosthodontics pertains to the replacement of missing teeth and contiguous oral structures with artificial substitutes that are readily removable. www.indiandentalacademy.com 95
  96. 96. Maxillofacial prosthetics pertains to the restoration of developmental or acquired defects of the stomatognathic system and associated facial structures with artificial substitutes. www.indiandentalacademy.com Fitzgibbon(1923) 96
  97. 97. WHY REPLACE A MISSING BACK TOOTH? www.indiandentalacademy.com 97
  98. 98. If we fail to replace an extracted back tooth with a false tooth, we could lose all of our teeth.. www.indiandentalacademy.com 98
  99. 99. Losing Teeth “Two-For-One” Recent extraction of a lower molar has created space X. Upper tooth 6 is now useless because it no longer has a tooth to chew against. • Therefore, losing one tooth can result in the loss of the use of two. Losing two teeth can result in the loss of the use of four, and so on. www.indiandentalacademy.com 99
  100. 100. A SERIES OF PROBLEMS BEGINS www.indiandentalacademy.com 100
  101. 101. Overeruption : • Back teeth have a lifetime tendency to erupt (move farther into the mouth). Only the presence of a tooth to chew against keeps a back tooth from overerupting. • This patient had a tooth extracted from space X. Upper tooth 6 has overerupted. www.indiandentalacademy.com 101
  102. 102. • The resulting unevenness among the upper back teeth has created areas between these teeth that trap debris. It is very difficult to keep spaces between uneven teeth clean, despite your best efforts at brushing and flossing. • Unclean teeth usually cause inflammation of the surrounding www.indiandentalacademy.com gums. They decay more readily too. 102
  103. 103. • Lower molar 7 is jamming food in between overerupted 6 and 7 during eating (arrow). • This pressure between upper 6 and 7 has caused upper 7 to move backward and separate slightly from upper 6. It has created a www.indiandentalacademy.com 103 space between these teeth (arrow).
  104. 104. • Food can pack into this space with great force during chewing. This creates a serious inflammation of the gum. • Note that overeruption of upper 6 has caused some of its root to become exposed. Exposed root decays faster than the crown www.indiandentalacademy.com 104 of a tooth, as we will see later.
  105. 105. Tilt and drift : Back teeth have a lifetime tendency to tilt (lean over) toward the front of the mouth. They also have the potential to drift (move) toward the front of the mouth. www.indiandentalacademy.com 105
  106. 106. • Now that a tooth has been extracted from position X, a space is left. This allows lower molar 7 to tilt and drift forward. • Lower 7 will tilt farther and farther over as you chew on it. www.indiandentalacademy.com 106
  107. 107. Gum pocket formation : A tooth tilted over will develop a gum pocket along its forward root, as shown here. Gum pockets are narrow, abnormal spaces or clefts that develop between the gums and the tooth root. These pockets trap food www.indiandentalacademy.com 107 debris and bacteria.
  108. 108. • A gum pocket is a problem, you can almost never keep it clean, even with the best brushing and flossing. • The debris and bacteria that collect in pocket lead to everworsening inflammation of the gums adjacent to the pocket. www.indiandentalacademy.com 108
  109. 109. Loss of bone supporting the tooth : • When an area of the gums is constantly inflamed, as you see in this gum pocket, the bone immediately adjacent to it can become inflamed too. Inflamed bone softens, and slowly begins www.indiandentalacademy.com 109 to disappear.
  110. 110. Destruction spreads : Lower molar 7 has drifted and tilted so far forward that upper 7 no longer bites on it. This allows upper 7 to overerupt too. Arrows (↑) show advancing gum pockets, gum inflammation, and bone loss. www.indiandentalacademy.com 110
  111. 111. • Decay has begun on upper teeth 6 and 7, particularly on the exposed portions of the roots of 6 and 7. Exposed roots are especially prone to decay. www.indiandentalacademy.com 111
  112. 112. • Both upper molars are deeply decayed. Decay has also started on lower 7. • Periodontal disease – gum pockets, gum inflammation, and loss of www.indiandentalacademy.com bone – continues to worsen. 112
  113. 113. • Deep decay has allowed bacteria to enter and infect the pulps (“nerves”) of upper 6 and 7. These two teeth have abscessed (become seriously infected). They are so badly damaged by decay www.indiandentalacademy.com that they must be extracted. 113
  114. 114. • Because of inflammation from the gum pocket of lower 7, bone loss (outlined by arrows) has spread around the front root of this tooth and extended to part of the back root too. This tooth has lost so much bone support www.indiandentalacademy.com and must be extracted. 114 that it is now loose
  115. 115. • Because all the molars on this side of the mouth have been removed, the upper and lower 5s have no support behind them and are forced backward by the action of chewing. www.indiandentalacademy.com 115
  116. 116. • Food jams between the separated teeth (arrows). Gum inflammation has begun. Gum pockets will follow, along with bone loss and decay.www.indiandentalacademy.comwill have to be extracted Eventually the 5s 116
  117. 117. • After the loss of the upper and lower 5s, the destructive process can move farther forward. The front teeth will start to spread apart, gum pockets will form, decay begin. • www.indiandentalacademy.com Now you may lose your front teeth too. 117
  118. 118. SUMMARY • So failure to replace a single molar tooth may start a chain of events : overeruption, tilt, gum pockets, decay, bone loss. • Over the years this chain of events can lead to the loss of all your teeth. • Inserting a false tooth today will avoid grief and much greater expense tomorrow. www.indiandentalacademy.com 118
  119. 119. INTRODUCTION TO FIXED PARTIAL DENTURES www.indiandentalacademy.com 119
  120. 120. • A fixed partial denture is defined as “A partial denture that is cemented to natural teeth or roots which furnish the primary support to the prosthesis” • A fixed prosthesis is defined as ‘A restoration or replacement which is attached by a cementing medium to natural teeth, roots or implants’. www.indiandentalacademy.com 120
  121. 121. INDICATIONS FOR FPD : A fixed partial denture is preferred for the following situations : • Short span edentulous arches • Presence of sound teeth that can offer sufficient support adjacent to the edentulous space. • Cases with ridge resorption where a removable partial denture cannot be stable or retentive. • Patient’s preference • Mentally compromised and physically handicapped patients who cannot maintain the removable prosthesis. www.indiandentalacademy.com 121
  122. 122. Contraindications for FPD : Fixed partial dentures are generally avoided in the following conditions : • Large amount of bone loss as in trauma. • Very young patients where teeth have large pulp chambers. • Presence of periodontally compromised abutments. • Long span edentulous spaces. • Bilateral edentulous spaces, which require cross arch stabilization. www.indiandentalacademy.com 122
  123. 123. • Congenitally malformed teeth, which do not have adequate tooth structure to offer support. • Mentally sensitive patients who cannot cooperate with invasive treatment procedures. • Medically compromised patients (e.g. leukemia, hypertension). • Very old patients. www.indiandentalacademy.com 123
  124. 124. Type of veneers : VENEERS Ceramic : • It is the most ideal veneering material when used with metal substructure or in all ceramic restorations. Acrylic : • Tooth colored acrylic can be used with metallic restorations as a veneer. They are not considered as a permanent material due to poor wear resistance. Recent advances include use of indirect composite resins as veneer materials. www.indiandentalacademy.com 124
  125. 125. Indications • Retainers of fixed partial dentures for abutments with sufficient enamel to etch for retention. • Splinting of periodontally compromised teeth • Stabilizing dentitions after orthodontics. • Medically compromised patients, who can not cooperate with long sessions of therapy. www.indiandentalacademy.com 125
  126. 126. Contra Indications • Patients with sensitivity to base metal alloys (Nickel). • Inadequate enamel surface to bond. • Deep vertical overbite. • Incisors with extremely thin faciolingual dimensions. www.indiandentalacademy.com 126
  127. 127. COMBINED ORTHO PROSTHO THERAPY www.indiandentalacademy.com 127
  128. 128. Treatment planning : A multidisciplinary approach • Treatment planning of the adult patient differs from conventional treatment planning of the growing patient in a number of ways. • First, the compromised malocclusions encountered in many adult patients are often associated with various degrees of edentulousness and with various stages of periodontal pathology. www.indiandentalacademy.com 128
  129. 129. • These observations clearly demonstrate that the dental needs of adult patients are challenging and unique. • The ideal goals of orthodontic treatment, which include good esthetics (facial as well as dental), function, and stability, may not always be necessary or realistic to achieve in all adult patients. www.indiandentalacademy.com 129
  130. 130. • Although one should always aim to achieve these ideal treatment goals with acceptable degrees of compromise which can be developed and may be more appropriate to obtain optimal multidisciplinary treatment results. • The multidisciplinary need that these patients present often includes ortho, operative, periodontal and prosthetic therapy as well as implants and surgery. www.indiandentalacademy.com 130
  131. 131. • Another important difference in approaching orthodontic therapy in adult patients involves the careful selection of an appropriate mechanotherapy. • Orthodontic tooth movement in adult patients with compromised dentition must be done carefully because of the possible reduction of bone support. www.indiandentalacademy.com 131
  132. 132. • When designing a treatment plan, it is important to decide exactly where the teeth will be moved, which type of tooth movement they will undergo (uncontrolled tipping, controlled tipping, translation, or root movement), and the required moment-to-force ratio for optimal tooth movement. Space closure www.indiandentalacademy.com Molar Uprighting 132
  133. 133. • Treatment planning of the adult patient includes a thorough extraoral and intraoral clinical examination and collection of adequate diagnostic records. • During the extraoral examination, the patient’s face is assessed in the frontal plane to check for symmetry, in the sagittal plane to check the convexity of the profile, and in the vertical plane to evaluate the vertical proportion of the face. • Particular attention is given to measuring the upper incisor display at rest and the amount of gingival tissue showing at rest and on smiling. • The intraoral examination includes a detailed periodontal evaluation with a recording of the areas of lost attached gingiva, dehiscences, abnormal frenum attachment, pockets, areas of inflammation, and gingival recession. www.indiandentalacademy.com 133
  134. 134. • The presence of dental pathologies is recorded, and the teeth are checked for the adequacy of existing restorations and the presence of caries. • The next step is to assess the dental occlusion in the sagittal, frontal and vertical planes. • Overjet and overbite relationship are noted along with the Angle classification. www.indiandentalacademy.com 134
  135. 135. • The presence of a centric relation-centric occlusion (Cr-Co) discrepancy is carefully recorded, and crossbites are evaluated in Cr and Co. Prematurities are also evaluated in relationship to the presence of a Cr-Co shift. • Lateral excursive movements are checked, and any balancing side interference is recorded. • Specific attention should be directed toward potential temporomandibular problems. www.indiandentalacademy.com 135
  136. 136. MISSING TEETH : SPACE CLOSURE VS. PROSTHETIC REPLACEMENT Space closure www.indiandentalacademy.com Molar Uprighting 136
  137. 137. Following are the factors we should keep in mind…. Old Extraction Sites : • In adults, closing an old extraction site is likely to be difficult. • The problem arises because of resorption and remodeling of alveolar bone. www.indiandentalacademy.com 137
  138. 138. • After several years, resorption results in a decrease in the vertical height of the bone, but more importantly, remodeling produces a buccolingual narrowing of the alveolar process as well. • When this has happened, closing the extraction space requires a reshaping of the cortical bone that comprises the buccal and lingual plates of the alveolar process. www.indiandentalacademy.com 138
  139. 139. Tooth Loss Due to Periodontal Disease : • A space closure problem is also posed by the loss of a tooth due to periodontal disease. • As a general rule, it is unwise to move a tooth into an area where bone has been destroyed by periodontal disease, because of the risk that normal bone formation will not occur as the tooth moves into the defect. • It is better to move teeth away from such an area, in preparation for prosthetic replacement. www.indiandentalacademy.com 139
  140. 140. Space regaining – Molar uprighting : • In clinical situations in which space closure is not a treatment option to address the loss of a permanent first molar, the presence of an edentulous space causes a number of occlusal problems that are challenging to correct orthodontically and restore prosthetically. www.indiandentalacademy.com 140
  141. 141. • The success of treatment depends entirely on a well-selected clinical situation. • Indications for molar uprighting include … • Mesially tipped teeth with enough vertical space to accommodate any extrusion of the teeth during its correction. • Mesially tipped teeth with mesial bony defects. www.indiandentalacademy.com 141
  142. 142. • The pocket depth reduction has been shown to average 3.5 mm on the mesial of the tipped molar as it is uprighted. • Teeth presenting periodontal involvement of the furcation are not good candidates for molar uprighting. Before any orthodontic tooth movement, thorough evaluation and treatment of the periodontal condition is a must. www.indiandentalacademy.com 142
  143. 143. • The potential for impaction of the tooth distal to the tooth to be uprighted should also be carefully evaluated. • In cases in which both second and third molars have tipped into a first molar extraction site, a decision as to whether to maintain or remove the third molar must be made.www.indiandentalacademy.com 143
  144. 144. • The third molar may be maintained if there is adequate space available for its uprighting while maintaining its function against the opposing arch. • If the second molar is compromised, it is desirable to keep the third molar. www.indiandentalacademy.com 144
  145. 145. • But if the second molar needs to be distalized as it is uprighted to reopen adequate restorative space for prosthetics, it may be advantageous to remove the third molar. • The decision to extract or maintain the third molar should be made after consultation among the orthodontist, periodontist, restorative dentist, and patient. www.indiandentalacademy.com 145
  146. 146. • Clinical records may include a set of orthodontic models and radiographs necessary to evaluate the root angulation and bone distribution and therefore assist in deciding what type of tooth movement is desirable for adequate correction. • Models are helpful in evaluating the amount of vertical space available between the arches to accommodate the corrected position of the tooth to be uprighted. www.indiandentalacademy.com 146
  147. 147. • In every case in which it may be possible to avoid the placement of a bridge, orthodontic therapy should be considered to achieve adequate space closure. • The prognosis of such a correction primarily depends on the basic malocclusion and the anticipated corrected occlusion. www.indiandentalacademy.com 147
  148. 148. • The presence of any radicular shape anomalies, root resorption, ridge atrophy, or periodontal disease would compromise the outcome of such a challenging treatment plan. • When we are planning for the patient who presents with edentulous spaces, the use of visualized treatment objectives is essential if excellent orthodontic and prosthetic results are to be achieved. Diagnostic wax up may prove helpful. www.indiandentalacademy.com 148
  149. 149. LATERAL INCISORS www.indiandentalacademy.com 149
  150. 150. • The occurrence of congenitally missing maxillary lateral incisors or abnormally shaped maxillary lateral incisors (Peg laterals) brings patients to consult for orthodontic therapy as part of the restoration of such occlusal problems. • Congenitally missing lateral incisors account for 11% of patients presenting with midline spacing. Missing lateral www.indiandentalacademy.com Peg shaped lateral 150
  151. 151. • Clinically, the absence of maxillary lateral incisors is reflected by the presence of anterior spacings, including a diastema between the central incisors and a mesial drifting of the cuspids. • When maxillary lateral incisors are small, midline discrepancy may also be observed according to the size of the teeth. www.indiandentalacademy.com 151
  152. 152. Treatment options include : 1) The opening of the space to replace the missing lateral incisors with bridges or implants when indicated. This treatment strategy is favored when the posterior occlusion is class I. www.indiandentalacademy.com 152
  153. 153. 2. The space corresponding to the missing lateral incisors may be closed by protraction of the cuspids and the buccal segments of teeth leading to a molar class II final occlusion. The cuspids can be reshaped into lateral incisors, bonded with composite, veneered, or crowned. www.indiandentalacademy.com 153
  154. 154. Contraindications : • Contraindications in reshaping the cuspids into lateral incisors include situations in which the cuspids are oversized mesiodistally or buccolingually. • The presence of a prominent cusp tip or cingulum is also a contraindication to this treatment approach. www.indiandentalacademy.com 154
  155. 155. • In some instances, space closure is the optimum treatment option when maxillary lateral incisors are missing because it avoids the need for prosthetic replacement of the lateral incisors. • A number of factors should be considered during treatment planning. The buccal occlusion and the amount of overjet usually indicate if retraction of the anterior teeth and protraction of the posterior teeth are desirable. www.indiandentalacademy.com 155
  156. 156. FORCED ERUPTION www.indiandentalacademy.com 156
  157. 157. Indications : • Teeth with defects in the cervical third of the root or isolated teeth with one or two walled vertical periodontal defects pose a complex dental problem. • These problems can arise after horizontal or oblique fracture, internal or external resorption, decay, pathologic perforation or periodontal disease. Crown Fracture at alveolar crest Internal root resorption www.indiandentalacademy.com 157 Vertical periodontal defect
  158. 158. • To obtain good access for endodontic and restorative procedures or to reduce pocket depth, it would be necessary to perform extensive crown lengthening that would produce poor esthetics and adverse changes in the crown-to-rootratio. www.indiandentalacademy.com 158
  159. 159. • Controlled extrusion is an excellent alternative. • Forced eruption also allows crown margins to be placed on sound tooth structure while maintaining a uniform gingival contour that provides improved esthetics. www.indiandentalacademy.com 159
  160. 160. • In addition, the alveolar bone height is not compromised, the apparent crown length is maintained, and the bony support of adjacent teeth is not compromised. As the tooth is extruded, the attached gingiva should follow the cementoenamel junction. www.indiandentalacademy.com 160
  161. 161. A: This central incisor had a crown placed after A being chipped previously, but now showed gingival inflammation and elongation. B: Apical radiograph revealed internal root resorption below the crown margin. The treatment plan was: B C: Endodontic treatment, than elongation of the root so that the new crown margin could be placed on sound root structure. C D: Initally elastomeric tie was used from an arch wire segment to an attachment on the post D www.indiandentalacademy.com cemented in the root canal 161
  162. 162. TREATMENT PLANNING www.indiandentalacademy.com 162
  163. 163. • Before beginning treatment, it is essential to have good periapical radiographs to examine the vertical extent of the defect, the periodontal support, the root morphology and position. The ideal morphology is a single tapering root. • Flared or divergent roots will result in increasing root proximity with extrusion and the possibility of exposing the root furcation area. www.indiandentalacademy.com 163
  164. 164. • As a general rule, endodontic therapy should be completed before extrusion of the root begins. • For some patients, however, the orthodontic movement must be completed before definitive endodontic procedures, because one purpose of extrusion may be to provide better access for endodontic and restorative procedures. www.indiandentalacademy.com 164
  165. 165. The distance the tooth should be extruded is determined by three factors : • The location of the defect (fracture line, root perforation, etc.) • Space to place the margin of the restoration so that is not at the base of the gingival sulcus (typically, 1 mm is needed). • An allowance for the biological width of the gingival attachment. www.indiandentalacademy.com 165
  166. 166. Orthodontic technique : • Since extrusion is the tooth movement that occurs most readily and intrusion that occurs least readily, ample anchorage is usually available for adjacent teeth. • The appliance need to be quite rigid over the anchor teeth, and flexible where it attaches to the tooth that is being extruded. www.indiandentalacademy.com 166
  167. 167. • This contraindicates the use of a continuous flexible archwire, which would produce the desired extrusion but also tip the adjacent teeth toward the tooth being extruded, reducing the space for subsequent restorations and disturbing the interproximal contacts within the arch. www.indiandentalacademy.com 167
  168. 168. • The alternative is to bond brackets to the anchor teeth, bond or band the tooth to be extruded, and use a modification of the T-loop appliance. www.indiandentalacademy.com 168
  170. 170. • One of the most complicated problem a clinician faces is when mandibular first molar is missing. • Perhaps the most complex aspect of the above sequelae is the mesially inclined second molar. www.indiandentalacademy.com 170
  171. 171. • Considerations associated with the malposed mandibular molar include inadequate parallelism, poor occlusal plane, lack of interproximal space, adverse root proximity, faulty occlusal landmarks, excessive tooth preparation with potential pulpal involvement, inadequate pontic space, prominent roots exhibited by rotated molars, as well as other periodontal soft and hard tissue deformities of the periodontal structures. www.indiandentalacademy.com 171
  172. 172. • The patients most likely to benefit from tooth movement are those that exhibit periodontal breakdown. • When the decision has been made to replace a strategic tooth (for example : lower first molar) to establish or preserve occlusal stability, the goal is to create a therapeutic occlusion. www.indiandentalacademy.com 172
  173. 173. • It is therefore not always necessary to correct to the orthodontic normal or Class I molar relationship. The objective is to develop an occlusal scheme in which the posterior teeth function to support the vertical dimension in maximum intercuspation and the anterior teeth function to disarticulate the posterior teeth during mandibular excursions. www.indiandentalacademy.com 173
  174. 174. DIAGNOSTIC CONSIDERATIONS IN CASE SELECTION • When the clinician selects a case for uprighting the mesially inclined molar, the patient that exhibits an acceptable occlusion is the best candidate. • The acceptable occlusion, basically, is one in which there is a local dental malposition without a significant skeletal dysplasia. www.indiandentalacademy.com 174
  175. 175. It is defined as having the following characteristics • A normal to mild Class II skeletal pattern in the sagittal dimension with no evidence of transverse or vertical dysplasia. • Posterior teeth present to support the vertical dimension. • Anterior teeth which provide incisal guidance. www.indiandentalacademy.com 175
  176. 176. A. Orthodontic Classification : Orthodontic classification involves a systematic description of the interrelationships of the patient’s a) Skeletal pattern, b) Musculature, and c) Dental arches and the tooth in the dental arch. www.indiandentalacademy.com 176
  177. 177. Analysis of the Skeletal Pattern : • Both arches are evaluated for symmetry of the basal support. Arch forms must be similar for them to occlude properly. 1) Assessment of the Sagittal Dimension : • In the sagittal (anteroposterior) dimension, it is critical to evaluate for the existence of a centric occlusion-centric relation discrepancy. www.indiandentalacademy.com 177
  178. 178. 2) Assessment of the Vertical Dimension : Examination of the facial form should also be made in the vertical dimension. An estimate is made of the open bite or deep bite skeletal pattern by looking clinically or cephalometrically. 3) Assessment of the Transverse Dimension : There should be no basal bone discrepancy in the bucco-lingual relationship of the posterior teeth. It is imperative that this evaluation be made in the retruded position (centric relation). www.indiandentalacademy.com 178
  179. 179. B. Analysis of the Musculature : • A clinical assessment should be made of the muscles of mastication. In the presence of tight or strong musculature, as determined by visual and tactile examination, there is potential for trauma to the tooth that is being uprighted and possibly less tendency for developing an open bite during mechanotherapy. www.indiandentalacademy.com 179
  180. 180. • In the presence of flaccid or weak musculature, during uprighting, there is the danger of extrusion that may be difficult to reverse. This is particularly true when there is both a superimposed skeletal open bite tendency and a weak musculature. www.indiandentalacademy.com 180
  181. 181. 3. Analysis of the Dental Arch and the Tooth in the Dental Arch : First the maxillary and mandibular arches should be evaluated for dental arch symmetry. Then, an assessment is made of the alignment and axial position of the lower molar and premolars relative to their basal support and the occlusal plane. www.indiandentalacademy.com 181
  182. 182. a) Assessment of the Anteroposterior Dimension : In the anteroposterior dimension, the molar should be only mesially inclined. Preferably, the tooth could be repositioned properly by distal tipping. If bodily movement forward is desired, an alteration in appliance design would be necessary. www.indiandentalacademy.com 182
  183. 183. b) Assessment of the Occlusogingival Dimension : In the occlusogingival dimension, the molar with a normal attachment apparatus might exhibit minimal extrusion. Intrusion of lower molars is extremely difficult to accomplish and requires gentle force over a prolonged period of time. www.indiandentalacademy.com 183
  184. 184. c) Assessment of the Buccolingual Dimension : In the buccolingual dimension, the molar that has severe lingual or buccal axial inclination should be avoided because of the amount of torque that would be necessary to properly reposition the tooth for restorative treatment. www.indiandentalacademy.com 184
  185. 185. PERIODONTAL MANAGEMENT www.indiandentalacademy.com 185
  186. 186. • If inflammation is not controlled, then tooth movement accomplished for a periodontally susceptible patient can result in irreversible crestal bone loss probably causing more harm than benefit to the patient. • Therefore before orthodontics is begun, thorough root planing and curettage must be done to eliminate all inflammation. www.indiandentalacademy.com 186
  187. 187. APPLIANCE DESIGN www.indiandentalacademy.com 187
  188. 188. A. Moderately mesially inclined molar with no distal drifting of premolars : 1. Initial arch wire The molar is tipped back into position. www.indiandentalacademy.com 188
  189. 189. 2. Finishing arch wire Rectangular arch wire for buccolingual control. www.indiandentalacademy.com 189
  190. 190. B. Moderately mesially inclined molar with distal drifting of premolars : 1. Initial arch wire www.indiandentalacademy.com 190
  191. 191. 2. Second arch wire • Once mild uprighting has been achieved, rectangular wire (0.018 by 0.25 in.) and an open coil spring should be inserted. • This is not recommended unless the patient has distal tipping and spacing of the premolars. www.indiandentalacademy.com 191
  192. 192. C. Severely mesially inclined second molar : • Initial arch wire may be a “T” loop in 0.016 in round wire. • Now the first appliance can be utilized for finishing as necessary. www.indiandentalacademy.com 192
  193. 193. D. Mesially inclined second and third molars : The third molar should always receive the buccal tube. 1. When using this appliance, it may be necessary to utilize several light, multilooped, round arches to achieve the bracket alignment necessary for rectangular arch engagement. www.indiandentalacademy.com 193
  194. 194. ORTHODONIC PROSTHODONTIC IMPLANT INTERACTION www.indiandentalacademy.com 194
  195. 195. Definition : An implant can be defined as, “A graft or insert set firmly or deeply into or onto the alveolar process that may be prepared for its insertion”. A dental implant is defined as, “A substance that is placed into the jaw to support a crown or fixed or removable denture. www.indiandentalacademy.com 195
  196. 196. Indications for implants : • Othodontic Anchorage • For completely edentulous patients with advanced residual ridge resorption, where it is difficult to obtain adequate retention. • For partially edentulous arches where removable partial dentures may weaken the abutment teeth and also provide reduced masticatory efficiency. • For single tooth replacements where fixed partial dentures cannot be placed. • Patient’s desire. www.indiandentalacademy.com 196
  197. 197. Advantages of using implants : • Preservation of bone : The implant stimulates the bone like a natural tooth thereby preventing the progress of residual ridge resorption. • Improved function : Implants can be designed such that the effect of harmful forces can be minimized. The chewing efficiency is greater than other prosthetic replacements. www.indiandentalacademy.com 197
  198. 198. • Aesthetics : Implants provide a natural emergence profile (appearance of the tooth as if it emerges directly from the soft tissues). • Stability and retention : Implants are more stable and retentive due to osseo-integration. www.indiandentalacademy.com 198
  199. 199. Disadvantages of implants : • It is very expensive. Patient affordability is the primary concern in the use of implants. • Cannot be used in medically compromised patients who cannot undergo surgery. • Many patients do not accept longer duration of treatment and tedious fabrication procedures. www.indiandentalacademy.com 199
  200. 200. • It requires a lot of patient cooperation because repeated recall visits for after care is essential. • It cannot be universally placed due to the presence of anatomical limitations. www.indiandentalacademy.com 200
  201. 201. • Adults presenting for comprehensive orthodontic treatment often have dental problems that require restorative as well as orthodontic treatment. • Such problems include loss of tooth structure from wear and abrasion or trauma, gingival esthetic problems, and missing teeth that require replacement with either conventional prosthodontics or implants. www.indiandentalacademy.com 201
  202. 202. Problems Related to Loss of Tooth Structure : The positioning of damaged, worn or abraded teeth during comprehensive orthodontics must be done with the eventual restorative plan in mind. Early consultation with the restorative dentist obviously becomes important. www.indiandentalacademy.com 202
  203. 203. • There are three particularly important considerations in deciding where the orthodontist should position teeth that are to be restored : • The total amount of space that should be created • The mesio-distal positioning of the tooth within the space • The bucco-lingual positioning. www.indiandentalacademy.com 203
  204. 204. • The orthodontic positioning obviously should provide adequate space for the appropriate addition of the restorative material. • The ideal position may or may not be in the center of the space mesio-distally. This would depend on whether the most esthetic restoration would be produced by symmetric addition on each side of the tooth, or whether a larger build-up on one side would be be better. www.indiandentalacademy.com 204
  205. 205. www.indiandentalacademy.com 205
  206. 206. • Similarly, the ideal bucco-lingual position of a worn or damaged tooth would be influenced by how the restoration was planned. • If a crown or composite build-ups are planned, the tooth should be in the center of the dental arch. • But if a facial veneer is to be used, the orthodontist should place the tooth more lingually than otherwise would be the case, to allow for the thickness of the veneer on the facial surface. www.indiandentalacademy.com 206
  207. 207. • Finally, better restorations can be done if the orthodontist provides slightly more space than is required, so there is room for the restorative dentist to finish and polish proximal surfaces. • The slight excess space can than be closed with a retainer. www.indiandentalacademy.com 207
  208. 208. Gingival Esthetic Problems : • Gingival esthetic problems fall into two categories : those created by excessive or uneven display of gingiva and those created by gingival recession after periodontal bone loss. • This can be an important consideration when one lateral incisor is missingsubstituting a canine on one side almost always results in uneven gingival margins, even if the crown of the substituted canine is recontoured. www.indiandentalacademy.com 208
  209. 209. • If several teeth have been worn or fractured, elongating them can create an unesthetic “gummy smile” even if the gingival margins are kept at the same level across all the teeth. • In that circumstance, it would be better to intrude the incisors to obtain a proper gingival exposure, and then restore the lost crown height. Dental esthetics is not just the teeth-the gingiva play an important role as well. www.indiandentalacademy.com 209
  210. 210. • A particularly distressing problem is created by gingival recession after periodontal bone loss, which creates “black holes” between the maxillary incisor teeth. • Even if periodontal therapy succeeds in obtaining some regeneration of the lost bony support, there is no way to regenerate the missing soft tissue. www.indiandentalacademy.com 210
  211. 211. • One approach to this problem is to remove some interproximal enamel so that the incisors can be brought close together. This moves the contact points more gingivally, minimizing the open space between the teeth. www.indiandentalacademy.com 211
  213. 213. • Major concerns when implants are to be placed are adequate bone in the edentulous area to support the implant, especially when the implant is to replace a congenitally missing tooth, and for single-tooth implants, adequate space between the roots as well as the crowns of the adjacent teeth. www.indiandentalacademy.com 213
  214. 214. • A successful implant requires adequate bone to support it. If there is no tooth to erupt into an area of the dental arch, little or no alveolar bone ever forms. • The result is a large defect in the alveolar process that can make implant placement almost impossible. www.indiandentalacademy.com 214
  215. 215. • Alveolar bone will form in a 2-4 mm area adjacent to an erupting tooth. • For this reason, when an implant is planned as the eventual replacement for a missing maxillary lateral incisor or mandibular second premolar (the most frequent congenitally missing teeth,) it is important for a tooth to erupt in the eventual implant area. www.indiandentalacademy.com 215
  216. 216. • The orthodontic plan would be to open the edentulous space and position the adjacent teeth after the permanent tooth has erupted and to place an implant to support the prosthetic crown after the vertical growth has completed. www.indiandentalacademy.com 216
  217. 217. • The timing of implant placement is particularly critical for adolescents and young patients. • Implants to support the restorations should not be placed untill all vertical growth has completed. • Once the implant has been placed, no further eruption of this tooth will occur, even though the adjacent teeth continue to erupt in response to increase in the patient’s vertical facial height. • The implant is analogous to an ankylosed tooth. www.indiandentalacademy.com 217
  219. 219. • Orthodontic treatment has been a valuable adjunct to prosthodontics for decades. • Indeed, certain prosthodontic treatments are not possible or would be severely compromised without preprosthetic orthodontic therapy. • This mutually beneficial orthodontic prosthodontic relationship has been significantly enhanced through advancements in adult orthodontic treatment. www.indiandentalacademy.com 219
  220. 220. • The use of implants for orthodontic anchorage can produce superior preprosthetic tooth alignments. • However the prosthodontic advantages of using implants for orthodontic anchorage are only fully realized when the location and angulation of the implants are carefully planned so that they are optimally located for prosthesis that will be placed after orthodontic therapy. www.indiandentalacademy.com 220
  221. 221. • A. Patient has extensive vertical overlap of anterior teeth. Mandibular incisors are contacting palatal soft tissue to create gingival trauma. • B. Six remaining mandibular teeth are proclined facially and malaligned. Because of lack of posterior anchorage, teeth for orthodontic retraction and realignment of these teeth cannot be effectively accomplished. www.indiandentalacademy.com 221
  222. 222. • C. Mandibular cast shows location of 4 endosseous root form implants that have been placed to provide posterior anchorage for retraction and realignment of anterior teeth. Implants are thereby located in position where they can be used to support definitive posterior prosthesis after completion of orthodontic therapy. www.indiandentalacademy.com 222
  223. 223. • D. Cast showing one of the orthodontic implant prosthesis that provided orthodontic anchorage. Anteriorly cantilevered pontic was veneered with resin and orthodontic bracket bonded into resin veneer. • E. Orthodontic treatment is nearing completion. Retraction of both maxillary and mandibular anterior teeth has improved their relationship, eliminated palatal soft tissue trauma and improved facial esthetics through changing lip contours. www.indiandentalacademy.com 223
  224. 224. • Without use of mandibular posterior implants, these improvements would not have been possible. Patient will soon be ready for definitive prosthodontic treatment that includes replacement of single incisor crowns and fabrication of maxillary fixed partial dentures from canines to first molars. • Mandibular posterior implants will be used to support and retain posterior prosthesis. www.indiandentalacademy.com 224
  225. 225. CONCLUSION It would do well for all of us to keep in mind that orthodontics cannot stand alone. We are after all dentists by profession. Thus it is our moral obligation to assess not just the teeth but also the surrounding structures . In this manner we elevate the standards of not just orthodontics ,but of dentistry within and outside our community. www.indiandentalacademy.com 225
  226. 226. References: • Maxillofacial prosthesis: William R. Laney • Contemporary fixed prosthodontics: Second edition Stephen F. Rosenstiel • Tylman theory and practice of fixed prosthodontics: 8th edition: W.F.P. Malone • Fundamentals of fixed prosthodontic: 3rd edition, Herbert T. Shillingberg • Fixed prosthodontics: Keith E. Thayer. • Implants in dentistry: Michael S.Block • William R. Profit 3rd edition Text book of orthodontics www.indiandentalacademy.com 226
  227. 227. • Text book of orthodontics : Sameer E. Bishara • T. M. Graber 3rd edition Text book of orthodontics • Endodontic therapy 6th edition Franklin S. Weine • Endodontics 2nd edition John Ide Ingle • Pathways of Pulp 5th edition Steephan Cohen & Richard C. Burns • Endodontics 3rd edition E. Nicholls • Dental clinics of North America : Adult orthodontics Part I and Part II www.indiandentalacademy.com 227
  228. 228. Thank You www.indiandentalacademy.com 228