THE ORTHODONTICS EFFECTIVE

ROLE IN PROSTHODONTIC FIELD

Khadiga.A.H.Mohamed BDS, MDSc

Lecturer, in Fixed prosthodontics Department Faculty of Dentistry,Benghazi
University, Libya
Member of Editorial Committee of Libyan Journal of Dentistry
 Introduction

The orthodontic intervention for dental rehabilitation treatment cases plays an active
role to return the esthetics, function, comfort, phonetics and oral health of the
patient.

The best treatment success rate requiring careful interdisciplinary planning approach,
based on a well-designed plan. However, the cooperate between the different
dental branches; orthodontics, endodontics, periodontics, surgery aesthetic
restorative dentistry, and prosthodontcs is mandatory access to achieve the
successfully desired goals.

Moreover, the restorative and prosthodontic dentists rely on orthodontics treatment

to create an optimal restorative environment as a means of providing more
comprehensive care to a wide variety of complicated cases according to the
biological and mechanical principles.
The Multidisciplinary Approach
The multidisciplinary approach treatment is a very effective way as one
specialist cannot deal with all the aspects of the case problems. It
is collaborative elements using and allows all specialists involved to
conduct a dialogue concerning patient care conditions.

The combination between the orthodontist and the prosthodontist

will enhance the treatment outcomes results. However, the
fabrication of the restorations on the malposed teeth using prostheses
alone will fail both esthetically and functionally. So that, the
adjunctive orthodontic treatment designed to creats more success of
the all aspects of the treatment channels.
(Kokich , Spear 1997)
Aim of the review
¨ Giving a wide view to the general dentists, and
specialists for the importance of the orthodontics
effective role in the prosthodontic field in
establishing the successful results through the
comprehensive treatment plan.

¨ Moreover, to insuring the optimal patient care

requires the team approach (collaboration
between the orthodontics with other dental
specialties in problem solving.
 Indications of orthodontics intervention before
fixed prostheses construction

In prosthodontics when the existing teeth positions making the restorations insertion is
impossible or difficult. Beside that, if there is a possibility of the restorations will
create a pathologic situation unless the tooth positions are altered which
Subsequently, directing the occlusal forces against the long axes of the teeth for a more
predictable prognosis , the orthodontics treatment will be as integral part of the plane.
The adjunctive orthodontic treatment is facilitating and improving the dental
restorative condition procedures of teeth at the level of the:
I. Arch (space management).
II. Roots (parallel abutments).
III. Bone height (periodontal considerations).
for the placement of well-adapted and contoured restorations, crowns or implants .
(Cohen 1995)
.
 Articulated Diagnostic Casts
The need for the proposed orthodontic
modifications in prosthodontics is
determined through a careful analysis of
articulated diagnostic casts. This facilitates
assessing the validity of any minor tooth
movement especially valuable when
explaining the treatment proposal to the
patient.
Diagnostic preparations and waxing
procedures made on these altered casts often
clearly show the benefits of minor tooth
movement. Moreover, the computer imaging
technology using to optimize the treatment
planning and improve patient communication
now. However, there are different situation
where the orthodontics inversion play an
important role which will illustrated in this
review.
(ROSENSTIEL :Contemporary Fixed
Prosthodontics Third Edition2001)
1-Orthodontics and Smile Design Rehabilitations
The ideal smile design depends on the symmetry and
balance of facial and dental components.

The orthodontic treatment rendered is an adjunct to

creates a optimal esthtics performance to the
prosthodontcs in the case of space management
with a more organized conservative biologically
sound interdisciplinary manner.

The orthodontic intervention is a viable modality to

correct occlusal, axial, rotational, and space
discrepancies before undertaking fixed prosthetic
rehabilitation. Which ultimately, facilitating the
path of insertion with a better pontic design in
more predictable esthetic and functional therapy
prognosis . (Konstantinova2014).

(Konstantinova2014).
 A- Management space loss for implant placement

The most common example of space management is the

maxillary lateral incisor agenesis. Where the case often
necessitate an interdisciplinary approach specialties care .
The treatment planning difficult due to:
1- Space limitations. 2-Uneven gingival margins
3-Occlusion factor.
The two major orthodontic alternative treatment options are:
1- The space closure and canine modification. Although,
there are objections for orthodontic space option
closure treatment outcome where the canine may not look
"natural. Furthermore, the functional occlusion is
compromised where the retention of the treatment result is
a very difficult.
2-The space opening for prosthetic replacements (single-tooth
implant.).
(Muhamad 2016)

¨
 A- Management space loss for implant placement

As a fact , it appears preferable esthetically and functionally to create space for

replacement of the missing lateral incisor with a single-tooth implant. Unless using
the orthodontic movement , the esthetic gingival architecture can not be achieved.
The gingival zenith around the implant created through the formation of two
papillae, which will be located at the mesial and distal sides of the implant . The
restorative approaches can be divided into two categories (single tooth implant, or
the tooth supported restorations.
The establishing space require many parameters such as:
1. The height and width of the ridge.
2. Occlusal context.
3. The interdental spacing.
4. Time factor.
(Abu-Hussein2015), (Muhamad 2016).
B- ( Decreased Pontic Space) Management
An another example for the orthodontic tooth
movements undertaken to create space for a
pontic or a dental implants when the mesio-
distal dimension available width is less than
the proposed pontic.

It is better to referred for orthodontic

treatment. Otherwise the fixed restoration will
be as unaesthetic manner. However, the
orthodontics improving the position and Konstantinova2014)
alignment of teeth prior to the replacement.
(Sebbar :Issues in Contemporary
Orthodontichttp://www.intechopen.com )

Paul H. Ling2007
 2-Orthodontics and Smile Design Rehabilitations
( Dastima )
Maxillary midline diastemas is a another esthetic problem that dentists
almost treat. There are many innovative therapies have been used which
varying from restorative procedures to surgical (frenectomies) and
orthodontics one.
In reality, the complexity of the management depends upon the etiological
factors that have caused that condition. Thorough diagnosis of the
contributing factors is essential to the success of the diastema
management .

As it is known the etiology of the midline diastema is multifactorial. So

that:
The proper diagnosis and timing is the important part of management.
A n orthodontic treatment is one of the different management options for
the space closure where the permanent retention is the most
important part of treatment.
(Tiyawongman 2017 ) (Abu-Hussei 2016) (Umar Hussain 2013),(Alam
MK )
2-Orthodontics and Smile Design Rehabilitations(
Dastima )
The smile design rehabilitations( with the missing of one
central or both of them in patient with dastima the
edentulous space will be more (including the diastmae
distance) than the missing tooth or teeth width ..
The diagnostic cast utilized to determine quantitative space
discrepancies and can accurately convey the feasibility of
space closure with prosthetic restorations.

Diastema closing with conventional fixed dental prosthesis (FDP)

without considering golden proportion would fail to create
an esthetically pleasing appearance and has detrimental
effects on the periodontium. However, the situation appears
more complicated

If the prosthodontist do not pay attention to that problem the

final result will be ugly( No symmstry between the RT , LT
Centrals .
For better esthteic results the treatment must be starting with the
orthodonticlly space management.
((Bhandari 2013)
 3-Black triangles as Esthetic challenging

Open gingival embrasures or black triangles observed in the cervical region between the
teeth result from a deficit of gingival papilla below the proximal contact points.
Open gingival embrasures or black triangles are often noticeably unaesthetic and
they impacts a negative affects on the smile design . The Amultidisciplinary
approach considered mandatory if a successful clinical outcome is to be achieved .

The absence or loss of interdental papillae can be due to several reasons:

1. Traumatic oral hygiene procedures

2. Abnormal tooth shape
3. Improper contours of the restoration
4. Spacing between the teeth.
(chimène chala, (Al-Zarea 2015)
 Black triangles Esthetic challenging
There are two approaches to solve the
black triangle esthtics dilemma:
1-Restorative/prosthetic restorations
approach:
The prosthetic technique could be chosen as one
options( laminate veneers, crowns) to close the
black triangles. But through the
restorative/prosthetic reshaping of the contours of
the teeth, the contact point may be lengthened
and located more apically; the embrasure is
reduced. Which allowing for closing the space.
Although , this will have some drawback effects
on the periodontal health performance.
 Black triangles Esthetic challenging
2- Orthodontic approach:
The orthodontic closure of the interdental space will cause some degree of
coronal “creeping” of the interproximal gingival tissue through the relaxtion
of the stretching transeptal fibers. Which ultimately the end result will be
narrower gingival embrasure thereby creating new papillae in an ideally
esthetic manner. While , in compromised cases, the restorative intervention
can mask the loss of tissues but rarely can they achieve ideal esthetics.

It has been proven that by maintaining or trying to correct the height of bone in
the interproximal area, an esthetic reconstruction of the papilla can be achieved
through the orthodontic treatment .(Singh 2013)
 4-Orthodontic forced eruption (OFE)
The prosthodontic implications incorporation of an alternative treatment
approach to surgical crown lengthening is the orthodontic forced
eruption (OFE) procedure.

(OFE) uses in the prosthetic field are :

v The pontic site management .

v The Implant site initiation prior to the extraction of the debilitated

tooth.
v In case of the subgingival root fracture creating the required ferrule.
Enabling the prosthodentist place margin of the restoration on the
sound root structure. The advantages of the orthodontic forced
eruption (OFE) are the alveolar bone height of the adjacent teeth is
not compromise and the attached gingival will be maintaining .
 4-Orthodontic forced eruption (OFE)
Tooth fracture is a very common complicated problem
seeking treatment especially when its level at the gum line
making a restoration of the tooth in absence of the ferrule
prone for failure.
The surgical crown lengthening may compromise the esthetic
outcome creating uneven gingival margins relative to the
adjacent teeth and long clinical crowns.

Orthodontic crown lengthening (extrusion) which provides

sufficient supra-gingival tissue to restore appropriately the tooth
with pleasing esthetic outcome. A strategy of rebuilding with a
core and erupting the root to achieve enough solid tooth for a
ferrule effect to get the restoring margin without impinging on
the biological width. However, saving the patient from having
an extraction and either a bridge or an implant. This is truly
minimally invasive dentistry

(Sharma 2012, Potashnick 1982, chimène chalal)

 4-Orthodontic forced eruption (OFE))

A pre-implant orthodontic extrusion of teeth in the prosthetic could be initiated prior to

the extraction of the compromised tooth to induce the buccal and coronal bone
formation as well as soft tissue preservation. The coronal shift of bone and gingiva
enhances the three dimensional topography before extraction of the teeth. As known as
after teeth extraction in many situations ridge deficiencies may occur necessitating the
hard/soft tissue augmentation to achieve the desired esthetics. Where is not always met
with favorable results. (Shyammoha2011).

The indication of a pre-implant tooth extrusion usually is in the anterior region of dentition
limited to moderate bony defect, where esthetics is a major concern., thereby bypassing
the need for additional pre-implant site enhancement surgical procedures. On the
other hand, severe hard and soft tissue defects are contraindications for orthodontic
extrusion, but rather for guided tissue regeneration procedure.

(Keceli 2014, Alsahhaf 2016)

.
 5-Correction of axial inclination
The presence of malposed teeth in case of
replacement complicating the situation and making
that is not so easy task. The correction of axial
inclination will prevent pulp damage during
preparation, as well as improving the periodontal
status of the involved teeth.

The orthodontically movement of malposed teeth make

them better abutments for prosthetic restorations.
Such procedures include the closing of diastemas,
making teeth upright or parallel, gaining of sufficient
pontic space, correction of anterior or posterior cross-
bite, and rotation, intrusion or extrusion of teeth.
(ROSENSTIEL Third Edition 2001)
 5-Correction of axial inclination
A common problem occurs with the tilted mandibular molar abutment where is
impossible to prepare for a fixed partial denture along the long axes of the
respective teeth and achieve a common path of insertion without damage to the
pulp.
In order to address with the cited problem, an orthodontic treatment is needed by
uprighting the tipped tooth when indicated.
The advantages of Uprighting tipped teeth prior to prosthetic restoration are
1. The correction of the axial inclinations will prevent pulp exposure during
preparation.
2. Elimination of periodontal problems which occur in the presence of tipped
molars.

3. Uprighting of tipped teeth will improve the distribution of occlusal forces, and the
teeth may optimally withstand these forces.

4. Improvement of crown/root ratios of periodontally involved molars

On the other hand there are different treatment options available where could be used
only when the orthodontic option is not indicated .
(Prasad 2016) (chimène chalal)
 6-Occlusal Vertical Dimension OVD
The vertical dimension is a term used in dentistry to
indicate the superior-inferior relationship of the
maxilla and the mandible when the teeth are occluded
in maximum intercuspation.
In the Prosthodontic the optimal vertical dimension is an
important factor for the restorations performance.
However, loss of the vertical dimension have a direct
effect on the whole procedure success rate.
There are different factors result in loss of OVD:
1- Posterior teeth missing a probably are the main cause
for loss of OVD.
2- The patients with a worn anterior dentition suffer from
a loss of clinical crown height subsequently
development of decreasing in OVD.
As a result, the aesthetic appearance is affected and the
anterior guidance is lost.
(Abduo2012)
 Dilemma of Generalized Loss of
(OVD
The prosthodnotist always faces a dilemma with the limited remaining
tooth structure which subsequently end by loss of OVD .
The vertical distance between the preparation margin and the occlusal-axial
line angle determines the active preparation height WHICH is
necessary for adequate retention and resistance of the restoration. So
the decreasing in the original tooth height will creates a difficult
situation.
In order to avoid compromising the preparation height, increasing the OVD
should be considered to provide adequate mechanical requirements. As
a result of this approach, the teeth will be subjected to less pulpal
trauma. In addition, by utilizing the available vertical height of the
tooth, the indication for adjunctive crown lengthening surgery is
minimized.

CLINICAL EVALUATION :The prosthetics strategies management

to increase the OVD usually involves multiple teeth in at least one
arch. So that, this approache regarded as an extensive, costly and
time-consuming procedure.
 6-Occlusal Vertical Dimension OVD
The orthodontist and prosthodontist can work together to solve
dilemma of Occlusal Vertical Dimension loss. Specifically, those
with anterior tooth wear presenting a unique esthetics challenge to
prosthodontist.

The orthodontic treatment include the intrusion of the the

mandibular , the maxillary incisors or both in order to create the
proper vertical space to restore the patient smile. Before the
orthodontic treatment begins, the restorative dentist and
orthodontist should meet in order to determine: Which teeth will be
intruded , how long the teeth will be held in position and how the
planned tooth movement . Moreover, the prevention strategies
measures should be the clinician’s main priority including the :
The dietary counselling, fuoride application through different
methods, Parafunctional habits controlling and the gastro-
oesophageal reflux disorder management .
(Burleso 2014) .
 Interdisciplinary Approach For OVD
Diagnosis and treatment planning involve
multidisciplinary and in-depth evaluation of etiological,
esthetic, occlusal, functional and preventive factors.
This is Comprehensive orthodontic treatment in adults
with several missing teeth requires an interdisciplinary
approach..

An increase of the vertical dimension supported by

endosseous dental implants was obtained early in the
orthodontic treatment; this facilitated the mechanics in
the mandibular arch and reestablished the smile
esthetics. The combination of well-planned treatment
and precise execution of the mechanics plan resulted in
good esthetics and occlusion results .
(Flavio Uribe 2013)
 Discussion
The patients usually come to the prosthodontist to replace their missing teeth.
Therefore, it is necessary to focus on the importance of diagnosis and the
development of a clear treatment plan through team specialty work.

The orthodontic management on this basis, play an important effective role in

some of cases by modifying the teeth alignment which gives the situation a
higher chance of successful goals and the best results. In addition to that, it
enable the prosthdontist avoiding the occurrence of multiple complications
may lead to the extraction of remaining teeth at the end. Moreover,
protecting the teeth from the danger of reaching the pulp or the serious
effects on the tempro-mandibular joint.

This will only be done through the work of each team according to its
specialization in order to achieve the most accurate results. Unless an
appropriate referral of patients with fine considerations to orthodontic
treatment the results will be unsatisfactory. The all possibilities, limitations
and risks factors should be prevalent for the patients .
 Conclusions
1. To the prosthodontist if any questions arise concerning the choice of
treatment, the collaboration between the orthodontist and prosthodontist is
imperative. So that, it should be pay in our mind as prosthodontists the
tipped teeth will compromise the final results biologicaly, mechanically
and esthetically if left without a proper management. .

2. The orthodontcs inertvesion before the prosthodontcs treatment when it is

needed accounts for the esthetic and functional success taking advantage
of the synergy of working together to maximize each clinician’s skill in
contributing to the best, most predictable, least invasive outcome for the
patient.

3. In addition to that , this approach can be cost-effective from the standpoint

of producing more stable, durable, and esthetic restorations. Moreover,
to promote a comprehensive, convenient, c and efficient treatment benefits
to the patients.
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