A Comprehensive Interdisciplinary Approach to the Predictable & Functional Esthetic Correction of Malaligned Teeth

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A Comprehensive Interdisciplinary Approach to the Predictable & Functional Esthetic Correction of Malaligned Teeth
Oral Health Journal
April 2006

By: Edward Lowe, BSc, DMD, Nelson Rego, CDT, Juan Rego, CDT

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Dental professionals are enjoying an era in which educated patients may be our best customers. Mainstream media have publicized the capabilities and benefits of today's esthetic restorative treatment options for solving a variety of dental problems, and among these solutions is "instant orthodontics." Unfortunately, despite patients' heightened awareness of advanced dental techniques, many are ignorant to the fact that the esthetic correction of anterior dental malalignment is often more complex than they might think. It is only after a comprehensive examination of the hard and soft tissues, muscles of mastication, and occlusion that the clinician can recommend the most appropriate corrective procedure(s).1

Ensuring the health and stability of each of these components is paramount to ensuring predictable treatment outcomes. Therefore, and particularly in cases for which the patient is found to be compromised in several aspects, coordinated interdisciplinary evaluation and treatment planning is essential for long-term functional and esthetic success.2 The creation of optimal esthetic results for patients with malaligned teeth should begin with a collaborative approach that ultimately increases benefits and reduces risks across periodontal, biomechanical, functional, and dentofacial parameters.1

Tooth misalignment includes tooth rotation, crowding, super-eruption, under-eruption, intrusion, diastemas, and tipping.3 It may also result from inappropriate arch form, position, size, or arch to arch relationships.3 Inherently the hard and soft tissues are affected by the malalignment. The problem may be corrected restoratively, orthodontically, or with a combination of both approaches.3,4 Restorative alternatives change tooth morphology and create the illusion of movement without altering the location of the tooth root.3 To actually move a tooth root, orthodontics is necessary.3 Tooth root location impacts smile esthetics because the maximum and minimum tooth width is determined by the root position and the adjacent teeth.3

Clearly, situations arise when patients are adamantly opposed or unwilling to undergo orthodontic treatment to correct tooth malalignment. If a thorough clinical examination reveals that they are candidates for alternative treatments, they may be able to achieve straight teeth with "instant orthodontics" and the placement of porcelain veneers and/or crown restorations.5 Prosthodontic alternatives can create immediate symmetry and harmony between a patient's vertical and horizontal planes, rather than he or she having to submit to the extended treatment times associated with orthodontics.6 Patients may be candidates for "instant" orthodontics if there is a need for tooth restoration regardless of whether traditional orthodontics is performed (e.g., to correct tooth color defects or structural losses);3 they have an ideal occlusion; the free gingival margin and papilla levels are manageable; they have a pleasing and esthetically acceptable contour; and required tooth preparations won't encroach upon the teeth structurally or biologically.4

However, esthetic correction of malaligned teeth may involve both restorative and orthodontic approaches when the patient simultaneously seeks to correct tooth color defects, repair structural losses or replace existing restorations and other complicating factors exist. For example, the clinician may be unable to correct the occlusal relationship of the maxillary anterior teeth by restorative means alone, as in the case of patients with inadequate or excessive overbites, overjets, or single-tooth anterior crossbites.4

Further, the esthetics or condition of the gingiva (i.e., free gingival margin; coronally positioned margin/deep sulcus) may best be corrected by moving the teeth-and hence surrounding tissue-into position using orthodontics.4 Of course, such considerations should be reviewed by the periodontist in an interdisciplinary manner.7 If any of the affected dentition have undergone previous root canal therapy--or there is concern regarding pulpal health during restorative procedures-then consultation with an endodontist is equally prudent.

This article demonstrates the manner in which an interdisciplinary team approach was undertaken in the treatment of a woman who presented with obvious and complex tooth malalignment. Although the patient initially was ready and willing to undergo "instant orthodontics," clinical evaluation revealed that the most predictable treatment outcomes could only be assured through collaborative efforts between the restorative dentist, periodontist, endodontist, orthodontist, and laboratory technician.

This presentation explains the role of each party in accurately and thoroughly diagnosing her condition; understanding her goals, expectations and limitations; and sequentially planning the treatment alternative that would ultimately yield the most benefits with the least amount of risk.1,4