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 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 25-29

Birds of a feather flock together: An inter-disciplinary orthodontic case report

Department of Orthodontics, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra, India

Date of Web Publication3-Jul-2017

Correspondence Address:
Sanket S Agarkar
Department of Orthodontics, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune - 411 018, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_61_16

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Use of orthodontics for tooth corrections has its own advantages with regards to the amount of tooth movement and the health of the supporting periodontal and alveolar bone. However, many times in cases that require a complex approach to treatment, only an orthodontist may not be able to accomplish the ultimate objectives unless associated with colleagues from other dental specialties. Thus, for an exemplary outcome, cooperation of other dental specialists working together is essential. Treatment carried out using periodontics, prosthodontics, and implant supported prosthesis for a patient undergoing orthodontic treatment and with congenitally missing maxillary lateral incisors, is presented as a case report.

Keywords: Crown, implant surgery, interdisciplinary orthodontics, MBT 0.018” fixed appliance, prosthodontic implant, riding pontic, veneer

How to cite this article:
Agarkar SS, Agarkar AS, Mall J. Birds of a feather flock together: An inter-disciplinary orthodontic case report. J Dent Res Rev 2017;4:25-9

How to cite this URL:
Agarkar SS, Agarkar AS, Mall J. Birds of a feather flock together: An inter-disciplinary orthodontic case report. J Dent Res Rev [serial online] 2017 [cited 2023 Mar 29];4:25-9. Available from: https://www.jdrr.org/text.asp?2017/4/1/25/209364

  Introduction Top

Clinical situations present problems that need a case specific and multidimensional approach to treatment planning. Orthodontics alone may not be at times sufficient. For an optimal outcome, integrating orthodontics in a multidisciplinary treatment approach would be the solution in such cases.[1] Interdisciplinary orthodontics would include procedures involving interrelationships with other fields of dentistry, namely, orthognathic surgery, frenectomy, pericision, and periodontally accelerated osteogenic orthodontic tooth movement. Replacement of missing teeth by space reopening for some form of prosthesis (implant retained or tooth supported) is an example of such a treatment and will be discussed in the present case. In such cases, orthodontic space closure with the movement of adjacent teeth [2],[3] may always be not possible. Alternative treatment approaches include replacement by premolar autotransplantation; implant site preparation for dental implants and/or resin-bonded bridges. Of these, the implant site preparation by opening space for placement of an implant could be considered of great value.[4] This would require the involvement of specialists such as an orthodontist, periodontist, oral surgeon, and prosthodontist working together for a common treatment objective, “just like birds flocking together to reach a common destination.”

  Case Report Top

A 39-year-old male patient reported with the extraoral features of straight profile and an anterior divergent face. He had a slightly deviated chin to the right side by 1.0–1.5 mm [Figure 1]. Intraorally, he had Angle's Class I malocclusion with anterior cross-bite in the right incisor-canine region, congenitally missing maxillary lateral incisors and uneven attritional wear of the central incisors. The right canines were in an end-on relation and left canines in Class I relationship with fairly good molar and premolar occlusion [Figure 2]. He had a chief complaint of spacing in upper anterior teeth, midline diastema, and malaligned teeth.
Figure 1: Pre- and post-treatment facial photographs

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Figure 2: Pretreatment intraoral photographs

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The model analysis of the patient's pretreatment study models showed an upper arch with a spacing of 11 mm and lower arch with crowding of 2 mm. The width of the central incisors was 8 mm each, and the Bolton's analysis showed 2 mm of lower anterior tooth material excess.

On the evaluation of the pretreatment lateral cephalogram [Table 1], the cephalometric diagnosis was skeletal Class I malocclusion with proclined lower incisors and slightly retropositioned upper incisors [Figure 3]. The pretreatment orthopantomogram showed missing upper lateral incisors and missing lower left third molars [Figure 4]. The patient did not give any history of extractions of these teeth thus indicative of their congenital absence.
Table 1: Pretreatment lateral cephalometric readings

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Figure 3: Pre- and post-treatment lateral cephalograms

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Figure 4: Pre- and post-treatment orthopantomogram

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Treatment plan

Considering the spacing and missing teeth; occlusion, age and facial morphology of the patient, a treatment plan was decided so as to achieve interdisciplinary objectives that included redistribution of spaces for prosthetic replacement of the missing lateral incisors (of width 6 mm) and correction of the malocclusion and incisal inclinations. The patient did not want partial or fixed partial dentures, so prosthodontic implants were planned. The option of veneers for the attrided central incisors was given to the patient, and he agreed for the same.

This would ensure good esthetics and adequate canine guidance on a natural tooth instead of an implant placed in the canine region and the natural canine mesialized in place of the lateral incisor.[5],[6]

Treatment progress

Fixed orthodontics was started with a 0.018” MBT appliance and removable lower posterior bite plate for the correction of incisor crossbite. Space was created for both the lateral incisors by closing the midline diastema using coil springs to distalize the right canine and mesialize the incisors. Furthermore, slenderization of the lower anterior teeth was carried out to gain 2 mm of space to align the lower anterior teeth using air-rotor stripping [6] followed by polishing with hand-held safe-sided stripes. At the mid-treatment stage after opening of spaces, adequate space was created/opened between adjacent roots to enable safe placement of the implant without risking contact with adjacent roots, i.e., 6 mm of space so that the implant can be placed safely with at least 1 mm between its surface and the surrounding root surfaces [7] [Figure 5]. Interim tooth replacement was done with riding pontics [8],[9] [Figure 6]. Based on clinical bone mapping done by the implantologist, prosthodontic implant placement was planned on the most favorable part of the bone, so as to achieve a healthy bone to implant integration as per the periodontal and prosthodontic evaluation. A cone-beam computed tomography (CBCT) was made to examine the implant site. The CBCT showed an alveolar ridge deficient for implant placement on the right side because of inadequate bucco-palatal bone in the center of the ridge thereby necessitating the use of bone augmentation procedures and an angulated abutment for the right lateral incisor [Figure 6]. Subsequently, the surgical procedure for prosthetic implant placement was carried out, and single-tooth implant placement for the missing lateral incisors was done [Figure 7]. The treatment was completed with implant crowns for lateral incisors and veneers for the attrided central incisors [10] [Figure 8]. We could achieve near normal angular and linear relationships as per the cephalometric analysis of the posttreatment lateral cephalogram and a comparison with the pretreatment readings [Table 2].
Figure 5: Mid-treatment images and riding pontics

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Figure 6: Cone-beam computed tomography for planning implant placement

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Figure 7: Single implant replacement for the missing lateral incisors

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Figure 8: Posttreatment intraoral photographs

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Table 2: Posttreatment lateral cephalometric readings and comparison

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A final evaluation of the posttreatment occlusion was done under all centric-eccentric movements. For an optimum function, the importance of canine protected occlusion on lateral movement has been emphasized.[11],[12] The same was accomplished for this case along with the prosthetic replacement of the lateral incisors and getting the canines into their position of guidance [Figure 9]. This emphasizes the fact that our colleagues of the other specialties in dentistry are not only our teammates in an interdisciplinary team but also could be called as “Friends from the other Dental Trends.”
Figure 9: Posttreatment incisal and canine guidance

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


Teachers and colleagues at the Department of Orthodontics, Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune friends, and my interdisciplinary colleagues.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Czochrowska EM, Skaare AB, Stenvik A, Zachrisson BU. Outcome of orthodontic space closure with a missing maxillary central incisor. Am J Orthod Dentofacial Orthop 2003;123:597-603.  Back to cited text no. 1
Zachrisson BU. Improving orthodontic results in cases with maxillary incisors missing. Am J Orthod 1978;73:274-89.  Back to cited text no. 2
Zachrisson BU, Stenvik A. Single implants-optimal therapy for missing lateral incisors? Am J Orthod Dentofacial Orthop 2004;126:A13-5.  Back to cited text no. 3
Arvystas M. Orthodontic management of agenesis and other complexities: An interdisciplinary approach to functional esthetics. London and New York: Thieme Publishing, New York Taylor & Francis; 2003. p. 227.  Back to cited text no. 4
Robertsson S, Mohlin B. The congenitally missing upper lateral incisor. A retrospective study of orthodontic space closure versus restorative treatment. Eur J Orthod 2000;22:697-710.  Back to cited text no. 5
Kokich VO Jr., Kinzer GA. Managing congenitally missing lateral incisors. Part I: Canine substitution. J Esthet Restor Dent 2005;17:5-10.  Back to cited text no. 6
Sheridan JJ. Air-rotor stripping. J Clin Orthod 1985;19:43-59.  Back to cited text no. 7
Sharma PK, Sharma P. Interdisciplinary management of congenitally absent maxillary lateral incisors: Orthodontic/prosthodontic perspectives. Semin Orthod 2015;21:27-37.  Back to cited text no. 8
Kinzer GA, Kokich VO Jr. Managing congenitally missing lateral incisors. Part II: Tooth-supported restorations. J Esthet Restor Dent 2005;17:76-84.  Back to cited text no. 9
Kinzer GA, Kokich VO Jr. Managing congenitally missing lateral incisors. Part III: Single-tooth implants. J Esthet Restor Dent 2005;17:202-10.  Back to cited text no. 10
Pini NI, Marchi LM, Pascotto RC. Congenitally missing maxillary lateral incisors: Update on the functional and esthetic parameters of patients treated with implants or space closure and teeth recontouring. Open Dent J 2015;8:289-94.  Back to cited text no. 11
Kokich VG. Make the correct decision mutually. Am J Orthod Dentofacial Orthop 2011;139:423.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]

  [Table 1], [Table 2]


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