Sequencing Complex Treatment
Sequence of Treatment
What is complex adjunctive orthodontic treatment?
We will define it as extensive treatment that involves multiple dental specialties in addition to orthodontics. These patients are likely to require endodontics, periodontics, oral/maxillofacial surgery, implants, and restorations of all types.
As an example, consider James’s problems.
He says, “I know it’s time to get my teeth fixed up.” He has lost multiple teeth, severe wear on lower incisors, evidence of active periodontal disease, and several teeth requiring restorations.
 Image 1, face: James, age 27, prior to treatment. |  Image 2, maxillary occlusal: James, age 27, prior to treatment. |
 Image 3, mandibular occlusal: James, age 27, prior to treatment. |
Sequence of Treatment (cont.)
Note the severity of the Class II malocclusion, with excessive overjet and overbite (images 1-3). This complicates the treatment of his other dental problems.
His facial proportions indicate (image 4) and cephalometric analysis confirms (image 5) that the malocclusion is due to a combination of maxillary dental protrusion and skeletal mandibular deficiency.
Note the relationship of the maxillary incisors to the maxilla: severely tipped and well forward from the anterior extent of their supporting bone.
Also note how far the chin is behind a true vertical line dropped from nasion. The maxilla (point A) is slightly behind this line, the mandible (points B and pogonion) are well behind it. The skeletal Class II, therefore, is due entirely to mandibular deficiency.
 Image 1, right lateral: James, age 27, dentition prior to treatment. |  Image 2, left lateral: James, age 27, dentition prior to treatment. |
 Image 3, frontal intra-oral: James, age 27, dentition prior to treatment. |  Image 4, profile: Note the mandibular deficiency and weak chin. |
 Image 5, ceph tracing: Note the mandibular deficiency and weak chin. |
Sequence of Treatment (cont.)
Given a patient with such extensive treatment needs, how do you sequence the treatment?
The principle is simple, though the application may not be.
First, active disease must be brought under control (image 1). This would involve extraction of hopeless teeth, periodontics at the level needed to control active disease, endodontics as needed to maintain important teeth, and restorations (perhaps temporary ones) for caries control. For James, the first step consisted entirely of perio control.
Second, correct the alignment and occlusion of the teeth and do what is necessary to obtain acceptable dental esthetics and facial proportions.
Keep in mind why James wants his teeth fixed: For better health and function, but especially to improve his chances of getting ahead in the world—which means that his post-treatment facial appearance is important.
This second stage involves orthodontics and, if needed, orthognathic surgery (image 2). For James, mandibular advancement surgery was needed to put him in a position where satisfactory replacement of missing teeth was feasible. It also removed the “weak chin” appearance. In this image, you can see the screws in the mandibular ramus to hold the segments while healing occurs after mandibular advancement.
 Image 1, disease control: First step: disease control. |  Image 2, dentofacial correction: Second step: correct facial proportions and dental occlusion. |
Sequence of Treatment (cont.)
Third, provide definitive periodontics (anything needed for long-term maintenance, for example, bone or soft tissue grafts) and definitive restorative dentistry. That could mean implants, onlays, crowns, fixed or removable partial dentures. Typically, it would include replacement of temporary restorations that were placed for disease control until the occlusion could be corrected.
At that point, the benefit of the orthodontic component of treatment for restoration of missing teeth becomes apparent. Because crowns/bridge abutments etc. can be fabricated more ideally, the restorative dentistry has a better long-term prognosis.
For James, the last step in treatment was extensive posterior restorations including bridges on the right side, which you can see in this cephalometric radiograph at the completion of treatment (image 1).
The facial change created by putting the mandible in its proper position can be seen in image 2. Would you agree that the stronger chin makes him look more confident and more competent? The pretreatment person would be easier to push around?
Because the dental relationships were normal after the mandibular advancement and orthodontic finishing, no compromises in the restorations were necessary (images 3-5). An implant-supported partial denture on the right side was deferred because of cost—premolar occlusion on that side was acceptable. It should be possible now for him to maintain dental health.
As often is the case, the treatment changed his own view of what he could accomplish. He quit his job in a service industry after taking classes in computer programming while the treatment was being carried out and embarked on a new career.
 Image 1, finish ceph: Cephalometric radiograph at completion of treatment. |  Image 2, facial change: Change in facial appearance. |
 Image 3, right lateral: Change in dental occlusion. |  Image 4, frontal intra-oral: Change in dental occlusion. |
 Image 5, left lateral: Change in dental occlusion. |
Sequence of Treatment (cont.)
Some special points about the sequencing of complex treatment.
(1) Teeth that have had endodontic treatment can be moved orthodontically. Their periodontal ligament remains normal, and the response to orthodontic force is similar. Some reports have indicated a greater risk of root resorption with tooth movement after endodontics, others have found no difference or even less root resorption. The best evidence is that root resorption is not a major concern when endo-treated teeth are moved.
But orthodontic movement may be the last straw for a tooth with a traumatized or sensitized pulp. A patient with a tooth that may need endo treatment must be warned that it is possible for it to flare up and require treatment when orthodontics begins.
For this patient (images 1-5), in order to align severely crowded incisor teeth, the lower left first premolar was extracted. Despite the periapical area that required apicoectomy, the first molar was retained, and it responded normally to orthodontic tooth movement after the endodontic re-treatment.
 Image 1, pre-treatment crowding: Mandibular arch prior to treatment. |  Image 2, pre-treatment periapical area: Periapical area lower left first molar prior to treatment. |
 Image 3, orthodontic progress: Orthodontic progress, premolar extraction space closed. |  Image 4, post-treatment periapical area: Orthodontic treatment in progress after apicoectomy. |
 Image 5, comparison: Comparison before/after space closure involving endo-treated molar. |
Sequence of Treatment (cont.)
Some special points about the sequencing of complex treatment.
(2) Temporary restorations to control caries or replace unsatisfactory ones often are needed prior to orthodontics or surgery to correct the occlusion, but the temporary restoration must last for the duration of the orthodontic treatment, i.e., up to two years.
Susan, who was a candidate for orthognathic surgery, had poor crowns on her previously fractured maxillary central incisors (image 1). These had to be replaced in the first stage of treatment (disease control) to control the gingival inflammation (image 2). Temporary acrylic crowns were used during the duration of the orthodontic treatment (image 3), then new porcelain crowns were placed soon after the orthodontic appliance was removed (images 4, 5).
Crowns on incisors in patients with excessive overjet often are made thick faciolingually in order to obtain occlusal contact of the incisors. The thick crowns make it impossible to correct the overjet during orthodontic treatment, so even a well-fitting crown on an upper incisor may have to be removed if it is too thick. Sometimes an old crown can be retained during treatment after it has been extensively reshaped, and then replaced after the occlusion has been corrected.
 Image 1, pre-tx crowns: Prior to treatment, unsatisfactory crowns on central incisors. |  Image 2, temporary crowns: Temporary crowns in place, just prior to orthognathic surgery. |
 Image 3, during tx: Temporary crowns, after orthognathic surgery, during finishing orthodontics. |  Image 4, permanent crowns: Permanent crowns, placed soon after completion of orthodontics. |
 Image 5, tx sequence: Overview of treatment sequence. |
Sequence of Treatment (cont.)
Some special points about the sequencing of complex treatment.
(3) It is critically important for patients with complex problems to be seen regularly for perio maintenance during active orthodontics. The recall schedule is established from the patient’s needs, but often scaling/curettage is needed at 2-3-month intervals.
For this patient, extraction of periodontally involved incisors with a poor long-term prognosis (image 1) made it possible to align the severely crowded anterior teeth in both arches (images 2, 3) and improve the chances of maintaining the remaining teeth. Continued perio recall at 3-month intervals during the orthodontic treatment was an important part of patient management.
Periodontal problems must be brought under control before orthodontic treatment begins and must be kept under control during the orthodontics.
 Image 1, pre-tx: Prior to treatment. |  Image 2, extractions: Incisor extractions, perio treatment continuing. |
 Image 3, progress: Alignment progress, frequent perio recalls scheduled. |
Sequence of Treatment (cont.)
Some special points about the sequencing of complex treatment.
(4) Careful coordination between the end of orthodontic treatment and the final restorative work is important. The time in orthodontic retainers before restorations are placed should be minimal. Waiting to start the restorative dentistry “until things settle down” is a recipe for problems.
Think of it this way: Bridges/implants serve as permanent retainers after the orthodontics. The removable retainers typically used after orthodontics in adolescents rarely are satisfactory even for short times in adults awaiting fixed prosthodontics. Bonded or thermoplastic (suckdown) retainers are better, but not as good as fixed prostheses.
Bottom line: When the braces come off, get on with the restorative work sooner rather than later. For James, the patient whom we just looked at, the bridges are permanent retainers.
Case #1: Implants or Bridges?
Case #1: Implants vs Bridges
Now let’s look at a patient who illustrates important considerations in answering two common clinical questions:
- close old extraction spaces, or open them for prosthetic replacements?
- implants or bridges to replace missing teeth?
June (images 1-5) was age 45 when she sought treatment. She was concerned about the appearance of her teeth and wanted her missing molars replaced. Her comment: “I paid for orthodontics for two kids and just finished putting both of them through college. Now it’s my turn.”
As she put it, she “smiled a crooked smile” because the maxillary left lateral incisor was congenitally missing. Composite had been added to the mesial of the canine to partially conceal the missing tooth, but the asymmetry was obvious when she smiled.
All four first molars were missing. In the maxillary arch the extraction space was closed on the right side, partially open on the left. Both lower second molars were severely tipped mesially, and the left second molar was also displaced buccally. There was a significant buccal crossbite on the left.
There were restorations in most posterior teeth, with recent composites placed for caries control in mandibular second premolars.
 Image 1, facial appearance: June, age 45, prior to treatment. |  Image 2, frontal intraoral: June, age 45, prior to treatment. |
 Image 3, right lateral: June, age 45, prior to treatment. |  Image 4, left lateral: June, age 45, prior to treatment. |
 Image 5, occlusal views: June, age 45, prior to treatment. |
Case #1: Initial Records
When these initial orthodontic records were taken, she had already undergone restorative and perio treatment for control of active disease. The displaced teeth are shown well on the panoramic radiograph. Note that there are no areas of extreme bone loss.
The key questions in planning further treatment were:
- how to manage the esthetic problem created by the missing maxillary lateral incisor
- how to manage the maxillary first molar extraction sites, one of which was already closed
- how to manage the mandibular first molar extraction sites, with severely tipped second molars
- how to replace missing teeth if spaces were opened (bridges or implants?)
Case #1: Treatment Plan
For incisor esthetics, symmetry is always important. This was a major factor in planning treatment for June. It would be very difficult to restore the maxillary left canine to make it an acceptable substitute for the missing lateral incisor, especially because its gingival margin was so different from the natural lateral on the other side. Opening space for replacement for the lateral incisor was feasible because space for the missing first molar in the same quadrant could be closed as this was done.
Her occlusion also was a factor: She was almost in anterior crossbite, and slightly advancing the maxillary incisors would improve the incisor relationships in function.
Thus the plan for the maxillary arch was to:
- open space for a prosthetic lateral incisor, and
- close the first molar extraction sites.
An important factor in the decision: Recent research has shown that unlike the lower arch, good periodontal health is possible with upper second molars tipped mesially, so there was no compelling reason to try to bring the roots of the upper second molars mesially.
Case #1, Treatment Plan (cont.)
In the mandibular arch, closing the old first molar extraction sites would be extremely difficult and time consuming. To do that, it would be necessary to place implants in the mandibular ramus to serve as anchorage to bring the second and third molar roots mesially. As these molars were moved mesially, they also would have to be moved even further lingually to correct the crossbite.
In contrast, if the mandibular third molars were extracted, tipping the second molars upright would be straightforward and would have the added advantage of improving periodontal health on the mesial of these teeth. Mesially tipped lower molars are at risk periodontally.
The question of implants versus bridges for the three replacement teeth that would be needed was left open at the time the orthodontics was begun.
Case #1, Treatment Plan (cont.)
For severely tipped lower molars, an auxiliary uprighting spring (images 1, 2) often is the most effective way to begin the necessary tooth movement. For June, the uprighting spring could be contoured to tip the lower right second molar lingually as it uprighted. Often lingual tipping is an undesirable side effect of uprighting springs—for her it was an advantage.
After 10 months of treatment, the lower molars had been uprighted (images 3, 4). The maxillary lateral incisor space had been opened, and a prosthetic lateral incisor was attached to the arch wire. This creates a highly esthetic replacement, but it needs to be attached to a rigid rectangular wire for stability.
Note the use of bonded attachments on the molars as well as the other teeth. If possible, bands should be avoided in patients with previous perio problems around molar teeth. In June’s case, curettage on the mesial of the second molars as they uprighted was an important part of the treatment.
At 14 months the maxillary space had been closed, but (as planned) the upper molars still were tipped mesially. As we have noted, mesially tipped upper molars are much more compatible with good periodontal health than mesially tipped lower molars. At that point uprighting of the lower molars had nearly been completed.
 Image 1, uprighting diagram: Diagrammatic representation, uprighting a severely tipped lower molar by tipping it distally. |  Image 2, uprighting spring: Uprighting spring in place. |
 Image 3, 10 months, right side: 10 months progress: molar uprighted, crossbite corrected. |  Image 4, 10 months, left side: Lateral incisor space opened, pontic in place; molar uprighted, crossbite greatly improved. |
 Image 5, 14 months, pan: 14 months progress. |
Case #1: Progress
At 18 months, treatment was nearly complete (images 1-5).
Between 14 and 18 months, a coil spring was used in the maxillary arch to make space for a larger permanent lateral incisor prosthesis. Coil springs were used to further open the mandibular molar extraction sites after the initial uprighting was completed, and then segments of closed coil over the arch wire were placed to maintain the space.
Note that there was minimal overjet at this point. Fortunately the upper second molars could be left in their mesially tipped position, because any force system to bring their roots mesially would tend to retract the upper incisors, and that would have brought her into anterior crossbite.
 Image 1, frontal: June, age 46, 18 months progress. |  Image 2, right lateral: June, age 46, 18 months progress. |
 Image 3, left lateral: June, age 46, 18 months progress. |  Image 4, max occlusal: June, age 46, 18 months progress. |
 Image 5, mand occlusal: June, age 46, 18 months progress. |
Case #1: Implant vs Bridge Decision
At this point, with orthodontic treatment nearly completed, decisions as to implants versus bridges had to be made. The greater cost of implants was a factor, but June wanted the best quality of result and would consider implants.
For her, a single tooth implant to replace the maxillary lateral incisor offered better esthetics than a bridge and would not require crowns on the central incisor and canine (image 1).
In the lower arch, however (image 2), implant placement was complicated by the loss of bone at the old extraction sites, especially on the left side. Bone grafting would be needed before an implant could be placed there. The lower second molars and the right second premolar needed permanent restorations and would benefit from crowns.
The decision, therefore, was an implant in the maxillary incisor region and bridges in the lower arch.
| Image 1, maxillary occlusal: 18 months progress, treatment nearly completed. | Image 2, mandibular occlusal: 18 months progress, treatment nearly completed. |
Case #1: Sequencing of Implant Placement with Final Orthodontics
The interaction between completion of orthodontics and implant placement is an important consideration. Note (images 1-3) that at 24 months after the beginning of treatment, an implant had been placed in June’s maxillary arch. The orthodontic appliance had been removed in the mandibular arch, and bonded wire retainers were in place, but the maxillary orthodontic appliance remains in place—why?
The reason is that the orthodontic appliance is an effective way to supply a pontic for the esthetically sensitive maxillary incisor area while healing around the implant site occurs. The pontic tied to the arch wire avoids any contact with the soft tissue over the implant. This could be a problem if a removable retainer with a replacement tooth were used.
Note the bonded retainers in the lower arch to maintain the incisor alignment and control the molar spaces. Fixed, not removable, retainers are preferred in complex treatment. Fabrication of the lower bridges could have started at this point but were delayed until the implant crown was completed.
With the orthodontic appliance still supplying the temporary pontic (images 4, 5), a connective tissue graft was placed on the facial of the lateral implant area, and a healing abutment was attached.
 Image 1, 24 months pan: June, age 47, 24 months progress, maxillary implant, mandibular fixed retainers. |  Image 2, maxillary occlusal: June, age 47, 24 months progress, maxillary implant in place but not yet uncovered, pontic tied to arch wire. |
 Image 3, mandibular occlusal: June, age 47, 24 months progress, mandibular fixed retainers in place, awaiting bridge fabrication. |  Image 4, connective tissue graft: Connective tissue graft to facial of implant. |
 Image 5, healing abutment: Healing abutment in place. |
Case #1: Completion of Orthodontic Treatment
Four months after that, the orthodontic appliance was removed, and the finished crown was placed on the implant. The fixed retainers remained in place in the mandibular arch until fabrication of the bridges was started. Fixed retainers are particularly advantageous when there will be more than a few months of delay between removal of the orthodontic appliance and placement of the permanent retainers (the bridges), as there was for this patient, while the implant crown was completed—but fabrication of the mandibular bridges could have been done at any time after the orthodontic appliance was removed.
 Image 1, frontal: Crown on implant, orthodontic appliance removed. |  Image 2, right lateral: Fixed retainer in lower arch. |
 Image 3, left lateral: Crown on implant, fixed retainer in lower arch. |
Case #1: Completion of Orthodontic Treatment (cont.)
Extracting the third molar and uprighting the second molar, as was done for June, brings the upper and lower second molars into occlusion. The sequence of treatment is shown in images 1-3. Bone fill-in on the mesial of the uprighted molar occurs if periodontal health is maintained in that area (which should be curetted during the uprighting).
Comparison of the panoramic radiographs before and after treatment (image 4) shows the tooth movement. Note that preparation of one of the bridges had begun at this point, soon after the upper appliance was removed and the crown was placed on the implant.
 Image 1, pre-tx: Mesially tipped second molar, third molar in place. |  Image 2, 3rd molar extracted: Mesially tipped second molar after extraction of third molar. |
 Image 3, 2nd molar uprighted: Note bone fill-in on mesial of uprighted second molar. |  Image 4, comparison: Pre- and posttreatment panoramic radiographs. |
Case #1: Completion of Treatment
June was pleased with the appearance of her teeth and especially with the improvement in her smile esthetics (image 1).
Although there were minimal changes in her profile, note that the treatment increased support for her upper lip (image 2). This was a part of the esthetic improvement.
With the bridges in place, she had satisfactory occlusion. Excellent dental health was observed on her recent 6-year recall (images 3-5). For her, this mixture of implant and bridges provided an excellent outcome.
 Image 1, smile change: June, age 45 to 47, change in smile esthetics. |  Image 2, profile change: June, age 45 to 47, change in profile. |
 Image 3, frontal: June, age 53, 6-year recall. |  Image 4, right lateral: June, age 53, 6-year recall. |
 Image 5, left lateral: June, age 53, 6-year recall. |
Case #2: Perio / Orthognathic Surgery / Restorative
Case #2: Orthognathic Surgery
Now let’s look at a second patient needing complex adjunctive treatment.
Jim sought treatment at age 43 because he needed a better replacement for his missing upper incisors. He didn’t like the appearance of his present partial denture when he smiled, felt that it didn’t fit properly anyway, and was concerned that he was on the way to losing all his teeth.
Facial proportions are somewhat difficult to assess in the presence of a beard—one of the reasons for wearing it, of course—but you can see that he has a degree of mandibular deficiency.
 Image 1, frontal: Jim, age 43, prior to treatment. |  Image 2, frontal smile: Jim, age 43, prior to treatment. |
 Image 3, 3/4 view: Jim, age 43, prior to treatment. |  Image 4, profile: Jim, age 43, prior to treatment. |
Case #2: Initial Intraoral Appearance
He had a very deep bite, with the lower incisors against the palatal portion of the partial denture when it was in place and right against the palate without it. The mandibular arch was almost telescoped within the maxillary arch.
All mandibular posterior teeth were missing on the left side, and the maxillary teeth had supererupted. The mandibular right first molar was missing, and the second molar had tipped mesially. Both second premolars had broken-down restorations and active caries.
There was evidence of active periodontal disease, i.e., bleeding on probing in several areas.
 Image 1, partial denture in: Jim, age 43, prior to treatment. |  Image 2, denture out, overbite: Jim, age 43, prior to treatment. |
 Image 3, right lateral view: Jim, age 43, prior to treatment. |  Image 4, left lateral view: Jim, age 43, prior to treatment. |
 Image 5, occlusal views: Jim, age 43, prior to treatment. |
Case #2: Initial Radiographs
Both mandibular second premolars had had previous endodontic treatment (image 1), and there was a questionable periapical area for the right second premolar. Moderate bone loss in both maxillary posterior quadrants was apparent.
In the panoramic radiograph, note the supereruption of the maxillary molars on the left side, where opposing teeth were lost many years previously. There is not enough vertical space for a partial denture for the mandibular left area.
The cephalometric radiograph and tracing (image 2) showed severe mandibular deficiency, with poor lip support from the teeth in both arches. Lower face height was short, both in comparison to normal dimensions and (more important) in relation to the width of his face. There was an extreme curve of Spee in the lower arch due to elongation of the mandibular incisors.
 Image 1, pan: Jim, age 43, prior to treatment. |  Image 2, ceph: Jim, age 43, prior to treatment. |
Case #2: Treatment Plan
The plan for Jim followed the sequence guidelines. The first thing to be done was to control his oral health problems (image 1):
- extract the mandibular right third molar
- perio control procedures
- temporary restoration of the mandibular right second and left first premolars, the previously endo-treated teeth
- reevaluate the endodontic status of these teeth
With the dental health problems under control, the plan for the second and third stages of treatment (image 2) was:
- maxillary orthodontic appliance, with replacement pontics for the upper incisors attached to it, to align and level
- mandibular orthodontic appliance, uprighting of second molar
- ramus surgery to lengthen the mandible
- postsurgical leveling of the mandibular arch
- replacement of missing teeth with a fixed prosthesis in the upper arch and on the mandibular right, and a removable partial denture for the lower left posterior area (selected instead of implants primarily because of cost).
 Image 1, stage 1 plan |  Image 2, stage 2-3 plan |
Case #2: Progress Presurgery
After 8 months, disease control and the presurgical orthodontics had been completed, and he was ready for the orthognathic surgery to advance his mandible and rotate it down anteriorly. At this point, of course, facial proportions were unchanged (images 1-3).
As soon as a rigid arch wire could be put in the upper arch, prosthetic teeth were tied to it. Although prosthetic teeth tied to an arch wire leave something to be desired in function, they look quite realistic, and his previous partial was so bad that almost anything would have been better.
In the cephalometric radiograph (image 4), the stabilizing arch wire to be used at the time of surgery can be seen, with the prosthetic teeth attached to it. The vertical hooks soldered to the arch wire, which can be seen in the radiograph, are used in the operating room to hold the teeth in the planned occlusion while screws across the osteotomy site are placed to hold the jaw segments during healing. With this approach, it is not necessary to wire the jaws together during healing, and patients are much more comfortable even though they still must be on a restricted diet. Patients often think that if the surgeon “breaks my jaw,” they will have to have their teeth wired together for weeks—not true now. You can reassure them that their jaw isn’t broken, it’s cut carefully, and that they won’t be wired shut.
 Image 1, frontal view: Jim, age 44, ready for surgery. |  Image 2, frontal, smile: Jim, age 44, ready for surgery. |
 Image 3, profile: Jim, age 44, ready for surgery. |  Image 4, lateral ceph: Jim, age 44, ready for surgery. |
Case #2: Progress Presurgery (cont.)
The heavy stabilizing arch wires placed in both arches for stabilization at surgery, with soldered brass hooks to facilitate wiring the jaws together in the operating room, can be seen in these presurgical views.
Note that the anterior deep bite has not been corrected prior to surgery. Instead, the mandible will be rotated so that the chin moves downward and forward, increasing anterior face height. This is an important part of the surgical change, which corrects not only the anteroposterior mandibular deficiency but also the short face height.
Note also the uprighting of the mandibular left second molar after extraction of the third molar. The coil spring used for distalization after uprighting is still in place, but it must be passive at this point. Further tooth movement can be accomplished postsurgically if needed. For Jim, the plan is leveling of the lower arch postsurgically after proper vertical incisor relationships are established.
Cephalometric superimposition on the cranial base for the presurgical phase of treatment (image 4, right) shows that some downward-backward rotation of the mandible occurred. Further mandibular rotation downward will be accomplished at surgery, along with advancement of the chin. This increases face height and allows correction of the anterior deep bite.
The maxillary and mandibular superimpositions (image 4, left) show the amount of tooth movement in each arch. Note the distal movement of the lower molar as it was uprighted.
 Image 1, right lateral: Jim, age 44, ready for surgery, stabilizing arch wires. |  Image 2, left lateral: Jim, age 44, ready for surgery, stabilizing arch wires. |
 Image 3, frontal: Jim, age 44, ready for surgery, stabilizing arch wires. |  Image 4, cephalometrics: Cephalometric superimpositions: cranial base (left), maxilla, and mandible. |
Case #2: Immediate Postsurgery
The facial photos in image 1 were taken at 6 weeks postsurgery, at the time he returned for completion of the orthodontic treatment. Despite the beard that he started regrowing immediately after surgery, the improvement in facial proportions is obvious. Often in mandibular deficient patients, increasing face height is as important as bringing the chin forward.
At that point, both the plastic splint that was maintained interocclusally after surgery and the stabilizing arch wires were removed. Downward rotation of the mandible as it was advanced had corrected the anterior deep bite (images 2-3). Lighter working arch wires were placed, and Jim wore light elastics as he accommodated to the new mandibular position (note the elastic hooks formed from modified ligatures on canine brackets). After patients have undergone jaw surgery, they are highly motivated to obtain an excellent result, so cooperation with elastics and other aspects of treatment rarely is a problem.
In the panoramic radiograph at 6 weeks postsurgery (image 4), the titanium screws used to hold the mandibular segments during healing can be seen. Although these can be removed, usually they are not, because unless they cause a problem, which is quite unusual, there is no reason to put the patient through additional surgery to remove them.
Cephalometrically, the improvement in mandibular position is apparent (image 5). The cephalometric superimposition pre- to postsurgery shows the extent to which both face height and chin prominence were increased by rotating the mandible downward as it was brought forward. This pattern of mandibular rotation at surgery is quite stable and predictable, which makes it the best way to correct skeletal deep bite (deep bite caused by inadequate face height).
 Image 1, post-surg face: Jim, age 44, 6 weeks after surgery. |  Image 2, right lateral: Jim, age 44, 6 weeks after surgery. |
 Image 3, left lateral: Jim, age 44, 6 weeks after surgery. |  Image 4, post-surg pan: Panoramic radiograph postsurgery: note fixation screws. |
 Image 5, ceph: Postsurgical ceph and superimposition: downward-forward movement of the mandible. |
Case #2: Completion of Orthodontics
Five months later, the postsurgical orthodontics was completed and the orthodontic appliance was removed. Since the maxillary incisor pontics were tied to the arch wire, replacement teeth were needed immediately (image 1). Correction of the deep overbite has made prosthetic replacement of the missing teeth much easier.
A temporary maxillary fixed bridge was placed as soon as the orthodontic appliance was removed (images 2-4). It served as a fixed retainer for the maxillary teeth. No other maxillary retainer was needed.
In the mandibular arch (image 5, top), a removable retainer was needed initially to maintain both the pontic space on the right side and the vertical space for lower replacement teeth on the left. The retainer was thick enough in the mandibular left posterior area to provide occlusal contact with the upper molars, to control any tendency for the upper teeth to elongate.
A temporary mandibular fixed bridge was placed in the mandibular right quadrant within the next month, and the removable lower retainer was modified to accommodate its presence (image 5, bottom). The removable retainer still was needed to prevent further eruption of the upper left teeth until a partial denture could be supplied.
 Image 1, post-treatment frontal: Completion of orthodontics, temporary pontics removed. |  Image 2, temporary bridge, occlusal: Temporary maxillary fixed bridge, placed immediately after removal of the orthodontic appliance. |
 Image 3, temporary bridge, right lateral: Temporary maxillary fixed bridge, placed immediately after removal of the orthodontic appliance. |  Image 4, temporary bridge,left lateral: Temporary maxillary fixed bridge, placed immediately after removal of the orthodontic appliance. |
 Image 5, mandibular arch / retainer: Top: Mandibular arch at end of treatment; bottom: lower removable retainer to maintain vertical position of upper teeth above the lower edentulous area. |
Case #2: Completion of Orthodontics
The panoramic radiograph at 3 months after the orthodontic appliance was removed (image 1) shows the crown/bridge preparations in both arches. Although the endodontically treated lower premolars were repositioned orthodontically, further endo treatment was not necessary—but the patient was prepared for that possibility.
The definitive prosthodontics, with fixed prostheses in the maxillary anterior and mandibular right posterior, and a mandibular removable partial denture to replace the missing teeth on the lower left (images 2, 3), was completed within the next 9 months. Jim was very pleased with the improved appearance on smile (image 4).
An alternative plan, of course, would have been placement of an implant in the mandibular left posterior region to serve as a posterior abutment for a fixed bridge. The additional cost and time of doing that, which would have required a bone graft before the implant could be placed, made the removable partial a better choice for this patient. Temporary bridges are satisfactory orthodontic retainers, so if these are used, there is less urgency to place the permanent restorations, but it is desirable to complete the prosthodontic phase of treatment as soon as possible after the orthodontics is completed.
The end-of-treatment panoramic radiograph (image 5) shows the final fixed prostheses in place, with good periodontal health at this point. The occlusion was stable during the fabrication of the prostheses.
For Jim, as for other patients with similarly complex problems, careful integration of the various phases of treatment was a key to success.
 Image 1, prosthetic progress pan: Panoramic radiograph 3 months after removal of orthodontic appliances. |  Image 2, lateral view, restorations: Completed restorations 9 months after completion of orthodontics, lateral views. |
 Image 3, occlusal view, restorations: Completed restorations, occlusal views. |  Image 4, frontal view: Dental and facial esthetics, frontal views. |
 Image 5, prosthetic completion pan: Panoramic radiograph after completion of restorations. |
Summary and Conclusions
In summary:
- Complex adjunctive orthodontic treatment requires a team of dentists for treatment because it requires orthodontics, periodontics, restorative dentistry and often other dental specialties (endodontics, prosthodontics, oral-maxillofacial surgery). A major goal of the orthodontic treatment is to facilitate treatment of the patient’s other needs.
- Sequence of treatment is important: First, disease control periodontics endodontics extractions temporary restorations Second, correction of the alignment/occlusion orthodontics orthognathic surgery Third, definitive perio/restorative/prosthodontics
- Important special considerations in complex adjunctive treatment: Tooth movement can be the last straw for a tooth on the borderline for requiring endo treatment; fortunately, endo-treated teeth can be moved orthodontically Temporary restorations will have to last for the duration of orthodontic treatment, so should be good for 2 years Perio maintenance during orthodontics often means frequent perio recall Coordination between the end of orthodontics and the final restorative/prosthodontic treatment is important—there should be minimal delay between the completion of orthodontics and the final restorations
Self-Test Referral
The self-test section of this program is designed to help you be sure you have understood the material. Take it now, and use it as a guide for further study and review.
Copyright 2003, UNC Dept. of Orthodontics
Self-Test
Question 1
Which of the following are appropriate treatment sequences for a patient with complex problems?
a. Extractions/endo/perio/restorative/orthodontics/restorative
b. Endo/perio/restorative/extractions/orthodontics
c. Perio/restorative/extractions/endo/orthodontics
d. Restorative/endo/extractions/perio/orthodontics/maxillofacial surgery
e. Extractions/perio/endo/restorative
- a, b, and c
- b, c, and d
- c, d, and e
- a, b, c, and d
- all of the above ✓
Correct
That’s correct, all these sequences are appropriate. Treatment to bring disease under control is the first stage of treatment and should precede any orthodontics. The sequence of procedures within that stage varies with the patient’s particular needs. The biggest pathologic problem gets treated first. And of course complex treatment doesn’t have to involve orthodontics or postorthodontic restorative and perio, so the final sequence also would be quite appropriate if no correction of malocclusion or no postorthodontic treatment was required.
Incorrect
No, that’s wrong. All these sequences are appropriate. Treatment to bring disease under control is the first stage of treatment and should precede any orthodontics. The sequence of procedures within that stage varies with the patient’s particular needs. The biggest pathologic problem gets treated first. And of course complex treatment doesn’t have to involve orthodontics or postorthodontic restorative and perio, so the final sequence also would be quite appropriate if no correction of malocclusion or no postorthodontic treatment was required.
Question 2
Which of the following are likely benefits from including orthodontics in complex treatment?
a. Improved self-esteem
b. Better long-term prognosis for fixed restorations
c. More successful endodontics
d. Control of TMD
- a and b ✓
- b and c
- c and d
- a, b, and c
- all of the above
Correct
That’s right, the first two statements are correct, the other two are not. Improved self-esteem is an important benefit that often encourages patients to change their expectations for job and social success after treatment. The long-term prognosis for crowns, bridges, and other definitive restorations is better when the position of the teeth allows them to be made more ideally. But orthodontics has nothing to do with the success of endodontic treatment, which should be completed if needed before orthodontics begins, and orthodontics cannot be expected to control TMD (although it can perhaps help as part of a more comprehensive plan for TMD).
Incorrect
No, that’s wrong. The first two statements are correct, the other two are not. Improved self-esteem is an important benefit that often encourages patients to change their expectations for job and social success after treatment. The long-term prognosis for crowns, bridges, and other definitive restorations is better when the position of the teeth allows them to be made more ideally. But orthodontic treatment has nothing to do with the success of endodontic treatment, which should be completed if needed before orthodontics begins, and orthodontics cannot be expected to control TMD (although it can perhaps help as part of a more comprehensive plan for TMD).
Question 3
Which of the following statements correctly describe the relationship of endodontic to orthodontic treatment in the treatment of complex problems?
a. Endo treatment always precedes orthodontics.
b. Endo treatment may increase the chance of root resorption during later orthodontics.
c. Endo treatment involving apical surgery should be avoided if orthodontics is planned.
d. For teeth with a doubtful pulpal prognosis, orthodontic treatment can increase the chance that endo will be required.
- a and b
- b and c
- c and d
- b and d ✓
- a, b, and d
Correct
That’s right, b and d are correct, but a and c are not. It’s true that for teeth with a doubtful pulpal prognosis, orthodontics may be the “last straw” so that endodontic treatment is required. In that situation the patient must be warned of this possibility, but endodontics after the orthodontics has started sometimes is necessary, so it doesn’t always precede the orthodontics. Some evidence suggests that endodontically treated teeth are more prone to root resorption. The type of endodontic treatment doesn’t affect later orthodontics, so if apical surgery is required to bring infection under control, later orthodontics is still possible.
Incorrect
No, that’s wrong, b and d are correct, but a and c are not. It’s true that for teeth with a doubtful pulpal prognosis, orthodontics may be the “last straw” so that endodontic treatment is required. In that situation the patient must be warned of this possibility, but endodontics after the orthodontics has started sometimes is necessary, so it doesn’t always precede the orthodontics. Some evidence suggests that endodontically treated teeth are more prone to root resorption. The type of endodontic treatment doesn’t affect later orthodontics, so if apical surgery is required to bring infection under control, later orthodontics is still possible.
Question 4
What is the optimum time after the completion of orthodontics before definitive restorative treatment should begin?
- As soon as possible ✓
- After initial orthodontic retention is completed
- Six months, to allow the occlusion to settle into final position
- 12 months, to be sure no further occlusal changes will occur
Correct
That’s right, definitive restorative treatment should begin as soon as possible. If changes in the occlusion occur before the permanent retainers (the definitive restorations) are placed, they are likely to be for the worse, not the better. In adjunctive treatment, there is no possibility that tooth positions will become stable after an initial period with full-time retainers, so there really isn’t any period of “initial orthodontic retention” or “final settling of the occlusion.” As a general rule, the longer the delay between orthodontics and the final restorations, the greater the chance of problems.
Incorrect
No, that’s wrong. Definitive restorative treatment should begin as soon as possible. If changes in the occlusion occur before the permanent retainers (the definitive restorations) are placed, they are likely to be for the worse, not the better. In adjunctive treatment, there is no possibility that tooth positions will become stable after an initial period with full-time retainers, so there really isn’t any period of “initial orthodontic retention” or “final settling of the occlusion.” As a general rule, the longer the delay between orthodontics and the final restorations, the greater the chance of problems.
Question 5
What is the most important aspect of esthetic replacement for a single missing maxillary lateral incisor?
- Crown form of the replacement tooth
- Gingival exposure of the replacement tooth
- Appropriate size for the replacement tooth
- Symmetry of the replacement tooth with the natural lateral ✓
- Orientation of the crown to obtain natural appearance
Correct
That’s correct, all of these things are important, but symmetry, making the replacement tooth as much as possible like the natural one, is the most important aspect of esthetic replacement of a single lateral. For that reason, closing the space on one side only often is not the best plan, because it’s so hard to achieve symmetry when that is done.
Incorrect
No, that’s wrong. All of these things are important, but symmetry, making the replacement tooth as much as possible like the natural one, is the most important aspect of esthetic replacement of a single lateral. For that reason, closing the space on one side only often is not the best plan, because it’s so hard to achieve symmetry when that is done.
Question 6
Which of the following are major contributors to the difficulty in closing an old mandibular first molar extraction space?
a. Large mesial root movement of the second molar
b. Loss of alveolar bone in the old extraction site
c. Periodontal problems distal to the second molar
d. Occlusal interferences that inhibit uprighting
- a and b ✓
- b and c
- c and d
- b and d
- a, b, and d
Correct
That’s right, a and b are correct, c and d aren’t. Uprighting a mandibular second molar by bringing its roots mesially is difficult under the best of circumstances because of the distance they would have to be brought forward. Loss of alveolar bone in the old extraction site makes it even harder, because as the ridge atrophies and becomes narrower, remodeling of cortical rather than medullary bone is required to allow the tooth to move. Periodontal problems distal to the second molar and occlusal interferences during the tooth movement can be important in patient management but don’t affect the difficulty of closing the space.
Incorrect
No, that’s wrong, a and b are correct, c and d aren’t. Uprighting a mandibular second molar by bringing its roots mesially is difficult under the best of circumstances because of the distance they would have to be brought forward. Loss of alveolar bone in the old extraction site makes it even harder, because as the ridge atrophies and becomes narrower, remodeling of cortical rather than medullary bone is required to allow the tooth to move. Periodontal problems distal to the second molar and occlusal interferences during the tooth movement can be important in patient management but don’t affect the difficulty of closing the space.
Question 7
Which of the following is the major advantage of an implant to replace a maxillary lateral incisor versus a fixed bridge?
- Better gingival esthetics
- Better crown form is possible
- Better crown esthetics for central and canine ✓
- Less total cost
Correct
That’s correct. The greatest advantage of an implant is that it makes it unnecessary to prepare the adjacent central incisor and canine as bridge abutments, and it takes great skill to make abutment crowns that look as good as unprepared natural teeth. Of course, if the potential abutment teeth need restoration anyway, this might tip the balance toward a bridge pontic, which can have gingival esthetics and crown form as good as an implant. Although the cost of implants is decreasing, the cost of an implant replacement would be more than that of a bridge under most circumstances.
Incorrect
No, that’s wrong. The greatest advantage of an implant is that it makes it unnecessary to prepare the adjacent central incisor and canine as bridge abutments, and it takes great skill to make abutment crowns that look as good as unprepared natural teeth. Of course, if the potential abutment teeth need restoration anyway, this might tip the balance toward a bridge pontic, which can have gingival esthetics and crown form as good as an implant. Although the cost of implants is decreasing, the cost of an implant replacement would be more than that of a bridge under most circumstances.
Question 8
What would be the effect on overjet of orthodontic treatment to bring the roots of maxillary second molars forward?
- Reduce it ✓
- No effect
- Increase it
- No way to predict, depends on the force system used
Correct
That’s right, the force system to bring maxillary second molar roots forward would have a reciprocal effect on the maxillary anterior teeth, pulling them back; so it’s predictable that overjet would decrease.
Incorrect
No, that’s incorrect. The force system to bring maxillary second molar roots forward would have a reciprocal effect on the maxillary anterior teeth, pulling them back; so it’s predictable that overjet would decrease.
Question 9
In a patient with a Class II deep bite malocclusion, how would mandibular advancement surgery facilitate replacement of missing anterior teeth?
a. Correct the deep bite
b. Allow correct incisor function
c. Make canine-protected occlusion possible
d. Decrease any posterior buccal crossbite tendency
- a and b
- b and c
- a, b, and c
- b, c, and d
- all of the above ✓
Correct
That’s right, all of these are correct. Mandibular advancement would correct the deep bite (if the mandible were rotated down as it was advanced, as it is in a deep bite patient). That would allow correct incisor function and make canine-protected occlusion possible. Since bringing the mandible forward makes it wider relative to the mandible, this also would decrease any posterior buccal crossbite tendency. If there is no buccal crossbite prior to mandibular advancement, one goal of the orthodontic treatment that accompanies this surgery is to control lingual crossbite after the advancement.
Incorrect
No, that’s wrong, all of these are correct. Mandibular advancement would correct the deep bite (if the mandible were rotated down as it was advanced, as it is in a deep bite patient). That would allow correct incisor function and make canine-protected occlusion possible. Since bringing the mandible forward makes it wider relative to the mandible, this also would decrease any posterior buccal crossbite tendency. If there is no buccal crossbite prior to mandibular advancement, one goal of the orthodontic treatment that accompanies this surgery is to control lingual crossbite after the advancement.
Question 10
Which of the following is the major problem when brackets are bonded to prosthetic teeth and these are tied to an arch wire to replace missing teeth during orthodontic treatment?
- Not good esthetically
- With a rigid arch wire, excessive function on these pontics can displace other teeth
- Pontics are not stable when a flexible arch wire is being used ✓
- TMD becomes more likely
Correct
That’s right, the biggest problem is that the pontics are not stable when a flexible arch wire is being used. A heavy rectangular wire is needed to hold them. They are very realistic, so esthetically they are quite good. Excessive function, even with a rigid wire, simply isn’t a problem, and their use has no relationship to TMD.
Incorrect
No, that’s wrong. The biggest problem is that the pontics are not stable when a flexible arch wire is being used. A heavy rectangular wire is needed to hold them. They are very realistic, so esthetically they are quite good. Excessive function, even with a rigid wire, simply isn’t a problem, and their use has no relationship to TMD.