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Revue de la littérature | Literature review



Chimène Chalala*

Abstract Résumé
Full comprehensive orthodontic treatment is often a requisite Le traitement orthodontique est souvent une phase néces-
in the rehabilitation of oral form and function specifically when saire pour la réhabilitation complète de la forme et de la fonc-
anterior restoration(s) is (are) needed. Patients with missing, tion, surtout en cas de restauration des dents antérieures. Les
abraded or fractured teeth, peg-shaped lateral incisors, or patients dont les dents sont absentes, abrasées ou fracturées,
other restorative needs may require tooth movement for optimal avec des incisives latérales riziformes, ou autres impératifs de
treatment outcomes. Such treatment necessitate collaboration restaurations, nécessiteraient un traitement orthodontique pour
between the orthodontist and others specialties, such as the res- optimiser les résultats. Un tel traitement exige la collabora-
torative dentist and / or the periodontist. tion orthodontiste/dentiste sur différents niveaux. L’indication
The major indication for adjunctive orthodontic treatment is to majeure de ce traitement est au niveau de l’arcade (créer l’es-
facilitate and improve the dental restorative conditions at the pace), des racines (pour un meilleur parallélisme des piliers) et
level of the arch (space management), roots (parallel abutments) de l’os (considérations parodontales) pour le bon placement des
and bone height (periodontal considerations) for the placement implants et la confection de couronnes bien adaptées.
of well-adapted and contoured restorations, crowns or implants. Les objectifs majeurs du traitement sont donc la fonction, l’es-
This interdisciplinary management will be illustrated through thétique et la santé parodontale.
specific dental treatment phases, in addition to the assessment L’approche multidisciplinaire est illustrée par des cas cliniques
of guidelines for general dentists, specialists, and orthodontists où sont développées les étapes de traitement dentaire, en plus
to establish a comprehensive treatment plan and execute it in an de l’élaboration d’un référentiel à l’intention des dentistes, des
orderly way toward successful results. spécialistes, et des orthodontistes pour établir un plan de traite-
ment global et pouvoir le réaliser dans les meilleures conditions
Keywords: Orthodontics – dental restoration - periodontics. de succès.

Mots-clés : orthodontie – restauration dentaire – parodontie.

* DESS Orthodontics
Clinical Associate, Faculty of Dentistry,
American University of Beirut
Instructor, Faculty of Dentistry, Lebanese University


Fig. 1: Orthodontic uprighting of mandibular right 1st molar.

Fig 2: Orthodontic crown lengthening for periodontal (biological width)

and esthetic considerations (gingival margins).

Introduction Periodontal management Orthodontics crown lengthening

Tooth fracture is a very common pro-
With patients’ increasing esthetics and Optimization of restorative blem and the level of fracture is an
functional demands, orthodontists conditions important factor that dictates the pro-
are solicited to manage and create Uncompensated old extractions gnosis of the tooth [3]. If the fracture
an optimal restorative environment. alter adjacent and antagonist teeth is cervical or more sub-crestal, an opti-
In fact, various dental specialties are position as well as their bone level: mal restoration cannot be achieved
available now to assure the ultimate the contiguous teeth will tilt toward without impinging on the biological
dental condition of the most critical the vacant space creating an angular width. In such situation 2 options of
cases. Thus the interdisciplinary mana- bony defect in addition to the loss of treatment are available:
gement is essential for the attainment the available space. a. Surgical crown lengthening to
of the best dental treatment outcome. In order to address these cited pro- recreate the proper biological width.
The purpose of this paper is not to blems, an orthodontic treatment is It may compromise the esthetic out-
criticize or support orthodontic ver- needed to eliminate the bony defect come, especially in the anterior region
sus non orthodontic approaches, but by uprighting the tipped tooth [1]. creating uneven gingival margins rela-
to emphasize the criteria by which Therefore, an amelioration of the tooth tive to the adjacent teeth and long cli-
we assess the multiple and available axis is often mandatory for a better nical crowns [4, 5].
treatment options. realization of the prosthetic crown b. Orthodontic crown lengthening
Orthodontics can support restora- and a better distribution of occlusal (extrusion) which provides sufficient
tive dentistry for periodontal, occlusal forces [2]. Orthodontics is essential to supra-gingival tissue to restore appro-
and dental considerations. recreate the adequate space for mis- priately the tooth with pleasing esthe-
sing teeth replacement with optimal tic outcome [6] (Fig. 2).
dimensions (Fig. 1).

Revue de la littérature/Literature review

IAJD Vol. 3 – Issue 2

Fig. 3: Orthodontic root extrusion of a subcrestal

fracture of maxillary central incisor.

Fig. 4: Black triangle between maxillary central incisors

(divergent roots) corrected orthodontically.

In both options, the length of the ning where tooth extrusion is promptly 4- Triangular-shaped crown with or
root is a crucial parameter mainly to achieved without the pursuing of the without bone resorption [10].
support a post crown and to finish with periodontium basically the bone (Fig. 3). 5- An increased distance from the
an optimal crown to root ratio. alveolar bone to the interproximal
In summary, the subsequent fac- Improvement of gingival contact resulting from a bone loss or
tors should be considered in planning esthetics from more incisally positioned inter-
extrusion of teeth: Interdental papilla proximal contacts [11].
- Root length and form: thick, Open gingival embrasures or black 6- Divergent roots [12].
non-tapered. triangles (Fig. 4) observed in the cer- Treatment of black triangles
- Level of defect or fracture. vical region between the teeth result depends first on a thorough evaluation
- Relative importance of the tooth. from a deficit of gingival papilla below of the etiology in order to insure the
- Esthetic considerations: amount of the proximal contact points [8]. best outcome. Emphasize on the inter-
visible gingiva upon smiling. The contributing factors to this disciplinary management of the cases
- Endodontic considerations: good unaesthetic situation are numerous is primordial with an ultimate collabo-
endodontic treatment, retreat- and summarized as follows: ration between the general dentist, the
ment or apicectomy (endodontic 1- Age. periodontist and the orthodontist.
lesions) 2- Attachment loss subsequent to The prevalence of open gingival
- Periodontal considerations, inclu- periodontal surgery or to periodontal embrasure between maxillary central
ding contra-indication of periodon- disease. incisors after orthodontic treatment
tal crown lengthening as: 3- Severe crowding specially of of adult patients is estimated to be
•Adjacent root exposure due to maxillary and mandibular incisors. around 40% [13, 14]. The age, the
flap design. Although according to Kokish [9], duration of active treatment and the
• Loss of the interdental papillae. pretreatment maxillary central incisor crown morphology were the parame-
• Uneven gingival margins [7]. rotation and overlap are not directly ters involved in the occurence of black
Forced eruption technique is a associated with post-treatment open triangles between mandibular incisors
method of orthodontic crown lengthe- gingival embrasures. after orthodontic treatment [15].


Fig. 5: Uneven gingival margins due to abrasion of incisal

edge of the tooth #11 orthodontically corrected.

Fig. 6: Retraction of canines in old extraction site had enhanced

the bucco-lingual width of alveolar bone.

Fig. 7: Intrusion of maxillary 1st molar

creating the needed space for the restoration
of the mandibular opposite site. Orthodontic
treatment was initiated to correct the
crowding and manage the optimal space
vertically and sagittally for proper restoration
of mandibular edentulous space.

Gingival margins should be slightly more occlusal then et al. [20] revealed that bone created
Uneven gingival margins are a the canines and the central incisors. by orthodontic separation of two teeth
major aesthetic problem especially in The contour of the gingival margin is much less resorptive over time com-
patients with gummy smile. They can should mimic the cemento-enamel pared to the amount of resorption fol-
result from inflammatory periodontal junction (CEJ) of the teeth. lowing tooth extraction.
deseases or from variable amount of
tooth wear and abrasion on different Horizontal bone regeneration Vertical bone regeneration
adjacent teeth (Fig. 5). Orthodontic sagittal movement can Orthodontic extraction of an unres-
In some cases, orthodontic intru- be a substitute for guided bone rege- torable tooth is an advantageous and
sion and restoration of incisal edge are neration, surgical bone augmentation an effective way to enhance the perio-
required. or bone grafting (Fig. 6). Atrophic bone dontal conditions for the replacing
The determining factors to correct in sites of tooth agenesis or previous implant [21, 22]. Such orthodontic
the gingival margins include the sulcus extraction of permanent teeth prevents extrusion will improve the alveolar
depth, the location of the cemento- the placement of implant in these areas bone and the gingival characteristics
enamel junction relative to the bone without requiring a bone augmen- of the recipient site prior to the pla-
level, the amount of existing tooth tation surgical procedure. However, cement of an implant. Furthermore, it
structure, the root-to-crown ratio and moving orthodontically a tooth in such is considered as a viable alternative to
the shape of the root [16]. atrophic areas can resolve the pro- the conventional surgical augmenta-
The gingival margin of the central blem by developing alveolar bone on tive procedures of bone in height [23,
incisors must be at the same level the tension side enhancing the width 24]
and the lateral incisors gingival level of the crestal bone [17, 18, 19]. Spears

Revue de la littérature/Literature review

IAJD Vol. 3 – Issue 2

Fig. 8: Reopening of an adequate space for the maxillary right

central incisor that was substituted by the lateral incisor.

Fig. 9: Closure of maxillary midline diastema and distribution of space

between all anterior teeth that will be restored with new crowns.

Dental Management Diastema closure is attributed Restoring tooth proportions

to aesthetic and psychological rea- The aesthetic rehabilitation of
Inter-arch space management sons rather than to functional ones. maxillary anterior teeth should empha-
Orthodontic intrusion to recreate Management of maxillary diastema size the importance of the width/length
an adequate prosthetic space can be a should resolve its etiology and cause ratio. The measurements of these teeth
substitute for coronoplasty and crown [27, 28, 29]. Oral habits, muscular are different and variable in width
lengthening or extraction (Fig. 7). imbalances, tooth-size discrepancies, and length. The width/length ratio of
pathological conditions as ectoder- maxillary central incisors is the largest
Intra-arch space management mal displasia, abnormal maxillary (85%) while the smallest ratio is for
Opening an optimal space for arch structure in cleft lip and palate the maxillary lateral incisors (79%) and
a missing tooth especially in the patients, and various dental anomalies the intermediate one is for the canines
anterior and premolar areas has an (supernumerary teeth, cysts…) are all (83%) [37, 38]. These dimensions give a
important impact on perceived smile etiological factors causing a diastema. positive impact on the esthetic assess-
aesthetics (Fig. 8). Proportional width The closure of maxillary diastemas ment of the final restorations.
of teeth relative to each others should is facilitated by a multidisciplinary To restore an abraded dentition in
be considered in order to manage approach [30] (Fig. 9) involving ortho- addition to an edge to edge anterior
the proper space for a pleasant result dontics [31, 32], restorative dentistry relationship (Fig. 10), an orthodontic
[25]. Along the crown, the width of the [33, 34, 35] and surgery. treatment is necessary in order to
contralateral will be the reference in According to Mulligan [36], control- create the needed overjet and overbite
case of unilateral missing teeth. Along ling the divergence of the incisal axis for the reestablishment of the optimal
the crest, 1mm between implant and and the vertical effects of occlusal aesthetic height. In most instances,
adjacent teeth is required for creating forces must be considered for long- conservative aesthetic therapies, such
adequate papillae [26]. term stability of the result much more as porcelain crowns, supplement
than the efficiency of the retainer.


Fig. 10: Abraded anterior teeth in edge to

edge relationship. Notice that the maxillary
anterior teeth are not visible upon smiling.

Fig. 11: Orthodontic treatment recreates the

appropriate overjet for full mouth restoration
with ceramic crowns.

orthodontic therapy to create a final Furthermore, the impact of the An appropriate referral of patients
result are possible only with singular media raising the slogan of Hollywood and fine considerations of the avai-
approach (Fig. 11). smile has lift up the challenge toward lable orthodontic treatment possibi-
a very high level of aesthetic accep- lities, limitations and risks are preva-
Discussion tance and execution which define new lent factors for general practitioners
criteria of a “beautiful smile”. This to admit any needed adjunctive dental
General dentists are the first to motto led to introduce the porcelain treatment [40]. The orthodontic- pros-
refer patients for a needed orthodontic veneer restorations and lumineers to thodontics - periodontic collaboration
intervention in order to correct a maloc- the dental practice and to execute a was conducted a long time ago [41]
clusion or to improve the status of the beautiful smile without implementing to assist dentists in their practice.
supporting structures. Optimizing a any orthodontic treatment. Such alter- Patients should be informed about the
healthy environment for dental resto- native has some limitations regarding ideal treatment option before conside-
rations is crucial for the longevity and the correction of gingival margins and ring the compromised approaches that
stability of the outcomes. papilla [39] and in some cases is less should be discussed thoroughly wei-

Revue de la littérature/Literature review

IAJD Vol. 3 – Issue 2

Treatment Advantages Disadvantages

- Fewer restorations
- No root canals or periodontal - Longer treatment
surgery - Need for retention
- Less cost

- Increased cost
- More restorations
Non orthodontics - Less time involvement
- Aggressive tooth Preparation
- Periodontal surgery needed

Table 1: Comparison of orthodontic and non orthodontic treatments.

ghting their risks and benefits. Finally,

the advantages and disadvantages of
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