Orthodontic vs. Restorative: Correction of Mal-Aligned Anterior Teeth

Every dentist has heard a patient say these exact words: “I don’t want orthodontics, can’t you make my teeth look better without me needing to wear braces?” The answer is sometimes yes and sometimes no – but how do you decide?

There are six questions you need to ask prior to making the decision, and also to convey the information that may be helpful in your conversations with patients. What I know for sure, is that some patients with mal-aligned teeth can be treated only with restorative dentistry and get an excellent result, while others would be much better off with orthodontics.

I also know that a patient saying, “I don’t want braces”, doesn’t necessarily mean they won’t do braces; it means they don’t want them. If after going through these six steps they say, “I won’t do braces,” there is a possibility they won’t, but in my experience there still is a chance they will.

Question 1: Will the teeth need to be restored even if orthodontics is completed?

One of the greatest benefits of orthodontics is that it can often eliminate the need for any restorative dentistry, a great savings in terms of dollar cost and tooth structure.^1,2,3 But if the teeth will need to be restored anyway, there has to be a compelling reason to do the orthodontics – something it brings that eliminates some other negative aspect that restorative dentistry alone can’t solve.

The first patient pictured is a perfect example of this question. (Figure 1)

She has very un-esthetic anterior teeth in terms of color, facial erosion and failing old restorations. Even if orthodontics was completed to align her teeth more ideally, she still would need the teeth restored. In her case, orthodontics really wouldn’t eliminate the restorative need and all the other parameters of her case didn’t need orthodontics aside from correcting the alignment issue. She was treated with restorative dentistry. (Figure 2)

Question 2: Can the occlusion be managed acceptably without orthodontics?

This question is used to address whether the occlusion can be developed to a level of functionality for that specific patient without orthodontics; it doesn’t necessarily mean the patient should have an ideal class I molar or class I canine relationship.

The second patient pictured is a good example. (Figure 3)

She is very young, early 20s, with an impacted maxillary right canine and peg lateral incisors. In addition the mandibular right canine is in cross-bite with the pegged lateral. She presented for a second opinion regarding the impacted canine.

The first opinion was to devitalize the mandibular right canine, warp it to the lingual with a crown as much as possible to jump the cross-bite, extract the impacted canine, then do a 3-unit FPD from the maxillary right first premolar to the maxillary right pegged lateral. This initial plan would be extremely compromised functionally over the remaining 70 to 80 years of her life.⁴

Instead, she was treated very conservatively with surgical exposure of the impacted canine, orthodontics to bring it into position and correct the occlusion and direct composites on the pegged lateral incisors. (Figure 4)

Question 3: Is the most apical papilla level esthetically acceptable?

This question is subtle and involves gingival esthetics, specifically the levels of the interdental papilla. The reason this question is important, is that it is easy to apically position a papilla surgically, which is often necessary in cases of anterior wear with secondary eruption, resulting in the teeth and soft tissues being coronally positioned.

But it is very difficult to surgically move a papilla coronally, and actually impossible if the reason for the apically positioned papilla is tooth alignment, such that the interdental contacts extend too far apically. For this reason, if the most apically positioned papilla isn’t acceptable, orthodontics is typically the only option for correction.

This is also true if the papilla is apically positioned due to interproximal bone loss; where extruding the adjacent teeth, and equilibrating their edges as they erupt, can move bone and soft tissue in a more coronal direction.

The third patient pictured is a good example for this question. (Figure 5)

She stated she wanted an ideal smile, 10 veneers and didn’t want orthodontics. But the papilla between the left central and lateral is positioned apically due to the rotation of the lateral incisor. (Figure 6)

She stated very clearly she wouldn’t do orthodontics, yet after helping her see that without orthodontics there would be a significant asymmetry between how the right and left sides looked after restoration, and that if she did the orthodontics she would only have to restore one tooth, the left central, she did orthodontic treatment. Because this is a problem of tooth position, not bone, the papilla moved into an ideal position as the lateral rotation was corrected. ^5,6 (Figure 7)

Question 4: Is the most apical gingival margin level acceptable?

This question is similar to the third question, but involves the gingival margin levels. The largest difference between these questions involves the fact that it is very predictable to graft facial gingival margin levels in a coronal direction, if there is root surface exposed. In other words if the gingival margin is too far apical due to recession, but the tooth is properly positioned, then grafting is a great choice.

But if the most apical gingival margin level is unacceptable due to a lack of adequate eruption, and the tooth has no recession, orthodontic extrusion to bring the tooth and tissue coronally is usually the only predictable option.^7,8 The fourth patient pictured is a great example for this question. (Figure 8)

This patient presented with irregular gingival margin levels, but the most apically positioned gingival margins, the canines and left central are acceptable, they don’t need to be moved coronally. Instead, the more coronally positioned gingival margins on the right central and left lateral need to be moved apically, which can be done without orthodontics.

But it is important to ask why the gingival margins are irregular – she has no tooth wear that would have lead to secondary eruption, and the eruption looks relatively normal when comparing incisal edge positions.

Instead what you see when looking from an occlusal view are the variations in facial lingual position of the anterior teeth. This leads to variations in facial gingival thickness, sulcus depth and gingival margin position. The right lateral and left central are positioned a bit to the facial, which thins the tissue, results in a facial sulcus depth around 1mm and more apically positioned gingival margins.

The right central and left lateral incisor, are positioned significantly to the lingual, resulting in thicker tissue, deeper sulcus depths, and more coronally positioned gingival margins. The sulcus on the right central probes 2.5 mm, the sulcus on the left lateral probes 4 mm.

The challenge of not doing orthodontics in these cases, is managing the long-term post surgical gingival margin position, since surgery isn’t correcting the underlying root position, only the gingival margin position. This patient chose the non-orthodontic option. The first step in the surgical correction was to perform gingivectomies on the right central and left lateral, idealizing the gingival margin position. In addition, the soft tissue dimension above bone on the left central, which had no surgery, was measured using sounding, it was 3 mm.⁹ (Figure 9)

The next step in the surgery is to sound to bone on the right central and left lateral, comparing the measurement to the normal left central. Even though the right central had 1.5mm of gingiva removed, and the left lateral 3mm of tissue removed, both of their sounding depths remained 3mm, indicating no bone removal is necessary. (Figure 10) The problem is the roots are to the lingual, and the tissue will want to rebound.

Had orthodontics been used to correct the facial lingual position, the gingiva would have been correctly positioned and stable. As it was done surgically, and the teeth are to the lingual, the restorative emergence profile on the facial has to be quite prominent to avoid the rebound.¹⁰ The 10-year recall photograph of the final result shows an acceptable result on the right central, but definite inflammation and redness on the left lateral. (Figure 11)

Question 5: Can an acceptable contour and arrangement be created without orthodontics?

This question addresses something I am asked frequently during workshops or seminars; a student walks up with a set of models and asks, “Do you think I can do this case without orthodontics?” The models typically show very crowded teeth, or teeth with large diastemas present. Often times in cases of crowding, the papilla levels or gingival margin levels will dictate the need for orthodontics, if an ideal result is desired. But regardless of the presentation of crowding or diastemas, the definitive way to identify what is possible is to perform a diagnostic wax-up.

The fifth patient pictured is a perfect example. (Figure 12)

He presented with pegged lateral incisors, and large diastemas in both the maxillary and mandibular anterior. He desires an improved smile, and is willing to do orthodontics. He is in his 50s, and has no occlusal or functional issues and his papilla levels and gingival margin levels are acceptable.  What orthodontics could potentially do is eliminate the need to veneer the centrals and canines, as the laterals would need to be restored regardless.

I presented the orthodontics versus non-orthodontic option, and explained the only way to truly visualize the result would be a diagnostic wax-up, which the lab completed. (Figure 13) The wax-up shows the spacing is easily managed without any need for orthodontics.

The challenge of diastema closure cases with restorations is carrying the restoration subgingival on the interproximal. If you don’t, you get essentially a ledge, or overhang of restorative material when carrying the contact to the tip of the papilla. In addition, the papilla will remain more blunted instead of taking on an ideal form. I personally find it easiest to manage the subgingival margin position with retraction cord, carrying the prep margin .5 to .7 mm below tissue. (Figure 14)

This allows the laboratory to create a much smoother emergence profile interproximally, which ultimately leads to a better papilla form in the final result. (Figure 15)

Question 6: Can the restorations be done without structurally debilitating the teeth if orthodontics isn’t completed?

This question typically shows up when significant tooth preparation would be necessary to correct tooth mal-alignment, such as the facially inclined left lateral incisor seen in Figure 16.

He is a male in his 50s, who desires a more pleasing smile, correcting the mal-alignment of the anterior teeth. The position of his left central is ideal in a facial lingual perspective, so the plan is to move the right central to the facial, and the left lateral to the lingual. The problem is he doesn’t want orthodontics. Prepping the left lateral enough to bring it into alignment will not only devitalize the tooth, but leave minimal tooth left to retain the restoration.

I presented the option of leaving the lateral out to the facial to avoid the endo, but he didn’t want that either. He had already had a dentist try to align the right lateral with a crown and ended up requiring endo on it, so in the end he chose the ortho. (Figure 17)

Because the orthodontics corrected the facial lingual inclination issues of all the anterior teeth, conservatively prepped veneers were used to correct the final position and appearance of all the teeth except the previously crowned right lateral. (Figure 18)

The one thing that orthodontics doesn’t always predictably correct, is facial gingival margin levels. In his case the previously crowned right lateral had its gingival margin level too far apically positioned, because the root is facially inclined. Eruption was used during the ortho to attempt to move the gingival margin level to a more coronal position; the tooth erupted but the facial gingiva didn’t move.^{11, 12} (Figure 19)

What the eruption did do was to expose root, so had it been critical to have the right lateral gingival level ideal – it would now be possible to move it coronally with grafting. In his case since his high lip line never showed the gingival levels, it was left as is and the restoration carried to the gingiva to hide the dark root. (Figure 20)

The goal for this article is to help you think through the process of why you might consider orthodontics alone, or in conjunction with restorative dentistry, to help you treat your patients. Hopefully these six questions will give you a structure for that thought process.

(Click this link for more dentistry articles by Dr. Frank Spear.)

References:

1. The Myth of Instant Orthodontics: An Ethical Quandry. Nancy Jacobsen and Charles A. Frank. JADA 2008: 139 (4): 424-434
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4. Long-term survival of complete crowns, fixed dental prostheses, and cantilever fixed dental prostheses with posts and cores on root canal-treated teeth. De Backer H, Van Maele G, Decock V, Van den Berghe L. Centre for Special Care, PaeCaMed Research, Unit of Gnathology and Temporomandibular Disorders, Dental School, Faculty of Medicine and Health Sciences, Ghent University, Belgium. Int J Prosthodont. 2007 May-Jun;20(3):229-34.
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12. Orthodontic therapy and gingival recession: a systematic review. Joss-Vassalli I1, Grebenstein C, Topouzelis N, Sculean A, Katsaros C. Orthod Craniofac Res. 2010 Aug;13(3):127-41. doi: 10.1111/j.1601-6343.2010.01491.x.