Our experiences in reconstructive dentistry have taught us that there are many instances in which the midline is not perfectly straight or centered on the patient's face. Without question, you either have or will treat a patient who wants esthetic dentistry performed on a not-so-perfect midline. Most of them aren't even aware that theirs could be imperfect, but the truth is, it's more common than most people think.
The most common cause of an angled midline is a missing tooth, by far. That empty space not only causes the teeth to shift to the side of the missing tooth, it also causes them to tilt. The only way to center a midline is through orthodontics, since the roots of the teeth need to be moved. However, restorative dentistry can straighten an angled midline in most cases, but there are some limitations. This provokes us to ask the question, when it comes to an angled midline, what are the challenges of restorative dentistry?
Tooth widths: Since restorative dentistry restricts you from moving the roots of teeth, straightening an angled midline will cause one central incisor to get wider and the other gets narrower.
Gingival margins: Most patients with an angled midline will have gingival levels that are more coronal on the side away from the angle. For instance, if the midline is angling left, the patient will most likely have more gingival display on the right side of the mouth.
Tooth reduction: When a patient's central incisors are overlapping each other, tooth reduction needs to occur. A technician cannot straighten up a midline or fudge tooth width unless you've prepared through the inner proximal. To avoid aggressive prep and devitalizing of incisors, orthodontics would be the best route.