This patient was referred to me after completing orthodontic treatment to address the congenitally missing lateral incisors. She was told to have the implant treatment or bridge work done as soon as possible after orthodontic treatment is complete. I was not involved in any pre-orthodontic prosthetic planning but I think this would have been be a case where prosthetic planning should have started prior to any orthodontic work. The patient’s chief concern was her obvious missing 12 22 but along with that was also the unaesthetic appearance of her teeth due to tetracycline staining. I don’t have any record of her pre-treatment occlusal relationship but I can tell the orthodontic movement has improved the positions of the teeth in the arch. But when you look at the wear facets, the patient has lost some tooth structure that will benefit from some form of restorative work as well as improving the aesthetics of these teeth. Prosthetic solutions for these cases can range from composite bonding, porcelain veneers and/or porcelain crowns. However, by merely moving the teeth in a better position in the arch and not addressing the tooth wear issue during orthodontic treatment can complicate prosthetic planning and treatment later when the patient is ready for it.
To address the patient’s chief concern of the missing lateral incisors and the unaesthetic appearance of her teeth, she really needs more than just looking at the missing 12 and 22. I had to re-educate her about the treatment solutions. While she already has done some research on these treatment options, she was not ready to embark on anything big at the time. For this case, even though, she has pretty much a full dentition, her occlusal relationship was really arbitrarily determined with no prosthetic planning at all. Teeth were just moved to the correct mesial distal, buccal lingual position in the corresponding arch. To me, the occlusal contacts were unstable. Her frenum attachment in the maxillary midline is very close to her teeth 11 21, her midline diastema are at high risk of opening up. I have reviewed the two most reasonable treatment solutions: implants or FPD. But with all the factors considered, in my opinion, a fixed partial denture of 13-x-11-21-x-23 would be the most sensible solution. It serves as a way of replacing the missing 12 and 22, correcting the colour and contour of adjacent teeth as well as serving as a permanent splint for the anterior teeth, preventing the midline diastema from opening up.
My preliminary -prosthetic treatment for her included the following:
1/Anterior deprogramming to record the proper jaw relationship
2/Diagnostic wax up and evaluation of the teeth based on the wax up
3/Composite bonding of U/L teeth to idealize occlusal contacts, form and contour as best as possible
This plan allows the flexibility of any future treatment of porcelain veneers and crowns of other teeth in the arch without compromising function and aesthetic. The preliminary wax up and bonding stabilize occlusal relationship and improve aesthetics. And when she is ready for more prosthetic treatment, she is ready to go.
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