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Treatment of migrating teeth with removable appliances
Treatment of migrating teeth with removable appliances
George V . Newm an, DDS, W est Orange, N.J.
Two adult case reports, one involving a mi grating maxillary left central incisor, the other a distolabially migrating left lateral in cisor, demonstrate the use of removable appli ances before oral rehabilitation involving per manent fixed splinting is performed. Both in stances of pathologic wandering involved a deep overbite and a loss of vertical dimension.
1. Loss of alveolar support negates extensive tooth movement. 2. Retention of migrated teeth usually re quires permanent fixed splinting. 3. Optimal esthetics and minimal treatment time are desired by the adult patient. 4. Economic factors must be considered. The following case reports describe two adult orthodontic treatment methods that can be used to aid in correcting pathologic wandering of teeth.
C a se 1
Migrating teeth (pathologic wandering) is diag nosed clinically as mobile and drifting teeth and radiographically as resorption of alveolar bone.1 Migration of teeth results from pressure exerted on the teeth by granulation tissue that has re placed the resorbed bone. Excessive occlusal stress increases the alveolar resorption and aggra vates the pathologic wandering.2 Generally, the patient seeks treatment after a long period of dental neglect (usually loss of pos terior occlusal support) causing anterior spacing or flaring, or both, of 1 or more teeth, which re sults in an unesthetic appearance. Orthodontic treatment for adults is limited to practical treatment rather than ideal treatment when they have migrating teeth because of sev eral factors: 870
■ History and clinical examination: Treatment of a 44-year-old woman, possessing a Class II, Division 1, malocclusion, was undertaken to re tract and align the maxillary left central incisor so she could wear a complete crown and bridge prosthesis. The patient complained of “loose ness” and protrusion of the central incisor; she was alarmed over its “sudden” movement. The prominence of the migrating incisor detracted from her physical appearance, she stated, and gave her an unfavorable appearance and smile. A dental history revealed that in her adolescence she had discontinued orthodontic treatment after the right and left maxillary first bicuspids had been extracted. The lower left second bicuspid was, subsequently, extracted because of dental caries. The loss of posterior occlusal support fos tered a deep overbite, causing traumatic occlusion
though there was loss of alveolar bone in the adjacent right central incisor and left lateral in cisor, the left maxillary central incisor had a longer extra-alveolar (clinical crown) lever and, therefore, migrated. ■ Treatment methods: A basic acrylic bite plate (anchorage) with 2 molar clasps (0.036-inch stainless steel), a labial arch with loops (0.028 inch) and a bite ledge to eliminate occlusal inter ferences was employed to affect tooth movement (Fig. 3 ). The labial arch was bent away from the left central incisor to limit the force to light elastics. A light rubber dam elastic,3 exerting a force of 2 ounces, when stretched from the right to the left loop of the labial arch, produced a lingual re tracting force against the protruding incisor. Since the incisor was elongated and retraction in creased elongation, an intrusive force was neces sary. This force was accomplished by stretching a rubber dam elastic (2 ounces) from a soldered brass loop on the labial arch over the incisal edge of the tooth to a U-shaped hook on the bite plate (Fig. 4 ). Consequently, there was a retracting and depressing action on the displaced incisor. The elastic pressure created a light constant diminishing force that was so minimal that it did
F ig .
1 ■ Top:
C ase
1.
L e ft
side
of
p a t ie n t
b efo re
t re a tm e n t. N o t e m ig ra tin g le ft c e n t r a l in ciso r. M a x i l la r y firs t
m o la r
has
m a n d ib u la r
firs t
into
e x tra c tio n
e lo n g a te d b ic u sp id sp ace .
b ey o n d
and
B o tto m :
firs t
o c c lu s a l m o la r
R ig h t
sid e
p la n e
have of
as
tip p ed p a tie n t.
N o te p oo r p o ste rio r o cc lu sio n a n d t r a u m a t ic o c c lu s io n o f inciso rs c a u s in g m ig ra tio n o f le ft c e n tra l in ciso r
of the lower left central incisor against the lingual surface of the upper left incisor. As a result of this occlusal impact, the maxillary left central incisor migrated labially and extruded (Fig. 1). ■ X-ray examination: X-ray examination of the left maxillary central incisor disclosed loss of alveolar bony support involving half of the length of the root (Fig. 2 ). The periodontal membrane was wide and the pocket formation deep. Al
L F ig .
2
■ N o te
loss
of
a lv e o la r
su p p o rt
of
e lo n g a te d
le ft c e n tra l in ciso r
Newman: TREATM EN T OF M IG R A T IN G TEETH ■ 871
F ig .
3
■ L ig h t
e la s t ic
fo rc e
e x e rc isin g
r e tra c tin g
an d
d ep re ssin g fo rces
F ig .4
■ E la s tic is s tre tc h e d fro m
loop on b ite p la te to e x e rt a n
loop on la b ia l a rc h to
in tru s iv e fo rce
not dislodge the bite plate. Occlusal interference was eliminated by using a bite ledge that allowed the incisor to be retracted and depressed without being traumatized by the impinging lower in cisors. Notice in Figure 4 that the acrylic resin in the bite ledge has been relieved several milli meters lingual to the incisor to allow for freedom of tooth movement and to prevent compression of the lingual tissues.4 The patient was instructed to change the elas tics once a week and to wear the appliance at all times. She was observed once every 3 weeks. Treatment time was 2 months and 1 week. Although unhurried, treatment was relatively short, since the tooth movements were predomi nantly of a tipping action and because of the loss of alveolar support. ■ Results: Figure 5 shows the treated incisor in a more pleasing alignment. A new acrylic re tainer was placed for temporary retention until the patient’s dentist could fabricate a pin-ledge splint for the maxillary anterior teeth and com plete her oral rehabilitation. Although an acrylic bite plate retainer could be worn indefinitely, the most effective means of retention is a permanent fixed splint. A fixed splint is indicated for wan dering teeth when there is reduced alveolar sup port and when it has not been possible to elimi nate the factors causing the migration. Failure to employ a retaining appliance would have doomed the treated tooth to a relapse and poor prognosis.
C ase 2
Fig .
5
■ A f t e r a d u lt o rth o d o n tic t re a tm e n t
Fig .
6
■ C a s e 2. P a t ie n t b e fo re tre a tm e n t. N o t e e lo n
g a te d a n d m ig ra te d
le ft la te ra l
incisor.
872 ■ JA D A , Vol. 73, Oct. 1966
■ History and clinical examination: This report of a 46-year-old woman is concerned principally with treatment of an extruded, distolabially mi grating left lateral incisor (Fig. 6 ). A diastema was present between the left central incisor and gingivally irritated left lateral incisor. As in the previous patient (case 1), there was a deep over bite and a loss of vertical dimension. The patient wore ill-fitting metal upper and lower partial dentures to replace missing posterior teeth. She stated that she feared the looseness and drifting of the lateral incisor was the beginning of the loss of her anterior teeth, which might lead to the wearing of complete dentures. Before beginning complete mouth rehabilita tion, her dentist suggested the closure of the dias tema and the alignment of the anterior teeth. This
to minimize alveolar crest loss. The partial den ture and its orthodontic attachments were used as a temporary retainer splint until the fixed pros thesis was instituted.
Sum m ary
Fig. 7 ■ Activation of the loops of the labial arch has closed the diastema. Activation of the spring has de pressed the left lateral incisor tooth movement would parallel the long axes of the incisors and facilitate their fixed splinting. ■ X-ray examination: An intraoral radiograph of the left lateral incisor revealed loss of alveolar support, pocket formation, and a general hazi ness of the alveolar bone. ■ Treatment method: Since the patient was un able to masticate without her partial dentures, a labial arch with loops (0.028-inch stainless steel) was soldered to the palatal surface of the upper partial denture to permit tooth movement. An 0.020-inch auxiliary spring was soldered to the labial arch and bent over the incisal edge of the lateral incisor to create a depressive action. The loops were gently adjusted to close anterior spaces while the spring was activated to depress the lateral incisor (Fig. 7 ).
Two case reports were presented to demonstrate the use of removable appliances to effect ortho dontic tooth movement to treat migrating teeth before oral rehabilitation involving fixed splint retention.
Doctor Newman is chief orthodontist of the Bureau of Health in Newark, and adjunct research professor of Newark College of Engineering in Newark, N.J. His address is 659 Eagle Rock Avenue, West Orange, N.J. 1. Thoma, K. H. and Goldman, H. M. Wandering and elongation of the teeth and pocket formation in parodontosis. JADA 27:335 March, 1940. 2. Gottlieb, Bernhard. The formation of the pocket: diffuse atrophy of alveolar bone. JADA 15:462 March, 1928. 3. Newman, G. V. Biophysical properties of ortho dontic rubber elastics. J New Jersey Dent Soc 35:95 Nov., 1963. 4. Newman, G. V. Removable appliances in preven tive orthodontics. J New Jersey Dent Soc 34:145 Dec., 1962.
■ Results: The result of orthodontic movement can be seen in Figure 8. Treatment time was 2 months and 3 weeks. Light forces were employed
First A spirin
A small-time Alsatian chemist, Charles F. von Gerhardt, apparently was the first man to make aspirin. He did so in 1853. His discovery lay idle, almost unknown until an American chemist, Felix Hoffman, began research fpr a similar product in 1898, and the patent was issued to his employer, Bayer, in 1900.
Fig. 8 ■ After orthodontic correction of lateral incisor
migrated
Pharmaceutical M anufacturers Association, news release, Washington, D.C., Feb., 1965.
Newman: TREATM EN T OF M IG R A T IN G TEETH ■ 873
George V . Newm an, DDS, W est Orange, N.J.
Two adult case reports, one involving a mi grating maxillary left central incisor, the other a distolabially migrating left lateral in cisor, demonstrate the use of removable appli ances before oral rehabilitation involving per manent fixed splinting is performed. Both in stances of pathologic wandering involved a deep overbite and a loss of vertical dimension.
1. Loss of alveolar support negates extensive tooth movement. 2. Retention of migrated teeth usually re quires permanent fixed splinting. 3. Optimal esthetics and minimal treatment time are desired by the adult patient. 4. Economic factors must be considered. The following case reports describe two adult orthodontic treatment methods that can be used to aid in correcting pathologic wandering of teeth.
C a se 1
Migrating teeth (pathologic wandering) is diag nosed clinically as mobile and drifting teeth and radiographically as resorption of alveolar bone.1 Migration of teeth results from pressure exerted on the teeth by granulation tissue that has re placed the resorbed bone. Excessive occlusal stress increases the alveolar resorption and aggra vates the pathologic wandering.2 Generally, the patient seeks treatment after a long period of dental neglect (usually loss of pos terior occlusal support) causing anterior spacing or flaring, or both, of 1 or more teeth, which re sults in an unesthetic appearance. Orthodontic treatment for adults is limited to practical treatment rather than ideal treatment when they have migrating teeth because of sev eral factors: 870
■ History and clinical examination: Treatment of a 44-year-old woman, possessing a Class II, Division 1, malocclusion, was undertaken to re tract and align the maxillary left central incisor so she could wear a complete crown and bridge prosthesis. The patient complained of “loose ness” and protrusion of the central incisor; she was alarmed over its “sudden” movement. The prominence of the migrating incisor detracted from her physical appearance, she stated, and gave her an unfavorable appearance and smile. A dental history revealed that in her adolescence she had discontinued orthodontic treatment after the right and left maxillary first bicuspids had been extracted. The lower left second bicuspid was, subsequently, extracted because of dental caries. The loss of posterior occlusal support fos tered a deep overbite, causing traumatic occlusion
though there was loss of alveolar bone in the adjacent right central incisor and left lateral in cisor, the left maxillary central incisor had a longer extra-alveolar (clinical crown) lever and, therefore, migrated. ■ Treatment methods: A basic acrylic bite plate (anchorage) with 2 molar clasps (0.036-inch stainless steel), a labial arch with loops (0.028 inch) and a bite ledge to eliminate occlusal inter ferences was employed to affect tooth movement (Fig. 3 ). The labial arch was bent away from the left central incisor to limit the force to light elastics. A light rubber dam elastic,3 exerting a force of 2 ounces, when stretched from the right to the left loop of the labial arch, produced a lingual re tracting force against the protruding incisor. Since the incisor was elongated and retraction in creased elongation, an intrusive force was neces sary. This force was accomplished by stretching a rubber dam elastic (2 ounces) from a soldered brass loop on the labial arch over the incisal edge of the tooth to a U-shaped hook on the bite plate (Fig. 4 ). Consequently, there was a retracting and depressing action on the displaced incisor. The elastic pressure created a light constant diminishing force that was so minimal that it did
F ig .
1 ■ Top:
C ase
1.
L e ft
side
of
p a t ie n t
b efo re
t re a tm e n t. N o t e m ig ra tin g le ft c e n t r a l in ciso r. M a x i l la r y firs t
m o la r
has
m a n d ib u la r
firs t
into
e x tra c tio n
e lo n g a te d b ic u sp id sp ace .
b ey o n d
and
B o tto m :
firs t
o c c lu s a l m o la r
R ig h t
sid e
p la n e
have of
as
tip p ed p a tie n t.
N o te p oo r p o ste rio r o cc lu sio n a n d t r a u m a t ic o c c lu s io n o f inciso rs c a u s in g m ig ra tio n o f le ft c e n tra l in ciso r
of the lower left central incisor against the lingual surface of the upper left incisor. As a result of this occlusal impact, the maxillary left central incisor migrated labially and extruded (Fig. 1). ■ X-ray examination: X-ray examination of the left maxillary central incisor disclosed loss of alveolar bony support involving half of the length of the root (Fig. 2 ). The periodontal membrane was wide and the pocket formation deep. Al
L F ig .
2
■ N o te
loss
of
a lv e o la r
su p p o rt
of
e lo n g a te d
le ft c e n tra l in ciso r
Newman: TREATM EN T OF M IG R A T IN G TEETH ■ 871
F ig .
3
■ L ig h t
e la s t ic
fo rc e
e x e rc isin g
r e tra c tin g
an d
d ep re ssin g fo rces
F ig .4
■ E la s tic is s tre tc h e d fro m
loop on b ite p la te to e x e rt a n
loop on la b ia l a rc h to
in tru s iv e fo rce
not dislodge the bite plate. Occlusal interference was eliminated by using a bite ledge that allowed the incisor to be retracted and depressed without being traumatized by the impinging lower in cisors. Notice in Figure 4 that the acrylic resin in the bite ledge has been relieved several milli meters lingual to the incisor to allow for freedom of tooth movement and to prevent compression of the lingual tissues.4 The patient was instructed to change the elas tics once a week and to wear the appliance at all times. She was observed once every 3 weeks. Treatment time was 2 months and 1 week. Although unhurried, treatment was relatively short, since the tooth movements were predomi nantly of a tipping action and because of the loss of alveolar support. ■ Results: Figure 5 shows the treated incisor in a more pleasing alignment. A new acrylic re tainer was placed for temporary retention until the patient’s dentist could fabricate a pin-ledge splint for the maxillary anterior teeth and com plete her oral rehabilitation. Although an acrylic bite plate retainer could be worn indefinitely, the most effective means of retention is a permanent fixed splint. A fixed splint is indicated for wan dering teeth when there is reduced alveolar sup port and when it has not been possible to elimi nate the factors causing the migration. Failure to employ a retaining appliance would have doomed the treated tooth to a relapse and poor prognosis.
C ase 2
Fig .
5
■ A f t e r a d u lt o rth o d o n tic t re a tm e n t
Fig .
6
■ C a s e 2. P a t ie n t b e fo re tre a tm e n t. N o t e e lo n
g a te d a n d m ig ra te d
le ft la te ra l
incisor.
872 ■ JA D A , Vol. 73, Oct. 1966
■ History and clinical examination: This report of a 46-year-old woman is concerned principally with treatment of an extruded, distolabially mi grating left lateral incisor (Fig. 6 ). A diastema was present between the left central incisor and gingivally irritated left lateral incisor. As in the previous patient (case 1), there was a deep over bite and a loss of vertical dimension. The patient wore ill-fitting metal upper and lower partial dentures to replace missing posterior teeth. She stated that she feared the looseness and drifting of the lateral incisor was the beginning of the loss of her anterior teeth, which might lead to the wearing of complete dentures. Before beginning complete mouth rehabilita tion, her dentist suggested the closure of the dias tema and the alignment of the anterior teeth. This
to minimize alveolar crest loss. The partial den ture and its orthodontic attachments were used as a temporary retainer splint until the fixed pros thesis was instituted.
Sum m ary
Fig. 7 ■ Activation of the loops of the labial arch has closed the diastema. Activation of the spring has de pressed the left lateral incisor tooth movement would parallel the long axes of the incisors and facilitate their fixed splinting. ■ X-ray examination: An intraoral radiograph of the left lateral incisor revealed loss of alveolar support, pocket formation, and a general hazi ness of the alveolar bone. ■ Treatment method: Since the patient was un able to masticate without her partial dentures, a labial arch with loops (0.028-inch stainless steel) was soldered to the palatal surface of the upper partial denture to permit tooth movement. An 0.020-inch auxiliary spring was soldered to the labial arch and bent over the incisal edge of the lateral incisor to create a depressive action. The loops were gently adjusted to close anterior spaces while the spring was activated to depress the lateral incisor (Fig. 7 ).
Two case reports were presented to demonstrate the use of removable appliances to effect ortho dontic tooth movement to treat migrating teeth before oral rehabilitation involving fixed splint retention.
Doctor Newman is chief orthodontist of the Bureau of Health in Newark, and adjunct research professor of Newark College of Engineering in Newark, N.J. His address is 659 Eagle Rock Avenue, West Orange, N.J. 1. Thoma, K. H. and Goldman, H. M. Wandering and elongation of the teeth and pocket formation in parodontosis. JADA 27:335 March, 1940. 2. Gottlieb, Bernhard. The formation of the pocket: diffuse atrophy of alveolar bone. JADA 15:462 March, 1928. 3. Newman, G. V. Biophysical properties of ortho dontic rubber elastics. J New Jersey Dent Soc 35:95 Nov., 1963. 4. Newman, G. V. Removable appliances in preven tive orthodontics. J New Jersey Dent Soc 34:145 Dec., 1962.
■ Results: The result of orthodontic movement can be seen in Figure 8. Treatment time was 2 months and 3 weeks. Light forces were employed
First A spirin
A small-time Alsatian chemist, Charles F. von Gerhardt, apparently was the first man to make aspirin. He did so in 1853. His discovery lay idle, almost unknown until an American chemist, Felix Hoffman, began research fpr a similar product in 1898, and the patent was issued to his employer, Bayer, in 1900.
Fig. 8 ■ After orthodontic correction of lateral incisor
migrated
Pharmaceutical M anufacturers Association, news release, Washington, D.C., Feb., 1965.
Newman: TREATM EN T OF M IG R A T IN G TEETH ■ 873