JIDAM

CASE REPORT

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CONSERVATIVE MANAGEMENT OF TOOTH

SIZE ARCH LENGTH DISCREPANCIES-A

REPORT OF TWO CASES

Dr. Shekar Shobana, Dr Krishnan Amudhalakshmi*

Department of Conservative Dentistry and Endodontics,

SRM Dental College and Hospital, Ramapuram, Chennai, Tamilnadu, India.

* Department of Dental Surgery, Government Vellore Medical College and Hospital, Tamilnadu, India.

BSTRACT

ngth discrepancies ideally require

ut in certain exceptional cases like

To access & cite t

ssive periodontitis, pathological

Website: jidam.ida

liance of the patient to undergo

ic procedure, the scenario demands

ine treatment approaches and to

t plan based on the patient’s needs.

o cases: midline diastema in

to pathological migration managed

ned by fiber reinforced composite

case discusses anterior crowding

by a fixed partial denture and the

DOI:10.37841/jidam_2

ned by fiber reinforced composite

etic

transformation,

cosmetic

forced composite, natural tooth

Address for correspondence:

Dr Shekar Shobana, MDS.,

No 4, 6th Avenue, Ramakrishna Nagar, Porur,

Chennai- 600 116

E mail id: drshobana.bds@gmail.com

Received - 26.7.2019

Accepted - 12.9.2019

Published - 27.12.2019

JIDAM/Volume:7/Issue:1/Pages 32 - 37/January - March 2020

Shobana et al : Management of tooth size arch length discrepancies

INTRODUCTION

First appointment:

The face is the most important part of the body when

During the first visit, a study model was taken to assess the

determining physical attractiveness and the order of

patient’s overjet and overbite relation. The maxillary and

increasing importance is the nose, facial structure, eyes and

mandibular anteriors were in normal overbite relation,

the mouth respectively.¹Aesthetics being a subjective factor,

whereas overjet was increased measuring about 4mm. Then

is often necessary to formulate treatment plan according to

the mesiodistal width of the mandibular centrals was

the patient’s requirement, within a short period of time. The

measured accurately using calipers to assess the amount of

condition might necessitate deviation from the established

tooth preparation required to accommodate the acrylic

clinical protocols and achieve optimal aesthetics meanwhile

pontic. A suitable acrylic teeth was selected after shade

adhering to the principles of minimal intervention.

matching.

Crowding and spacing of teeth are the two most

Electric pulp testing for

41 exhibited normal

commonly encountered malocclusion problems. These cases

response whereas 31 exhibited delayed response. On clinical

are usually treated by orthodontic correction. In exceptional

examination

31 revealed grade II mobility and gingival

cases, it may be necessary to manage the above mentioned

recession. Intentional root canal treatment was planned for

conditions conservatively. This case report describes

31.

management of two common malocclusion(s) - crowding

and spacing managed by conservative aesthetic approach.

Digital Vernier calipers were used to measure the

First case discusses lower anterior spacing due to

space and mesio distal dimension of 41 and 31 which was

pathological migration managed

tively. This gave a total of 14 mm

retained by fiber reinforced com

f 31, 41 and diastema). It was thus

describes the management of

mesio distal dimension of 4.6 mm

anteriors with mesiodens by extr

c denture pontic. As 31 was to be

and restoration with a fixed partial

ore reduction was planned in 31

mandibular anteriors was man

be stripped ultra conservatively

malposed teeth which was retai

spect to create a total space of 4.6

natural tooth pontic. Cosmetic r

ure pontic. Thus 31 and 41 in the

composite restoration was done.

ere stripped proximally and the

pontic was also trimmed to check

CASE REPORT 1

A 27 year old female

Department of Conservative Den

referred from the Department of

d visit, intentional single visit root

management of spacing in the low

in 31.

pathological migration of teet

evaluation of

31 and 41. The m

periodontally compromised and

follow-up phase after periodontal

sequent visit

41,31 were stripped

the lower anterior region was of

e proximal aspect to accommodate

patient that raised the need for aesthetic intervention.

the acrylic pontic [Fig 1(b)]. Space of approximately 0.5 mm

should exist between the pontic and the abutment teeth,

Intra-oral Examination:

which provides additional bulk of composite material and

hence stronger connectors.²

Intra-oral examination revealed localized aggressive

periodontitis involving 31, 41 with pathological migration

Under rubber dam isolation using the split dam

[Fig.1(a)] which revealed a space of 3.5 mm between the

technique, Class III cavities were prepared in 31 and 41

mandibular central incisors as measured with digital

[Fig.1(c)] from the lingual approach. The cavities were

calipers. The patient’s periodontal condition precluded the

etched for 20 seconds using 37% orthophosphoric acid (N-

use of 31,41 as abutments for fixed prosthesis whereas the

Etch, Ivoclar Vivadent, Leichenstein, Germany), rinsed for

spacing posed a potential threat to patient’s aesthetics. As an

20 seconds and air dried. Bonding agent (Tetric-N-Bond,

interim management it was planned to close the space by

Total Etch Dental Adhesive, Ivoclar Vivadent, Leichenstein,

using acrylic tooth pontic stabilized with fibre reinforced

Germany) was applied and cured for 10 seconds. The acrylic

composite.

tooth pontic was positioned and stabilized from labial aspect

with flowable light cured composite resin

(Te-Econom

Treatment plan:

Flow, Ivoclar Vivadent, Leichenstein, Germany). The

acrylic pontic was prepared as to maintain a modified ridge

lap relation with the alveolar ridge.

JIDAM/Volume: 7/Issue: 1/Pages 32 - 37/January - March 2020

Shobana et al : Management of tooth size arch length discrepancies

maxillary mesiodens and missing 11, Ellis class II fracture in

The desired length of the glass impregnated braided

41.

fiber reinforced composite (Interlig, Angelus, Londrina, PR

Brazil) was measured and cut. The class III cavities in 31

and 41 were coated with flowable composite to ensure

maximum wetting of the fiber and was stabilized in position

using a Teflon coated composite instrument. The material

was then light cured for 40 seconds [Fig.1(d)]. A second

increment of flowable composite was added and again light

cured for 40 seconds. Final finishing was done with Optra

Pol (Ivoclar Vivadent, Leichenstein, Germany)

[Fig1(e)].

The post-operative image shows the acrylic tooth pontic in

place [Fig 1(f)].

Fig 2(a): Pre-operative labial view. Fig 2(b): Pre-operative

lingual view Fig

2(c): Labial view after extraction of

mesiodens. Fig 2(d): Intentional RCT in 12, 21, 22. Fig 2(e):

Mock tooth preparation on diagnostic cast. Fig 2(f): Mock

nostic cast. Fig 2(g): Silicone putty

ck wax up. Fig 2(h): Silicone putty

tooth preparation. Fig 2(i): Lines

he teeth lying within the arch form

Fig 1(a): Pre-operative facial view

; blue, yellow and red lines denote

of the lower anteriors . Fig 1(b): Se

ning of 22,12 and 21 respectively

the acrylic tooth as pontic. Fig 1(c)

rm which will requires elective

cavities in 31 and 41 for placemen

abutments within the desired arch

Fig 1(d): Acrylic tooth pontic try

ed crown preparation in 12,11,21.

Fig 1(e): Lingual view of the re

he secondary cast

Labial view of the acrylic pontic

dure:

CASE REPORT 2

tment plan was as follows: For the

A 23-year old male patient

l root canal treatment in 12,21,22,

complaint of crowded upper and l

fixed partial denture in 12,21,22.

referred from the Department of O

: extraction of

32, the crown of

was not willing for comprehensiv

FRC retained natural tooth pontic,

The patient was seeking aestheti

nd light cure composite restoration

duration of treatment and financial constraints were

oral prophylaxis, extraction of

exercising a great influence on the treatment plan.

mesiodens was done [Fig 2(c)] followed by intentional root

canal treatment of 12,21,22 (Fig 2(d)]. This was followed by

Extra-oral examination revealed that the patients

the extraction of the maxillary mesiodens. Using the

profile and divergence were within normal limits. No

diagnostic casts as guidance, mock tooth preparation was

skeletal malocclusion was evident.

done on the study model [Fig 2(e)] and a mock-up wax

pattern was made with the mockup wax

[Fig

2(f)]. A

Intra-oral examination:

silicone putty index was made over the mockup to guide the

tooth preparation [Fig 2(g)] and also to determine the facial

Intra-oral examination revealed the presence of

and incisal position of the final restoration. The putty index

severe crowding of maxillary anteriors. Patient gives recent

was placed periodically over the abutment teeth during

history of extraction of 11 which was labially placed. 21 was

preparation to assess the amount of clearance obtained and

disto labially rotated along its long axis and mesiodens was

also to conserve tooth structure that was lingually inclined

present. Mandibular anteriors were crowded with gingival

[Fig 2(h)]. Figure 2(i) is a depiction of the analysis of the

recession in 31, 41 and Ellis class II fracture was present in

relative labio-lingual positioning of teeth. Fig 2(j) shows the

41 which was labially malposed [Fig 2(a) & (b)]. Overjet

completed tooth preparation done with the putty index as the

and overbite were within acceptable ranges. The case was

guide. Impressions were recorded with elastomeric

diagnosed as Angle’s Class I molar relation with crowded

impression materials and the secondary casts were

maxillary and mandibular anteriors and the presence of

articulated [Fig 2 (k)]. Porcelain fused to metal crowns were

fabricated and cementation was done with Fuji Type I glass

JIDAM/Volume: 7/Issue: 1/Pages 32 - 37/January - March 2020

Shobana et al : Management of tooth size arch length discrepancies

ionomer luting cement

(GC, Tokyo, Japan).

13 was

duration makes alternative options like recontouring and

recontoured and restored with light cure composite

direct restorations feasible.^5,6 The patient’s choice of

restoration to mimic 12 (TetricN-Ceram, Ivoclar Vivadent,

treatment is a vital element for the success of any procedure

Leichenstein, Germany).

as it involves the psychological, physical and financial

dimension of the individual.⁷

Case

1: In the first case, there was localized

aggressive periodontitis of the lower anteriors and the

patient was in the follow-up phase of treatment. An interim

aesthetic procedure was needed before a definitive treatment

could be instituted.

Case

2: In the second case, owing to patient’s

aesthetic needs and non-compliance towards orthodontic

treatment a conservative management was planned.

Fig 3(a): Extraction of the lingually aligned 32. Fig 3(b):

Mesiodens was extracted and fixed partial denture was

Extracted tooth stored in sterile saline. Fig

3(c): Natural

planned using 12, 21 and 22 as abutments to replace 11, 21,

tooth pontic prepared proximally to fit in the space between

22. Aesthetic pre-evaluative temporary technique (APT) is

31 and

33. Fig

3(d): Decoronation and lingual slot

usually used to guide tooth preparation for veneers.⁸In this

preparation of natural tooth pontic 32. Fig 3(e): Class III

case, the silicon putty index served as a guide to tooth

cavity preparation in 31 and 33.

preparation depth as the abutments

composite retained natural tooth po

reparations due to severe rotation.

aesthetic transformation is a well

the literature.^3,9,10,11In this case, 13

Under local anaesthesia w

12 by additive technique with

(Lignox, Warren pharmaceuticals

echnique is both biologically and

done [Fig 3(a)] and stored in steri

nd requires less appointments.¹⁰

extracted tooth was decoronated a

debrided. The prepared tooth wa

s, it was not possible to establish

until further use. After one week, th

ry. Pinho et al¹² has stated that

proximally sliced to fit into the ex

ceptible when equal to or greater

and the pulp chamber was seal

ists and

3 mm for Prosthodontists

Cement (Fuji II, GC Tokyo, Ja

make no detections in midline

measuring 2 mm was placed on the

al¹³has concluded from his study

3(d)]. Under rubber dam isolation

ble deviation variations for smile

prepared on the mesial and dis

, and practitioners should avoid

respectively [Fig 3(e)] and FRC ret

patients to minor discrepancies”.

was done as previously discusse

operative and post-operative comp

composites (FRC) are used as long

Figures 4 (a), (b) and (c) respective

ey overcome the drawbacks of

like low fracture resistance and

resilience. Many investigators have confirmed the

reinforcing effect of FRCs on different polymer types^14,15

This reinforcing effect can be attributed to the transfer of

stresses from the weak polymer matrix to the fibers with

high tensile strength.¹⁶In the present case, Interlig (Angelus)

was used, which is an impregnated, braided, glass fiber

reinforced composite with the ability to dissipate forces in

all directions. Glass fibers are treated with silane chemical

coupling agent to allow dental resins to chemically adhere to

the glass fiber strands.¹⁷Kolbeck et al reported that glass

fibers performed better than polyethylene fibers due to pre-

Fig 4(a): Pre-operative labial view. Fig 4(b): Post-operative

labial view. Fig 4(c): Post-operative profile view

impregnation with light cured composite which ensures a

good bond with the composite resin making Intelig

(Angelus) the ideal material of choice in this case.¹⁸

DISCUSSION

In case

1, there was spacing due to pathological

Even though multidisciplinary treatment is the key

migration related to localized aggressive periodontitis of the

to establish an ideal and a perfect smile component,^3,4the

mandibular anteriors, not associated with tooth loss. A

need to attend to the patient’s aesthetics within a short

definitive management in this case would be an implant or

JIDAM/Volume: 7/Issue: 1/Pages 32 - 37/January - March 2020

Shobana et al : Management of tooth size arch length discrepancies

fixed partial denture. But due to the poor prognosis of the

evaluation form. Dent Clin North Am

2011;

abutment teeth (31,41), placement of a fixed prosthesis or

55(2):

187-209.

implant was contraindicated in that region because of the

Dietschi D. Optimizing smile composition and

existing pathological destructive process in the bone. So this

esthetics

with resin composites and other

case became an ideal candidate for acrylic pontic and FRC

conservative esthetic procedures. Eur J Esthet

resin. A chairside FRC prosthesis offers a fast, minimally

Dent 2008;3(1):14-29.

invasive approach for tooth replacement that combines all of

the benefits of the FRC material for aesthetic, functional and

Mathias P, Freitas da Silva EV, Aguiar TR

potentially durable result. An acrylic tooth or a natural tooth

,Andrade AS, Azevedo J.A Conservative esthetic

(in the case of extraction of a periodontally-involved incisor)

approach using enamel recontouring and composite

can be used as a pontic.

resin restorations. Case Rep Dent

2016; 2016: 1-5.

FRC has an acceptable strength because of good

Chu CH, Zhang CF, Jin LJ. Treating a maxillary

integration of fibers with the composite resin, leading to

midline diastema in adult patients—a general

clinical longevity and can be completed in a single

dentist’s perspective. J Am Dental Ass

2011;

appointment. In addition, the appliance can easily be

142(11):

1258-1264.

repaired in case of fracture due to wear and tear. Moreover,

it meets patients’ aesthetic expectation1.⁹

Gurel G, Morimoto S, Calamita MA, Coachman

C, Sesma N. Clinical Performance of Porcelain

CONCLUSION

Laminate Veneers: Outcomes of the Aesthetic Pre-

rary

(APT) Technique. Int J

Aesthetic dentistry is purely

rative Dent 2012;32:625-635.

patients dictates the choice of tre

discretionary income. The succes

sformation of a lateral incisor to

depends on motivation and aesthe

with a ceramometal crown. Rev

emotional. It would be prudent to

989 Sep-Oct;18(5):385-93.

clinical decision making coupl

principles of aesthetics helps to ac

Atzeri G, Collares FM, Hirata

outcomes and aids in establishing

ntouring for achieving anterior

span of time.

thet Dent

2019;14(2):134-146.

tzikos T, Shamus IL . Esthetic

FINANCIAL SUPPORT AND

am approach. N Y State Dent J

SPONSORSHIP:

Nil

, Faber J, Lenza MA . Impact

tries on the perception of smile

CONFLICTS OF INTEREST:

J Orthod Dentofacial Orthop.

There are no conflicts of interest.

Fields HW, Beck M, Rosenstiel

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