Figure 1
Patients with anterior spacing often consider this as a significant aesthetic impairment, and will go to great lengths to have this resolved. However, spacing of the anterior teeth tends to have a low score both for the dental health component and the aesthetic component of the Index of Orthodontic Treatment Need (IOTN).
This lady presented in her early 20’s complaining that she disliked the gaps between her upper front teeth. Her dentist had provided composite build-ups on the mesial and distal surfaces of both upper central incisors and on the mesial surface of her upper right lateral incisor (fig 1).
However, she felt that her upper central incisors were now too large compared to her lateral incisors, too wide relative to their height and also a rather odd shape.
Extra-oral assessment
She presented with a Class 2 skeletal base with a prominent pogonion, a low maxillary mandibular planes angle and a reduced lower anterior face height.
Intra-oral assessment
She was in the permanent dentition with an unrestored dentition with the exception of the build-ups on her anterior teeth. Her oral hygiene was good.
The mandibular arch was mildly crowded and the maxillary arch spaced.
In occlusion, she had a Class 2 division 1 incisor relationship with an increased overjet and overbite. The molar and canine relationship on the right was ¾ unit Class 2 and on the left ¼ unit Class 2.
Radiographic assessment
The panoramic radiograph confirmed the presence of all permanent teeth, with root lengths and bone levels within normal levels. Analysis of the lateral cephalogram indicated a Class 2 skeletal pattern with proclination of the upper incisors and retroclination of the lower incisors.
Aims of treatment
Sagittal correction of the occlusion
Leveling and aligning
Class 1 molar and canine relationship
Space closure
Treatment plan
Removal of composite build-ups
Upper and lower pre-adjusted edgewise fixed appliances (0.022 x 0.028 inch slot MBT prescription)
Mandibular subapical osteotomy
Figure 2
The risk and benefits of treatment where discussed at length especially due to its complex nature and she decided to commence with treatment. The composite build-ups were removed (fig 2) and upper and lower fixed appliances placed for decompensation prior to mandibular surgery.
Figure 3
Initial alignment was commenced with 0.016 nickel titanium archwires progressing to 0.018 x 0.025 nickel titanium until 0.019 x 0.025 stainless steel working archwires could be placed (fig 3). Space closure was performed using power chain in the upper labial segment and nickel titanium closing springs in the buccal segments. Pre surgical orthodontics took 11 months and she was debonded 6 months after surgery (fig 4).
Following debond she was fitted with upper and lower vacuum formed retainers.
Figure 4
Closure of anterior spacing always presents a dilemma. Is it possible to close the spaces with orthodontics alone or a restorative solution alone or is a combination of orthodontic redistribution of the spaces followed by aesthetic build-ups of the teeth required? In this case, although her upper laterals are slightly small the patient was delighted with her new smile (fig 5). All orthodontic work carried out by Fiona McKeown.
Figure 5
