Switch to Dark theme

References

Cunningham SJ. The psychology of facial appearance. Dent Update. 1999; 26:438-443
Shaw WC, Meek SC, Jones DS. Nicknames, teasing, harassment and the salience of dental features among school children. Br J Orthod. 1980; 7:75-80
Johal AJ, Cheung MY, Marcenes W. The impact of two different malocclusion traits on quality of life. Br Dent J. 2007; 202:(E6)1-4
Cons NC, Jenny J, Kohout FJ DAI: the Dental Aesthetic Index.Iowa: College of Dentistry, University of Iowa; 1986
Snow K. Articulatory proficiency in relation to certain dental abnormalities. J Speech Hear Disord. 1961; 26:209-212
Bankson NW, Byrne MC. The relationship between missing teeth and selected consonant sounds. J Speech Hear Disord. 1962; 27:341-348
Khalaf K, Miskelly J, Voge E, Macfarlane T. Prevalence of hypodontia and associated factors: a systematic review and meta-analysis. J Orthod. 2014; 41:229-316
Graham JW. Temporary replacement of maxillary lateral incisors with miniscrews and bonded pontics. J Clin Orthod. 2007; 41:321-325
Wilmes B, Neinkemper M, Renger S, Drescher D. Mini-implant supported temporary pontics. J Clin Orthod. 2014; 48:422-429

Options for replacing missing teeth during orthodontic treatment

From Volume 11, Issue 3, July 2018 | Pages 106-109

Authors

Niamh O'Rourke

BA, BDentSc, MClin Dent, MOrth RCS(Eng)

Post CCST in Orthodontics, King's College Hospital and Royal Surrey County Hospital, Egerton Road, Guildford, Surrey GU2 7XX, UK

Articles by Niamh O'Rourke

Nigel Taylor

MDSc, BDS, FDS RCS(Ed), MOrth RCs(Ed), MDSc, BDS, FDS RCS(Ed), FDS RCS(Eng), FDTFed RCS(Ed), M'Orth RCS(Ed), D'Orth RCS(Eng), Consultant Orthodontist

Consultant Orthodontist, Royal Surrey County Hospital, Guildford, UK

Articles by Nigel Taylor

Abstract

Abstract: Patients presenting for orthodontic treatment with missing teeth in the anterior region have an added concern about how aesthetics will be affected over the duration of treatment. It is important to maintain the best possible aesthetics during treatment as this may affect patient confidence, motivation and enthusiasm. This paper reviews the techniques used to maintain aesthetics during orthodontic treatment for patients who require eventual replacement of a missing tooth. The advantages and disadvantages of the different treatment options are discussed.

CPD/Clinical Relevance: To understand the treatment options for temporary replacement of missing teeth during orthodontic treatment.

Article

Niamh O'Rourke

Anterior teeth play a vital role in aesthetics, function and psychosocial wellbeing of patients.1, 2 Spacing in the upper labial segment has been shown to have a high impact on the quality of life of patients.3 A missing anterior tooth has been considered to be the most unattractive occlusal trait in at least one study4 and associated speech difficulties have also been reported in the literature.5, 6 Absent incisors can affect self-esteem, as well as social interaction, and it is important as orthodontists to be aware of the impact of such features of malocclusion. A recent systematic review and meta analysis of the prevalence of hypodontia reported the prevalence of missing upper central and lateral incisors to be 24.3% and 1%, respectively.7 The prevalence of missing lower incisors was reported as 6.1% and 4.3% for central and lateral incisors. Upper and lower canines were missing in 2.5% and 1.3% of subjects. Concern about missing units during orthodontic treatment is common and often patients presenting with missing teeth in the aesthetic zone have the added concern about how aesthetics will be affected over the duration of treatment. In cases where treatment is planned to open space for the missing tooth or teeth, a small space becomes larger and, if left throughout treatment, can present a real concern to the patient.

This short clinical paper highlights the various options to maintain aesthetics during treatment for patients who require eventual replacement of a missing tooth. Patients find spaces a source of social embarrassment and it is reassuring for them to know that missing units can be replaced on a temporary basis before orthodontics is completed. Temporary pontics can prove challenging to fit and maintain, particularly during the early stages of treatment. A number of techniques are available and will be described considering the advantages and disadvantages of each individual technique.

Temporary pontics

Temporary pontics, also often called riding pontics, are temporary prostheses used during orthodontic treatment to replace missing teeth and can be used to replace any missing tooth. Replacement is especially beneficial to patients when one or more anterior teeth are missing.

Benefits of using temporary pontics

Patient benefits

Provides an instant cure for an unpleasing dark space in the aesthetic zone, encouraging a confident and motivated patient.

Operator benefits

  • Quick and inexpensive;
  • Exact mesiodistal width of the missing tooth can be maintained, eliminating the use of numerous lengths of closed coil. The pontic tooth supplied can be adjusted by the addition of composite or removal of acrylic during the treatment should it not be the exact size when first placed;
  • Can be used to aid gingival architecture: use of an ovate pontic is hygienically superior to a saddle–lap pontic and can, in some cases, aid the creation of a natural emergence profile for the prosthetic replacement;
  • The temporary pontic can be used in the retention phase prior to the eventual prosthetic replacement of the tooth.

    • Disadvantages of temporary pontics

  • Disadvantages associated with temporary pontics can be mostly overcome with judicious preparation and consideration when planning the orthodontic case.
  • The patient may be unhappy with the space whilst awaiting creation of adequate space for an ideally sized pontic to be placed. Composite can be added to the adjacent teeth if this is a major concern to the patient;
  • Rotational control of the temporary pontic is difficult with round archwires, however, movement can be limited with rectangular archwires. Movement can also be limited by undertying or overtying the pontic to the adjacent teeth with a 0.08” or 0.10” stainless steel long ligature;
  • Bond failure of the pontic may occur during treatment: this can be overcome by carefully creating an undercut on the labial surface of the pontic for added macro-mechanical retention;
  • Shade and shape matching: care for optimum colour matching is vital and it is preferable to have an impression taken of the arch so that the laboratory technician can prepare a tooth which is similar in size and proportions to the contra lateral tooth, if available.

    • Clinical examples

    1. Pontic on removable appliance

    In cases where a removable appliance forms part of the patient's treatment plan, a temporary pontic can be easily added. A simple impression of the arch along with a shade, matching that of the adjacent teeth, is sent to the laboratory for fabrication.

    Advantages

  • This design can be easily incorporated into any removable appliance used in the patient's treatment plan, including bite planes and functional appliances;
  • Can be used on a retainer following removal of the fixed appliances.

    • Disadvantages

  • Can fracture and thus the space maintainer effect can be lost;
  • It is important to incorporate stops adjacent to the pontic, however, these can occasionally be unaesthetic.

    • 2. Bracket bonded to pontic (Figure 1)

    Figure 1. (a, b) Orthodontic bracket bonded to archwire and tied to adjacent teeth with ligature wire.

    An impression and shade is taken on the visit prior to the pontic addition when sufficient space is available and the laboratory can provide the pontic tooth. Otherwise, the clinician can choose a suitably sized and shade-matched acrylic denture tooth and adjust chairside as required. The bracket is then added to the labial surface of the denture tooth using a light-cured bonding agent. It is important to roughen the surface to improve mechanical retention. An acrylic primer can also improve the retention. Alternatively for added macro-mechanical retention the denture tooth can be prepared by creating an undercut using a small round dental bur on the labial surface in the region of bracket placement prior to bonding of the orthodontic bracket. Retention of the pontic tooth can be further enhanced by ligating the pontic tooth to adjacent teeth by use of a stainless steel ligature.

    Advantages

  • There are similar aesthetics to adjacent teeth;
  • Provides an ideal guide for the amount of space required;
  • Can be easily adjusted at the chairside if required.

    • Disadvantages

  • The bonded attachment may debond;
  • The pontic may rotate around a round wire and therefore it is prudent to wait until rectangular wire has been placed due to rotation of a bracketed tooth around a round wire.

    • 3. Pontic bonded directly to archwire (Figure 2)

    Figure 2. Pontic bonded directly to archwire.

    In this case, the orthodontic bracket is bonded directly onto the archwire using a bonding agent and a light-cured polymer resin. There is no requirement for a bracket.

    Advantages

  • Very quick and easy technique;
  • Cost-effective as no requirement for an orthodontic bracket;
  • Can be bonded to round flexible wires early in treatment.

    • Disadvantages

  • There is no bracket placed so it is dissimilar to adjacent teeth and the eye may be drawn to the pontic.

    • 4. Natural tooth used as pontic (Figure 3)

    Figure 3. (a−c) Natural tooth used as pontic.

    In this case, the crown of the natural tooth is used as the temporary pontic. Rarely does this clinical situation occur and it may be suitable for use in the case of a traumatized and ankylosed tooth where the plan is for extraction or decoronation in order to preserve the vertical alveolar bone height in a growing patient.

    The natural tooth can be prepared chairside at the extraction appointment or shortly thereafter. The crown is removed and the pulp contents or the crown extirpated, the pulp chamber washed, dried and filled with an acid-etched composite filling material. The surface of the crown is prepared to accept a bracket in the same way as applied to the rest of the teeth in the arch; using self-etching primer or etch and bond in two stages.

    Advantages

  • No laboratory involvement is needed and the tooth will be similar to the adjacent tooth;
  • This technique offers an instantaneous treatment so no time is spent without a replacement for the missing tooth;
  • It will usually be the same size as the contralateral tooth and can be used as a template for space maintenance;
  • The bracket is bonded to enamel and the bond strength is higher than when a bracket is bonded to an acrylic surface. This will result in fewer bond failures on the pontic.

    • Disadvantages

  • The tooth may be discoloured, especially if there was a history of trauma or endodontic treatment;
  • Is still subject to labio-palatal rotation on round archwires.

    • 5. Transpalatal arch with pontic in its design (Figure 4)

    Figure 4. (a, b) Pontic attached to Nance palatal arch.

    A transpalatal arch or Nance palatal arch can be used to support a temporary pontic. Bands are chosen for the upper first or second molars and an impression is taken with the molar bands in situ. A shade is taken for the pontic. The laboratory can then fabricate a transpalatal arch from 0.9mm stainless steel modified by placing a pontic in the required position on acrylic extending from the palatal arch.

    Advantages

  • It can be used early in treatment even when a round or flexible wire is in place;
  • There is a reduced chance of bond failure or loss occurring.

    • Disadvantages

  • This pontic will not move as adjacent teeth move but can be easily removed and bonded to the archwire as in example 1.

    • 6. Lingual arch with pontic (Figure 5)

    Figure 5. (a, b) Pontic attached to lingual arch.

    The fabrication of a lingual arch is similar to the transpalatal arch example. The arch is made from 0.9 mm stainless steel and fixed to two lower molars.

    Advantages

  • Facilitates the placement of a stable pontic in an area where stability can be difficult to achieve.
  • Often the tongue or bite forces will displace any temporary pontics placed in the lower labial segment.

    • Disadvantages

  • This can flex due to occlusal forces if the supporting wire is not rigid.

    • 7. Mini-implant with composite crown

    A pontic made from composite moulded into a celluloid crown is fabricated and this can then be attached to the head of a temporary anchorage device using orthodontic acrylic. This method has been described in the literature.8 A further advancement of this technique has also been described involving the use of an impression and laboratory analogue for the fabrication of a resin core and laboratory made pontic to fit over this core, both of which are attached to the mini-implant with a small fixation screw.9

    Advantages

  • The mini-implant may be used for anchorage anteroposteriorly, transversely and vertically, depending on the clinical need.
  • This can remain in situ as a medium term prosthetic replacement if the mini-implant is sited vertically in the edentulous space.8, 9

    • Disadvantages

  • To be able to avail of this technique, the mini-implant must be placed vertically along the edentulous ridge in the space of the missing tooth. This is not always an ideal position for its use as an anchorage device.
  • This technique can rarely be employed early in orthodontic treatment as there needs to be enough inter-radicular space for placement of the mini-implant.
  • This method may be less cost-effective than other methods, especially if a system requiring laboratory analogues and porcelain pontics is required.
  • Surgical skill and knowledge is required for the placement and use of mini-implants.
  • This method is more invasive for the patient as placement of the mini-implant requires local anaesthetic.

    • 8. Retention

    Hawley retainers (Figure 6)

    Figure 6. (a, b) Pontic attached to Hawley retainer. (c) Metal stops incorporated into Hawley retainer to maintain space for prosthetic teeth in case of fracture of pontic from retainer.

    The denture tooth is embedded in acrylic during the laboratory fabrication of the Hawley retainer. Ideally stainless steel ‘stops’ should be placed mesial and distal to the edentulous space in order to maintain it, in the case of loss of the pontic tooth (Figure 6c). If there is no onsite laboratory the bands can be removed at an appointment prior to removal of fixed appliance and the technician can fabricate a retainer after carefully carving the brackets from the model. The retainer can therefore be fabricated in advance.

    Advantages

  • Easily incorporated into the retainer design.

    • Disadvantages

  • May detach due to occlusion or incorrect handling of retainer;
  • Stainless steel stops can be unsightly;
  • Not fixed, therefore subject to the usual disadvantages of removable retention including breakages, losses and issues with patient's compliance with wear.

    • Vacuum-formed retainers (Figure 7)

    Figure 7. (a, b) Pontic on vacuum-formed retainer.

    An impression is taken and sent to the laboratory. The pontic can be adjusted to fit the edentulous space on the plaster model over which the vacuum-formed retainer can be made.

    Advantages

  • Maintains aesthetics whilst in the retention phase allowing settling of the gingival margins and maturation of the gingival fibres around adjacent teeth whilst maintaining space and aesthetics for future restorative treatment.

    • Disadvantages

    Not fixed therefore subject to the usual disadvantages of removable retention.

    Conclusion

    Patients who present with missing teeth in the aesthetic zone can be offered a number of simple options to improve smile aesthetics during the course of orthodontic treatment. This paper describes a number of techniques which can be used to replace missing units in different situations. The addition of a temporary pontic is important to many patients and may enhance patient satisfaction and compliance throughout orthodontic treatment. Selecting the most appropriate option to replace missing teeth can improve patient aesthetics and simplify treatment progress.