There was not enough room for dental implants
This Lake Bluff, IL patient was looking for a new job and wanted to look her best. She had 2 dental bridges on her upper front 6 teeth to replace 2 missing lateral incisor teeth. The existing old bridgework had teeth that were angled and were unnatural in appearance. Implants would have been an excellent treatment option to fill the spaces between her cuspids (eye-teeth) and her central incisors but there was inadequate space to fit the implants in. The old bridgework was replaced with new bridges.
All-Porcelain zirconium bridgework can be placed when implants won't fit
The new all-porcelain bridges had a more uniform and natural look. These bridges were made of three layers. Each layer was a different type of porcelain. The supporting substructure was zirconium for strength (remember that bridges have 2 teeth doing the work of 3). To create a beautiful natural look, beautiful E Max porcelain was pressed over the zirconium to simulate natural dentine, and then finally a superficial layer of freehand stacked feldspathic porcelain which created the chroma gradients and translucency of enamel in natural teeth.
Congenitally missing lateral incisors
It is fairly common to be missing one or both of the adult lateral incisors (one out of 50 people). These are the smaller neighbors to the upper front two teeth. These teeth normally erupt at age 7 but proper radiographs taken by your family or pediatric dentist can forecast the lack of development of these teeth at age 4-5. When the lateral incisors do not develop, the other adult teeth often drift into the space. Orthodontics is needed to keep the two front teeth from separating (forming a gap) or having the eye teeth tipping forward. Prior to the development of implants, it was common for orthodontists to move the eye teeth into the missing tooth positions. This led to more abusive occlusal relationships of the back teeth. The other option was for the orthodontist to maintain the normal tooth positions leaving a space where the congenitally missing tooth was supposed to be. A fixed / cemented bridge was then later made to fill the gap/s. Today, with the refinements of implant dentistry, dental implants have become the preferred mode of replacement for missing teeth. Implants can be placed about 1-2 years after the individual’s jaws have stopped growing. For young women, this is around age 18 or 19. For young men, this age is 20-21. Traditional orthodontic treatment can be finished by the age of 12-17 years. This means that usually, orthodontic treatment is completed on kids long before they are old enough to have implants placed. There are very specific retention recommendations to maintain the correct tooth placement while waiting for the future implants to be placed.
Post-orthodontic management of congenitally missing laterals
Retainers are often used to hold teeth in the proper arrangement after orthodontic treatment until the jaws are done growing. Standard retainers are not appropriate to maintain the space for future implants because it is common to need to wait 6-7 years after braces are removed before the implant can be placed. The roots can drift closer together causing there not to be enough room for the implant to be placed. The only way to fix this is to redo the orthodontics. The average width of a lateral incisor is 6.5mm and the orthodontist hopefully leaves at least 6mm of space between the central incisors and the eye teeth from the clinical crown all the way to the tip of the roots. This gives room for the surgeon to later place the implant. Standard orthodontic retainers will hold the space at the crown level but offer no retention of the root positions.
The best way to make sure that adequate room for the implant is maintained is to use a “Maryland bridge”. A Maryland bridge provides a temporary crown that is bonded into the lateral position between the central incisor and the eye tooth. The temporary crown has metal wings on each side that attaches to the backside of the proximal teeth. This effectively maintains the exact parallel relationship of the central incisor and eye tooth that the orthodontist created.