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The use of a removable orthodontic appliance for space management combined

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 « ∑—πµ ®ÿÓœ 2555;35:131-40
CU Dent J. 2012;35:131-40

Original Article
∫ ∑ «‘ ∑ ¬ “ ° “ √

The use of a removable orthodontic

appliance for space management combined
with anterior esthetic restorations:
a case report
Pasumon Sawangnimitkul DDS1
Chalermpol Leevailoj DDS, MSD, ABOD, FRCDT2
1Graduate Student, Esthetic Restorative and Implant Dentistry Program, Faculty of Dentistry,
Chulalongkorn University
2Esthetic Restorative and Implant Dentistry Program, Faculty of Dentistry, Chulalongkorn University

Abstract
Spacing in the esthetic area results in an unconfident smile. To solve this problem, many
alternative treatments can be used with multidisciplinary knowledge: for example, orthodontic
treatment and restorative treatment. The treatment plan should be performed under conservative
consideration, while the esthetic outcome should persist in the long term. Instead of using only
restorative treatment to close several spaces, minor tooth movement before restorative procedures may
achieve a preferable result since the teeth can be realigned to the proper position; it also requires less
tooth structure preparation. This case report demonstrated the use of a removable orthodontic appliance
to distribute the anterior space before restoring the bilateral peg-shaped lateral incisors with porcelain
laminate veneers to close all the spaces in the maxillary anterior area. This resulted in a natural
appearance with healthy gingival tissue during the 8-month follow-up period. This treatment
principle can be applied for use in other small spacing cases.
(CU Dent J. 2012;35:131-40)
Key words: esthetic; interdisciplinary approach; peg-shaped lateral incisor; porcelain veneer;
removable appliance; spacing
132 Sawangnimitkul P, et al CU Dent J. 2012;35:131-40

Introduction outcomes are satisfactorily achieved.4,9 However, in

Today, most people are concerned about their some cases the clinical situation is somewhat more
health and appearance; this includes healthy teeth and complex and may not be able to be corrected by only
a beautiful smile, which will increase their confidence restorative means. When teeth are severely misaligned,
when out in public. The so-called esthetic zone in the an orthodontic appliance can contribute to creating the
anterior maxilla has the greatest impact on smile proper tooth position prior to any restorative treatment.
design. Tooth anomalies occurring in this area-such as Furthermore, in some cases, periodontal surgery may
misalignment, discoloration, or malformed and missing be indicated in order to improve the gingival levels to
teeth-can lead to unattractive smiles with non-harmo- create a more desirable symmetry and harmony of the
nious pink and white esthetic in the esthetic zone, which pink esthetic.
may sometimes reduce a personûs confidence in Removable orthodontic appliances could be
smiling during their social lives.1 considered as an alternative treatment for patients with
One common esthetic problem in the maxillary a single or a few misaligned teeth. Patients feel more
anterior area is a peg-shaped or mesiodistally deficient comfortable with removable appliances compared to
maxillary lateral incisor. The definition of a peg-shaped fixed appliances since they can be removed occasionally.
lateral incisor is given in the çGlossary of Prosthodontic A removable appliance will not compromise the patientûs
Termsé (2005) as an çundersized, tapered toothé.2 oral hygiene, and it requires less clinical chair time
Atypical tooth shape may result from an inappropriate since the appliance is fabricated in a laboratory.10 It
proliferation of the tooth bud cells during tooth can only apply tipping force to move the misaligned
formation.3 Peg-shaped lateral incisors may cause tooth; therefore, the treatment needs strict supervision
spacing in the anterior maxilla, transposition of by the dentist. Moreover, accomplishment of the
adjacent teeth, and prolonged retention of deciduous treatment depends on the patientûs cooperation. It is
canines.4 The incidence of peg-shaped lateral incisors also difficult to create complex tooth movement
is approximately 2% to 5% of the population, and because the removable appliance cannot achieve
occurs more frequently in females than in males.5,6 two-point contacts on teeth, which are necessary to
Anatomically, peg-shaped lateral incisors are found control tooth movement in three dimensions.10,11 In
predominately on the left side of the arch.5,7 addition, the acrylic plate may affect speech and cause
discomfort while wearing the appliance.10
There are two alternative treatments for peg-shaped
lateral incisors. The first option is to move the canine A removable appliance with clasps and finger
forward with a fixed orthodontic appliance to close the springs may be used for minor tooth movement in the
space between the lateral incisor and canine, and then anterior area, such as a small median diastema
reshape the lateral incisor to make it appear more approximately 2 millimeters or less. Palatal finger springs
normal. The other treatment is to maintain the canines are often used to move teeth in a mesiodistal direction
in Angleûs class I relationship and restore the in orthodontic treatment. 11 Optimum force for
malformed teeth with resin composites, porcelain continuous tooth movement in a single-root anterior
veneers or crowns. These restorations are used to close tooth is approximately 25-40 grams.10,12 Activation of
the space and change the peg-shaped lateral incisors the palatal finger springs at 1.5 to 2 millimeters
into their natural shape.8 The treatment time of the distance can move the maxillary central incisor about 1
latter method is less, and the esthetic and functional millimeter in one month. Excessive force can complicate
« ∑—πµ ®ÿÓœ 2555;35:131-40 æ ÿ¡πµå  «à“ßπ‘¡‘µ√°ÿ≈ ·≈–§≥– 133

the treatment, and insufficient force can prolong the In this case report, the patient was treated by
treatment time.10 Although removable appliances with minor tooth movement with a removable appliance to
a finger spring can shift the tooth to the correct position, distribute the spacing more favorably. Then esthetic
the tooth does not have bodily movement in the same restorations were performed by correcting the peg-
way as with a fixed appliance because the finger spring shaped lateral incisors with ceramic veneers.
has only a point contact on the tooth. Therefore, only
the tipping movement can be performed by removable
Clinical report
appliances.10
A 19-year-old male patient was referred to the
Peg-shaped lateral incisors need restoration, such
Esthetic Restorative and Implant Dentistry Clinic,
as direct resin composite or porcelain laminate veneers,
Chulalongkorn University, for closing the space in the
to restore the tooth shape and close the space.13,14
upper anterior maxillary region and to change both
While composite veneers have the advantage of being
lateral incisorsû shape. Intraoral examination revealed
a low-cost conservative procedure, porcelain laminate
spacing between teeth 11 and 21 due to the distal
veneers have other advantages such as high longevity,
migration of tooth 21 approximately 0.5 millimeter,
material biocompatibility, and a highly esthetic
while the mesial of tooth 11 coincided with the dental
result.14,15 Porcelain can mimic the natural appearance
and facial midline. The shifting of tooth 21 was
of enamel.16 Moreover, porcelain veneers retain less
likely caused by malformation of the lateral incisors.
staining and are more durable compared to resin
The patient presented with two peg-shaped lateral
composite.15 Friedman and colleague reported that the
incisors, teeth 12 and 22 (Fig. 1A). Tooth 13 was
long-term clinical longevity of porcelain veneers was
slightly mesiolingually rotated. All of the teeth were
up to 15 years, with only 7% failure rate due to
sound and asymptomatic. The patient had 2 millimeters
fracture, leakage, or veneer debonding. This indicates
of overjet and 2 millimeters of overbite. Radiographic
that porcelain veneers are very predictable restorations.17
examination found that tooth 21 was minorly tipped
However, in order to fabricate a high-quality porcelain
to the distal. Teeth 13 to 23 had an intact lamina
veneer, teeth need to be prepared to allow for adequate
dura, with no periapical radiolucency observed
thickness of the material. Generally a feldspathic
(Fig. 1B-D).
veneer requires a minimum thickness of 0.3 millimeters.16
However, the fabrication of a 0.3-millimeter-thick Our treatment plan was to do minor tooth movement
high-strength leucite-reinforced veneer is very difficult. of tooth 21 to close the median diastema (without
One study revealed some cracking of 0.3-millimeter-thick moving tooth 11) by using a removable orthodontic
veneers during cement polymerization when the veneers appliance, and then to restore both peg-shaped lateral
wrapped over the incisal edge.18 From these data, the incisors with ceramic veneer facings. The orthodontic
recommended thickness for the veneers should be at removable appliance was composed of one finger spring
least 0.5 millimeter if they cover the incisal edge or at distal of tooth 21, which generated force to move
interproximal area.18 However, peg-shaped lateral tooth 21 mesially, and one acrylic stop at distal of
incisors need minor preparation because the teeth have tooth 11, which helped stabilize the tooth 11 when
enough space for porcelain veneer fabrication except at tooth 21 was moved into contact. This procedure needed
the cervical margin. Sufficient tooth preparation at the two weeks of force application and two weeks of
cervical margin is recommended in order to avoid an stabilizing the tooth in position before the final
overcontoured restoration.18 restorations were performed. The case was finished by
134 Sawangnimitkul P, et al CU Dent J. 2012;35:131-40

Fig. 1 Pretreatment. 1A, Tooth 21 aligned distally while tooth 11 coincided with the facial and dental midline.
1B-D, Radiographic examination revealed sound maxillary anterior teeth and tooth 21 minorly tipped to the distal.

Fig. 2 Wax-up model was fabricated to present the possible outcome to the patient.

placing ceramic veneers on the two lateral incisors to either resin composite or ceramic, which might result
close the space and change the tooth shape. The patient in unequal size of the central incisors. Under the
was asked to wear a full-time retainer for three months proposed treatment plan, the two central incisors would
to stabilize the anterior teeth and continued to wear a not be prepared. Their alignment would be corrected
part-time retainer for a year.10 by means of minor tooth movement. The two peg-shaped
With this preliminary condition, if the space was lateral incisors would be the only teeth that needed
managed without using a removable orthodontic restoration. Consequently, the patient accepted our
appliance, the median diastema would be closed by proposed treatment plan.
« ∑—πµ ®ÿÓœ 2555;35:131-40 æ ÿ¡πµå  «à“ßπ‘¡‘µ√°ÿ≈ ·≈–§≥– 135

Fig. 3 Minor tooth movement with removable orthodontic appliance and tooth preparation. 3A, Removable
orthodontic appliance with a finger spring at distal of tooth 21 and an acrylic stop at distal of tooth 11.
3B, The removable orthodontic appliance was inserted in the mouth. 3C, Frontal view after minor tooth
movement was achieved. 3D, Minimal preparation on teeth 12 and 22 without using local anesthesia.

Clinical procedures The selected shade was 2M1. Teeth 12 and 22 were
prepared for porcelain veneers using a conservative
On the first visit, oral examination and smile
approach by removing minimal tooth structure at the
analysis were performed. Then the patientûs present
cervical margins and labial surfaces, and shaping the
dental condition was recorded, including radiographs
incisal edges without using local anesthesia (Fig. 3D).
of teeth 13 to 23. Impressions of maxillary and
A final impression was taken with light-body and putty
mandibular teeth were taken for preparing the study
polyvinyl siloxane (Flexitime, Heraeus Kulzer, USA)
models.
using double-mixed single-impression technique prior
On the second visit, a wax-up model was used to to fabricating the working model. Bite registration was
communicate with the patient about the treatment plan, taken using Blu-Mousse (Parkell, USA). Temporary
treatment procedures and the outcome (Fig. 2). Then restorations were carried out using resin composite
the removable orthodontic appliance, composed of one (shade A2, Premise; Kerr, USA) with spot etching.16
finger spring and one acrylic stop, was fabricated. The temporary restorations were finished out of
On the third visit, the spring-activated removable occlusion, and the patient was instructed to clean
orthodontic appliance was delivered, and oral hygiene gently and avoid biting on these areas.
instructions were given (Fig. 3A and B). A photograph with shade tab and a drawing of
Two weeks after appliance application, the space the color mapping were used to mimic the nature of
between teeth 11 and 21 was evaluated. The space tooth (Fig. 4A and B). Then, two Empress Esthetic
was closed completely, as shown in Fig. 3C. Radio- veneers (Ivoclar Vivadent, Liechtenstein) were fabricated
graphic examination showed minimal alteration of the with layering technique to create high translucent areas
angulation of tooth 21. at the incisal third (Fig. 4C).

Shade selection for porcelain veneers was Clinically, the veneers were tried in after temporary
performed using a Vita 3D-Master Shade Guide (Vident, veneers were removed. Resin cement (bleach shade,
USA) by selecting value, chroma and hue, respectively. NX-3 Nexus; Kerr, USA) was used to cement both
136 Sawangnimitkul P, et al CU Dent J. 2012;35:131-40

Fig. 4 Color mapping and shade selection of tooth 22. 4A, Drawing of tooth 22, showing color mapping and tooth
characteristics, was sent to communicate with the laboratory technician. 4B, Photograph of adjacent teeth with
matched shade tab. 4C, Veneers fabricated with translucent area and characterized to mimic adjacent teeth.

veneers. The inner surfaces of the veneers were treated center of resistance as possible to reduce toothûs
with 4% buffered hydrofluoric acid gel (Porcelain etchant, rotation movement.11 The use of a finger spring
Bisco, USA) for 4 minutes, and rinsed; then silane generates a center of resistance to the tooth at the middle
(Monobond-S; Ivoclar Vivadent, Liechtenstein) was of the root. The movement of the tooth is perpendicular
applied, and dried with warm air for 1 minute.19 Tooth to the tangent of the tooth surface at the contact point
surfaces were treated with 37.5% phosphoric acid gel of the spring.12 With a finger spring, it is not possible
for 15 seconds (Gel Etchant; Kerr, USA) and then to move both the crown and the root simultaneously
rinsed. Primer and bonding agents (OptiBond FL; Kerr, because the direction of the springûs force cannot pass
USA) were applied following manufacturerûs instruction. the center of resistance. As a result, the root apex will
Bleach shade resin cement was applied on the inner move in the opposite direction compared to the crown.12
surfaces of the veneers, which were subsequently Furthermore, the finger spring contacts the tooth at
cemented on both teeth and light-cured for 2 minutes. only one point, which leads the tooth to tip mesially or
After cementation, occlusal adjustment was done and distally.11 Minor tooth movement with a finger spring
excess cement was removed. The patient satisfied with is acceptable in the case of tooth movement of a few
the result (Fig. 5). During the 8-month follow-up millimeters. However, control of the root is needed
period, the patient was recalled and the veneers when moving the tooth crown more than 3 to 4
maintained their natural appearance with healthy millimeters.10 As mentioned above, these are the
gingival tissue (Fig. 6). limitations of a removable appliance with finger spring.
However, the finger spring is appropriate in a case
Discussion where the tooth needs uprighting in order to move the
In this case report, the finger spring was designed tooth to the right place, and it is inappropriate in a case
to be used with a slightly displaced tooth in the mesio-distal where the tooth is already angulated in the desired
direction, since this spring has minor force that only direction.11
lasts for a short period. The direction of the force from Orthodontically treated teeth tend to relapse over
the spring should be perpendicular to the long axis of time, after the appliances are removed. A few factors
the tooth, and the force should pass as close to the are the major causes of relapsing. In this case report,
« ∑—πµ ®ÿÓœ 2555;35:131-40 æ ÿ¡πµå  «à“ßπ‘¡‘µ√°ÿ≈ ·≈–§≥– 137

Fig. 5 Pretreatment and posttreatment of both peg-shaped lateral incisors. 5A and B, Equal spaces of teeth 12 and
22 were accomplished after tooth 21 was tipped mesially by using removable orthodontic appliance. 5C and
D, Natural appearance of teeth 12 and 22 was achieved after veneer cementation.

Fig. 6 Comparison photos of pretreatment (left), and 8-month follow-up (right). 6A and B, The change in the
facial appearance and the new smile refreshed the whole facial composition. 6C and D, The veneers gave
the patient more confidence which showed in new natural smile. 6E and F, The veneers remained in
natural appearance with healthy gingival tissue.
138 Sawangnimitkul P, et al CU Dent J. 2012;35:131-40

the primary cause was periodontal and gingival tissue with the laboratory technician, a drawing describing all
reorganization. A previous study demonstrated that the the characteristics and color mapping should be sent
periodontal ligament needs 3 to 4 months to reorganize to the laboratory in combination with pictures of the
itself, but the collagenous and elastic fibers in the adjacent teeth and matched shade tab.16 In our case,
gingival tissue need 4 to 6 months to do so. The a drawing of tooth 12, which also simulated the
supracrestal fiber can remodel extremely slowly, and may characteristics of tooth 11, was sent to the laboratory
cause the tooth to displace within 1 year after treatment. technician. Pronounced vertical and horizontal lines
This is why every patient needs to wear a full-time with some white spots were indicated in the drawing.
retainer for at least a few months, and this should be Highlighted edges with gray area at the incisal third
continued for 12 months as a part-time retention.10 showed the translucent area of the teeth. A photograph
Daily oral hygiene maintenance of the veneers is with shade tab 2M1 from the Vita 3D-Master Shade
similar to that for natural teeth. Normal toothbrushing Guide was sent at the same time.
twice a day and flossing are recommended for daily Marginal gingival recession is caused by many
care. One advantage of a porcelain surface is that there factors, including inflammatory periodontal disease,
is less plaque and calculus deposition compared to a ageing, faulty tooth alignment, traumatic toothbrushing
natural tooth surface.16 Therefore, it is not necessary to injury, orthodontic forces, pressure (bands, arch wires,
use an ultrasonic scaler to clean the veneers. Dentists clasps or denture bars) and deleterious habits.22 The
should also be aware that the ultrasonic scalerûs tip most common cause is traumatic toothbrushing injury.23
may create roughness, scratches or chips on the porcelain The defect dominantly occurs on left canine area in
surface.20 Patients should take special care when biting right handed patients.22 And it was found more
on hard foods.20 The gingival margin area is important; frequent at facial surface than palatal side.23 Moreover,
if gingival recession occurs, the veneer margin will be the traumatic toothbrushing habits often relate to good
exposed and contribute to unesthetic outcomes. In oral hygiene.23 In the present case, small gingival
addition, the veneers should be inspected regularly.20 defects were shown at marginal gingiva of teeth 22 to 24.
For veneer preparation, the peg-shaped lateral Faulty toothbrushing technique may be the cause, as
incisors are already undersized. They only need minor noticed by good oral hygiene and the area of the defects.
preparation because there is already enough space for Proper oral hygiene instruction was given, however,
creating the porcelain veneers. However, preparation the defects persisted after the treatment was completed.
of the teeth is necessary to define the veneer margins The patient was reinstructed and informed about
during fabrication, so that they can be created with the disadvantages of toothbrush injury. The patient understood
proper thickness. In addition to mimicking the translucent and attempted to follow the oral hygiene instruction.
area of the natural teeth, incisal reduction may be needed. Although the restorations look natural and achieve
Thus, restoring the peg-shaped lateral incisors with a highly esthetic result, their function and the patientûs
veneers is appropriate due to the conservative oral health are the most important issues. The patient
treatment aspect, longevity, and highly esthetic results must be informed of the entire treatment plan prior to
compared to resin composite filling.16 the beginning of the treatment, including oral hygiene
Communication between the dentist and laboratory instruction. The patient must be aware that the focus
technician is an important issue. Simply selecting needs to be not only on the restored area, but also on
a shade tab is inadequate for creating the desired the entire mouth, in order to maintain the esthetic
restorations.21 In addition to effective communication appearance and the longevity of the veneers.
« ∑—πµ ®ÿÓœ 2555;35:131-40 æ ÿ¡πµå  «à“ßπ‘¡‘µ√°ÿ≈ ·≈–§≥– 139

Conclusion Am J Orthod Dentofac Orthop. 1987;92:249-56.

The use of a simple removable orthodontic 9. Kokich VO Jr., Kinzer GA. Managing congenitally
appliance combined with porcelain laminate veneers missing lateral incisors. Part I: Canine substitution.
can be used to manage spacing in the maxillary J Esthet Restor Dent. 2005;17:5-10.
anterior area with peg-shaped lateral incisors. This 10. Proffit W, Fields H. Contemporary orthodontics.
conservative treatment can achieve a highly esthetic 3rd ed. St. Louis: Mosby, 2000:418-48.
outcome, with healthy gingival tissue. The treatment 11. Cobourne MT, DiBiase AT. Handbook of
principles described in this case report can be extended orthodontics. 1st ed. St. Louis: Mosby, 2010:209-34.
to the treatment of other small spacing issues present 12. Jones ML, Oliver RG. Walther and Houstonûs
in other cases. orthodontic notes. 5th ed. Oxford: Wright, 1994:
133-56.
13. Izgi AD, Ayna E. Direct restorative treatment of
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