Jae Hyun Park
Missing teeth create challenges for nearly every dental specialty. They may be absent because of trauma, periodontal disease, caries, or a congenital defect, and the open space can vary widely in location: anterior or posterior, maxillary or mandibular, and single or multiple. Regardless of the clinical scenario, dental implants are often considered to be the preferred option when a patient declines space closure with orthodontic treatment. For orthodontists, this often requires treatment to open, maintain, or distribute the space and diverge the adjacent roots to prepare for implant placement. ,,,, However, these decisions must also account for the long-term occlusal changes that may arise once an implant is placed.
Johnny, a former patient who was treated many years ago, has returned to your office with a new concern: his front teeth are no longer even. You remember his case clearly. As a child, he had traumatically lost a central incisor, and with careful orthodontic management, you preserved the space for a future implant and provided him with the temporary solution of a pontic until his growth was finished. You recall that when he received his implant postgrowth, it was well placed, and you had even captured final photographs. Now, however, nearly 2 decades after the implant was placed, you notice a pronounced vertical discrepancy between his natural central incisor and the implant crown. What could have caused this?
Increasing evidence has shown that dentoalveolar development continues well into adulthood, long after skeletal growth has ceased. Dentoalveolar changes can compromise both the esthetic integration of an anterior implant and the stability of the occlusal relationship. Just as we are mindful of the impact of physiological changes on implants in adolescents, we must exercise equal caution when planning implants for adult patients. Because implants lack a periodontal ligament, they cannot undergo normal physiological movement. Functionally, an implant behaves much like an ankylosed tooth, remaining stationary while the natural dentition continues to drift both vertically and horizontally. Over time, this discrepancy can manifest as implant infraocclusion.
The article, “Orthodontic perspective on treatment recommendations for missing maxillary incisors: a contemporary guideline,” published in this issue of the American Journal of Orthodontics and Dentofacial Orthopedics, highlights the implications of implant submersion and underscores the need for clinicians to discuss these possibilities with patients to avoid future misunderstanding. Many clinicians view implants as the default replacement option for missing teeth, largely because they eliminate the need to remove unnecessary adjacent tooth structure for a fixed prosthesis. Although this is a meaningful advantage, the risks of potential periodontal complications, esthetic challenges, or additional corrective treatment should be weighed against the benefits of an implant. ,
Multiple publications have documented ongoing dentoalveolar remodeling in adults. The implications of these changes on implant esthetics and functional outcomes need to be carefully considered. In this contemporary guideline, alternative treatment strategies that maintain favorable occlusion and smile esthetics are identified, while addressing common clinical concerns. In particular, orthodontic space closure is regarded as a conservative and effective approach for both young and adult patients in the long term, offering minimal drawbacks and negligible effects on the occlusion, esthetics, and temporomandibular joint health when compared with the complications of other approaches.
Treatment options for young patients with missing anterior teeth are often limited by ongoing growth. Beyond that, the evidence presented in the guideline, which draws from over 10 studies, notably demonstrates that implant infraposition occurs in both adolescent and adult populations, with some weakly identified differences between genders and age groups. Unfortunately, the current literature has not identified reliable risk factors to predict which patients will experience implant infraposition.
Implantology has dramatically expanded the possibilities for tooth replacement, benefiting clinicians and patients alike. However, given the consistent evidence of dentoalveolar change across all ages, proper patient selection and a thorough informed consent are imperative. Alternative modalities, particularly orthodontic space closure, should also be considered when appropriate. Ultimately, the most ideal treatment is one that promotes long-term stability, esthetic success, and minimal future complications for both clinicians and patients.
Therefore, we must stay mindful of the repercussions of growth on the treatment provided, whether orthodontically or restoratively, to ensure clinical success.
The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and none were reported.
Given his role as Editor-in-Chief, Jae Hyun Park, DMD, MSD, MS, PhD, ABO-Board Certified, had no involvement in the peer review of this article and has no access to information regarding its peer review.
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