Implant indications

Replacing missing upper lateral incisors presents a clinical challenge. When a patient comes to our dental office with this problem, we have four different treatment options:

1. Orthodontics
2. Prosthesis
3. Implants
4. A combination of the above

In cases involving missing lateral incisors, space closure (when it is available) has been suggested as a more predictable treatment option in the long term from an aesthetic and periodontal point of view (Josefsson & Lindsten. 2018). Neither periodontal impairment nor temporomandibular joint dysfunction (TMD) has been reported as a result of space closure in long-term follow-ups (Rosa et al. 2016).

“It should be noted that further growth can also be expected in adults”

Compared to implant placement, a resin-bonded bridge which can later be replaced may be a good option. It should be noted that further growth can also be expected in adults, which can change the relative positions of teeth and, over time, produce infra-occlusion in implant restorations (Rosen et al. 2016).

Of the above options, implant placement has been shown to lead to the worst periodontal status after five years (Jamilian et al. 2015). This is why the replacement of missing upper lateral incisors with implants is currently debated. According to the speaker, implants should be avoided if possible in these cases.

“Implants should be avoided if possible in young patients with missing upper lateral incisors”

If we know all possible treatment options, they can be included in digital planning processes. There are tools available which let us simulate the different outcomes of treatment options using CAD-CAM technology. But the speaker asked: if CAD-CAM is so useful, fast, predictable and accurate then why is it still not common practice to incorporate it into orthodontics?

“There are tools available which let us simulate the different outcomes of treatment options using CAD-CAM technology”

The speaker described a step-by-step method for including CAD-CAM technology into orthodontic treatment.

The first step in digital planning is to apply a Digital Smile Design® (DSD) to orthodontics (where feasible) to check the different treatment options and simulate their different outcomes. This helps to inform the patient and get their consent for the chosen treatment plan (Figure 1).

Once this has been made, treatment results can be virtually planned with a combination of DSD and Invisalign® to optimise aesthetic and periodontal results. These can be shared with patients to make sure they agree with the results.

“The potential applications of CAD-CAM are not limited only to orthodontic aligners”

But the potential applications of CAD-CAM are not limited only to orthodontic aligners. Bracket treatment can be planned in this way, too. Individually customised brackets systems can be used with wires which have been pre-bent using CAD-CAM according to the computer’s virtual planning. This allows the clinician to anticipate the results before commencing treatment (Figure 2). Further, the incorporation of CBCT in the digital planning stage can also predict how difficult or complex a treatment will be (whether there is a risk of fenestration, root alignment, etc.).

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