Spacing Diagnosis Treatment

This guide organises possible treatment options for a spacing diagnosis. The document is a treatment planning tool to assist you assist how to best treat patients. Treatments are graded by complexity, ranked by the orthodontic technique required, as a guide to the efficacy of treatment and enable providers to select cases that best matches their ability to apply advanced techniques. In this regard, it is particularly useful for dentists who are just beginning to provide clear aligner treatment.

Disclaimer

As doctors are solely responsible for the treatment they’re providing their patients, they should understand their limits and not hesitate to consult a specialist for further guidance when required. Note when applying this guide only general, high-level information on how each isolated condition might be treated is provided. The relationships between different conditions that exist in the majority of patients are not addressed. In this regard, always consider each patient’s individual dental and periodontal condition, restorative needs, facial proportions, and age when considering treatment options.

Spacing

Spacing

A significant percentage of the general population has interproximal spaces. Spaces are most commonly due to a tooth size discrepancy, missing teeth, proclined teeth or any combination. Spaces can be distributed anywhere in the dental arch, with anterior spacing more easily treatable. Spacing can be divided into three main categories: simple, moderate and severe.

Simple anterior spacing can usually be closed completely with Proligner alone by retracting the crowns and constricting the arch circumference. Simple anterior space closure often allows the practitioner to treat only one arch, provided the constriction in arch circumference does not create occlusal interferences.

Moderate anterior spacing can be resolved with retraction when the teeth are significantly proclined and of normal size. If there is a tooth size discrepancy and/or the teeth are not proclined, then closing all of the space with retraction usually results in poor aesthetics and/or premature anterior contact. If contact with the lower anterior teeth prevents the uppers from being retracted, you may need to consolidate the spaces in the upper arch and close the remaining spaces with dental restorations.

Severe spacing greater than 6mm is not just confined to the anterior most of the time. If there are posterior spaces, closing them can require moving the teeth forward (referred to as mesialisation). To close all of the space while maintaining the crowns and roots in a good aesthetic and functional position almost always requires a combination of Proligner and restorative dentistry, because of the mesial tipping that can occur.

In general, Proligner is this clear choice for treating cases with spacing, especially when confined to the anterior, as long as the following rules are kept in mind during the diagnosis and treatment planning.

1. Create and maintain good arch form using the alveolar denture base as the template. Over-retraction and/or constriction can result in asymmetry.

2. Establish or maintain good inclination (torque) to create the best aesthetics, function and stability. Problems usually arise when the teeth are inclined too far lingually with over-retraction.

3. Significant tooth size discrepancy most of the time requires restorative dentistry along with Proligner.

4. The periodontal tissues need to be adequate to support the desired tooth movements. This applies most often to posterior spaces where the alveolar bone isn’t adequate to accommodate tooth movement into the ridge. Attempting to move teeth into an area that lacks bone will result in crown tipping.

With all space closure cases, post-treatment retention is the key to long-term stability. This is an important discussion point with patients before and after treatment.

Mild

Close all spaces Novice (0-15 cases)

Closing all of the space with Proligner is most effective when teeth are proclined and can be retracted uprighting the crowns over the roots. Be careful not to over-retract the incisors. Maintaining arch symmetry as the spaces are closed is important. Over-retracting any segment should be avoided. The overbite will increase as the teeth are retracted changing the crown inclination. If a slight tooth size discrepancy exists, a small amount of IPR can be performed in the appropriate arch. Otherwise, slight anterior equilibration may be needed to settle the posterior bite.

Consolidate spaces, followed by restorative dentistry if desired Novice (0-15 cases)

It may not be possible or desirable to close all of the spaces, especially when a tooth size discrepancy exists. This situation most commonly exists when the maxillary lateral incisors are smaller than average. Space can be distributed in the appropriate places preparing those teeth for post-Proligner restoration. Most experts agree that the space around the lateral incisors, on average should have 1/3 on the mesial and 2/3 on the distal. But this setup can be adjusted according to your preferences.

IPR/retract lower to create positive overjet, retract upper to close spaces Novice (0-15 cases)

If inadequate overjet prevents upper anterior retraction, one treatment approach is to retract the lowers by first creating space with IPR. The resulting overjet will allow upper retraction.

Moderate

• Generalised (spaces throughout)

Close all spaces Novice (0-15 cases)

Closing all of the space with Proligner is most effective when teeth are proclined and can be retracted uprighting the crowns over the roots. Be careful not to over-retract the incisors. Maintaining arch symmetry as the spaces are closed is important. Over-retracting any segment should be avoided. The overbite will increase as the teeth are retracted changing the crown inclination. If a slight tooth size discrepancy exists, a small amount of IPR can be per- formed in the appropriate arch. Otherwise, slight anterior equilibration may be needed to settle the posterior bite.

Consolidate spaces, followed by restorative dentistry if desired Novice (0-15 cases)

It may not be possible or desirable to close all of the spaces, especially when a tooth size discrepancy exists. This situation most commonly exists when the maxillary lateral incisors are smaller than average. Space can be distributed in the appropriate places preparing those teeth for post-Proligner restoration. Most experts agree that the space around the lateral incisors, on average should have 1/3 on the mesial and 2/3 on the distal. But this setup can be adjusted according to your preferences.

IPR/retract lower to create positive overjet, retract upper to close spaces Novice (0-15 cases)

If inadequate overjet prevents upper anterior retraction, one treatment approach is to retract the lowers by first creating space with IPR. The resulting overjet will allow upper retraction.

• Localised (isolated region)

Partially close with Proligner, and follow with restorative dentistry if desired Novice (0-15 cases)

When there is a localised space that either can’t be fully closed or the desire is not to close it, then an option is to move the tooth or teeth into a pre-restorative position. When restorative treatment is incorporated along with Proligner usually the tooth movements don’t need to be as precise because most limitations can be overcome with the restorative work.

IPR/retract lower to create positive overjet, retract upper to close spaces Novice (0-15 cases)

If inadequate overjet prevents upper anterior retraction, one treatment approach is to retract the lowers by first creating space with IPR. The resulting overjet will allow upper retraction.

Fully close spaces with Proligner and auxiliary or fixed treatment as needed Experienced (16-50 cases)

Closing localised spaces fully with the crowns and roots upright (bodily) can be a challenge with Proligner only. To optimise tooth movement(s) auxiliary appliances can be used. The most common auxiliary appliances are sectional fixed orthodontic brackets and wires.

Severe

Partially close with restorative dentistry if desired Novice (0-15 cases)

Restorative treatment is complementary to Proligner treatment and essentially is required when spaces are severe. Using only Proligner as the orthodontic appliance means you have to be able to plan your tooth movements that are predictable and use restorative work to finish the case. It usually means consolidating some spaces and or maintaining others. An important point to remember is that if you are only able to achieve 80% of the desired tooth movements the restorative work can still be done to idealise.

IPR/retract lower to create positive overjet, retract upper to close spaces Experienced (16-50 cases)

If inadequate overjet prevents upper anterior retraction, one treatment approach is to retract the lowers by first creating space with IPR. The resulting overjet will allow upper retraction.

Fully close spaces with Proligner and auxiliary or fixed treatment as needed Experienced (16-50 cases)

When closing more severe spaces, it may be helpful to only move a few teeth at a time. For example, retracting canines first before closing spaces around the incisors. Using attachments on the bicuspids to help anchor the aligner may be helpful for retention as the teeth become more upright. Auxiliary appliances may be required.