Closing the Gaps Braces Could Not

The Patient's Journey

This patient had completed orthodontic treatment at another office, and by the measure orthodontics uses the treatment had worked. Every tooth was where it should be. He still had visible spaces across the front of his upper arch, and he was still missing tooth eight, one of the two central incisors.

What he wanted was the missing tooth replaced. He was also dissatisfied with the spacing around his lateral incisors, which had not closed and which he had assumed the braces would deal with.

Understanding the Challenge

Orthodontics moves teeth. It does not change their dimensions, and that distinction is the whole of this case. His lateral incisors were peg laterals, a developmental variation in which the tooth forms narrower and more conical than normal, tapering towards the biting edge instead of presenting a full width.

An arch containing two undersized teeth has more space in it than teeth to fill, and that surplus has to go somewhere. Orthodontics can gather it into one location or distribute it evenly between the teeth, but it cannot remove it, because the deficiency is in the width of the teeth rather than in their arrangement. Closing the spaces by moving teeth together would simply have crowded the arch and put the midline in the wrong place.

The missing central incisor complicated the arithmetic. Tooth eight sits immediately beside the midline, and a restoration there governs how the entire anterior segment reads. Its width could not be settled independently of the veneers on either side of it, since the four restorations together had to account for the surplus space the peg laterals had left.

How Dr. Mehdizadeh Approached Treatment

Whitening came first, upper and lower, and the shade was allowed to stabilize before anything was recorded. Ceramic does not respond to peroxide, so the natural teeth have to reach their final color before the restorations that must match them are made.

An implant was placed at tooth eight and left for two months to osseointegrate. An implant was chosen over a bridge because the teeth adjacent to the space were sound. A conventional bridge would have required both of them to be prepared for crowns, which on a young adult means removing healthy structure from two teeth in order to replace a third.

The four anterior restorations were then designed as one set: an implant crown at tooth eight and porcelain veneers at seven, nine and ten. Designing them together is what resolves the spacing, because the surplus width is divided deliberately across four units rather than left concentrated wherever the orthodontics finished. The peg laterals are widened to normal proportions, the central incisors are matched to each other across the midline, and the spaces close without a single tooth being moved.

The Result After Four Months

The missing tooth is replaced, the peg laterals are full-width, and there are no residual spaces across the upper anterior segment. The overall color is lighter than he arrived with because the natural teeth were whitened before the ceramics were matched to them.

His orthodontic result was not wasted. The teeth were in the correct positions when he arrived, and that is what allowed four restorations to finish the case rather than a full arch of them. Restorative treatment corrects width and shape efficiently and corrects position expensively, which is why the two disciplines are sequenced in that order rather than substituted for one another.