Differential Diagnosis and Management of Flared Maxillary Anterior Teeth
Gary Greenstein, DDS, MS,
John Cavallaro, DDS,
David Scharf, DDS and
Dennis Tarnow, DDS
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ABSTRACT
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Background. Flaring of maxillary anterior teeth can be caused by primary or secondary occlusal trauma. A differential diagnosis needs to be made with regard to the etiology of the problem to establish a proper treatment plan.
Types of Studies Reviewed. The authors reviewed relevant articles in the literature addressing migration of maxillary anterior teeth to ascertain the proper diagnosis and methods of therapy pertaining to migrated maxillary anterior teeth.
Results. The authors identify critical questions that clinicians must answer to ascertain which forces cause flaring of maxillary anterior teeth. They describe treatment methods relevant to flaring of teeth associated with primary and secondary occlusal trauma. The authors provide diagnostic and treatment flowcharts to guide clinicians in making therapeutic decisions.
Clinical Implications. Failure to treat maxillary flared anterior teeth can result in an unappealing esthetic appearance. Furthermore, if these problems are not treated in a timely manner, they can become worse and result in loss of teeth. Initiation of proper therapy may include occlusal equilibration, periodontal therapy, orthodontic retraction—alone or in combination with each other—and, in certain types of cases, splinting of teeth.
Key Words: Tooth; oral pathology; occlusion; occlusal splintsAbbreviations: CEJ: Cementoenamel junction. • PDL: Periodontal ligament.
Undesired migration of maxillary anterior teeth is referred to as "spreading," "splaying," "fanning," "tipping" or "flaring." Pathological migration may include extrusion and rotation of anterior teeth. The ability to resist tooth-displacing forces is attributed to a healthy periodontium, normal bone level, occlusal stability (manifested in such characteristics as absence of occlusal prematurities and absence of posterior bite collapse), integrity of the occlusal arch and absence of abnormal external forces (such as parafunctional habits) that induce orthodontic movement. If dislodging vectors exceed the resistance of the periodontium, teeth will move, and they may manifest increased hypermobility. The prevalence of pathological tooth migration among patients with periodontitis is about 33 percent.1–3 To reposition teeth to their proper location, the clinician must identify and eliminate forces causing tooth movement. Subsequently, dislodged teeth may require periodontal treatment, retraction and stabilization.
In this article, to facilitate discussion regarding the diagnosis and treatment of spreading anterior teeth, we address the status of the periodontium and contributing occlusal factors. In addition, we present diagnostic and treatment flowcharts that can be used to identify reasons for tooth migration and direct management of this predicament.
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LITERATURE REVIEW
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The authors conducted a MEDLINE search for articles published from 1961 through November 2007. They used the following terms to find articles related to flaring of anterior teeth: flared anterior teeth (13 articles), migrated anterior teeth (eight articles), pathological migration of teeth (23 articles) and tooth migration therapy (197 articles). The authors hand searched the references of all studies concerning flared anterior teeth for other articles addressing this issue. They excluded investigations that did not specifically address the diagnosis and management of flaring of anterior teeth.
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BACKGROUND: THE PERIODONTIUM AND PRINCIPLES OF OCCLUSION
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The periodontium.
In a normal (not reduced), healthy periodontium, no signs of periodontal disease are apparent, and bone support for a tooth is found within 0.33 to 2.36 millimeters (mean 1.11 mm) of the cementoenamel junction (CEJ).4 Coronal to the bone is the connective tissue attachment, which is about 1 mm wide and extends to the CEJ.5 The junctional epithelium (approximately 1 mm wide) is located on the enamel, coronal to the connective tissue attachment. A reduced but healthy periodontium is characterized by previous clinical attachment and bone loss. Diminished periodontal support for a tooth can occur owing to an accident, disease (that is, periodontitis) or ostectomy (such as crown lengthening), and it can be seen after successful periodontal therapy in patients who had periodontitis.
Occlusion.
The term "occlusion" refers to contact relations between teeth or prostheses.6 A physiological occlusion demonstrates no signs of occlusion-related pathosis. A nonphysiological occlusion may be associated with disturbances of the teeth, supporting structures of teeth, the muscles or the temporomandibular joint. The term "trauma resulting from occlusion" refers to tissue injury that occurs when occlusal forces exceed the periodontium’s adaptive capacity.7 The phrase does not denote the type of force that induced the damage. The injury may be caused by increased occlusal forces or a reduced capacity of the periodontium to withstand normal forces.
Occlusal trauma.
"Primary occlusal trauma" indicates that the damage is due to excessive forces applied to a healthy, normal periodontium.7 It can be caused by an occlusal prematurity (such as a high restoration), extrusion of teeth into spaces created by unreplaced teeth, poorly fitting prostheses, parafunction (bruxism or clenching), a habit such as biting on the stem of a pipe and orthodontic movement.
In contrast, when an injury is attributed to diminished capacity of the periodontium to withstand normal occlusal forces, this is referred to as "secondary occlusal trauma."7 Bone loss usually is the result of previous or ongoing periodontitis. In general, teeth with a reduced periodontium are more susceptible to occlusal trauma because they have decreased osseous support. Accordingly, secondary occlusal trauma can be induced by either normal or excessive occlusal forces.
Occlusal trauma can precipitate migration of teeth, pain during function and patterns of increased mobility.8,9 The box
lists clinical and radiographic signs and symptoms associated with occlusal trauma.
Posterior bite collapse.
Posterior bite collapse can contribute to migration of anterior teeth, and clinicians should consider it in the differential diagnosis of pathological tooth movement.10,11 The term "posterior bite collapse" denotes loss of occlusal vertical dimension. This loss can arise from premature loss of posterior teeth without proper replacement, orthodontic deformity and arch crowding, loss of proximal contacts at an excessive rate (as a result of caries, for example), abnormal wear of teeth and reduction of occlusal contacts because of caries or poor operative dentistry. Posterior bite collapse often is associated with overclosure, which can result in the maxillary incisors’ being forced toward the buccal aspect by the mandibular incisors. In addition, increased force often is exerted on anterior teeth because the posterior teeth fail to distribute occlusal stresses. When these vectors exceed the capacity of the periodontium to resist displacement, anterior teeth can migrate buccally, incisally and possibly mesially or distally. If this condition contributes to flaring of maxillary anterior teeth, rehabilitative therapy should begin in the posterior segment of the dentition to reestablish the occlusal vertical dimension. This therapy will eliminate displacing forces on the anterior teeth.11
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FORCES AFFECTING MAXILLARY ANTERIOR TEETH
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Maxillary anterior teeth are subject to pressures from the opposing teeth, the adjacent teeth, the perioral musculature (lips, cheek and tongue) and sometimes foreign objects. These dislodging vectors can cause teeth to migrate.
The amount of occlusal force placed on the dentition during function is 20 to 30 pounds per square inch, but it can range from 50 to 500 psi during parafunctional activity.12 Masticating forces are applied to the teeth about nine minutes per day.13
Swallowing occurs 24 hours per day (25 times per hour while awake and five times per hour while sleeping).14 During each swallow, the tongue can exert momentary pressure of 1,009 to 1,679 newtons per square meter on the surrounding structures of the mouth.15 This pressure can push teeth forward or apart. In contrast, the lips and cheeks tend to oppose tongue forces. Habits such as pipe smoking or nail biting also can generate vectors that can induce pathological tooth migration.
The interproximal force resistant to dislodging vectors provided by periodontal fibers is estimated to be in the range of 6 to 87 grams.16 This vector, in conjunction with the forces of the lips and cheek, probably counteract the outward thrusting force of the tongue.17
Determining therapeutic course by diagnosing forces that induce migration.
Figures 1 and 2 are flowcharts that can be used in the differential diagnosis of the cause of tooth migration, and they provide guidance for management of migrated maxillary anterior teeth. They differentiate between primary (Figure 1) and secondary (Figure 2) occlusal trauma and various sources of pathological forces that can affect teeth and the periodontium.
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Figure 1. A flowchart demonstrating differential diagnosis and treatment of migrated maxillary anterior teeth with primary occlusal trauma. *Action necessary only if teeth have not retracted on their own.
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Figure 2. A flowchart demonstrating differential diagnosis and treatment of migrated maxillary anterior teeth with secondary occlusal trauma. *Action necessary only if teeth have not retracted on their own.
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The following discussion describes how to apply the flowcharts in daily practice. The biological rationales for therapies addressed in this article are listed in Table 1.18–28
Determining whether the occlusal trauma is primary or secondary.
Displaced anterior teeth are the result of either primary or secondary occlusal trauma. The clinician can differentiate between these types of trauma by examining radiographs to evaluate the level of alveolar bone with respect to the CEJ. In addition, he or she can assess clinical attachment levels to determine if periodontal support is diminished. The CEJ is used as a reference point because it represents the true normal level of connective tissue attachment. Detection of any alveolar bone or clinical attachment loss in conjunction with tooth displacement underscores that tooth movement was associated with secondary occlusal trauma.8,20,27
Ascertaining the force causing tooth migration.
To determine the origin of the force causing tooth movement, the clinician must evaluate the occlusion and perioral musculature. Regardless of whether the patient has primary or secondary occlusal trauma, the clinician must address the following four questions because they are important in selecting the proper occlusal therapy:
- – Do the flared teeth contact the opposing dentition in centric occlusion or protrusive or lateral excursions?
- – Does the patient have habits such as tongue thrusting, lip biting, pipe smoking or other such behaviors that can be ascertained by means of an interview?
- – Is the posterior occlusion stable, or is there posterior bite collapse?
- – Does the occlusal force on displaced teeth seem excessive compared with that on adjacent teeth?
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TREATING OCCLUSAL TRAUMA
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As noted above, occlusal trauma can be classified as primary or secondary. The following text and Figures 1
and 2 provide guidance for treatment of these differing types of trauma.
Primary occlusal trauma.
After determining that the patient is undergoing pathological tooth migration and that there is no bone loss or clinical attachment loss, the clinician should proceed to address the four clinical questions listed above.
Contact and habits.
After the clinician determines that the patient is undergoing pathological tooth migration and has no bone loss (primary occlusal trauma), the first thing he or she should evaluate is whether the displaced teeth contact the opposing dentition in centric occlusion or in lateral or protrusive excursions. When flared teeth do not contact the opposing dentition, the clinician can deduce that the occlusion is not the cause of tooth movement. Therefore, the vector inducing tooth displacement is a habit. Such behavior may include lip and cheek biting, tongue thrusting, pipe smoking, oral-finger habits, and occupational-oral habits such as holding nails between the teeth. The clinician needs to identify the habit and eliminate it, or help the patient do so. Then he or she can retract the displaced teeth into position orthodontically if they do not retract on their own. Splinting of realigned teeth will not be necessary if the unwanted behavior can be eliminated because the periodontium is intact and the dislodging force has been removed.
Excessive occlusal forces.
If migrated teeth contact the opposing dentition in centric occlusion or lateral or protrusive excursions and the posterior occlusion is stable, then the clinician should equilibrate the displaced teeth to remove any fremitus. When hypermobile teeth are equilibrated, their mobility should decrease within several weeks as the periodontium heals.29,30 After this is done, the displaced teeth may return to their original position spontaneously within several months owing to pressure from the lips. 30–34 Gaumet and colleagues35 also suggested that teeth may return to their initial location spontaneously owing to wound contraction during healing. Otherwise, the dislodged teeth can be retracted orthodontically. The previously flared teeth do not need to be splinted because the displacing force has been eliminated and there is adequate osseous support to maintain the tooth in its correct position. However, if it is difficult to alter the habit that resulted in tooth migration, then use of a nightguard or retainer might be beneficial after the displaced teeth are repositioned.8,27
Posterior bite collapse.
If the posterior bite has collapsed, the clinician should not equilibrate the migrated teeth. Instead, he or she should reestablish the occlusal vertical dimension, which probably will result in disclusion of the anterior teeth.11 This correction can be accomplished with either a fixed or a removable prosthesis and may include dental implants. The migrated teeth may retract on their own owing to forces generated by the lips, once the displacing forces are eliminated. If they do not, then the clinician should relocate the displaced teeth orthodontically. Splinting is not necessary to retain the teeth in position if they have normal bone levels. If teeth are hyper-mobile, within several weeks after removal of dislodging vectors, mobility patterns should decrease.8,20,29,30
Additional scenarios that may cause migration of anterior teeth.
Several other situations can result in flared anterior teeth when there is no bone or clinical attachment loss. For instance, spacing of the anterior teeth can be caused by a size discrepancy between the maxillary and mandibular anterior teeth.36 If the maxillary anterior teeth are narrow compared with the mandibular teeth, the maxillary teeth can be displaced. Besides measuring the teeth, the clinician can determine whether tooth size is the culprit by assessing whether the spacing always has existed or is a recent development.25,36
Flaring of the maxillary anterior teeth also can be caused by a naturally occurring deep overbite. In this situation, as with posterior bite collapse, the lower incisors contact the maxillary anterior teeth, producing labial displacement of the incisors.37 Proximal wear of teeth can result in mesial migration of teeth and reduced arch length. However, in the absence of rapid wear, the overbite and overjet tend to remain stable; therefore, mesial migration usually is not a cause of flaring of anterior teeth.38
Secondary occlusal trauma.
Patients with secondary occlusal trauma are evaluated in the same sequence as are patients with primary occlusal trauma; however, there are differences concerning the differential diagnosis and therapy.
Need for periodontal therapy.
As expected, sites in patients with periodontitis or history of periodontitis demonstrate a greater incidence of tooth migration than do teeth without bone loss, because of reduced osseous support.1,39,40 Accordingly, among patients with secondary occlusal trauma, if periodontal therapy (whether surgical or nonsurgical) is needed, the clinician should perform it before repositioning teeth orthodontically. Periodontal therapy usually is initiated first to eliminate inflammation and thereby maximize bone repair during and after orthodontic movement.41–43
Contact and habits.
Similar to the assessment of the patient with primary occlusal trauma, the clinician should determine if there is contact between migrated teeth and the opposing dentition in centric occlusion, lateral or protrusive excursions, or all of these. If there is no contact with the displaced teeth, then the clinician can assume the tooth dislodgement was caused by a habit. This behavior needs to be eliminated and, if necessary, the clinician should treat the periodontium to eliminate signs of inflammation. Then the dentist should retract and splint the malpositioned teeth to retain them in position. In this regard, the literature indicates that if the periodontium is healthy, mobility does not initiate periodontal disease, and the amount of hypermobility is not progressive.8,20,27 However, there is controversy as to whether maximum healing can be attained if teeth are loose.8,20,27 Therefore, the determination regarding splinting and how long to retain the splint must include an evaluation of the amount of bone loss, the number of teeth involved, root lengths, the patient’s comfort during mastication and the potential for relapse of retracted teeth if the splint is removed. Nevertheless, despite successful realignment after orthodontic therapy, the chance of maintaining incisor alignment may be diminished due to bone loss. Therefore, the clinician should consider permanent splinting and alternate therapies (such as temporary and provisional splinting) and discuss them with the patient. Splints may be classified as temporary, provisional or permanent21 (Table 2). The type of splint (such as a fixed prosthesis or an A-splint) is selected at the clinician’s discretion.
Repositioning migrated teeth.
Four possible scenarios apply to repositioning migrated teeth among patients with primary or secondary occlusal trauma: removal and replacement of teeth if the displacement is severe, spontaneous correction after periodontal therapy when the patient is in an early stage of tooth migration (Figures 3–6), limited orthodontic treatment (such as a Hawley retainer) and conventional orthodontic therapy.32 Selection of a treatment method depends on the severity of tooth migration and the amount of support left to retain the tooth. In patients with severe periodontitis, extraction of migrated teeth may be the only practical solution. Patients with reduced osseous support may undergo orthodontic therapy, but inflammation must be managed before, during and after tooth movement.41–43 Spontaneous repositioning after periodontal therapy is not predictable. However, Gaumet and colleagues35 found that if a diastema recently formed and was less than 1 mm wide, then complete closure occurred at 79 percent (26 of 33) of equilibrated sites. Minor tooth movement can be accomplished with a removable device, and investigators have reported major tooth repositioning that included intrusion of teeth with conventional orthodontic care.44,45
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Figure 3. Initial photo of tooth no. 8. The tooth is in secondary traumatic occlusion and has migrated labially, creating a 2-milllimeter space between teeth nos. 8 and 9. There is a 6-mm pocket on the mesiolingual aspect.
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Figure 4. Four weeks after an occlusal equilibration and periodontal surgery on the mesiolingual aspect of the tooth, it has returned to its original position spontaneously.
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Figure 6. Three months after nonsurgical therapy and an occlusal equilibration, tooth no. 7 returned to its original position.
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Splinting mobile teeth.
After migrated teeth are repositioned, splinting often is advocated, because teeth with secondary occlusal trauma have reduced bone support (Tables 1 and 2).27 However, clinicians must use their clinical judgment as to the need to splint teeth, which will depend on the extent of bone loss and tooth hypermobility. Other factors also may affect whether teeth should be splinted. For instance, mobility needs to be reduced if the patient is unhappy with loose teeth or experiences discomfort while chewing.8,27
Excessive occlusal forces.
When assessing the posterior dentition, if the clinician finds that the posterior occlusion is stable (no posterior bite collapse) and there are excessive occlusal forces on the migrated anterior teeth, then he or she should equilibrate the displaced teeth until they demonstrate no fremitus. If necessary, the clinician should treat the periodontium to eliminate signs of periodontitis before retracting and splinting the migrated teeth. Sometimes the clinician must place a temporary splint at the time of surgery to stabilize hypermobile teeth until they become firmer and the patient is more comfortable.8,27
A common sequence of events resulting in displaced anterior teeth is as follows. After inflammation develops, bone is lost, and the tooth may extrude out of the alveolar socket and drift incisally. The cingulum becomes a prematurity, and the tooth is forced buccally. Correction of incisal drifting often requires shortening of the tooth in conjunction with equilibration and tooth retraction. Therefore, careful analysis is required before therapy begins because if too much incisal reduction is needed, it may preclude an esthetic result. Furthermore, if the pattern of buccal and incisal movement is not corrected in a timely manner, it may continue until the tooth catches the lower lip (Figure 7). The force of the lower lip can move the tooth further buccally. In such a case, tooth migration may be so severe that extraction and tooth replacement are needed to restore form and function.
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Figure 7. If tooth migration is not corrected, it may continue until the tooth catches the lower lip. The pressure from the lower lip then moves the tooth further buccally.
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An anterior tooth subject to excessive forces will react until it accommodates the dislodging vector. This accommodation may be manifested by bodily movement of the tooth, a widened periodontal ligament and hypermobility. A tooth also may migrate because of increased occlusal forces (such as those arising from a high restoration that results in a prematurity) and then stop moving once tooth movement mitigates the displacing force. Such a tooth may not demonstrate fremitus. Accordingly, when a tooth is out of normal position, the clinician should evaluate the occlusion to determine if it has been altered by displacing forces. If the posterior occlusion is stable and the maxillary and mandibular anterior teeth contact in centric occlusion or lateral excursions but the forces are not excessive (there is no fremitus), the clinician should initiate periodontal therapy if needed. He or she should adjust the occlusion to create space to facilitate retraction of the displaced teeth and, if necessary, splint these teeth to retain them in position.
Posterior bite collapse.
When the posterior bite has collapsed, the clinician should initiate periodontal therapy if necessary.10,11 Then the posterior occlusion is reestablished to eliminate excessive forces on the maxillary anterior teeth; the clinician retracts and splints the displaced teeth into position. Similar to therapy with primary occlusal trauma, when the posterior bite has collapsed, the clinician does not need to equilibrate the migrated anterior teeth because reestablishment of a stable occlusal plane and vertical dimension usually results in elimination of the displacing occlusal forces.
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CONCLUSION
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A multidisciplinary approach to therapy often is needed to manage migrated anterior teeth. The flowcharts presented in this article (Figures 1 and 2) provide a blueprint for evaluating a patient and ascertaining the cause of anterior tooth migration and the need for therapy. In patients with primary or secondary occlusal trauma, any needed periodontal treatment should precede orthodontic therapy. Subsequently, the clinician may need to initiate prosthodontic management. Spontaneous correction of migrated teeth is possible in the early stage of tooth displacement; however, once spaces are greater than 1 mm, this occurrence is unpredictable. In general, the clinician can prevent migration of teeth if he or she controls periodontal disease and establishes a stable posterior occlusion. Since migration of anterior teeth is of concern to patients and may be costly to correct, it is advantageous to avoid this dilemma.
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FOOTNOTES
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Dr. Greenstein is a member of the Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York City. Address reprint requests to Dr. Greenstein at 900 W. Main St., Freehold, N.J. 07728, e-mail "ggperio{at}aol.com".
Dr. Cavallaro is an associate professor, Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York City.
Dr. Scharf is an associate professor, Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York City.
Dr. Tarnow is a professor and the chairman, Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York City.
Disclosure. None of the authors reported any disclosures.
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ABSTRACT
LITERATURE REVIEW
