Message Boards
Today's Active Topics Today's Active Cases Browse Forum Categories My Recent Activity My Messages Private Groups My Marked Threads My Subscriptions
Today's Active Images Today's Active Polls Most Active Topics Global Townie Map Advanced Message Board Search Message Board Terms of Use

Large Space Due to Multiple Missing Teeth Ken Fischer, DDS

Start Discussion More by this author (2)

KZ, a 38-year-old male, presented with a narrow upper arch, Class I, lower crowding, and an upper midline off to the right due to missing his upper right lateral incisor, cuspid and first bicuspid. He lost these teeth approximately 25 years previously in an automobile accident and has been wearing a "flipper" to fill this space. He was interested in orthodontic treatment in order to idealize his upper and lower arches for implants and restorative dental work to replace the missing teeth. He was not interested in addressing his retrognathic maxilla, surgically or otherwise. This patient is a policeman and intensely refused fixed appliances, insisting that we use Invisalign. Back in 2003, early in the understanding of the scope of treatment with aligners, designing a correction with aligners spanning such a large space was a challenge (Figs. 1-10).

Our treatment goals were to expand the upper arch, align the midlines, correct the crowding in the lower arch, and idealize the space created by the missing teeth for implants. In addition to coordinating the upper and lower arches, expansion of the upper arch was intended to optimize the skeletal base for bone augmentation in preparation for the implants. We accomplished the expansion with a removable, hyrax-type expander, which the patient wore six months and activated one turn per day. To better satisfy the patient, pontics were fabricated into this appliance to replace the missing teeth (Fig. 22).



Following the arch expansion, Invisalign aligners were delivered with "virtual" pontics for the upper right lateral incisor, cuspid, and first bicuspid (the missing teeth). These empty pontic spaces were filled with a tooth colored pontic material provided by Align Technology (Fig. 11). Unfortunately, the initial aligners did not adequately obturate the superior space between the gingival aspect of the aligners and the boney defect in the area of the missing teeth. This condition allowed air leakage which seriously affected the patient's speech and satisfaction. After the first two aligners, mid-course correction aligners were ordered with the buccal and palatal edges of the aligners extended in the area of the missing teeth so that the pontic-filling material could be added sufficiently to completely fill the space and prevent any air leakage. Although this required a large amount of pontic-filling material for each and every aligner, this solution was aesthetic and satisfied the patient's needs throughout the course of the 15 MCC aligners and the additional four refinement aligners.

In a little less than one year, the patient was ready to have bone implanted in the area of the missing teeth to augment the boney support for the three new implants (Figs. 12-21). Due to the alveolar expansion of the upper arch and the boney augmentation, the placement of the implants was able to be optimized and the resulting crowns were constructed without compromise (Figs. 23-28).

This is an interesting case for a number of reasons:
  • The orthodontic treatment made a notable contribution to the complete restorative needs of this patient.
  • The design of the expansion appliance included plastic pontics for the missing teeth.
  • In a "pre-TAD" era, how would this long span of missing teeth have been stabilized so the orthodontic movement could have been accomplished?
  • The patient's demands for treatment without braces were satisfied with Invisalign and he was able to continue his law enforcement occupation.
  • The filled virtual pontics for the missing teeth provided an
    acceptable aesthetic solution during the term of the active treatment.
Author’s Bio
Dr. Ken Fischer graduated from UMKC for dentistry and UCLA for orthodontics. He is in private practice but devotes considerable time to education and professional service to orthodontics. He has been published in several orthodontic publications and is the forensic odontologist for the Orange County Sheriff's Department. Dr. Fischer is an original member of the Align Alpha Group and is on the Clinical Advisory Board. He is also a member of the Orthotown Magazine Editorial Advisory Board.
Orthotown Magazine
September 2025
Orthotown Magazine September 2025 Read Current Issue Read Archived Issues
Sponsors
Townie® Poll
Do you have a dedicated insurance coordinator in your office?
  
Site Menu
Message Boards Magazine Continuing Education Podcasts Blogs Classifieds News Events Townie® Poll Ebooks Townie Choice Awards
Company Info
Contact Us Advertise With Us Howard Farran DDS, MBA Policies and Agreements
Site Help
Sally Gross, Member Services Specialist
Phone: +1-480-445-9710
Email: sally@farranmedia.com
©2025 Orthotown, a division of Farran Media • All Rights Reserved
9633 S. 48th Street Suite 200 • Phoenix, AZ 85044 • Phone:+1-480-598-0001 • Fax:+1-480-598-3450