Closing orthodontic gaps by splint therapy

Many people want a beautiful smile without gaps – irrespective of their age. Hence, correction of dental malposition is an issue for adults as well. However, their therapeutic demands are high: The appliances are expected to be convenient to wear, not to cause problems with speaking and preferably not to be seen. With an almost invisible splint therapy, today even more difficult cases can lead to the desired success. In the case reported, the treatment was performed using In-line splints produced by Rasteder Orthodontic Laboratory.

Initial situation

The patient came into the practice with an aesthetic request. She felt that her appearance was spoilt by the gap positions, in particular by the gap between the teeth 13 and 11 in FDI notation (Figures 1-3).

There was non-development of the teeth 12 and 22, disto-occlusion with an overjet of eight millimetres and a frontally and laterally open bite. In addition, there was crowding with levelling of the mandibular front. In her youth she had received orthodontic treatment to close the gaps in the area of the non-developed teeth.

The patient had already discussed veneers with her dentist, but due to the awkward position of the teeth it would not have been possible to obtain a satisfactorily aesthetic result using these.

Therefore, the dentist had advised to orthodontically close the gaps first, in order to subsequently obtain an optimal result with veneers.

Therapy decision
The patient came into the practice already with a desire for an invisible splint therapy for correction of the maxillary front. During consultation, she was informed about the existing mandibular malposition and the correction options using fixed appliances – and also in combination with surgery for dysgnathia, if desired.

However, the patient rejected extensive treatment and fixed appliances. Since physical movement of teeth can be achieved only to a limited degree using splints, there was a borderline situation for splint therapy with regard to the desired therapy goal. In order to nevertheless achieve sufficient physical movement, treatment with In-line was recommended and discussed.
From previous experience, I have found that the type of plastic used in the manufacture of In-line splints is able to move the teeth more effectively than systems made from hard plastic. On the other hand, it must be accepted that with the advantage of higher elasticity there is a disadvantage of greater material thickness.

The patient was also informed that after one to two weeks the splints may experience increasing slight discoloration. Additionally, further modelling of the mandibular front was discussed for solving the crowding and in particular for reducing the incisor overjet.

Treatment planning
The planned measures were first implemented in a digital set-up by Rasteder Orthodontic Laboratory. After examination on my part with regards to feasibility and requests for modifications, the splints for all the treatment steps leading to correction were produced. For complete closure of the front gap, teeth 13 and 23 were slightly mesialised, and to this end minor residual distal gaps by the canines were accepted.

Per splint, the lab provided for a movement of the teeth of 0.3 mm to 0.5 mm. For the treatment of the maxilla, seven splints, and for the mandible, five splints were produced and also one retention splint per arch. Maxilla splints 1, 2, 4, and 5 were slit incisally for greater flexibility. In order to achieve more physical movement, splints 3 and 6 were closed.

Therapy
The patient wore the individual In-line splints with a high level of motivation (in the daytime as well), so that – depending on the progress of the treatment – they could be exchanged on average after three to four weeks. The next splint was inserted every time the pre-programmed change of position had been effected.

By this stage the patient no longer felt any pressure on her teeth from the splints.
Thanks to the extremely positive compliance of the patient, the therapy goal was achieved within seven months. In the present case, this course corresponded exactly to the original set-up (Figures 4-6).

For long-term stabilisation, retainers were bonded to mandibular and maxillary teeth after the patient first had not been able to make up her mind in favour of a subsequent veneering (Figures 7 and 8). The maxillary retainer was fixed as gingivally as possible so that the patient had the option of having composite superstructures built mesially on teeth 13 and 23 by her dentist (Figure 9).

During a later control session, grinding of the cutting edges resulted in further aesthetic improvements which brought the canines into a more harmonious appearance in the dental arch (Figures 10 and 11).

Result
The relatively large gaps could be closed very well using the correction splints, and the overjet was reduced from an initial eight millimetres to three millimetres. The result showed a markedly good correspondence with the set-up created at the beginning of the treatment.

Here, the excellent compliance was crucial for the swift and thorough success of the treatment. From my point of view, precise and realistic information with regard to all advantages and disadvantages of the various therapy options and exact definition of the therapy goal prior to commencement of the treatment were pivotal for the patient’s complete satisfaction.

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