Saudi Dental Journal (2020) 32, 7–14

King Saud University

Saudi Dental Journal

www.ksu.edu.sa
www.sciencedirect.com

REVIEW ARTICLE

Pre-prosthetic orthodontics
Hayam Alfallaj *
Department of Dentistry, College of Dentistry, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
Department of Prosthetics and Dental Geriatrics, Faculty of Dentistry, The University of British Columbia, Vancouver, Canada

Received 3 May 2019; revised 19 August 2019; accepted 21 August 2019

Available online 27 August 2019

KEYWORDS Abstract For some patients, pre-prosthetic orthodontic intervention is necessary to optimize both
Orthodontics; esthetic and functional aspects of dental treatment. This review will focus on the following topics:
Interdisciplinary; orthodontics treatment with multiple missing teeth, correction of anterior deep vertical overlap,
Crown-lengthening; anterior worn dentition, up-righting of tilted teeth, and orthodontic crown lengthening. This review
Worn-teeth; will aid restorative dentists in identifying which patients could benefit from orthodontic interven-
Tilted-molar tion, and in understanding how orthodontic treatment can be utilized to improve patient prognosis
in restorative treatment.
Ó 2019 Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2. Pre-prosthetic orthodontic intervention:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.1. Orthodontics treatment with multiple missing teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.2. Excessive vertical overbite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.3. Worn anterior teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.4. Up-righting of tilted molars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.5. Orthodontics extrusion for crown lengthening purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Ethical approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Declaration of Competing Interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

* Address: King Saud bin Abdulaziz University for Health Sciences, College of Dentistry, PO Box 3660, Riyadh 11481, Saudi Arabia.
E-mail address: [email protected].
Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

https://doi.org/10.1016/j.sdentj.2019.08.004
1013-9052 Ó 2019 Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
8 H. Alfallaj

1. Introduction Pre-prosthetic orthodontic intervention is needed in a vari-

ety of situations. For brevity, this review will focus on the fol-
The need for orthodontic tooth movement prior to restorative lowing topics:
treatment is necessary for some patients, in order to optimize
both esthetic and functional aspects of dental treatment.  Orthodontics treatment with multiple missing teeth.
Within the literature, most articles regarding pre-prosthetic  Correction of anterior deep vertical overlap.
orthodontics are either clinical reports or clinicians’ opinions,  Anterior worn dentition.
both of which are among the lowest levels of evidence  Up-righting tilted teeth.
(Richards et al., 2008). Nevertheless, such articles can help  Orthodontics crown lengthening.
restorative dentists to recognize which patients could benefit
from orthodontics intervention, and to understand how
orthodontics treatment can be utilized to improve the progno- 2. Pre-prosthetic orthodontic intervention:
sis of restorative treatment.
Planning for treatment of patients who require pre- 2.1. Orthodontics treatment with multiple missing teeth
prosthetic orthodontics must always begin with a diagnostic
wax-up, which is an important tool that enables both the A notable situation that requires prosthetic orthodontic
orthodontist and the restorative dentist to visualize the final interdisciplinary treatment is when a patient requires com-
results. The orthodontist should confirm that the changes in prehensive orthodontics treatment to correct tooth alignment
tooth position on the diagnostic cast can be achieved in the in combination with multiple missing teeth. In these cases, a
patient’s mouth; the restorative dentist should confirm that thorough communication between the restorative dentist and
tooth position is ideal for future restorations that are both the orthodontist is essential in order to decide whether space
esthetically and functionally acceptable. Adequate communi- closure or space opening is more appropriate for the final
cation and planning between the restorative dentist, orthodon- treatment outcomes. Moreover, the selection of the final
tist, and other clinicians before the implementation of any prosthetic treatment, whether removable partial denture,
treatment is a very important step; each of these clinicians fixed partial dentures, or implant-supported prosthesis is
should know the particular stage at which he or she should also required at the start of the planning process, to cor-
intervene, how much time is needed to fulfill the objectives rectly plan spaces between the teeth for future pontics or
of his or her intervention, and the cost of the provided treat- implant-supported crowns (Pinho et al., 2012; Uribe et al.,
ment. The patient will expect to know this information before 2013).
agreeing to the proposed treatment plan (Kokich and Spear, Given that the anchorage provided by the reduced number
1997). of teeth is limited in such cases, the orthodontist can use either
Before discussing orthodontic interventions that can be TADs, or for those have selected implant-supported prosthesis
used for restorative purposes, it is important to understand as the final treatment, the implant could be placed before or
the concept of anchorage. Proffit defined anchorage as ‘‘resis- during the orthodontics treatment to anchor the teeth during
tance to unwanted movement.” Accordingly, for every favor- subsequent movement (Kokich, 1996a, 1996b; Uribe et al.,
able force that causes desired tooth movement, there is an 2013). Implant placement before or during orthodontics treat-
equal unfavorable force in the opposite direction, which is ment increases the risk of improper implant positioning, which
exerted by the same orthodontics appliance. Anchorage is may compromise the esthetic and function of future implant
the resistance to these undesired forces. Generally, anchorage crowns. Therefore, diagnostic set-up for the corrected tooth
is provided by the teeth; however, many adult patients may position and wax-up for the missing teeth are essential at the
not have an adequate number of teeth, or may have periodon- planning stage; these enable accurate planning of the final
tally compromised teeth with insufficient strength to resist implant position (Kokich, 1996a, 1996b; Mitrani, 2008). In
undesired forces. Therefore, orthodontists sometimes recom- order to construct a surgical guide for implant placement,
mend the use of Temporary Anchorage Devices (TADs), the orthodontist should change the position of the existing
which are small titanium alloy or stainless-steel screws mainly teeth on a cast to simulate the outcome of the treatment objec-
used for adult patients with multiple missing teeth, or used in tives, then the restorative dentist should plan the position of
cases where absolute anchorage is required (Mizrahi and the implants based on a wax-up of the future implant crowns,
Mizrahi, 2007; Bidra and Uribe, 2012). TADs are typically the information regarding implant position should then be
placed in the buccal or palatal alveolar bone, in a location transferred to the original cast since the guide will be seated
dependent on the required movement, and are attached to on the existing teeth before the orthodontic treatment. New
the bone by mechanical means without osseointegration; there- digital software may be valuable in such situations to design
fore, they can be easily removed when treatment is completed. and fabricate a surgical guide to place definitive implants
TADs have different lengths (5–12 mm) and diameters before orthodontic therapy (Bayraktaroglu et al., 2015). The
(1.2–2 mm); the orthodontist must place them carefully to software enables clinicians to virtually change the position of
ensure that there is adequate attached gingiva and a minimum the existing teeth, and planning the size, shape, and location
space of 2 mm between the roots. Complications of these type of the future implant-supported crowns, in order to fabricate
of screws include: contacting the adjacent root, implant loos- a surgical guide that will set on the patient teeth and guide
ening or fracture, and damage to the adjacent anatomical the surgeon to place the implants in proper future implant
structure (Mizrahi and Mizrahi, 2007). abutment position.
Pre-prosthetic orthodontics 9

2.2. Excessive vertical overbite excessive anterior vertical overlap, followed by restorative
treatment (Akerly, 1977; Capp and Warren, 1991; Beddis
According to the glossary of prosthodontics, the term ‘‘vertical et al., 2014). Deep vertical overbite can be treated orthodonti-
overlap” has been defined as ‘‘the distance teeth lap over their cally by either intrusion of anterior teeth, extrusion of posterior
antagonists as measured vertically; especially the distance max- teeth, or a combination of both. However, extrusion of poste-
illary central incisal edges extend below those of mandibular rior teeth is more prone to relapse, as the contraction of masti-
teeth” (The Glossary of Prosthodontic Terms: Ninth Edition, catory muscles may return the posterior teeth to their original
2017). In general, vertical overlap is a situation in which one- positions. Thus, segmented intrusion of the anterior teeth is
third of maxillary anterior teeth cover the mandibular incisors; preferable in adult patients (Weiland et al., 1996). The use of
there is extreme variation in the extent of anterior vertical over- implant anchorage is helpful in such patients, as it provides
lap in clinically healthy dentitions (Akerly, 1977). However, absolute anchorage to manage the intrusion of anterior teeth
there are some situations of excessive vertical overlap that (Ohnishi et al., 2005; Ishihara et al., 2014).
can cause trauma to the soft tissue or tooth wear; in addition, For orthodontic treatment of patients with deep vertical
‘‘deep bite” or ‘‘overclosure” can preclude restoration of miss- overlap, Kokich recommended the following approach
ing anterior teeth with removable or fixed restorations at the (Kokich, 2008):
existing incisal plane, without compromising the esthetic nature
of the dentition, its function within the patient, or the structural 1. Identify the correct occlusal plane on cephalometric radio-
integrity of the restoration itself (Torbjorner and Fransson, graph using a fixed landmark. Posteriorly, the occlusal
2004; Beddis et al., 2014). Such traumatic overclosure exists pri- plane originates from the contact between maxillary and
marily in patients with Angle class II malocclusion; the man- mandibular 2nd molars. Anteriorly, the other end of the
agement of these situations requires more complex treatment. occlusal plane may be regarded as the level of the upper
Notably, some situations may require restorative treatment lip at rest (Fig. 1).
alone; this treatment will involve an increase in the vertical 2. By studying the relationship between maxillary and
dimension through restoration of the occlusal surface of poste- mandibular anterior teeth with the correct occlusal plane,
rior teeth with direct or indirect restorations, which will provide the clinician can determine whether the deep vertical over-
more space for the anterior restorations (Torbjorner and bite is caused by overeruption of maxillary or mandibular
Fransson, 2004; Ergun and Yucel, 2014). Another method to anterior teeth. This determination can be made by identify-
manage such situations is orthodontic correction of the ing the incisal edge of the maxillary central incisor and mea-

Fig. 1 Cephalometric tracing for a patient with excessive anterior overbite. The red line indicates the correct occlusal plane connecting
the occlusal surface of the second molars posteriorly and upper lip in rest position anteriorly.
10 H. Alfallaj

suring its distance from the correct occlusal plane. Notably, o Importantly, prior to the implementation of any
age affects the distance between the incisal edge and upper orthodontics treatment, restorative dentists and
lip. Thus, maxillary anterior teeth are expected to be orthodontists should agree on a specific treatment plan
2–3 mm below the anterior end of the plane in young and must use the gingival margins (not the incisal edge)
people; this distance is shortened for older people. If the as a reference for tooth intrusion, particularly if the
distance exceeds expected values, the maxillary anterior patient shows a high smile line.
teeth are the likely source of the deep bite. For mandibular 4. Most patients with deep anterior overbite can be treated by
anterior teeth, the incisal edge should be at the level of the orthodontics treatment alone. However, for patients with
occlusal plane; if these teeth are above the occlusal plane, severe facial disproportion, surgical intervention is required
they are over-erupted and may need to be intruded. to correct excessive vertical overlap. For example, in
3. Evaluate the gingival margin position: patients with significant shortening of lower facial height,
o If the gingival margins of the central incisors are located orthodontic treatment will correct the deep overbite, but
coronally to the canines, the clinician should identify the cannot enhance facial appearance. Therefore, a mandibular
cause of this uneven gingival margin. sagittal split osteotomy and rotation of the mandible in the
o If the cemento-enamel junction is within 1 mm of the chin area will decrease vertical overbite and increase lower
gingival margin and the incisal edges of the anterior facial height.
teeth show a degree of tooth wear, the anterior teeth
may have experienced compensatory eruption or den-
toalveolar extrusion. Thus, the clinician would need to 2.3. Worn anterior teeth
further intrude the teeth apically, in order to correct
the gingival margin position; in this situation, the Another type of challenging situation that requires a multidis-
width-to-length proportion of the final restorations that ciplinary approach involves short anterior clinical crowns due
fit the patient’s esthetic would be an important determi- to a habit of anterior bruxism, combined with posterior teeth
nant for the extent of intrusion. However, if the cemen- of normal height that maintain their vertical dimension
toenamel junction is located more than 1 mm apical to (Fig. 2). In this type of situation, the anterior teeth will con-
the gingival margins, the gingiva may have experienced tinue to erupt with the bone and surrounding tissue (compen-
altered passive eruption and its length should be cor- satory eruption), thereby maintaining contact with the
rected surgically (Kokich, 1996a, 1996b). opposing teeth; this will result in short clinical crowns and

Fig. 2 Intra-oral photographs for a patient with anterior worn-down dentition due to protrusive bruxism habit. A: anterior retracted
smile view, shows anterior teeth with short clinical crown and inconsistent gingival margins level, and posterior teeth with normal clinical
height. B and C: Maxillary and mandibular occlusal view, shows signs of moderate to severe tooth wear on anterior teeth only.
Pre-prosthetic orthodontics 11

inconsistent marginal gingiva (Turner and Missirlian, 1984; need to be removed, thus allowing the restorative dentist to
Kokich, 2008). build provisional restorations using composite material on
To restore the anterior dentition in such situations, the the anterior dentition. Orthodontic brackets can then be
restorative dentist can use one of the following approaches: bonded again to continue the orthodontics treatment or com-
plete the stabilization period (Kokich and Spear, 1997;
1. Orthodontics intrusion of the worn anterior teeth. Kokich, 2007; Kokich, 2008; Spear, 2016). Following
2. Surgical crown lengthening of the worn anterior teeth. orthodontic correction of the gingival margin, the position
3. Enhancement of the vertical dimension through restoration of the teeth should be maintained for at least 6 months to
of the occlusal surface of posterior teeth, thereby gaining aid in reorienting the periodontal fiber into a more stable
the space needed for restoration of anterior teeth. position, thus preventing re-extrusion of the teeth. After the
4. Utilization of the Dahl concept worn anterior teeth have received final ceramic or metal-
ceramic restorations, the patient should be provided with a
A. Orthodontics intrusion of worn anterior teeth bite splint and asked to wear it while sleeping; this is
regarded as a method of stabilizing the occlusion and can
Although orthodontics intrusion is a lengthy treatment that help to protect the final restorations (Kokich, 2007).
requires a high degree of patient compliance, it is an ideal A restorative dentist should consider a few aspects when
treatment option because of its less invasive nature, compared referring a patient for orthodontics intrusion. Notably, in a
to other options; this aids in correction of the gingival margin comparison of the bone level and root length of 57 periodon-
and eliminates the need to perform incisal reduction for crown tally sound anterior teeth using periapical radiography,
preparation (Fig. 3). Bellamy et al. studied the effect of tooth intrusion on the
At the planning phase, the restorative dentist can use the surrounding bone and root length. They found that the
amount of tooth displayed at rest and the amount of lip alveolar bone level of intruded teeth remained relatively
mobility to determine how he or she will lengthen the short constant relative to the cementoenamel junction, which
worn down anterior teeth, then in most of the cases, the indicated that the bone would follow the teeth during intrusion
treatment will be a combination of orthodontic intrusion movement. Moreover, they found significant apical root
and restoratively adding to the incisal edge (Spear, 2016). resorption for maxillary and mandibular anterior teeth
In such situations, the gingival margins should be used as a (1.73 mm and 1.37 mm, respectively), following the intrusion.
reference for intrusion of worn teeth, rather than the incisal These findings suggest that the restorative dentist should con-
edges. The guide for the amount of anterior tooth intrusion sider the future crown to root ratio for patients who require
will be determined on the basis of adjacent non-worn teeth. orthodontic intrusion (Bellamy et al., 2008; Spear, 2016).
For example, if central and lateral incisors are worn and
over-erupted, the central incisor should be intruded until its B. Surgical crown lengthening
gingival margin reaches the same level as the gingival margin
of the non-worn canine; while the gingival margin of the lat- Another method to treat patients with anterior attrition is
eral incisor should be located 1 mm coronally (Kokich, 2007). the application of a surgical crown lengthening procedure to
In addition, the width-to-length proportion of the final correct the discrepancy in gingival margins and achieve greater
restorations that fit the patient’s esthetic is an important retention and resistance for future restorations. Typically, this
determinant for the amount of intrusion (Spear, 2016). Dur- procedure is followed by elective endodontic treatment, post
ing orthodontics treatment and after intrusion of teeth, dis- and core buildups, and restoration of the teeth (Kokich,
crepancy in the incisal edges becomes more apparent and 2007; Kokich, 2008). Table 1 shows the differences between
may result in an anterior open bite. Therefore, to establish surgical crown lengthening and orthodontic intrusion for worn
proper anterior guidance, the orthodontics bracket might anterior teeth.

Fig. 3 Illustrations for anterior worn-down dentition case treated with a combination of orthodontic intrusion of anterior teeth followed
by restorative treatment to build the incisal guidance and to improve the esthetic of the anterior teeth. A: An illustration for the clinical
presentation of worn-down anterior teeth due to anterior bruxism habit. B: Orthodontic treatment to intrude the short anterior teeth, the
gingival margins of the adjacent non-worn teeth should be used to determine the amount of tooth intrusion. Red dotted lines indicate the
future restoration outline. C: clinical presentation of the case after completion of the restorative treatment.
12 H. Alfallaj

2.4. Up-righting of tilted molars

Table 1 Differences between surgical crown lengthening and
orthodontic intrusion for worn anterior teeth.
Tilted posterior teeth constitute a common clinical problem
Crown lengthening Orthodontic intrusion
that interferes with restorative treatment and replacement of
Incisal reduction is required, Preserves tooth structure (incisal missing teeth. This occurs mainly because of the loss of the
which might necessitate reduction is not required) interproximal contact due to tooth extraction, or the loss of
intentional endodontics
tooth tissue structure (e.g., extensive proximal caries); this
treatment (Kokich, 2007)
causes loss of proximal contact area and eventual tilting of
Affects crown to root ratio by
Affects crown to root ratio apical resorption (Bellamy et al., adjacent teeth, ectopic eruption of some teeth, and ankylosed
(Kokich, 2008) 2008) infra-eruption (Stern et al., 1981; Kennedy, 2009). The most
frequently affected tooth is the mandibular second molar, as
Invasive treatment (Kokich, Long treatment time (Saha and the first mandibular molar is frequently lost. It is important
2008) Summerwill, 2004)
to note that not all teeth adjacent to the edentulous area are
Margins on root surface; patient subjected to tilting. If the remaining teeth are well intercus-
may experience sensitivity from Requires patient compliance pated by the opposing arch, drifting or tilting will be minimal
exposed root surface (Saha and (Saha and Summerwill, 2004) and rare (Stern et al., 1981; Simon, 1984).
Summerwill, 2004) Consequences of tilting typically involve the formation of
Black triangles are expected infrabony defects on the mesial side of the tilted tooth. Alter-
between the teeth, which ations of this area are likely to result in a defect of gingival
compromises the esthetic tonus and the formation of a pseudo-pocket, thereby rendering
outcome. This happens the tissue more susceptible to periodontal disease (Stern et al.,
primarily due to the wide 1981).
discrepancy in the incisal In patients who require replacement of a missing tooth
dimension of the crown
adjacent to a tilted molar, the restorative dentist can use the
compared to the narrower
following approaches (Revah et al., 1985):
diameter root (Saha and
Summerwill, 2004)
 When the tilt of the molar tooth is not severe, the dentist
can perform enameloplasty on the tilted tooth, if the
C. Increasing the occlusal vertical dimension with posterior restorative plan is to replace the missing tooth with an
restoration implant or removable denture. Slight modification of tooth
reduction will be sufficient when preparing the tooth for
The occlusal vertical dimension can be increased by restor- fixed partial denture.
ing posterior teeth in one or both arches, thereby providing  Use of a locked attachment or telescopic crown.
restorative space for worn anterior teeth (Turner e  Alignment of the tilted tooth via orthodontic treatment.
Missirlian, 1984; Kokich, 2008).
There are several advantages of aligning the tooth via
D. Dahl concept orthodontic treatment. This approach can eliminate the infrab-
ony defect on the mesial side of the tilted tooth, simplify the
This simple orthodontic concept has been described as a preparation of the tilted abutment tooth to receive a fixed par-
noninvasive technique to create anterior interocclusal space tial denture, aid in aligning the occlusal plane, and aid in trans-
for restorative material without affecting clinical crown height mission of occlusal forces through the long axes of the tooth
(Dahl et al., 1975). This concept begins with the use of a (Becker et al., 1982). For adjunctive orthodontics treatment
removable chrome cobalt appliance that solely covers the pala- to return the tilted tooth to its normal position, both remov-
tal surface of the anterior teeth, thus allowing disocclusion of able and fixed prosthodontics appliances can be used, each
posterior teeth. Over a period of time, the posterior teeth will with unique benefits and limitations. Fixed appliances gener-
over-erupt to reestablish occlusion; this creates interocclusal ally require more technical skills for application, but any tooth
space between anterior teeth, through a combination of the movement can be achieved if adequate anchorage is provided
intrusion of the anterior teeth in contact with the appliance (Becker et al., 1982). Anchorage can be obtained by utilizing
and the eruption of posterior teeth. Subsequently, the concept the anterior two premolars and canine, or by using a mini
can be used with many direct and indirect fixed restorations orthodontic implant. This movement will result in distal and
(Dahl et al., 1975; Hemmings et al., 2000; Saha and lingual tipping of the second molar, and the treating dentist
Summerwill, 2004; Poyser et al., 2005). should eliminate any occlusal interference that might result
The disadvantage of this concept is that the patient will from treatment (Simon, 1984). In contrast, removable appli-
experience difficulties in chewing and speaking, and periodon- ances are dependent on patient compliance, and are limited
tal and pulpal symptoms are expected to be caused by the to tipping movement without bodily or root movement. How-
application of excessive occlusal forces to the anterior teeth. ever, they can be used to temporarily increase the vertical
In addition, the duration needed for these appliances is unpre- dimension, thus clearing the tooth for movement without
dictable and might range from 6 to 24 months. Finally, some occlusal interferences (Becker et al., 1982).
reports have described failure of the posterior teeth to reestab- The average time required for such treatment is 3 months;
lish occlusion (Poyser et al., 2005). however, this time is affected by the extent of tooth tipping,
Pre-prosthetic orthodontics 13

root length, remaining periodontal support, and amount of 3. Conclusion

applied forces (Simon, 1984).
 Understanding the influence of orthodontic treatment on
2.5. Orthodontics extrusion for crown lengthening purpose esthetic and functional outcomes will facilitate proper plan-
ning of restorative treatment.
Maintenance of the restorative margins within 0.5 to 1 mm in  Adequate communication between the orthodontist and
the gingival sulcus and approximately 3 mm coronal to the restorative dentist prior to orthodontics intervention, dur-
bone level is crucial for ensuring the health of the periodon- ing treatment, and before bracket debonding is essential
tium (Baba et al., 2014). However, in patients with subgingi- for success in multidisciplinary treatment scenarios.
val caries, deep existing restoration, or subgingival defect, the  Diagnostic wax-up is a critical tool in nearly all situations
restorative dentist might need to refer the patient for clinical involving pre-prosthetic orthodontics, as it helps clinicians
crown lengthening to prevent invasion of the biological to establish their treatment objectives and visualize the final
width. In this situation, the clinician must choose one of results of the treatment.
two options: surgical crown lengthening or orthodontic
crown lengthening with rapid and high extrusion forces,
which may result in movement of the tooth without the Ethical approval
attachment apparatus (Potashnick and Rosenberg, 1982;
Alsahhaf and Att, 2016).
No ethical approval required.
The advantages of orthodontic extrusion over surgical crown
lengthening are that orthodontic extrusion provides a more
Declaration of Competing Interest
favorable crown to root ratio, eliminates the risk of compromis-
ing the alveolar bone support of the adjacent teeth, and will not
No conflict of interest.
compromise the esthetic of the tooth that requires crown length-
ening (Potashnick and Rosenberg, 1982). Some authors have
described the need for corrective surgical crown lengthening References
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