A month or so ago I had a patient come in with a lateral incisor fractured off. After gathering all of our diagnostic records and sitting together to discuss his options, a treatment plan was created that included Invisalign therapy to unravel his anterior tooth alignment, shallow his guidance and setup being able to create edge to edge and crossover. The lateral will be removed and replaced with an implant and an equilibration completed to finalize the occlusion. Everyone was in agreement, and the only remaining challenge was dealing with the lateral that had embarked us on this process. The preference is to hang on to the root as long as possible until we are ready to place the fixture so we preserve bone. The patient requested not to have a missing tooth for the duration of the ortho therapy, but would prefer not to have endo, a post and temporary crown for a tooth that is scheduled to be removed in 4 months.
The solution has been to use his Invisalign trays to move his teeth and visually replace the missing tooth. I left the root in place, and we were able to ascertain we can complete the ortho and this root will not impede the movement of any other teeth. We are however, prepared to remove it part way through ortho if need be. I sealed the top of the root with composite, and then began playing with the Invisalign trays. The challenge is to fill the space visually, not add a large amount of work to customize every upper tray, and not to place material inside the tray that would impede tooth movement on either side. The solution, to create a facial facade with flowable composite in each tray. The first few trays were a test, but we have perfected the technique. I air abrade the inside of the tray where the labial surface of the lateral would be. After rinsing and drying, I apply dentin adhesive to the tray on this abraded surface. Finally I paint a 1mm thick layer of flowable composite to create the appearance of a tooth in this space. Once cured, this has been highly successful.
My learning has been that the air abrasion is a very critical step, prior to doing this the flowable was popping out when he removed the trays. The next critical step is the 1mm thickness of material, it is not so much that it creates a contact the adjacent teeth may bump, but thick enough that the flowable gets opaque enough to make it look as if there is a tooth present. Each time I see the patient to dispense his next three sets of trays we customize them for him. It takes a little of my time to do this, which we reflected in the Invisalign fee, but saved him the cost and chair time of several procedures so I could provisionalize this tooth.