Mesial tipping behind an extraction site is a normal phenomenon that can be corrected using a simple acrylic wedge and some patience, from both patient and dentist.
Here I show how to distalize a tooth in order to correct the mesial tipping without using orthodontics.
*this is the continuation of the previous post, which shows the surgical soft tissue management phase
First make your design and explain it to the patient and to your dental technician.
First make your design and explain it to the patient and to your dental technician.
The goal in this case was to fit a longer disto-mesial crown on the back implant that tilts the second molar back to a more upright angle.
Notice that is is reciprocal. The crown won’t fit in the place unless the gap is made somehow bigger before the insertion.
For that we need a simple aid. That is, for example, a chairside made acrylic wedge that you make over the future crown abutments on the cast model or directly in the mouth. It can also be done in the lab, if you prefer.
There are, however, two ways to approach the solution at this point:
- You make the acrylic wedge with the actual size, then you add acrylic distal increments
- This is more precise, but it requires a second impression and thus, more time.
- You take some cast material from the mesial side of the tooth to be tipped back, then you build the acrylic wedge on the model.
- This allows to prepare the final crown and to have it ready as soon as the molar tips back and lets the crown in.
- But not valid for screwed crowns if the gap opening is more than 1″ on average.
In this clinical case I chose the second way and I gave the patient both the edge and the crowns, instructing her to take them in and out until the crowns fit in.
A second molar can hardly be tipped back if there is a wisdom tooth behind it. So I extracted the third molar and inserted the acrylic wedge on the same day.
On the hand design you may see I planned to insert the front crown and only a wedge on the back implant, but the I tested it and realized that the wedge was more stable with a double post retention. But it could have been also done with one abutment.
The wedge must adapt passively on the front and ut must have an inclined rear surface that pushes the molar back while the occlussion keeps the wedge in place.
There will be subsequently an increased bite heigth, resulting in no front contacts and premature contact on the wedge and the implants underneath.Caution:
- You may want to allow the implants a longer healing period just to assure full osseointegration.
- You need to tell the patient that he/she should not overload the implants by bitting hardly on them, and that the molar will move back gently in a few days or a few weeks, depending on different factors (bone density, extraction distally, degree of tipping vs. amount of distal movement).
- You may need to schedule some control appointments, checking how the molar moves back and the bite closes down. If that doesn’t happen, you may need to introduce some changes in your wedge design or confirm that the patient carries it at all times.
There will be a moment, days or weeks later, when the crown can be placed on the abutment and fits in with more or less pressure. This can be done by the dentist or also by the patient at home, providing he/she was properly instructed on this task. Normally it is the crown itself that pushes the tooth back the last tenths of millimiter and falls right in place.
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