Anterior Spacing in Dentistry Female Patients: Causes and Solutions.


A smile is one of the most universally recognisable facial expressions. Besides, a smile may also help convey healthy teeth and gums and research evidence claims that gum disease may negatively affect an individual’s smiling pattern and deter someone from displaying positive emotions through a smile. (Turn that Frown Upside Down- Healthy Gums are Something to Smile about 2008). The human mouth is a complex ecosystem that houses several bacterial species, and the unique anatomy of mouth’s floor plays an important role in the development and extension of intraoral infections, which begins with a periapical dental abscess of the second or third mandibular molar. Recent researches demonstrate that “a person’s total health is indeed related to his or her oral health,” and periodontal disease is linked with cardiovascular and respiratory disease; premature or underweight births; and early indicator of diabetes (Drisko 2000). Because of unique hormonal changes during the life of women they are more susceptible to dental health problems, and untreated gum disease may lead to tooth decay and ultimately its loss.

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Literature review

Periodontal disease represents “an infectious disease affecting more than 23 percent of women between the ages 30 and 54 years” (Bobetsis, Barros and Offenbacher 2006). “The gingivae are target tissues for the actions of steroid hormones, and clinical changes in the tissue of the periodontium have been identified during periods of hormonal fluctuation (puberty, stages of the menstrual cycle, pregnancy, the menopause, and use of hormonal contraceptive)” (Soory, 2000). Women in particular may undergo a decrease in bone mass during menopause, affecting sites such as the alveolar and jaw bones, which secondarily produces periodontal gingival-tooth disease (Lopez Marcos 2005). It is hypothesised that the periodontal pathogens and their virulence may have consequences beyond the periodontal tissues and could act as a source of complication in pregnancy. An evaluation of studies involving the treatment of periodontal disease in pregnant women by Bobetsis and colleagues revealed that “untreated periodontal disease may increase the risk not only of unfavorable pregnancy outcomes, but also of developing conditions that may affect the well-being of the offspring”.

Hormonal changes and periodontal disease

The changes in the sex hormones, progesterone and estrogen, when girls reach puberty and during monthly cycle of menstruation, while using oral contraceptives, during pregnancy, as well as during the onset of menopause, women are prone to periodontal disease. The hormonal changes may sensitise gum tissues and make the gums tender and swollen, due to bacteria build up, leading to accumulation of dental plaque, bad breath, bleeding of the gums, its separation from the teeth, loose or protruding teeth, increased space between teeth, and eventual destruction of dentures. With the onset of menopause women may opt for hormone replacement therapy (HRT), to overcome physical and psychological manifestations associated with menopause. Decrease in estrogen production during the time of menopause can cause depressive symptoms and mood swings, reduced vaginal lubricants making sexual relations uncomfortable, and hot flushes, which may respond to HRT. A two year follow up study of 42,171 post menopausal women showed that the risk of tooth loss was significantly lower amongst women receiving hormone treatment for treatment of menopause (Soory, 2000). But the decision for HRT should be based on knowledge of the possible immediate and long-term consequences and weighing the known benefits and risks of the same. Though studies have established that estrogen replacement treatment can reduce the risk of coronary heart disease, and prevent osteoporosis in post-menopausal women, there is increased risk of cancer of the endometrium and breast. Studies also showed that women taking hormonal contraceptives for more than 1.5 years exhibited greater periodontal destruction and levels of gingivitis were significantly higher. Extracting the infected teeth and placing an immediate implant into the socket is a common approach for treating patients with damaged maxillary interior teeth having periodontal disease and periapical pathology with infected lesions or cyst.

Oral health and Diabetes

Several oral manifestations are associated with diabetes that includes decreased polymorphonuclear leukocyte function leading to impaired resistance, abnormal collagen metabolism, and prolonged wound healing time. Impaired use of glucose, due to altered protein metabolism in diabetic patients, increases breakdown of collagen in the connective tissue and exacerbate the impaired healing response. Decreases in salivary flow in diabetic patients also contribute to increased caries susceptibility, as the elevated salivary glucose level increases bacterial substrate that supports caries and periodontal disease. (Rylander et al.1987). who compared the periodontal condition of insulin controlled diabetic patients with healthy adults, found gingival inflammation in diabetic patients with retinopathy and nephropathy, and diabetic related microangiopathies also have been shown to encourage periodontal disease (Tervenon and Olver 1993). All dental procedures in diabetic patients should be performed with caution, and treatment should not be performed in a patient with uncontrolled diabetes, because of impaired healing response. Rather than fixed or removable appliances, good oral hygiene with a fluoride-rich mouth rinse can provide preventive benefits, because “fixed or removable appliances promotes increased plaque retention”, which could easily cause tooth decay and periodontal breakdown in diabetic patients. (Bobetsis, Barros and Offenbacher 2006). 

The mandible plays a special role in facial appearance and the growth and developmental anomalies of mandible influence the maxilla in its development, as an abnormal mandible can have a very negative influence on chewing and speech function (Obwegeser 2000, p.9). The open bite occurs due to the anomaly of either the maxilla or mandible or both, and the open bite produces anterior and total open bite due to the position of the anterior maxillary segments that is too high or too low, which presents an overaggressive curve of spee. ‘Posterior crossbite’ is the term used to describe the situation when the top back teeth bite inside the bottom back teeth, which occurs when the top teeth or jaw are narrower than the bottom teeth and can happen on one or both sides of the mouth. Clinical trial evidences that removal of premature contacts of the baby teeth is effective in preventing a posterior crossbite by perpetuated to the mixed dentition and adult teeth. After a review randomized and controlled clinical trial done by Harrison and Ashby they opine that if grinding is not effective then a fixed brace (quad-helix) is the preferred method of preventing crossbite in the mixed dentition (2008). Use of short implants in the posterior region is practised for bone augmentation during implant placement and the reduced surgical risks for sinus perforation or mandibular paresthesia, which may allow recovery of large quantities of living bone particles. But, it is essential to maintain minimum crown height of the implant for reducing stress on the implant as excessive stress may adversely affect the bone tissue leading to hypertrophic response and local overload could induce bone loss in the locations of the acting force. As such, implant design, its properties, and the surface condition of the implant is important for maintaining greater bone contact and reducing stress to the bone-implant interface, which will regenerate bone and soft tissue surrounding the implant.

Influence of medication in gingival enlargement

Study results by Ozcelik and colleagues (2006) have revealed that the prolonged use of anabolic androgenic steroid (AAS) is closely associated with significant levels of gingival enlargement. It is known that “gingival overgrowth occurs as a consequence of the administration of anticonvulsants, calcium channel blockers, and immunosuppressant” (Popova and Mlachkova 2007).Though the pharmacological effects of these drugs are specific, the clinical and histological features of enlargement caused by the different drugs are similar. The clinical problem of drug-induced gingival overgrowth, depending on the clinical features, can be corrected with scalpel gingivectomy. Good maintenance care with oral hygiene, chlorhexidine gluconate rinse, and regular professional recalls are also critical for diminishing recurrences of gingival overgrowth

Esthetic dental treatment

There is an unprecedented increase in the number of patients seeking treatment for dental and facial abnormalities in recent years as facial anomalies negatively influence both the patient’s self-confidence and his interpersonal relationships. Three most common problems in dentistry are dental caries, periodontal diseases, and malocclusion that are generally associated with genetic and environmental contributions and dental occlusion reflects the connection between many factors including tooth size, arch size and shape, the number and arrangement of teeth, size and relationships of the jaws, and also the influences of the soft tissues of the mouth. Adult patients seeking orthodontic treatment are increasingly motivated by esthetic considerations, and majority reject wearing labial fixed appliances. Hence, poor esthetic of fixed orthodontic appliances prompted the development of alternative treatment options like Essix retainers, Trutain retainers, lingual orthodontics and invisalgin appliances, of which invisalgin appliance is most successful for treating mildly maligned malocclusions, deep overbite problems, nonskeletally constricted arches and mild relapse after fixed-appliance therapy. But, invisalign appliance has limited success in anterior open bites, crowding and spacing over 5 mm, posterior dental intrusion, and tooth movement, yet it can provide “an excellent esthetic during treatment, ease of use, comfort of wear, and superior oral hygiene.” (Phan & Ling 2007). Generally patients prefer less invasive restorative dentistry and orthodontic treatment than extensive full coronal restorations and aligners are best alternative to fixed appliances as aligner use is found to decrease plaque and gingivitis. Observational studies by (Boyd 2008) demonstrated that a variety of complex malocclusions, including correction of moderate crowding, moderate Class II division 1, and deep overbite, can be successfully treated using new treatment protocol for Invisalgin. Literature reviews indicate that better treatment planning for each case and the adaptation and improvement of the surgical protocols and available technology are paramount to improve the overall survival rates of short implants

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Turn that Frown Upside Down- Healthy Gums are Something to Smile about. (2008). American Academy of Peridontolgoy. Web.

BENSCH, Luc. Orthodontic Treatment Considerations in Patients with Diabetes Mellitus. [online]. American Journal of Orthodontics and Dentofacial Orthopedics.Vol.123 (1). Pages 74-78. doi:10.1067/mod.2003.53. Web.

BOBETSIS, Yiorgos A., BARROS, Silvana P., and OFFENBACHER, Steven.

(2006). Exploring the Relationship Between Periodontal Disease and Pregnancy complications. [online]. JADA: Continuing Education. Vol.137. 2008. Web.

BOYD, R L. (2008). Esthetic Orthodontic Treatment Using the Invisalgin Appliance for Moderate to Complex Malocclusions. J Dent Educ. Vol 72 (8). Pages 948-967.

DRISKO, Connie H. (2000). Trends in surgical and nonsurgical periodontal treatment. JADA. Vol 131. 2008. Web.

HARRISON, J E., and ASHBY, D. (2001).Orthodontic treatment for posterior crossbites. Cochrane Database of Systematic Reviews.

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LOPEZ MARCOS, Joaquin Francisco et. al. (2005). Aspectos Periodontales en mujeres Menopausicas con Terapia Hormonal Sustitutiva: Periodontal Aspects in Menopausal Women Undergoing Hormone Treatment Therapy. Special patients: Oral Cir Bucal. VOL 10. pages 132-41. 2008. Web.

OBWEGESER, Hugo L., LUDER, Hans – Ulrich. (2000). Mandibular Growth Anomalies: Terminology, Aetiology, Diagnosis, and Treatment. [online]. Springer Link. 2008. Web.

OZCELI, Onur., HAYTAC, M.Cenk., and SEYDAOGLU, Gulsah. (2006). The Effects of Anabolic Androgenic Steroid Abuse on Gingival Tissues. [online]. Journal of Periodontology. Vol. 77. Pages 1104-1109. Web.

PHAN, X., and LING, P H. (2007). Clinical limitation of Invisalgin. 

POPOVA, C and MLACHKOVAl A. (2007). Surgical Approach to Drug-Induced Gingival Enlargement in Renal Transplant Patients. [online]. Journal of IMAB, Annual proceeding (Scientific Papers), book 2. Web.

RYLANDER, (1987). Prevalence of periodontal disease in young diabetics. J Clin Periodontol, Vol.14. Pages 38-43.

TERVENON, T., and OLIVER R C. (1993). Long-term control of diabetes mellitus and periodontitis. J Clin Periodontal. Vol. 20. Pages 431-5.

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