Combined orthodontic and implant treatment is an innovative approach that merges the two disciplines to achieve superior functional and esthetic outcomes. This interdisciplinary collaboration can be used to address the challenges of complex cases, including malocclusion, missing teeth, and bone deficiencies, paving the way for more stable and harmonious restorations. By leveraging advancements in diagnostic tools, such as cone-beam computed tomography (CBCT) scanning and digital planning, dental professionals can create customized treatment plans that are tailored to patients' individual needs, optimizing the positions of teeth and implants to deliver the most ideal restorations possible. This article explores some of the indications, benefits, challenges, and best practices for integrating orthodontics with implant dentistry and highlights how effective collaboration and precise treatment sequencing are key to successful outcomes and patient satisfaction.
Indications for Combined Treatment
"The initial assessment for combined orthodontic and implant treatment revolves around a comprehensive understanding of the patient's dental and skeletal relationships, occlusion, and esthetics," explains Daniel Berant, DMD, a dual-trained specialist in periodontics and orthodontics who practices in New York City. "Critical factors include evaluating the space available for implants, periodontal health, bone quality and quantity, and the alignment of the adjacent teeth. I prioritize diagnostic tools like CBCT scans and digital models to ensure precise planning."
Orthodontic treatment can play a critical role in optimizing conditions for implant placement in various clinical scenarios. In cases involving missing teeth where malocclusion is present, orthodontics can correct misalignment or space issues caused by the tipping, drifting, or overeruption of adjacent or opposing teeth. These corrections enhance the prosthetic replacement of missing teeth, allowing implants to be placed in the most ideal position and orientation, which improves function, esthetics, and hygiene.
The early loss of primary teeth often necessitates space maintenance, and factors such as the presence of permanent teeth, the timing of additional permanent tooth eruption, and the extent of crowding must be carefully considered. For young patients with mixed dentition who present with issues such as congenitally missing permanent teeth, ankylosed permanent teeth, and other conditions, orthodontic management can help to maintain space and ensure proper eruption paths until they have completed jawbone development and can receive an implant.1
Orthodontic treatment is also valuable for patients who require implant site development because it can improve bone and soft-tissue volume in sites with deficiencies. Orthodontic forced eruption, or orthodontic extrusion, can serve to increase the available bone, correct periodontal defects, and prepare the implant site for optimal outcomes.2 When indicated, surgically facilitated orthodontic therapy can further aid in improving dentoalveolar deficiencies and addressing dentofacial disharmony.3
Benefits of Combined Treatment
The first step in any combined treatment plan should be patient education. Berant emphasizes that patient education should begin with clear, relatable language. "I explain that combining orthodontics and implants can provide the best outcomes for both function and esthetics but that it requires careful planning and commitment," he says. "Visual aids, such as digital simulations, can help patients visualize the transformation of their smiles. I also address potential challenges, such as extended treatment timelines or the need for additional procedures such as grafting. Setting realistic expectations and involving patients in decision-making ensures that they feel informed and engaged throughout the process."
Incorporating orthodontic therapy into comprehensive treatment planning offers significant benefits, including improving tooth alignment and ensuring that implants are placed in the most optimal positions, which can not only improve the esthetics of restorations but also their chances of long-term success. Furthermore, techniques such as orthodontic extrusion can help achieve better gingival levels, creating outcomes with esthetics that closely mimic those of the contralateral teeth.4 Functionally, combined treatment can enhance occlusion, reduce the risk of implant failure and other complications through precise placement, and increase implant stability. "Orthodontically addressing space requirements, both mesial/distal as well as interarch, will allow sufficient room for the restorative components, thereby improving the long-term success of the implants and restorations," explains Rebecca Bockow, DDS, MS, a dual-trained specialist in periodontics and orthodontics who practices in Seattle, Washington.
For cases involving future implant sites with tissue deficiencies, orthodontic eruption of a tooth prior to extraction can serve to augment the hard and soft tissues at the site, further improving the final results. "In cases where forced eruptions are deemed necessary, they have to be done properly with proper consideration and realistic expectations regarding bone formation," explains Berant. "Timing is everything. For example, forced eruptions are completed before implant placement with enough time to ensure the bone and soft tissues have fully matured."
Although orthodontic therapy often precedes implant placement in combined treatment, the reverse approach can also be advantageous. Implants or temporary anchorage devices can serve as reliable anchorage during orthodontic treatment, particularly in complex cases. Studies show that implants placed in alveolar bone resist orthodontic forces, offering effective skeletal anchorage and enabling superior preprosthetic tooth positions.4-6 According to Berant, the treatment sequence should be dictated by the case's complexity. "In cases where implants will serve as anchorage or if there is adequate space prior to ortho placement and the adjacent teeth don't need to be moved significantly, the implants may be placed earlier," says Berant. "Collaboration between the orthodontist and surgeon is essential to customize the sequence to each patient's needs."
Andrew Ferris, DDS, MS, an orthodontist in Santa Barbara, California, notes that "understanding the capabilities of orthodontics, especially in adult patients, allows general dentists to leverage implants during treatment for significant benefits." This integration of orthodontics and implant dentistry can enhance predictability, reduce the need for extractions and bone grafts, and minimize complications, ultimately improving patient outcomes and long-term success.
Challenges and Risks of Combined Treatment
Combined orthodontic and implant treatments present unique challenges and risks that require careful planning and collaboration to address effectively. Orthodontic complications include issues related to moving teeth around an implant site, such as root resorption, damage to adjacent teeth, or inadequate site preparation, as well as the risk of orthodontic relapse following the completion of treatment if there is no plan to manage it. "Managing the occlusion will help aid in long-term success," says Bockow. "Understanding growth patterns, especially vertical changes in the esthetic zone, will help reduce the likelihood of unwanted or unexpected vertical changes, both at the gingival margins and occlusally."
Many of the risks associated with combined treatment can be minimized through clear communication and thorough planning from the outset, particularly when digital tools are employed.7 "Orthodontics is really all about anchorage-getting the teeth you want to move to move and keeping the others in place," Ferris explains. "With software, we can plan long-term, allowing us to place an implant early, and even if it initially might not appear to be in the proper site, our planning ensures that it ultimately aligns correctly."
Implant complications can arise if teeth are moved too aggressively or if implant placement is not well-coordinated with orthodontic forces. Strategic planning is essential to determine the optimal timing and location for implant placement. Ferris emphasizes the importance of predictive modeling, noting, "If you're strategic, software can help model and predict tooth movement, leading to more precise implant placement." In addition, orthodontic forces can sometimes lead to soft-tissue complications around implants, which underscores the need for a comprehensive and coordinated approach to minimize risks and optimize outcomes. The appropriate orthodontic intervention may involve adjunct tooth movement to facilitate other dental procedures or comprehensive orthodontic treatment to correct a malocclusion-all of which will affect the appropriate timing of implant placement.
When it comes to interdisciplinary care, timing is especially critical. "Bone augmentation typically requires 4 to 6 months to mature before implant placement, and after implants are placed, an additional 3 months is usually needed for osseointegration before restoration," explains Bockow. "Therefore, the interdisciplinary team may opt to initiate bone augmentation 9 to 10 months before completing orthodontic care in order to coordinate the completion of alignment with the restorative phase. For younger patients, the team must carefully assess skeletal growth status. Serial lateral cephalometric radiographs, taken annually and superimposed using the cranial base, can help determine when vertical growth has ceased. However, because the alveolar processes continue to remodel over time, the placement of implants in the esthetic zone should be deferred for as long as possible."
The Collaborative Approach
A collaborative treatment plan can only be executed with clear communication between all parties involved, including the general or restorative dentist who coordinates the care and manages the referrals, the orthodontist, and the periodontist or implantologist. "When different providers are treating the same patient, communication is of the utmost importance to ensure that each provider's role can be fulfilled," explains Stephen Dadaian, DDS, a general dentist in Cresskill, New Jersey who places implants and offers orthodontics. "I have seen cases where new patients presented with adequate space clinically after orthodontic treatment and were told to find a restorative dentist to complete treatment; however, the roots were not torqued to proper position to allow for proper implant placement. Therefore, these patients could not proceed to the surgical phase until the teeth adjacent to their edentulous sites were corrected. Although this was fixable, it delayed treatment, which can sour the experience for patients who easily get overwhelmed if additional time is required for something that was avoidable."
Interdisciplinary care requires meticulous management, both in the communication between the doctors and with the patient as well. "First, it's important to assess patients' goals and expected outcomes in combination with their past medical and dental histories to see if they are good candidates," says Dadaian. "Typically, patients who are agreeable and amenable to such a treatment plan are well-suited because they are understanding and willing to put their efforts into achieving the best possible results. Compliance is a significant challenge with long-term treatments, especially those that rely heavily on patient adherence, like aligners. Patients must follow instructions to complete each treatment stage before moving to the next. Fortunately, frequent orthodontic follow-up visits allow providers to monitor progress, adjust plans, and address compliance issues. After treatment, although implants are rigid and immobile, they remain susceptible to occlusal forces, and neighboring teeth may relapse. A maintenance plan for both retention and hygiene should be established and discussed with patients."
In interdisciplinary care, the use of shared diagnostic tools, such as CBCT scans, intraoral scans, and digital planning software, is paramount for accurate treatment planning. "Digital imaging and digital software allow the interdisciplinary team to collaboratively set up and treatment plan cases," explains Bockow. "Space requirements for final restorations and implants can be digitally vetted in advance, bone augmentation can be sequenced and planned in conjunction with the orthodontic care, and digital treatment plans can be shared virtually, facilitating enhanced communication. In addition, updates can be shared throughout the course of treatment, ensuring consistent coordination and teamwork."
Ferris notes that the advancements in software over the past decade have been transformative. "Today, some platforms are beginning to integrate capabilities for orthodontists, surgeons, and restorative dentists, enabling us to coordinate and plan complex interdisciplinary cases more effectively," he says. "However, there's still a way to go in creating a single platform that all specialists prefer."
Advancing the Standard of Care
Combining orthodontic and implant treatment opens up a world of opportunities to enhance both functional and esthetic outcomes. Although this interdisciplinary approach results in improved occlusion and more idealized implant-supported restorations with less complications and a greater chance of long-term success, careful collaboration between restorative dentists, orthodontists, and implant specialists is necessary to properly sequence treatment plans and coordinate their execution.
Rapid technological advancements in digital imaging and treatment planning tools have opened new pathways for improved collaboration between the specialties within dentistry; however, in the future, further integration of and advancements in artificial intelligence (AI) may offer exciting opportunities to establish extremely individualized and accurate treatment plans. "Looking ahead, advancements in bioengineering, such as scaffold-based tissue regeneration, and AI-driven planning tools promise to further elevate the success and feasibility of combined treatments," predicts Berant.
The potential to deliver seamless, coordinated care has never been greater. Dental professionals are encouraged to embrace collaborative care models and leverage the strengths of combined orthodontic and implant treatment to better serve their patients who require tooth replacement. Through a commitment to such innovative collaborative approaches, the profession can continue to elevate the standard of care and improve outcomes for patients.
References
1. American Academy of Pediatric Dentistry. Management of the developing dentition and occlusion in pediatric dentistry. The Reference Manual of Pediatric Dentistry. Chicago, Ill.: American Academy of Pediatric Dentistry; 2024:475-493.
2. Huang G, Yang M, Qali M, et al. Clinical considerations in orthodontically forced eruption for restorative purposes. J Clin Med. 2021;10(24):5950.
3. Mandelaris GA, Huang I, Relle R, et al. Surgically facilitated orthodontic therapy (SFOT): diagnosis and indications in interdisciplinary dentofacial therapy involving tooth movement. Clin Adv Periodontics. 2020;10(4):204-212.
4. Rose T, Jivraj S, Chee W. The role of orthodontics in implant dentistry. Br Dent J. 2006;201(12):753-764.
5. Huang L, Shotwell JL, Wang H-L. Dental implants for orthodontic anchorage. Am J Orthod Dentofacial Orthop. 2005;127(6):713-722.
6. Melsen B, Lang NP. Biological reactions of alveolar bone to orthodontic loading of oral implants. Clin Oral Implants Res. 2001;12(2):144-152.
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