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Difficult Case Types, Part 1: A Discussion of Adult Short-Term Orthodontics

Difficult Case Types, Part 1: A Discussion of Adult Short-Term Orthodontics

Six Month Braces for adults.

Originally posted on Dentistry Today.

INTRODUCTION
Short-term orthodontics (STO) has exploded in popularity during the past 10 years. Adults are discovering that they are able to straighten their anterior teeth cosmetically without undergoing 2 years of bite-changing orthodontics, and are enthusiastically seeking out this treatment.
Since I first wrote about “Adult 6-Month Orthodontics” in 1999 for Dentistry Today,1 Ryan Swain (Six Month Smiles) and other general dentists and some orthodontists, have been teaching STO in the United States, Europe, and Australia to enthusiastic audiences. There is good reason for this—orthodontists have not supported a strong case for routinely prescribing 2-year orthodontics with a Class I molar occlusion as its focus. Moreover, the evidence in the literature for the benefits of moving molars already in functional occlusion (except, for example, correction of a posterior edge-edge bite causing attrition) is underwhelming.
Adults do not generally seek orthodontic treatment and wear braces mainly for their molars, and 2-year treatment for profile change is not generally possible nonsurgically in the adult patient. When it is done, profile changes are difficult to retain. Although visits must be longer for STO and retention protocol more stringent, it is a great new service that is bringing many back to dentistry. As Dr. Gordon Christensen stated, “I feel certain that may more people would have orthodontic therapy if it could be simplified and made more acceptable to them as adults….I congratulate you for your innovative and thoughtful approach to the subject” (Dr. Gordon Christensen, personal correspondence in writing, January 4, 2000 and January 29, 2004). A general practice performing this treatment will experience a boon to its periodontic, endodontic, and restorative services, in addition to its bleaching and veneer offerings, as a healthy mouth precedes the healthy smile in treatment planning. This is truly a valuable service to the public.

Orthodontist Jack Sheridan2 pioneered interproximal reduction in the 1970s and promoted chief complaint orthodontics for years. His criteria was: (a) the occlusion is functional and the patient eats comfortably; (b) the patient’s chief complaint is crowded anterior teeth; (c) the crowding can be resolved without expansion and usually air-rotor stripping; (d) treatment time should be minimal, preferably about 6 months; (e) patients understand nighttime retainer wear may be permanent; and (f) patients understand that treatment is aesthetic only in nature (Dr. Jack Sheridan, personal correspondence in writing, June 5, 1997).

The cosmetic dentistry revolution has brought STO to the forefront, and it has become a field all its own. A wide array of problems can be dealt with in a different way when the focus is cosmetic. “Camouflage treatment” can be performed on Class III skeletal patients who decline orthognathic surgery by tipping mandibular incisors into a Class I incisor relation. Slight tipping of maxillary molars can be done in lieu of palatal surgery for the posterior edge to edge bite. Anterior crossbites can be corrected through lower incisor extractions if the patient’s profile is acceptable. As with many difficult cases, there often exist various solutions. With any new treatment approach, though, there also exist certain caveats, areas to watch out for, and pitfalls to avoid.

This article will be a review some of the most difficult cases I have seen during the past 20 years of performing STO on a wide variety of case types. Although there are traditional orthodontists and general dentists who would see this as an opportunity to categorically criticize STO, it is my hope instead that they seek to better understand the treatment, and to realize that it has a place in an array of cosmetic treatment options. Someday, they too may want to consider offering accelerated orthodontic treatment in adult cases that are strictly cosmetic, as it can be a superior and less invasive service than crowning or veneering crowded teeth. It should also be noted that many of the difficulties in the cases presented might have occurred with a longer treatment period.

 

CASE TYPE I: BRUXERS
Severe bruxers who do not wear their nightguard often experience relapse after orthodontics. The patient in Figure 1 underwent STO for anterior space closure and achieved a nice aesthetic and occlusal result. However, retention for bruxers hinges on strict adherence to retainer wear as well as diligent nightguard use. As new abfractions are evident in the recall photo, he did not comply.

Throughout a period of 14 years post-treatment, the patient’s vertical dimension of occlusion (VDO) decreased. Two crowns were done to cover fluorosis. Although the protrusion and diastema did not significantly relapse, the deep bite returned (Figure 2). Though this may also occur in 2-year orthodontic cases, I more thoroughly emphasize strict adherence to nightguard use indefinitely in these cases. I inform bruxers that orthodontics is of minimal or no benefit if they are not prepared for a lifelong commitment to retention. Despite some relapse, he is still a satisfied patient in our practice 14 years later and fully understands the responsibility of retention lies with him through wearing his nightguard-Hawley combination at night.

Figure 1. Preoperative: Before with diastema and deep bite from bruxing. Figure 2. Postoperative: The 14-year recall after 6-month short-term orthodontics (STO). The patient did not wear his nightguard.
Figure 3. Preoperative: Clencher before STO. Figure 4. Postoperative: Clencher, splinted.

Similar to case 1, this patient was splinted and still experienced some relapse of her VDO at recall because of bruxism and limited nightguard wear. However, her alignment was maintained (Figures 3 and 4).

Figure 5 shows another patient who is a severe bruxer with flat plane occlusion. He experienced buccal migration of his upper first bicuspids post completion due to no nightguard wear. This occurred before postorthodontic settling took place, and articulating paper showed these bicuspids more heavily in occlusion than his molars. When he bruxed laterally, the buccal bone (which had not yet solidified) did not resist buccal tipping from the lateral forces on these teeth during parafunction.
Rarely is every tooth in complete occlusion postorthodontics, even with comprehensive treatment. Bruxers and clenchers usually experience more rapid post-treatment settling with more complete interdigitation than nonbruxers. But when the patient is a severe bruxer, selective migration may occur, especially if this is a flat plane occlusion with no cusps. This patient was rebracketed for 2 months before having a complete occlusion equilibration at the day of debracketing. Nightguard wear was strictly emphasized and the final result was stable.

 

CASE TYPE II: OBSESSIVE COMPULSIVE DISORDER TYPE COSMETIC PATIENTS
Another case type to watch for is the cosmetic patient who wants to dictate the treatment plan. While it is tempting to want to “please” a cosmetic patient, as it is an elective procedure after all, forging into a new area or performing a procedure with which you have less experience means less predictability in the final result. Doing this on patients who have exacting personalities and have a specific end result in mind further increases the risks involved. As with the bruxer category, patients like this can be red flags in cosmetic dentistry. These patients often start out with enthusiasm and seem to grasp the nuances of cosmetic dentistry, understanding the details of smile design. We may feel on the same page as these individuals who share our love for cosmetic excellence, and this makes dentistry fun. But when enthusiasm morphs into unrealistic expectations of perfection, and the patient cannot fully understand that there are limitations, difficulties may arise. Do we always know exactly what end result can and cannot be achieved? Are computer simulations really honest predictors of the end result, and should we depend on them to be accurate in every case? In a perfect world, we could predict all contingencies as well as the final result. But unless one has done every possible case type on every possible personality type with the various biologic limitations, there is no way anyone can predict the myriad of possibilities which may arise in every cosmetic case.

 

Case 1
This first case involves a simple level and alignment type orthodontic case with a slight open bite (Figure 6). Toward the end of treatment, though, the patient decided she also wanted anterior bonding to change her basic tooth shape from round to square. She brought in close-up photos of a famous American supermodel, and wanted her teeth to resemble this model’s smile. These teeth are square, slightly flared forward, and appear wider at the incisal than at the height of contour, usually the widest part of the tooth. When the patient presented for treatment, there was no indication her preferences were so specific. At this point in treatment, we are “married” to our patient, and separation is unfulfilling for both patient and dentist. After treatment, retention and incisal bonding were combined with a composite-Ribbond splint (Figure 7).3

Figure 5. Preoperative: Bruxer with flat plane
occlusion.
Figure 6. Preoperative: STO with open bite.
Figure 7. Postoperative (after STO): Patient requested long square teeth like a famous supermodel she admired. Figure 8. Preoperative (before STO): Patient recently completed Invisalign treatment in another office.
Figure 9. Postoperative to short-term lingual orthodontics with custom requests. Patient wanted his centrals to be longer and a bit more protrusive and brought in a photograph of a famous actor’s teeth to copy. Figure 10. Preoperative: before STO.

The splint helps to support more durable lengthening of the incisal edges, often done with porcelain veneers. While the orthodontics went smoothly, the final step of aesthetic bonding and recontouring was tedious and difficult.

Case 2
This patient had not long before completed Invisalign treatment elsewhere with acceptable results, but had very specific requests and a particular mental picture of how he wanted his teeth aligned and shaped. I was hesitant to take the case, as his alignment was already fairly good (Figure 8). A chief complaint list was made at the initial consult and twice reviewed with the patient. He chose lingual braces, the most difficult to control. He was advised that we may need to do some finishing with labial brackets in the final weeks. During treatment, his requests grew even more specific and he brought numerous hand-drawn sketches and a picture of a famous American actor’s smile to copy. More frequent visits were required, but the teeth were aligned in 4 months to his specifications, like this actor’s smile, with the upper centrals slightly protruding and longer (Figure 9). The patient completed treatment very happy with the result, but it is still risky to accept this case type knowing the patient has such a specific result in mind.

Case 3
This patient had become addicted to cosmetic surgery at a young age. At the consult, he expressed his dissatisfaction with his plastic surgeon despite what seemed were good results. Because his occlusion, crowding, and tooth morphology were so unaesthetic, it seemed that significant aesthetic improvement would not be difficult (Figure 10). However, the patient had numerous specific demands, including exact measurements for the lateral incisor veneers done after Figure 11. The final results were excellent but, again, the process difficult due to specific requests.

Figure 11. After STO, but before porcelain veneers on teeth Nos. 7 and 10. Figure 12. The patient had central incisors extracted at a young age, before conventional 2-year orthodontics.
Figure 13. After distalizing lateral incisors. Figure 14. After retreatment with laterals brought back to mesial and 4 splinted crowns.

 

CASE TYPE III: PATIENT ALTERS TREATMENT PLAN
To what extent do we try to please the patient? Figure 12 shows a patient who had orthodontics at age 13 years. Due to protrusive maxillary central incisors, the orthodontist decided to extract them and move laterals into the centrals’ position. With relapse, the spacing and recession is highly conspicuous. A simple treatment plan was given to consolidate the space through space closure and to provide 4 splinted crowns. When treatment began, however, the patient decided he wanted to re-establish the space for the missing central incisors to have a natural complement of teeth. As this was a patient in his 40s, the bone was not malleable. When space was established and a temporary bridge placed (Figure 13), there was slight overjet. Although I have before left overjet to provide space for a maxillary lingual splint without patient objection, this particular patient was not comfortable with his new incisor position forward. He felt that his maxillary incisal edges were noticeable, at times touching on his lower lip, although there was no deep bite. I referred him to a board-certified prosthodontist who felt there was nothing wrong with the bridge and that he could not improve significantly on the result. After a hiatus, the decision was made to retreat the case (at no change) and follow the original plan; consolidate the incisor space, and place splinted crowns. The end result satisfied the patient, and was more aesthetic, but the circuitous route there was difficult and spanned 4.5 years (Figure 14).

Bruxers, patients with obsessive compulsive disorder, and patients who alter their treatment plan represent challenging cases even when one is prepared for them and has treated similar cases previously. This is because no 2 orthodontic cases are ever identical when one considers the complete aesthetic, biologic, and interpersonal picture. We can only diligently try to consider all contingencies.

 

CLOSING COMMENTS
Treating such a variety of cases makes aesthetic orthodontics fascinating. Specialty orthodontic training often has a different focus which does not always encompass the adjunctive cosmetic dimension and adult psychological aspect central to success in some of these adult cosmetic cases. Furthermore, patients do not always afford us the 2 years of treatment time often needed to cross-refer across specialties and follow the traditional channels from decades past. As we listen more to our patients, the future of adult orthodontics is finally evolving, becoming a distinct area and more integrated with cosmetic dentistry.

In part 2 of this article, I will discuss transfer cases, improper use of enamel reproximation, cases with special retention needs, temporomandibular disorder sequelae, large tongues, problem profiles, and multidisciplinary cases that have unique challenges which fall out of the norm of traditional orthodontic cases.


References

  1. Georgaklis CC. Six-month adult aesthetic orthodontic treatment. Dent Today. 1999;18:110-113.
  2. Sheridan JJ, Ledoux PM. Air-rotor stripping and proximal sealants. An SEM evaluation. J Clin Orthod. 1989;23:790-794.
  3. Georgaklis CC. Anterior retention with a reinforced composite resin splint after cosmetic orthodontic treatment.
  4. ‘;. 2002;21:54-57.
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Redefining Adult Cosmetic Orthodontics

Redefining Adult Cosmetic Orthodontics

Six Month Rapid Braces treatment.

Originally posted on Symbiosis.

In the early 1900’s, Edward Angle was a pioneer that lead orthodontics into becoming its own speciality. He founded the first school of orthodontics, the American Society of Orthodontia in 1901, and the first orthodontic journal in 1907. As the “father of modern orthodontia”, he heavily influenced treatment towards establishment of an Angle Class I occlusion, classifying malocclusions as Class I, II, and III based on molar occlusion. Yet the meaningfulness of this classification system is often brought into question [1]. There is less disparity among orthodontists when classifying occlusions according to incisal classifications of overjet and overbite, as many do in Britain [2]. There has yet to be definitive evidence in the literature to support lengthening treatment to establish a Class I molar occlusion if it is otherwise functional.

When the popularity of orthodontic treatment surged in the 1950’s, esthetic dentistry had not yet come into its own. America’s dental awareness and cosmetic expectations were low. With the advent of acid etching, cosmetic bonding, and later porcelain veneers, the practice of cosmetic dentistry progressed. Slowly more adults began to undergo orthodontic treatment also. They usually wanted straight teeth and a pretty smile. Over time, orthodontists began to notice that the general public wanted straight teeth and was less concerned with the type of occlusion and cephalometric measurements than they were [3], as long as they functioned without attrition, open bite, periodontal loss, or other health related issues.

Bonding brackets instead of banding made it possible to judiciously make space locally through the interproximal reduction of enamel surfaces, popularized by Dr Jack Sheridan [4]. It has taken decades for enamel reproximation to become more accepted, and now it is widely used over the all or none measure of bicuspid extraction, which requires closing a greater amount of space made far from the crowded incisors. Single lower incisor extraction also came into use in the 1970’s [5] and 1980’s.

Let’s Try Something Different

After learning about these two simple less invasive ways of making space, I was instantly hooked. Brainwashed by long term treatment dogma in dental school, I was convinced I was doing something wrong, or just missing something. The potential to shorten treatment was readily apparent as I began my first cases in general private practice in 1991. As the teeth straightened quickly by creating space locally, as well as through nickel titanium wire use, patients were asking why the braces needed to be on longer. As they generally had begun with well functioning occlusions, I had no answer. My orthodontic treatment times were reduced with limited occlusal change (treating crossbites, anterior deep bites, and overjet reduction) to 6 months or less when I wasn’t extracting bicuspids- which was done rarely. Through the use of fixed anterior composite bite planes behind the incisors, deep bites corrected quickly through passive supraeruption of molars, and some intrusion of the incisors. I started treating a wide variety of cases and occlusions in an ethnically diverse city. I found that resolving incisal Class III occlusions and posterior cross-bites usually could also be treated in a short time frame. Although not all of my patients have finished with a Class I molar occlusion over the last 24 years, they function well over time at recalls, just like molar Class I cases. Bruxers experienced attrition with whatever type of occlusal guidance or molar occlusion they had. It was obvious they needed a nightguard, rather than choosing which teeth they would wear down and have abfractions on. I could not discern any differences in stability or attrition at recalls between patients finished with a molar Class I, II, or III. “Less than 15% of the population develops a normal occlusion defined by Angle in the permanent dentition. The term ‘ideal’ may therefore be a more appropriate description, and deviations from this esthetic and functional optimum should not be considered abnormalities in the true sense of the word. Current research indicates that few malocclusions compromise dental, periodontal or temporomandibular health” [6].

Treatment of TMD is another controversial area in which we have used long term bite changing orthodontics. Many claim TMD improvement and the cessation of bruxism during their orthodontic treatment as proof of successful occlusal rehabilitation, and therefore predictive of long term joint health. Given the sparseness of research supporting this, the more likely reason for improvement is teeth are too sore to be clenching during active treatment. Though I never promise TMD resolution in performing orthodontics, I have had remarkable long term success in TMD cases through avoiding retrusive incisor contact. Establishing liberal overjet avoids retrusive anterior contact and disc impingement, even if there is relapse or non-compliance with retention. After numerous studies, comprehensive 2 year orthodontic treatment has not been proven to improve TMD [7].

Those who claim long-term successful resolving TMD through orthodontic treatment would do well to put forth more definitive research supporting it.

So from 1991 – 1999 in my general practice, with a cosmetically focused treatment approach I discovered that the majority of adult cosmetic orthodontic cases could be aligned in 6 months time or less having treated hundreds of cases, and decided to write about it (Georgaklis, 1999). Many of these cases had significant crowding and were finished with a highly cosmetic result that excited the patients and myself.

An example of the typical case we see for adult accelerated orthodontics (AAO) with upper and lower splinting canine to canine for reliable retention. We recommend the splints stay on for a minimum of 5 years before sequential removal.

Many principles of smile design are incorporated into adult accelerated treatment (AAO) beyond alignment such as decreasing gingival display and addressing tooth proportions, shape, and color.

These cases are also stable by avoiding posterior lateral expansion, maintaining arch circumference and functional posterior occlusion. There are very few tooth movements (of erupted anterior teeth) that take greater than 6 months to align if space can be made without bicuspid extraction. I used to think that shorter treatment times would bring more root resorption, based on the assumption that greater force was used. But greater force is not what makes shorter treatment time possible, but that space is made locally near the crowding. There is less tooth movement, less bone remodeling, less inflammation, and less time for the roots to resorb, if the individual is prone to this distinctive hyper inflammatory response. It is longer treatment times using extractions that has been repeatedly and conclusively proven to be the cause of significant root resorption [8].

The Age of Accelerated Adult Orthodontics (AAO)

After practicing AAO for 24 years, I believe that avoiding difficult and lengthy adult molar translational movements that are nearly impossible to retain (in an attempt to obtain a molar Class I) is truly beneficial for the patient. “Minimally invasive cosmetic dentistry” as Maini [9] describes adult aesthetic orthodontics, can be an effective tool for adults with a cosmetic chief complaint. As many practitioners of AAO know, the three most important reasons for treatment are “aesthetics, aesthetics, and aesthetics” [10]. Perhaps the acronym should include ADULT ACCELERATED AESTHETIC ORTHODONTICS and be AAAO. So far everyone has their label. But everyone knows treatment is accelerated for aesthetic reasons, so the word “aesthetic” is redundant. Many patients are coming back to the dentist for this service who has been avoiding us. 2/3 of them in my practice have frank caries and other restorative and periodontal issues. AAO is a more appropriate and conservative treatment than some the most well intentioned restorative dentistry replacing enamel and dentin with porcelain or composite in “restoring smile harmony” [11].

Although AAO is not yet standardized, the simplified approach is growing [12]. The foundational thinking is listening to the patients chief complaint and treating it, suggesting (but not deciding for them) what they must endure to get the smile they came for. Suggesting excessive overjet reduction when it exists is necessary, changing molar occlusion can be very helpful (especially with crossbites), but insisting on both across the board can legitimately be considered overtreatment that I would not want for myself or my children. As Mohlin [13] said on malocclusions and aesthetic treatment, “The mere presence of deviations from the concept of the ideal occlusion should have no influence on orthodontic treatment decisions. According to studies, the influence of malocclusion on periodontal health, speech and chewing is fairly minor. Neither can orthodontic treatment be justified as an effective means of preventing TMD but it may be indicated to reduce the existing signs and symptoms of TMD in certain carefully selected cases. Interceptive or preventive orthodontic treatment may be indicated to reduce the negative influence on growth and occlusal development of functional malocclusions (anterior or lateral forced bite) or ectopic tooth eruption. Similarly, early correction of large overjet may be valuable in order to reduce the risk of traumatic injuries. Such treatment is usually motivated during the primary or mixed dentition periods. From the teenage period onwards, psychosocial or aesthetic reasons for orthodontic treatment are dominating. Decisions to start orthodontic treatment in order to improve aesthetics should usually not be taken before the child has reached sufficient maturity for these decisions, normally after the age of 12 years.” This well summarizes my treatment approach on AAO, pediatric treatment, and TMD orthodontics.

Since the arrival of Invisalign, which was specifically formulated for anterior alignment in the adult cosmetic patient about 15 years ago, the limited treatment concept does not seem so controversial. Perhaps this is because the method of delivery is less invasive with removable appliances. But when I began marketing cosmetic orthodontics in 1991-1992, it was considered radical. With AAO, straight teeth are just a starting point though. There are various other modalities that are incorporated into treatment that haven’t yet been because of the narrow occlusal focus of the past. Teeth can be straight but appear unaesthetic.

Treatment in the above case shows lack of attention to anterior tooth morphology, incisal congruence, stepping, and proportion, gingival display and height, and color- despite proper alignment and open bite closure. The final result also ignores the gingival and anatomical accommodations needed on the right side for canine substitution.
So what is different about AAO?

Accelerated treatment time and lingual orthodontics: We know that long treatment time is one of the greatest barriers to orthodontic treatment. Though thermally activated, nickeltitanium wire use, limited occlusal change, enamel reproximation, lower incisor extraction, and to some extent lingual orthodontics, you would have to live under a rock not to realize that adult orthodontics has undergone a rebirth [14]. Any arch expansion treatment past the age of alveolar growth (usually 12-14 years old) will be more prone to relapse [15], so we avoid expansion and bicuspid extraction when possible. In cases with significant crowding or spacing I suggest canine to canine splinting. Posterior cross bite correction in adults requires permanent removable retainer wear at night. While it is far more difficult to control tooth movements with lingual orthodontics, it is another option that eliminates objections to treatment. It is far easier to perform lingual orthodontics when focusing on the anteriors and the occlusion is maintained.

Fine tuning proportion: In my office, interproximal reduction is performed with Brasseler diamond discs of .15mm thickness, so very little enamel is removed, even if the same contact is disked on multiple visits. After measuring the mesialdistal dimensions of disked anterior teeth on castes before and after treatment in multiple cases, I could not detect the difference because it was so small. When making space on multiple visits, wide teeth are disked to maintain symmetry. Incisal edges can also be adjusted to maintain proportion.

This excellent orthodontic result could have been made better through enamelplasty.

We re-establish proportionate interproximal and incisal embrasures so teeth maintain their shape.

Teeth are “shrunken” in every dimension, not just interproximally. No one should be able to detect where enamel was removed.
The positioning of facial line angles also changes perceived width as shown on the left. Using high magnification we can modify facial-interproximal line angles to change the apparent widths of facial surfaces so they relate to other teeth in the Golden Proportion shown above right.

Although both smiles show the Golden Proportion in widths relative to other teeth in the arch, the length to width ratio on the right simulation is more appealing. Shortening anterior teeth on the left dentition would provide better proportion.

Narrow teeth such as peg lateral incisors are bonded before space closure. I reshape incisal edges noting proper offsets, and facial surfaces to change apparent root angulations. I bond or bleach uneven, chipped, fluorosed, decalcified, or dark teeth, and establish proper gingival display of 0-2mm [16] through gingival surgery. If the deficient dimension of the tooth is on the incisal due to attrition, bonding or porcelain is added. While thin incisal composites normally fracture, the thickness is greater when supported by a lingual splint and remarkably durable.

We can deliver a white, wide, full arch smile that is retained where necessary through splinting, in a timely manner in the vast majority of cases. Thoughtful delivery of finishing procedures according to each patient delivers the ideal result.

Tooth morphology should be custom. Unless the patient specifies otherwise, I prefer the rounded incisor appearance.
While orthodontics leveled the plane of occlusion, corrected the cross bite, and positioned roots, porcelain was needed to address the peg lateral on the right, canine substitution on the left, and replacement of both mobile primary canines which were extracted.
Acid erosion diminished incisor widths and congruence, especially in the incisal third. After orthodontics a composite splint retained the result and added proportion, without extensive removal of enamel for crowns. Thin sections of composite match well and can be hard to detect.

This involved case demonstrates the manipulation of line angles, incisal edges, and gingival contour essential when performing canine substitution for missing upper lateral incisors. After the impacted upper right canine was extruded, both canines were reshaped, bonded, and made into a lateral incisor. Deep bite correction was achieved through a fixed flat composite bite plane lingual to 8 and 9. Moving the canine facial-interproximal line angle to the center of the tooth narrows the facial aspect, turning each canine into a lateral. Shortening the point, flattening the face, and adding incisal corners hides the cylindrical qualities of the canine. Bicuspids were flattened facially on the incisal third to resemble canines- anatomical hybrids of incisors and bicuspids.

Soft tissue aesthetics and congruence: Gingival contour and position can often be manipulated because many cases in the younger population undergoing AAO and cosmetic dentistry require removal of gingiva to establish congruence more than addition. Most patients with high smile lines do not have concurrent recession problems due to the thick bone and gingiva, as shown below.

This case was treated through intrusion of the maxillary incisors in conjunction with successive gingivectomies. A periodontal pocket was re-established to maintain biologic width and minimize regrowth of gingiva post treatment. Photo on right was after emax crown cementation on #8 with the lingual splint bonded directly to the tooth.

If the gingival level after surgery does not allow for biologic width defined as the space between alveolar bone attachment and the free gingiva margin, the gingiva will regrow to re-establish a protective zone for the bone. After performing a gingivectomy I use a narrow fluted burr to make a shallow pocket of 1-2 mm severing the crested periodontal attachment (an “augmented gingivectomy”) to prevent regrowth of the gingiva back to its previous level. This limits regrowth of gingival.

After AAO, and 2 days after augmented gingivectomy.

As moving teeth together for space closure can constrict, enlarge, and lengthen the papillae, deficient papillae can be made to fill black triangular spaces. Overgrown swollen papillae should be trimmed as they collect more plaque and are unaesthetic. Triangular shaped teeth can have recession of the papillae because the contact point is more incisal and the bone crest is more apical which results in a flatter papilla [17]. A flatter contact after reproximation usually elongates the papilla so that it is “pinched”, and often able to fill the black triangular space though. This commonly occurs in space closure. Many times I treat black triangular spaces in this way, saving the patient an involved periodontal surgical procedure.

Brandao [18], an orthodontist in one of the most esthetically conscious countries in the world (Brazil) well described finishing procedures in orthodontics; “Treatment quality is directly related to the amount of procedures implemented by the orthodontist, associated with concepts and resources from Periodontics and Dental Prosthesis. Microesthetics cannot be seen in isolation, but rather as the key to establish a pleasant smile (miniesthetics) in addition to a harmonious face (macroesthetics) and a human being with high self esteem (hyper-esthetics).” Occlusion is no longer the sole focus of orthodontics, and that the “attainment of perfect occlusal results does not ensure stability” [19]. Many know that the “ideal posterior occlusion concepts as a general orthodontic treatment goal should be reconsidered” [20]. Patients can tell their type of incisor occlusion, but it does not correlate with molar occlusion. Posterior occlusion is difficult to maintain, and even mandibular incisor relapse has been termed “inevitable” [21]. Any tooth movement when done past the stage of growth and alveolar arch adaptation is more likely to relapse [15], especially expansion of the intercanine width [22].

Fortunately anterior teeth that have been moved can be splinted. Expecting the majority of the adult population to reliably wear removable retainers permanently (as textbooks say) is unrealistic. For any significant anterior tooth movement, upper or lower, I strongly suggest a bonded splint. Anterior fixed retention prevents the “inevitable” incisor rotations while still allowing posterior settling [23]. Once teeth are straight patients focus on other dental imperfections, so identifying aesthetic restorative and periodontal treatments should be part of the plan.

Conclusion

The patient should understand the full scope of the problem and treatment plan at the initial consult to avoid disappointment by undergoing orthodontics alone. Few orthodontic practitioners address comprehensive dental esthetics because of the different skill sets involved. Ultimately we seek to deliver straight, white teeth, with symmetry, proportion, lip support, minimal gingival display, attractive facial embrasures, and a durable result, in an efficient treatment time, that the patient is happy with years later. It is thrilling to hear a patient say it was the best thing they ever did for themselves.

A brilliant smile is a puzzle integrating various small parts. Cosmetic dentistry is long past focusing only on whitening (although some endodontically treated dark incisor roots can still be hard to opaque from light refraction coronally). Putting the pieces together for a spectacular lasting result is within our grasp for the majority of cases, thanks to the evolution of materials, techniques, experience, and creative thinking.

See references here.

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Best Boston Cosmetic Orthodontics

boston cosmetic orthodontics

Getting your teeth aligned for a beautiful smile is something that many people aren’t able to do when they were a teenager. Traditionally, teens are the ones who get braces for straight teeth. Adults who wanted the confidence that comes along with a perfect smile felt like they missed there chance. Now, however, there are a number of cosmetic orthodontic options available designed just for adults. Rapid Braces offers a number of different adult orthodontic treatments so everyone can get the smile of their dreams.

Braces for Adults

Rapid Braces understands the feeling of embarrassment that can come with wearing braces as an adult. Many people can’t even imagine going out in public while wearing traditional metal braces so they don’t get braces at all. The cosmetic orthodontics options at Rapid Braces are designed to be discreet, comfortable and fast so they won’t be too disruptive. Rapid Braces adult orthodontic treatment can be completed in less than 6 months so you can get back to what matters most.

There are a few different types of adult braces available at Rapid Braces. Lingual, or incognito braces are a popular choice for many adults. Lingual braces are placed behind the teeth so they can’t be easily seen but still offer excellent control of teeth alignment. Clear braces work similarly to traditional braces but the brackets and bands are clear so they will be tough to notice. Keeping cosmetic orthodontic treatment hidden is important to many patients and a focus of the Rapid Braces practice.

All of the cosmetic orthodontic treatment plans at Rapid Braces start with an initial consultation. At this meeting you can let us know what you’re looking for and any concerns you may have. Dr. G and the expert staff at Rapid Braces can complete an examination of your mouth to see exactly how your teeth are aligned. After getting a good look at your mouth we can then suggest what the best treatment options would be. Each option will have benefits that we will go over with you so you can make the best possible choice to get straight teeth fast.

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Bite Alignment with Rapid Braces

6 month braces result

Bite Alignment with Rapid Braces

Are you one of the millions of Americans with a crooked smile? At Rapid Braces in Brookline, MA we offer state-of-the-art adult braces, Invisalign and orthodontic treatment to address bite alignment. Dr. Clifton Georgaklis is the inventor of the 6 month Rapid Braces program.

Our custom approach to adult braces is able to correct most cases of bite misalignment. Whether you have an overbite, underbite, or scissor bite, it can greatly effect the shape of one’s speech, lips and mouth. In our clinic we offer the best in digital imaging services to address bite alignment. Our visualization process and allow patients to see their treatment plan in 3D. With this information, our dental specialists are able to assess the best method for the Rapid Braces program.

How a Bite Misalignment can harm dental health

If the overbite, underbite, or scissor bite is not corrected it will compromise the enamel of teeth. This can lead to speech issues and increase wear on the edges of teeth. In the case of an overjet- which is the distance between the top and bottom incisors, bite correction can be achieved through a combination of adult orthodontic options. In the case of open bite, the front teeth are pushed outward and do not connect.

In addition to 6 month braces, we also offer a range of adult orthodontic options including lingual braces, behind the teeth braces, clear braces and Invisalign. The future of dentistry is now, what once took years of consistent adjustments to fix bite alignment now takes less then 6 months.

The braces we had as kids have come a long way. Adults can choose braces that have evolved to offer sophisticated modern orthodontics.  Cleveland Circle Dental Associates offers a range of subtle and invisible solutions to bite misalignment. Techniques such as Invisalign, clear braces, and behind the teeth braces can address even the most severe cases. With Rapid Braces’ 6 month braces treatment option we are able to complete over 90% of our orthodontic cases in 6 months or less. Our patients are able to fit our Boston area orthodontic treatment to obtain bite alignment into their tight schedules because of the shorter treatment periods.

Dr. G and his team are ready to help you feel great about your smile. Contact us today to schedule a consultation and to find a solution within your budget.

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Straight Teeth Fast with Adult Braces

Many adults wish they had a better smile. Having overcrowded teeth or big gaps in between your teeth can cause individuals to shy away from social situations. A better smile would eliminate these fears and allow an adult to feel confident in any social setting. Getting straight teeth has traditionally been something for teenagers and not adults. Today, however, Rapid Braces in Brookline offers a number of braces alternatives for adults that will improve your smile in 6 months or less.

Adults who didn’t get braces when they were a teenager often have a number of questions about adult orthodontic treatment. The most important is whether our patients even need braces in the first place. The following are three common signs that you need braces, regardless of how old you are.

adult braces alternatives

Food gets stuck between your teeth.

Food getting stuck means that there are some sizable gaps between your teeth. If you don’t regularly floss this food can stay in your mouth for weeks, presenting an opportunity for plaque to build up and cavities. Close any gaps between your teeth with the expert Boston orthodontic treatment available at Rapid Braces.

Your teeth are overcrowded.

If your teeth are too close together it can be impossible, even for a professional hygienist, to ensure that your mouth is completely clean. Get overcrowded teeth room to breath with a braces alternative for adults at Rapid Braces.

Your bite is uncomfortable.

Having a bite that doesn’t fit together properly can lead to discomfort. Eating and chewing can be a problem if your bite doesn’t line up. Get rid of any discomfort with Boston’s number 1 orthodontist at Rapid Braces.

Schedule an appointment at Rapid Braces today if any of the conditions listed above apply to you. Dr. G has years of experience giving adults straight teeth with the best alternative braces options. Rapid Braces offers invisible braces, braces behind the teeth, clear braces and invisalign so our patients can get a perfect smile without having to let the world know they’re wearing braces. Rapid Braces gives its patients the most personal orthodontic service in the Boston area. Call us today to learn more about how you can get a better smile in 6 months or less.

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Straight Teeth with Boston Braces for Adults

Rapid Braces has been offering fast orthodontic treatment to patients in the Greater Boston area for over 20 years. Dr. G invented the 6 month braces treatment option and has been able to finish more than 90% of the orthodontic cases he takes on in 6 months or less. A number of different Boston braces options are available at the Rapid Braces office in Brookline. Behind the teeth braces, clear braces and Invisalign are all available so adults can find the braces that work best for them.

fast adult braces

Often the thought of getting braces put on scares many adults away from starting orthodontic treatment. A potential patient may have dreamed about getting a perfect smile for their entire lives but undergoing orthodontic treatment that can last up to 3 years is not normally a possibility. Dr. G developed the 6 month braces treatment option after seeing many adults decide not to start treatment because of the lengthy treatment times. With the 6 month braces technique, Dr. G and his expert staff focus on the end result of the treatment to get you the results that you want fast. Now more adults than ever are getting the smile of their dreams with Rapids Braces’ 6 month braces technique.

So many adults are choosing Rapid Braces for an improved smile because of the personalized service that we offer. We understand that patients have busy schedules and ensuring that our treatment plans won’t interrupt any other obligations is a top priority. The modern adult braces alternatives that we offer are the most comfortable braces options yet. Many of the types of braces available at Rapid Braces are also very easy to keep hidden from others so patients concerned about how their mouth will look with braces don’t need to worry. Behind the teeth braces are placed on the inside of a patient’s mouth so they won’t be visible to anyone on the outside. Clear braces and Invisalign both utilize a clear plastic material that is practically invisible.

Schedule an initial consultation at Rapid Braces to get started with our 6 month braces adult orthodontic treatment. At the first meeting, Dr. G will personally meet with you so he can get a good look at how your teeth are aligned and get to know you. Rapid Braces schedules fewer daily appointments so we are able to give our patients the most individualized adult orthodontic treatment in the Boston area. Come visit to get straight teeth fast.

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Show Off Your Smile with 6 Month Braces

One of the first things that people notice when you first meet them is your smile. Being confident to show your smile off is important and can have a number of benefits. Smiling has been proven to have a positive impact on the people around you and can play a bigger part in success than you might think. Having straight teeth can impact one’s ability to get a job and comfort level in social situations. Boston braces are available to patients at any age at Rapid Braces, so everyone can get a perfect smile fast.

6 month braces

Crooked teeth can be straightened out at any age for a better smile. A number of new methods for getting straight teeth have been developed recently so more and more adults are getting braces. Rapid Braces offers a few of these braces alternatives that we have found to be the most successful. Lingual braces, clear braces, and Invisalign are all available for our patients and have helped us get fantastic results fast. These alternate braces options are all much more comfortable than traditional metal braces and easier to keep hidden. Adults won’t have to worry keeping braces that are almost impossible to see in the first place hidden.

Closing the gaps between your teeth can help you avoid more serious issues in the future. Misaligned teeth are much more likely to have plaque and food buildup between your teeth. The food buildup will lead to tooth decay and can also be a precursor to more serious issues such as gum disease. Patients who get perfect smiles at Rapid Braces will be able to easily keep their mouths clean.

The number one reason that so many adults are getting braces put on for a better smile is the improved treatment time. In the past, getting braces meant signing up for 2 to 3 years of wearing annoying metal brackets in your mouth and frequent orthodontist appointments. The lengthy treatment and overall discomfort are things that many adults aren’t able to take on so Dr. G developed the 6 Month Braces treatment method. He puts an emphasis on the end result so more time is spent getting your teeth into perfect position and you can finish treatment fast. 90% of patients at Rapid Braces are able to get their braces off in 6 months or less using the 6 Month Braces method developed by Dr. G.

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Get Braces Off in 6 Months or Less

Many adults spend their entire lives wishing that they could have a better smile. Big gaps and crooked teeth can cause individuals to constantly worry about covering up their smile, leading to unwanted anxiety. The thought of getting braces to get a perfect smile is often enough to scare adults away due to the painful treatment and long treatment times. Luckily, today there are a number of adult orthodontic treatment options available that can fit into any adult’s busy lifestyle.

6 month orthodontic treatment

Dr. Georgaklis began developing the 6 month braces technique more than 20 years ago and has received acclaim from fellow orthodontists worldwide. The technique was created because Dr. G realized there was an overwhelming need for fast adult orthodontic treatment. Adults were too often choosing not to get braces because of the demanding appointment schedule and lengthy treatment time. In the past it would regularly take a patient between 1 and 3 years to get straight teeth and a beautiful smile. Using the 6 month braces method that he created, Dr. G is able to finish over 90% of his cases in 6 months or less.

Come visit Rapid Braces in Brookline to learn more about our 6 month braces treatment option. Our expert staff strives to offer the most personalized orthodontic treatment option in the Boston area. With individualized treatment plans in place we are able to closely monitor your teeth’s movement and make any changes that will lead to better end results and a quicker completion time. Each case that we take on will start with a consultation so Dr. G and his trained staff can get a good look at how your teeth are aligned and put together an adult orthodontic plan tailored specifically for your needs.

Get started with 6 month braces treatment at Rapid Braces and you’ll be amazed at how quickly you get fantastic results. A better smile can significantly help with self-confidence. Former patients often drop by to let us know how happy they are with their new smile. Call Rapid Braces today to learn more about how to get started with the fastest and most comfortable adult orthodontic treatment in the Boston area.

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Straight Teeth with Invisalign Brookline

Many adults know that having straight teeth can significantly improve your self-confidence, self-image, and professional image. Misaligned and crowded teeth can be difficult to keep clean and make anyone feel intimidated in social situations. Starting adult orthodontic treatment to get straight teeth for a perfect smile can help any professional get on the track to success. Many adults, however, choose not to see a Boston orthodontist because getting braces is very time consuming, uncomfortable, and can hurt how they are perceived at work. Rapid Braces in Brookline aims to change how adults think about getting braces by offering a variety of modern braces alternatives and quick adult orthodontic treatment plans.

invisalign brookline

One of the most popular braces treatment options that is offered at Rapid Braces is Invisalign clear braces. With Invisalign, Dr. Georgaklis is able to straighten his patients teeth with a series of custom, clear aligner plates. The clear plates will be regularly replaced with new ones during Brookline adult orthodontic treatment to gradually realign your teeth. Each Brookline Invisalign aligner will be custom-made to fit in your mouth perfectly and gradually shift your teeth. The Invisalign aligners can also be removed at anytime like a retainer for eating, brushing, and flossing.

The biggest reason many patients choose to get a perfect smile with Invisalign Brookline at Rapid Braces is how they look with the aligners in their mouths. Invisalign aligners are clear so they won’t be noticeable to anyone when they are in your mouth. Patients can say goodbye to any unwanted attention that traditional metal braces would bring with Invisalign. Patients don’t need to feel scared about getting their teeth straightened with Invisalign.

Call Rapid Braces today to get started with a Brookline Invisalign treatment plan. Our adult orthodontic treatment programs all start with an initial orthodontic consultation so Dr. G and the expert staff at Rapid Braces can see how your teeth are aligned and get to know you. After getting a look at your mouth we can present a number of different treatment options so that you can choose the one that works best. Rapid Braces strives to offer the most personalized adult orthodontic service in the Boston area. Come visit today to find out how easy it is to get straight teeth with Invisalign Brookline at Rapid Braces.

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Patient Comfort a Priority at Rapid Braces

At Rapid Braces in Brookline we treat a number of patients who have tried to get Boston orthodontic treatment with other practices. Most of them complain of awkward metal braces, painful teeth, and obnoxious appointment times that they were unable to keep up with. Before too long all the trouble wasn’t worth it and they had to stop their treatment without getting the perfect smile that they’ve always dreamed of. The expert staff at Rapid Braces knows how difficult it is to wear braces as an adult and strives to make the entire Boston orthodontic treatment process as comfortable as possible for patients of all ages.

The biggest reason Rapid Braces is able to offer the most comfortable orthodontic experience in the Boston area are the multiple cutting-edge braces alternatives we offer. These modern Boston braces alternatives were designed to be comfortable to wear, easy to keep clean, and remain hidden while you are wearing them. Many of our patients are hesitant to begin Boston orthodontic treatment because of all the unwanted attention metal braces attract. We offer behind the teeth braces, invisible braces, and invisalign at Rapid Braces in Brookline so every patient can find the perfect orthodontic option for them.

comfortable braces brookline

We also ensure that scheduled appointments with Dr. Georgaklis are comfortable for our patients as well. Dr. G makes it a point to schedule less patient appointments each day so he can give each patient the attention they deserve. More time allows for a more personalized orthodontic treatment than most practices offer and faster results. At each scheduled orthodontic appointment Dr. G will monitor the progress of your treatment and make any adjustments that are necessary.

Fast orthodontic treatment time is another reason why many adults are choosing to get straight teeth at Rapid Braces. Dr. G developed the 6 month braces technique almost 20 years ago and has been making improvements ever since. Today he is able to complete 90% of the orthodontic cases that he takes on with his 6 month braces treatment option. We are able to achieve such fast results by paying attention to every small detail and focusing on the end result of your treatment. Call Rapid Braces today to get started with Boston’s best orthodontic treatment for adults.

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