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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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Wearing Braces Back to School

Wearing Braces Back to School

It’s that time of year again when students of all ages are going back to school. Children start a new grade and adults may be beginning a new career path. In either situation, the first day of school can be nerve-wracking. This feeling can intensify if you recently were told you needed braces. But don’t let that stop you from enjoying your first day back to school! Dr. Georgaklis offers many alternative options to help you feel more confident. And he has even revolutionized the practice with his Rapid Braces method — most patients can be treated in just six months.

Here are two options for hiding those braces from your new friends at school:

Clear Braces:

The most cost effective way of hiding your braces is with clear braces. Dr. Georgaklis recommends clear braces to many patients because they are cost effective and provide great results in a short period of time. Some patients would rather consider clear retainers like Invisalign, but these don’t use the same force as real braces do. They sit over your teeth, instead of attached to them, which makes them less effective and require more treatment time.

 

Lingual Braces:

Lingual braces, otherwise known as “invisible braces,” are braces attached to the inside of your tooth (tongue side) — hidden from view! This option is popular amongst adults who want straight teeth but don’t want to deal with braces. Once un place, these braces work just like regular ones. These are a better option than Invisalign because Dr. G will have full control over teeth movement and maintenance. Plus, they don’t need to be replaces like the retainers for Invisalign do.

Dr. G works with every patient on a personal basis. He will meet with you for an initial consultation to hear your concerns, talk about budget and other options. Whether you’re going back to school, starting a new job or just afraid to have braces, Dr. G will make sure you feel confident in his hands! Contact us today to get started on your new smile!

 

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Adults Wear Behind The Teeth Braces

Do you want a perfect smile but can’t commit to years of wearing braces? Getting patients of all ages straight teeth fast is our specialty here at Rapid Braces. We understand that the process of getting braces as an adult can seem overwhelming. That’s exactly why Dr. Georgaklis at Rapid Braces created the 6 Month Braces treatment so adults can get the smile they’ve always dreamed of.

Traditional braces are placed on the front of the teeth, require a lot of maintenance and can make whoever is wearing them feel very self-conscious in social settings. At Rapid Braces, you can forget all of the hassle associated with traditional braces. Our patients’ treatment plans start with an initial consultation so Dr. G and his expert staff can get a look at your mouth and recommend what would work best. Dr. Georgaklis gives his patients the flexibility to choose from a variety of braces options for a plan that works best.

One of the most popular choices for adults who want straight teeth are Lingual Braces. Lingual Braces are braces that are placed behind the teeth. The brackets, wires and cement are all placed on the tongue side of your mouth (lingual side). Once in place, behind the teeth braces work like traditional metal braces except they can’t be seen. This is a perfect option for patients who would like to keep their braces hidden, but still want the perfect smile they’ve dreamed of. Lingual, ‘incognito’ braces are an alternative to Invisalign but don’t require new aligner plates to be made on a regular basis.

While Invisalign requires a series of predetermined application, lingual braces gives Dr. Georgaklis full control over teeth movement and allows for a fast and timely procedure. Contact us to schedule an initial consultation and see why so many people are going to Rapid Braces for straight teeth fast today!

 

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