Straight Teeth in Six Months
Call Now for a Free Consultation: (617) 277-5200

Call Now for a Free Consultation: (617) 277-5200
Brookline rapid braces

All Posts Tagged: boston braces expert

Difficult Case Types: Part 2, A Discussion of Adult Short-Term Orthodontics

Difficult Case Types: Part 2, A Discussion of Adult Short-Term Orthodontics

Clear or Invisible braces for adults.

Originally posted on Dentistry Today.

In part 1 of this article, I discussed the evolution and rationale of short-term orthodontics (STO); and how it dovetails with aesthetic dentistry and other disciplines to provide treatment by one provider in a coordinated and timely manner. I briefly discussed issues involving treating patients who present with bruxism, patients who have unrealistic cosmetic demands or obsessive-compulsive disorder, and those personality types who wish to alter or control their treatment plan. Though STO is oriented toward the patient’s aesthetic chief complaint, we must still limit the patient’s involvement in the treatment planning and smile design to meet “real world” expectations.
At the initial consult, it is helpful to provide cosmetic orthodontic patients with before and after pictures of what they may expect, along with a list of what can and cannot be achieved. All common significant questions should be addressed on one’s Web site, in addition to a consultation photo book given to new patients before seating. Actual pictures of one’s own work can be a fair representation of what to expect, providing an honest and direct dialogue that can be very beneficial to both the patient and the provider.
The case types discussed in the second part of this article include interesting aspects of transfer cases, the judicious use of enamel reproximation, cases with particular retention needs, cases with temporomandibular disorders (TMD), large tongues, profile problems, and a complex multidisciplinary case. These difficult case types offer an opportunity to present pearls that can enhance treatment for both STO and conventional orthodontics alike. The greater focus and time per visit required for STO (I prefer one-hour visits) also bring greater reward and satisfaction for both the patient and the provider.

While some believe that they can nonsurgically expand the dental arch through orthodontics in an adult patient, it has been proven that “expansion” (crown tipping in an adult) at past the age of 13 years is not significant, and it is prone to relapse.1Posterior crowns tip to the buccal without significant root translation resulting in an unaesthetic and unstable result also prone to gingival recession.

Figure 1. Patient first came into our office with teeth tipped outward through use of removable expansion appliances. There was sufficient space for alignment, but the roots were in unstable positions with crowns tipped to the buckle. Figure 2. A stable result must maintain arch circumference in an adult patient with the teeth in cortical bone to prevent inward collaspe post-treatment.
Figure 3. Patient presented with narrow incisors due to previous treatment that relied too heavily upon enamel reproximation and scarificed tooth proportion and aesthetic outcome.

Patient in Figure 1 was referred by an orthodontist in Los Angeles for lingual orthodontics. He expanded her for one year with Crozat appliances, leaving sufficient space to align the teeth (Figure 1). At this point, she moved to Boston, where we commenced lingual orthodontic treatment which proceeded smoothly. Brackets were removed with an aesthetic result. However, in the months after completion, the arch form and tooth roots continued to collapse inward. Expansion had spread the teeth laterally into an unstable position outside the cortical bone. The patient needed a brief course of retreatment with enamel reproximation which yielded a far more stable result which has been maintained well (Figure 2).

While the previous case showed an under-reliance on enamel reproximation, this case shows overreliance on it. Lack of flexibility and overreliance on any one treatment modality has its perils, though. The patient in Figure 3 was looking for retreatment despite the fact that her teeth were straight. In order to achieve an ideal occlusion nonextraction by the treating orthodontist, the teeth had been interproximally reduced to the point that they were unaesthetic, lacked embrasure space, and were not self-cleansing. This resulted in unaesthetic tooth proportions and perpetually inflamed papillae. Minor alignment was done along with recontouring. The teeth were shortened to establish better proportion, and embrasure spaces were opened to allow better self-cleansing.

The Class II, Division 2 is a common type of crowding where the upper centrals tip palatally and the laterals flare labially (Figure 4). Aesthetically conspicuous, it is usually a simple case to align dentally with enamel reproximation. These patients do not usually have a profile problem needing orthognathic surgery. As they are fully grown adult patients, skeletal change and complete overjet correction is not usually possible nonsurgically, so the upper central incisors will always tend to relapse palatally. Therefore, this is an ideal case for maxillary lingual splinting of teeth Nos. 7 to 10 or teeth Nos. 6 to 11. Slight overjet allows a durable splint to be placed out of occlusion in a case type that would otherwise be very prone to relapse. Recognizing the instability of cases that have a skeletal component is essential, and this patient’s aesthetics are basically identical today to the result (Figure 5), 12 years after completion, with no noticeable relapse due to her upper and lower lingual fiber-reinforced composite splints (Ribbond).

Figure 4. Adult Class II, Division 2 is very prone to relapse. Figure 5. Splinted result maintained well (at 12-year recall).
Figure 6. Large diastema needing fixed retention. Figure 7. After short-term orthodontics (STO) with splinting.
Figure 8. The 3.5-year recall with fiber-reinforced composite (FRC) (Ribbond) splints. Figure 9. Severely rotated incisor.
Figure 10. This rotation could never be maintained without a splint. Figure 11. Four-year recall with maxillary FRC splint.

Large diastema cases (Figures 6 to 8) also have special retention needs (a maxillary splint), as do severely twisted teeth (Figures 9 and 10). Though it requires overjet be left in the final result, the maxillary splint provides excellent retention, though it can require maintenance. Removable retainers would almost surely fail to retain these particular tooth movements. However, with the maxillary splint, the excellent results were well-retained in both cases at the 3- and 4-year recalls (Figures 8 and 11). Few orthodontists finish cases with the overjet needed to allow for placement of a maxillary splint.

CASE TYPE VII: Temporomandibular Disorder 
This patient was a bruxer whose crowding and anterior recession were worsened by bruxing forward, causing anterior displacement of an upper central incisor (Figure 12). As a prominent cosmetic dentist, he came to Boston for rapid cosmetic orthodontics. The alignment proceeded smoothly with one exception: I allowed the likable dentist-colleague to limit my enamel reproximation in the lower arch. Therefore, my ability to retract the lower incisors and establish sufficient overjet also became limited. Parafunction usually ceases at the beginning of orthodontic treatment, but then returns once the teeth are no longer sore. Once the parafunctional bruxing returned, the upper central (that now had been retracted back) caused a more retrusive and limiting anterior guidance on the mandible (Figure 13). The new incisal guidance brought less freedom of the mandible during bruxing, pushing it backward, so disc compression and tinnitus followed.

Figure 12. Bruxer, before STO, with protruded tooth No. 8 from bruxism. Figure 13. Bruxer, after STO, with normal incisor occlusion.

Our typical treatment method of leaving overjet avoids any retrusive incisor contact on the mandible, and avoids TMD sequelae. The lack of tight anterior coupling in my finished orthodontic cases accounts for the fact that I rarely see TMD in my patients after STO—a remarkable statistic, especially considering occlusal change is not the primary treatment focus. One must be very cautious when leaving a case with the incisors tightly coupled together in occlusion, as any lower incisor relapse or change in jaw position forward may cause disc compression and the pain that may or may not have been poresent beforehand.

Patients with a large tongue often have anterior spacing. The patient’s tongue in Figure 14 already fills the space available and goes to the lingual surfaces of the teeth. While the anterior spacing can be reallocated distal to the canines, the incisors cannot be retracted and maintained inside the neutral zone with long-term stability. The tongue pressure will push the teeth forward unless tongue reduction has occurred. In such cases, we always explain to our patients at the initial consult that space will be redistributed distally to maintain an incisor position that is in harmony with the tongue, instead of a retracted incisor position when the tongue will not allow them to be maintained and would cause relaspe.

There is no STO solution for cases with an unaesthetic facial profile and lip incompetence. This case needed bicuspid extraction because the amount of upper incisor retraction required cannot be done with enamel reproximation alone (Figures 15 and 16).

Figure 14. Large tongue prohibited the retraction of incisors. Figure 15. Bicuspid extraction case with lip incompetence.
Figure 16. After bicuspid extraction treatment. Figure 17. Surgical case that requires a referral to the surgeon-specialist team.
Figure 18. Canine substitution needed for missing upper lateral incisors. Figure 19. Final result; bonded and splinted upper canines and bicuspids without any bridgework or implants.

Even more involved, the skeletal case in Figure 17 clearly needs orthognathic surgery.

This case cannot be done with orthodontics alone (Figures 18 and 19). Treatment involved surgical exposure and bringing down impacted canines throughout one year (still considered STO due to the complexity of the case), as well as splinting with reshaping and bonding. Canine substitution was done for the missing upper laterals incisors. With some creative thinking, this patient avoided any bridgework or implants as this result was achieved solely with orthodontics and bonding. Most patients enjoy a result with greater simplicity, stability, and predictability, while eliminating implant surgery and minimizing treatment time and expense. This type of thinking can bring people back to dentistry, especially adult patients like this with aesthetic problems who have not sought out care sooner due to obstacles inherent in a conventional and more involved treatment plan. Patients opt out of 2-year treatment when there is a shorter plan with proven results.

As dentists, we have a myriad of responsibilities that can make dentistry complex as well as rewarding. Diagnosis and treatment planning, patient management, and retention protocol all vary with a need to understand and accommodate each patient’s teeth and character. Comprehensive 2-year orthodontics may better address more complex cases, but there is also a demand for more rapid orthodontic treatment for the typical adult cosmetic cases.
We must always remember that elective cosmetic dentistry of any type often comes with a human dimension of personal preferences that is often distinctive. These preferences must be understood, addressed, and ideally, satisfied, within the parameters of a healthy and stable long-term result.


  1. Bishara SE, Jakobsen JR, Treder J, et al. Arch width changes from 6 weeks to 45 years of age. Am J Orthod Dentofacial Orthop. 1997;111:401-409.
Read More

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.

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.


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.


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
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.


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.


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.


  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.
Read More