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All Posts in Category: Adult Braces

Alternative Orthodontic Treatment for Adult Crossbites and Overbites

Alternative Orthodontic Treatment for Adult Crossbites and Overbites

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Orthodontic treatment for deep bite cases in adults has traditionally involved either a removable anterior bite plane to supraerupt posterior teeth, or active intrusion of anterior teeth using reverse curve archwires. Headgear and the Nance appliance are also used, but are more appropriate for growing patients. Resolving deep bites may become a necessity in order to bracket lower anterior teeth. As many patients with deep bites exhibit decreased vertical dimension caused by insufficient eruption of posterior teeth appropriate treatment allows their supra-eruption to a normal vertical dimension.  Although bite plane therapy causes some intrusion of anterior teeth, the greater part of deep bite correction results from posterior extrusion and occurs within 6 months, effectively. Increasing vertical dimension has been accomplished to restore lost ver­tical dimension due to enamel ero­sion, and in certain cases it may aid in temporomandibular disorder treat­ment. Removable anterior bite planes can accomplish this, but require con­tinuous patient compliance and are difficult to use while eating, a time when posterior re-intrusion may occur.

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Anterior Retention With a Reinforced Composite Resin Splint After Cosmetic Orthodontic Treatment

Anterior Retention With a Reinforced Composite Resin Splint After Cosmetic Orthodontic Treatment

Originally posted on Dentistry Today.

It has become increasingly clear that making space in the crowded adult dentition by orthodontic expansion of the dental arch is prone to relapse.1,2 Moreover, the intercanine distance has actually been shown to decrease as early as mid-adulthood.1,3 Even cases treated to stability during late adolescence are prone to “late incisor crowding” by 34 years of age,4and the presence of third molars does not significantly contribute to this.5 Even though other skeletal factors and even facial bone dimensions may not significantly decrease until a later age, the influence of naturally decreasing intercanine distance on anterior dental aesthetics has been grossly underestimated. This basic misunderstanding of the early maturation of adult jaw dimensions has enormous repercussions for orthodontic treatment philosophy, as well as implications for the necessity of long-term retention.

Therefore, in cases where one must choose between slight contraction of the intercanine dimension through lower incisor extraction or expansion, the former may prove more stable. Anticipating “intercanine shrinkage” may help prevent future crowding years later when the doctor and patient have presumed stability, and retention has been discontinued. A cosmetic splint anchoring each anterior tooth individually serves to prevent this common and unaesthetic phenomenon of anterior orthodontic relapse.

Traditionally, orthodontists in the 1950s used a prefabricated metal bar fixed to only the canines for lower retention, with the rationale being the effects of arch expansion would be maintained until it was removed. Any incisor relapse would be inconsequential because it would just be an “aesthetic” consideration (Figure 1). Now that dentistry has accepted that the major reason adult patients seek treatment is aesthetics, we can properly address this essential aspect of retention. Some began affixing a customized bar with incisor pads or braided wire bonded to each incisor,6,7 which represented an improvement but still required placing metal in an aesthetic area. It was rationalized that the elastic property of a thin wire allowed physiologic mobility helpful in the periodontic patient.7 This is to be differentiated from the orthodontic patient with healthy periodontium, where the aim is to provide a window for bone and PDL fibers to reorganize with rigid reinforcement.

Also presented for periodontal patients have been reinforced composite splints using TMS pins8 and bondable reinforcement ribbon.9 With the boom in cosmetic dentistry and cosmetic orthodontics, the ribbon is proving useful for the stabilization of adult patients. Unlike the lingual bar this splint can be later removed incrementally as the patient desires.10 As 50% of relapse has been shown to occur in the first 2 years after orthodontic treatment,11 the splint should remain intact for longer than 2 years.

The main purpose of the splint is rigid fixation of the teeth. This immobilization, however, also accelerates the growth of supporting tissues, as the alveolus and PDL fibers can reorganize around the teeth in their new positions without interference from tooth mobility inherent in orthodontic treatment. In addition, this technique enables cosmetic augmentation of the final orthodontic result, as black triangular spaces, incisal discrepancies, or the lengthening of teeth can be achieved with more strength than free-standing incisal composites, which lack the thickness or support of a reinforcement material on the lingual aspect (Figures 2 and 3). Except for those few cases where the patient has a perfect orthodontic result and well-proportioned white teeth without any incisal defects, anterior bonding attached to and reinforced by the splint can greatly enhance the final aesthetic result.

If a maxillary splint is planned and the patient presents with overjet, the overjet should be preserved to allow space for the maxillary splint (Figure 4). This is in contrast to traditional orthodontic philosophy of complete elimination of overjet, even if the overjet represents the natural skeletal position. Skeletal changes cannot be permanently retained without surgery. Adult overjet, such as in a class 2, division 2 case (Figure 5), will be more stable if the overjet is maintained.

Figure 1. Lingual metal bar fixed only to the canines allows incisor relapse, which is not acceptable in cosmetic orthodontic patients. Figure 2. Class 2, division 2 before incisors are tipped forward giving overjet. Note attrition from deep bite on palatally tipped incisors.
Figure 3. After a 6-month treatment time with lingual braces, patient is splinted. Irregular incisors may be lengthened with more durability than with incisal composites not supported by a splint. Figure 4. Slight overjet in final result helps allow the necessary thickness for a durable maxillary splint.
Figure 5. Once completed, an adult class 2, division 2 case will result in overjet without surgery. Figure 6. Etching can include incisals should there be discrepancies that need correction.
Figure 7. Initial layer of composite should be a strong material and kept away from papillae. Figure 8. Splint-It! reinforcement material is placed into composite and cured.
Figure 9. Placement of addtional composite to cover reinforcement fibers. Figure 10. Occlusion is checked before final recontouring and polish.

SPLINTING STEPS

Step one. Complete enamel etching with recontouring on buccal and incisal for aesthetics, and on lingual if necessary to allow splint thickness with occlusion (Figure 6).

Step two. Bonding layer with composite is kept away from gingiva (Figure 7).

Step three. Two strips of Splint It! (Jereric/Pentron) or Ribbond (Ribbond Inc) reinforcement material are pressed into composite. Excess material is placed over reinforcement and cured (Figure 8).

Step four. Addition of final layer of composite (Figure 9).

Step five. Occlusion is checked preceeding recontouring embrasures with a Brasseler No. 8392-31 016F interproximal diamond and polishing bur (Figure 10).

SUMMARY

Even in the most stable types of orthodontic treatment, any relapse at all may be unacceptable cosmetically. Through the placement of a reinforced composite splint, the teeth can be held in position and more significantly recontoured, thus augmenting the final result. Subsquent splint removal can be done incrementally 3 to 5 years after placement as the patient desires.

Author’s Note: I was saddened to hear of the passing of Dr. John Witzig on December 3, 2001. Dr. Witzig was a true innovator who was not afraid to fight the tide of consensus in orthodontics. He brought many  people together in the field (I met my wife at his course). We all owe him a debt of gratitude, and he will be greatly missed. Thank you, John.


References

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

2. Rossouw PE, Preston CB, Lombar CJ, et al. A longitudinal evaluation of the anterior border of the dentition. Am J Orthod Dentofaciai Orthop. 1993;104:146-152.

3. Sinclair PM, Little RM. Maturation of untreated normal occlusions. Am J Orthod. 1983;83:114-123.

4. Bondevik O. Changes in occlusion between 23 and 34 years. Angle Orthod. 1998;68:75-80.

5. Harradine NW, Pearson MH, Toth B. The effect of extraction of third molars on late lower incisor crowding: a randomized controlled trial. Br J Orthod. 1998;25:117-122.

6. Becker A, Goultschin J. The multistrand retainer and splint. Am J Orthod. 1984;85:470-474.

7. Oikarinen K. Comparison of the flexibility of various splinting methods for tooth fixation. Int J Oral Maxillofac Surg. 1988;17:125-127.

8. Rosenberg ES, Garber DA. A temporary-permanent splint. Refuat Hapeh Vehashinayim. 1979;28:27-30,33-37.

9. Ferreira ZA, de Carvalho EK, Mitsudo RS, et al. Bondable reinforcement ribbon: clinical applications. Quintessence Int. 2000;31:547-552.

10. Sheridan JJ. Incremental removal of bonded lingual retainers. J Clin Orthod. 1988;22:116-117.

11.Kuijpers-Jatman AM, Al Yami EA, van’t Hof MA. Long-term stability of orthodontic treatment. Ned Tijdschr Tandheelkd. [in Dutch] 2000;107:178-181.

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Occlusal Change Through Orthodontics in TMD Patients

Occlusal Change Through Orthodontics in TMD Patients

Originally posted on Dentistry Today.

Although some claim that occlusion has little effect on a healthy TMJ and is not generally a causal factor in TMD,1,2 many have made emphatic claims to the contrary.3 Many orthodontic practices are positioned in the marketplace as providing proven treatment for TMD, yet some patients seem to experience TMD as a consequence of orthodontic treatment.
While existing literature reports that orthodontics can both helpand worsen TMD, this paper describes 2 cases where TMD relief was successfully achieved through orthodontic therapy. More specifically, these cases lend credence to the theory that increasing the vertical dimension5 and removing retrusive forces on the mandible may help recapture the disc that can be displaced by over-closure of the mandible.

CASE 1

Figure 1. Photos of patient when she presented for fixed orthodontic treatment. She had been wearing a removable splint and was asymptomatic but splint dependent.

Case 1 describes treatment that utilized a hard acrylic, flat-planed splint to alleviate TMD symptoms of pain, popping, and clicking by advancing the mandible and increasing vertical dimension. The patient was “splint dependent” but symptom-free at the stage she was transferred for orthodontic treatment (Figure 1). The pain returned whenever she was not wearing her splint for consecutive days because she returned to an “over-closed” position. Once orthodontic treatment commenced, the splint was reduced incrementally, allowing teeth to supra-erupt. This was done sequentially until the natural occlusion mimicked the patientís occlusion with the splint. It was reduced from the posterior forward, allowing the second molars to supra-erupt in a controlled fashion. It was also sequentially reduced in thickness. Mobility from the orthodontics facilitated this occlusal setting. Three distinct aspects of the patientís occlusion were changed, which helped provide TMD relief:

(1) The maxillary incisors were flared labially with treatment. Lingually inclined  lower incisors translate occlusal force into a retrusive direction as the patient closes, especially during protrusion. This was eliminated as labially inclined upper and lower incisors deliver chewing force in a more vertical direction into the alveolar bone, decreasing the tendency of the mandible to be pushed backward and minimizing disc trauma.

(2) Similarly, the incisors had greater vertical overlap initially. This compounded the problem caused by the retroclined position, as the entire facial surface of the lower incisors was acting as a receiving surface for ìpoundingî by the maxillary incisors. The posterior dentition better tolerates this vertical chewing force.

Figure 2. Cross-arch vertical elastics used to bring posterior extrusion without tipping. The splint was reduced incrementally.

(3) The molar extrusion and improved interdigitation, in conjunction with occlusal adjustment, provided a more stable posterior occlusion. This offers better protection against retrusive slides in centric and during mastication, which can further exacerbate TMD. Molar extrusion achieved using cross-arch elastics (Figure 2) from the buccal of the upper teeth to the lingual of the lowers as well as lingual of the upper teeth to the buccal of the lowers served to extrude the posteriors with greater control and no buccal-lingual tipping.

Figure 3. Occlusion after removal of braces.

Although the causal factors of TMD are often a mystery, this case demonstrates that eliminating obvious and severe occlusal abnormalities through splint therapy and gradually through or-thodontics may provide TMD relief and minimize occlusal wear as the traumatic occlusion is eliminated (Figure 3). Two years after treatment, the patient was orthodontically stable and symptom-free.

CASE 2

Figure 4. Patient’s occlusion before treatment. Figure 5. Progress at 5 months.
Figure 6. “After” photo with upper and lower teeth splinted and incisals restored. Figure 7. Eleven-month recall.

The second case shows a patient who had bilateral TMJ clicking and tinnitus. He had second molar occlusion only, a constricted maxillary arch, occlusal trauma, and wear (Figure 4).
The patient wore posterior cross-arch elastics from the lingual of the maxillary posteriors to the buccal of the mandibular posteriors to achieve proper intercuspation and bilateral, evenly distributed tooth contacts, as a posterior cross-bite has been associated with TMD.6 The upper posteriors were stabilized with a Hawley retainer. The upper and lower anteriors were stabilized with lingual Ribbond splints (Ribbond) canine to canine.
This effectively stabilized rotated teeth (in conjunction with a fiberotomy) and provided proper resistance form to the restored incisal composites, necessary because of the previous occlusal trauma (Figures 5 and 6). The incisal edges became much more durable once connected to the splint because of increased thickness. The TMJ, occlusion, and restored incisal surfaces were all stable at recall (Figure 7).

CONCLUSION

While TMD is often a mystery and is even seen in many normal occlusions, frequently other factors7 exist, such as a history of trauma, bruxism, or degenerative joint disease of a systemic nature. However, these 2 cases show at least one obvious and proximate cause for their TMD, which is an unstable occlusion.
Acute inflammation can be mitigated through ice, NSAIDS, and splint therapy until subsequent inevitable exacerbations occur. Definitive treatment through permanent occlusal change sometimes is the only hope for these patients, and is still not a panacea if disc damage has occurred or if occlusal abnormalities are not corrected.
While all aspects of orthodontic TMD treatment have not been substantiated in the literature, providing the patient with a stable, evenly distributed occlusion with correct buccal-lingual molar and nonretrusive incisor relationship, as well as providing an increased vertical dimension, may be a good place to focus in treating this elusive problem.

References

  1. Gesch D, Bernhardt O, Kirbschus A. Association of malocclusion and functional occlusion with temporomandibular disorders (TMD) in adults: a systematic review of population-based studies. Quintessence Int. 2004;35:211-221.
  2. Gesch D, Bernhardt O, Mack F, et al. Association of malocclusion and functional occlusion with subjective symptoms of TMD in adults: results of the Study of Health in Pomerania (SHIP). Angle Orthod. 2005;75:183-190.
  3. Reinhardt R, Tremel T, Wehrbein H, et al. The unilateral chewing phenomenon, occlusion, and TMD. Cranio. 2006;24:166-170.
  4. Henrikson T, Nilner M, Kurol J. Signs of temporomandibular disorders in girls receiving orthodontic treatment. A prospective and longitudinal comparison with untreated Class II malocclusions and normal occlusion subjects. Eur J Orthod. 2000;22:271-281.
  5. Hisano M, Ohtsubo K, Chung CJ, et al. Vertical control by combining a monoblock appliance in adult class III overclosure treatment. Angle Orthod. 2006;76:226-235.
  6. Thilander B, Rubio G, Pena L, et al. Prevalence of temporomandibular dysfunction and its association with malocclusion in children and adolescents: an epidemiologic study related to specified stages of dental development. Angle Orthod. 2002;72:146-154.
  7. Clark GT. Etiologic theory and the prevention of temporomandibular disorders. Adv Dent Res. 1991;5:60-66.
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A Six-Month Orthodontic Solution to Space Closure and Bite Collapse

A Six-Month Orthodontic Solution to Space Closure and Bite Collapse

Originally posted on Dentistry Today.

For patients who exhibit missing posterior teeth, bruxism, and a concomitant loss of vertical dimension often commonly occurring with anterior flaring and spacing1 (Figures 1 to 3); mainstream treatment consists of 1.5 to 2 years of orthodontic treatment to retract the anteriors and re-establish the collapsed vertical dimension. This is usually followed by removable retainer wear. It is important to restore the missing posterior support,2 and the patient should be given implants or bridges afterward.

CASE REPORT

Figures 1 and 2. Note palatal occlusion.
Figure 3. Note attrition.
Figures 4 and 5. Composite bite plane on teeth Nos. 6, 8, 9, and 11 intruded the anteriors and allowed passive eruption of posteriors.
Figure 6. After bridge cementation. Additional whitening procedures were recommended.

A patient who came to our general practice was given this treatment plan by 2 previous dentists with specialists in their offices. Eager to seek other alternatives, she presented for attenuated orthodontic and restorative treatment.
Treatment consisted of short-term, 6-month, fixed-orthodontic treatment by retracting the incisors to their original position before they migrated forward. The collapsed vertical dimension was increased through use of an anterior fixed composite bite plane. This is a flat-planed composite bite plane bonded to the lingual of the upper central incisors3 (Figures 4 to 6), prohibiting full closure. Through lack of posterior occlusion, within 3 to 4 months the posterior teeth exhibited significant passive supra-eruption, even without posterior vertical elastic wear (which may be used as an option to accelerate the process). At the same time, the incisor region is intruded through chewing. This occurs throughout the entire anterior region, as the teeth are essentially “splinted” through the orthodontic wire. In this way, even teeth without the composite bite plane are intruded. The ratio of posterior extrusion to anterior intrusion has been shown to be approximately 60:40.4

DISCUSSION

Figure 7a and 7b. Before and After.

Secure retention is an essential aspect of this case. Removable retainers are inadequate, as even slight space relapse will be cosmetically obvious; this is likely in an adult patient with fully formed dental arches and some bone loss.5,6 In addition, our practice occupies a niche in treating adults through short-term cosmetic orthodontics,7 and this demographic desires retention that is aesthetic. Furthermore, treatment is orthodontic in these cases and not orthopedic, so the results are less stable, thus requiring fixed retention. A lingual composite splint (Ribbond [ribbond.com]), where composite covers most of the tooth’s lingual aspect and can overlap onto the buccal aspect, is preferred. This can serve to augment small teeth, change shape and width by enhancing line angles, fill chips, and restore surfaces with attrition.8
In conjunction with the orthodontic space closure, posterior support must be provided, as the splint will fracture without posterior protection and incisor flaring will return.9 The increased vertical dimension would also be lost, since the posteriors would intrude. If implants are part of this plan, they should be placed before or during orthodontic treatment, not after. This case utilized 3 fixed bridges, helping to correct some mesial drift which may be caused by transseptal fiber contraction.10Temporary bridges were inserted the day the braces were removed, and the splints were placed. Permanent impressions were taken one month later to allow for gingival healing and minor occlusal settling (Figures 7a and 7b).

CONCLUSION
This treatment approach shows a rapid, straightforward solution for this common functional and aesthetic dental problem, which is frequently treated with a more complicated long-term plan, often prone to relapse.

CONTACT RAPID BRACES


References

  1. Kelly JT Jr. A multidisciplinary approach to restoring posterior bite collapse. Compend Contin Educ Dent. 1997;18:483-485,488-490.
  2. Reshad M, Jivraj S. The influence of posterior occlusion when restoring anterior teeth. J Calif Dent Assoc. 2008;36:567-574.
  3. Georgaklis CC. Alternative orthodontic treatment for adult crossbites and overbites. Dent Today. 2001;20:60-63.
  4. Lei Y, Zhang S. Clinical study on the orthodontic treatment of deep overbite with bite plane [in Chinese]. Hunan Yi Ke Da Xue Xue Bao. 1998;23:465-466.
  5. Brunsvold MA. Pathologic tooth migration. J Periodontol. 2005;76:859-866.
  6. Martinez-Canut P, Carrasquer A, Magán R, et al. A study on factors associated with pathologic tooth migration. J Clin Periodontol. 1997;24:492-497.
  7. Georgaklis CC. Six-month adult aesthetic orthodontic treatment. Dent Today. 1999;18:110-113.
  8. Georgaklis CC. Anterior retention with a reinforced composite resin splint after cosmetic orthodontic treatment. Dent Today. 2002;21:54-57.
  9. Greenstein G, Cavallaro J, Scharf D, et al. Differential diagnosis and management of flared maxillary anterior teeth. J Am Dent Assoc. 2008;139:715-723.
  10. van Beek H. Dissertation 25 years later. 1. Mesial drift of teeth by occlusal forces [article in Dutch]. Ned Tijdschr Tandheelkd. 2004;111:48-51.
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Adult Orthodontics and a Post-Treatment Bonded Splint: A New Cosmetic Subspecialty

Adult Orthodontics and a Post-Treatment Bonded Splint: A New Cosmetic Subspecialty

Originally posted on Dentistry.com

As the field of cosmetic dentistry is still rapidly evolving, we have not yet integrated the various specialties to provide seamless care in a case that requires multiple disciplines. For example, a patient needing orthodontics, crown and bridge or implants, gingival recontouring, orthodontic retention, and bonding will normally be cross-referred between their GP, periodontist, orthodontist, and perhaps an oral surgeon1,2 (4 doctors). While specialists normally provide the highest level of care, there exist certain cases where a “cosmetic subspecialist” may be best suited to create a final result that is harmonized in concept, proportion, and materials.
The following case would often be treated with orthodontics and retainers, and then relapse because of the unusual nature of the case and high tendency to relapse with removable retainers3 regardless of the duration of the orthodontics. The relapse in the anterior segment in adult patients is especially high.4 This patient had 3 missing anterior teeth as well as an impacted canine (Figure 1). Most orthodontists are not accustomed or trained to incorporate significant bonding and reshaping into their treatment plans, so the missing lateral incisors spaces would usually be opened up for implants or 6 units of crown and bridge to provide traditional canine guidance. Yet, there is insufficient bone for an implant for No. 7, and there are alternative treatment options that are simpler, far shorter in duration, and less expensive. Nontraditional thinking is required in this case, especially from an orthodontic perspective, as ideal treatment is most likely impossible.

CASE REPORT (FIGURE 1)

Figure 1. Patient is missing 3 lateral incisors. Tooth No. 6 was fully impacted in bone before surgical exposure, and was used to substitute for the missing tooth No. 7 through extrusion, mesialization, reshaping, and bonding. Figure 2. Bonding and reshaping was also done to the enamel and gingiva of the bicuspids to make them into canines. The front 6 teeth were splinted and bonded. This case has no implants or bridges.

The patient had been to 3 orthodontists and was looking for treatment alternatives, as all 3 offered 2- to 3-year treatment plans with no promise of a satisfactory result because of bone issues surrounding tooth No. 6, among other things. The patient was not willing to crown all his anterior teeth, which had also been proposed. Our treatment plan involved surgical exposure and super-eruption of tooth No. 6, then making teeth Nos. 6 and 11 into lateral incisors through mesial movement and bonding, making teeth Nos. 5 and 12 into canines, minimizing the lower canine cusps, and connecting all anteriors with a Ribbond/composite splint for stability as well as to support the extra bonding that would be necessary (Figure 2).5
Instead of dividing the treatment by “specialty” and fragmenting the plan with 3 providers, in this way the case may be managed by one practitioner who is experienced in performing splinted retention with concurrent bonding. I previously wrote of a porcelain pontic veneer placed over a Ribbond splint used for orthodontics.6 This case shows how the splint can support significant bonding and provide needed fracture resistance to canines, which are made into laterals, and bicuspids which are made into canines. Equally important is the required fixation, as any relapse would reveal their deficient anatomy and ruin the “camouflage” effect of the bonding. Most orthodontic cases have some degree of relapse, and that would be unacceptable in cases such as this.
This treatment reflects a paradigm shift. Instead of providing a traditional orthodontic result by adding prosthetic lateral incisors, other teeth are moved shorter distances and bonded, providing a faster, simpler, and less expensive result. This is preferable for many patients who are more interested in avoiding gaping holes in their smile than committing to a 2-year treatment plan with endosseous implants. While patients are made aware of treatment alternatives, specifically what will not be provided in this plan, they overwhelmingly choose a method that resolves their chief aesthetic complaint. They are generally satisfied years at recall as well. Should they choose to crown or veneer this result in the future when more stability has been achieved, that option is still available to them.

CONCLUSION

 

Reshaping teeth via splinting and bonding is a practical, aesthetic alternative which addresses the high incidence of relapse still seen in orthodontics today. Simultaneously, this can serve to resolve some difficult and unusual aesthetic predicaments.


References

  1. Chadroff B. The interdisciplinary approach to implant dentistry. Gen Dent. 2004;52:321-326.
  2. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc. 2006;137:160-169.
  3. Hirschfelder U, Hertrich K. The treatment of deep bite in adults. Fortschr Kieferorthop. 1990;51:36-43.
  4. Lang G, Alfter G, Goz G, et al. Retention and stability—taking various treatment parameters into account. J Orofac Orthop. 2002;63:26-41.
  5. Kokich VO Jr, Kinzer GA. Managing congenitally missing lateral incisors. Part 1: Canine substitution. J Esthet Restor Dent. 2005;17:5-10.
  6. Georgaklis CC. Anterior retention with a reinforced composite resin splint after cosmetic orthodontic treatment. Dent Today. Jan 2002;21:54-57.
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6 Month Braces: How Is It Possible?

6 Month Braces: How Is It Possible?

Get straight teeth in just six months with Dr. Georgaklis’ Rapid Braces treatment. He specializes in clear braces or invisible braces for adults and promises to give you your best smile.

rapid braces Boston

Adults who need braces shouldn’t have to suffer for a long time period with metal brackets on their teeth — let Rapid Braces be the solution for you! This Brookline dental office is the only office to complete 90% of cases in six months or less. Adults can wear clear braces or invisible braces and see results faster! These also are a better alternative to Invisalign, as they control your teeth with more force and take less the time.

How does Dr. Georgaklis do it?

First, he makes sure that every patient at his Boston area dental office gets personalized treatment the moment they walk through the door. He schedules each patient for longer visits, allowing him to get more done during one appointment. Most orthodontists see their patients for five to fifteen minutes, while Dr. G sees his patients for an hour.

Dr. Georgaklis uses his professional experience to mix cosmetic dental practices with orthodontic techniques to give his patients straight teeth fast.

In order to treat patients within six months, this Boston area dentist uses special techniques like:

  • using special wires that don’t fatigue
  • sanding in between the teeth
  • not removing any teeth
  • reshaping gums and teeth
  • not changing the bite or profile unless needed (although this can often times be done in six months)
  • straightening front teethadult braces

These procedures give you a perfect smile with proportionate and straight teeth! After six month braces, Dr. Georgaklis fits his patients with a fixed retainer behind the teeth. This lingual retainer prevents movement, giving you straight teeth for life!

To learn more about the Six Month Braces treatment, click here. You can book your free consultation today!

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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.

INTRODUCTION 
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.

CASE TYPE IV: TRANSFER CASE WITH TIPPED POSTERIOR TEETH
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).

CASE TYPE V: OVERUSE OF ENAMEL REPROXIMATION
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.

CASE TYPE VI: SPECIAL RETENTION NEEDS; ADULT CLASS II, DIVISION 2; LARGE DIASTEMA, SEVERE ROTATION 
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.

CASE TYPE VIII: LARGE TONGUE 
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.

CASE TYPE IX: PROTRUSION WITH UNAESTHETIC PROFILE
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.

CASE TYPE X: MULTIDISCIPLINARY CASE
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.

CONCLUSION
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.


Reference

  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.
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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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Can I Eat Halloween Candy with Braces?

Can I Eat Halloween Candy with Braces?

Trick or treat! After a night out going door to door collecting candy with your children, younger siblings or friends, you find yourself sticking your hand in the bowl to treat yourself. But wait! You have braces! Can you eat that?

Most orthodontists will say NO! Don’t eat candy! Dr. Georgaklis wants you to know that there are definitely candies to avoid, but some could be okay. Dr. G introduced Rapid Braces, using practices provided by Brookline area orthodontists to give patients straight teeth within six months. If you’re a patient of Dr. G’s, you wouldn’t want to prolong that process, right? Here’s a few tips for safe Halloween candy to eat with braces.

  • DO eat chocolate! It’s the softest candy and melts in your mouth so you don’t need to worry about it getting stuck on your braces. Try to avoid frozen chocolate, solid chocolate bars or chocolate with nuts or caramel. That’s when things get messy.
  • DO eat mint candies! Buttermints, peppermints, Junior Mints or Peppermint Patties are totally okay. It’s okay to suck on a hard candy, but resist the urge to bite down.
  • DO opt for other options like soft cookies or cupcakes. You may not find these options while trick or treating, but look for them at Halloween themed parties.
  • DON’T eat anything gummy, chewy or sticky. The consistency makes it almost impossible to clean from braces. Even harder chews are not okay – they could get stuck to the metal and ruin it.
  • DON’T eat small coated candies like M&Ms or Skittles. The sugary shells break into small pieces, getting stuck in hard to reach spots on your braces.

It’s important to remember you have your braces on and are on your way to having a perfect smile! Don’t ruin it with candy! 6 Month Braces treatment time will increase if pieces get stuck in your braces or you have to have something replaced. Don’t hesitate to call Dr. G and the expert staff at Rapid Braces if something doesn’t feel right with your braces, we’re here to help. And remember, candy gives you cavities!

If you’re looking for Rapid Braces, invisible braces or just have any questions, Dr. Georgaklis is your go-to guy for Brookline 6 Month Braces. Other orthodontists in the area can’t offer personalized 6 Month Braces treatment like Rapid Braces. For more information, contact Dr. Georgaklis.

 

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