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

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Healthy-Smile-Holiday

Keep a Healthy Smile with Dental Health Resolutions

If you’re looking for ways to have healthier teeth in the new year, we’ve got you covered! Our Brighton cosmetic dentists are highly trained in all things that have to do with healthy teeth. Maybe you already have healthy teeth, but if you’re looking for ways to be healthier take some of the tips & tricks from our Brighton cosmetic dentists!

 

  1. Brush your twice a day – This may come as obvious to most, but sometimes it can be forgotten. Brushing your teeth twice daily helps prevent gum disease and keeps your teeth clean and happy. Make sure you’re brushing your teeth properly – our Boston cosmetic dentists recommend using soft bristles and paying attention to the gum line.
  2. Floss your teeth daily – Again, this may come as obvious to some but flossing can oftentimes be forgotten. At a bare minimum you should be flossing once a day, but our Brighton cosmetic dentists recommend that you floss twice a day to ensure your teeth are kept healthy.
  3. Avoid sodas and sugary drinks – Avoiding drinks with high sugar content is extremely beneficial to your teeth according to our Brookline cosmetic dentists. Over time, drinks with high sugar content can cause cavities and erode your enamel which can make for some pretty painful times. It’s okay to enjoy these drinks once in a while but they shouldn’t be a part of your daily routine for healthy teeth!
  4. Brush your tongue – Your teeth and gums are important for a perfect smile but your tongue holds a lot of bacteria that needs to be cleaned, Your tongue is actually home to the most bacteria in your mouth so making sure to brush your tongue should be a part of your daily dental routine!
  5. Change your toothbrush – If you’re using a non-electric toothbrush make sure you change it every three months, and buy a new one. If you’re using an electric toothbrush, make sure you change the head every three months to avoid the growth or harmful bacteria and keep your mouth healthy.
  6. Schedule regular check ups – Our Brookline cosmetic dentists also do check ups, we recommend that you get your teeth cleaned by a professional dentist every six months as a preventative measure. Scheduling regular check ups with your Brookline Dentist can ensure that you keep your teeth in optimal shape.
  7. Stop Smoking – We all know how bad smoking is for your health, but did you know how bad it is for your teeth? It can have as harmful effects on your mouth as it can on the rest of your body. Smoking is associated with many harmful risks, our Brookline Cosmetic Dentists recommend that you quit smoking.
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Benefits of a Great Smile

There is no secret that when you smile more, you just simply feel better. Smiling has many documented social benefits. A Genuine smile can make you seem more likable, attractive, intelligent, and even trustworthy. Perhaps the biggest surprise to benefits of smiling, however, is that it can improve your health & even help you live longer. Here are some of the surprising health benefits of smiling.

  • Everyone feels down sometimes and smiling is the most simple, and the best way to improve your mood. So if you are having a bad day try smiling, improve your thoughts, and it may just lead to a genuine smile to lift your spirits.
  • Smiling and general laughter appears to help lower peoples’ blood pressure, and all around heart health. The reason is that laughter causes an initial increase in heart rate, followed by a period of muscle relaxation. The decrease in heart rate and blood pressure helps you reduce your risk of developing heart disease.
  • When you are in a stressful situation, try smiling! Smiling helps your body deal with stressful situations more effectively. Smiling results in a lower heart rate, telling your body that you have full control of the situation. Stress is generally caused by increases in heart rate and blood pressure. Maintaining a smile will provide you with both psychological and physical health benefits.
  • Have you noticed that you are drawn towards people who smile a lot? This is because people who smile are perceived as being more likable than those who don’t. Being likable makes it easier to build and maintain a better relationship with other people. This is important for overall health, well-being, more stable marriages, and better interpersonal skills than people with negative emotions. Keeping a smile on your face truly helps create healthier and stronger social bonding.
  • An incredible discovery is that laughing and smiling helps boost your body’s immune system. Laughter and positive thoughts release chemicals in your brain that fight stress and illness. Laughter therapy has even shown to increase immune responses in women who have just had babies. Positive thoughts really do have a physical presence in the health of the body, so always keep positive.
  • It turns out that the fountain of youth has been within you all along. It has been discovered that smiling and positive emotions are associated with increased lifespans. Now that is a reason to keep smiling.

The lesson here is, the next time you feel down, try wearing a smile even if it is uncomfortable. Your fake smile will turn into a genuine one, all while gaining benefits for your mind, body, and overall well-being. Set up an appointment with us to get your best smile, and wreak the benefits while looking great doing it.

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Choosing the Right Type of Braces

6 Month Braces Options

Getting braces as an adult is becoming more and more common as people come to realize that your teeth never stop adjusting. It is becoming more and more common for adults to get braces as they realize it’s never too late to get a beautiful smile. There is no shame in having to get braces to get your teeth straightened. In fact, 20% of orthodontic patients are over 18 years old.  If you would like to detract from showing your braces, there are multiple solutions that we can help you resolve this problem.

Options For Straighter Teeth

The braces in the orthodontic industry today have been developed to be more comfortable and less obtrusive than those of the past. The evolution of braces has created many more options for you to chose your preference on how to adjust your smile. Invisalign is a popular option for adults. Invisalign is an invisible set of braces that are not noticeable as long as good oral hygiene is maintained. Invisalign is easily removable as it made from SmartTrack material that predicts controlled tooth movements and adapts accordingly. Lingual braces are another alternative to traditional metal braces. Lingual braces are braces that are on the tongue side of your mouth, and invisible from the outside. These are more costly because of the specialized tools required to attach and adjust the braces on your teeth. If you want quicker results and a less expensive option, then clear braces are the way to go. Clear braces use more force than an Invisalign retainer, are tough to notice, and the highly recommended option of Dr. Georgaklis.

How To Schedule An Appointment

Dr. Georgaklis can set up an appointment with you, once you contact him on our contact page. A date will be set for you to visit our Brookline office for an initial consultation. Once we are able to see how your teeth are aligned we can recommend treatment options and you can choose the best adult braces treatment for you. Our 6 Month Braces can give you a great smile in a short amount of time, as Dr. Georgaklis completes 90% of cases in as little as six months. Dr. Georgaklis’ attention to detail and extended personalized service to each individual patient are other reasons patients love 6 Month Braces treatment.

Never Too Old For Braces

Many people feel they’ve missed their chance to get braces after their teenage years, but this is a common misconception of the truth. The social stigma of braces is that only children and teens can have them. The facts are that more adults need braces than children as our teeth are always adjusting and have no age limitations on treatment. The main issue with adult braces is the “embarrassment” of people knowing you have them. Here at Rabid Braces, we get the job done quickly for you so that your worries don’t last long. We understand our customer’s concerns which is why we implement our multiple strategies to hide braces from covering your smile. We want every last one of our patients to smile confidently, and worry-free after an appointment with us.

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Braces for Adults in Boston

Braces for Adults in Boston

Braces aren’t just for kids anymore — now there are options for braces for adults! More and more adults are looking into their options to get straight teeth. Dr. Georgaklis has revolutionized the way adults get straight teeth with his Rapid Braces method. He combines his dentistry expertise with orthodontic practices to give each patient a unique experience and perfect smile.

clear braces orthodontic treatment

People who need braces in the Boston area can benefit from Dr. Georgaklis’ expert treatment and get straight teeth in six months! Adults can choose from clear braces or behind the teeth braces. Both of these options give you straight teeth while “hiding” your braces. Many people might turn to other treatments like Invisalign, but Dr. G’s method can give you straight teeth in half the time!

Clear braces can be considered invisible braces. They mount to the front of your teeth like typical braces, but use clear brackets and wiring for that see-through effect. Learn more about clear braces here!  Lingual braces, or behind the teeth braces, mount to the back of your teeth. These braces are hidden and can only be seen if you tilt your head back! Dr. Georgaklis is able to use a combination of these braces and retainers to give you a perfect smile. Learn more about lingual braces here.

Getting straight teeth as an adult doesn’t need to be a hassle or an embarrassment. It just takes six months to fix your teeth and have you loving your smile! Contact us for a free consultation!

 

 

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Six-Month Adult Aesthetic Orthodontic Treatment

Six-Month Adult Aesthetic Orthodontic Treatment

Straight teeth in just six months.

Posted on Glidewell Laboratories.

While cosmetic dentistry has commanded more attention with recent breakthroughs — such as all-ceramic crowns, veneers, composite materials and intraoral cameras — the demand for adult cosmetic orthodontic treatment has also increased. It has been estimated that in 1970, only 5 percent of adults aged 18 or older sought consultations for comprehensive orthodontic treatment.1 In 1990, four times that number sought consultations for orthodontics.

Currently, adults present with chief complaints about the crowding of their teeth more frequently than anything else.2 Many adult patients want to straighten their teeth, but they are unwilling to wear braces for two or more years. Patients presenting with a physiologic occlusion and a desire for aesthetic improvement can benefit from orthodontic correction that requires only a short treatment time of six months or less. Adults who have their teeth straightened experience a better body self-image and higher self-esteem.3,4 The general public is focused on a noncrowded, aesthetic tooth arrangement more so than orthodontists, who are also concerned with occlusal and skeletal relations.5 A short, six-month treatment can very well enhance periodontal and occlusal aspects of the patient’s dentition. Treatment, therefore, serves as an adjunct to final periodontic and restorative treatment, even though the main focus remains cosmetic.

Simultaneously treatment planning the orthodontics with the cosmetics, crown & bridge, and periodontics in the same office facilitates a well-orchestrated cosmetic result, which can be more difficult to achieve through cross communicating between specialists. In this context, limited cosmetic orthodontic treatment is best done on patients who otherwise may not opt for comprehensive orthodontic treatment.

Method

The first aspect of case selection involves a discussion of the patient’s chief complaint. Patients are given a list of orthodontic and cosmetic problems, and asked to indicate their objective(s) for seeking treatment. In almost 90 percent of adult cases, relieving anterior crowding is the primary concern. This figure is based on 20 to 25 new orthodontic consults per month for six months in my general practice.

When the patient is committed to treatment, a database of information should be obtained: panoramic and full-mouth radiographs, intraoral and extraoral photographs, and models. A problem list is then reviewed with the patient, followed by a comprehensive treatment plan. The orthodontic aspect should be cosmetically oriented, specifically excluding skeletal problems. Because the profile and posterior occlusion are not to be changed significantly, a lateral cephalometric X-ray is not necessary.6

The treatment sequence includes the following:

  • Data collection and records;
  • Prophylaxis, fluoride application, oral hygiene instruction, and endodontic and periodontic disease resolution;
  • Extraction of third molars and a lower incisor when necessary (other teeth may rarely need to be extracted);
  • Cosmetic orthodontics; and
  • Bleaching, crowns and cosmetic bonding when indicated

If the patient prefers not to wear Hawley retainers, teeth can be retained by splinting once settling has occurred.

The Case for Enamel Reproximation

Because the postextraction health of the temporomandibular joint has been questioned, bicuspid extraction is now done with less frequency than in the past. It provides a result that is not always aesthetic or stable, has been slowly decreasing in popularity (almost 8 percent between 1988 and 1993), and remains controversial, varying widely among practitioners.7-10 Almost one and a half years is required to close the extraction spaces, and nonextraction patients have fuller lip support following treatment.11 Expansion is also a questionable method of treatment because long-term stability is doubtful.12

However, enamel reproximation allows for minimal localized tooth movements, fewer extractions, maintenance of lip support and shorter treatment time. Begg theorized that crowding of most dentitions is actually the result of decreased proximal wear, which our evolutionary predecessors once experienced.13 Therefore, enamel reproximation would seem to be the most natural available remedy for relieving crowding.

Enamel reproximation (air-rotor stripping) can be done for up to a 10 mm arch-length discrepancy. Sheridan recommends limiting reproximation to 1 mm per contact or 0.5 mm per proximal surface.14,15 Frequently, more than this can be done without noticeable change in tooth morphology or sensitivity because it’s done throughout six months in conjunction with fluoride treatments. It has also been theorized that the resultant flat interproximal contacts may actually increase post-treatment stability.16 Anterior lower arch crowding greater than 4 mm should be treated with the extraction of a lower incisor, followed by reproximation to minimize the black triangular space at the gumline. In most cases, a space determination is performed by resetting the teeth on the models with wax to measure the space required. This also allows a preview of the aesthetic result for both patient and doctor.

Appliances

Brackets should be bonded to the first molars using a straight-wire technique and NiTi wires. Posterior brackets with a larger (0.022) bracket slot placed in an ideal, aligned position minimize posterior occlusal changes. Successive reproximation using double-sided fine diamond discs (Brasseler) is followed by the use of fluted carbide burs for finishing and rounding enamel edges. Interproximal over-reduction can rarely cause transient tooth sensitivity.

All teeth should be gradually aligned with local reproximation, progressively heavier wires and chain elastics. The principal tooth movements include rotations, tipping and vertical movements as opposed to translation and root torquing. By minimizing root movement and bone remodeling, treatment time is decreased. Profile change, relapse and root blunting are also minimized, which is significant because root blunting can occur when moving roots greater distances throughout a longer period.

Retainer wear is recommended for six months (full time), six months (at night) and three nights per week until stability is achieved. Post-treatment fiberotomies should be performed for all rotations. Following two months of retainer wear to allow for occlusal settling, cosmetic alterations may be performed, such as cosmetic bonding, bleaching, all-ceramic crowns, enamelplasty and gingivectomies. Teeth deficient in a mesial-distal dimension (peg laterals, enamel erosions or broken teeth) should be built up before treatment to allow for proper final tooth positioning.

Case I

The patient presented with typical Class I crowding with aesthetics as the chief complaint. Rather than expand the arches into an unstable position prone to relapse in the adult patient, or reproximate lower incisors so much that they impinge on the gingival embrasures, it was decided to remove a lower incisor. The uppers were reproximated using a Brassler diamond disc and edges recontoured. The treatment was seven months and the patient was splinted afterward. Some molar supra-eruption occurred because of an anterior composite bite plane that relieved the deep bite and decreased the likelihood of further attrition in the anteriors.

Case 1 - overcrowding teeth

Results after 7 months of treatment

Case II

The patient was referred by a local dentist who had done simple orthodontics, but who was not willing to treat occlusal problems. The patient had crowding with a bilateral crossbite that was causing both anterior and posterior attrition at a young age, requiring orthodontics.

The crossbite was corrected through the use of cross-arch elastics from the lingual of the upper molars and bicuspids to the buccal of the lowers. Enamel reproximation made space to treat the anterior crowding. Upper and lower bonded Ribbond splints served to reinforce the bonded incisal areas caused by attrition. It also provided resistance to fracture, as the splints produce a greater bonded surface area and composite thickness. An upper posterior Hawley retainer prevented relapse of the posterior crossbite.

Case 2 - Patient with crowding and a bilateral crossbite.

Case 2 - The crossbite was corrected through the use of cross-arch elastics.

Case III

This patient presented with the chief complaint of a large diastema. She had advice from numerous orthodontists who expressed different opinions regarding how to correct this (because of her deep bite and lack of lower spacing), as well as reservations regarding the possibility of successful retention. At our consultation, it was explained to the patient that our plan would include:

  • Upper and lower anterior retraction and possibly lower enamel reproximation because of extra space on the uppers;
  • A fixed composite bite plane on #8 and #9 lingual to relieve the deep bite by causing posterior supra-eruption;
  • Possibly redistributing excess space to the distal of the upper canines to limit the retraction required; and
  • An upper splint, which would be required. Removable retention is unacceptable in these cases. Therefore slight overjet in the final result is planned to make space for the splint.

Case 3 - Patient with large diastema.

Case 3 - Patient after five and a half months of treatment.

Per usual protocol, a prophy, bitewings, panoramic X-rays and restorative work were completed first. The patient’s treatment lasted five and a half months, with splinting and bleaching occurring on the final visit. At recall, the patient’s Ribbond splints were intact as she was not a bruxer. It is unlikely that this case would have succeeded without fixed retention.

It has been estimated that in 1970, only 5 percent of adults aged 18 or older sought consultations for comprehensive orthodontic treatment. In 1990, four times that number sought consultations for orthodontics.

Conclusion

Six-month adult cosmetic orthodontic treatment has a 60 percent acceptance rate among new patient consults in my practice, and post-treatment satisfaction is high. Many adults who undergo treatment have previously declined comprehensive treatment in other offices. Enamel reproximation, extraction of a lower incisor for space and limited occlusal change are among the modalities making this treatment unique and well accepted by patients. Offering clear or lingual appliances increases the patient’s cosmetic options. Treatment planning the orthodontic and restorative phases together facilitates patient understanding and communication, and delivers an outstanding cosmetic service. Patients with TMD, skeletal chief complaints, severe over/underjet, occlusal problems or very deviated midlines may opt for comprehensive treatment by an orthodontist. However, for the majority of adult patients with simply unaesthetic, crowded, spaced, functionally efficient and non-TMD dentitions, dentists should focus on the aesthetic chief complaint by performing conservative attenuated treatment in the general practice.

References

  1. Gottlieb EL. 1990 JCO study of orthodontic diagnosis and treatment procedures: results and trends. J Clin Orthod. 1991;24:145-56.
  2. Nattrass C, Sandy JR. Adult orthodontics—a review. Br J Orthod. 1995 Nov;22(4):331-7.
  3. Varela M, García-Camba JE. Impact of orthodontics on the psychologic profile of adult patients: a prospective study. Am J Orthod Denofacial Orthop. 1995 Aug;108(2):142-8.
  4. Lew KK. Attitudes and perceptions of adults towards orthodontic treatment in an Asian community. Community Dent Oral Epidemiol. 1993 Feb;21(1):31-5.
  5. Cochrane SM, Cunningham SJ, Hunt NP. Perceptions of facial appearance by orthodontists and the general public. J Clin Orthod. 1997 Mar;31(3):164-8.
  6. Proffit WR. Contemporary orthodontics. 2nd ed. St Louis: Mosby; 1993. p. 155.
  7. Little RM, Riedel RA, Engst ED. Serial extraction of first premolars—postretention evaluation of stability and relapse. Angle Orthod. 1990 Winter;60(4):255-62.
  8. McReynolds DC, Little RM. Mandibular second premolar extraction—postretention evaluation of stability and relapse. Angle Orthod. 1991 Summer;61(2):133-44.
  9. Weintraub JA, Vig PS, Brown C, Kowalski CJ. The prevalence of orthodontic extractions. Am J Orthod Dentofacial Orthop. 1989 Dec;96(6):462-6.
  10. O’Connor BM. Contemporary trends in orthodontic practice: a national survey. Am J Orthod Dentofacial Orthop. 1993 Feb;103(2):163-70.
  11. Paquette DE, Beattie JR, Johnston LE Jr. A long-term comparison of nonextraction and premolar extraction edgewise therapy in “borderline” Class II patients. Am J Orthod Dentofacial Orthop. 1992 Jul;102(1):1-14.
  12. Glenn G, Sinclair PM, Alexander RG. Nonextraction orthodontic therapy: posttreatment dental and skeletal stability. Am J Orthod Dentofacial Orthop. 1987 Oct;92(4):321-8.
  13. Begg PR. Stone Age man’s dentition. Am J Orthod. 1954;40:298-312.
  14. Sheridan JJ, Ledoux PM. Air-rotor stripping and proximal sealants. An SEM evaluation. J Clin Orthod. 1989 Dec;23(12):790-4.
  15. Sheridan JJ. The physiologic rationale for air-rotor stripping. J Clin Orthod. 1997;31:609-12.
  16. Peck H, Peck S. An index for assessing tooth shape deviations as applied to the mandibular incisors. Am J Orthod. 1972 Apr;61(4):384-401.
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Alternative Orthodontic Treatment for Adult Crossbites and Overbites

Alternative Orthodontic Treatment for Adult Crossbites and Overbites

Contact Rapid Braces

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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Improve Your Life with Straight Teeth

Straight Teeth Can Improve Your Life

Build your self confidence with straight teeth! Change your life in just six months with adult braces from Rapid Braces.

straight teeth fast bostonDr. Georgaklis is an expert in dentistry. He combines orthodontic techniques with cosmetic practices to give you a straight smile. And the best part about his work? It’s done in just six months! No case is too difficult for Dr. G. — 90% of his patients get straight teeth in six months or less.

As an adult, it can be embarrassing to have crooked teeth or wear braces to fix them. At Rapid Braces, adult braces are clear or lingual. You can have braces on the back of your teeth! This way, you can fix your smile without showing off the process. Behind the teeth braces or clear braces are a better option than Invisalign because they work faster.

Straight teeth will boost your self confidence, but there are also benefits beyond the cosmetic improvement:

  • Individuals with straight teeth chew better.
  • Having a perfect smile will give you a better bite.
  • Straight teeth can help you speak more clearly.
  • No gaps between your teeth will make them easier to clean and contribute to better gum health.

Rapid Braces is here for you. Dr. Georgaklis treats every patient like a friend. His appointments run closer to an hour, so he can get more done; which means he only sees eight to twelve patients a day. Each visit is customized to give you the best results. This Boston dentistry offers clear braces, lingual braces and different retainer options.

Having straight teeth can improve your life! Inquire now for a free consultation!

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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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