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All Posts in Category: Braces Behind Teeth

boston-lingual-braces

What You Should Know About Lingual Braces

Roughly one-quarter of all orthodontic patients are adults. The embarrassment of wearing braces has shown to be what makes most potential adult orthodontic patients shy away from the idea. Our Boston based orthodontics practice offers a few different options to alleviate the apprehensions of our adult braces patients. Aside from being able to correct most smiles in just six months, we also offer braces that aren’t easily visible to anyone else. In fact, with lingual (invisible) braces, no one else will ever know that you’re wearing adult braces unless you tell them.

Lingual braces go behind teeth

Lingual or sometimes known as invisible braces go behind or on the lingual side of the teeth. With the braces on the inside of your bite, they are undetectable by passers-by. Studies have shown that those who wear lingual braces experience less pain in their first month of treatment compared to those who wear traditional style braces.

When you first get any type of braces you will have to make some lifestyle changes. You’re going to have to learn how to clean your teeth differently with the braces attached. It is likely that you will only be able to eat soft foods until your mouth is used to have the new brackets installed. Due to the fact that the brackets, wires, and elastics are on the inside of the teeth, patients have reported that they have to make fewer lifestyle changes with lingual braces than those wearing labial braces. Anything pressing on the front of your mouth like playing a wind instrument will be far more comfortable with invisible braces.

Lingual braces have been shown to be far more effective than clear aligners at certain tooth movements. The fact that the braces pull on the back of the teeth allows for them to make adjustments to your bite in ways that clear aligners just can’t. The position of the brackets on the back of the teeth allows them to move teeth quickly and efficiently.

If you are an adult who is considering correcting the alignment of your teeth lingual braces are a great option. When you decide you pair them with the 6 month braces strategy you are sure to complete the process as quickly and efficiently as possible. Our Boston based cosmetic orthodontics practice can offer solutions to your issues with your smile. We focus on correcting the issues that matter most to you about the process rather than taking months to correct for the perfect bite. Our goal is to have the process be as fast and as smooth as it possibly can be for you.

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Most Popular Options for Adult Braces

Even if you’ve had braces in your youth, your teeth can shift as you age. Adult braces are becoming increasingly popular and improvements due to modern technology mean there are options for everyone. Making the best choice for yourself requires a lot of research into the different adult braces options available in the Boston area. Some things to consider are how comfortable it is to wear the braces, how visible the braces will be and how long they will have to be on your teeth.

Some of the more common options to consider are:

Metal Braces

When most people think of braces this is the image that pops into their mind. Metal braces adhere directly to the teeth and remain in place until the treatment is complete. When it comes to food and drink there are some restrictions when using metal braces. You have to consider how hard it is going to be to clean the food out of the braces, and if the items may break the braces.

Lingual Braces

Having the same components as conventional braces, lingual braces adhere to the back of the teeth, on the tongue (lingual) side. The fact that they are on the inside of the teeth means they are virtually undetectable by other people. This makes them a very popular choice for braces among adults.

Clear Braces

Working in the same way that metal and lingual braces do, clear braces adhere to the teeth and are tightened with wires. They are made out of porcelain, plastic, or ceramic. Being invisible and providing strong results, clear braces are very popular among adults. Achieving the same results in the same way lingual and metal braces do, clear braces are typically worn for 1-3 years.

Many Boston orthodontists require 1-3 years to take braces off for straight teeth but Rapid Braces can complete treatment faster with our 6 Month Braces option. Dr. Georgaklis specializes in getting patients straight teeth fast with his six-month braces procedure. Most orthodontists spend a significant amount of time perfecting the molar bite into the “ideal bite” typically not taking your concerns into consideration. Dr. Georgaklis and those who practice his short-term philosophy, do little or no modification of the bite if it is functional and does not present a problem. Focusing mainly on the front teeth and not the molars accelerates treatment. The timeline to straight teeth is much shorter as a result. In 90% of cases, the process is shortened to just six months.

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Are Invisible Braces Right For Me?

Braces are a necessary part of growing up for many people. Visits to the Boston orthodontist were needed to get straight teeth and the patient got a beautiful smile after the braces were taken off. Unfortunately, not everyone is able to get braces when they are younger for a variety of reasons and then feel stuck with teeth that aren’t aligned as well as they could be. Adults are often hesitant to get braces because of the obvious impact on their appearance and put off getting cosmetic orthodontic treatment completely. Today, however, there are a number of different Boston Adult Braces options offered at Rapid Braces that can give you a beautiful smile in 6 months or less.

boston invisible bracesFor many people, the number one concern about getting Adult Braces is how they will affect their appearance. The experts at Rapid Braces understand how wearing braces can make anyone feel socially awkward and have options to help you keep your braces as hidden as possible. Invisible braces are put on the lingual side (behind the teeth) of your mouth so they can’t easily be seen. Once you’re wearing them, invisible braces work the same way that traditional braces do to straighten your teeth but the fact that they’ll be doing their work behind your teeth means that you’ll be the only one who knows you’re wearing braces.

Boston Invisible Braces are a good option for a wide range of patients. They can be custom made to fit your mouth and fix a variety of alignment/spacing issues. Our Invisible Braces option is also popular because you can get straight teeth fast with Rapid Braces 6 Month Braces treatment. The quick 6 month treatment is perfect for adults who don’t have much time for appointments or want an awesome look for a big event coming up. Over 90% of cases treated by Dr. Georgaklis at Rapid Braces have been completed in 6 months or less.

Schedule a consultation at Rapid Braces today to find out more about how we can help you get a beautiful smile with Boston Invisible Braces. We can get a good look at how your teeth are aligned and make recommendations for best adult braces options. Once you decide on a treatment option we’ll schedule the first appointment to get started with adult braces. We strive to make appointments as convenient as possible, it is important that you don’t miss any scheduled appointments if you would like to finish treatment as quickly as possible. Please contact us if you have any questions about Boston 6 Month Braces.

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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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Adult Invisalign Alternatives

Invisalign Alternatives for Adults

Invisalign is one of the most popular choices to get braces for adults. Patients of all ages have welcomed Invisalign because of its discreet treatment method. The Clear Plastic trays are perfect for adults who would like to keep their braces hidden from co-workers or friends. The Invisalign plastic slowly adjusts your teeth. Every couple of weeks, a new set of Invisalign trays are set to replace the old set. Invisalign is so popular, not only because of its discreet appearance but because of its discrete adjustments to your teeth with no pain.

For Adults that never got the Orthodontic attention they needed as a teenager, cosmetic orthodontic treatment with methods like Invisalign are becoming popular. Because so many adults are looking for discreet treatment options, we offer Invisalign alternatives at Rapid Braces that can get you a beautiful smile.

Incognito Braces

Incognito braces are the latest orthodontic trend for alternatives for adult braces. Incognito braces are hidden from your smile as they are affixed to the back of the teeth. This technique allows the braces to be virtually invisible. The Incognito braces also eliminate the concern of braces damaging the front of the teeth. Your white smile cannot be damaged with this orthodontic treatment.

Clear Braces

Getting Clear Braces is another way to avoid unattractive metal braces during 6 Month Cosmetic Orthodontic Treatment. Clear Braces use clear bands so they can’t be seen easily and are more affordable than lingual braces put behind the teeth. Clear Braces are perfect for adults who don’t want the attention that orthodontic treatment can bring. Fixing your smile as an adult is easier than you can imagine. Schedule an appointment at Rapid Braces and we can take a look at your teeth and see which Invisalign Alternatives would be best for you.

clear braces orthodontic treatment

Why Rapid Braces?

Here at Rapid Braces, we understand the importance of giving each patient enough time to make sure all questions are answered. Patients have specific needs and we make sure to develop a personalized plan for everyone we see at Rapid Braces. Rapid Braces provides a relaxed environment so our patients can be as comfortable as possible when visiting for an appointment. Our team loves to welcome in any new patients and help them get straight teeth fast with our 6-month braces treatment.

To learn more about the alternatives to braces for adults offered by Rapid Braces, visit our office, or reach out to us through our Contact Form.

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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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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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