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

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

All Posts Tagged: short term braces

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.
Read More

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.

Read More

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.
Read More

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.

Read More