Merging Orthodontics and Restorative Dentistry: an Integral Part of Esthetic Dentistry

Merging Orthodontics and Restorative Dentistry: An Integral Part of Esthetic Dentistry

BOZIDAR L. KULJIC, DDS*

ABSTRACT This article discusses the different approaches in treatment planning of patients who desire an esthetic and functional improvement of their dentition but are hesitant to sacrifice healthy tooth structure. Preservation of tooth structure, whenever possible, should be paramount to any practicing dentist. The importance of such an approach, as taught for so many years, appears to be fading away lately under the pressure of advertisements full of promises for quick esthetic solutions. Exploration of the link between orthodontic and conservative restoration, along with minor use of periodontal procedures, will give another perspective in solving the esthetic dilemma. CLINICAL SIGNIFICANCE Often underutilized, the combination of procedures such as orthodontics and composite bonding gives practicing clinicians conservative, predictable, esthetic, and functional results. (J Esthet Restor Dent 20:155–164, 2008)

INTRODUCTION expense of healthy tooth structure involvement. By spending time and n today’s world, the media often and under the name of “instant discussing all of the positive and Idictates the desirable appearance orthodontics.” Modalities such as negative aspects of extensive restor- among which the smile plays an orthodontic movement of the teeth ative work, we should give the important part. Under the influ- along with resin bonding are patient enough information so ence of such advertisements, conveniently skipped under the there will not be remorse at the patients seek these labeled smiles at assumption that patients are not end of the treatment. their dentist’s office. In trying to willing to wear braces. In all satisfy their clients’ desires, clini- honesty, they have been softly sug- It is true that modalities such as cians often rush to offer an gested to take other avenues. Even orthodontics and operative services “instant smile” design without in some of our dental tabloids in cannot solve all problems. They, considering the long-term health justification of a proposed treat- too, have their own shortcomings. and well-being of the patients.1,2 ment plan, authors briefly mention The need for an interdisciplinary Namely, all-ceramic crowns and that the “patient has refused orth- approach that involves other spe- porcelain veneers (aggressively pre- odontic treatment” and, as a solu- cialties such as prosthodontics, pared) are used all too often to tion, extensive restorative dentistry periodontics, oral surgery, and correct structural damage as well is recommended and later per- orthodontics is always present.3–5 as orthodontic discrepancies at the formed with significant financial Unfortunately, the use of direct

*Assistant clinical professor, Department of Prosthodontic and Operative Dentistry, Tufts School of Dental Medicine, Boston, MA, USA; private practice, Beverly, MA, USA

Figure 1. Note the irregular occlusal plane Figure 2. Midline shift and the upper left canine positioned and a discrepant smile line. too buccally.

resin restorations, enamel reshap- ing, and vital bleaching as parts of esthetic dentistry is largely neglected even though they can add value and lower the total cost of the treatment.

CASE REPORT The patient presented is 52 years old. She was not happy with the appearance of her upper left canine Figure 3. Wear of the lower incisors indicative and her overall smile (Figures 1 of a restricted path of closure. and 2). Her ability to finance extensive dental treatment was somewhat limited. Nonetheless, she arch and were planned to be with the maxillary second premo- was willing to explore other dental restored accordingly (Figure 3). lars and first molars, exhibited a options if that meant preserving The patient was missing her upper Class I to Class II mobility. They healthy tooth structure and bring- right first premolar. As a conse- also showed a moderate amount ing the cost of treatment to a level quence, the midline had shifted of enamel wear. Crack lines were with which she was comfortable. 4 mm to the right. Her upper right visible on both maxillary central She is healthy without compromis- second bicuspid was in a crossbite incisors. The patient was aware of ing medical conditions. Clinically, and was rotated 180 degrees occasional clenching, which she the patient exhibits good oral (Figures 4 and 5). Her overbite was ascribed to stress associated with hygiene. She is periodontal AAP 4 mm and her overjet was 2 mm. her work. She experienced frequent Type II (American Academy of The TMJs were not tender to pal- spells of headaches along with Periodontology). A few failing pation although bilateral clicking occasional pain/tenderness in her amalgam and composite restora- existed upon opening. All upper temples as well as in the occipital/ tions were noted in the mandible and lower central incisors, along neck area. Her anterior path of

Figure 4. Upper right second premolar is in a crossbite. Figure 5. Upper dentition showing maxillary constriction that caused the upper left canine to be positioned too buccally. closure was somewhat restricted coincide, the removal of her upper angled teeth. The upper canines and had contributed to the wear of left first premolar would be neces- presented the greatest challenge, both her upper and lower incisors. sary. Her choice was to keep the because of their rotated position. She had a moderate to high smile tooth and accept the limitation. It was almost certain that the left line. Upon careful analysis of the She understood, too, that her canine would require intentional clinical data, the patient was direct composite restorations endodontic treatment in order to presented with two different would need periodic repolishing visually position the future full treatment options. over time to bring back the surface coverage restoration into proper luster to the restorations.7 alignment with the rest of the TREATMENT OPTIONS upper dentition (Figure 6). The first option consisted of orth- Treatment time would require 12 odontic treatment with the goal of to 15 months to finish the case The right canine was too rotated bringing the arches into a more and would not involve any fixed to receive a thin porcelain veneer. rounded (to allow a better esthetic prosthodontic services. The amount of tooth reduction outcome) and stable position (to would be too great and would make treatment more functionally The second option consisted of leave the majority of the bonding predictable).6 Additionally, it reconstructing the entire posterior surface of the tooth in dentin. included the placement of a few quadrants of either the upper or This would significantly compro- direct resin-bonded composite res- lower dentition, opening the OVD mise long-term bonding and would torations as a relatively inexpensive and improving the restricted path result in a poorer prognosis transitional solution to make up of the closure. To make the smile of the restoration. Therefore, for the lost tooth structure. The design more desirable and harmo- a full coverage restoration was patient was made aware of the nious, all upper premolars along deemed necessary to bring this limitations of achieving an ideal with the upper incisors would tooth into visual alignment with result (midline shift) because of the need porcelain veneers. This the rest of the teeth. Estimated missing upper right first premolar. approach would broaden the smile time to finish the treatment was Nonetheless, to make the midlines and give the illusion of properly between 5 and 7 weeks. Significant

VOLUME 20, NUMBER 3, 2008 157 MERGING ORTHODONTICS AND RESTORATIVE DENTISTRY

Figure 6. Black line shows future buccal position Figure 7. Upper arch, after orthodontic treatment, of the upper teeth. showing the ideal alignment of the upper teeth.

tooth reduction and financial com- The wire sequence started with opened the space for the upper left mitment would be needed for this “cat” wire 0.0175 inch (Ortho canine to be brought into alignment approach. Organizers, Carlsbad, CA, USA) with the other teeth (Figure 7). In and progressed to a rectangular contrast to the upper jaw, the lower After a thorough consultation and wire 0.19 ¥ 0.25 inch. The great arch exhibited slight crowding in review of all options, the patient benefit of rounding out the arches the anterior quadrant. Composite elected to pursue the first treat- is that the arch is expanded, creat- “ramps” were placed over the ment option. The potential to ing spaces to better allow for occlusal surfaces of the lower remove composites in the future optimal positioning of the mala- second premolars and the first and with minimal potential damage ligned teeth. In a case when second molars to allow for rapid (should she desire to replace them expanding the arches is not enough correction of the crossbite. This with more definitive restorations to allow complete and ideal align- also allowed for more spaces such as porcelain veneers) helped ment of all teeth, proximal enamel between the arches and prevented to make her decision easier. stripping is indicated. frequent dislodgement of orthodontic brackets. As orthodontic treat- Orthodontic Treatment In this case, the upper left quadrant ment progressed, the “ramps” were All preoperative data were col- exhibited excessive intra-arch con- gradually lowered and, at the end lected and orthodontic treatment striction such that the upper left of the treatment, only a small was initiated. As there was moder- canine largely stayed out of proper amount of composite was left on ate wear of the incisal edges of the upper arch alignment. By stripping the lower first molars and lower upper incisors, brackets were the interproximal aspects of the right second bicuspid. They would placed, taking into consideration upper left bicuspids with a Quik- be removed during the replacement the future position of the gum line Strip (Axis Dental, Coppell, TX, of the existing restorations. The instead. As a result, the incisal USA), additional space was created. wire sequence, along with minimal edges were not going to be even at The upper left premolars were interproximal stripping of the inci- the end of the treatment. moved more distally, which also sors, was all that was needed to

Figure 8. Lower arch retained with bonded lingual Figure 9. Crossbite corrected. bar.

achieve ideal tooth position in the Although there is insufficient appropriate length of the central lower arch. research data on which to base and lateral incisors. Analyzing the clinical practice on retention at smile line and the relationship A Hawley appliance (Great Lakes present, the remaining restorative between incisal edges of the upper Orthodontics, Ltd., Tonawanda, and periodontal part of the case centrals and the lip in repose posi- NY, USA) was used as a retainer was scheduled 4 months after tion, it appeared that adding 1 mm of choice for the upper arch. The the completion of active to the incisal edges was indicated patient was instructed to wear it orthodontic treatment.9 to create the most appropriate pro- for 18 out of 24 hours for the portion (8 mm width and 10 mm first 6 months and then to wear Restorative Treatment length) without compromising the the appliance overnight for an Before the restorative treatment width-to-length ratio (Figures 10 extended period of time. Because was begun, vital teeth whitening and 11). Studies have shown that of a tendency to relapse, the was initiated. Whitening trays the majority of the human popula- lower teeth were retained by a were fabricated from the final tion, regardless of gender, exhibits bonded lingual bar (Figure 8). It is orthodontic models. Whitening clinical crown length in excess interesting to note that, at the end was performed with Opalescence of 10 to 11 mm for maxillary of the orthodontic treatment, the gel PF 10% (Ultradent, South central incisors.13 patient reported complete absence Jordan, UT, USA) applied once a of headaches and neck stiffness.8 day for 2 hours for 7 days.10 The Freehand direct resin restorations At the end of the orthodontic patient was instructed to wait 10 were used to compensate for the treatment, it was obvious that days after the last session of lost tooth structure along the some of the preexisting shortcom- bleaching so that no adverse incisal edges.14–16 Vit-L-escence, ings (missing upper right first pre- effects on enamel bonding would shade Pearl Frost (Ultradent) was molar and 180-degree rotated be encountered.11,12 used as a lingual layer that would upper right second premolar) prohibit complete light penetration would prevent an ideal orthodon- Along with vital bleaching, time through the restoration. It is a tic outcome (Figure 9). was used to determine the hybrid resin that adds to the

VOLUME 20, NUMBER 3, 2008 159 MERGING ORTHODONTICS AND RESTORATIVE DENTISTRY

Figure 10. The incisal edges of the upper incisors Figure 11. The occlusal plane is corrected and canines stayed uneven after orthodontic after orthodontic treatment. treatment.

structural strength of the final restoration. The middle layer, a microfill resin, Durafill VS Shade OA2, (Heraeus Kultzer GmbH, Hanau, Germany) was used to make up for the missing dentin.

Because of the excellent polishing properties, microfill resin, Durafill VS Shade A1 (Heraeus Kultzer Figure 12. Note the positive smile line and GmbH) served as the final outer even incisal edges after finishing the case. enamel layer. After creating appropriate shapes and contours of the restorations, the final pol- (Figure 13). The upper right side bone crest over the upper second ishing took place. The Sof-Lex XT posed a greater challenge. Even premolar and finding Pop-On Discs (3M ESPE, St. Paul, though the upper second premolar that it was 5 mm from the free MN, USA) were used in the was taken out of crossbite, it gingival margin, it was determined sequence recommended by the remained an esthetic problem. A that there was only 2 mm of the manufacturer. After the central 4-mm discrepancy of the gingival gingival tissue that could be con- and lateral incisors were finished, margins between the second servatively removed without the slight enameloplasty was per- premolar and the upper right violation of the biologic width.17,18 formed on the upper left canine canine remained. In addition, Gingival recontouring was to reduce the pointedness of the the emergence profile of achieved using an electrosurge incisal contour (Figure 12). The the right bicuspid, because of the unit (Macan Engineering and upper left premolars did not rotated position, was not Manufacturing Comp, Chicago, need any additional correction favorable. Sounding the buccal IL, USA).

Figure 13. Gingival harmony and ideal position of teeth on the Figure 14. Gingival improvement of the upper right upper left side. side.

Figure 15. Improved alignment and corrected incisal edges of Figure 16. Corrected anterior crowding and rem- the upper teeth. nants of composite “ramps” left after orthodontic treatment.

By placing composite resin over the canine had a cusp tip that ment was performed without a buccal aspect of the tooth, the remained slightly palatal and single diamond or carbide bur emergence profile was improved as needed to be brought more buc- (Figures 15–17). well as the width-to-length ratio of cally. By placing a thin layer of the clinical crown (Figure 14). resin composite over the coronal DISCUSSION Because of the precise bracket third of the tooth, the discrepancy With recent advancements in placement, no additional gingival was corrected. Finally, it is worth bonding, wear, and polishability, recontouring was needed in the mentioning that, using this new resin composites offer excep- anterior region. The upper right approach, an entire smile enhance- tional opportunities to practicing

VOLUME 20, NUMBER 3, 2008 161 MERGING ORTHODONTICS AND RESTORATIVE DENTISTRY

4. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc 2006;137(5):584; author reply 584.

5. Roblee RD. Interdisciplinary dentofacial therapy (IDT): a comprehensive team approach. Ann R Australas Coll Dent Surg 1998;14:41–7.

6. McIntyre FM, Jureyda O. Occlusal func- tion. Beyond centric relation. Dent Clin North Am 2001;45(1):173–80.

7. Redman CD, Hemmings KW, Good JA. The survival and clinical performance of resin-based composite restorations used to treat localized anterior tooth wear. Figure 17. Occlusal view of a finished upper arch. Br Dent J 2003 24;194(10):566–72; discussion 559.

8. Zafar H, Nordh E, Eriksson PO. Tempo- ral coordination between mandibular and head-neck movements during jaw opening-closing tasks in man. Arch Oral dentists to merge restorative, substantial monetary savings, Biol 2000;45(8):675–82. orthodontic, and periodontal treat- appears to be a great incentive in 9. How Kau C. Orthodontic retention ments to achieve the most conser- accepting the proposed treatment. regimes: will we ever have the answer? vative and cost-effective approach An honest, straightforward, and Evid Based Dent 2006;7(4):100. to solving many esthetic challenges. clear presentation of the treatment 10. Haywood VB. Frequently asked questions This approach also is suited for plan, along with full disclosure about bleaching. Compend Contin Educ Dent 2003;24(4A):324–38. patients with a limited budget of possible shortcomings, is of 11. Shinohara MS, Peris AR, Pimenta LA, and a great concern for the great importance. Ambrosano GM. Shear bond strength removal of healthy tooth structure evaluation of composite resin on enamel DISCLOSURE and dentin after nonvital bleaching. for esthetic purposes. J Esthet Restor Dent 2005;17(1):22–9; The author does not have any discussion 29.

Although the author realizes that financial interest in any of the 12. Cavalli V, Reis AF, Giannini M, there are a number of patients manufacturers whose products are Ambrosano GM. The effect of elapsed time following bleaching on enamel bond who would not accept any orth- mentioned in this article. strength of resin composite. Oper Dent odontic treatment regardless, it is 2001;26(6):597–602. his clinical experience as well as REFERENCES 13. Chu SJ. Range and mean distribution fre- 1. Simonsen RJ. Commerce versus care: quency of individual tooth width of the professional conviction that there troubling trends in the ethics of esthetic maxillary anterior dentition. Pract Proced is a significant part of the patient dentistry. Dent Clin North Am Aesthet Dent 2007;19(4):209–15. 2007;51(2):281–7. population willing to consider 14. Fahl N Jr. Optimizing the esthetics of orthodontic treatment if time is 2. Heymann HO, Kokich VG. Instant Class IV restorations with composite orthodontics viable treatment option or resins. J Can Dent Assoc taken to explain its true benefits “quick fix” cop-out? J Esthet Restor 1997;63(2):108–11, 114–5. in preserving tooth structure. The Dent 2002;14(5):263–4. 15. Fahl N Jr. Predictable aesthetic recon- preservation of healthy tooth 3. Spear FM, Kokich VG. A multidisci- struction of fractured anterior teeth structure wherever possible, and plinary approach to esthetic dentistry. with composite resins: a case report. Dent Clin North Am 2007;51(2):487– Pract Periodontics Aesthet Dent often with the added benefit of a 505, x–xi. 1996;8(1):17–31.

16. Baratieri LN, Ritter AV. Critical variables. J Esthet Dent 1994;6(1):3– appraisal. To bevel or not in anterior 9. Reprint requests: Bozidar L. Kuljic, DDS, composites. J Esthet Restor Dent 900 Cummings Center, Suite 106T, Beverly, 2005;17(4):264–9. 18. Kois JC. The restorative-periodontal MA 01915, USA. Tel.: 978-922-4200; Fax: interface: biological parameters. Period- 978-922-1288; email: [email protected] 17. Kois JC. Altering gingival levels; the ontol 2000 1996;11:29–39. restorative connection. Part 1: biologic

VOLUME 20, NUMBER 3, 2008 163