JCD international journal of cosmetic as an adjunct to restorative dentistry - an illustrative case Peter Huntley BDS MSc FDS MOrth

Introduction History height was slightly reduced as was the Frankfort-mandibular planes Masking of underlying malocclusion Emma was aged 36 when she was angle (Figure 1a and b). The soft can result in compromises when referred in 2004 by her general tissues were balanced, with undertaking restorative treatment. dental practitioner regarding the competent lips and a high lip line, The degree and consequences of persistent bonding failure of the producing a smile which was such compromises will vary from veneers on the upper incisors. These somewhat gummy, with 2-4mm of case to case, and an analysis and had been made four years previously gingival show extending to the discussion of these should form a to mask the irregularity and buccal segments, combining with part of the consent process. This discolouration of the upper incisors. narrowness across the premolars to case illustrates some of the pitfalls Emma was happy with the aesthetics produce significant buccal corridor that can be associated with a of the veneers, but becoming shadows (Figure 1c). The TMJs were restorative-only approach, which increasingly concerned regarding healthy and the and were solved by joint orthodontic- their regular bond failures. general dental condition were good. restorative management. Medical history The labial surfaces of the upper There was a benign mild mitral valve incisors were well aligned, having prolapse for which antibiotic (AB) been restored with porcelain cover was recommended by the veneers. The palatal aspects of cardiologist for exposure prone these teeth were irregular confirming procedures. the underlying incisor crowding (Figure 1d). Oral examination The skeletal pattern was symmetrical The overbite was increased and and mildly class 2. The lower face complete to soft tissue, the

Figure 1: a-b – Pre-treatment facials

Figure 1: c – Pre-treatment smile

Figure 1: d – Occlusal view upper arch Figure 2: a-d – Pre-treatment intra oral views

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Figure 3: c-d – Steep anterior Figure 3: a-b – Palatal margin guidance displacing veneer Orthodontic diagnosis

Class 2 division 2 incisor relationship on a mild skeletal 2 base with an average lower face height and mild incisor crowding in both arches. The smile was somewhat gummy. The case was complicated by previous loss of 16 and 35, and by the camouflaging of upper incisor crowding with porcelain veneers which were unstable.

Aims of treatment: • Reduce overbite • Decrease inter-incisal angle • Camouflage underlying skeletal discrepancy • Eliminate buccal corridor shadows retroclined upper incisors having • Harmonise occlusion for over-erupted. The canines were restoration of the upper incisors. partially class 2 on both sides. There was mild crowding of the Treatment plan: lower incisors and a fairly marked • Extract 25 (under AB cover) to curve of Spee, combining to produce balance 16 loss, improving the uneven lower incisal edge wear canine relationship as all upper (Figure 2a-d). spaces close • Upper and lower fixed appliances Observations using rectangular wires to control • Removable retainers to be worn in Class 2 division 2 relationships incisor torque both arches until the completion produce steep guidance in all • 35 space to be kept and restored of the restorative phase. excursions, and most patients after orthodontic phase, lower function mainly in centric and arch expansion being necessary to Treatment time was estimated at 2 protrusion. This, combined with reduce overbite and camouflage years. Emma requested the use of stronger than average muscular skeletal discrepancy aesthetic appliances, upper lingual forces associated with this • Fully bonded appliances to avoid fixed appliances offering particular malocclusion type, make the the need for AB cover during advantages in this case. bonding problems with veneers in appliance fitting Routine use of this case less than surprising 0.2% chlorhexidine mouth1 rinse Lingual brackets with bite planes are (Figure 3a-d). However, progression prior to appliance adjustments highly effective at overbite to full coverage restorations would following BOS guidelines reduction, and gave the additional have been highly destructive due to • Fixed retainers to be fitted to advantage of avoiding bonding to the underlying rotations of the support the upper and lower tenuous veneers. incisors. It was at this point that anterior teeth and kept in place reorganisation of the occlusion by permanently provided hygiene In the lower arch Emma opted for the orthodontic means was considered. allows it use of labial ceramic fixed appliances. september 2011 ● vol.2 no.1 41 JCD international journal of cosmetic dentistry

Figure 4: a – Lingual appliance incorporating bite planes Figure 6: a-b – Left side before (left) and after (right) space closure

Figure 4: b – Immediate disclusion effect Orthodontic prescribed during space closure to treatment progress correct the canine relationship and facilitate overbite reduction. As A laboratory set up of Ormco 7th upper arch spaces were closed, the generation 0.018" slot brackets was lower arch was expanded, slightly prepared, allowing indirect bonding increasing the 35 space, and space using a transfer tray. These brackets for lower incisor alignment gained by incorporated a bite plane which their proclination. Such movement produced immediate disclusion camouflages a skeletal 2 (Figure 4a and b). No bonding discrepancy, but as proclined teeth failures of the veneers occurred after occupy more arch length, the canine appliances were bonded. relationship usually remains slightly Once initial upper arch alignment class 2, as in this case (Figure 6a had been achieved, the lower arch and b). was bonded with 3m Unitek Clarity 0.022" slot brackets with MBT As space closure neared completion prescription (Figure 5a-c). the restorative reviewed the occlusion and requested that the Once alignment had been achieved, overbite be made incomplete. This rectangular stainless steel wires would allow full coverage porcelain were fitted in both arches to allow restorations to be created whilst space closure with 3-D control. minimising the amount of palatal Expression of these wires caused a tooth reduction. Bends were placed change in upper incisor inclination distal to 33 and 43 to achieve this and an opening of the contacts (Figure 7). between the veneers. Nocturnal Figure 5: a-b – Front view, class 2 intermaxillary elastics were Treatment progress was somewhat day of lower bonding interrupted by the diagnosis of Crohn’s disease which required hospitalisation. After two years and six months of treatment, fixed appliances were removed under AB cover and upper and lower lingual fixed retainers bonded at the same appointment. Interdental brushes were demonstrated for daily use. Upper and lower vacuum formed retainers were fitted for nocturnal Figure 5: c – Occlusal view, day of bonding Figure 7: Bends to further reduce overbite

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Figure 9: a-b – Temporary restorations

Figure 8: b – Smile at end of Figure 8: a – Pre-treatment smile orthodontic phase

wear, and the patient advised to during the orthodontic phase (Figure Luxatemp finished with Luxatemp attend for retainer checks after any 8a and b). It has been suggested2 glaze (Figure 9a and b), were joined restorative procedures. that this might be due to changes in to prevent orthodontic relapse. lip retraction resulting from palatal Restorative phase root movement (Figure 8c). This was The all-ceramic crowns (Figure 10a-c) refined by surgical crown were fabricated from Emax and Nocturnal home bleaching with 10% lengthening, excluding 22. cemented with Nexus Clear. carbamide peroxide was undertaken soon after debond. Six months after the removal of fixed One week later a fixed retainer was appliances, the upper incisors were refitted, extending from 13 to 23 and Significant reduction in the prepared for full coverage crowns. utilising hydrofluoric acid etch and gumminess of the smile occurred The temporaries, fabricated from silane bonding agent (Figure 11a).

Figure 7: c – Diagram of possible mechanism of reduction in gumminess (from Costa et al.2) september 2011 ● vol.2 no.1 43 JCD international journal of cosmetic dentistry

Figure 10: a-c – Final restorations

and mutual understanding are essential to success.

Acknowledgements I would like to thank Dr Dominic Hassall for providing the post orthodontic restorative treatment in this case.

Restoration of 35 space has been Discussion References deferred by the patient and so 1. Orthodontic management of the nocturnal wearing of a vacuum- This case illustrates some of the medically compromised patient. formed retainer is continuing in the compromises and risks associated British Orthodontic Society Advice meantime (Figure 11b and c). with masking aspects of a significant Sheet number 25. malocclusion by restorative means 2. Costa MO, Costa MC, Pinho C, only. Such an approach may well be Quintao C. Correction of severe preferred by the patient, but a overbite and gummy smile in discussion of its shortcomings and patients with bimaxillary risks should form part of the consent protrusion. J Clin Ortho 2010 process. 4: 237-244.

Following an initial unstable restorative-only approach, Further reading orthodontic treatment produced an • The Art of the Smile-Integrating increase in the inter-incisal angle, , Orthodontics, Figure 11: a – Final fixed retainer overbite reduction, alignment, an Periodontics, Dental Technology, increase in smile width and a and Plastic Surgery in Esthetic reduction in the gumminess of the Dental Treatment. Romano (ed). smile. This contributed to a greatly Quintessence Publishing. improved overall outcome (Figure 12a and b).

It should also be considered that once a restorative-only path is followed, subsequent orthodontic correction of other aspects of the malocclusion may be more difficult or impossible. The restorative dentist should be aware that the alternative of orthodontic treatment prior to restorative treatment can produce a range of improvements, and a far superior functional and aesthetic outcome in some situations. Where separate individuals provide these Figure 11: b-c – Vacuum formed lower retainer preserving 35 space treatments, good communication Figure 12: a-b – Overall treatment change

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