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Rehabilitation of the worn dentition Nancy Ward, of the Pankey Institute Visiting Faculty presents a case report integrating restorative and orthodontic treatment approaches

here are many challenges when treating posterior slide into maximum intercuspation adult patients. Decreased cell turnover, was evident. 4-5 mm pockets in between the Tno potential of growth modification, first and second molars were also noted. The complicated medical histories, and previous oral patient was referred for periodontal treatment disease (periodontal disease, caries, tooth wear, where the periodontal condition was stabilised temporomandibular dysfunction) have been prior to initiating any further treatment. reported as major considerations when treating Problem list: adultsREF1. In adults, often compromises have • Severe wear of the anterior teeth to be made, especially in terms of • Supra-eruption of the attachment and anterior coupling when the foundation apparatus around the incisors due (ie occlusal relationships) are not going to to wear of the incisal edges be changed. Without proper alignment: • Increased overjet • Poorly aligned teeth can create abnormal Figure 1a: Pre-trial smile • Class II Division 2 with lateral force and stress on surrounding narrow arches (Figure 2). teeth and periodontal structuresREF2 Aims of Treatment: • Severe bruxism and wear of anterior teeth a. Create a Class I canine relationship can cause the attachment apparatus to b. Level align and rotate teeth extrude with the wear of the incisorsREF3 c. Round the arches • Periodontal surgery is often needed to d. Intrude upper central incisors to establish proper gingival architecture create proper gingival architecture • Alignment of the teeth prior to restorative e. Proper alignment of the upper enables the establishment central and lateral incisors creating of a physiologic occlusion space for restorative material. • Alignment also allows for minimally To create a physiologic occlusionREF4, invasive restorative dentistry. the following principles were to be followed: This case report highlights a multi-disciplinary Figure 1b: Trial smile Anterior View (by Dr. Jhonson Haygood • Maximum number of posterior teeth Pankey Composite Course) approach to treating an adult patient with touch simultaneously in severe wear on the anterior teeth. arc of closure with the occlusal forces directed down the long axes of the teeth Case presentation • When force is applied no teeth are Virginia is a very outgoing person who loves to moved and the jaw does not deviate be around people. She was embarrassed about • Posterior teeth disoccluded by anterior her smile. A family member told her that she teeth in excursive movements looked like a vampire, which prompted her to • Condyles seated on the disc in their most seek advice. Economics was a major concern superior, anterior, medial unstrained position. to Virginia and she therefore volunteered to have a trial smile done at a composite course Treatment options (Figure 1a, 1b, 1c). The trial smile showed her 1. Veneers from UR6 to UL6, the possibilities of what could be achieved Figure 1c: Trial smile Profile View with no orthodontic treatment, as shown with the trial smile Nancy Ward DDS, MAGD qualified from 2. Orthodontic treatment without University of Maryland, Baltimore College with a cosmetic make over. The trial smile surgery, creating a Class 2 Division 1 of and went on to gain a was used to establish incisal display when occlusion without anterior coupling and Mastership in the Academy of General Dentistry the lips were at rest and also showed the accepting the increased overjet, followed and the status of Premier Provider for Invisalign. architecture of the gingival display (Figure 1b). by veneers on the upper incisors. Dr Ward completed the continuums at the 3. Orthodontic treatment including the LD Pankey Institute in the late 1980’s. She has Comprehensive Exam extraction of UL4 cantilever and UR4 to allow been a member of the visiting faculty at the A comprehensive exam revealed missing retraction of the anterior teeth to create a Pankey Institute since 1995 and served on the UR8, UL4, UL8, LL8 and LR8. The patient Class I canine relationship, with simultaneous foundation board since 1990. She has lectured for Align Technology at both its GP Summits had lost UL4 which was replaced with a mesialisation of the upper premolars and and GP Forums. cantilevered from the UL5. The patient molars to close any residual spaces. Intrusion www.pankey.org had no other restorations. A large centric of the severely worn upper central incisors interference was noted and an 8mm anterior/ could also be incorporated to allow bonding

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Figure 2: Pre-treatment photographs in maximum intercuspation

of the upper incisors (composite bonding Initially, the patient used the CII elastics or veneers). Fixed appliances and Invisalign running from upper 3s to lower 6s. When the (with the use of auxillaries) were provided upper 7s started mesialising (aligner 19) in this as treatment options to the patient. case, the patient was instructed to start wearing 4. Orthodontic/orthognathic surgery the elastics in a CIII direction, from lower 3s involving rounding of the arch, leveling and to the upper 7s. The combination of both CII alignment of the gingival heights, followed and CIII elastics staged at different points in the by orthognathic mandibular advancement treatment allowed for the extraction spaces to to create a Class 1 canine and molar be closed without mesial tipping of the molars. relationship. This would then be completed Vertical rectangular attachments with veneers on the upper incisors. were placed on the upper 6s to help with the translation of these teeth to close Treatment overview the extraction spaces (Figure 3). The patient opted not to have orthognathic Because optimised attachments could surgery and proceeded with treatment option 3. not be combined with button cutouts on The UR4 was extracted. The cantilever UL4 was the upper 3s, due to insufficient space on sectioned. Invisalign treatment was carried out with the use of auxillaries (buttons were placed on canines and first molars to run Class II and Class III elastics). Both arches were rounded out Figure 4: Use of occlusal markings on the study models to show the centric by buccal tipping of the premolars and molars. record. The upper central incisors were intruded so that the gingival margins of the upper central the aligners for both features, the optimised incisors matched the gingival margin levels attachments were removed and replaced with of the upper lateral incisors and canines thus conventional vertical rectangular attachments. avoiding the need for lengthening. The elastics were worn from the outset, ¼” The CC treatment plan included U33/ 4oz. The patient was very compliant with elastic L12 number of aligners, resulting in a wear, only removing the elastics when eating. treatment length of 15.5 months. The The elastics were changed three times a day. patient lived 1,800km away and could only My top tips for setting the occlusion be seen three times during the treatment. in centric relation (CR) on the CC: Optimised and conventional attachments • Record a centric relation bite using a were placed on nine teeth. Intrusion of 5mm facebow and have the models mounted onto was achieved with the use of the 20 aligners. Figure 3: Conventional attachments on upper 6s to prevent tipping and on a semi-adjustable articulator (Kavo). • Mark The upper anterior teeth were over-retracted upper 3s to accommodate button cutouts. Note pontic on upper 4s, which the first point of the occlusion on the stone in the CC, so that the lingual root torque will be masked with composite or Align’s proprietary pontic kit material models. Thereafter, photograph the mounted could be requested in the refinement. until the spaces are closed models using the same intraoral series of

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Figures 5a: Clinical photograph and Clincheck in maximum intercuspation

Figure 5b: Study model vs Clincheck in centric relation

photographs as per the original submission Conclusion (Figure 4). These photographs can be emailed By adopting the use of a trial smile, the to Align Technology, which will allow the patient was able to visualise the end result technician to set the occlusion in CR. if she opted for some type of treatment. • Another option would be to mark Invisalign, in conjunction with additive Figure 6: Pre-refinement and pre-bonding photos (post- the patient’s occlusion in the mouth using bonding proved to be an excellent treatment Invisalign) articulating paper and photograph the option for this patient who expressed some patient’s occlusal shots showing the occlusal financial restrictions. The patient has the markings. It is important to photograph the option to have veneers on the upper incisors lateral and facial views in centric as this allows at a later date. The use of Invisalign to the technician to see the distance between correct the gingival contours eliminated the teeth in each arch in centric relation. the need for periodontal surgery. Treating Intraoral photographs, photographs an extraction case with Invisalign and of the study models and CC screenshots auxiliaries is possible using the tips provided in maximum intercuspation and centric in the main report. Where necessary, use relation are shown in Figures 5a and 5b. the Clincheck software program to re- Figure 7: Centric relation/occlusion - pre-equilibration and bonding, The pre-refinement photographs establish centric relation of which some highlighting the spaces around the lateral incisors to allow for additive are shown in Figure 6. guidance on this has also been provided. bonding Following the initial set of aligners, the The integration of a multi-disciplinary patient had composite bonding carried out approach (perio-ortho-restorative) was on the upper 3-3 to test the length of the key to the success of this treatment. incisors and to create ideal proportions of the lateral incisors when compared to the References central incisors and canines (Figure 8). 1. Gill DS (2008). Orthodontics at a glance. Following this initial bonding, a United Kingdom: Blackwell Publishing. 92-93. refinement was carried out for this patient. 2. Staufer K and Landmesser H. Effects Figure 8: Anterior view post-bonding (pre-refinement) The goals of the refinement included: of crowding in the lower anterior • Continue to align the gingival contours of the segment--a risk evaluation depending incisors by intruding UR1 to the level of UL1 upon the degree of crowding. J Orofac • Round out both arches in the Orthop. 2004 Jan;65(1):13-25. premolar area and molar area 3. Kokich VG, Spear FM and Mathews DP. • Torque the roots of the incisors as over- Mandibular Incisor Intrusion: An Adjunct to retraction was planned in the original treatment restoring short, abraded anterior teeth. Inside • Align the lateral incisors leaving space to Dentistry April 2008, Volume 4, Issue 4. bond/ the small lateral incisors 4. Dawson PE. Determining the • Close the space between UL3-UL5. determinants of occlusion. International Pre- and post-Invisalign photos, prior to Journal of Periodontics and Restorative Figure 9: Before and after pictures - pre-Invisalign on the left and refinement, are highlighted in Figure 9. Dentistry. 1983; 3(6):8-21. post-Invisalign and bonding on the right

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