Written by Joseph A. Whitehouse, MS, DDS Tuesday, 31 August 2004 19:00
Moving teeth has been a dental treatment modality for decades and was perhaps the first true cosmetic dental care. Orthodontics is generally minimally invasive. As a result, it has become a more accepted treatment for adults in the last 10 years or so. It would be hard to define an exact period of time for this change, but in my view, many more adults are willing to wire up. With the addition of such approaches as Invisalign (Align technology), many more adults are excited about working toward straighter teeth.
One reason for this transition is the desire simply to look better. No one has to mention that baby boomers desire a younger, more attractive appearance, and television is projecting this image overtly. Those patients who have undergone smile makeovers are testament to this issue.
|Figure 1. The beginning case: when the option of extracting that tooth was broached and moving the others orthodontically, she accepted.||Figure 2. Outcome with 3 veneers (to go along with her upper veneers).|
For example, a physician's 65-year-old wife hated her out-of-alignment tooth No. 23. Figure 1 shows the beginning case. When the option of extracting that tooth and moving the others orthodontically was broached, she accepted. Figure 2 shows the outcome with 3 veneers (to go along with her upper veneers).
ADULT ORTHODONTICS FOR COSMETIC RESTORATIVE REASONS
Figure 3. By using space-gaining techniques, a smile makeover can afford a better outcome.
Figure 4. Lack of space for a pontic.
Figure 5. The space gained for the resulting smile.
Figure 6. This patient had been in my practice for years before she decided to undergo cosmetic care.
There are times when the easy restoration for cosmetic reasons will not lead to a nice outcome. I have seen many cases from various clinicians that would have been enhanced had the teeth been placed in a better position. Figure 3 is one of these cases that could be done without moving any teeth, but what would the proportions of the teeth look like? By using space-gaining techniques, a smile makeover can afford a better outcome. Figure 4 shows the lack of space for a pontic, and Figure 5 shows the space gained for the resulting smile seen in Figure 6.
The aforementioned patient had been in my practice for years before she decided to undergo cosmetic care. I never told her she needed to change her smile, but I did occasionally ask at her recall appointments. If you could change your smile, would you like to? She eventually asked how it could be done. I told her the only way to do it well was by moving teeth. By the next recall appointment, she was ready. She was a dual-insurance patient who was going to have a lot of out-of-pocket expense, so we started placing brackets that day.
ADULT ORTHODONTICS TO SAVE A ROOT
Once I learned fixed orthodontics from Dr. Brock Rondeau, I saw opportunities to use my skill in rescuing numerous disasters (to the patient) in order to achieve a better outcome. How often have we seen anterior teeth broken at the gum line, usually treated endodontically, with the patient holding the crown? The usual treatment plan involved extraction and the placement of a bridge and, today, an implant. The bridges often did not match the surrounding teeth and necessitated the reduction of virgin teeth.
|Figure 7. Tooth No. 11 broken at the gum line.||Figure 8. Eruption giving approximately 6 mm for a crown prep.|
A strategy of rebuilding the root with a core and erupting the root to achieve enough solid tooth for a ferrel effect is the desired course. Figure 7 shows tooth No. 11 broken at the gum line. I don't know about you, but I have had my failures when I just built up the tooth with a new post and core and did not achieve sufficient ferrel effect. Those days are gone. I will only do a case like this with super-eruption.
This is the one type of case in which I believe every dentist can use fixed orthodontics. As long as the root is of adequate length, one may proceed. The technique is to acquire a set of brackets for 3 to 5 teeth. I have erupted teeth with brackets on the subject tooth and proximal teeth only. In this case, I chose to bracket more teeth in order to align additional teeth.
In placing the brackets, you need to bracket the subject tooth on the new buildup very close to the gingival tissue. The brackets on the proximal teeth need to be of equal distance from their incisal edges and placed closer to the incisals. Using ice to soften the 0.018 x 0.022 nickel titanium wire, the wire is placed in the brackets and ligated. The loop to the subject tooth will exert a straightening force and thus erupt the rebuilt tooth. Do not forget to sever the periodontal attachment with a scalpel. This is critical so the bone will not move with the root.
ADULT ORTHODONTICS FOR DISTALIZING AN ABUTMENT
Although implants are wonderful in helping patients restore distally lost teeth, there are times when adequate bone is not available for placement. In the case presented here, the periodontist found inadequate bone buccal-lingually distal to tooth No. 29, where we wanted to place at least one implant. Therefore, the patient was asked if she would be willing to wear braces to distalize tooth No. 29. With the only other option being the placement of a mandibular partial denture, the patient chose the orthodontic option.
|Figure 9. Missing molars Nos. 30 and 31.||Figure 10. The resulting bridge. This case took 8 months to complete. The patient was very happy with the result.|
Figure 9 shows the missing teeth Nos. 30 and 31. By bracketing from teeth No. 22 to No. 29, cross-arch stabilization was achieved. A rectangular nickel titanium wire was placed with enough wire beyond tooth No. 29 to allow for the movement of the tooth using a nickel titanium spring.
Figure 10 shows the resulting bridge. This case tooth 8 months to complete. The patient was very happy with the result.
ADULT ORTHODONTICS FOR INTRUSION OF SEVERELY BRUXED TEETH
I have written about tooth surface loss being the least treated condition in adults. Orthodontics can play a nice role in the intrusion of lower incisors that will be veneered. I have treated several cases this way with good outcomes. (I currently have a 65-year-old retired fireman undergoing this procedure.)
|Figure 11. Severely bruxed lower 4 incisors of a 38-year-old man.|
Figure 11 shows the severely bruxed lower 4 incisors of a 38-year-old man. I had known him for years before he became a patient of mine. For several years, I would put a 28x image of his severe condition on a monitor and review his long-term goals. Since one of his goals was healthy teeth, I would point out that these teeth were becoming less healthy with time. Finally, after several years of these reviews, he chose to intrude them by wearing braces. (This also can be done with Invisalign.)
The starting point for the brackets and wire were standard; ie, the wire was placed in the central slots of brackets that were placed as close to the incisal edges as the occlusion would allow. Once the teeth were intruded as much as the wire could accomplish, the wire was moved on top of the brackets.
|Figure 12. Teeth in the final position before preparation for veneers. This course of action took approximately 6 months.||Figure 13. The final result.|
Figure 12 shows the teeth in the final position before preparation for veneers. This course of action took approximately 6 months. Figure 13 shows the final result.
Why intrude severely bruxed incisors? Considering the need for restoration of teeth that have little prospect of holding up well for the next 30 to 40 years, veneers or crowns placed on short teeth are unaesthetic. As people age, they show more of their lower incisors, and to make incisal coverage look normal, intrusion provides for a normal-appearing height indefinitely. All patients receiving this care wear night guards.
ORTHODONTICS TO GAIN SPACE FOR IMPLANTS
A patient with 2 primary teeth wanted to receive implants in their place. The periodontist to whom I referred this patient made me aware of the need for more space to place the narrowest implants he used, a 3.5-mm root form. He also noticed that the root of tooth No. 5 was too mesial for correct placement of the tooth No. 6 implant.
|Figure 14. Short-rooted teeth Nos. C and D the patient wanted removed and replaced with implants.|
|Figure 15. Active treatment of space gaining with the desire to make the space on the right side equal to that of the left side.|
|Figure 16. Once the teeth had been moved, the implants could be placed.|
Figure 14 shows the short-rooted teeth Nos. C and D that the patient wanted removed and replaced with implants. With the above considerations and the desire of the patient to move ahead, orthodontics was offered for gaining space. The patient accepted.
ORTHODONTICS TO PREPARE FOR A SMILE MAKEOVER
As previously mentioned, many smile makeovers are accomplished where the teeth are not in the ideal position. Patients may have been offered orthodontic positioning and refused, or the dentist opted to treat with the teeth in a (perhaps) compromised position, resulting in the need for larger amounts of porcelain to correct rotations and/or malpositioned teeth.
|Figures 17 and 18. The poor positions of teeth in the anterior of both the maxillary and mandibular arches.|
In the case illustrated here, one can see in Figures 17 and 18 the poor positions of teeth in the anterior of both the maxillary and mandibular arches. Could one construct new smiles with the teeth in these positions? Yes, it could be done. However, by asking the patient if she would be willing to wear braces for a better outcome, her answer was yes.
|Figures 19 and 20. The resulting arch form as seen here provided a better outcome with no restorations being abnormal in size or shape. The end result was better than without the orthodontics.|
The resulting arch form seen in Figures 19 and 20 provided a better outcome with no restorations being abnormal in size or shape. The end result was better than without the orthodontics.
Adults are now much more in favor of receiving orthodontic treatment than in the past. The baby boomer generation has a deep desire to keep their and is willing to invest in such. Along with this attitude has come the ability to treat malocclusions and other clinical deficiencies with new products that decrease the treatment time.
Nickel titanium wire has revolutionized the mechanics of treatment, so that often only one wire need be used throughout treatment, and the time of care has been reduced. Invisalign has resulted in higher acceptance rates for treatment that was passed up before. Although Invisalign has its limitations, for most basic alignment, it can provide a nice result. Patients who might come to an office for Invisalign can be open to braces if Invisalign will not correct their problem.
In this article, several uses of adult orthodontics have been shown. It behooves the general practitioner to refer those cases that can benefit from the multiple uses of orthodontics. Should the GP desire to learn to perform any or all of the tooth movements necessary to create a more desired outcome, there are several marketed orthodontic courses that will provide the knowledge necessary.
Finally, I encourage those who would enjoy treating patients with orthodontic needs. I have found it to be very rewarding to work toward a shared outcome that is often a less invasive treatment. Patients really enjoy the results.
Acknowledgement: The author wishes to thank Sam Ramon Dental Lab for all of its fine lab work.
Disclosure: Dr. Whitehouse is founder of the Dental Learning Center, which provides communication skill workshops and cosmetic dentistry hands-on courses.
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