Patient-Friendly Short-Term Orthodontics

INTRODUCTION
Adults comprise a large part of the population in need of orthodontic treatment to correct misalignment. While the benefits of orthodontic treatment include a healthier mouth, the most obvious is a cosmetically enhanced and more pleasant smile. However, people needing orthodontic treatment generally are more likely to suffer from or develop periodontal disease, temporomandibular joint (TMJ) disorders, headaches, and neck, shoulder, and back pain, all of which can often be avoided with orthodontic treatment.1
Unfortunately, adult patients often express trepidation about undergoing orthodontic treatment and routinely forego this therapy because of the stigma associated with metal braces.2
The extended time frame and the embarrassing, unattractive look of metal braces many times keep patients from choosing orthodontics to enhance their smiles. As a result, the vast majority of adults and older teen patients opt out of a treatment modality that could enhance their smile and oral health. Compounding the problem is the fact that because orthodontics is a specialty, many general dentists do not feel confident offering orthodontic consultations or treatments to their patients.
As alternatives are discussed with patients, the type of treatments that are possible to create a straight-looking smile are often reviewed, including “instant” (ie, restorative) orthodontics. When educated about minimally invasive techniques, most patients would want to conserve tooth structure, rather than grind down natural dentition to place veneers and other restorations.3,4 However, some orthodontic techniques that are more appealing to patients than braces (such as aligners) are not as predictable as expected,5 and lack of patient compliance may impede their success.

Short-Term Orthodontics
Short-term orthodontics is breaking down barriers between patients who could benefit from braces and the treatment itself. More patient-friendly than comprehensive orthodontics, short-term orthodontics enables general dentists to provide a treatment that is beneficial to patients who present with cosmetically driven alignment issues, rather than requiring changes in angles class. Short-term orthodontics is typically an option to meet the patient’s goals for an enhanced smile appearance as long as the jaw and mouth are fully developed and a stable and healthy occlusal foundation requiring minimal adjustments is present.6,7
Unlike most traditional braces treatments, short-term orthodontics generates an aesthetically pleasing smile within 6 months for most patients. This adds to the concept’s already patient-friendly attributes of requiring no personal compliance on the patient’s part of adhering to schedules, as well as being both comfortable to wear and aesthetically pleasing. As a result, vanity issues associated with the appearance of metal braces are eliminated.
Additionally, while everyone has a right to basic oral healthcare and a straight, healthy smile, not everyone has the financial means to obtain their desired smile through comprehensive orthodontic treatment and cosmetic procedures. Many individuals subsequently forego oral healthcare services and live with unappealing and oftentimes damaged smiles.
Short-term orthodontics is therefore also more patient-friendly from a financial perspective, since it provides individuals who are financially challenged with the opportunity to have the smile they have always desired. Because treatment expectations and outcomes are, and always should be, thoroughly discussed, patients can make informed decisions about cost versus benefit. Short-term orthodontics emphasizes moving teeth efficiently into the appropriate position to affect a cosmetic change, rather than addressing every imperfection. By simply and effectively moving teeth into proportion to the patient’s face and stature, improvements to the overall symmetry of the smile can be made.8 Therefore, patients are more likely to accept and dentists to recommend short-term orthodontic assistance.
Patients tend to feel a sense of relief when they wear braces. Although there is a stigma associated with metal braces, undergoing orthodontics indicates to the public that the person is making an effort to straighten hie or her teeth, and that raises ones perceived position within society.9

CASE REPORT
Diag is and Treatment Planning

A 44-year-old man presented with a chief complaint about the appearance of his smile (Figure 1). He developed a habit of covering his mouth with his hand when he smiled to avoid revealing the severe spacing and misalignment. Although he had wanted braces for more than 30 years, he was unable to undergo orthodontic treatment for numerous reasons, including financial limitations and the stigma associated with unaesthetic metal braces.

Figure 1. Right side view, demonstrating patient’s slightly open bite.
Figures 2 and 3. Tooth No. 11 has already moved quite a bit after just 8 weeks of treatment (Six Month Smiles).

A thorough examination was performed. The patient was classified as having a Class I molar relationship and missing teeth Nos. 2, 4, and 15 due to decay. Additionally, tooth No. 11 erupted toward the facial/cervical area. Due to overall crowding, tooth No. 11 had always been crowded out of the arch. Teeth Nos. 8 and 9 were chipped, but had been repaired with composite bonding that had stained over time.
The patient presented with a prior understanding of his condition and knowledge of various treatment options. He had consulted with a local orthodontist about comprehensive orthodontics, but he immediately declined this option due to appearance issues and the 2- to 3-year treatment time. During his first consultation at this office, removable aligners (eg, Invisalign), a removable aesthetic appliance (eg, Snap-On Smile [DenMat]), and short-term orthodontics (eg, Six Month Smiles) were discussed as treatment alternatives.
The removable aesthetic appliance was dismissed because treatment would present complications with tooth No. 11, since that tooth and all of the rotated teeth would be difficult to cover. The patient also declined the removable aligner option based on the length of treatment time (about 2 years), as well as limitations with the device associated with erupting and rotated teeth. Additionally, the patient would require several attachments on his front teeth, which would present the same aesthetic hindrances as comprehensive orthodontics, the necessity of having to wear aligners, and a higher price fee for services.
After discussing all of these considerations, the patient elected to undergo short-term orthodontic treatment. He was thoroughly informed about the treatment relative to his expectations and diagnosis, and preferred the more permanent solution to his smile problems that this treatment would provide. The patient also appreciated the shorter treatment time, minimally invasive treatment plan, and the ability to stay within his budget. Additionally, as a businessman who spends the majority of his day face-to-face with people, the cosmetic nature of this short-term orthodontics system would allow him to undergo treatment in an unobtrusive manner.

Treatment Protocol
Systems that unite and simplify clinically proven orthodontic technologies and the science of traditional braces with the ease of use of aligners (eg, Six Month Smiles) enable general dentists to provide patient-friendly short-term orthodontic treatments. This type of treatment addresses a patient’s principal cosmetic concerns while minimizing the complexity of the braces placement process. As a result, patients can elect to undergo a minimally invasive procedure to enhance the alignment of their teeth, after which they may choose to pursue future elective cosmetic treatments such as whitening or composite bonding.10
When a well-planned, short-term orthodontics system is used, general dentists can straighten their patient’s teeth using specialized materials designed to effectively and efficiently treat cosmetic dental cases. Contributing to the patient-friendly nature of the treatment are the clear brackets and tooth-colored wires that blend with natural dentition.11 The Lucid-Lok (Six Month Smiles) wires gently and consistently apply pressure to straighten and align the patient’s teeth.
To initiate treatment, impressions were taken of the patient’s upper and lower arches and models were poured. These were forwarded to the Six Month Smiles Case Processing Center. There, a bracket specialist/technician set up the case by creating a customized patient tray kit (PTK), which would be returned to the dentist to begin treatment. The PTK included bonding trays that facilitated a one-step bracket seating process. The brackets were accurately positioned into the bonding trays to ensure precise intraoral placement.
At the braces placement appointment, the patient’s teeth were etched where appropriate, rinsed, and died. The adhesive obtained from the PTK was applied to the etched teeth, and the bonding trays were seated intraorally. Once the brackets were secured (light-cured) onto the patient’s teeth, the tooth-colored wires and ties that blend with the natural teeth were attached and adjusted accordingly.11

Alignment Progress
The patient returned to the office periodically for minor adjustments. After 8 weeks in the short-term orthodontic braces, tooth No. 11 had already moved quite a bit (Figures 2 and 3), and teeth Nos. 25 and 26, which had been very lingually placed, were moving facially (Figure 4). Targeted interproximal reduction was completed as needed to accommodate movement of tooth No. 11.

Figure 4. Lingually positioned teeth Nos. 25 and 26 were also moving facially at 8 weeks of treatment. Figure 5. Left side view, taken at 10 weeks of treatment, illustrates additional movement of tooth No. 11.
Figure 6. At the 10-week follow-up, the patient expressed concerns about teeth Nos. 9 and 10 sloping upwards, which resulted from the high position of tooth No. 11. Figure 7. After 24 weeks of treatment, a significant improvement was observed in the alignment of tooth No. 11, following use of elastics.
Figure 8. This view, captured while changing wires, demonstrates how the upper left teeth are approximating the anticipated position. Figure 9. Upon removal of the short-term orthodontic braces, the patient was thrilled that his chief complaints had been
successfully addressed.

After 10 weeks of treatment, tooth No. 11 continued to demonstrate significant movement (Figure 5). However, elastics were discussed with the patient to facilitate downward movement of this tooth into occlusion and relieve the upward sloping of teeth Nos. 9 and 10 (Figure 6). After 24 weeks in braces, and following the use of elastics from tooth No. 11, a significant improvement in tooth alignment was obvious (Figure 7).
At a later follow-up appointment to change wires, the patient’s teeth appeared to approximate their desired position on the upper left (Figure 8). At this time, the lower teeth were aligned and only required incisal shaping. However, teeth Nos. 10 and 11 were not completely in position, so it was determined that the patient would wear elastics for one more month.
At the braces removal appointment after approximately 9 months of treatment, it was apparent that the patient’s chief cosmetic complaints had been resolved (Figures 9 and 10). The patient was very pleased with the final results of his short-term orthodontic treatment, which addressed all of his primary concerns. Although his smile still presents minimal appearance issues and would not be considered perfect according to orthodontic standards, the patient’s cosmetic objectives were met. As a direct result of his new and improved smile, the patient has developed elevated self-esteem and confidence compared to his demeanor pretreatment. He has become more talkative and outgoing, and he smiles all the time (Figure 11), something he never felt able to do in public before treatment.

Figure 10. By moving tooth No. 11 incisally into alignment, the patient experienced complete relief of his intense allergies and sinus problems. Figure 11. Post-treatment right lateral retracted view. A few months later, tooth No. 4 was restored with an implant-supported all-porcelain crown. 
Figure 12. Post-treatment left lateral retracted view. Interproximal reduction was required around tooth No. 11 and the surrounding teeth, rendering its shape slightly more slender than ideal. However, the patient was opposed to any tooth extraction, requiring tooth movement into position with more aggressive interproximal reduction and rounding of the arches. Figure 13. Our very happy and smiling patient!

It is important for patients to be fully aware that even with orthodontic treatment to correct tooth alignment, there is always the likelihood that if proper maintenance, such as wearing a retainer or mouthguard, is not strictly followed, undesirable tooth movements may occur. It is strongly recommended to note and take into consideration that teeth move and may relapse after treatment.12 For this reason, bonded lingual retainers were placed on both the maxillary and mandibular arches (Figure 12).

DISCUSSION
Unlike traditional braces, short-term orthodontics (such as Six Month Smiles) is specifically tailored to treat and correct cosmetic cases, rendering it patient-friendly and uncomplicated for general dentists to incorporate into their practices. It is also minimally invasive. Therefore, the fear of painful and time consuming dental procedures that oftentimes impede patients from receiving orthodontic care is eliminated.
Additionally, short-term orthodontics can predictably achieve a wide range of tooth movements, including extrusions, rotations, intrusions, and various types of tipping.13 Successful treatment is predicated on careful case selection and on understanding the patient’s expectations for braces treatment, as well as what is possible with this treatment modality.
The vast majority of adults with malpositioned teeth are candidates for short-term orthodontic treatment which, depending upon the patient’s objectives, can most often be completed within 6 to 9 months. In this case, due to the patient’s extensive gaps between teeth, and because the natural teeth required more extensive movement to achieve alignment, the procedure took nine months to complete. The longer time frame was compounded by the patient’s choice to not remove any permanent teeth.14

CONCLUSION
The case described here has demonstrated the power and ability of dentistry to fundamentally change people’s lives by enhancing their smile. This patient’s short-term orthodontic treatment dramatically improved his appearance by achieving a smile that is considerably straighter and more aesthetically pleasing (Figure 13).
While comprehensive orthodontics remains the gold standard for addressing problems involving a patient’s entire occlusal scheme, short-term orthodontics is a patient-friendly treatment option for resolving cosmetic-related concerns involving malalignment in the anterior upper and lower teeth during the smile process.15


References

  1. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St. Louis, MO: Mosby; 2007.
  2. American Academy of General Dentistry. InfoBites: Orthodontics align crooked teeth and boost self-esteem. knowyourteeth.com/infobites/abc/article/?abc=O&iid=322&aid=1301. Accessed January 24, 2013.
  3. Spear FM. The esthetic correction of anterior dental mal-alignment conventional vs. instant (restorative) orthodontics. J Calif Dent Assoc. 2004;32:133-141.
  4. Christensen GJ. Informing patients about treatment alternatives. J Am Dent Assoc. 1999;130:730-732.
  5. Kravitz ND, Kusnoto B, BeGole E, et al. How well does Invisalign work? A prospective clinical study evaluating the efficacy of tooth movement with Invisalign. Am J Orthod Dentofacial Orthop. 2009;135:27-35.
  6. Parker MW. The significance of occlusion in restorative dentistry. Dent Clin North Am. 1993;37:341-351.
  7. Mount GJ, Ngo H. Minimal intervention: a new concept for operative dentistry. Quintessence Int. 2000;31:527-533.
  8. Chiche GJ, Pinault A. Smile rejuvenation: a methodic approach. Pract Periodontics Aesthet Dent. 1993;5:37-44.
  9. Williams AC, Shah H, Sandy JR, et al. Patients’ motivations for treatment and their experiences of orthodontic preparation for orthognathic surgery. J Orthod. 2005;32:191-202.
  10. Milnar FJ. Mastering minimal intervention and discretionary esthetic procedures when placing direct composites. Pract Proced Aesthet Dent. 2005;17:428-432.
  11. Swain R. The six month smiles system: Creating dramatic changes in tooth position and smile symmetry with a novel orthodontic system. Inside Dentistry. April 2012. dentalaegis.com/id/2012/04/the-six-month-smiles-system. Accessed January 24, 2013.
  12. Ackerman MB, Thornton B. Posttreatment compliance with removable maxillary retention in a teenage population: a short-term randomized clinical trial. Orthodontics (Chic.). 2011;12:22-27.
  13. Skidmore KJ, Brook KJ, Thomson WM, et al. Factors influencing treatment time in orthodontic patients. Am J Orthod Dentofacial Orthop. 2006;129:230-238.
  14. Mavreas D, Athanasiou AE. Factors affecting the duration of orthodontic treatment: a systematic review. Eur J Orthod. 2008;30:386-395.
  15. Sarver DM. Principles of cosmetic dentistry in orthodontics: Part 1. Shape and proportionality of anterior teeth. Am J Orthod Dentofacial Orthop. 2004;126:749-753.

Dr. Nauman is a general dentist in Tulsa, Okla. After graduating from the University of Nebraska College of Dentistry, she spent 9 years working part-time as an associate. Two years ago, Dr. Nauman started Glisten Dental, a practice committed to providing excellent dentistry with an emphasis on patient education, high technology, colorful and modern surroundings, and a support staff dedicated to making patients comfortable. Because short-term orthodontics is a large part of Glisten Dental, Dr. Nauman and her team are rewarded daily by seeing straight, beautiful smiles change their patients’ lives. Dr. Nauman is a member of the ADA, Oklahoma Dental Association, and Christian Dental Society. She can be reached at drangienauman@gmail.com.

Disclosure: Dr. Nauman reports no disclosures.

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