Restorative Orthodontics With Injection Overmolding: Intra-Arch and Inter-Arch Case Solutions

Dr. Jihyon Kim

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INTRODUCTION
“Restorative” Orthodontics vs “Instant” Orthodontics

The concept of “instant orthodontics” is well known but has a somewhat dubious reputation within the dental profession. Visually aligning the teeth instantly in the smile zone with restorative dentistry is appealing to many adult patients wishing to achieve a smile makeover without orthodontics. Hence, many practices can be found advertising instant ortho as an option, promoting a 2-visit vs a 2-year (or greater) treatment time span.

Figure 1. Bioclear Anterior Matrix Kit and Bioclear Heat Sync Heater.

An aesthetic result can certainly be achieved with restorative options that range from the most conservative to the most extreme. Within our profession, a broad range of opinions can be found regarding the moral acceptability of removing healthy tooth structure for an elective aesthetic treatment. As a clinician, my own comfort zone is toward the more conservative end of the spectrum. The term “restorative orthodontics” is more honest, as it highlights the fact that a restorative procedure is being done to achieve a visual, instead of a true, orthodontic alignment.

To Do Ortho or Not To Do Ortho?
We can probably agree that no adult patient enthusiastically wants to have orthodontic treatment later in life. Fortunately, more aesthetic options with clear aligners and brackets have made orthodontic treatment more acceptable and no longer relegated as a right-of-passage in the adolescent years. Some patients may suspect that orthodontics is a likely treatment option but are certainly happy to discuss an alternative. Our obligation in discussing treatment options is to discuss the associated benefits and risks of orthodontics.

Orthodontics can offer enormous benefits in helping to correct issues with general arch form, occlusal relationships, unfavorable axial inclinations or positions of teeth, and airway problems. Barring such larger concerns, when is orthodontics a necessary benefit, and when is it simply more unnecessary treatment? To answer that question, the first consideration should be whether orthodontics will negate or minimize the need for restorative dentistry on otherwise healthy teeth or destructive dentistry on malpositioned teeth. This is an important discussion based on the patient’s specific aesthetic concerns. Orthodontics will not correct color issues and can often trade crowded teeth for open gingival embrasures in adult patients.1 A secondary question would be whether gingival- or papilla-level concerns exist that cannot be addressed surgically and if this might be best managed with the orthodontic repositioning of the tooth.

The Bioclear Method
In this article, we will look at the Bioclear Method and injection overmolding as a treatment option that can be used to treat a variety of aesthetic concerns in lieu of traditional orthodontics. With the Bioclear Method, composite resin is heated and then injected into anatomic matrices, resulting in a tooth “shrink-wrapped” in a monolithic form (Figure 1). The process of wrapping the restorative material around the tooth, instead of shaping the tooth to fit the path of draw and dimensional needs of a restoration, allows for ultimate flexibility and conservation of tooth structure.

Each of the 3 example cases presented herein were treated with an additive solution. Previously restored teeth had restorations removed and retreated with Bioclear injection overmolding. Some previously unrestored teeth may have been reshaped with minimal enameloplasty.

CASE REPORTS
Intra-Arch Case: Solution 1

A 48-year-old female presented with a physiologic occlusion. Her chief complaints included chipped incisal edges on teeth Nos. 8 and 9 that were incurred during a childhood accident, open gingival embrasures, and concerns about tooth color. Other aesthetic issues (not mentioned by the patient) included mild rotations and jagged incisal embrasures that detracted from a pleasing smile arc. The patient had a strong desire for an aesthetic improvement without removal of tooth structure. She had previously explored the option of prepless veneers but was unhappy with the bulky contour of the restorations.

From an orthodontic perspective, the patient had mild rotations, and orthodontic treatment would not be able to address her aesthetic concerns nor improve the open gingival embrasures. In fact, the mild rotations provided space for the improvement of color and treatment of the chipped incisal edges without any reduction of tooth structure or excessive bulk. This patient was restored by overmolding teeth Nos. 6 to 11 using Scotchbond Universal Adhesive (3M), Filtek Supreme Ultra Flowable Restorative (3M), and Filtek Supreme Ultra Universal Restorative (3M) (shade WB) (Figures 2 to 6).

Intra-Arch Case: Solution 2
A 47-year-old female presented with previously restored teeth Nos. 7, 9, and 10. The patient’s chief complaint was the discolored composite bonding that had been done to treat an undersized tooth No. 7 about one year prior. Other aesthetic issues noted were an anterior open bite and a reverse smile from an anterior tongue posture, mild crowding, a midline open gingival embrasure, and lower anterior crowding.

The patient’s smile arc, anterior open bite, arch form, and crowding would potentially be best addressed with orthodontic treatment. However, the patient presented with a speech-related habitual tongue posture. Without concurrent myofunctional therapy, orthodontic treatment in such cases is at high risk for relapse. The patient’s tongue position and suspected tight neutral zone would also make orthodontic treatment less predictable. These same factors also make indirect and non-reversible restorative options a higher risk. Because the patient had a comfortable occlusion and some other medical concerns, she declined an orthodontic treatment option. This patient was restored by overmolding teeth Nos. 7 to 10 using Scotchbond Universal Adhesive, Filtek Supreme Ultra Flowable, and Filtek Supreme Ultra Universal (shade A1) (Figures 7 to 12).

Inter-Arch Case Solution
A 63-year-old female presented with discolored silicate restorations on teeth Nos. 7 to 10 and anterior and posterior crossbites. She was previously treatment planned for 8 maxillary crowns for teeth Nos. 5 to 12. An orthodontic treatment option was discussed to correct the overall arch form as well as the inter-arch relationship issues. Having no functional concerns, the patient declined orthodontics. What she desired was a more conservative restorative alternative to crowns. This patient was restored by overmolding teeth Nos. 5 to 12 and 23 to 27. The silicate composites were removed, and light beveling of enamel was done around the old preparations. In addition, 1 to 2 mm of incisal reduction was done on teeth Nos. 6 and 24 to 27 prior to overmolding. These minimal preparations and this treatment of the lower teeth were done to correct the crossbite issues. The anterior relationship was moved into an end-to-end relationship in order to enable full display of the smile arc. This patient was restored using Scotchbond Universal Adhesive, Filtek Supreme Ultra Flowable, and Filtek Supreme Ultra Universal (shades A1 and A2) (Figures 13 to 19).

CLOSING COMMENTS
Chairside smile design and the Bioclear Method of injection overmolding for anterior teeth offer a third option for aesthetic treatment. The advantages of direct composite restorations, single-visit treatment, lesser financial cost, and preservation of tooth structure are combined with the advantages of porcelain, better strength, integrity, and aesthetics. With this option, the patient does not have to compromise aesthetics, restorative longevity, or tooth structure. Preservation of tooth structure maintains all treatment options for the future. With the increase in average patient life span and improved dental maintenance, the Bioclear Method is an attractive conservative treatment alternative for our patients.


References

1. Kim J, Clark DJ. Full-mouth black triangle treatment protocol. Dent Today. 2017;36:72-77.


Dr. Kim is co-director of and full faculty at Bioclear Learning Center (BLC) International in Tacoma, Wash. She actively teaches and develops newcurricula for BLC. She also maintains full-time patient practices in Tacoma and Bellevue, Wash. She can be reached via email at jihyonkim@bioclearmatrix.com.

Disclosure: Dr. Kim reports no disclosures.

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