Aesthetic dental procedures are routinely employed to improve a patient’s smile. Direct resin bonding gives one of the quickest aesthetic improvements available. This case report shows how the clinician can apply direct resin for mock-ups so patients can see immediate improvements that motivate them to initiate treatment which they may be hesitant to begin. I used this concept to motivate a teenage girl to begin orthodontic movement of a malposed, partially erupted maxillary cuspid. This case report also describes a rapid segmental orthodontic approach to properly positioning the cuspid with sound physiological results. The case involved a 17-year-old female who was looking forward to her prom. She had a naturally attractive smile with only one flaw—a partially erupted cuspid (Figure 1).
|Figure 1. The patient presented with a partially erupted cuspid that was a major aesthetic concern.
This one flaw was significantly magnified if the patient turned to her left side, giving the appearance of a huge black hole in her charming smile. Her pediatric dentist had said full braces were the only solution. However, the young patient would not undergo orthodontic appliances at any cost. After all, she had just been asked to the prom. Even though it was apparent to both the young lady and her parents that something had to be done, social pressures were huge at this time, namely, the prom was coming up in just 5 short months. Being adamant that full braces were out of the question, the patient had her heart and mind set on what she thought was a quick solution—extract the tooth because it was barely visible in her mouth, and place an artificial tooth in its place! Simple.
I explained to the parents and daughter (while she was crying hysterically) that an extraction would create a hole much larger than the present one, making the replacement tooth a calamity. This did not matter to the young lady. As she put it, “You can’t see it up there anyway. I don’t smile.”
The bells and whistles of creativity and compromise went off in my head. I asked her, “What if we put a tooth in that spot right now so you have something to smile about (I was thinking instant gratification), and hide the braces above the tooth until the end of treatment, when you won’t mind showing a little of the braces for a short period of time.” I was treading water, trying to stay afloat. My young patient stopped the tirade just long enough for me to say, “Give it a try, and if you don’t like it we will think of something else.”
EXAMINATION: INITIAL FINDINGS
|Figure 2. Four mm of exposed distal-facial surface of tooth No. 6 was present at the gingival crests of the adjacent teeth.
|Figure 3. A metal orthodontic bracket had been placed on tooth No. 6 by the patient’s pediatric dentist.
My examination revealed an intact, normal functioning, class I occlusion with few restorations. The patient’s periodontic health and hygiene were very acceptable. There was 4 mm of the exposed distal-facial surface of tooth No. 6 present at the gingival crests of the adjacent teeth (Figure 2). The tooth was rotated mesial-lingually and buccally to the alveolar ridge. The pediatric dentist had placed an orthodontic button on the tooth. This metal bracket contributed to the young lady’s fear of the metal “brace-face” look (Figure 3).
A radiograph revealed a fully developed root and a normal periodontal ligament space. The percussion test was normal. There was a 2-mm band of attached gingiva present. The tooth did not appear to be ankylosed, but had not erupted beyond the adjacent CEJs (Figure 3).
My treatment was to use direct bonding to tooth No. 6 to create the appearance of a full tooth, then use rapid orthodontic eruption of the cuspid over 3 to 4 months to position the tooth in the arch. This would be followed by a fixed lingual retainer to allow reorganization and stabilization of the periodontium.
RATIONALE FOR TREATMENT
Direct resin bonding for mock-ups, veneers, and general restorative procedures is routine. Many clinicians are now using direct bonding for transitional restorations1 in situations requiring occlusal alterations or cosmetic changes. I intended to create a transitional veneer for tooth No. 6 while orthodontics could be performed.
Rapid orthodontic treatment, such as extruding the cuspid in this case, can be safely achieved as long as inflammatory diseases are not present.2 Rapid extrusion of the tooth brings the entire dentogingival complex down with it. The alveolar process will follow the periodontal attachment, resulting in a new and stable attachment formation. Therefore, the expected outcome was full aesthetics and function.
Radiograph examinations were planned to ensure that undesired iatrogenic effects of root resorption did not occur. The challenge of this case was to design a suitable orthodontic appliance that could be inconspicuous enough to persuade my patient to undergo treatment. The forces delivered to the malposed cuspid needed to be the interrupted type instead of the light and continuous forces that normally apply.3 This interrupted force is used for short durations (up to a few weeks). The force would initially be high (50 to 80 g), and then dissipate as the tissue went through reorganization. The force of 50 to 80 g can be expected to deliver a movement of 0.5 to 1 mm every 2 to 4 weeks. The anchorage design needed to prevent movement of the adjacent teeth and be small and inconspicuous. The occlusion was to be adjusted at each follow-up visit, along with meticulous oral hygiene.
The cusp tip of the cuspid would provide enough enamel support to cantilever direct resin into the form of a full-sized, normally positioned tooth. Phosphoric acid etching was performed, followed by the application of a single component bonding agent (Cabrio, Discus Dental). The dentin form of the tooth was sculpted with a nonstick anterior hybrid composite shade A3 (Matrixx-AH, Discus Dental). This allowed suitable strength for the occlusal trauma that would occur as the tooth moved into position, as well as opacity to block out the darkness of the intraoral cavity. The enamel was built to full contour with a highly polishable microfill composite shade A2 (Matrixx-AM, Discus Dental), but was not cured.
|Figure 4. Finished direct-bonded restoration in place on tooth No. 6, and ceramic brackets placed on teeth Nos. 4 through 7.
The A2 was cut back along the incisal 1.5 mm and cured. A bleached shade AO was placed at the cutback, cured, then layered with additional A2. This created the hypocalcification effect seen on the adjacent teeth. The restoration was finished, then polished with silicone carbide impregnated brushes (Jiffy Brushes, Ultradent). The patient was so happy with her new tooth she reluctantly permitted placement of the orthodontic appliances. Ceramic edgewise brackets (Tip Edge, TP Orthodontics) were applied in a straight line to teeth Nos. 4 through 7. Figure 4 shows the finished direct bonded restoration on tooth No. 6 and the ceramic brackets in place.
|Figure 5. The direct-bonded veneer and ceramic brackets were relatively inconspicuous.
The straight-line setup maintained the position of the anchored teeth. A fiber-reinforced splint was placed on the lingual of tooth No. 7 and splinted to No. 8. The root surface area of the splinted teeth was now greater than that of the cuspid, thereby minimizing the movement of the anterior teeth from the reciprocal forces placed at the cuspid. The bonded veneer and ceramic brackets were inconspicuous enough for my patient to proceed with treatment (Figure 5).
|Figure 6. The eruption process was accelerated by using a “sling shot” 2-oz elastic placed at the gingival of the cuspid and adjacent anchorage teeth.
|Figures 7 and 8. Final orthodontic results after 3 months treatment time.
A super-elastic nickel titanium square wire was light cured into place. The square wire prevented rolling of the wire in the bracket slots and increased rotation of the cuspid. Three weeks later the tooth had moved 1.5 mm, and the composite veneer cuspid was trimmed to allow occlusal clearance. This process of eruption and adjustment was repeated at 2-week intervals. When the cuspid had erupted into the arch form, the ceramic brackets were replaced with combination Begg/Edgewise brackets (Tip Edge, TP Orthodontics) to facilitate final rotation of the cuspid. The eruption process was accelerated with a “sling shot” 2-oz elastic placed at the gingival of the cuspid and the adjacent anchorage teeth (Figure 6). Periapical radiographs were performed after 1 month to monitor the bone and root tissue. A final 0.018 X 0.018 wire was placed on the brackets, and continuous elastic was placed from teeth Nos. 4 and 5 to the No. 6 bracket. This allowed the distal rotation of the cuspid. The total orthodontic treatment time was 3 months. The final result was quite acceptable (Figures 7 and 8).
The cuspid was positioned for cuspid/bicuspid group disclusion. The cuspid was stabilized with a fiber-reinforced composite splint (B) from teeth Nos. 5 through 7. Follow-up visits evaluated the periodontic pocket depths and stability. The postoperative radiograph in 6 months revealed a normal periodontal architecture.
Composite resin applications are used routinely for veneering. The continuous improvement of resin materials in the area of strength and aesthetics allows clinicians to be creative with their usage. This case illustrated resin veneering to facilitate a transitional restoration. The resin veneer also allowed space maintenance during the orthodontic treatment. But most importantly, it created the opportunity for the patient to see the value of entering treatment.
Patients do not buy elective services based on logic. They buy on emotion and make impulse decisions. For cosmetic treatments to be accepted, there must be self-proof evidence that a need exists. The transitional veneer in this case provided the patient with that evidence. Use of the transitional veneer created a sense of urgency for the patient that allowed her to make the decision to begin treatment. In addition, the rapid aesthetic orthodontic treatment presented was successful for a malposed cuspid, a situation that occurs quite frequently.
|Figures 9 and 10. Final aesthetic results show dramatic improvement of the patient’s smile.
My patient was extremely grateful that she was able to gain a beautiful smile without compromising her social life. Her parents were relieved she chose the right course of treatment for her long-term oral health. By using improved resins, quality orthodontic materials, and a creative approach to the patient’s desires, we were able to provide a first class, healthy, beautiful smile (Figures 9 and 10).
1. Lewis AM. Open your vertical and your smile, part 2: porcelain-fused-to-gold, full-mouth rehabilitation. Dent Today. 2000;19(10):50-55.
2. Vanarsdall RL Jr. Tooth movement as an adjunct to periodontal therapy. In: Genco RJ, Goldman HM, Cohen DW, eds. Contemporary Periodontics. Philadelphia, Pa: CV Mosby Co; 1990:505-513.
3. Thilander B. Orthodontic tooth movement in periodontal therapy. In: Linde J, ed. The Textbook of Clinical Periodontology. Copenhagen, Denmark: Munksgaard; 1989:565-566.
Dr. Rosenberg maintains a private practice in Philadelphia, Pa, emphasizing restorative and aesthetic dentistry. He is a fellow of the Academy of General Dentistry and holds associations with various restorative, aesthetic, and orthodontic organizations. He publishes in this field to increase awareness of high-tech materials and procedures and performing dentistry more efficiently and with higher quality. Dr. Rosenberg places hundreds of bonded restorations monthly and has a patent pending in the area of nonmetal dental restorations. He is also the head of The Dental Healthcare Group, which provides high-quality continuing education in the Philadelphia area. He can be reached at (215) 592-4747.