The Ortho-Restorative Interface: Invisalign and Veneer Case Presentation.
Featured Products Promotional FeaturesPosted by: Dental Design 23rd April 2023
Dr Lydia Sharples, Director of the Education & Social Calendar for the British Academy of Cosmetic Dentistry (BACD), shares a recent case study that highlights how useful a multidisciplinary approach can be in certain situations.
A 39-year-old female patient attended the practice looking to improve her smile. She wanted greater symmetry and to show more of her front teeth on smiling. She was interested in finding out more about composite bonding to achieve this.
A full medical and dental history was taken, revealing little previous dental treatment other than orthodontic treatment that was carried out 10 years ago to align the teeth and move UR3 into the position of the congenitally missing UR2. The missing UR2 significantly contributed to the asymmetry of her smile.
In addition to the missing UR2, the clinical assessment found a crossbite at UR3-LR2,3 and a reduced overjet of less than 2mm. The envelope of function was reduced, which was causing mild tooth wear.
It was explained to the patient that any composite bonding performed would likely chip due to the position of teeth, reduced overjet and anterior crossbite. The patient was keen to avoid drilling the teeth down and preferred to find a minimally invasive, yet long-lasting treatment solution. Based on the clinical findings and patient preferences, Invisalign was recommended to move the teeth into the ideal position, aiming to increase the overjet and correct the crossbite to achieve an improved bite before improving the shapes, sizes and proportions of the teeth with four minimal preparation porcelain veneers.
The patient was happy to proceed with the proposed treatment, as it met her objectives of being:
- Long lasting and predictable
- Minimally invasive
The first step of the treatment plan was Invisalign and teeth whitening. Treatment planning was supported by ClinCheck software, which ensured an adequate overjet and overbite could be achieved, as well as correcting the crossbite and perfecting the alignment. The SAFE assessment and 4-Sentence Prescription (4STP) [Aulakh R, Toy A] were used to plan the case with the patient.
Interproximal Reduction (IPR) was used in the lower right quadrant to enable LR1-LR4 to move lingually, and the upper anterior teeth were moved 0.5mm buccally to aid in correcting the crossbite and increasing the overjet. The resulting ClinCheck was used to perform a simple smile design on an iPad with apple pencil, in preparation for the veneers. This involved careful evaluation of ratios and Bolton analysis of UR3 and UL2.
The orthodontic stage of treatment proceeded as planned. The patient changed her aligners weekly, for 19 weeks. Night time whitening using 10% carbamide peroxide for two weeks followed by 16% carbamide peroxide for one week was completed in the aligners. Patient compliance was excellent and alignment was concluded in the first set of aligners without need for refinements.
The next phase was the restorative aspect of treatment. A handmade mock-up was completed with DMG Luxaflow to lengthen the incisal edges and create symmetry [Jethwa S]. The Gurell technique was used to ensure the most minimal preparation possible was carried out. UR3, UR1, UL1, UL2 were prepared for 4 minimal preparation E-max porcelain veneers. The temporaries were fabricated using a putty index of the mock-up, and were refined using flowable composite and Sof-Lex discs (3M) until the desired aesthetics were achieved. The focus was on making UR3 and UL2 as symmetrical as possible, while improving the smile arc and parallelism of the incisal edges to the lower lip when smiling, as well as achieving an appropriate amount of incisal edge display at rest.
During the initial assessment, 1.5mm of recession was noted on the UR3. It was decided not to take the veneer up to the margin as the patient had a low lip line and this was not visible. The preparation was so minimal that the margin could be blended confidently, so the option of soft tissue grafting remained possible in the future, and the veneer would be bonded entirely to enamel.
The porcelain work was completed by Densign Laboratory, who copied the handmade trial smile design after the patient had ‘test driven’ the design for a week to ensure functional and aesthetic goals were met. The veneers were tried in, and once approved by the patient, bonded into place.
The patient was delighted with the outcome achieved as all of her concerns were addressed in a minimally invasive way. This case demonstrates the importance of a multidisciplinary approach – it would not have been treated as conservatively with only restorative dentistry, nor would the aesthetic outcome be as good with only orthodontic treatment.
Collaborative treatment planning and patient education were key. In this case, the orthodontic stage of treatment took less than 6 months, and whilst the Invisalign alone didn’t transform her smile from an aesthetic point of view, the patient understood the importance and value of fixing the bite issues to enable more minimally invasive preparation for the restorative treatment and increased predictability long-term.
For clinicians wishing to expand their skillset and become more confident in utilising ortho-restorative treatment plans, the BACD offers various educational opportunities. The 2022 Annual Conference included three ortho-restorative lectures from Dr Chris Orr, Dr Karla Soto and Dr Stephane Reinhardt. Dr Sam Jethwa also presented a hands-on day as part of the BACD Education Calendar in 2022 on porcelain veneers. Upcoming events and topics can be viewed on the website for 2023.
Figure 1 – Pre-op smile
Figure 2 – Pre-op retracted
Figure 3 – Pre-op upper occlusal with fixed retainer
Figure 4 – Pre-op lower occlusal with fixed retainer
Figure 5a – Pre-op right lateral
Figure 5b – Pre-op left lateral
Figure 6a – Initial overjet
Figure 6b – Predicted resulting overjet
Figure 7 – Post alignment smile
Figure 8 – Post alignment retracted
Figure 9 – Post alignment upper occlusal
Figure 10 – Post alignment lower occlusal
Figure 11 – Post alignment right lateral
Figure 12 – Post alignment left lateral
Figure 13a – Veneer preparations
Figure 13b – A handmade trial smile
Figure 14 – Post-restorative smile
Figure 15 – Post-restorative retracted
Figure 16 – Post-restorative right lateral
Figure 17 – Post-restorative left lateral
For further enquiries about the British Academy of Cosmetic Dentistry visit www.bacd.com
Author:
Dr Lydia Sharples first joined the BACD as a student. She chaired the Young Membership Committee and the Membership Committee, and is now Director of the Educational & Social Calendar.
Lydia works in private practice in Marlow, Buckinghamshire, and is committed to providing the highest level of care possible for her patients. Her dedication to providing clinical excellence has led her to undertake a number of post-graduate qualifications in aesthetic and cosmetic dentistry.
