In my experience, a significant number of adults present looking for an aesthetic improvement in the appearance of their smile, but are unwilling to invest time in comprehensive orthodontic treatment or are unwilling to undergo more invasive procedures such as veneers and/or crowns to achieve their desired results. For these patients we need to offer suitable treatment alternatives, which although may not be ideal, are minimally invasive and offer a significant improvement in aesthetics. It is important not to underestimate the psycho-social impact of an aesthetically pleasing smile, after all.[i], [ii], [iii]
Patient AD presented for a consultation concerned about the appearance of his teeth and was looking for a quick restorative solution. He was experiencing crowding of approximately 5mm in the upper arch and 4mm in the lower arch. The patient had attended previous orthodontic consultations over the years, as this was deemed the ideal way to treat his concerns, however he had dismissed this option due to the time commitment of between 18-24 months for treatment. As a semi-professional mixed martial arts competitor this had an impact on the possible treatment options as the patient had a small window of opportunity each year in which he was not competing.
Effective solutions
We had a detailed discussion regarding the options available to him, which included comprehensive orthodontics, as well as aligners, lingual or labial fixed braces for cosmetic tooth alignment only. Aligners were not used because the patient was concerned about compliance and treatment time, and a lingual appliance was not financially viable. We decided to proceed with an upper and lower fixed labial orthodontic appliance to align just the anterior teeth, following which there would be a course of teeth whitening and composite bonding as required. This progressive approach to smile design allows for a minimally invasive process to be adopted while meeting the patient’s aesthetic demands. It can be summarised as a an “ABC” approach to smile design:
A – Align the anterior teeth. This can be done in a number of ways according to the patient’s preference.
B – Bleaching or teeth whitening.
C – Correction, usually using composite or ceramic to rectify any wear or irregularities in size, shape or colour of the newly aligned teeth.
It must be stressed at this stage that the initial alignment should not be confused with orthodontic treatment. Yes, we are carrying out orthodontic tooth movements, but this does not equate to orthodontic treatment in the true sense. We are not trying to correct any malocclusions or improve jaw relationships in any way. The patient has been offered the orthodontic option and has declined this approach. Instead, the idea of the initial alignment is to make any subsequent restorative treatment simpler and minimally invasive.
The term Short Term Orthodontics, STO, has become widely used to describe this initial alignment phase but I believe that this term is quite misleading and can be confused by both dentists and patients into thinking it is an abbreviated form of orthodontic treatment – it is not. As such, the term Cosmetic Tooth Alignment or Pre-restorative Alignment is a more accurate in describing the aims of this stage of the procedure.
Putting it into practice
The patient opted for a fixed labial appliance and the Cfast self-ligating brace was used to complete this stage of treatment. The brace was fitted using an indirect approach with the brackets held in a laboratory constructed stent and cemented a quadrant, six brackets, at a time. Interproximal reduction (IPR) was carried out in the upper arch between the 12, 11 of approximately 0.15mm. In the lower arch IPR was carried out using a 0.1mm IPR strip between all the incisors.[iv]
A very light 0.014” nickel titanium (NiTi) wire was placed to initiate tooth movement. (Fig 10)
The patient was reviewed 5 weeks later, (Fig 11) and even after this short period there was a significant aesthetic improvement, and one of the patient’s main presenting complaints, the anterior crossbite, had already been corrected.
Further IPR was carried out in the lower arch only and the patient was referred to the dental hygienist as some gingival inflammation was noted, especially around the 22, 23 region. The patient was then reviewed 4 weeks later, and where it was observed that the teeth were almost fully aligned and the gingival condition had greatly improved. (Fig 12)
Alignment continued in this fashion until it was mutually agreed that there was enough of an improvement in tooth position to proceed to the next phase of treatment and subsequently the braces were removed. (Fig 13)
Following alignment
The patient then proceeded to have his teeth whitened using a take home whitening system of 15% carbamide peroxide. Composite bonding was carried out on several teeth to correct the effects of differential incisal edge wear as well as to mask some discolouration. (Fig 14-17)
To ensure the stability of the final appearance, the patient was given both fixed and removable retainers which were stressed at the outset as an indefinite requirement. The patient did not want metal bonded lingual retainers, so we opted for a fibre reinforced composite resin retainer using an indirect approach. Fibre reinforced composite resin retainers are an alternative to metal lingual bonded retainers.[v], [vi], [vii] (Fig 18, 19)
Overall, the ABC approach to smile design allowed us to achieve a significant improvement in the patient’s dental appearance without the need for protracted orthodontic treatment or potentially quite destructive restorative approaches. (Fig 20, 21)
Summary
In my opinion, it is no longer acceptable in the provision of cosmetic dentistry to simply pick up the drill and cut healthy tooth tissue without consideration of tooth alignment in the treatment planning phase.
As the dental profession generally moves towards more minimally invasive techniques to provide cosmetic improvements, there is a need to offer solutions to patients that will greatly reduce or completely remove the need for any enamel preparation. These solutions should, of course, include idealistic treatment options that will correct any underlying malocclusion. However, for a significant number of patients, this is not acceptable as the time taken to achieve these more idealistic treatment plans is unrealistic.
As the late, renowned and visionary orthodontist Dr Vince Kokich is quoted as saying, “Children should be treated idealistically and adults should be treated realistically.”
With the development of simple and well supported, GDP focused, cosmetic tooth alignment procedures, it is possible to practice truly minimally invasive cosmetic dentistry. It is incumbent on dentists that these techniques be routinely incorporated into the treatment planning phase of all elective cosmetic and restorative procedures.
Case images
Fig 1, Pre-treatment, crowding in the upper and lower arches
Fig 2, Pre-treatment, smile view
Fig 3, Pre-treatment, anterior view
Fig 4, Pre-treatment, anterior open view
Fig 5, Pre-treatment, right lateral view
Fig 6, Pre-treatment, left lateral open view
Fig 7, Pre-treatment, left lateral view
Fig 8, Pre-treatment upper arch, occlusal view
Fig 9, Pre-treatment lower arch, occlusal view
Fig 10, Placement of a 0.014″ NiTi wire after IPR, anterior view
Fig 11, 5 weeks after wire placement, anterior view
Fig 12, 9 weeks into treatment with improvement to the gingival condition, anterior view
Fig 13, Following the removal of the fixed braces, anterior view
Fig 14, Following composite bonding, anterior view
Fig 15, Following composite bonding, anterior open view
Fig 16, Following composite bonding, right lateral view
Fig 17, Following composite bonding, left lateral view
Fig 18, Fibre reinforced composite resin retainers on the upper arch, occlusal view
Fig 19, Fibre reinforced composite resin retainers on the lower arch, occlusal view
Fig 20, Final outcome, full face view
Fig 21, Final outcome, smile view
Dr Biju Krishnan is currently taking referrals for cosmetic and orthodontic cases at the One To One Dental Clinic in London. Visit https://121dental.co.uk/for-dentists/referrals/ to find out more.
Author Bio
Dr Biju Krishnan qualified from Dundee University in 1993, and has gone on to become an award-winning dentist focused on providing high-quality and minimally invasive cosmetic and orthodontic treatment. He is founder of the CFAST (Cosmetically Focused Adult Straight Teeth) cosmetic tooth alignment system, and has lectured around the world on the topic of cosmetic tooth alignment. Dr Krishnan is delighted to have recently joined the One To One Dental Clinic in Harley Street, London, where he is actively taking on referrals for cosmetic and orthodontic cases.
[i] Davis LG, Ashworth PD, Sprigs LS. Psychological effects of aesthetic dental treatment. J Dent. 1998;26(7):547–554. doi: 10.1016/S0300-5712(97)00031-6.
[ii] Dental Esthetics and Its Impact on Psycho-Social Well-Being and Dental Self Confidence: A Campus Based Survey of North Indian University StudentsJ Indian Prosthodont Soc. 2013 Dec; 13(4): 455–460.
[iii] Johal A, Alyaqoobi I, Patel R, Cox S. The impact of orthodontic treatment on quality of life and self-esteem in adult patients. Eur J Orthod. 2015;37(3):233–7.
[iv] Inter-proximal enamel reduction in contemporary orthodontics J. Pindoria,*1 P. S. Fleming2 and P. K. Sharma3
BRITISH DENTAL JOURNAL | VOLUME 221 NO. 12 | DECEMBER 16 2016
[v] Survival of post-treatment canine-to-canine lingual retainers with fiber-reinforced composite resin: a retrospective study. Davide Farronato, DDS, PhD1 Roberto Briguglio, MD, DDS et al. Annali di Stomatologia 2014; V (3): 81-86
[vi] Bonding Fiber-Reinforced Lingual Retainers with Color-Reactivating Flowable Composite MARC GESERICK, DDS JUDITH BALL, BCD, MSC, MOrth ANDREA WICHELHAUS, DDS, PHD JCO/OCTOBER 2004 VOLUME XXXVIII NUMBER 10
[vii] Comparison of survival time between two types of orthodontic fixed retainer: a prospective randomized clinical trial Salehi et al. Progress in Orthodontics 2013, 14:25
