Dr Michael Santangeli presents a long-term solution to a Class II division 2 malocclusion with mild to severe incisal wear.
A 36-year-old male patient presented to me with concerns about the aesthetics of his dentition, primarily regarding mild to severe wear on his anterior dentition. A regular attendee of the practice, we had discussed his compromised anterior envelope and how his teeth were in a non-harmonious position for optimal function in previous appointments. He was interested in learning about the potential treatment options available to him to improve function and aesthetics.
A full orthodontic assessment was carried out. Mild wear was observed on the upper incisors, and moderate to severe wear on the lowers, creating concerns about the functional viability of these teeth in the long-term. This was compounded by a Class II division 2 malocclusion and a restricted anterior envelope of function. Each of these factors can significantly exacerbate tooth wear which lead to his condition and, without appropriate intervention, would have worsened. Digital scans were used to assess the existing intercuspal positions, and unfavourable results were observed in the incisal areas.
X-ray assessments were completed, and the patient was deemed to have adequate bone health for orthodontic treatment. His oral hygiene was acceptable, but he was a habitual nail biter. This parafunctional habit is well known as a potential cause of tooth wear.[i] Intraoral images were attained with a DSLR camera.
A number of treatment plans were prepared and presented to the patient. Soft splint therapy and continual monitoring of the dentition was discussed. Whilst this would be a more affordable form of treatment for the patient, it would not address the cause of tooth wear entirely, merely mask it.
Taking a Dahl approach was discussed, readjusting the bite to create space in the anterior dentition and then building up the incisors with composite to restore aesthetics and function. This too would not be enough to prevent long-term problems, as the restricted envelope of function meant that he would still be prone to wear upon the restorations. The patient appreciated the alignment of the dentition would need correcting.
To ensure longevity of the restoration, it was proposed that the patient undergo a course of orthodontic treatment to correct the mild crowding in the upper arch and moderate to severe crowding in the lower dentition, whilst intruding both the upper and lower anterior teeth, This would be achieved with a view to create space in the intercuspal positions in order to restore the lower incisors to the correct height and anatomy, in turn reversing years of non-carious tissue loss and minimising the risk of it happening again.
This approach leaned heavily on the skills and insights I acquired from the Align, Bleach & Bond (ABB) course with the IAS Academy. Without the experiences the course gave me in aligning and restoring complex cases, I may have only been able to provide a soft splint, which is ultimately not the most optimal outcome for the patient, and so need to refer the case for orthodontic treatment. The approach also leant on the philosophy of minimally invasive, but long-term care, which was imparted onto me by the tutors.
Each treatment plan was presented to the patient with its positive and negatives, and he was receptive to each. He provided informed consent to proceed with orthodontic treatment with clear aligners, followed by composite restorations.
Clear aligners were the chosen orthodontic approach due to their aesthetic advantages. In total, 20 appliances were used throughout the process, with the patient instructed to wear them for a minimum of 22 hours a day. He was also advised on how to maintain his oral hygiene to an optimal standard, with direction to routinely clean the aligners. Each aligner was worn for around seven days at a time, and the patient experienced no issues. He was exceptionally compliant and the treatment plan tracked with the in vivo outcomes, requiring no adjustments during the process.
Post-treatment scans displayed that the desired movements had been achieved from the clear aligner therapy. With successful intrusion of the incisors, there was adequate intercuspal space for restorations to be built in the lower arch. A digital wax up allowed for precise planning of this aspect, and also the chance to visually display the treatment to the patient. Using technology in this way means clinicians can create a ‘trial smile’ which can assess function and aesthetics reliably before further treatment is provided, creating a more predictable outcome.
Following the completion of orthodontic care, the patient underwent a course of whitening to achieve an aesthetic, bright shade. His lower incisors were built up with the G-ænial Universal Injectable and the EXACLEAR clear VPS, utilising a composite injection moulding technique. This approach is favourable as it allows a clinician to effectively build height whilst retaining aesthetics and durability. The upper incisors were restored with free-hand edge-bonding, another technique that I was able to refine though the ABB course from the IAS Academy.
The restorations were checked to ensure they optimised the occlusal contacts, resulting in a restored anterior dentition with improved aesthetics and function in everyday life. Removable clear retainers were provided to be worn nightly, and the patient was instructed to keep up his oral hygiene routine and regularly clean the new appliances.
The patient was delighted with the outcome, and agreed that the extra steps for orthodontic treatment were worth the extended period of care. I was equally delighted, not least for the immediate result, but knowing that it would be a long-term solution. Had the teeth been left in malocclusion, the failure of restorative work is almost an eventuality, suffering the same fate as the natural dentition. We discussed techniques the patient could implement to halt his parafunctional habits, but ultimately restoring a functional occlusion was the only way to optimise restorative results for years to come.
Without improving my clinical knowledge through advanced training courses, it would be impossible for me to deliver such results to my patients without referrals. Taking courses like the Align, Bleach & Bond course from the IAS Academy allows me to present these complex treatments in house, and make patients for life.
For more information on upcoming IAS Academy training courses, please visit www.iasortho.com or call 01932 336470 (Press 1)
Author bio:
Dr Michael Santangeli graduated from Liverpool Dental School with honours and distinctions in all subjects. He received multiple academic prizes upon graduation, including the prestigious Malcom Foster Medal, awarded to the student with the highest overall finals grade. Dr Santangeli currently treats patients at Starbeck Dental Centre in Harrogate, where he provides high-quality general dentistry, orthodontic and restorative care. Outside of dentistry, he enjoys running and spending time with his wife Annie, son Raife and miniature sausage dog Noah.
[i] Algadhi, A. (2021). Tooth surface loss: definitions, prevention and diagnosis. Saudi J Oral Dent Res, 6(3), 129-133.
