Case Study: 2011–2012
You could say that I live in a strange country. When people come to our practice, most of them have only a vague understanding of what they need or want. Of course they all want beautiful and healthy teeth but that is too limited to act on. This patient was not like most people. Being a 43-year-old male lawyer, he contacted us to advise him about the very specific cosmetic issues he told us he had.
Initial Appointment
As with every new patient we reserved for him an initial discovery appointment. In our practice this initial appointment is typically 45 minutes. During this appointment we try to accomplish three goals. First we try to give the patients a general idea of what is going on in their mouths and what could be done. Secondly we try to build a perception of us and our practice into the patients’ mind. In our case, that perception is one of comfort and professionalism. We want our patients to understand that mutual respect and trust governs our relationships. Third, we want our patients to have a look of what the financial implications of their possible treatment could be. Especially in our country, with only a very limited social dental assurance, our patients have to pay their treatments almost 100 percent out of their own pockets.
Diagnosis
Just like the patient told us on the telephone, it was immediately clear that he had severe crowding in the upper and lower anterior regions, his buccal corridors were deficient and his canines were too prominent. Also there was a natural mismatch between the length/width ratios of his two central upper incisors (Fig. 1). Digital photos were taken and reviewed with the patient. The patient was informed that the treatment would exist of two major parts, one orthodontic part and one ‘veneer’ part. The patient agreed with the proposed treatment.
FIGURE 1. Before./201504090852290yczcocbyklde2245nvnh4h45.jpg)
Digital Orthodontic Treatment
For the orthodontic part Invisalign was chosen because of its ability to digitally treatment plan the teeth movements. Because of the mismatch between the length/width ratios of the upper centrals, the orthodontic therapy also included the creation of the proper spacing between the upper centrals; and with the Invisalign Clincheck the actual treatment could be reviewed before the start of the treatment (Figs. 2 and 3).
FIGURE 2. Clincheck before./201504090852291yczcocbyklde2245nvnh4h45.jpg)
FIGURE 3. Clincheck after./201504090852292yczcocbyklde2245nvnh4h45.jpg)
Invisalign is a great way to do orthodontics but it has some major flaws in my own hands. First case selection is critical; for me Invisalign is best suited for well-selected mild or moderate cases. Second patient selection is maybe even more critical. Too many patients don’t wear their aligners as instructed with the result being that the treatment fails.
In this moderate difficult case we were lucky. We had a patient that was so cooperative that he even flew in from his holiday in the Côte d’Azur just for his Invisalign visit. The initial treatment was composed of 30 aligners. The refinement phase consisted of 10 aligners.
After the Invisalign treatment the crowding was solved, the buccal corridors were expanded and last but not least, spaces were created between the upper front teeth (Figs. 4, 5 and 6).
FIGURE 4. Invisalign after./201504090852293yczcocbyklde2245nvnh4h45.jpg)
FIGURE 5. Invisalign after./201504090852294yczcocbyklde2245nvnh4h45.jpg)
FIGURE 6. Invisalign after./201504090852305yczcocbyklde2245nvnh4h45.jpg)
Diastema Closure with Direct Composites
The option of closing the created diastemas with resin composites was presented to the patient, who agreed to the proposed treatment plan. An intraorally mock-up was made to evaluate where dental composite needed to be added. For the best result, only to the mesial of tooth #11 and to the distal of tooth #21 needed to be added to (Figs. 7 and 8).
FIGURE 7. Mock-Up./201504090852306yczcocbyklde2245nvnh4h45.jpg)
FIGURE 8. Mock-Up./201504090852307yczcocbyklde2245nvnh4h45.jpg)
Before starting the treatment, the right color was selected. This was done by putting a piece of composite at the middle of the teeth, putting a matrix strip above it and then light curing it. The Rite Lite device from Addent was used to confirm that the color of the composite was the same as the color of the teeth.
For this treatment Filtek Supreme XTE (3M ESPE) was chosen because thi
s material can be handled without slumping or sticking. No preparation was necessary. Only air abrasion was done (Figs. 9 and 10).
FIGURE 9. Air Abrasion./201504090852308yczcocbyklde2245nvnh4h45.jpg)
FIGURE 10. Air Abrasion./201504090852309yczcocbyklde2245nvnh4h45.jpg)
After the air abrasion a mylar strip was put into place to separate the teeth for etching and bonding. A one-minute etching was done followed by putting a bonding agent (Clearfill SE Bond), thinning it and light-curing it. Only using the bonding agent was possible because only enamel needed to be bonded to.
The mylar strips were removed and shaded resin composite was placed and countered to optimal contour. A small brush (GC) with a tiny amount of Composite Wetting Resin (Ultradent) was use to blend the composite over the facial surface. The countered composite was light-cured with a Led light for 20 seconds lingually and 20 seconds buccally.
The teeth were separated by the technique referred to as “The Mopper Plop” because it gives a plop sound when separating the teeth with a dental spatula. Soflex discs and fine diamond burs without water were used to remove any excess of material. K-Jelly was put on the surfaces of the restorations and the restorations were light-cured through the K-Jelly with a plasma light (Rembrant) for 20 seconds lingually and 20 seconds buccally. Finally the restorations were polished to high glaze using fine soflex discs, polishing strips (Epitex, GC) and Flexibuffs with Enamelize (Cosmedent).
Refinement
While reviewing the photos after the initial treatment an incongruence of the emergence profile between the distal of teeth #11 and #21 was noticed (Fig. 11). Although the lip line of this patient was very low I decided to create a beautiful emergence profile. Therefore composite was added to the distal of tooth #11.
FIGURE 11. Emergence profiles. FIGURE 2. End result./201504090934590yczcocbyklde2245nvnh4h45.jpg)
/201504090934591yczcocbyklde2245nvnh4h45.jpg)
FIGURE 13. End result. FIGURE 14. End result./201504090935002yczcocbyklde2245nvnh4h45.jpg)
/201504090935003yczcocbyklde2245nvnh4h45.jpg)
Figures 12, 13 and 14 show the final result. Please also note the newly created length/width ratios of the upper centrals.OH
Mr. Luc Vanderborght maintains his private practice in Belgium. He graduated as a dentist at the Free University of Brussels. He has a Fellowship with the IADFE and with the ICOI. He is a member of the ASDA and a participating member of the AACD.
Oral Health welcomes this original article.
