Photo Essay: Utilizing Limited Orthodontics in a No-Prep Veneer Case
Chairside Magazine: Volume 9, Issue 2
article by Michael C. DiTolla, DDS, FAGD
When this patient came in wanting to improve his smile, it was clear this wasn’t going to be a straightforward veneer case. I used to do orthodontics in my practice, and I’m comfortable using removable appliances to correct clinical conditions such as crossbites, so I had Space Maintainers Laboratory fabricate a removable appliance for me. I could have used a fixed appliance with either an anterior or posterior bite plane to correct the crossbites, but the patient convinced me he would wear the removable appliance as instructed. These types of cases take a while to reach completion, especially when the patient tells you that fixed orthodontics (brackets and archwires) are off the table. You could always refer the ortho portion of the case to a specialist, but most of the dentists that I speak with enjoy the process of minor tooth movement, whether it is with an appliance like the one I use in this case, or a series of clear aligners.
Figure 1: I don’t recall ever seeing a patient before with three anterior teeth in crossbite and one anterior tooth in essentially a perfect position. Orthodontics in esthetic anterior cases is almost always both a viable option and the most conservative option. In this case, orthodontics is mandatory. However, orthodontics doesn’t address tooth size and shape discrepancies, undesirable shades, or other esthetic issues.
Figure 2: The first thing that jumped out at me while looking at this occlusal view is how wide the patient’s upper arch appears to be; I expected it to be narrow with more crowding. We definitely need some room to unravel what crowding there is in the anterior, and those spaces between #4, #5 and #6 will come in handy. There is an outside chance he might need a cleaning and an extraction, too.
Figure 3: VPS impressions and a bite registration were sent to Space Maintainers Lab, and this is a look at the tissue side of the appliance we received back. My explorer is touching one of the three recurved finger springs that are currently in their inactivated state. These springs will help to rotate the three teeth in crossbite into proper alignment. I will remove the portion of the acrylic that covers the springs when I am ready to activate them, making them much easier to adjust.
Figure 4: Here is a look at the tongue side of the appliance. This type of expansion screw is typically used in the midline of an appliance like this to broaden the arch. Here, it is being used to move the three teeth in crossbite into the proper arch form. The yellow arrow shows the patient which direction to turn the screw twice per week.
Figure 5: The retention for this appliance is primarily from an Adams clasp on the molar. The bends of the Adams clasp engage the interproximal undercuts of the molar, and can be tightened or loosened as needed. It also crosses over the occlusal surface, so you need to make sure you have occlusal clearance for the clasp. There is also a wire clasp for the bicuspid that has been soldered to the distal end of the labial archwire.
Figure 6: On the contralateral side, a hook has been soldered to the Adams clasp. This gives us a posterior anchorage point where we will be placing elastics later to help distalize some anterior teeth. You will notice the labial archwire continues past the cuspid, and is soldered to the mesial portion of the Adams clasp for stability.
Figure 7: Space Maintainers also included two bondable buttons. The tooth side of the button has a mesh framework that uses mechanical retention to keep the resin bonded to it. As you may have guessed, these buttons will be at the other end of the elastics that will attach to the hook on the Adams clasp. Your ability to move a tooth increases exponentially when you bond a button or (especially) a bracket to the tooth.
Figure 8: I place and remove the appliance the first few times to check its fit, but I will definitely make the patient do it several times as well. With the appliance in place, we are getting some additional retention from the occlusal surfaces of the posterior teeth, which are indexed in the appliance as though it were a bite splint. The thickness of the occlusal pads is enough to ensure we can jump the crossbite.
Figure 9: The bite is checked to make sure that the patient is hitting the posterior pads equally on both sides. If there is a prematurity on either side, it has a tendency to pop the other side of the appliance off when the patient bites down. We remind the patient that the more he wears this appliance, the faster we can correct the crossbite, and the faster we can stop using the appliance.
Figure 10: We are also going to cement the two buttons at this appointment, so we begin by cleaning the enamel surfaces with Preppies™, the unit-dose pumice from Whip Mix (Louisville, Ky.). We need to ensure we get a good bond here: There is going to be a lot of force on these buttons, much more than on a typical composite restoration.
Figure 11: Because the buttons need to coexist with the appliance, I have placed the appliance prior to acid-etching the tooth so I can see exactly where the buttons need to be. Space Maintainers designed the labial archwire so that there would be room for the buttons between the archwire and the gingival margin.
Figure 12: After rinsing off the etch and placing some GC Fuji ORTHO™ LC cement (GC America; Alsip, Ill.) on the tooth side of the button, I place the button and adjust it to its final position. The more gingival we place the button on the cuspid, the better the chance of moving the tooth bodily to the distal, as opposed to just tipping it to the distal. If the button were placed at the incisal edge, you can imagine how it would just tip the tooth, rather than move it bodily.
Figure 13: The button has been placed and positioned on the first bicuspid as well, and both have been light-cured. The appliance has now been removed, and we are going to clean up the excess cement around the buttons with a finishing bur. If you look back to Figure 2, you will notice we have space distal to both of these teeth, and we are going to move them both in that direction to create space in the anterior.
Figure 14: Both of the elastics are attached to the hook on the Adams clasp, and then one attaches to the button on the bicuspid and one attaches to the button on the cuspid. It’s hard to tell from this photo, but the bicuspid is not indexed in the appliance. If it were, it would be impossible to move it distally.
Figure 15: The patient returns a week later for us to evaluate how he is doing with the appliance. Besides having to speak a little slower than usual due to the appliance, the patient is tolerating it well, and is able to eat with it in place. Because of this success, we now show him the expansion screw, the key, and the yellow arrow that indicates in which direction one full turn of the screw is to be made once on Wednesday and once on Sunday.
Figure 16: When the patient returns six weeks later, the progress of the expansion screw is evident. At times, the acrylic ramp can have a tendency to slide up the lingual surfaces of anterior teeth (as opposed to pushing them forward) due to lack of undercut on the lingual. If this starts to happen, small composite buttons can be placed on the lingual to create those undercuts for the acrylic ramp to engage.
Figure 17: Compared to Figure 2, we have made some decent progress, both in distalizing the cuspid and bicuspid, and in anteriorizing the three teeth in crossbite. We still need more room for tooth #7, but we aren’t done distalizing #5 and #6. The patient still has another 4 mm to go in terms of advancing the acrylic ramp.
Figure 18: Six weeks later, the patient comes in again. This is a shot of the appliance in the patient’s mouth. We’ve had more advancement of the acrylic ramp, but I feel like the labial archwire is hindering the movement of tooth #10. The patient’s upper lip actually acts as a great labial archwire: The more the teeth are moved to the labial, the more the lip pushes them back to the lingual.
Figure 19: The first bicuspid is now contacting the second bicuspid, meaning that we are finished moving it distally, so I want to lock it in place. I roughen the inside of the appliance in the area of the first bicuspid, place some methyl methacrylate, and reseat the appliance to index the occlusal surface of the first bicuspid. It still needs to be trimmed, but you can see that this tooth will now be locked into place.
Figure 20: I can see I am still seriously short on space for tooth #7. I can push all I want from the lingual with the acrylic plate, but #7 is not going anywhere until I can create some space for it. With an ultra-fine diamond bur, I am opening the contact between the cuspid and bicuspid by recontouring the proximal surfaces. This will allow me to move the cuspid further distally.
Figure 21: You can see the increased space I now have to move the cuspid distally, and I am also going to create a small space between #6 and #7 to “unlock” #7 and start to get some labial movement. Tooth #7 is still in contact with tooth #8, but if I create this space on the distal, the tooth will move labially and distally as well.
Figure 22: Now that the first bicuspid is indexed in the appliance, it can be used as an anchorage unit, allowing me to place a power chain from the bicuspid to the cuspid. Usually, this would pull these two teeth together; but with the bicuspid locked in, the cuspid is forced to move distally. Now the patient doesn’t have to replace the elastic every time they take out the appliance to brush, due to the fact that it’s no longer attached to the appliance.
Figure 23: Two weeks later, the patient is back again because the power chain needs to be changed. You can see the dramatic difference between the new power chain on the left and the two-week-old one on the right. Once this permanent deformation occurs, it is no longer moving the cuspid distally and needs to be replaced. Unlike elastics, patients can’t change power chains on their own.
Figure 24: With the appliance in, I can see that I have finally had some labial movement on the lateral incisors. Also, if we compare the space between #5 and #6 with how it looked in Figure 21, we have definitely had some distal movement of the cuspid as well. We have reached the full length of our expansion screw’s ability to move the acrylic plate to the labial, so it’s time to check the patient’s bite with the appliance and see how we are doing.
Figure 25: It’s been three months since treatment began. The good news is once you correct an anterior crossbite, it will not relapse. Because the incisal edges of the three maxillary teeth are now in the correct position relative to the lower incisors, the patient could stop wearing the appliance today, if I didn’t need those recurved finger springs on the lingual to try to correct the rotations, too. We can now focus more exclusively on creating the space for, and moving, teeth #7 and #9, as well as working on rotating tooth #10.
Figure 26: The occlusal “before” shot and an occlusal shot from today shows how the crowding has slowly started to unravel. Three months is a pretty short period of time, and while we will need more time to finish this phase, the good news is that everything is moving in the correct direction. I might even have enough room for tooth #7, but I will have to move it distally to verify that.
Figure 27: I’m going to need some anchorage on this tooth to really move it effectively. I could place a button on the tooth, but then I would pull it on a diagonal and not to the distal. If I place this bracket, it will allow me to place a power chain on the mesial portion of the bracket. Not only will this move #7 distally, it will also rotate the tooth as it does it, pulling the mesial to the labial and the distal to the lingual.
Figure 28: Now that the cuspid has been moved distally, I would like to lock it in place. Because I can’t index it in the appliance, I am going to anchor it to the bicuspid with a ligature wire. Moving these two teeth distally is like sliding beads on a necklace: Once they get to the desired position, they need to be held there to keep them from moving back. This is also plenty of anchorage to move the lateral incisor.
Figure 29: With the power chain in place, I am hoping to get some rotation on #7 as it moves distally, but that would take a fair amount of luck. In reality, I will be happy with any continued movement in the right direction and confirmation of whether or not I will need to create more space.
Figure 30: This is a better view of tooth #7 and the available space we have for this tooth to move into. It still looks like we might be short on space, but I want to give this power chain a chance for a couple of weeks to rotate this tooth into position and see what happens. Ortho is always a work in progress, and you typically get many opportunities to correct your course.
Figure 31: Two weeks later, the patient comes back in, and this is a shot with the appliance in place. Tooth #7 looks like it’s going to slide into that space after all. The three recurved finger springs have been activated with some #139 bird beak pliers, and are helping to direct the teeth into place. You can place a composite ledge across the lingual to create an undercut, if necessary, so that you can engage with the recurved finger spring.
Figure 32: Two weeks later, the patient is back again, and I have gone from wondering if I have enough space for tooth #7 to being amazed that I have a slight excess of space. In reality, the tooth is probably slightly overrotated, and that has created this space. If we take off the power chain, this tooth will quickly rotate back to close that diastema.
Figure 33: With tooth #7 in the arch form now, I am ready to take off the two buttons and the bracket. When you engage a bracket with pliers and squeeze it, it’s easy to deform the bracket and pop it off the tooth. The resin cement typically remains on the tooth, and can be removed with a finishing bur and polishing cup. In five months, we have been able to correct the anterior crossbites.
Figure 34: We placed the patient on a three-month recall, and this is how he looked when he returned. Because we used a removable appliance and corrected the crossbite primarily by tipping the teeth, we have some gingival discrepancies to deal with. If we had done fixed ortho with brackets and archwires, the gingival levels on teeth #7 and #9 would look better, with the root in the correct position.
Figure 35: The patient preferred using a removable appliance rather than fixed ortho, so gingival recontouring is about our only option. Prior to placing the veneers, I want to recontour the gingiva so that the clinical crown sizes of the anterior teeth will match better. As I probe the pockets on the anterior teeth, I can see that I have room for some recontouring, and I will probe to the crest of the bone at the next appointment.
Figure 36: We took an impression last appointment and sent it to the BioTemps® department (Glidewell Laboratories; Newport Beach, Calif.). I had them design a smile stent for me with the central incisors measuring 10.5 mm in length and the rest of the teeth according to golden proportion. This is an ideal setup for most patients, although there is no need to strictly adhere to these numbers; they are merely guidelines.
Figure 37: I placed the smile stent in the patient’s mouth and gave him a mirror, and he liked how the setup looked. I anesthetized him, put the stent back in, and outlined the gingival levels with a surgical skin marker. We might not be able to achieve these gingival levels without doing hard-tissue crown lengthening — removing some bone to reestablish a proper biological width.
Figure 38: After the patient is numb, I can probe to crestal bone and know how much soft tissue I can safely remove without violating the biological width. I need to leave 3 mm from the crest of the bone to the gingival margin in order to have stable periodontal structures. I begin using the diode laser to strip away the soft tissue. Even if I can’t remove as much gingiva as I would like, I am still going to use the shape of the stent to guide me.
Figure 39: After doing the initial recontouring on the tissue, I am using hydrogen peroxide in an Ultradent syringe with a tufted tip to clean things up. I am not dabbing it on, but actively scrubbing against the tissue to remove small tags. The hydrogen peroxide will also remove the surgical skin marker from the tissue once you are done with the recontouring.
Figure 40: When I am finished recontouring the tissue, I want to double-check and make sure that I am still good on the biological width. As I check the sulcular depth on tooth #7, I can see that I still have 3 mm from the gingival margin to the crest of the bone, as the first 3 mm of the probe is colored green. Besides working well in photos, it’s a good visual aid when you want a patient to watch you probe in their mouth.
Figure 41: I like how the teeth are looking after the gingival recontouring, at least in terms of clinical crown sizes. We have 3 mm between the gingival margin and the crest of the bone on all of the anterior teeth, so I am going to push my luck and take a final impression for the no-prep veneers today.
Figure 42: The best part of a no-prep veneer case is that the prep appointment is simply a matter of cleaning the facial surfaces of the teeth with a prophy cup and some unit-dose pumice. Even though there are no true margins on these restorations, it is important to treat it as though you were taking a regular crown and bridge impression. Retraction is optional, but be sure to syringe-wash material around the gingival margin so the model is crisp and clean.
Figure 43: Two weeks later, the patient returns, and we try in the veneers and give the patient a hand mirror to get his approval. He was pleased with how they looked, although patients are often more pleased with no-prep esthetics than dentists are, because no-prep restorations by definition are always going to be bulkier than their minimal-prep counterparts. The tissue has healed well in the weeks since the last appointment, and I feel comfortable going ahead with the bonding procedure.
Figure 44: One of the challenges with traditional veneers is dealing with the health of the gingival margin at the seat appointment. Temporary veneers are always a challenge to get an effective gingival seal, meaning you’ll need to be careful when getting etch in the vicinity of irritated gingiva. One of the fun parts of no-prep veneers is not worrying about that, but because of the laser recontouring two weeks ago, I am keeping my eyes on the gingiva while I etch.
Figure 45: After etching the enamel for 15 seconds, we rinse it off, place the bonding agent, air-thin and cure it for 10 seconds. I always place the veneers on #8 and #9 first, without any of the other veneers, to ensure that they are placed correctly. These two veneers will make or break the smile, and it is imperative that they are placed together without any of the other veneers.
Figure 46: Once the veneers are in the correct position, we do the “tack and wave” procedure. We cure for three seconds while waving the tip of the curing light to make sure we don’t over-cure the resin cement. We want to be able to peel it off with an explorer and clean it up without having to use a bur. It’s always better to under-cure than to over-cure so that you can clean up the excess resin cement prior to final curing. I always run a piece of floss between #8 and #9 prior to final curing as well, to keep from bonding these teeth together.
Figure 47: Once #8 and #9 are bonded into place, I then typically start placing the rest of the veneers two at a time. Because in this case I just have one bicuspid on one side, I am going to place three veneers at a time. I always make sure that the operatory light is turned off while I am doing three veneers to ensure I don’t inadvertently cure the resin cement around the margins prior to cleaning it up in the gel state.
Figure 48: Once all the veneers are in place and are cleaned up and cured, we polish the restorations with a bristle brush at slow speed and Diashine polishing paste from VH Technologies (Bellevue, Wash.). One of the nice things about polishing the veneers after bonding them into place is the fact that it helps show you where excess resin cement might have cured on the facial, allowing you to remove it with a scalpel.
Figure 49: I’m guessing you didn’t need me to label these images as “before” and “after.” As much as I cringe a little when I see no-prep veneers because they often appear to be swollen teeth, there is no denying that in this case, the patient experienced a tremendous improvement from his pre-op smile to his post-op smile. This is a patient who made an effort to keep his lips closed when he would smile.
Figure 50: One of the benefits of providing orthodontic treatment in addition to the veneers is that we are able to correct the alignment of the teeth, rather than just correcting the facial arch form while ignoring the lingual; although we did not have to be quite as precise with our orthodontics as might normally be required due to the use of veneers.
Figure 51: The maxillary midline is still off, just as it was in the “before” photo. In order to correct a midline, we would need to achieve bodily movement of the central incisors, and the only way to achieve that would be through the use of brackets, archwires and elastics. Bodily movement of teeth is beyond the capabilities of removable appliances.
Figure 52: Frequently with cases where the patient has not smiled naturally for many years, there is a period of retraining that goes on as the patient learns the new habit of showing their teeth while they smile. This portrait was taken one month after the veneers were placed and the patient is well on his way to learning to smile again without reservation. Again, this case would simply not have been possible without orthodontic intervention.