Case 95: ‘Instant Ortho’ Expediency vs Long-Term Preservation of Tooth Structure

The patient was referred to our prosthodontics practice by his general dentist. He had undergone full-banded orthodontic treatment 25 years earlier because he disliked the Class II, division 2 flared maxillary laterals. He ended up having the wires removed once the maxillary laterals were in better alignment but before the completion of the orthodontic plan. About 10 years ago, the patient started Invisalign orthodontic therapy for unknown reasons but stopped wearing the aligners almost immediately. At the time he presented to our practice, he was concerned about the excessive wear on the mandibular anterior teeth. His general dentist had created a treatment plan that involved opening the bite and crowning all the teeth, which the patient declined partly for financial reasons and partly because it seemed excessive. His general dentist then referred him to our practice for a second opinion.

Medical History

The patient was in excellent health. He took no medications and had no allergies or other medical issues.

Diagnostic Findings

Extraoral/Facial

Normal facial symmetry.
The dental midline is slightly to the right of the facial midline. The mandibular dental midline is 2 mm to the left of the maxillary dental midline.
There is slightly excessive maxillary gingival display on the right side in exaggerated smile. Lip movement and gingival display on smiling are otherwise normal.

TMJ/Mandibular Range of Motion/Muscles of Mastication and Facial Expression

Other than some mild disc slippage on the left side, the temporomandibular joints are normal.
Normal range of motion.
No history of pain, clicking, or locking.
No muscle pain or tenderness on palpation.

Intraoral Findings

Dental

Teeth nos. 3, 7, 10, 15, 18, 19, and 31 have amalgam restorations. Tooth no. 14 has a composite restoration. Tooth no. 30 has a gold crown.
Tooth no. 28 is in complete lingual crossbite.
Excessive wear on teeth nos. 7–10 and 27.
Excessive to extreme wear on teeth nos. 22–26.
Retrusive and narrow maxillary dental arch.
Retrusive and wide mandibular dental arch.

Periodontal

Fair plaque control/oral hygiene.
Tooth no. 2 mesiolingual and tooth no. 3 distolingual have 5 mm pocket depths. Tooth no. 14 distofacial and tooth no. 15 mesiofacial have 7 mm pocket depths. Tooth no. 15 mesiolingual has a 6 mm pocket depth. All other teeth have pocket depths of 4 mm or less.
Class I mobility teeth nos. 7–10 and 23–26.
No furcation involvements or attached tissue issues.

Occlusal Notes

Centric relation coincident with maximum intercuspation position.
Tooth no. 28 in complete lingual crossbite.
Complete anterior vertical overlap with minimal centric stops for teeth nos. 22, 24, and 25 and no centric stops for teeth nos. 23, 26, and 27, which occlude on the palatal tissues.

Class II molar and canine relationships.
Patient has difficulty sliding in any excursive movement and immediately wants to open and place his tongue between the teeth.
No posterior excursive interferences.

Radiographic Review

All four third molars are full boney impacted.
Minor foreshortening and blunting of the maxillary and mandibular incisor roots.
Low mandibular plane angle and severe brachyfacial pattern.

Pretreatment FMX

Diagnosis and Prognosis

Diagnosis

Mild gingivitis (AAP Stage II localized, Grade A).
Non-smoker, normoglycemic.
Dental and skeletal Class II malocclusion.
Extreme vertical overbite, inadequate anterior coupling, and steep anterior guidance.

Prognosis

Good for all teeth.

Summary of Concerns

Is it possible to restore the worn anterior teeth without opening the bite and crowning all the teeth per the general dentist’s recommendation?
Is it possible to restore the worn anterior teeth at the current vertical dimension without orthodontics?
If we determine that the best treatment plan includes a third attempt at orthodontic treatment, how do we convince the patient to accept the plan?

Proposed Treatment Plan

Phase I: Diagnostic Work-up

Obtain diagnostic casts, centric relation and protrusive records, facebow transfer, clinical and periodontal charting, intraoral and panoramic radiographs and photos.
Schedule an interdisciplinary treatment planning consult between prosthodontic and orthodontic specialists.

Phase II: Case Presentation and Initial Periodontal Therapy

Help the patient understand the different objectives we are trying to achieve with a third round of orthodontics compared to the first two failed rounds.
Help the patient understand why the viable nonorthodontic treatment plan he received from his general dentist of “opening the bite and crowning all the teeth” is an extremely excessive and destructive treatment plan.
Establish gingival health and idealize plaque control habits.

Phase III: Orthodontic Therapy

Correct tooth no. 28 complete lingual crossbite.
Intrude all the maxillary and mandibular anterior teeth to properly align the cementoenamel junctions and gingival tissues and to create restorative space without changing the vertical dimension.
Reduce the depth of the anterior guidance, intrude the anterior teeth, correct the current Class II occlusion to a Class I occlusion, and horizontally align the anterior teeth so the future restorative treatment can create normal centric stops on the maxillary cingula.

Phase IV: Definitive Restorative Treatment

Restore tooth no. 15 with composite.
Restore teeth nos. 3, 14, 18, 19, 30, and 31 with gold onlays/crowns and finalize the posterior occlusion.
Restore teeth nos. 6–11 and 22–27 with monolithic IPS e.max crowns (Ivoclar Vivadent) and finalize the anterior guidance and occlusion.

Phase V: Maintenance

Instruct the patient on oral hygiene maintenance procedures.
Fabricate a maxillary Hawley orthodontic retainer with an anterior bite plate and a mandibular Hawley orthodontic retainer.

Active Clinical Treatment

Review of Treatment Goals

It was clear that a treatment plan that did not include excessive amounts of restorative dentistry would necessitate orthodontics. The question was whether the patient would accept and complete a third round of orthodontic treatment.

Phase I: Diagnostic Workup

Diagnostic casts, centric relation and protrusive records, facebow transfer, clinical and periodontal charting, intraoral and panoramic radiographs and photos were obtained.
An interdisciplinary treatment planning consult between prosthodontic and orthodontic specialists was completed.

Phase II: Treatment Presentation

Our discussions with the patient about possible treatment plans were made easier with the mounted models which clearly showed the complete vertical overlap of the anterior teeth and the lack of room to restore his worn lower front teeth (his primary concern) to their normal size and shape. We discussed how his general dentist’s treatment plan of “opening the bite and crowning all the teeth” was a valid plan. When we “opened the bite” on the articulator it was easy to show the patient why that would mean having to crown all the teeth. After looking at the photos of his minimally damaged posterior teeth (including nine virgin teeth) and realizing all those teeth would need crowns for primarily occlusal reasons, the patient asked if there were any other possible plans. At this point we presented the orthodontic option of moving the teeth into their proper positions rather than restoring them. When the patient understood that his previous attempts at orthodontic treatment were esthetically driven and that our proposed plan was occlusion, longevity, tooth structure preservation, and health driven, he readily agreed to the plan.

Phase III: Periodontal Therapy

Several hygiene appointments including deep scalings were completed to establish gingival health and idealize plaque control habits. Once the patient understood the importance of maintaining ideal plaque control and how difficult the orthodontic appliances would make that, he maintained a monthly recall for the entire 3+ years of the orthodontic treatment.

Phase IV: Orthodontic Therapy

The goals of orthodontic therapy were to correct tooth no. 28 complete lingual crossbite, intrude all the maxillary and mandibular anterior teeth to properly align the CEJs and gingival tissues, and to extrude the posterior teeth to create restorative space with only minimal change in the vertical dimension. The objective was also to shallow the anterior guidance and correct the Class II occlusion to as close to Class I as possible. Finally, horizontal alignment of the anterior teeth was addressed so future restorative treatment could create normal centric stops on the maxillary cingula.

Treatment started with self-ligating lingual brackets on the maxillary arch and self-ligating facial brackets on the mandibular arch. Bite Turbos were placed on the posterior teeth while intruding the incisors, then were gradually removed to allow extrusion of the posterior teeth as the anterior teeth intruded.

Temporary anchorage devices were placed palatally between teeth nos. 6, 7 and 10, 11, and facially between teeth nos. 22, 23 and 26, 27 so that elastic chains could help intrude the anteriors.

Buccal tubes were added on teeth nos. 3 and 4 and clear facial self-ligating brackets were added on teeth nos. 7–10 so that maxillary utility wires could intrude teeth nos. 7–10 while controlling the root torque and keeping the roots centered in the bone.

Phase V: Periodontal Surgery

The orthodontics had aligned the CEJs of teeth nos. 6–11 correctly, however the gingival tissue of tooth no. 7 remained too coronal. Esthetic crown lengthening of tooth no. 7 created ideal gingival contour symmetry.

Phase VI: Definitive Mandibular Restorative Treatment

Teeth nos. 6–11 were rebuilt with composite resin to create ideal final contours.
The upper posterior teeth were recontoured to create an ideal occlusal plane.
Teeth nos. 18, 19, 30, and 31 were prepared for cast gold restorations.
Teeth nos. 22–27 were prepared for monolithic e-max crowns.
Three weeks later the final restorations for teeth nos. 18, 19, 22–27, 30, and 31 were cemented.

Phase VII: Definitive Maxillary Restorative Treatment

Teeth nos. 3 and 14 were prepared for cast gold restorations and tooth no. 15 was restored with a composite resin.
Teeth nos. 6–11 were prepared for monolithic e-max crowns.
Three weeks later the final restorations for teeth nos. 3, 6–11, and 14 were cemented.
The occlusion and envelope of function were finalized.

Phase VIII: Maintenance

A maxillary Hawley orthodontic retainer was fabricated with an anterior bite plate lingual to teeth nos. 6–11 to prevent deep bite relapse and C-clasps on teeth nos. 2 and 15 to maintain space closure. A mandibular Hawley orthodontic retainer was fabricated with C-clasps on teeth nos. 18 and 31 to maintain space closure. The patient was placed on a regular hygiene maintenance schedule.

Commentary

The patient had previously started and stopped orthodontic treatment as a teenager and again as an adult so we were concerned if he would actually complete our orthodontic treatment plan. Although the patient completed treatment, it took a great deal longer than anticipated and caused lots of headaches for the orthodontist. Lingual approach orthodontics became a considerable maintenance nightmare as the patient continually dislodged the brackets. Treatment was also more complicated because the patient refused to allow further TAD placements at the 10 month mark in course of therapy. He also wore his elastics only at night instead of the recommended 22 hours per day. Despite those compromises, our orthodontist was able to obtain an excellent result primarily through three plus years of stubborn persistence.

It is our belief that many dentists have lost the respect for natural teeth and enamel. The concept of ‘instant ortho’ with a mouth full of veneers is promoted as a quick way to ‘straighten’ teeth. Unfortunately, after practicing prosthodontics and orthodontics for 35+ years each and seeing waves of similar overaggressive non-tooth preserving treatment options periodically sweep through our profession, it has been indelibly implanted in our brains that nothing is better than the bond of enamel to dentin. This case is an example of solving a severely compromised occlusion with excessive to extreme wear of anterior teeth by restoring only those teeth that needed restoring anyway and orthodontically moving the teeth that didn’t otherwise need restorations into their proper places.

Peter Fay, DMD, is a prosthodontist practicing in Kahului, Maui, Hawaii, a visiting faculty member at the Pankey Institute, and director of the Maui Postgraduate Dental Forum Seattle Study Club.

J. Mickey Damerell, DDS, MS, is an orthodontist practicing in Wailuku, Maui, Hawaii, and orthodontic advisor of the Maui Postgraduate Dental Forum Seattle Study Club.