Pre-Restorative Orthodontics: A Cornerstone of Comprehensive Care

INTRODUCTION
There has never been a better time to be offering and delivering comprehensive care in dentistry. Thanks to research and development in all areas of dentistry, we have the ability to offer our patients healthy, natural-looking, metal-free restorative solutions. The advancements in ceramics give us the opportunity to replace lost, worn, or missing tooth structure in a manner that reflects the original shape, size, contour, and anatomy of our patients’ teeth. The development and improvements in adhesive dentistry offer longevity to our healthy, stable, functional, and aesthetically pleasing restorative procedures. The most important aspect in delivering comprehensive care is establishing a stable, healthy, and functional occlusion upon which to build the above-mentioned restorative techniques. Thanks to sophisticated technological developments in orthodontics, we have Invisalign (Align Technology) to offer to our adult patients. Invisalign is a clear, comfortable, and hygienic orthodontic system capable of correcting our patients’ malocclusions prior to any restorative work. I have been using Invisalign to set up my restorative cases for more than 10 years now. Heather is a patient who is representative of this treatment philosophy and will be the focus of this clinical article.

CASE REPORT
Diagnosis and Treatment Planning
Heather presented to my office in early 2009 to discuss veneers as an option for her maxillary teeth. Her chief complaint was unhappiness with the appearance of her teeth and smile for several years and she wanted to fix it.

After a short discussion at the initial appointment, Heather understood that a comprehensive examination and a complete set of diagnostic records would be needed, followed by a consultation to discuss the findings and all available options for treatment, including sequencing and timing. Therefore, Heather was advised to schedule 2 appointments.

When she returned for the diagnostic records appointment, a full-mouth set of radiographs, diagnostic casts and photographs, periodontal probing and charting, and a comprehensive clinical examination were done. The digital photographs were taken by my chairside assistant with an easy-to-use, team-friendly digital camera (Pentax Optio WG-1 [Lester Dine]). Heather was scheduled for the consultation appointment after the collection of the diagnostic records, the comprehensive examination, and scaling/root planing and polishing were completed (Figures 1 to 5). The consultation process included an explanation of the diagnosis, treatment options, risks and benefits of all, as well as sequencing and timing, using the photos to teach the patient.

Figure 1. Preoperative anterior view.	Figure 2. Preoperative maxillary occlusal view.

Figure 3. Preoperative mandibular occlusal view

To be certain, Heather was mainly concerned with aesthetics as she was asymptomatic and pain-free at the time of examination. However, we took the opportunity to discuss the obvious existing damage to her teeth, and she was aware that some of it was self-induced. Heather clarified that during college she had struggled with an eating disorder. However, she proudly explained that she had conquered the eating disorder shortly after college and had been healthy for 14 years. Heather also explained that she was reminded daily of her past history by the appearance of her teeth, along with her inability to smile confidently. She understood that an eating disorder would adversely affect the care in which she was about to invest. Our next step was to teach Heather about her anterior open bite and posterior edge-to-edge malocclusion.

At the consultation appointment, Heather learned about her bite and that her teeth were connecting in ways that contributed to the existing aesthetic compromise. Heather was aware that her front teeth did not meet, and she learned that this type of bite was called an open bite. She also learned that her back teeth were coming together inappropriately, and that the way her teeth were coming together was called a malocclusion (or “bad bite”), and this had an impact on the health, stability, and longevity of her teeth as well as the restorations she would be receiving. Heather learned that there was a difference between a “good” bite and a “bad” bite. It was pointed out that her existing bite was the reason for the irregular gumline across the upper teeth.

As professionals, we use the word malocclusion; however, this word does not register with most of our patients. A good bite is described as being protective and a bad bite being destructive. A good bite exists when the teeth come together and contact each other where they were designed to contact. A good bite will lead to excellent mastication of food, while protecting the teeth, dental restorations, gums, bone, jaw joint, and musculature from the ill effects of malocclusion. A bad bite exists when the teeth come together and contact each other in places they weren’t designed to contact. A bad bite will allow mastication of food but, throughout time, can deteriorate the teeth, dental restorations, gum, bone, jaw joint, and musculature. Heather understood that her bite was a bad bite that had been destructive to her teeth, gums, bone, jaw joint, and surrounding muscles. We discussed that the desired long-term aesthetic outcome as well as the health and stability of her gums and that the planned dental restorations depended on creating a good bite for her through the course of dental treatment. I explained that utilizing orthodontics to position the teeth correctly to allow us to create a good bite would achieve the desired goals.

As an adult, traditional “braces” were not appealing to Heather, so our discussion turned toward the benefits of a much more aesthetic option, Invisalign. Heather learned that Invisalign was the most aesthetic, efficient, comfortable, hygienic, and capable way to correct her bite. After Invisalign treatment, her teeth could be restored to achieve a beautiful and healthy smile. With Invisalign, the teeth could be moved into a position in which the bite would improve and the gum tissue would remodel to a normal and level result. This treatment option would likely help Heather to achieve superb aesthetics without having to perform gum procedures (such as grafts).

The discussion then turned to the restorative component of the comprehensive care treatment. Heather came to the consultation with a basic desire for and knowledge of veneers. At this point, Heather learned that veneers were not an acceptable restorative option for her due to the amount and location of missing tooth structure. Heather learned about the reasons and rationale for full-coverage restorations called crowns. The opportunity to have all-ceramic crowns after Invisalign was appealing to Heather. So, she accepted the recommended treatment plan of Invisalign first then crowns second. After the thorough examination, diagnostic records, and discussions in the consultation appointment, and having been thoroughly informed of all her options, she was ready and excited to begin the recommended treatment.

Figure 4. Preoperative right lateral view.	Figure 5. Preoperative left lateral view.

Figure 6. After pre-restorative orthodontic treatment using Invisalign (Align Technology).

Comprehensive Care: Orthodontic Phase
In order to provide Invisalign, vinyl polysiloxane (VPS) (Imprint 4 [3M ESPE]) impressions were taken and submitted for the manufacture of the aligners. Heather’s Invisalign case would be designed to move all 28 teeth into proper position. The goals of this pre-restorative orthodontic treatment would be to achieve a good overbite, overjet, canine protected occlusion, and proper intercuspation of the posterior teeth, with no interferences. Her Invisalign was set up to establish proper arch form and proper arch width as well as proper buccolingual inclination.

Four weeks later, Heather returned to begin her clear aligner treatment. The composite attachments required for Invisalign were placed using a flowable composite resin (Premise [Kerr]). The first sets of aligners were delivered with instructions. Invisalign aligners can also double as bleach trays, so she was given 10% Opalescence (Ultradent Products) whitening gel to lighten the shade of her teeth in preparation for the restorative work. Heather was seen for follow-up Invisalign visits at 6-week intervals until her treatment was completed.

In less than 9 months, and after 18 aligners, Heather’s Invisalign orthodontic treatment was completed. Her bite was checked to confirm that our initial goals related to her bite had been achieved. Heather now had the appropriate overbite, overjet, and Class I occlusion with proper posterior intercuspation, all with no interferences. Heather’s anterior open bite and posterior edge-to-edge malocclusion were corrected and her healthy occlusion was already being reflected in her gum tissues. What was originally an uneven gumline was now level, thanks to the remodeling of the dento-alveolar complex by the Invisalign treatment. In addition, her gingival tissues were stippled, clean, pink, tight, and displayed shallow pocketing of one to 3 mm with no bleeding (Figure 6). She now presented with oral conditions that were much more amenable to achieving a stable and successful aesthetic restorative outcome. With this minimally invasive approach to the pre-restorative care, it is important to note that the gingival tissues were never touched by a scalpel, laser, or any other periodontal procedure (other than the original scaling and root planing). Invisalign had successfully established the foundation for the cosmetic and reconstructive dental needs of our patient.

Comprehensive Care: Restorative Phase
The attachments were polished off and post-orthodontic diagnostic models and photos were taken. Heather was instructed to wear the last aligner until her restorative appointment about 3 weeks later. The diagnostic models were sent to Kuwata Pan Dent Laboratory (Cedar Knolls, NJ) for a full diagnostic wax-up of the upper arch and to fabricate a clear stent that would be used to make the temporary restorations (Figures 7 and 8). The diagnostic wax-up extended from teeth Nos. 3 to 14 (upper first molar to first molar). (Teeth Nos. 2 and 15, the upper second molars, did not require dental restorations.)

When the diagnostic wax-up was returned, it showed teeth that demonstrated very natural shape, size, and contour. The ability of the lab team to provide more ideal work was due to the pre-restorative orthodontic care. My own team was very excited at the opportunity to transfer the wax-up into temporary restorations for Heather, because we knew this alone would make a significant and immediately noticeable aesthetic difference.

Figure 9. Taking the core (stump) shade of the prepared teeth using the Chromoscop shade guide (Ivoclar Vivadent).	Figure 10. The temporary (one-piece) restoration (Luxatemp [DMG America]).
Figure 11. Zoom! Whitening (Philips Oral Healthcare) and shade selection.	Figure 12. Postoperative anterior view after delivery of the lithium disilicate (IPS e.max [Ivoclar Vivadent]) crowns. The excellent result was made possible by the foundational work done with the pre-restorative orthodontics (Invisalign).
Figure 13. Postoperative maxillary occlusal view of the completed case with lithium disilicate crowns.	Figure 14. Postoperative mandibular occlusal view of the completed case showing the natural aligned dentition.
Figure 15. Postoperative right lateral view of the completed case.	Figure 16. Postoperative left lateral view of the completed case.

Heather returned for “the appointment,” the one that she had been waiting 14 years for. The first step was to anesthetize her upper teeth. A Benzocaine 20% topical (Keystone Industries) was applied and then 4% Septocaine (Septodont) (with 1:100,000 epinephrine) was used to anesthetize the upper arch. Teeth Nos. 3 to 14 were prepared using diamond burs (Brasseler USA). All preparations were gingival-level preparations (Figure 9). After preparing the right side, a 30-second VPS bite registration (Blue Velvet [J. Morita USA]) was made. Then, after preparing the left side, the right VPS bite record was inserted and the left VPS bite record was recorded. The core (stump) shade of St 9 was selected using a Chromascop shade guide (Ivoclar Vivadent).

Gingival retraction was achieved using a gingival retraction paste (Expasyl [Kerr]) for 2 minutes. The Expasyl was then rinsed away and the prepared teeth were gently air-dried. A full-arch upper impression was taken by syringing Imprint 4 light body around all the prepared teeth, while the Imprint 4 heavy body was dispensed into the impression tray. The upper tray was inserted over the light body covered teeth, and the Imprint 4 was allowed to set for 2 minutes. The impression tray was removed and inspected for accuracy around all 12 prepared teeth.

Next, the clear stent that was vacuum-formed over a diagnostic model of the wax-up was used to fabricate the (one-piece) temporary restorations. A strong and aesthetic bis-acryl provisional material (Luxatemp [DMG America]) (shade A2) was loaded into the stent to fill teeth Nos. 3 to 14. The stent was then placed over the prepared teeth and allowed to set for one minute. The stent was then removed and the temporary was trimmed, polished, and cemented with Temp Bond NE (Kerr) temporary cement. At this point, the temporary restoration was connected so it acted as the retainer while the final restorations were made. Upon examination after the temporary restoration was cemented, it was evident that the gingival architecture and levels were appropriate to proceed with final restorations without performing any periodontal procedures (Figure 10). The Invisalign pre-restorative orthodontic treatment had established the healthy and aesthetically pleasing gingival levels for the restorative phase.

While the Opalescence 10% gel did lighten the shade of the teeth, this was an excellent opportunity to perform some more whitening before selecting a final shade. A session of in-office whitening (Zoom! [Philips Oral Healthcare]) was performed. This session helped to change the shade from 2A-130 to 1A-120. Digital photographs were then taken with the Pentax Optio WG-1 camera for shading and customization purposes (Figure 11). The final impressions and bite registrations, along with the original wax-up and diagnostic models, were then sent to the dental lab team for the fabrication of 12 individual lithium disilicate (IPS e.max [Ivoclar Vivadent]) crowns. In addition, the digital photographs were emailed to the Kuwata Pan Dent team.

Heather returned in 3 weeks for the “grand finale.” She was anesthetized (in the same manner described above) and the temporaries were removed. The prepared teeth were polished to remove any residual temporary cement. Then, the e.max crowns were tried-in and all flossing contacts confirmed. Marking paper (articulating paper [Bausch]) was used to check the occlusion, and no occlusal adjustments were needed. Heather was then able to inspect the restorations, and she was very excited about the results. Her bite seemed comfortable and she loved her new smile. The crowns were cemented using a universal resin cement (Multilink Automix [Ivoclar Vivadent]). To complete the treatment after curing and then clean up of any excess adhesive cement, a final bite check was performed (Figures 12 to 16).

Comprehensive Care: Retention and Maintenance Phase
After the restorations were cemented, final retainers were fabricated. VPS impressions of both arches were taken and then sent to Invisalign to fabricate Vivera (Align Technology) retainers. The Vivera retainers are made as a set of 4 identical retainers, each designed to last about one year. These retainers take about 2 weeks to obtain from Invisalign after receiving the prescription and impressions. As a result of this time delay in getting the retainers back from Invisalign, an alginate impression was made of the upper arch so that an in-office Essix ACE 040 (DENTSPLY Raintree Essix) vacuum-formed temporary retainer could be delivered to Heather. This would ensure that the teeth had continuous retention throughout treatment. She was instructed to wear the new temporary upper retainer, along with the last lower aligner, full time until she returned in 2 weeks to receive the Vivera retainers.

One day later, Heather’s husband called to thank our entire office for the care we provided. He explained that she was so happy that she could not stop smiling and that she said that she felt like a new person. He thanked us for the impact that we had on her happiness with the comprehensive care outcome. He described her as a new woman and he couldn’t thank us enough for helping her.

Heather returned in 2 weeks to receive her Vivera retainers. Marking paper (articulating paper) was used to confirm the occlusion, and floss was used to confirm all contacts. Heather was instructed to wear the Vivera retainers every night while sleeping. Heather’s maintenance was set at 6-month recare visits for hygiene and periodic exams and, in addition, her Vivera was inspected at these visits. As of the writing this article, each set has been lasting about 1.5 years each, she is on her fourth set now and will need a new set of Vivera next year. Heather understands that every 6 years she will need a new set of retainers and she will continue to wear them nightly.

CLOSING COMMENTS
Heather’s comprehensive care treatment was completed in 2010. When we first met Heather, she was unhappy with her teeth and was unable to confidently smile. Correcting the malocclusion directly contributed to the improvement in the architecture and health of the gum tissue. The restorative dentistry was accomplished successfully, thanks to the gum tissue being leveled, pink, healthy, and stippled with shallow pockets. Five uneventful years have passed and Heather has enjoyed stability, health, and a beautiful smile.

Essential to periodontal health and to a stable restorative outcome is the correction of any malocclusion. In comprehensive aesthetic and restorative treatment plans, such as presented herein, pre-restorative orthodontics is a cornerstone to the treatment protocol and to a successful long-term result.

Acknowledgement
The author wishes to thank the talented team of dental technicians at Kuwata Pan Dent (Cedar Knolls, NJ) for their exceptional work represented in the restorative phase of this case.

Dr. Miraglia graduated from the State University of New York at Buffalo School of Dental Medicine in 1993. He is a member of the Omicron Kappa Upsilon Dental Honor Society. He completed a general practice residency program at Danbury Hospital in Connecticut and for 22 years has practiced privately in Mt. Kisco, NY. He is a graduate of the United States Dental Institute (USDI), where he learned his nonextraction and nonsurgical orthodontic philosophy. He was appointed to the USDI faculty in 2008 and teaches nationally for them. He is a member of the Invisalign faculty and has trained thousands of dentists in Invisalign techniques. He has been providing Invisalign with a comprehensive care philosophy for the last 10 years. He is on the board of directors of the American Academy of Cosmetic Orthodontics as well as the American Academy of Physiological Medicine and Dentistry. He was recently honored with a position on the President’s Council of Northern Westchester Hospital in Mt. Kisco. He can be reached at (914) 241-1191 or via email at the address benmiraglia@optonline.net.

Disclosure: Dr. Miraglia reports no disclosures.