The New Age of Ethical Cosmetic Dentistry: Implementing the Concept of Progressive Smile Design

INTRODUCTION
What Makes Patients Want to Improve Their Smile?
Smile design principles give us a guide as to what is considered aesthetic.¹ Undoubtedly, visual communication has done huge amounts to allow patients to see the potential improvements available. The media constantly bombards the public with before and after images of weight loss, breast enhancement, facial aesthetics, and of course, cosmetic dentistry. Even to the most cynical, transformations of the human form do attract attention.
Traditionally and still currently, cosmetic dentistry has been diagnosed and assessed, with its benefits conveyed to patients through the use of diagnostic wax-ups and computer imaging software.
Those of us practicing cosmetic dentistry have used high-tech imaging software to simulate potential results. This can often break down barriers a patient may have to treatment. It is no different from having a simulation of a hairstyle or even a simulation of a proposed kitchen. We like to know what we are spending our money on and how it is likely to look.
This article will look at how cosmetic dentistry has now come full circle with treatment planning and actually how cosmetic imaging may not just be a sensible procedure with many patients looking to have elective dentistry.

Limitations With High-Tech Imagery
The problem with imagery is that it is just that: it is a static view of a proposed outcome. There is nothing dynamic about it, and there is no way of measuring the patient’s response to many analogue improvements in his or her smile.
A combination of a “perfect” visual target and arguably lack of real information about the alternatives will encourage a patient into a decision that might result in 8 to 10 ceramic units being placed in a short period of time. Should we really be helping our patients make irreversible and potentially life-changing decisions based on viewing static images for an hour or so during the treatment planning consultation?
The following female patient once considered the use of 10 ceramic veneers to straighten her smile.

CASE REPORT
In this case, what seems like an orthodontic problem alone is far more than that to the patient. There are a number of problems that combined to make her deeply unhappy with her smile (Figures 1 to 3):

• Tooth color issues with shades, ranging from gray to light brown
• An old PFM crown with a visible margin
• A low gumline with irregular gingival zeniths, making a gummy smile aesthetically worse
• Two short lateral teeth, creating an uneven incisal-edge outline
• Crossbites on the upper right lateral and upper right premolar, causing functional issues.

These issues are what made her want 10 veneers, because this seemed like a fast solution to her concerns, and she had been previously sold the concept with high-tech imaging software. In my opinion, I am not sure imaging software should be used in this way, without allowing patients to see their own teeth improve with alignment first. With a progressive smile design concept, a patient is able to visualize improvements in situ and make choices based on real visible changes.
This concept and process of progressive smile design was outlined to the patient, and she then understood that our aim was to straighten and whiten her teeth. After this had been achieved, she could then make a decision on which of the final aesthetic choices would be best.
A full range of orthodontic solutions was offered and explained to her in detail. The patient wanted a simple orthodontic solution that was fast and removable. In addition, she did not want this to impinge on her budget in case she still wanted veneers, so she agreed that using an Inman Aligner was the way to go. This option was chosen because it would help her meet her goals of shorter treatment time, the ability to remove her aligner for a few hours a day, and to preserve some of her budget for other cosmetic treatment that might be needed. In is interesting to note that these factors are often the key to acceptance for many of our patients.
The patient also understood that a retainer would be essential after treatment.

Treatment Protocol
Space calculations were carried out to ensure that the proposed treatment was suitable using a digital form of Hancher’s technique.² Impressions were taken and the Inman Aligner was constructed. There was 5.2 mm of crowding present, according to digital software (Spacewize, the Diagnostic Dental Crowding Calculator) that calculates the amount of crowding in a proposed arch form. The proposed arch form was designed to respect the current envelope of function. We simply wanted to move the upper right lateral and premolar across the bite and align the incisors.

Figure 1. Preoperative smile.	Figure 2. Preoperative occlusal view.
Figure 3. Close-up preoperative anterior view.	Figure 4. The 3D Expander (NimroDENTAL Orthodontic Lab) in position.
Figure 5. At 6 weeks postexpansion.	Figure 6. After Inman Aligner and whitening.
Figure 7. After alignment and simultaneous bleaching.	Figure 8. After crown temporization and additive-edge bonding on laterals.

This was slightly outside of the normal range of treatment for an Inman Aligner on its own, so a separate expander was used beforehand. A 3D Expander (NimroDENTAL Orthodontic Lab) also incorporated a bite-raising appliance. One component was designed to push the upper right premolar over the crossbite and the other component was designed simply to push the anterior teeth, especially the in standing lateral, more anteriorly to create space.
Three mm of lateral expansion was applied to the premolar and 1.5 mm of anterior movement to the lateral tooth (Figure 4). This was carried out during 6 weeks.
At 6 weeks (Figure 5), a space calculation was carried out to ensure that Inman Aligner treatment was suitable. Impressions were taken, and the Inman Aligner was constructed. The patient carried on wearing the expander, but no longer activated it.
One week later the Inman Aligner was fitted. It had an incorporated bite-raising appliance. Strategic progressive and anatomically respectful interproximal reduction (IPR) was carried out to allow the lateral to come forward. Many authors acknowledge that the reduction of one half of the interproximal enamel on the mesial and distal of each incisor tooth as a safe technique.^3-7 A composite anchor was also placed on the incisal of the upper lateral tooth. During the next 10 weeks, the lateral tooth jumped the bite and the anteriors aligned and were retracted a little. IPR was carried our progressively around the anterior teeth, but never more than 0.12 mm per contact to ensure it was carried out in a progressive and yet anatomically respectful way.
During the last 2 to 3 weeks of alignment, tooth whitening was started; carried out when the aligner was out of the mouth. After 16 weeks, after the Inman Aligner and whitening, the patient could then see her teeth better aligned and whiter (Figures 6 and 7). It became clear to her that the whiter and straighter surfaces were actually quite aesthetic, and that the main visual issues were that of the dark crown and the irregular tooth outline. Mock-up composite tips on the short laterals were previewed directly in the patient’s mouth and she was delighted. We affirmed that, at this point, no veneers would be necessary, and we could simply edge bond the laterals with composite resin and replace the old PFM crown.
At the next appointment, the PFM crown was removed, and the prep and existing metal core assessed. A good seal was evident and the post was of good quality, so the surface was sandblasted and an opaquer (Renamel Pink Opaquer [Cosmedent]) was applied to the facial surface.
The laterals were also built-up with a nanohybrid composite (Empress Direct [Ivoclar Vivadent]) (shade B1 with dentin and enamel layers), then polished with an assortment of finishing discs (Soflex [3M ESPE]; Pogo [DENTSPLY Caulk]; Flexibuff [Cosmedent]).
An impression was taken and a new temporary crown was placed. A lithium disilicate crown (IPS e.max [Ivoclar Vivadent]) was fabricated. This was then delivered 2 weeks later (Figures 8 and 9). In the meantime the patient had been using her clear retainer for 20 hours a day. The patient understood a permanent retainer was the best option.⁸
At the delivery appointment, an impression was taken of the final position with crown in place for a multistrand retainer wire9 (to be fitted the following week). The retainer was preformed and placed on a jig by the orthodontic lab. One week later it was transferred to the mouth and checked for fit. The teeth were slightly roughened10 and the palatal surfaces etched. Then, the crown was etched with hydrofluoric acid and the wire was bonded using a flowable composite (LuxaFlow [DMG America]) as there were no occlusal interferences (Figure 10). The jig was then cut and removed, and the ends were smoothed. A final clear retainer was made over the wire that the patient could use in the event of a debond of the wire.

Figure 9. Close-up view after alignment, bleaching, bonding, and one crown.	Figure 10. Postoperative occlusal view with retainer.
Figure 11. Before side-smile view; patient prepared to have 10 all-ceramic restorations at this stage.	Figure 12. Side-smile after Inman Aligner, bleaching, composite edge bonding, and one crown.
Figure 13. Preoperative view.	Figure 14. Postoperative retracted view.

Figure 15. Postoperative smile view.

The patient was delighted with her final outcome (Figures 11 to 15 show before and after views). She was also very pleased that this had been done with the virtually no tooth reduction. She stated that we had had made her own teeth “look more beautiful.” She had also been in full control of the treatment process; at any point she was empowered to stop, review, and make a decision in her own time.
The number of times cases have gone this way in similar circumstances is no coincidence. In my experience, many patients will change their minds about what they thought they wanted once they see their own teeth align and whiten and so arguably should consider this route every time if they are willing to undergo short-term orthodontics. Less preparation of course means less physical risk and less cost/risk.
Patients leading the treatment choices should also mean there is less chance of patients feeling pushed into elective treatment options and the medico-legal consequences of this. More importantly, a far wider range of patients could potentially be treated with this philosophy. Up to now, due to costs and risks, cosmetic dentistry has not been available to all patients and many dentists too; as a result it has filled a niche. If this patient had chosen to have veneers, only a limited amount of dentists would have been able to provide a quality result. Arguably, only a limited amount of patients would also have been able to afford it.

CLOSING COMMENTS
The approach to the case outlined here offers a stark contrast between the way cosmetic dentistry is more traditionally carried out over much of the world and how it could change and be improved by employing a more progressive approach.
While no-prep and minimally invasive veneers can offer amazing outcomes, arguably these approaches ought to be considered at the end the treatment planning pathway. The concepts and techniques, as described herein, have the ability to make computer image-derived ceramic makeovers (even with no-prep veneers) unnecessary in some cases. In cases where the use of ceramics is essential and indicated, teeth can be prealigned simply to minimize the amount of tooth reduction required. Furthermore, the utilization of progressive smile design, and the primary use of alignment bleaching and bonding, is a process that any dentist can offer to any patient.

Acknowledgment
The author wishes to acknowledge the talented team at Knight Dental Ceramics for the fabrication of the lithium disilicate crown delivered in this case.

References

1. Morley J, Eubank J. Macroesthetic elements of smile design. J Am Dent Assoc. 2001;132:39-45.
2. Hancher P. Orthodontics for esthetic dentistry, part1. J Cos Dent. 2005;20:4.
3. Sheridan JJ. Air-rotor stripping. J Clin Orthod. 1985;19:43-59.
4. El-Mangoury NH, Moussa MM, Mostafa YA, et al. In-vivo remineralization after air-rotor stripping. J Clin Orthod. 1991;25:75-78.
5. Radlanski RJ, Jager A, Zimmer B. Morphology of interdentally stripped enamel one year after treatment. J Clin Orthod. 1989;23:748-750.
6. Heins PJ, Thomas RG, Newton JW. The relationship of interradicular width and alveolar bone loss. A radiometric study of a periodontitis population. J Periodontol. 1988;59:73-79.
7. Tal H. Relationship between the interproximal distance of roots and the prevalence of intrabony pockets. J Periodontol. 1984;55:604-607.
8. Blake M, Bibby K. Retention and stability: a review of the literature. Am J Orthod Dentofacial Orthop. 1998;114:299-306.
9. Becker A, Goultschin J. The multistrand retainer and splint. Am J Orthod. 1984;85:470-474.
10. Hadad R, Hobson RS, McCabe JF. Micro-tensile bond strength to surface and subsurface enamel. Dent Mater. 2006;22:870-874.

Dr Qureshi, who trained at King’s College, serves as the president of the British Academy of Cosmetic Dentistry. He is an outspoken advocate of ethical and minimally invasive cosmetic dentistry, and he has a special interest in simple orthodontics using removable appliances. Dr. Qureshi lectures internationally on these topics and has had numerous articles published in the dental press worldwide. He can be reached at tifqureshi@mac.com.

Disclosure: Dr. Qureshi teaches Inman Aligner Education for Straight Talks Seminars, who provide the only accreditation for Inman Aligner.