Prerestorative Ortho to Maximize Aesthetics and Function · tive part of full-mouth rehabilitation. Prerestorative Orthodontic Treatment Objectives of orthodontic phase of the treatment

INTRODUCTIONAttempting to achieve ultimate facial anddental aesthetics can be challenging for adentist. “Some dentists may not considerthat facial aesthetics has much to do withthem.”1 Nevertheless, using an interdiscipli-nary approach allows the practitioner to seta challenging goal to dramatically improvea patient’s facial appearance.

“Interdisciplinary treatment gives thedental team the opportunity to change,shape, or develop an individual’s appear-ance, character, or self-image, and at thesame time provide a restoration that is func-tional and enduring.”2 In his article, Rod -riguez Flores3 says: “Interdisciplinary treat-ment that combines orthodontics, im -plantology, and prostheses helps us to obtaingood, predictable results that are stable overtime, aesthetic and functional in the cases of

adults with large edentulous spaces andmultiple problems in dental arch.”

The goal of this article is to lay out theframework for a unique treatment philoso-phy. This philosophy is based on a differentset of priorities in aesthetic treatment plan-ning, which places the improvement offacial beauty and the creation of properfacial proportions and balance at the top ofthe list. An interdisciplinary approach,starting with dentofacial orthopedic andorthodontic treatment, allows the dentist tofocus on facial appearance of the patient,instead of just treating occlusion and teeth.In his article, Jefferson4 states that: “There isa universal standard for facial beautyregardless of race, sex, and other variablesand is based on divine proportion.” Thus,following this universal principle, one ofthe objectives of the treatment of complicat-ed cases should be the enhancement of thepatient’s external appearance.

The presence of preexisting malocclu-sions in adult cases requiring full-mouthrehabilitation makes the accomplishment ofthe above mentioned goals more challengingand difficult to implement using only one

treatment modality. The cases presented inthis article can be seen as an illustration ofhow the interdisciplinary approach can helpin the planning and execution of complextreatments of patients with preexisting mal-occlusions. Orthodontic treatment in thebeginning, with special attention to dentofa-cial orthopedics, will place teeth and jaws ina position that ensures the successful com-pletion of the subsequent prosthetic phase ofthe patient’s full-mouth rehabilitation andgreatly improve the overall aesthetic result.

CASE 1Diagnosis and Treatment Planning

A 55-year-old female patient presented witha constricted maxilla and bilateral crossbite.Her previous request for cosmetic improve-ment of her smile was rejected by numerouspractitioners due to very unfavorable posi-tion of her maxillary teeth (Figures 1 to 3).

Clinical analysis along with evaluationof the patient’s photographs, radiographs,and models showed that prerestorativeorthodontic treatment was indicated inorder to meet the patient’s expectations.

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Figure 2. Preoperative retracted view, in occlusion(Case 1).

Figure 4. Retracted view of the right side occlusionat the end of the orthodontic phase of the treat-ment, before removal of the brackets (Case 1).

Figure 5. Retracted view after orthodontic phase ofthe treatment (Case 1).

Figure 3. Preoperative right lateral view, in habitualcentric occlusion (Case 1).

Leonid Rubinov,DDS, PhD

Prerestorative Ortho to MaximizeAesthetics and Function

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Figure 6. Preorthodontic maxillary model (Case 1).

An interdisciplinary approach...allows the dentist to focus on facialappearance of the patient, instead of just treating occlusion and teeth.

Figure 1. Preoperative facial view (Case 1).

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Prerestorative OrthodonticTreatment

Orthodontic treatment started withthe use removable functional-ortho-pedic appliance (Schwarz appliance)in order to eliminate the constrictionof the maxilla and bring its size intoproper relation to the mandible.

Several months later, 6.0 mm ex -pansion of the maxilla was achieved.Once the size and width of the maxillawas deemed sufficient, braces werethen placed on both upper and lowerarches in order to move the teeth intomore favorable positions for the futurerestorative phase of treatment. Fourmonths later, the objectives of this partof the treatment with braces wereachieved (Figure 4) and 2 months laterbraces were removed (Figure 5). Thenew positions and relations betweenupper and lower teeth had becomemuch more favorable for the plannedsubsequent restorative treatment. Infact, the size and shape of the maxillachanged significantly (Figures 6 and 7aand 7b). The patient’s facial appear-ance, occlusion, and position of herteeth had improved considerably.

Restorative Treatment The restorative phase of treatment wasinitiated with the preparation of toothNo. 5 for an all-ceramic zirconia (NobelBio care) crown, teeth Nos. 11 to 13 (toreplace existing restorations) for a 3-unit all-ceramic zirconia (Nobel Bio -care) bridge, and teeth Nos. 6 to 10 forporcelain (DENTSPLY Ceramco) ve -neers. Then, final impressions (Flexi -time [Heraeus Kulzer]) were taken andall necessary information was sent intoour dental laboratory team for fabrica-tion of the restorations.

Two weeks later, the finished res -torations were inserted. Zirconia crownand bridge was cemented on RelyX lut-ing cement (3M ESPE). Porcelain ve -neers were cemented using 37% etch,prime and bond adhesive (DENTSPLYCaulk), and NX3 cement (Kerr). Effectof the treatment on patient’s facialappearance, occlusion, function, andaesthetics of the smile was prettyremarkable (Figures 8 and 9).

Six months after the completionof the treatment, the patient waschecked and the results were found tobe stable and very satisfactory to thepatient (Figure 10).

CASE 2 Diagnosis and Treatment Planning A 50-year-old male patient presentedwith a skeletal Class III malocclusion

and anterior crossbite which adverse-ly affected his facial appearance andability to chew food (Figures 11 and12). His teeth had extensive toothstructure loss due to severe grindingand erosion from pathological occlu-sion (Figures 13 and 14).

Clinical analysis along with evalu-ation of patient’s photos, radiographs,and models showed that initial ortho-dontic treatment was indicated inorder to improve patient’s appear-ance, function, and smile.

To optimize the patient’s condi-tion before restorative work was car-ried out, an orthodontic phase of treat-ment was proposed and accepted. Aremovable (sagittal) appliance wouldbe used to torque his upper anteriorteeth forward and also to redevelop hispremaxillary area. The other goalwould be to substantially open thepatient’s vertical dimension in orderto improve facial proportions and cre-ate necessary conditions for restora-tive part of full-mouth rehabilitation.

Prerestorative OrthodonticTreatment

Objectives of orthodontic phase of thetreatment were accomplished in just8 months. The facial appearance ofthe patient, his occlusion, vertical di -mension, and position of his frontupper teeth had changed substantial-ly at this point of the treatment(Figure 15).

Cephalometric x-rays of the pa -tient before and after this phase of thetreatment illustrate the changes thathave occurred not only in the positionof the upper front teeth, but in themaxillary alveolar bone itself (Figures16 and 17).

Restorative Treatment The restorative phase of treatmentwas begun with the preparation of thepatient’s maxillary and mandibularposterior teeth (teeth Nos. 4, 5, 12 to14, 19 to 21, 28, and 29) for PFMcrowns to reestablish vertical dimen-sion of his occlusion and to restorehis ability to chew. Full-mouth reha-bilitation of this patient was complet-ed by fabricating 6 zirconia all-ceram-ic (Nobel Biocare) crowns on teethNos. 6 to 11, and also in splinting themandibular anterior teeth. Ribbondand associated with it Ribbond wet-ting agent and resin were used forsplinting.

The effect of the treatment on thepatient’s facial appearance, occlusion,function, and aesthetics of his smilewas incredible and satisfying for theboth patient and the doctor (Figures18 and 19).

DISCUSSIONThe prevailing treatment philosophyin general dentistry and orthodonticsis based upon the assumption ofimmovability of the alveolar bone;after the development of the dento -alveolar complex is complete and thepermanent teeth have erupted. Con -ven tional understanding is that thelabial alveolus is immovable based onresearch done by Engelking andZachrisson5 and Thilander et al,6 whoshowed that “dehiscences or fenestra-tions can be produced in the buccal

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Prerestorative Ortho...

Figure 8. Facial view of the patient afterrestorative phase of the treatment (Case 1).

Figure 11. Preoperative facial view (Case 2).

Figure 12. Preoperative left lateral facial view(Case 2).

Figure 14. Preoperative maxillary occlusal view,showing severe wear of the teeth (Case 2).

Figure 13. Preoperative retracted view inhabitual centric occlusion (Case 2).

Figure 9. Retracted view of the patient smileafter restorative phase of the treatment(Case 1).

Figure 10. Natural smile of the patient 6months after completion of the treatment(Case 1).

Figure 7. (a) Postorthodontic occlusal viewof the maxilla. (b) Post-ortho model of themaxillary arch (Case 1).

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b

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alveolar plate by moving teeth in afacial direction.”6 On the contrary,data from Lindskog-Stokland et al7and Melsen,8-10 advocate that the den-toalveolar complex is much moremalleable than previously believed.The interdisciplinary approach to aes-thetic dentistry, as described in thisarticle, sides firmly with the latterconception.

In their article “Beyond the Lig -ament: A Whole-Bone PeriodontalView of Dentofacial Orthopedics andFalsification of Universal AlveolarImmutability,” Williams and Mur -phy11 wrote: “When a theoreticalbasis for manifestly successful clini-

cal outcomes cannot be fortified bytraditional orthodontic tooth move-ment biology (that focuses solely onthe periodontal ligament as the oper-ant organ), a new hypothesis shouldbe built on the old. It is forces actingbeyond the ligament that may be sig-nificant determinants of the alveolusand the consequent dentofacial form,which lives, thrives, and dies by thegrace of dental root positions. Dento -facial orthopedic physiology of thealveolus does not deny the relevanceof periodontal ligament phenomenabut merely goes beyond the ligamentto analyze the alveolar response toorthopedic force from a ‘whole bone’perspective. The behavior of the bonecannot be explained totally with aperiodontal pressure-tension model.”

The cases presented in this articleshow that the remodeling and rede-velopment of the patient’s facial anddentoalveolar structures can be per-formed using a dentofacial orthope-dics approach regardless of age. Thechanges undergone in patients’ faces,the size of the jaws, and the occlusionand teeth position cannot be ex -plained by simple tooth movementbut rather by response of the alveolar

bone as a “whole.” A high rate of theosteoblastic/osteoclastic activity andbone turnover are contributing to thecontinuing adaptability of the adultdentoalveolar complex, where alveo-lar bone moves in conjunction withthe teeth to effectively build newbone while resorbing old bone.

Orthopedic changes in patients’jaws and their relationships are gen-erally responsible for overall im -provement in facial appearance andthe creation of much better ground-work for subsequent restorative pro-cedures.

Both patients underwent comput-ed tomography (CT) scan examina-tions several months after the com-pletion of the treatment (Figure 20).The goal of this research was to evalu-ate the long-term effect of the com-pleted interdisciplinary treatment onthe condition and integrity of thealveolar bone and on the position and

stability of the roots of the teeth with-in the bone.

The assessments of these imagesare consistent with the picture of nor-mal alveolar bone with roots of theteeth positioned proportionally with-in the boundaries of the bone. There isno visible damage, dehiscences, or fen-estrations in the buccal alveolar plateand no bone loss can be observed.

These CT scans illustrate the“whole bone” remodeling response tosuccessfully performed orthodontictreatment.

CONCLUSION An interdisciplinary approach to full-mouth rehabilitation of complexcases that may include preexistingmalocclusions can result in signifi-cant enhancement of the patient’soverall facial appearance, occlusion,functional, and aesthetic aspects ofthe smile. This treatment philosophygives the dentist an opportunity toassess patients in a different way,beginning with an evaluation of thepatient’s overall facial beauty.

The ensuing orthodontic treat-ment with special attention paid todentofacial orthopedics allows for the

remodeling of a patient’s alveolarbone. The bone movement creates aproper orthopedic relationship be -tween the jaws with stable results,regardless of the patient’s age. Theaddition and implementation of thisphase of treatment will help to ensurethat the teeth and jaws are in a morefavorable position, thus dramaticallyimproving the dentist’s chances forcreating more optimal dentofacialaesthetics and better occlusal/func-tional results.�

AcknowledgementAuthor thanks Drs. Jerald Friedmanand Zev Schulhof from North JerseyOral and Maxillofacial Surgery fortheir help in obtaining CT Scan exam-inations of the patients. The authoralso thanks Joseph Passaro PorcelainStudio from New York, NY, for provid-ing excellent restorations.

References1. Sarver DM. Growth maturation aging: how thedental team enhances facial and dental esthet-ics for a lifetime. Compend Contin Educ Dent.2010;31:274-283.

2. Winter RR. Interdisciplinary treatment planning:why is this not a standard of care? J EsthetRestor Dent. 2007;19:284-288.

3. Rodriguez Flores JM. Multidisciplinary orthodon-tic treatment in adult patients: the future oforthodontics. Int J Orthod Milwaukee.2010;21:11-21.

4. Jefferson Y. Facial beauty—establishing a univer-sal standard. Int J Orthod Milwaukee. 2004;15:9-22.

5. Engelking G, Zachrisson BU. Effects of incisorrepositioning on monkey periodontium afterexpansion through the cortical plate. Am JOrthod. 1982;82:23-32.

6. Thilander B, Nyman S, Karring T, et al. Boneregeneration in alveolar bone dehiscences relat-ed to orthodontic tooth movements. Eur J Orthod.1983;5:105-114.

7. Lindskog-Stokland B, Wennström JL, Nyman S, etal. Orthodontic tooth movement into edentulousareas with reduced bone height. An experimentalstudy in the dog. Eur J Orthod. 1993;15:89-96.

8. Melsen B. Biological reaction of alveolar bone toorthodontic tooth movement. Angle Orthod.1999;69:151-158.

9. Melsen B. Tissue reaction to orthodontic toothmovement—a new paradigm. Eur J Orthod.2001;23:671-681.

10.Melsen B. Dr. Birte Melsen on adult orthodontictreatment. Interview by Vittorio Cacciafesta. JClin Orthod. 2006;40:703-716.

11.Williams MO, Murphy NC. Beyond the ligament: awhole-bone periodontal view of dentofacial ortho-pedics and falsification of universal alveolarimmutability. Seminars in Orthodontics.2008;14:246-259.

Dr. Rubinov graduated from New York University(NYU) College of Dentistry in 1992. He is also aforeign trained dentist who received his dentaldegree in Leningrad, Russia in 1974. In 1984Dr. Rubinov obtained a PhD degree in dentistryin Leningrad. Dr. Rubinov is an active memberand instructor of International Association forOrtho dontics, Member and Fellow of theAmerican Association for Functional Ortho -dontics, and is clinical assistant professor ofNYU College of Dentistry. Dr. Rubinov maintainsa full-time private practice in Cliffside Park, NJ,providing cosmetic dentistry along with ortho-dontics for children and adults and TMJ treat-ment. He can be reached at (201) 941-8877, [email protected], or at realsmile.com.

Disclosure: Dr. Rubinov reports no disclosures.

INTERDISCIPLINARY DENTISTRY

Figure 15. Postortho facial view (Case 2).

Figure 19. Lateral facial view after restora-tive phase of the treatment (Case 2).

Figure 20. Computed tomography scans several months after treatment. Left image(Case 1); right image (Case 2).

Figure 16. Preortho cephalometric radiograph(Case 2).

Figure 17. Postortho cephalometric radi-ograph (Case 2).

Figure 18. Retracted view after restorativephase of the treatment was completed (Case 2).