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Inside
Esthetics
Instant Orthodontics
by Ana El ashvi l i, DDS, MS; Gera ld E. Denehy, DDS, MS
A case report using direct resin composite for malpositioned
anterior teeth.
Modern resin composite systems provide excellent strength,
smoothness, color stability, and longevity. Because
they often require minimal or no tooth structure removal,
composit e resin restorati ons are t he treatment of
choice in many unesthetic situations, including those of
malpositioned anterior teeth.
There are several tr eatment alternatives for slight-t o-moderat
e anter ior t ooth malposit ioning. The fir st optionto be
considered should be ort hodontic t reatment, especially in younger
pati ents with unrestored teeth.
However, the cost or l ength of orthodontic t reatment often
makes this t reatment undesirable for many patients.
Recent literature suggests that minor tooth-alignment issues,
such as facio-lingual displacement and crowding,
may be resolved wit h indir ect porcelain veneer restorati
ons.1,2
However, others have questioned the value of
this t reatment because of the nonconservati ve nature of the
indir ect pr eparat ions.3,4
There are many cases where, in lieu of orthodontics,
less-aggressive procedures such as bleaching and direct-
bonded restorations can be combined to achieve excellent
esthetic results with good longevity at an affordable
cost. In many cases, composite resin restorations require
minimal or, in some cases, no tooth structure removal.
They also can be repaired or replaced more easily and less
expensively then porcelain veneer restorations. 1
This article will describe a malalignment case that was
successfully treated with composite resin and discusses
the steps that are cr it ical t o success wit h this
procedure.
History
The patient, a 64-year-old woman, pr esented for an esthetic
consult ation stati ng that she wanted straight
teeth. The pati ent confessed that she always covered her mouth
when she laughed. She did not want to go
through orthodontic t reatment at her age and was seeking alt
ernative t reatment. Her dental history revealed
regular dental vi sits wit h several moderate-sized dir ect r
estor ations and crowns on poster ior teeth.
Clini cal Findi ngs
A comprehensive examination of the pati ent revealed unrestored
anteri or teeth, good periodontal health, and
no apparent areas of decay. Her gingiva was healt hy wit h no
bleeding upon probing. She presented wit h an
Angle Class I poster ior relat ionship and a 50%overbit e in t
he anter ior. The temporomandibular j oint had no
history of sounds or pain. Teeth Nos. 7 through 10 were in
function only during protrusive movement.
The estheti c fi ndings included malaligned maxillary anteri or
t eeth. Tooth No. 8 was rotated wi th t he mesial l ine
angle facial to t he rest of t he arch curvature. Tooth No. 9
was lingually posit ioned wi th a small overlap of t ooth
No. 8 on the mesial. The incisal t hird of t ooth No. 10 was
facial t o the rest of the arch curvature (Figure 1 View
Figure and Figure 2 View Figure). The patient had a low lip-
line smile covering the gingival areas of the
maxill ary anterior teeth (Figure 3 View Figure).
Treatment Plan
The patient was provided wi th all alternati ve t reatments opt
ions including the advantages, disadvantages, and
relati ve costs of each t reatment . She declined ort hodontic
tr eatment and selected the options of bleaching
foll owed by realignment wit h direct resin composit es.
Treatment
Preplanning is crucial to success in any dental procedure and
direct realignment is no exception. Study casts are
important to the success of composite resin restorations for
several reasons in malalignment situations. First,
the clinician can determine if any tooth str ucture needs to be
removed fr om the malposit ioned teeth before
restor ati on placement. Second, an ideal wax-up can be perf
ormed, which helps the clinician to visuali ze the
thickness and contours to be developed during the placement of
the resin composite (Figure 4 View Figure and
Figure 5 View Figure). Wax-up models are also important for
patient education and decision-making. An
additional mock-up with resin composite can be done at chairside
if desired.
An important step i n restori ng slight- to-moderate tooth
malposit ioning with resin composite is preoperat ivetooth whit
ening. To correct t he malalignment to the desired arch curvature,
enamel r econtouring is oft en
needed. To avoid creating a shade change difference in this
case, preoperative tooth whitening is important.
Color change after teeth whitening occurs throughout the
dentin.5-7
By lightening the dentin shade similar to
that of the enamel, any recontouring and thinning of the enamel
does not produce a higher chroma effect. This
establishes a good basic tooth color, thus eliminating the need
for a thicker layer of composite to disguise
discolorations.
Preoperative bleaching trays with 10%carbamide peroxide
(Opalescence, Ultradent Products Inc,
http:/ / www.ultradent.com) were delivered to the patient w it h
instr uctions to use overnight. The tooth color
recorded at baseli ne was shade A3 using t he Vitapan Classical
Shade Guide (Vident, http:/ / www.vident.com).
After 2 weeks of use, the teeth had lightened to an A1 shade.
The patient was satisfied with the shade, and was
scheduled for composite resin veneer placement 2 weeks after
bleaching completion.
The four maxillary i ncisors were r estor ed to create t he
estheti c il lusion of alignment. The mesio-facial li ne angle
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of tooth No. 8 and the incisal facial third of tooth No. 9 were
reshaped using a medium-grit diamond. Figure 6
View Figure and Figure 7 View Figure show the maxillary i
ncisors after t he enamel r econtouring. Notice that the
overlap of t ooth No. 8 was corrected before placement of t he
direct r estorations. The teeth were isolated
(OptraGate, Ivoclar Vivadent, http:/ / www.ivolcarvivadent.com)
and clear matr ix str ips were used to isolate
adj acent t eeth. Bonding was done one toot h at a time. A
three-step, et ch-and-ri nse bonding system (OptiBond
FL, Kerr Dental, http:/ / www.kerrdental.com), was used. Because
all bonding surfaces were in enamel, the
surface was thoroughly dried and only the adhesive was used.
Teeth were etched with 37%phosphoric acid for
20 seconds, rinsed, and thoroughly dried. Adhesive was applied
and light-cured for 20 seconds.
A nanofil l composit e resin composit e (Fil tekSupreme Plus, 3M
ESPE, http: / / www.3mespe.com) in the A1 body
shade was used to individually restore the facial contours of
teeth Nos. 7 through 10. The material was placed
and smoothed using a Gold Microf il Instrument (Almore, http:/ /
www.almore.com), an IPC instr ument
(Cosmedent , http: / / www.cosmedent. com) and a #3 sable brush.
Composite resin additions also wereindividually placed to align the
lingual contour of teeth Nos. 8 and 10. Placement of composite
resin on the
lingual surfaces is an important step for realignment as it
helps to create a uniform thickness of the incisal
edges when viewed from different angles. To accommodate thicker
incisal edges, such as those established with
this pati ent, the incisal edge needs to be inclined toward the
li ngual t o result in bett er esthetics. Each
restoration was light-cured for 40 seconds.
Contouri ng was done wit h f inishing burs, coarse f inishing di
scs (Sof-LexXT, 3M ESPE), and f inishing diamonds.
Finishing st ri ps (Epit exStr ips, GC America, http: / /
www.gcamerica.com) were used to poli sh the interpr oximal
surfaces (Figure 8 View Figure). Final polishing was done with
polishing cups and points (Diacomp, Brasseler
USA, http: / / www.br asselerusa.com) followed by a polishing
paste (Enamelize, Cosmedent) using felt discs
(FlexiBuff , Cosmedent).
The finished composite resin restorations are seen in Figure 9
View Figure and Figure 10 View Figure. The
patient was very pleased with the outcome. The postoperative
smile 11 months after treatment is shown in
Figure 11 View Figure.
Conclusion
This article describes an alternative treatment to orthodontics
using resin composite. An outstanding cosmetic
result can be achieved with resin-based composite restorations.
Proper case selection, diagnostic casts,
wax-up, and preoperative tooth whitening are all essential steps
for success.
References
1. Chri stensen GJ. Veneer mania. J Am Dent Assoc.
2006;137(8):1161-1163.
2. Jacobson N, Frank CA. The myth of instant orthodontics: an
ethical quandary. J Am Dent Assoc.
2008;139(4):424-434.
3. Heymann HO, Kokich VG. Instant orthodontics: vi able tr
eatment opt ion or quick fi x cop-out? J Esthet
Restor Dent . 2002;14(5): 263-264.
4. Spear FM. The estheti c correcti on of anteri or dental
mal-ali gnment conventi onal vs. i nstant (restorative)
orthodontics. J Cal if Dent Assoc. 2004;32(2):133-141.
5. Joiner A, Thakker G, Cooper Y. Evaluation of a 6%hydrogen
peroxide tooth whitening gel on enamel and
dentine microhardness in vi tr o. J Dent . 2004;32(Suppl
1):27-34.
6. McCaslin AJ, Haywood VB, Potter BJ, et al. Assessing dentin
color changes from nightguard vital bleaching. J
Am Dent Assoc. 1999;130(10):1485-1490.
7. Whit e DJ, Kozak KM, Zoladz JR, et al. Ef fects of t
ooth-whitening gels on enamel and dentin ult rast ructurea
confocal laser scanning microscopy pilot study. Compend Conti n
Educ Dent. 2000;29(Suppl ): S29-S34.
Figure 1
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