Cosmetic Tooth Movement for AdultsPractice Potential:

How often have you had a patient come inand ask if you could just straighten onetooth to give them a better looking smile?It’s a fact that most adults are unwilling toundergo complete orthodontic care. Yet,many of them would love you to dosomething to improve the way their teethlook. Fortunately there are many minortooth movement procedures that you cando that will give your patients the estheticresult they are looking to achieve. In thisPractice Building Bulletin, I will share someof the more common procedures used everyday to help you give your patients thebeautiful smile they want.

Description:

Unraveling Upper Anteriors Prior toPlacing Veneers

A typical example of adult minor toothmovement is illustrated here (see photos,bottom of this page). This patient hasoverlapping centrals and two peg lateralsthat are lingually placed. After a diagnosticwax up was completed, it became clear thatthe patient had two choices. He couldeither have his teeth prepared for four

crowns and possibly have to haveintentional root canal therapy, or he couldundergo some minor tooth movement torealign and evenly space out the anteriorsprior to placing some veneers. The patientchose the less invasive orthodonticapproach. In this case using a simpleHawley retainer with distal kickers to movethe centrals distally and finger springs tomove the laterals labially was enough tocomplete the orthodontics. The totaltreatment time prior to placing the veneerswas less than three months. After theveneers were completed a TalonTM splint wasused as a final retainer. This type ofretention was chosen because the patienthad a previous bruxism problem. TheTalonTM splint was used because its internallayer is made from a soft thermoplasticmaterial.1 This material protects against thepossibility of an abnormal acrylic pressurepoint being placed on the porcelain veneersby the splint.

Minor Tooth Movement for Esthetics vs.Comprehensive Orthodontic Care.

This female patient (see pictures, upper leftpage 2) presented with a bilateral posteriorcrossbite due to an underdeveloped maxillathat was not treated at an earlier age. Shealso had a blocked-out lingually placed

lateral incisor. After a thoroughexamination by an orthodontist, it wasrecommended that because of her age, sheundergo maxillary surgery and completeorthodontic care to correct her skeletalcross-bite. Although this was an excellenttreatment plan, it did not take intoconsideration the patient’s desires. All shewanted was to straighten out the oneblocked-out lateral to improve her smile.Because her cross-bite was not causing anyfunctional problems (i.e. TMJ dysfunctionor improper mastication) and herperiodontal health was excellent, a minortooth treatment procedure was done thatgave her the esthetics she desired. Acombination fixed/removable swing lockretainer was used. This appliance allowedthe cuspid to be brought back distally usingan elastic force into a space created by asmall amount of enamel re-contouring.Once that was accomplished, the rest of thespace needed to move the lateral intoposition was gained by opening the swinglock expansion screw2 and enamel re-contouring the mesial of the cuspid, mesialand distal of the lateral and the distal of thecentral. This combination of movementsallowed the space to be gained for theblocked-out lateral without disturbing theocclusion or removing an excessive amountof enamel from the adjacent anterior teeth.

Facial view post orthodontics but prior to veneer placement.

Occlusal view post orthodontics but prior to veneer placement.

Occlusal view after veneer placement. Facial view after veneer placement.

Facial view of overlapping centrals andpeg laterals prior to treatment.

Occlusal view showing the labial position of the central.

An intraoral camera can give the patientan idea of the expected esthetic results.

Mesial kicker springs and recurved springswere used to reposition the teeth.

The Practice Building Bulletin

Unraveling Upper Anteriors Prior to Placing VeneersDr. David Ouelett

The lateral was then moved into position using a re-curved spring.This minor tooth movement took less than four months tocomplete. Once completed, the active appliance was used as a finalretainer. Notice that the patient has bleached her teeth. It is notuncommon for patients who have undergone a minor toothmovement procedure to follow it up by bleaching their teeth.

Correcting Lower Anterior Crowding.

One of the most common complaints that adult patients ask theirdentist about is crowding of the lower anteriors. Correcting thisproblem can often be easy if you take the time to carefully evaluatethe severity of the crowding and the relationship of the upper andlower anteriors to each other in occlusion.

In the clinical case shown here, a minimum amount of loweranterior crowding occurred because the patient did not wear hisfinal retainers after completing his orthodontic treatment.Although this crowding may not appear serious, once theinterproximal contact points have been broken the drifting andcrowding will only get worse over time if it is left untreated.

When crowding of the lower anteriors is 1 1/2 mm or less, it canusually be corrected by recontouring the interproximal enamel ofeach tooth from cuspid to cuspid and placing a retainer called aSpring Hawley retainer. To accomplish this, you must first send an

accurate set of upper and lower dental casts to the lab. The lab willthen reset the lower anteriors aligning them into their ideal position.The Spring Hawley retainer is then made to this pre-set ideal position.3

On the day of delivery of the appliance, and not before, the enamel re-contouring is done. This will allow the teeth to be guided into the idealposition pre-set by the appliance. If the patient’s bite relationship is toodeep and the lower anteriors already make contact with the upperanteriors, you will not be able to move them, regardless of the amountof re-contouring performed or force exerted by the appliance. So it iscritical that you evaluate the relationship of the upper and loweranteriors to each other prior to selecting this treatment approach.3

In this case, however, there was enough clearance with the opposingarch to allow the teeth to move back into alignment. Once this wasaccomplished, an indirect matrix was used to bond a retention wireto each individual tooth. This retainer is called an E-Z Bond.

Forced Eruption Prior to the Placement of an Esthetic Restoration.

Today it is not uncommon to see patients with severely brokendown teeth that appear unrestorable. Fractures that are below thecrest of the bone and teeth that have extensive recurrent decay arejust a few of the problems we face daily.4

There are several common methods available to manage a tooth thatis severely broken down. These include extraction of the remaining

The appliance used was a swing lock retainer with a recurved spring.

Occlusal view in treatment. Space has beengained and the lateral was guided labially.

Facial view of an adult patient with a bilateralposterior crossbite and a blocked out lateral.

Occlusal view clearly shows the blocked outlateral that is the patient’s main concern.

Facial view of the completed treatment. Occlusal view of the completed treatment.

Minor Tooth Movement for Esthetics vs. Comprehensive Orthodontic Care.

The Spring Hawley Retainer made to ideal anterior position.

Occlusal view of the Spring Hawley retainer in place.

Lower anterior crowding often re-occursafter orthodontic treatment.

Lab resets the lower anterior teeth in their ideal position.

Post treatment - lower anteriors re-alignedand etched for placement of EZ Bond.

Placement of a final retainer called the EZ Bond.

Correcting Lower Anterior Crowding.

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root followed by a prosthetic replacement, and techniques to exposesound tooth structure such as osseous surgery. 4

Surgical exposure of sound tooth structure is fraught with compromise.Gingival and osseous surgery cannot be limited to the involved toothand must be extended to adjacent teeth in order to blend the gingivaland osseous contours. The ultimate result is a sacrifice of supportingbone on several uninvolved teeth. This can cause root sensitivity, exposefurcations, and in some cases can involve the maxillary sinus.4 Whencrown lengthening is done in an anterior region, it can result inunaesthetic open embrasures and long clinical crowns. 5

Extracting a tooth may appear to be a simple solution. But tooth extractioncan cause a decrease in the height and thickness of the alveolar bone. Thismakes it much more difficult to accomplish an esthetic restorative resultregardless of whether you utilize an implant or place a fixed partial denture.5

Whether you plan to do an osseous surgery or extract a tooth, forced eruptionis often an important first step to help achieve the best esthetic result.

Forced eruption can be defined as an orthodontic movement in acoronal direction through the application of gentle, continuousforces.2 Specifically when a root segment is forcefully erupted, theforces stretch the gingival and periodontal fibers producing acoronal shift of gingiva and bone. If done slowly, the gingiva andsupporting bone will follow to a position that is further coronal thanthe adjacent teeth. These gingival and osseous changes can be usedto manage many restorative problems.

In the example shown here, tooth #8 is missing and tooth #9 has avertical fracture making it unrestorable. Just extracting tooth #9would cause a decrease in the height and thickness of the alveolarbone, making it impossible to achieve an esthetic result withoutperforming a ridge augmentation surgery. Instead a removableforced eruption appliance, that included a tooth to replace tooth #8,was used to coronally shift the gingiva and bone until it estheticallymatched the existing pontic site. Once this was accomplished #9was extracted and the area was allowed to heal. This cosmeticorthodontic procedure was finished in six weeks.

Molar Uprighting to Enhance a Restorative Result

Perhaps the most common use of orthodontics to aid in restorativework is the uprighting of a tipped molar. All of us see mesiallytipped molars on a daily basis. The typical clinical picture consistsof extrusion and migration of teeth, accelerated mesial drift, unevenmarginal ridges, angular bony crests, altered coronal to gingivalform, food impaction, caries, periodontal disease, and ultimatelyposterior bite collapse with loss of the occlusal vertical dimension.6

Why then is treatment so often ignored? Worse yet, why are wetempted to place a bridge before returning this tipped tooth to itsnormal occlusal position? Leaving a molar in the tipped position canhave a profound effect on your prosthetic therapy. It leads to:

Forced Eruption in progress slowly extrudingthe tooth will improve the bony ridge.

Forced Eruption completed. This tooth hasalmost been completely erupted.

Facial view of an esthetically compromised anterior ridge.

Active interim partial used to erupt tooth#9 while maintaining esthetics.

Surgical extraction of the remaining roottip after forced eruption is completed.

After healing, the ridge is nicely shaped andready for placement of an esthetic bridge.

A saggital appliance tipped the molar back toits original position regaining the lost space.

Occlusal view of the appliance in place during treatment.

Second molar is impinging upon the spacenecessary to restore the implant.

Buccal view of the lost space due to thesecond molar drifting forward.

Molar Uprighting to Enhance a Restorative ResultForced Eruption Prior to the Placement of an Esthetic RestorationDr. David Levine

Occlusal view of the treatment completed.The implant is once again restorable.

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• Inadequate parallelism of bridge abutment teeth.• A poor occlusal plane.• A lack of interproximal space between teeth.• Adverse root proximity.• Faulty occlusal landmarks.• Excessive tooth preparation with potential

pulpal involvement.• Inadequate pontic space.• Hard and soft tissue deformities of the

periodontal structures.• Teeth that are more difficult to clean. 7

• Bruxism and clenching habits • Occlusal trauma.

In this unique clinical example, the patienthas had an implant placed ideally in thelower first molar position. Unfortunatelythe implant space was not properlymaintained with an interim bridge orpartial. In less than eight months, thesecond molar drifted and tipped mesiallymaking it impossible to restore the implant.To correct the problem a removableappliance with an expansion screw was usedto distalize and upright the molar. In fourmonths, the second molar was back into itsnormal position and the space necessary torestore the implant was regained.

Choosing Cosmetic ToothMovement Appliances

Most esthetic tooth movement procedures canbe accomplished with either fixed orremovable appliances. In cases where eitherappliance will accomplish the same result, thefollowing check list will help you decide whichapproach may be best suited for your patient

Fixed appliances are best used when: 8

1. Bodily movement of the teeth is needed.

2. Wearing anterior brackets and wires areacceptable to the patient.

3. The patient has excellent oral hygienemaking the possibility of decayminimal.

4. Patient cooperation in wearing aremovable appliance is doubtful

5. There are enough teeth present to createa proper anchorage unit.

Removable appliances should be used when: 8

1. Bodily movements of the teeth are notrequired, as removable appliancesmainly provide a tipping action.

2. Esthetics is important. The patientneeds an inconspicuous appliance that

can occasionally be removed.3. Bracketing teeth is inappropriate. For

example, placing brackets on porcelainveneers or crowns is contraindicated, asthe bonding process will damage theirfinish.

4. The patients do not have enough teethto use as an anchor. A removableappliance allows you to use the softtissue, teeth, and the appliance to forman anchor against your active toothmovement.

5. The patient is cooperative andresponsible; i.e. they will wear theappliance as prescribed and will guardagainst loss or breakage.

Care for the Appliances:

Both fixed and removable appliances needspecial care. Some of the most commonproblems are addressed below:

1. Fixed orthodontic appliances willdemand special oral hygiene care. Wehighly recommend the use of fluoride tohelp prevent caries activity.

2. It is often a good idea to give yourpatient some Brace Relief (a medicatedorthodontic wax) to protect their tissuesfrom being irritated by the brackets andwires.

3. Never allow a removable appliance nearhigh temperatures or allow it todehydrate for more than 24 hours.

4. All appliances should be kept moistwhen not in use. A retainer case worksnicely. The patient should simply placethe appliance in the case with a smallpiece of wet paper towel.

5. All appliances should be cleaned everyday. A soft brush and toothpaste, orsoaking it in a cleaner like Clean ‘N’Fresh, is all that is needed.

6. Removal of an appliance is bestaccomplished by using equal pressureon both sides of the mouth. This willminimize the chance of damage to theresilient portion of the appliance.

Contra Indications and Concerns:

1. Careful diagnosis and treatmentplanning are the key elements to success.Before starting a minor tooth movementprocedure, the patient should beinformed of all the possible treatmentoptions and the total treatment requiredincluding periodontal, orthodontic andprosthetic therapy.

2. During tooth movement, the clinicianmust accept responsibility for keepingthis area free of inflammation. This willrequire regular maintenance throughouttreatment. In fact, the frequency ofvisits during tooth movement is notdetermined by the orthodonticadjustments. Instead it is determined bythe necessity to keep the soft tissue freeof all inflammation and to preventcrestal bone loss during appliancetherapy.6 To achieve this, weeklyappointments may be necessary.

3. All new or recurrent caries should betreated prior to the fabrication of anappliance because wearing orthodonticappliances can often exacerbate anexisting problem. Prophylacticmeasures such as the regular use offluoride can help to preventdecalcification and caries in the teethcontacted.

4. When initiating a cosmetic toothmovement procedure, occlusalinterferences are often created whichcan cause a patient to clench or grind. 9

To prevent this occlusal trauma duringtooth movement, one can use acombination of a bite plane forposterior disarticulation and selectivegrinding of the teeth in trauma.

5. When performing adult orthodonticson a patient, who has never experiencedorthodontic care, it is important toinform them that their teeth are goingto be uncomfortable during the therapy.

6. Appliances can only be effective whenthey are properly designed to adhere tothe principles of retention, forceapplication and anchorage. Therefore,it is very important that some form ofretention be placed as near as possible tothe active components of the appliance.

7. When using clasps for retention careshould be taken not to interfere with thepatient’s normal occlusal pattern.Occlusal interferences will usually causethe patient not to wear the appliance.

8. A removable appliance must never beunilateral. A unilateral appliance offersa definitive hazard because the patientmay swallow or aspirate the prosthesis.

9. When using a fixed appliance whereteeth need to be banded, werecommend that the bands for theseappliances be lab made. Only in thisway can we assure that proper contoursand embrasure spaces will be respectedin the appliance fabrication.

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Lab Requirements:

Space Maintainers’ goal is to give you thebest service possible. To help us provide youwith the best appliances in a timely manner,we need the following:

1. Fill out a detailed prescription. If youare having a problem designing anappliance, have a look at the PracticeBuilding Bulletin called The ApplianceTherapy Worksheet. After a littlepractice using this sheet you shouldhave no problem designing anappliance. But if you are still unsure ifyour appliance design is correct, justgive one of our designers a call.

2. Always give us the date wanted and,when appropriate, the patient’sappointment date. If there is a problemin meeting the due date, the lab will call.

3. Send us accurate upper and lower castspoured in stone (do not use die stone)that capture all the teeth and land areas.Air bubbles or holes on tooth surfacesare unacceptable as they can negativelyeffect the fit of the appliance.Unfortunately, we can only guaranteethat your appliance will fit the model.So making sure that your casts areaccurate before you send them to the labwill save you chair time and a lot ofmoney.

4. For any appliance that requires anocclusal surface, always provide acarefully taken construction bite thatrepresents the exact vertical and APposition that you desire in the finishedappliance. Then carefully wrap the biteseparately for shipment.

Lab Fees:

Lab fees range from $50 for a simpleremovable appliance to move a single toothto $130 for a complete set of brackets andwires for aligning a crowded lower arch.The average cost for an upper and lowerappliance is $75 a piece.

Supply List:

Whether you have been practicing for onemonth or forty years, you will find that youalready have almost everything on thissupply list. Be sure to take a moment andreview it. Is there a favorite instrument thatyou use that I have left out?

❑ Appliance therapy design worksheet*❑ Alginate*❑ Mixing bowl and spatula❑ Dental stone❑ Vibrator❑ Impression trays*❑ Tray Tree*❑ Bite registration material❑ Bite sticks*❑ Elastic separators*❑ Articulation paper❑ Diamond burs❑ Acrylic burs*❑ Acrylic repair kit*❑ Pressure pot*❑ 139 Bird beak pliers*❑ Three prong pliers*❑ Expansion screw key*❑ Stiff Robinson brush*❑ Micro-screw screwdriver*❑ Boley gauge or diagnostic calipers *❑ Cheek retractors*❑ Pumice❑ Etchant*❑ Fluoride releasing band cement*❑ Composite resin for bonding fixed

brackets e.g.(rely-a-bond)*❑ Cotton pliers or bracket placement

tool*❑ Elastic ligatures*❑ Needle nose hemostat or ligature tie

placement forceps*❑ White utility comfort wax or brace

relief*❑ Direct bond bracket removing plier*❑ High speed finishing burs❑ Abrasive polishing discs ❑ Interproximal stripping tool*❑ Clean ‘N’ Fresh Appliance Cleaner*

* Available through Success Essentialscatalog.

Customary Fees andIncome Potential:

Adding cosmetic tooth movement to yourrestorative skills will give you the flexibilityto treat those cases that would otherwise beleft untreated. It is not unfair to say thatyou cannot call yourself a cosmetic dentistif you do not have the ability to move atooth. Minor tooth movement proceduresare usually easy and predictable. In fact,these cases can be the bread and butter ofyour practice. Once you are looking forthem don’t be surprised if you begin to starta couple cases a month.

Fees for adult minor tooth movement willdepend upon the complexity of the case,the type and number of appliances, and theestimated length of treatment time. Yourfees will also vary depending on your area.As I have lectured around the country, Ihave found that the fees for these types ofprocedures range between $500 and $1500.At an average fee of $1000 you can expectto add $24,000 - $36,000 to your yearlygross production.

Rob Veis, D.D.S.Director of Practice Development

REFERENCES:

1. Talon® Laboratory Technique Manual:Thermoplastic Resilient Polymer forInterocclusal Dental Appliances.

2. Veis, Salzer, Christian, Manual ofAppliance Therapy for Adults andChildren, 1994. Chapter 8, pp 8-2 &8-3.

3. Veis, Salzer, Christian, Manual ofAppliance Therapy for Adults andChildren, 1994. Chapter 11, pg 11-2.

4. Marks, Corn: Atlas of AdultOrthodontics, Philadelphia, Lea &Febiger, 1989. Chapter 19, pp 413-447.

5. Oesterle, Wood: Raising the Root, JADA,July 1991, Vol 122, pp 193-198.

6. Marks, Corn: Atlas of AdultOrthodontics, Philadelphia, Lea &Febiger, 1989. Chapter 18, pp. 391-412.

7. Pritchard, J: The Diagnosis andTreatment of Periodontal Disease,Philadelphia, W.B.Saunders Co., 1979.Chapter 25, pp. 462-503.

8. Veis, Salzer, Christian, Manual ofAppliance Therapy for Adults andChildren, 1994. Chapter 1, pg. 1.

9. Brown,S: The Effect of OrthodonticTherapy on Certain Types ofPeriodontal Defects, J. Periodontal.,Dec 1973, Vol 44, #12, pp. 742-756.

The Practice Building Bulletin is a special service of Space Maintainers

Laboratory produced solely for the private use of our clients. It is

designed to help expand and enhance your ability to provide

comprehensive patient care. As an active client, you will continue to

receive all future editions at no charge. Subscriptions are available for

$98.50 for 10 bulletins and includes a free three-ring binder with all

back issues to date. Information included is the opinion of the author

and may not be reproduced in any form without written consent.

World Wide Web: http://www.smldent.com

Vol. III, Number 3 • Chatsworth, California

Copyright © 1998

Space Maintainers Laboratory

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