When planning orthodontic and restorative treatment, it is important that the collaboration between the dentist and orthodontist is interdisciplinary. This means that the communication between clinicians should start at the treatment planning phase to formulate the agreed treatment goals, with progress relayed throughout the treatment until completion. The emphasis in all ortho-restorative cases is on having a minimally invasive approach, planning for stability and a patient that is well-informed.
The Clincheck software programme utilised with the Invisalign system can be used to treatment plan orthorestorative cases to achieve optimal aesthetics and function as described in the case below.
Presentation
This 38 year old male initially presented with a skeletal class II, class II subdivision, deep bite and large central diastemas in both arches. There was an inter-arch tooth size discrepancy (TSD) with disproportionately small anterior teeth in the lower relative to the upper arch. As well as the TSD associated with the small mesio-distal dimensions of the lower anterior teeth, the lower incisors were also worn at the incisal level (fig 1a and 1b). This initial photo is also seen as a digital study model using the Clincheck software programme in figure 1c.
Treatment planning
Options for treating this case after stabalising the oral hygiene included:
- No treatment.
- Restorative treatment alone.
- Orthodontic treatment alone (extraction/non-extraction).
- Orthodontic treatment in combination with restorative treatment.
Restorative treatment alone would prove challenging given the amount of space available and destruction to tooth substance, along with compromising the final aesthetic result for the patient. By including orthodontic intervention, the ideal treatment plan would involve closing the upper and lower central diastema, reducing the deep overbite, creating an ideal overjet and inter-incisal angle, whilst maintaining the buccal intercuspation.
After a comprehensive orthodontic assessment combined with a collaborated evaluation with the restorative dentist, the solution of an ortho-restorative approach was clear. The Clincheck software provided the ability to relay the information visually between the clinicians and patient.
For the benefit of the patient who was keen on a non-extraction approach which involved minimal restorative intervention, alternative treatment plans were made. The first Clincheck treatment plan was devised where all of the spaces on the upper and lower arches were closed. The Clincheck software allows the clinician to move the teeth into the proposed new position like a virtual digital Kesling setup. The Clincheck showed orthodontic space closure of all the spaces; however this treatment plan indicated an increase in the overjet due to the retraction of the lower incisors. Furthermore, it showed a loss of transverse arch coordination at the canine and premolar region
due to the lower arch constriction from the space closure. This could affect the canine coupling and be detrimental to occlusal function in the long-term. Because the tooth-sized discrepancy had not been addressed in this treatment plan, an ideal occlusion could not be achieved (fig 2).
A second treatment plan had also been devised which involved moving the upper incisors together to close the diastema. However the lower incisors would be moved to leave evenly measured spacing between the lower incisor teeth of 1mm. This pre-restorative position would allow the restorative dentist to have space to build the teeth up with composite at both the mesio-distal and incisal level with minimal preparation bonding. Not only would this aid in the correction of the tooth-sized discrepancy, but the overjet would also be corrected. Furthermore, an improvement in arch coordination would also result from this treatment plan (fig 3).
Figure 4 illustrates the additive composite bonding (in yellow) which could be performed to achieve the end result after pre-restorative orthodontics.
At this point, both Clincheck treatment plans were presented to the patient. Advantages and disadvantages of both treatment plans were discussed and ultimately the patient opted for the ortho-restorative treatment option. The duration of the orthodontic treatment was under 10 months in total. The patient was seen for orthodontic appointments on an eight week basis to check the fit of appliance and supervise treatment progress. A total of 20 aligners were required, with aligners to be worn sequentially for two weeks at a time for a minimum of 20 hours a day to achieve the desired movement. After the orthodontic treatment was complete, the lower teeth required minimal preparation and only additive bonding with composite to restore them to the correct dimensions. Figure 5 illustrates treatment progress following the Invisalign treatment and additive bonding.
Once both the restorative dentist and orthodontist were happy with occlusal function and compliance with the retention protocol. The patient had the upper central incisors restored with crowns as illustrated in figure 6.
Conclusion
The principle aim of the orthodontic treatment for this case was to assist in space closure in the upper arch and to correct the tooth size discrepancy (TSD) in the lower arch. The occlusion and tooth wear would be improved by correcting the deep bite. Additionally pre-restorative orthodontics would facilitate the restoration of the worn lower anterior teeth.
The Clincheck software provided inter-disciplinary treatment planning and allowed for easy discussion between the orthodontist, restorative dentist and patient. The clinicians had realistic clear treatment goals from the start which both could adhere to as part of a collaborated approach.
Understanding and using the Clincheck software programme as a diagnostic tool can help to solve many orthodontic and aesthetic problems in a systematic and predictable manner. An interdisciplinary approach was used to provide the patient with an optimal aesthetic result while providing minimally invasive treatment. The use of only an orthodontic or restorative approach would not have produced a satisfactory result for this case.