ABC concept: smile transformation

Kunal Rai utilises the align, bleach, contour (ABC) concept in smile transformation.

A nervous patient (in his mid-20s) presented at the practice unhappy with his smile and the shade/shape of his anterior teeth, which was affecting his self-confidence. He reported no acute pain. He wanted to have his teeth treated, but was unprepared to have fixed braces at his age. He sought to have braces that were invisible and did not regress his confidence further.

His last dental visit was more than four years ago due to a traumatic past experience. He was referred to the practice through a friend.

As with any assessment, we started off discussing the patient’s main concerns and build a rapport with him so he felt at ease. We then moved on to discussing his medical history and social history.

The patient was generally fit and well, taking no medication and no known allergies. Alcohol consumption was moderate and he was a non-smoker. Furthermore, his oral hygiene was good, brushing twice daily with an electric toothbrush and occasional flossing.

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Clinical Examination

Extraorally, no signs of any pathology and all were functioning within the normal parameters. Intraorally, all the soft tissues were within the normal limits and no signs of pathology were visible apart from generalised marginal gingivitis. He had a thick bio-type.

Regarding dentition, there was an enamel fracture on the UL1, missing teeth and multiple restoration present.

Orthodontic review:

• Molar relationship: NA (RHS) and class 1 (LHS)
• Canine relationship: class 1 (RHS) and class 2½ unit (LHS)
• Incisal relationship: class 3
• Cross bite: not present
• Scissor bite: not present
• Overjet: 2mm (UL1 and LL1)
• Overbite: decreased 20%
• Open bite: not present
• Crowding: mild (upper and lower)
• Arch shape: V-shaped (U and L)
• Lateral excursion: canine guidance (RHS and LHS)
• Protrusive guidance: UR1, UL2 vs LR1, LL3
• TMJ: no clicks or pain
• Cant to the UL1
• Deficient buccal corridor.

An OPT was taken to assess for any pathology in the upper and lower arch. Caries identified on LL8MO and peri-apical pathology under LR5.

When tested, the LR5 was not tender to percussion and gave a negative response to ethyl chloride.

The results of the extraoral and intraoral examinations are summarised in a problem list (Table 1). Based on this list, an interdisciplinary approach helped to define all the potential treatment goals.

Table 1: Problem list

The scope of the treatment goals achievable were presented to the patient with advantages and disadvantages of the alternative treatment plans. The treatment goals (listed in Table 2) were agreed and defined.

Table 2: Treatment goal (non-extraction approach)

A: Alignment

Clincheck treatment planning

Specific instructions were provided in the form of a four-sentence prescription to the Invisalign technician and included the following:

Patient’s chief complaint: patient does not like his smile at all. Please improve the upper and lower crowding and widen the smile. Level the gingival margins of the upper anterior teeth. No movements on the LR5 until aligner number 12

Anterior reference point: tip UR1 1mm buccally and use this to align the upper anterior teeth

Posterior reference point: use the distobuccal cusp of the upper sevens to widen the smile

Overjet/overbite: please provide an overjet of 3mm and overbite of 30%.

Treatment summary

The original treatment plan included 15 aligners on the top and bottom arch. Optimised attachments were placed on the upper arch from UR5 to UL5 and on LL6 to LL4 and LR3 to LR6 (Figures 11-13).

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Treatment progress

The patient completed his alignment journey with 15 aligners on top and lower. No refinements/additional aligners were needed. This equated to a treatment time of approximately four months.

This was based on the patient being fully compliant and wearing each aligner for seven days with at least 20 hours’ wear a day. The patient was asked to replace the aligners at night to ensure it inflicted minimal pain.

B: Bleaching

To lift the shade of the teeth, Boutique Hybrid Pro whitening (syringes) was carried out while the patient had his aligners on from day one.

The patient was asked to continue doing the whitening until he was happy with the shade (continued whitening up to week 10 going through 2.5 syringes).

To get the best possible outcome, the patient was recommended and shown to apply a pea-size amount of gel on his aligners every night.

The peroxide diffuses through the composite buttons and lifts the shade of the dentine; effectively saving time for both the clinician and the patient. Figures 14 to 22 show the post-treatment photos. The patient’s initial main concerns of his smile alignment, shade and crowding were all resolved. An improved inter-incisal angle and contact were created.

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C: Contouring

An acceptable aesthetic result was achieved with minimal restorative work. Additive bonding was applied to the upper anteriors to improve the shape and shade of the teeth.

Furthermore, the arrested caries on the buccal surface of UL4 was treated with Icon and composite bonding.

The composite bonding was done under strict regime of rubber dam isolation to ensure a safe environment and appropriate moisture control.

The non-working/adjacent teeth were isolated with polytetrafluoroethylene (PTFE) tape. The composite chosen for this case was Ivoclar Empress BL-XL shade, as it exhibits high physical strength under compression.

The composite was heated using the C-Flo from Bryant Dental at 44oc to allow a smooth flow. Optrasculpt from Ivoclar was used to apply and blend the composite to the existing tooth surface.

The polishing was done using Optragate and polishing spirals and points to achieve a high lustre, respecting the tooth anatomy.

Figures 23 to 26 demonstrate the improvement of the smile using a combination of orthodontic, whitening and additive composite bonding.

Following the contouring process, the patient was ecstatic to see his final smile revealed.

Although the patient had seen the trial smile at an earlier stage in the treatment, he had not fully appreciated what could be achieved with composite or the difference it would make.

The patient was really happy with the outcome, so we decided that the treatment should be concluded.

An intraoral scan was done using the Itero to fabricate the Vivera upper and lower retainers for lifelong night-time wear.

The retainers are 0.4mm thick and can also be used for any future tooth whitening.

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Conclusion

Invisalign can be used for a variety of cases from simple to complex; however, it is the responsibility of the dental clinician to work within their comfort zone as well as their capabilities.

For me, the biggest advantage of using Invisalign is the ability of having a Clincheck to demonstrate to the patient exactly what results can be expected at the end of the aligner journey.

These days, with the use of digital smile design, we can go one step further and use the STL file to do a digital mock-up on the final teeth position, showing the outcome of any contouring work (prosthetics and/or composite).

Products used:

• Boutique Hybrid Pro – Boutique.
• Icon – DMG.
• Empress Direct, Optrasculpt, Optragate – Ivoclar Vivadent.
• Clincheck, Itero, Vivera retainers – Align.
• C-Flo – Bryant Dental.