When this patient came in wanting to improve his smile, it was clear this wasn’t going to be a straightforward veneer case. I used to do orthodontics in my practice, and I’m comfortable using removable appliances to correct clinical conditions such as crossbites, so I had Space Maintainers Laboratory fabricate a removable appliance for me. I could have used a fixed appliance with either an anterior or posterior bite plane to correct the crossbites, but the patient convinced me he would wear the removable appliance as instructed. These types of cases take a while to reach completion, especially when the patient tells you that fixed orthodontics (brackets and archwires) are off the table. You could always refer the ortho portion of the case to a specialist, but most of the dentists that I speak with enjoy the process of minor tooth movement, whether it is with an appliance like the one I use in this case, or a series of clear aligners.
Figure 1: I don’t recall ever seeing a patient before with three anterior teeth in crossbite and one anterior tooth in essentially a perfect position. Orthodontics in esthetic anterior cases is almost always both a viable option and the most conservative option. In this case, orthodontics is mandatory. However, orthodontics doesn’t address tooth size and shape discrepancies, undesirable shades, or other esthetic issues.
Figure 2: The first thing that jumped out at me while looking at this occlusal view is how wide the patient’s upper arch appears to be; I expected it to be narrow with more crowding. We definitely need some room to unravel what crowding there is in the anterior, and those spaces between #4, #5 and #6 will come in handy. There is an outside chance he might need a cleaning and an extraction, too.
Figure 3: VPS impressions and a bite registration were sent to Space Maintainers Lab, and this is a look at the tissue side of the appliance we received back. My explorer is touching one of the three recurved finger springs that are currently in their inactivated state. These springs will help to rotate the three teeth in crossbite into proper alignment. I will remove the portion of the acrylic that covers the springs when I am ready to activate them, making them much easier to adjust.
Figure 4: Here is a look at the tongue side of the appliance. This type of expansion screw is typically used in the midline of an appliance like this to broaden the arch. Here, it is being used to move the three teeth in crossbite into the proper arch form. The yellow arrow shows the patient which direction to turn the screw twice per week.
Figure 5: The retention for this appliance is primarily from an Adams clasp on the molar. The bends of the Adams clasp engage the interproximal undercuts of the molar, and can be tightened or loosened as needed. It also crosses over the occlusal surface, so you need to make sure you have occlusal clearance for the clasp. There is also a wire clasp for the bicuspid that has been soldered to the distal end of the labial archwire.
Figure 6: On the contralateral side, a hook has been soldered to the Adams clasp. This gives us a posterior anchorage point where we will be placing elastics later to help distalize some anterior teeth. You will notice the labial archwire continues past the cuspid, and is soldered to the mesial portion of the Adams clasp for stability.
Figure 7: Space Maintainers also included two bondable buttons. The tooth side of the button has a mesh framework that uses mechanical retention to keep the resin bonded to it. As you may have guessed, these buttons will be at the other end of the elastics that will attach to the hook on the Adams clasp. Your ability to move a tooth increases exponentially when you bond a button or (especially) a bracket to the tooth.
Figure 8: I place and remove the appliance the first few times to check its fit, but I will definitely make the patient do it several times as well. With the appliance in place, we are getting some additional retention from the occlusal surfaces of the posterior teeth, which are indexed in the appliance as though it were a bite splint. The thickness of the occlusal pads is enough to ensure we can jump the crossbite.
Figure 9: The bite is checked to make sure that the patient is hitting the posterior pads equally on both sides. If there is a prematurity on either side, it has a tendency to pop the other side of the appliance off when the patient bites down. We remind the patient that the more he wears this appliance, the faster we can correct the crossbite, and the faster we can stop using the appliance.
Figure 10: We are also going to cement the two buttons at this appointment, so we begin by cleaning the enamel surfaces with Preppies™, the unit-dose pumice from Whip Mix (Louisville, Ky.). We need to ensure we get a good bond here: There is going to be a lot of force on these buttons, much more than on a typical composite restoration.
Figure 11: Because the buttons need to coexist with the appliance, I have placed the appliance prior to acid-etching the tooth so I can see exactly where the buttons need to be. Space Maintainers designed the labial archwire so that there would be room for the buttons between the archwire and the gingival margin.
Figure 12: After rinsing off the etch and placing some GC Fuji ORTHO™ LC cement (GC America; Alsip, Ill.) on the tooth side of the button, I place the button and adjust it to its final position. The more gingival we place the button on the cuspid, the better the chance of moving the tooth bodily to the distal, as opposed to just tipping it to the distal. If the button were placed at the incisal edge, you can imagine how it would just tip the tooth, rather than move it bodily.
Figure 13: The button has been placed and positioned on the first bicuspid as well, and both have been light-cured. The appliance has now been removed, and we are going to clean up the excess cement around the buttons with a finishing bur. If you look back to Figure 2, you will notice we have space distal to both of these teeth, and we are going to move them both in that direction to create space in the anterior.
Figure 14: Both of the elastics are attached to the hook on the Adams clasp, and then one attaches to the button on the bicuspid and one attaches to the button on the cuspid. It’s hard to tell from this photo, but the bicuspid is not indexed in the appliance. If it were, it would be impossible to move it distally.
Figure 15: The patient returns a week later for us to evaluate how he is doing with the appliance. Besides having to speak a little slower than usual due to the appliance, the patient is tolerating it well, and is able to eat with it in place. Because of this success, we now show him the expansion screw, the key, and the yellow arrow that indicates in which direction one full turn of the screw is to be made once on Wednesday and once on Sunday.
Figure 16: When the patient returns six weeks later, the progress of the expansion screw is evident. At times, the acrylic ramp can have a tendency to slide up the lingual surfaces of anterior teeth (as opposed to pushing them forward) due to lack of undercut on the lingual. If this starts to happen, small composite buttons can be placed on the lingual to create those undercuts for the acrylic ramp to engage.
Figure 17: Compared to Figure 2, we have made some decent progress, both in distalizing the cuspid and bicuspid, and in anteriorizing the three teeth in crossbite. We still need more room for tooth #7, but we aren’t done distalizing #5 and #6. The patient still has another 4 mm to go in terms of advancing the acrylic ramp.
Figure 18: Six weeks later, the patient comes in again. This is a shot of the appliance in the patient’s mouth. We’ve had more advancement of the acrylic ramp, but I feel like the labial archwire is hindering the movement of tooth #10. The patient’s upper lip actually acts as a great labial archwire: The more the teeth are moved to the labial, the more the lip pushes them back to the lingual.
Figure 19: The first bicuspid is now contacting the second bicuspid, meaning that we are finished moving it distally, so I want to lock it in place. I roughen the inside of the appliance in the area of the first bicuspid, place some methyl methacrylate, and reseat the appliance to index the occlusal surface of the first bicuspid. It still needs to be trimmed, but you can see that this tooth will now be locked into place.
Figure 20: I can see I am still seriously short on space for tooth #7. I can push all I want from the lingual with the acrylic plate, but #7 is not going anywhere until I can create some space for it. With an ultra-fine diamond bur, I am opening the contact between the cuspid and bicuspid by recontouring the proximal surfaces. This will allow me to move the cuspid further distally.
Figure 21: You can see the increased space I now have to move the cuspid distally, and I am also going to create a small space between #6 and #7 to “unlock” #7 and start to get some labial movement. Tooth #7 is still in contact with tooth #8, but if I create this space on the distal, the tooth will move labially and distally as well.
Figure 22: Now that the first bicuspid is indexed in the appliance, it can be used as an anchorage unit, allowing me to place a power chain from the bicuspid to the cuspid. Usually, this would pull these two teeth together; but with the bicuspid locked in, the cuspid is forced to move distally. Now the patient doesn’t have to replace the elastic every time they take out the appliance to brush, due to the fact that it’s no longer attached to the appliance.
Figure 23: Two weeks later, the patient is back again because the power chain needs to be changed. You can see the dramatic difference between the new power chain on the left and the two-week-old one on the right. Once this permanent deformation occurs, it is no longer moving the cuspid distally and needs to be replaced. Unlike elastics, patients can’t change power chains on their own.
Figure 24: With the appliance in, I can see that I have finally had some labial movement on the lateral incisors. Also, if we compare the space between #5 and #6 with how it looked in Figure 21, we have definitely had some distal movement of the cuspid as well. We have reached the full length of our expansion screw’s ability to move the acrylic plate to the labial, so it’s time to check the patient’s bite with the appliance and see how we are doing.
Figure 25: It’s been three months since treatment began. The good news is once you correct an anterior crossbite, it will not relapse. Because the incisal edges of the three maxillary teeth are now in the correct position relative to the lower incisors, the patient could stop wearing the appliance today, if I didn’t need those recurved finger springs on the lingual to try to correct the rotations, too. We can now focus more exclusively on creating the space for, and moving, teeth #7 and #9, as well as working on rotating tooth #10.
Figure 26: The occlusal “before” shot and an occlusal shot from today shows how the crowding has slowly started to unravel. Three months is a pretty short period of time, and while we will need more time to finish this phase, the good news is that everything is moving in the correct direction. I might even have enough room for tooth #7, but I will have to move it distally to verify that.
Figure 27: I’m going to need some anchorage on this tooth to really move it effectively. I could place a button on the tooth, but then I would pull it on a diagonal and not to the distal. If I place this bracket, it will allow me to place a power chain on the mesial portion of the bracket. Not only will this move #7 distally, it will also rotate the tooth as it does it, pulling the mesial to the labial and the distal to the lingual.
Figure 28: Now that the cuspid has been moved distally, I would like to lock it in place. Because I can’t index it in the appliance, I am going to anchor it to the bicuspid with a ligature wire. Moving these two teeth distally is like sliding beads on a necklace: Once they get to the desired position, they need to be held there to keep them from moving back. This is also plenty of anchorage to move the lateral incisor.
Sarasota Dentistry creates beautiful and natural-looking porcelain veneers, customized to each patient’s desired look – from straight and white to stained and discolored. The patient has complete control over the final results. Veneers are an ultra thin layer of porcelain bonded to the surface of the tooth, designed to cosmetically improve the color, shape, and size of teeth, as well as strengthen the tooth’s surface. Not unlike the facade or exterior of a house, veneers are what the world sees when you smile. Dr. Michael and his team of dental experts work with patients to create the smile they want, using the latest in cosmetic dentistry technology.
What are Porcelain Veneers?
Veneers are an ultra thin layer of ceramic porcelain applied to the tooth’s surface, designed to improve the look of your teeth by changing the color, size or shape. Veneers can also be used to close gaps between teeth and lengthen or shorten teeth – for a more smooth and even smile. In addition to improving the visual look of teeth, veneers can also improve the strength and resilience of teeth because of how much it replicates natural tooth enamel.
Who are Porcelain Veneers For?
Veneers can be a great cosmetic option for people who have stained teeth but don’t respond well to teeth whitening procedures, people who have spaces between teeth that they want filled, those who want to improve the appearance of teeth that are worn, discolored, crooked, chipped, fractured, or people who need a tooth re-positioned to remedy minor bite-related problems. Many people choose veneers simply because they want an improved smile or younger-looking teeth.
What is the Process of Getting Porcelain Veneers?
First, you will meet with Dr. Michael to find out if porcelain veneers are right for you. If it’s determined that they are, you will discuss your specific goals and objectives in terms of your desired outcome (how you want your teeth to look). Molds of your teeth will be taken and a diagnostic wax-up of the desired smile will be created on the models – much like a blue print is created to design a building. You will review the wax-up or mach up of your smile with the doctor prior to the actual porcelain veneer preparation. You can easily make changes to the wax-up prior to the procedure. The next step is the porcelain veneer procedure. A small amount of your original tooth enamel may need to be removed to make space for the veneer covering. This will ensure that the veneer will fit comfortably in your mouth and not feel bulky or change your normal tooth function. Most porcelain veneers are made by the dental laboratory and require about 2 weeks to process. During this time, you are wearing a set of acrylic veneers. One week after the temporary veneers are placed, you will return to the dental office for an impression of the approved temporary veneers. If you have any hesitation about the shape, size or color… this is the time to make the doctor aware. He can easily modify or re-make the temporary veneers in a different color prior to proceeding with the final porcelain veneers. Once you are absolutely happy, the impression of approved temporaries is sent to the lab for the final fabrication. The final visit is to have the veneers “installed” or “Seated”. They are first seated with try-in paste where you can inspect the final smile prior to the permanent bonding of the seated porcelain veneers. At this point, it is rare that any modifications are necessary and the porcelain veneers are permanently bonded. Resin is used to bond the veneer to the tooth, then hardened and secured with a high-intensity curing light. The excess resin bonding is carefully removed and polished and the final bite is also checked and adjusted if necessary.
How to Care for Porcelain Veneers
Porcelain veneers are relatively easy to maintain since they mainly require regular dental hygiene. However, there are some oral habits that can damage a porcelain veneer (or a natural tooth for that matter). Habits such as biting your finger nails, opening wrappers with your teeth or cutting fishing line or thread with your teeth. Using common sense is the best way to prevent damage to a porcelain veneer. Additionally, Dr. Michael recommends wearing a night guard in your sleep to protect the porcelain veneers from any incidental grinding in your sleep. Following this protocol along with regular dental cleanings and checkups can lead to many years of service.
Benefits of Porcelain Veneers
Porcelain Veneers, or porcelain crowns, are natural-looking, strong, long-lasting, stain-resistant, easy-to-care-for, affordable, and a low-risk way to make noticeable changes to your smile. A beautiful smile then results in more self-confidence which ultimately leads to more success in your business and personal life. Cosmetic dentistry with porcelain veneers is a life changing experience you don’t want to miss out on. Call or email Dr. Michael at Sarasota Dentistry today to schedule a consultation.
Porcelain Veneer Shapes/Styles
According to the LVI Smile Library*, porcelain veneers can be classified into 12 different styles describing the characteristic smile they wish to portray.
- Aggressive–square, round central and lateral incisors with gently curved or semi-straight canines. This is perfect for men as well as women who may want to project a rather strong personality.
- Dominant–square, round central incisors, rounded far corner of lateral incisors, and sharply pointed canines; lateral incisors are chipped a little bit higher than the central incisors.
- Enhanced–slightly rounded edges of both central and lateral incisors with the lateral incisors slightly higher or shorter than the central incisors to give it a gull-wing appearance; canines are bluntly pointed. This style of smile particularly is one of the most popular styles of porcelain veneers chosen by females those who wish to compete in beauty pageants as well as engage in photo-op sessions where a perfectly looking pearly whites is a must.
- Focused–similar to an Enhanced Style unless the central incisors are square without rounded edges.
- Functional–similar to an Enhanced Style except the canines are more pointed.
- Hollywood–similar to an Aggressive Style but with the lateral incisors slightly offset or shorter from the central incisors. This is one of the most sought after porcelain veneer styles among males as it provides an excellent show of teeth without being overly aggressive.
- Mature–similar to an Aggressive Style but with the canines slightly more pointed.
- Natural–similar to an Enhanced Style but with the canines more aggressively pointed
- Oval–similar to an Aggressive style unless all the incisors and canines take on a more rounded or oval shape.
- Softened–similar to an Oval Style but with a less pronounced curvature of the edges of the teeth.
- Vigorous–similar to an Aggressive Style unless the canines are more pronounced, is protruding well into the oral cavity like a fang.
- Youthful–similar to an Oval Style but with more pronounced and protruding canines like in a Vigorous Style.
*Developed by Dr. William Dickerson of the Las Vegas Institute for Advanced Dental Studies.