Why You Need to Understand Orthodontics
Minimize invasiveness and maximize effectiveness of restorative treatments
Several years ago, a dentist in the United Kingdom referred a patient to a colleague for minor orthodontic treatment prior to the delivery of veneers. In addition to crooked teeth, the patient had a narrow smile and excessive gingival display. After having her teeth straightened and bleached, however, the patient had a revelation. "Now that I can see how my teeth look when they are straight," she said, "I love them, and I do not want all of that other work done." The original dentist fixed only some minor chipping, and the case ended up being a long-term success. Today, that case has stuck with the dentist who performed the orthodontic treatment, Tif Qureshi, BDS. "It was so powerful," he says. "A minimally invasive approach with the aid of orthodontics can be just as esthetic, if not much healthier, for the patient in the long term."
That approach is not very common in the United States or worldwide, according to Qureshi and others who preach the benefits of orthodontic-restorative treatment. Despite the soaring popularity of clear aligners, they are utilized more for the esthetic straightening of teeth than for the interdisciplinary treatment of adult patients. However, even dentists who have no intention of implementing clear aligners into their own practices can benefit from incorporating orthodontics into their treatment plans.
"Most dentists have cases for which they believe they have no alternative to aggressive dentistry-cutting back teeth, crown lengthening, endodontic treatment, and more," says Drew Ferris, DDS, an orthodontist in Santa Barbara, California. "So many of those cases could become simpler, with better results and longevity, if orthodontic treatment were incorporated."
Of course, that disconnect is not one-sided. Orthodontists need to understand restorative needs and the potential for their work to impact restorative treatment. "Orthodontists who practiced general dentistry for a few years and understand restorative principles are the best ones to refer to," Qureshi says. "Orthodontics is not just moving teeth around; it is setting teeth up for correct function and occlusion."
The Primary Goal
Whether for a single crown or a full-mouth rehabilitation, orthodontic treatment can help minimize the invasiveness of restorative treatment and maximize the long-term success of a case. For certain situations, such as complex cases involving occlusal plane discrepancy, it is essential.1
"Part of our goal as dental professionals is to be minimally invasive," says Peter Pizzi, MDT, CDT, owner of Pizzi Dental Studio in Staten Island, New York. "Everything we do is to try to save tooth structure and avoid more restorative work or larger volumes of restorative work."
Qureshi's patient who decided not to fix her narrow gummy smile returned several years later with a tooth fracture, but before even seeing it, Qureshi knew it would be an easy fix. "Anyone who does ceramic knows your stomach drops when you see ‘tooth fracture,' but in this case, I knew it would require only a tiny edge bond," he says. "She was in and out in 10 minutes."
Conversely, he says that any patient having restorative work performed on crooked teeth should be followed up, and retainers may be necessary. "I made the classic mistake 20 years ago that many cosmetic dentists make in simply veneering crooked teeth and sending patients back to their general dentists," Qureshi says. "One patient came back after 17 years with his teeth as crooked as they had first been. If you place ceramic on a patient's teeth, you must follow that patient up."
Far too often, however, cases like these are only treated with more and more invasive restorative work. "So many dentists jump right into veneers and other restorative work because that is a realm they know," says Robin Bethell, DDS, a private practitioner in Austin, Texas. "Everything looks like a nail when you only have a hammer."
A variety of factors can indicate that orthodontic treatment should be considered. Crowding is the most obvious, but other conditions include hypodontia,2 discrepancies in tooth size,2 and the need to rehabilitate anterior guidance.3
"Oftentimes, dentists or hygienists see a lot of wear on the teeth and assume the patient is grinding, so they just provide a night guard, but a functional issue is actually causing the wear during chewing," Ferris says.
When planning implant placement, the dental team should consider whether orthodontics could be used to create a more ideal space.4,5 "In many cases, a patient is missing a first molar from a young age, causing the second molar and second premolar to collapse slightly. Simply regaining the space to allow for the correct-sized crown can be easily accomplished with aligner treatment," Ferris says. "Additionally, periodontal conditions can be addressed. Often, recession can be a result of a narrow arch with the teeth being very lingually inclined, so the roots are actually out of the bone on the buccal, and the tissue has nothing to hold on to. In those cases, we can upright teeth and tuck roots within bone, which does not regrow tissue but does create a healthier environment for grafting."
Orthodontic treatment can also sometimes be used to improve airway issues. "Increasing intraoral volume through expansion can positively impact airflow," Ferris says.
Of course, orthodontics may not be best for everyone. Patient-specific factors, such as age, should be considered. So-called "instant ortho," whereby aggressive restorative treatment is utilized in place of orthodontics, might make more sense for an elderly patient.
"Minimally invasive dentistry should always be our goal, especially when the long-term survival of our restorative options is the end result we seek," Pizzi says. "Unfortunately, as people age, bone density changes, and tooth movement may become more challenging. Each case must be driven by the physical, functional, and esthetic concerns of our patients, and there are times when aggressive preparations are the proper treatment plan. I have made this case with material options before because limited reduction does drive or limit the material choices."
For an interdisciplinary team to function effectively, both knowledge and buy-in are required from each individual member, starting with the restorative dentist. Although the orthodontist can supply the expertise on how exactly to accomplish the tooth movement, the restorative dentist must possess a strong grasp of what is possible. Leaning too heavily on partners or technology can lead to a less informed treatment plan. However, being able to recognize when to rely on the expertise of certain team members is essential as well.6
"A strong foundation of orthodontic principles, biomechanics, diagnosis, and tactics is most important," Bethell says.
In addition, the old adage regarding the significance of "knowing what you don't know" is critical. "I teach basic, fundamentally anterior orthodontics," Qureshi says, "but understanding what you are not treating posteriorly or what might require a referral is important."
Qureshi, who is a strong proponent of the aligner-bleaching-bonding method, adds that every dentist should practice some degree of orthodontic-restorative work, starting with monitoring the tooth movement of everyday patients. "This early interventive treatment can stop someone from going down the pathway of heavy ceramic cases," he says. "Teeth are continually moving, so the patients who are sitting in your chair every single day are the ones you should be treating. Dentists compete so hard for new patients, but when your routine examinations include looking at the patient's anterior and posterior function, most of your larger treatments can end up being your own checkup patients."
For more complex cases, orthodontists need to understand how their work fits into the bigger picture. "Putting teeth where they look best esthetically is easy," Pizzi says. "Understanding the functional management of tooth positioning is more challenging. Our occlusal concepts and beliefs are so important for the final results."
The most important person on the interdisciplinary team, of course, is the patient. None of this is possible without the patient's consent and buy-in. The dentist must confidently explain the benefits of orthodontics as well as the risks involved in pursuing more aggressive restorative treatment than is necessary.
"Within cosmetic dentistry," Qureshi says, "dentists often ask the patient, ‘Do you want orthodontic treatment?' The patient says, ‘I understand you are offering me orthodontic treatment, and I don't want that; I want veneers.' Dentists think they have consented the patient, but they have not. What they should have said is, ‘I understand you don't want orthodontic treatment and you want veneers, but if we do that, will you wear a retainer?' What patients do not understand is that if we crown or veneer crooked teeth and do not retain those teeth, there is a significant risk of those teeth continuing to move underneath. When I put it that way, most patients quickly agree to the orthodontics."
Earning the buy-in of both patients and members of the dental team has become easier in recent years with clear aligners. Orthodontic treatment can be faster, more precise, and more patient friendly. The capabilities of clear aligners continue to expand as well.
"Traditionally, restorative dentists are sometimes hesitant to send patients to orthodontists because it could be this black hole where they do not see the patient again for 2 to 3 years. Maybe the patient comes back for the restorative treatment, and maybe not," Ferris says. "Now, aligners are part of this whole digital platform that continues to evolve. We can place patients in aligners and send them back to the restorative dentist for provisionals, and they can get the implant placed so it integrates while they are in provisionals. It is no longer just orthodontics for a certain length of time with no contact with the rest of the team."
For restorative dentists who want to keep some of the clear aligner treatment in-house, a number of options are available. Despite the availability of user-friendly software, Bethell cautions that education is necessary to begin offering aligner therapy. "Above all else, you need to respect the skeleton," he says. "Know the limitations of each case before starting it. Know where the bone is. Know where teeth can be moved safely. Know whether a case is right for you to start in-house. If you are a general practitioner who is just beginning, I would advise against trying to move molars in the sagittal plane; try to limit yourself to understanding movements from second bicuspid to second bicuspid."
Beyond the obvious financial benefits of keeping clear aligner treatment in-house, it can become easier for the practice to obtain patient acceptance. "A one-stop shop is a more efficient and better experience for the patient," Bethell says.
Conversely, for more complex treatments, developing connections with like-minded orthodontists can prove highly beneficial. Bethell says that he refers out approximately half of his cases and that orthodontists subsequently refer their own patients to him as well. "It has created some really great partnerships," he says.
Many resources are available for dental professionals who seek to further their education on orthodontic-restorative principles. The Seattle Study Club, the Kois Center, and Vizstara are just a few examples.
"From an interdisciplinary planning standpoint, there is no better resource than the Seattle Study Club," Ferris says. "The interdisciplinary approach is at the core of their clubs. The Kois Center is amazing in that regard as well."
Bethell recommends that any restorative dentist offering his or her own aligner treatment for these purposes should take fundamental orthodontics courses. He suggests the American Academy of Clear Aligners and American Orthodontic Society for online resources as well as manufacturer courses.
Qureshi offers online courses on orthodontic-restorative principles through the IAS Academy. One important component of those courses is a follow-up mentoring program. "Any dentist getting into this sort of thing should be mentored when they start working on cases," he says.
Of course, as more is learned about the various elements of oral healthcare, the concept of orthodontic-restorative dentistry continues to evolve. For example, it is now a consideration in the burgeoning field of airway management.
"Not long ago, I would look at a case and say, ‘We only need to pull the lower front teeth back slightly and intrude them to fix the functional envelope and minimally invasively restore," Pizzi says. "Now, as we understand more about airway, tongue positioning, tongue thrusting, and breathing, we cannot make assumptions about tooth position or movements without asking about breathing habits, snoring, etc. We do need to rethink the process."
Nonetheless, the process starts with a willingness among all parties to work together and embrace concepts that might be new to them. Once that occurs, the quality of treatment can be elevated. "Aligned teeth in good occlusion are the biggest indicator for lifetime oral health," Bethell says. "If you ignore occlusion and arch alignment to do ‘cosmetic dentistry,' then your dentistry is more likely to fail. With a healthy orthodontic foundation, restorative outcomes are better."
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4. Alsahhaf A, Att W. Orthodontic extrusion for pre-implant site enhancement: principles and clinical guidelines. J Prosthodont Res. 2016;60(3):145-155.
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