E2 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Improving the facial balance in an adult using slow arch development techniques Fig. 2: The Homeoblock appliance. By Dr Derek Mahony, Australia, & Dr Theodore R. Belfor, USA Introduction Anti-ageing is a branch of medicine focused on how to prevent, slow or reverse the effects of ageing, thus helping people to live longer and healthier lives. Recently, however, more evidence-based medicine has led to anti- ageing becoming a multi- billion-dollar industry. In the past few decades, the market for anti-age- ing products and services has grown into a global industry valued at an estimated US$261.9 billion in 2013, up from US$162 billion just ﬁve years before, according to BCC Research, a publisher of technology market re- search reports based in Wellesley in the US.1 The recent medical literature and evidence-based medicine show that, as we age, there seems to be a loss of fat volume in some areas of the face, as well as a change in the mor- phology of the facial skeleton. Facial soft-tissue augmentation by injec- tion has become increasingly popu- lar as a minimally invasive option for patients seeking cosmetic facial enhancement. Replacing lost soft- tissue volume allowed for a more comprehensive approach to total fa- cial rejuvenation. It has been demon- strated that orthodontic treatment with an intra-oral orthopaedic den- tal appliance (Homeoblock, Ortho- Smile) increases soft-tissue volume and enhances facial symmetry, pro- ducing soft-tissue changes consist- ent with improved facial esthetics.2 Fig. 3: The pretreatment face, the post-treatment face at six months and nine months, and ﬁnally, a morphometric evaluation of the change. This appliance can be added to the treatment protocol of facial injection to create a relatively non-invasive in- terdisciplinary approach to midface enhancement. With this article, we show how or- thopaedic/orthodontic appliance therapy, in conjunction with the placement of dermal ﬁllers for the reduction of lines/wrinkles and de- pressions in the face, can produce desirable facial soft-tissue enhance- ment. Furthermore, we show that the volumetric changes achieved by this combined treatment approach can produce a desirable result, name- ly a more youthful appearance. Case study A healthy woman in her mid-sixties presented for treat- ment with a strong desire to improve her facial appearance (Fig. 1). Her oral hygiene was good and there was no active periodontal disease. She had head- ache symptoms and clinical exami- nation showed a disc displacement with reduction on her right side, with a maximum jaw opening of 38 mm. Her centre line was displaced 2 mm to the right and lined up when she opened < 10 mm, indicating that she had a mandibular displacement to the same side. A Homeoblock ap- pliance, with a 5 mm bite block on the right side (to decompress her temporomandibular joint), was fab- ricated and delivered (Fig. 2). When she closed on the bite block, her oc- clusion freed up and the muscles realigned the mandible so that her centre line lined up correctly. Her headache symptoms were relieved in three weeks and her maximum opening was improved to 42 mm. The patient continued Homeoblock treatment for nine months. Intra-oral and extra-oral photo- graphs were taken to monitor treat- ment, and 3-D stereophotogramme- try was performed. Extra-oral 3-D digital photographs were taken with a facial capture system (3dMD). A fa- cial capture system (3dMD/Kodak) and stereophotogrammetry were used to generate a clinically accurate digital model of the patient’s facial surface. It uses a technique of stereo- triangulation to identify external surface features viewed from at least two cameras. This approach incor- porates the projection of a unique, random light pattern that is used as the foundation for triangulating the geometry in 3-D. The capture takes < 2 ms per frame. The data is processed and a highly precise < 0.5 mm root mean square of the distance meas- ured is calculated, creating a digital model of the patient that is ready for immediate clinical use. Stereo- photogrammetry for quantifying facial morphology was introduced in a study published in the Journal of Dentistry in 1996.3 It was concluded that “stereophotogrammetry is a suitable 3-D registration method for quantifying and detecting develop- ment changes in facial morphol- ogy”.3 Evaluating the patient’s face over the nine months of Homeoblock treat- ment for her temporomandibular dysfunction showed a change in the morphology of the face (Fig. 3). Mor- phometric analysis was performed by superimposing before and after 3-D images and using ﬁnite element modelling. Thousands of triangu- lar reference points were used to establish the change. The blue area indicated no change and the red to orange areas showed an increased di- mension of up to 2.9 mm. We saw an increased volume above and under the eyes, the zygomatic region, the upper lip, and the marionette and pre-jowl areas. From the facial pho- tographs, we could see a reduction in the lines, wrinkles and depressions (Figs. 4 & 5). After nine months, the patient’s fa- cial changes prompted her to go for- ward with injections of dermal ﬁll- ers. She was given 1 ml of Restylane (Galderma) for lip enhancement and two 1.3 cc corrections with Radiesse (Merz Aesthetics) in the pre-jowl and marionette areas and along the inferior border of the mandible, and the inferior and lateral borders of the zygoma (Fig. 6). Results Post-treatment, the patient’s face appeared more youthful with better deﬁned cheekbones and a ﬁrmer jaw line. The skin appeared smoother with fewer lines, wrinkles and de- pressions (Figs. 7a & b). Fig. 1 Pretreatment facial and anterior intra-oral photographs (note deep dental overbite). with an increase in structural com- plexity, in association with biological processes.”4 Palatal expansion pre- sumably, switches on osteoblastic genes associated with active boney deposition and concomitant remod- eling of the spatial matrix ensues.”4 In relation to the changes around the eyes, we must recall that the max- illa forms the ﬂoor of the orbit and skeletal changes may become ap- parent after expansion;4 speciﬁcally, changes in orbital morphology may be reﬂected on the skin of the face: as the lower eyelids become tighter, the lateral canthus becomes more horizontal; facial width increases, particularly at the zygomatico-max- illary sutures; and the craniofacial form, putatively, not only functions better, but looks more attractive.4 These changes have been docu- mented in children, where palatal expansion is an everyday occur- rence. The current article documents similar changes in a non-growing adult. Combining the results of pala- tal expansion and the placement of dermal ﬁllers, we obtained a very satisfactory improvement in facial aesthetics. Editorial note: A list of references can be obtained from the publisher. This article was originally published in ortho international magazine of orthodontics, Issue 2/2018. Discussion Facial changes related to palatal ex- pansion are clearly outlined in Sin- gh: “The maxillary complex shows a change in size (and/or mass) allied Dr Derek Mahony is a Specialist Orthodontist. He can be contacted at derek.mahony@fullfaceorthodontics. com.au Fig. 4: Morphometric evaluation of the ﬁnal results: ﬁnite element analysis showed increased facial volume with a directional change of almost 4 mm, indicated by the red to orange colour. Fig. 5: Superimposing the red post-treat- ment face over the blue pretreatment face, we can graphically illustrate the volumetric changes that occurred during our treatment. There was an increase in volume in the frontal, supraorbital, infe- rior orbital, zygomatic, nasal base, upper lip, nasolabial depression, and marionette and pre-jowl areas. Fig. 6: Morphological facial changes in the lips, zygoma and jowl area after the placement of 1 ml Restylane and 1.3 cc Radiesse. Note the deeper red to orange colour in the areas where the injections were placed. Figs. 7a & b: Before and after facial photographs.
Dental Tribune Middle East & Africa Edition | 2/2019 ORTHO TRIBUNE E3 Indirect bonding: Digital technique vs conventional method By Drs Arturo Fortini, Alvise Cabur- lotto, Elisabetta Carli, Giulia Fortini & Francesca Scilla Smith, Italy One of the peculiar features of straight-wire techniques is the in-built tip, torque and in-out ad- justments in the brackets, which reduces the need for making ﬁrst-, second- and third-order bends on the arch. It follows that the pre- cision in the positioning of the brackets is of fundamental impor- tance for making the correct ad- justments and for the consequent predictability of the result, thus making bonding one of the most important steps of the whole treat- ment. With direct bonding, there is a high margin of error in bracket positioning, due both to the den- tal professional’s experience and to difﬁculty with visualisation. The positioning errors that can be made are on the horizontal, verti- cal and mesiodistal axes, and can create the need to reposition the brackets during orthodontic treat- ment, resulting in a waste of time. Over the years, indirect position- ing techniques have been devel- oped to make positioning more precise and to make the procedure as fast as possible. The aim of this study was to compare a new, digi- tally assisted method of indirect bonding (Transfer Bite Leone) with the conventional clear two-tray technique, using the split-mouth method to evaluate the amount of remaining composite around the base of the bracket in both proce- dures. In order to avoid differences due to placement, we used the same dedicated programme for both methods. STL ﬁles, obtained from intra-oral arch scanning or stone model scanning, were loaded and processed with the Leone Maestro 3D Ortho Studio software (AGE So- lutions). This digital tool permits the segmentation and width and height measurement of the teeth, and the subsequent determination of the long axis and the average height of the clinical crowns, in or- der to virtually arrange the brack- ets in the correct position. The dentist can later change the posi- tioning height, the torque, the tip and the rotation to obtain an abso- lutely individualised and strategic positioning of the brackets for the case (Fig. 1). Once the ideal position of the brackets had been obtained, we used the Maestro 3D software to obtain a ﬁle that allowed the 3-D printing of the model in which, in the left hemi-arch, the brackets were integrated to be able to use it to produce the conventional thermoformed clear trays that would contain the brackets to be placed in the mouth. In the right hemi-arch, using the software, we designed a Transfer Bite that per- mitted precise positioning of the brackets. The Transfer Bite is made of biocompatible material and is produced using a high-precision 3-D printer according to speciﬁc parameters. Our split-mouth clinical investiga- tion protocol was accepted by the American Association of Ortho- dontists committee for the table clinics that we presented at the 2017 annual congress in San Diego in the US (Fig. 2). This procedure Fig. 1: Dental studio-Ortho Studio Module. clearly demonstrated the limita- tions of the conventional two-tray technique: inconsistent accuracy, an excess of composite around the base of the bracket that cannot be removed during the bonding step, and difﬁculty in removing the thermo-printed support (Figs. 3 & 4). The Transfer Bite system with po- sitioning devices was found to be better because it allows the clini- cian to have a complete view of the base of the brackets, optimising the removal of excess composite (Fig. 5). In addition, the Transfer Bite, compared with the thermo- formed trays, has greater stability on the dental arches, with an even better precision result, and aids the dentist in repositioning the brack- ets in a detachment case. Our experience of using the Trans- fer Bite system on 12 patients al- lows us to conﬁrm that this new indirect bonding method is sim- pler, easier and more accurate than the conventional method. Further- more, it proved to be a less opera- tor-dependent technique, allowing even less-experienced clinicians to achieve optimal results. Editorial note: This article was originally published in ortho international magazine of orthodontics, Issue 1/2018. Dr Arturo Fortini is a specialist in orthodontics and in pri- vate practice in Florence in Italy. He can be contacted at email@example.com. Dr Elisabetta Carli is a specialist in orthodontics and in pri- vate practice in Fivizzano in Italy. Dr Alvise Caburlotto is a specialist in orthodontics and in pri- vate practice in Venice in Italy. Dr Giulia Fortini is a specialist in orthodontics and in pri- vate practice in Florence. Dr Francesca Scilla Smith is a specialist in orthodontics at Nova Southeastern University, College of Den- tal Medicine, in Fort Lauderdale in the US. Fig. 2: Indirect bonding though Leone’s JIG and brackets. Figs. 3 & 4: Limitations of the conventional method, such as non-constant accuracy and excess of composite around the base of the attachment. Fig. 5: Leone’s Transfer Bite system. AD What is the ClearSmile Aligner? ClearSmile Aligner employs a series of plastic appliances, called aligners, to gently reposition and align the teeth creating a beautiful new smile. A L I G N E R Made in Dubai supervised by orthodontists in UK www.clearsmilealigner.com www.iasortho.com www.mdentlab.com Tel : 04-332901 Whatsapp +971 557590217 firstname.lastname@example.org
E4 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Happy patient with durable, natural outcome Andy Wallace describes a case that successfully combines ﬁxed orthodontics and bleaching with the strength of composite edge-bonding restorations By Dr Andy Wallace, UK A 49-year-old female attended Bachelors Walk Dental because she was unhappy with the appearance of her upper and lower front teeth (Figures 1a and 1b). She wanted them straightened to create a more attrac- tive smile and was hoping to have removable orthodontic appliances. I explained to the patient that with- out treatment, the malalignment might worsen but there were a range of options she could consider. ‘Instant orthodontics’ could be ac- complished with veneers but this method would require heavy prepa- ration, which could result in signiﬁ- cant damage to the tooth structure and possible loss of vitality. Veneers placed after invasive preparation would probably have a lifespan of less than ten years. She was also ad- vised that her teeth could continue to crowd, even after veneers were ﬁtted. Therefore, retainers might still be required. Orthodontic choices The Inman Aligner, clear aligners or ﬁxed appliances were the options offered to the patient. The Inman Aligner would be a quick and inex- pensive way to correct the incisors, but would have limited success with the canines and gum levels. Clear aligners could potentially re- sult in a similar outcome to ﬁxed braces. They are discrete, but have a longer treatment time and are more expensive. Fixed appliances offered the most potential for improving the aesthet- ics, and could be used to achieve the most controllable and predictable outcome. A full orthodontic and diagnostic assessment was undertaken. The patient had a skeletal I classiﬁcation, with moderate upper and lower in- Figs 1a and 1b: The patient was unhappy with the appearance of her upper and lower front teeth Figs 2a and 2b: The patient had a skeletal I classiﬁcation, with moderate upper and lower incisor crowding Figs 3a and 3b: The patient opted for ﬁxed braces, using clear brackets Fig 4: After alignment, additional composite bonding would be required Fig 5: A colour change from A1 to BL4 shade was recorded cisor crowding (Figures 2a and 2b). She wanted the ﬁnal outcome to be as successful and efﬁcient as possi- ble, so opted for ﬁxed braces using clear brackets (Figures 3a and 3b). The patient was made aware that inter- proximal reduction (IPR) was needed to avoid excessive proclination of the incisors. the ﬁxed retainer wires were bonded. To ensure correct positioning during cementation, the retainer wires were fabricated by the laboratory on an acrylic placement jig. Before bond- ing, I checked the passive ﬁt of the retainer and jig. I assessed where the wire was going to sit, then removed both the wire and jig. Permanent ﬁxed and removable re- tainers were also required after treat- ment, as her teeth would continue to move throughout her lifetime. Effective alignment It was clear that the wear on the teeth would result in an irregular incisal edge, once the teeth had aligned. The patient was informed that after alignment, additional composite bonding would be required (Figure 4), using the align, bleach and bond (ABB) protocol, pioneered by Tif Qureshi (Qureshi, 2011). The relative positions of the teeth, lips and face were recorded using Spacewize, the diagnostic dental crowding software developed by In- telligent Alignment Systems (IAS). This calculates the space require- ments and serves as a prescription to the laboratory for the Archwize digital preview. Monocrystalline sapphire brackets were pre-positioned and transferred into indirect bonding trays, ready to be bonded intraorally. The brack- ets were placed in the ideal position outside the mouth to save time and reduce the possibility of any errors during the bonding process. The teeth were isolated and the brackets attached, following standard resin cementation protocols. A series of nickel titanium wires were used, ranging from .012 to .016 to 20 x 20, as the arches aligned. The pa- tient was seen for review at monthly intervals. The teeth were shaped pro- gressively with IPR strips to create the necessary space. IPR of 1.4 mm was carried out on the upper arch and 1.6 mm on the lower arch. Alignment was completed after sev- en months and the patient approved the end result. Whitening and retention Following bracket removal, impres- sions were taken to allow tempo- rary vacuum-formed retainers and bleaching trays to be manufactured. Chairside whitening was completed with Philips Zoom 6% hydrogen per- oxide gel and the Philips Whitespeed lamp. A colour-change from A1 to BL4 shade was recorded (Figure 5). In order to enhance the chairside result, the patient was provided with home- whitening trays and Philips Zoom Daywhite 6% hydrogen peroxide, take-home whitening treatment to use for one week. At the three-week review, the ﬁnal shade was recorded as BL3/BL4, and The back of the teeth were ‘tickled’ with a bur to roughen and remove some of the outer layer of enamel, which cannot be etched well. At this stage, I sometimes sandblast with aluminium oxide to remove any bioﬁlm and the highly-ﬂuoridated surface layer of enamel. This reduces surface tension, allowing a better etch pattern. The teeth were etched with 37% phosphoric acid etch gel and bonded using Kulzer Ibond Uni- versal. Ibond was used because of its simple bonding protocol. The wires and jig were put back in the mouth and a thin layer of Kulzer Ve- nus Diamond Flow was placed, just deep enough to cover the wire. The composite was light -cured, as per the manufacturer’s instructions. The jig was cut off and more Dia- mond Flow was applied to the rough edges of the wire, followed by further curing. Venus Diamond Flow offers ideal viscosity, making it perfect for the placement of indirect ﬁxed-wire retainers (Figures 6a and 6b). Composite aesthetics and strength The edge-bonding was completed using Kulzer Venus Pearl (Figures 7a and 7b) during the same appoint- ment. The shade was selected from the Venus Pearl shade guide and judged to be between Bleach Light (BL) and Bleach Extra Light (BXL). Tooth preparation using a diamond bur included the removal of unsup- ported enamel and minimal rough- ening beyond the enamel composite interface. Venus Pearl Opaque Light Chromatic (OLC) shade was placed in a triangular section, following the ‘reverse triangle technique’, as described by Tif Qureshi (Qureshi, 2016). The BL enamel shade, with small BXL highlights, was placed in a sin- gle layer. This technique offers an aesthetically pleasing outcome by helping to address irregularities and incisal edge wear, as well as minimis- ing chair time and increasing the strength of the restoration. Both ap- plying a single layer of the opaque dentine shades and the chosen shade of the enamel composite reduces the risk of introducing errors or bubbles. I have been using Kulzer Venus com- posites for a number of years. Venus Pearl lends itself very well to the re- verse triangle technique. The enamel shades are sufﬁciently opaque to ÿPage E6
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E6 ◊Page E4 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Figs 6a and 6b: Venus Diamond Flow offers ideal viscosity, making it perfect for the placement of indirect ﬁxed-wire retainers Figs 7a and 7b: The edge-bonding was completed using Kulzer Venus Pearl Fig 8: At the three-year recall appointment, only the very slightest loss of shine can be seen Fig 9: The patient was so pleased with the ﬁnal result, she has since recommended several new patients to the practice mask the joins when edge bonding and lengthening teeth. They blend well to the natural enamel and adapt perfectly to the colour of the sur- rounding dentition. Durable result Polishing was completed using the Kulzer Venus Supra Polishing kit. Its extensive silicone range is ﬁlled with microﬁne diamond powder. The pink pre-polishers are effective for removing scratches and creating secondary anatomy, while the grey ones give a great, long-lasting ﬁnish. A ﬁnal lustre was achieved using alu- minium oxide paste on a felt wheel. New vacuum-formed retainers and bleaching trays were fabricated for the new shape of the teeth. They would help to retain the treatment outcome and maintain teeth whit- ening. I recommended three to four days of top-up bleaching, using Philips Zoom Daywhite, three times per year. At the three-month follow-up ap- pointment, I found that the upper retainer wire had debonded. The patient was instructed to wear the re- movable retainer full-time while the laboratory made a new wire. The patient attended the surgery the following week and the new retainer wire was bonded in place. New vac- uum-formed retainers were fabri- cated after approximately two years. The patient continues to be seen every six months for her examina- tion and review. We were both delighted with the ABB treatment outcome. The compos- ite provided a long-lasting, natural restoration. At the three-year recall appointment, the edge-bonding had no chips or appreciable wear. No fur- ther polishing had been undertaken since the original treatment and only the very slightest loss of shine can be seen (Figure 8). At the next appoint- ment, I plan to spend a few minutes re-polishing. The patient has maintained the whit- ening beautifully, using the ‘three by three’ protocol - three days whiten- ing, three times per year. The patient was so pleased with the ﬁnal result, she has since recom- mended several new patients to the practice (Figure 9). Most have pro- ceeded with similar minimally-inva- sive treatment. Offering alignment, bleaching and bonding is a very ef- fective way of attracting new clients. References Qureshi T (2011) Who needs veneers? Re-thinking the order of smile design planning. J Cosmet Dent 27(1): 86-94 Qureshi T (2016) Technique Tips – Composite Edge Bonding – the Re- verse Triangle Technique. Dent Up- date 43 (1): 95-97 Editorial note: The article was origi- nally published in Dentistry Issue February 2019 Dr Andy Wallace BDS (QUB) MClinDent Prosthodontics (KCL) MFGDP (RCS Eng) Dentist at Bachelors Walk Dental, & Vice President of the ESAO Andrew is a general dentist with special interest in Prosthodontics and Orthodon- tics and accepts referrals for full mouth rehabilitation, treatment of tooth wear, cosmetic dentistry and endodontics. AD Final Programme Ihssan Hamadeh, Syria Round Table Presentation: Gradia Plus: Aesthetics and Functionality Vincent Fehmer, Switzerland Round Table Presentation: Advances in Digital Dentistry – for your daily practice Elie El Khoueiry, Lebanon Round Table Presentation: Perspectives of CAD/CAM Technology Germen Versteeg, The Netherlands Round Table Presentation: Digital Denture Design with 3shape in Combination with 3D Printing on the Nextdent 5100 Axel Dittrich, Germany Round Table Presentation: How many types of zirconia do I need? Frederick Romer, Germany Round Table Presentation: How many types of zirconia do I need? Stanislav Shishkov, Bulgaria Round Table Presentation: How to Prepare Printed Metal for Porcelain 12 April 2019 Madinat Jumeirah Conference Centre | Dubai | UAE Round Table Trainings TABLE 1 TABLE 2 TABLE 3 TABLE 4 TABLE 5 TABLE 6 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 Session A: 10:00 - 11:30 Session B: 11:30 - 13:00 Session C: 14:00 - 15:30 Session D: 15:30 - 17:00 Session E: 17:00 - 18:30 www.cappmea.com/dtim-2019 Tel: +97143476747 | Mob: +971502793711 | E-mail: email@example.com
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