N L Y A L S O N F E S SI O O R T A L P N E D PUBLISHED IN DUBAI www.dental-tribune.me September-October 2021 | No. 5, Vol. 11 Align Technology introduces ﬁrst professional whitening system Align Technology introduces ﬁrst professional whitening system optimized for invisalign aligners and vivera retainers powered by ultradent’s opalescence tooth whitening systems By Align Technology, DUBAI, UAE: Align Technology, a leading global medical device com- pany that designs, manufactures, and sells the Invisalign system of clear aligners, iTero intraoral scan- ners, and exocad CAD/CAM software for digital orthodontics and restora- tive dentistry, today announced an exclusive supply and distribution agreement with Ultradent Products, a leading developer and manufac- turer of high-tech dental materials, devices, and instruments worldwide. As part of the multi-year agreement, Align will offer Invisalign trained doctors an exclusive professional whitening system with the leading Opalescence PF whitening formula from Ultradent, optimized for use with Invisalign clear aligners and Vi- vera retainers. The system will carry the co-branded name of Invisalign AD Virtual/Hybrid Streamed Worldwide Dental Conference 05-26 NOV 2021 CAPP November Dental L I V E S T R E A M 2 0 2 1 Free Registration for all Conferences 16th CAD/CAM & Digital Dentistry Conference 11-14 Nov 2021 Dental Hygienist Seminar 26 Nov 2021 13th Dental Facial Cosmetic Conference 18-21 Nov 2021 Digital Orthodontics Symposium 26 Nov 2021 Dental Technician Int’l Meeting 05 Nov 2021 Dental Hybrid/Online Courses 05-26 Nov 2021 Tel. /WhatsApp: +971 50 279 3711 | Email: firstname.lastname@example.org www.cappmea.com Professional Whitening System – powered by Opalescence and will offer the same great whitening out- comes and streamlined practice ex- perience dental professionals expect from the Opalescence PF product during active tooth movement with Invisalign aligners, as well as during passive retention using Vivera re- tainers. The Invisalign Professional Whitening System will be commer- cially available globally in 2022. “A brighter, whiter smile is an im- portant part of the Invisalign pa- tient journey. In fact, a survey of North American Invisalign practices1 shows that half of their patients ask for teeth whitening during or after they complete Invisalign treatment,” said Raj Pudipeddi, Align Technology chief product and marketing ofﬁcer, and SVP and managing director of the Asia Paciﬁc Region. “We believe that by providing an all-in-one solu- tion that combines a leading teeth- whitening system with the most advanced clear aligner system in the world, we enable Invisalign trained doctors to enhance their patients’ treatment experience with a seam- less workﬂow that also enables prac- tice efﬁciency and growth. We’re very excited to partner with Ultradent to offer the ﬁrst professional whiten- ing system optimised for use with Invisalign clear aligners and Vivera retainers. Invisalign system trained doctors can use Opalescence PF for in-ofﬁce teeth whitening treatment and for doctor supervised at-home whitening.” “We’re honoured to partner with Align to make the top professional teeth whitening products avail- able to more clinicians and patients around the world,” said Ultradent President and CEO Dirk Jeffs. “Pro- viding Align with teeth whitening products, ideal for use with Invis- align aligners and Vivera retainers, is a considerable step toward our mis- sion of improving oral health glob- ally and we look forward to pursuing this mission together.” “Many of my patients would like whiter teeth as well as a straighter smile,” said Dr. Brian Amy, an ortho- dontist and Align Faculty member practicing in Oklahoma City. “The new Invisalign Professional Whit- ening System allows me to provide both simultaneously using the brands I trust.” “After testing this system in my prac- tice, I can conﬁrm that the Invisalign Professional Whitening System is easy to administer and offers a great patient experience by combining whitening with Invisalign aligners or Vivera retainers,” said Dr. Jennifer Bell, a restorative and cosmetic den- tist and Align GP Advisory Board Member practicing in Holly Springs, North Carolina. “The simple order- ing mechanism minimizes burden on my practice to store and manage whitening products, while providing the brighter, whiter smiles we have come to expect from the Opales- cence PF product.” Ultradent is an ISO13485 certiﬁed fa- cility and will manufacture the prod- ucts according to those standards. References 1. 2017 online survey of Invisalign doctors, data on ﬁle at Align Technol- ogy.
D2 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 5/2021 Post-orthodontic restorative approach for young patients with missing anterior teeth No-preparation and ultra-conservative techniques By Dr Didier Dietschi, Switzerland Introduction Congenital aplasia or the early loss of permanent teeth after trauma may be corrected by means of orthodon- tic or implant treatment. The proper diagnosis of dental and skeletal con- ditions normally guides the choice between the treatment options.1,2 The need for long-term mainte- nance of prosthetic restorations and their potentially negative inﬂuence on periodontal health3 have always been considered main shortcomings favouring an orthodontic solution.4,5 However, different anatomical, functional and aesthetic anomalies may result from the orthodontic approach. The increasing desire of our patients for aesthetics obliges restorative dentists to consider these deﬁciencies and to propose appro- priate solutions. Well-known treat- ment modalities such as whitening and composite resin bonding have gained popularity as they have im- proved in practicability, efﬁciency and predictability.6–8 Table 1: Decision parameters for the treatment of pa- tients with missing anterior teeth. The aim of the present paper is to review and outline the interest of direct restorative modalities aimed at correcting anatomical, functional and aesthetic anomalies after ortho- dontic treatment in patients with missing anterior teeth. The use of such a therapeutic means in com- prehensive treatment planning will be discussed. Treatment decision rationale There are different decision levels for the treatment of young patients with missing anterior teeth (Table 1). Each of them should be carefully weighed during treatment planning, as both orthodontic and prosthodontic treat- ment options are in principle irrevers- ible. Essentials of orthodontic treat- ment strategy Initial skeletal conditions as well as inter-arch and intra-arch dental relationships will determine the op- portunity for orthodontic space clo- sure. In the absence of evidence of malocclusion requiring mandibular tooth extractions, Class I occlusion cases usually favour treatment of the edentulous section/s by space maintenance or opening, followed by prosthetic replacement of the missing tooth/teeth. Conversely, the presence of Class III malocclusion contra-indicates orthodontic space closure of missing maxillary ante- rior teeth. Maxillary anterior spaces should be closed orthodontically in Class I extraction cases (severe crowd- ing) or in some Class II cases where al- veolar and skeletal growth potential preclude an orthodontic correction of the Class II relationship. It should be stressed that, in any clinical situa- tion, a trial diagnostic set-up is man- datory for anticipating the inﬂuence of orthodontic treatment on occlusal, periodontal and dental conditions. Figures 1a to c depicts the most com- mon clinical problems and their possible restorative solutions, after orthodontic space closure. Space maintenance or opening Depending on the occlusal condi- tions and particularly on the pa- tient’s age at the time of treatment planning, the alternative option to orthodontic space closure is space maintenance or opening, followed by prosthetic replacement of the missing teeth. The three major treat- ment options for anterior tooth re- placement are implant-supported crowns (Figs. 2a–d), metal-based or all-ceramic adhesive bridges and re- movable dentures, which are mostly considered for provisionalisation, especially in young patients when deﬁnitive treatment has to be post- poned. Because implants will not follow alveolar bone growth, ﬁxture placement should not be used in young patients until full jaw growth has been attained, from 18 to 25 years of age and even later.9,10 Ultra-conservative restorative pro- cedures after space closure The anatomical and aesthetic anom- alies that result from spontaneous space closure or orthodontic proce- dures may be corrected by choosing the appropriate restorative modali- ties, often involving a multidiscipli- nary approach (Figs. 3 & 4).2 Recontouring Recontouring or odontoplasty may be performed during or after ortho- dontic treatment. For instance, when ÿPage D3 Fig. 1a: Missing or impacted canines. The best option is space mainte- nance or opening with implant-supported restorations. During surgery, proper soft-tissue anatomy will need to be reestablished. Fig. 1b: Missing lateral incisor. Space closure is a frequent treatment op- tion and results in the following anatomical and aesthetic discrepancies: excessive canine coronal and cervical diameters (blue arrow), a deﬁcient canine incisal proﬁle (circle), an apically displaced gingival zenith (red arrow) and a premolar that is too short, both cervically and incisally (red and brown arrows). Fig. 1c: Missing central incisor. Space closure is less frequently chosen. If it is, it will result in the following anatomical and aesthetic discrepancies: a lateral incisor that is too narrow and short, both cervically and incisally (red, blue and brown arrows), ﬂat mesial and distal papillae around the lateral incisor (circles), and a canine and premolar with the same deﬁ- ciencies as described for the space closure for a missing lateral. Fig. 2a: A 21-year-old patient completed orthodontic space opening after extraction of impacted canines. Fig. 2b: Intra-op views showing extreme bone defects extending all the way to the palate, which necessitated extensive guided bone regenera- tion. Implants were placed in a second phase (stepped approach). Fig. 2c: Zirconia abutments in place. Fig. 2d: Post-op view showing good gingival and anatomical integration. Space opening and implant-supported restorations are nowadays the most appropriate therapeutic option. Fig. 3a: A 17-year-old patient with congenitally missing lateral incisors completed orthodontic space closure. The canines had a very unusual sharp appearance. The optimal smile line and gingival proﬁle were su- perimposed on the photograph to demonstrate the various anatomical and aesthetic deﬁciencies, such as described in Figure 1b. Fig. 3b: Aesthetic analysis was done on the computer and served as proper communication with the patient and for the detailed treatment planning. Fig. 3c: In-ofﬁce whitening was performed to unify tooth colour; this treatment modality was chosen in this case owing to the limited colour correction needed. Figs. 3d & e: Post-op views after full smile enhancement using freehand direct bonding following the natural layering concept (inspiro, Edelweiss DR). Central incisors were restored mainly with a single layer of achromatic enamel. Note that the gingival proﬁle correction shown in Figure 3a was not performed owing to the young age of the patient and limited gingival display (low lip line).
Dental Tribune Middle East & Africa Edition | 5/2021 ORTHO TRIBUNE D3 ◊Page D2 Fig. 4a: A 16-year-old patient completed orthodontic space closure after the traumatic loss of the maxillary right lateral and maxillary central incisors. Apart from the numerous aesthetic and anatomical discrepan- cies, gingival hyperplasia required some correction before initiating the restorative corrections. Fig. 4b: Postsurgical view after gingivectomy and a slight reduction of the cervical diameter of both canines. Fig. 4c: Try-in of the mock-up enabled selection of the right anterior tooth length and display. Fig. 4d: Intra-op view showing the application of the body shade (den- tine) and the incisal build-up of the incisors with enamel, using an index replicating the mock-up conﬁguration (inspiro Body i2 and Skin White, Edelweiss DR). Figs. 4e & f: Post-op views showing the signiﬁcant improvement of the tooth anatomy and anterior inter-arch relationship, although such a treatment approach implies intrinsically some compromises related to tooth diameter, proportions and gingival proﬁle. AD canines have to be moved into the positions of the lateral incisors, there is usually a space discrepancy. In this situation, the careful reduction of canine diameter and palatal volume will improve the inter-arch relation- ship as well as reconstructive proce- dures (Figs. 4a & b). The ratio of the root diameter to the crown diameter will dictate the amount of tissue that can be removed interproximally, provided that corrections can be made entirely in enamel to avoid dentine exposition or root proxim- ity. Whitening A problem of tooth colour often aris- es when the canines are in a more mesial position. These teeth present with a more saturated colour (nor- mally, a similar hue but a higher chroma) compared with that of inci- sors (Figs. 3a & c). After the required odontoplasty has been performed, colour correction should be tried, using one of the available whitening techniques for vital teeth, namely chairside whitening or home whit- ening.6–8 Direct composite bonding Modern composite resin kits pro- vide very performant restorative materials. Besides the dramatic im- provements made in their physico- chemical properties, modern com- posites have satisfactory colour stability and aesthetic potential.11–13 Among the various layering op- tions, the which became the refer- ence in reliability and simplicity is the natural layering concept, which corresponds to a bilaminar, ana- tomical application of dentine- and enamel- like shades which closely emulate natural hard tissue. When forms or dimensions have to be only slightly modiﬁed, a mono- laminar approach can be followed, using an enamel shade (achromatic) exclusively (Figs. 3a & d). For larger corrections, the bilaminar approach with dentine and enamel masses is to be applied (Figs. 3d & 4d–f; e.g. inspiro, Edelweiss DR). Gingival and periodontal recon- touring In many circumstances, gingival recontouring is indicated to correct minor defects of soft-tissue con- tours or to modify the clinical crown length. This can be achieved using electrosurgery, laser or traditional surgery (Fig. 4b), provided the pro- cedures respect the biological width and do not result in an excessive loss of keratinised gingiva. Conclusion The two basic therapeutic approach- es for the replacement of anterior teeth in young patients are space clo- sure or maintenance, which require orthodontic or prosthodontic pro- cedures, respectively, to be applied. To satisfy new demands regarding tissue conservation, function and aesthetics, treatment decision pa- rameters have to be redeﬁned. An extended list of general, local and secondary parameters have now to be taken into consideration to pro- pose the best available solution to the patient. The most common problems after teeth have been orthodontically transposed are unusual function, shape, dimension and colour or de- ﬁcient periodontal integration while with prosthetically replaced miss- ing teeth, long-term maintenance will be critical, including implant- supported restorations. This article has also presented clinical outcomes demonstrating the beneﬁts and pos- itive impact of direct composite ap- plication to improve aesthetics and function after orthodontic space closure. Editorial note: This article was ﬁrst published in the September 2016 issue of the Italian Journal of Dental Medi- cine, and an edited version is provided here with permission from “il dentista moderno”. References 1. Meng HP, Ingervall B, Hess D, Marmy O, Buser D. Kieferorthopädie: Nichtanlagen. Die Behandlungs-pla- nung von Malokklusionen mit par- tieller Anodontie [Orthodontics: the absence of tooth primordium: treat- ment planning of malocclusions with partial anodontia]. Schweiz Monatss- chr Zahnmed. 1990;100(2):188–204. French, German. 2. Dietschi D, Schatz JP. Current re- storative modalities for young pa- tients with missing anterior teeth. Quintessence Int. 1997 Apr;28(4):231– 40. 3. Rohner F, Cimasoni G, Vuagnat P. Longitudinal radiographical study on the rate of alveolar bone loss in patients of a dental school. J Clin Peri- odontol. 1983 Nov;10(6):643–51. doi: 10.1111/j.1600-051x.1983. tb01302.x. 4. Tuverson DL. Orthodontic treat- ment using canines in place of miss- ing maxillary lateral incisors. Am J Orthod. 1970 Aug;58(2):109–27. doi: 10.1016/0002- 9416(70)90065-5. 5. Nordquist GG, McNeill RW. Ortho- dontic vs. restorative treatment of the congenitally absent lateral in- cisor—long term periodontal and occlusal evaluation. J Periodontol. 1975 Mar;46(3):139-43. doi: 10.1902/ jop.19126.96.36.199. 6. Hasson H, Ismail AI, Neiva G. Home-based chemically- induced JL, Neukam in adults. whitening of teeth Cochrane Database Syst Rev. 2006 Oct 18;(4):CD006202. doi: 10.1002/14651858.CD006202. 7. Heintze SD, Rousson V, Hickel R. Clinical effectiveness of direct ante- rior restorations—a meta-analysis. Dent Mater. 2015 May;31(5):481–95. doi: 10.1016/j. dental.2015.01.015. 8. Haywood VB, Heymann HO. Nightguard vital bleaching. Quintes- sence Int. 1989 Mar;20(3):173–6. 9. Balshi TJ. Osseointegration and orthodontics: modern treatment for congenitally missing teeth. Int J Periodontics Restorative Dent. 1993 Dec;13(6): 494–505. 10. Berten FW, Wichmann M, Schliephake H. Fachübergreifende Behandlungsp- lanung zur Implantatversorgung während der Adoleszenz bei Hypo- dontie oder vorzeitigem Zahnver- lust. Implantologie. 1994;4:301–16. 11. Ardu S, Braut V, Gutemberg D, Krejci I, Dietschi D, Feilzer AJ. A long- term laboratory test on staining sus- ceptibility of aesthetic composite resin materials. Quintessence Int. 2010 Sep;41(8):695–702. 12. Dietschi D. Optimizing smile com- position and aesthetics with resin composites and other conservative aesthetic procedures. Eur J Esthet Dent. 2008 Spring;3(1):14–29. 13. Villarroel M, Fahl N, De Sousa AM, De Oliveira OB Jr. Direct esthetic res- torations based on translucency and opacity of composite resins. J Esthet Restor Dent. 2011 Apr;23(2):73–87. doi: 10.1111/j.1708-8240.2010.00392.x. About the author Dr Didier Dietschi Dr Dietschhi is a senior lecturer in the Division of Cariology and Endodontology of the section of dental medicine at the University of Geneva in Switzerland and an adjunct professor in the Department of Comprehensive Care at Case Western Reserve University School of Dental Medi- cine in Cleveland in the US. He also runs a private education centre in Switzerland and is in private practice at the Geneva Smile Center.