Why You Need to Understand Orthodontics
Minimize invasiveness and maximize effectiveness of restorative treatments
Jason Mazda
Several years ago, a dentist in the United Kingdom referred a patient to a colleague for minor orthodontic treatment prior to completing a veneer case. In addition to crooked teeth, the patient had a gummy smile and a narrow buccal corridor. 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 that other work done." The dentist fixed only some minor chipping, and the case ended up being a long-term success. More than a decade later, that case has stuck with that second dentist, Tif Qureshi, BDS. "That was so powerful," he says. "A minimally invasive approach with the aid of orthodontics can be just as esthetic, and potentially much healthier, for the patient in the long term."
That approach is not very common in the US 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 esthetic straightening of teeth than for interdisciplinary treatment of adult patients. However, even the dental laboratory that has no intention of implementing clear aligners into its own portfolio can benefit from recommending orthodontics as part of treatment plans.
"When you combine treatment modalities, you tend to have better clinical and esthetic outcomes. Both dentists and laboratories need to use all the tools in their toolkits," says Philip Kim, CEO of Paramount Dental Studio in Huntington Beach, California. "Sometimes in restorative dentistry, so many contraindications exist that the only remaining options make it impossible to satisfy either the clinician or the patient—or both. Utilizing orthodontics allows you to be more agile and causes impossible cases to become possible."
Still, so many restorative dentists do not utilize orthodontics; sometimes because they prefer not to, but often because they are unaware of the potential benefits.
"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 the treatment and maximize the long-term success of the case. For certain situations, such as complex cases involving occlusal plane discrepancy, it is essential.1
"Teeth that are in the correct placement do not need to be prepared as much," says Inside Dentistry Editor-in-Chief Robert C. Margeas, DDS, a general and cosmetic dentist in Des Moines, Iowa. "When teeth need to be prepared into orthodontic alignment, excessive amounts of tooth structure are destroyed. So orthodontic treatment not only can help the dentist be conservative, but it also can lead to stronger restorations. I use my orthodontist on a routine basis because younger patients with beautiful teeth can avoid invasive veneer preparations in so many cases. As John C. Kois, DMD, MSD, says, ‘There is no dentistry better than no dentistry.'"
Qureshi's patient who decided not to fix her gummy smile and narrow buccal corridor 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 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 up with that patient."
Far too often, however, cases like those are treated only 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."
Knowing When
A variety of circumstances could indicate that orthodontic treatment should be considered. Crowding is the most obvious, but other conditions include hypodontia,2 tooth size discrepancies,2 and rehabilitating anterior guidance.3
"Often, 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 create a more ideal space.4,5
"In many cases, when a patient is missing a first molar from a young age, it causes the second molar and second premolar to collapse slightly; simply regaining the space to allow 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."
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 or other specific situations.
"If orthodontics will not make a significant enough difference, it might not be worthwhile," Margeas says. "If a tooth is short with an altered passive eruption, crown lengthening or opening the interocclusal space posteriorly might be better options. Additionally, some teeth are ankylosed. Some patients might refuse orthodontics.
"However, if orthodontics is the best option and the patient declines, I do not start the case. I will not compromise my treatment. The patient might not want orthodontics, but that does not mean they will not accept it if I explain it correctly."
Teamwork
For an interdisciplinary team to function effectively, both knowledge and buy-in are necessary from each individual member. While the orthodontist can supply the expertise on how exactly to accomplish the tooth movement, the dental laboratory and 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, recognizing when to rely on certain team members' expertise is important as well.6
"A strong foundation of orthodontic principles, biomechanics, diagnosis, and tactics is most important," Bethell says.
Kim's laboratory does not fabricate aligners and has no intention of doing so in the future, preferring instead to focus on their core competencies, but they frequently offer input on orthodontics.
"We provide expert opinions," Kim says, "on how certain tolerances or moving teeth a precise amount will impact the restoration."
A strong relationship and line of communication is essential in having those opinions heard. Both patients and dentists themselves often must be persuaded to utilize orthodontics.
"We push back quite often, especially on larger cases when we know the teeth are not in an ideal position and the patient wants ideal restorations," Kim says. "Sometimes the challenge is convincing the patient to go through a longer treatment that might cost more money in the short term but likely will save them money in the long term. Other times, it becomes apparent that the dentist has never done an aligner case and has no desire to do one. They do not even consider it as a potential avenue. However, a strong relationship can help the laboratory make the dentist see the benefits of this option."
Even once the restorative dentist has bought in, orthodontists must understand how their work fits into the bigger picture.
"When the patient has peg laterals or missing teeth, for example, the orthodontist needs to know where the restorative team wants those teeth to be placed," Margeas says. "There might be a tooth size discrepancy, whereby the space cannot be closed because the teeth are too small. We need to tell the orthodontist, for example, if we want the tooth moved more toward the distal of No. 8, or if we want the space opened and the tooth moved more toward the mesial of No. 6. Everything depends on esthetics and the restorative plan. So orthodontists must know tooth sizes, space requirements for implants, whether roots need to be torqued, etc."
Of course, none of this is possible without the patient's consent and buy-in. The dentist must confidently explain the benefits of orthodontics—and the risks involved with more aggressive restorative treatment than is necessary.
"Within cosmetic dentistry," Qureshi says, "often the dentist asks 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.' The dentist thinks 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."
Evolving Tools
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.
"Restorative dentists traditionally 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 the patient 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 laboratories that want to fabricate clear aligners in-house, a number of options are available. Despite the availability of user-friendly software, Bethell cautions that education is necessary to begin offering aligners.
"Above all else, you need to respect the skeleton," Bethell says. "Know the limitations of each case before starting it. Know where the bone is. Know where teeth can be moved safely."
Resources
Several resources are available for dental professionals who seek to further their education on orthodontic-restorative principles. Seattle Study Club, the Kois Center, and Vizstara are a few examples.
"From an interdisciplinary planning standpoint, there is no better resource than the Seattle Study Club," Ferris says, "because the interdisciplinary approach is at the core of their clubs. The Kois Center is amazing in that regard as well."
Kim has taken courses through a manufacturer, and he says even if a laboratory does not gain a mastery of orthodontics through these courses, simply seeing what clinicians are learning can be priceless.
"Once I understand the clinician's viewpoint, I can propose certain strategies," Kim says. "Being able to talk on their level earns their respect, and once we have that, we can take a collaborative approach to treatment that benefits everyone."
Of course, as more is learned about various elements of oral healthcare, the notion of orthodontic-restorative dentistry continues to evolve. For example, the burgeoning field of airway management is now a consideration.
"Orthodontics is being used now to expand arches, along with orthognathic surgery to pull the jaw forward and make more room for the tongue," Margeas says. "If you restore a patient without taking airway into consideration, you may have solved their esthetic issue but either neglected or worsened their sleep issue."
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."
References
1. Ferris A, Alexander M, Bienstock M. Optimizing the Occlusal Plane Prior to Restoration. Inside Dentistry. 2020;16(11):28-35.
2. Gahan MJ, Lewis BRK, Moore D, Hodge TM. The orthodontic-restorative interface: 1. Patient assessment. Dent Update. 2010;37(2):74-80.
3. Faus-Matoses V, Faus-Matoses I, Jorques-Zafrilla A, Faus-Llacer VJ. Orthodontics and veneers to restore the anterior guidance. A minimally invasive approach. J Clin Exp Dent. 2017;9(11):e1375-e1378.
4. Alsahhaf Abdulaziz. Orthodontic extrusion for pre-implant site enhancement: Principles and clinical guidelines. J Prosthodont Res.2016;60(3):145-55.
5. Celenza F. Implant interactions with orthodontics. J Evid Based Dent Pract.2012;12(3 Suppl):192-201.
6. Preston K. A Communication Guide for Orthodontic-Restorative Collaborations: An Orthodontic Perspective on the Importance of Working in a Team. Dent Clin North Am. 2020;64(4):709-718.
