The art of Detailing - How minimal can "Minimaly Invasive" be.
By Dr. Amir Horowitz
1. Why did I choose this specific case?
The combination of “complexity, though simplicity” is the reason this case was chosen. The challenge was to overcome a wide spectrum of substantial esthetic problems, at the tooth level, gingiva level and their mutual interface, using minimally invasive procedures, or perhaps a non-invasive treatment.
2. In what parameters did it challenge my skills and specialization?
The most challenging aspect of this case was the interface between the gingival line and the teeth, mainly closing the huge black triangle between the central incisors by enabling the central papilla to slowly crawl along the mesial walls of the central incisors.
3. In retrospection on the case, what would I have done differently today?
The treatment would have been executed in the exactly the same way if confronted today, especially due to the fact that the patient was only 17 years old when treated and therefore future treatment options are enabled without limitations.
Fig. 1. A young 17-year-old lady presented to the clinic, referred by the orthodontist for esthetical consultation, with the aim of obviating orthodontic treatment if possible, due to the fact that she had a fairly stable and aesthetic occlusion with very focused problem of distal crown tipping of the upper central incisors with an unaesthetic diastema between them.
Fig. 2. Close up look at the front occlusion of the patient.
Orthodontic deliberations were:
a. Pronounced frenum with very thin interdental bone renders orthodontic movements risky
b. Fairly good occlusion
c. Need for permanent retention due to high frequencies of relapse
d. Long treatment with high anchorage demands
Fig. 3. Prosthodontic and esthetic considerations were:
a. Mesially tilted central and lateral incisors
b. Central papilla is missing with big black triangle between the 2 central incisors
c. Asymmetry between right and left central incisors
d. Short canines
e. Decalcification defect on the buccal aspect of tooth #21
f. Uneven gingival line
g. Pronounced frenum
h. Thin alveolar bone
Fig. 4. Mesially titled upper central and lateral incisors, on both the right and the left side towards the midline, creating a “black triangle" in the aesthetic zone.
Fig. 5. Panoramic view of the tilted central incisors. Note that the overall occlusion is fairly good.
Fig. 6. A very pronounced and aggressive frenum. The literature found strong correlation between a clinically abnormal frenum and a midline diastema
Fig. 7. Close-up look at the midline frenum and the big black triangle between the central incisors. In order to efficiently remove the frenum, an incision must be made across the base of the frenum at its attachment. The dissection must be carried down to the periostium. The wound edges must be undermined. Relaxing incisions must be made and, ultimately, the wound must be sutured. This surgery was planned close to the completion of the treatment.
Fig. 8. The treatment plan was to first bleach all teeth; then, perform non-invasive intervention with composite resin restoration, without any tooth preparation at all, and, finally, a frenectomy.
Fig. 9. Frontal view of the non-invasive direct composite restoration, before polishing and finishing. The reason this technique is considered a “non”-invasive intervention and not minimal intervention, is that there is no tooth preparation at all, except for sandblasting and etching.
Why was Sandblasting performed in this case?
a. Intraoral sandblasting prior to etching can significantly (p < 0.001) increase the adhesive strength between enamel and bonding material.
b. Intraoral sandblasting could significantly enhance the shear bond strength between enamel and composite resin
c. Surface treatment significantly affected the composite-composite bond (p > 0.05). Air abrasion, regardless of curing atmosphere, resulted in the strongest bond (p < 0.05).”
Fig. 10. Frontal view of the composite restorations.
Why composite resin?
a. Only with composites can we achieve a real non-invasive treatment.
b. Composite restoration is the first choice of 95% of the author’s patients. “I would not like my teeth to be prepared or ground.”
c. With composites we can achieve very good aesthetic results.
d. Composites can be fixed fast and easily in case of damage.
e. It is a durable and reliable treatment modality as long as the clinician has a comprehensive understanding of the material.
f. It can be maintained and renewed over the years.
g. It enables completion of the restoration in a single visit.
h. There are no lab fees and no provisional.
i. There is no interaction with technicians.
Fig. 11. Lateral view of the composite restoration: the composite used in this case was
3M ESPE FILTEK ULTIMATE (3M ESPE AG, ESPE Platz, 82229 Seefeld, Germany), and A1 E, and W E were the colors used.
3M ESPE FILTEK ULTIMATE is a nano-composite whose characteristics are:
1. Contains nano-particles of 5 – 75 nm
2. Has low shrinkage average of 2.09 %
3. It offers the polish of a microfill with the strength of a hybrid composite
4. It offers shades of dentine, body, enamel and transluscent
5. Nano-technology makes the product lighter, stronger and more precise.
Fig. 12. Right lateral view. This specific case was performed free-handedly without the aid of wax-up, silicon key and a mock-up.
Fig. 13a . Left lateral view 2 weeks after completion of the restorations. Usually, it is highly recommended to be assisted by the dental technician in planning such a case and use wax-up, silicon key and mock-up.
Fig 13b. A different demonstrates the use of wax-up as prepared by the technician in the laboratory. A mock-up in the patient's mouth using the silicon key helps the dentist to meet the expectations of both patient and doctor.
Fig. 13c. Final restorations are carried out using the silicon key as a guide.
Fig 14. Six months after completion of the composites, a frenectomy was performed.
5 months later the beginning of closure of the "black triangle" can be seen, by the growth of the interdental papilla.
Fig. 15. 15 months after the completion of the composites and 9 months after the frenectomy, full closure of the black triangle was achieved with a perfect scalloping and even gingival line.
Fig. 16. The photo depicts the straightened crowns that were mesially tilted at the beginning of treatment.
Fig. 17. Close-up view of the frenum area 9 months after the frenectomy.
Fig. 18a. The NTI device is an anterior bite stop, which is indicated for the prevention and treatment of clenching, bruxism and temporomandibular disorders (TMDs), tension-type headaches and migraine. NTI is justified when a reduction of jaw closer muscle activity (e.g., jaw clenching or tooth grinding) is desired. It has a strong and lasting inhibiting effect on EMG activity in masseter muscles during sleep.
NTI stands for Nociceptive Trigeminal Inhibition.
Fig. 18b. Incisors edge contact allows for 30% of maximum clenching forces.
Canine contact (true long axis) allows for 70% of maximum clenching forces.
Molars contact allows for 100% of maximum clenching forces. In order for the jaw clenching and teeth grinding to achieve pathologic intensity, the molars and/or the canines must be touching each other, or another object (like a traditional night guard).
The NTI device eliminates all contact on posterior teeth. It transfers the occlusal forces to the two lower central incisors, which are in effect the weakest teeth.
Figs. 19a-b. Close-up look at the patient's smile 4.5 years post op. The case is stable, renders a highly aesthetic result in all parameters, with no need for long and risky orthodontic treatment and, most importantly, is non-invasive and reversible.
Fig. 20. Frontal view of the occlusion 4.5 years post op. During these years, the restorations underwent only 3 polishing and finishing sessions.
Fig. 21. Patient's smile. Note the preservation of the aesthetic guidelines in shape and color. In its entirety, treatment duration was of 6 hours only in comparison with the alternative of orthodontic treatment which definitely would have taken more than a year with the risk of root resorption and future relapse and consequently the need for permanent retention.
Simplicity is the ultimate complexity. The concept of non-invasive, or minimally invasive, dentistry grows in popularity year after year.