Tif Qureshi the pioneer of align, bleach, bond and progressive smile design, explains how this proven technique avoids complex and expensive treatment.
Traditional cosmetic dentistry has historically focused on large, high-end cases and this, I believe, has been a very short-sighted approach. It became a niche market that only very few patients could afford, carried out by a small number of dentists, as many patients simply did not have the budget or want to take the risk.
With progressive smile design, including alignment, bleaching, and bonding, a wider range of patients can potentially be treated by a larger number of dentists at much lower risk. In my experience, patients who initially thought they wanted traditional smile design changed their minds once their teeth started to align, were whitened, and edge-bonded.
They were also happy to accept compromises, which they would not have realised were an option, if they had gone straight to a final eight- to 10-unit result.
The case outlined below shows how a patient achieved a dramatic improvement in her smile, aesthetics, and function through alignment, bleaching, and bonding, with hardly any tooth preparation. Most importantly, the patient changed her overall perception of her smile, once small changes began to occur.
I believe this kind of dentistry is achievable by any general practitioner, not just high-end cosmetic ‘gurus’ (Qureshi, 2011a; Qureshi, 2011b).
Assessment to improve smile
A 25-year-old female came to see me because she was considering ceramic veneers to improve her smile (Figures 1 and 2). She was concerned about the amount of preparation needed, so was happy to have her teeth aligned and whitened beforehand.
I explained to the patient that there were alternatives to ceramic veneers available to her, including traditional comprehensive orthodontic treatment or a range of techniques for anterior alignment only.
A full orthodontic and functional assessment diagnosis was undertaken (Figures 3-5). The patient had a skeletal classification of II, with decreased Frankfort mandibular plane angle (FPMA). The canines were half class II on the right, and half class II on the left. A class II division II incisor relationship, and molar three-quarter unit class II on both the right and left sides were also identified.
The patient had an increased overbite of 75% and an overjet of 4mm. Her upper laterals were crowded and the centre line was coincident. No abnormalities were detected with the soft tissue, and her lips were symmetrical and competent, with a high lip line. Lower face height was slightly reduced and canine guidance was positive. There was no posterior interference on the anterior slide and the patient did not have any temporomandibular joint disorder complaints or symptoms.
On examination, her teeth were retroclined and the edges were chipped. The lower teeth had slightly worn irregular lower edges, which were causing chipping on the upper teeth because of parafunction.
Treatment options and planning
After consultation and presentation of the findings, all orthodontic options were discussed with the patient, including a referral to a specialist. A comprehensive versus compromised plan was offered. This included fixed, clear and Inman Aligners. The patient declined comprehensive treatment and chose simple anterior alignment with removable appliances.
She chose the new Super Slim Inman Aligner, which uses a clear bow and is much thinner than the previous design (Figure 6). This makes the lip seal less difficult to achieve, and speech far easier as a result. The patient’s plan, at this stage, was to avoid any tooth preparation but to still have ceramic veneers.
The 3shape Orthoanalyzer was used to plan to carefully procline the upper centrals forward, while also retracting the laterals. This ensured there would be space for a wire retainer to be bonded, using composite, to the back of the anteriors, to regain the occlusal stop. The ideal curve was digitally plotted using Spacewize software. This enables the practitioner to be in control of the occlusion, eliminating the risk of flaring out and causing potential occlusal issues.
The upper teeth had exactly 1mm of crowding. Over three appointments, interproximal reduction was carried out progressively, with strips. The patient wore the Super Slim Inman Aligner for 18 hours a day. The lowers were aligned using a single Inman Aligner.
After eight weeks, simultaneous bleaching commenced. Super-sealed home trays were used with Philips Zoom! Daywhite. This whitening system contains 6% hydrogen peroxide, and the patient bleached for two 30-minute sessions a day, over a two-week period, while the Inman Aligner was out of the mouth.
Alignment was virtually complete after 10 weeks. After adjustment to the alignment and colour of her teeth, the patient could see a dramatic improvement in her smile (Figures 7-9). At this point, she decided not to have ceramic veneers. Without this opportunity to see the changes, she would have progressed to having more invasive treatment.
Strong, aesthetic restorations
After two weeks, direct composite bonding with Kulzer Venus Diamond was placed on the upper lateral incisal edges, to restore the original shape. The Opaque Light (OL) and B1 enamel shades were applied in layers. The same material was used on the palatal of the upper cuspids for a better rise (Figures 10 and 11). The composite was laid in a reverse triangle technique, which blocks out the light transmission on the join, so no preparation is needed.
I like the strength offered by Venus Diamond. I have been using the material for more than seven years and it has proved to be very fracture resistant. The composite is predictable and adapts perfectly to the colour of the surrounding teeth. It is easy to mask the join when edge bonding and lengthening teeth.
Initial polishing took place with felt-coated discs and aluminium oxide polishing paste. Two weeks later, the patient returned for a follow-up appointment and secondary polishing was completed using the simple-to-use and predictable Venus Supra Polishing Kit.
The permanent wire retainer was bonded during the same visit using Kulzer Venus Flow to prevent tooth relapse (Figure 12). Venus Flow has great handling and has been extremely reliable as a flowable composite over the last seven years.
An indirect Essix retainer was made to fit over the bonded wire and the patient was instructed to wear it only at night.
Cost-effective and attainable
Patients often choose veneers because they assume orthodontics will take a year or so to complete. In order to make an informed choice, it is essential they are made aware that anterior tooth alignment can be completed much faster, with a variety of appliances, as less movement is required.
The argument of ‘patient did not want ortho’, simply does not wash, if it is later discovered that the only orthodontic choice given was a comprehensive one, which might take up to, or over, a year to complete. It is important to offer both comprehensive and compromised options, with the patient being fully aware of the outcomes and goals.
In this case, if the patient had expected the orthodontics to take one year, she would have chosen ceramic veneers. What could have been complex ceramic treatment, carried out by few dentists and affordable only by a minority of patients, turned into a simple alignment, bleaching, and edge-bonding case.
Progressive smile design is cost effective for patients and attainable by many more dentists. All the tools are readily available to clinicians. There are various options of tooth alignment to choose from, effective whitening, and predictable, easy-to-use bonding materials, such as Venus Diamond.
The patient was delighted with her teeth. The result was just how she had imagined veneers could look (Figures 13 and 14), but involved no invasive tooth structure preparation. The treatment cost her far less financially and presented no biological risk. At the two-year review (Figures 15 and 16), the patient was still happy with her new smile and no adjustments were needed.
Qureshi T (2011a) Minimally invasive cosmetic dentistry: alignment, bleaching and bonding (ABB). Dent Update 38(9): 586-588
Qureshi T (2011b) Who needs veneers? Re-thinking the order of smile design planning. J Cosmet Dent 27(1): 86-94