Tif Qureshi demonstrates how the align, bleach, bond technique can achieve aesthetic success that patients seek without the need for invasive tooth preparation
This case study will look at one of many of my cases where a patient had previously wanted a porcelain veneer makeover, but as they see their smiles improve with alignment and whitening, their perceptions and desires changed dramatically.
Often the patient’s awareness of their un-aesthetic smile is built on several factors that they might not fully appreciate at the outset. It is easy to lump colour, shape, surface anatomy and alignment into one problem and assume that there is therefore one solution.
Our beliefs of the principles of smile design often short-cut the potential alternatives that are available, because many teachers in cosmetic dentistry have often told us that the ‘patients don’t really know what they want’, therefore, follow the guide, get golden proportion correct, widen buccal corridors, get the gingival heights symmetrical, get the embrasures progressive, get the line angles correct.
There is nothing wrong with any of these suggestions. Altogether they produce a beautiful smile, but in the process of deciding to use ceramic veneers to change a smile and achieve all of this rapidly, there is not any option or time for a patient to look at these improvements in stages and see if they meet their expectations.
Patients who present wanting a smile makeover because of colour, alignment, and tooth shape issues can very quickly change their minds about using veneers once their teeth align, whiten, or both. As soon as line angles start to correct and light reflections balance out and become more symmetrical, it becomes very apparent that the incisal outline becomes the main visual focus.
After alignment, this could not be simpler as it can be done with virtually no prep or local anaesthesia required. If the teeth have been whitened effectively, it is easier to match the shade too with simple composite bonding.
This patient presented with what she described as a ‘crooked smile’. She understood the concept of an eight- to 10-veneer smile makeover, so understood some of the aims of smile design. However, on studying her teeth it was clear that there might be some potential to pre-align first.
Her upper laterals were mesially rotated by about 30° and the upper left lateral was in-standing and in cross bite. Previous trauma to her upper central tooth had never been corrected for over four years. The patient had just got used to hiding her smile.
On viewing the occlusal view, the patient became aware exactly how much aggressive tooth preparation would be required to place veneers, especially on the laterals. She understood that she should have her teeth aligned first before deciding on the next step in design.
All options were considered, but because the patient wanted simplicity and the ability to whiten simultaneously, an Inman Aligner was used.
Figure 1: Pre-treatment – frontal view
Figure 2: Pre-treatment – left
Figure 3: Pre-treatment – right
Figure 4: Pre-treatment close-up – frontal view
Figure 7: Situation following alignment and bleaching but pre-bonding – left
Figure 8: Post-bonding – front
Figures 9 and 10: Post-bonding – left
Figure 12: Post-treatment close-up
Figure 13: Eight years post-treatment, top-up whitening conducted
Figure 14: The patient post-treatment
An Inman Aligner was used over the period of 10 weeks to de-rotate the laterals and to treat the cross bite. The patient was instructed to wear the Inman Aligner for 18 hours a day.
At week eight of alignment when the teeth are close to alignment, bleaching was started using 35-45 minutes a day using Philips Daywhite H2O2 gel. Simultaneous whitening is a very attractive part of aligner treatment, as it helps motivation dramatically. The patients are particularly compliant as they are used to the routine of aligner wear. Clear instructions are given and the patient uses a super sealed tray that will still grip and seal the gel even in the last phases of orthodontics.
After alignment and whitening, the case was re-examined. The patient could suddenly see that her problem was now more about edge shape. The edge shape post-alignment was actually worse because there had been differential wear as well as trauma. It was very clear to the patient that really only the incisal edges needed building. Suddenly she didn’t want veneers anymore.
Simple direct edge bonding was placed to improve the outlines and match the colour achieved by the Daywhite whitening. A retainer was fitted and after this a new whitening tray was provided to ensure the patient could perform whitening long term, which only consists of three to four days of 35-45 minutes a day using Daywhite every six months or so. We can see her results at nearly eight years on (Figure 13).
It was especially nice to retain the natural aesthetic characterisation of this patient.
Ceramic work, as beautiful as it can be, would certainly have changed her appearance more. Some may say for the better, but that was not what the patient actually wanted.
The patient told us that what we had produced with her own teeth, with effective whitening and some minimal composite was more than she had hoped for. There are natural imperfections but the route to this result was arguably far more ethical and patient centric than a result that might use multiple ceramic veneers.
It is an interesting case in that it asks the question – what is more important: aesthetic perfection at the cost of heavy tooth preparation, or minor aesthetic imperfection with real patient consent, and no invasion at all?
This kind of treatment is also far more affordable for most patients and achievable by many more dentists.
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