kulzer.com Minimally invasive, natural smile makeover delights patient Dr 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 8-10 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’ (1,2). 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 22 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 to 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 per cent and an overjet of 4 mm. 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 1 mm of crowding. Over three appointments, inter-proximal reduction (IPR) 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™. Dramatic improvement After eight weeks simultaneous bleaching commenced. Super-sealed home trays were used with Philips Zoom! Daywhite. This whitening system contains six per cent 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 to 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