Ideally, Orthodontic-Restorative cases are planned alongside from the beginning, however, in some instances the restorative dentist encounters the patient for esthetic evaluation near the end of orthodontic phase. This is a high-stakes evaluation because the decision to remove brackets implies that refinement of tooth positioning cannot occur unless the patient re-enters orthodontic treatment. One challenge in multidisciplinary treatment is accommodating effective communication between providers and employing Digital Smile Design outline tool as a visual aid can help optimizing treatment outcome. This article discusses the importance and steps utilizing digital outline tool to provide quick and effective communication on treatment progress and recommendations.
Key points
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Orthodontic-restorative multidisciplinary collaboration is a critical aspect in esthetic and functional treatment outcome.
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Ideally, orthodontic-restorative cases are planned jointly.
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Facially driven esthetic evaluation sequence is imperative for structured and organized treatment planning, and the digital outline tool is used to streamline the team’s communication, which can support orthodontic-restorative improved treatment outcome.
Introduction
Whenever orthodontic-restorative treatments are performed, it is essential to comprehensively assess the case, establish treatment objectives, and plan the sequence and execution of the interdisciplinary treatment in advance of starting any procedure. Not including all providers early in the treatment planning process can potentially increase overall treatment time, as well as be burdensome for the patient if changes need to be made unexpectedly due to lack of communication. For instance, the restorative dentist may be put in the position of restoring the dentition with compromised spacing and clearance when simple communication between providers could have prevented this concern. Alternatively, if a dentist proceeds with placing restorations before the patient initiates orthodontic treatment, the occlusion may change and merit costly restorative replacement and additional treatment.
Communication and progress follow-up are critical when seeking ideal outcome. One additional challenge in the orthodontic-restorative collaborative case management is the ability to evaluate case readiness for the completion of the orthodontic phase. Often in the final steps of the orthodontic treatment, the orthodontist will refer the patient for a restorative esthetic evaluation and verification before removing the orthodontic appliances. At this point, the restoring dentist will often be asked to determine if the position of the teeth is appropriate for completion of the orthodontic phase and initiating of the restorative phase of the treatment. This article discusses a workflow that can streamline the team’s ability to establish treatment strategies, evaluate progress, and effectively communicate course of action when needed.
Considerations for multidisciplinary team members
The multidisciplinary patient care approach has been shown to be undeniably advantageous for patients as well as providers. The ability to include a number of qualified providers with specific skill sets while developing a coordinated treatment strategy enables us a far more controlled treatment environment and ultimately improved outcome. To support the excellence of the team, members should continue to educate themselves as treatment protocols evolve as well as strive to maintain excellent communication. Likewise, it is important to share similar evidence-based treatment philosophies to support treatment decisions.
From the restorative dentist’s perspective, it is essential that the orthodontist in the team will know what the restorative possibilities are, understand material limitations and space requirements, and develop an ability to visualize proper tooth position to accept restorations once the orthodontic treatment has been completed. Just as orthodontists should have awareness of restorative concepts, restorative dentists must also have a respect and appreciation for orthodontic concepts, which includes fundamental biologic limitations of the periodontium with regard to tooth movement. Orthodontists also incorporate growth and development principles in their treatment planning, and can aid the restorative dentist in planning the timeline for definitive restorative care. Dentists must recognize how orthodontics can serve as a preparatory step before reductive restorative treatment is initiated, know fundamental orthodontic terminology, and be aware of biomechanics and other restrictions when planning a treatment.
Common orthodontic-restorative cases critical for close coordination and communication
The following is a general list of common interdisciplinary orthodontic-restorative cases encountered in our patient population.
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Spacing and space management: crowding, diastema, hypodontia and partial edentulism, and microdontia (ie, peg laterals). , ,
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Worn dentition: with or without loss of vertical dimension of occlusion (VDO).
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Position and realignment of teeth to allow more conservative tooth reduction for direct or indirect restorative treatment.
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Gingival disharmony: excessive gingival display, disharmonious levels, as well as architecture and imperfect contours. ,
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Orthodontic extrusion to create a nonsurgical ferrule to restore root canal–treated teeth with post and core.
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Correction of occlusal plane and improved envelope of function. , ,
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Reposition teeth to allow space for implant placement, implant site switching, and forced eruption to improve bone level. , ,
Purpose of digital smile design tool in orthodontic-restorative communication
Ideally, the restorative dentist should have an opportunity to conduct his or her own assessment before placement of orthodontic appliances. Having these appliances in place makes it particularly challenging to visualize teeth positions, contours, and anatomy. Moreover, the gingiva is often hypertrophic due to inflammation during orthodontic treatment, and it is a suboptimal environment to acquire an impression for proper diagnostic evaluation. These are important considerations for planning a treatment that is, designed to optimize the overall facial and smile esthetics.
The beauty of applying facially driven smile design fundamentals with basic digital smile design tools (DSD) is that they can be used in case planning before or even during orthodontic appliance therapy, and therefore minimize much of the aforementioned concerns. The outline component of this tool is perhaps the most critical in optimizing near-immediate communication between providers and patients. This tool can help dentists and patients visualize possible outcome, communicate goals, and evaluate progress and ultimate readiness related to the esthetic outcome in orthodontic-restorative cases ( Fig. 1 ).
The overall dentofacial evaluation sequence is outlined in Box 1 . More detailed evaluation is described by the macro-esthetic and micro-esthetic evaluation, which is ultimately communicated using the DSD outline tool. Macro-esthetics and micro-esthetics will be evaluated once the teeth outline has been established later in the protocol. For the purpose of this article “macro-esthetics” refers to teeth relative to the patient’s face and smile dynamics, whereas “micro-esthetics” refers to tooth shape and size, interdental and intradental proportions, as well as arrangement in the arch. ,
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Midline and horizontal lines
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Identify maxillary incisal edge position
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Establish and follow smile-line
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Proper central incisor proportion
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Interdental proportion
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Teeth outline and arrangement
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Teeth general shape
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Smile line
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Incisal arrangement (flat, gal-wing)
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Transfer outline to smile and full-face image.
Restorative dentists should assess the following macro-esthetic and micro-esthetic components to determine case progress and readiness for the restorative phase, as indicated in Boxes 2 and 3 .
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Midlines
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Smile line
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Occlusal canting
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Dentogingival interface
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Gingival display
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Gingival canting
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Gingival levels and harmony
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Gingival symmetry
- a.
- 1.
Individual tooth shape
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Individual tooth size proportion (intradental)
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Teeth proportions (interdental)
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Teeth arrangement
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Teeth axis and angulation
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Dentogingival interface
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Gingival architecture
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scalloping
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Overbite
It is important to note, however, that certain limitations exist in using the DSD outline tool. Due to the 2-dimensional system, it might prevent evaluation of teeth proclination, overjet, open bite, malocclusion, plane of occlusion, and anterior-posterior (A-P) dimension relative to tooth display. Furthermore, because of photographic limitations, we cannot rely on the digital outline alone and must also supplement with more precise measurements (ie, interbracket space distance, 3-dimensional scanning, impressions, and other measurement tools) in the assessment, particularly as the case is nearing completion of orthodontic treatment. Therefore, these detailed supplemental measurements must be evaluated before finalizing the orthodontic phase of treatment. , ,
Photographs required for digital smile design
At minimum, 5 images are required to produce a proper smile evaluation using the DSD tool, which ultimately all will serve to produce the final smile evaluation. These photographs, when sequenced as described, can be considered as layers supportive of one another to collectively develop the smile esthetic evaluation on its own as well as in harmony with the face as whole. Additional images, videos, and patient feedback, as well as clinician observation and artistry can all be valuable in augmenting the esthetic assessment. , ,
These photographs should be uploaded and imported into the dentist’s or technician’s preferred software (Keynote, PowerPoint, or comparable smile design program can be used). The images ( Box 4 ) are used as indicated in the following:
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The portrait images (smile, retracted, lips at rest) aid in facially driven smile design evaluation. These involve full-face images that serve as initial orientation. Once close-up images are assessed, we return to the portrait images in the final step.
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The smile image is used to establish facial midline, horizontal lines, and smile line, as well as to evaluate gingival display.
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The retracted portrait image allows visualization of the teeth in space without being obscured by surrounding facial soft tissue, and is used to evaluate horizontal cants.
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Lips at rest image is used to evaluate incisal display; typically, 2.0 to 4.0 mm of incisor display at rest is considered esthetically favorable , , and serves as our starting point for placing the maxillary incisal edge position.
- i.
- 2.
Close-up images of the dentition are acquired during smiling and lip retraction. The development of the smile design is performed on these images, before transferring back to the full-face portrait for final evaluation.
