An Openbite Case by Dr Mohsen Tehranian

Prior to her own treatment, the patient in this case had been accompanying her husband to his visits. He had been referred to me by a colleague for correction of moderate crowding.

At one of his appointments we managed to talk about her own teeth and we set-up an examination date. She had already investigated improving her malocclusion and was told she would possibly need maxillary surgery, fixed braces and implants.

The factors which most concerned her were how invasive these treatments would be and the length of time for all the procedures to be completed.

The main presenting problems were that she had an obvious openbite, a midline shift/drift due to the missing upper right canine and narrow arches. While there was a significant inclination to the right of the upper incisors, and crowding of the lower teeth, these factors were of less concern.

I discussed three potential treatment options with the patient:

Option 1: No treatment.

Option 2: Treatment with fixed braces. This would involve the possible extraction of UL4, correcting the midline and making space for an implant at the UR3 area. The possibility of bone grafting and healing time were also discussed.

I had consulted our in-house Orthodontist concerning this option and was told that the openbite could be reduced without surgery, but maybe not completely treated. Treatment time of approximately 18-24 months was estimated.

I also discussed the implant option for the UR3 with our Oral Surgeon. A waiting time of 6-12 months after completion of orthodontic treatment was suggested before any implant placement could take place.

This would be due to reduced bone density in the newly created space.

The patient had already ruled out the idea of fixed braces and implants even before hearing the length of time that it would take to complete, however it was important to fully investigate this option.

Option 3: Treatment with Invisalign aligners and minimal preparation veneers. Having successfully treated similar cases, I felt confident that this option would treat, or at least significantly improve the openbite.

The midline shift, the midline inclination and the missing canines were all complications that had to also be taken into consideration.

Image: the patient’s ClinCheck treatment plan

She was already aware of the processes involved with Invisalign, having observed her husband’s treatment. She was also impressed by the effects of her husband’s treatment.

This treatment option would then involve minimal preparation veneers (mostly with no preparation) for eleven maxillary teeth (first molar to first molar). This would give the arch more width, correct the tooth size discrepancy and transform the appearance of UR4 into that of a canine.

The Invisalign treatment plan included a shift of the midline with some minor distalization on the molars. The plan also involved interproximal reduction (IPR) on the UL3 to premolars, leaving a space between UR1 UL1 for the wider central incisors and leaving enough space between UR4 and UR2 to disguise UR4 as a canine.

The patient understood that in the initial stage of pre-restorative Invisalign treatment the smile may not be improved and that there may be visible spaces that were not there before.

I believe the whole Smile Design concept which is promoted around the globe, does not give enough credit to pre-treatment through orthodontics/Invisalign. I personally find Invisalign with ClinCheck 5.0 the ultimate tool in pre-restorative Smile Design treatment.

The patient ultimately chose option 3 for her treatment.

iTero Digital scan, clinical photographs and radiographs were acquired and sent for initial planning to Align Technology. In the following few days I fine-tuned the ClinCheck several times. The new 3D controls provide real time, precise control, and visualization of effects and the consequence of the movements planned on the whole dentition and occlusion.

The next stage was to discuss the ClinCheck with our dental technician, Julian Reed. I have worked with Julian over the last eight years on many no-preparation or minimal preparation veneer cases, but this case required some careful planning.

I need the approval and input of the dental technician as this significantly reduces time and errors after the orthodontic treatment. This has been made easier with ClinCheck Pro and the new ClinCheck 5.0.

The ClinCheck was shared with Julian and my idea was approved. Nowadays, I would not start a pre-restorative case with Invisalign without sharing the ClinCheck with a dental technician.

Without ClinCheck 5.0 this kind of treatment is incredibly difficult to plan. In fact before G4 and G5 innovations, I would not have even imagined touching this case. In my opinion Invisalign has proved to be the best orthodontic appliance to correct openbite.

An openbite can be a functional health related issue causing excessive wear on posterior teeth. Increased bite force on the posterior teeth due to the aligner thickness intrudes the posterior teeth. The anterior teeth with the help of optimized extrusion attachments slowly extrude to close the openbite.

Treatment plan: Total number of stages: 22 stages (10 months), bi-weekly change at the time of treatment. No auxiliaries were used to complete the treatment.

Outcome: We achieved about 90% of the planned openbite closure. The planned spaces, and alignment finished as predicted.

One benefit of the fact that the openbite did not fully close was that this reduced the amount of reduction needed for the E-max veneers, allowing me to wrap the incisal edge with minimal reduction to it.

Impressions were taken and two weeks later a waxup with two silicone preparation guides and a stone model preparation guide were presented to the patient as part of the consent process.

I want to be very clear on how much tooth reduction is needed pre-op with my patient. Allowing the patient to see the amount of approximate reduction in 3D is important. In this case the amount of proposed tooth reduction was minimal.

Image: Putty matrix and laser gingival re-contouring

Image: Final E-max Press veneers

I used the putty matrixes that Julian had pre-made to complete my veneer preparation. This helped me accurately follow the planned wax-up. The tooth reduction during preparation was very conservative. No local anaesthetic was used for the upper left teeth. By leaving as much enamel as possible I was able to reduce the risk of sensitivity complications and achieve substantial bond strength between the E-max veneers and enamel.

I also used a Diode Laser to reshape the gingival margin around the UR2 and UR4, achieving gingival symmetry, another step in the transformation of a premolar into a canine.

Impressions were taken and provisional veneers, from the wax-up were fitted.

2 weeks later the final veneers were successfully bonded.

Mohsen Tehranian is Practice Principal of Dream Smile Dental Clinic in South London. He qualified from Carol Davila Dental Institute with distinction in 1998. Since 2001, Mohsen has been working as a private associate in Boots Dental Care, The Dental clinic and Swiss Smile aiming for high-quality, minimally-invasive dentistry. He is one of few Dentists in the UK to have achieved the Diamond Award from Align Technology having completed over 2,000 Invisalign cases and was the first dentist in the UK to submit an Invisalign i7 case. Mohsen is passionate about the latest dental technology and his was also one of the first practices to use the Itero scanner for his digital impression taking. He is a clinical speaker for Invisalign.