Minimally Invasive Cosmetic
Dentistry: Alignment, Bleaching
and Bonding (ABB)
Abstract: This article will outline how combining existing techniques in a new and unique manner can potentially redefine the traditional
approach to smile design planning and execution. Alignment, tooth whitening and edge bonding with new highly polishable nano-
hybrid composites can make cosmetic dentistry far simpler and less invasive. Patients’ perceptions of their end smile result can change
dramatically if they are allowed to see their teeth improve gradually.
Clinical Relevance: This technique will highlight a choice of pathways available in cosmetic dentistry making it much less invasive for the
patient and less risky for dentists.
Dent Update 2011; 38: 586–592
The United Kingdom has seen a large Gingival aesthetics increases as the dentition progresses away
increase in the demand and provision of from the midline;5
Gingival aesthetics particularly
cosmetic dentistry over the last 10 years. Symmetrically reducing contact points
relates to gum health. Unhealthy and
Smile Design Principles from the incisors to the canines often
inflamed gums may be generally considered
have provided a format for dentists and following a 50–40–30 rule6 of tooth length in
unaesthetic. Too much gum display is also
orthodontists to create what has been proportion to contact point length;
sometimes considered unaesthetic, even if
widely accepted as an aesthetic target to Harmonious but gently medial tipping of
the gums are healthy and pink.
achieve in the treatments of their patients. the axial inclinations of the anterior teeth;7
Smile design theory can be Width of the buccal corridor. It is generally
broken down into four components:1 Microaesthetics considered more aesthetic for the teeth
Facial aesthetics; behind the canines to be visible in a wide
Microaesthetics relates to specific
Gingival aesthetics; smile.8
anatomical details that characterize teeth,
Microaesthetics; and These elements have traditionally
such as surface contour and texture, incisal
Macroaesthetics. been important when assessing patients
translucency, halo effect.
requesting cosmetic dentistry. Many patients
currently experiencing cosmetic dentistry
Facial aesthetics may be shown their teeth improving with
Facial aesthetics forms the frame Macroaesthetics imaging software or through wax mock-ups.
of the smile with the lips and surrounding The macroaesthetic requirements While these tools can be useful for conveying
soft tissues, which vary from patient to for smile design theory may be considered the possibilities, there is also an argument
patient and can change depending on to encapsulate several requirements to that they set up an ‘ideal image’ in a patient’s
various positions of speech and when achieve what is arguably a correct aesthetic mind to the point where alternative options
smiling or laughing. smile. are not fully considered or previewed. As a
These include: result, many patients requesting cosmetic
Position and direction of the facial midline dentistry often ended up with multiple veneer
related to the central incisor teeth;2–4 preparations.
Tif Qureshi, BDS, President Elect of the Incisal embrasures, which are the pattern However, with ABB the
British Academy of Cosmetic Dentistry, of edges of the maxillary teeth against the progressive nature of the treatment allows
General Practitioner, Dental Elegance, darker background. The size and volume the patients to visualize the appearance of
Sidcup, Kent DA15 8PT, UK. of the incisal embrasures between teeth their teeth improving and see their own teeth
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looking more attractive. They can then decide
at any point whether they are satisfied.
While textbook, full-mouth,
non-compromise orthodontics should
always be offered, practically speaking,
patients may be put off by the time, cost
and perceived discomfort involved and
instead choose veneers. Combined ABB,
while sometimes being a compromise on the
Figure 2. Before smile view.
ideal, could potentially offer patients who
were considering irreversible, potentially
destructive dentistry a real practical
alternative. Figure 1. Before full facial
The case described will highlight
also made aware of the need for permanent
Case example retention and the potential for relapse if this
The patient, a 27-year-old female, was not maintained.
requested an improved smile. Her main
complaint was that her front teeth were
protruded and she had a large diastema. Patient selection criteria
Figure 3. Side profile view.
She complained that she couldn’t smile with Case selection for the Inman
confidence. She was considering veneers to Aligner is critical. Only certain types of
perform an instant smile make-over and had movement are possible and some patients
attended another practice where a digital will still need conventional orthodontic
simulation of her corrected smile had been treatment or indirect restorations.
given. She was considering heavy tooth Certain criteria were met before
preparations just to achieve this proposed her treatment was carried out:
result. Her case should require movement of
On examination, several incisor and/or canine teeth only;
aesthetic problems existed. Her front teeth Root formation of the teeth to be moved
were protruding but occlusal space existed was complete; Figure 4. Close front view.
to retract these and this would close the Crowding or spacing was to be 3 mm.
diastema. The teeth were also clearly Arch evaluation would be performed to
different lengths meaning that, even when determine the amount of space required
the teeth retracted, they would still have an (see next section);
irregular outline. The teeth were also shade The patient’s posterior teeth were well
A2–A3 (Figures 1–4). positioned to facilitate retentive clasps,
All options were presented in with a reasonably well-aligned arch form
detail. The patient was shown side and to facilitate the path of insertion of the
occlusal photographs of her teeth and it was appliance;
clear that a large amount of tooth structure She had good periodontal health. Cases
would need to be removed if veneers were should be stable or preferably free from
to be used without orthodontics. The patient periodontal disease;
had previously seen a specialist orthodontist Compliance: The patient agreed to wear
and considered fixed and clear braces but the aligner for about 20 hours a day and to
refused both options, based on the lack of be responsible for good appliance and oral
removability of fixed and the time quoted for hygiene; Figure 5. An Inman Aligner.
clear aligners. Compliance: The patient accepted the
The patient wanted a removable need for some measured inter-proximal
solution and something that would work reduction (IPR) to be carried out if necessary. performed before any aligner case is
quickly. She understood that the Inman attempted. This is to ensure that the case is
Aligner (Figure 5) could only treat the suitable and, if not, what additional space
anterior region. She was made aware that Model evaluation/arch analysis creation techniques will be needed to allow
a small space mesial to her upper right with Spacewize the Inman Aligner to work. The amount of
premolar would not close totally. She was Arch analysis should be crowding or spacing present is calculated9
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incisal contacts, with a small amount of IPR
needed to upright the teeth. The Inman
Aligner was made on this model. Anterior
and canine guidance would be protected
and potentially improved.
On the first appointment, the
Aligner was fitted and the patient shown
how to insert and remove it. Instructions for
use and oral hygiene were given. The patient Figure 7. Before retracted view.
was asked to wear the aligner for 18–20
hours a day, removing the Aligner every few
Figure 6. Spacewize™ result.
hours to eat. As intermittent forces are less
likely to cause root resorption, it is important
for patients to remove their braces for a few
hours a day.10–12 The palatal component of
by measuring the sum of the mesial-distal
the Inman Aligner was removed at this stage
widths of the teeth to be moved. This
to improve comfort and to ease speech.
distance is called the ‘Required Space’ or
It would be needed later but currently,
‘The Teeth’. If canines and incisors are to be Figure 8. Inman Aligner in position.
because the main movement was retraction,
moved, this distance will be measured from
it could be removed. Two composite anchors
the distal surface of one canine to the distal
were placed on the upper central incisors
surface of the other.
about 4 mm from the gingival margins.
Using a jeweller’s chain or a
These were placed to ensure the labial bow
polishing strip, the ideal arch form is then
stayed in the incisal third to ensure good
measured from the distal of each canine
and letting it align with the most ideal
The patient returned 3 weeks
arch form after orthodontics. Critically, the
later and movement was already evident.
curve needs to run through the suggested
The Aligner was checked to ensure that
position of the contact points and not Figure 9. Inman Aligner after 10 weeks.
the bow was still tensioned and seating
the incisal edges. This is described as the
‘Available Space’ or ‘The Curve’.
The patient returned again after
Now it is possible to perform
another 3 weeks and the contacts were
this task more quickly and accurately with than 0.1 mm per contact was carried out
starting to close. The palatal bow of the
software such as Spacewize™. Just one over six contacts.
Aligner was re-inserted to help control the
simple occlusal photograph is required, Studies by El-Mangoury et al13
final movement. Approximately 0.1 mm
taken at the chairside. and Radlanski14 have shown that there is no
per contact of IPR was carried out from the
One tooth needs to be increased risk of caries after IPR provided
mesial of the upper left canine to the mesial
measured for calibration. A curve can be surfaces are smoothed correctly.
of the upper right canine at this stage to
set up digitally and this is normally easier Studies by Heins et al15 and Tal16
allow a little more retraction. This was carried
when observing the patient’s aesthetic have shown that there is no increased risk of
out using a 0.1 mm Vision-flex diamond strip.
requirements and occlusion directly; a periodontal disease despite the decreased
result for the amount of crowding can be interproximal space. Indeed, they showed it
produced immediately (Figure 6). Simultaneous whitening to be beneficial to periodontal health.
It was clear from this digital The patient returned after a Three weeks later the patient
calculation that, even with the large amount further 2 weeks. Her teeth were found to be returned. Her teeth had moved fully to the
of space present, some inter-proximal aligning well and the midline diastema was position determined by the Inman Aligner.
reduction (IPR) would need to be carried out closing. At this point impressions were taken Her teeth had also whitened from A2/A3
once the spaces closed and a good incisal for home whitening. Instructions were given to B1 shade. At this point she commented
position was achieved and close-fitting sealed trays were provided that she felt her teeth were more aesthetic
to the patient. She would whiten her teeth and that she was very pleased with the
with Day White ACP™ (7.5% hydrogen outcome. The only problem now was the
Treatment peroxide) (supplied by Discus Dental, Philips irregular incisal edge outline. This outline
Impressions were taken and the Oral Healthcare, Guildford) for 35 minutes a was due to differential toothwear which
Aligner was constructed on a Kesling model day during times when the Inman Aligner may become more apparent when teeth
set up in wax according to the Spacewize™ was out. A small amount of IPR was carried reach alignment. This was confirmed by
prescription. It was clear that there was out with hand strips on the tight contacts measuring the lengths of the teeth. Rather
space to retract the teeth and regain anterior from the mesial of canine to canine. No more than resort to porcelain veneers, it was clear
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Figure 12. Venus Diamond dentine OL and B1
Figure 10. Close view after retraction. Figure 11. Preps-roughened edges. placed.
Figure 13. Venus Diamond incisal clear enamel. Figure 14. Basic polish. Figure 15. High polish.
that simple incisal edge bonding could application of Incisal CL clear was layered over
improve the outline and final aesthetics. the facial surface and incisal edge to build and
Flowable composite was used to mock up enhance the outer aesthetic layer. This was
a potential outline for the patient and she repeated on each tooth from canine to canine.
was pleased with the set up. The patient was The initial contouring was carried
then provided with a clear Essix retainer to out with a medium then fine roughness
maintain the position and to wear full time soflex disc. A rubber Pogo stick from Dentsply
(Figures 7–9). (Weybridge, UK) was then used, polishing Figure 16. Before occlusal view.
vertically to hide the join. Enamelise diamond
polishing paste and Flexibuff discs were then
Incisal edge bonding
used to heighten the polish. A high level of
One week later the patient
chameleon-like blending is possible with
returned for edge bonding on the front six
materials such as this. Large bevels are not
teeth. No local anaesthesia was required. No
required as much as with previous materials
bevels were cut. A nano-hybrid material was
because of the better opacity of the dentine
chosen for strength in thin sections and ease
of colour blending. Venus Diamond (Heraeus
The occlusion was checked, then
Kulzer, Newbury, Berks, UK) was chosen for Figure 17. After ABB-retainer in place (12 weeks).
lateral and canine guidance checked to ensure
positive deflection, but also to ensure that the
The front six teeth were dried,
guidance was not too steep (Figures 10–15).
the teeth lightly roughened to improve bond
strength and the incisal thirds were etched correct seating.
with phosphoric acid. Optibond FL (Kerr, Retention In the mouth the teeth were
Peterborough, Cambs) was used as a bonding At this point an impression was isolated and the palatal surfaces of the teeth
agent. The composite was built incrementally taken for a permanent wire retainer to be roughened slightly using a diamond bur
to replace and enhance the short-incisal edge fitted in a week. The previous Essix retainer to ensure the composite used to bond the
outline to a more aesthetic position. This can was cut back so that the incisal edges poked retainer was exposed to subsurface enamel.21
be made easier by ordering a wax-up and through to allow fit and temporary stability. The teeth were etched with phosphoric acid
creating a silicone stent that is placed in the The patient was instructed to continue for 15 seconds, washed, Optibond Solo was
mouth so that the composite can be built into wearing the retainer full time. used as the bonding resin, cured, then the jig
it to make placement easier. One week later a retainer was was reseated and flowable composite used to
This case was carried out free fitted.17–20 This was made using a technique bond the wire on each tooth from canine to
hand. Shade OL dentine was used initially to where a multistrand stainless steel wire is canine. The jig was cut free from the wire, the
replace the missing dentine layer. Shade B1 pre-bent by a technician on the finished occlusion was checked and residual resin was
was used to build the core outline, then a thin model. An acrylic jig is then made to allow removed using interdental brushes and the
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imaging at a previous consultation, desired
a result that classically fitted into traditional
smile design rules.
Because of the speed and
removability of the Inman Aligner, she
was prepared to have this done first. As
her treatment progressed, her perceptions
changed dramatically. She started to
appreciate her own smile improving and
those rules became less important (Figures
Figure 18. Side smile view before. Figure 19. Side smile view after ABB. 18–24).
The concept of progressive smile
design vs computer imaging carried out in a
single first consultation can create a dramatic
contrast in pathways of potential treatment.
A more minimally invasive
outcome is possible if alignment and
whitening techniques are carried out before
Figure 20. Before smile view. Figure 21. After alignment, whitening. any tooth preparation is even considered,
because patients’ own perceptions of what
they find aesthetic and what suits them can
change if they are allowed to see their teeth
transform progressively. Now that new nano-
hybrid composite materials are available,
edge bonding has become simpler and more
predictable to place for a natural aesthetic
Figure 22. After incisal edge bonding. Figure 23. Profile view after ABB at 12 weeks. Acknowledgements
The author thanks Donal Inman
CDT Inman Orthodontic Laboratory, Coral
Springs Florida and Nimrodental Ortho Lab,
the flexibility of the archwire allows for
physiological tooth movement and reduces
the risk of bond fracture through occlusal References
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CAn FISSURe SeAlAnTS DelIveR A chemistry and dental material science especially for your patient. The curing
‘DoUble-whAMMy’? involved, but concludes that the sealants ability of three curing lights was tested on
In situ evaluation of the remineralizing containing ACP and/or fluoride were a 2mm thick sample of composite resin.
capacity of pit and fissure sealants able to promote in situ remineralization Full polymerization was achieved if the tip
containing amorphous calcium phosphate of artificially induced carious lesions of the most powerful light was held 15mm
and/or fluoride. Silva KG, Pedrini D, Delbem on smooth enamel surfaces. This in situ from the material, whereas the weakest
ACB, Ferriera L and Cannon M. Acta Odont methodology was able to distinguish the light had to be only 6mm away. If the light
Scand 2010; 68: 11–18. effect of fluoride and calcium-phosphate is held at a greater distance than these
releasing materials using different analyses then full depth curing – that is at the top
Fissure sealants are a powerful weapon in and may be applied in tests of new and the bottom of the restoration - may
prevention programmes, but some people formulations of dental materials. not occur.
still express concern on the possibility An interesting paper, from both The resultant restoration may
of inadvertently sealing over an active a dental material science and a clinical therefore depend on three factors. First,
carious lesion. [Clinically the technique of dentistry perspective. the output of the curing light, which varies
the preventive resin restoration, whereby with different models and which should be
a suspicious fissure was investigated IS TheRe A lIGhT MeTeR In yoUR tested regularly using an appropriate light
with a bur before applying the sealant, PRACTICe? meter. Second, the distance the curing tip
has now been termed the destructive Curing efficiency of three different curing is held from the surface of the restoration,
resin restoration and has largely been lights at different distances for a hybrid ensuring that the distance remains
abandoned in teaching centres.] This composite. Zhu S and Platt JA. Am J Dent constant throughout the procedure.
paper reports early work with a new form 2009; 22: 381–386. Thirdly, although this is not mentioned in
of fissure sealant that contains amorphous this research paper, is the training given to
calcium phosphate (ACP). Three different Research papers, especially those reporting the dental nurse responsible for holding
commercial sealants containing a mixture a laboratory based study, often appear the curing light. This paper may be a useful
of ACP and fluoride were tested to boring and irrelevant to the busy general reference during a staff training session, to
compare the remineralization of artificially practitioner faced with a pile of journals show how apparently esoteric academic
induced carious lesions in ten volunteer to read after a busy day in practice. The research is actually very relevant to
patients who wore acrylic palatal devices American Journal of Dentistry always everyday clinical practice. Evidence based
for the five days of the double-blind includes a paragraph entitled ‘Clinical dentistry in a different form?
experiment. Significance’ and for this particular piece Peter Carrotte
The paper describes the of research it really is quite significant, Glasgow
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