Nishan Dixit describes a minimally invasive case of edge alignment, whitening and bonding in which the patient was “happy and confident” after his smile was transformed.
This case highlights how the aligner, bleach and bond approach can be a simple and conservative technique to help transform a smile. The three steps work together perfectly: first aligning the teeth, then whitening, followed by complex edge bonding to complete the ortho-restorative process. Each stage complements and improves on the previous one, resulting in a minimally invasive makeover and avoiding more complicated and expensive treatment.
A 38-year-old lady attended Blue Court Dental because she was concerned about a chipped front tooth that had been damaged by a fork when she was younger (Figures 1 and 2). She was interested in aligning her teeth to address upper and lower anterior crowding (Figure 3).
In the long term, she was willing to replace some existing amalgam restorations (Figures 4 and 5). The patient was also unhappy with the color of her teeth and felt that their overall appearance prevented her from smiling.
Clinical examination and orthodontic evaluation
During an in-depth consultation, an Itero 3D intraoral scanner was used to report findings regarding the teeth and gums. Orthodontic and functional evaluation revealed that the patient had a class III skeletal pattern, high Frankfort-Maxillary plane angle (FMPA) and average lower facial height.
A class III incisor relationship and a class III molar and class III canine were also identified on both sides (Figure 6). He had an anterior crossbite, reverse overbite, and mild crowding of the upper and lower labial segments. The center lines did not coincide and her lips were symmetrical and competent.
Clinical examination also concluded that the patient had good general dental and periodontal health with no outstanding problems. He had no complaints or symptoms of temporomandibular joint (TMJ) disorder.
Treatment options and planning
Several orthodontic options were discussed, including fixed braces, clear aligners, and a referral to a specialist. The patient was interested in clear removable aligners as they would have less of an impact on her daily lifestyle.
She was shown a simulated smile on the Itero scanner, which depicts the proposed result after a course of Invisalign treatment. After confirming that she was happy with the preview of her new smile, a treatment plan was carried out with Clincheck.
The 3D animation shows the predicted results during and after Invisalign treatment, including the position of the composite brackets and the required amount of intraproximal reduction (IPR) (Figures 7 and 8). The patient elected to proceed with orthodontic alignment using Invisalign clear aligners, followed by whitening and composite edge bonding. After alignment, a welded retainer will be placed for permanent retention.
Teeth alignment and whitening
Initially, a series of 13 custom digitally designed alignments were constructed, followed by a further 11 alignments to allow refinements to be made. This was necessary due to a lack of compliance during the latter stages of the first set of discs.
The patient was told that she would have to wear each aligner for 10 days, 22 hours a day, removing them only for eating, drinking and oral hygiene. Before starting the alignment, the patient attended an appointment with a hygienist.
IPR was performed according to Invisalign digital software. Composite attachments using Venus Pearl One were temporarily placed on 11 upper teeth (UR6, UR5, UR4, UR3, UR2 and UL1, UL2, UL3, UL4, UL5, UL6) and seven lower teeth (LR1, LR3, LR4, LR5 and LL5 , LL4, LL1) (Figures 9 and 10). Attachments were placed to provide additional leverage points to aid tooth movement and increase appliance retention (Figure 11). The alignment was completed in about eight months (Figures 12 and 13). At the final orthodontic visit, upper and lower lingual stainless steel wire retainers were secured using Kulzer Venus Diamond Flow to prevent tooth recession (Figure 14).
The flowable composite has good bond strength, which helps to securely bond the lingual retainer to the teeth. The material also allows for smooth and uniform bonding of the retainer, minimizing any potential interference with the patient’s bite and creating a more aesthetic appearance.
The patient received a two- to three-week home whitening course using the Boutique system, which included 10% carbamide peroxide to be used at night on her last set of aligners. B1 was listed in the Vita shade guide after the home whitening course.
Complex restorations
Composite edge bonding was performed on UR1 two weeks after completion of tooth whitening. The waiting period allows the shade to stabilize and ensures welding efficiency, predictability and accuracy. It also helps minimize sensitivity.
The margins were beveled and the tooth was etched with 37% phosphoric acid etch gel and bonded with Kulzer Ibond Universal using a selective etching technique. Ibond is easy to apply and does not cause sensitivity.
Kulzer Venus Pearl A1 shade was my formulation of choice in this case because of its easy and convenient handling. Sculpting and contouring is simple and straightforward without any pullback. The material has excellent color matching and shines with a high gloss.
The composite was placed by hand and built gradually using a single shade (Figure 15). The UL1 was sanded with Sof-lex discs and then finished using the Kulzer Venus Supra Polishing Kit. Amalgam restorations are gradually being replaced. To date, LR5 and LR4 have been restored using Venus Pearl One (Figures 16 and 17). I find the composite to have a ‘chameleon effect’ as the shade One blends seamlessly with the surrounding dentition.
The material has good aesthetics when placed in small cavities and is easy to handle, contour and carve. The composite material also offers high strength and durability. Once fully cured, the composite restorations were finished with Sof-lex discs and the Kulzer Venus Supra Polishing Kit, which creates a long-lasting, high-gloss shine in just two working steps, with minimal material abrasion.
Secondary polishing was completed with aluminum oxide paste and a felt-coated polishing point, which gives the restorations an extremely high gloss. After the anterior repair, the patient returned a few weeks later for a review. This appointment included a hygiene visit and the weld on the UR1 was given a final polish.
Successful aesthetic result
A successful esthetic result was achieved over approximately 14 months using the minimally invasive approach of alignment, bleach and bonding (Figures 18 and 19). However, replacement of amalgam fillings is ongoing.
The patient was thrilled with the result (Figure 20) and posted a five-star review, commenting that she had the most incredible smile transformation. She was thrilled and the treatment gave her so much confidence in all aspects of life.
