Instant Ortho Made Easy
The Irreversible Mockup!

By Tom Orent, DMD

Would you like to significantly increase the number of terrific cosmetic cases you're currently performing? Become the local expert on "instant orthodontics." It is the hottest esthetic "quick fix" we offer today. A large number of new cosmetic patients to my practice, the Center for Esthetic Dentistry, are looking for that non-orthodontic quick fix. Done well, the results are spectacular. Patients, dental team members and doctor alike enjoy a highly rewarding sense of satisfaction from the "wow" factor from seeing these cases completed - often in just two visits.

Although there are many facets to consider in this technique, there are two that will significantly contribute to consistently successful dramatic results.

Preoperative Wax-up

If there are enough crooked, overlapped, malaligned teeth that you are uncertain exactly where you're heading, invest the time and effort to complete a preoperative wax-up. If you have the skills, time and interest, doing it yourself will aid in your planning of the final preparations. In effect, you will have completed the case, once pre-op, as a "dry run." Otherwise, simply send study models to your lab, and request that they perform the wax-up for you. Advise them that you are attempting to achieve the most ideal arch form possible. The same goes for golden proportion ratios. One bit of information they will need from you (something they can't determine on the lab bench) is the desired incisal edge position and length. Since this requires the ability to compare the soft-tissue with the existing dentition, you will need to help them here.

If, for example, the teeth are crowded, which are more representative of the desired arch placement? Should they try to align with those that are currently more lingually placed, or with those slightly labial to the others? This is to be determined partially from the room afforded by the existing occlusion, and partially by the effect of the arch form on the patient's lips. Involve the patient, as well. Ask them how they feel about the way the lip rests on their teeth. If the lip appears to be stressed labially, attempting to align the new arch form with those teeth further lingually positioned may be helpful. Assuming of course that the occlusion allow for this correction.

The lab will also need to know where, in relation to the existing incisal edge line, you would like them to place the waxed version. This is determined by the relationship of the incisal edges with the resting upper lip line. Have the patient speak a few words, and then relax, with their lips slightly parted, in a comfortable resting position. Young adults should show a minimum of 2 to 2.5 millimeters of incisal edges past the resting upper lip. Older adults ideally reveal 1.5 to 2. Let your lab know where they are at now, and what changes in length (if any) you'd like to see. There is no way for your lab to anticipate where to place the incisal edges without your guidance. With this information plus a good set of study models and mounting, your lab should be able to render an excellent diagnostic waxup of the anticipated final result. Full-face photos would also be of great value to the lab at this point. A silicone putty registration (followed by a PVS wash reline) of the waxup works as an incredible form from which to make the final temporaries right in the mouth. A number of new materials are great for the task: Integrity, Luxatemp, and Turbotemp (Danville Materials).

The Pre-Operative (Irreversible) Mockup

This is not the mockup we use during case presentation. This is the "Real McCoy" and is irreversible. The reason this is so different is that you are not only adding composite, but you are removing tooth structure as well. So if this isn't done to help "sell" the case, what's the purpose?

There are three reasons I routinely perform a pre-operative mockup on difficult "instant ortho" cases.

1. To ensure proper tooth reduction.
   
   Armed with the knowledge of the required reduction for the material we've chosen, preparation is usually straightforward; that is, if the teeth are in perfect arch form and alignment. However, given the labial/lingual discrepancies and incisal-edge repositioning typical of these cases, preparation is anything but straightforward.
   

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   In fact, if you were to go about your preparation using depth cutting burs, and reduce the typical amounts required for porcelain fabrication…you'd unwittingly replicate the problem with which they presented!

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   Using your waxup as a guide, first reduce all areas outside of the desired final result. Important note: we are attempting to achieve a mockup of the desired result here. Do not prepare the teeth to what you imagine will be the final preparation at this point. Simply, as Michelangelo carved the David out of stone, you will remove excess enamel where required.
   
   Next, you will need to augment deficient areas to the desired result. For instance, if a central incisor was rotated mesially 20 degrees along its long axis, the distal-facial line angle will protrude labial to the plane of the desired final arch form, while the mesial-facial line angle will be lingual to its desired plane. This condition calls for reduction of the mesial-lingual edge of the tooth, as well as the distal-labial edge. After this reduction, the mesial-facial and distal-lingual edges will require augmentation.
   
   Without any adhesive bonding steps, simply apply some older expired composite to the areas that need to be built up. For a faster, smoother modeling of the composite, use Cosmodent's number 1, 2 or 3 brushes, and dip into a tiny drop of dentin bonding resin. This will enable a very fast, smooth sculpting of the resin augmentation. Once you've removed excess enamel, and augmented areas lacking, lightly reshape the case to the desired morphology and alignment. It is at this point that I will hand the patient a mirror and say, "Mrs. Jones, what you are about to see is a very close likeness of the result I intend to achieve. Is there anything about this look that you would have me change?" Patients undergoing instant ortho are usually floored by the esthetic improvement achieved by this fairly rapid preoperative mockup. We can determine occlusion and esthetics at this point.
   
   Once we've completed this mockup, we are ready to prepare the teeth for the lab. All of the guesswork has been removed. It is as if we are working with an ideal case to prepare. Now is the time we can simply employ our knowledge of required cutback for the specific porcelain chosen. Choose the appropriate depth-cutting burs, and commence the preparations. Depending upon the initial placement of the teeth, your depth cuts in some areas may actually be entirely in composite - in this case you would simply create finish lines at the margins, without any further need for labial reduction. Conversely, if you are doing a labial prep on an area that was initially labially malposed, your depth cut may bring you close to (or into) the pulp chamber.
   
   The pre-operative waxup can be helpful to predict these concerns in advance. Consequently, you may inform your patient prior to performing an irreversible preparation. Armed with this knowledge, inform your patient that there is a chance that they may experience thermal sensitivity that may never improve - and that the worst-case scenario may include removal of the nerve in order to achieve the desired result.
   
   If a tooth was initially significantly labially malposed, your composite mockup will have extended a fair distance along the lingual face, up toward the cervical gingival margin. I will frequently mark the cervical-most extent of composite with an indelible marker to remind me where I need to place my lingual finish line. Depending upon the initial extent of labial malpositioning, the final preparation may be that of a ¾ crown.
   
   
2. The second reason for performing the pre-operative mockup concerns fabrication of the provisional restoration. Whether or not you had your lab perform a pre-operative waxup, you may choose to use the intraoral pre-operative mockup as a guide for the provisionals. Using a triple tray (if more than 6 teeth, use full-arch for easier reseating) and polyvinylsiloxane, you can make a terrific form now, to be used after the final impressions to fabricate the provisionals.
   
   
3. Even in cases where preoperative waxups were performed, a PVS impression of the intraoral preoperative mockup is a wonderful lab guide for the final restorations. You may also opt to have the patient wear the provisionals for a period, after which you take alginates from which you send the lab "approved" models.

Although these may seem like time-consuming, costly steps, they are really neither. Just the opposite. By performing the steps necessary to work out the intricacies of the case in advance, you will typically save time, as well as assure all parties a satisfying and dramatic esthetic result.

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