Twisted crowded teeth

Although orthodontics is most often the best way to correct crowded teeth, it is not the only way. Less expensive and less time- consuming methods may be used if the problem is not too severe. Although the teeth may not be in perfect alignment, creating the illusion that they are may allow you to achieve your esthetic goal.

Crowded or crooked teeth may require a combination of techniques described below. Your ideal treatment, for example, may include orthodontics to reposition the teeth followed by bonding, veneers, or crowns to improve esthetics. The choice of treatment ultimately depends upon your commitment of time and money, as well as your dental and esthetic needs.

Cosmetic Recontouring

Cosmetic contouring is a simple and painless reshaping procedure in which tooth structure is contoured with finely ground diamonds. It’s used to improve the appearance of the teeth by giving the illusion of uniformity and alignment.

Although its simplicity generally makes it the most preferred therapy, cosmetic contouring is not right for everyone. Cosmetic contouring may be the best option if you:

• Have only slightly crowded teeth
• Do not wish to have an anesthetic administered
• Prefer a relatively inexpensive and quick procedure
• Agree with a compromise solution

Before selecting cosmetic contouring:

• Your dentist should evaluate the effect contouring may have on your teeth. Your bite must continue to be correct if the
• health of the teeth, as well as the proper distribution of pressure during normal oral functioning, is to be maintained.
• The thickness of the tooth enamel must be checked, the removal of too much enamel can expose the dentin, resulting in discoloration and possibly sensitivity.
• A conflict may arise between maintaining optimum function and achieving maximum esthetics. In these cases, the final decision should be based on a trade-off among esthetics, the degree of bite change, and the health of the teeth.
• A plaster cast may be constructed so that you can see the limitations in your particular case.
• Cosmetic contouring should not be performed on children’s teeth. It can cause slight sensitivity—not only during the procedure, but afterward—because they have a larger amount of sensitive pulp tissue.

Bonding–Quick compromise

If cosmetic contouring alone cannot shape up your smile, it can be combined with composite resin bonding to “build out” the fronts or backs of the teeth to fall in line with neighboring teeth. The result is an illusion of straightness that can be quite pleasing.

Orthodontics

Orthodontics is the treatment of choice when the top priority is keeping the teeth natural and unaltered. It is, without a doubt, the best way to correct malpositioned or crooked teeth. With orthodontic treatment, the teeth eventually will become aligned proportionally, making it your safest bet for a long-lasting, economical, and esthetic solution.

In years past, orthodontics was shunned by many adults because treatment was lengthy, and traditional metal braces were conspicuous and unattractive. Now dentistry has seen the advent of tooth-colored brackets, lingual (“behind the teeth’) braces, and removable appliances. The newest orthodontic treatment is “invisible” braces (such as invisalign), a series of clear, removable, transparent matrices that are changed every 2 weeks. Each matrix moves the teeth to a specific position according to the custom computerized plan until the ideal placement is achieved. Most minor crowding can be corrected in 4 to 12 months, while more complex problems can be resolved in 18 to 30 months. However, compliance in wearing the appliance approximately 22 hours a day is mandatory. Invisible braces are easy to maintain with proper home hygiene and require less time in the dentist’s chair since there are no wires or brackets to replace, making them a great option for adults. An added benefit is that, if advised by your dentist, you can place bleaching gel inside the matrices and bleach your teeth at the same time you are straightening them.

Occasionally, the orthodontist may recommend that a tooth or teeth be extracted prior to realigning the teeth to make space, particularly in case where crowding is causing bone loss between the teeth.

Porcelain Veneers

In many cases, porcelain veneers can also provide a reasonable compromise when you want to avoid orthodontic treatment. Crooked and crowded teeth laminated with porcelain veneers will usually give the result of a polished, natural looking smile.

Crowns

Crowns are another way to correct teeth. Although they may be more costly and time-consuming than most of the previously discussed cosmetic procedures, they can produce a more dramatic change and may be a preferable alternative, particularly when teeth are erupting, damaged, or receding at extreme angles from the root structure.

If you think you may want to crown your crooked teeth, it’s wise to spend a little extra money for a wax-up or trial smile. This will allow you to see the intended result before your natural teeth are prepared. You can make a serious mistake by crowning crooked teeth and thinking they will look terrific. You may not be happy with the result since the final crowns may be much thinner than your own teeth. In such cases, you will not only have lost the money spent on crowns, but you will probably end up undergoing the treatment you should have gotten in the first place-orthodontics.

Choose crowns with caution

Crowns have limited use for crowded and crooked teeth because the orientation of the teeth to be crowned must be aligned with the surrounding teeth. If they aren’t, the crowns won’t be able to compensate for the difference. In other words, the same problem that existed with the natural teeth may also exist with the crowns.
Tooth size is another major factor to consider because each tooth needs to be- or at least appear to be—proportional. The more teeth that are treated, the less obvious any distortions will be. If only one or two teeth are crowned, however, there may be a noticeable difference between the crowned teeth and the natural ones, depending on the space involved. Careful cosmeticcontouring of both the teeth to be crowned and the adjacent teeth may make the final result appear more harmonious in size.

Cosmetic Contoring	Bonding	Porcelain Veneers	Crowns	Orthodontics
Treatment Time
About 1 hour or less	1-2 hours per tooth	2 office visits; 1-4 hours each (more time needed for more extensive treatment)	2 office visits;1-4 hours each for up to 4 teeth (more time needed for additional teeth or more extensive treatment)	6-30 months, depending on amount of crowding and method selected
Maintence
Brush and floss daily	Have a professional cleaning 3-4 times per yearEat wisely-bonded teeth can chip more easily than your enamel Push floss in and pull it through teeth rather than popping it out See dentist for repair as necessary	Have a professional cleaning 3-4 times per yearTake special care when biting into or chewing hard foods Get yearly fluoride treatment Brush and floss daily Use a fluoride toothpaste and mouthwash as prescribed by your dentist	Avoid biting down on hard foods and iceGet yearly fluoride treatments Brush and floss daily Use a fluoride toothpaste and mouth-wash as prescribed by your dentist	Brush and floss daily with special careHave a professional cleaning 3-4 times per year Schedule adjustment checkups every3-4 weeks during treatment Wear retainers indefinitely, at least a few nights per week
Results
Immediate reshaping of tooth structure, making crowded teeth appear to be the appropriate size and straighter	Straighter teeth in 1 office visit	A polished, natural-appearing result that can make teeth seem straighter and is more stain resistant than bonding	The best esthetic results in terms of reshaping teeth	Crowded and overlapping teeth can be straightened
Treatment Longevity
Indefinte	5-8 years	5-12 years	5-15 years (directly related to fracures, problems with tissues, and decay)	Generally permanent if retainer is worn at least a few nights per week
Cost
£90 to £180 per arch	£150 to £180 per tooth (repairs may cost £145 to £180)	£400 to £600 per tooth	£400 to £600 per tooth	£1500 to £3500 depending on the number of teeth involved and the appliance used;lingual braces may cost up to £3000 more per arch
Advantages
Less expensive than other forms of esthetic treatmentPermanent results Immediate correction Minimum treatment time Generally painless; no anesthetic required	Conservative (little or no tooth reduction)Less expensive than veneers or crowns No anesthetic required Teeth appear and feel straighter	Less wear and chipping than bondingExcellent bond to enamel Minimal staining and loss of color or luster More proportional results due to lab construction Long-lasting results -Gum tissue tolerates porcelain well	Teeth can be lightened to any shadeLess time required than orthodontics Less staining than bonding Last longer than bonding or veneers Offer greatest opportunity to improve tooth form	Straightens misaligned teethPermanent results for most people if retainers are worn Little or no tooth reduction required Usually less expensive than veneers, crowns, or bonding, depending on number of teeth involved Improved tissue health due to better cleaning access following treatment
Disadvantages
Does not reposition teethImprovement may be limited by functional considerations Can cause discomfort for children with large pulp canals Does not improve color	Does not reposition teethDoes not address gum inflammation due to crowding Can stain or chip more easily than veneers or crowns May require frequent repair Teeth may appear and feel thicker	More expensive than bondingDifficult to repair if the veneer cracks or chips Margins may “wash out” and require repair	Can fractureRequire an anesthetic Not a permanent solution More expensive than contouring or bonding Irreversible Can trigger pulp irritation Can induce tooth sensitivity for a short time	Time consumingTeeth may return to original position if retainers are not worn May take a few weeks to get used to appliances Brackets can irritate soft tissue Thorough cleanings are more difficult during treatment

Broken teeth

The main reasons for broken and fractured teeth include aging or incorrect fillings, bad bite, grinding/clenching or eating very hard food on a weak portion of your tooth or filling.

Several solutions include:

Recontouring

Cosmetic contouring is a cost-effective and minimally invasive way to repair small chips or fractures in teeth

Cosmetic contouring may be the best option if you:

• Have a very small fracture or chip in your tooth
• Want to invest a minimal amount if time and money in the procedure
• Have teeth that are long enough that contouring will not make them appear too short, aged, and/or worn

Composite Filling

If the cavity left by the removed decay or filling isn’t too large, composite resin can provide a cosmetically appealing filling alternative, particularly in lower back teeth that show when you smile or laugh.

Tooth-colored composite resin offers a conservative but esthetic approach to filling cavities. A composite filling may be the best option if you:
Are getting a small filling in an area that is visible during smiling or talking
Want to keep cost and time of treatment to a minimum
Are willing to accept an option with reduced longevity and resistance to wear and staining
Want to keep as much of your existing tooth structure as possible

Inlays or Onlays

Inlays and onlays are particular types of fillings made of composite resin, porcelain, or gold. An inlay is custom-made to fit the prepared cavity, while an onlay covers the entire chewing surface of the tooth. The primary disadvantage of inlays and onlays is their higher cost relative to traditional composite and amalgam fillings.

Inlays and onlays are durable alternatives for restoring large cavities. An inlay or onlay may be the best option if you:

• Don’t mind spending more time and money to get a long-lasting result
• Have a large cavity to be filled
• Want to avoid staining

What you should know

Gold
doesn’t discolor or stain the teeth and has a longer life expectancy than silver. It can be placed esthetically into upper back teeth ere it doesn’t show; however, it shouldn’t be placed opposite porcelain, because porcelain tends to wear gold rapidly during chewing.

Porcelain
Research shows that bonded porcelain inlays and onlays can equal the strength of natural teeth, making them particularly attractive choices when both esthetics and strength are required. However, extra stress can fracture porcelain just as it can natural teeth.

Composite resin
Although not as long lasting as gold or porcelain, composite resin inlays and onlays are an esthetic and less expensive option.

Porcelain Veneers

Porcelain veneers are a highly esthetic option for restoring front teeth. However, they are more expensive than composite fillings and require reduction of natural tooth structure. Porcelain veneers may be the best option if you:

• Have front teeth with extensive decay or old fillings that are discolored
• Would like to close minor spaces between your front teeth
• Are frustrated by fillings that continue to stain or are too visible
• Want a smile makeover that will improve tooth shape and brighten tooth color

Crowns

Crowns represent a long-lasting treatment alternative involving reducing the tooth and covering the remainder with a custom-made restoration. Although it’s always preferable to preserve the structure of the natural tooth, if a tooth is severely decayed or stained following the removal of a large filling, placing a crown may be the best option.

Crowns can produce near-perfect esthetic results. However, both the cost and the number of office visits required may make this treatment prohibitive for some patients. Crowns may be the best option if you:

• Have extensive decay and/or severe staining following the removal of a large filling
• Are looking for the most beautiful, long-lasting result possible
• Are willing to undergo more extensive treatment and incur higher costs
• Have additional esthetic or functional concerns that can be best addressed with crowns

Composite Filling	Inlays or Onlays	Porcelain Veneers	Crowns
Treatment Time
Approximately 1hour per tooth	Usually 2 office visits; 1-2 hours each per tooth	2 office visits; 4 hours each	2-3 office visits; 1-2 hours each per tooth
Maintenance
Brush and floss dailyUse a fluoride toothpaste and mouthwash as prescribed by your dentistAvoid biting down on hard foods and ice	Brush and floss dailyUse a fluoride toothpaste and mouthwash as prescribed by your dentistReduce intake of refined sugars and chewy foods such as caramels	Avoid use of ultrasonic scaler and air abrasives during hygiene office visitsBrush and floss dailyUse a fluoride toothpaste and mouthwash as prescribed by your dentistReduce intake of refined sugars and chewy foods such as caramels	Brush and floss dailyUse a fluoride toothpaste and mouthwash as prescribed by your dentistReduce intake of refined sugars and chewy foods such as caramels
Results
Esthetic replacement of old silver fillings or new decay areasMay not be perfect color blend but much improved over metal surfaces	More conservative than a full crownGold is most functional and longest-lasting method of restoring teeth, but large restorations tend to show metalPorcelain can be a highly esthetic replacement for discoloured or metal posterior fillingsComposite resin can match tooth color well	Can be highly esthetic but eventually may darken if the underlying tooth structure becomes darker.	Can achieve the best results in tooth shade, shape and size
Treatment Longevity
5-8 years	Gold: 6-20 years Porcelain: 5-15 yearsComposite resin: 5-12 years	5-12 years	5-15 years
Cost
£90 to £180 per tooth	Gold:  £400 to £450 per toothPorcelain:  £400 to £600 per toothComposite resin:  £120 to £180 per tooth	£400 to £600 per tooth	£400 to £600 per tooth
Advantages
Esthetic (tooth-colored)InsulatingCompleted in 1 office visitExtremely good bond to tooth structureLess expensive than crowns or inlays More conservative than crowns because less tooth reduction required	Well-suited for large cavitiesGold: Longest lasting Wears more like tooth structure Will not fracturePorcelain: Esthetic (tooth-colored) Stronger than posterior composite resin Extremely good bond to tooth structure Will not stain InsulatingComposite resin: May be less expensive than other options	Excellent bond to enamelLess tooth reduction required than crowningColor change is possibleLess staining than bonding	The dentist can improve shape of teethSome realignment or straightening of teeth is possibleCan be all-ceramicThe greatest esthetic change is possible with this option
Disadvantages
More expensive than amalgamWears easilyCan stain, chip, or fractureMay have a shorter life expectancy than silver, gold, or porcelainLess suited for large cavities	More expensive than amalgam Gold: Metal can show Takes 2 office visits Noninsulating (conducts heat and cold)Porcelain: Can fracture Takes 2 office visits (unless it is designed and created by machine in the dentist’s office) Possible wear of opposing natural tooth Composite resin: Wears faster	Difficult to repair if the veneer cracks or chipsIrreversible if much enamel is removedStaining can occur between the porcelain and the margin of the toothCannot be lightened or bleached	Can fractureRequires an anestheticInvolves reduction of a significant amount of tooth structureMore expensive than amalgamMay decay if cement washes out

Ceramic Inlay/Onlay of a tooth is a fantastic solution for restoring decayed, broken or a previously filled tooth.

Clinical studies indicate exceptionally high success rates for CEREC restorations. The CEREC 3D technology enables patients to have treatment in a single stress free appointment. CEREC is capable of producing any single tooth restoration, whether it is an inlay, crown or veneer.
Benefits include: Single visit Single local anaesthetic No temporary No impression Less drilling Minimal removal of tooth tissue Strong, healthy, metal-free, aesthetic restoration Excellent biocompatibility 20 year clinical history showing longevity of restorations	Dentist comment:Dear Dipesh TJust a little note to say Thank you for fixing my ttoth Im so glad I had the cerec it gas made such a differnec when I eat I keep having to look at it and am amazed at the difference. Thank you!

Cerec 3D

The Solution:

A CEREC parital crown produced at the chairside stabilizes the remaining tooth and largely conserves the healthy tooth structure. Today, there is over 10 years of clinical experience with CEREC. 5,000 users, already trust in adhesive bonding and the special properties of CEREC-ceramics.

CEREC restorations can be made and fitted at the chairside. This saves on the hygiene costs of the second session. And your patients gain too: no impressions; no temporaries! Fascinating treatment with an excellent result about which patients are bound to tell their friends, acquaintances and relatives.

Broken Teeth / Fractured Teeth

Although in some cases cosmetic contouring is an ideal treatment by itself, it also can be useful in conjunction with most other esthetic procedures. For example, if you are having one or more of your teeth treated with bonding, veneers, or crowns, your dentist can cosmetically contour adjacent or opposing teeth to create a more attractive and harmonious smile line. Also, cosmetic contouring often is used as a final touch following orthodontic treatment.

Bonding Laminates

Veneers

Although bonding is a quicker and more cost-effective treatment alternative than porcelain veneers, if your adjacent teeth have been rebuilt in porcelain, your fractured tooth should be restored in porcelain. The fractured tooth will match the adjacent teeth more closely because the same material has been used. Porcelain veneers or crowns may also be a preferred option if there are multiple teeth to be restored.

Luminears

The main difference is that Lumineers are made from a special patented cerinate porcelain that is very strong but much thinner than traditional laboratory-fabricated veneers. Their thickness is comparable to contact lenses, and so they are often called contact lenses for your teeth. The main advantage of these ultra-thin veneers is that minimal tooth preparation is required. In other words, very little – if any – of your natural tooth structure needs to be removed through shaving or grinding prior to bonding the Lumineers over your natural teeth. As a result, the procedure is often reversible, since your natural tooth structure is left intact, unlike traditional veneers, where a significant amount of your tooth structure may need to be removed.
Lumineers are so versatile that they can be placed over existing crown and bridge work, without the need to replace them. They are the perfect solution for stained, chipped, discoloured or slightly misaligned teeth.

Crowns

Crowns offer an esthetic solution when little tooth structure remains following a fracture. Crowns may be the best option if you:

• Have lost too much tooth structure to allow contouring or bonding
• Are willing and able to spend more time and money on the procedure
• Want an esthetic solution that allows change in tooth shade and shape

If you fracture a front tooth so badly that there is little tooth structure left, a crown is probably the treatment of choice. If a back tooth fractures, it also may be best to restore it with a crown. The procedure should be performed immediately, especially if the pulp is exposed and living nerves are unprotected.

Cerec 3D

The Solution: 

With CEREC you become flexible. For example, by using a thin CEREC veneer with an individually colored undersurface, the surface contour and texture can be modified chairside. Why not give it a try and see just how easy it is to grind and polish CEREC ceramics?

Cosmetic Contouring	Bonding	Porcelain Veneers	Crowns
Treatment Time
15-60 min	1 hour per tooth	2 office visits; 1 hour or more per tooth	Usually 2 office visits; 1-4 hours on up to 4 teeth (more time needed for additional teeth or more extensive treatment)
Maintenance
Brush and floss daily.	Have a professional cleaning 3-4 times per year.Avoid biting down on hard foods and ice, and floss carefully as these teeth can chip easily.See dentist for polishing or repair as necessary.Get yearly fluoride treatment.	Have a professional cleaning 2-4 times per year.Avoid the use of ultrasonic scalers and air abrasives during hygiene office visits.Take special care when biting into or chewing any hard foods.Use your back teeth to avoid placing torque on the veneer.Get yearly fluoride treatment.	Avoid biting down on hard foods and ice.Get yearly fluoride treatments.Brush and floss daily.Brush your teeth properly to avoid gum recession that may expose the margin of your crown.
Results
Teeth can appear straighter immediately	Most fractures and chips are easily repaired.	Fractured teeth can be restored or even improved.	Badly fractured teeth can be repaired and reshaped as desired.
Treatment Longevity
Indefinite	5-8 years, with professional finishing once every few years	5-12 years.	5-15 years (directly related to fracture, problems with tissues, and decay)
Cost
£120	£180 to £200 per tooth	£400 to £600 per tooth	Approximately £400 to £600 per tooth; expect to pay much more if a front tooth must be matched to other teeth
Advantages
No anesthetic requiredPermanent resultsNo maintenanceMost conservative optionQuickest option	No anesthetic requiredLittle tooth reduction required.Immediate results.Teeth can be lightened.Less expensive than veneers or crowns.	Less chipping than bonding.Color change is possible.Excellent bond to enamel.Gum tissue tolerates porcelain well.Can improve entire smile if treating more teeth.	The dentist can repair the chipped or fractured tooth.Teeth can be lightened to any shade.Some realignment or straightening of teeth is possible.
Disadvantages
Too much reduction can adversely affect the smile line.Your bite may limit how much of the tooth can be removed.In rare instances, sensitivity may be a problem.	Can chip or stainHas a limited esthetic lifeMay not be effective for severe fractures	More expensive than bonding.Difficult to repair if the veneer cracks or chip.Staining may occur between teeth, depending on how the veneer is prepared.Irreversible if much enamel is removed.Usually requires an anesthetic.	Can fracture.Requires an anaesthetic.Tooth form is altered (most of the tooth enamel is removed).Not a permanent solution.-More expensive than bonding.