Recession / black triangle / filling during or after ortho treatment

I started my treatment almost one year ago. Unfortunately, I am having both recession and black triangles. I guess I will have to do a gum graft and some bonding after my treatment is completed. I am also planning to get my filling changed to tooth color composite. I am wondering did any of you do any of those prior to the end of the treatment? I would think I should not touch anything prior to the end, but I am curious.

If done after the treatment, my concerns are:

1) if having a graft, will I still be able to wear a retainer (regardless of the type) since I cannot brush the affected area for weeks. This is especially important for the invisalign looking kind of retainer (not sure what is it called), I can imagine how bad it is going to be to cover any unbrushed area with the retainer.

2) if doing bonding, obviously the retainer will no longer fit. For the hawley retainer, I heard that it is adjustable, but let’s say if the arch is, for example, increased by 1mm, I am wonder how will the ortho be able to determine what is the difference with naked eyes, and accurately adjust (manually bend?) the retainer? For the invisalign kind, then I would believe a new impression will need to be done for a new set of retainer? If so, that means the patient will have no choice but leaving the teeth to shift until the new retainer is ready?

3) if doing / changing filling, I would guess the wire kind of retainer won’t be affected. But a new set of retainer will be needed for the invisalign kind?

Thanks

33333 reply
Black triangle treatment.

"The Mother of All Black Triangles" Case

Has anyone tried this?

josie reply
Hi – Well you really should speak with your ortho about all of those questions, since only s/he will be able to answer them properly for your individual case.

With the dreaded black triangles, the first solution orthos try is to do some IPR – which means shaving down the tooth fractionally, between the teeth, so that the tooth is less of a triangular shape and slightly more rectangular. This means the teeth next to it can be shifted closer and it closes the black triangles often. Not always though. The drawback to IPR is that you are removing healthy tooth and also, dependent on tooth shape to begin with, it can be difficult to get a natural-looking shaped tooth which also closes the black triangles: If you shave too much off and make it too rectangular, it will look awful. (Like a tall building, rather than a triangular tooth!).

Most of my black triangles were fixed with IPR on my top (visible) teeth. There are still 2 small triangles on either side of one tooth, but any more IPR would have made it look worse, not better, so we left that one. My lower teeth have several black triangles, but they’re not visible when I smile and, because they are smaller teeth, being on my lower arch, I think they would also look worse with IPR – becoming more rectangular quickly.

You should talk with your ortho about your triangles now, before your braces come off, because IPR can only be done in braces – as you need the braces to close up the gaps you create by shaving the teeth down.

With the bonding, I believe this is very much only the solution if IPR can’t fix it and you’re still not happy with the gaps. But if you do have bonding done after ortho work (I will be having bonding on my front incisor to make it the same length as the one next to it), your ortho may well make you another retainer to fit after the bonding. My ortho has given my a retainer to use immediately after braces were removed, whilst I whiten my teeth. Then, when my teeth are the right colour, I go back to my dentist and get the bonding done. Then I go back to my ortho to get another retainer fitted. Your ortho shouldn’t leave your teeth without a retainer, especially just after the braces have come off.

If you are planning on whitening your teeth at all, do this before any bonding or fillings are changed, so it can match the whitened teeth. (I’m currently whitening mine, and let’s just say it is taking bloody ages to get to the right colour and I’m on my second product – Crest Whitestrips Supreme – after the stuff my dentist gave me 1) cost about 6 x more than it does online and 2) didn’t work at all. It is now 2 months since my braces were removed and I’m still whitening, having never whitened in my life before, it is taking a while.)

Re your gum graft, again speak to your ortho or periodontist. But I’d imagine a Hawley retainer would be much easier, since it doesn’t fit snugly around the gum line like the Essix does, but only has a bar across the teeth themselves. If you’re not supposed to brush, you probably shouldn’t put on a snug fitting retainer over your gums either.

33333 reply
Thanks for the reply josie.

It will be a while until my next appointment, and it’s always good to have the opinions from someone who had the first hand experience. =)

I’ve had one round of IPR done on a few areas. It sounded like there will be a second round. My black triangles are HUGE, so I know there is no way IPR could close them while maintaining a natural proportion.

It sounds like they can make you a retainer on the spot for the same appointment? If so, then it would solve my problem. Was that retainer temporary?

Can I ask why you didn’t do the whitening with the dentist? I wonder if the bonding composite can be whitened too.

josie reply
Hi – Well I just posted a long post in the ‘Whitening’ forum here about my whitening efforts and composite build-ups matching that etc etc…

It’s best to wait and see what happens a bit, since the braces do move the teeth and sometimes gum can move back and fill in the black triangles (not always). When I told my ortho at first that I wasn’t happy with the black triangles on my lower jaw, he said to leave it a few months and see if it changes at all, and if I still don’t like it, we’d need to put braces back on that jaw and do some IPR again. I really don’t want to go back into braces again, and you can’t see my lower teeth when I smile, and I think IPR on them would make them look weird, so I’m just going to leave it.

No, they can’t make you a retainer on the spot: You get the moulds taken the day your braces come off, then you return in about 4-5 days to pick the retainer up. My ortho does an early Monday morning appointment to take the moulds, and then they are ready by Thurs the same week – so the weekend doesn’t get in the way. I still have that retainer now. When my build-ups have been done, I will return to my ortho and get new moulds taken for the new retainer.

No, composite resin cannot be whitened. (Permanent fillings/bonding.) But temporary fillings can be, it looks like – since mine seems to be whitening along with the rest of my teeth at the moment. That is why you need to make sure your teeth are the shade you want them to be, before you get the permanent bonding done. And then to be aware that, if your teeth discolour, you will need to whiten them again – since otherwise you will have bright white bonding and yellower teeth!!

I don’t know where you’re based, but I’m in the UK. Here the ortho does all ortho treatment, but your regular dentist deals with whitening and cosmetic build-ups/dental work. The orthos try not to take work away from the regular dentist, since they get referrals from the regular dentist and want to stay on the good side of them. So now I’m like bouncing between ortho and dentist.

To be honest, I’m starting to wonder if I can’t just keep my ‘temporary’ build up – and if it comes off or chips, go get another one. I’ve had these now for a good 10 months. At least then all my teeth would whiten, unlike if I had a permanent build up, and I don’t have to worry about committing to the colour my teeth are.

33333 reply
Josie, I read that post and understand your concern. And I actually have the same concern about the potential different "discolor rate" of the bonding and the teeth. Like you said, I’ll need to keep whitening my teeth as long as I want the color to match, which to me is a pain.

I’m not exactly sure how bonding it done, but from the link I posted, seems like they put a layer on the front side of the teeth as well when covering the black triangle, i.e. all visible areas are covered with composite? If so then the concern of discoloring is solved. If your dentist could do that then it would be perfect!

I believe there’s some kind of whitening that can be done in one appointment? Does it cost a lot more, so you chose the longer route?

josie reply
I spoke to my ortho, my dentist and my hygienist (actually 3 different practices – long story) and all recommended that I do the at-home whitening rather than the in-office. They said it would be much cheaper and the same result, and as it’s more gradual, I will be able to stop when I want. I do think it is the same result (eventually) but it takes much looonger.

As for the reason they dissuaded me from the in-office whitening, I think it might be in case it didn’t achieve the colour I wanted – being either too white or not white enough – and then they would be responsible for that. Or perhaps because they have to use much harsher products/higher peroxide levels to get results in one treatment, and that is not great for your gums.

It does cost a lot more to do the one-off treatment at the office. I think it also depends a lot on whether you’ve whitened before – if you haven’t, you are starting from scratch with (for me!) 34 yrs of unwhitened teeth to undo. Some folk are just doing touch-ups and have whitened before. So that is another reason it is taking ages.

I called and made an appointment with my ortho for this Thurs, to talk about these issues – my worry about having to maintain the same shade of bonding and teeth forever more. I’ll ask him about having temporary bonding, as I have now, and getting that fixed up if it comes off. I’m sure he will not like that idea because it does smack of not doing things ‘properly’.

I don’t think the permanent bonding would go over the surface of the teeth, no – for me, it’s not about the black triangles, but about building up a tooth by about a quarter, at the end of it. So the bottom end of the tooth would end up being a different colour to the top end. I really wanted to shave the longer tooth down, rather than do this building up thing – but my ortho said that there was too much of the tooth to shave down, and it might go too close to the nerve and I could risk having a sensitive tooth forever more.

I’m also a bit worried because, having the temporary bonding that I have at the moment, I asked my dentist how he would know where the bonding ended and my tooth began – when he removed the temp bonding to put the perm bonding on. He said he might end up removing a miniscule amount of my tooth, past the bonding. eek.

I dunno. I just feel like being as non-interventionist as possible about this one, but I also don’t want to have 2 substantially different-lengthed front teeth!!

33333 reply
I’m thinking the bonding material can be applied on the front side of the teeth too if needed be. I had a couple of dents on my front incisors, my dentist just covered them with composite. However, the job was done poorly so there were two little bumps. My ortho filed them down a little but it still looks like there were some foreign material glued on those teeth. The ortho said I will need a new layer on the top to fix it completely. So I think it’s doable, but of course, it’s case by case. Good luck and keep us posted!

josie reply
Ok, the only reason I wasn’t sure they’d want to put composite over the front is (firstly) wouldn’t someone just have a veneer done, if they were going to do that?

And also, when my braces came off and I had the damn black triangles on the bottom teeth, I asked my ortho about using bonding to get rid of them (since I was going to have this other bonding done to build the tooth up, it made sense to me to get that done at the same time), but my ortho said to give it a few months and see if the black triangles go. He said that, if they didn’t and if I still wasn’t happy, then he’d put my bottom braces back on again and do some IPR on the teeth and close the gaps that way.

Which led me to believe that IPR is the favoured approach wherever possible and orthos are reluctant to use bonding for this. Not sure why… But if he’d be prepared to go to the hassle of putting braces back on again and doing IPR in order to avoid some quick bonding, there must be a good reason.

33333 reply
You have a point there. But I guess it comes down to the "style" of the dentist/ortho and whether the case is suitable for certain procedures. Like the particular cases I posted, one of the reasons that the dentist preferred to use composite instead of veneer to close the black triangle was because the composite can go around the tooth, squeeze and "re create" a fuller looking papilla, whereas a veneer can just block the space.

But anyway, if my ortho wants me to do a 2nd round braces then I’d rather to just have the black triangles closed by a cosmetic dentist.