Utilising fixed orthodontics with minimally invasive finishing touches
Featured Products Promotional FeaturesPosted by: Dental Design 16th May 2021
A female patient presented to the practice with concerns about the appearance of her smile. She disliked the upper and lower crowding and was looking for a solution. A full medical history was taken and no abnormalities were found. The patient had undergone orthodontic treatment as a teenager, but had since experienced relapse.
As per the IAS Academy protocol, a comprehensive orthodontic assessment was conducted (Table 1). The patient’s oral hygiene was good, the gingivae were healthy and no bone loss was evident from the radiograph taken. A grade 2 gingival biotype was recorded in the lower anterior region.
Table 1
| Skeletal Pattern | Class III | |
| FMPA | Reduced | |
| Lower Face Height | Increased | |
| Facial Asymmetry | None | |
| TMJ | None | |
| Soft Tissues | Lips forced competent, hypotonic lips, lip line normal, nasiolabial angle increased | |
| Overjet | 2mm | |
| Overbite | 20% | |
| Crossbite | None | |
| Displacement on closure | None | |
| Incisor relationship | Class III | |
| Molar relationship | Right: Class I Left: Class I | |
| Canine relationship | Right: Class I Left: Class III ¼ unit | |
| Teeth Present | 7654321 | 1234567 |
| 7654321 | 1234567 | |
| Centrelines | Coincident | |
Approximately 5mm of crowding was identified in the labial segment of the lower arch and the lower canines were mesiobuccally rotated. In the buccal segment, there was 1mm of crowding on the left-hand side. For the upper arch, 2mm crowding was recorded, with triangular central incisors.
The possible treatment options were presented and explained to the patient. The ideal treatment would have involved a surgical aspect to correct the skeletal base, as well as the upper and lower arch crowding. However, the patient was keen to avoid this and so was more than happy to accept a slightly compromised result (Table 2).
A Spacewize™+ online calculation was made to determine the overall amount of space that would need to be created – 2.44mm in the lower arch and 0.7mm in the upper – and treatment with the ClearSmile Brace was proposed. All the benefits, limitations and risks associated with treatment were discussed in detail with the patient, who provided informed consent to get started.
Table 2
| Problem list |
| • Class III Skeletal base
• Class III incisor relationship • Upper and lower crowding • Reduced Overbite • Triangular shaped upper centrals (black triangle risk) • Uneven wear of upper and lower incisors |
| Ideal treatment aims |
| • Correct to Skeletal Class I
• Achieve Class I with incisors, canines and molars • Normal Overbite • Relieve upper and lower crowding • No black triangles • Restore worn incisor edges |
| Compromised treatment aims |
| • Maintain overbite and improve with composite edge bonding
• Relieve 6-6 upper and lower crowding only • PPR to reshape upper centrals (no black triangles) • Restore worn incisor edges |
Treatment provision
The ClearSmile Brace was bonded in October 2018 and the standard IAS Academy archwire sequence was followed. Progressive proximal reduction (PPR) was performed on the central incisors to encourage tooth movement and de-rotation as and when it was required. The lower incisor brackets were repositioned approximately 5 months into treatment in order to further improve the movement of the teeth.
The patient remained compliant with oral health instructions throughout treatment and attended all review appointments as scheduled. By September 2019, she was very pleased with the alignment achieved and we agreed together to bring this phase of treatment to a close. Impressions were taken for a bonded retainer, which was fixed a few weeks later during the debond appointment.
In November 2019, composite edge bonding was performed on the canines to enhance the aesthetics of the teeth and finish off treatment. The patient was delighted with the result.
Case appraisal
Overall, I am extremely happy with the outcome of this case following alignment. I managed to use PPR on the distal aspect of the upper centrals to reduce the triangular appearance of these teeth and avoid the risk of black triangle formation. This has allowed us to use the space required to achieve alignment, while also reshaping the upper centrals to provide a more aesthetic result. Throughout, both good interdigitation and the Class I canine and molar relationships in the buccal segment were maintained. The gingival levels of the upper and lower incisors are also now coincident and the reduced overbite has been maintained.
In addition, the overbite was improved by the composite edge bonding after alignment, which restored the lost incisor wear. The result prior to edge bonding gave the appearance of uneven incisor edges, so adding the composite in a minimally invasive way therefore elevates the final result. It provides both a more aesthetically pleasing and more functionally stable outcome.
Treatment in this case was probably delayed somewhat by bracket positioning in the lower incisors. This is an area that I am focusing my learning on as I wish to develop my skills to avoid this issue in the future.
Images
For more information on upcoming IAS Academy training courses, including those for the Inman Aligner, please visit www.iasortho.com or call 01932 336470 (Press 1)
Author bio:
Dr Sebastian Crudden is an associate dentist at Kelly Dental Care in Derry City.
