Progressive orthodontic treatment – Kirsten Andersen

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  Posted by: The Probe      11th August 2019

Progressive orthodontic treatment

In April 2018, an existing but irregular patient enquired about orthodontic treatment. Her friend had pointed out that one of her lower incisors was taller than the adjacent anterior teeth and she had become conscious that the tooth had moved and was ‘pushed inwards’. She was also concerned that her teeth would move more in time.

The patient’s two adult children had previously undergone treatment with ClearSmile Aligners with excellent results and she was interested in something similar. Her main goal was to align the lower incisors and treat the intrusion of the elongated lower front tooth. She also expressed interest in slightly proclining her upper centrals.

Initial consultations

As with all my orthodontic smile consultations, I explained to the patient that I am part of IAS Academy and provide anterior alignment only, which will not address posterior occlusion. It was also explained that I am not a specialist, but can always offer comprehensive orthodontic treatment by referral to an orthodontist as an alternative.

The orthodontic pathway was discussed, including the possibility of bleaching and composite edge bonding, as well as the mandatory retention after orthodontic treatment. Furthermore, models of the Inman Aligner, ClearSmile Aligners, ClearSmile Brace, fixed bonded retainers and Essix appliances were demonstrated, with benefits and limitations of each explored. It is paramount that the patient is fully informed before they embark on the anterior alignment journey. This patient expressed a strong desire for clear aligners.

 

Assessment

A thorough IAS orthodontic assessment was carried out (Table 1) including the IAS Academy photo protocol. Measurements with digital callipers were taken for the Spacewize™+ crowding calculation, with measurements UL1 8.04mm and LL1 5.42mm. This is an extremely useful tool that helps to predict the amount of crowding/spacing, therefore indicating whether a case may be suitable for anterior alignment.

 

Table 1:

Skeletal Pattern Class I
FMPA Average
Lower Face Height Average, normal nasio-labial angle
Facial Asymmetry None
Soft Tissues Average lip line, competent lips, recession on UR6 1mm, UL6 2mm, LR1 1mm and LR4 2mm, all 1mm deep
Overjet 2mm
Overbite 4mm
Crossbite None
Displacement on closure None
Incisor relationship Class I
Molar relationship Bilateral Class I
Canine relationship Bilateral Class I
Teeth Present 7654321 1234567
7654321 1234567
Centrelines Lower deviated right by 0.5mm

 

The Spacewize™+ indicated this case’s suitability for treatment and we proceeded with two-stage putty/wash impressions of both arches for the Archwize™ planning. The Archwize video and results were shown to patient. These suggested five upper aligners with a total IPR (interproximal reduction) of 1mm, and 10 lower aligners with 2.5mm of IPR. The risks of recession and black triangles post orthodontics were highlighted, before the final treatment plan was presented to and agreed with the patient (Table 2).

 

Table 2:

Problem List
LR1 over-erupted

UR1/UL1 retroclined

Mild upper and lower crowding

Centreline deviated 0.5mm 

 Ideal Treatment – Aims:
Correct centreline

Procline UR1/UL1 mildly

Gently rotate UR2/UL2 into the arch

Intrude LR1

Align lower anteriors

Correct recession

Compromised Treatment – Aims:
Correct centreline

Procline UR1/UL1 mildly

Gently rotate UR2/UL2 into the arch to close gaps

Intrude LR1

Align lower anteriors to incisal level

Treatment

 

During the first appointment, composite anchors were placed on the teeth from UR4 to UR2, UL2, UL4, LR4 to LR2, and LL2 to LL4, using a template from the IAS Laboratory for greater predictability. The patient was shown how to insert/remove and clean the ClearSmile Aligners herself and advised to wear them for 22 hours a day. She found insertion really challenging throughout treatment as all the aligners were extremely tight, but with determination she managed.

In accordance with the Archwize planning, half the suggested IPR was completed initially on the lowers and 90% of the estimated IPR on the uppers. Remaining IPR was carried out over subsequent review appointments, which were scheduled roughly every four weeks.

At aligner no. 5 for the upper arch and no. 6-10 for the lower, two stage putty/wash impressions were taken for the fabrication of refiners. Further impressions were then taken for lower refiners after the no. 10 aligner, to achieve ideal positioning.

During alignment, the patient performed tooth whitening at home (White Beauty 10% Carbamide Peroxide night time). Final photos were taken and while the patient was very happy with the result, I could see room for improvement and suggested composite edge bonding for enhanced aesthetics. This was performed on the LR2 to LL2, and UR1 to UL2 using Venus Pearl B1 in accordance with Tif Qureshi’s bonding technique from the IAS Orthodontic Restorative Course.

To ensure longevity of the results, a fixed retainer (Wildcat 0.0175 from IAS Laboratory on a jig) was fitted with flowable composite on both the upper and lower arches, and Essix retainers were provided for the patient to wear every night for the first six months, and a few times each week thereafter.

  

Outcome

 

This was a challenging but very rewarding journey for both the patient and I. The patient was extremely pleased with the result and during subsequent visits, has reported that she cannot stop smiling and is so proud of her ‘new teeth’. It is truly what makes you tick when you know treatment has made a significant difference to a patient’s life. She admitted that she had initially been very sceptical about the edge bonding and thought it wasn’t really necessary, however, afterwards she realised this was the jewel in the crown.

I am pleased to have developed my skills regarding Progressive Smile Design – a concept I learnt from Tif Quereshi on his many courses. Apart from ‘just’ aligning, whitening and edge bonding the teeth, I have managed to improve the envelope of function and I trust that treatment will benefit my patients for life.

I would like to thank IAS Academy, the mentors and the IAS Lab for their fantastic support. I am extremely grateful for the mentoring, the readiness and the enthusiasm of all the professionals at IAS Academy. All my questions to the online ClearSmile Aligner Forum have been answered speedily and in-depth. Only with this feedback and the knowledge shared by the committed and very talented mentors, have I been able to take on more challenging cases. This allows me, as a general dentist, to embark on a new journey and take on new challenges in my dental life. Thank you very much to IAS Academy.

IMAGES

Figure 1 – Pre treatment

Figure 2 – Pre treatment anterior smile

Figure 3 – Pre treatment right lateral

Figure 4 – Pre treatment left lateral

Figure 5 – Pre treatment retracted closed bite

Figure 6 – Pre treatment retracted open bite

Figure 7 – Pre treatment chin up view

Figure 8 – Pre treatment upper occlusal

Figure 9 – Pre treatment lower occlusal

Figure 10 – Post treatment

Figure 11 – Post treatment smile

Figure 12 – Post treatment right lateral

Figure 13 – Post treatment left lateral

Figure 14 – Post treatment retracted closed bite

Figure 15 – Post treatment retracted open bite

Figure 16 – Post treatment upper occlusal

Figure 17 – Post treatment lower occlusal

For more information on upcoming IAS Academy training courses, including those for the Inman Aligner and Aligner system, please visit www.iasortho.comor call 01932 336470 (Press 1)

 

 

Author bio:

 

Kirsten Andersen is a general dentist at Envisage-Emsworth, Hampshire and Cornerways Dental Practice, West Sussex. She started the IAS Academy pathway by becoming a certified provider of Inman Aligner in 2013, followed by the ClearSmile Aligner and ClearSmile Brace in 2016. She has also completed the IAS Advanced Ortho-Restorative Course (2016) and IAS Photography and Record Taking Course (2017).

 

Kirsten’s passion is inaesthetic dentistry with an emphasis on minimal intervention, particularly anterior alignment orthodontics with whitening and bonding. She lives and works by the ethos: respect, responsibility and appreciation.

 

 

 


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