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  Posted by: The Probe      20th April 2021

A female, 37-year-old patient presented at Digital Dental Office in Ulaanbaatar, Mongolia, in September 2018. She did not like her crowded teeth and was seeking a smile correction.

Upon enquiry, the patient’s medical history was clear. The comprehensive intraoral evaluation (Table 1) identified weakened enamel and some teeth erosion. She was missing her lower right premolar, which she was conscious of. A full set of clinical photographs and an OPG were taken as part of the initial assessment.

 

Table 1: Assessment

Skeletal Pattern Class II mild
FMPA Average
Lower Face Height Average
Facial Asymmetry None
TMJ NAD
Soft Tissues Lips competent
Overjet 2.5mm
Overbite 30%
Crossbite Yes – UR4 tipping to rotated LR5
Displacement on closure None
Incisor relationship Class II Div I
Molar relationship Right: Class II ¼ unit Left: Class I
Canine relationship Right: Class II ½ unit Left: Class III ¼ unit
Teeth Present 87654321 12345678
8765321 12345679
Centrelines Upper deviated by 2mm to the left

 

All possible treatment options were discussed with the patient that might help her achieve her desired outcome. The recommended course of treatment was alignment with a fixed orthodontic appliance, due to the amount of movement that would be required. This process was explained in detail, with the importance of oral hygiene maintenance and retention emphasised. A Spacewize™+ calculation was created to determine the amount of space that would need to be created in order to align the teeth, which estimated 3.30mm in the upper arch and 0.3mm in the lower.   

 

Table 2: ideal vs. compromised treatment aims

Problem List
Moderate crowding

Skeletal mild Class II

Incisal Class II relationship

Molar Class I on right and Class II ¼ on left

Canines Class II ½ on right and Class III ¼ on left

Upper midline shifted to the left by 2mm

Rotated LR1,3,4,6 and UR1,2,4,5 and UL1,3,4

Tipped UR2-5, UL2-4, LR2,3,4 and LL2,3,4

4 impacted third molars

 Ideal Treatment – Aims:
Skeletal, incisor, canine and molar Class I

Correct upper and lower crowding

Correct midline

Correct rotations

Correct tipping

Compromised Treatment – Aims:
Correct upper and lower crowding

Correct midline

Correct rotations

Correct tipping

 

A treatment planned was formed, involving the placement of ceramic braces 0.22 Roth, with fixed orthodontics appliances on the upper and lower 6-6. A wire sequence of 0.12, 0.16, 0.20×0.20 and 0.19×25 was proposed, as was a powerchain to encourage correct of the upper midline shift. Both fixed and removable clear retainers would be required upon completion of alignment to help maintain results for life.

The orthodontic assessment and treatment plan with initial Spacewise™+ digital measurements were posted on the IAS Academy’s ClearSmile Brace support forum. It was revied by the highly experienced instructors, who approved the case for treatment with the appliance, without any extractions.

Treatment

The patient commenced treatment in October 2018 using 3M Advanced Clarity fixed ceramic braces with 0.012 NiTi wire. A small amount of build-up composite was placed on the buccal aspect of the upper second molars to prevent the patient from biting on the occlusal surface of the upper second molars to prevent the patient from biting on the brackets of the lingually tipped premolars. Short ligatures were used on the rotated teeth. During the treatment period, the patient was advised to use MI Paste (GC) to help protect her demineralised enamel surfaces and prevent caries development. 

In December, we started sequential interproximal reduction (IPR), based on the Spacewise™ digital analysis for space creation. Approximately 0.96mm of IPR was performed on the mesio-distal aspect of the upper canines and centrals using diamond serrated strips (yellow 0.08mm-red 0.10mm-blue 0.12mm). More MI Paste was applied. Progressive proximal reduction (PPR) was also performed using Sof Lex dics (3M) on the distal edge of the upper canines.

In January 2019, the archwire was changed to 0.016 NiTi. The patient continued to visit the practice regularly for review.

The case was complete in October 2019. The ABB (Align, Bleach and Bond) concept was applied and the patient offered whitening and edge bonding. A course of home whitening – Opalescence 10% Ultradent worn at night for 2 weeks – was completed and some composite bonding was placed on the teeth that were affected by enamel erosion to enhance the overall aesthetics of the smile. Due to her enamel demineralization, the patient felt some mild sensitivity during home whitening and she was recommended to use UltraEZ gel as a desensetising agent when necessary.

Case appraisal

The IAS Academy ClearSmile Brace support forum was utilised throughout this case to ensure that the safest and most effective treatment was always being delivered. Guidance ranged from when and where to place different sized ligatures, to when it was suitable to move onto the next archwire in the sequence. IAS academy’s mentorship helps us to implement our orthodontic treatment in the right way and in the right sequence to make our patients happy and deliver treatment with confidence.

In hindsight, I would increase her maxillary transerse measurement and premaxilla area with three screwed, removable expanders before fitting the orthodontic appliance and help her maxilla grow forward to make more room for mandible movement. 

Images

 

For more information on IAS Academy membership and upcoming training courses, please visit www.iasortho.com, email courses@iasortho.com or call 01932 336470 (Press 1)

 

Author:

Dr Bilgee Jigjid qualified in 1995 from the medical University of Mongolia. She went on to complete various postgraduate courses and qualifications in operative dentistry and periodontal therapy. She was initially introduced to IAS Academy in 2010 and has since taken an array of ortho-restorative courses with the Academy.




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