Dr Rebecca Williams discusses a case of mild crowding and overbite, and the lengths she went to for an excellent result.
A 40-year-old woman presented with concerns about the appearance of her teeth, having previously been recommended two new veneers on her central incisors in her upper jaw, UL1 and UR1.
She already had two composite veneers on her UL1 and UR1, but was concerned with the wear and staining they had sustained. She was generally fit and healthy, with no caries, and overall displayed good oral hygiene. Her teeth were an A3 on the Vita shade guide, but she wanted a whiter smile. There was also an uneven lower gingival zenith, which the patient hadn’t been concerned by.
The orthodontic assessment demonstrated a Class III skeletal relationship, with some rotated teeth. The UR1 was rotated mesio-palatally, resulting in the LR1 being pushed lingually – if this wasn’t corrected, it was likely that the crowding would worsen. She had a Class I incisal relationship and a Class I molar relationship on the left side; though there was no molar relationship on the right, owing to no such teeth in the mandibular area. Furthermore, a Class I canine relationship, 2mm overjet and 80% overbite were recorded. Following a DPT radiograph, she was judged to have good bone levels.
The patient also expressed she had some temporomandibular joint (TMJ) dysfunction, and was regularly wearing a nightguard in an attempt to alleviate the associated pain and discomfort.
Assessing treatment options
Possible treatment options were discussed with the patient, including the suggestion from her previous clinician. This would simply replace the composite veneers with porcelain, but concern was expressed that the occlusal issue would not be treated.
The alternative treatment option was to remove the composite veneers, undergo orthodontic treatment – using fixed or removable appliances – and later assess the options available to restore the central incisors after alignment. This solution was preferred due to its potential for both longevity and aesthetics. All prospective advantages and disadvantages of this treatment were presented to the patient in detail.
I consulted my IAS Academy mentor, Claudia Waddell, who helped me throughout my training, and continues to do so to this day. She agreed that the case was well within my abilities and advised on how I could optimise the treatment plan.
We agreed that the outcome needed to meet both functional and aesthetic expectations. This meant the approach to interproximal reduction (IPR) would need to be well thought through, sometimes only needing a delicate touch of an IPR strip to attain an optimal finish. Taking on this case with an almost artistic approach, planning for the shapes and width of teeth from the very beginning, made each appointment more rewarding than the last.
To name one final key moment before treatment began, a digital smile simulation of the patient’s predicted final result was created and shared. Upon seeing the result, the patient was understandably excited and emotional. It was a real sign of how much this treatment would mean to her.
First steps
After an oral hygiene appointment and the removal of the composite veneers, the teeth underneath were in great condition and of an aesthetic shade – replacement veneers might not be needed after all!
The Spacewize+ digital space calculator was used to help assess the need for IPR and predictive proximal reduction (PPR) to detriangulate teeth in the mandible. Approximately 2.3mm of IPR was needed here, with just 0.3mm in the upper arch. ClearSmile Aligners from the IAS Laboratory were optimal for the upper dentition, whereas an Inman Aligner was ideal for the lower, especially considering the absence of molars in the LR quadrant which would have made aligners more difficult to manage.
To effectively engage the aligners, composite buttons were placed using Venus Pearl composite, in the shade A1. It’s my go-to material for orthodontic attachments and the fixing of bonded retainers, with superior handling qualities, aesthetics and functional results.
Following the fitting of the first ClearSmile Aligner, the patient was given oral hygiene instructions and advised to wear her aligners for 22 hours a day. She returned every two weeks for reviews of her progress. This gave the best opportunity to adjust the Inman Aligner and provide new ClearSmile aligners, as well as complete any necessary IPR.
With the help of the Inman Aligner, treatment was completed for the lower dentition in just 2 months. The dentition in the maxilla required a sequence of 15 ClearSmile Aligners over 10 months, but tooth movement tracked as expected.
For the final aesthetic enhancements, we had agreed that her old composite veneers need not be replaced, and the patient opted for whitening. For the last two weeks of orthodontic treatment, the patient used Philips Zoom! Day Whitening kits from the IAS Lab, containing a 6% Hydrogen Peroxide formula. The patient was advised to use this for 35 minutes at a time, resulting in teeth between the shades Vita B1 and Bleach 3.
Final outcomes
The final alignment of the dentition was considered a success by both the patient and myself. Minimal contouring was used to perfect the edges of her teeth for a fantastic smile.
The patient was delighted with the appearance of her teeth, including the removal of gaps and the presence of a new, vibrant smile. I recommended the patient employ retention for life with both fixed wire retainers and removable retainers for the upper and lower dentition.
The patient has visited the practice in the years since this case, and she has remained delighted with her dentition. The patient has also shared that her TMJ pain had ceased since completing treatment.
This case displays a number of crucial elements of my orthodontic care. Firstly, that a clinician’s main aim should always be to marry aesthetics and function together for a greater outcome. It’s also important to create effective treatment plans, and take a minimally invasive approach. As seen with my use of IPR, making the smallest changes can have the greatest impact, with a natural, aesthetic and functional result, all in one. Even years on, I wouldn’t have approached it any differently.
I also found the help of my IAS Academy mentors an immense benefit in this case, and others since, especially Claudia. The support is always positive, and allows you to constantly develop new insights over time. Disclosing with your patients that you are being mentored is important to me. I have had nothing but positive reactions, and it shows a passion to learn and develop your craft with each case – what patient wouldn’t want that from their dentist?
For more information on upcoming IAS Academy training courses, please visit www.iasortho.com or call 01932 336470 (Press 1)
Author Bio: Dr. Rebecca Williams
Dr Rebecca Williams is an Associate Dentist with the Cox and Hitchcock Dental Group in Cardiff, Wales. Since attaining her BDS from the University of Wales in 2007, Dr Williams has fuelled her passion for aesthetic dentistry and orthodontics with a number of courses from the IAS Academy, and will begin the Advanced Diploma Course in June 2024. She would like to thank Claudia Waddell for all of her guidance, Phil Jones from Kulzer for support with the Venus Composite range, her Principals, David Cox and Robert Hitchcock, for their amazing support, and her Dental Nurse, Robyn Hurley. Dr Williams’ work can be found on Instagram at @rebecca_dentist_art.
