Dr Rebecca Williams presents an orthodontic treatment for crowding following the extraction of a supernumerary tooth, including the use of power chains and elastics.
A woman in her early 30s presented to the practice with concerns regarding crowding throughout the dentition. She was seeking a solution that would optimise aesthetics, and give her confidence in her smile.
A brief assessment highlighted a supernumerary tooth in her lower lateral dentition, which was exacerbating the crowding. Her oral hygiene was good with no restorative concerns. To understand more, a thorough assessment of the dentition was enacted.
The patient had a Class I skeletal relationship and average FMPA, with average lower face height and no asymmetry. She had a Class I incisal relationship, with a 1mm overjet and an overbite of 3mm. The central line was Class I, and she similarly had a Class I relationship throughout both the left and right molars.
On the left, her canines exhibited a Class I relationship, and the right side had a Class II relationship by half of a unit. The lower arch had crowding throughout the lower 6-10 teeth. Standard radiographs, including an OPG X-ray and bitewings, were taken with no abnormal findings.
The patient was deemed appropriate for orthodontic care and a dedicated treatment plan was devised.
Treatment options
Successful treatment would reduce crowding throughout the lower incisors, where it was most prominent, whilst correcting the overjet and overbite that was present. A minimally invasive approach is always preferred. In this case, extraction of the supernumerary incisor was recommended, as this would create space and, therefore, reduce the need for interproximal reduction (IPR).
Clear aligners are a popular orthodontic treatment approach for many individuals due to improved aesthetics and comfort when compared to fixed solutions. However, the patient was advised that traditional fixed braces would provide enhanced control over tooth movement, and aid the movement of the lower anterior teeth after extraction of the supernumerary incisor (LR2).
Other treatments were discussed, including the option of no orthodontic treatment and the continued monitoring of oral hygiene, but the patient was interested in resolving the crowding. With all relevant information presented, and informed consent attained, the patient elected to undergo fixed orthodontic care with a tooth extraction.
As this was one of my first orthodontic cases utilising the extraction of a tooth, I consulted each step with Dr Pinkoo Bose, a mentor at IAS Academy. Following the completion of many of IAS Academy’s engaging orthodontic courses, I had the skills to carry out such a case, but the guidance of an experienced and knowledgeable professional provides further confidence in the treatment plan; the patient was informed that I would be supported by a mentor throughout the case, and she expressed that she was happy with this approach.
A Spacewize+ assessment was completed to assess the necessary space creation for the desired orthodontic tooth movements, and an Archwize assessment informed the IPR recommendation. This was shared with Dr Bose, and due to the helpful visuals, was shown to the patient to further inform her of the planned care. The use of IPR in the upper dentition was expected to create black triangles, which could be corrected with cosmetic composite restorations alongside tooth whitening after the completion of the orthodontic regimen.
With an appropriate plan in place, and complete patient consent, care could proceed.
First steps
The extraction of the supernumerary LR2 was completed by the oral surgery team within the practice, ensuring the patient had the best available care. She experienced no complications with this, and healing progressed as planned.
IPR was carried out throughout the upper dentition, creating a total of 2.3mm of space, as indicated by the Spacewize+ and Archwize assessments. This equated to 0.3mm IPR canine to canine and 0.4mm at the distal of the canines. Once again, the space created in the lower dentition eliminated the need for further IPR, maximising the conservation of the existing enamel.
Clarity fixed brackets from Solventum were placed using the Clarity Digital Bonding system. This enabled optimal placement to be planned digitally, and then replicated accurately with full-arch bracket placement, ensuring predictable tooth movement. 0.12 NiTi wires were implemented across the dentition; both brackets and wires were tooth-coloured to maximise aesthetics.
The patient was provided with oral hygiene instruction and advice to optimise the healing of the extraction site.
Progression of care
After a review at six weeks, the wires were replaced in accordance with the pre-planned sequence. Images were regularly shared with Dr Bose, who could provide feedback and recommended amends for the next stages of care, and also confirm when the correct steps were taken; this helped to instil confidence throughout the workflow and ensured the patient received effective care.
As expected, interproximal spaces were created throughout the dentition as treatment progressed. A single power chain is conventionally used to eliminate these; Dr Bose recommended that the use of a power chain both above and below the NiTi wire would work for closing these, accelerating treatment whilst also ensuring accuracy.
During this phase of treatment, it was important to try and match the centre lines as best as possible. Elastics enabled this movement to be controlled, and as it was my first time implementing them, each planned step was shared with Dr Bose for review. A unilateral class 2 traction was implemented on the right side, and a class 3 was implemented on the left. This action of push and pull would ensure optimal movement. Dr Bose provided an annotated image of where to place crimp hooks, and which elastics to use, ensuring these could be provided to the patient without misinterpretation.
Throughout care, the patient experienced build-ups of tartar in the newly created interproximal spaces, which were removed with the help of professional oral hygiene treatment. This ensured periodontal health was maintained throughout care, and is especially necessary in fixed orthodontic treatment when many patients may struggle with thorough plaque removal.
Final Result
At the end of treatment, the patient’s overjet and overbite were eliminated, with optimal occlusion achieved. The brackets and wires were debonded, and fixed retainers were applied to the lingual surfaces of the upper and lower dentition. Clear removable retainers were also provided for maximum support. Tooth whitening was performed, and any minor spaces left due to IPR were treated with the placement of composite.
The patient, like myself, was happy with the outcome, and delighted with the aesthetic result. I shared the outcome with Dr Bose, who also noted the treatment as a success. If I attempted the case again, I would focus further on the movement of the LR3 into the space created by the extracted supernumerary tooth, as well as wire bending in the final stages of treatment.
Support from an IAS Academy mentor on this case was extremely beneficial, with the ability to see new approaches to the case, and receive confirmation on prospective treatment elements. This ensured that, as my first case with a tooth extraction and the use of elastics, each step was taken with confidence and with the patient’s needs immediately in mind.
The outcome was a success, with a natural-appearing result that treated the present crowding effectively and maximised aesthetic and function.
Author Bio: 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 fueled her passion for aesthetic dentistry and orthodontics with a number of courses from the IAS Academy. She would like to thank Professor Ross Hobson and Dr Pinkoo “Pinks” Bose for all of their support and mentorship, 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_hyrox.
