Case of the Month: July 2017

This case presented in May 2016 with her chief complaint “I would like to have straighter teeth”. She presented with a Class II buccal relationship bilaterally and a 4mm overjet and 6mm overbite with mild crowding present in her upper and lower anterior segments. She was missing her maxillary and mandibular first premolars as well as the mandibular left second molar, and she had underwent orthodontic treatment 30 years’ ago with the extraction of four premolar teeth. Since then she has had some mild relapse in her upper and lower anterior regions.

This case was presented with three orthodontic options.

(a) The ideal approach would have been upper and lower fixed appliances to improve her dental alignment and then orthognathic surgery in the form of a Mandibular Advancement to provide her with an ideal overbite/overjet and optimal buccal occlusion.

(b) Her second option was to utilise Smilefast Braces for approximately 9 months to improve her dental alignment but she was advised that she would be left with approximately 4mm of overjet in the final result.

(c) A third option that we suggested was Invisalign therapy on the upper and lower arches. This treatment option would take approximately 18 months to complete and there would probably be little improvement with regards to her deep overbite and she would be left with a mild overjet of 3 to 4mm.

She opted for the second option utilising Smilefast Braces on the upper and lower teeth, because this was the quickest approach and most cost effective. We then obtained a full set of orthodontic records including an intra-oral scan to perform a digital setup and finalise ideal bracket placement.

In July 2016 we utilised an indirect bonding approach on upper and lower 6-6 utilising ceramic brackets and placement of a 0.014 Nitinol wire in both the upper and lower arches and tied the orthodontic arch wires with single alastic ties. In retrospect we should have placed bite-turbos on the upper canines as there was contact on the upper canines with the lower canine brackets. We performed hi-speed PPR distal and mesial to 21, mesial to 13, mesial to 41, and mesial to 34. In addition we did blue IPR on the upper and lower 3-3.

In August 2016 we retied the upper and lower arches with alastics and performed some further blue IPR on the lower 3-3.

In September 2016 there had been significant progress with regards to the alignment of the upper and lower anterior teeth and we placed upper and lower 016 Niti wires with some yellow IPR performed mesial and distal of 31.

In October 2016 we placed upper and lower 018 Niti wires and placed a ligature tie on the 31 with the pigtail to the mesial to aid the correction of that tooth.

In November 2016 we placed a powerchain from the 26 to 21 to aid in the rotation of the 21 and perform some further yellow IPR on the mesial and distal of the originally lingually displaced 31. We also determined that we would probably consider rebonding the 21 and 31 at the next visit.

In December 2016 we rebonded the 21 and 31, and maintained the existing upper and lower 018 Niti wires and performed some further yellow IPR on the 21 and 31.

In January 2017 we placed a lower 018 Niti and retied the existing upper wire.

In February 2017 I felt that we needed a little more torque on the upper anterior teeth and as such placed a rectangular 20×20 Niti wire.

In March 2017 all looked very good indeed from an alignment perspective and as such we took an impression for a lower bonded retainer and scheduled an appointment a few weeks’ later for the final deband.

On 29 March 2017 we removed the upper and lower orthodontic appliances, placed a lower bonded lingual retainer and placed an upper Essix retainer and we have advised her to wear her upper Essix retainer full-time for 12 months, then the following year on a night time basis and then a year later, ie, two years after deband, she will be wearing it two to three times a week on a night time basis indefinitely.

By comparing the initial photos to the final photos, an excellent aesthetic result was achieved but we could have improved the angulation of her 11 and 21 slightly and reduced the black triangle between her 11 and 21 with some further rebracketing of her maxillary central incisors to bring the roots together and some IPR on her triangular shaped 21 as well to flatten the contact point and close those spaces with a six unit powerchain on a 018 Niti wire.

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