Orthodontist Case Study with John Booth BDS

Introduction

Since graduating in 1992 I had done little in the way of orthodontics. However, the teaching methods and mentorship provided by the IAS Academy has given me the confidence to treat some relatively straightforward cases. From the initial full orthodontic assessment and throughout treatment, feedback and guidance is provided via the online forum based on photographs posted as treatment progresses. The following case was my first upper and lower arch ClearSmile Aligner 2.0 case.

Assessment

A 42-year-old patient attended the practice concerned with the appearance of her lower left lateral, which was lingually placed, over-erupted and discoloured due to staining. She was a regular attender to both the dentist and hygienist and medically fit and well.

On examination she had a Class I incisor and molar relationship on a Class I skeletal base. Mild crowding was present in the upper arch and moderate crowding in the lower arch anterior. Periapical radiographs showed normal root morphology and bone levels.

Treatment planning

Full mouth photographs were taken, study models created and Spacewize+ arch evaluation software used to calculate the amount of crowding present. It was clear at this point that both arches would need to be treated to achieve the desired result.

All possible treatment options were discussed with the patient, including ClearSmile Aligner, ClearSmile Inman Aligner or referral to an orthodontist for gold standard specialist treatment. The patient was uninterested in fixed braces because of their appearance and was concerned only with the anterior arch alignment. After researching the different methods suggested, she decided that the ClearSmile Inman Aligner might be too bulky and affect her speech too much. The patient therefore opted for the ClearSmile Aligner 2.0, as this seemed the least intrusive.

The technique involved, estimated treatment length and the process of interproximal reduction (IPR) and predictive proximal reduction (PPR) was fully demonstrated and explained to the patient at this point, who was keen to go ahead with ClearSmile Aligner 2.0 treatment for both the upper and lower arch. The limitations of the treatment modality were highlighted, including gingival levels and the potential for uneven incisal tips, which could be bonded at the end of treatment. The need for long-term retention was also discussed at this initial stage and photographs of a bonded retainer and Essix retainer were shown to the patient.

Silicone impressions were taken using a two-stage technique with a thin polythene spacer. The impressions were sent to the lab for an Archwize evaluation and 3-D printed models to show the patient at the next visit. This is an invaluable step in the process, because it enables the patient to see the predicted results and discuss any compromises to treatment such as centre lines, overjet/overbite and possible black triangles.

The printed models and Archwize analysis were shown to the patient and she was happy to proceed. Treatment was estimated to take 24 weeks to complete, with 0.3 millimeters of IPR required in the upper arch and 3.5mm IPR in the lower. The lab was instructed to proceed with fabrication of the appliances.

Treatment provision

During the fit appointment, force drivers were bonded to the lower 4's using the template provided, IPR/PPR was carried out as per prescription and the patient was instructed on fitting and removing the aligners.

The patient was reviewed at 2 weeks and everything was progressing as planned. A further appointment was arranged for 2 weeks later and when the final aligner had been worn for a week, silicone impressions were taken for box 2 of the upper and lower ClearSmile Aligners. Further IPR/PPR was carried out at the fit of aligner 7.

After upper aligner 12, a box of finishers was needed to close the space between 21 and 22. Composite edge bonding was performed on 11, 12 and 21 and a bonded retainer was fitted with an Essix retainer provided to position over the top.

The lower arch required another box of aligners, which were fitted after 0.1mm of IPR was carried out between the premolars. Following this box, a lower bonded retainer was fitted, again with an Essix over the top. The patient was very happy with the end result and said, "I just can't stop smiling!"

Mentorship

The support received from the IAS Academy mentors was invaluable. By uploading photographs of the case as it progresses to the online forum, the tutors are able to see how the teeth move week by week. From start to finish having experienced practitioners to provide help and guidance was very reassuring.

Case self-appraisal

I found that accurate IPR was essential for smooth case progression. This involved lots of digital calliper measurements during treatment. IPR/PPR during the first visit was the most crucial and predictable before the teeth became mobile. Using interproximal strips alone didn't give me a reliable amount of reduction, but the use of discs, a leaf gauge and digital callipers worked very well for me.

Both the patient and I were happy with how things progressed and the final outcome. Being able to offer this minimally invasive treatment option to my patients is proving invaluable.

The ClearSmile Aligner 2.0 course is the recommended second step in the GDP's journey in developing their orthodontic skills through the IAS Academy training pathway.

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