Fixed Anterior Alignment

Fixed Anterior Alignment by Dr Nick Simon

Dr Nick Simon is a former IAS teacher and Mentor. He was a delegate on the first cohort of the Advanced Fixed Course taught by Prof Ross Hobson, and this case won the Best Advanced Case at IAS Academy’s 2018 international symposium in London. This case shows the advantage of a systematic educational pathway and mentorship by an orthodontic specialist giving advice and confidence to the treating dentist—in this case, Prof. Ross Hobson from IAS Academy’s online mentoring forum.

CONTACT INFORMATION

Straight White Teeth London
6 Drayton Green Road,
West Ealing,
London,
W13 8RY

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Case Study: MK

Background

My patient was referred by her friend, who had completed orthodontic treatment with me. Her chief complaint was the gaps between her teeth which she had longed to have closed since her teenage years. The patient’s gaps were hereditary, and I was cautious to plan retention carefully because the tongue is a significant soft tissue aetiological factor.

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Assessment

I didn’t have my patient turn fully for the lateral profile photo. The image shows some strains on the neck muscles, and I’ve since learnt to position the patient more favourably. Preop lateral retracted photos were also not properly orientated, and the patient had a higher lip line than the pre-treatment photos depict.

Measurement Result
Skeletal Pattern Class II Mild
FMPA Average
Lower Face Height Average
Facial Asymmetry No
Soft Tissues Details: Competent Lips, low smile line, acute NLA
Teeth Present All teeth present
Incisor Classification Class III
Overjet 1mm
Overbite 0%
Centrelines Upper and lower left by 1.5mm
Displacement on closure No
Molar Relationship Right Class I, Left Class I
Canine Relationship Right Class I, Left Class I
Crossbite No
Spacing/Crowding Upper Arch 8mm, Lower Arch 10mm

Treatment

The patient was very compliant, and her progression was smooth. I warned her before treatment that extractions may be indicated should she slip into reverse overjet. Fortunately, this didn’t happen, and Class III elastics helped to maintain positive overjet.

I am pleased that the Class I canine and molar relationships were maintained.  The initial photos may not have shown the Class I relationship.

A specialist from a previous orthodontic course recommended double fixed retainers in a large diastema case, which drew some discussion on the IAS Forum.

I recently reviewed the patient, and stability has been maintained. On reflection, there is room for marginal improvement on the tip of the upper incisors. I spent some time improving the detailing with repositioning brackets, and I have since identified detailing my wire bending skills as a new learning target.

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Case Study: SS

Dr Nick Simon is a former IAS teacher and Mentor. He was a delegate on the first cohort of the Advanced Fixed Course taught by Prof Ross Hobson, and this case was mentored by Zaid Esmail, an orthodontic specialist and IAS Advanced Course mentor, on IAS Academy’s Advanced Post-Training Forum.

Assessment 

The patient presented with class I, division 2 incisors, increased overjet, increased overbite and other issues.

Measurement Result
Skeletal Pattern Class II Mild
FMPA Low
Lower Face Height Average
Facial Asymmetry No
Soft Tissues Competent lips, acute NLA, low smile line
Teeth Present 8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8, 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7
Incisor Classification Class II Div 1
Overjet 12mm
Overbite 70% overlap and complete
Centerlines Coincident Upper, Deviated Lower, Right by 1mm
Displacement on closure No
Molar Relationship Right Class II Full, Left Class II Full
Canine Relationship Right Class II Full unit, Left Class II Full unit
Crossbite No
Spacing/Crowding Upper Arch 1mm, Lower Arch 1mm

Planning

I planned extraction of both upper first premolars, followed by treatment with an upper Nance appliance and fixed braces with teeth whitening and composite bonding to upper anterior teeth to complete.

Treatment

I extracted the upper first premolars and first fitted a Nance appliance (for increased anchorage) before fitting a 3M upper fixed appliance with Unitek Gemini brackets. Here, you can see the laceback on the upper first molar and second premolars and a power chain running from the upper second premolars to the upper canines.

Here you can see the canines are now retracted and the full power chain applied.
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Case Study CW

Dr Nick Simon is a former IAS teacher and Mentor. He was a delegate on the first cohort of the Advanced Fixed Course taught by Prof Ross Hobson.

My patient felt like she needed orthodontics as a child but had missed out. She presented with severe crowding, which detracted from her smile and left her low on confidence.

Pre Treatment
Pre Treatment
Pre Treatment
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Pre Treatment
Measurement Result
Skeletal Pattern Class I
FMPA Average
Lower Face Height Average
Soft Tissues Details: competent lips, acute NLA, average smile line
Teeth Present 8 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7 8, 7 6 5 4 3 2 1 | 1 2 3 4 5 6 7
Incisor Classification Class I
Overjet 4mm UL1
Overbite 40% overlap
Centerlines Coincident upper, Deviated Lower Right by 2mm
Molar Relationship Right Class I, Left Class III
Canine Relationship Right Class 1, Left Class 3 1/4
Crossbite Yes, UR2 and UL2
Crowding Upper Arch "Severe crowding anteriorly, UR3 and UL3 high and buccal.
Posterior teeth generally aligned", Lower Arch "Severe crowding anteriorly, LR3 blocked out of arch buccally and mesially inclined, LR1 mesiolingually rotated
Posterior teeth generally aligned"

Case Planning

I planned to use upper and lower fixed appliances following the extraction of all the first premolars. I planned to use upper Nance and lower lingual arch appliances as I knew the inclination of the canines would create high anchorage demands. I felt the patient would need upper and lower retainers and planned to review her retention progress regularly after treatment.

Treatment

Once the canines were sufficiently retracted, I ligated the upper and lower incisors into the bracket slots. The upper Nance and lower lingual Arch were removed once I had run through the complete wire sequence and into 0.019” x 0.025” NiTi wire, and the lower centreline had been established.

At bond-up, the upper and lower incisors were only minimally engaged to prevent them proclining. Lace-backs were applied at each quadrant between the first molars and second premolars. A power chain was used to retract the canines from the laced back second premolars. Upper Nance and lower Lingual Arch appliances were used to provide additional anchorage.

Mid Treatment
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Outcome

The patient was pleased with her treatment and said it had a positive impact on her day-to-day well-being and confidence. IAS mentors were instrumental in helping me achieve success with this case. 

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