Dr Kate Walker presents her alignment of the anterior dentition for a 64-year-old patient with a high risk of gingival recession.
Presenting Complaint
A 64-year-old woman presented with concerns about the aesthetics of her dentition. She expressed that she “hated” her anterior teeth, especially her UL1, which she felt had moved and become prominent over a number of years.
The patient also had a veneer on the UL2. The margins of the veneer were becoming visible and a shade discrepancy had developed between the veneer and her natural teeth.
After an interest in orthodontic treatment was expressed, a full clinical assessment was carried out.
Assessment
Extraoral Examination
The patient was assessed to have a mild Class II skeletal relationship. Lips were competent at rest, and the upper lip was forgiving enough that she didn’t have a high smile line.
The smile showed a slightly discoloured veneer compared to the natural teeth, and some mild crowding.
Intraoral Examination
The patient was a regular patient for general dentistry, and consistently maintained an excellent level of oral hygiene over the years. She did, however, have a thin gingival biotype and was prone to recession; this had stabilised somewhat over the past 10 years.
There was mild crowding in both the upper and lower arches. Class 1 molars and canines on the right side; the left side was 1/2 unit Class 2 molars and canines. The left premolars were in crossbite; possibly due to arch discrepancy and the upper arch being a narrower/more triangular arch-form compared with the lower arch. The incisal relationship was Class 1. Overjet was 2mm and the overbite was slightly decreased.
As mentioned previously, mild recession was present on the upper incisors and canines, as well as the lower incisors. There were also abfraction lesions on the upper canines and premolars, and the lower premolars and molars.
A space analysis was carried out using Spacewize+, the diagnostic digital crowding calculator.
Radiographs displayed adequate bone health, and no dental pathology, making her an ideal candidate for orthodontic treatment.
Treatment Objectives
We initially discussed full comprehensive treatment, treating both arches to relieve crowding, align, level, achieve a better overjet and overbite. We discussed the higher risk of recession and black triangles due to the shape of the patients teeth, the history of previous recession and thin biotype, and also the patients age.
An alternative treatment option included only treating the teeth which bothered the patient the most; in this case it was the UL1 and the upper anterior teeth. Although there may still be a risk of recession and black triangles, this would be minimised as only a few select teeth would be moved. We would also aim to replace there UL2 veneer post aligner treatment, and close any black triangles with composite bonding.
The patient decided to proceed with aesthetic alignment of the upper anterior teeth only, and not to treat the lower arch. She also opted for aligners over fixed braces due to aesthetics. After discussing the comparative treatment times with the above options, she opted for ‘realistic’ treatment as opposed to ‘idealistic’ treatment.
Treatment Plan
The patient opted for Reveal clear aligners. The initial set-up moved the premolars, and after a few proposed treatment simulations we decided on one which would only move the UL1/2 and use interproximal reduction (IPR) at select points in the dentition to facilitate movement.
The treatment plans were initially presented to my mentors at IAS Academy, who supported the refinement of each potential approach. Through insightful, guided discussion, we concluded that not only would a single arch treatment reduce the chances of gingival recession, but it would be beneficial to target the problematic anterior teeth alone.
The patient was advised that if excessive recession was observed, for both oral hygiene and aesthetic purposes, treatment would cease. Informed consent was provided, and aligner treatment could begin.
Treatment Progress
After approving a simulated treatment plan, A single attachment was placed on the UL1 with composite resin to guide movement. IPR was carried out at three sites, with a minimal 0.3mm used to facilitate movement.
The patient was provided with the first sets of aligners, and advised on how to maintain an effective oral hygiene routine throughout her treatment.
The patient returned for new aligners and a review of her progress every 6 weeks. There was some discomfort in the first few days of fitting the first aligner, but the patient was to instructed to take paracetamol as required.
Each aligner was worn for two weeks. As this patient was at a greater risk of gingival recession, the slower approach, with more minimal changes, would reduce the extent to which the soft tissue was affected.
The patient was exceptionally compliant with both the instructions to wear the aligner and with her oral hygiene routine.
Near treatment end, it was necessary to replace the UL2 veneer. The patient was referred directly to the dental laboratory for an optimal shade match, who returned the new veneer for placement. The original veneer was designed to not only improve the position of the tooth, but mask dark fluorosis present on the underlying structures. This latter aspect unfortunately affected the final result. Whilst the patient was happy with the restoration, concern about the present discolouration was shared, and she agreed that further time spent to rectify this would be beneficial.
A replacement veneer was placed, with the patient and dental team delighted with the outcome.
Refinement focused on the positioning of the UR1-2. Further IPR was carried out at these sites, and composite bonding was introduced to mask the black triangles that developed as a result of the minimal recession.
Following this, a composite veneer was placed onto the UR2 to match the UL2 veneer, and I also bonded the cervical lesions of the upper centrals; because they were triangular teeth, the risk of black triangles increased after orthodontic care, and composite bonding here secured an aesthetic finish.
A fixed retainer was placed on the UR2-UL2 and removable retainers were provided to be worn at night.
Reflecting on care
I was pleased with the final result, and delighted with the patient’s response, proudly smiling again.
It is sometimes easy to aim for perfection and a clinical ‘ideal’, however, by simply addressing the patient’s concerns, whilst taking into account her age and recession risk, simple movements of the teeth delivered a brilliant result. I feel it highlights the fact that simple treatment, with the right case selection, should not be overlooked. It can make all the difference to a patient, and this must not be undervalued.
I really appreciated the confidence and support offered by mentors at IAS Academy when it came to this case. It was my first clear aligner case that I took on after completing the Confident Smile Makeover Masterclass with Dr Tif Qureshi, IAS Academy founder and clinical director. I was always able to ask questions about how to progress with treatment, and felt confident in forming a methodical, structured approach as a result.
For more information on upcoming IAS Academy training courses, please visit www.iasortho.com or call 01932 336470 (Press 1)
