Treatment modalities for Upper Arch Moderate Crowding and Lower Arch Mild Crowding

Treatment carried out by Dr Funmi Sijuwade

Dr Funmi Sijuwade has had about 16 years of extensive dental experience in both hospital and general practice. She has a post-graduate certificate in Cosmetic and Aesthetic Restorative Dentistry and is currently studying for a Masters’ degree in Restorative and Aesthetic Dentistry at the prestigious University of Manchester. Funmi is a full member of the British Academy of Cosmetic Dentistry (BACD), has a special interest in aesthetic dentistry and is passionate about preventative care. She is very good at putting anxious patients at ease and is dedicated to the provision of high standard quality dentistry with patient care being of paramount importance.

CONTACT INFORMATION

Bucklersbury Dental Studio Hertfordshire
27 Bucklersbury
Hitchin
Hertfordshire
England
SG5 1BG

Website: Click Here

I have always been passionate about minimally invasive treatment and now, thanks to the IAS Inman Aligner, I am able to provide an alternative orthodontic solution that is safe, gentle and effective for my patients. Aligning teeth before restoration affords the dentist an opportunity to be minimally invasive, yet able to produce an aesthetic smile that suits patients’expectations. I find the IAS Inman Aligner appliance a very useful tool in achieving this; it is a single, simple appliance both for the dentist and the patient. Plus, it is removable, which encourages patient compliance and is more time-effective than traditional fixed orthodontic brackets.

In this case, a 41-year-old male patient presented to the practice to discuss treatment options to correct the appearance of his anterior teeth. The patient’s notes showed that buccal composite fillings had been placed in the past on UR2, UR1, UL1 andUL2–which had become stained and worn–and that he had undergone root canal treatment eight years ago on UR2 as a result of pulpal necrosis. Examination revealed attrition to UR1, UL1, LR2, LR1, LL1 andLL2 with distal caries present inUL1. The patient is a self-confessed tea and coffee drinker, smoker and only brushes once a day.

Orthodontic Assessment

The orthodontic assessment revealed moderate anterior segment crowding in the upper arch with a palatally displaced UL2, distolabially rotated UR2 and a slight labial tilt of UL1. In the lower arch, there was a slight buccal displacement of LL1and mild crowding with a midline shift to the right. (Table 1.)

Measurement	Result
Skeletal	Class I
FMPA	Average
Lower Face Height	Average
Facial Asymmetry	No
Soft Tissues	Low lip line and coronal gingival zenith of central incisors
Overjet	3mm
Overbite	30 per cent overlap of incisors
Displacement on Closure	None
Incisor Relationship	Class I
Molar Relationship	Right: Class II 1/4 \| Left: Class II Full
Canine Relationship	Right: Class II 1/2 \| Left: Class II 3/4
Teeth Present	7654321 \| 7654321 \| 12345678 \| 1234567
Centrelines	Deviated to the lower right by 3mm

After discussing the advantages and disadvantages of the various orthodontic treatment options the patent opted for an Inman Aligner. The ideal outcome was to align the anterior teeth and shift the midline to the right, but due to limitations in tooth movement, the upper arch was never going to perfectly align with the mandibular midline. The patient was, however, happy with this compromise.

Using the IAS Academy’sSpacewize+arch evaluation software, I calculated that approximately 3.5 mm of space was required in total, which was achieved by interproximal reduction (IPR) of UL1, UL2, UL3, UR1, UR2 and UR3. I also used the Archwize orthodontic planner, which was a valuable communication tool in showing the patient the projected outcome

Treatment

Appointment
One	Clinical examination carried out and took radio graphs and photographs. • Patient diagnosed and treatment options discussed . • Referral letter sent to specialist endodontist for second opinion on UR2.
Two	Took impressions for study models and IAS Inman Aligner . • Old distal composite filling and caries removed, and GI filling placed as an interim therapeutic restorat ion (ITR) at UL1 . • Teeth scaled and polished by hygienist and fluoride varnish applied . • Provided dietary counselling .
Three	Dietary advice reassessed and analysed to ensure patient compliance . • Initial interproximal reduction and removable orthodontic appliance fitted – patient advised to wear for at least 16 hours a day .
Four	Took impressions for upper Essix retainer (doubled as whitening tray) and lower whitening tray . • Teeth scaled and polished and oral health information given .
Five	Whitening trays fitted, gel applied and instructions given for bleaching .
Six	Whitening review . • Took impressions for cast model for diagnostic wax up .
Seven	Verified model mounted in centric occlusion . • Silicone matrix made from diagnostic wax up filled with temporary composite . • UL1 ITR removed as well as old composite restorations. • UR2, UR1, UL1 and UL2 etched using 37 per cent phosphoric acid and the total etch technique – bond and primer also applied and cured . • Distal - palatal and palatal composites placed on UL1 and UR2 . • Silicone matrix made from the wax up to use as a guide. HR composite placed at UR2, UR1, UL1 and UL2 using the polychromatic layering technique with dentine shades UD2 and UD1 and enamel shade s UE3 and OB to create the mamelons at the incisal edge. Composite added to incisal palatal edge of UR3 and UL3 to maintain shallow canine guidance. • Checked occlusion and initial finishing and polishing done . • Took impressions for fabrication of clear retainer and fixed bonded retainer
Eight	Two - week review – patient was happy with the outcome. • Final polishing completed using three micron and one micron polishing paste and cup and interdental finishing strips used. • Fixed retainer bonded to upper labial arch. • Took impression s for soft occlusal splint.
Nine	Occlusal splint fitted with postoperative instructions given. Dietary and interdental cleaning advice given. Post treatment photographs taken.

Case Summary

In the finishing stages, otherwise known as the maintenance phase, orthodontic retention was crucial to preventing relapse, especially as research suggests that there is a high risk of relapse in the upper anterior region. An occlusal splint was also necessary to protect the restorations. Altogether, the patient was very pleased with the final result of the restoration.

Self-appraisal

AlthoughI had initial reservations about using composite as I felt that ceramic would have been more aesthetically pleasing, I too am happy with the outcome, especially as literature cites composite as a suitable restorative material for worn dentition. It is also important to note that composite can be easily repaired, and if in the future the patient decides to have porcelain restorations, they can still be done. In spite of the financial and time challenges expressed by the patient, I made sure that there were no compromises in following necessary protocols such as EDEC (Examine, Design, Execute, Check), which proved invaluable to the final result.