Utilising fixed orthodontics with minimally invasive finishing touches

Utilising fixed orthodontics with minimally invasive finishing touches by Dr Seb Crudden

Treatment carried out by Dr Sebastian Crudden. Dr Crudden is an associate dentist at Kelly Dental Care in Derry City.


10 Clarendon St, Londonderry, BT48 7ET

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A female patient had concerns about the appearance of her smile. She disliked her upper and lower crowding and was looking for a solution. A full medical history was taken and no abnormalities were found. She had undergone orthodontic treatment as a teenager but had since experienced a relapse.

Orthodontic Assessment

As per the IAS Academy protocol, a comprehensive orthodontic assessment was conducted (Table 1). The patient’s oral hygiene was good, the gingivae were healthy and no bone loss was evident from the radiograph taken. A grade 2 gingival biotype was recorded in the lower anterior region. 

Measurement Result
Skeletal Class III
FMPA Reduced
Lower Face Height Increased
Facial Asymmetry None
TMJ None
Soft Tissues Lips forced competent, hypotonic lips, lip line normal, nasolabial angle increased
Overjet 2mm
Overbite 20%
Crossbite None
Displacement on Closure None
Incisor Relationship Class III
Molar relationship Right: Class I Left: Class I
Canine relationship Right: Class I Left: Class III ¼ unit
Teeth Present 7654321 | 1234567 | 7654321 | 1234567
Centrelines Coincident

Approximately 5mm of crowding was identified in the labial segment of the lower arch and the lower canines were mesiobuccally rotated. In the buccal segment, there was 1mm of crowding on the left-hand side. For the upper arch, 2mm crowding was recorded, with triangular central incisors.

The possible treatment options were presented and explained to the patient. The ideal treatment would have involved a surgical aspect to correct the skeletal base, as well as the upper and lower arch crowding. However, the patient was keen to avoid this and so was more than happy to accept a slightly compromised result (Table 2).

A Spacewize™+ online calculation was made to determine the overall amount of space that would need to be created – 2.44mm in the lower arch and 0.7mm in the upper – and treatment with the ClearSmile Brace was proposed.

All the benefits, limitations and risks associated with treatment were discussed in detail with the patient, who provided informed consent to get started.

Problem List
Class III Skeletal base
Class III incisor relationship
Upper and lower crowding
Reduced Overbite
Triangular shaped upper centrals (black triangle risk)
Uneven wear of upper and lower incisors
Ideal Treatment Aims
Correct to Skeletal Class I
Achieve Class I with incisors, canines and molars
Normal Overbite
Upper and lower crowding
Relieve upper and lower crowding
No black triangles
Restore worn incisor edges
Compromised Treatment Aims
Maintain overbite and improve with composite edge bonding
Relieve 6-6 upper and lower crowding only
PPR to reshape upper centrals (no black triangles)
Restore worn incisor edges


The ClearSmile Brace was bonded in October 2018 and the standard IAS Academy archwire sequence was followed. Progressive proximal reduction (PPR) was performed on the central incisors to encourage tooth movement and de-rotation as and when it was required. The lower incisor brackets were repositioned approximately 5 months into treatment in order to further improve the movement of the teeth.

The patient remained compliant with oral health instructions throughout treatment and attended all review appointments as scheduled. By September 2019, she was very pleased with the alignment achieved and we agreed together to bring this phase of treatment to a close. Impressions were taken for a bonded retainer, which was fixed a few weeks later during the debond appointment.

In November 2019, composite edge bonding was performed on the canines to enhance the aesthetics of the teeth and finish off the treatment. The patient was delighted with the result.

Case Appraisal

I was very happy with how this case progressed, and the patient was delighted with the result. I was surprised at how quickly the power chain sling moved LR1 buccally, fortunately, causing no buccal recession. (The patient had been warned that this was possible due to her thin gingival biotype.) It was great to learn how to use this, and it increased my confidence in providing fixed anterior aesthetic alignment solutions for more patients.

I thought that I would need two clear finishers at the end to align the LR1. However, between debonding the lower brackets and fitting the temporary Essix retainer, LR1 aligned on its own.

In hindsight, I would have liked to keep the upper brackets on for another two weeks to retract the upper centrals and laterals more. However, the patient was happy, and I had been advised to debond as quickly as possible in order to reduce the risk of gingival recession given the thin biotype. I would have also placed the composite bite guards on the palatal cusp of the upper second molars rather than the lower second molars. Finally, I hope to improve my dental photography skills in order to enhance the images for my records and marketing materials.

Pre treatment
Post treatment
Pre Treatment Right Lateral
Post Treatment Right Lateral
Pre Treatment Left Lateral
Post Treatment Left Lateral
Pre Treatment Upper Occlusal
Post Treatment Upper Occlusal
Pre Whitening
Post Whitening