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Treating orthodontic relapse

27 March 2019

Treating orthodontic relapse

In this case, a 28-year-old woman presented to the practice with concerns about crowding in both her lower and upper arch. Her notes showed that she had undergone a full comprehensive orthodontic treatment five years prior to this but no retentive therapy was implemented post-treatment, resulting in a relapse. The initial examination revealed that the lower right lateral had moved considerably (Table 1).

 

Table 1. Initial examination

Skeletal

Class I

FMPA

Average

Lower Face Height

Average

Facial Asymmetry

No facial asymmetry

Soft Tissues

Healthy gingiva, no retractions

Incisor Relationship

Class I

Overjet

2 mm

Overbite

20 %

Displacement on Closure

No displacement of closure

Molar Relationship

Right:Class I

Left:¼ Class III

Canine Relationship

Right:¼ Class II

Left:¼ Class III

Teeth Present

All teeth from second molar to second molar present

Centrelines

Lower midline 2mm to the right

After the clinical examination, the patient expressed that the midline deviation was less of a problem than the increasingly anterior crowding. She also accepted a reduced overbite and slightly open bite in the right lateral area. She was informed that edge bonding could be performed on the right upper and lower laterals after treatment if she wanted (Table 2).

Table 2. Clinical examination

Problem list:

  • Mild upper and lower crowding
  • Movement of the lower right lateral
  • Cantered midline
  • Reduced overbite

Treatment aims – ideal:

  • Align upper and lower arch
  • Move and rotate lower right lateral into ideal position
  •  To achieve Class I relationships of molars and canines
  • Improve overbite
  • Remove midline deviation
Treatment aims – compromised:
  • Align the upper and lower arch
  • Accept midline deviation and the existing canine and molar relationships
  • Accept slightly reduced overbite

 

Figure 1. Pre-treatment upper occlusal.

Figure 2. Pre-treatment lower occlusal.

Figure 3. Pre-treatment smile.

 

Figure 4. Pre-treatment chin up.

Figure 5. Pre-treatment right lateral closed bite. 

Figure 6. Pre-treatment left lateral closed bite. 

Case planning

A number of treatment options were discussed in depth at this time, including comprehensive orthodontics, which she declined. Instead, the patient opted for the ClearSmile Inman Aligner for the lower arch and ClearSmile Aligner for the upper arch. To determine the suitability of using both of these appliances, the IAS Academy’s Spacewize+ arch evaluation software was utilised. This predicted that 1.3mm of space would need to be created in the upper arch and 2.7mm in the lower arch. This was within the parameters of the ClearSmile appliances, confirming case suitability. The patient received the IAS consent form regarding alternative treatment options as well.

Figure 7. Spacewize calculations for upper arch. 

Figure 8. Spacewize calculations for lower arch. 

Treatment

On receiving the appliances back from the lab, the patient was shown how to remove and apply the aligners safely. She was instructed to wear the ClearSmile Inman aligner for at 18-20 hours per day and the clear aligners all the time, except when eating and drinking. Alongside this, the patient received oral hygiene advice.

During treatment interproximal reduction (IPR) was carried out from canine to canine progressively. Predictive proximal reduction (PPR) was also performed on the most triangular teeth with a coarse polishing disc, during the first appointment. The patient was instructed to exercise reading out loud for approximately 15-30 minutes in the evening in order to improve speech while wearing the ClearSmile Inman Aligner during the day at work.

After PPR was performed in the lower arch at the first visit, a lingual anchor was placed on the right central. When the right central was correctly aligned, the anchor was removed and two further composite anchors were placed on the right lateral – one distolingual and one mesiofacial to derotate the lateral. Some flowable composite was also placed on the distal aspect of the facial bow to tighten it when the teeth were nearly aligned. In the upper arch, no composite anchors were used.

In total, eight ClearSmile Aligners were used in the upper arch, alongside ClearSmile Inman Aligner treatment in the lower. The patient was very happy with the final result achieved – she was surprised at how easily the treatment progressed and that she was capable of wearing the ClearSmile Inman aligner at work. Fixed retainers were bonded onto the upper and lower 3-3 to provide retention for life and Essix removable retainers were provided for wearing at night for at least the first year, and for 2-3 nights a week thereafter.

Figure 9. Post-treatment upper occlusal

with bonded retainer.

Figure 10. Post-treatment lower occlusal

with bonded retainer. 

Figure 11. Post-treatment smile.

 

Figure 12. Post-treatment chin up.

Figure 13. Post-treatment right lateral closed bite. 

Figure 14. Post-treatment left lateral closed bite.

Author: Erik Svendsrud, Cand odont Oslo 1987, has worked in his own private practice in Oslo, Norway since 1990 with a special interest in preventive and minimally invasive dentistry. Inspired by his mentor, Sverker Toreskog‘s way of thinking since 1993, Erik lectures around the world. He is also the former president of the SAED (Scandinavian Academy of Esthetic Dentistry).

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