Case study JM By Dr Preet Bhogal, Specialist Orthodontist at the London Smile Clinic

Introduction

As dental professionals, we are all aware of the difference an improved smile can make to our patients. There’s inevitably an increase in self-assurance, they’re quick to smile more frequently and this positivity impacts on almost every aspect of their lives. A large number of adults in the UK are dissatisfied with their teeth - 45% according to a recent YouGov study[1] - but are put off rectifying any problems for a number of reasons, such as lengthy treatment time and fear of pain. With a combined treatment approach, we are able to offer a bespoke solution that unites the benefits of minimally invasive dentistry and a faster treatment process to achieve excellent results.

Adult orthodontics has come a long way in recent years and has much to offer in a huge number of cases. Referring dentists are pleasantly surprised when I explain how orthodontic treatment can transform a tricky case to a very straightforward one where extractions, restorative or implant treatment is either minimal or not required at all.

History

This case report demonstrates the joint treatment of a 63-year-old female with a combined orthodontic and restorative approach. Her initial complaint was that she did not like her uneven and worn teeth and in particular “a lower tooth that was crowded out.”

When she was initially seen and examined, it was decided that a satisfactory restorative solution alone would be difficult to achieve due to her upper incisor positions and reduced overjet. This was also a likely factor in her anterior tooth wear, as she was edge to edge. She was subsequently referred for orthodontic alignment of her crowded dental arches and in particular to provide sufficient clearance for placement of new upper anterior restorations, facilitated by a positive overjet. Her medical history was clear.

Clinical Examination

The patient presented with a class III incisor relationship on a skeletal I base, with an increased Frankfort-Mandibular planes angle and increased lower face height. The upper lip line was high and she had increased gingival display on smiling. The overjet and overbite were reduced and showed an edge to edge relationship. There was mild lower arch crowding and a spaced upper arch, with a midline diastema. She had a fairly heavily restored dentition and signs of anterior tooth wear attributed to her malocclusion. Her oral hygiene was satisfactory.

Treatment Plan

Several treatment options were discussed in-depth with the patient. It was felt that a restorative solution alone to restore the worn upper teeth would not be sufficient to achieve a stable long-term, aesthetic solution. The longevity of such restorations simply could not be guaranteed due to the nature of her current occlusion. She was also unhappy with her lower teeth and preferred a more comprehensive approach to improve the look of all of her teeth, in the most conservative approach possible.

It was agreed to provide upper and lower fixed orthodontic appliances to relieve the lower crowding, reduce the upper spacing (whilst maintaining a discrete diastema) and create a normal overjet, overbite and class I incisor relationship. She was happy to have labial ceramic fixed braces and was aware that interproximal enamel reduction (IPR) was necessary in the lower arch in particular. She was also happy to wear elastics to facilitate retraction of the lower labial segment and control the correction from a class III to a class I incisor relationship. Permanent bonded retainers (PBRs) in addition to removable vacuum formed retainers (VFRs) were planned from the outset and the importance of long-term retention of the final result was stressed. The total orthodontic treatment time from start to finish was five and a half months.

This was to be followed by restoration of her worn incisors and replacement of old discoloured fillings.

Post-orthodontic treatment plan

The treatment plan was revised to account for the reduced need for invasive preparation of the newly aligned teeth. Conservative anterior composite bonding and contouring was carried out using a silicone index method. The patient also had her teeth whitened.

Patient feedback

Primarily motivated by her family to change her smile, the patient is ‘absolutely delighted with the results’. She described the whole experience as ‘brilliant’ and felt fine during the treatment process, in no small part thanks to a reassuring and professional team. The patient said her new smile has exceeded her expectations and given her more confidence.

Summary

By utilising a combined orthodontic and restorative approach at the London Smile Clinic with good communication between each clinician an aesthetic, well aligned and well interdigitated class I occlusion was achieved in a conservative manner.

The result was a much-improved aesthetic and functional dentition and the total treatment duration was just under six months.

The patient was initially very reluctant to the idea of wearing a fixed appliance. This is a very common situation that can be very easily overcome in adult patients. Initially I considered offering her a lingual appliance due to her hesitation but found that she had never seen, let alone held a typodont with a ceramic fixed appliance in-situ and was pleasantly surprised at how discreet and aesthetic it actually was. Backed up by examination of treated cases and good photos, she had no hesitation in proceeding with treatment with ceramic labial appliances over lingual appliances, in this case, as she felt they were “quite attractive in fact!” I have found this time and again that people who initially opt for a more invasive treatment approach, due to the stigma attached to wearing braces as an adult, are happy to proceed with orthodontic therapy following a thorough discussion of the advantages and demonstration of the appliances up close.

This case demonstrates the simple and effective method in which a combined approach can be utilised to give a highly aesthetic and conservative result, which the patient was very pleased with. Clear, effective communication between the orthodontist and restorative dentist is essential, with each clinician working to their respective strengths.

Almost every adult patient can benefit from some form of orthodontic treatment from mild crowding through to the more complex multidisciplinary cases, often requiring surgery. We are responsible as trustworthy clinicians for providing all the relevant and appropriate treatment options to our patients, in order to provide informed consent and avoiding coercion into one particular treatment that we may prefer. As demonstrated, where there is any doubt refer to a specialist in orthodontics who can substantiate the pros and cons of the orthodontic element with solid evidence-based research.

Author

Dr Bhogal graduated from Birmingham Dental Hospital in 2000, winning the Walpole-Day Prize in Orthodontics. He then undertook several posts including Oral and Maxillofacial Surgery and Paediatric Dentistry and worked for several years in general dental practice. In 2003 he obtained Membership of the Faculty of Dental Surgery at the Royal College of Surgeons of England and in 2008 obtained his Masters in Orthodontics, MPhil (Orthodontics) and Membership in Orthodontics (M Orth) at the Royal College of Surgeons of Edinburgh. Dr Preet Bhogal is listed in the General Dental Council’s Specialist Register and therefore entitled to use the term “Specialist Orthodontist,” recognising that he has followed the highest standard of training possible in orthodontics in the UK.

Dr Bhogal has a keen interest in the field of contemporary adult orthodontics, interdisciplinary treatment and the use of aesthetic hidden braces, including clear aligner systems (e.g. Invisalign) and lingual fixed appliances (e.g. Incognito Braces)

Follow Dr Bhogal on Twitter at @PreetBhogalUK.