Dr Eamon O’Reilly: Complex Orthodontics

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Dr Eamon O’Reilly: Addressing complex orthodontics without orthognathic surgery

A 32-year-old male patient presented with concerns regarding the appearance of his smile. He had previously attended the practice and received a small amount of restorative dentistry, but his general oral hygiene was good.

Assessment

A comprehensive intraoral assessment was conducted (Table 1). Crowding was recorded in both arches – 2mm of crowding in the lower labial segment, 8mm in the lower buccal segment, 10mm in the upper labial region and 3mm in the upper buccal region.

Some tooth wear was identified, as was a reverse Curve of Spee in the lower arch and triangular-shaped upper and lower incisors. An occlusal cant was also present, though this was of no concern to the patient.

Clinical photographs were taken along with a radiograph, from which no abnormalities were detected. During the examination, the lower face height appeared increased on a skeletal Class II base, so a ceph X-ray was also taken to assess it, confirming a class II skeletal appearance with an average lower face height.

All the possible treatment options were discussed with the patient, including the potential advantages, disadvantages and limitations of each. It was explained to the patient that in order to achieve the very best result, orthognathic surgery would be required to correct the maxillary and mandibular hypoplasia.

The patient was not keen on surgery and was consequently willing to accept a slightly compromised outcome. We therefore planned fixed orthodontic treatment, with possible restoration of the damage caused by tooth wear, and tailored our approach to optimise results.

Treatment

We planned the treatment in detail before commencing and ensured that the patient understood each step of the procedure. Once informed consent was obtained, we were able to get started.

Initial treatment consisted of extracting the lower 5’s and the UL4, followed by retraction and space closure. Clear brackets were bonded onto the upper and lower arches as per our plan. The anchorage requirements were high, so a nance arch on the uppers 6’s was added to help.

Placement of the bracket on the UL7 was designed to provide increased anchorage and to help address both the crossbite on the UL5 and the angulation of the UL3. A chicane was used to bring the UL2 into alignment and the archwires ran through. Class II elastics were utilised very successfully to take the canines to a Class I.

Interproximal reduction (IPR) was performed progressively throughout treatment to create space for tooth movement, particularly among the upper anterior teeth. The standard archwire sequence recommended by IAS Academy was followed to ensure a safe and predictable process.

Once alignment was complete and the patient was satisfied with the results achieved, the brackets were debonded and impressions taken. Fixed retainers were bonded to both the upper and lower arches, and removable retainers were provided for night time wear.

At this point, restorative solutions to address the damage caused by previous tooth wear were discussed again with the patient. Composite edge bonding was provided on the upper anteriors to improve the shape of the teeth and create a more even appearance. As per the ABB (Align, Bleach and Bond) Concept, tooth whitening was also offered, but the patient declined, happy with the aesthetics as they were.

Case appraisal

This was a challenging case and several complications were overcome thanks to careful planning and continuous guidance from Professor Ross Hobson (a Specialist Orthodontist with IAS Academy). Key difficulties included a missing lower incisor upon presentation and complex extractions given the position of the teeth.

The upper left central was also slightly discoloured and there was a risk of this devitalising during treatment – though this did not happen thanks to vigilant monitoring.

In terms of the result achieved, the overbite has not been fully reduced, so in a perfect world I would have liked to continued treatment for a little longer. In addition, the patient found treatment difficult initially, so in hindsight, it may have been useful to manage his expectations differently.

Despite this, the result was a good one, especially considering the complexity of the case. The patient was very pleased with the outcome and his opinion is ultimately the one that counts regarding treatment success.

Author:

Dr Eamon O’Reilly graduated in 2009 and worked in Northern Ireland for five years before moving to a practice in Navan, Ireland. He has a keen interest in cosmetic dentistry, having undertaken further training in orthodontics, restorative dentistry and smile development utilising minimally invasive techniques.

Dr O’Reilly currently offers clear aligners, cosmetic braces and comprehensive orthodontics for both children and adults. For more information on upcoming IAS Academy training courses, including those for the Inman Aligner and Aligner system, visit www.iasortho.com or call 01932 336470 (Press 1)