Stephanie Oiknine presents a case study where she treated a class lll malocclusion on a mild skeletal lll base and increased vertical proportions using a fully customised lingual appliance.
Presenting case
A 30-year-old female general medical practitioner, whose main concern was the crooked appearance of her teeth wished to have the confidence to smile, without worrying of people’s perception her teeth. She had been thinking of having orthodontic treatment for many years.
Due to the ‘people facing’ nature of her profession, she was particular that the appliance must be ‘invisible’. The patient was keen to avoid any orthodontic extractions, as had been recommended by other orthodontic consultations.
Medical history: Fit and healthy
Relevant dental history:
- Idiopathic enamel hypoplasia, with no post eruptive enamel loss
- No history of previous orthodontic treatment, trauma, extractions or periodontal disease
Diagnosis
The patient initially presented with class lll malocclusion on a mild skeletal lll base and increased vertical proportions.
The malocclusion was complicated by:
- Gingival recessions with:
- Anterior crossbite in the UR3 and UL2 region without associated displacement
- Reduced overjet
- Reduced overbite
- Moderate crowding in both the upper and lower arches
- Molar relationship 1/4 unit class lll, on both left and right side
- Canine relationship 1/4 unit class lll on the left and 1/4 unit class ll on the right.
Treatment objectives:
- Relieve crowding
- Levelling and align the arches.
- Correct the overbite and overjet
- Correct crossbite.
- Finish to class 1 molars and canines
After careful assessment of the patient and the records, the following treatment plan was recommended:
- Upper and lower fully customised Lingual Win appliance.
- Interproximal reduction in the lower arch, to relieve crowding and avoid over proclination of the lower labial segment.
- Upper and lower fixed and removable retainers.
A fully customised lingual appliance allows for no compromise on aesthetics due to its complete ‘invisibility’. The manufacturers have incorporated functionality, practicality and precision, into the design concept of the system. As a result, the system is simple to use for the clinicians, easy to maintain and offers a positive patient experience.
Treatment summary
A fully customised Win Lingual appliance was bonded from second molar to second molars, in both upper and lower arches. The lower appliance was bonded at the first visit and the upper appliance was placed four weeks later, to allow the patient to adjust to the appliance.
Half occlusal pads were prescribed on the second molars and lower first premolars to compensate for low crown height. Sandblasting followed by etching was performed on the lingual aspects of all the teeth and also occlusal surfaces of the teeth, bearing occlusal pads.
An indirect bond up was carried out using silicon trays. The appliance was bonded with Maximum Cure Sealant (Reliance, Itasca, IL).
Once Maximum Cure was set, the silicon trays were lifted and excess bonding material was removed from the teeth and contact points, with hand and ultrasonic scalers. Patency of the contact points was then checked with dental floss.
Upper and lower 0.014’ Nickel Titanium (Niti) fully customised Win lingual wires were inserted and ligated with over ties behind the occlusal wings of the anterior segments. This was due to the degree of crowding, where the wire could not be fully ligated in the vertical slot.
Interproximal reduction was partially performed at the bond up appointment and was completed by the third visit. This was key in order to avoid over proclination of the lower labial segment and avoid risk of loss of attachment. Lassos were placed at alignment on 0.014’ Niti to correct rotations.
The patient was scheduled for appointments at six week intervals and was also instructed to have hygiene appointments every three months.
Wire sequence
All wires were fully customised Win lingual wires that were made as per the set up. The wires were individual wires as it was a non-extraction case. Straight wires are recommended in extraction cases, or if more than 4mm space closure is to be achieved.
The wires that were used were:
- 0.014’ Niti
- 0.016×0.022’ Niti
- 0.016×0.025’ Stainless steel
- 0.018×0.018’ Titanium Molybdenum Alloy (TMA)
The stainless steel wire was inserted after seven months of treatment and TMA wire was placed for the last two months of treatment. At this stage the occlusal pads were removed. The patient was also asked to wear triangular intraoral elastics (3/16’ 3.5 Oz by Ormco) at night, from buttons that were placed on the buccal surfaces of upper canines to the lower canines and first premolars. This is to allow for optimal occlusal settling.
Treatment assessment
The overall treatment progressed smoothly and patient compliance was excellent, with no breakages. The patient quickly adapted to the lingual brace with minimal discomfort at four weeks into treatment.
At the end of the treatment upper and lower bonded fixed retainers were placed. Essix retainers were given to be worn at on a daily night time basis for the first year, then alternate nights for the following year. As well as indefinite wear for two to three nights per week. Treatment was also completed within 12 months.
Patient testimonial
‘I consulted Dr Oiknine regarding lingual braces in February 2015. I had seen another orthodontist prior to this for a lingual brave consultation and was informed that I needed four teeth removed! That’s when I decided to seek a second opinion from the highly recommended Dr Oiknine. After 12 months, I achieved my perfect smile and managed to retain all my teeth! I found my orthodontist to be thorough, efficient, professional and she displayed great experience with lingual braces. The results speak for themselves. Thank you Dr Stephi!’
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