Fixed and removable orthodontic appliance case study


Dr. Andrew Wallace uses the principles of “smile design” for a patient seeking cosmetic improvement of his upper and lower teeth

A patient’s own self-perception and body image can be a motivating factor for cosmetic treatment, including cosmeticdentistry and orthodontics (Davis, Ashworth, and Spriggs, 1998), and patients expect to have an improvement in posttreatment (Pabari, Moles, and Cunningham, 2011). It has been shown most patients do see an improvement in body image and self-esteem after treatment (Pabari, et al., 2011) (Gazit-Rappaport, Haisraeli-Shalish and Gazit, 2010).

Dental appearance can have a significant effect on the patient’s self-perception and social interaction (Davis, et al, 1998). Dental professionals in respect to cosmetic dentistry often focus on providing the patient with an idealized smile — translating the elements of a beautiful smile into proportions, ratios, rules, etc., that can be easily conveyed to a dental technician, easily reproduced, easily taught and remembered (Schabel, Franchi, Baccetti, and McNamara, 2009; Ward, 2007). This rigid adherence to smile design principles may in some circumstances result in patients having overtreatment and unnecessarily destructive dentistry (Qureshi, n.d.). Moreover several studies showed that the patient’s goal is a natural smile (Davis, et al., 1998), and that smiles that do correspond to these idealized principles are not actually viewed as any more esthetic  (Schabel, et al., 2009).

It has been shown that there can be a low correlation between what a clinician believes requires esthetic correction and the patient’s view (Tortopidis, Hatzikyriakos, Kokoti, Menexes, and Tsiggos 2007). Less invasive alternatives can offer significant advantages in financial and biologic cost (Burke, et al., 2011), and while they may not be viewed by the clinician as the perfect result, they can satisfy the patient, particularly if they have been involved in the decision-making process (Nalbandian and Millar, 2009; Spear, 2004). Minor deviations from the ideal are generally not noticed (Kokich, Asuman Kiyak and Shapiro 1999).

The knowledge of the principles of “smile design” should be used to aid in the planning process and help determine where a smile deviates from the ideal, but an ideal smile may not necessarily be the ultimate goal. In my view, our goal in esthetic dentistry should be a smile that the patients view as meeting their esthetic goals and requires the least amount of tooth tissue loss at a reasonable cost, rather than necessarily being able to stand up in front of our peers and present the perfect case or gain accreditation or praise from our colleagues in an organization or academy, although some more forward-thinking organizations are now updating their accreditation requirements. A progressive approach (Qureshi, 2002), where the smile is gradually improved and the patient is allowed to see and assess the improvement before committing to the next stage, is a sensible and pragmatic approach.

Case study

Presenting condition

A 22-year-old male attended the practice as a new patient seeking cosmetic improvement of his upper and lower teeth. His main concern was the crookedness of his upper and lower front teeth. He requested treatment with removable orthodontic appliances, if possible. He had not had any form of orthodontics prior to this. Examination was carried out, and orthodontic records were taken (see photos and assessment).

Figures 1A-1L: Pretreatment images


Dental Class 1 on a skeletal Class 2 with moderate upper crowding and moderate lower crowding. Dental midlines were non-coincident, and the upper midline was canted to the patient’s right. He had a minimally restored dentition with good oral hygiene.

Treatment options

The treatment options were discussed for anterior alignment of the patient’s teeth. These options included:

  • Inman aligner
  • Clear aligners
  • Fixed appliances with tooth-colored brackets and wires.

Other options discussed restorative treatment, including indirect porcelain restorations, including the possibility of elective endodontics on at least two teeth.

The advantages and disadvantages of the alternatives were discussed, including the differences in outcomes and where the compromises of each outcome lay. The patient opted for orthodontics using fixed appliances with clear brackets, as the outcome we expected with these was closer to the patient’s goals.

Potential adverse outcomes were detailed, as was the need for slenderizing the teeth using IPR and Predictive Proximal Reduction (PPR). The possibility of “black triangles,” the need for edge bonding, and lifetime retention were discussed, and the patient agreed to the treatment.

I consulted with an orthodontic mentor about the case, and we agreed the treatment objectives were possible using the system, including that the right side crossbite was related to the angulation of the teeth on the right side and that this could be corrected by uprighting the teeth. A crowding analysis was carried out, and from this prescription, a predicted outcome was carried out using 3Shape® software by the lab, and these diagrams were used to further relay to the patient the expected outcome. I feel this is an important step where the main objective in seeking treatment is a cosmetic one. An indirect bracket-bonding setup was carried out by the lab and was fitted at a subsequent appointment.

Treatment carried out

Treatment took a total of 7 and a half months in fixed appliances; the patient was seen at 4 weekly intervals where progress was assessed, IPR was carried out as required with the total amount required having been determined by the laboratory beforehand, and the wires changed.

Records taken at each appointment included: IPR carried out, wires used, and patient complaints and questions were addressed. Particular attention was paid to the shape of the teeth during IPR and PPR so that they were detriangulated to reduce the risk of black triangles. Detriangulation of bulbous teeth allows for a longer contact point, closer to the underlying crestal bone, thus reducing the risk of lack of papilla infill in the gingival embrasures. At regular intervals, I consulted with mentors on case progress using digital photography and records.

Following debonding of the appliances, the patient had removable retainers fitted immediately, had in-surgery Zoom whitening shortly after, and subsequently, fixed bonded wire retainers were made and fitted. Removable retainers were fitted as well; the patient was instructed to wear full time for 3 months and during nighttime only after that.

The patient was unhappy with the shape of the canine teeth, and these were reshaped using a single layer of Venus® Pearl (Heraeus) composite. The patient did not wish to have the incisal edge of the upper left central incisor bonded to address the minor tooth surface loss, even though this was part of the treatment plan from the outset.

The outcome of the case is shown in the photographs. The molar and canine relation remains Class I with the incisor relation Class I with overjet  3 mm and overbite 3 mm. The canted midline is corrected, and the dental midlines are now coincident.

Figures 2A-2F: 5-month review

Figures 3A-3F: 6-month review

Figures 4A-4B: Final retainers

Patient testimonial

“I was considering getting braces for a few years as I noticed my teeth were getting worse. When I was in my teens, I was told that I needed braces by my dentist; however, I didn’t like the idea of the traditional metal braces. When I noticed a dental surgery was offering braces which were clear in color, I jumped at the chance. Before my treatment, I didn’t like smiling, and my teeth didn’t help my confidence at all.

“My main concerns were my front teeth top and bottom, so I tried my best to hide them 6 months down the line, and that’s not the case anymore. My front teeth are completely straight, and even my back ones too, which I wasn’t expecting! I am amazed with the results, and I smile every chance I get now to show of my new teeth. I can’t thank the dental surgery enough; they have turned my life around, and I am extremely grateful for their help! I would definitely recommend this treatment to anyone else considering getting braces — it’s well worth the money.”

Figures 5A-5L: Final photos


We know from the literature that cosmetic dental procedures can improve patient’s own body image and self-esteem (Varela and García-Camba, 1995, Sarin, et al., 2004 ). Anecdotally, with this young man, I noticed a distinct change in attitude as his treatment progressed; he started becoming more outgoing, friendly, and confident.

With a framework in place identifying clearly what should can be treated in general practice and what should be referred to specialist colleagues, with the mentoring and support from experienced colleagues and specialists, this sort of treatment is well within the remit of adequately trained general dentists and is a very rewarding type of dentistry to provide.

Andrew Wallace, BDS (QUB) MClinDent Prosthodontics (KCL), MFGDP (RCS Eng), is a general dentist with special interest in prosthodontics and orthodontics. Having qualified from Queens University Belfast in 1998, Dr. Wallace gained his master of clinical dentistry (MClinDent) in fixed and removable prosthodontics from King’s College London in 2015. He has been a partner in Bachelors Walk Dental since 2004 and also works in the multi-award-winning Cranmore Dental and Implant Clinic accepting referrals for restorative dentistry and endodontics. Dr. Wallace is a member of the IAS Academy and a lecturer, trainer, and mentor for Clearsmile Brace and Inman Aligner systems. He is the incoming president of the European Society of Aesthetic Orthodontics, a key opinion leader for Philips Oral Healthcare, and an honorary clinical teacher in King’s College London.

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