Correcting malocclusion and improving self-esteem – Annika Patel

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  Posted by: Dental Design      6th August 2019

A 45-year-old male presented with a Class I incisor relationship on a Class I skeletal base, with average vertical proportions. His malocclusion was complicated by generalised spacing in both arches, tooth surface loss associated with the mesial aspect of the upper right central incisor and a midline diastema of 6mm exacerbated by a prominent upper labial frenum. The chief patient complaint was the spacing between teeth, which was affecting his self-esteem.

Treatment with an upper and lower Incognito lingual appliances – 3M Oral Care – (0.0182” x 0.025” slot) was indicated to facilitate space closure. An upper midline frenectomy and restorative camouflage of the UR1 and UL1 with home whitening and conservative edge bonding were recommended to enhance aesthetics.

The patient was fit and well, with no known drug allergies and no current medications. He had an average Frankfort-Mandibular plane angle, average lower facial height proportions, average nasio-labial and average labio-mental groove. The lips were incompetent at rest with 5mm incisal show at rest and 6mm incisal show when smiling.

The soft tissues were pink and healthy and fair generalised staining was identified. The unrestored dentition was caries-free, with some tooth loss on the mesial aspect of the UR1. There was a Class I incisor relationship, a 2mm overjet and 2mm overbite. The upper centreline was coincident with the mid-facial axis, while the lower centreline deviated 1mm to the left. With regards to crowding, 10mm of space needed to be created in the maxillary arch and 7mm spacing was required in the mandibular arch.

Problem list

• Generalised staining
• Generalised spacing in both arches
• Prominent upper midline frenum
• Tooth Surface Loss (TSL) associated with the mesial aspect of the UR1
• Centreline discrepancy (lower to the left by 1mm)

Aims and objectives of treatment

• Maintain a good level of oral hygiene throughout treatment
• Level and align both upper and lower arches
• Upper mid-line surgical frenectomy to aid in stability of space closure post- treatment
• Orthodontic space closure in both arches using fully customised, fixed lingual appliances (Incognito)
• Correct the lower dental centreline
• Class I incisor, canine and molar relationship
• Create a functional, aesthetic and stable end occlusion
• Indefinite retention with bonded retainers and vacuum formed removable retainers

Treatment plan

Appliances and additional treatment
• Appliances to use upper and lower Incognito lingual appliances from 3M Oral Care (0.0182” x 0.025” slot)
• Restorative edge bonding of the UR1 and UL1 with home whitening to improve aesthetics and reduce the amount of orthodontic space closure by 2mm

Proposed retention strategy
• Upper and lower bonded retainers
• The patient will be asked to wear upper and lower vacuum formed retainers at night-time for 6 months. Lifelong retention advice will be given for indefinite wear 1-2 nights per week after the first year.

Prognosis for stability
• The need for long-term retention was discussed at the start of treatment with the patient
• Good Class I interdigitation between the upper and lower arch, will aid stability
• The need for an additional upper midline surgical frenectomy was discussed at the start of treatment
• Discussed need for lifelong maintenance of the restorative treatment

Treatment began in May 2015 with the taking of impressions for tooth bleaching trays with Enlighten Home Whitening. A diagnostic wax-up of the predicted outcome was created and direct composite bonding was added to the UR1 and UL1. The following month, silicone putty heavy body and light body impression materials were used to take impressions for fabrication of the fully customised Incognito lingual brackets and archwires.

The appliances were bonded onto the upper and lower teeth with 0.014” Nickel Titanium (NiTi) archwires used for initial levelling and alignment. Within two months, the archwires were replaced with 0.016” x 0.022” NiTi for final levelling and alignment, with stainless steel ligatures on the upper and lower anterior 3-3 to prevent any tipping during alignment. These were changed for upper and lower 0.016” x 0.022” S/S two months later. An elastomeric chain was fitted on the upper and lower 3-3 to encourage intra-arch space closure and the upper anterior anchorage was reinforced with extra labial crown torque between the UR2 and UL2.

Over the next few appointments, an upper midline surgical frenectomy was performed under local anaesthetic with Dr Clare Gleeson. The archwires on the upper and lower arches were replaced with 0.016” x 0.024” S/S, encouraging space closure in both arches with a new elastomeric chain. Bilateral intermaxillary class III elastics were also provided for the patient to wear at night only, in order to allow for space closure and maintain a class I incisal relationship.

The upper and lower lingual brackets were debonded in June 2016 and bonded retainers for the upper and lower 3-3s were fabricated and fitted. Vacuum-formed removable retainers were also provided for night time wear.


In this case, treatment successfully achieved all the desired outcomes. The patient demonstrated excellent compliance with his diet and experienced no breakages of the lingual fixed appliances. However, he did present with generalised gingival inflammation, requiring a number of hygienist visits and intensive oral hygiene instruction prior to orthodontics.

In addition, the patient had a degree of macroglossia, meaning it took time for his tongue to adapt to the lingual lower appliance. The mechanics during upper and lower space closure therefore had to be performed in sections, making the treatment time relatively lengthy – although this did facilitate maintenance of the patient’s incisal and buccal segment relationship to Class I. He has demonstrated his enthusiasm and motivation and has remained a compliant and regular attender.


Figure 1 – Pre treatment smile

Figure 2 – Pre treatment anterior

Figure 3 – Pre treatment right lateral

Figure 4 – Pre treatment left lateral

Figure 5 – Pre treatment upper occlusal

Figure 6 – Pre treatment lower occlusal

Figure 7 – Mid treatment smile

Figure 8 – mid treatment anterior

Figure 9 – Mid Treatment upper occlusal

Figure 10 – Mid Treatment lower occlusal

Figure 11 – Post treatment smile

Figure 12 – Post treatment anterior

Figure 13 – Post treatment right lateral

Figure 14 – Post treatment left lateral

Figure 15 – Post treatment upper occlusal

Figure 16 – Post treatment lower occlusal



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Author bio:

BDS (London), MJDF RCS (Eng), MSc (London) MOrth RCS (Edin)
Annika qualified with both her undergraduate Bachelor of Dental Surgery degree and postgraduate Masters in Orthodontics from King’s College London.
She undertook further training in maxillofacial and oral surgery and paediatric dentistry before embarking on her specialist training in Orthodontics at Guy’s Hospital and the Queen Victoria Hospital, East Grinstead. This allowed her to treat both children and adults, requiring multidisciplinary care from other specialties. In addition Annika has treated a number of adult patients requiring the diagnosis and treatment of Obstructive Sleep Apnoea.
Her Masters research has recently been presented at a Medical World Congress in Maui, Hawaii and is due to be published in the European Journal of Orthodontics. She

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