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Townie Treatment Case: Sight Unseen by Dr. Robert Lee

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Categories: Orthodontics;
Townie Treatment Case: Sight Unseen 

Orthodontic treatment with hidden fixed appliances

by Dr. Robert Lee

The demand for aesthetic orthodontic treatment continues to rise in teenagers and adults, especially because of the advent of social media and the “Zoom effect.” Hidden fixed appliances, which are bonded on the lingual, can help address this increasing demand for more discreet orthodontic treatment. This case report presents a patient who was getting married and required treatment to be fully hidden on the lingual.


Diagnosis and treatment plan
The 26-year-old patient (Fig. 1) presented for a consultation with the chief complaint of crooked teeth, which he wanted to fix before his upcoming wedding. He was looking for the most aesthetic option, in case his treatment was not complete before his engagement photos and wedding, so he elected for hidden fixed appliances with InBrace instead of clear aligners or traditional braces.
Lingual Braces Case
Fig. 1

The patient presented with a skeletal and dental Class I relationship. His upper arch had minor crowding with moderate rotations in his upper lateral incisors, while his lower arch had moderate crowding. There was inadequate space to bond a bracket on UL2, LL1 and LR3 at the beginning of treatment.

The treatment objectives were to maintain the Class I relationship and resolve the crowding through a combination of interproximal opening loops, interproximal reduction (IPR) and proclination.


Treatment progress
Treatment began with indirect bonding of both the upper and lower arches (Fig. 2). Light and flexible customized archwires were engaged in the upper and lower arches. There was inadequate space to bond brackets ideally on UL2 and LL1 with the indirect bonding trays, so the archwire was bonded directly to each tooth instead. These customized archwires had interproximal loops between each tooth, so bonding the archwire directly to the tooth compressed and stretched the interproximal loops adjacent to UL2 and LL1. As the interproximal loops returned to their programmed shape, the unloading force resulted in space creation and derotation of the teeth.
Lingual Braces Case
Fig. 2

There was also inadequate space to bond a bracket or the customized archwire to LR3, so the archwire was left unligated. The unligated archwire still was partially activated because the interproximal loops between LR2 and LR4 were slightly compressed to engage these brackets, acting as an opening loop, so mild space creation was expected for LR3. About 0.1 mm of IPR was performed between U3–3 and L4–4 at this appointment, with an IPR strip to help unravel the crowding.

At the patient’s next visit, two months later (Fig. 3), upper and lower alignment had significantly improved where the archwire had created more space for LL1, UL2 and LR3. At this appointment, brackets could be direct-bonded to LL1 and UL2, and the archwire was engaged into these brackets. There was still insufficient space to bond a LR3 bracket, however, so the archwire was bonded directly to the tooth for LR3 to further compress the interproximal loop between LR2–3 and further stretch the interproximal loop between LR3–4. Another 0.1 mm of IPR was performed between U3–3 and L4–4 at this appointment with an IPR strip to help unravel the crowding.
Lingual Braces Case
Fig. 3

At six months, enough space had been created by the archwire being directly bonded to the tooth for LR3 where the LR3 bracket could be direct-bonded to its ideal position, and at eight months (Fig. 4), more rigid and larger customized archwires were placed on the upper and lower to finish out leveling and aligning.
Lingual Braces Case
Fig. 4

At 10 months, the patient was ready to begin detailing, so patient records were taken to create a new digital setup, which allowed for the fabrication of updated customized archwires to begin final detailing. In the setup, more upper and lower IPR was prescribed to continue reducing the protrusion, and final detail bends were planned into the updated customized archwires. Those included stepping down UR2 and UR3, stepping in LR2 and adding mesial-in/distal-out rotation to LR3. At 11 months, the updated customized archwires were engaged and the prescribed upper and lower IPR was performed.

At 13 months (Fig. 5), the upper detailing was complete and minor detailing on the lower remained where LL1 needed more mesial-in rotation. The remaining goals at 13 months were to increase the overbite and perform final detailing of the lower arch. However, it was observed that the patient was occluding on the upper anterior brackets, which would prevent overbite correction. This is a common challenge when finishing with lingual appliances, so the plan for finishing this case was to debond the upper arch first, to remove the anterior interference with the upper brackets, in conjunction with a second update to the lower customized archwire to perform additional detailing of the lower arch.
Lingual Braces Case
Fig. 5

At 14 months (Fig. 6), the upper arch was debonded and a fixed retainer was placed. Enameloplasty and a gingivectomy of the upper central incisors were performed. An upper retainer with cutouts on the upper lateral incisors was provided to the patient to be worn at nighttime. Buttons were bonded on the lower lateral incisors and the patient wore anterior box elastics (¼ inch, 2½ ounces) at night to extrude the lower incisors to increase the overbite.
Lingual Braces Case
Fig. 6

At 16 months and after 10 appointments (Fig. 7), the overbite had increased, so all goals had been achieved. The lower arch was debonded and a lower fixed retainer was placed. The patient was instructed to wear upper and lower Essix retainers at nighttime.
Lingual Braces Case
Fig. 7


Case discussion
The lingual archform is much narrower to work on than the labial archform. When working on the lingual archform in crowded situations, as seen in this case, some brackets often cannot be bonded at the beginning of treatment, so the first goal is to create sufficient space to bond these brackets on the teeth.

There are several approaches in lingual mechanics to create space, including open coil springs, lasso ties, and interproximal opening loops. This case elected to use interproximal opening loops because it can be programmed into a customized archwire, reducing the need for external auxiliaries. When an interproximal opening loop needs additional activation, the archwire can be directly bonded to the tooth in a position that increases the compression and unloading force, which was shown in this case.

When working with brackets on the lingual of the upper anterior, patients may occlude on them in the planned finish. When this occurs, such as in this case, the upper arch should be debonded first to remove the premature anterior interference with the upper brackets, and an upper retainer with cutouts can be used to use elastics and help settle the occlusion. In situations where the upper arch also requires minor tooth movements for finishing, a few active retainers with cutouts can be used to help settle the occlusion and complete any final detailing.


Conclusion
Hidden fixed appliances can help address the growing consumer demand for aesthetic orthodontic treatment. This patient underwent orthodontic treatment with hidden fixed appliances that was completed in 16 months and 10 appointments. Throughout the entire duration of treatment, the patient was able to experience major life events, such as his own wedding, without anybody being able to tell that he was undergoing orthodontic treatment.

Author Bio
Dr. Robert Lee Dr. Robert Lee earned his DDS from UCLA and his MS and orthodontic certificate from UC San Francisco. Lee is the co-inventor of InBrace, for which he currently serves as the head of clinical affairs and senior clinical advisor. He also was the principal investigator for the InBrace Generation 2.0 clinical trials. Lee is a diplomate of the American Board of Orthodontics, a clinical assistant professor at UCSF and works in private practice in Tustin, California.



 
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