Ortho and an English patient

Last year I had a teenage patient, Josie, who presented with buried upper canines that were buccally placed in the bone but apparently unwilling to erupt. We referred her to the local hospital which recommended that, as an initial strategy, we uncover the canines and treat the case with twin blocks before another assessment, so this is how we began.

We were also told that the ultimate strategy would probably include extractions, fixed appliances and perhaps extra-oral anchorage. But as a clinician I had worries. First, Josie is a semi-professional actress so her work would be hampered by fixed appliances. And although her dentition was caries- and restoration-free it had the general look of teeth that were often in contact with refined carbohydrates.

Looking at Figure 1 of Josie (taken in May 2005), when she was 14 years and 10 months old, I’m sure most practitioners would agree with my suspicions. These were confirmed when the truth came out that Josie was overly fond of a well-known brand of canned orangeade.

With Josie, as with any normal teenager, I had reservations about accepting any assurance that she would be able to kick this orangeade habit during a two-year course of fixed appliances. And what other habits did I not know about?

Fixed appliances are difficult to keep clean at the best of times, and hamper full examination of the dentition at each check-up. And when a patient asks: ‘How long will I have train tracks?’ how easy it to give a fair and accurate answer?

So the case for fixed appliances was becoming weaker all the time. I therefore decided it was in Josie’s best interests to treat her case with Invisalign. The advantages were:

• Invisalign allowed me to quantify the treatment time span to the nearest week

• It allowed Josie to remove the aligners for eating, drinking – and, best of all, brushing

• Josie was able to get on with her acting without any problems with speech or appearance

• Her bone structure is similar to that of the actress Sarah Jessica Parker and it was requested that her smile, if possible, should have a similar ‘design’. The Invisalign technique allows for this, as it enables me to be very specific about where the teeth should be and how the smile should look

• Also, at the Clincheck stage, I could make alterations and take on board any reservations Josie may have had.

In the end the treatment plan involved no extractions. The upper premolars and molars were inclined to cross-bite so there was some expansion and a little interproximal reduction, but obviously this was preferable to extractions because it involves far less loss of tooth substance. And to help the aligners grip the upper canines well, I temporarily added some composite to make their crowns easier to grip the plastic. Basically, I was creating temporary undercuts.

In Figure 2 (late July ’05) Josie is wearing her aligners. Figure 3 was taken in October ’05 and Figure 4 taken in the first week of January 2006.

It is a very brave dentist who would now look this 15-year-old in the eye and say: ‘Look, you should have had four teeth taken out and then had train tracks for a couple of years and possibly a cat’s whisker, but certainly some elastic bands. And no, I don’t know exactly how long this will all take.’

And it is a brave dentist who would have said such things to her parents – I know, because I am her father. By contrast, Josie was Invisalign’s 501, 195th patient and my 70th. She took eight months of active treatment and just under four hours of my clinical time.

Obviously I still have a little fine-tuning to do for this budding Sarah Jessica Parker but Invisalign, which was developed for ‘fussy’ American patients, excels at fine-tuning. The only mystery is why more British patients aren’t treated this way.

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