Going Digital with ISD (case study)


Daniel Woricker, who practices at Longwell Green Dental & Implant Clinic in Bristol, has realised the potential and opportunities digital is bringing. Now, more than ever, digital has become an important aspect of peoples lives and it’s something he believes patients expect when they walk through the door. Going digital started with the treatment plan and the Integrated Smile Design – something he couldn’t do without now having seen the benefits.

Hear Dan talk through ISD in our short 2 minute preview below where he saw extraordinary ROI and his treatment plan uptake increase from 31% to 85%.

The patient was recommended to Daniel by a friend, whom Daniel had treated. After some needed restorative work was completed, a set of clinical photographs were taken which allowed him to start her treatment plan. Daniel can then start looking at facial proportions, skeletal pattern, occlusal relationships, arch form and tooth positioning.

INTEGRATED SMILE DESIGN


 


CASE SUMMARY

RELEVANT MEDICAL HISTORY: Nil

CLINICAL EXAMINATION: EXTRA-ORAL FEATURES

Skeletal pattern: class 2

Frankfort mandibular planes angle: average

Facial proportions: average

Soft tissues: lips competent

TMJ: no abnormality noted

Asymmetries: none detected

CLINICAL EXAMINATION: INTRA-ORAL FEATURES

Soft tissues: healthy

Oral hygiene: moderate

Erupted teeth present:

U: 7 6 5 3 2 1 | 1 2 3 5 6

L: 7 6 4 3 2 1 | 1 2 3 4 6

General dental condition: good

Crowding/spacing: moderate crowding upper arch, mild lower

Incisor relationship: class 2 div 1

Overjet: 6mm

Overbite: reduced

Centrelines: Upper midline shifted 1mm to the left, Lower midline shifted 2mm to the left

Displacements: None detected

Other occlusal features: distally rotated 22, 16 and 15 tipped palatal and in crossbite, 35 rotated nearly 90deg


Once the assessment is completed, the final desired position can be created to improve the patients smile. Once the smile design is completed, simulated treatment outcomes are presented to the patient for discussion.

This is a great part of the smile design presentation as the patient is more involved in their treatment planning.

The patient agreed that her centrals would appear better proportioned if they were narrower, and she was able to see how doing this also helped to align the teeth and reduce the overjet she disliked.

When the patient was happy with the proposed plan, Daniel went on to discuss the different options available to achieve this. Examples of different fixed labial brackets, lingual braces and aligners along with there pros/cons and cost were shown and discussed.

The patient decided to go with ICE upper and lower fixed brackets, and was shown how this may look using the smile design.

SMILE DESIGN


SIMULATED TREATMENT


ANIMATED SIMULATION

TREATMENT PLAN AND PROGRESS

TREATMENT AIMS

1. Relief of crowding

2. Level and align the arches

3. Correct the overbite

4. Correct the overjet

5. Retention

TREATMENT PLAN

1. Upper and lower fixed appliances

2. Wire sequence – Niti 0.014, 0.016, 0.018, SS 0.018, NiTi 0.016 x 0.022

3. IPR – focusing on improving shape of centrals as very wide

4. Cross arch elastics and composite occlusal stops to correct rhs crossbite and expand arch

5. Upper and lower removable and fixed retainers

6. Whitening


When the presentation of their smile design is complete patients are emailed a pdf presentation to look over, show their family and friends before they decide to go ahead.

This gives them time to make sure they are happy with the proposed plan and to bring up any questions they may have. It is also nice as it shows that the smile design is there to help them get the smile they want, not for the clinician to pressure them into any treatment.

The smile design given to the patient also includes several slides on all the risks such as pictures of root resorption, decalcification, relapse etc.

Finally there are some slides on cost and finance and what to do once they have decided to go ahead.

BRACES FITTED 14TH DECEMBER 2016

Patient attended for the fit appointment of her upper and lower ICE brackets.

They were indirectly bonded using the vacuum formed guides provided by the Wired orthodontics laboratory.

The process was quick, simple and the patient found the process comfortable.

I like how quickly the brackets can be placed indirectly and the confidence that they are in the correct position saving me from lots of wire bending or bracket repositioning later on.

The patient was given wax and good oral hygiene and diet was reinforced.

Patient was happy with the appearance of the brace.

23RD JANUARY 2017

TREATMENT PROGRESS

Patient attended for her 1st review appointment.

Quickties were placed on her upper 2-2 as she was unhappy with staining of the elastic o-rings.

Occlusal view of lower arch showed teeth already in good alignment.

Occlusal view of upper showed slight improvement in 11 positioning but 22 still quite rotated.

Cross bite on RHS unchanged.

18TH MAY 2017

5 months into treatment.

Occlusal stops have been placed along with a palatal button on the 16 to help correct the rhs cross bite.

This has also expanded the arch and given more space to retrocline the 11.

Upper and lower arches have started to align and level.

Power chain placed to help retrocline upper centrals and reduce OJ.

Patient is very happy with how the treatment is progressing.





17TH JULY 2017

TREATMENT PROGRESS

7 months into treatment.

Occlusal stops and palatal button removed as rhs cross bite had corrected.

LW was shown how to place class 2 elastics to improve occlusion.

IPR completed to reduce width of centrals and create space to reduce OJ.

15TH AUGUST 2017


COMPARISONS


TREATMENT IN PROGRESS

8 months into treatment.

Patient is very happy with the result and we are planning to debond soon.

Patient was vocal about how good they look which was great to hear.

During the treatment patient has also given up smoking thanks to improved pride over the appearance of her teeth and has been told by her family and friends that she is smiling much more than she ever used to.

I am looking forward to completing this case and seeing how close we came with the smile design to the final result.

The progress so far looks promising!

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