Dental Tribune US Edition, Vol. 5, No. 19

Clinical COSMETIC TRIBUNE | September 2010 f CT page 2C kept. An in-surgery fluoride rinse or application of topical fluoride is rec- ommended after any enamel reduc- tion procedure. El-Mangoury et al.8 and Radlanski9 have demonstrated that there is no increased risk of car- ies after IPR, provided surfaces are smoothed correctly. Heins et al.10 and Tal11 have demonstrated that there is no increased risk of periodontal disease, despite the decreased inter- proximal space. Critically, Inman Aligner treat- ment uses progressive, anatomically respectful IPR. While the extent of IPR required is already known, it is never carried out in one treatment. In order to ensure minimal risk, IPR (0.13 mm per visit per contact point) is carried out only in small increments. The patient is sent away with the Aligner. Owing to the Aligner forces, the gaps will be closed after two weeks. Interproximal reduction is performed at each appointment only as needed, using strips or discs, which ensures the stripping is far more anatomically conservative than would be the case using burs. This significantly reduces the risk of excess space formation, gouging or poor contact anatomy. Lingual/labial anchors Composite resin just incisal placed either incisal or gingival to where the bows contact will help them to func- tion more efficiently. This can also be used for the labial surface, espe- cially in cases in which teeth are being retracted. Strategic placement is vital for success and can be very helpful in the treatment of rotated teeth and the extrusion of teeth. Appliance adjustment The forces can be varied by adjust- ing the spring components or replac- ing springs for larger, longer springs. Generally, adjustments are not neces- sary, except in more complex cases, for which training is required to understand the correct spring types and compression rates to use. Case No. 1 The 25-year-old female patient com- plained about the appearance of her lower anterior teeth. She gave a his- tory of orthodontic treatment in her teenage years, having a fixed appli- ance fitted for a period of two years. She had been given a retainer at the time but was told to wear it at night for three months only. She had noticed her lower four incisors starting to become crowded again. Treatment options discussed were invisible braces, conventional fixed brackets or an Inman Aligner. The amount of space required for reduction was calculated as 3.5 mm. Interproximal reduction was per- formed using diamond strips (Bras- seler). A reduction of 0.13 mm at each contact point was achieved at the fitting appointment. This was verified with a thickness gauge. The patient was seen three weeks later and a fur- ther 0.13 mm reduced at each contact point. The teeth were aligned in just over nine weeks. The Aligner was left in for one month to stabilise the tooth posi- tions. Tooth whitening was under- taken for two weeks during the last two weeks of treatment. Simultaneous bleaching is a significant advantage in removable systems and helps patient motivation. Finally, an orthodontic retention wire was bonded in place on the lin- gual surfaces, ensuring the patient could still use super floss for hygiene. Case No. 2 A female patient presented complain- ing mainly about her rotated upper right central tooth. She was consider- ing veneers to redistribute the space over the four front teeth. This would have meant that she would undergo three aggressive preparations and one invasive preparation with endodontic treatment of the upper right central tooth. Space calculation with model anal- ysis indicated that treatment would be possible with an Inman Aligner. Because of the relatively low cost, the patient selected this option, under- standing that we would not be able to achieve Golden Proportion, owing to the width and length of her lateral teeth. A midline screw was incorporat- ed to allow for a small amount of operator-controlled expansion to pro- vide a little more space. (Incorporated expanders can be used to release extra space in cases with very con- strained space.) Up to 2 mm of space can be created by expansion, which has the effect of pushing the cuspid away from the lateral. After alignment, this expansion will just relapse. It is a temporary tech- nique to create sufficient space to align the anterior teeth. After align- ment, the expander can even be unwound if required. Treatment took 13 weeks with three sessions of IPR. A total of 3 mm was stripped and 1 mm was gained with the expander. The teeth were retained using orthodontic gold chain bonded from canine to canine. An upper Essix Retainer was also worn nightly as back-up for retention. Case No. 3 The patient in this case originally presented for porcelain veneers on her upper anterior teeth. The prepara- tions would have required root-canal treatment of two of her incisors in order to achieve adequate emergence profiles. After case options had been dis- cussed in detail, the patient decid- ed upon an Inman Aligner to align the teeth with veneers following this treatment. The patient was aware that after alignment, retention would be mandatory. Spacewize arch analysis calculated only 0.8 mm crowding in deviation from the ideal curve. An upper Inman Aligner with com- bined expander was fabricated and fit- ted. Minimal IPR was carried out with a 0.1 mm reproximation strip to sepa- rate the teeth. The patient turned the screw every five days for six weeks, which created nearly 2 mm of space. This allowed space for the centrals to advance and de-rotate. At this point, the expander was unwound to ensure that any mild residual spacing had closed. The teeth were aligned within nine weeks. An Essix Retainer was used to retain the teeth passively for a further four weeks, after which a bonded wire retainer was placed. The patient was very pleased with the alignment and decided that she would not need veneers. Veneers could always be used at a later stage if necessary, after more enamel has eroded with age and when veneers can be placed additively, for example. The result was not a perfect smile with regard to the criteria defined by Smile Design theory. Yet, that she no longer wanted veneers arguably provides us with a far better and more ethical outcome long term. Retention Retention for anterior alignment is essential.12–14 Recommended retainer types are bonded canine-to-canine fixed retainers commonly fabricated from .0195- or .0175-inch multi-strand stainless-steel wire. An indirect meth- od can be used to adapt the wire to a working model. This can then be transferred to the teeth, using a specially made jig and bonded with flowable compos- ite resin to the backs of the aligned teeth. The occlusion must be clear when placing a retainer on the max- illary arch. Advantages of this method are that the flexibility of the arch wire allows for physiological tooth movement and prevents bond fracture through occlusal forces. Periodontal ligament stability is also achieved with this technique.15 4C Essix Retainer This retainer is a thermo-formed, clear, thin appliance that is eas- ily made and very comfortable for patients. The recommended post- operative regimen for Inman Aligner treatment is to wear the retainer at night for 18 months and after that for two nights a week indefinitely. Conclusion With the Inman Aligner, patients pre- viously put off by the treatment time and fixed brackets of traditional orth- odontic techniques or the expense of more recent invisible braces, could, if their case is suitable, achieve anterior tooth alignment far more quickly with a simpler, single appliance. Inman Aligners are suitable for alignment of incisors and canines with up to 3 mm of crowding — 5.5 mm once the treating clinician is trained in using the system — and represent a very conservative and potentially rev- olutionary alternative to radical tooth preparation for achieving tooth align- ment using porcelain restorations. The Inman Aligner allows for a rapid and aesthetic alignment at low risk and cost to our patients. The patient is able to preview the staged changes of alignment, perhaps fol- lowed by bleaching and bonding. As a result, the Inman Aligner is profoundly changing the approach to cosmetic dentistry by those using it with the advanced techniques of domino effect, combined expansion and strategic anchor placement in the UK and Europe. Thisnewapproachtocosmeticden- tistry in the U.K. has been confirmed by figures from the British Academy of Cosmetic Dentistry (BACD). The 2008 study of data from 200 BACD members demonstrated a massive 345 percent increase in orthodontics used in cosmetic cases but no increase in the use of veneers. Of this increase, 230 percent was solely due the use of the Inman Align- er in cases in which patients would not otherwise have had their teeth treated, owing to the time cost of fixed braces and no desire to have appli- ances adhered to their teeth. Many of these patients were those who would have opted for aggressive preparation of their teeth for veneers, before the Inman Aligner. CT Acknowledgements I would like to thank Donal Inman CDT (Inman Orthodontic Labora- tory), NimroDENTAL Orthodontic Laboratory — the only STS-certified Inman Aligner laboratories — and Dr James Russell for Case III. Fig. 9: Close side view before treat- ment. Fig. 11: Occlusal view before treat- ment. Fig. 8: Smile view after treatment. Fig. 10: Close side view after treat- ment.

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