DTME0910

T his article will outline how the combined and simul- taneous use of the Inman Aligner, tooth whitening followed by edge bonding can redefine the ap- proach taken to smile design. It also highlights how it will help dentists respect a patient’s decision as their treatment progresses rather than shortcutting to an end result using ceramics setup with classic smile design principles. Discussion. “Changing cosmetic dentistry“ might seem like a pretty big goal, but It’s become very clear from lecturing and writing about this particular dis- cipline that it creates a huge amount of excitement and positive reaction. Dentists see the logic in it very quick- ly and can also see how, with some education, they can employ a safe, low risk technique that they know their patients will want and will massively change their approach to cosmetic and aesthetic dentistry. They also understand that there is a massive market of patients who will accept this kind of non-invasive treatment happily. Treatment with the Inman Align- er has been further developed in the UK where techniques are used to make it dramatically effective as a solution for certain mild and moder- ate anterior orthodontic issues. Cas- es, which traditionally would take six-10 months with clear aligner sys- tems can, with education, be treated in six-16 weeks. We have all seen how bleach- ing can affect a smile. We know how much bonding can improve aesthetics and tooth anatomy. Now that alignment is potentially so simple, these three disciplines have been brought together to cre- ate results that easily challenge tra- ditional veneer based smile make- overs. And, if the three treatments are combined with some thought, it is possible to massively improve a patient’s smile in around three months. All of a sudden the six-10 unit ve- neer case used for a smile makeover can look ridiculous and be seriously in danger of becoming over treat- ment. There are always situations where ceramics are highly appropri- ate, such as in wear cases or in major reconstructions, but for anyone with good quality intact enamel, I believe this kind of treatment represents a far more ethical, patient centric ap- proach. This is because I believe the way smile design is approached, and perhaps even taught, is wrong. The final outcome, for what is aesthetic is important. Golden proportion ide- als, tooth width length ratio, gingival zeniths etc all together create some- thing we know to me almost math- ematically correct. The problem is that most dentists’ experience their smile design education attached to a lecture or course based on veneer dentistry. As a result dentists will naturally think this to be the only and perhaps fastest way to achieve a “perfect smile”. If we assess a patient’s smile and try to preview an end result at the first consult, using imaging soft- ware, a wax up or even a preview try in, we are not really letting the patient see their teeth improve at different stages to see if their expec- tations are being met along the way. The smile design rules are there, but how many patients if they see their teeth improving with align- ment then bleaching and then bond- ing, would actually then take an- other step with porcelain and some tooth destruction to achieve total perfection? In my experience, very few. Some still do go further, but at least by then their teeth are straight and we can use truly minimal and almost no prep veneers to improve the aesthetics further. Most of the time, once we are ¾ through alignment and start to bleach it becomes very clear that simple bonding is all that will be needed to create a very aesthetic smile that previously would only have been achieved with aggressive veneer preps. The case outlined below is a typi- cal case of a patient who once want- ed and considered having porcelain veneers. Instead she opted to align her teeth then bleach and bond. Case and Diagnosis This 32-year-old patient complained about the “crooked look” of her smile. The patient was aware of what a smile makeover could achieve, but wanted to achieve something with- out damaging her teeth. On examination several prob- lems existed. Firstly her teeth were moderately misaligned. This creates aesthetic issues immediately. Large unsightly embrasures were made worse around the canines. The in- standing laterals appeared darker and in the shadow of the lips, the left one being in slight cross-bite. With the centrals splayed out and rotated the line angles of the four incisors were all different. It was clear at the start by ex- amining the incisal edges that there had been differential degrees of wear meaning that even if the teeth were aligned, the incisal outline would ABB (Alignment, Bleaching, Bonding) The Treatment Sequence that should change Cosmetic Dentistry says Tif Qureshi ‘If the three treatments are combined with some thought, it is possible to massively improve a pa- tient’s smile in around three months.’ still look uneven - this meant we needed to have a conversation about some potential edge build ups after. All options were discussed. The patient ruled out fixed brac- es, even with more recent faster techniques because she wanted, something removable and we had also discussed the possibil- ity of simultaneous bleaching during the alignment phase. We assessed for an Inman Aligner. At the consultation the occlusion was examined and it was clear that the laterals had room to advance labially and the centrals could also be derotated. We then needed to assess the actual amount of space needed. Inman Aligner cases should be planned carefully to ensure the case is suitable and also to un- derstand how much space needs to be created. This can be done with models using Hanchers technique (1) . The SpaceWize tm crowding calculator was used to assess the patient in the chair. An occlusal photo was taken with a mirror and the upper cen- tral tooth was measured with digital calipers to help calibrate the software. The occlusal photo is up- loaded and the calibration tooth details entered. The mesial dis- tal widths are simply drawn on for the all the teeth to be moved which in Inman Aligner treat- ment is always the front 6 teeth. The software calculated the total of the mesial distal widths and this is described as the Required space. An ideal curve is then plotted with the software with the proposed final position. This is made with occlusion, aesthet- ics and function taken into con- sideration. The curve can be manipulated easily with the soft- ware and this gives us the Avail- able space. The difference be- tween these two measurements is calculated automatically and this is the amount of space that needs to be created to achieve the final result. As can be seen in the Spacewize tracing, 3.1mm of crowding was present. This may seem less than expected when considering the degree of crowd- ing when looking at the occlusal photo, but because the laterals are advancing forward, this will actually create space. It was decided that an In- man Aligner with incorporated expander would be used to treat the case. Incorporated expand- ers are a useful tool to create space supplementary to IPR or as an alternative. They must not be expanded beyond 2.5mm and only supply a temporary degree of space to allow the anteriors to align. The small degree of pos- terior expansion will always re- lapse and the midline can even be unwound after the anteriors have aligned. Each turn produc- es 0.25mm of space. Treatment sequence The Inman Aligner was fitted at the next appointment. In- structions were given and only a small degree of IPR was per- formed over the front teeth (0.1 mm per contact). No IPR was performed ini- tially around the centrals be- cause with the degree of crowd- ing it would be easy to miss the contact point. Instead the teeth are stripped strategically and progressively meaning we re- lease a little room to allow the teeth to align then we re-perform IPR over several visits again only performing a little at a time. Critically Inman Aligner treatment uses progressive ana- tomically respectful IPR. Despite calculating the amount of crowd- ing present, the IPR is never car- ried out in one go. IPRs strips or discs are only used. This gives the opportunity to ensure the stripping is far more anatomi- cally respectful than using burs or heavy discs. This massively reduces the risks of excess space formation, gouging or poor contact anatomy. The contacts are smoothed and the fluoride gel is applied each time.(2-9) . Composite anchors were also placed on the palatal incisal edge of the instanding lateral teeth to ensure the palatal bow engaged correctly. The patient was also shown how to turn the midline screw. She was instructed to do this once a week and did this for sev- en weeks, but was seen every 2-3 weeks to check progress and re- perform a little IPR if necessary. The patient was instructed to wear the Inman Aligner for 16- Media CME DENTALTRIBUNE Middle East & Africa Edition6 (mCME articles in Dental Tribune (always page 6) has been approved by HAAD as having educational content acceptable for (Category 1) CME credit hours. Term of approval covers issues published within one year from the distribution date (September, 2010). This (Volume/Issue) has been approved by HAAD for 2 CME credit hours. 2 Hours