Elhical
andaffordable desig
sniilG
Andrew presenfs
Wallace lhecase ofa pafienl
sfudy
lreated
i There has probably never
I been a better time to practise
i dentistry. However, dentists
and patientsare bombarded
I with a large silver amalgam
by imagesof the beautiful
smile and, for many years,
practitioners have been
pressuredinto believingthat
porcelainveneersare the only
i answer.
Of course,there are many
situations where veneersare
the ideal treatment,and when
well placed and properly
bonded to enamelthey will
last for many years(MagneP,
BelserU, 2003). Layton and
Ii Walton (2007) showed a 73olo
survival rate at L6 years for
veneersbonded to enamel.
Unfortunately,in my practice
theseideal casesrarely come
through the door.
Most of the patients
I coming to the practicefor
cosmeticdentistrydo so for
more severeproblems.
Crowding of the upper and
lower teeth is a common
condition that adult patients
would like improved.
Porcelainveneersand
'instantorthodontics'
designedto treat this will
often lead to excessiveenamel
removal,risking pulp vitality
and compromisingbond
Andrew Wollace gained his
BDSfrom Queen'sUniversity
Belfast in 7998.As well as
practisingfull-time in pri.vate
practice in BachelorsWalh
Dentol Surgery, Lisburn, he
is studying at King's College
Londonfor an MClinDent in
fixed and removable
prosthodontics.He is a full
member of the British
Academy of Cosmetic
D entistry (BACD). Andrew
gained certification on lnman
aligner tr eatment thr ough
Straight Talh seminars in
tanuary 2009.
16 | Irish DentistI October 20lO
wifhfhelnman
aligner
strengths,or over-contoured
restorations,which can
compromiseplaque control.
Poor root position will also
compromisethe emergence
profiie. The patient,who by
now has also enteredthe
'restoraiive cycle',will require
the periodic replacementof
theseveneerswith more
lnvasive restorations(Kim J,
Chu S, Gurel G, CisnerosG,
2005;JacobsonN, Frank CA,
2008). Burke and Lucarotti.
(2009) showedthe survival
rate of veneersin England
and Walesto be
approximately10.5 years.
Meanwhile, the Inman
aligner has proved to be a
valuableapplianceto help
patientswith mal-aligned
anteriorteeth (QureshiA,
2008; WarunekSP,Willison
BD , 2 0 0 5 ).
(asepresenlalion
The patientwho attendedwas
a 19-year-oldwoman
requestingcosmetic
improvementof her upper
and lower teeth. Her chief
complaint was that she was
'unhappy'with her smile and
that her 'front teeth are out of
shape'.
The patient was a regular
attendeewith her general
dental practi.tionerand
dentally healthy.Other than
her aestheticconcerns,she
displayedno dental complaints
and had no history of bleedi.ng
gums or sensitivity
Upon enquiring further,
she mentionedshe had been
consideringhaving treatment
to improve her smile for the
Iast year and had a family
wedding coming up in just
over l2 months.The patienL
was happy with the shapeof
her upper and lower teeth-
she said she would havejust
liked them to be a liule
whiter and straighter.
From the examination it
was ascertained that she had
minimally restored dentition
filling in her lower lefr first
molar and some hypoplastic
enamel in her upper right firsi
molar.
Her upper left first molar
was missing, but with no
residual spacing due to mesial
movement of the second
molar. Her lower third molars
were unerupted with mesio-
angulhr impaction. She had a
thin scalloped gingival
biotype.
The patient's iower incisor
teeth had moderate crowding,
with good positioning of the
canines. The upper incisors
displayed mild crowding,
with the mesial edge of the
upper right central incisor
overlapping with the upper
left central incisor by 2mm.
A full discussion was
undertaken with the patient
about the possible options:
. No treatment
. Comprehensive orthodontic
treatment
. Fixed short-term
orthodontic treatment
. Removable alignment
treatment
. Restorative treatment/
'instant orthodontics'.
The patient did not want
restorative treatment and
dismissed the idea of crowns
or veneers when we expiained
the excessiveamount of
enamel removal. The patient
was open to the concept of
fixed bracket orthodontics but
was much happier with the
idea of a removable appliance
for lifestyle reasons.
We went'into the specifics
of interproximal enamel
reduction (lPR) and the
patient expressed that she was
happy with this small amount
of enamel removal to create
space for tooth movement.
Irealmenl
A lull set ol clinical
photographs were taken (in
accordance with American
Academy of Cosmetic
Dentistry guidelines) and
upper and lower alginate
impressions were recorded.
The exact areas of the
patient's smile that caused her
concern were discussedusing
the photographs, and we
discussed the tooth movemen-rs
that would be possible with the
alignment treatment.
Once the models were czLit
from the impressions, we
were able to assessthe
a m o u n t o l cr o w d i n g . Th i s i s
done in a very simple fashion
when using an Inman
aligner - the maximum width
of each inclsor and canine
tooth is measured using a
simple micrometer. Using an
i n t e r p r o x i m a l m e ta l str i p , th e
required space of the optimai
arch form is then measured
from the distal o[ one canine
round to the contra-lateral
canine. The difference is equalll
to the required amount of
interproximal reduction. anci
for this young woman it was
found to be 1.2lmm.
U p t o 3 . 5 m m o f cr o w d i n s
can be treated with a standard
l n m a n a l i g n e r d e vi ce u si n g
just IPR. More severe
crowding can be addressed
with an lnman aligner
incorporating a palatal
expander.
An upper serles of three
clear aligners and a lower
Inman aligner were prescribed
and the patient consented to
the treatment as described.
The models were sent to
Nimrodental Laboratory,
which is the UK's only Inman
aligner laboratory.
The Inman aligner is
fabricated on a Kessling
model. The prescri.bed
i n t e r p r o x i ma l r e d u cL i o ni s
www.IrishDstiv.ir
 carriedout on the plaster
model, the teeth are removed
and then replacedon the
model in wax on the ideal
arch form.
The first upper clear
alignerand lower Inman
alignerwere fitted on the
sameday Extensive
discussionwas undertaken
with the patienrabout what to
expectover the coming days
and weeks.
A small amount of
interproximaireductionwas
undertakenusing metal
interproximalstrips on all the
interproximalsurfacesof the
lower teeth, from mesialof
the caninesround to the
contra-lateralcanines,and on
the upper teeth,as per rhe
laborato ry instructions.
IPR is carriedout in this
fashionto respectthe anatomy
o[ the tooth.simplymaking
the teethmore slender.
The patient was seenevery
four weeksfor the fitting of
eachof the upper alignersin
the series,and to carry out
further interproximal
reductionon the lower teeth.
After threemonths, the
upper alignmentwas
completeand the lower teeth
were almoststralght.
After four monrhs,the
alignmentof the lower teeth
wascompleteand impressions
were taken for a fixed bonded
retalner- a muiti-strand
stainlesssteelretalnerbonded
to the palatalsurfaceof the
front six reethwith the aid of
a customplacementjig,
Due to the typeof occlusion,
the patient continuesto wear
an Essix-typeretaineron the
upperteerh.
Discuslion
This self-consciousyoung
woman was concernedabout
the appearanceof her teeth,
which were becoming
increasinglymore crowded.In
four months, her upper and
lower teeth were alignedfor
lessthan the cost of four
porcelainveneers.
The photographsshow the
detail of the morphologyand
shadecharacteristics of the
teeth- reproductlonof this
would haveproved a
www.IrishDentist.ie
chalienge for even the most
gifted dental technician.
Just a few years ago, the
options open to her or her
dental practitioner wouid
have been limired to full
orthodontic treatment or
restorative treatment. The
restorative options would
have involved either excessrve
removal of enamel and
dentine for porcelain veneers
or excessi.velybulky and over-
contoured restorations with
poor interproximal contacts.
Now clinicians have the
option of an altogether more
satisfacrory approach.
Alignment treatment such
as thar olfered by the Inman
aligner can offer rapid
cosmetic improvement of
moderately crowded front
teeth or orthodontic relapse.
Becauseone appliance does
almost all of the tooth
movement, the reduced
laboratory cost allows for a
more affordable option for
patients, increasing patient
uptake.
Caseselection is key and a Figures 1 and 2: Lower teeth betore treatment (top) and following
fuil discussion with the four months of treatment
patient about their complaints
and what they wish ro have
corrected is vital, because
only correction of the fronr
teeth is possible. Incisors can
be rotated and tipped
reiatively easily with limited
movement of the canine teeth
possible.
The clinical study
presented here was an ideal
case and the four-month
treatment time required for
this patient is not unusuai.
With others, it may be
essential to talk the parient
through what they can expecr
to be.corrected and what will
not be possible.
Often, this form of
treatment will be a precursor
to restorative treatment; pre_
alignment can allow us to
offer the ideal cosmetic result
with a much reduced
biological cost in enamel and
dentine removal, and an ideal
emergence profile. Often only
minor enameloplasty or
enamel bonding is required
after aiignment to correct the
differential wear we often see Figures 3 and 4t llpper teeth prior to treatment (above) and after
with crowded teeth. four months of treatment
october 2010 | Irish DentistI 17
Figures 5t A pre-op smile from the patient
Interproximal reduction
has been shown to be a safe
way of creating sPace for
iooth movement. Zachrisson
(2007) followed up Patienis
10 years after IPR and found
no increased caries risk,
bleeding on probing, gingival
recession or periodontal bone
Ioss in these patients
(Zachrisson BU, NyoYgaard L,
Mobarakc K,2007).
The interdental sPace
required is often created bY
rounding out the arch and
moving teeth forward that are
Iingually placed and Placing
them on a wider arc.
(onclusion
The Inman aligner is not a
replacement for conventional
orthodontics but does ailow
clinicians to offer quick and
affordabletooth alignmenLin
general dental practice. MY
provision of cosmetic
dentistry treatments has
grown significantly since
introducing the Inman aligner
to pru.ii.e offering.
-y
References
AACD (20 10) PhotograPhic
documentation and eYaluation
in cosmetic - a guide
dentistrY
to accreditationPhotograPhY.
American Academy of
CosmeticDentistrY,
Wisconsin,USA
Burke FJ,LucarottiPS (2009)
Ten-yearoutcomeof
porcelainlaminateveneers
placedwithin the general
l8 I Irish DeitistI October 2010
dental servicesin England
and wales.J)urnaL0J
Dentistry37(f): 31-8
JacobsonN, Frank CA (2008)
The myth of instant
orthodontics:an ethlcal
quandary.J Am Dent Assoc
I39:424-434
Ki m J . C h u S , G urelG,
CisnerosG (2005)
Restorativespacemanage-
ment: treatmenL plann ing
and clinical considerations
for insufficient space.Pract
Proced Aesthet Dent 17(l):
1 9 -2 5
Layton D, Walton T (2007)
An up to l6-year
prospectivestudYof 304
porcelainveneers.
InternationalJournal oJ
dontics20 (4) :
Pro st'ho
389-96
MagneP,BelserU (2003)
Bonded porcelainr estordtions
'in theanteriordentition.A
-n
biomimeticapproach.
Quintessence Books,London
QureshiA (2008) The Inman Figures 6, 7 and 8" A successfu I, retatively fast and affordable
alignerfor anteriortooth result, as demonstrated by the happy patient
alignment.Dent Update35:
5 6 9 -5 7 6 MobarakcK (2007) Dental Acknowledgementl
healthassessed more than The author would like to
Warunek SB Willison BD l0 yearsafter interProximal thank Dr Tif Qureshi and
(2005) Incisor alignment enamelreductionof DrJames Russellfor their heJP
with the Inman aligner. mandibularanteriorteeth. in planning his early cases.
J o u rn aol JC o smel D
i cenl i stry Americanlournal of
20(4):80-92 Orthodontics and Dr Waliace has no connection
DentofaciaI Or thoPedics to Straight Talks Seminars or
BU. NyoygaardL.
Zachrisson r:1(2): r62-L69 Nlmrodental laboratorY.
mnr,IrishDsrtisl.ie
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