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Dental Tribune Middle East & Africa Edition

30 Dental Tribune Middle East & Africa Edition | January - February 2014Ortho Tribune required, which can be taken chairside. One tooth needs to be measured for calibration. A curve can be digitally estab- lished and the extent of crowd- ing is immediately calculated using such software. Laboratory requirements Accurate upper and lower im- pressions are taken, preferably two of the arch being treated. Simple alginate can be used if cast quickly. A bite registra- tion and prescription should be completed and sent to a certified Inman Aligner Labo- ratory. The technician should be informed of the amount of crowding calculated. The teeth to be repositioned should be noted clearly. The prescrip- tion should provide full details to the technician regarding the teeth to be moved, the area they are to be moved to and the distance they are to be moved. A Spacewize trace of the ideal curve can also be submitted. Interproximal reduction Interproximal reduction (IPR) is begun at the fitting appoint- ment using abrasive strips or discs. The model analysis will have already calculated the ex- tent of IPR required. Many authors acknowledge that the reduction of half of the interproximal enamel on the mesial and distal of each inci- sor tooth is a safe technique.4-7 This equates to 0.5mm per contact point, creating 2.5mm of space between the canines. In some cases, the distal of the canine and mesial of the premolar can be reproximat- ed allowing for a total of 3.5 to 4.5mm. These cases will require more experience in using the system but offer a number of possibilities for cli- nicians once trained to use the system correctly. Meticulous records of the amount of stripping performed should be kept. An in-surgery fluoride rinse or application of topical fluoride is recommend- ed after any enamel reduc- tion procedure. El-Mangoury et al8 and Radlanski9 have demonstrated that there is no increased risk of caries af- ter IPR, provided surfaces are smoothed correctly. Heins et al10 and Tal11 have demonstrat- ed that there is no increased risk of periodontal disease, de- spite the decreased interproxi- mal space. Critically, Inman Aligner treat- ment uses progressive, ana- tomically respectful IPR. While the extent of IPR required is already known, it is never car- ried out in one treatment. In order to ensure minimal risk, IPR (0.13mm per visit per con- tact 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 re- duction is performed at each appointment only as needed, using strips or discs, which ensures the stripping is far more anatomically conserva- tive than would be the case us- ing burs. This significantly re- duces the risk of excess space formation, gouging or poor contact anatomy. Lingual/labial anchors Composite resin placed just in- cisally either incisal or gingival to where the bows contact will help them to function more ef- ficiently. 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 ad- justing the spring components or replacing springs. Gener- ally, adjustments are not nec- essary, except in more com- plex cases, for which training is required to understand the correct spring types and com- pression rates to use. Case I The 25-year-old female pa- tient complained about the appearance of her lower an- terior teeth. She gave a history of orthodontics in her teenage years, having a fixed appliance 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 3 months only. She had noticed her lower four incisors starting to become crowded again. Treatment options discussed were invis- ible braces, conventional fixed brackets or an Inman Aligner. The amount of space required for reduction was calculated as 3.5mm. Interproximal re- duction was performed using diamond strips (Brasseler). A reduction of 0.13mm at each contact point was achieved at the fitting appointment. This was verified with a thick- ness gauge. The patient was seen three weeks later and a fur- ther 0.13mm 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 positions. Tooth whit- ening was under- taken for two weeks during the last two weeks of treatment. Simulta- neous bleaching is a signifi- cant advantage in removable systems and helps patient mo- tivation. Finally, an orthodontic retention wire was bonded in place on the lingual surfaces, ensuring the patient could still use super floss for hygiene. Case II A female patient presented complaining mainly about her rotated upper right central tooth. She was considering ve- neers to redistribute the space over the four front teeth. This would have meant that she would undergo three aggres- sive preparations and one in- vasive preparation with endo- dontic treatment of the upper right central tooth. Space cal- culation with model analysis indicated that treatment would be possible with an Inman Aligner. Because of the rela- tively low cost, the patient se- lected this option, understand- ing that we would not be able to achieve Golden Proportion, owing to the width and length of her lateral teeth. A midline screw was incorporated to al- low for a small amount of operatorcontrolled expansion to provide a little more space. (Incorporated expanders can be used to release extra space in cases with very constrained space.) Up to 2mm of space can be created by expansion, which has the effect of push- ing the cuspid away from the lateral. After alignment, this expansion will just relapse. It is a temporary technique to create sufficient space to align the anterior teeth. After alignment, the expander can even be unwound if required. Treatment took 13 weeks with three sessions of IPR. A total of 3mm was stripped and 1mm was gained with the expander. The teeth were retained using orthodontic gold chain bonded from canine to canine. An up- per Essix Retainer was also worn nightly as back-up for retention. Case III The patient in this case origi- nally presented for porcelain veneers on her upper anterior teeth. The preparations would have required root-canal treat- ment of two of her incisors in order to achieve adequate emergence profiles. After case options had been discussed in detail, the pa- tient decided upon an Inman Aligner to align the teeth with veneers following this treat- ment. The patient was aware that after alignment, retention would be mandatory. Space- wize arch analysis calculated only 0.8mm crowding in devia- tion from the ideal curve. An upper Inman Aligner with combined expander was fab- ricated and fitted. Minimal IPR was carried out with a 0.1mm reproximation strip to separate the teeth. The patient turned the screw every five days for six weeks, which created nearly 2mm of space. This al- lowed space for the centrals to advance and de-rotate. At this point, the expander was un- wound 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 cri- teria defined by Smile Design theory. Yet, that she no longer wanted veneers arguably pro- vides us with a far better and more ethical outcome long term. Retention Retention for anterior align- ment is essential.12-14 Recom- mended retainer types are bonded canine-to-canine fixed retainers commonly fabricated from .0195” or .0175” multi- strand stainless-steel wire. An indirect method can be used to adapt the wire to a work- ing model. This can then be transferred to the teeth, us- ing a specially made jig and bonded with flowable com- posite resin to the backs of the aligned teeth. The occlusion must be clear when placing a retainer on the maxillary 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 Essix Retainer This retainer is a thermo- formed, clear, thin appliance that is easily made and very comfortable for patients. The recommended post-operative regimen for Inman Aligner treatment is to wear the retain- er at night for 18 months and after that for 2 nights a week indefinitely. Conclusion With the Inman Aligner, pa- tients previously put off by the treatment time and fixed brackets of traditional or- thodontic techniques or the expense of more recent in- visible braces, could, if their case is suitable, achieve ante- rior tooth alignment far more quickly with a simpler, single appliance. Inman Aligners are suitable for alignment of incisors and canines with up to 3mm of crowding - 5.5mm once the treating clinician is trained in using the system and represent a very conserva- tive and potentially revolution- ary alternative to radical tooth preparation for achieving tooth alignment using porcelain res- torations. The Inman Aligner allows for a rapid and aesthetic alignment at low risk and cost to our pa- tients. The patient is able to preview the staged changes of alignment, perhaps followed by bleaching and bonding. As a result, the Inman Aligner is profoundly changing the ap- proach to cosmetic dentistry by those using it with the advanced techniques of domi- no effect, combined expansion and strategic anchor place- ment in the UK and Europe. This new approach to cos- metic dentistry in the UK has been confirmed by figures from the British Academy of Cosmetic Dentistry (BACD). The 2008 study of data from 200 BACD members demon- strated a massive 345% in- crease in orthodontics used in cosmetic cases but no increase in the use of veneers. Of this increase, 230% was solely due the use of the Inman Aligner 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 appliances adhered to their teeth. Many of these patients were those who would have opted for aggres- sive preparation of their teeth for veneers, before the Inman Aligner. Editorial note: A complete list of references is available from the publisher. Figure 7. Smile view before treat- ment. Figure 9. Close side view before treatment. Figure 11. Occlusal view before treatment. Figure 13. Side smile view before treatment. Figure 8. Smile view after treat- ment. Figure 10. Close side view after treat- ment. Figure 12. Occlusal view after nine weeks with an Inman Aligner. Figure 14. Side smile view after treatment. Dr. Tif Qureshi is the Past Presi- dent of the BACD. He presents hands on courses and lectures on the Inman Alig- ner worldwide. For information on courses please go to: www.inmanalignertraining.com or contact Caroline Cross on Tel: +44845 366 5477 Contact Information

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