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26Dental Tribune Middle East & Africa Edition | July - August 2014 cad/cam | digital tribune < Page 25 tooth shaping with PPR (predic- tive proximal reduction). This made it far easier for him to un- derstand the processes required to create the space. Finally he could also see the differential wear in his tooth outline that would be evident after align- ment. He clearly understood that edge bonding and tooth contouring might be required after alignment and bleaching were complete. That is assum- ing he did not want to continue with porcelain veneers. It was noted that the patient had reviewed and understood the 3-D model and what it was pro- posing. The Inman Aligner was then built and fitted. Treatment Inter-proximal and Predictive proximal reduction were car- ried out in a progressive and measured manner over 3 visits. This was done to ensure good anatomy and to reduce the risk of gouging, over stripping and poor contacts. With Inman Aligner treatment stripping is never carried out in one go. Composite anchors were also placed in a timed and sequenced manner to ensure the forces could be directed at the right time. This allows for rapidly in- creased treatment times. After only nine weeks the pa- tient’s anterior teeth had nearly aligned. Bleaching trays impres- sions were taken at this stage. Super sealed trains are used with 6% day white from Phillips. The patient bleaches 35 to 45 minutes a day while the aligner is out of the mouth. After a week the patient re- turned his teeth had improved in alignment already but with the improvement in color as well made him view his teeth in a dif- ferent way. At this point he decided not to have porcelain veneers and instead to ask for composite bonding and buildups. He had seen examples of this already. We used some mockup flamma- ble material to show the patient what was possible and he was thrilled with the results. So an appointment was booked for 2 weeks to have this done. Figure 6: Before Close front view Figure 7: After alignment and bleaching at 10 weeks Figure 8: Immediately after bonding Composite bonding was carried out on the 7,9 and 10. A com- posite veneer was placed on the 11. All these were carried out with only roughening and no prep or bevel. Venus Diamond composite from Heraeus Kulzer was used. I find that the Opaque shades allow superb blocking out of light meaning that if lay- ered as dentine, it means a long bevel is not required to block out the join. Enamel shade can then be placed thicker towards the in- cisal edge. A wire retainer was fitted and the guidance adjusted to ensure there were still balanced excur- sive contacts on the left side so the load was not focused on the deciduous tooth. Roughening, total etch Opti- bond solo and Venus flow were used to bond the wire in place. A clear essix retainer was also given to the patient to wear at night initially then to use occa- sionally and to have as a back up if the wire de-bonded. Discussion Figure 9: Before front smile view Figure 10: After Alignment and bleaching at 10 weeks Figure 11: After Edge bonding and retainer Figure 12: Side profile before Figure 13: Side Profile after Figure 14: Side Smile before Figure 15: Side Smile After align- ment and bleaching Figure16:SideSmileat6months Figure 17: Before occlusal Figure 18: After occlusal at 10 weeks Figure 19: After 6 months with retainer Figure 20: Before Full face Figure 21: After full face (at 6 month review) On viewing the sequenced shots it is clear to see the changes. The patient was delighted that he had emerged from the treatment with his own teeth looking more attractive rather than having ceramic porcelain veneers. As good as ceramic restorations are, they will al- ways require further treatment/ maintenance and replacement. On a 22 year old if alignment, bleaching and bonding can sat- isfy the patient that it has to be better than placing ceramic ve- neers. The problem with digital smile design is that the patient is not really given the opportunity to see the teeth change slowly and in situ. It is fine if whitening, bond- ing and alignment are part of those protocols but arguably patients should not be shown images of multiple veneers un- til they can visualize their own teeth looking better. You can see how very sub- tle changes can dramatically improve the appearance. Even though the colour is not truly homogenous and the teeth have a mottled appearance the most important thing here is that the patient was completely delight- ed with the treatment. Ultimately a patient being happy with their own smile has to far outweigh the parameters that are set up traditional smile design. Final images at the 6 month re- view are also shown. Dr Tif Qureshi teaches Inman Aligner Training For course info visit: www.inmanalignertraining.com or email: inman@mdentlab.com Contact Information Figure 20 Figure 21 Figure 8 Figure 6 Figure 7 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 Figure 15 Figure 16 Figure 17 Figure 18 Figure 19