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20 Dental Tribune Middle East & Africa Edition | September-October 2014ortho tribune > Page 21 Pre-Align then design By Dr. Tif Qureshi T if Qureshi, Past President of the BACD shows how the combination of pre- alignment with simple orthodon- tic techniques and ceramic tech- nology have created a paradigm shift in the way cosmetic dentist- ry can be carried out. If the nineties were the decade of the Ultra White Hollywood Smile the noughties seem to have ush- ered in an era of more refined tastes in smile design. While there is still demand for whiter teeth many patients are now ask- ing for a more natural look rather than the over-bright identikit smile designs of the last decade. In keeping with this more con- servative mood patients are also becoming more aware of the good sense of preserving as much of their own tooth struc- ture as possible and are question- ing how their restorations will af- fect the health of their teeth. Can combination therapy with ortho- dontics and minimal thickness veneers satisfy patients demands for minimum intervention, natu- ral aesthetics and a rapid result? Smile makeovers with ceramic veneers can certainly achieve patients desire for an instant cosmetic result, for patients with mild misalignment good aesthet- ic outcomes can be achieved with minimal enamel loss. However for patients with moderate to se- vere misalignment deep prepa- ration into dentine and possible devitalisation may be the result of trying to align by tooth prepa- ration alone. Frequently adult misaligned pa- tients have explored and rejected orthodontic options as too slow a route to their aesthetic goal and are willing to risk their pulp to have the perfect smile for their wedding, holiday or new part- ner. Many of these patients can now be offered a safer way to the ideal smile. The risk of re- storing these patients has been reduced by two recent develop- ments, rapid adult orthodontics and emax high strength pressed ceramics. Appliances such as the Inman Aligner have speeded up the alignment process to as little as four weeks for moderate mis- alignment to 8 weeks for severely misaligned cases. While emax has enabled thinner, stronger ve- neers to produced with a natural appearance. For older patients misalignment is often associated with occlusal abnormalities and enamel wear which paradoxically may be- come more visible after aligning. Misaligned anterior teeth often show irregular incisal edge wear which after aligning becomes more apparent due to the differ- ing lengths of the teeth. While the arch alignment may have been perfected the crooked inci- sal line now becomes more ap- parent. Starkly outlined against the darkness of the oral cav- ity the differing incisal outlines of the incisors require further treatment before the ideal smile can be achieved. Lengthening the incisal edges with composite tips may pro- vide a medium term solution particularly on the lower ante- riors where the occlusal forces are mostly compressive and less likely to debond the composite from the tooth. In the upper arch however incisal tips are subject to more shear stress during func- tion and guidance and in this situation composite tips are more likely to chip or debond than a well-designed incisal wrap ce- ramic veneer. The Inman Aligner This patient presented com- plaining that he hated his smile. He felt they were dark, short and crooked. On examination several key problems existed. Firstly his anterior teeth were badly mis- aligned. They were also dark having had years of staining and this had been compounded by oc- clusal trauma that had worn the edges of his teeth badly allowing of absorption of stain through the tips. The misalignment and oc- clusal wear also meant that his teeth were actually quite differ- ent lengths. He wanted a great smile and he wanted it quickly. Several options were available and outlined: 1) Fixed orthodontics - the pa- tient did not want fixed brackets placed in his mouth even with short term ortho being presented as a compromised alternative to a referral for ideal specialist or- thodontics. 2) Invisible clear aligner braces - the patient refused this because of the time quoted for treatment, but was keen on the removability. The cost was also an issue be- cause the patient would still need further aesthetic/restorative treatment afterwards. 3) Veneers placed instantly were requested by the patient, but due to the massively destructive preparations, were discouraged immediately. An occlusal view showing the amount of tooth de- struction needed was enough to convince the patient that it was a poor choice. 4) Inman Aligner - the patient accepted this because of the short-expected treatment time and because he wanted remov- ability. Our plan was then to perform anterior alignment of the teeth with simultaneous whitening and then to re-assess the smile design and occlusal function af- terwards to realign, then design. Treatment A full examination with x-rays and occlusal analysis was car- ried out. Full BACD style photos were taken. Analysis of the occlu- sal photo showed that there was 3.3mm crowding. We chose to use an Inman Aligner with com- bined expander. The Aligner was used over 12 weeks by the patient and only worn 16-18 hours a day. The patient turned the midline expander once a week and some Figure 1. Lateral view Figure 7. Final Alignment Figure 8. Occlusal after with fixed retainer Figure 9. IPS Emax veneers Figure 3. Occlusal pre op Figure 4. Pre op smile view Figure 5. Inman with expander Figure 6. 12 weeks of aligning whitening Figure 2. Spacewize capture showing 3.3mm crowding