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21Dental Tribune Middle East & Africa Edition | September-October 2014 ortho tribune Dr. Tif Qureshi teaches Inman Aligner Training. Inman Aligner courses can be booked at: www.inmanalignertraining.com For course info visit: www.inmanalignertraining.com or email: inman@mdentlab.com Contact Information < Page 20 progressive, anatomically re- spectful IPR was carried out. At week 9 of alignment, bleach- ing trays were constructed and short acting Day - white whiten- ing gel was used to whiten over the same period. Because the Inman Aligner can be removed and because it only needs to be worn a maximum of 20 hours a day, it is very easy for the patient to whiten at the same time. This is excellent for motivation. By week 12 the patient’s teeth were whiter and straighter. The patient was then held in retention on a temporary essix retainer. However at this point we needed to reassess including the patient’s perception of the aesthetics. The patient’s posterior occlusion was balanced but he had no ante- rior or canine guidance. After alignment we offered the patient the option to simply use edge bonding on the upper teeth as we commonly do but he ex- pressed a wish to still have ve- neers to give a fuller look. Upper edge bonding was simulated by adding composite in a mock up fashion. He viewed the result but still felt his teeth looked flat and wanted them to appear fuller. So at this point a purely additive wax-up was made and a direct preview was placed in the mouth from a silicone stent taken from the wax up. The patient was happy with the new tooth length and dimen- sions. At the next appointment, Edge bonding was placed from lower premolar to premolar to open the bite and enhance guidance. The Dahl principle was used and no more than 2mm of composite was added anteriorly with most loading on the canines and a long centric on the incisors. (-Within 2 months the posteriors were in full contact again) One week later the upper teeth were prepared. Minimal prepa- rations could be used because the teeth were in the right posi- tion so the preparations could be truly in enamel. Temporaries were placed imme- diately based on the silicone stent of the wax up. At this point no retainer was needed because the temporar- ies were locked together except of course at the gingival embra- sures where small interdental brushes could be used to ensure adequate hygiene. Aesthetics, function and phonet- ics were checked, rechecked and modified over a 4 week period. Guidance corrections were made in situ on the temporaries and the lower composite edge bondings. Once the patient was happy and fully comfortable, an accurate silicone rubber impression was given to the technician and he then had an exact copy to follow for the final veneers. The patient visited the lab for a shade match and discussion on tooth characterization. His input and requirements were noted by the technician. In the lab once the veneers were made, an impression was taken of the veneers on a solid model and this was used to produce an immediate temporary retainer. Of course once the temps are removed the teeth will still need retaining so this could be used before a fixed retainer was fitted later. On the fitting appointment, the temporary veneers were re- moved and the finals tried in. The patient was happy and the veneers were then bonded. A new impression was taken to make a wire retainer. In the meantime the patient wore the temporary essix made on the ve- neer cast. One week later a wire retainer made by the orthodontic lab was bonded to the back of the upper 6 front teeth. Because the preps were minimal the veneers were only on the facial surface so bonding to the back of the teeth was easy. The patient was thrilled with his result not only because he achieved a natural more attrac- tive smile, but also he did it with the minimal amount of invasion needed. Emax veneers Due to it high strength of 400- 500mpa (compared to feldspatic ceramic 100mpa) emax ceramic veneers may be fabricated as thin as 0.2mm. The high strength and resistance to chipping when polishing fine edges make Emax veneers ideally suited to mini- mal prep techniques. With such a thin veneer the skilled ceramist has little space to create his mag- ic with internal layering tech- niques. In order to create the illu- sion of depth in the ceramic very subtle washes of almost invisible colour must be applied layer on layer and fired after each colour to build up an almost three di- mensional effect. The other challenge technician with ultrathin veneers is to cre- ate a natural surface texture on such a fine sliver of ceramic. In order to create the micro fine surface texture in such a delicate structure standard dental labo- ratory burs are often too course and bulky. Fine dental surgery burs in a low speed electronic contra-angle motor are ideal to reproduce the subtle surface de- tail of the natural tooth. Glazing locks in the colour wash- es and protects the effect. The glaze is then hand polished us- ing silicon rubbers, fine pumice and diamond polish. This is done to achieve the texture and feel of teeth polished for years by the tongue, cheeks and lips. The dif- ference in feel and appearance of hand polished ceramic to glazed ceramic is noticeable and pa- tients often comment on the nat- ural feel of the restorations. The high strength and polish-ability of the Lithium Disilicate Emax ceramic allows hand finishing with a low risk of fracture during the process. For the patient with more com- Figure 10. Close view before Figure 11. Close view after align- ment Figure 12. Close view after ve- neers Figure 13. Fine anatomy carved with fine FG diamonds Figure 14. Enhancing colour with surface shades Figure 15. Natural surface mor- phology and subtle colouring be- fore glazing and polishing Figure 16. Final IPS Emax veneers plex aesthetic or functional / oc- clusal issues or high aesthetic de- mands a combination therapy of realignment and minimally in- vasive ceramic restorations can be the solution that satisfies both the patients desire for great aes- thetics and the clinicians desire to conserve enamel. An added advantage of this approach is that the pre-alignment of the teeth ensure much less dentine expo- sure during prep and a greater area for the stronger enamel bonding. Conclusion This multidisciplinary case shows what is possible when or- thodontics, whitening, and ad- vanced ceramic techniques are combined and sequenced. Everything is done to simplify the treatment and lower risk to make the results more predict- able and importantly to involve the patient along the way with decision-making. The smile design is performed progressively not instantaneous- ly. It allows the patient to see the improvements in their alignment and whitening before a final de- cision on ceramics is made. This is fundamentally different ap- proach to what has gone before and thanks to the new techniques available such as simpler anterior orthodontics and Emax technol- ogy it is now making advanced cosmetic dentistry far simpler and safer for all.