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Dental Tribune Middle East & Africa Edition

14 Dental Tribune Middle East & Africa Edition | November-December 2014Aesthetics A multi-disciplinary
approach to minimally invasive functional aesthetic dentistry > Page 15 Figure 1. Close view before. Figure 6. Retraction before. Figure 7. Retraction with temps. Figure 9. Side close before. Figure 10. Side close after.Figure 8. Retraction after emax crowns. Figure 2. Crowns removed. Figure 3. Temps in place. Figure 4. Lowers before. Figure 5. Lowers after 7 weeks. By Dr. Tif Qureshi, UK S imple tooth alignment is rapidly becoming accepted as the norm in cases that previously would have been treated with porcelain veneers. However, patients often present with a mix of problems such as previous metal ceramic work, the treatment of which should be integrated as part of the treat- ment plan. Timing becomes a vital part of the treatment when mixing restorative care, align- ment, tooth whitening and oc- clusal planning. The following case illustrates an effective ap- proach to treatment. Case report A patient presented complain- ing that “his two front teeth [old upper anterior crowns] felt as if they were too large and were always hitting the lower teeth”. In addition, his bite never felt “right” (Figure 1). He also want- ed to try to improve the appear- ance of his teeth. He was aware of what could be done with por- celain veneers, but wanted to try to make the best of his own teeth. Examination On inspection, it was clear there were several issues: 1. Occlusion - The irregular alignment of the lowers and the thickness of the upper old crowns were adding to the prob- lem of unbalanced anterior con- tacts. The back of the crowns, especially the upper left central, were hitting the front of his low- er teeth, in particular the lower left central. A heavy, not long centric con- tact was present in MIP, which was causing slight deflection of the central. This meant that the upper central crown had been placed quite labially and because it was metal ceramic, made it feel particularly thick. 2. Thickness/aesthetics of crowns - The occlusion meant that the upper crowns had been placed quite labially and be- cause they were metal ceramic, made them feel particularly thick. They also appeared rather opaque. 3. Lower crowding - The pa- tient was also keen to improve the aesthetics of the lower teeth as the incisors had an irregular outline. The incisal edges ap- peared to be of different heights. This was down to the varying anterior-posterior position. 4. Colour - The old crowns had been made at A3/A3.5 and the natural teeth had darkened a lit- tle with age. Treatment plan A combination of techniques and good timing can make sure we optimize the opportunity for treatment. In this case, the treat- ment plan was as follows: 1. Remove the two upper crowns and replace them with tempo- rary composite crowns; 2. Simultaneously fit a lower In- man Aligner to align the lower incisors into a better functional position, while using bespoke clear aligners to slightly tilt the uppers into better alignment. The rationale for using upper clears and a lower Inman was that only 1 mm of movement was needed for the uppers and about 2.5mm of movement was required for the lowers. Inman Aligners are much faster than clear aligners with these kinds of movements. And 2-3 clear align- ers can be just as quick with very small movements of 1 mm and be a little more cost effective if made bespoke. It would also al- low us to treat both arches more or less simultaneously. 3. Whiten the teeth (during last phase of alignment).
 4. Change the composite temps to all ce- ramic crowns to match. 5. Retain the lower arch. Our aim was to try to treat these multiple issues simultaneously so that treatment could be com- pleted over a few months. Alternative options Alternative options were dis- cussed. Fixed braces were dis- counted because of the cost, the difficulty in simultaneous whitening and added difficulty in having the crowns as tempo- raries through treatment. The patient’s posterior occlusion was also good. Full anterior veneers were discussed, but after the patient understood how simply and quickly the alignment could be done, seemed a completely ridiculous and unethical solu- tion. Treatment On the initial appointment the two old crowns were removed (Figure 2). The preps were merely cleaned and treated as conservatively as possible. Tem- porary crowns, which could be adjusted, were placed (Figure 3). Upper and lower impressions weretakenforupperclearalign- ers and for a lower Inman Align- er. A prescription of the tooth movement using SpacewizeTM software was given to the tech- nician so they were aware of ex- actly where we wanted the teeth to be moved. Spacewize also cal- culates a figure for the amount of crowding present giving us an idea of the total amount of space that would need correcting and whether the case is suitable for Inman Aligners or not.1 Two weeks later, the patient re- turned. The Inman Aligner and clear aligner were fitted on the lower and upper teeth respec- tively. Minimal interpromixal reduction (IPR) was started. Despite knowing how much we are likely to need, with Inman Aligner treatment, we never complete all the IPR in one go.
 Despite calculating the amount of crowding present, the IPR is never carried out in one go. Only IPR strips or discs are used. This gives the opportunity to ensure the stripping is far more ana- tomically respectful than using burs or heavy discs. This mas- sively reduces the risks of excess space formation, gouging or poor contact anatomy. No more than 0.13 mm per contact on the anterior teeth were adjusted on this single visit. The contacts are smoothed and fluoride gel is ap- plied each time.2-9

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