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Dental Tribune Middle East & Africa Edition | January-February 2016 43 General dentistry Inman Aligner Certification Course 26 February 2016 Sirona Showroom, DHC, Dubai, UAE Trainer Dr. Gun Norell, Sweden ◄ Introductionandphilosophy,historyofspringaligners,problemsofpreviousdesigns ◄ TheWorkingsoftheInmanaligner ◄ CaseSelection ◄ ArchEvaluation,Spacecalculation,Inter-proximalreduction,expansionandretention ◄ CasePresentations.ALargeportfolioofvariedcaseswillbeshownandwillbediscussed andexplainedindetail ◄ InmanAlignersBeforeVeneersandEthicalConsiderations ◄ UseofclearalignerstofinishInmanAlignercases (15%discountavailableintheUKandDenmarkonclearalignersfollowingInmanAlignertreatment) COURSEOUTLINE ContactUs Mobile:+971502793711 Telephone:+97143616174 E-mail:dtmea@dental-tribune.me 7 ADA C.E.R.P CE CREDITS HAAD 7 CME < Page 42 rior and canine guidance. The Treatment Her Inman Aligner treatment took 10 weeks with three ses- sions of IPR and no more than 0.13mm of adjustment per tooth per appointment. This staged IPR approach is far safer than performing all of it in one go, as often less IPR is needed than expected. It avoids excess space formation and the destruction of contact point anatomy, which is so often seen when IPR is done all at once. Anatomically respectful IPR should be performed by anyone creating space to move teeth. The patient was also instructed to remove the aligner for at least four hours a day. At seven weeks, the patient started whitening with Zoom! DayWhite (Philips Oral Health- care) when not wearing the aligner. Whitening can be highly effective if the right instructions are given to the patient. Dry teeth will whiten better, so we not routinely tell patients to swallow, then suck air over their teeth before the tray is inserted. This is something I have done for the last couple of years and it has made whitening far more predictable and the results have been consistently better. A short-acting hydrogen per- oxide gel that requires only 45-minute application each day is ideal. With sealed rubber trays, it does not matter if the teeth are still aligning. After eight weeks, they are usually 60-75% aligned. The tray will still fit at the end, but, of course, a new tray is made over the composites and wire retainer. Performing whitening in this way adds massive value and re- duces chair time and, of course, can only be done with remov- able braces. You cannot, and should not, use short-acting concentrated gels in rigid clear aligner trays as they are not sealed and the gel will contact the gum line. Low- er percentage materials are in- dicated. At 12 weeks, the composite tips were placed all in one go. It is quite possible to have your technician construct a wax-up of the proposed outline. It is also quite possible to do this with ar- ticulated models and a wax-up. You can then use a putty stent to help you create an accurate outline. Note how upper alignment has improved on its own by just aligning the lowers correctly Personally, I have always pre- ferred to build free-hand. I try to visualize the original anat- omy of the teeth before they were worn. The new initial contact position is slightly pos- terior to maximum intercuspal position. Very minimal feather preps were used to literally just roughen the bonding surface. The teeth were then etched, bonded and an initial outline of the load bearing areas were built-up with a nano-hybrid composite. A dentine shade, then an in- cisal enamel shade, is layered over. The composite is then pol- ished back with fine burs and smoothed with Soflex discs and Pogo rubbers. Eight composites were placed in this way. They were built-up using different amounts but in a way that aligned the incisal out- line and that opened the bite on the anterior teeth. It was impor- tantthattheircontactsarefairly even but with more load on the canine and premolar and a long centric contact on the incisors. At this point, the patient’s poste- rior teeth were discluded and a visible space was present. The patient continued to wear her Inman Aligner and an im- pression was taken for a jig that would hold a stainless steel re- tainer to be fitted next time. A bonded retainer was fitted to the lingual surface from canine to canine and the patient was instructed on the use of inter- dental brushes. The results The patient was seen after 3 weeks to ensure there were no premature posterior contacts. On return after a few months (Figure 4), it was noted that the posterior teeth were now in full contact again. Lateral excur- sion showed good predictable canine guidance and anterior guidance was also now com- pletely discluding the posteri- ors. Whether this has happened due to passive eruption, ante- rior intrusion or even some re- positioning of the condyle can be argued. The point is that the patient’s deep bite was reduced, her occlusal symptoms disap- peared and the aesthetics had massively improved. She had improved canine and anterior guidance and, one year on, she has had no issues, chips or even stains. A potentially difficult treat- ment plan turned into a simple non-invasive technique and the photographs show a pleas- ing result. The patient reported an improvement in symptoms. However, we always give the patient a bite guard to wear in case of periods of bruxism. Conclusion We have all read articles show- ing cases like this that eventu- ally end up prepped heavily for ceramic restorations. Patient like this left untreated long term will become more worn and eventually might need full mouth or extensive treatments. While I certainly cannot pro- fess the Dahl principle to be the answer to all occlusally com- promised cases, I suspect that with the recent trend towards non-invasive treatments and rapidly rising litigation, this kind of less destructive solution might become more popular. The key is to pick up on likely candidates early and treat them with alignment and bonding or just bonding to help prevent wear in later life. In my opinion, if patients knew the benefits and the problems they could Figure 10. Occlusal after eight weeks of align- ment and commencement of bleaching. Figure 14. Close view before. Figure 12. Close side view before. Note differen- tial wear. Figure 16. Patient protrusive, edge to edge be- fore. Figure 11. After 12 weeks with bleaching com- plete and additive bonding in place. Figure 15. Close view after. Figure 13. Close side view after alignment with Inman Aligner, bleaching and Dahl principle bonding. Figure 17: After protrusive. Note how upper alignment has improved on its own by just aligning the lowers correctly. save themselves from, there would be millions of potential candidates for this kind of treat- ment. Editorial note: The full list of references is avail- able from the publisher. Dr. Tif Qureshi is in private practice in the UK and is the Immediate Past President of the British Academy of Cosmetic Dentistry. He leads the Global Inman Aligner Training Pro- gram. About the Author Dental Tribune Middle East & Africa Edition | January-February 201643