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Dental Tribune Middle East & Africa Edition No.2, 2016

Fig.7.10yearsafterIA treatment 2015 Fig.8.Before treatment 2007 Fig.18.Before treatment Fig.13.7yearslater2014 Fig.9.9weekslater2007 Fig.19. After3stepsmile Fig.14.Occlusalview Fig.10.7yearslater Fig.20.Occlusalafter treatment withretainer Fig.15.Spacewize throughlandmarkpoints Fig.11.Before treatment Fig.21.Before treatment Fig.16.Chinupviewbefore Fig.12.9weekslater Fig.22.2yearreview Fig.17.Printedmodelset tospacewize Dental Tribune Middle East & Africa Edition | 2/2016 32 general dentistry for two main reasons. The first high- lightsthepointnowwidelyaccepted that retention after orthodontics is forlife. The second point is even more im- portant- that in adults with mild or moderate crowding, the arch length willreduceregardlessofwhetherthe patienthadorthodonticsornot. This is a critical point for all dentists to understand especially anyone carrying out restorative treatment. That is the teeth you have restored, thatyoumayexpecttoremainsame position through life will keep mov- ing and the functional contacts will change. It is one typical reason why composite fillings classically chip on the front teeth. Basically if you have crowded it will get worse and arch width will collapse which may have aneffectonthepatient’sguidance. It also means that lower incisors, whichhavewearfacetsduetocrowd- ingcausedbyirregulardynamiccon- tacts, will get worse and wear faster causing more dentine exposure and darkeningfromthesoakingofstain. These two patients were told 25-30 years ago that the upper teeth need- ed treatment but the lowers were not crowded enough to treat. At the timetheywerenotthatcrowded,but over time as per the findings of Lit- tle’s study the teeth have continued to crowd causing the evident result. (Fig.1,2) These two patients both had com- prehensive orthodontics but no fixed retainers were used and no long-term follow-up was carried out by their orthodontist -as a result the patient teeth relapsed almost to the originalposition.(Fig3,4) This patient was treated 10 years ago for mild crowding having relapsed 3 years after comprehensive treat- ment. There was differential tooth wear already visible and at the 10 years follow up there’s been no ir- regular wear because the teeth have been held in the correct position. Her teeth were aligned with an In- man Aligner in 4 weeks and fixed retained. The original retainer has remained in place for 10 years. Being aregularpatient,inGDPpractice,the retainer can be reviewed at correct intervals.(Fig-5-7-Lucy) This patient was only 21 and her crowding was getting worse, as was the differential tooth-wear on her lowerteeth.Hercanineguidancewas collapsing and she was slowly mov- ing into group function. Her lower incisors were starting the wear dif- ferentially.Afteraligningherteethin 9weeksandfix-retaining,hercanine width was increased and held, func- tion returned and 7 years later there has been barely any increase in wear intheloweredgesFig.8Cara. Detailedcase This case example will go through the steps needed for the three-step smile, and outlined planning and consentingprocessesinvolved. This patient presented originally wantingporcelainveneers. However he was aware of the high costs and that it would involve heavy prepa- ration on his teeth so he decided to consideraligninghisteeth. Whenhe was shown the results possible with combined bleaching and bonding the patient decided against veneers altogether. After a full examination and ortho- dontic assessment, our first step was to decide on a landmark reference tooth. This is a tooth, which is con- sidered aesthetic by the patient and aesthetic and functional to the clini- cian. An Arch evaluation and an occlusal trace is carried out with this refer- ence point in mind using Spacewize software, so that the 3-D setup cre- ated by the technician following the exact prescription of the dentist. In this case it was decided that the ca- nines were in an ideal position so we certainly should not be flared on thesetup.Thecurvestrictlydictated the position to be achieved (Fig SW trace). It was discovered when considering the landmark point in looking at a chin up view, that to achieve the ideal upper position, a lower tooth wasinthewayandwouldneedtreat- ment.(Fig) A full 3D digital setup was produced bythelaboratorybasedonthiscurve - this was checked by the dentist be- fore going ahead. A 3-D model was then produced the before and after positions. Thepatienthasshownthe print before any aligners were built. This ensured he was fully consented that he understood the potential compromises of only treating the anterior teeth. The patient reviewed the models in his hand and was hap- py with what was proposed. The 3-D models were returned to the lab and an upper Inman aligner and lower Clear Smile aligners were built on thesetups. A full Inman Aligner space creation guide with provided that outlined not only IPR but also PPR (predictive proximal reduction) -understanding this makes the difference between average aesthetic and superb aes- theticresults. Progressive space creation was car- ried out over a period of 12 weeks. Thepatient’steethstartedtoalign. Simultaneousbleaching Towards the last part of treatment bleaching trays were made the pa- tient started bleaches teeth simul- taneously. Impressions were taken and super sealed trays were made on the nearly aligned teeth - 6% Day white whitening from Philips was giventothepatientwithfullinstruc- tions. Hecarriedoutwhiteningonce to twice a day for 35 minutes at a time. At two weeks notice a significant im- provementinthetoothcolour. A mockup outline was carried out using flowable composite- and the patient was happy with the pro- posed build-ups, which involved 4 teeth. EdgeBonding 2 weeks later the edges were perma- nently built using Venus Diamond and a very simple 2-layer reverse tri- angletechnique.Nopreparationwas required. The retainer was fitted on the same day using a jig made on an impres- sion post alignment. This was bond- edusingVenusFlow. Conclusion One can see the natural- looking end result of this patient. He was thrilled with the fact that the treatment sim- ply made his own teeth look as good as they possibly could, rather than totally changing his appearance and feeling as if someone else’s teeth were in his mouth. More significant is the fact that this could be done by any dentist with the simple “Three step smile” alignment bleaching and bonding, with far less risk, better consenting and arguably a far more natural outcome than traditional veneer preparations. With upper and lower fixed retainers in position canine widths and guidance can also be maintained meaning reduced chance of composite fracture better long-term function and better long- term aesthetics. The 2 year follow up showed no changes in occlusal con- tactsorshiftsinguidance. ◊Page30 ““Threestepsmile”alignment bleachingandbonding,withfar lessrisk,betterconsenting andarguablyafarmore naturaloutcomethantraditional veneerpreparations.” Dr.Tif Qureshi, UK. He is a Director of Intelligent Align- ment Systems. You can learn about the Unique mentored Path- way of Learning from IAS starting with Inman Align- ersandClearSmile Aligners, then Clear Smile Braces right up to Clear Smile Advanced taught by Professor Ross Hobson by visiting www. Iasortho.com Dr. Tif Qureshi will give two hands-on courses at 11th CAD/CAM & Digital Den- tistryInt'lConferenceinDubai.

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