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fixed without orthodontic treatment inaveryshortperiod?Inorderforthe general dentist to answer this ques- tion, he or she should first establish whether the patient does not wish to pursue orthodontic treatment be- cause of the time commitment and cost. Would he or she also refuse short-termanteriortoothalignment? Would the occlusion be improved even though a Class I molar or Class I canine relationship may not be achieved? Patients may prefer short- term alignment techniques because of the shorter treatment time and thelowercost. Case1 The first case presented is a good example of a scenario relevant to the question above. The patient was a young woman at college who pre- sented at my office requesting a full smile makeover of 20 veneers; she desired a “Hollywood smile” as ex- pressed in her own words. Her com- plaint was the retracted maxillary right and left central incisors, the in- cisal edge wear on the maxillary cen- tralincisorsandmandibularanterior teeth, the pointy shape of the maxil- lary and mandibular canines, and the yellow colour of her teeth overall (Figs. 4 & 5). It could be argued that it would be highly unethical to prepare the sound enamel, transforming her ten maxillary teeth into stumps, for the rest of her life, especially at this young age. After long discussion and explanation of the disadvantages of the shortcut route of preparing her teethforceramicveneers,thisoption was excluded. Several other options wereavailableanddiscussedwithher, but because she wanted a smile en- hancement in a short period of time, conventionalfixedorthodontictreat- ment was also excluded. After check- ingherbite,itwasobservedthatthere was insufficient interocclusal space to shift the maxillary central incisors forwards without opening the bite. However, the patient accepted use of theInmanAlignersystemowingtoits short treatment time and flexibility regardingbeingabletotaketheappli- anceoffduringthedaywhileeating. The treatment plan was to follow the ABB protocol (alignment, bleach- ing and bonding). This concept still constitutes a smile makeover but in a very conservative manner. Taking into consideration her age and her sound enamel tissue, this was agreed to be the most progressive means of carryingouthersmileenhancement. First,hermaxillaryteethwerealigned using the Inman Aligner with an expander for nine weeks. Two extra- clear aligners were used in the last two weeks of treatment to de-rotate the maxillary left lateral. Once the maxillary teeth had been aligned andinthelasttwoweeksoftreatment, theteethwerebleachedwithcustom- fitted super-sealed trays (Fig. 6). Now that the teeth had been straightened and whitened, the patient became more aware of the differential wear on the incisal edges of her anterior maxillary and mandibular teeth. Incisal edge bonding using com- posite was completed using a simple direct technique. The patient was very happy with the final result (Figs.7–19). Case2 The second question to be consid- ered regarding treatment: would some of the teeth be aggressively prepared or end up with root canal treatment if treated with restorative dentistry without alignment and would the overall outcome be better with alignment rather than without? This question addresses the ethical dilemma general dentists face every day. We often have cases with over- lapping anterior central incisors in ouroffice. The patient presented in this case wasbotheredbythelookofhisover- lapping maxillary central incisors (Figs. 20 & 21). His mandibular teeth were also crowded, but for some rea- son, his concern was only with his maxillary teeth. He had started to hide his smile in front of his friends, feeling embarrassed to show his maxillary teeth. After the full ortho- dontic examination and discussion about all of the treatment options, includingcomprehensiveorthodon- tic treatment, the patient chose the removable Inman Aligner system owing to its flexibility in that the wearer is able to remove the appli- ance for several hours a day and because of its short treatment time. The maxillary left central incisor would have been aggressively pre- pared had it been treated restora- tively.7–9 By using a simple anterior alignment technique, the treatment took only eight weeks to straighten the teeth and a great deal of sound enameltissuewaspreservedbycon- servatively resolving the unattrac- tive appearance of the maxillary teeth(Figs.22&23). Case3 The third question to be consid- ered:willtheteethrequirerestorative workanyway,evenafteralignment? The case presented serves to demonstratethenecessityofaligning theteethevenbeforeplacingceramic veneers.10–13 The patient in this case exhibited moderate misalignment with major anterior edge wear due to occlusaltrauma.Inaddition,theteeth weredarkenedthroughyearsofstains being absorbed through the worn dentine of the incisal edges (Fig. 25). Thepatientinitiallyrequestedinstant veneers to resolve his smile problem, but after mocking up the design di- rectly in his mouth, he was discour- agedfrompursuingthisoptionowing the amount of tissue that would be lost. The aggressive preparation of thetissuewasexplainedtohimusing the occlusal image of his maxillary teeth. After an extensive orthodontic examination and discussion of the options, the patient refused fixed or- thodontic treatment, as well as clear aligners. He refused the first option because he did not want anything fixed in his mouth, and he refused the second option because of the proposed time involved. The Inman Alignersystemwasintroducedtothe patient, and he quickly accepted this option owing to the short treatment timeandremovability. The treatment plan was to align theteethfirstandthentoreassessthe restorative work needed (Fig.26). The appliance was used for 12 weeks and onlywornfor16to18hoursaday.Dur- ingthelastthreeweeksofalignment, the patient began to bleach his teeth. Byweek12,theteethwerestraightand white (Fig. 27). At this point, a direct mock-up was done to show the patientthesmiledesignthatcouldbe achievedwithcomposite.Hefeltthat the teeth were still flat and wanted a fuller smile. Because we had aligned the teeth, only minimal preparation was needed as evident from the wax- upandthedecisionwasmadetofabri- cate ceramic veneers instead (Fig.28). Thiscaseshowsthatforcomplexsitu- ations and considering patients’high aesthetic demands, pre-alignment is essential to produce minimally inva- sive veneers with minimal enamel loss. This clinical approach guaran- tees that the strength of bonding to theenamelismuchgreater. Conclusion The goal of this article is to en- courage general dentists to reflect on the importance of considering short-term tooth alignment alone or in conjunction with restorative dentistry when treating patients. Hopefully,thesethreequestionsand caseswillpromptreadersinthinking through the process of this treat- mentmodality. Disclosure: Dr Chayah is the trainer for Inman Aligner Training in the Middle East. He provides hands-on full-day certificate coursestogeneralpractitioners. Acknowledgement: I wish to thank Dr Tif Qureshi,thefounderandDirectorofInman AlignerTraininginLondon,forhismentor- ingandsharingthelastcaseinthisarticle. Editorial note: A complete list of references isavailablefromthepublisher. 19 Cosmetic Tribune United Kingdom Edition | 10/2016 COSMETIC TRENDS DrRamiChayah runs a cosmetic dental practice in Lebanon with an emphasis on minimally in- vasive dentistry. Heseekstoshare his passion for photographicand video production and believes that through his personalised dental ap- proach, he can demonstrate a more positive way of practising dentistry, helping other dentists to view the dental domain in a different way. You can reach Dr Chayah through his socialmedia:facebook.com/ramichayah andhttp://instagram.com/ramichayah www.inmanalignertraining.com 20 21 Case2—Fig.20:Frontalviewshowing theoverlappingcentralincisorsbefore treatment.—Fig.21:Sideviewshowing theoverlapping centralincisorsbeforealignment.—Fig.22:Frontalviewshowingtheteethafteralignment.—Fig.23:Sideviewshowingtheteethafter alignment.—Figs.24a&b:Sideviewsshowingthemoderatelycrowdedandwornteethbeforetreatment. 22 23 24a 24b Case3—Fig.25:Occlusalviewshowingthetoothmisalignment.—Fig.26:Occlusalviewshowingtheresult of treatment.—Fig.27:Maxillary teethafteralignmenttoreassesstherestorativeworkneeded.—Fig.28:Natural-lookingthinmaxillaryveneersowingtoaligningtheteethfirst. 25 26 27 28 2021 2223 2526 2728