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Dental Tribune Middle East & Africa Edition | 1/2017 16 Inclined Central Incisors: The Use of a Straightforward Aligner for a Simple Case ByDrNishanDixit,UK Demand for adult orthodontics has grown enormously in recent years, with an increasing number of peo- ple wishing to straighten their teeth in pursuit of an improved smile. As a result of the various time and fi- nancial restrictions faced by many patients today, anterior alignment orthodontics has become particu- larly popular, offering a safe, highly effectiveandefficientsolution. CasePresentation A healthy 33-year-old female pre- sented to the practice with concerns about the appearance of her central incisors – which had become pala- tally inclined following poor reten- tion after previous orthodontic treatment. Her main intention was to align the anterior teeth, without using fixed braces again. The patient was a non-drinker, non-smoker, regularly attended dental appoint- ments and followed a strict oral care regimen that included brushing twice a day and flossing. Her dental notes also revealed that her upper premolars were extracted at the time of her previous orthodontic treatment. OrthodonticAssessment Assessment confirmed good oral healthwithnosignsofperiodontitis, though the patient did show signs of discolouration as a result of tea con- sumption. There were no signs of a crossbite and lips were competent atrest. An orthodontic assessment was also carriedout(Table1). DigitalCasePlanning Once the necessary examinations were complete, the patient was pre- sented with the various treatment options – these included clear align- ers, fixed orthodontics, veneers and the IAS Inman Aligner removable appliance.Asthepatientwasdesper- ate not to undergo comprehensive orthodontic treatment again and ve- neers are considered to be the more invasiveoption,sheoptedfortheIAS InmanAligner–muchmoreidealfor tipping the incisors than clear align- ers. She was also made fully aware that there would be an increase in overjetfollowingproclination. To confirm suitability of the treat- ment method, I utilised the IAS Academy’s Spacewize+™ arch evalu- ation software. The results of the crowding calculator concluded that approximately 0.75mm of space would need to be created, ensuring that the IAS Inman Aligner was appropriate for the patient’s needs. After sub- sequent photographs and radiographs were taken, study models were put to- gether. Through these, the patient was able to see the expectedresults,whichwas a great tool for boosting motivation and ensuring compliance. Treatment (Table3) Self-Appraisal As we managed to address the patient’s concerns and improve her smile with minimal tooth reduction, I am pleased with the out- come of the case. We had Figure16:Post treatment retracted Figure17:Post treatment upperanteriors Figure18:Post treatment upperocclusal Figure11:Pre treatment lowerocclusal Figure6:Pre treatment retracted Figure7:Pre treatment upperanteriors Figure 8: Pre treatment retracted right view Figure9:Pretreatmentretractedleftview Figure10:Pre treatment upperocclusal Figure12:Post treatment Figure1:Pre treatment Figure2:Pre treatment lipsat rest Figure3:Pre treatment smile Figure4:Pre treatment right view Figure5:Pre treatment left view Figure13:Post treatment lipsat rest Figure14:Post treatment right view Figure15:Post treatment left view Figure19:Post treatment lowerocclusal Table1 Table3 Table2 Skeletal MildClassII FMPA High LowerFaceHeight Normal/average FacialAsymmetry None SoftTissues Pink,healthyandwellhydrated IncisorRelationship ClassIIdivisionII Overjet Reduced(0mm) Overbite Increased(90%overlap) Displacement onClosure Nonedetected MolarRelationship Left:ClassII Right:ClassII CanineRelationship Left:ClassIRight:ClassI TeethPresent 8765321 1235678 87654321 1234567 Centrelines Coincident Appointment Stage One •Upperandlowerimpressionstaken. •Biteregistrationtaken. Two •StartedIASInmanAlignertreatment –patient shown howtoinsert andremoveapplianceandadvisedtowear between16and20hoursaday. •Oralandappliancehygieneinstructionsweregiven. •Placedcompositeanchoronthebuccalsurfaceofthe upperright lateralincisorwiththeaimtokeepthealigner bowinplaceformoreefficient toothmovement. •Nointerproximalreduction(IPR)at thisstage. Three •Patient wasseenforacheck-uptoreviewcompliance andmonitortoothmovement –modelswere usedasareferencetoshowprogress. •Alignerbowandspringswerecheckedforfunction. Four •Functionoftheapplianceandmovement checkedagain. •IPRcarriedout distallyonUL1andmesiallyanddistallyon UL2usingyellowstrips(0.08mm),followedbypolishing andapplicationoftopicalfluoride. Five •Thepatient wasinformedoftheprotocolforretention. •Upperandlowerimpressionsweretakeninputty/wash materialforacustommadefixedlingualretainer. •Arecordofthebitewasalsotaken. Six •Compositeanchorremovedfromupperright lateralincisor. •Fixedlingualretainerfittedwithcomposite. •Guidancegivenontheimportanceofretentionand advisedtokeeptheIASInmanAlignerapplianceincase relapseoccursinthefuture. •Appointment madewiththehygienist. Problemlist Mildupperincisorcrowding Mildlowerincisorcrowding ClassIIdivisionIIincisorrelationship Reducedoverjet Increasedoverbite Molarrelationship–classIIontheright IdealTreatment Aims Correct upperandlowercrowding Correct deepoverbite Correct molarrelationshiponright-handside CompromisedTreatment Aims Correct upperincisorcrowding Correct deepoverbite Improveincisoroverlapandoverjet Accept lowerincisorcrowding Accept molarrelationship aimed to do the case without any toothreduction,butinordertoclose or reduce the black triangle towards the interproximal area of the upper central incisors, a small amount of IPR was necessary, which the patient consented to. The patient was very happy with the final result and can nowsmileconfidently. In a review, ten days after the com- pletion of the treatment, the patient had adapted to the fixed retainer well, and had not reported any com- plications or discomfort. Because of past problems, we will continue to monitor the patient’s retention, that way she can ensure that no further orthodontic treatment is needed in thefuture. Editorial note: A list of references is availablefromthepublisher. DrNishanDixit is the FounderandPrincipal Dentist ofBlueCourt DentalinHarrow, Middlesex.Heisalso thecurrent Scientific Directorof theBritish AcademyofCosmeticDentistry(BACD). Withaspecialinterest insmilemakeovers andcosmeticorthodontics,DrDixit de- tailsacaseusing theIASInmanAligner. GENERAL DENTISTRY TeethPresent 87653211235678 876543211234567