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16 GENERAL DENTISTRY Dental Tribune Middle East & Africa Edition | 6/2017 Upper Arch Alignment with the ClearSmile Inman Aligner By Inman Aligner Treatment planning In this case, the patient contacted the clinic because she was both unhappy with her upper anterior teeth and worried about the increasing crowd- ing. At this time, she did not feel that crowding in the lower arch was a problem. She made it clear she was not motivated for fi xed orthodontics and was interested to know if her up- per anterior teeth could be aligned with the ClearSmile Inman Aligner. After an orthodontic assessment, UR2 was identifi ed as the landmark tooth, and the SpacewizeTM crowd- ing calculator showed that the dif- ference between the available space and required space was 2.2mm. When the case was submitted to the IAS Academy’s online support along with clinical photographs and Space- wizeTM analysis, the trainers con- fi rmed that it was a suitable case for the ClearSmile Inman Aligner with a combined expander, and would help to unlock the overlapping central incisors. The trainer also said that it may not be possible to completely align the upper arch while the lower arch remained crowded, so a digi- tal setup was requested from the laboratory to ascertain exactly what could be achieved. Using the digital setup, I was able to discuss the fi nal outcome with the patient, as well as explain the com- posite bonding process that would take place at the end. The treatment goal was to achieve straighter, more natural looking teeth and restore incisal wear in UR1 and UL1 while preserving the enamel. Information about the bonded retainer was also given at this time and the impor- tance of retention. After she consent- ed to the treatment plan, impres- sions were made and the appliance was ordered from the laboratory. Mentorship At every step of the way the trainers were available via the online support platform to provide advice on how best to approach the treatment path- way. In appointment order, their guidance was as follows: Skeletal FMPA Lower face height Facial asymmetry Soft tissue Incisor relationship Overjet Overbite Displacement on closure Molar relationship Canine relationship Teeth present Centrelines Class I Average Average No Normal NL angle Class I (crowded) 4mm (at UR1) 30 per cent overlap of incisors No Class I Class I All present 2mm deviated to the right in upper • Remove anchor from UR1 to drive out UL1 before starting the rotation of UR1. • Wait for the front teeth to unwind, focusing on the expansion. • Don't turn the expander too quick- ly as it will induce unwanted tooth movement. After the fourth appointment, I also received feedback from one of the trainers suggesting that I should have waited until the UR1 distal was a little further forward before adding the labial anchor, which in hindsight would have been a better approach. Self-appraisal The patient was very satisfi ed with the results, especially the fact I was able to improve her smile without affecting the integrity of the enamel. I sent before and after images to the patient at the end of her treatment pathway so that she could see the difference, and she was amazed at how much the aesthetics of her teeth had changed. I was also very happy with the outcome – with the help of the IAS Academy and digital plan- ning tools, treatment was safe and predictable. Dr Solveig Skaar Dr Solveig graduated from the University of Bergen in 1998 and purchased her own dental clinic in 2005. Now, she is a member of the Scandinavian Academy of Esthetic Dentistry and has been a certifi ed user of the ClearSmile In- man Aligner since 2013 (she took the ad- vanced course in 2014). Here, she details the case of a 28-year-old female patient who received upper alignment treatment using the ClearSmile Inman Aligner. Appointment Stage 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. At the initial appointment, palatal anchors were placed, with interproximal reduction (IPR) and predictive proximal reduction (PPR) carried out using the guide issued from the laboratory. The patient was instructed on how to turn the expander. Aligner in situ. UR1 anchor removed, and IPR and PPR carried out using discs for canines and blue/red strips for anterior teeth. Progress with crowding on target at this point thanks to use of expander. IPR strips used and space between UR1 and UL1 polished. Patient had turned the expander eight times by this point – instructed to stop. PPR carried out on the central incisors, with space between UR1 and UL1 polished again. Discs used distally on the canines, with a composite anchor placed on UR1 and composite anchor removed from UL1. Impressions were taken for ClearSmile Aligners. First ClearSmile Aligner fi tted. Second ClearSmile Aligner fi tted and worn for two weeks solid before being used at night to aid retention. At this point there was a break in treatment, as the patient was breastfeeding her baby. After a couple of months, treatment recommenced with bleaching and impressions were taken for a retainer. Fixed retainer bonded followed by composite bonding of UR1 and UL1 using the reversed triangle technique. The benefi ts of this technique include: • Affordable • Ethical (preserves tooth structure) • Aesthetic • Simple • Complements alignment therapy Afterwards, the restoration was polished with both fl exi disks and Mini FlexiBuff with Enamelize polishing paste. At the end of this appointment, new impressions were taken for new bleaching trays and an Essix retainer. Composite re-polished and patient given bleaching tray and retainer to wear at night. Table 1 – Assessment / Diagnosis Table 2– Treatment pathway Fig. 1: Pre treatment anterior Fig. 2: Pre treatment right lateral Fig. 3: Pre treatment left lateral Fig. 4: Pre treatment retracted right lateral open bite Fig. 5: Pre tretament retracted right lateral ÿPage 18 Fig. 6: Pre treatment upper occlusal Fig. 7: Pre treatment lower occlusal