ethical smile design
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8/8/2019 Ethical Smile Design
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Elhicalnd ffordableniilGesigAndrewallaceresenfshe asefudyfapafienlreatedifhhenmanligner
There has probably never
beena better ime to practise
dentistry.However,dentistsand patientsarebombardedby images f the beautifulsmile and, for many years,practitioners havebeenpressurednto believing hatporcelain eneers re he onlyanswer.
Of course, here aremanysituations where veneersarethe deal reatment, nd whenwell placed and properly
bonded to enamel hey willlast or many years MagneP,BelserU, 2003). LaytonandWalton (2007) showed a 73olosurvival rateat L6 years orveneers onded o enamel.Unfortunately, n my practicethese dealcases arelycomethrough he door.
Most of the patients
coming o the practice orcosmetic entistrydo so formore severe roblems.
Crowding of the upper andlower teeth s a commoncondition hat adult patientswould like improved.
Porcelain eneers nd'instant rthodontics'designed o treat this willoften ead o excessive namelremoval, isking pulp vitalityand compromising ond
Andrew Wollace gained hisBDS rom Queen'sUniversityBelfast n 7998.As well aspractising ull-time in pri.vatepractice n BachelorsWalhDentol Surgery,Lisburn, heis studying at King's CollegeLondon or an MClinDent in
fixed and removableprosthodontics. e is a fullmember of the BritishAcademyof CosmeticD entistry (BACD). Andrew
gained certification on lnmanaligner tr eatment thr oughStraight Talh seminars n
tanuary 2009.
16 | Irish Dentist October 20lO
strengths, r over-contouredrestorations, hich cancompromise laquecontrol.
Poor root positionwill alsocompromisehe emergenceprofiie. The patient,who bynow has alsoentered he'restoraiiveycle',wil l requirethe periodic eplacement fthese eneerswith more
lnvasive estorations Kim J,Chu S, GurelG, CisnerosG,2005; acobson , FrankCA ,2008). Burkeand Lucarotti.(2009)showed he survivalrateof veneersn Englandand Wales o beapproximately 0.5 years.
Meanwhile, he Inmanalignerhas proved to be avaluableappliance o helppatientswith mal-alignedanterior eeth(QureshiA,2008; WarunekSP,Willison
BD,2005).
(ase resenlalionThe patientwho attendedwasa 19-year-old omanrequesting osmeticimprovementof her upperand ower teeth.Her chiefcomplaint was that she was'unhappy'with her smileandthat her front teethareout ofshape'.
The patientwas a regularattendeewith her general
dentalpracti.tioner nddentallyhealthy.Other thanher aesthetic oncerns, hedisplayedno dental complaintsand had no history of bleedi.nggumsor sensitivity
Upon enquiring further,shementionedshehad beenconsidering aving reatmentto improve her smile for theIast year and had a familywedding comingup in just
over 2 months.The patienLwashappywith the shapeof
her upper and ower teethshesaidshewould have ust
liked them to be a liulewhiter and straighter.
From the examination it
was ascertained hat she had
minimally restored dentition
with a large silver amalgam
filling in her lower lefr first
molar and some hypoplast ic
enamel in her upper right firsi
molar.
Her upper left first molar
was missing, but with no
residual spacing due to mesialmovement of the second
molar. Her lower third molars
were unerupted with mesio-
angulhr impaction. She had a
thin scalloped gingival
biotype.
The patient's ower incisor
teeth had moderate crowding,
with good positioning of the
canines. The upper incisors
displayed mild crowding,
with the mesial edge of the
upper right central incisor
overlapping with the upperleft central incisor by 2mm.
A full discussion was
undertaken with the patient
about the possible options:. No treatment. Comprehensive orthodontic
treatment. Fixed short-term
orthodontic treatment. Removable alignment
treatment. Restorative reatment/
'instant orthodontics'.
The patient did not wantrestorative treatment and
dismissed the idea of crowns
or veneers when we expiained
the excessiveamount of
enamel removal. The patient
was open to the concept of
fixed bracket orthodontics but
was much happier with the
idea of a removableappliance
for lifestyle reasons.
We went'into the specifics
of interproximal enamel
reduction (lPR) and the
patient expressed hat she washappy with this small amount
of enamel removal to create
space for tooth movement.
IrealmenlA lull set ol clinical
photographs were taken (in
accordance with American
Academy of Cosmetic
Dentistry guidelines) and
upper and lower alginate
impressions were recorded.
The exact areas of the
patient's smile that causedher
concernwerediscussed singthe photographs, and we
discussed the tooth movemen-rs
that would be possible with the
alignment treatment.
Once the models were czLit
from the impressions, we
were able to assess he
amount ol crowding. This is
done in a very simple fashion
when using an Inman
aligner - the maximum width
of each inclsor and canine
tooth is measured using a
simple micrometer. Using aninterproximal metal str ip, the
required space of the optimai
arch form is then measured
from the distal o[ one canine
round to the contra-lateral
canine. The difference is equalll
to the required amount of
interproximal reduction. anci
for this young woman it was
found to be 1.2lmm.
Up to 3.5mm of crowdins
can be treated with a standard
lnman al igner device using
just IPR. More severecrowding can be addressed
with an lnman aligner
incorporating a palatal
expander.
An upper serles of three
clear aligners and a lower
Inman aligner were prescribed
and the patient consented to
the treatment as described.
The models were sent to
Nimrodental Laboratory,
which is the UK's only Inman
aligner laboratory.
The Inman aligner isfabricated on a Kessling
model. The prescri.bed
interproxima l reducLion s
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carriedout on the plastermodel, he teethareremovedand then replaced n themodel n wax on the dealarch orm.
The first upper clearalignerand ower Inmanalignerwere itted on thesameday Extensivediscussion asundertakenwith the patienraboutwhat toexpectover he comingdaysandweeks.
A smallamountofinterproximai eductionwasundertaken singmetalinterproximalstripson al l theinterproximalsurfaces f thelower teeth, rom mesialofthe canines ound to thecontra-lateral anines,
nd onthe upper teeth,as per rhelaboratoy instructi ns .
IPR s carriedout in thisfashion o respecthe anatomyo[ the ooth.simplymakingthe teethmoreslender.
Thepatientwasseeneveryfour weeks or the fitting ofeachof the upper alignersnthe series, nd to carryoutfurther interproximalreductionon the ower teeth.
After threemonths, heupper
alignmentwascompleteand the ower teethwerealmoststralght.
After four monrhs, healignmentof the ower teethwa scomplete nd mpressionswere aken or a fixedbondedretalner a muiti-strandstainless teel etalnerbondedto the palatalsurface f thefront six reethwith the aid ofa customplacementig,
Due o the ypeof occlusion,the patientcontinueso wear
an Essix-typeetaineron theupper eerh.
DiscuslionThis self-consciousoungwomanwasconcerned boutthe appearance f her teeth,which werebecomingincreasinglymorecrowded. nfour months,her upper andlower teethwerealigned orless han the costof fourporcelain eneers.
Thephotographs how he
detailof the morphologyandshade haracteristicsf theteeth reproductlonof thiswould haveproveda
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chalienge for even the mostgifted dental technician.
Just a few years ago, theoptions open to her or herdental practitioner wouidhave been limired to full
orthodontic treatment orrestorative treatment. Therestorative options wouldhave involved either excessrveremoval of enamel anddentine for porcelain veneersor excessi.velybulky and over-contoured restorations withpoor interproximal contacts.
Now clinicians have theoption of an altogether moresatisfacroryapproach.
Alignment treatment suchas thar olfered by the Inman
aligner can offer rapidcosmetic improvement ofmoderately crowded frontteeth or orthodontic relapse.Becauseone appliance doesalmost al l of the toothmovement, the reduced
laboratory cost allows for amore affordable option forpatients, increasing patientuptake.
Caseselect ion s ke y an d afuil discussion with thepatient about their complaints
and what they wish ro havecorrected is vital, becauseonly correct ionof th e fronrteeth is possible. Incisors canbe rotated and tippedreiatively easily with limitedmovement of the canine teethpossible.
The clinical studypresented here was an idealcaseand the four-month
treatment time required forthis patient is not unusuai.With others, it may be
essential o talk the parientthrough what they can expecrto be.corrected and what willnot be possible.
Often, this form oftreatment will be a precursorto restorative treatment; pre_alignment can allow us tooffer the ideal cosmetic resultwith a much reduced
biological cost in enamel anddentine removal, and an idealemergenceprofile. Often onlyminor enameloplasty or
enamel bonding is requiredafter aiignment to correct thedifferential wear we often seewith crowded teeth.
Figures 1 and 2: Lower teeth betore treatment (top) and followingfour months of treatment
Figures 3 and 4t llpper teeth prior to treatment (above) and afterfour months of treatment
october 2010 | Irish Dentist 17
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Figures5t A pre-op smile from the patient
Interproximal reduction
has been shown to be a safe
way of creating sPace or
iooth movement. Zachrisson
(2007) followed up Patienis10 years after IPR and found
no increased caries risk,
bleeding on probing, gingival
recessionor periodontal bone
Ioss n these patients
(Zachrisson BU, NyoYgaard L,
Mobarakc K,2007).
Th e interdentalsPace
required is often created bY
rounding out the arch and
moving teeth forward that are
I ingually placed and Placingthem on a wider arc.
(onclusionThe Inman aligner is not a
replacement for conventional
orthodontics but does ailow
clinicians to offer quick and
affordable ooth alignmenL n
general dental practice. MY
provision of cosmetic
dentistry treatments has
grown significantly since
introducing the Inman aligner
to-y
pru.ii.eoffering.-n
ReferencesAACD (2010) PhotograPhic
do um nt tion andeY luati n
in cosmeticentistrY a guide
to ac reditationPhotoraPhY.
AmericanAcademyof
CosmeticDentistrY,
Wisconsin,USA
BurkeFJ,LucarottiPS 2009)
Ten-year utcomeof
porcelain aminate eneers
placedwithin the general
l8 I Irish Deitist October 2010
dentalservicesn England
and wales. )urnaL J
Dentistry 7(f): 31-8
JacobsonN, Frank CA (2008)
The myth of instant
orthodontics: n ethlcal
quandary. Am Dent Assoc
I39:424-434
KimJ. ChuS,GurelG,
Cisneros (2005)
Restorativepacemanage-
ment: reatmenLla n ngand clinicalconsiderations
for insufficient space.Pract
Proced esthet en t17(l):
19-25
LaytonD, WaltonT (2007)
An up to l6-year
prospective tudYof 304
porcelain eneers.
International ournaloJ
P ost'hoontics 0 4)
389-96
MagneP,BelserU (2003)Bonde porcelain e tor tions'intheanterior entition.
biomimeticpproach.
Quintessence ooks,London
QureshiA (2008)The Inman
aligner or anterior ooth
alignment.DentUpdate 5:
569-576
Warunek SBWillison BD(2005) ncisoralignment
with the Inman aligner.
Journal JCosmelicenl istry20(4):80-92
Zachrisson U. Nyoygaard .
Figures 6, 7 and 8" A successfu I, retatively fast and affordable
result, as demonstrated by the happy patient
MobarakcK (2007)Dental
healthassessed ore than
l0 yearsafter nterProximal
enamel eductionof
mandibularanterior eeth.
Americanournal ofOrthodonticsnd
Dentof ci I O hoPdic
r :1(2) : r62-L69
AcknowledgementlThe author would like to
thank Dr Tif Qureshi and
DrJamesRussell or their heJP
in planning his early cases.
Dr Waliace has no connection
to Straight Talks Seminars or
Nlmrodental laboratorY.
mnr,IrishDsrtisl.ie
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