ethical smile design

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

www.IrishDstiv.ir



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

www.IrishDentist.ie

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



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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