Case of the month by Dr Line Engelstad

  • Before
  • After
  • Before
  • After

Treatment carried out by Dr Line Engelstad


Line Engelstad DDS is a general practitioner working in a private clinic in Oslo, Norway, with a special interest in minimal invasive dentistry. Following hands-on training, she gained certification to provide the IAS Inman Aligner in Oslo in 2014. Here, she discusses a recent case…

A 22-year-old female patient was referred to me by the hygienist, who had concerns about the lingual position of 41, which made it difficult to effectively clean that region. The patient was also unhappy about the appearance of her smile in photographs.

Clinical Examination
The clinical examination revealed an Angle Class I malocclusion with anterior open bite and proclined maxillary upper central incisors. Crowding was present in the lower arch as a result of the lingual malposition of 41 and a slight midline deviation was identified. Despite this, the patient had no temporomandibular joint and muscle disorder concerns, oral parafunctions or pain and discomfort. The patient was, however, diagnosed with gingivitis and was thus informed about the pathogenesis of the disease and given instruction on hygiene techniques and the importance of daily flossing.

Treatment Options
As the patient had no previous history of orthodontic treatment, all possible options were discussed in length, taking into consideration the patient’s motivation and expectations of outcome.

The first option to be explored was the IAS Inman Aligner, with emphasis placed on the principles of the IAS Academy treatment pathway – correct assessment, diagnosis, treatment planning and appropriate treatment. As it was unclear at this time whether this would be suitable, alternative options were presented including other orthodontic appliances and a referral to a specialist orthodontist for gold standard comprehensive orthodontic treatment. She was informed that the latter could correct her anterior open bite and midline deviation. After the advantages, disadvantages, economic issues and prognoses were thoroughly discussed, the patient opted for the IAS Inman Aligner; she expressed that she only wanted her anterior teeth aligned and was not interested in a fixed appliance. The patient also revealed that her main priority was the alignment of the lower arch, despite the proclination of the upper anterior teeth and misalignment of 21 and 22.

Treatment planning
From there, pre-treatment periapical X-rays and a series of intraoral and extraoral images were taken, followed by two alginate impressions for study casts, two silicone impressions for the laboratory and bite registration. Having been made aware of the risks and prognosis of the appliance, the patient gave oral consent.

Thereafter, analysis was carried out on the study casts and the Spacewize+™ arch evaluation software was used to determine the suitability of the IAS Inman Aligner. It calculated that the patient had 0.5mm crowding in the upper arch and 2.3mm in the lower – well within the IAS Inman Aligner’s 3mm limit.

At this stage, the clinical photos and treatment plan were uploaded to the IAS Academy’s online support. The mentors advised that to improve the overall aesthetics and reduce the frontal open bite, the upper arch would need to be aligned with a slight retroclination. I also sent the impressions to the certified laboratory but only requested a 3D set up and printed models at this stage.

During the second appointment the patient was informed of the IAS Inman Aligner’s suitability. We once again discussed the alignment of both arches and after seeing the 3D before and after models, the patient provided written consent to undergo both upper and lower alignment. It was highlighted that the appliance would need to be worn for at least 15-20 hours a day followed by life-long retention to achieve optimum results.

To minimise the risk of gingival inflammation returning, the patient received a scale and polish during her second appointment. Two weeks later, alignment commenced on the upper arch using the IAS Inman Aligner and initial interproximal reduction (IPR) was completed. A composite anchor was also placed on the distal palatal surface of 22. She was given instructions for use and a thorough demonstration of how to insert and remove the appliance safely.

After two weeks, the patient attended the practice in high spirits – besides some isolated tenderness to the targeted areas and some minor difficulties with speech during the first week of wear, there were no issues. A composite anchor was placed on the distal buccal surface of 21 to assist with correcting the retroclination. Once removed, the process was complete and a silicone impression was sent to the laboratory for a fixed retainer. During the wait, the patient was given an Essix removable retainer and advised to wear it day and night. Oral hygiene instruction as also given to ensure effective cleaning , particularly interdentally, and therefore optimise dental health and longevity of the achieved outcome.

When the lower IAS Inman Aligner was fitted, initial IPR and predictive proximal reduction (PPR) were completed to reduce crowding by 1mm. A composite anchor was also placed on the mesial lingual surface of 41.

During the lower arch treatment, the upper wire arrived and was bonded into place. Progressive IPR with discs and strips continued to be performed on the lower arch with the patient wearing the aligner for up to 22 hours a day until alignment was complete. Again, a wire retainer was fixed for life-long retention.

Case Outcome
With its safe and predictable approach, the IAS Inman Aligner is an ideal treatment pathway for any patient with simple to moderate protruding or misalignment. In this case, where the patient’s complaint was malposition, the intended outcome was achieved and both the patient and I were extremely pleased with the end result.

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