Case of the month

Treatment carried out by Dr Salman Siddiqi

Adell initially came to see me for a consultation to discuss concerns about her smile. She was unhappy with the appearance of her ‘prominent’ and ‘gappy’ upper front teeth and wanted to discuss her options.

Assessment

A comprehensive dental and orthodontic examination was carried out and the full series of IAS photographic views recorded.

Summary of findings:
• Class II Div 1 incisors relationship on class II skeletal base with increased overjet of 8-9mm
• Mild lower labial segment crowding
• Spacing >10mm in upper labial and buccal segments with missing upper 5s.
• Centreline deviated (lower to right of centreline by 4mm)
• Molars and Canines class II relationship RHS and LHS
• Diastemas present between and distal of centrals and distal to canines (more prominent UR34)

Discussion of treatment options

A full discussion was then carried out explaining to Adell the options available to meet her treatment goals.

I explained to her given the marked class II div 1 malocclusion a specialist ortho referral could be made to consider fixed appliance treatment. Adell was not keen to wear a fixed appliance and wanted to focus on a more flexible solution given her busy working lifestyle.

I discussed the Inman Aligner with her and explained the benefits and limitations of the appliance. A quick chairside SpaceWize analysis showed simple anterior alignment and reduction of the overjet could be achieved within limits. I explained some spacing would remain following completion of the alignment and offered composite bonding the close any residual diastemas or spaces. Adell liked the minimally invasive approach the Inman Aligner would allow and was keen to proceed with treatment. A 3D printed Archwize model made by the IAS lab was also used to allow fully informed consent for treatment. The 3D printed allows an excellent simulation of the final proposed setup and was key in allowing Adell to fully visualise the plan before we commenced treatment

Treatment

Alignment

PVS imps of both arches, a bite registration and clinical photos were sent along with a prescription to the IAS lab. An ArchWize 3D plan was then sent to be 6 days after sending the impressions which I approved following review. The ArchWize shows the proposed final position of the teeth after anterior alignment and gives a visual ‘mock up’ of the before and after.

The Inman Aligner was then sent back to me the following week and fitted for the patient. The total IPR figure was very low at just 0.90mm as spacing was already present. I did half of the total IPR at the first appointment and placed a composite ‘anchor’ on UL2 which was the most ‘in-standing’ and palatally crowded tooth.

The patient was reviewed at 2 weekly intervals for further IPR and replacement of composite anchors as needed. Occlusal and retracted photographic views were recorded at each review appointment to which acts as a valuable tool in achieveing good patient compliance and progressing the case more efficiently. A significant reduction in the overjet and closure of spacing was achieved over 12 weeks by retracting the central incisors and providing mild tipping of the UL2.

Bleaching

I followed up with some external tooth whitening over 2-week using 10% carbamide peroxide. Retention was maintained using the inman aligner during the whitening phase of the treatment.

Bonding

To finish off composite bonding was carried out under full rubber dam isolation to the following areas:
1) Build up the worn UL2
2) Direct composite veneer UR2
3) Edge bonding to reshape the embrasure space between the centrals
4) Diastema closure between UR3-UR4
A bonded retainer was then placed at the 2-week polishing/review appointment and an Essix retainer provided.

Outcome and final thoughts

Adell was pleasantly surprised with the finished outcome of her treatment and impressed at how close to the 3D Archwize model the finished result was!

The IAS ethos of providing minimally invasive orthodontic treatment allows GDPs to treat cases like Adell’s with predictability and in a very well supported system. The online support I have received since completing the IAS Inman Aligner course 3 years ago has been second to none and pivotal in allowing me to treat a wider variety of anterior alignment cases. The potential of the Inman Aligner combined with bleaching and bonding techniques has transformed my own clinical practice and for patients seeking cosmetic smile improvements.

I would like to thank the IAS mentors and lab team for their continued help and support as without them I can’t deliver the high-quality cases I aspire to achieve every time! I’d also like to thank Dr Monik Vasant for his continued feedback and mentoring in helping me improve my composite bonding skills. His course allowed me to put the crucial finishing touches in my anterior alignment cases and has truly been a game changer! Thanks also to all the team at Thornaby Dental who work so hard and support me daily.

Treatment carried out by Dr Salman Siddiqi

Introduction/Presenting Complaint

Emma came to see me in May 2016 for a consultation regarding improving the appearance of her teeth. She reported a history of previous orthodontic treatment in her teens which had relapsed and led to minor crowding of the upper and lower arches. He main concern was the ‘crowded and crooked’ appearance of her upper front teeth.

Assessment

A comprehensive clinical and orthodontic examination revealed the following key points:
• Class I incisor relationship on a class I skeletal base
• Average FMPA and Lower face height
• Soft tissues – lips competent at rest, normal tongue position and size, no posturing of
mandible at rest and no habits reported
• Centreline deviated to RHS by 2mm
• Class I Molar and Canine relationships bilaterally
• Mild upper labial segment crowding with well aligned upper buccal segment
• Slightly retroclined UR1 with distally rotated and overlapping UL1
• Some gingival recession seen at UL2 but otherwise periodontally good health

A full series of photographs were recorded as per the IAS protocol and measurements made of the widths of the upper teeth using digital calipers. This information was used to digitally plan the case using the SpaceWize software.

All options for orthodontic treatment were discussed including fixed appliance treatment by a specialist orthodontist. Emma was not keen on undergoing fixed appliance therapy and preferred the flexibility of wearing a removable Inman Aligner appliance as it was better suited to her busy working lifestyle.

Treatment

Valid written consent was obtained after discussed all risks, benefits, advantages and alternatives. The IAS Consent forms for Inman Aligner are a fantastic resource and allowed me to have comprehensive discussion with Emma about the specific risks of having treatment. Accurate PVS impressions in rimlock trays and a CR bite registration was recorded and a prescription requesting a ‘Standard Inman Aligner’ with a plan of the proposed tooth movements sent to Nimro Dental in London.

The Appliance was fitted after 2 weeks as requested in June 2016. The first composite anchors were placed on the most ‘in standing’ teeth UR1 and UR2. Space was created between the teeth at each 2 week appointment using graduated IPR strips and PPR was carried out where needed with sofflex discs. PPR was important to progress this case as it allowed more efficient alignment of any crowded contacts. Topical fluoride was applied to the surfaces all teeth where IPR was carried out and oral hygiene reinforced at each appointment.
The total treatment time was 14 weeks. At the end of treatment a bonded palatal retainer was provided with a clear essix for night time wear. 2 weeks of external vital bleaching was also carried out using 10% Carbamide Peroxide in close fitting trays. The final cosmetic improvement was done by providing composite bonding to the UR2 and UL1 to improve the proportions of previously worn and chipped edges.

Mentor Support

I have been a certified provider of the Inman Aligner since 2015. I found the hands on course very accessible with excellent teaching and demos on the IPR and PPR techniques. As a complete beginner to anterior alignment orthodontics I found it reassuring that the IAS ethos placed heavy emphasis on comprehensive orthodontic examination and appropriate case selection.

The IAS Inman Aligner forum is a fantastic resource for all GDPs providing this treatment. The one to one support provided online by the team of mentors is always excellent and very prompt. The forum is regularly checked to ensure all members are well supported and no posts go missed.

I am a great supporter of the IAS Inman Aligner and truly feel it has given me a new outlook to approaching anterior cases. The ability to predictably improve the position of any crowded or retruded anterior teeth allows me to provide minimally invasive solutions in ortho-restorative cases which would have otherwise required heavy preparations for crowns/veneers.
I would recommend the IAS Inman Aligner Accreditation course to colleagues who are considering starting their anterior alignment journey as the support and teaching is in a league of its own !

Patient Testimonial - Emma

‘’After having braces as a teenager, I was really unhappy when my upper teeth started gradually moving, giving them a very crooked appearance.

When I saw the advertisement for the Inman Aligner, and having talked it through with Salman, I couldn't believe how easy and quick it all sounded and I decided to proceed with the treatment.

Sure enough my teeth looked noticeably straighter within a few weeks and the treatment was virtually painless. I am over the moon with the results and would recommend the Inman Aligner to anyone ‘’

Treatment carried out by Dr Richard Field

Patients testimonial

"It’s not often you hear someone say ‘I enjoy going to the dentist’ – but I can, hand on heart, verbalise the sentiment without any hesitation. Dr Field is professional, a master of his trade, but above all – just a really nice, genuine guy. His knowledge of the dentistry world is impalpable and whatever challenge I gave him, he tackled with enthusiasm and an inquisitive mind, which is vital for the technology in the dentistry world to keep on evolving.

I was one of the first patients of Dr Field’s to try out the new slim line Inman Aligner, and it worked wonders. I also had a discoloured tooth that despite following industry norms wouldn’t bleach out. Dr Field promised me I wouldn’t be left with two different coloured front teeth and he went away and came back to me with a solution. And I now have two very beautiful (matching coloured) front teeth.

I cannot recommend Dr Field enough. He talks you through each procedure so you know what you’re in for, but also his cheery and delightful personality instantly puts you at ease. I am so happy with the end result of my teeth – a true testament to Dr Field’s hard work. Thank you."

Treatment carried out by Dr Erik Svendsrud

Woman 28, she had ortho for 5 years earlier without getting retention after treatment. She observed that it has been increasingly crowded in the lower but also in the upper. She has seen that especially right lateral has moved facially. 
Skeletal class 1, Face height average, Molar right and left side; class 1, canine right side 1/4 class 2, left side class 1, lower midline deviation approx. 2 mm to the right, she is not bothered by the midline deviation, she notices increasingly open bite between upper right lateral and lower right lateral/canine. She was informed about all options also referral to orthodontist which she declined. We used Inman aligner in the lower and clear aligners in the upper. Treatment time was 4 months.

Treatment carried out by Dr Alexander Herz

Here, Dr. Alexander Herz, a practice owner and dentist in Vechta, Germany, outlines a case using the ClearSmile Inman Aligner. Dr Herz has been a certified user of the appliance since 2014.

I first heard about the ClearSmile Inman Aligner from Michael Nix, one of IAS Academy’s German trainers, which led me to take the course – since then, I have become an extremely enthusiastic user! For anterior crowding or protrusion, I find this particular solution to be a great minimally invasive treatment, one that allows me to treat a number of simple to moderate cases. In comparison to the cases that I took on in the following months after I became a certified user of the IAS Academy appliance, I am able to address much more complex alignment issues. This is made all the much easier thanks to the outstanding support that is available from the online platform.

Assessment

One of my most recent cases was a 31-year-old female who presented to my practice having been recommended by her brother-in-law, whom I had previously treated with an aligner with successful results. Medically, her records indicated nothing untoward, while her dental records revealed that she had undergone previous orthodontic treatment during childhood. Due to failed retention, the patient had become dissatisfied with the position of her upper anterior teeth. The clinical examination revealed misalignment in the lower arch too, but at this time the patient wished to focus on the uppers only. It was explained to her that a much more stable and accurate result could be achieved should she agree to undergo treatment on both arches simultaneously, but it was her intention that we simply monitor and reassess in the future. After the regular dental examination, impressions of the upper and lower arches were taken as well as X-Rays of the anterior teeth.

Digital Case Planning

During the digital case planning, the Spacewize+™ arch evaluation software estimated that roughly 1.8 mm of space would be needed to achieve the intended outcome. This was later confirmed as 2.2mm by the lab. Digital images also revealed the extent of malocclusion in UR1, but as planning indicated the alignment of UR2 would create some space, there were no concerns about the result.

The only other concern at this point was whether the patient’s deep bite would leave enough room for the placement of the retainer. Just in case, it was explained to her that implementing the Dahl principle might be a possibility if problems occurred with positioning the retainer after alignment treatment was complete. To give the patient an idea of what the final result would look like, we had a digital mock up done, which she said was extremely helpful.

Treatment Process

First Appointment
• ClearSmile Inman Aligner fitted with lateral bite planes
• 0.18 interproximal reduction (IPR) on UR4-UR3
• 0.13 IPR on UR3-UR2
• 0.1 IPR on UR2-UR1
• 0.1 IPR on UR1-UL1
• 0.1 IPR on UL1-UL2
• 0.13 IPR on UL2-UL3
• 0.18 IPR on UL3-UL4
• Predictive proximal reduction (PPR) was carried out on UR1 and UL2 on mesial surface and on mesial and distal surfaces of UL1

Second Appointment
• Same IPR and PPR as previous appointment

Third appointment
• No PPR needed in this appointment
• 0.13 IPR on UR4-UR3
• 0.1 IPR on UR3-UR2
• 0.08 IPR on UR2-UR1
• 0.1 IPR on UR1-UL1
• 0.1 IPR on UL1-UL2
• 0.13 IPR on UL2-UL3
• 0.18 IPR on UL3-UL4

Fourth Appointment
• Alignment of UL1 complete at this stage
• Vestibular anchor placed UL2
• Contact between the outside bow and UR1 and UR2 reduced
• Springs on the outside bow activated
• No PPR
• 0.08 IPR on UR4-UR3
• 0.08 IPR on UR3-UR2
• 0.08 IPR on UR2-UR1
• 0.08 IPR on UR1-UL1
• 0.08 IPR on UL1-UL2
• 0.13 IPR on UL2-UL3
• 0.18 IPR on UL3-UL4

Fifth Appointment
• Impressions taken for fixed retainer (final results meant that it was not necessary to raise the bite in the end to make room for the retainer)
• Composite placed on UL1 to match the length of UL1
• In addition to a fixed retainer, the patient was also given a removable essix retainer and advised to wear for one year during the night

Self-Appraisal

Overall, both the patient and myself are very happy with the final result, though, of course, the preferred outcome would have been to align the lower arch too. As of yet, the patient has not made her decision regarding the treatment of the lower anterior teeth. As such, I have suggested that she uses a retainer to prevent any further relapse.

The ClearSmile Inman Aligner course is part of the IAS Academy pathway of training for GDPs. The course is now a continuum and 2 cases must be submitted and evaluated on completion for website listing.

For more information on ClearSmile IAS Inman Aligner and upcoming training courses, please visit www.iasortho.com or call 020 8916 2024

Biography

Dr. Alexander Herz, born 1971 in Bremerhaven, Germany
Married, two children

1991-1996 Martin-Luther-university, Halle/Saale
2000 doctor’s degree
1996-2006 service as a dentist in the German Air Force
since 2006 work in own dental office in Vechta, Germany
since 2014 Inman Aligner user
since 2016 Clear Smile Aligner user

Treatment carried out by Dr Calum Imray

My first Inman Aligner case involved a young female patient who wanted to correct a mild alignment issue before her wedding. Her main complaint was the slightly protruding upper left central incisor. The mild crowding of the lower anterior teeth did not concern her. The posterior occlusion was stable with a class 1 molar relationship and canine guidance and there was no history of parafunction or cusp fractures.

Spacewize analysis showed approximately 1.6mm of space would need to be created by interproximal reduction (IPR) in order to align the teeth. Considering the beauty of the unrestored anterior teeth and the minimal amount of tooth preparation required in this case, the patient and I agreed that orthodontic alignment and some tooth whitening would be preferable to more extensive restorative approaches such as direct or indirect veneers.

After posting the initial photographs on the online forum and receiving advice from two IAS academy mentors, a full treatment plan and 3D printed models of the potential end result were requested from the lab along with the Inman Aligner itself.

At the fit appointment, a small amount of IPR was performed and the patient was instructed to wear the aligner for around 20 hours per day, removing it to eat and brush. After just 10 days she returned with a noticeable improvement and subsequent rounds of photographs and IPR were posted on the forum every two weeks until the case was complete. In total she wore the Aligner for 10 weeks before a fixed retention wire was placed and was delighted with her results!

Looking back at the case, I realise the importance of consistent positioning for clinical photographs, particularly the occlusal mirror shots. I could have displayed the final results more effectively with a little more care when positioning the mirror. In an ideal world we would also have aligned the very slightly crowded lower incisors before they can move any further & require more extensive IPR, but this was not her primary concern and can be addressed at another time.

The support and guidance from the IAS academy mentors on the online forum throughout the case was fantastic and the speed of tooth movements with the Inman Aligner far exceeded my expectations.

Treatment carried out by Dr Rune Henriksen Bones

Case Details

The patient has all her life been bothered by her smile. She said to me she didn't want to smile, because she was embarrassed by her teeth. Her main concern was her upper left central incisor which was positioned far labially in the arch, but ideally she wanted all the front teeth straightened. She had heard about Inman, and didn’t want fixed braces, so she asked me if it could be addressed.

After measuring the width of the central incisor, I plotted the numbers in Spazewize, which confirmed that this was a possible case. Afterwards I posted the pictures on the forum and got some good tips there. The mentors told me to inform the patient thoroughly the things we couldn’t address. I informed her that we would not correct her over-jet with Inman, but she didn’t mind this at all. She just wanted her smile to improve. So we ended up ordering an Inman with combined expander.

I got the aligner back from the lab, and had the patient in for seating the IA. Everything fitted well, and I performed IPR and PPR as prescribed. I informed the patient how to use the expander, and how often to turn the screw, also that she could experience some slight discomfort in the following days. She was very motivated for the treatment, and I had a good feeling this would be a nice case.

So after performing progressive IPR/PPR for every visit, we got the result we wanted. Impressions was taken and sent to the lab for making a fixed bonded wire retainer. While we waited for the lab to make the wire, bleaching trays were made, and she bleached during the hours she was not using the IA. This was really the frosting on the cake for this case. When the retainer came back, this was easily fitted and bonded with flowable composite.

This patient was extremely happy with the result to say the least. After all these years, she finally can smile without hiding her teeth. Now she smiles all the time! This case was really rewarding for me too, it’s nice to help someone get the smile they want, and at the same time in a conservative way. Align Bleach Bond is a fantastic way of doing minimally invasive dentistry.

Patient testimonial

“The Inman Aligner has been a fantastic treatment for me. Now I have the smile I always wanted, and achieving this was faster and easier then I thought. I would recommend this treatment to everyone who wants their teeth aligned”

Anita Jakobsen

Treatment carried out by Dr Alina Lazar

Minimally invasive preparation treatment

In this case, the patient – a 47-year-old female – approached the practice after finding us on the internet. She came to me because she was not satisfied with the shape, the colour and the position of their teeth. The patient had a great cold sensitivity.
We opted for the Smile Design Step by Step

Expander and IAS Inman Aligner Treatment

The first step needed to achieve the intended outcome was to complete a full orthodontic treatment. As the patient wanted an effective, safe and minimally invasive solution to anterior alignment, she opted for the IAS Inman Aligner. Although the initial examination showed no abnormalities, the model analysis and Spacewize+™ arch evaluation software calculations revealed that 1,8mm

Following professional tooth cleaning, the patient was shown how to use and remove the IAS Inman Aligner appliance and was instructed to wear this for18 hours a day. Interproximal reduction (IPR) was also performed progressively every three weeks throughout the course of the IAS Inman Aligner treatment. Once the desired outcome was achieved on the upper anteriors, a fixed retainer Venners from 14 to 24.

Bleaching

At this time the patient also had a filling (class five) and performed home bleaching with Opalescence® PF 10%, which was followed by the use of Relief Oral Care Gel to reduce the sensitivity caused by the whitening treatment. An individual vacuum-formed template was created to help guide tooth preparation. Essentially, the digital smile design allowed me to create a virtual mock-up, which was applied to a plaster model, and ultimately improved the effectiveness of treatment planning.

Veneers, Non-Prep Veneers and Crown Lengthening

The next step was to direct mock-up with composite. It was at this point that photographs were taken to monitor the development of the treatment process. It was very rewarding to see the patient become emotional as she realised the changes that were being achieved.

Once the digital smile design analysis and mock-up were complete, only the finishing touches were left. The initial part of this was crown lengthening to 21 which took place at the same time as the preparation. Shortly after, non-preparation veneers were placed on 14, 24 and veneers were placed on 13- 23. and an IPS e.max Press from Ivoclar Vivadent was used on the incisors – the MT Ingots chosen were A1 and were modified using both the cut-back and layering technique

After the anterior alignment, bleaching, mock-up and finishing treatments, the process was complete and both the patient and I were very happy with the final results.

Author Bio:

Dr. Alina Lazar has been practising dentistry since 1994 and founded ‘Praxis Dr. Alina Lazar’ in Germany in 2001. She completed further qualifications to become a Specialist in Aesthetic Dentistry in 2012 and a certified provider of the IAS Inman Aligner in 2013. Since 2013 Digital Smile Design certified provider. Alina also completed the IAS Advanced training course in 2014 to develop her knowledge and skills in anterior alignment. 2016 February - case of the month in IAS Forum. 2016 September - IAS Advanced Ortho Restorative

Treatment carried out by Dr Finn Andre Hammer

Author bio:
• Graduated from the University in Oslo 1995
• Started up my own private practice in Fredrikstad, Norway in 1998
• Started Fredrikstad Private Tannhelsesenter in 2010,together with Dr.Kai Hannestad, a mixed private dental office with specialized and general dentists.
• Member of NTF,SAED and AACD
• Member of the IAS Academy,Inman Aligner instructor in Norway
• Worked with Inman Aligner since 2011 and Clear Smile Aligner/Invisalign since 2015
• Lecturing aesthetic composite classes and workshops in Norway.

About the case:
• 32 year old lady called for an orthodontic assessment after she had seen Inman Aligner on my website
• Never had ortho before
• Shows a lot of her upper teeth when smiling.
• Not happy with her upper front teeth and smile.
• Good posterior occlusion,Angle Kl.I
• UR1 tipped mesial over UL1, that is palatinal in the bow.
• Minor lower crowding, that doesn't concern her

Orthodontic assessment:
• Good lateral occlusion ,Frontal crowding
• X-ray studied and no pathology or risk factors were found
• We discussed optional treatment with fixed ortho, Clear Aligners before we decided to treat the upper jaw with Inman Aligner
• We also discussed the risk of “Black Triangle” UR1/UL1 because of the tipped UR1 over UL1
• Inman Aligner was chosen because of the fast treatment time.
• I selected a standard Inman Aligner with an ex.screw to speed up and “unlock “ the teeth
• Treatment time was estimated to 14-16 weeks

Treatment:
• Clinical and x-ray examination
• Planned the treatment with Spacewize and digital SetUp from Esbjerg lab.
• Since I have worked a lot with Inman Aligners, I didn't use the forum help on this case
• Next appointment checked the fit of the aligner.IPR and PPR and putting on the palatinal buttons
• When UL1 was aligned out in the bow, buccal buttons was placed .
• Bleaching with White Dental beauty 30 min for 7 day very happy s the last period of the treatment.
• Total treatment time ended at 12 weeks.
• Patient very happy with the treatment

Treatment carried out by Dr Kelly Toft

Author Bio:

Kelly qualified from Guy's, King's and St Thomas' in 2003. She is currently working as an associate at Regency Dental, Swanage and has been a member of the IAS Academy since completing here initial training in 2015.

The Case

A 48-year-old female patient was referred to me by a colleague in-house. She was unhappy with the appearance of her rotated upper centrals and misaligned lower incisors as they were difficult to clean and kept getting stained. She had been considering veneers when she saw information on the IAS Inman Aligner in the waiting room.

With very little dental history, no restorations and a regular attender to the dentist and hygienist, the patient was medically fit and well.

A thorough orthodontic assessment revealed a Class I occlusion on a Class I skeletal base. There was mild crowding in the upper and lower labial segments, the upper centrals were rotated and the upper canines buccally placed with space distal to these. Periapical radiographs taken of the anterior teeth were clear.

The treatment options available were discussed with the patient in detail. She had already spoken to a specialist orthodontist regarding fixed braces, but the cost and the thought of the suggested four extractions proved inhibitory. My colleague had discussed veneers / crowns and the biological risk to these unrestored teeth, plus the possible aesthetic consequences. The patient was keen on the IAS Inman Aligner as it could be removed to eat or for special occasions. The possibility of whitening and edge bonding were also discussed as part of the ABB (Align, Bleach and Bond) approach.

A full set of photographs were taken and Spacewize+™ arch evaluation software employed to determine the amount crowding present and the ideal tooth positions using the upper laterals and the LL1 as the landmark teeth. Silicon impressions were sent to Nimrodental for a diagnostic set up to ensure the patient was happy with the final smile before the appliances were made and treatment commenced. She was advised that the upper canines would not be moved with this appliance. The patient was happy and full valid consent was obtained.

Treatment began on the lower jaw. The appliance was checked for fit and the patient was shown how to place and remove it. Interproximal reduction (IPR) was carried out from canine to canine as per lab instructions and predictive proximal reduction (PPR) performed on the mesial aspect of both lower laterals. Composite anchors were placed on the lingual aspect of LR1 and LL2.

At the first review appointment further IPR was carried out and composite anchors placed on the buccal aspect of LL1 and LR2. The lingual anchor was removed from LR1 and placed on the disto-lingual of LR2. By the next appointment the teeth were aligned and impressions were taken for a fixed retainer. This was bonded with Venus Diamond flow two weeks later.

In the meantime, the patient was keen to start with the upper jaw and actually wore the two appliances at the same time for two weeks. Again the fit was checked, a composite anchor placed palatally on UL1, IPR carried out as per lab instructions and PPR on the UR1 mesially.

At the first review appointment the patient mentioned that the UR1 had become quite painful and she’d needed pain relief. In a previous de-rotation case another patient had experienced similar problems that eased after a few days, so this patient was reassured that it should pass. The IAS support forum was consulted and one of the mentors noticed that UR1 looked slightly greyish in comparison to UL1. The tooth was vitality tested and it had become devitalised. The possible reasons and causes were discussed with the patient and it was thought that perhaps past trauma to the tooth had made it susceptible to devitalisation. Treatment was halted and an Essix retainer was made while root canal treatment was carried out, uneventfully.

Once she was pain-free the patient was keen to continue alignment. IPR was performed from 3-3. At the second review, the patient reported no further problems so buccal anchors were placed on both central incisors mesially and the palatal anchor was removed from UL1.

The labial bow was later tightened by adding composite to the springs. I’d received some useful advice from other dentists on the IAS forum with regards to lightening the UR1 and impressions were taken for bleaching trays. The temporary filling and some GP were removed one week later from UR1 and a GIC plug was placed at the neck of the tooth. The patient was shown how to place the bleach in the palatal cavity of UR1 with the tray over the top and advised to do 45mins twice daily. One week later the shade of UR1 had improved and the patient started whitening the remainder of the teeth. Impressions were also taken for a temporary Essix retainer and a fixed retainer.

Once the patient was happy with the shade of her teeth we waited two weeks (as bleaching can affect the bond strength of dental adhesives) before fitting the wire retainer, which was fixed with Venus Diamond Flow. Edge bonding was also performed with Tetric Evoceram to level out the upper centrals. Impressions were taken for final Essix retainers/bleaching trays for optimal retention.

The patient loved the final result, happily showing off her smile as much as possible. I am pleased with the outcome too – we avoided invasive restorative dentistry and gave the patient something that is easy to maintain long into the future. The UR1 will continue to be monitored and further bleaching carried out if the shade isn’t maintained.

This case highlighted for me the importance of going through all the risks associated with any treatment, however rare they may be. The IAS Academy mentors had never seen a tooth devitalise using the IAS Inman Aligner before, although it is a theoretical risk with any orthodontics. Full documentation including photographs and radiographs before treatment begins, is also a must. I don’t think it would have made any difference to what happened in this case, as it couldn’t have been predicted, but in this time of litigation I know I have all the information to show it was okay to proceed with the case at the time. The support from the forum was invaluable during this time to reassure the patient and I that everything would be fine in the end. It is an excellent resource and I’m sure other dentists following my case on the forum will also have learnt from my experiences, although I hope this is the first, and last, case of a tooth devitalising during IAS Inman Aligner treatment.