Treatment carried out by Dr Kelly Toft
71 Kings Road West
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.
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.