Dr Jack Gardner presents a case utilising Inman Aligners and a palatal expander to treat malocclusion
A regular attendee at the practice expressed interest in orthodontic treatment as she was concerned with the appearance of her UL2. It was a perceived issue in photographs, and had an overall damaging effect on her self-confidence. The patient wanted the upper and lower arches treated to create a uniform smile. In order to assess whether treatment was suitable, a comprehensive assessment of the dentition was completed.
Patient presentation
The UL2 was proclined, and the UL1 and UR1 were retroclined and crossed. The patient had a posterior crossbite on the left-hand side, with a 3mm overjet and no overbite. The upper centre line was deviated to the right by 1mm.
Molars on the right side were in a class I relationship, with those on the left in a class II relationship by a quarter. The canines were in a class 1 relationship.
Crowding was present throughout the dentition, with 4mm in the upper ach and 1mm in the lower arch, demanding effective space creation. Another concern was the level of wear present; the upper incisors had been shortened over time and would need building up for the ideal result.
The patient had good oral hygiene, with minimal plaque present throughout the dentition. Grade 1 mobility was found for the LL8, and the patient was advised on the need for effective oral hygiene routines at home, supported by the practice.
Standard X-rays were taken alongside intraoral images, and conventional impressions were taken for both arches.
Treatment planning
It was vital to balance the patient’s preferences throughout treatment with what would ultimately be beneficial for her oral health. Orthodontic care was pursued, as opposed to continued monitoring, and treatment plans were subsequently devised. Traditional fixed appliances, though recommended to the patient, were not preferred. This was primarily due to the reduced aesthetics of such a solution when compared to clear aligners. The patient was informed on the benefits and risks of the latter option, including tooth sensitivity and the need to maintain oral hygiene routines, and she was willing to proceed.
After further planning, and discussion with the laboratory team, we considered the use of a palatal expander. This would be integrated with a super slim Inman Aligner in the upper arch. By expanding the upper palate, movement could be achieved with a reduced need for interproximal reduction (IPR). This is preferable as a less invasive approach to care. In the lower arch, a standard Inman Aligner was chosen. The patient was fully informed on the treatment process, and consent was received to proceed with care.
Treatment approach
The treatment plan was shared with mentors at IAS Academy, who provided guidance throughout this course of treatment. At each step, they would give advice and expert insights on elements such as space creation, and optimal movement for each aspect of the dentition. This meant each step was taken with confidence, for a predictable outcome.
Following a conventional polish and clean session, IPR was carried out at select sites to facilitate tooth movement. This was staggered across multiple sessions; in the first two, IPR in the upper arch was performed as follows:
- UR1 7.56mm taken to 7.3mm, 7.61mm taken to 7.45mm, D 0.2mm, M 0.25mm
- UR2 0.2mm, 0.4mm
- UR3 0.2mm, 0.4mm
- UL1 0.25mm, 0.4mm, D 0.4mm
- UL2 0.25mm, 0.25mm taken to 0.5mm
- UL3 0.25mm, 0.25mm taken to 0.5mm
With a palatal expander integrated into the upper Inman Aligner, a provisional 4mm of IPR could be reduced to around just 2.5mm. This approach also helped with managing the patient’s crossbite, expanding the benefits achievable.
The patient was shown how to perform optimal maintenance routines. Composite buttons were placed throughout the dentition to further aid movement. In addition, the patient was shown how to tighten the palatal expander, and was advised to do so once per week.
Progress was assessed at regular intervals using radiographic imaging, and this was used as an opportunity to check in with the IAS mentors. They helped to establish where the treatment plan could be adjusted or, more often, to confirm current progress
Ensuring patient compliance was not a difficulty, but she experienced some challenges with the appliance. Firstly, after around four months, the patient had lost the palatal expansion key. This was only a small problem, and it could easily be replaced. The results of the palatal expansion up until that point were successful, and the reduced level of IPR in the upper arch was appreciated; it was used sparsely in the following months, only when absolutely necessary for movement.
Fitting the upper aligner was also becoming difficult. The composite buttons placed throughout the dentition were thick, and required movement down each tooth. With small adjustments, the patient was able to more easily and consistently place the aligner. At this point, she also noted that she had struggled to speak at points due to both aligners, and asked if they could be removed whilst working; it was noted that it would be preferable to keep at least one aligner in, and that removing one would improve comfort, but extend treatment time.
This imbalance led to the lower arch being completed prior to the upper dentition. A retainer was provided here to avoid relapse whilst treatment continued.
The final steps of care focused on refining the position of teeth in the upper arch. This was especially the case with the UL1 and UR1, which needed some final rotations for a completely functional and aesthetic result. On the UR1 in particular, minute movements were facilitated, with a composite button moved up incisally. Palatal expansion allowed for the final movements to be made without excessive IPR. This rotation process took some time, but this is an inherent disadvantage with removable aligner systems when compared to fixed orthodontics.
Following completion of the orthodontic process, composite build-ups were applied to the UL1, UL2 and UR1. Removable upper and lower retainers were provided, and a fixed upper retainer was placed to optimise long-term results.
Case review
The patient was ultimately pleased with the final results, and so was I. It was my first case utilising a palatal expander and Inman Aligners, and the support of the IAS Academy mentors meant it was possible to reduce invasive elements such as IPR to an absolute minimum. Whilst some aspects of this case would have been simpler to tackle with a fixed orthodontic appliance, this approach was necessary to adhere to the patient’s preferences.
Support from mentors here was especially beneficial as advice was detailed, with explanations of why to take each step. This is important, as once you understand why you tackle a problem in a specific way, you can implement it when you come across a similar case in the future. This gives you independence and confidence in the treatment you provide, and is something I have taken into many cases since.
For more information on upcoming IAS Academy training courses, please visit www.iasortho.com or call 01932 336470 (Press 1)
