History, examination and proposed treatment
When a 39-year-old male patient presented to the practice for a comprehensive examination, he revealed that he had not visited the dentist since he was 17 – that’s a staggering 22 years without dental treatment or a check-up!
The full examination and periapical radiographs revealed that the patient had minimally restored upper and lower molars and had previously received composite restoration on the upper centrals due to trauma. Not surprisingly, the patient had occlusal decay on 37, impacted third molars, mild periodontitis and misalignment.
As a result, it was proposed that the patient receive full debridement and a course of periodontal treatment, a referral to an oral surgeon for removal of all 4 impacted/problematic wisdom teeth, composite restoration of 37 and orthodontic treatment. He had received comprehensive orthodontics when he was younger – he wore full headgear – but he had found it very traumatic and didn’t want to go down that path again. Consequently, the patient opted for minimally invasive anterior alignment treatment. Once Spacewize+™ arch evaluation software had been used to calculate the level of crowding and confirm the suitability of the case, the patient agreed to undergo treatment with the IAS Inman Aligner. The patient was advised that he would need edge bonding or restorations on 21 and 11 (upper central incisors) at the end of the alignment procedure. It was also suggested that composite restorations rather than ceramics alternatives should be used, as it would be a more conservative approach to maintaining the natural tooth structure. It would also leave the option to progress to ceramic in the future if necessary.
The patient was also a very fastidious and detail-oriented person, so as part of the treatment plan presentation the various scenarios for treatment and non-treatment were provided in great detail.
Once debridement, periodontal treatment, extractions and composite restoration of 37 had been completed, treatment with the upper IAS Inman Aligner commenced. Composite anchors and springs were placed palatally on 21 and 22 to help tilt them forwards with and interproximal reduction (IPR) was carried out using red strips on almost all areas. After that, 11 was tilted palatally and the P spring on 21 activated, followed by placement of a composite anchor bucally on 11 and IPR with yellow strips on the central incisors.
Although at that point the treatment was on track for the intended outcome and the model of the finished result was greeted with enthusiasm by the patient, the alignment was not as progressive as I would have liked. Retrospectively, more predictive proximal reduction (PPR) was needed on the central incisors and 21 could have been moved outwards a bit more to allow for the palatal bow to be tightened.
Shortly after, the lower IAS Inman Aligner was fitted. At first the patient expressed concern about the movement of his lower anteriors and he felt like he wanted to move the appliance with his tongue, but in the end he accepted he needed to get used to the adjustment. During this time, IPR and PPR were carried out distally on 33 and 43, seating of the appliance was checked and an upper palatal IAS Clear Aligner replaced the IAS Inman Aligner. When it came to adjusting the appliances the teeth seemed to have aligned well, but when the retainers were placed, 16 and 17 were not fully seated.
The patient informed me that his back teeth weren’t touching unless they moved to a retruded contact position, so a composite anchor was placed bucally on 41 to stop it sliding down over night. I informed the patient this was OK as a short-term fix as the anterior teeth had changed position so it was likely that the posterior teeth would move into position as well.
After this the labial bow was activated on 41 followed by impressions – an upper impression for a clear removable retainer and a lower impression for a fixed retainer. The seated lower IAS Inman Aligner was tight at this point and the upper final retainer had been fitted in place of the IAS Clear Aligner. The patient was advised to wear 24 hours a day for three months and then at night thereafter. Tooth whitening was also performed around this time, and 11 and 21 were restored with composite.
By the completion of treatment, this very exacting but compliant patient was very happy with the outcome. It was useful to have described at the outset the potential range of time needed for treatment, the likely need for edge-bonding and the vital role that home compliance plays.