A 23 year-old patient came to me with complaints about the appearance of her smile. Her chief concern was that her lateral incisors were rotated and protruded far too much. After the initial assessment, I found she had class II division 2 malocclusion with a deep bite.
At this point, there were several treatment options available to her, and we discussed the following:
- conventional fixed orthodontic braces,
- short-term-ortho (STO) fixed orthodontics,
- removable orthodontic options such as clear aligner systems.
After considering all the advantages, disadvantages, risks and possible alternatives of each treatment, we were able to eliminate those the patient was not comfortable with. As she did not want a long treatment time or extractions, the fixed braces were not a suitable option. Although fixed STO did not involve extractions she disliked the idea of having brackets fixed to her teeth. In the end it was the speed, reliability, cost effectiveness and removability features of the Inman Aligner that most appealed to her. She was happy to proceed with the treatment using the appliance with a combined expander.
Arch analysis
The amount of crowding was measured using Spacewise – the dental diagnostic crowding calculator, designed specifically to aid accurate treatment planning with the Inman Aligner. Within minutes, the programme had confirmed the total crowding present was just over 3mm, which ensured good case selection for the appliance and I was able to tell the patient there and then that we could proceed. Through the same software I was then able to show the patient what her resulting smile could
look like and she was able to give a fully informed consent.
Treatment
The protocol we planned to follow was the ‘ABB’ (Align, Bleach and Bond). The initial inter-proximal reduction (IPR) was performed using diamond strips 0.08mm (yellow colour coded), 0.10mm (red colour coded), and 0.12mm (blue colour coded), after which the Inman Aligner was fitted with a combined expander. The patient was given full instructions on how to remove and replace the appliance and 16-20 hours wear was recommended a day with four hours of rest. I also informed the patient of how to carry out expansion by turning the screw once a week for up to eight weeks.
There is a limit to the amount of expansion that can be done without effecting the occlusion significantly and this expansion is in many cases a temporary gain only whilst the anterior teeth are aligned. If the expansion is relied on too heavily the case will be less stable and more prone to relapse.
Inter proximal reduction was carried out progressively on current contact points at two week intervals. This was mostly on accessible contact points and the non-accessible contacts were freed with a yellow diamond strip to facilitate tooth movement. A total of 1mm IPR was divided between U4 to 4 (mesial of first premolar to the mesial of first premolar). Most space was gained through expansion and distilisation of the canines and by moving the centrals labially, thereby facilitating derotation of the laterals to position them in the arch and achieve a uniformly rounded arch form. Predictive proximal reduction (PPR) was also carried out on future contact points using Soflex disc 0.15mm. I used Komet Visionflex diamond strips for IPR (yellow, red and blue) and 3M Soflex disc for PPR.
For this type of treatment, the sequence for placing anchors was very important and palatal anchors were first placed on the palatal of the centrals to move them facially. Once they were in the desired position, labial anchors were then placed on the disto-labial & mesio-palatal aspect of the laterals to achieve derotation and move them palatally at the same time. Intra-oral photographs were taken at two-week intervals to record our progress and offer the patient a comparison since the start of
treatment.
Results
The case was almost complete by the end of 12 weeks, and two clear aligners were worn for seven days each to achieve nice rounding of the arch and complete this stage of treatment. Home bleaching was carried out during these last two weeks with six per cent H2O2 for 45 minutes a day. With no sensitivity, the patient’s compliance was good and she was very pleased with the resulting colour.
The final edge bonding was carried out using Ivoclar Empress Direct on the UR2 and UL2 to counter the differential wear on the laterals. Laboratory fabricated fixed bonded wire retainer was then bonded using nano hybrid flow composite (Venus Flow) to prevent relapse.