ABB Smile Makeover By Dr Salman Siddiqi

by Dr Salman Siddiqi

Dr Salman Siddiqi shares an anterior alignment orthodontic case

Anterior alignment orthodontics (AAO) has created a paradigm shift in modern cosmetic dentistry and influenced current thinking in our approach to anterior aesthetic cases (Qureshi, 2010). Recent studies have shown adult orthodontic treatment not only provides improvements in dental aesthetics but also has a significant positive impact in the psychosocial aspects of the patient’s life (Gazit-Rappaport, 2008).

The minimally invasive philosophy that extends across the IAS Academy teaching syllabus ensures GDPs like me provide safe, predictable outcomes for patients and avoid an early transition into the ‘restorative cycle’. I have been a keen user of the ClearSmile Inman Aligner since completing the hands-on course in 2015 and find it to be an invaluable tool in treating patients who present with concerns about their anterior dentition.

The aligner is a highly effective and unique evolution of the traditional spring retainer and uses superelastic nickel-titanium open coil springs to move upper and lower anterior teeth.

Very light but consistent forces are provided by the spring mechanism, enabling correction of anterior crowding, rotations and some types of spacing (Qureshi, 2008).

The following case was treated recently using the aligner, along with some external bleaching and composite bonding.

Patient background
A new patient presented to our practice requesting some improvement to her existing smile. Her main concerns discussed at the consultation appointment were her ‘flared’ and ‘prominent’ upper front teeth. She was becoming conscious of the fact that her overjet was gradually increasing and making the spacing between her upper front teeth more prominent. She reported having removable orthodontic treatment with a twin block appliance as a child, but didn’t recall any retainer being given after treatment.

The patient’s main goals were to reduce the overjet, close the spacing/diastemas and improve the overall colour of her smile.

Orthodontic assessment
A thorough assessment was initially carried out, including an orthodontic assessment, full IAS Academy protocol photos (Figs. 1A–1C), and digital calliper measurements of upper 3-3. The IAS assessment forms allow for a comprehensive record to be completed efficiently and are invaluable when reviewing the salient features of the patient’s malocclusion.

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  Fig. 1A: Row 1 assessment

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  Fig. 1B: Row 2 assessment

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  Fig. 1C: Row3 assessment

Orthodontic assessment summary

Orthodontic diagnosis

• Moderate skeletal Class II base
• Average FMPA
• Lips competent at rest
• Class II, Division 1 incisor relationship
• RHS full unit Class II molar relationship
• LHS ¾ unit Class II molar relationship
• RHS ¾ unit Class II canine relationship
• LHS ¾ unit Class II canine relationship
• Overbite increased (40% coverage lower incisors)
• Overjet increased at 9mm
• Dental centre noncoincident with lower 3–4mm to the left of the facial midline
• 2mm crowding and 8mm spacing upper arch
• 3mm crowding lower arch

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

Given the marked Class II, Division 1 malocclusion, a specialist orthodontist referral was offered to consider fixed-appliance treatment in conjunction with orthognathic surgery. We also discussed the possibility of using indirect and direct restorations only to meet her treatment aims, but highlighted the risk of further orthodontic relapse that would inevitably increase the overjet.

A discussion was also had about the high biological cost of potentially heavy preparations that would be needed to reduce the overjet. The patient was not keen to wear a fixed appliance and wanted to focus on a more flexible solution, given her busy working lifestyle.

The ClearSmile Inman Aligner was discussed, including its benefits and limitations. I explained that a course of AAO would have low impact on the structural integrity of the unrestored anterior teeth, unlike indirect restorations. The compromises of the appliance were also deliberated, in particular that posterior teeth would not be moved, some small diastemas would still remain at the end of treatment and the skeletal Class II discrepancy would not be corrected.

Treatment planning
A quick chairside Spacewize+ digital analysis (Fig. 2) showed simple anterior alignment and reduction of the overjet could be achieved within limits. I explained that some spacing would remain after completion of the alignment and offered composite bonding to close any residual diastemata or spaces. The patient liked the minimally invasive solution that the aligner would allow and was keen to proceed with treatment. An Archwize digital plan (Figs. 3A and 3B) and a corresponding 3D printed model made by the IAS lab were then used to allow fully informed consent for treatment. The 3D printed model (Fig. 4) allows an excellent simulation of the final proposed setup and was key in allowing the patient to fully visualise the plan before treatment commenced.

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  Fig. 2: Upper arch in digital analysis.

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  Fig. 3A: The digital plan for Row 1, before treatment.

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  Fig. 3B: The digital plan for the same row, after treatment.

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  Fig. 4: A 3D printed model of what would be the final result.

Treatment provision

1. Alignment

PVS impressions of both arches, a bite registration and clinical photos were sent along with a prescription to the IAS lab. A 3D plan was returned six days after sending the impressions, which I approved after review. The plan shows the proposed final position of the teeth after anterior alignment and gives a visual ‘mockup’ of the before and after.

The aligner was sent to me the following week and fitted for the patient. The total IPR figure was very low at just 0.90mm because spacing was already present. I performed 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 biweekly intervals for further IPR and replacement of composite anchors as needed. Occlusal and retracted photographic views were recorded at each review appointment, acting as a valuable tool in achieving good patient compliance and progressing the case more efficiently (Fig. 5). 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 UL2.

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  Fig. 5: Progress views occlusal and retracted profile.

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  Fig. 6: ABB sequence, labelled.

2. Bleaching

External tooth whitening was performed over two weeks using 10 percent carbamide peroxide. Retention was maintained using the aligner during the whitening phase of treatment.

3. Bonding

To finish off, composite bonding (Fig. 6) was carried out under full rubber dam isolation to the following areas:

• Build up the worn UL2.
• Direct composite veneer UR2.
• Edge bonding to reshape the embrasure space between the centrals.
• Diastema closure between UR3–UR4.

A growing body of current evidence supports that relapse towards the patient’s original malocclusion can occur after treatment as a result of periodontal, gingival, occlusal and growth-related factors, (Littlewood et al., 2017). To reduce this risk, long-term retention was provided for this patient using a bonded intercanine wire retainer and an Essix appliance.

Outcome and case appraisal
The patient was pleasantly surprised with the outcome of her treatment (Fig. 7), and impressed at how close to the 3D model the finished result was (Figs. 8E and 8F).

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  Fig. 7A: Row 1

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  Fig. 7B: Row 2

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  Fig. 8E: Row 2 digital model

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  Fig. 8F: Row 2 finished result model

I was able to deliver a minimally invasive treatment outcome to meet the patient’s initial aims and finish the case within her requested timeframe.

The IAS online mentor support I have received since completing the ClearSmile Inman Aligner course three 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 appliance combined with bleaching and bonding techniques has transformed my own clinical practice for patients seeking cosmetic smile improvements.

I would like to thank the IAS Academy 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 Tif Qureshi for his continued feedback and mentoring in helping me improve my knowledge of the ClearSmile Inman Aligner and giving me the confidence to tackle more challenging cases. His recent ABB course allowed me to put the crucial finishing touches to 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.

The ClearSmile Inman Aligner course is part of the IAS Academy pathway of training for GDPs.

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  Fig. 8A: Row 1 occlusal views

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  Fig. 8B: Right profile smile.

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  Fig. 8C: Left profile smile.

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  Fig. 8D: Row 2 retracted profile.

References
1. Littlewood, SJ, 2017. Retention and relapse in clinical practice.. Australian Dental Journal, 62, 51-57.
2. Gazit-Rappaport T, Haisraeli-Shalish M, Gazit E, 2008. Psychosocial reward of orthodontic treatment in adult patients. European Journal of Orthodontics, 32, 441-446
3. Qureshi, Tif, 2008. The Inman Aligner for anterior tooth alignment.. Dental Update, 35, 377-384
4. Qureshi, Tif, 2010. The Inman Aligner— An effective tool for minimally invasive cosmetic dentistry (Part I). Cosmetic Dentistry, 2, 6-12