A New Dawn in Cosmetic Dentistry and Orthodontics

I believe that cosmetic dentistry is about to turn a corner. Over the last 5 years, thanks to tremendous input and teaching from cosmetic dentists practicing in the United States of America, the United Kingdom has seen a massive boom in elective cosmetic dentistry procedures. Patients are becoming more aware of the how they can improve their appearances by enhancing their smiles with makeover programs promising fast changes using whitening techniques and porcelain laminates. This is driving the demand for elective treatment and some patients are choosing to have irreversible procedures done. This article is not being written to criticize or judge one type of treatment over another; rather its purpose is to emphasize that some patients have another treatment option available with the introduction of an appliance called the Inman Aligner.
For those of us who have practiced cosmetic dentistry, we know that when patients present to us desiring a beautiful smile, we need to offer them all the possible treatment options. This is the ethical thing to do and not doing so could land us in trouble. Patients make the ultimate decision as to which path they may choose, but it is our responsibility as practitioners to ensure that we are offering them all viable alternatives.
Currently many patients are opting to have porcelain veneers placed to achieve their ideal smile. One has to ask, why do they choose that option? In some cases, where there has been structural damage, deep staining, caries, and/or old restorations in poor condition, beautiful porcelain veneers can provide huge aesthetic and functional benefits. There are very few restorations that can match the combination of strength and beautiful aesthetics as with well-done porcelain veneers. In the past, in cases where the teeth are simply crowded and out-of-position, veneers were often the treatment of choice by most patients. This is because, until recently, the orthodontic alternatives have been limited. These include the following: unattractive, fixed brackets, which often take months if not years in treatment; or “invisible” (clear or lingual) braces which also involve considerable time in treatment with potentially high cost. Many adults are just not patient enough to endure a long phase of treatment. This has certainly been the story in Great Britain.


Figure 1. Diagram of an Inman Aligner showing force direction.

THE INMAN ALIGNER VERSUS VENEER “INSTANT ORTHODONTICS”

If it were possible to align the teeth in a much shorter time and at lower cost, and if the diagnosis allowed, how many patients would still choose to have veneers? And, in cases where veneers might still be the optimal solution, wouldn’t patients prefer to align their teeth first, before veneer preparations are done? This could avoid the more drastic removal of tooth structure and, in some cases that present with more severe crowding, the potential risk of endodontics.
The Inman Aligner is a removable-spring aligner that can correct mild and moderate crowding cases in the anterior region only. When used in the appropriate cases, it can do so with relative ease and efficiency. Cases with 3.5 mm of crowding can be corrected with simple interproximal reduction. This aligner uses nickel titanium coil springs on lingual and labial components to push the teeth to their final position, but with constant and gentle pressure. This is why the aligner works so quickly. With more experience, cases just beyond 3.5 mm can be treated using expansion techniques (Figure 1).
It was working within the British Academy of Cosmetic Dentistry (BACD) that nurtured my passion for innovative techniques and minimal preparation. This forward-thinking, highly ethical organization gave me terrific feedback and assistance in understanding the possibilities of the Inman Aligner. (The BACD is an official affiliate of the American Academy of Cosmetic Dentistry. Currently in the UK, only BACD dentists are performing this technique).
I have been using the Inman Aligner for more than 3 years and have finished more than 300 cases with this appliance. Many of these cases would have had veneers while the other patients had totally ruled out conventional orthodontics because of the long treatment period. Of course, case selection is critical, as not every case is suitable for this technique. This is because it is only indicated for correcting the anterior teeth. Large side shifts, intrusions, and extrusions are impossible to treat with this technique. However, rotations, tipping, bucco-labial bodily movements, and diastema closures in protrusive cases, are all possible as long as the case selection criteria have been met. Let’s look at some cases that have been done recently employing the Inman Aligner.


Figure 2. Case 1. Full smile, before.

Figure 3. After 11 weeks (including 2 weeks of bleaching).

Figure 4. Lateral view, before.

Figure 5. Lateral view, after.

Figure 6. Anterior-occlusal view, before.

Figure 7. After 11 weeks, anterior-occlusal view.

CASE 1

A 24-year-old female was concerned about the appearance of her lower anterior teeth. Her lower central incisors were moderately crowded and beginning to wear irregularly. Her alternative treatment options were conventional fixed brackets or invisible braces. She had visited several orthodontists but was not happy with the amount of time that would be required for treatment (12 to 18 months).
An arch evaluation was performed because the Inman Aligner will not work in every case. The amount of crowding was calculated using a simple technique and we deemed her case suitable for this aligner technique. Impressions and bite records were taken and sent to the laboratory. (At the time of writing this article, there was only one certified Inman Aligner Laboratory in the UK). After a couple of weeks, the patient returned. The aligner was fitted, checked, and full patient instructions were given.
Space can be easily created with carefully measured interproximal-reduction (IPR) and expansion. This is started on the first appointment. The patient was seen every 3 to 4 weeks for reviews and a small amount of measured IPR. Within 9 weeks, the desired alignment was achieved (Figures 2 to 5).
The patient then wore a clear, Essixtype retainer for a period of one month. After that, a fixed, stainless steel retainer wire was bonded to the lingual surfaces. This was a simple procedure since the laboratory technician fabricated a jig with the prebent lingual wire. This prebent wire was placed and bonded onto the teeth. The jig was then cut free. The patient then went on to complete her cosmetic goals by whitening (bleaching) her teeth (Figures 6 and 7).


Figure 8. Case 2. Lateral view, before.

Figure 9. After 12 weeks, lateral view.

Figure 10. Occlusal view, before.

Figure 11. Occlusal view, after.

Figure 12. Lateral smile, before.

Figure 13. Lateral smile, after.

CASE 2

A 22-year-old female was referred to me by Luke Barnett, who is a BACD-accredited technician, based near London. A dentist had referred this patient to Barnett to assess her for cosmetic treatment with porcelain veneers. Barnett was correctly concerned, when considering the patient’s age and the health of her enamel, that it would have been unethical to have started veneer preparations before fully exploring all possible options, including orthodontics. The patient was not keen on fixed brackets or a long period of treatment. She wanted her teeth straightened within a few months if possible. Barnett knew about the Inman Aligner and referred her to me.
Space calculation again showed that this case was amenable to treatment with an Inman Aligner and the patient accepted the proposed procedure. The aligner was constructed and fitted one week later. A carefully measured IPR was performed and the patient was seen every 3 to 4 weeks for further IPR and minimal appliance adjustment. In less than 12 weeks, the teeth were fully aligned.
A clear Essix type retainer was then made and delivered. She wore this full-time for a short period, and then nightly (Figures 8 to 11).
The patient was thrilled because she had eliminated the need to have from 8 to 10 veneer preparations done. In her case, the preparations would have been done with a fairly high risk of needing later endodontics due to the amount of tooth removal that would have been needed to accomplish a truly aesthetic result. Thinking ahead, if the patient would ever opt/need to have any restorative care in the future, her teeth would be in a far better position for such treatment (Figures 12 and 13).


Figure 14. Case 3. Before Smile View.

Figure 15. After 13 weeks, bleaching and no-prep bonding has also been done.

Figure 16. Lateral smile, before.

Figure 17. Lateral smile, after.

Figure 18. Occlusal view, before.

Figure 19. Occlusal view, after.

Figure 20. Postoperative smile.

CASE 3

A 28-year-old female presented initially wanting 8 to 10 porcelain veneers on her maxillary anterior teeth. Upon examination of her photos, it was clear that her rotated incisors would need fairly heavy preparations at their most protruded aspects. This would undoubtedly expose dentin in the process. There would have even been a slight risk of pulp exposures due to the position of the teeth and the resulting cutback needed to reposition the final restorations correctly in alignment. It was important to convey this to the patient using an occlusal photo as shown below.
It was clear to me that her case was ideal for an Inman Aligner because her crowding was less than 3.5 mm. Therefore, all of her orthodontic options were explained. She was not keen on fixed brackets and was not happy to spend a large fee on an invisible braces technique, especially since she was aware that she would still need to treat her wear and color problems. She was informed that the Inman Aligner would take approximately 3 months. We also planned some whitening and direct resin bonding to follow the alignment (Figures 14 to 17).
An upper standard Inman Aligner was constructed. IPR was completed over 3 review appointments. It was carefully measured and recorded.
Within 3 months, the teeth were fully aligned. An Essixtype thermoplastic retainer was made and delivered to the patient. She wore it full-time for one month, and then only at night.
A course of home bleaching was then performed. After a few weeks, minimally-invasive, direct-resin composites were placed virtually without preparations. A stainless steel, multi-strand retainer wire was then bonded from tooth Nos. 6 to 11 on the lingual surfaces. This was easily placed using a jig made by the dental technician. The jig was fabricated on a model poured from an impression which was taken after completion. Again, as described in Case 1 above, the practitioner only needs to bond the wire into place and then cut the jig off (Figures 18 to 20).
The patient was thrilled with the results. We had given her the smile that she wanted without any invasive, irreversible dentistry. Clearly, aesthetic goals can be achieved more easily with porcelain laminate restorations, but a very pleasing result can also be achieved at far less cost and risk for the patient by using this aligner technique.
Obviously, a retainer is required, and undoubtedly, the composite resin applications will need some maintenance over time. However, compared to the risks and costs involved with heavily prepared veneers, this is an option that should be considered and offered to all patients.

CONCLUSION

The Inman Aligner can be used in selected cases as a prerestorative positioner.
It is very simple to use once case selection and movement potential is fully understood. This orthodontic technique usually takes only a few weeks to complete. By taking this approach, minimally invasive restorative preparation can be performed with a lowered risk of iatrogenic pulpal damage. Of course, retention issues must be considered when undertaking these cases. However, the advantages of this aligner technique are great and patients will appreciate the results. I believe that this technique has huge implications for cosmetic dentistry.

Dr. Qureshi runs a hands-on certification course for the Inman Aligner with expert hands-on assistance from Drs. Tim Brad-stock Smith and James Russell at the BDA with Straight-talks Seminars. For more information, visit straight-talks.com. He can be reached at atifqureshi@btinternet.com.

Disclosure: Dr. Qureshi runs the teaching courses on the Inman Aligner in the UK and other European Countries.

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