Short-term gains…long-term problems? - The emergence of STO and its future implications in general practice. / Individuals play the game - but teams win championships / Conservative smile design for the general dentist
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ORTHOTRIBUNE
The World’s Orthodontic Newspaper · Asia Pacific Edition
www.dental-tribune.asia
Published in Hong Kong
Vol. 14, No. 7+8
Short-term gains…long-term problems?
The emergence of STO and its future implications in general practice. By Aws Alani, UK.
The provision of orthodontics can
be a life-changing experience for
young patients whose “crooked”
teeth can affect their confidence
and self-esteem. Indeed, where
mature patients present with a history of malalignment, equally beneficial and fulfilling results can be
achieved. In government-funded
systems, patients with congenital
abnormalities receive treatment
that is essential to their ongoing
oral health. Restorative dentists
work closely with orthodontists,
who can appreciate how small details can aid in achieving positive
restorative outcomes.
As a young dentist, I corrected
a tooth in crossbite with a simple
T-spring appliance. It was enjoyable and brought a different type of
delayed gradual satisfaction to the
more cerebral but tenuous molar
endodontics or the more artistic
and instant composite build-up.
I was not a specialist, but I managed to do some orthodontics. In
contrast to my experience, general dental practitioners are now
more routinely providing tooth
movement with the emergence of
short-term orthodontics (STO). This
has resulted in some conjecture
as to the methods of achieving
“straighter” teeth. Indeed, some
may consider STO as an emerging
entity competing with specialist
orthodontics, but should it be?
The specialist training pathway for orthodontics involves
a competitive-entry three-year
full-time course linked with the
achievement of a master’s level
qualification that many may feel
daunted by. Indeed, navigating
the pathway from start to finish
can be difficult academically and
financially when factoring in fees
and loss of earnings during training. Once qualified, the majority
of these specialists reside, like the
majority of all specialists, in the
south-east of England. With this
skewed distribution of specialists
and assumed need for access, it
might seem prudent for general
dental practitioners to contribute
to meeting the need for orthodontics.
Indeed, the long-cited managed clinical networks have yet
to be fully realised, although all
planning and documentation related to managed clinical networks identify general dental
practitioners as integral to the
function of the network. The number of orthodontic therapists has
gradually increased over the last
ten years or so since inception of
the first courses in Wales and
Leeds. Therapists are allegedly
more cost-effective to train and
employ in a large orthodontic
practice; however, unlike their
hygiene or therapy colleagues,
they cannot practise without a
specialist’s treatment plan and
supervision.
Patients who qualify for orthodontic treatment under the UK
government-funded system need
to be assessed according to the
index of orthodontic treatment
need. There will be an obvious
shortfall of adults or adolescent
patients with minor malocclusions who do not meet the criteria who would like their teeth
straightened. This cohort may
have to seek treatment privately
from orthodontic specialists or
general dental practitioners. As
such, these minor or straightforward cases may be managed in
a number of different settings
utilising various techniques with
the advent of STO. This may have
resulted in some territorial paranoia between the two camps of
traditional orthodontics versus
STO systems. Conversely, it may
and learns by way of osmosis
from those of individuals one
hopes to emulate. Becoming an
expert in many a field requires
time, effort and experience.
Orthodontics is a complicated
discipline that is difficult to
deliver optimally and efficiently.
Treatment planning should be performed in person not only to appreciate the challenges the patient
presents with but also to develop
a lasting patient rapport. Equally
important, patients need to be diligent during treatment and forever
more for purposes of retention.
Is it possible that a one- or two-day
course with a treatment plan lasting half a year or less can provide
equally op-timal results to a specialist ortho-dontist utilising traditional means?
© Alexis Photo/Shutterstock.com
be that differing scientific, technical and ethical ethos on managing
the same problem is the source of
the debate.
Quick and easy?
Commercialisation has modified the provision of orthodontics
in the UK. Indeed, there are now
orthodontic brands with courses
attached and a faculty of individuals who promote their particular
product. Companies tend to boast
that their product is the best with
limited complications and treatment being low risk, predictable
and easy. Somewhat surprisingly,
courses are being run on how to
convert patients into orthodontic
clients. There are books describing strategies on promoting and
increasing revenue. They outline
detailed strategies on attracting
more patients than one’s local
competitor—or is that colleague?
Sounds more like capitalism than
commercialism to many interested observers.
The rapid development of STO
has not escaped the venture (or
some may say vulture) capitalists.
In the same vein as DIY whitening
and sports guards, one can now
have one’s teeth straightened via
online companies using products
delivered by Her Majesty’s Royal
Mail and so cut out the middleman (i.e. the dentist). To my knowledge, STO has yet to make it on
to the price list of Samantha’s,
a beauty salon in Peckham.
What may cause fear and
worry is that the provision of
tooth movement set against a
backdrop of a focus on increasing
revenue and patient conversion
may detract from the real reasons
we are providing the treatment.
The risk and benefit of treatment
must remain balanced or be rebalanced in favour of the patient.
The best things in life are rarely
quick, easy and without reflection.
While learning or training, one
gains stature from one’s mistakes
In any case, placing a time limit
on any treatment could be considered contentious. Patients ask me
all the time ‘How long is this treatment going to take Doc?’ I always
reply ‘Ill tell you when its finished’.
As such I am rarely wrong.
Advertising cosmetic
treatments the fair
dinkum way
The Australian health ministry—recently examined the provision of cosmetic procedures and
in particular the modes of promoting the treatments. The working group found that advertising
and promotion more often than
not focused on the benefits to the
consumer, downplaying or not always mentioning risks. The group
went on to identify advertising
practices that were not driven by
medical need and where there
was significant opportunity for financial gain by those promoting
these. They identified the need to
” Page 18
DT launches new international ortho mag
By DTI
HONK KONG: The orthodontic
segment has grown significantly
within the past 20 years owing
to new technologies and products,
as well as an increase in adult
patients requesting orthodontic
treatment. In response to this
trend and to update dentists on
the most significant developments in the field, Dental Tribune
International (DTI) has added
ortho—international magazine
of orthodontics to its portfolio.
The 2016 issue includes articles on
clear aligners, vibration therapy
and rapid maxillary expansion,
as well as the latest product information and event previews.
The new high-gloss Englishlanguage magazine adopts an
interdisciplinary approach involving orthodontics, oral surgery,
periodontics and restorative den-
tistry, and aims to serve as
an educational tool, providing
comprehensive knowledge and
information on the newest technology that can profitably be integrated into treatment concepts.
The publication, which will be distributed at all major international
orthodontic congresses and exhibitions, presents the latest research and case studies, as well as
trends in procedures and techniques.
In order to connect with orthodontic specialists, the DTI team
is scheduled to attend a number
of orthodontic events around the
globe in 2016, including the 92nd
Congress of the European Orthodontic Society, which will take
place between 11 and 16 June in
Stockholm in Sweden; and the
fourth Scientific Congress for
Aligner Orthodontics, to be held
on 18 and 19 November in Cologne
in Germany. DTI will be providing
comprehensive live coverage of
these and other events on its
website. In addition, e-newsletters
about the respective events will be
sent to orthodontists worldwide.
From 2017, a new issue of the
ortho magazine will be published
twice a year with a print run of
4,000 copies. An e-paper edition
of the magazine is available free
of charge via the DTI online print
archive.
[2] =>
ORTHO NEWS
18
“ Page 17
regulate promotion and advertising ethically with factual, easily
understood information from
a source that is independent of
practitioners and promoters. This
is unfortunately not always readily available. In some Australian
jurisdictions, there are specific
guidelines that need to be adhered
to for promotion of cosmetic treatments and they specifically cover
before and after treatment adverts, which we know in the UK is
a popular practice among the
cosmetically driven. This is commonly one ideal, perfect case
showcased on the front end of the
practice website with no mention
of any problems, either acute or
chronic. Another aspect of the
report detailed prohibition of
time-limited offers or inducing
potential customers through free
consultations for the purposes of
treatment uptake. The latter is
something that has seen STO promoted by way of voucher deals on
the Internet or via smartphone
applications. Others may consider
such a practice as loss leading; one
could ask who is losing and who is
gaining and at what price?
One important aspect of the
report identified the wider social
impact of cosmetic procedures in
that people may become increasingly dissatisfied with themselves
and their appearance, culminating in deeper concerns for the person and reducing scope for indi-
Ortho Tribune Asia Pacific Edition | 7+8/2016
viduality. Many dentists throughout the country may have a
slipped contact here, a rotation
there or a space distal to a canine
who are unlikely to be waiting in
earnest for the next voucher deal
alert on their iPhones. Inducing
misgivings or raising concerns
about the patient’s tooth position
where the teeth are otherwise
healthy and the patient presents
with no concerns could be considered unethical and worryingly
dishonourable.
AD
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Relapse of confidence
In a recent publication from
an indemnity provider, orthodontics was identified as an emerging
area for claims against their clients.
This is likely to be the tip of the
iceberg, whose size will probably
continually grow as more and
more orthodontics is provided
and the repercussions of which
may only become apparent gradually in the future.
In the now highly litigious
arena of UK dentistry, the failure
of orthodontic treatment against
the backdrop of Montgomery v.
Lanarkshire Health Board is likely
to result in increased litigation.
The movement of teeth into what
the patient and the dentist feel
is the correct position may be
possible in the short term, but
in the long term complications
may arise owing to a variety of
soft- and hard-tissue factors that
cannot accommodate this new
and supposedly “right” position.
Indeed, orthodontics requires the
appreciation of detail where symmetry and alignment are “king”,
but long-term stability is the likely
“empress”. Relapse of position is
a common complaint and where
patients have paid handsomely
for a result they may have been
happy with at the time of the
cheque clearing, over time tiny
tooth shuffles can result in disproportionate and vehement dissatisfaction. Where teeth are moved
indiscriminately, recession in the
labial segment is a complication
difficult to explain and remedy in
the high lip line of a conscientious
and ambitious corporate female
patient. Indeed, more haste, less
speed may result in a case being
etched longer in the memory of
the patient and the clinician for
the wrong reasons.
Clear steps to
business building
Vol. 1 • Issue 1/2016
issn 1868-3207
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term owing to their positive experiences. Focusing on short-term
gains without due consideration
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[3] =>
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[4] =>
DTUK0116_21_OTCraven 28.07.16 13:45 Seite 1
ORTHO TRENDS
20
Ortho Tribune Asia Pacific Edition | 7+8/2016
Individuals play the game, but teams
win championships
What it takes to build the ultimate practice unit
By Lina Craven, UK
do attitude makes the impossible
possible.
It is said that all teams are groups,
but not all groups are teams. What
separates the two is interdependence. A true team is focused on a
common purpose; team members
support one another and enhance
each other’s work and contribution. Andrew Carnegie captured
this accurately when he said,
“Teamwork is the ability to work
together toward a common vision.
It is the fuel that allows common
people to attain uncommon results.”
I know that achieving the ultimate team is possible, because
when I was a dental nurse many
years ago in America, I was part of
an ultimate team. What made us
great was our leader, Dr Derick
Tagawa. He and his partner had
a very clear vision and they knew
exactly what was needed from
each one of us to ensure the
practice achieved its desired results. In turn, each one of us
knew that every challenge we
faced was an opportunity for personal, professional and practice
growth.
Practices with a motivated,
focused and empowered team
produce excellent results; consequently, patient satisfaction is
high and practitioners realise
increased financial rewards.
Achieving such a team is not pie
in the sky, but it does require complete commitment from the
whole team. Based on my own experience of being a part of a highperforming team and my observations as a consultant to practices, here are my key principles
for the creation of an ultimate
team.
Do not confuse being the boss
with being a leader. Leaders set
the tone for the practice. They
lead by positive example. Successful teamwork starts at the top
with leaders who provide strategic vision and establis h team
goals. Effective leaders clearly define their vision and share it with
their team to establish a common
purpose.
Any successful relationship can
only survive if values are shared,
believed and agreed upon; values
like honesty, respect, integrity,
commitment to each other, commitment to the practice success.
Shared values help to build an
effective team and to establish
its culture, conduct, rules and
policies. The key is to ensure
the entire team agrees on the
same values and is prepared to
work by them. According to the
Consistency is critical to creating the ultimate team; it fosters credibility and trust. Ken
Blanchard and Sheldon Bowles
wrote in their book Raving Fans,
“customers allow themselves to
be seduced into becoming raving
fans only when they know they
can count on you time and time
again”. This is also true for teams:
just replace the word “customers”
with “team members”. I often
hear people say things like “one
day we’re instructed to something and the next day it becomes
something else”. If you want to
be part of the ultimate team, be
consistent.
world’s finest flight demonstration team (the Blue Angels, US
Navy), “without shared values,
peak performance isn’t possible”
and “a team’s values must align
with its purpose, mission, and
actions”.
Every team member, from the
leader to the cleaner, must learn
to communicate clearly and effectively. Successful relationships
are built on positive, honest and
open feedback. Is information
shared openly and honestly in
your team? Does gossip or negative chatter exist in your practice?
Team members must learn to address concerns, deal with conflict
and accept responsibility for the
success of other team members.
When conflict occurs, it must be
dealt with honestly, directly and
openly as soon as possible and
in line with the team’s adopted
values. Foster positive attitudes
and creative thinking—attitudes
can either make or break the team
dynamics, so there is no place for
negative people.
Do all your team members have
clear and up-to-date job descriptions? Are they all qualified to
undertake their roles? Are there
written procedures for every area
of the practice? I often hear team
me mbers say they are not sure
who is responsible for something,
or they do not have a job description, or they were promised
training when they started, but
have not yet received any owing
to the practice being too busy.
Empowerment results from clearly defined roles and practice
procedures and a shared understanding of one another’s roles.
Cross-training increases efficien-
cy and makes each person more
productive and valuable to the
team.
Each team member is a cog in
the practice’s wheel of success.
However, many are often underutilised to his or her full potential
where staff were expected to be
(from the rota) and anyone off
that day. It only took 5 minutes for
the update and 5 minutes more to
review the day before regarding
what had worked well and what
had not. It helped us to focus on
the day ahead.
It is said that what motivates individuals the most is recognition
—a pat on the back or a word of
praise here and there for a job well
done. Embrace this principle and,
although it may feel awkward at
first, if it is done often enough
it becomes a habit. Sam Walton,
founder of Wal-Mart Stores, said:
“Appreciate everything your associates do for the business .
Nothing else can quite substitute
for a few well-chosen, well-timed,
“Successful leaders embrace the power of
teamwork by tapping into the innate
strengths each person brings to the table.”
Blue Angels, US Navy
and thus become bored or complacent. Dr Tagawa believed in
providing the best training for his
staff. He also recognised that he
may lose some individuals who
desired greater career progression than the practice could offer.
He knew nevertheless that those
who remained would perform at
their peak and more than justify
his investment.
Every morning in Dr Tagawa’s
practice as part of our commitment to the team, we would meet
10 minutes prior to the start of
the day to prepare for the show.
The head receptionist had a simple but effective system for updating us with vital information,
including how many patients we
would be seeing, special recognitions (like patients’ birthdays),
identifying difficult patients,
Walt Disney once famously
said, “You can dream, create, design and build the most wonderful place in the world, but it
requires people to make the
dream a reality.” Imagine a girl
visiting Disney World hoping to
see Cinderella, but when she
encounters her, Cinderella is
chewing gum and has a can’t-do,
won’t-do attitude. Is Cinderella
playing her role? It takes the right
attitude and focused commitment from every member of the
team to turn the vision into a reality. When that patient your practice dreads is due to arrive, how
do you all respond? With “I will
not take any nonsense from this
patient today!” or “I’ll show her
who’s right!”? When we choose
the right attitude and choose to
stay true to our purpose, we will
help others to do the same. A can-
sincere words of praise. They’re
absolutely free and worth a fortune.”
Building the ultimate team
does represent a challenge, but
once achieved it is hugely rewarding. There is no point implementing one principle in isolation.
It is like baking a cake without
the eggs.
Lina Craven is
founder and Director of Dynamic Perceptions,
an orthodontic
m a n a g e m e nt
consultancy and
training firm in
Stone in the UK,
and has many
years of practice-based experience. She
can be contacted at info@linacraven.com
[5] =>
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[6] =>
DTUK0116_22-23_OTChayah 28.07.16 13:51 Seite 1
DTUK0
ORTHO TRENDS
22
Ortho Tribune Asia Pacific Edition | 7+8/2016
and should look for any skeletal discrepancies. Compromises
must be signed off.
Conservative smile design
for the general dentist
1
By Dr Rami Chayah, Lebanon
Abstract
This article discusses the advantages of short-term anterior tooth
alignment using the Inman Aligner
system, particularly for general dentists. The article will give a brief description of the Inman Aligner appliance and its use in short-term orthodontics, and it will answer three major
questions the general dentist should
ask himself or herself during the treatment planning process. In support of
this treatment modality, three case
scenarios general dentists see daily
will be given as examples.
Treatment
concept
and case
presentation
treatment or Class II or III treatment.
Only certain types of movements are
possible and some patients will still
need conventional orthodontic treatment or indirect restorations. Certain
criteria should be met before treat-
ment proceeds. At consultation, other
orthodontic alternatives should be offered. The dentist must quote for the
long-term retention maintenance
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Dentists need to consider three
questions about treatment during the
treatment planning process. The first
question: can the patient’s teeth be
Introduction
General dentists face the daily challenge of performing instant veneers
for patients with misaligned anterior
teeth who refuse orthodontic treatment, many of whom regard fixed
orthodontic treatment as too long
a commitment for achieving their
desired aesthetic results. In today’s
fast-paced life, some patients are not
prepared to wait or to go through
long treatments.1, 2 One of the greatest
benefits of short-term anterior alignment is that many people who would
refuse comprehensive orthodontic
treatment may accept short-term removable alignment techniques such
as the Inman Aligner system.
The Inman Aligner is a simple removable appliance, a modification
of the removable spring retainer. It
uses super-elastic coil springs to apply
highly efficient light and consistent
forces on both the labial and lingual
surfaces of the anterior teeth (Figs. 1 & 2).
The appliance is fabricated on a cast
on which, based on a surgical model,
the anterior teeth needing correction
have been removed and reset in the
ideal position in wax on the working
cast.3 When the patient wears the appliance, the built-in forces generated
by the spring coils will correct the
misaligned anterior teeth (Fig. 3).
What distinguishes the Inman
Aligner appliance from other shortterm orthodontic systems such as
Invisalign (Align Technology) and
Six Month Smiles is its low cost, low
risk and short learning curve for general practitioners. Only one appliance
is used from the start to the end of
the treatment. Sometimes, several
clear aligners may be used to de-rotate
resistant canines. The system is well
received by patients because it is fast
and relatively cheap. It also accommodates today’s active lifestyle. Usually,
most cases take from six to 16 weeks.
Patients can take the appliance out
during meals or work meetings.
As with any other treatment techniques, the Inman Aligner has its
limitations. Hence, case selection is
imperative, as the Inman Aligner is
not suitable for posterior orthodontic
Fig. 1: Inman Aligner appliance.—Fig. 2: Illustration of the Inman Aligner showing the appliance components.—Fig. 3: Inman Aligner appliance in the mouth. Case 1—Fig. 4:
Frontal view with the teeth in occlusion before treatment.—Fig. 5: Frontal view with slightly open bite showing the status of the teeth before treatment.—Fig. 6: Frontal view
with the teeth in occlusion after alignment and bleaching.—Fig. 7: Close up frontal view of the maxillary teeth after ABB.—Fig. 8: Right side view of the maxillary teeth before ABB.
—Fig. 9: Right side view of the maxillary teeth after ABB.—Fig. 10: Left side view of the maxillary teeth before ABB.—Fig. 11: Left side view of the maxillary teeth after alignment
and bleaching.—Fig. 12: Full face before treatment.—Fig. 13: Full face after treatment.—Fig. 14: Frontal view showing the patient’s natural smile before treatment.—Fig. 15:
Frontal view showing the patient’s natural smile after treatment.—Fig. 16:Full face showing the patient’s natural smile before treatment.—Fig. 17:Full face showing the patient’s
natural smile after treatment.—Fig. 18: Occlusal view showing the maxillary arch before treatment.—Fig. 19: Occlusal view showing the maxillary arch after treatment.
[7] =>
DTUK0116_22-23_OTChayah 28.07.16 13:51 Seite 2
ORTHO TRENDS
23
Ortho Tribune Asia Pacific Edition | 7+8/2016
fixed without orthodontic treatment
in a very short period? In order for the
general dentist to answer this question, he or she should first establish
whether the patient does not wish
to pursue orthodontic treatment because of the time commitment and
cost. Would he or she also refuse
short-term anterior tooth alignment?
Would the occlusion be improved
even though a Class I molar or Class I
canine relationship may not be
achieved? Patients may prefer shortterm alignment techniques because
of the shorter treatment time and
the lower cost.
Case 1
The first case presented is a good
example of a scenario relevant to
the question above. The patient was
a young woman at college who presented at my office requesting a full
smile makeover of 20 veneers; she
desired a “Hollywood smile” as expressed in her own words. Her complaint was the retracted maxillary
right and left central incisors, the incisal edge wear on the maxillary central incisors and mandibular anterior
teeth, the pointy shape of the maxillary and mandibular canines, and
the yellow colour of her teeth overall
(Figs. 4 & 5). It could be argued that it
would be highly unethical to prepare
the sound enamel, transforming her
ten maxillary teeth into stumps, for
the rest of her life, especially at this
young age. After long discussion and
explanation of the disadvantages of
the shortcut route of preparing her
teeth for ceramic veneers, this option
was excluded. Several other options
were available and discussed with her,
but because she wanted a smile enhancement in a short period of time,
conventional fixed orthodontic treatment was also excluded. After checking her bite, it was observed that there
was insufficient interocclusal space
to shift the maxillary central incisors
forwards without opening the bite.
However, the patient accepted use of
the Inman Aligner system owing to its
short treatment time and flexibility
regarding being able to take the appliance off during the day while eating.
The treatment plan was to follow
the ABB protocol (alignment, bleaching and bonding). This concept still
constitutes a smile makeover but in
a very conservative manner. Taking
into consideration her age and her
sound enamel tissue, this was agreed
to be the most progressive means of
carrying out her smile enhancement.
First, her maxillary teeth were aligned
using the Inman Aligner with an
expander for nine weeks. Two extraclear aligners were used in the last
two weeks of treatment to de-rotate
the maxillary left lateral. Once the
maxillary teeth had been aligned
and in the last two weeks of treatment,
the teeth were bleached with customfitted super-sealed trays (Fig. 6). Now
that the teeth had been straightened
and whitened, the patient became
more aware of the differential wear
on the incisal edges of her anterior
maxillary and mandibular teeth.
Incisal edge bonding using composite was completed using a simple
direct technique. The patient was
very happy with the final result
(Figs. 7–19).
Case 2
The second question to be considered regarding treatment: would
some of the teeth be aggressively
prepared or end up with root canal
treatment if treated with restorative
dentistry without alignment and
would the overall outcome be better
with alignment rather than without?
This question addresses the ethical
dilemma general dentists face every
day. We often have cases with overlapping anterior central incisors in
our office.
The patient presented in this case
was bothered by the look of his overlapping maxillary central incisors
(Figs. 20 & 21). His mandibular teeth
were also crowded, but for some reason, his concern was only with his
maxillary teeth. He had started to
hide his smile in front of his friends,
feeling embarrassed to show his
maxillary teeth. After the full orthodontic examination and discussion
about all of the treatment options,
including comprehensive orthodontic treatment, the patient chose the
removable Inman Aligner system
owing to its flexibility in that the
wearer is able to remove the appliance for several hours a day and
because of its short treatment time.
The maxillary left central incisor
would have been aggressively prepared had it been treated restoratively.7–9 By using a simple anterior
alignment technique, the treatment
took only eight weeks to straighten
the teeth and a great deal of sound
enamel tissue was preserved by conservatively resolving the unattractive appearance of the maxillary
teeth (Figs. 22 & 23).
25
20
21
22
23
24a
24b
Case 2—Fig. 20: Frontal view showing the overlapping central incisors before treatment.—Fig. 21: Side view showing the overlapping
central incisors before alignment.—Fig. 22:Frontal view showing the teeth after alignment.—Fig. 23:Side view showing the teeth after
alignment.—Figs. 24a & b: Side views showing the moderately crowded and worn teeth before treatment.
dentine of the incisal edges (Fig. 25).
The patient initially requested instant
veneers to resolve his smile problem,
but after mocking up the design directly in his mouth, he was discouraged from pursuing this option owing
the amount of tissue that would be
lost. The aggressive preparation of
The treatment plan was to align
the teeth first and then to reassess the
restorative work needed (Fig. 26). The
appliance was used for 12 weeks and
only worn for 16 to 18 hours a day. During the last three weeks of alignment,
the patient began to bleach his teeth.
By week 12, the teeth were straight and
loss. This clinical approach guarantees that the strength of bonding to
the enamel is much greater.
Conclusion
The goal of this article is to encourage general dentists to reflect
on the importance of considering
short-term tooth alignment alone
or in conjunction with restorative
dentistry when treating patients.
Hopefully, these three questions and
cases will prompt readers in thinking
through the process of this treatment modality.
Disclosure: Dr Chayah is the trainer for
Inman Aligner Training in the Middle East.
He provides hands-on full-day certificate
courses to general practitioners.
26
Acknowledgement: I wish to thank Dr Tif
Qureshi, the founder and Director of Inman
Aligner Training in London, for his mentoring and sharing the last case in this article.
Editorial note: A complete list of references
is available from the publisher.
27
28
Case 3—Fig. 25: Occlusal view showing the tooth misalignment.—Fig. 26: Occlusal view showing the result of treatment.—Fig. 27: Maxillary
teeth after alignment to reassess the restorative work needed.—Fig.28:Natural-looking thin maxillary veneers owing to aligning the teeth first.
Case 3
The third question to be considered: will the teeth require restorative
work anyway, even after alignment?
The case presented serves to
demonstrate the necessity of aligning
the teeth even before placing ceramic
veneers.10–13 The patient in this case
exhibited moderate misalignment
with major anterior edge wear due to
occlusal trauma. In addition, the teeth
were darkened through years of stains
being absorbed through the worn
the tissue was explained to him using
the occlusal image of his maxillary
teeth. After an extensive orthodontic
examination and discussion of the
options, the patient refused fixed orthodontic treatment, as well as clear
aligners. He refused the first option
because he did not want anything
fixed in his mouth, and he refused
the second option because of the
proposed time involved. The Inman
Aligner system was introduced to the
patient, and he quickly accepted this
option owing to the short treatment
time and removability.
white (Fig. 27). At this point, a direct
mock-up was done to show the
patient the smile design that could be
achieved with composite. He felt that
the teeth were still flat and wanted a
fuller smile. Because we had aligned
the teeth, only minimal preparation
was needed as evident from the waxup and the decision was made to fabricate ceramic veneers instead (Fig. 28).
This case shows that for complex situations and considering patients’ high
aesthetic demands, pre-alignment is
essential to produce minimally invasive veneers with minimal enamel
Dr Rami Chayah
runs a cosmetic
dental practice
in Lebanon with
an emphasis on
minimally in vasive dentistry.
He seeks to share
his passion for
photographic and
video production and believes that
through his personalised dental approach, he can demonstrate a more
positive way of practising dentistry,
helping other dentists to view the
dental domain in a different way.
You can reach Dr Chayah through his
social media: facebook.com/ramichayah
and http://instagram.com/ramichayah
www.inmanalignertraining.com
[8] =>
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