Ortho Tribune UK No. 1, 2016

From straightforward to complex cases / “We will be able to treat pretty much everything in the future” / Individuals play the game - but teams win championships / Conservative smile design for the general dentist

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ORTHO TRIBUNE
The World’s Orthodontic Newspaper · United Kingdom Edition
www.dental-tribune.co.uk

Published in London

Vol. 10, No. 1+2

INTERVIEW

MANAGEMENT

SHORT-TERM ORTHODONTICS

Dr Graham Gardner about the
European Aligner Society and the
importance of aligners in orthodontics.

Practice consultant Lina Craven,
Dynamic Perceptions, explains
what it takes to build the ultimate
practice team.

Conservative smile design for
the general dentist. Three cases
involving the Inman Aligner appliance.

” Page 20

” Page 21

” Page 22

From straightforward to complex cases
The new NimrodAligner and why it can be the ultimate orthodontic removable aligning system
By Nimrod Tal & Lauren Flannery
As a dental practitioner, helping your
patient look to improve their smile
by undergoing orthodontic treatment with one of the many aligning
systems available can be a very
daunting decision to make when it
comes to choosing the right system.
Whatever their lifestyle, the attributes most commonly sought after
are typically comfort, discreteness
and for the treatment time to be as
speedy as possible. Depending on
the case, it can sometimes be quite
difficult to achieve all of these aims
within one single aligning system,
as each are designed to achieve very
specific and individual movements,
and not all are designed to do this
with the whole arch.
As an orthodontic laboratory, we
are introduced to hundreds of very
individual cases on a weekly basis,
where more often than not patients
will have specified that the above
attributes are key to their decision
making process when we assess for
the appliances that will be best suited
to their particular case. After having
been faced so regularly with the task
of assisting our clients to make the
decision that will benefit their patients in as many aspects as they
can, we had a thought—what if the
advantages of each of these aligning
systems were combined, and the
disadvantages eliminated? It was
from this that the idea of our brand
new NimrodAligner stemmed.
Designed to move from 5-5 in all
directions, and also widen the molars
(Fig. 1), the NimrodAligner comprises
of lingual and labial arch wires attached to individual cups that seat on
each tooth with the aid of a composite anchor, and a connecting bar to
seat on the palate or the lingual area,
that are attached to molar cups. After
having spent four years researching
the most effective components and
combining them using prototypes
with 3-D printers, we have combined
the biomechanics of straight wire,
Clear Aligners and a spring aligner
to reduce the downsides of having
treatment considerably and focus
more on the positive features.
Typically most common with
adolescents, fixed brackets appear

Figs. 1–5: Designed to move
from 5-5 in all directions,
and also widen the molars,
the NimrodAligner comprises of lingual and labial
arch wires attached to individual cups that seat on
each tooth with the aid of
a composite anchor, and a
connecting bar to seat on
the palate or the lingual
area, that are attached to
molar cups.

and are typically only at their most
active in just the first seven days.
On the other hand with the
NimrodAligner, NiTi wires ensure
that the pressure is gentle, yet provide continuous support.

to be decreasing in popularity,
mostly due to the fact that they are
not particularly aesthetically pleasing and can therefore encourage a
feeling of embarrassment for adults
when in public. Combined with
hours of clinical time spent fitting
and repositioning the individual
brackets, hygienic problems owing
to not being able to brush or floss
properly, as well as the discomfort of
their often sharp exterior both labially and lingually, it is no surprise
that they are not as often requested
as more popular removable aligners. The NimrodAligner has the
fixed brackets arch wires biomechanics incorporated within the removable appliance so clinical time
is extremely minimal. The teeth and
gums can also be cleaned to the
proper standard and at only 2 mm
in thickness (Fig. 5) – as opposed to
the standard 3 to 3.5 mm thickness
of fixed brackets – so the overall feel
is very anatomically friendly.

Multiple Clear Aligner trays can
also become very tedious for both
patient and dentist, particularly
when frequent appointments are
necessary and stages of interproximal reduction (IPR) have to be carried
out. IPR can be a huge factor in the
progress of Clear Aligners as each
aligner is made to incorporate the
necessary IPR after each stage and the
fit of following trays will be affected
if not enough has been done. This is
not a problem for the NimrodAligner
as it will not affect the fit of the appliance if there has been insufficient
IPR on the previous appointment.
The patient can continue to wear
it and IPR can be completed where
necessary on the next appointment.

Clear Aligners are the most
anatomically friendly appliances
on the market today, and are
mostly popular because of just how
discreet they are. Despite these
advantages, the force and pressure
induced during the initial days of
wear can be very painful. Although
a sign that they are working as
they should, the aligners tend to
become passive as time passes

Similarly, spring aligners can
also continue to be worn and fit
correctly in between appointments if not enough IPR has been
done previously, however they’re
widely known for limited movement to just four incisors. It may be
good for labial/lingual movement
using the ‘squeeze’ effect, and some
rotation, but Clear Aligners can
often be required to finish.

e|̈»é¡̌e¤|ù"7ØÁe|Y"¡|D"
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- welcome to the leading annual dental fair in Scandinavia

SCANDEFA invites you to exclusively meet the Scandinavian dental market
and sales partners in wonderful Copenhagen.
Why exhibit at SCANDEFA?

Who visits SCANDEFA?

SCANDEFA is a leading, professional branding and
sales platform for the dental industry.

In 2015 over 7,500 dentists, dental hygienists, dental assistants and dental technicians visited SCANDEFA. For further statistical information please see
scandefa.dk

In 2016 we are pleased to present Scandefa with
"5ÎUﾍ"ûÎ ﾒ"Îrû"Î"n ﾍž":ž Uåež"ï ﾍﾒž"ｸﾍ FﾍÎnnž"
at the Annual Meeting. In addition to sales, branding
and customer care, the new format gives you the
ｸｸ ﾍ rU "5 ﾍ"rž
ﾍbUrFù"ﾒ Î6"ïÎﾍžù"ｸﾍ 5žﾒﾒU rÎe"
inspiration and competence development.
SCANDEFA is organised by Bella Center and held
in collaboration with the Annual Meeting organised
by the Danish Dental Association (tandlaegeforeningen.dk).

How to exhibit
Please book online at scandefa.dk or contact SalesÚ" H QUåU U r" \ÎrÎFžﾍ" \UÎ" 9ežnžr " ́ ﾒžr UrFž"
mro@bellacenter.dk/+45 32 47 21 33.

Where to stay during SCANDEFA?
Two busy fair days require a lot of energy, and
therefore a good night’s sleep and a delicious
breakfast are a must.
ž" 55žﾍ" Îee" 5" ﾍ" ž QUåU ﾍﾒ" Î" ﾒｸžïUÎe" ｸﾍUïž" 5 ﾍ"
both our hotels, AC Hotel Bella Sky Copenhagen
– Scandinavia’s largest design hotel – and Hotel
Crowne Plaza – one of the leading sustainable
hotels in Denmark.
We also offer free and easy shuttle service transport between the airport, the two hotels and Bella
Center.

SCANDINAVIAN DENTAL FAIR
28 - 29 APRIL 2016

scandefa.dk

[2] => Untitled

ORTHO NEWS

Ortho Tribune United Kingdom Edition | 1+2/2016

Figs. 6–9: By combining all of the positive aspects of different orthodontic appliances, the NimrodAligner can be suitable for most cases from straightforward to complex.
AD

In some instances, a separate expansion appliance may be required
prior to treatment, which essentially boosts costs and adds time
onto treatment overall. We have
reduced this concern by offering
this stage for such cases within
the NimrodAligner singularly.
The arch can gain molar width by
pre-setting the molars in a wider
position when it comes to making
the movements on our 3-D system,
and the connecting bar can act as
a spring thanks to its flexibility.
The rest of the teeth will continue
to be aligned during this process.

The Dental Tribune International
C.E. Magazines
www.dental-tribune.com

In more complex cases however
whereby a separate expansion appliance is unavoidable, two NimrodAligners will be provided. The caps
will not fit on the teeth that are
blocked in otherwise, so the initial
appliance will create space for the
blocked teeth. Once they have been
exposed, the second appliance would
be provided to sit on all of the teeth.

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During our research and production stages, we aimed to create the
ultimate orthodontic removable
aligning system that could potentially be the answer to the prayers of
dentists and patients alike. We have
reduced clinical time dramatically by
removing the time-consuming hassle of fitting appliances such as fixed
brackets by providing a bespoke prealigned appliance that simply needs
to be placed on the teeth. We have
taken into consideration the fact that
multiple appliances can sometimes
be necessary to achieve the desired
result, and have eliminated the need
for this by designing the NimrodAligner in a way that allows the entire
arch to move in any direction. In case
expansion is also required, we have
this incorporated (Fig. 1).
We have adapted the force and pressure of the movement to be effective
for just sixteen hours a day, allowing
the patients to remove the appliance
for an entire eight hour working day
if they wish, to grant the roots a sufficient amount of time to recover.
By combining all of the positive aspects of the orthodontic appliances
mentioned above, the Nimrod Aligner can be suitable for most cases
from straightforward to complex.

Nimrod Tal is
the director of
NimroDENTAL
Orthodontic Solutions in London.
He can be contacted at contact@
nimrodental.co.uk

[3] => Untitled

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ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

[4] => Untitled

ORTHO NEWS

Ortho Tribune United Kingdom Edition | 1+2/2016

“We will be able to treat pretty much
everything in the future”
An interview with Dr Graham Gardner, UK, President of the European Aligner Society
in materials and 3-D printing will
render manufacture and the product itself more cost-effective. For
example, 3-D printers could allow
individual practices to print their
own aligners in the future.

The European Aligner Society is an
international organisation established in 2013 that aims to promote
education and research in aligner
therapy. Trained in South Africa and
with 22 years of clinical experience,
Dr Graham Gardner has been running his own private practices in the
UK since 2008. In an interview with
Dental Tribune, the EAS President
shares his ideas and views about
the importance of aligners in orthodontics and about the EAS, which
he believes will become the society
for aligner therapy.
Dental Tribune: Dr Gardner, you
have been working with aligners
for more than a decade now. What
convinced you initially of this
treatment method and what are
the main advantages in your experience?
Dr Graham Gardner: From the beginning of my career in the early
1990s, a time when ceramic brackets and lingual braces became
available, I was certainly aware of
the fact that aesthetic appliances
were going to be the future of
orthodontics.
In 2001, I was fortunate to attend a certification course for Invisalign, which was truly a watershed moment in my orthodontic
career because I saw the value and
potential of aligner therapy for
both dental professionals and
patients. In my opinion, aligner
therapy opened the door for a
huge cohort of patients who would
not have considered orthodontic
therapy in the past mainly owing
to aesthetic concerns. In addition
to aesthetic benefits, aligners are
far more comfortable than fixed
appliances, as they are removable
and hence facilitate oral hygiene
during therapy. They also move
the teeth more gently with less
pressure, which is favourable with
regard to patient comfort and
from a biological perspective too.

Overall, with technological advancements and increasing patient acceptance, we will be able to
treat pretty much everything in
the future in my view.

Dr Graham Gardner.

confirm biomechanics in a far
more in-depth way than ever before, orthodontics is now catching
up with the high-tech world we
live in—it is twenty-first-century
orthodontics.
When aligners were first introduced to the market, there were
some limitations and we could
only treat mild malocclusions.
However, aligner therapy has
come of age and is now a genuine
appliance system with which

How have developments in the
European and the overseas market
differed?
Dentistry as a profession is very
conservative and dentists in the
US, for example, are perhaps a bit
more progressive. However, with
regard to aligners, I no longer really see a great difference between
Europe and America. The movement is global and I suspect the
advancements we are now seeing
in Europe will match those in
America and Asia, where aligner
therapy is also very popular.
There are always regional differences, also partly related to legal
restrictions, but the trend towards aligner therapy is a global
phenomenon.

main motivation behind the foundation of the EAS was to establish
a neutral body—an international
society that is independent of any

“...aligner therapy opened
the door for a huge cohort of
patients who would not have
considered orthodontic
therapy in the past...”

aligner company and open to all
dentists using aligners for orthodontic treatment.
The work of the EAS is characterised by three cornerstones.
The first is education, namely arranging conferences and regional
meetings and introducing clinical

Today, I treat over 75 per cent of
patients with Invisalign in my
practices.
In recent years, clear aligners have
become a favourable treatment
alternative to fixed appliances,
and the global orthodontic supplies
market is expected to reach about
US$3.9 billion (€3.6 billion) by 2020.
In your professional opinion, how
will this market develop in the near
future?
Over the past decade, aligners
have become mainstream orthodontics and I definitely see this
trend continuing and expanding.
With the technological advancements, including 3-D and CAD/
CAM, that allow the clinician to
diagnose, plan the treatment and

“...the advancements we are now
seeing in Europe will match those
in America and Asia...”
we can treat the majority of malocclusions.
At the moment, however,
aligner therapy is still a fairly expensive form of orthodontics.
Thus, I hope that improvements

How does the EAS address the
current trends in orthodontics?
Aligner therapy has seen huge
advancements over the past
decade, with an increasing number of manufacturers offering
different systems today. Thus, the

information about aligner therapy and that members can consult
for guidelines. Research is our
third column, which is currently

online forums, through which
members can interact and share
experiences and ideas. The second
column of the EAS’s philosophy
is communication. We aim to be a
neutral organisation that patients
can turn to for comprehensive

lagging behind. Eventually, we
hope to have our own aligner journal or magazine and grant annual
awards for excellence in aligner
therapy.
With the help of our sponsors,
the EAS will grow and become an
international umbrella organisation to help promote education
and research and development for
aligner therapy.
The EAS is a fairly young organisation and hosted its first congress on
13 and 14 February in Vienna. What
was the idea behind this event?
The EAS’s primary objective is
education because, obviously, education underpins every profession and without it we simply
stagnate. Therefore, we decided
that our first event should be
a congress held in the heart of
Europe offering a broad spectrum
of informative lectures and a
showcase of different systems
and products. At the first congress
in Vienna, internationally distinguished speakers shared their
views and expertise about aligner
therapy. Moreover, the event offered manufacturers an independent forum for exhibiting
their solutions.
Can dental professionals look forward to another EAS congress next
year?
Based on the success of the
inaugural event over the past
weekend, we definitely want the
congress to become a regular
event in the calendar. While we are
planning to hold the EAS congress
every two years, we will be organising smaller regional forums on
a continuous basis throughout
every year.
Thank you very much for the interview.

[5] => Untitled

ORTHO TRENDS

Ortho Tribune United Kingdom Edition | 1+2/2016

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 establish 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
members 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

[6] => Untitled

ORTHO TRENDS

Ortho Tribune United Kingdom Edition | 1+2/2016

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

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.

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ORTHO TRENDS

Ortho Tribune United Kingdom Edition | 1+2/2016

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).

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.

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.

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

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[cover] => Ortho Tribune UK No. 1, 2016

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