A multi-step approach

crowdingSamuel Wong describes the treatment of moderate crowding using removable appliances. 

At dental school we were taught that removable appliances have limited effect on malocclusion. So when I took the Clearsmile Inman Aligner online training course back in October 2011 I was a bit sceptical. 

However, after my first case aligning my colleague’s teeth, I was amazed at the speed and the effectiveness of the IA appliance. 

As such, I decided to take the hands-on course in May 2014, the Orthodontic Restorative course in May 2016, and IAS Advanced course in November 2016. I was looking for an alternative orthodontic pathway that offered step-by-step training and guidance. 

IAS Academy fit that bill down to a tee. Since becoming a certified user of the appliances, the Academy’s online forum has been instrumental in helping me deliver safe, effective and ethical treatment to my patients.

I have also learned a lot from other general dental practitioners. As well as from the Clearsmile Inman Aligner trainers, which has helped me to refine my skills.

Assessment 

  • Figure 1: Full facial view pre-treatment

In this case, the patient was referred to me for anterior alignment treatment of her upper anterior teeth. 

She was self-conscious about her teeth and felt she couldn’t smile properly without everyone staring at them. She wanted to improve their appearance before she got married. 

Due to time constraints, the patient was advised the treatment would likely need to be carried out in two parts either side of the wedding.

The patient demonstrated very good oral health, with no signs of clicking or pain. 

From an orthodontic perspective, the patient had moderate crowding in both upper and lower arches, with a maximum opening of 34mm, while movement range on the right side was 4mm and the left side was 6mm (Table 1). 

Table 1: Patient diagnosis

Treatment planning

The patient’s ideal treatment aims were to align the anterior upper incisors and correct the crossover of the central incisors before her wedding day. 

In order to achieve the optimal results, several treatment pathways were discussed, including:

  • Comprehensive orthodontics with fixed braces
  • The Clearsmile Inman Aligner
  • The Clearsmile Aligner. 

The patient opted for the Clearsmile Inman Aligner removable appliance with a fan screw, followed by Clearsmile Aligners. 

At this stage, it was decided the overbite would have to be accepted, as the posterior bite would need to be opened towards the end of the treatment so a fixed retainer could be bonded. 

The patient was also informed that the overjet increase after treatment would need to be accepted. This was due to the limitations of the Clearsmile Inman Aligner. Also, the anterior teeth could possibly end up being out of contact after the movement of the teeth. 

She was happy with the projected outcome. As soon as case suitability was confirmed by the IAS Academy’s Spacewize+ digital crowding calculator (the difference between available and required space was 4.1mm), impressions were taken and sent to the laboratory. 

Typically, the recommendation is 3mm. However, as she was just over, the case was given the all clear by the trainers via the online forum with the recommendation to use a fan screw before the alignment began. 

  • Figure 8: Spacewize calculations

Treatment

As predicted, there was a pause in treatment as the patient took some time out to get married. 

Between this break and the fact that the patient could not always attend appointments at the necessary times due to work commitments (the patient is a teacher). The process took significantly longer than usual (Table 2). 

Table 2: Treatment timeframe

Self-appraisal 

  • Figure 17: Anterior view post-treatment

This was a very challenging case, especially as the ideal outcome was compromised by large time gaps between appointments. 

In order to achieve optimal results, I would have liked to have seen the patient more often and have more control over the case. 

The placement of anchors was not very effective at first. I learned how small corrections can make a big difference over the course of treatment.

It was the first time I used the Clearsmile Aligner stent, which was a huge learning curve for me. 

Overall, however, the patient and I were happy with the outcome. 

She is far more confident and enjoys showing off her smile.   


This article first appeared in Clinical Dentistry magazine. To read more articles like this sign up to Clinical Dentistry magazine here.

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