It is great to help a person in need but I have to disagree with Ash’s choice of cosmetic case.

The patient has mild to moderate crowding with anterior upper discolouration.
She was not keen on braces, but was a discreet system like Invisalign ever offered?
The crowding is a contraindication to minimally invasive veneers and the minimal overbite could lead to veneer chipping or decementation.
The upper lateral incisors look nearly edge to edge which would lead to veneer failure.
The patient is having free cosmetic dentistry as a prize, but at the detriment to her enamel.

It would take about 12 months and in that time the teeth would be noticeably whiter and straight.

My option would be to have done Invisalign and deep night bleaching and I would offer her the treatment free to prove my point.

Dr R Kumar BDSLDSRCS

In 2004 I had maintained a private practice in the West End for over 9 years and I was doing a lot of cosmetic smile makeovers.

So I naturally wanted to progress and learn more about the art of smile makeovers from the US.

I knew of an eminent clinician in New York who ran a veneer course. So I Googled him, but I came across some very bad reviews. On one website I found an image of one of his failed veneers:

I naturally did not want to fall into the trap of promising excellent cosmetics on shaky ground such as the prepped tooth above.

Now we all know veneers can be very thin or even non prep but how many patients do you see that have straight teeth and want veneers?

In 2004 at an orthodontist’s open evening I stumbled upon Invisalign. I went on the course and certified as an Invisalign provider.

On the Monday morning after the first patient that I saw had come in with multiple spaces and protruding teeth. He had come asking for veneers, but then I thought if I do veneers, he will end up looking like Jim Carrey in the Mask.

I convinced him that he would look silly and he needed orthodontics. I showed him how Invisalign works; he was my first case.

After 9 years and 760 cases of Invisalign I have never looked back. In fact I have done only 3 smile makeovers in that time; 2 were replacing old veneers .

Invisalign

Invisalign as many of you know is a clear aligner system. The parent company is Align Technology and is based in California. They have scanning facilities in Costa Rica, research facilities in USA, UK, Israel, Holland etc. At a recent conference I was informed that Align spent $45,000,000 last year in R&D.

Invisalign is a series of aligners that are planned with computer aided design and scanning (CAD), and created with 3D printing (CAM). Each aligner exerts a small force and the teeth usually move according to plan.

Impressions are taken as 2-stage silicone impressions or you can take digital impressions with the new Itero scanner.

I would like to describe an interesting case of moderate to severe crowding in a class 1.

Invisalign case

Dr KN had just recently qualified as a medical doctor and came in from a recommendation.

He was very quiet, did not smile and wanted his teeth straightened. He did not want to have fixed braces.

Start images

My findings were:

Class1: collapsed posterior segments: moderate upper, severe lower crowding: centrelines were not coincidental: mild class2 canine RHS.

I agreed that we could try Invisalign as the lower arch was very crowded and that the scans would show if lower extractions were necessary.

The planning was done by me and I wanted to avoid extracting upper premolars because the patient was very conscious of his smile and he did not want prolonged treatment if possible.

Treatment schedule:

The aligners came back as 39 uppers and 29 lowers. The upper arch was expanded and interproximal reduction was carried out at the 2/3rd stages in order to help shift the upper centre line and to

reduce interproximal triangular spaces. Lower first premolars were extracted at the beginning.

I saw the patient every 6-8 weeks for reviews. I checked the aligner fit, attachment activation, contacts and collisions.

Over time his crowding was alleviated and he started to chat and smile more often.

After a period of 18 months we took refinement impressions for minor corrections and closing the extraction spaces. There were 7 refinement aligners in total.

Refinement images

Final images

Things that I did not do

I did not consider class 1 canine positions important because that would have involved removing 2 upper premolars or unnecessary stripping. The lower incisors were not in the midline as that would have involved either LHS molar distalisation and longer treatment, or aggressive stripping LHS and shifting all the lower RHS teeth to the LHS.

Patient was not concerned and was happy with the treatment time.

Conclusion

Orthodontics for a general dentist is always a steep learning curve. It takes about 1 year to see results and you do not really know whether they will be as expected.

Invisalign is a system that is easy to use for the patient, but difficult for the dentist to implement. If you have a non-compliant patient then the results will be less than satisfactory.

But a well planned and well explained treatment using Invisalign with a compliant patient is a new way to do orthodontic treatment.

Orthodontics is the art of moving teeth to a place of patient satisfaction. We do not cut, trim, mask or cover teeth to get this desired position. We have to use our skills as dentists to propose a series of tooth movements and the teeth must follow.
Tooth movement does not always go to plan and that is why it is imperative that the patient attends regularly for review of treatment.
About 18 months ago a couple turned up and the groom wanted his teeth straightened. The problem was that he was leaving in the next weeks for India and would not be back for 12-16 months.
He had:
upper centre line was off to the right
upper and lower crowding
upper lateral incisor was in a crossbite and not visible on smiling
So I examined the patient and assessed his condition and with some trepidation, agreed to provide Invisalign.
Invisalign is a series of clear aligners that are changed in a series every 2 weeks creating orthodontic movements.
Invisalign also needs some interproximal spaces and composite attachments
that are usually done after the scanning and planning process.
But the patient was leaving soon and could not come back when the aligners were here.
So I had to give him attachments and make spaces.
Attachments are usually put on after the aligners arrive as the box contains a template for the attachment process.
So at day 1 I improvised.
I had a patient case unused with an attachment template and used it to place attachments where I deemed them necessary.
I also carried out some interproximal spacing where I thought necessary.
I then took the impressions.
It is very unusual to start a case with attachments already on, but Invisalign did not notice.
I viewed the scans and agreed with the movements.
I stipulated that there should be no more spacing/dentist intervention until the end.
The braces arrived and the patient paid for them to be delivered to India.
BUT customs got hold of them and wanted money.
They were held up in customs for 2 months before the patient got hold of them.
During the treatment he sent me some pictures of the aligners in the mouth.
18 months he came back and WOW
the teeth were exactly as the scan and I had predicted.
He had some cleaning to do and very little else. But to get his moneys worth he wanted a little more pushing out of the aligner…cheeky bugger.
Anyway enjoy the picture of Invisalign 18 months in 1 visit