Case Study: Stephanie

This article contains a case report of a “typical” Smilefast patient from start to finish, demonstrating the ease of the system and the “typical” end-result that can be expected for whose patients who are eligible for treatment utilising the Smilefast system.

Stefanie is a 24-year-old female who presented in July 2013 with a chief complaint of “I don’t like my crooked upper and lower teeth and my eye teeth are sticking out too far”. Her medical history revealed that she had Coeliac Disease. She also stated “I’ve seen three other specialist orthodontists who have all said that I need jaw surgery but I am really only concerned about the crowding of my upper teeth”.

Evaluation of Stefanie’s facial appearances reveals a mesofacial to dolicofacial pattern with a slightly obtuse nasolabial angle and convex profile with a slightly retrognathic mandible. She has a normal lower facial height with both her upper and lower lips retrusive in relationship to her nose and chin (Figures 1a to 1c).

Her orthodontic evaluation revealed she had a bi-lateral Class II buccal relationship with a 50% Class II occlusion on her right hand side and 100% Class II molar and canine relationship on her left hand side. Her upper and lower incisors are significantly retrusive, giving rise to her 5mm overbite and 4mm overjet. She has significant rotations in her upper anterior segment with her 13 and 23 displaced labial to the arch. She had approximately 7mm of maxillary arch length deficiency with 4mm of lower anterior crowding. She had no signs or symptoms of TMJ dysfunction and no evidence of any bruxism (Figures 2a to 2g).

Evaluation of her OPG revealed that her 18, 28 are present with her 38 and 48 vertically impacted (See Figure 3). Her lateral cephalometric radiograph using our Smilefast Cephalometric Analysis indicated a slightly dolicofacial growth pattern, with a normal facial height, retrusive lips in relationship to her E line. Her upper and lower incisors are retrusive and she had a Class II skeletal relationship with a retrusive mandible (Figures 4a-4b).

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The following treatment options were discussed:

Ideal approach
The placement of upper and lower fixed orthodontic appliances for approximately 15 months in order to improve her upper and lower dental alignment and remove the existing dental compensations by advancing her upper incisors to a more normal position over the maxillary basal bone and then perform a surgical mandibular advancement procedure.

This would provide her with an ideal Class I skeletal relationship and optimum overbite/overjet and improve the position of her retrognathic mandible/chin. The 18, 28, 38 and 48 would need to be removed within six months of her orthodontic treatment commencing. Following her surgical mandibular advancement procedure, six months of post-surgical orthodontic detailing with the use of intermaxillary elastics would be required to perfect her buccal occlusion.

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Option 2
To place upper and lower fixed appliances in conjunction with the removal of her 14 and 24 in order to allow us not only to resolve her upper anterior crowding, but also to allow retraction of her upper incisors and provide space to retract her labially positioned canines. This option would provide her with an ideal Class I canine relationship bi-laterally (leaving her with a Class II molar relationship on both sides) and optimum overbite/overjet. It was explained to Stefanie that there may be some retraction of her upper lip as a result of this but would have a minimal change compared to her existing upper lip position.

Option 3
A third option was presented to Stefanie involving the use of the Smilefast braces system on her upper and lower arches for approximately nine months purely to improve her anterior dental alignment and resolve her crowding situation. Due to her existing Class II buccal relationship, she would be left with approximately a 7mm overjet in her finished result. It was also explained that minimal IPR would be required in order to help provide sufficient space to align her crowded anterior teeth, and by performing differential IPR (with more IPR in the upper arch than the lower arch), we could also help to retract her upper incisors a little further and reduce the overjet to approximately 5mm.

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Option 4
The fourth option we offered Stefanie was Invisalign treatment on her upper and lower arches for approximately 24 months and once again, our aim would be purely to improve her dental alignment. I advised Stefanie that minimal correction of her Class II buccal relationship would be achieved with Invisalign therapy and she would be left with a considerable overjet of approximately 7mm. I also explained to Stefanie that with this Invisalign approach, attachments would be required on her teeth and IPR would be required. Also, we could utilise Class II intermaxillary elastics in an attempt to help reduce her overjet, but it was unlikely to have any significant effect. After thoroughly reviewing the different treatment options with Stefanie, she decided to proceed with Option 3, being the Smilefast approach, as she only wanted an improvement in her dental alignment and was happy to be left with a residual overjet at the end of treatment provided the teeth weren’t too proclined.

Appointment 1
In June 2013, we performed an ITERO scan and then proceeded with our digital orthodontic setup with digital bracket placement to obtain the best bracket positioning in the most efficient manner. We utilised this digital setup to show Stefanie the anticipated orthodontic result and to ensure that she would be happy with the overjet that was anticipated in our final outcome (Figures 5a to 5g).

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Appointment 2
In July 2013, we placed aesthetic orthodontic brackets on her upper and lowerarches from 16-26 and 36-46 utilising an indirect bonding technique through our digital orthodontic setup. At this appointment, 014 upper and lower aesthetic orthodontic archwires were placed and bite turbos were bonded on the palatal aspect of her 12 and 22. This was done in order to allow us to level her Curve of Spee and reduce her deep bite relationship in the most effective manner, as well as to ensure clearance of the lower anterior brackets with her upper incisors. IPR was performed on her upper and lower anterior teeth and we utilised PPR (preventative proximal reduction) on the mesial aspect of her 21, the distal aspect of her 13 and 23, the distal aspect of her 32, 41, and the mesial aspect of her 43 (Figures 6a-6e).

Appointment 3
In September, we placed an upper 016 NiTi and retied her lower 014 NiTi. Minimal IPR was performed on the upper and lower anterior segment (Figures 7a to 7e).

Appointment 4
In October 2013, we retied the existing upper 016 NiTi and existing lower 014 NiTi and performed minimal IPR on the upper and lower 3-3 segment.

Appointment 5
In November 2013, we placed an upper 018 NiTi and we tied the upper 3-3 with ligature ties and placed a lower 016 NiTi with ligature ties on the 33 and 41 to correct the rotations of these teeth
(Figures 8a to 8e).

Appointment 6
In January 2014, we retied both the upper and lower arches with minimal interproximal reduction (IPR) distal to the 32 and 41 and placed powerchain from 35 to 32 to aid derotation of the mesio-lingually rotated 32 (Figures 9a to 9e).

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Appointment 7
In February 2014, we placed a lower 018 Nitinol wire and rebounded the 41 and ligature tied the lower anterior segment. We also placed an upper 2020 NiTi wire in order to improve the labial/lingual position, torque of the upper incisors.

Appointment 8
In March, we assessed Stefanie and we had performed her alignment to her satisfaction and referred her to a Periodontist for crown lengthening of the upper incisors to improve her anterior aesthetics. At this appointment, we obtained impressions for a lower bonded lingual retainer.

Appointment 9
In April 2014, we removed her upper and lower orthodontic appliances and placed a lower bonded lingual retainer and provided her with a removable upper Essix retainer. We have suggested she wear this removable upper Essix retainer fulltime for 9-12 months, then night time for a further 12 months and following this, every 2nd night to ensure stability of our final result (Figures 10a- 10h).

Following nine months of aesthetic orthodontic treatment, we have provided Stephanie with her orthodontic objective by improving her dental alignment and her dental appearance in a very short period of time utilising our Smilefast approach. The key to our success was our digital treatment setup and digital bracket positioning. This meant we were able to locate these brackets in the correct position via an indirect bonding setup to ensure the most efficient tooth movement.

In addition, Stefanie was very comfortable with undertaking this recommended course of treatment because she knew the final outcome of her treatment prior to commencing therapy. This was achieved through the Smilefast viewer, which showed the initial 3D malocclusion and the anticipated final result in the 3D world (Figures 11a to 11b shows the comparison photos from her initial presentation and her final orthodontic outcome).

A very successful result was achieved through these mechanics and through many of the tips and tricks used in the Smilefast approach to ensure efficient tooth movement. In normal conventional orthodontic cases, the most time-consuming tooth movements are correcting rotations and reducing deep overbites.

Through Smilefast, we teach numerous tricks to improve the efficiency of those movements which can normally take a great deal of time if using purely conventional orthodontic treatment approaches of allowing the wires “just to do their work”. This outcome can be achieved by ANY dentist utilising the Smilefast technique and can be learnt in two days!

In addition, Smilefast is a very profitable procedure for the dentist. Table 1 outlines the visits, the doctor time per visit, the hygienist/therapist time per visit and total chairside time. Table 2 shows the total fee, the laboratory and materials fee, the gross hourly rate and the net hourly rate after laboratory and materials cost.

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