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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 those patients

who are eligible for treatment utilising the Smilefast system.

For more information on Smilefast, see Smilefast - The predictable short-term cosmetic orthodontic treatment, Australasian Dental Prac-tice, Vol. 26 No 1, January/February 2015.

Case report for Stefanie

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 pro-file 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 signif-icantly retrusive, giving rise to her 5mm overbite and 4mm overjet. She has significant rotations in her upper anterior segment with her 13 and 23 dis-placed 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 radio-graph 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).

The following treatment options were discussed:

Smilefast - predictable short-term cosmetic orthodontics: A case report

By Geoffrey Hall, BDSc (Melb), Cert.Orth (Penn)

clinical | EXCELLENCE

“In conventional orthodontic

cases, the most time-consuming

tooth movements are correcting rotations and

deep overbites. Smilefast teaches numerous tricks

to improve the efficiency

of those movements...”

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Figures 1a to 1c. Extra-oral photographs.

Figures 2a to 2g. Intra-oral photographs.

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Ideal approach

The placement of upper and lower fixed orthodontic appliances for approxi-

mately 15 months in order to improve her upper and lower dental alignment and remove the existing dental compensa-tions 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 over-bite/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 man-dibular 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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Figure 4a. Lateral cephalometric radiograph. Figure 4b. Smilefast cephalometric analysis.

Figure 3. Panoramic radiograph.

Option 2

To place upper and lower fixed appli-ances 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-lat-erally (leaving her with a Class II molar relationship on both sides) and optimum overbite/overjet. It was explained to Ste-fanie 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 situ-ation. Due to her existing Class II buccal relationship, she would be left with

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approximately a 7mm overjet in her fin-ished 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 per-forming differential IPR (with more IPR in the upper arch than the lower arch), we could also help to retract her upper inci-sors a little further and reduce the overjet to approximately 5mm.

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 align-ment. I advised Stefanie that minimal correction of her Class II buccal relation-ship would be achieved with Invisalign therapy and she would be left with a con-siderable 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 dif-ferent 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 dig-

ital orthodontic setup with digital bracket placement to obtain the best bracket posi-tioning 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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Figures 5d to 5g. Digital setup with bracket placement in original maloccuded position.

Figures 5a to 5c. Digital setup with bracket placement in final position.

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Appointment 2

In July 2013, we placed aesthetic ortho-dontic brackets on her upper and lower

arches from 16-26 and 36-46 utilising an indirect bonding technique through our digital orthodontic setup. At this appoint-ment, 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. Min-

imal 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 min-

imal interproximal reduction (IPR)distal to the 32 and 41 and placed powerchain from 35 to 32 to aid derota-tion of the mesio-lingually rotated 32 (Figures 9a to 9e).

Figures 6a to 6e. Brackets bonded, archwires ligated and bite turbos in place.

Figures 7a to 7e. September 2013 appointment.

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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 posi-tion, torque of the upper incisors.

Appointment 8

In March, we assessed Stefanie and we had performed her alignment to her sat-

isfaction and referred her to a Periodontist for crown lengthening of the upper inci-sors to improve her anterior aesthetics. At this appointment, we obtained impres-sions 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 pro-vided 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 fur-ther 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 objec-tive 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 comfort-able 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).

Figures 8a to 8e. November 2013 appointment.

Figures 9a to 9e. January 2014 appointment.

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Table 2. Treatment profitability

Total fee $6,500.00

Laboratory fee (includes braces, wires, indirect $1,299.00 bonding, digital setup, miscellaneous supplies)

Lab fee for retainers $140.00

Total lab and materials fee $1,439.00

Total gross fee $6,500.00

Total chairside - 6 hours

Gross per hour $1,083.00

Fee (after lab/materials) $5,061.00

Total Chairside time - 6 hours

Nett per Hour $843.50

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-con-suming 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 profit-able 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 nett hourly rate after laboratory and materials cost.

Table 1. Chairside time (mins) per visit by practitioner

Appointment Hygienist Dr Time Total Time

1. PVS impressions/Photos 25 5 30

2. Bonding appointment 80 10 90

3. Archwire change 25 5 30

4. Retie and IPR 25 5 30

5. Archwire change 25 5 30

6. Retie, IPR, PC 25 5 30

7. Archwire change 25 5 30

8. Assess for deband 25 5 30

9. Deband appointment 55 5 60

Total 310 50 360

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Figures 10a to 10h. Final deband images.

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Figures 11a (Above) to 11b (Below). Comparison of initial presentation and final orthodontic outcome.

About the author

Dr Geoffrey Hall completed his dental training at the University of Melbourne in 1983 followed by postgraduate orthodontic training at the University of Pennsylvania in 1990. Since returning to Australia, he has practiced as a Specialist Orthodontist in Caulfield, Victoria. Dr Hall is the founder of many Study Clubs including the Australasian Orthodontic Study Club, DentalEd, Victorian IDSC, Melbourne Seattle Study Club, New Horizons Study Group, Southern Cross Study Club and Australasian Orthodontic Lingual Society. He was the first Orthodontist outside of the USA to use Invisalign and is a clinical consultant for several orthodontic companies and dental laboratories. He holds several patents and has a special interest in digital technology. He is a sought after lecturer, both nationally and Internationally and regularly lectures to orthodontic and dental professionals in the Asia Pacific region and USA.