Dr. Muhammed Kathrada

A 33 yr old female patient presented at the practice wanting veneers for 6 upper teeth. She was also aware that she grinds her teeth at night.

Clinically she presented with a Class 2, Div 2 Malocclusion complicated by a deep overbite and asymmetrical gingival contour and after discussing with her all the treatment options and the risks of veneers fracturing due to bruxism and the invasive preparations that would be required on her canines, she selected the Six Month Smiles treatment option.

Her Chief Complaint was that she hated her “fangy” smile especially the left side.

Dr. Kathrada’s patient’s “fangy” smile before treatment.

Treatment Plan
We asked the lab to set the upper incisor brackets to idealize the incisal levels. This would effectively intrude the upper incisors, opening the deep bite. At braces on, we placed second molar bite guards and long tied the upper canines through first molars for added anchorage until the arch wire had a chance to level the upper arch enough that the lower brackets were clear of contact. The patient was then offered an opportunity to open her bite further by placing anterior bite guards and posterior box elastics which she declined. It was also possible to control upper incisor proclination and mitigate the increase in overjet by adjusting the upper IPR.

The patient during Six Month Smiles Treatment.

Treatment took 5.5 months to complete and the patient was absolutely thrilled with the result so much so that she mentioned it in her blog.

Challenges During Treatment
The biggest challenge faced during treatment was severe bruising in the right buccal mucosa at the level of the lower right second bicuspid.

Due to the space between lower right second bicuspid and the lower right second molar, the arch wire was digging into the patient’s mucosa causing pain and ulceration.

This was overcome by cutting the archwire distal to the LR second bicuspid and placing flowable composite on the cut end of the wire to prevent any bruising.

Another option would have been to place a tube over the arch wire on the affected side.

Dr. Kathrada’s patient after Six Month Smiles.

I just want to thank, our great Six Month Smiles Instructors and Mentors for being able to achieve this fantastic result. Also, a special “thank you” to Noel Ananthan for his generous and at times almost instant advice on cases. This is easy.

This is SS, a case that I previewed on the Six Month Smiles Online Forum a few weeks ago. Her treatment is a perfect showcase of the power of Six Month Smiles in treating seemingly complex challenges with familiar techniques when you have an understanding of how they can be applied.

SS is 29 years old and presented with a Chief Complaint of wanting to address the spacing between her teeth. She had no specific concerns regarding the overjet or deep bite and had previously had a comprehensive ortho consult in which she was advised that she would require orthognathic surgery in conjunction with full fixed orthodontic treatment.

My treatment plan simply involved creating the interarch clearance needed to retract the upper anteriors and, as intimidating as it initially appears, the actual treatment was a very routine process. At braces on, I placed biteguards on the upper canines, full upper arch elastic thread, and powerchain from upper canine to canine and lower canines through first molars. As many of you know from my Online Forum posts, my preferred protocol for dealing with spaced cases is to retract the canines first and then long tie the canines through first molars, for anchorage and stability. Then, I use canine to canine powerchain for more efficient anterior space closure and retraction. This also allows time to generally align the teeth and, if full arch elastic thread is used under the arch wire, anterior retraction will be started as well.

We saw SS on a 2 week adjustment schedule, changing the powerchain each time and the elastic thread every 4 weeks in order to maintain elastic pull. This was important because powerchain, elastic thread, and even donuts lose their elasticity and effectiveness with time, especially in the harsh oral environment. The only real challenge here was the amount of bite opening needed to allow full upper retraction and space closure. I actually added to the biteguards twice after braces on, once mid-treatment and again near the end of treatment to ensure adequate clearance for the upper fixed retainer. With each increase in the biteguards, we started SS on posterior box elastic use again to close the posterior bite. Toward the end of treatment, I repositioned the brackets on the upper centrals rotated 10 degrees (counterclockwise for the upper right and clockwise for the upper left) in order to correct the mesial tipping that often occurs with space closure.

We finished with electrosurgical gingival recontouring to enhance the proportions of the upper teeth and reduce slightly the gumminess of the smile. I waited until immediately following the recontouring to take the impression for the upper Essix retainer and had SS wait in the office as we fabricated it. This immediate delivery allowed the Essix to act as a healing stent for the gingival tissues and minimize any ‘creeping’ back. Total treatment time was 7 months.

SS was ecstatic with her new smile. She said that she couldn’t stop staring at it in the mirror- something that we all hear often from our patients and part of what makes Six Month Smiles so gratifying.

Patient’s Chief Complaint: Crowded upper and lower incisors

Total Treatment Time: 8 months

Marcie, a 21 year old female, came to our practice in October 2011 hoping to improve the appearance of her smile. Her chief complaint was her crowded upper and lower incisors.

A full examination was carried out and some photographs were taken to properly assess her dentition. Marcie hadn’t been to a dentist in a number of years and a certain degree of dental neglect was noted. She had a few carious teeth requiring fillings and she had extensive gingivitis due to her poor oral health.

The photos showed that Marcie had fairly minor crowding in the upper arch and more severe crowding in the lower arch. She also had a cross bite with her lower right canine and had a slight tendency towards a Class 3 jaw relationship. Due to the extent of lower arch crowding and the jaw position, I felt that a lower incisor extraction would be needed.

I discussed the option of referring Marcie for comprehensive orthodontic treatment, but she wasn’t keen on this due to the time it would likely take to complete the treatment. We made appointments for Marcie to get her teeth cleaned up by the Hygienist and to have the necessary restorations before we took impressions for Six Month Smiles braces. A payment schedule was also arranged.

Marcie’s braces-on appointment was at the beginning of December 2011. I extracted her lower right central incisor, as this had the greatest amount of gingival recession. When I sent in my case to Six Month Smiles, I asked them to rotate the brackets on lower left central counter-clockwise, and lower right lateral clockwise by 10 degrees to help bring the roots of these teeth closer as the space was closed. Minor IPR was carried out on the upper arch and .014 wires were fitted. Powerchain was attached from LL central to LR lateral.

I saw Marcie again in mid-January for her first adjustment. She was doing really well, no report of any problems. We replaced the arch wire to .016 on the upper and pc stretched from LL canine to LR canine.

We continued to following normal 6MS protocol in her remaining appointments. By August 2012, all the teeth were nicely aligned and spaces closed. We followed 6MS retention protocols, and placed a permanent retainer on both arches. Final photos were taken and removable retainers fitted a week later. Both Marcie and I were delighted with the result.

As can be seen in the after photos, Marcie has a much larger resting smile than before treatment, she is much more confident with her smile now that she has straight teeth. Also of note is how much her gingival health has improved, with her teeth being straighter it’s easier for Marcie to keep her teeth clean.

Observations and lessons learned from this case:

• Six Month Smiles brings patients into your practice with other treatment needs such as fillings or periodontal issues, which can increase practice income.

• Straight teeth make it easier to implement good oral hygiene practices.

• Patients love having straight teeth and show it with a much bigger smile.

• Good communication with the Six Month Smiles Case Processing Facility will allow them to place the brackets in the ideal position which enables smooth treatment.

• I could have completed this case at least two months earlier, but the patient disappeared for her college holidays for all of April and July.

Becky had a special event coming up and wanted straight teeth. She had previously turned down conventional orthodontics due to the 2.5 year treatment time. She also looked into aligners, but was told that her case would take a minimum of 12 months. Becky’s 21st birthday was coming up in 9 months and she wanted to smile big on her special occasion.

When the braces were removed, Becky was delighted. She exclaimed “Thank you so much, I love my teeth!”

Patient’s Chief Complaint: Upper four incisors don’t show when smiling or speaking

Total Treatment Time: 11 months

Our patient, Cliff, stopped by the practice after hearing our radio ad. His chief concern was that his upper four incisors didn’t show when he smiled or spoke.

We discussed the option of orthodontics followed by orthognathic surgery but Cliff was not open to both the time and the surgery proposed.

I explained to him that his major issue was a skeletal problem and an extraction on the lower incisor was needed to avoid an edge to edge bite which was more likely to relapse. My plan was to improve an anterior crossbite by retracting the lowers as much as possible and advance the uppers with the Lucid-Lok® wires. Later, I would add Gruin Locks onto the wire which would allow me to advance the final wire 2 to 3mm ahead of the incisors and further advance the uppper incisors and “trap” the mandible for increased stability of the final result.

We took impressions and records for Cliff and gave him 5% off for paying full in advance. After the case came back from the Six Month Smiles case processing facility, we extracted tooth #24 , and placed .014 wires on the uppers and .018 on the lowers. We placed bite guards on #18 and #31.

The next month I placed .016 wires to align #23 and used OCS over #29 to allow it into the arch. Treatment progressed through the wire sequence with no upper IPR. Lower stripping, discing, and the bur were used as required to retract. I also used a powerchain under the lower wire to aid lower space closure at 24. I finalized upper alignment by powerchaining #9 to #10 and #7 to #8 to spin the laterals into proper facial alignment.

At 10 months, I added Gruin Locks onto the upper wire 1.5mm ahead of the molar. This had the effect of advancing the archwire 3mm ahead of the anterior teeth and further expanded the arch. Gruin Locks are a one piece nut and bolt that threads onto the wire and is secured with an arch lock wrench.

The incisors advanced over the bite in 1 month and were long tied, the next month everything was aligned, spaces closed, and impressions were taken for retainers after removing brackets. Three weeks later, the patient had bleached teeth and retainers were fitted. His reaction was “Amazing! I have straight teeth at last!”

As you can see, this was not your typical Six Month Smiles case. If there is one thing I would encourage you to take away from this article, it is the importance of thinking outside the box. Overall, this was a great challenging case, and I was happy to help Cliff, who was a great patient!

Patient Name: Betty
Treatment Time: 6 months
Chief Complaint: lateral incisors in cross-bite

Demand from the public for an improved smile is on the increase. More patients are aware that having a great smile is no longer restricted to celebrities. However, they are also increasingly aware that the preparation of teeth for crowns and veneers can have a significant biological and financial cost. Many also have objections to conventional orthodontic treatment, due to the visibility of braces and lengthy treatment times.

Hot off completing my Six Month Smiles course, I picked up my phone on Monday morning and started calling patients that I had previously identified as wanting straight teeth, but did not want to be treated with traditional ortho or clear aligners. One patient was a 29 year-old local nurse named Betty. She had a class I relationship, an admitted self-conscious smile, and I knew correcting her chief complaint would give her a dramatic and fantastic result. She already had the desire, she just needed the opportunity. I offered Betty a $500 discount if she would be one of my first five to start Six Month Smiles treatment. Her response was a resounding yes.

Betty’s chief complaint was centered on her lateral incisors in cross-bite, which made her canines appear more pronounced, and in her opinion made “it look like I am missing teeth.” Following my examination and completed records , I felt like we could correct the anterior cross-bite by allowing the Lucid-Lok® archwire to round out both arches in addition to some mild IPR in the maxillary arch as needed. I also identified a posterior cross-bite with teeth #4 and #29 that we would attempt to correct.

I had confidence in my treatment plan, but I distinctly remember utilizing both the Six Month Smiles Online Forum for advice from other Six Month Smiles Providers, as well as the Six Month Smiles Jump-Start Webinar. Both sources gave me confidence that I was moving in the right direction, as well as some tips to make treatment more efficient. I was advised to pay close attention to avoid creating an open bite in the anterior by doing appropriate and timely IPR coupled with anterior vertical or box elastics if necessary.

As I learned in the course, the day the braces went on, I immediately put my priority on creating space for the laterals. I did some light IPR to free up the proximal contacts, but felt like correcting rotations of adjacent teeth would create enough room in the arch. I utilized the open coil spring to rotate the canines and centrals away from the space, which simultaneously exaggerated the force applied by the .014 wire to round the arch. I then utilized the elastic ligature to tie the bracket to the wire to initiate a light buccal movement as that space was created. I placed bite guards on the upper 2nd molars, and followed otherwise conventional Six Month Smiles protocol.

What I saw in one month was impressive, and what little doubt I had left was blown away. The patient was ecstatic too. I removed the coils and placed power chains to facilitate the final rotation of the centrals and the canines (5-6, 8-9, 11-12). At 8 weeks, the wire was tied in to engage the slots on the brackets of teeth #7 and 10. One week later at nine weeks of treatment, the laterals had taken position bucco-lingually in the arch, the posterior cross-bite was corrected, and biteguards were removed. The remainder of treatment utilized some anterior vertical elastics to facilitate final coronal position of the laterals, the P.O.P. pliers to rotate the distal aspect of the laterals into the patients desire, and powerchains to close all contacts throughout both arches. A fixed bonded lingual retainer was placed on the lower prior to debonding the brackets and a clear essix-style retainer was fabricated for both arches and delivered that day. We removed the brackets at 23 weeks, just shy of six months.

As a nurse, Betty is pretty good at showing restraint and not revealing her emotions, so I was not surprised that there was no crying when treatment was completed, but a polite “Wow!” and “Thank you”. Her actions spoke a little louder than her words did. It was revealed to me that night by a coworker that she went straight to work, on one of her few days off, to show off her new smile. She had every right to do so. She was proud of her new smile and my staff and I were excited about the results we achieved in less than six months.

With the help of proper training and planning, my first case was a great success. I look forward to continuing to give my patients straight teeth in a short amount of time. Six Month Smiles provides a minimally invasive and cosmetic solution for my adult patients with misaligned, crowded, or spaced teeth. I am so glad that I committed to take the course and can proudly offer Six Month Smiles to my patients.

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]]> http://blog.6monthsmiles.com/my-first-six-month-smiles-case/feed/ 0 http://blog.6monthsmiles.com/a-straighter-smile-without-ipr/ http://blog.6monthsmiles.com/a-straighter-smile-without-ipr/#comments Thu, 08 Nov 2012 14:37:30 +0000 6monthsmiles http://blog.6monthsmiles.com/?p=358 A Case Study by Dr. Noel Ananthan

Patient’s Chief Complaint: A straighter smile without IPR

Elvia is a 28 year old whose CC was that she wanted a straighter smile. The key elements in the initial assessment were the impacted UL canine and the UL lateral incisor in cross-bite. Because we had determined through an oral surgery consultation that the canine was favorably situated for exposure and alignment, the treatment plan appeared to be a textbook 6MS approach: space creation and alignment through IPR and rounding with the addition of bringing the canine down.

However during the consultation/work-up process, Elvia decided that she wanted absolutely no IPR performed as a part of her treatment. Despite my best efforts to educate her (putting on my best ‘co-discovery’ face) that it was safe and extremely conservative, Elvia remained adamant that we carry out treatment without IPR. Even after I told her that the only alternative was an extraction in each arch, she still did not want IPR to be performed.

I chose a staged approach to deal with this case. The first stage was overall alignment and space closure, which took about 3 months. This consisted of:

• extracting the UL first bicuspid and LR central incisor at the braces on appointment;
• placement of second molar biteguards to open the bite to allow the UL lateral incisor to clear the cross-bite;
• lower arch powerchain to close the extraction space; and
• simply ensuring proper wire engagement to correct rotations and allow the brackets and wires to align the teeth.

This first stage allowed me to stabilize the arches, and most importantly the teeth adjacent to the impacted canine, with long ties for anchorage before moving on to stage two which was exposing and engaging the UL canine. Stage 2 involved engaging the arch wire, powerchain and interarch elastics to guide and help movement. Anchorage is a key fundamental concept in orthodontics and learning to both respect and use it makes treatment much more efficient.

Because of the pre-treatment rotations in Elvia’s right anterior area, a further potential problem that we faced (and had warned the patient of) was the shifting of the upper midline as alignment progressed. Unfortunately, there was no easy solution for this so we did see the midline shift slightly to the left, although Elvia was perfectly happy with the end result. I addressed a small black triangle between the LL central and LR lateral incisors which remained from the space closure (and also a potential problem with ‘crossed’ upper incisors) through simple bonding. Elvia was ecstatic with her new smile. She now feels that it better represents how not only she sees herself, but also how she would like others to see her.

I hope that this case has illustrated that 6MS uses sound orthodontic principles to achieve great results, even with complications such as impacted teeth. In hindsight, if I could change anything with this case, I would have taken greater care to manage the presentation of information to Elvia to have made IPR acceptable to her. But that is my dentists’ bias coming through. We always have to respect that there is a real person attached to the teeth that we treat which makes the Chief Complaint nature of 6MS an even greater service and value to our patients.

]]> http://blog.6monthsmiles.com/a-straighter-smile-without-ipr/feed/ 0 http://blog.6monthsmiles.com/straighten-teeth/ http://blog.6monthsmiles.com/straighten-teeth/#comments Mon, 08 Oct 2012 15:32:25 +0000 6monthsmiles http://blog.6monthsmiles.com/?p=339 A Case Study by Dr. Jennifer Huston, Ireland

This 35 year old secondary school teacher always disliked her smile.  She saw many of her students wearing braces, however she felt that at this stage in her life, she did not want to go through years of “metal train tracks” to straighten her teeth.

When she heard a local radio advertisement for Six Month Smiles, she called  for a consult. Her chief complaint was the crowding of her upper and lower front teeth, the pointy shape of her canines and the dark appearance of the upper right central and lateral incisors, above which she would regularily find a gumboil.

She was keen to proceed with Six Month Smiles treatment as the tooth coloured appearance of brackets and the aesthetically focused treatment plan appealed to her and her lifestyle.

Examination revealed a draining labial sinus relating to the UR1 (#8) and UR2 (#7).  These teeth were non vital and were treated endodontically. I used an internal bleaching technique to whiten the teeth.

The UL1 (#9) was considerably longer than the UR1 (#8) as it was positioned labial to the maxillary arch, out of  occlusion. You can see the presence of mammelons on this tooth in the pre-operative photograph.  This meant we had to adjust the incisal edge of the UL1 (#9) during treatment as the discrepancy in length between the incisors became apparent.

I started the treatment with the 0.014 Lucid Lok™ archwires and followed the 6MS protocol. The patient was diligent with her oral hygiene regime and the treatment proceeded uneventfully. Some recontouring of the canines and composite bonding were required for the UR1 (#8) and UR2 (#7).

I removed the braces after seven and a half months. A small black triangle remains between the upper central incisors.  As the contact point is under 5mm from the crest of the interproximal bone, I expect the papilla to regenerate in this area in six to twelve months.  I discussed this with the patient however it was not of concern to her!

With this case I took regular photographs during the treatment. This allowed me to examine the progress of the case in my own time after each appointment. I would recommend using a good quality camera, macro lens and ring flash to achieve consistency with your dental photography.

The patient is delighted with the results.  She is getting married in two weeks  and cannot wait to show off her new smile to her family, friends and future in-laws!

]]> http://blog.6monthsmiles.com/straighten-teeth/feed/ 0 http://blog.6monthsmiles.com/six-month-smiles-in-the-uk/ http://blog.6monthsmiles.com/six-month-smiles-in-the-uk/#comments Thu, 20 Sep 2012 18:18:10 +0000 6monthsmiles http://blog.6monthsmiles.com/?p=327 A Case Study by Dr. Andy Denny, UK

Carole is a delightful 68 year-old regular patient of our practice. She has had a lot of dentistry done in the past, most many years ago.

When asked at her annual Dental Health Review if her crowding bothered her she said “Yes, it always has, I’d love to have straighter teeth but it’s not really possible at my age is it?”

Obviously I corrected her misconceptions and asked more about her issues.

She didn’t like her gap and fallen over tooth on her upper right, the slight lower crowding but mainly the crossed over front teeth. Carole didn’t wish any major makeover or changing of her old restorations, “I’m not moving to Hollywood” she said.

I discussed her options and offered her comprehensive ortho, which she declined as she was going to New Zealand in eight months to see her family.

We decided to retract her upper right premolar and achieve some space to recreate a canine.

We looked at the differential wear that was present on her upper centrals and chose to align the gingival levels, which meant incisal bonding would be required and that her midline would be out by up to 3-4mm.

Records were taken and her PTK ordered. Once fitted a standard 6MS case protocol was followed initially, starting on a 0.014 wire.

No IPR was required as rounding out gave us plenty of space, in fact a little too much space and in her lower arch we needed to double up with power chain and elastic thread to close a stubborn midline space as well as power chain UR2-UL2 to keep the anterior block together whilst we modified her upper right canine space. At this point we bonded a composite tip on UR1 to improve aesthetics and check dimensions.

Buccal and palatal two-link power chain was used to evenly retract UR4 (utilizing palatal buttons).

It was decided to IPR distal of UR4 to give more space and that by providing a cantilever bridge UR4-UR3 we could modify the tooth anatomy to give an acceptable cosmetic result.

We debonded the case and provided Essix retainers whilst providing her bridge and final bonding. She didn’t mention her midline discrepancy, and even when I pointed it out she couldn’t see the issue.

Carole was delighted with her final result, “I love my straight teeth and no more gap. I really can’t believe how quickly it was all done, thank you so much.”

Key points for Six Month Smiles providers are:

• Talk to all your patients about Six Month Smiles. You never know who may say “yes!”
• Age is not a barrier to achieving a great result with Six Month Smiles.
• Provide patients with the result they want.
• Address their ‘Chief Complaint’. Don’t over complicate things.
• Discuss all possible outcomes and potential issues that may arise and ensure full consent is attained.

 

 

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]]> http://blog.6monthsmiles.com/six-month-smiles-in-the-uk/feed/ 0 http://blog.6monthsmiles.com/the-six-month-smiles-system/ http://blog.6monthsmiles.com/the-six-month-smiles-system/#comments Mon, 17 Sep 2012 15:58:03 +0000 6monthsmiles http://blog.6monthsmiles.com/?p=309 Dr. Ryan Swain, Founder and CEO of Six Month Smiles, Inc. recently had an article featured on www.dentinaltubules.com. The article titled “The Six Month Smiles System” is an overview of what the Six Month Smiles System is and how patients and dentists can benefit from using the system.

To read the full article please go to: http://www.dentinaltubules.com/ryanswain1

 

 

 

 

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