Digital Treatment Planning Improves Outcomes

Rafaela Vaccaro Zakula, DMD


Most of our adult patients need cosmetic improvements to their teeth at some point. When we discuss options available to them, many patients immediately ask for veneers; several of them know about this treatment modality and believe it is their only option. On the other hand, most dentists do not feel comfortable with some of the aggressive preparations that may be required to achieve the desired aesthetic results. This article showcases a tooth alignment system (Six Month Smiles) as a minimally invasive option for improving aesthetics. One of the great advantages of a tooth alignment protocol is that it provides a practical and conservative alternative to more invasive procedures (such as veneers and/or full-coverage crowns). It is also a great opportunity for patients who are not interested in 24-plus months of comprehensive orthodontic treatment.

Six Month Smiles is an excellent treatment option that allows general practitioners (GPs) to offer short-term and very straightforward orthodontic treatment for adult patients with misaligned teeth. This treatment is primarily focused on addressing the patient’s chief compliant that, in the majority of cases, is related to correcting the patient’s anterior malocclusion and smile. In contrast to an approach using comprehensive orthodontics, the Six Month Smiles treatment is not intended to address molar class changes, transverse development, overjet and midline correction, or root alignment. However, with experience, providers can partially address overjet, midline, and minor root alignment issues. In fact, in the first case presentation, progressive interproximal reduction (IPR) was used to improve the patient’s overjet. By utilizating patented clear brackets, and tooth-colored NiTi wires, the system allows for efficient tooth movement to achieve excellent cosmetic outcomes using a minimally invasive treatment protocol.

Case 1

In this first case, our patient was a 21-year-old woman who did not like her “crooked teeth” and wanted to improve her smile. She and her family had been patients of record for a long time, and we had a relationship that was built on trust. It was after we had started a Six Month Smiles treatment on her brother that she decided it was the best option for her too. Previously, she did not want to wear metal braces for 2 years or accept a premolar extraction to align her anterior teeth. We considered using a removable appliance, but realized that we would not have as much control to achieve the desired results as we had with brackets, and the patient would have to be committed to wearing them all the time.

The patient has a Class II canine and molar relationship, unilateral anterior open bite, and misaligned teeth in both arches. She also presented with a severe cant of her upper left central with the potential risk of creating a black triangle as a sequela of aligning the teeth (Figure 1).

After reviewing and discussing the treatment options and expectations, we agreed that the Six Month Smiles treatment protocol would be the best approach for her, as it would provide the most conservative way to get a beautiful smile while preserving healthy enamel. Successful treatment depends on good records which, in this case, included impressions, intraoral scans, radiographs, and a full diagnostic set of photographs. The collected information was sent to Six Month Smiles and prepared for digital analysis with CONFIDEX Digital Treatment Planning. CONFIDEX utilizes sophisticated dental CAD software that gives providers a 3-D visualization of the case from start to finish with customized treatment planning solutions. After reviewing the 3-D video simulation of the predicted tooth movement, the treatment plan was designed (by orthodontists on the Six Month Smiles team) and the brackets were accurately placed on 3-D printed models (Figure 2).

I received a month-by-month detailed treatment plan with predictable tooth movements recorded on the simulation video along with a complete Six Month Smiles patient tray kit. The kit included custom-made indirect trays (specially designed for this patient), wires, and additional items needed for the next 6 months of the treatment.

The Digital Treatment Plan
The standard Six Month Smiles prescription was followed: the brackets were placed centered on the buccal surface of each tooth in the upper arch and 1.0 mm below the central line in the lower arch. To help bring the upper left central upright, the bracket was rotated 15° clockwise according to the long axis of the tooth. The bracket was repositioned and centered to the surface of the tooth once the tooth was upright (Figure 3). In accordance to the treatment plan, at braces-on, we carried out IPR of the full upper arch using a diamond strip (0.13-mm thickness) and placed a Six Month Smiles powerchain from the upper first molar to canine on both sides to retract the canines. Given the patient’s Class II relationship, I wanted to take advantage of this to retract the upper canines to improve the overjet and canine relationship. Compared to comprehensive orthodontic treatment that uses mechanics on a rectangular stainless steel wire, Six Month Smiles created special tools and techniques that can be used on a NiTi round wire to achieve faster tooth alignment. The powerchain that was used from molar to canine for retraction would also serve to speed up the correction of mesial rotation of both canines and to help close the anterior open bite. In this way, the IPR was distributed along the full upper arch, instead of just on the anterior teeth. However, trying to reduce the overjet increased the treatment time by 3 more months. We then carried out a very light IPR in the lower arch to help with alignment and to get as much rounding out as possible to decrease the overjet.

Quickties (ligature wires) were used to fully engage the wire on the severely rotated teeth in both arches. Biteguards were placed on the upper second molars, just high enough to clear any contacts with lower brackets and prevent the patient from biting on them. During the treatment, they were reduced as the teeth aligned (Figure 4).

After the upper canines were retracted, a long wire tie was used to lace all the posterior teeth together and to start retracting the anterior teeth in the upper arch. IPR was carried out on only the anterior teeth to retract them. Additional IPR was carried out between the upper central incisors to prevent black triangles appearing in that area. The teeth started retracting on the 0.016-inch round wire using full-arch elastic thread from right first molar to left first molar in combination with the powerchain from canine to canine. The powerchain was changed every 2 weeks for more efficient retraction, since it loses its elasticity and strength even after the first week.

The patient presented with an anterior open bite at the beginning of the treatment and was advised to wear triangular elastics from upper left canine to lower left canine and first premolar. Retraction of the upper anterior teeth also helped to control the anterior bite. When the desired retraction and tooth position was accomplished, upper and lower fixed retainers were bonded from canine to canine, and removable retainers for both arches were given for the following 6 months. The patient found full treatment very comfortable and easy and was extremely happy with a new smile that greatly improved her level of personal confidence (Figures 5 and 6). By adding CONFIDEX to my Six Month Smiles treatment, it made this procedure easier and more predictable. This treatment protocol, supported with modern digital technology, permits GPs to achieve amazing cosmetic results in a conservative and minimally invasive manner.

Case 2
This case presentation will serve as another example of what is possible with Six Month Smiles. Compared to the first case, this patient presented new challenges as her lower arch had crowding in the anterior and posterior regions. This presentation would lead many doctors to consider an extraction.

The patient came to my office for a consultation with the chief complaint of upper and lower crowding and a specific request for nonextraction treatment after refusing comprehensive orthodontic treatment that had been planned to include bicuspid extractions.

After reviewing the photographs, models, and radiographs, as well as interviewing the patient about her expectations, we came to the conclusion that Six Month Smiles was the best option for her. The patient was nearly a Class I, with crowding in the upper and lower arches. She wanted to keep her lower bicuspids and to have them aligned within the arch. A digital treatment plan was created, and the appliance was specially designed for this patient.

Aside from the standard bracket positioning and protocol, open coil spring and special brackets designed for this type of situation (clearlets) were used to align the lower bicuspids in the arch. Lingual buttons were used to help correct the mesial rotation of the lower second premolar (Figure 7). Minimal amounts of IPR were carried out and, having the CONFIDEX treatment plan integrated into the Six Month Smiles treatment, we had the information required to do the exact amount of IPR needed to align the teeth in the arch. Being able to visualize the case helped me with planning and, when we showed the simulation to the patient, also helped to convince her that this was the correct treatment, thus motivating her to get it started.

Figures 8 and 9 show the treatment as it had progressed in the upper and lower arch, respectively. Following the standard Six Month Smiles and CONFIDEX protocol while using light consistent forces, the teeth were leveled and aligned, and the lower second bicuspids were preserved and fully aligned in the arch. The patient was absolutely delighted with the results and happy that we were able to address her complaints.

Since patients talk about their smiles, we have found that our patients have become our greatest referral source. Our practice has grown to a level where I am now exclusively focusing on Six Month Smiles and comprehensive orthodontics for more complicated cases.

My experience with this technology began after attending a Six Month Smiles course in Dublin, Ireland, in 2013. I immediately recognized the quality and advantages that this treatment can offer and even chose to have this minimally invasive protocol used in treatment done on me, as a patient. I became passionate about wanting to share this opportunity of giving a beautiful smile with others, thus becoming the first Six Month Smiles provider in Croatia, where I now treat patients from many countries.

Dr. Zakula graduated from the University of Rijeka in Croatia in 2010. She maintains a private practice in Pozega, Croatia. She also has a special interest in orthodontics and cosmetic dentistry, and she serves as a mentor dentist for Six Month Smiles. She can be reached via email at

Disclosure: Dr. Zakula reports no disclosures.

Related Articles

A Simple and Effective Way for General Dentists to Cosmetically Align Teeth

Living in the Material World

Treatment Planning for Implant Dentistry