Cosmetically Focused Adult Straight Teeth Certification Course

Part 3 - How Cfast works

Instructors:

Dr. Michael Miyasaki, DDS

Dr. Michael Miyasaki, DDS

Dr. Michael A. Miyasaki is a 1987 graduate of the University of the Southern California School of Dentistry, and has been involved in dental education for over 21 years, 12 of which he was involved in live-patient treatment programs internationally giving him a unique perspective on the global challenges of the dental professional.

Dr. Miyasaki reviews how to place the brackets and wires as well as what considerations need to be made prior to treatment.

All right, so let's talk a little bit about how CFAST actually works. There are again the two components, the wires and the brackets. And that's really what we need to understand and we need to be able to visualize how the wires and the brackets are going to then move the teeth. Remember these wires have memory. What they want to do is they want to go straight. So if we put any kind of bends or curves on those wires, what the wires are going to do is exert a force to go straight again. So they have memory. Our brackets are the way that we're going to transfer the force of the wire to the teeth. In this case, we're going to use wire brackets. We have what we called an archwire slot that the wire will run through. So why don't more dentists do orthodontist with brackets, why do we like to clear trace them so much? Well because we don't know what to do with the brackets. And so what we're going to do is we're going to talk about CFAST and how CFAST makes the bracket positioning very easy to do and figure out. Some of the terms again the bracket is the orthodontic attachment that we secure to the tooth so we can attach our archwire. The archwire is the orthodontic wire that actually exerts the force to guide the tooth movement. The ligature is what we place to fix the archwire to the bracket. It can either take the form of a rubber O-ring or a metal tie. And then we have a tube. So, on our first molar we place a bracket on the buccal that actually has a tube. And the tube is a small tube that we run the archwire through. It allows it to slide through. With adult bracket placement it's a little bit different. We can not just measure from the incisal edge because again with adults they can have uneven incisal edge wear. So what we're going to do is we're going to figure out from soft tissue perceptive cervically, incisally, interproximally how best to position that bracket. What we're going to do is we're going to actively position the brackets from cuspid to cuspid. By active we mean that the wires will exert an active force on those anterior teeth to move them. On the posterior teeth the brackets will be place passively. So if you've got a rotated bicuspid and you don't specify that you want to actually un-rotate that bicuspid, the laboratory is just going to place the bracket straight on the buccal. And so when you put the wire through the bicuspid will not be rotated so we don't change the bite. But what the wire is going to do is it's going to be position on the cuspid to cuspid area so that we then rotate the teeth, align the teeth, intrude, extrude, whatever we need to do to get that patient the most ideal arch alignment that we can. So one of the questions that I'm often asked is well is CFAST being slow quick detrimental to the teeth. And I respond no. Cause remember, again, we're using very light forces and we're only moving the six anterior teeth. We're not trying to move all the teeth and arch. We're not trying to extrude posterior teeth. We're not trying to upright posterior teeth. We're working with single rooted anterior teeth that lie nears where the bones are a little bit less dense especially in the anterior maxilla area. Primarily what we're doing is we're tipping, we're rotating, intruding and extruding and those movements happen very quickly. And then we're using the big anchors of those posterior teeth, the back teeth that we're not trying to move. We're able to kind of push against those. And the movement is biomechanical. What we're going to do is we're going to use a bunch of different instruments. Some of these instruments are instruments that maybe you haven't used since dental school. You know many of us had our orthodontic training in dental school were we learned enough to identify a crooked teeth, malalignment of the arches and then be able to refer our patients out. So a lot of these tools and we'll go through them in more specifically in a little bit later are things like the Mathieu pliers. The Mathieu pliers are like little [0:03:38][inaudible] hemostat that help us tie on our ligatures to our brackets. The bracket holders we have some larger and smaller ones and those help us to position the brackets if one should fall off. We have [0:03:50][inaudible] and regular wire cutters and those help us to trip the archwire. We have what we called ligature director which will often help us guide the arch wire into our archwire slots and our brackets. We have the bracket remover so when we're done the CFAST treatment we can actually pop the brackets off the teeth or de-bond them. Another thing I like to use is an explorer. An explorer helps us to place the elastics and often helps us to remove them. And the lip and cheek retractors. When I first started doing CFAST I'd use the retractors often for the bracket placement. And today, I don't use them so much. I use the check retractor probably more just for the photography that we do today. The basic components required again we will go through. Here's a list of some of the basic ones things like pumice, etching, flowable composite which is our cement, the bracket securing light to bond the brackets to the teeth, the Ni-Ti, the nickel-titanium wires that are arch wires, the elastomeric ligatures, the metal ligatures to secure the archwire to the brackets, a power chain. We'll talk about that. A power chain is like a connected band of O-rings that help to pull the teeth towards the center of the power chain, IPR interproximal reduction tools, a little sandpaper disc to slenderize the teeth, then maybe a polishing paste. So when we're doing removing the brackets and taking of the excess flowable composite or the bonded flowable composite off the buccal facial of our teeth we can polish the teeth back up. We'll talk about all of that. What I recommend is if you haven't done an orthodontic procedure in a long time and you don't have the ortho tools that we're talking about and you'd like to order them, give us a call because at CFAST we have starter kits. So it has everything that you need. It has all the different tools. It has extra brackets, extra O-ring. There's extra metal ties. It has a power chain. Everything that you need to do a CFAST case successful. So if you look at that long list and you don't want to go shop for each one independently, just give us a call and we'll provide all the tools for you. Some of the pre-treatment considerations is just to perform a comprehensive dental exam. Again, we don't want to be doing orthodontics on a patient that has active periodontal disease or active decay. We want to make sure that you follow that exam form, the CFAST exam form or if you have that you feel comfortable with that you go through that first. So you obtain their radiograph and then figure out implant wise is CFAST appropriate for that patient and how long will the CFAST treatment take. Explain to the patient all the risks and the benefits of providing CFAST treatment and their preconceived deployments. Typically what we're going to do is we're going to take an impression. And with that impression we're going to send that impression or the models to the lab so the lab can figure out where to position the brackets. We'll get the patients back about two weeks later so we can bond the brackets on and put the first archwire on and get the patient back every four weeks for a monthly visits were we either change out the elastics or do that and also switch out the archwire to the next bigger one. So again discuss the risk, the benefits, the alternatives, and set out your patients so they understand the expectations. What I really want you to do is make sure that you start with a healthy patient even when it comes down to the joint evaluation. Again, if a patient has clicking, popping joints, it doesn't necessarily mean I won't provide CFAST treatment. But what I want them to understand is they have clicking popping joints before we're providing CFAST treatment. Some patients have clicking popping joints and they just have forgotten it's even there. They just become so accustomed to it. Once you put the wires and the brackets on they're thinking more about their mouth and all of the sudden they go when I open and close my jaws are clicking and popping. I think it began when I started CFAST. If you can go back to your exam form and say well do you remember when we did our initial exam form we noted that you had the clicking and popping before we started the CFAST and it seems like it's the same right now. Then that kind of takes that off your shoulders. Whereas if you went back to your exam form and you had not made a note of any clicking and popping before you place the CFAST appliance as with anything we do in the mouth whether it'd be CFAST or occlusal sealant then it's up to us to prove to ourselves and our patients that we are not the cause of that. And often times we're not. It's a long term problem with the patient. They're just kind of become accustomed to. So what we're going to do is we're going to look for different types of pathology, caries, periodontal disease, joint pathology. Make sure that everything is stable and that their oral hygiene and homecare is stable before you provide the CFAST treatment. Then what we're going to do is we're going to just make the patient aware of everything. We're going to again mention the midline that we may not get the midline to line up if that looks like that may be the case. We'll look at the simile line. When they smile do you see a lot of the soft tissue, the cervical area of other teeth or is it just the incisal edges. Because if all you see is the incisal edges even when they go to big smile maybe that cervical positioning of the teeth won't be as important. So let's talk about getting started now. The first visit again is about 30 to 45 minutes. It goes again faster and faster as you become more comfortable with the CFAST technique. So assuming that you've completed all the paperwork and maybe at the previous visit you'd introduced the idea of CFAST. You have given your patient an estimate of the cost and now they're ready to go and they've actually made the payment to get started. What you want to do is again explain to them what you expect their final case to appear to look like. We'll talk more about that. But if they have a lot of incisal tooth wear I'd explain to them that hey you're going to have straight teeth but you're going to have straight teeth with lot of incisal tooth wear. Or if they have very dark teeth because they smoke or maybe drinks lots of coffee and teeth, what I'd explain to them is you're going to have very straight dark teeth. Just so they know that they're not going to have that perfect smile just from the CFAST tooth alignment. But we do have other ways to treat the color and the contour. Go through the consent for. In CFAST we have a consent form. You can modify that. Make sure you go through some of the highlighted points with your patient and have them fill it out so they understand one that you remember to go through each point. But two that they record that yes you did review that with them before providing CFAST treatment. You've done your full clinical exam. You've got your radiogram, the appropriate ones. Now all we have to do is take our impression. So we take an upper impression and lower impression, a bite registration if you feel that the lab is going to have any difficulty in aligning the arches and then a series of photos. So all we're going to have to do is we're going take our impression. When we take these impressions, again remember these brackets were on the buccal facial of the teeth. So if you have a tray that's too small, when you play that tray in the patient's mouth that rubs against the facial buccal surface and distorts that area of your impression. What I recommend that you do is pop another impression. Again the occlusal surfaces at this point aren't as critical. We don't have to have all the details of the occlusal grooves or the first or second molar, but we need to have groove representation at the base of tooth form and the buccal, facial surfaces of the teeth. I then like to go to the informed consent and take our photograph records. So photograph record wise, it's nice to have a full face shot. It's nice to have a nice close up smile shut where you get a little bit of the nose and maybe half of the chin, not just the close up of the teeth but a little bit of the soft tissue gives you a little bit better perspective of the case. Had the patient put the retractors in, bite down, get a frontal photo with the teeth together but then also the teeth apart because you can see in this case the photo on the left hand side with the teeth apart you can see that the lower incisal edges and the lower crowding. And then have the patient bite down and take a right lateral shot and a left lateral shot. You can take a mouth mirror, put it in the mouth and try to get a nice maxima occlusal shot and a nice mandibular occlusal shot. And those are really for your records. At this point, if you like to you can actually email those photos to myself or the CFAST just info@cfastsmile.com and we'll take a look at those photos and give you any advice about the case that we can. So all you have to do to submit a case is take probably a PVS impression and typically I would just use a medium body impression. I don't do a light wash. I just take the medium body impression material, fill my full arch tray up on the maxillary arch, seat that for the appropriate amount of time designated by the manufacturer 2.5-4 minutes is typical. Pull that out and then do the same thing on the lower arch. Again a bite registration only if you feel like it's going to be difficult for the lab to line the stone models up. But we have our upper PVS, our lower PVS impression, take some photos. You can either email those photos to us or print them out, put them in the box with lab prescription such as this and then send it out to the lab. Now the way that this works is you just check off what you want. Do you want an upper tray, lower tray, just an upper tray, just a lower tray but what we're going to concentrate now is just that upper left hand column. We're sending this case out. If you have any notes in the middle area that lab slip, you just want to write down the notes. Let's say you have a lot of tooth wear on the upper right central and you want to not align at the incisal edges but the cervical area. So I would just clarify that with the lab. I understand we have a lot wear on the upper right central. I don't want to try to align that incisal edge with the upper left front tooth; otherwise, the soft tissue contour will be too far down incisally. So let's line up the soft tissue contour and I'll worry about that incisal edge later and restore that restoratively at a later date. So here's what you'd send it. Upper impression, a lower impression, a bite registration if you feel that was necessary with the eight photos. And it's all what you have to do along with a lab slip. So we go through the post placement instructions. A lot of times it's nice to go through this leisurely when your patient comes in for those impressions because there's less stress. This impression is fairly easy. It's just an upper and lower impression and it kind of sets them up on what to expect after their next visit, after you place those brackets and wires. You know the tooth sensitivity, the things that they should avoid eating and drinking. So go through that. And what you're going to do is a couple of weeks later you're going to get back from the lab a box, and in that box you will have the indirect bonding trays with the brackets in place. You will get the archwire, three per ach the 14, the 16 and the 18 wires, the O-ring elastics that you need for that case. If there's any other communicates the lab wants to share with you, if they haven't called you beforehand, they'll probably have a note in there. I've had the lab say you know what, we feel like this case has a lot of crooked teeth. Instead if starting with the 014 wire we've actually included a 012 wire in there to help you do that with the first wire up. One of the nice things about the lab setting this case up with the indirect bonding is they're able to do it very precisely. So they're able to take the models in front of them. They can trace out where the midline is. They can look at the heights and more precisely I feel position the brackets onto the stone models. It removes operator error. When we're working on the mouth a lot of it depends on as far as the bracket position from what angle we're looking at it or viewing our patient's mouth. So it removes a lot of that operator error. You know having a mold in front of you is much different than trying to look into our patient's mouth. It's less stressful. If I've got the bracket position all determine for me by direct bonding trays, I'm going to be able to do it much quicker which reduces my stress which reduces the stress of our patient because we gone through this procedure much quicker and overall if I'm able to have my patient in the chair less amount of time it actually becomes more profitable for our practice. So here are the trays that you'll get back, so at the second visit two weeks later. Here are the trays. So you can see that we've got two trays for the upper arch. We have one for the upper right quadrant and one for the upper left quadrant. And the lower arch we've got one for the lower left and one for the lower right. So the tray is just split. Now the cementation or the bracket placement appointment will take you about 45-60 minutes. You'll get quicker and quicker again as you do it more often. The way these trays are made are the brackets are place on the stone cast and there's a more pliable plastic material kind of like the [bleach tray] material that goes over the bracket. And then over that tray is the stiffer plastic that helps you in the positioning. So this is what you'll get back from the lab. What we then do is the patient is now on our chair. We go ahead and with an oil-free I use Ω flour pumice and Ω coarse pumice, I mixed together with a little water. I go in there and just clean off the pollical and the stain off the facial buccal surfaces from first molar to first molar. We rinse that off and then we place our etching. Here we're using a 32%-37% phosphoric acid etching and I try to place it where I think the brackets are going to go. We don't have to be too accurate with this. Just try not to spread the etching all over the teeth because if you spread the etching all over the teeth and some of our cement gets on the cervical or the incisal edge we're not going to be able to just to flick that off, we're going to have to actually polish it off. So here we actually place etching where the bracket, approximal bracket will be. Rest there for 20 second and rinse that off. After we rinse that off we have dry frosty squares. So again if you get really messy and you get etching all over the teeth and you have a lot of excess cement go either cervically, interproximally or incisally it's going to make your clean up much much harder. Here you can see that we have these little frosty rectangles on the teeth. So even if we get excess cement on the incisal edge, it will just flick off because it's not on an etched surface. So now what we do with the teeth is we're taking the bonding agent. We're just painting the areas that we etched with a little bit of bonding agent. What my assistant also is doing at the same time is she's applying a little bit of adhesive to the internal aspects of all the brackets, the metal and the ceramic brackets. And then we lightly air dry that to evaporate off the carrier. In this case it was acetone type of carrier. And here we're taking a little bit of flowable composite and putting just a little bit of flowable composite on the internal surface of each bracket. We then take the trays. We seat that complete in our patient's mouth in the appropriate quadrant of the arch. Once it's fully seated we come in with a curing light. And I applied gentle pressure from the facial towards the lingual for 5 seconds. I tack each bracket in. So we have six brackets central to first molar. Each one for 5 seconds so it's going to take us about 30 seconds to tack those in. Once we got those tacked in we peeled out that outer harder tray leaving the more pliable tray in place. Here we're peeling that off. Then we come back in with the curing light and I cure each one, each bracket, for another 10 seconds. And after we cure it for 10 seconds, we actually are able to pull that inner tray out and we'll go through this more when you kind of do a hands on demonstration. And then we'll repeat that sequence in the maxillary left arch then the mandibular arch one quadrant at a time. Again when you're on the lower quadrant same thing as we do our etching, our primer adhesive and our bracket placement we just want to make sure we maintain a dry feel environment. We don't want to saliva to get up underneath our brackets and compromise our bond. So here are just some photos showing the sequence again on the lower arch. And now we have our bracket placement. So it goes very quickly, probably get all four quadrants of brackets in in about 20 minutes when you get good at it. Sometimes you have patient that has ceramic crowns or even gold metal crowns. So what we do in those situations, here's a PFM situation is I'll go ahead. I'll kind of take my micro-etch and break the glaze of the porcelain. Then I'll go ahead and use hydrofluoric acid etching. The Ultradent one is the one that I use. Etch the porcelain for about 60 seconds, rinse and dry that off and then I will use Monobond Plus which is an Ivoclar product. I'll paint that on over the porcelain or if this was a metal crown I'd be doing the same thing. I'd micro-etch the crown just to create a little bit of roughness, put some Monobond on there, some adhesive, air dry that. And then I'd go ahead and just bond my brackets on as if it's a natural tooth. So here are some of the products I use when I'm bonding either to porcelain or gold. So I'm using things if I'm etching porcelain I use Ultradent's porcelain etching. And if I'm bonding to [0:20:13][inaudible] I use Monobond Plus from Ivoclar. Here's a micro-etcher. So again if you're doing a metal crown or if you're bonding to porcelain PMF type of crown or a ceramic crown like an Empress or E.max I just micro-etch. Sometimes when you peel that inner tray off you'll actually get a bracket that comes off in that tray. And again there's no reason to panic. All you do is you can leave the bracket in that soft tray. You're not going to be able to take that soft tray and place it back into that quadrant because that soft tray is going to have to fit around each of the other brackets. Many times maybe it's just one bracket that pops off. So what I do is I take that soft tray and I cut the tray anterior to that bracket in that tray and I cut the tray posterior to that bracket in the tray. So I just have the segment of the plastic placement tray with that one bracket on the buccal or the facial. So I cut the tray and I clean the tooth off if there's cured composite on that tooth surface or if there's a lot of cured composite on the internal surface of the bracket I go and clean that up. And then we re-etch. We reapply our primer adhesive. We take a little flowable composite. Again put that on the internal surface of our bracket, seat the bracket using that little segment of the tray as a positioner. Again light cure for 5 seconds to tack it. And then I come in and I light cure it for another 10 seconds. And if it has come off I might do an additional 5 seconds for a total of 20 seconds to cure that. And then peel that tray off then we're set and ready to go. If for some reason you feel you can as you can actually just take the bracket cause sometimes the bracket will come off of the tooth and actually out of the tray. And if that happens again what I do is I clean the excess cement off of the tooth, clean the excess cement off of the internal surface of that bracket. Go ahead and re-etch primer adhesive on both. Take a little bit of flowable composite and actually freehand place that bracket back into place. And we'll talk more about how to do that. Wire placement. What we're going to do is we're going to start with the smallest [stem] of the wire typically the 14 wire and then we're going to move up from 14 to 16 to 18. Now some people say just the put the largest wire on that you can. So if the teeth are fairly lined up let's start maybe with a 16 wire. And if the teeth are very crooked and out of position a 16 wire is going to be too stiff so it's going to be too hard to get into those archwire slots. So let's go ahead and start with a thinner wire first. To tell you the truth, the way that I do it is I just try to keep the system the same. Remember that philosophy of practice just have a system and a consistent system, I keep it the same every time. So typically even if the teeth and the arch form is fairly straight, I'd still start with the 14 wire. I do that for at least a month and I go with the 16 maybe for a month or two and then I'll finish off with the 18 wire, again the 18 you know thicker. So when we have our archwire and again we'll go through this with a little bit close-up detail. But I'll take the archwire I'll line up on the models on our patient and I'll trim the archwire because if they're longer in length than what you need, I'll trim the wires distal to the second molar. And remember we're only going to bracket to the first molar and on that first molar we're going to have a tube and the tube is going to allow that wire to slide in and out. So why do we cut the wire distal to the second molar. Well remember that the archwire right now on the molar is following a straight line in the patient's mouth. This wire may go out facially, come back lingually, may have to go up cervically, come back down incisally. So it's going to follow a longer path and that's why you want to have a little extra length. So if we cut it distal to the second molar it's not so long that we're going to be poking our patient's throat or cheeks or tonsils. It's going to make it more manageable but we'll have enough extra length to take care of those extra curves. So what we do is we trim that wire distal to the second molars. Then we slide that wire into those first molar tubes, the left first molar and the right first molar we just slide that wire into those tubes. Once we've done that it's stabilizing the posterior segment but the anterior segment is flapping up and down. So what I do is I just go to the anterior segment. I look for that bracket where the archwire just kind of falls in place the best cause it's going to be the easiest one to place our first elastic. So in this it could be the patients upper left centrals, the wires kind of go into the archwire flat. Let's go ahead and just place elastic on that too. So here we use a Mathieu pliers and our fingers to stabilize that elastic and we just stretch the elastic over the four corners of that bracket. Now if we have teeth that are way out of alignment what will sometimes happen is the archwire will actually begin to pull away from the bracket. So in this case you can see that little elastic O-ring is being stretch out. The archwire isn't lying in the archwire slot. And that case what we kind of like to do is we can take a metal ties. These metal ties or we called them quick ties don't have that elasticity. So if we put that metal tie around that bracket and we tighten that up, and again we'll look at this when we get to the hands on portion, you can see we can snag that archwire right into the archwire slot and because of that put more force on that tooth. Once we have the wire kind of tied into all the brackets, we can take our end cutting, wire cutters and distal to the first molar tooth we cut the archwire so it doesn't poke the patient's cheek. In some cases, we'll be challenged because the patient has a very deep overbite. If the patient has a very deep overbite the brackets being out the buccal facial lower arch, those brackets will be traumatized by the upper incisal edges banging into them. So the patient if you don't address that, you let the patient go and they'll call you back in a day or two saying you know what they pop off the bracket. So what do we do in that case for the patient has a deep overbite. What we do is we place bite stops. And by bite stops what we do is we just take some composites and we place that on the lingual surfaces sometimes to the cuspid or sometimes a little lingual cuspid or the bicuspids. So when the patient bites down we actually open their bite up. So the upper incisal edges don't crane into those lower brackets. Before I do that I try to advice the patient in before we put the brackets on that we're going to need the bite stops. And I try to tell the patients when we put the bite stops on, the reason why we do this so that your upper teeth don't knock the lower brackets off. But when we open that bite up, what that all means is back teeth are going to come together. It means that they're not going to be able to eat as well. So I often joke at the patient. I say you know when we do this bite stop placement, you're going to have them on for maybe 2-3 months and during that time you'll probably going to lose about 20 pounds. I never have anybody lose that much weigh and I never have it be a health issue. Patient somehow finds a way to eat and chew even though their back teeth don't come together and again it's for a very short time. But in this case what we did is we place a little bit of composite. Just etch the lingual surfaces of those cuspid. Rinse out the etching, little primer adhesive, cure that, place some composite back there and have the patient bite down so that when they did bite and close on those stops that the upper incisal edges could not bang into the lower brackets. Just showing how that was the only point in contact where the cuspid area. And again the patient accommodated to that very well. So again you can see the esthetics. This patient has the wires, the brackets. She has the composite bite stops in place but from a distance of a foot to two you can't even tell if there's bracket there. When I have my CFAST brackets on I often walk into the hygiene room. I'm just a couple of feet away from the patients. I'm talking to them without my putting my mask on. I put my mask on and do my exam. And as I was looking at the teeth and I was mentioning how some of the teeth were crowded. I mentioned CFAST as a possible solution. And I often step back from the patient, pull my mask down and let the patient see that I have CFAST on and what they would often say is you know what I didn't even notice you had brackets and wires on. So again it's very esthetic. Now with post placement instructions what we want to do is we want to make sure the patient understand what to avoid so they don't knock the brackets off. I tell a patient we're beginning to move the teeth so you might feel some soreness to the teeth. And if you feel any soreness or if it's very uncomfortable or if it's uncomfortable enough take some Tylenol or some Advil. I'll tell you the majority of our adult patients it's like a minor nuisance that they feel anything at all. I advice the patient that they might notice the bite changes a little bit because we are beginning to move the teeth. And so it makes sense to them that if we're moving the teeth they might experience some bite changes. We try to explain to them what not to eat or drink. Things like sticky hard food they should try to avoid because the sticky foods will stick to the wires and to the brackets and the hard foods could bend the wires or knock the brackets off. Again, even like granola bars. I found that when I have the CFAST appliances on I was eating into nutty granola bars that I sometimes would loosen up a bracket. Things to avoid to drink. Going back to the foods too. Again we place the brackets we have fresh resin all over it. Try to avoid the curry type of foods because I had a patient, we place all the brackets and the elastics and she went and had Indian food with the curry and it turned everything yellow. Again this was just like superficial stain. We can polish it. In this case what we did we just switch out the elastic so we could take that orange color out of her elastics. But I try to advice the patients to avoid curries or any type of those foods. And then red wines. Cause again the elastic and smoking. Patient that smokes that will be absorbed by the elastics and so when the come back in four weeks the elastics instead of being clear might be slightly red or brown. We try to inform the patient to have good oral hygiene. One of the tools that I found works out really well is Rotadent from Zila because it has a little tip and that little tip you can get up, in and around the wires and brackets. So again you might give the patient a Rotadent or at least advice them how to use their conventional toothbrush and floss to get up around the brackets and the wires. And after care kit. One of the most important things to put in the kit if you're going to make an after care kit for your patient is orthodontic wax. Because I tell a patient I go for the first few days the inside of your mouth are very tender and as I rub those brackets and wires, you may get some sore spots. If you give them a little bit of orthodontic wax and we just give them a little box of it and typically they won't even go through the entire box, the little package during the 5-7 months. But if they have a little sore spot they can take some of the ortho wax roll it between their fingers to heat it up and soften it. Place it over the area that's irritating the tissue and they'll be fine. And then what we'll do is we tell the patient we're going to see you back in about four weeks. So every month we're going to be getting you back. We're going to check elastics. We're going to check the wires. When it's appropriate we're going actually step you up to the next wire. The next wire is going to be a little bit thicker. It will put a little bit more force on the teeth and therefore move them. We give them again the post placement instruction. They may have forgotten what it was that we told them during the last appointment and basically they're set and read to go. Some of the things I like to explain to the clinician because we're all worried when a patient calls up and they have any kind of untoward effect because of our CFAST treatment. Soreness. Again typically that's going to resolve very quickly. It's going to be a mild ache that they feel. I tell the patients again take Tylenol or Advil if you feel anything at all. Again many of our adult patients it hasn't been an issue. When I was going through CFAST there were certain days that when I would bite down a tooth that we're moving it might be a little sore to that biting pressure. But if I wasn't biting on it, it was fine. So I never have to take Tylenol or Advil because the soreness I felt because of the CFAST. Another thing that you might be concerned about if we're using nickel-titanium wires and you have especially female patients that are allergic to costume jewellery and the nickel that the jewellery contained. You might think well that wire irritate them or cause any kind of allergic reaction to the soft tissues intraorally. And again I have not seen that happen in any of our CFAST cases even with those patients that had the nickel allergies because again our wires are coated on the outside. So what little nickel there is in that wire will not be making contact with the soft tissue. So there has been some documentation that those patients that had nickel allergies but we've got coated wires typically will do fine. Mobility. I try to explain to the patient that we are moving the teeth and the root to the bone and because we're doing that the teeth will have some mobility, some looseness. And again that's going to be okay while we're going to the CFAST treatment. Once we get the teeth in a power position we're going to hold them there. We're going allow that phone and that soft tissue to reorganize around the rest of the teeth to kind of solidify once again. If we ever feel like there's excessive tooth movement, we can just stop. We can either take the wire off of that tooth or just take the wire, the elastic that holds that wire against that bracket. Take that off and let the tooth kind of relapse, relax before we put that wire back on. Again I haven't seen that as a problem in any of the case that we've done. But again I want to point out to you that we have ways to take care of excessive mobility. Tooth gets too loose. Let's just deactivate it for a while. Let it rest. Let it heal up a little bit then we'll reattach it to the wire. One of the things I found in the research I was doing was sometimes you can have a tooth and the tooth could be kind of on the edge and need of root canal. And as we go ahead and put the tooth under additional stress to move it sometimes that will put too much duress in the pulp and maybe the tooth is going to then need a root canal. Again I haven't seen this as a problem. It hasn't happened to me. But in some of the research and the reading that I've done that's one of the risk that I mentioned to that patient. If they got a tooth that looks like its fairly weak or they have a very invasive procedure done to it, restorative procedure possibly, I would just advice the patient. You know what we're going to put this tooth on a little bit more stress because we're going to move. There's a possibility that if this tooth becomes sensitive we may need to do a root canal. So just advice patient if you see that that's advisable and needed. What we're then going to do is in 4 weeks is we're going to get the patient back for what we called a monthly review appointment. What we're going to do at that appointment is and typically this is something that's primarily delegated by me to my assistant is I'll walk in. I see how the patient is doing and make sure all the brackets are attached. If a bracket has become detached from the tooth, I'll go ahead and just clean it up, re-etch it, bond it back on to the tooth and then my assistant will take the old wires off, take all the old O-rings off and replace them as needed. So if there's a bracket that's come off I'll go ahead and re-bond that on. If I feel like we may need to do some interproximal reduction, some stripping interproximally of the teeth, I'll go ahead and do that. Then I'm out of the room. Cause I'll just tell my assistant just go ahead and put the next wire on, possibly maybe we start the 14 and now I think the 16 is going to be the appropriate wires so I tell my assistant let's go ahead and put the 16 wire on and put the elastics back on. So basically I just have to check and I'm out of the room. So it should be something you can delegate to the assistant. So one of the things that we'll also be checking is the bite because if I put those bite opening stops in the patient's mouth and now the bite has changed such that I don't need the stops I'll go ahead and take them off as soon as I can. Because one it's going to be much more comfortable with the patient. And then I have to worry less about possible extrusion of the posterior teeth. And then we also check the oral hygiene. If the patient comes in and their gums are bloody or they're very irritated because they're not brushing or flossing then I'm going to advice that patient let's go ahead. Let's review the tooth brushing procedures, the floss when you go home. Have you do really good oral hygiene. Because we don't want to compromise the health of the bone and the soft tissue moving the teeth so that's an added stress and have an active chronic infection in your mouth. If a bracket comes off, I think one of the important things to remember is it's not the end of the world. It's not like a crown has come off. So when the patient calls our front desk and says you know what I knock the bracket off. My front desk says you know what it's typically not a big issue unless it really bothers you and we'll get you in the time that's convenient for you and also convenient for us. So the patient doesn't have to get in typically in the next half hour. They could wait a day or two and things are going to be fine. So let's assume that they're three weeks into this four-week period. They come in, they have loose brackets. So we'll go ahead and do as we'll re-secure that bracket but what we're going to do is we're going to do everything that we would have done at the four week appointment, during this appointment so the patient doesn't have to come back and we can get everything done which makes it much more efficient again for our practice. So when they come in we'll reattach that bracket. If they're in the 14 wire and I deem that now they can to 16, we'll go ahead and change the wire at this bracket replacement visit. So we'll go ahead and take care of that. It's better for us. It's better for our patient. So again what we're going to do is we're going to start with the 14 then we're going to go with the 16 then we're going to go with the 18. And that's the typical sequence we'll always going to follow. If you have teeth that are very crooked and the wire you think is going to have to follow a very curvaceous path, that's going to be hard to lock that wire into each bracket. The lab may give you a 12 wire. But I'll tell you in the last year there's only been one case where the lab felt it'd be better to give me a 12 wire and it did help. It made the initial wire replacement much easier. If you've got spaces cases or a case where the teeth are fairly lined up you may be able to start with a 16 wire but again I try to stick to a system just so I know where I need to be and my team knows where I need to be. So the first wire I always place is that 14 wire and then the next one is the 16 and the 18. So although I might be able to start with the 16, I start with the 14. I try to do it consistently every time. And then when you get to that 18 wire, that 18 wire is one where I kind of finish and tweak things at the very end before I take everything off. So here you can see that the 14 wire in this case we have very crooked teeth. The 14 wire is going to be the wire that we can bend back lingually to pick up the laterals and we can bring up facially to pick up the centrals and then go back in. So again the thicker wires are going to be harder to follow that curve. In this case, the lab might even give you a 12 wire and say we'll try the 12 wire if you can't get the 14 in there. In this example, you can see the arch form is fairly round the teeth are in good alignment. So the lab and you might think well I'll start with the 16. And I will tell you in this case you can probably start with the 16 wire but again because I try to stick with the system I will start with the 14. So I'll go with 14 wire at least for four weeks. It allows things to round out. It allows the body to kind of activate that biochemical system, to activate the osteoblast and the osteoblast to activate that biologic system. So what we're able to do is we're able to get the osteoclast and the osteoblast in motion with the 14 wire and I think it's going to be much more comfortable for the patient. So again the sequence with the 14 maybe for 1 or 2 months, the 16 wire maybe 1 or 2 months then the 18 wire maybe 1 or 2 months which means ultimately we'll finish the cases typically between 5 and 7 months. So again the bracket de-bonds. Don't panic. What we can go ahead and do especially with a molar bracket coming off is if the molar bracket keeps falling off, I've had cases where the first molar is a gold crown. I'm just having a hard time getting that bracket to stand in the gold crown whether it'd be the bite or the metal bond. But I've got the first bicuspid, the second bicuspid. They're healthy teeth with good roots. Sometimes what I'll do is I'll just tell the patient you know what let's just leave that molar bracket off. It keeps popping off and I don't want it to bother you. We really don't need it because we have good anchorage from this other bad teeth. So let's go ahead and leave that off. So I trim the wire distal to the second bicuspid bracket either first molar bracket off and don't worry about wearing the wire that far back and things turn out fine. The most common areas I find that patients knock the brackets off are typically in the cuspid, bicuspid area. And again it has to do with that's where they're doing a lot of the chewing. And I explain to the patients that these brackets aren't meant to be on their permanently because within the next 5-7 months we're going to be taking them all off and if they're on permanently we can possibly do tooth damage. So I'd rather have a bracket be able to pop off if there's too much pressure being put on it versus it being permanent and me damaging the tooth 7 months later trying to remove. If it keeps coming off, one thing is to watch out for is the bite. And discuss the diet with the patients. I had patients where they just would come in you know I knock one of the brackets off because I was eating something hard or chewy. They knew they were doing something they shouldn't be doing but they did it anyway. Sometimes it is because of the bite and we have to put bite opening stops in or maybe we have to add some height to our bite opening stops to create a little bit more vertical clearance. So one of the things that we need to do is we need to check the bite. We have to kind of consult with the patient to see what it is that they are eating and chewing on. If we have to replace a bracket, what we're going to do is we're going to align the bracket up so the horizontal archwire slot is basically parallel to where we want the final occlusal plane to be. The vertical slot will follow the long axis of the tooth. And many times what I will do is if the bracket has come off, I can visualize where I need the bracket to go. Now we'll talk about this more as far as intrusion or extrusion of the teeth. But here's a quick video again just showing how when we place the brackets what we want to do is we want the bracket, the archwire slot to be parallel with that incisal edge. Now the vertical positioning of that bracket will affect are we going to extrude or intrude that tooth a little bit. So what I typically try to do is if the tooth is in fairly good alignment with its neighbourhoods is I'll just put the archwire slot from the tooth that I'm replacing the bracket onto. I'll put it so it's in alignment with the archwire slot of the adjacent teeth. Because you can see when we put the bracket on that tooth if it's parallel to that incisal edge going up and down the midline of that tooth that once you put the wires on, the wire is just going to straighten that guy out and position it properly vertically. So in this diagram you can see how we're just positioning that archwire slot parallel to the level of the maxillary occlusal plane. So how do we re-bond the bracket if the bracket comes off? Again don't panic. Just tell the patient that's fine. We'll get you in once it's convenient for you. What we're going to do is we're going to first remove the excess cement from the internal surface of the bracket. Remove the excess cement that may still be attached to the facial buccal of the tooth. We are going to then place etching on the tooth, rinse that off with a little bit of primer adhesive on the internal surface of the bracket and on the tooth, the dry surface of the tooth. We're going to lightly air dry that primer adhesive. Light cure the primer adhesive that was place on the tooth and take a little bit of flowable composite. Put it in the internal surface of the bracket with our little bracket tweezers position that bracket. Again typically so the archwire slots are in alignment with the tooth in front and in back of that tooth. Once we seated that bracket we go in and just cure that into place. Clean up the excess cement if there is any at all and then we're set and ready to go. So it doesn't get much simpler than that. So here are some other cases too with treating necrotic cases. Again, we have those overlapping front teeth again just to visualize the arch form and how much space we have. So how do we figure that out? Well there are different ways for us to figure out how much space we have in the arch. One is to eyeball it. One is to measure it out and one is to just let the lab do it. Eyeballing is probably the way that I use the most. You know I'll look at the patient. I'm doing the exam on the patient. Maybe it's on the hygiene chair. My hygienist has mentioned that [Celia] would like to have straighter teeth. And they're asking me do you think [Celia] is a candidate for CFAST. And I'll just take a quick look, possibly at this arch and I'll just try to eyeball. Let's say maybe I'm a millimeter there. Maybe there we're okay. Maybe I'm a half a millimeter deficient in this area. Maybe half a millimeter here and I kind of add that up. And if I feel like once I put place an archwire and we round that arch out and we get a millimeter or maybe more running that arch out. And then any other space discrepancy I can do some standardization between the teeth. I just tell the patient looks like you're a good candidate. What we may need to do though because your teeth is so overlapping we may need to standardize by taking a little sandpaper going between the teeth and narrowing the teeth out a little bit, [not into the] tooth structure. We're not going compromise the health of the teeth but we're going to slenderize the teeth a little bit so we can get them shoulder to shoulder again. So eyeballing works out very well. It's a quick down and dirty way of doing it. We can kind of visualize how much space we're deficient in that arch. In this case 2.5 mm. A tool works out very well for me is this 4-inch digital caliper and you can get them at harborfreight.com. Typically, they're going to cost you less than $20 and it's just a good way. What you can do if you have models especially you just measure the actual widths of all those teeth. Add up those widths. Then take an archwire and position that archwire where the ideal arch is going to be. So if you got teeth that are lingualized you're going to round that arch out and probably pull them out more facial labially. So what you do is you position that wire where the ideal archform will end up being, mark that wire distal to each cuspid on each side then take that wire, straighten it out to figure out how much arch space you have. Now you've already measured each tooth so you add up all the widths of the actual teeth and you can figure out how much space you have from your archwire measurement and you can figure out how deficient it would be. Again in this case, we're still going to be deficient. So I need to visualize as I allow that archwire to round out that arch, am I going to pick up enough additional arch length to allow me to straighten those teeth out without having to do any kind of interproximal standardization or will I have to. Again what I typically do just kind of my risk benefits discussion with the patient is I'll tell them we may have to do some of that slenderization. And if we end up not having to do it, that's even better. So how much space can we gain with IPR. Again looking at this chart, we can pick up sometimes 4mm-6mm depending on how much tooth structure we have down there. So with these crowding cases and IPR and again it goes under many different interdental stripping, stripping, re-proximalization, tooth slenderization. I actually just like to tell the patient we're going to be slenderizing the teeth. What we want to do again is to be very conservative. We don't want to conjure up images that we're going to be taking away a lot of good tooth structure. So there are studies showing that if we do this and we're very careful in the way that we're going to do that we're not going compromise the health of the teeth. One of the questions that patients will have, are you going to take so much tooth structure out, they're going to have sensitivity. Again I tell them we're going to try not to do that. I don't think we're going to do that because again we're just going to be working the enamel. So I just try to reassure the patient that they're not going to have any sensitivity issues. If you think they could have sensitivity issue what you may do after you do your interproximal standardization is apply some fluoride into those areas. Another question patient often asked well if you take that sandpaper and you create a little bit of roughness between my teeth will I be more prone to decay on those areas, and again what we try and explain to the patients is that research shows that they will not be more prone to decay. So we want to be very conservative with our IPR. We want to maintain the natural tooth contours. That's why typically when I do IPR I like to use just the diamond strips, the metal type of strips so I can contour that and maintain the anatomy of the tooth. Another primary role of IPR is we don't want to do the IPR until we know we need to. So when you place that first archwire I'm going to allow that archwire to round out the arch often times expanding it out. And as we do that we gain arch length. So I may go ahead and do my 14 wire, allow that wire to be in there. I might even put the 16 wire into allow more rounding in that arch to occur. And if I have overlapping tooth structure, I'll go ahead and do IPR but I try to be very conservative. And one of the reasons that I try to be conservative is because if you look at these type of cases so if you have not done a lot of ortho and you're trying to visualize how much arch space you have, you might be wondering do I have to do IPR. So when we look at this occlusal view we see the centrals are locked lingually to laterals. Now if I'm envisioning that I'm going to pull those laterals out or pull the laterals back and the central out, are we going to be able to do that without doing a little bit of IPR. Well in this case what we're going to do is we're going to go ahead and put the brackets on. We'll put the first archwire in. We'll allow our first archwire to round that arch out. And you can see within a 4-week period we've rounded that arch out and now we have too much space. So if we have done IPR beforehand we would have even more space, a space issue to deal with. So here we are. We've rounded everything out. You can we did not have to do IPR. You can see the better arch form. You can see in the anterior segment we rounded that arch out. In the bicuspid area is still a bit of a compromise because again in CFAST we're contouring the anterior. Now as you get more comfortable with CFAST working the anterior you can ask the lab to position the bracket to move the bicuspids out. So finish case, pull the teeth back together and we have a nice end result. So these are the little metal strips that we can get interproximally. Each one is color coded to provide a different amount of tooth reduction. I like that take that in. Wrap it around the teeth so that we may maintain the facial and lingual embrasures. Try to make sure we don't end up with a nice long flat contact as you often see when you use a polishing disc. Now a polishing disc in my hands doesn't work the best. If you give me a disc and I take that interproximally to the teeth, I'd probably remove the tongue, the check, the lip. So I often just prefer to take the metal strips in there even though I know sometimes it's not easy to do especially with a tight contact. I feel like it gives me more control. Now if you have larger areas of tooth structure you think you're going to have to recontour then go ahead and use some diamond disc. You know you can use coarse or medium coarse diamond disc to do some of your gross re-contouring and then step it down to a fine diamond and then get back in there and polishing this up with the strips. So if I've got a lot of tooth structure, I think I need to remove or contour I'll go ahead and get in there with the bur. Again what you're trying to remember is where you want the final contact to be. Again don't take too much tooth off. Don't make it too vertical, too straight. You want to maintain the natural esthetic anatomy of the tooth. You want to have the curvature there because that's how natural tooth appears to be. So when we're done with the IPR we want the contacts to be able to close up. We want to have a nice curvature, a nice point contact, not a long contact because if we straighten the mesial contours of the teeth and squeeze them together. We want to maintain the natural anatomy. So here are some other thoughts. Here's a lower incisor case and what I'm going to ask you is would you exact the tooth or recommend IPR. So in this case you see that lower central that's lingualized, the adjacent teeth are almost touching. What would you do? Again I would advice the patient there's a chance we're going to have to slenderize the teeth because the teeth are so overlapping. We don't know if we can pick up enough space. There's a good chance in this case we'll have to use some slenderization. We want to take the width of the lower teeth and kind of slenderize it and make them a little bit narrow so they can go shoulder to shoulder again. Or another option that we have is to extract that tooth. But in this case we're going to try to do and do the slenderization and keep that tooth there. And you can see in the end we did not have to take that tooth out. We've aligned the teeth at the lower arch and we get a nice frontal result. Here's again a lower case. If you look at the patient's dentition, we have a lot of overlap. Again I'd advise the patient we don't know how much arch space we're going to pick up as we put the archwire in. We try to pick up as much as we can but there's a chance that we may need to slenderize the teeth and/or extract the tooth. So it this case a tooth is taken out. So as we take this tooth out, central you could see it creates a triangular dark space down in the papilla area. This area may grow back in from the crest to the bone to the bottom of that contact within about 5mm. The papilla may grow back in there. Another option is to do some slenderization kind of elongate the contact between those two teeth and squeeze them together to close up some of the dark triangular space. We take some composite down there. We can add composite down there. Or these days some docs are taking derma fillers and pumping that papilla back up. Those are some of the risk you have to consider if you extract the tooth is the soft tissue triangular area how are you going to manage that. With space cases so here's a patient with a diastema. So kind of reverse of what we were just talking about where we have too much crowding. So here's a spacing case. Now if I put an archwire in there and kind of run and I round out the arch, am I going to make that diastema even larger. Well what we're going to do is we're going to use the archwire to level everything out, to create that ideal arch form and then we're going to use a power chain. A power chain is kind of a string of O-rings and they're all attached. And what that string of O-rings is going to do is it's going to apply a pressure to draw the teeth to the center of that power chain. So if we got a diastema space and I power chain the teeth together, we're going to pull the teeth together and take that diastema and actually close it up and we'll talk more about that more in the hands on portion. So there are the teeth at the power chain. And again power chain is tooth colored are clear. But it's like those O-ring elastic but instead of individual O-rings they're all connected together and it just creates one big rubber band to pull the teeth together. When we do the power chain kind of the rule of thumb is when we're on the 14 wire, we don't want to power chain more than four teeth. When we're on the 16 wire, we don't want to power chain more than six teeth. And when we're on the 18 wire well at that point we can power chain the entire arch. Typically I'll do a power chain when I get to the 18 wire. The longer the power chain and the thinner the wire, it can actually cause that wire to buckle. And if that wire buckles it's going to be harder to get the teeth to slide along the wire with their brackets and it can actually distort that wire which can cause unwanted tooth movement. So again we're trying to keep things as simple as we can. I hope at this point even if you never done ortho it's been a while since you have done with brackets and wires that you can see it's going to be very simple. We're going to send an upper and lower impression to the lab. The lab is going to going to actually figure out where the brackets need to be place. They make these indirect placement trays for us. If we bonded the restoration in our patient's mouth before doing a direct composite, we can brand these brackets on. So we just go through. We bond the brackets to the teeth, guided by the placement of those trays. Once we get the brackets on to the teeth what we're going to do is we're going to put the 14 wire on and just use the elastics to hold the wire to the brackets. Then four weeks later we're going to possibly take that 14 wire off and put a 16 in and elastic back in. When the patient comes back four weeks later, we might step up from the 16 to the 18 wire, put the elastic back in, let that finalize the case and now the patient comes back with nice straight teeth. It doesn't get much easier than that.