Cosmetically focused adult straight teeth for the General Practitioner

Part 4 - Integration

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 discusses how to incorporate CFast into your practice.

So what we're going to do is we're going talk about setting up our patient's expectations. Again, CFAST is meant to be a limited orthodontic procedure not a comprehensive orthodontic procedure. So I want to make sure that what I expect the treatment to provide for that patient is what they expect or visualize in their minds. So what we to do is we have to clearly define what that end goal is going to be. Predominantly what we're going to do is we're going to take your front teeth cuspid to cuspid and we're going to try and align those as esthetically as we can. You know if you've got worn teeth or dark teeth, we're not going to address that with CFAST but we'll address that after you're provided the CFAST alignment. So we have to have that clearly defined. If the patient expects more then I'm going to refer that patient to my colleague orthodontist and recommend comprehensive orthodontics. What we're not going to try to do is we're not going to try to correct skeletal discrepancies. So if a patient has a very pronounced class 2, CFAST may correct that if we round out that lower arch, may push those teeth out labially or facially but we're not going to try to change it skeletally. It's not one of the things we're trying to do. We're not starting off with a lateral set to measure all the different angles. We can change and tip the teeth out maybe facially but then again we're limited. If we tip them out too far we can run in some soft tissue issues. Here's a case where we have to discuss with the patient possible edge challenges. So in this patient if we look at her smile, it's a pretty nice smile, interested in CFAST, wants a little bit more ideal alignment. But if you look at the upper arch, the upper arch already has a fairly nice curve to it. If you look at the lower arch, the lower interiors go straight across. One thing that we have to visualize is if we put a lower arch wire down there and we round that lower arch out, are we going to move those lower anterior teeth out facially possibly creating traumatic edge bite. So we have to think about those issues. What would I do with this patient? Often times I'd advice them that we'll go ahead and put the archwire on. We'll see how the teeth move. If it looks like we're getting to that edge position or worst yet maybe on a lower anterior crossbite I may just let the archwire wore off and let the teeth relapse. What we may also do is slenderizes lower anterior teeth. So not only are we going to round that arch out, which may move the teeth out labially or facially a little bit, but then we'll slenderize the teeth, power chain them in that way kind of retract the teeth again. So now she'll have straighter teeth. She'll have nice round arch form but we won't have that edge to edge bite. One of the things that we had to discuss with the patient is that differential tooth wear. So if they have teeth that have been traumatized because of bite issues. So a case like this where tooth no. 9 or the upper left front tooth has been occlusal situation that has worn its incisal edge, we have to advice the patient again we can give you straight teeth but these straight teeth they're going to have wear. And once we're done aligning the teeth we're going to have to adjust those issues. So again just set out the patient's expectations. Again patients aren't dentist. They can possibly think hey if I do CFAST because it's going to give me that pretty smile then I'm going to have not only straight teeth but white perfect teeth. And they will not just from the alignment procedure. But no worries we can go ahead and take care of things. So here's the case post CFAST treatment and now we're going to have to take care of the occlusal wear issues with bonding or veneers or whatever is most appropriate in your hands. Black triangle formations. So if I have teeth that are overlapping one of the thins that I might have to think about is if we correct these teeth and I take the two upper centrals and I spread them apart, do I have to worry about a black triangle being formed especially interdentally between the two centrals which would be very un-esthetic. That's a possibility. Now how are we going to handle that? Well again we've talked about this before. One thing we could do is slenderize the teeth and maybe power chain them together to bring them together, create a longer contact but kind of squeeze the papilla together. What we could do is we could take a derma filler. We can inject that into a papilla and actually kind of plump it up. Another thing we could do is we can take some composite. That ultimately was done in this case and just add some composite to the mesial, the upper right central, upper left hand central on the papilla area to kind of squeeze the papilla together and fill in that dark triangle. But again those are things that we can handle if we can foresee it and advice our patients about it before we begin to trim it, it is even better. But if there's any kind of compromises it's good for us to discuss that with the patient. And if we have to take photos, if we have to document that in the chart, it's always good to do that. So if there's an issue where there's a lot of diastema. I've had patients like this where there's a lot of spacing and I tell them you know what I'm going to try to pull the teeth together, but agan it's going to take us more time typically than our 5-7 month window. So I may elect not to do this case. But I have a case that I'm finishing up right now and it is taking me longer. It's taking me about 10 months but she had multiple diastema spacing. And I told her, you know, a CFAST we may or may not be able to pull the teeth together. I just saw her a couple of weeks ago, the spaces all the diastema are closing up very nicely and she's a happy camper. So it went over my timeframe. One of the reasons why I did do a case like this that went over that 7 month period is ultimately we're going to have to place some veneers to kind of give her that ideal smile. In a case like this where the bicuspid are tucked in lingually. Now again CFAST is concentrating predominantly on a cuspid to cuspid area so I would tell the patient hey we could use CFAST and we can align the cuspid to cuspid area. But I may elect to leave the brackets place past the bicuspid, not purposely try to rotate them, not purposely try to expand that palate. So in this case CFAST may not be the best answer for this patient or the best solution. But something I want discuss with the patient first because some patient says you know what I really don't care about those back teeth, I just want my front teeth to be straight. So in that case, CFAST may be something that we could consider. So again remember to go through the informed consent, remember to discuss all limitations to CFAST with your patient. Make sure things are clearly define so that when you provide that treatment, you'll end up with a patient that's happy in the end and then where you've met their expectations. All right, I'm going to go on section 5. I don't want you down here. Don't move. I moved cause I got to switch my computer. Oh my gosh, I just took 30 years off your life. You did. You got rid of all the wrinkles. I did actually. You send it to Irene to say this is your new husband. Say this is what living Texas would do for me. You know that problem I'm going to have with this part is, I guess I can read it. Do you want to step up a little bit. No, it's okay. I just want to make sure what the fine print says. One, two, all set. All right. Now we're going to talk about the integration of CFAST into your practice and some of the marketing aspects. Because it's great if you're excited about CFAST but you also want the patient to be asking you for the CFAST treatment. So that's what we're going to discuss next. As you start with CFAST the first few cases you want to do are those where you know you're going to have success. So try to start with the ideal case. Pick somebody who already has good dental health periodontally, joint wise, restoratively everything is nice and stable. Make sure that they understand that we're going to be moving the anterior teeth, the canine to canine area, the area that they see predominantly when they smile. You want to start with cases where if there's crowding there's not too much crowding. Maybe 4mm of crowding tops. Two millimeters would probably be ideal. If they have spacing, diastema, we've like to have no more than 6mm of space if you added up all the space between the diastema. Again 2mm or so would be great for the first case just so you get a feel of how CFAST and minor tooth movement type orthodontic works. You want the posterior teeth to be fully erupted. You want the root to be completely formed and that's one of the reasons why we try to avoid CFAST with kids. And you want to make sure that your patients are periodontally healthy that occlusal that they feel like their joints are healthy and that they got a good bite. Often times what I'll do is I ask the patient how does your bite feel. If they say hey my bite feels good then I consider them a good CFAST candidate. If they come in and say you know what my joints hurt, I got headache pain, my bite has never felt right then what we need to do is address those maybe first before you move into CFAST. What we need to do is we need to talk about CFAST with the team. Because now that we've gone through this with you as the dentist, the clinician and you appreciate what CFAST can do, what you need to have is for you team to appreciate that too because everybody in your office needs to be speaking positively about CFAST treatment. And then what I'd like you to do is set some goals. So explain to your team. What you'd like to do is find one patient a week that wants to start CFAST or maybe two patients a week that want to go through CFAST. If you don't have the instrument, call us up, ask for a starter kit of instrument and supplies. That way you'll have elastic. You'll have extra archwire. You'll have extra brackets. You'll have all the pliers and all the different instrument and you'll be ready to go and then find that ideal case. Talk to your team about the benefit of CFAST and I think that they are many. One it's minimally invasive. It can be more affordable to your patient to provide them with the esthetic smile if they want and we can do it very quickly often times between now and the next cleaning. It's a good way to attract new patients. Go ahead and mark it that you provide a very esthetic way, a very quick way, affordable way to give a patient a newer smile in the most conservative way possible. And what I would encourage you to do is to learn some of the new minimal no prep veneer techniques. Now you're able to align the teeth and without even having to give the patient a shot, give them that ideal smile, straight teeth, white teeth of that ideal contour. Figure out who would be a good patient to discuss CFAST with during your morning huddles. You know many times your hygienist, your assistant or your front desk even they know which patients are most interested in that ideal smile. So you might mention you know what today at 10 o'clock we have John coming in and he's always thought about straight teeth maybe we should at least discuss CFAST with him. And then be comprehensive. And that what I mean is don't get so excited about a patient saying yes to CFAST that you overlook the fact that you have to now step back and make sure that comprehensively they're ready to go through CFAST treatment again soft tissues, joints, carries free. And if you think that they need more than just the anterior segment of teeth move which is all about CFAST and comprehensive orthodontics would be better, refer them out. You need to explain to your team which cases are best, what they should be looking for. I'd tell you in our practice, our hygienist actually often times find the patients that wanted to go through CFAST. So I'll walk into the hygiene room to do my exam and my hygienist will say patient Sally is interested in having straight teeth. I mentioned CFAST, what do you think. Very quickly I'll kind of do my eyeball guesstimate, figure out if CFAST would be appropriate, maybe schedule the patient back for further exam or if I have time to do it right then and maybe even take models and get the case going. Remember to set your fees determined for your practice what the appropriate fees would be. Often times it's going to be less than what a comprehensive orthodontics case would cost you in your community. So if in your community comprehensive orthodontics would cost $6000 maybe $6500 you might price your CFAST treatment to be $1000 and $1500 or even $2000 less depending on what the going price is in your locale. And then discuss how to discuss with your patients. Go look at the brochures, go to the website, see some of the ways that we describe CFAST and share that with your team. Explain to them the system especially with your assistant and your front desk that what we need to do is once the patient accepts CFAST treatment, the front desk will discuss the finances, will discuss kind of the timeline that we're looking at. Then what the assistant will need to do is maybe grab some photos upper and lower impression, send that to the lab with the lab script filled out. The front desk will need to schedule the patient back a couple of weeks later once that case is back from the lab. We'll actually bond the brackets into our patient's mouth. Our assistant can then put the wires and elastics on to activate that case. The front desk will then schedule that patient to come back every four weeks until we're done. Explain to your assistant that you'll be checking the wires at appropriate time. You might indicate to you assistant let's take all the elastics off, let's move up to the next bigger wire, re-elastic the case and then get the patient going on their way for another four weeks. Explain to your assistant who will be sending the cases in what the lab requirements are. Hey we need a good upper impression, a good lower impression. Again typically I just use a medium body PVS impression material. I don't reline it with a wash. I don't need that accuracy in my impression. I take a medium body upper, a full tray impression, same thing on the lower, send that into lab. Your assistant do not even have to pour up those PVS impression, the lab would take care of that for you. So if the patient has crooked teeth they've been identified. Remember about 75% of our patients have crooked teeth. Now if they are periodontally in joint stable they're still a good CFAST candidate. But if I look at that case and think well it's going to make maybe a year to finish that case then I'll refer them for many comprehensive orthodontics. But if I look at that case and I think I can finish that in 3-5 to maybe 7 months, they're still a good CFAST case candidate. Again pricing suggestions. Average fee that I hear around the country when I go and present this for two arches anywhere between $3500 and $4500, for single arch the average fees go from $3000 to $3500. How would you build this out? Again, I know the CDT code changed just this year so I need to reconfirm these codes. But when you charge the patient out for the very first visit maybe for diagnostic cast you may charge them out for panoramic x-ray or full mouth series of x-rays cause you want to make sure that the bone and the teeth and the roots and everything are all good and healthy. We might take some diagnostic photographs. You might have a fee for that. You might do a pre-orthodontic treatment visit. You might charge out for that and then for the actual CFAST case that we bill as a limited orthodontic treatment case. And again we're trying to stay away from comprehensive orthodontics. Those of you that want to learn how to do comprehensive orthodontics I think if you get comfortable CFAST then you move in the comprehensive ortho that transition would be very quick and easy for you to go through. What I now need to do is talk about the team training. You know you need to explain to them why we need to gather all these information and gather again the frequency of the appointments. Once they understand this and they're able to advice the patient that yes they think they're a good candidate and they'll refer and pass it off to you. Again we're set and ready to go. You set the goals up. You want to have one patient a week that we identify and we get going in CFAST. Add that to your monthly [meeting]. In our office, what we try to do is once a month we go through our numbers. We kind of review what work, what hasn't, areas that we can improve in. And what I do is I add a little number to our monthly review sheet. How many starts did we have with our CFAST cases? If we're aiming for four a month, one a week then just write that number down. Have your front desk your monthly meeting that hey we had five starts that's a great month or maybe we had two or below our goal. What do we need to pick that up? So submit that first case, get it going now. Cause one of the things is you watch this program and you say you know I've got a lot of patient that need this. But then you put it off. You don't actually follow through. You don't recommend CFAST. What I recommend that you do is again if you don't have the equipment, call us up say you need the supply, you need the backup supplies, extra O-rings, archwire, brackets. You need the instruments. Just call us up. We can get that to you. Now what you need to do is once you feel comfortable, your team understands all about CFAST, you feel comfortable with CFAST, you've got all the tools you need to provide that treatment, now you need to get that word out through marketing. And what we'd advise you to do is we've got posters, videos, brochures, put the brochures in your office, put them in a new patient packet if you mail those out, put the posters up in your office. I think they're very tasteful. Put your certificates up. When you complete this course you're now maybe a certified CFAST provider. Go ahead and put that certificate up in your office. We have a CFAST provider logo that you can put on your newsletters, on your website, but I would exhibit that because you are one of the few trained in CFAST. We have sample press releases that you could give out to local papers. Talk about CFAST with all your patients, take photos. One of the big things about the photos is every four weeks when your patients come back for their monthly appointments, put out that preop photo or have that preop models out because I'll tell you I even forget how much their smiles are improved. It's such a gradual thing. You forget what they looked like 2 months or 3 months ago. But just the other day, I was going through some old models and there are models and cases that I finished up and I couldn't believe how crooked some of these patients teeth were when you started because over the last 3-4 months I've been seeing them I've been seeing a straight teeth and I was just amazed by that change. Well your patients forget where they started also. So if you have the preop photo or the preop model and every month you show them where you started, one, they appreciate the changes that are occurring. They appreciate what you're doing. They value what they're doing. And you're hoping that they'll go and tell their friends and family, wow, you won't believe how much my smile has changed with CFAST and it's been so easy. I think one of the big things is to always have fun. What we want to do is we want to have fun with this. Remember it's very conservative. There's no injection. It's very easy to do. Here's a video that you can actually put in your waiting room or maybe on your website. But it doesn't have sound but it just ask questions. Are there things about your smile you don't like? Do you feel like you cover your smile up when you're talking or cover your mouth up? Do you try to hide your mouth? Do you feel like it's affecting your career? Just ask some very simple questions and it just shows a few simple images. It explains to your patients that hey within 6-month period, you could have straighter teeth just ask about it. If you have any interest, you can ask us. So again it's a very good video, very simple, it's very quick. It doesn't take much or long for your patients to view the entire video. And I would use it as a tool to increase the interest that your patient is having at CFAST. So CFAST is fast. It's discreet. Everything is tooth-colored. Ceramic brackets, white wires and it can be very affordable. So Chet Holmes who recently passed away but he was one of the top of the sale game or the game of sales. So the study shows that 85% of all motivation optically stimulated. Can you build some visual aid that will help you communicate more effectively? And that's why we have things like the wall posters. Put those up. And just ask. And shows on the bottom left hand corner before and after but it ask your patients would you like to have a better smile. We had the brochures. Put the brochures throughout your entire office, in the reception area, the front desk, in the operatory, in your new patient packets. Just get the word out. We have a before and after book. So it's a book that has before and after photos. And we put those in all of our operatory. We put that in our reception area, at our front desk. So patients when they're standing or waiting, they can flip through the pictures. And a lot of times as they flip through the pictures, they'll turn to me say can you do this for me. And again that takes the whole proposition of sales out of our hands and now we are just providing the solution to something they're seeking. When you become a certified CFAST provider, you'll get a certificate and we'll have your name on a certificate. And I suggest you put that up on the wall. We also give this logo and this is the logo that you can put on your website, you can put on your newsletter. We actually put this in our patient newsletter just to let them know that we are certified CFAST providers. Actually here's a copy of that newsletter and actually put a picture of myself just showing hey I'm the dentist providing you with all the dental treatments that you come to our office for. And I believe so much in CFAST that in this photo I actually have CFAST in my mouth. We actually have press releases that we can give you so you can issue those out to the local newspapers. See if it can get pick up and then just talk about it. Your front desk should talk about CFAST. Your hygienist can talk about CFAST. Your assistant can talk about CFAST. And you as the clinician should be talking about CFAST. We also have a CFAST provider locator. So once you've become a certified CFAST provider, we'll put you information on a locator so if patients are interested in CFAST and they want to find a provider close to them they can just go to this website. What we hope to do is actually help you develop your social media marketing. If you want to get into a direct mail campaign and we have tools to help you do that. In office electronic education programs we can help you with that. And what we can really help you with is tying this all together with whitening and minimally invasive veneer techniques. So some studies and it's a study that we can provide with you, just showing that even if you have brackets on, if your patients want to go through the bleaching process, have trace made while they have brackets and wires on that that bleach will actually get up underneath the brackets and whiten the teeth. So that when you take the brackets off and if they have been using a tray whitening technique they won't see dark spots where the brackets were place originally. And then I also teach other programs in minimally invasive esthetic. Minimally invasive actually no prep veneers. We have programs on the HDiQ website that go more into that. So really we want you to have fun. Just three words. Just do it. I think CFAST is a great service to provide for your patients. There are other systems out there that are similar. Again I recommend that you look at all of them and find the one that you feel works out best for you. You go to CFASTmodels.com for more resources. We're always putting more resources through HDiQ. We're putting more programming and we really want to provide you with the tools to make you more successful. One of the people I like to read who is kind of a leadership type of writer and speaker John Maxwell tells a story about five frogs sitting on a log. And I guess this was a story about when he was a child growing up his father would kind of share with him as a riddle. And the riddle starts out five frogs sitting on a log. Four decided to jump off, how many are left. And so again John being asked this by father would ponder. All five frogs on a log, four jumped off, probably one. So the first time he said one. No, his father responded, five. And why is that? Because there's a difference between deciding and doing. Often times we decide hey CFAST looks like a great service to be provide for my patients but we keep putting it off. The point was John's father was trying to drive home was American politician Frank Clark said what great accomplishments we have in the world if everybody had done what they intended to do. Most people don't act as quickly as they should on things. They find themselves subject to the law of diminishing intent which says the longer you wait to do something you should do now, the greater the odds that you would never actually do it. So the reality is you will never get as much done unless you go ahead and do it before you're even ready. Some of you will say well I want to learn more about ortho. I want to take more ortho classes so you'll put it off. And I will tell you I think in that situation not only do you lose but your patient also lose. What I would encourage you to do is see this program again if you feel like you need to. You can call us up for support. You can find those patients where you think they might be suitable CFAST candidates. You can send us photos. You can send us models. We'll walk you through those cases as you first get started. So here's our contact information. You can look us up at www.cfastsmiles.com. You can email us at info@cfastsmiles.com or you can contact at toll free at 800-725-2327 and we're really here to help you succeed. W got tools. We're creating more resources. We've got the starter kits. We can get you up and running very quickly. So again I hope you've seen this as a program that can provide value to you, to your patients, to your practice, and I hope you enjoy providing CFAST smiles. Thank you very much.