Cosmetically focused adult straight teeth for the General Practitioner

Part 1 - Overview

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 what CFast is and why patients want this type of treatment.

Hi, I’m Dr. Michael Miyazaki and during this program I want to introduce you to a new technique that we’re using called CFAST. What CFAST stands for is cosmetically focused adult straight teeth. And basically that name describes everything we’re going to talk about over the next couple of hours during this program. Cosmetically focused means that we’re going to talk about straightening the front teeth, the teeth that the patient sees when they smile and they are most concern about, typically the cuspid to cuspid on the upper arch and cuspid to cuspid on the lower arch. CFAST is more for adults not for young children with still developing teeth. So it’s cosmetically focused cuspid to cuspid. It’s for adults and to give them straight teeth. So I think CFAST describes this that we’re going to talk about very well. The objectives for this program are one to discuss this treatment for your patient. How its better I think for your patients to offer to them. It has a good return on your investment and the time and the investment in learning how to provide the treatment. Again with any clinical procedure that we performed, case selection is often the key to success. We’ll discuss what kind of cases CFAST is most appropriate for. Then we’ll also talk about the biology, the mechanics, the instruments, the treatment flow and the protocols, the entire system. At the very end, we’ll talk about how to implement CFAST into your practice and some of the marketing tools we developed for you to use. The basic philosophy of my practice is that our treatment team involved the alteration of as little tooth structure as possible and should affect as few teeth as possible ultimately meeting the condition of total body health. So when I see a patient for the very first time we try to do a very comprehensive examination. We’re looking at their teeth, the gum, looking at airway. We’re looking at TMJ the jaws how the muscles are functioning. And if we have to make any corrections, it’s not my goal to do a full mouth rehab on them. It’s my goal to provide them with the treatment necessary by being as conservative with their tooth structure as possible. We should also strive to develop simplicity not complexity. But when we dealt with complex situation, we should be able to perform it superbly in exact and systematic fashion. Meaning if we have that complex case then we want to give the assistant to evaluate it, to treat it, and make it a clear cut system. And what I’m going to be able to do during this program is give you the system to provide CFAST treatment I think very effectively and efficiently for you and your patient. Our finish work results a maintainable health, comfort and ultimately beauty. And one of the things that we can do for our patients is we can now get them straighter teeth, making it easier for them to keep those teeth clean, easier for them to brush and floss. Gives the more comfort, often times it actually improves their bite and improves the esthetic for sure. And then overall that improves our patient’s beauty. And I think one of the things I applaud you for observing this program or watching this today for is you’re constantly learning so you can provide your patients with the very best and the latest. So CFAST overall with my practice philosophy fits very well into the way I practice my dentistry. I’ll state this as an example. When you look at this case, how might you think about treating this case? We have a lot of crooked teeth in that esthetic zone that patient sees all the time. We have an adult patient here. So again this could be a perfect CFAST candidate. But many of us who don’t know how to do the CFAST procedure will look at this case and the patient will ask us how could you improve my smile. We might be thinking of things like veneers or maybe crowns and we’re limited to kind of more invasive procedures. And I kind of think about this as a bookcase. You know sometimes you’ll see those bookcases with a backing, a little cardboard backing. And on the shelves we got a couple of solutions we can offer our patients, the crown, the prep veneers we open up all the contacts, takeaway a lot of tooth structure. That’s what we see. But what I hope to provide you after watching this program is a couple of other things to put on the shelves. So in the bookcase with the backings right now we can only see certain solutions to this program. But to somebody who has a CFAST background if we’re to flip that bookcase around in the cubicles with those backings we might see other solutions like whitening, CFAST to align the teeth and actually no prep veneers. We no longer have to prep tooth structure away. So three of the reasons that CFAST I think is a potential for your practice growth from this year on is that according to the national health services or national center for health statistic about 75% of Americans are suffering from crooked teeth. Think about in your practice, how many patients come to your practice and have straight teeth. The ACD American Academy of Cosmetic Dentistry says the majority of Americans feel that having not ideal smile can actually affect our happiness or success in our careers. And I think more important we understand now if we have chronic inflammation in any part of our body and think again of how many of our adult patients have crowded crooked teeth, that makes it difficult for oral hygiene. And they have areas of chronic inflammation and maybe areas of active periodontal disease how that creates a systemic and chronic inflammation situation of the mouth that affects us systematically. So I think CFAST has those indications but also it’s the wants. Think about the baby boomer generation. Many of us that are baby boomers had ortho when we’re in elementary school, maybe junior high, high school and we had straight teeth. The orthodontist we were seeing at the time gave us some type of retention. A retainer we never wore. Our teeth have relapsed. We have crooked teeth. And what we’re trying to do is we’re trying to look younger and have a better smile. CFAST can answer or provide a solution to that want cause how many baby boomers actually try to look their age. Most of us are trying to look a little bit younger and a little bit healthier. So let me give you a little bit of background information on CFAST and we’ll go from there. Again, the evolution of instant orthodontics. If we were talking about this subject a decade or two decades ago instant ortho often meant we were going to do veneers. We’d have to take away a lot of good tooth structure, put porcelain or another material over the top of those teeth to provide the color and the contours that the patient desires. Today in 2013 and moving on, we’ve got things like CFAST which again is a way straighten the teeth so that we can provide the proper alignment. And then if we have to improve contour and colors, we can do minimal to no prep veneers over the top. So what is cosmetically focused movement. It’s really a mini invasive solution for some patients, for some adults who are seeking a better smile and better oral health. I like to think about it as it’s a solution I offer to the patient. So if the patients are interested, we go more deeply into what CFAST really is. There are some patients that don’t mind their crooked teeth. You know what at this point when we present CFAT maybe it’s not the right thing for them but we can just plant the seed. Really what we’re trying to do is we’re trying to combine conserve anterior esthetic with conservative tooth movement. So we’re trying to move those front teeth so that we can provide very conservative treatments later. It’s really again not for kids. Why not for kids? Well with kids we have the skeletal growth. We can actually idealize a lot of skeletal features and alignments. So let’s go ahead and do more comprehensive ortho. And I’ll tell you again in my general practice I really don’t want to provide comprehensive ortho just because it takes so much time. In order for it to be win-win for me and my patients I’ve had to charge a higher fee. Now what I’d rather do is I’d rather keep those relationships I have with my orthodontist and my community, refer the kids, refer the adults that need the comprehensive orthodontic work to them. I’ll take more the simple cases. So let’s think about it. If adult patient enters our practice and we see the have crooked teeth and we mention ortho, first thing that they conjure up are lots of reason why they don’t have the orthodontic treatment. One of those is time. When I asked many of patients how long do you think it’s going to take to have straight teeth? They think well I had ortho before it took 2, 3 or 4 years. They were thinking if we do ortho again, it’s going to take the same amount of time. What I try to explain to them is again if we’re concentrating the anterior, the front teeth, the front teeth we can move much more quickly and we can probably have the alignment of teeth corrected within 5 to 7 months. So by the time they come in for their next cleaning if they’re on a 6-month cleaning schedule they can have straight teeth. And that often kid of opens their minds to the possibility of CFAST. The other objection is the appearance. They don’t want to have that metal mouth look. They’re in their 40s, 50s, 60s. I have patients that are doing CFAST in their 70s. They don’t want to have that metal mouth. So I just tell them you know with CFAST we use clear brackets, we use ceramic brackets and white colored wires. So again esthetically people really don’t even notice that you have the appliances in. Here’s a couple of photos. Here’s a woman with the CFAST. The appliance is in, the ceramic brackets and white colored wires. You barely see them at all. Here’s another gentleman with the same thing. Again very esthetic. The third reason why a lot of patients aren’t thinking about orthodontist is the cost. When they have ortho done before as a child it was expensive and today their kids maybe going through orthodontics. It can be $5000 or $6000. Again what I try to tell the patient is because the timeframe of this orthodontic procedure is much shorter it’s going to be less in cost. So it’s going to cost less than traditional orthodontics which also again is a very positive thing. So some clinicians will say well what about my orthodontist. Am I stepping on the toes on my orthodontist and kind of their turf or dental field? And I say no. Because what we’re going to do is those patients, especially as we become more comfortable with moving teeth around, we’re going to identify more patients that need comprehensive orthodontic work and those are the patients that we’re then going to refer to our orthodontists. Right now in your practice you may refer a lot of the children out and maybe not a lot of adults. But as you identify more adults who could benefit from comprehensive orthodontics or are interested in and you feel more confident about more of those patients who then accept the consultation appointment and you’ll be referring them out to your orthodontist. So I really think again it’s going to be a win-win situation. So now with CFAST what it’s going to provide you is just other options. It’s very simple. It’s going to be a fixed technique. It’s going to offer another income stream. It’s going to be very tooth friendly. So if you look at all the benefits of CFAST and how you’re going to offer that benefit now to you patients, it really becomes win-win. So bottom-line, I think ethically if a patient has crooked teeth, we should at least offer them a solution, CFAST. You know what we can do is we can actually straighten these teeth out. If you want nicer smile and you want wired teeth, we can straighten the teeth out and then bleach the teeth. Again very conservative. It helps our patients look their very best. It will help them take better care of the teeth and it’s very conservative. Other than right now you might say well you have crooked teeth, we can offer you prepared veneers or we could offer you crown maybe crown type of work. We have to take away a lot of sensitive tooth structure. So I really think it’s the right thing to do. Again we’re not going to force on a patient. We’re just going to say if you ever thought about having straighter teeth, here’s an option you now have. CFAST we bill out as limited orthodontic technique which really means that we’re going to work on a limited area of the mouth. Again, we’re not trying to be comprehensive orthodontics. We’re just doing limited orthodontics. And because of that we’re not trying to change skeletal features alignment. The nice thing about that is I believe CFAST is unlimited potential. If the average CFAST case is $4500 and you do two cases per week that could add another $9000 per week of revenue to your practice or another $36,000 per month. So again that’s just doing two cases a week. And you might like to do one or maybe four cases a week. So what I really want you to think about is I want you to think about the patients where CFAST might be appropriate for them. So again the system as a whole is let’s go ahead and aligned the teeth and we’ll use CFAST to do that. Many of our adult patients have crooked teeth that are dark. So if they have crooked teeth that are dark and we align them they’re going to have straight dark teeth. What we can then do is then offer some type of bleaching whether bleaching whether it be an in office or take home. So now we’ve got aligned, straight, white teeth. But again many adult patients will have worn their teeth down maybe the incisal edges or maybe the tooth is rotating, the incisal edge is worn unevenly. So now what we do is we align the teeth, we whiten the teeth and those that need to have the color or contour restored to them we can then do with very conservative no prep to minimal prep veneers. When I’m looking at CFAST, I’m looking at patient what I often look up mentally is how much space do I have between the teeth. If I have overlapping teeth and I need to straighten those out. Do I have enough room in the arc to go ahead and do that? We’ll talk about that. I’m looking at the cervical position incisal position of the tooth. One of the differences in doing an adult case is that many times they’ve worn the incisal edge off. With children they don’t have that incisal wears so when the brackets are place often times it’s measure from a measurement up from the incisal edge. Well if we try to do that with adults and the adult patient that we’re seeing we are seeing has incisal edge wear that’s different between the teeth and we position the brackets to line the incisal edges, often times what they’ll do is they’ll throw off soft tissue symmetry. So when we’re doing an adult type cases, we’ve got to figure out do we align the soft tissue positions up or do we align the incisal edge positions up. Again if we do the soft tissue we might align the soft tissue and then go ahead and some kind of restorative procedure to even out the incisal edges or if we level off the incisal edges, what we might do is maybe a soft tissue laser procedure to align the gums. So we have many more options. And then I’m also interested in the facial lingual positions of the upper jaw and the lower jaw. Cause if we put brackets on the lower teeth and I have a deep overbite are the upper teeth going to knock those brackets off? So those are some of the four major areas I’m looking at when I’m looking at a case. From a small design perspective, what we’re trying to do is we’re trying to line the teeth out. We’re trying to have a mesial type of inclination to the teeth so it looks like they’re all kind of pointing towards the belly button. We’re trying to get gingival symmetry on the teeth and we’re trying to position the gingival zenith to the highest point of the curvature of the soft tissue, slightly distal to the midline to accentuate that mesial inclination. And we’re trying to finish with a smile where the incisal edge is are fairly level. The incisal edges laterals maybe up a little bit from that occlusal plane but fairly level way across. With an adult smile, often times we’re not able to do that. So in this diagram again the upper right central has more incisal wear. So if we level out the cervical positions, our incisal edge on that upper right central is going to be shorter than that of the upper left. So what are we going to do with that? We may elect to restore the upper right central with a veneer or maybe some bonding. So the options that we have when we’re looking at a case from a CFAST perspective are numerous. But again it’s benefit for the patient because it’s very conservative. We’re not trying to take a lot of tooth structure. Here’s a patient that we treated. Again she has veneers on the upper arch. So if you see the upper incisal edges on the bottom on the photo there, you can see how uniform the teeth look. But on our lower arch, she had a lot crowding. And what she wanted us to do is she wanted us to straighten out the lower teeth. So our mid treatment photo you see on the side here with the wire there as you can see how that orthodontic wire is straightening out and rounding out that lower arch and leveling out the occlusal plane of that lower arch. Here’s another example where we have on the left hand side the preop of a slight lower crown of the lower arch and how you put that orthodontic wire with the clear bracket on that lower arch within a month or two we’ve rounded that arch out. We’ve gained the space. And as the previous one you might think well maybe we have to do some interproximal reduction near the teeth to get them to fit. What will actually happen in many cases is we round that arch out, we actually gained more arch length and the teeth can then fit shoulder to shoulder. So here’s a case where the upper arch we got cuspid where this wasn’t enough room. It was a little bit higher than the occlusal plane. And again mid treatment what you see on the right hand side is how the wires begin to level everything out. Again these cases are done in under 4-5 months. So what I want you to think about is CFAST you can recommend your patient where their teeth don’t have to be way way off or way out of alignment. Sometimes it’s just correcting a single tooth. Here we have the two centrals that are overlapping. And it’s not an ideal posture to that area. But if the patient comes in and she wants to straighten those centrals out, CFAST can provide a solution for that. What we then do is once we have the teeth straighten out, we’ll talk about this later in the program, is we do some type of retention to prevent relapse of the arches. So when the teeth were crowded and we then straightened them out they do want to go back to that [preaching] position and relapsed. What we’ll do often times is we’ll put a fixed lingual arch wires. Sometimes when the upper arch and the lower arch to keep those teeth in position and we’ll talk about our different forms of retention later on. Here’s another example. So CFAST again. Here’s a case where just straightening the teeth out you can see the laterals and just kind of leveling the occlusal plane out. Here you see an upper left lateral just straight out, making the arch form a little bit more uniform and just how the subtle changes that these patients accomplished three CFAST in just a short amount of time. It’s really what a lot of our patients are looking for. So let’s talk a little about the mechanics. Teeth are always sort of in motion. We’ve got the tongue pushing out. We have the lips and the cheeks kind of pulling in. And there is kind of a threshold limit that’s tolerated by our periodontal ligament. So the teeth have a little bit to give. And when we look at our patient’s teeth we can wiggle them a little a bit. We know that within in normal limits, that’s going to be a normal amount of movement to have. When we have removal appliances, one of the hard things about removal appliance is having the patient be compliant. If they have a retainer, if they have clear trays and they don’t wear them, the teeth don’t move. And I’ve experienced that with some of the clear tray technique, which I think are very good. But I’ve had patients wear the first 3 or 4 months the teeth are moving and they’re moving very well as planned. And then we got deliver a next set of trays and when they put those trays in they go my teeth are starting to back out. They’re starting to relapse unless the patients haven’t been wearing the trays. And many times they have not been wearing the trays as regularly as they were the first couple of months. So maximum efficiency is attained if the patients wear whatever appliance it is 24/7. One of the nice things about CFAST is we bond the brackets one. We have wires. Wires are affixed to the brackets of the last six with metal ties and 24/7 those teeth are being moved. Again as we moved the teeth we’re going to do it very physiologically. We don’t want to put the bone or teeth under any kind of duress. So we’re going to use light forces so we get frontal or direct reabsorption of the bone. We got our primary players osteoblast and osteoclast. What we’re going to do is we’re going to actually apply continuous force to the bone. In doing that we’re going to be able to move the teeth the most efficiently that we can. So we’re going to put a wire. We got through 3 wires we called the 0.014, the 0.016 and the 0.018 [0:19:30][inaudible] wire. The higher the numbers, the larger the wire. So we do first we start with the 0.014. I just called it the 14 wire. As the teeth begin to move, that wire begins to lose some of its force so a month later we might put in a 016 wire. That again is a little bit thicker, a little bit stiffer so it begins to move the teeth and now will die off after a while. And then we’ll put in the 018 to kind of fine-tune the teeth. So we always have a continuous force going 24/7. One of the nice things about 24/7 is we’re able to use a lighter force which means it would be less discomfort for our patients. When I talk to many of our patients after they come for their 1-month review appointment, how ask them how are the teeth been or how are the teeth right after our last appointment. And many times they say you know there really was not discomfort associated with that change at all. So what are we doing, we’re going to use the wires to put pressure on the bone. We put pressure on the bone. We’re actually getting some resorption where we can press the bone or the PDL and we stretch PDL out and create tension. We’re going to actually get more osteoblastic activity to deposit the bone. The way that CFAST works is we use wires and brackets. The wires provide the life force for the frontal direct resorption. The wires also want to go back to their original form being straight. And so the brackets then help us to direct the forces. So, what’s going to move and which way. We’re going to anchorage which means we’re going to anchor the wires in the back to move those front teeth. So there are different forms of anchorage in orthodontist. We have extraoral anchorage like headgear whether it’d be from the back or from the front. We’ve got implants, the type of appliances we can put into the bone and use to move teeth whichever you want to move. And we’re going to talk about CFAST intraoral anchorage and that means using the size of the root of the posterior teeth that large surface area and from there we’re going to push remove the anterior teeth. So the posterior teeth are multirooted. They have a lot of surface area. They’re fairly fixed. The front teeth had the smaller root. The single rooted teeth and we can move them much more quickly. And with CFAST we’re going to use is we’re going to use the posterior teeth as anchors to cause anterior teeth to move. The brackets on those posterior teeth are a place most often passively. We’re not trying to move the back teeth. We’re just trying to actively move the front teeth. So we have active force in the front, passive forces in the back. So when I look at a case like this the way that I’m visualizing this is those back teeth, the molar bi area, that’s our anchor. And it’s going to be the cuspid to cuspid area. We’re trying to create that movement. So there are different types of movement we can create. We can tip the teeth. We can intrude, extrude. We can rotate the teeth and that’s primarily what we’re trying to do with CFAST. That simple movement. The movements that happen quickly. We try to avoid a lot of the [0:22:23][inaudible] movement or the Torquing at least with this initial program. So if we have a patient and we correct their smile with CFAST you can see a very subtle change but all that subtle is very dramatic. So we have overlapping teeth. The laterals don’t have the mesial inclination that we wish for. They’re position a little bit more out distally. What we’re going to do is we’re going to put the brackets on the teeth. Now what are the brackets position, how does that affect the tooth movement. Well the wire wants to go straight. So what we’re going to do is we’re going to put the brackets on the anterior teeth so the brackets basically parallel the incisal edges. Now in this case, you can see that the ankles are going to be on the posterior. The brackets parallel the incisal edges of those anterior teeth that are all crooked and some are going way mesial and some going distal. We’re going to attach our wires to those brackets. The wires are going to straighten out. And as it straightens out it’s going to straighten out the alignment of the teeth. So this is what the wire is going to try to do. The wire is going to try to go straight. What you can see in order for it to go straight, it’s going to have to move the brackets. As the brackets begin to move, the tooth move, the roots move and we can now align that maxillary arch. So you can see now the brackets are parallel to the incisal edges. The wire has leveled out the bracket position so the incisal edge position is now level. So here’s a quick video just kind of demonstrating how this works. We got crooked teeth. Again the brackets are parallel to the incisal edges. The wires want to go straight. So not only from a frontal view but from this occlusal view, you can see how even the arch form rounded out because the wire wants to regain its original shape. So the wire made basically a perfect U and it want is it wants to create an upper arch alignment that again reflects that perfect U. So what we don’t try to correct with CFAST. One of the things that we don’t try to correct are again skeletal deficiency. So angles class. If the patient have deep overjet, overbite, if they had class 2, class 3 we’re not trying to change the skeletal position of the bones, the jaw bones. If they have deep overbites, we’re not trying to verticalize the posterior teeth to decrease the overbite. Midline shift. Sometimes we can correct midline shift, sometimes we can’t. But one of the things that I try to tell clinician is don’t get too focused on that. Posterior crossbite we’re not trying to correct. Cause remember again we’re working cuspid to cuspid. If a bicuspid or a molar is in crossbite often times it’s really not a problem to our patients, maybe more to us. So I point that out to the patient. Have you ever notice that one of your back teeth is out of alignment with the rest of the teeth in that arch. Does that bother you? Many of my patients, all the patients will way no it doesn’t bother me. If it did, what I would do is refer them out for comprehensive orthodontist. So again CFAST we’re not trying to replace comprehensive orthodontist. We’re just trying to offer our patients a solution to improve their anterior tooth alignment. If you feel like they got a deep overbite and they can benefit from comprehensive orthodontist then again I refer that up to orthodontist colleague. If they have a severe class 2, class 3 tooth alignment. Maybe we see some wear and tear going on because of that, I would then again refer them to my orthodontist colleagues. If they got posterior cross bites and that posterior crossbite does bother a patient maybe esthetically and/or functionally, I’d refer that patient out to our orthodontist. So again CFAST is meant more for those easier cases. The eons that we can take care in a very short time frame, very efficiently for our patients and I think it’s better for our patients and our practice. And again the clear tray technique moving teeth are often very good for our patients. So I offer them that too. I asked the patient what they prefer to do. We have comprehensive orthodontist. We have the tray, clear tray orthodontics and we have CFAST that kind of falls in the middle. And I go through the risk benefits and alternatives of each one and let the patient decide. So again we’re not trying to change a class 3 patient to a class 1 or deep class 2 to a class 1. We’re not trying to correct deep overbite. Again these are the cases where if you really think it’s going to be beneficial to correct skeletal relationship or deep overbite or overjet, under jet position like this, refer them out to your orthodontic colleague. Because we’re doing limited orthodontics, we don’t worry about taking a lateral set because we’re not trying to change the skeletal relationships. Again, we’re only trying to correct the alignment of the anterior teeth cuspid to cuspid. So there are many celebrities that we see where they have that midline. And even though the midlines are off, they’ve still become very successful and they look good. So I tell the patient I go the biggest thing for us isn’t to get the upper midline and the lower midline in alignment. What the big thing for us to do esthetically is to get tem straight up and down. If they’re crooked that’s what people notices esthetically. If they go straight up and down but they’re off a millimeter or two either way when you bite down that’s something most people will never notice because we’re talking or when we’re standing in front of people usually we’re not biting down trying to show them our midline alignment where our teeth are apart. So it becomes much harder for people to tell. In this photo, you can see that the lower right first molar is in crossbite. So one of the things that we’d asked the patient is okay we can straighten your front teeth and again that smile zone cuspid to cuspid but notice how your back teeth is kind of in the outside of your upper teeth. That’s what we called a crossbite. Does that bother you? And again I would say for most patients, the layman patient that does not bother them at all. So one of the things that we’ll look at is we’ll look at the treatment flow. We’ll talk about the examination of the records. We’ll talk about treatment planning, the sequencing, figuring out this is true a CFAST case or not. We’ll talk about fitting the appliances, the monthly adjustments appointment that the patient comes back for and then finishing a retention. And then one of the last things we’ll talk about in the overall scheme of this is how to integrate it, market it in your practice. One of the things that we do provide is applying an exam form. And I usually give this in a word format so you can change it for your individual practice. Some doctors already have exam forms that they really like. And some don’t have one, so we again offer this exam too. One of the benefits in this little blue box area and that’s again where we look at the incisal edge position, we look at the cervical position. We look at the interdental spacing and the overjet underbite position. So that little box is kind of specific to help to help me discern if this is a good CFAST case or not. And then we have a treatment plan [sequencing] sheet. And on this sheet what I try to remind the doctor is as you become more comfortable in providing CFAST, you’ll have a better idea of how many employments you think it’s going to take. And if you think in treating a case with tooth movement through CFAST is going to take you more that 6-7 months, I’d probably consider referring that patient out. Unless there’s some reason you want to take that case on and follow all the way through. Each of these cases when we complete them within that 5-7 month period, again economically make sense to the practice. When these cases go maybe 12 months or 20 months it really becomes a loss for the practice financially and because of all the time that we had to put into that case. So with those cases I’d probably then elect to refer the patient out unless there was again some reason why it’s beneficial for me to finish that case. Maybe I’m going to get the proper toot alignment or alignment that I want so I could do a veneer case afterwards or correct the color and alignment. And then we have other sheets in here case management forms. When the patient comes back it just kind of a checklist of all the things to check off when the patient comes back. And it just helps you to monitor the case as you’re going through the CFAST procedure. So let’s talk about the cases that are appropriate for CFAST. CFAST are great for grounding out the arches, leveling and aligning those front teeth as we talked about before. It’s great for moderate crowding cases to correct those situations. So as we go through this, what I want you to do you to do is think about the patients in your mind that maybe you’ve seen this last week and that you’ll see hopefully tomorrow in the coming weeks.