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Two 10-minute YouTube videos on OJW (Orthodontic Jaw Wiring)

Some of the many orthodontics techniques I use in my office

iBraces certificate

iBraces
Customized Lingual (behind-the-teeth) Braces from 3M-Unitek

July 12, 2008

KD gets his iBraces:

I have been practicing doing lingual braces since 1988 when they were first introduced.  Consequently, the segue to the latest version of lingual braces called "iBraces" was as natural and easy as getting up in the morning.

However, I admit it was my first case of iBraces and different because I placed the upper and lower iBraces all in one 90-minute visit with the help of two key office staff and two representatives from iBraces (3M-Unitek--Lingual care division). They were most helpful and without them would have been 35% more burdened.

Below you will find some illuminating text and photos to show you how iBraces is done; so follow along with me on my excursion into the land of iBraces:

 

KD's original models:
Patient's chief complaint: "My teeth are too far out in front".  Diagnosis: "Bimaxillary Protrusion": teeth too far out in the front.
Treatment plan: Remove four teeth (the first upper and lower premolars)
KD's Preferred braces: "Cosmetic" lingual (no show, comfortable, low-profile
Type of braces chosen:
iBraces (high tech). 
First visit: bond on the upper and lower braces, followed by removal of fours first premolars and placement of temporary fillers in upper extraction spaces and placement of upper and lower arch wires.

Top left and right are the electronically precise wires produced  by the high-tech robot wire bending machine at the iBraces laboratory. For this case 3 upper sequential arch wires and three lower arch wires were provided, See above.

Models of teeth (left upper and right lower) created by iBraces lab and utilized to design the braces and showing the desired final result with extraction spaces closed.

Bottom: The transfer case within which are embedded the braces: (left side for the upper teeth and right side for the lower teeth (the brackets are embedded in the purple which is surrounded by the white silicone.

 

 

Close up of the transfer casings showing the embedded iBraces brackets: (the brackets that will end up on the front teeth are visible (dark) but the ones that will go on the back teeth are barely discernible both in this photo and in actuality when inspecting the trays.

However, Hold on to your seats and look at the photos below showing them after they are transferred on to the teeth by the miracle of bonding...they are simply gorgeous, although my photos don't do them justice.

 

 

Here you can hear KD speak and judge for yourself as I did that in his speech totally unaffected:  Hear him speak.

Photos taken during 90-minute appointment of placing upper and lower iBraces coming here.

The trays have been tried in, their center line marked and the brackets cleaned with 100% acetone (professional nail polish). The lingual surfaces of the teeth have been cleaned with non-fluoride prophy paste, and then micro-etched and acid-etched. Finally, just prior to placement of the tray the brackets and teeth are painted with a mixture of Part A and Part B adhesive and the tray seated on the teeth.

The curing agent (adhesive) I use is recommended by Lingual care --a division of 3M-Unitek: Reliance's Maximum Cure, (sealants Part A and Part B in 20 g/bottles). Keep refrigerated.
Setting time 30-45 seconds, and even more when used on a cold slab. Mix 4 drops of A and B for each arch.

After holding the tray in for three minutes the tray is removed.  I press on the lingual of the tray against the bracket as I peel the tray buccally and labially. You can hear crackling as the tray detaches from the brackets.

I have placed elastics around the brackets for patient comfort.   At this visit I matched the shade of the upper first premolars for the temporary gap fillers that I am going to bond to the buccal (outside surface) of the second premolars, and prescribed the removal of all four first premolars at one visit.

At the next visit the temps will be bonded and the first upper and lower arches will be placed.

Photo documentation to be continued.

I asked KD to describe his experience having four teeth removed:

               Back to DrTedHomepage      Back to Article RemovingWisdomTeeth       PreventionofDrySocket         ExtractionComplications

August 16, 2008

Having never visited the dentist for anything more than a checkup or a cavity filling, I was a bit uneasy about having four teeth pulled in one sitting.  Although I initially thought that the procedure would need to be performed by an oral surgeon, Dr. Ted assured me that a general dentist could do the job just as easily.  He even helped me book the appointment.

The teeth that I was due to have extracted were the first premolars on each side of my mouth (both on the top and the bottom).  The first thing that my dentist did was to inject Novocain all around the extraction sites.  I believe it was six injections in all.  They were relatively painless, with the only unpleasantness being a slight pinch with each one.  Once the Novocain set in, I could have been hit with a hammer and not felt anything.  The dentist then went about extracting the teeth.  One by one, he grabbed each tooth with a tool that resembled a miniature set of pliers and jerked back and forth until the tooth eventually slid out.  While the process seemed rather crude, it did the job.  There was surprisingly no pain the entire time.  The entire job took about 45 minutes.  Once all the teeth were removed, he applied gauze over the extraction sites and sent me on my way.

Immediately after the extractions, my mouth was still completely numb for a few hours.  There was a good deal of bleeding, which required changing the gauze every hour or so.  Once feeling returned to my mouth, there was no immediate pain, just an overall soreness and sensitivity around the extraction sites.  The sensitivity gradually subsided over the following 3 days, during which time I felt a bit uncomfortable.  I avoided eating solid foods and was careful to keep the extraction site clean, lest it become infected.  Because the teeth I had removed were near the front of my mouth, I had some trouble speaking clearly and there were some noticeable gaps in my smile until I had my temporary teeth mounted.

Overall, the process was more uncomfortable than painful, but in having four teeth removed in one day, I expected to experience some discomfort.  I had prepared myself for the worst, but fortunately, my fears were never realized.

 

August 21:

Here you see I have bonded the temporary space filler on to the buccal of the  2nd premolar. Patient was pleased with the shape and color match. The lab work I received required much final detail work.  No temps were intended for the lower.

 

August 21:

A super NiITi  .016 arch was placed on the upper 7-7. In addition, at this visit, UL3 and LR3 brackets, which were detached when the teeth were removed, were rebonded. They had become detached during teeth removal.

The protocol and adhesive ("Band Lock Blue", a light cure adhesive) was used.

 

August 21:

A super NiITi  .016 arch was placed on the lower 7-7.

This visit required 90 minutes.

I asked KD to describe his difficulties with  having both upper and lower arches placed at the same visit:

August 16, 2008

Here's the summary you asked for.  Hopefully it's helpful:

Although Dr. Ted rarely places the upper and lower wires in the same visit due to the discomfort it causes, my busy schedule necessitated that I have both done in one trip to his office.  Once the wires were in place, Dr. Ted cautioned that I would feel some pain over the course of the next week and gave me some Advil to keep handy.  I was still recovering from having had four teeth extracted a few days earlier, so I was hoping that having the wires placed so soon afterward would not severely compound my discomfort.

The initial feeling was one of tension as opposed to pain, as I could seemingly feel my teeth being pulled back into place.  For the first evening, I dealt with the tension without taking medication, but when I awoke the next morning, the constant strain was too much for me to bear.  I was beginning to get a headache, so I took a dose of Advil.  I stayed on pain relievers for much of the next three days and was able to keep the discomfort in check.  My front teeth remained sensitive whenever I would eat or drink hot or cold liquids.  The pain and discomfort gradually subsided, with the first 3-4 days being the worst. 

Aside from the pain, the lingual braces themselves took some getting used to.  I had to learn to eat and chew in a way that would reduce the food that got caught in my braces.  I was also sure to carry a toothbrush and floss wherever I went.  The brackets and wires also felt quite sharp, cutting my tongue on a number of occasions.  Dr. Ted had provided me with wax for such instances.  The wax was helpful in smoothing over the rough surfaces until I could get used to them.

Within 7-10 days, all of the problems that I mention above were gone.  I no longer felt any pain, was able to eat comfortably, and was not troubled by the wires and brackets.  In retrospect, I glad that I got it all done at once as opposed to having only one wire placed at a time and going through this process twice.

 

September 2, 2008 placed temporary teeth extraction spaces for comfort and speech.

 

 

Note above that hooks for elastic have been bonded on the second molars and the canines. Here you see the use of powerchain to accomplish the space closing. The patient would replace the powerchain every two weeks. I gave K. the choice of using powerchain every two weeks or using Pete elastics and changing them daily. The space in front of the temporaries (about 2.5 mm) I expect will be closed in 3-4 months at which time another orthodontist abroad will have to sand away some of the plastic on the temporaries to allow the continuation of space closure.

Office visit of 11/26 At the office visit of 11/26  I removed the upper and lower arch wires and placed an .009 ligature wire from the upper right canine to the upper left canine  ("Figure 8") and did the same in the lower anterior arch. Then with great difficulty (I was doing it for the first time) I placed upper and lower .0182x .0182 TMA arch wires and ligated each bracket with .009 stainless steel arch wire. Placing these wires requires that the wire be twisted labially and gingivally so that when it is seated in the vertical slot of the ibraces bracket it is exerting a 15 degree lingual root torque. I did both upper and lower since the patient let me know that he was going abroad for 6 months and by completing this step I would accomplish a major milestone for the completion of the treatment plan. It was DIFFICULT!  The orthodontist must twist the wire to insert it in the bracket. One must have supreme confidence that the bracket will not detach when inserting the wire in the bracket since it felt like it required quite a bit of force to twist the wire in to the path of insertion demanded by the vertical slot position.

BEGIN STAGE III: RETRACT THE FRONT TEETH AND CLOSE THE SPACES RESULTING FROM THE REMOVAL OF THE FOUR FIRST PREMOLARS.

Office visit of and 11/28:  At this visit I bonded metal hooks on the upper and lower right and left second molars and I bonded clear plastic hooks on the upper and lower right and left canine teeth. Then I placed power chain on lingual side from the first molars to the canines on the the upper and lower arches. In addition I showed the patient how to place Unitek elastics (Pete) 3/16"(4.5mm) 2oz from the 2nd molars to the clear hooks. The patient could easily accomplish removing and replacing the power chain on the lower lingual but it was uncertain whether he could replace the power chain on the upper lingual. I provided him with the above picture to assist him.  The first molars were not ligated in the belief that the wires were firmly  held in the molar slot because of the wire being ligated firmly to the bracket in 2nd premolars and the second molars behind. Moreover, that  not ligating the first premolars would reduce the friction and binding and thus permit the anteriors to retract more rapidly.

The next day we exchanged the following communications:

Dr. Ted: Quick question: would it help speed the retraction at all if I used two rubber bands at a time as opposed to one?  Please let me know when you have a moment. Thanks

Dear K., I'm not sure. I don't think by doubling up on the "pete" elastics it would do any harm. In subsequent visits I will inspect for the fact that retraction is in fact taking place and that the retraction in occurring in a more or less symmetrical fashion without any movements of teeth that were untoward as a result of elastic forces that ere excessive.  The elastics I chose were typical. I expect the teeth to track correctly, but I never really know until the results start coming in. Dr. Ted

 

12/18/08    K. leaves for six months on Friday for advanced education in Israel. This appointment took about two hours:  The button hooks on the upper canines were repositioned closer to the gums for cosmetics.  Two button hooks were added to the temporaries to deflect the elastics away from the gums. NiTi coils (200gm) were placed (and tied as securely as possible). Unitek (pete elastics 3/16" 4.6 mm,  light 2 oz, 56 gms) elastics were supplied to the patient to change each day. The upper anteriors were ligated  together at the previous visit and the temporaries were sanded to allow a wide space to allow anterior retraction.  You can see that Kobiashy ties were placed on the upper first molars to facilitate the attachment of the NiTi spring. Complete instructions for untoward problems were provided, and I supplied K. with spare buttons, brackets, chains and elastics and  some names of orthodontists who provide iBraces in Israel.

Here you see the lower with anterior retraction being accomplished with  Unitek pete elastics 3/16" 4.6 mm,  light 2 oz, 56 gms ON THE BUCCAL and power chain on the lingual. It proved difficult fro the patient to attach the powerchain to the molar hook on the lower 6's so K. was given the option to attach it to either the hook on the lower 7's or even the part of the wire passing out beyond the tube.   K . was advised to be aware of possible inward rotations of the molars.  I provided him with a microhemostat pliar to help with the placement of the powerchain on the lower since it difficult to attach the powerchain to the inside of the lower molars. Just in front of the LL4 I noted an upward slant of the wire which gave me pause for concern, I advised K. of the possibility that it would cause a problem with the movement of the teeth on the lower left side.

 
January 28, 2009: Email received from KD now residing temporarily in Isreal: 
Well it finally happened.  One of the brackets got detached.  It's the one all the way in the back on the right side.  I don't think it's broken, but its definitely not attached to the tooth and the wire is sticking out.  Like I said last time, I found an orthodontist who does lingual braces other than Dr. R.  She's experienced and has done lingual braces but not iBraces. 

January 29,  I went on the iBraces site and found a dentist, Michael Tulchinsky, who is going to see me in a few minutes at 11:45 (4:45 AM for you).  I'll email you when I return and let you know what he does.    

January 29 In a following Email: We're back on track!  The dentist was able to reattach the bracket.  He had to remove the wire and reinsert it, but did that with little trouble.  He also cleaned out the bottom brackets, as he said there was a lot of food particles built up.  Thank you for the help overnight! 
Ps: The bracket came off while I was eating.  I unexpectedly bit down on something hard and I felt it pop off.

Note:  KD had caused the last bracket on the lower right side to become detached.  My initial thought was to leave it because he could still attach an elastic (see above)
from the last bracket I has placed on the cheek-side of the last teeth for just such an emergency. I explained to him the the undesirable side effect of leaving the detached
bracket off.  Fortunately, Dr. Tulchinsky skillfully removed  the wire (not easy), rebonded the bracket by eye, (not easy) and replaced the wire (not easy).  So dear Dr. Tulchinsky KD and I thank you very much (Todah Rabah) in Hebrew. ;-)

 

February 23,
Dr. Ted,

I just wanted to let you know that my lower teeth have now fully retracted.  They moved a bit quicker than the upper, but the uppers are not too far behind.  Is there anything different that I should begin doing now or is there another wire that I will need to have inserted?  Also, I mentioned that a few spaces have opened up on the bottom as the teeth have moved back.  Since you're not here to patch things up, I thought of an idea but wanted to get your opinion before I try it.  I was thinking of placing a rubber band around the front teeth (using the hooks and connecting it from LR3 to LL3).  Would that help squeeze the teeth together or just pull them forward?Thank you, K.      (I advised him it was ok to try doing that.)

March 1,

I noticed that I have two white bumps protruding from my gums beneath my lower front teeth.  I'm fairly certain that the bumps were not there prior to my treatment with you.  They don't bother me at all, but I wanted to ask you if this is something you've encountered. Please let me know when you have a moment. Thanks, Keith

Dr. Ted Responds:

Dear K,
Could be the tips of the roots of the lower front teeth.
In theory as the elastics tip the crowns of the teeth toward the tongue the arch wire sitting in the bracket slots of the lower front teeth act on the roots of the lower front teeth to lean them toward the tongue as well so that the tooth moves from / to / by a series of infinite little movements like this: / \ / \ / \  if the crown is tilting in faster than the roots the roots may poke through, resulting in / \ / \ /  note last slash (crown leaning in root leaning out.)  assuming the wire is in the bracket slots correctly I would advise you to decrease the force of the elastic to "neutral" allow the torquing action on the roots to predominate. Dr.Ted
 
The process we are trying to effectuate is called "Lingual Root Torquing"


 

Back to Resume         Back to Site additions (081208)

Two 10-minute YouTube videos on OJW (Orthodontic Jaw Wiring)