1. To cement the RPE, start by having the proper set up. Make sure you have the expander, the glass ionomer cement, a band remover, band pusher and a bite stick. You will also want an air water syringe and small suction ready to go at your station.

**When you get the patient into the chair, it is easiest to show the patient and the parent the expander before it goes inside the patients mouth. You can explain how it works, what it looks likes, what it feels like etc.

2. Before adding the glue and cementing the appliance, you want to make sure it fits! So before the glue is added, using the band pusher and bite stick you are going to fit the appliance. Gently go from side to side having the patient bite on the bite stick fully, sitting each band. If any parts of the band do not seem to fit, you can use the pusher to secure the band, but in most cases the bands are made to fit each tooth. You can always confirm with your team lead or doctor if you are unsure about it fitting. The expander should not rock from side to side, or have large amounts of the band sticking out. These would be signs that the expander would not fit and cause problems long term.

When you are sure that the appliance fits, using the band remover, gently pull on the bands sliding them off of each tooth. Now it is ready to place it for real!

3. To mix the glass ionomer, take 1 1/2 scoops of the powder and about a dime size of liquid, and gently fold the two together. Continue to blend and mix the two together until it has reach a solid consistency (this can take anywhere from 15-30 seconds). This glue does not set up super fast but you still want to work quickly. Once the glue has been mixed, use the spatula to place a light layer of cement around the whole band on each side. You want to make sure that there is enough! Don't worry about too much because it can always be removed.

4. Before placing the RPE, use the air syringe to make sure that the teeth are dry. They do not have to be 100% isolated like bonding, but as dry as possible. Just like you did the first time you are going to place the appliance, have the patient bite on the bite stick, fully seating the bands. There will be extra glue that gets pushed out the sides, so have small cottons at hand to wipe the glue away as needed. Make sure and be careful with the extra glue because you do not want to cure it on other teeth, or get it stuck in buccal tubes that will be used in the future.

5. CURE EACH BAND FOR 60 SECONDS!! If another assistant is available, it is nice to have another pair of hands that can help cure, or you can use two lights at the same time. Just make sure the appliance is secure if you are using both of your hands to cure. Once each band has been cured for 60 seconds, allow the patient to go rinse and brush to get the bad taste out of their mouth.

The appliance will feel funny at first and take a couple of days to get use to. Let the patient and the patient's parent know that slurred speech is normal and the patient may talk with a lisp but that will go away with time. The patient may also have a hard time eating at first due to the location of the expander in the palate and a soft food diet may be encouraged in the beginning, but overtime the patient will get more comfortable and should be encouraged to eat more normal foods as soon as possible.

6. The patient will start with one turn every night for two weeks (14 turns). Once the 14 turns are complete, the patient will return for a 15 minute appliance check. The doctor will evaluate the expansion and where we will go from there. The patient may be instructed to perform more turns, or we may just hold expansion, but the doctor will be the one to make that decision. The expander will stay in for a minimum of 6 months but can be in as long as a year, depending on the progress and the doctors recommendation.