Placing The TAD's

The first step of the placing TAD's appointment is to make sure that the patient has an updated x-ray. The doctor uses this x-ray to check the root positions when placing the anchors.

After the patient is seated, make sure to discuss any questions or concerns before the doctor comes over to the chair. The patient will be nervous, so make sure to help calm the patient and ease their nerves. Due to proper and efficient timing, the doctor will come get the patient numb before the assistant removes or replaces any wires. If two TADS are being placed only 1 carp of lidocaine will be needed, but if there are 4 TADS then 2 is needed. I always have 2 at the station just in case. If the second one is not used it can always be sterilized and put away, plus it is always better to be over prepared than underprepared!

Once the patient is numb, the doctor will leave the chair and let the topical sink in for 5-10 minutes. During this time you can remove the wires and decide what wires we will be going into today. If you think you have time to replace them within the 10 minute window, typically Niti wires, then you can tie the patient back in. If you are placing stainless steel wires and you know it will take you longer than that time window, then wait to place the wires back in. The doctor will be coming back over to place the TAD and you want to make sure the patient is in the prime time of being numb so you do not have to give them more anesthetic.

When the doctor comes back over to the chair, first he will use the PK SHAW2 instrument in the cassette to make sure that the patient is fully numb and also mark where the TAD is going to be placed. Then, as the assistant, you will have the driver ready with the proper TAD in place ready to hand to him. The doctor will then place the TAD. You will continue these same steps until all of the TAD's are in place.

Before the doctor leaves, make sure to confirm wires, RB's, how to tie, etc. Once the doctor leaves, you can finish replacing wires and hooking up the TADS (as shown below). Take full photos after the appointment and make sure the patients future appointments are set up.

The patient will come back every 2 weeks to retie the powerchain and get progress photos and every 4-6 weeks for adjustments. They will go straight from 14x25 CuNiti upper and lower to 18x25 upper and 16x25 lower, then stainless steel wires until they are done intruding. Once we are done intruding, we will go back and do a pano repo to make sure that we have ideal bracket position before continuing to the finishing stages. (This appointment sequence is ideal for straight forward cases, but can be accustomed to change depending on the patient and their treatment plan).

Intruding With Powerchain

Powerchain is used for intrusion when we are in CuNiti wires, typically 14x25. If the patient is in a lighter wire than 14x25 then you have to tie the TADs with surgical thread until you get to this wire. We have to start with light forces because the CuNiti wire can be distorted, so typically 3-4 links of powerchain is used.

The Doctor or your clinical lead can help you decide how many links will be needed (depending on how high the TAD is placed). You will cut that number of links of power chain for however many TAD's you are tying. Then take a piece of wire tie and cut it in half. If the wire tie is too long it can be hard to control. Take one end of the power chain and place the wire tie through it. Then thread the opposite end of powerchain underneath the wire where it will be connected. Make sure you know where the doctor wants you pulling on the wire for the intrusion, it varies case by case. Once the power chain is under the wire, take both ends of the wire tie and place them through the last link of powerchain threaded underneath the wire. Gently pull on the wire tie until the powerchain loops through itself and onto the wire. Make sure that the powerchain is secure before removing the wire tie. After the wire tie is removed, grab the end of the powerchain using the mathieu and stretch it up directly to the TAD. Continue this same step for all of the TAD's.

Make sure to take great progress photos after the TAD's are placed. The patient will come back every 2 weeks to retie the powerchain and get progress photos and every 4-6 weeks for adjustments. They will go straight to 18x25 upper and 16x25 lower, then stainless steel wires until they are done intruding. Once we are done intruding, we will go back and do a pano repo to make sure that we have ideal bracket position before the finishing stages.

Intruding With Vector Springs

Vector springs are used to intrude only when the patient has good oral hygiene/healthy gum tissue, and in a 19x25 Stainless steel wire. This will be decided by the doctor, but typically used for patients that travel and cannot come back every 2 weeks to re-tie the powerchain, or patients that have a lot of intrusion. The doctor will also decide what size spring will be used, and once it is placed it is not removed until we are done intruding.

To place the vector spring, you start by connecting the first end of the spring around the base of the TAD. Then you pull/thread the second end of the spring underneath the wire and grab onto it with a scaler or mathieu. Then, use the weingart to loop the second end of the spring around the base of the TAD.

There is nothing needed to secure the spring on the TAD, but always educated the patient about taking care of the TAD's. The patient needs to brush around the springs and the TAD's, but should never tug or pull on the spring. If the tissue around the TAD gets inflamed, it can push the TAD out and it will have to be replaced. That is why it is super important to stress to the patient how critical it is to take care of them.

Closing Space With TAD's and Vector Springs

Besides intruding, TAD's are also used for maximum anchorage when space is being closed. In the case above you can see that the patient is missing the LL6. There are two ways we can close the space, the first being only using powerchain and no TAD. This is known as minimum anchorage. This would mainly bring the whole lower left anterior segment back, pulling everything to the molar, making the patient severely class II. The second way is maximum anchorage by using a TAD, a temporary anchorage device, and a vector spring to pull the posterior segment forward. This holds the patients bite and helps keep the anterior segment where it is at, allowing minimal movement and bringing the posterior segment forward to close the space.

There is no right or wrong way, both are proper ways to close space, it just depends on what outcome you want. This is dependent on airway, facial features, profile, occlusion, etc. and will all be talked about and decided by the doctor in the consultation. If you are confused or unsure you can alway ask :)

The TAD is placed exactly the same as above, it is just hooked up different. To close space using a vector spring, the patient has to be in stainless steel wires, allowing us to apply maximum force to close the space. The wire is left long distal to the 6 (or wherever the spring is being placed) with a glue composite on the end for patient comfort. The spring is then placed distal to the lower left 6 and stretched forward to the post on the wire. The spring itself is not placed around the hook, there is a wire tie that connects through the spring and tightly placed around the hook. The wire tie keeps the spring from sliding off the hook (we had to learn this by experience). The end of the wire tie is the gently tucked underneath the wire and bracket so it does not poke the patient or come undone.

When we are closing space using vector springs, we have to make sure there is equal force lingual and buccal to keep the molars from rotation. To do this, as seen in the picture above, a kaplan hook is bonded to the 6, and a button is bonded to the cuspid. Powerchain is then lightly stretched from the kaplan hook to the button, apply equal force to the buccal side. This is done is every case unless instructed otherwise.

The powerchain will be changed out every 3 weeks, but the springs will not be removed until we are done closing the space, unless they are being changed out to stronger springs. The patient will get progress photos every time they come in for an adjustment or retie.