Initial Bonding

This is the most important appointment to master out of any of them. This appointment and the experience the patient receives will set the tone for their whole entire treatment. Whenever doing an initial bonding, the goal is to obviously prep well and make sure everything stays isolated, but more importantly make sure the patient is at ease and feels the most comfortable they possibly can. Always over explain each step you're doing, that way the patient knows what to expect and it will calm their nerves for the most part. The child knows they are getting an appliance but they will be very nervous for the process and the after care.

Before calling patient back, make sure you have all of the necessary supplies and instruments needed or this appointment. Also be sure all of your brackets are set up and the torques are correct. Most importantly make sure the appliance is in! Once that is all done, you may begin the appointment.

1. Call the patient back and escort them to the clinic. On the way back, introduce the brushing station so they know where they can rinse out throughout the appointment today.

2. Once seated go over how the appointment will go. 9 times out of 10 the patient is very anxious and doesn’t know what to expect. OVER explaining everything will ease the patients nerves and will give them a better experience.

3. Once you are ready to start the prepping process, take a look at the schedule and make sure it is a proper time to start prepping your patients teeth. Ideally you would want to bond brackets first, before placing the telescoping herbst, but If it is closer the 30min mark of the hour, it would be time efficient to start cementing the appliance and then prep the teeth when you know that doctor will be able to bond right away. (The treatment coordinator should get Dr Frost on the 30 min mark every hour and will be gone on average about 10 minutes for the exam). It is better to get something done than sit and wait, even if the appliance is only half cemented before you start prepping. Cementing a telescoping herbst and tying everything in can be time consuming, so make sure you are as efficient as you can through the entire appointment.

4. When you are officially ready to start the prepping process, lean the patient back and prophy paste the upper arch to ensure any plaque or leftover breakfast is removed ;) Please be sure to take a good 2 minutes scrubbing so we have a nice clean slate to bond a bracket to. Once the teeth are all scrubbed, walk patient to the brushing station and let them rinse with water. Make sure they rinse out a few times so all the paste is gone (they should NEVER rinse with mouthwash before prepping a tooth, the alcohol base in the mouthwash can effect the prepping process)

NOW YOU ARE READY TO START PREPPING!! WITH TELESCOPING HERBST'S ONLY THE UPPER ARCH WILL BE BRACKETED!!

5. No driangles are needed since the band of the herbst will go around the 6's and in most cases the 7's are not in yet, so they will get bonded when the herbst is removed. So, start the appointment by inserting the white cheek retractors (Use the red retractors only when absolutely necessary).

6. With any other bonding you will place a cotton roll underneath the tongue to help with isolation, but since the lower arch will not be bonded at this time, no cotton roll is needed.

7.Have patient tilt their head to the right slightly and place in the suction on the right side of their mouth.

8. Thoroughly dry all teeth you are bonding. Once dry you can start etching. Grab a micro-brush and start on the LR7. Dabbing the etch (not scrubbing), make your way up to the LR1. Then go to the UR7 and make your way to the UR1. Once those are all etched you will start on the LL7 and make your way to the LL1. Then move to the UL7 and go to the UL1. As soon as you are done with the UL1 you are ready to rinse the LR segment (etch should sit on for 30 second, no more or less than that ). As soon as you are done etching grab 3 micro brushes that are dipped in ortho solo and set that on your tray right above the patient. That will be needed in a few minutes.

9. The rinsing process is the MOST IMPORTANT PART because if you are not careful, you can easily contaminate the teeth.

10. With the small suction still on the right side, you will get the high speed suction and place it on the left side of the patients mouth near the very back molars. Start rinsing the lower right segment up until the LR1. Each tooth should be rinsed for about 3 seconds. Once that segment is rinsed, move on to the upper right segment. Keep in mind you are still holding the high speed suction in your left hand while rinsing with your right hand

11. Now you are ready to rinse the left side. You will follow the same steps with rinsing, like you did when etching. Start with the lower left side and then upper left.

12. While keeping both suctions in the mouth, high speed on the left, slow speed on the right, completely dry the lower teeth off and make sure no saliva flies up on any of the teeth. Also dry the U6’s and 7’s. Take a very close look and make sure every tooth is frosty. If the are completely frosty, grab a micro brush that you wet with ortho solo earlier (see step 4)

13. Ortho solo the whole lower segment(with a very light layer of ortho solo) and the U6’s and 7’s. Dry those specific teeth.

14. Now you will remove the wet cotton roll that is underneath the patients tongue and place a new one. ( we always ortho solo the lower segment and U molars before removing the suction and the cotton roll because the likely hood of those getting wet is highly likely)

15. Once new cotton roll is placed and suction is back in on the right side, you will re dry everything (with the high speed suction on the left side to make sure when drying no saliva flies up). Now you can ortho solo everything (re ortho solo the lower segment and upper molars). Make sure you are applying a light layer of ortho solo. The thicker the layer, the harder it is to dry.

16. Once everything is ortho solo’d, dry every tooth thoroughly. Once you are done, you are ready for Dr Frost to come over and bond the brackets.

***If you are every worried a tooth was contaminated, keep an L-pop near you so you can use that if needed. My philosophy is better to be safe than sorry, you would hate for a patient to come back the next day to get a bracket rebonded!

17. After every bracket is on, go back through and cure each bracket for 5 seconds.

**WHEN CURING, PLACE LIGHT INCISAL OF THE BRACKET***

18. Remove cheek retractors and driangles, and let the patient rinse out. (I always tell them to not bite down all the way just in case they bite down on a bracket and it comes off) They can now rinse with mouthwash if they’d like.

19. Now its time to cement the herbst.

20. Place arch wires. The upper wire will go from 6-6 and lower will go 5-5 cinched in a circle distal to the 5’s. If there are any rotations that require the wire to be placed 6-6, secure with a composite stop distal to the 6’s.

**HOW TO CINCH A WIRE CORRECTLY***

1. Grip onto the end of the wire

2. Curl wire back and make a loop.

21. Review if any elastics need to be started, where the hooks should be placed and what size elastics should be worn (see elastic configuration page for instructions).

22. Go over instructions with patient and parent. Be sure to show them where they wires are placed in their mouth and what constitutes an emergency. If a bracket is lost that is not included in the wire it can wait to be re-bonded at their next appointment.

23. Next adjustment should be scheduled 10 weeks out unless they have open coil spring (ocs) or anything that would require them to be seen sooner (adj surg, retie tads, etc) . If so, they would be seen in 6-8 weeks.