Top Ten Most Critical Considerations

1. Choose the right appliance. The standard NightShift^® appliance is the most efficient for full-time and nighttime only wear. If a patient chooses full-time wear for faster treatment time, but wants something more esthetic, make certain you can achieve what you need without the stainless steel labial bow. It provides numerous functions unobtainable with the other options.
   
   
2. Understanding space requirements is important. It may be necessary to treat the upper anteriors to provide sufficient space to treat the lowers. Assess both arches together. Interproximal reduction is an option, but if successful treatment can occur without IPR, we recommend it.
   
    
3. For the shortest treatment time possible, the patient should wear Nightshift appliances full-time, removing them only to eat and brush. For nighttime only wear, recommended use is from early evening until morning, 7 days per week and whenever else possible. For optimal performance readjust every four weeks – every two is feasible for very time sensitive cases.
   
    
4. When you receive the appliance the springs are pre-activated and should not require further adjustments on the initial visit, though it may be necessary to adjust clasps, bow and/or loops to maximize retention for optimal activation potential and patient comfort. Adjustments should take about five minutes per visit. Adjustment photos follow this text.Adjustment videos are found on the training CD and the website.
   
    
5. The appliance should fit snugly, though it will tend to bounce in the patient's mouth from the spring tension. Bounce in the appliance is not a problem, but rather a sign the springs are sufficiently activated. Greater retention will provide for less bounce, though bounce should always be noticeable.See the bounce video.
   
   
6. The springs are durable and relatively flexible and do not require extremely delicate handling, though over-aggressive adjustments will tend to dislodge the appliance and force the springs to the incisal edge. This can deter patients from suggested wear. Over-adjusted springs can be recompressed with the Howe pliers, but overly stressing the alloy decreases its performance.
    
7. To maximize spring activation potential without contraindications, you can bond a line of composite on the lingual to keep the springs from riding to the incisal. This isn’t necessary, but will optimize for faster treatment if desired.
   
   
8. Larger springs are capable of a greater distance of movement than smaller ones. In cases with both, about 3 - 4mm of movement is the most efficient range. For greater movement, a second appliance can increase efficiency or may be necessary. Monitor progress to determine.
   
   
9. Most patients experience some discomfort during the first week, typically slight in nature. It’s usually more noticeable when they take the appliance out and after actual movement begins.
   
   
10. Study ALL training materials thoroughly, including the training CD and adjustment videos. You’ll get more done in less time and enjoy what you’re doing more fully. This should be fun, not work.

From case selection to case completion, including adjustment photos:

Case analysis: This appliance is primarily designed for esthetic treatment of the anterior teeth, though functional results can occur when taking teeth out of cross bite or freeing a trapped mandible. Cases that require more sophisticated functional correction are currently not within the scope of this appliance.

This is only a reference guide. The training presentation or CD should be your main information source.

The NightShift appliance is much better at making space than closing it. It is best suited for buccal movement and excellent at unraveling crowded teeth and efficiently directing them into proper arch form by translating, rotating, tipping and uprighting. Intrusion and extrusion are also possible, but require composite to be bonded to the indicated tooth/teeth at a point which allows the spring to be bent enough to set it above or below the composite to effect the indicated movement.

Cases with significant spacing issues greater than can likely be corrected by closing the labial bow or adding some power chain to bring them lingual, if space permits, are better suited for braces or Invisalign. In the cases most commonly treated with the standard 6 spring appliance, widening typically occurs in the anteriors from cuspid to cuspid. It can be constructed with expansion screws to widen the entire arch if indicated. You can also opt to add QuikSprings™ to individual posterior teeth for limited applications.

Because this appliance is capable of very efficient individual tooth movement on a concurrent or sequential basis as indicated, treatment will often require minimal to no interproximal reduction (IPR) in comparison to appliances that limit individual tooth movement by their encompassing design or mandatory group movement.

Deep bite cases can present with insufficient overjet to successfully treat mandibular crowding, though there may be room for minor buccal movement or rotations without excessive IPR. In these types of cases, sufficient space can often be provided by also moving the maxillary teeth forward enough to align the lower anteriors. It is typically suggested to use an appliance with a bite plane which opens the bite and allows the posterior teeth to super erupt to open the deep bite. Time span to open a bite is fairly unpredictable and patients need be advised. In some cases, especially with adult patients, the posterior teeth may not super erupt using only a bite plane appliance and may require braces or other alternative to achieve the objective.

The most common problem we encounter in cases we receive is a prescription for a mandibular appliance only, when there is insufficient room in the maxillary to achieve the objective. The maxillary arch can usually be treated alone in most situations and most cases can be treated when both arches are treated simultaneously.

We believe it is always in the patient's best interest to treat both arches, if by doing so you can achieve the desired outcome without stripping.

Adjustments: Be sure to view the various adjustment videos on the training CD ROM. When the appliance is shipped to your office it should already be pre-activated and pre-adjusted and should likely require no additional adjustments upon delivery, other than possible minor adjustments to the ball or molar clasps and/or labial bow and/or labial loops for optimum retention.

For example, the ball clasp may need to be tucked more properly into the interproximal and the labial bow may require adjustments consisting of tightening/closing the loops slightly or bending the bottom of the loops inward somewhat to achieve optimal retention.

Before placing the appliance in the patient’s mouth, be certain to take digital photos with the appliance in and out. Photos should be used to compile a show and tell book for educating future patients. Also give copies of the beginning and progress photos to the patient at whichever point during treatment that you feel the patient is most excited and you feel results are clearly visible. The patient’s excitement level can be effectively combined with their photos and several patient flyers to generate referral s and should not be over-looked.

The patient should certainly be able to feel increased pressure against the teeth after adjustments. You should tell the patient that the bounce they feel is a good thing and not a problem. As the teeth begin to move, the appliance will settle in and begin to feel less tight. Remind patients treatment time can be significantly shortened for both full-time and nighttime wear by following the prescribed recommendations in #3 above.

Tell patients to take their appliance out to eat and brush. The only required maintenance on the patient’s behalf is to prevent tarter and food build-up by regularly brushing both sides of the appliance and springs with tooth paste each time they brush their teeth. We also have an excellent effervescent retainer cleaner you can offer.

To remove the appliance the patient should be told to grasp both loops of the labial bow at once, so as to not cause excess fatigue to the wire by grasping only one side or the other. They should also be encouraged not to chew gum with the appliance in the mouth.

From the lab, the labial bow extends cuspid to cuspid at the center of the crowns. It’s constructed to be passive in nature and will be adjusted as necessary by the clinician throughout treatment.

The labial bow will likely need to be opened slightly at each appointment to remain about 1 mm ahead of the advancing teeth. Initially, the primary function of the spring is that of a lever tensioned against the tooth. Initially, it should be at an angle to the tooth and not perpendicular to it. As tooth movement occurs, the spring will become more perpendicular to the tooth and will provide more of a compression force than a lever force.

Your first follow up visit or two you will likely be bending the spring away from the acrylic more than extending it buccally, attempting to keep the spring head in the same plane as the labial bow. The springs should be directed to seat somewhere in the gingival third to center third of the crown.

The labial bow on this appliance is utilized in many different ways in conjunction with the springs. Primarily the labial bow is used to stop forward advancing teeth from over-tipping to the labial and should therefore not be allowed to be positioned too far ahead of the teeth. The labial bow also serves to provide opposing and lingual force when indicated.

For example, when the most buccal point of a rotated tooth has reached the desired point in the arch form, the bow should actually rest against the tooth at that point. The spring would be directed to the opposite side of the tooth and it would be “spun” into place with the bow holding the most buccal point in place and the spring moving the lingual portion to the bow. If the most buccal point were too far buccal, rather than rest the bow on that point, a back bend would be placed in the bow at that point to bring it lingual while the spring concurrently brings the lingual portion of the tooth to the buccal.

The labial bow can also be closed or drawn back to close space. For example, a small space between the right cuspid and bicuspid can be closed after alignment and rotations are achieved, by pinching only the right loop closed the indicated amount, thereby moving the entire anterior segment to close the space. This is possible because the entire arch is supported by flexible springs and not a solid acrylic backing as in a standard Hawley.

First and foremost, remember the spring to tooth and spring to bow relationship should remain on the same plane as much as possible inside the target area of the middle third of the crown throughout treatment, unless tipping or uprighting are desired. As adjustments are made, the spring will tend to head toward the incisal. As movement occurs, the spring will begin to lower toward the gingival. This relationship between the bow and the spring can be manipulated to achieve root torquing, tipping and uprighting as indicated and is shown in the diagrams following the adjustment photos. The most thorough details are found in the training presentation or CD.

Generally speaking, at each appointment you would check the retention of the clasps and adjust as necessary, bend or extend the springs and advance the labial bow to keep it slightly ahead of the teeth without interfering. The springs in the NightShift appliance are quite durable and flexible due to the heat-treating process utilized.

Replacement or repairs are very uncommon. If for some reason a spring may need to be replaced, it is usually not necessary to send a model. Such repairs on active cases will take priority and will be addressed promptly upon receipt. These repairs are often at no charge unless it is clearly evident that breakage was due to abuse by the patient, for example; dog chewing, stepping on, etc.

Once finished you must choose fixed or removable retention. The NightShift applianceswhich were used to straighten the teeth can continue to be used as an active final retainer. Unlike other retainers, it can reposition the teeth if periods of non-compliance are allowed to occur. Every night for a year is suggested and from there on as often as necessary to keep the teeth from relapsing at all. Generally, retainer wear is suggested for life.

		Pictured here is a new NightShift® appliance before any adjustments. Be sure to watch each of the short instructional videos on the various adjustments that can be made and the objective each can accomplish.
		Note that the springs and the labial bow are in the same plane or parallel. The appliance is fabricated so the springs and bow can act optimally as coupled forces when indicated. The springs should generally be activated in the middle third of the crown.
		There are five different spring sizes manufactured to best fit tooth size. There are also left and right-handed springs in each size for optimal efficiency in mesial or distal rotations. Specialized QuikSprings™ can sometimes be fabricated for special applications.
		Here is the progression of a spring from unextended to fully extended. Note: An overextended spring provides reduced force and progress would be better attained with a second appliance if further correction is indicated, though not frequently needed. This adjustment is best achieved by using Howe pliers or Mosquito forceps when space is limited.
		Due to the shape of the cuspids, the cuspid springs should be adjusted as shown to hug the tooth for optimal contact and control. This type of adjustment is best achieved by fine optical pliers on the center of the spring.
		Shown here is an example of what your adjustments might look like to rotate the distal of both centrals to the labial. This type of adjustment is best achieved by using Howe pliers.
		Shown here is an example of what your adjustments might look like to rotate the mesial of both centrals to the labial. This type of adjustment is best achieved by using Howe pliers.

Required Tools

(Complete Set Available for $80)

Shown above are the required adjustment instruments; the mosquito forceps, the fine optical pliers, the Howe pliers, the bird beak pliers (fine and standard) and the three prong pliers.

IMPORTANT: When you first place the appliance, note the original spring angle to the tooth and the location of the spring on the crown. The relationship of the spring to the crown will generally remain constant to the middle third of the crown throughout treatment. Typical spring movement per adjustment is generally away from the acrylic and outward as indicated, though early adjustments will likely not allow for extension as the teeth have progressed little.

		Here’s a treatment planning tip that may help. If you pencil along the incisal edge of the teeth you can get a better look at where they should go. Both laterals and the left central should go buccal, not the right central lingual as the prescription had requested.
		Depicted here is a typical adjustment made to the ball clasps to tighten them by ensuring the ball portion of the clasp is securely seated in the interproximal, the same as with standard retainers.
		The labial loops should also be contoured for maximum retention. To achieve an optimal fit, use the optical pliers as shown, hollow beak to the outside, to place a slight inward bend in the labial loop as shown, which will provide additional grab. Be careful not to create patient discomfort.
		Shown here is a typical early stage rotational adjustment made to a central spring by bending the top finger of the spring for a slight rotation.
		Shown here is the view from the front of a spring adjusted as is shown above.
		Shown here is a more pronounced rotational adjustment made to a central spring.
		Shown here is another view of the adjustment made above.
		Shown here is an adjustment made on a cuspid spring using a fine optical pliers, hollow beak down, to gently crimp the first loop of the spring to contour it to hug the cingulum, thereby improving the ability to control rotations and basic buccal movement.
		Shown here is another view of a cuspid spring that has been contoured to hug the cuspid using the technique shown above.
		Shown here is a slight rotation being made to a contoured cuspid spring by bending the first loop of the spring head away from the acrylic and outward slightly. This is an early stage rotational adjustment, when the teeth have not advanced labially enough to accept a significant twist buccally due to a lack of space between the spring and the tooth.
		Shown here is a similar adjustment with no rotation using the Howe pliers to bend the entire spring head away from the acrylic. This is done when the teeth have not progressed far enough to extend the spring outward to the buccal.
		Here’s another angle of the same adjustment as above. Note: The mosquito forceps may be used as an alternative to the commonly used Howe pliers if space is more limited and a smaller pliers fits more easily.
		Here’s how you would typically extend a spring once the teeth have advanced enough to do so. Use your thumb as a fulcrum and grab the center of the spring head easing it straight forward. Use the mosquito forceps if space is too tight to use the Howe.
		After extending the springs you’ll typically need to advance the bow to allow progress to continue. The loops of the labial bow will need to be opened to advance it gradually. Review the detailed instructions on page 16. The labial bow should typically be 1-1.5mm ahead of the teeth. Progression of any portion of a tooth will stop when it touches the bow.
If maxillary intrusion or mandibular extrusion are desired, you’ll need to grind away the acrylic covering over the spring as shown, so the spring can be bent enough to activate it on the composite ledge you bond to the indicated tooth. This is unnecessary for maxillary extrusion or mandibular intrusion.
Here are two examples of the distals and mesials of both centrals being rotated to the labial while the entire spring has also been extended to continue labial progress. Have the most labial point of the rotating tooth touch the bow as an opposing force when that point is where it should be.
		Shown here is an appliance which has had retention bends or offsets placed into the labial bow to keep specific teeth in the exact positions desired during treatment or retention. See the adjustment video on offsets for clear instruction on how this is done.
		After the proper arch form is attained, should there be diastemas to close, you would then pinch the loop on the labial bow to the extent indicated on the side of the diastema. If the space is between the centrals, you would close both loops evenly to exert equal force from both sides of the labial bow. Because there are springs behind each tooth and not rigid acrylic, the entire arch form can be made to shift to close such small spaces.

NightShift^® Adjustments - Using The Labial bow

The primary function of the appliance is to generate forces from the lingual of the teeth on the entire anterior segment to move them buccally, thereby opening space for malposed or crowded teeth to be realigned into a proper arch form.

The appliance uses the labial bow in conjunction with the springs and can achieve rotations, tipping, uprighting, translation, intrusion, extrusion and root torquing. The springs and the labial bow are used together to control the entire tooth (crown and root) to a greater degree than might be expected of a removable appliance.

The labial bow on this appliance also serves as a safety measure to prevent over-advancement of teeth to the labial during treatment. The labial bow is continually adjusted throughout the treatment to allow room for the advancing teeth.

It can also be used to create opposing lingual force to retract teeth into proper alignment by closing the loops of the bow to bring all or part of the arch lingual or by placing a highly directed back bend in it to place lingual force on a specific point of a specific tooth.

Lastly, slight bends (offsets) can be placed in the labial bow to retain an entire tooth or teeth, or just specific portions of them, in their desired positions while allowing any other teeth that have not yet reached their desired positions to do so.

Changing the relationship between the bow and the spring can produce different outcomes.

Bodily Movement - Keeping the labial bow in the same plane as the springs in the center of the crowns will achieve bodily movement of the teeth. To allow the teeth to advance, the labial loops should be opened gradually in small equal increments. When the bow is touching the teeth no movement will occur because the bow provides a stronger opposing force than the springs.

Tipping - If tipping is desired, the labial bow should be kept in a plane below the spring, towards the gingival third of the tooth.

Uprighting - To upright a tooth the labial bow should be kept in a plane above the spring, towards the incisal third of the tooth.

Bodily Progress – Pictured below is the progression of a tooth bodily moving in a mandibular case, showing the changing angle of the spring in relation to the tooth and labial bow. The spring is initially bent downward away from the acrylic and subsequently extended as the tooth advances. Note that the plane of the spring and labial bow remain relatively level in bodily movement.

*Note angle gets smaller as teeth advance and spring is extended

Tipping Progress – Pictured below is the progression of a mandibular tooth tipping, showing the changing angle of the spring and its relationship to the tooth and labial bow as the spring is bent downward, away from the acrylic and extended to the labial.

Uprighting Progress - Pictured below is the progression of a mandibular tooth being uprighted, showing the changing angle of the spring and its relationship to the tooth and labial bow as the spring is extended downward and to the labial.

The two most common adjustments to the labial bow are the opening or closing of the loop. When the labial bow loop is opened or closed, the angle of the elbow ideally needs to be re-established to a right angle (See following examples). A combination of any of the three loop forms described below may exist at the start of any given case depending upon the objectives on either side of the arch.

		Closed Loop - Shown here is a loop that is formed partially closed in fabrication. This is the most typical loop form in fabrication as it allows the bow to be opened for the gradual progression of labially advancing teeth. As the springs are periodically adjusted, the bow is also adjusted accordingly as indicated. To advance the bow with a 3 prong pliers, place 2 prongs inside the loop as depicted and squeeze gently. The bow will also come downwards. To redirect the bow back to the center of the crowns place the single prong inside the distal of the loop as depicted. You can also open the bow by placing the flat of your large bird beak pliers inside the bottom of the loop.
		Opened Loop - Shown here is a loop that is left slightly open in fabrication to allow for gradual closure of space as the teeth are lingualized. This would typically be seen in extraction or diastema cases. These adjustments would be made gradually on one or both sides of the archwire as indicated. For example, a diastema at the midline would require both loops to be closed equally. Also, after proper rotations and alignment are achieved the entire arch could be brought back, if needed, to close space. To close the bow place the single prong of your 3 prong pliers inside the loop as depicted. As the bow comes back it also rises. To bring it back down to the center of the crowns place the single prong near the mesial junction as depicted and squeeze gently. You can also close the bow by placing the round side of large bird beak pliers inside the bottom of the loop.
		Standard Loop Form - Shown here is what the loop form typically approximates at the completion of a case after having made all necessary adjustments throughout treatment.