Anterior teeth have a complex incisal edge anatomy that creates both the esthetic appearance of the tooth and the function of the upper and lower incisors against one another.

Often in both ceramics and in composite we do not recreate the full anatomic form of the tooth. This results in both esthetic and functional challenges for the patient.  When we look at incisal edges from a lateral perspective there are three components, the pitch and two bevels. The Pitch is the flat top of the incisal edge. On both the labial and the lingual the transition zone between the pitch and these surfaces is a bevel. One is referred to as the leading edge and one is referred to as the trailing edge.

The Pitch has dimension or labio-lingual width, usually at least 1mm. This width increases as the patient shortens the tooth from Attrition, if they parafunction in an edge to edge position. The pitch is not always parallel to the horizon, but it’s relative position depends on the inclination of the incisor. When the incisors are optimally inclined, just slightly further to the labial at the incisal edge the pitch is slanted upward toward the lingual. This creates the incisal edge esthetic effect of thinner enamel at the labio-incisal junction and creates visual translucence. If the pitch is level to the horizon it changes light reflection and the appearance of the tooth. These two factors together is often what changes in restorative material.

We create a pitch that is level to the horizon, and then to gain translucence we decrease the width of the pitch, sometimes to a knife edge.

The challenge with this, is that patients sit in edge to edge position often to incise food and some for parafunction. If there is insufficient width to the pitch they may experience functional challenges.

The bevels on both sides have a variable width, but can be between a portion of a millimeter to multiple millimeters long. The bevels get longer in patients who grind their teeth in an excursive pathway pattern. Patients who parafunction edge to edge can often eliminate the bevel, making it easier to shear off enamel on the labial or lingual side of the tooth, or chip the edge enamel. The bevel functionally is a transition zone to create smooth functional movement as we pass from excursive movements onto the pitch. The Intercuspal stops on lower incisors is often on or gingival to the bevel.

Whether we are finalizing an equilibration or finalizing the occlusion on composites or ceramics perfecting the anterior guidance requires both pitch and bevel surfaces, it is a perfect example of the marriage between form and function.

Solving common problems in the dental practice is all about mindset. Solutions tend to come from a better inherent understanding of your practice’s values and vision. Clarity of vision makes problems simpler. Thus, one powerful way to use your vision is to make it the basis for how you practice. But first, you must revitalize or find it through a model such as the Appreciative Inquiry Model.

Revitalize and Problem Solve in Your Practice

Part of the problem solving process is finding the disconnect between what you say and what you do. Problems can be worsened if something is clear for the dentist and not for the team.

Vision is the life-blood of a practice. It is the dream that feels within reach, that is worked toward because it is understood to be achievable. So how do you figure out what yours is?

Using the Appreciative Inquiry Model

A problem solving model is not your friend in searching for a viable vision. Why is this? Problem solving models start by identifying a problem and analyzing it. This is then used to guide action.

The flaw in this seemingly sensible model is that it begins from a place of ‘wrongness’ or ‘missing.’ Instead, it is more productive to focus on what is currently good about what you have and how you can enhance it. This a subtle shift in perspective and mindset that sets the tone of the ‘problem-solving’ conversation.

What I’ve just described is known as the Appreciative Inquiry (AI) Model. It begins with appreciation and valuing what is, then transitions to envisioning what might be, and concludes with a dialogue about what should be.

The envisioning portion is all about considering values, vision, and vitality. You look forward, not backward, because that is the best way to deliberately stumble upon a new or more inspiring vision.

What gives your practice life? It would be difficult to find out by focusing on the negatives. There is a kind of magic to looking around with fresh eyes and realizing the positive attributes you already possess.

AI enables you to ask what you want, rather than what you don’t want. It focuses on building from a foundation you already have, so that you are not resource poor, but in fact capable of changing based on the abundance you already contain.

What is your practice vision and how did you come to it? We’d love to hear your thoughts in the comments! 

It is estimated that 22 million Americans suffer from sleep apnea, with 80 percent of the cases of moderate and severe obstructive sleep apnea undiagnosed. Integrating dental sleep medicine into your practice can be a great way to engage your self and your team and serve your patients in a powerful way that will improve their overall health.

Dental Sleep Medicine Involves the Whole Team

Adding dental sleep medicine to your mix of services requires the entire team to gain new knowledge of the role of sleep and the diagnosis of a sleep breathing disorder, as well as how we can utilize dental devices as an adjunctive therapy. This has to be combined with ‘dental’  concerns such as muscle pain, temporomandibular joint disorders, missing or loose teeth to finalize a treatment recommendation. Working through complex multi-factorial diagnostic and treatment planning decisions is part of practicing dentistry, and we simply apply these skills to the additional medical information that is pertinent for patients with a sleep breathing disorder.

When any new service or technique is added to our daily repertoire in a busy dental practice it can cause disruptions, stress, and challenges that some dental teams won’t be able to see past to get the rewards that come from all the hard work. In addition to acquiring the technical expertise make sure you have prepared your team, and you may benefit from expert advice and finding meaningful mentors that can assist you.

A complicating factor for many offices is the choice to submit sleep therapy to medical insurance. Most dental offices are not equipped for medical billing and many financial administrators, perfectly comfortable with dental claim forms, find themselves mystified at the nuances of submitting to a host of unfamiliar payers. Fortunately, professional medical billers have stepped up to help, but even making this agreement requires dentists to stretch their knowledge and get expert advice in new areas of healthcare.   

Choosing Dental Sleep Medicine

Why do this? While dentists often improve people’s lives in fantastic ways with pain relief, reducing infection and inflammation, and beautifying smiles, rarely do we have the opportunity to give them a chance to live longer. Obstructive sleep apnea left untreated is proven to shorten life expectancy.

Treating the disease will enable people with persistent hypertension to reduce their blood pressure. Bed partners of snorers whose airways are opened improve their quality of life. Often married partners who had chosen to sleep separately reconcile into one bedroom. When someone sits with our team and tells us how much better they enjoy dreaming again after years of missing it, our days are brighter!

Are you trying to decide if treating sleep-disordered breathing is right for you? Dental continuing education provides plenty of introductory courses. I’m honored to be the editor of Dental Sleep Practice Magazine, dedicated to practical education.

There are academies and associations dedicated to supporting every member of the dental team as we expand our medical involvement to provide a service that only dentists are capable of performing. Mini-residencies are forming at leading educational institutions to provide in-depth, multi-disciplinary learning.

Is it worth the effort?

The first time your team celebrates together after a happy patient gives everyone a hug because of how much better they feel now that they’ve used your oral appliance, I think you’ll know the answer.

Part of knowing yourself is knowing what you want. Is what you want crystal clear to you? Does it inspire you to action? Is it a powerful enough motivator that it can survive the resistance you will encounter in your pursuit of it? Do the people around you know what you want and why it is important to you?

These questions are just the beginning. They are also essential if you are going to move in the direction of your dreams.

Envisioning Your Dream

If you are not moving and seem stuck, then a powerful vision of your dream is both a requirement and a determinant. It is the spark to start your engine. Most of us struggle to gain a distinct understanding of what we truly want at any level, but especially at the deepest level.

A blind person wants to see. A lame person wants to walk. A person in pain wants comfort. There are no competing agendas nor is there any confusion about what is most important to them. That is what I mean by clarity and passion for the cause.

Leadership & Influence

Leadership is about influence. The most important person you will ever lead is yourself. You are influencing yourself 24/7/365. Knowing yourself and taking every thought captive toward becoming what you were meant to become is the most powerful weapon that you have. Use it.

The journey of a thousand miles begins with the first step. Here are several:

1. Reflect on what you would be doing with your life and career, if you knew that you couldn’t fail. Do whatever it takes to get into the mindset to let go and believe.

2. Secure the best expertise that you can find. Build a relationship of trust and intimacy with mentors. Begin a very detailed and guided examination of yourself. Listen, observe, and experience what happens to you in this process.

3. Trust yourself. Act on what you discover. Do it again.

4. Contact me and we will celebrate your successes!

This post is a continuation of the leadership conversation I started in my previous blog. Check it out here.

For the student of the Pankey Philosophy, ‘Know Yourself’ is a familiar phrase. Dr. Pankey spoke often about understanding your own temperament, circumstances, and objectives. Those are the things that are usually known to us and the people around us.

Valuing the Deep Structure of Ourselves

Modern psychology might call that the surface structure of our thinking, feeling, and behavior. Knowing these things is critical to our decision making and moment-to-moment activities. Dr. Pankey was also a student of and eventually a master of the deep structure that is composed of our emotions and the memories from our life’s experiences that fuel those emotions.

Those emotions and memories are less well known to us and their impact is less appreciated by us. However, they are very powerful drivers of our current ways of thinking, feeling, deciding, and experiencing the world around us. The deep structure is the enormous part of the iceberg that is hidden underwater.

That part can represent great strength, endurance, and possibility. It can also be very unknown, dangerous, and limiting. How well we understand ourselves and what we do with that understanding will determine how much we limit our lives or whether we approach the limits of our human possibilities.

Using Personal Insight to Develop Leadership Skills

Twenty years ago, I did not know myself very well. I knew about my surface structure and very little about my deep structure. That knowledge got a huge jumpstart in a leadership workshop with Brian DesRoches, Phd.

Brian artfully blended the use of assessments, the teaching of contemporary brain science and modern psychology, as well as small group experiences to help each of us deepen and broaden our understanding of ourselves.

Subsequently, my professional coach has helped me to continue that development. Just as we rely on superb clinical teachers to develop our clinical skill sets, this kind of work requires the expertise of a trusted professional. That kind of helping relationship provides insights, observations, expertise, experience, and accountability.

Each of us needs this to see ourselves as we truly are. In my view, it is necessary to have professional expertise to grow your understanding of yourself. Knowing yourself is the foundation of change. You can’t start soon enough. There are no substitutes. It requires collaboration, intention, and patience.

When we ask patients what they really want, we can drastically improve our case acceptance. 

In my last blog, I talked about the path that led me to start asking patients: “Is there anything about the way your teeth look that you would like to change?”

Surprisingly, this one sentence has transformed my practice. The answers often surprise me. Countless patients with chipping, crowded, discolored teeth respond without hesitation, “Nope!” and many others with what I think are quite lovely smiles respond with a laundry list of things they would like changed.  

Transforming Your Dental Practice

Now that I wait for patients to tell me what they want, I no longer waste time on case work-ups that never turn into productive treatment. And because I found a way to zero in on the cases that I like doing the most, I have transformed my practice into one where I get to do more of the procedures that give me a higher level of satisfaction and happen to also be quite profitable.  

My message is this: First, figure out what your dream practice looks like. I think the best way to do this is to pursue high quality continuing dental education, get a great foundation in comprehensive dentistry, and find the areas you like most.  

Second, figure out how to do more of those things. Find ways to give patients permission to ask you for that treatment. If you love treating TMD, allow patients to uncover problems that will get them excited about the treatment you can provide to alleviate their pain. If you love seeing infants with tongue-ties, include questions on your new patient paperwork about breastfeeding. If you love placing implants, make sure your patients know you can provide them with long-term solutions for missing or hopeless teeth.  

Now that’s not to say that all I do all day is esthetic dentistry. I do plenty of posterior composites and single-unit crowns. However, having some challenging esthetic cases in progress, the ones that give me a lot of gratification and really do change lives make dentistry so much more enjoyable.  

Define your dream practice and eventually you may find yourself living it.  

Assessing and managing the papilla is particularly important when we are treatment planning esthetic cases. Usually, we pay attention to the papilla when planning anterior implants and are less focused on this when we are treatment planning natural teeth.

The papilla is valued in cosmetic dentistry because it is an essential element of smile esthetics. If we want patients to be truly happy with their results, we must include it in our early considerations.

Papilla Tips and Why They Matter

Many of our patients who are in their sixties and seventies will still show the tips of the papilla. This isn’t the case for other aspects such as the gingival margin. Because of this, it’s critical that we don’t ignore them when treatment planning a smile.

Two main aspects to focus on when diagnosing papilla esthetics are symmetry and papilla height compared to contact length.

Papilla Symmetry

Papilla heights should be symmetric across the midline. Papilla tips will vary for patients, with some creating a straight line when connected and others having a line that tips up toward the canines. Regardless, the left and right sides should mimic one another. For example, if the papilla tip is shorter between the canine and lateral, it should do this on both sides.

Papilla Height

Papilla height compared to contact length is also important. The papilla tip should take up 45-50% of the total length of the tooth from the gingiva to the end of the contact. Then the contact should use up the remaining 50-55% of this distance.

Looking at the existing papilla symmetry and height enables you to decide if the esthetics are acceptable. Your goal will be to maintain them optimally. If they are where you want them to be esthetically already, then you have a reference to determine the positive or negative effect treatments like crown lengthening, ortho, and restorative procedures could have. If papilla esthetics are not where you want them to be, you can use these parameters to evaluate treatment options and improve them.

What is your favorite part of treatment planning a case? We’d love to hear your thoughts in the comments!