The new challenge facing us in dentistry is how to incorporate technology into our daily practice. Digital splints specifically are a subject I have been working on for about a year. 

We have had the technology available to mill a splint out of acrylic for a few years now. However, we have not had a good protocol that meets all our needs. 

Digital Splints: Challenges

Some of the problems we face are as follows:

1) Lack of digital articulators that make all of the movements we are able to with semi adjustable articulators, such as crossover transitions. 

2) Absence of centric relation record mountings in software on a computer.

3) No rotational path insertion we can achieve from relines in the mouth. 

4) Few materials that are as good or better than we have now.

I believe we are well on our way to solving these issues. The biggest problem I see is something Dr. Pankey was dealing with many years ago. He talked about how the majority of dentists are indifferent to good comprehensive care dentistry. Therefore, most of the manufacturers of our dental equipment and software are catering to a majority that does not share our own clinical demands. 

These companies give me answers like, “That sounds great doc but who will I be able to sell that to?” I think we have to find workarounds for now that will encourage development in these technologies. Keep in mind, all of the workarounds I will explain are in line with what we teach at the Pankey Institute. 

Digital Splints: Opportunities

We also need systems we can duplicate and teach without compromising the quality of care or experience for patients. I believe there is great potential for higher quality materials and great fitting splints without relines. These two potentials alone can create more value and better experiences for patients.

Today I have a protocol that is some digital and some analog. I intraoral scan our impressions with the TRIOS scanner. I believe most of the scanners on the market today work very well and produce very accurate files that can be printed into models. I also use the TRIOS because it communicates very well with the 3SHAPE units most labs use. 

Now that I have files and models I have to mount them. This is our first problem to solve. I still use an analog facebow or facial analyzer. I mount these models on an articulator like the Denar Mark 330 because this is an articulator model programmed into the 3SHAPE software. 

To be continued…

How do you ensure aspects like pitch, bevel, crossover, and trailing edges are taken into account? Here, Dr. Green continues his commentary on this valuable aspect of dentistry.

A Flaw of Design: Why Leading & Trailing Edges Matter

While I was helping in the Pankey Scholar Program, the participants would video their patient during the post-case conversation. They would record the movements of the patient in protrusive, left, right radial lateral into crossover, and lateral protrusive.

As I was observing patients in the videos, I would occasionally notice a hesitation once they got to the tips of the cuspid. Sometimes there would also be a quiver of the jaw or muscle twitch. I would usually review the video later with the participant and look at the finished case on the articulator with them. We would talk about how they could put a ‘landing facet’ on cuspids too since they are anterior teeth.

They were beautiful porcelain cases, so I would show them on another set of models how easy it was to do. I told them they would know it was right when the patient’s eyes smiled and the hesitation and muscle twitching went away. Another benefit of a facet on a cuspid is that it is gentler on opposing incisal edges of centrals and laterals in all mandibular movements.

Talking About Edges

One way to talk about the leading and trailing edges: on upper anterior teeth, including cuspids, the leading bevel is at the lingual-incisal junction. The bevel develops naturally on natural teeth. With restorations, the dentist creates it.

The leading edge of the lower incisors, including cuspids, is on the facial incisal junction. It is created in natural teeth with normal function. When restorative material is used, it must be managed by the dentist.

The trailing edges and bevels (labial-incisal edge of upper anteriors plus cuspid and lingual-incisal edges of lower anteriors, including cuspids) are always shaping with function. This can lead to micro-fracturing or major sheering of enamel vertically. Therefore, the trailing edge bevel must always be managed by the dentist with intention. The goal should be preventive with natural tooth or any restorative material.

Once a natural tooth has been worn to the point of losing incisal embrasure, the medial and lingual marginal ridge convex Shaw on the lower can act like a chisel against the labial incisal edge of the upper. This is seen often in a crossover position.

Edges, bevels, and pitch may not be simple, but awareness comes in the doing and observing!

When Dr. Richard Green read Dr. Lee Ann Brady’s blogs on pitch and bevels, he decided to jump in with a thoughtful response. Read on for more discussion of this fascinating topic.

Crossover and Movement: Consider the Edges

I loved Dr. Brady’s article concerning edges (pitch and both bevels) and the conversation about natural teeth, composition, and porcelain. I was reminded of some of my learning with and from Henry Tanner while refining my occlusion in the mid-70s. It worked for me no matter what material and bite splints were used.

Henry was the first to introduce me to ‘crossover.’ At the time, one of the anterior teeth you did not talk about were the cuspids. They too have important facets (pitch and two bevels) that need to match cusp tip to cusp tip, regardless of the material.

When moving into crossover and the cuspid tips touch, if the pitch facet does not match or is pointed, sloped, or rounded, you often see the masseter or temporalysis muscle twitch. This occurs as the patient hesitates in their movement. That smooth transition back to the incisal edges of the centrals and laterals is important.

I also realized during my career that certain patients (teens, golfers, baseball players) would often stabilize their head while their teeth were cuspid tip to tip or in a crossover position at the point of their impact with the ball.

Improvements can be accomplished by simply taking the flat portion of a ½ J (wheel fine diamond) and creating matching facets on upper and lower cuspids. Polish them and both the leading and trailing bevels so that the movement becomes smooth. If the patient wants to stop cusp tip to cusp tip on the upper and lower cuspid, there is a stable stop and the muscles are comfortable.

To be continued…

Dive into this case for a look at Dr. Owen’s thought process and treatment protocol leading to porcelain restorations. 

Angela was 27 when she came to us asking about options to improve her smile. She was getting married within a year. She hated the appearance of the bridge #3-6 that had been placed in high school. It was repaired at the buccal margin of #6 the day of delivery. She also said she wanted to avoid implants because of time issues and she didn’t want more crowns.

Patient Background

Angela was congenitally missing #4, 7, 10, 12, 13, 20, and 29. In the past, she had implants to replace the lower bicuspids and said the process took too long. Her previous dentist had placed two upper bridges – #3-7 with pontics on #4 and #7 and #14-10 with pontics on #13 and #10. The space for #12 did not exist.

Treatment Plan

I noticed her narrow central incisors compared to her laterals and the general contour and color of the bridges. I knew we could improve her smile with all porcelain restorations. Implants to replace missing teeth and veneers on the centrals would make a difference. We did a wax up that she took home to study, comparing it to the model of her existing restorations. She visited the periodontist who would do the implants and I showed her lots of photos of other cases similar to hers.

Creating Porcelain Restorations

Ultimately Angela agreed with our plan. She had implants replacing #7, 10, and 13. We used Zirconia abutments and e.max crowns, as well as an e.max crown for #14. She opted for a Zirconia bridge #3-5. While she was healing, we made provisional bridges, including the cantilevers for the laterals. She was hesitant about the veneers on #8 and #9, but before we began I removed the bridges and created a trial restoration with the wider veneers and proper bridge contours. I took photos and let her think about it before she agreed. She got married with a beautiful new smile.   

What interesting cases are you currently working on? 

Many dentist-patient interactions operate under the assumption of limited time on our part and limited ability to accurately explain on theirs. After engaging in hundreds of pre-clinical interviews and conversations during appointments, you will have naturally developed your own preferred style for questioning. But how well does it really serve you?

If you feel something is lacking in your patient care, yet your clinical skills and execution seem immaculate, the problem might be about language. When you communicate with your patients, do you get the sense that they feel limited, misunderstood, or unsatisfied? This could be a direct result of using language to discuss ‘disease’ rather than ‘health.’

Use the Language of Health to Connect With Your Patients

Getting out of the rut of a traditional hygiene appointment starts with how you communicate. Even minor shifts in your word choice can have a profound effect on the patient’s sense of comfort. Open up a discussion about their health to connect with their needs.

A great way to follow this path is to abandon the typical impersonal medical jargon. Instead of asking if there have been changes to the patient’s medical history, pose a question about how their health has been since you last saw them.

Right out of the gate, you are presenting yourself as empathetic rather than turning into the classic brusque medical professional. Ask about how they are feeling, whether they have been taking care of themselves, and what changes they have made in their lifestyle.

These types of questions capitalize on expressive language to make the most of your time. Having the patient rattle off changes in their medical history without knowing how they feel about those changes isn’t as useful. People will generally open up when they are given a safe, non-judgmental space to discuss their health. After all, it is often one of the central preoccupations of our interior lives.

What questions do you think are most productive during appointments? 

In fifth grade, I knew I wanted to be in dentistry. Unfortunately, I thought that meant either being a receptionist, assistant, or hygienist. The thought of being a dentist never entered my mind until I was finishing up my dental hygiene program.

Pivotal Dental School & Career Moments

After several more years of working and evening classes, I was accepted to dental school. I was extremely grateful to get in. I loved dental school and sought out the best instructors so I could learn as much as possible.  

One instructor in particular invited me to help her in the TMJ Clinic. Back in 1988, exposure to splint therapy and equilibration techniques was rare. She impressed upon me the importance of stable joints and occlusion. I was able to work with her on two patients my senior year. At the time, I did not realize what a gift this had been. She was also one of several instructors who recommended the Pankey Institute to me. Turns out that was a gift as well.

Following graduation and a GPR, I started practice as an associate with my uncle. In 1994, I began my journey at the Pankey Institute. I had no idea just how much coming to Key Biscayne would change my life.

Although we learn so much throughout the continuums, the emphasis on stable joints and occlusion has been critical to my success as a dentist. Most of the failures we encounter are a direct result of not doing a thorough enough evaluation of our patients before treatment begins. Learning how to do a comprehensive examination and achieving stability is absolutely essential for preventing mistakes and failures.

During the second continuum, I discovered my own TMJ dysfunction and was treated with splint therapy, orthodontics, and equilibration. Going through these procedures enabled me to witness why it is so important to have stability.

Had I not been introduced to TMJ concerns in dental school and later gone to the Pankey Institute, I would not have gained the knowledge to anticipate and prevent failures for my patients. The strong emphasis on a comprehensive evaluation enabled me to treat patients successfully and have an enjoyable and meaningful career.

What are your most memorable or formative moments from dental school? 

The comprehensive exam sets the stage for the quality of your dentistry. The information you gather is instrumental in guiding your treatment plan, getting to know your patient, and helping you effectively relieve pain or discomfort.

The temporomandibular joint is one of the 4 exam areas that comprise a comprehensive functional exam. Ascertaining where we believe the disc is relative to the condyle and whether or not we detect the presence of inflammation are the goals. We want to understand if the joint is stable, adapted or currently undergoing breakdown.

Refresh Your Joint Exam Technique

A good place to start is with lateral pole location. While the patient is lying back, place three fingers lightly in the lateral pole region. Then have them open and close. As they are opening and closing, locate the lateral poles. Observe and record palpable joint noise sounds and motion. Make sure you are documenting your findings clearly throughout the process.

You should also reference maxillary midline to mandibular midline and record opening and closing deviations from the midline. There is so much that can be learned from this basic exam protocol.

Next, move on to joint auscultation in translation and excursions. Using your stethoscope to listen, you can direct the patient to again open and close without touching, as well as move their jaw excursively. You’ll verify palpable sounds and listen to both rotation and translation…

What do you consider critical elements of a joint and muscle exam? 

Do you feel reticent about having someone other than you use the facebow? 

A Spatial Reference Point Story

Recently over the holidays as I was “channel surfing” I came across the movie Apollo 13. This is one of those movies that no matter how many times I have watched it, I just have to stop and watch it one more time. Every time I do, I can’t help but get misty-eyed when it gets to the part when the crew make it back to Earth safely (SPOILER ALERT … But you probably read this in the history books anyway).

For me, there is one super exciting moment in the film when Astronaut James Lovell (aka Tom Hanks) has to find a reference point to correct their descent back to Earth from space or burn up on re-entry. Since he cannot use his on-board computers, he lines up his spaceship with the Earth in his window.

“Keep the Earth in the window!” A spatial reference point! Too much correction and their spaceship burns up on re-entry. Too little and they skip off the Earth’s atmosphere.

Make Your Facebow Process Simpler

In our dental offices, the facebow is used to give us a spatial reference point for mounting diagnostic or working models of our patient’s dentition. This is done onto an articulator that approximates the realities of our patient. Sure, you might be able to mount casts arbitrarily, but is your accuracy reproducible? The facebow is a simple tool in our armamentarium to make our life easier.

The question remains, “Is this a task that the dentist must perform?” In my office when we create exquisite dental mountings, I delegate this task to my awesome dental assistants.  With a little training they can do this immediately and the procedure only takes a few minutes.

This involvement is a great way for them to demonstrate their knowledge. It paves the way for more opportunities to open conversations about the Dentist’s Care, Skill, and Judgement. They become your chairside cheerleader and highlight your expertise. They will also express how a critical bite registration record or protrusive record performed by the dentist will only enhance the outcome of treatment.  

Information gathered through the use of a facebow makes our dentistry more predictable. It distinguishes you and your team as a highly trained dental practice.

Don’t burn up on re-entry or skip off into space. Glide effortlessly into beautiful predictable dentistry by using your facebow. Keep your Earth in the window!

Okay teams, here I go again talking about basic phone skills. It might seem as though this is a pretty old horse that has been beaten to death one too many times. The reality, though, is that your phone continues to be the single most important tool in your office.

Why Phone Call Communication Skills Still Matter

The other reality is that all too often, this valuable instrument is under-functioning due to the lack of intention, precision, and focus of the people answering it. I love referring to your phone as an ‘instrument’ as it takes a skilled musician willing to put in time and energy for it to sound magical.

And yes, there is a very sweet recipe made up of having a talented individual that LOVES answering the phone combined with appropriate training in facilitation. Only this can create a truly extraordinary experience for the patients that are calling your office.

How to Improve Calls Through Coaching

Not sure if this is happening in your practice? I have one simple suggestion: record your calls and make time on a regular basis to listen to them. Learn for yourself exactly what is occurring.

After listening to hundreds of calls this past year alone, I can tell you without a doubt there are always opportunities for improvement on basic (and of course advanced) phone skills.

As you listen to calls, I invite you to become and stay interested in a number of things:

• Does your team member have a warm and welcoming spirit?
• How quickly is a caller asked for their name?
• Do they sound genuinely interested in the person on the other end?
• Are they inviting the patient’s story? Responding appropriately?
• How much value building is there for your practice?
• In what ways is the patient assured that they called the right place?
• Are potential patients being asked to schedule?

Listening to calls with individual team members can be a wonderful coaching opportunity! Although it may take some time and energy to create a safe environment in which to do this, I find the process engaging, enlightening, and potentially transformational. What do you say? Is it time to see if your phone is making magical music?

It’s time to forget your New Years resolutions for a night (or morning) at our top four favorite Miami dessert spots.

Dental continuing education should always come with a hefty serving of fun in addition to all of the personal and career development. What could be more fun than sugar, sugar, and more sugar?

Best Desserts in Miami (AKA Bring on the Cavities)

When you visit Pankey, it would be a shame not to leave Key Biscayne at least once to explore mainland Miami. Not only does the city boast a fascinating assortment of culture, it’s also known for world-class cuisine.

But where to go and, most importantly, what restaurant(s) should you visit? Don’t worry, we’ll lead you on the path of dessert decadence:

1. A Simple Slice of Pie at The Dutch

Pie, you ask? Really? Oh yes. Choose the pie of your heart’s desire at this eclectic American-style bar, restaurant, and oyster room on Miami Beach. Salted lime, caramel apple, and banana cream pies are made fresh daily.

2. An Insane Milkshake at Bocas House

Whether you’re on Instagram or not, you will have to get a picture of your Bocas House milkshake to share with all close and not-so-close acquaintances. Their whimsical masterpieces like the Nutella and Golden Milkshakes are topped with everything from brownies to ice cream cones.

3. A Sophisticated Flourless Cake at Chef Sucre Cafe

This Coral Gables eatery is a foodie’s dream. Order the flourless chocolate cake (gluten free, for those wondering) and enjoy the lingonberry chutney prepared alongside chantilly cream. It’s an unforgettable dessert experience.

4. A Jaw-Dropping Deep Fried Oreo at Yardbird

Gone are the days when deep fried oreos were only considered festival fare. Yardbird turns the tables with this shocking dessert. It’s honestly a meal of its own, though you might find the other dessert offerings (mini nutella-filled beignets, bacon butterscotch cake, and more) difficult to pass up.

There are endless Miami desserts that could have made it onto this list, including our favorite Gelato right on Key Biscayne at Bertoni. If none of our choices suit your taste buds, go ahead and explore! The local fare is always full of surprises.