Give patients opportunities to discover what lies beneath their smile

Ewelina is part of my office team. She’s from Poland. She’s beautiful but early in our doctor-patient relationship, I realized she had a closed-smile grin. One day, I asked her if she was aware that she was guarding her smile. She wasn’t but the question made her curious. Later, she came by and said, “I realize it now.”

So, I raised another question, “Now that you notice this, what do you think about your teeth? Were you guarding them subconsciously?”

She thought momentarily and said, “I wasn’t happy with their appearance. I think I unconsciously I do guard my smile.”

So, I raised one more question, “At what point in your life did you say to yourself, I wish my teeth were more attractive?”

Her answer surprised me: “I thought about it when I got married and bleached them, and after I had kids, I thought my teeth looked more unattractive than they did years ago.”

I spoke to Laura Harkin, a dentist I admire, about this. She said that it’s common for women to become more critical of their appearance after having children. Their bodies have gone through so many changes. Ewelina seemed to guard her smile long before she had children so I wondered if there may be cultural differences between her old and new adopted home. I asked her if she became more self-conscious about her teeth after coming to the United States. She answered in the affirmative, “People’s teeth generally look better here than in Poland.”

I loved that there was a long thoughtful pause before her answer. I intentionally gave her time to think between questions. I offered to give her a smile makeover, which she readily agreed to. In doing my case workup, we found she had a two-step occlusion that needed to be corrected. When I got to my wax-up, the anterior changes were minimal and I did an equilibration on the wax-up to try out the results. This set the stage for the changes we would try out in provisional.

Provisional restorations are something I always do to test if the speech will be affected, whether the new occlusion is comfortable, and if the patient feels “good” psychologically about all the changes — not just the aesthetics.

While wearing the provisionals, she began to smile with a Duchenne smile. In photos, I could see a postural difference, too.

My ceramist did an amazing job duplicating in ceramic the provisionals that I created. When the case was completed, I asked Ewelina how she felt. She said, “Great, happy, healthier, cleaner, brighter, very happy.” Cleaner, brighter, healthier, happy – that was a huge learning moment for me! Not once did she mention her teeth, just the feelings around her treatment outcome. It began to dawn on me how much we not only change teeth, but we can change lives!

“I’m happy,” she said. “I think I smile more and I feel like they’re my natural teeth. It’s hard to explain, but I feel like these are the teeth I’ve had all along.”

“How does your bite feel?” I asked. “Were you surprised how the small adjustments made big differences?”

“Before, I felt a little muscle soreness and dull pain back here, but after a day or two of the adjustment, I felt nothing. I feel great,” she said with a big, broad smile.

I think if we spend a lot of time with our patients and develop relationships, it’s ideally like psychological therapy. We give patients opportunities to discover what lies beneath their smile, show them a vision of what could be, and lastly, help them to reach their full potential, as described in Part 1, with a beautiful, confident Duchenne smile.

We have a unique opportunity to not only restore teeth but also change lives through our efforts.

Wax-ups are essential for my aesthetic case designs

Part 2 was originally presented to the Restorative Nation in February of 2023: It’s All In The Smile: Psychologic & Technical Considerations – Restorative Nation

My esthetic evaluation is similar to the curriculum taught in the Pankey Institute Essentials and Aesthetic Focus courses. I generally like to look at every aspect of a patient’s smile through photography, with emphasis on the following:

1. Facial Height – To evaluate possible skeletal defects that can lead to a smile not appearing attractive, I measure the middle 1/3 of the face and the lower 1/3 portion of the face. If there is a one-to-one (1:1) ratio, then I can essentially rule out either vertical maxillary excess or loss of vertical dimension. If there is a one to greater than one (1:>1) ratio, I can look at vertical maxillary excess. If there is a one to less than one (1:<1) ratio, I can look for extreme wear and loss of vertical dimension.
2. Lip Length — The average woman’s lip is 20 to 22 millimeters in height, and the male’s is 22 to 24 millimeters. Our lips, like everything else sag over time. We lose a mm of tooth display after age 41 at a rate of about one more millimeter per decade.
3. Lip Mobility — How high does the lip rise when the patient smiles? The average amount of lip mobility is between six and eight millimeters. A hypermobile lip can give the “gummy smile” and fool us into thinking that there is a vertical maxillary excess
4. Upper Lip Drape — Generally, we like the lip to fall at the free gingival margins of the canines and the central incisors.
5. Lower Incisal Edges –We like the lower lip to cradle the lower teeth with the line formed by incisal edges following the shape of the lower lip.
6. Gingival Heights — We like our gingival heights to be symmetrical. I like canines even, the centrals even with the canines, and the laterals a little lower.
7. Central Incisor Length and Width — The average central incisor is about 10 to 11 millimeters in length, and the average width of a central incisor is about 75% of the length.
8. Other Anterior Teeth Length and Width — The rule of Golden Proportions says that a central incisor should be proportional to a lateral incisor by a factor of 0.6, and the canine should be proportional to the lateral by a factor of 0.6.
9. I photograph the patient in repose, their “regular” smile, and then their “biggest E” smile in order to get a sense of how they look when they present with the Duchenne smile. Patients often will give you some form of a guarded or half smile on photographs and that presentation can be misleading. We need to see their full tooth and tissue display to properly evaluate esthetics.

Once I have had a chance to evaluate the virtual patient via photos, printed study models mounted on articulators, and radiographs, I can then propose esthetic changes. I am a huge proponent of fabricating my own “working wax-up” as I like to call it. It is not presentation quality and can be made from wax or old composite. The importance is that it previews the changes that I am proposing, and I use those workups to either make a silicone index for provisionals or I send them to the lab for cleanup and completion. I always keep an original mounted study cast and then have a second model that I play with.

I always start my working wax-ups by placing upper incisors exactly where I want them in the most esthetic position, then I make the rest of the anterior teeth proportional to those incisors. Once the upper anterior teeth are in optimal position, I’ll place or wax the lower teeth to be parallel to the upper and in contact with the upper lingual surfaces of the anterior teeth. In E4 we teach all of the above concepts and discuss how vertical dimension can be evaluated and altered appropriately with the anterior esthetic evaluation. We then look at developing the axial inclination of teeth and posterior occlusal planes to be in harmony with the anteriors.

I encourage all dentists to practice with “working wax-ups.” It truly shows the patient our expertise and artistry in action not just what the laboratory fabricates for us.

Want to see some of the more complex cases I have done? I invite you to view the Restorative Nation video linked above.

Smile behavior is influenced by the individual’s feelings about their smile.

Smiles are an integral part of human communication. They make us appear more attractive, approachable, happy, agreeable, and attentive. Studies have shown that people who are happy with their smiles are more confident, have a greater sense of well-being, and this is also reflected in their behavior. In one study, subjects were shown photos of people with nice smiles. The subjects deemed these people as being more socially competent, with greater intellectual achievement and better psychological adjustment. These smiles are contagious and It’s easy to reciprocate when someone gives you that “genuine smile.” We’ve all seen this smile, but what makes it genuine?

There are a variety of smiles that reflect a wide array of emotions. From flirtatious to embarrassed, our smiles reflect our mood and communicate our thoughts. Or do they? When people are unhappy with the appearance of their smile they present a variety of guarding. There’s upper lip guarding, lower lip guarding, both lips guarding, covering one’s mouth with a hand, and of course close lip grins.

As dentists, we must be able to spend time with our patients, to see those smiles, and to delve into why a patient may be guarding. In a sense, we must become esthetic psychologists. It is not an overstatement to say that as dentists, we don’t just change teeth; we can change lives. We can shape how others see our patients. If a patient cannot give a genuine unencumbered smile, perhaps, they’ll miss an employment opportunity or meeting that special someone. Perhaps they’ll be seen by others as unfriendly or unapproachable.

So, is there a “genuine smile” that can be quantified? In the 1800s, a French anatomist by the name of Guillaume Duchenne sought to answer that question. Duchenne, through stimulating facial muscles, found that the most genuine, sincere smile occurred when 3 muscle groups fired: the orbicularis oris and zygomaticus major in the mouth and the orbicularis oculi of the eye forming crows’ feet.

Most consider the resulting Duchenne smile to be the genuine smile that is spontaneous and sincere. Studies have shown that this type of smile can elevate mood, change body stress response, and is responsible for the release of endorphins, dopamine, and serotonin. In all, the Duchenne smile is the Holy Grail. It is certainly about the smile but a major component is the formation of crows’ feet around the eyes. Just think of the song When Irish Eyes Are Smiling. The Duchenne smile in all its splendor is sure to steal your heart away. My point is that we need to remember that the Duchenne smile is about the mouth AND the eyes; these elements are interconnected.

What we’ll need to evaluate as Dentists is whether Botox injections and plastic surgery affect the Duchenne smile. Certainly, in the case of the Botox smile, the answer is yes since the elevator muscles of the mouth are injected thus altering the Duchenne muscle contractions. Obviously, it is vital then to take a good health history and determine whether a patient is smile guarding or simply cannot fire the muscles that make up the Duchenne smile.

In making dental changes, we change lives. We shape how others see our patients and how they see themselves. This is priceless work. It is worthy work. But until a patient desires the best results that today’s dentistry can achieve and trusts us to execute the technical aspects of their new smile, we are in listening, understanding, and guidance mode. We are leading them forward with primary, essential care and taking them on a long journey to achieve what is possible. With each new dental restoration, they may smile more broadly and lift their head higher. They will feel the release of endorphins and serotonins. They will experience the positivity of greater self-confidence.

Artful comprehensive dentists are like behavioral psychologists who have the sincere intention of doing their utmost for the benefit of their patients.

You know what greater smile benefits are possible if the patient understands and wants to continue with aesthetic treatment. Patience is a virtue. So, spark the curiosity of your patients and lead gently but with confidence. Never forget that a patient who is concerned about the cost of elective treatment today will be thanking you profusely two to three years from now and saying the decision to move forward with a comprehensive smile makeover was one of the best decisions of their life.

When I first came out of dental school, palate expansion with an orthodontic device was limited to children and young adolescents. We thought the palatal suture was closed and fused, and we could no longer use a fixed orthodontic device to change the shape of the maxillary arch and expand the palate. Today we know that we can do palate expansion for patients who are older, and we have the additional ability to do surgically facilitated orthodontic treatment.

Why is this important?

Because today we understand how the shape of the maxillary palate, the shape of the arch form, and the ability to put the tongue solidly against the roof of the mouth have a positive impact on eliminating apnea, hypopnea, and breathing issues.

At what age is palatal expansion with an orthodontic device no longer effective?

I asked this question to two board-certified orthodontists whom I respect. And interestingly, I got the exact same answer. They both said that until age 35 we can get palatable expansion with a fixed orthodontic device. And after age 35, it may work but it becomes unpredictable. The older a patient is beyond their mid-thirties, the less predictable the results are. The patient must understand this when they accept treatment.

When I inquired if they had attempted palatal expansion on a patient over 35, both orthodontists said they had done so with good results, but treatment is slower and thus takes longer. They explain to patients that they can try surgically facilitated ortho with a palate expander, and if it doesn’t work, there is a pure surgical solution. The patient can choose to skip over the orthodontic device and go straight to the surgical solution. They fully inform the patient about the options, and the risks and benefits of treatment. They’ve had adults over 35 choose to proceed with treatment.

Up until age 35, palate expansion with an orthodontic device is predictable and a treatment we can confidently recommend. There are alternative treatments for adults over age 35.

Can Invisalign or other aligners expand the palate?

Aligners do not expand the palate. They can, however, widen the arch and alveolar bone by 1 to 2 mm. Putting this in perspective, this is a widening of less than a tenth of an inch (about 0.08 in). Aligner treatment can be used to reposition the teeth to make more space for the tongue to press solidly or more solidly against the roof of the mouth. For many adult patients, this is a treatment modality that improves their airway.

The goals of palate expansion with an orthodontic palate expander or pure surgery are to achieve greater than 1 to 2 mm of expansion.

At the Pankey Institute

Comprehensive dentistry that addresses the airway and breathing is a common topic of conversation among dentists who participate in Pankey courses. We welcome these conversations. Because every patient presents with a complex of factors, I advocate for a holistic approach to looking at underlying causes of apnea, hypopnea, and breathing issues.

At Pankey, we have a very in-depth Essentials Series that cover an array of important dentistry topics. During our Essentials 1 course, we include a special Airway Management section for dentists to practice on a regular basis. Check out our upcoming course dates here.

Here are four Pankey Webinars you may want to view to develop your understanding of the importance of the airway in the patient’s total health and what dentists are doing to integrate airway support in their practice. It’s exciting to see the expertise that has developed among our faculty and participants. Some have developed into niche providers to better serve the needs of their communities.

1. The Goals of New Orthodontics: How Airway Thinking is Impacting Dentistry
2. Breathing and Airway Support
3. Open the Airway Tonight and Other Tips from the Dental Sleep World
4. Airway Centric Dentistry

We have a buffet of restorative materials to choose from today. Accurate preparations are fulfilling the promise of digital design and precision-based dentistry to deliver the highest level of restorative treatment with efficiency. The microscope has changed the way I personally approach dentistry, and it has heightened my passion for precision dentistry.

The world of dental microscopy has opened my eyes to see and know more. The microscope has allowed me to improve my dentistry through ergonomics, improved illumination, and magnification. I am astonished and, at the same time, feel humbled to be able to see detail and precision at such a high level of magnification.

An Opportunity to Teach Propelled Me

My introduction to using a dental microscope began five years ago through the University of Pennsylvania Dental School where I was invited to teach a novel program introducing the idea of restorative dentistry with the utilization of dental microscopes. The purpose of the program was to introduce concepts of precision-based dentistry in our ever-changing digital dental world. We wanted our students to appreciate the value of details and how marginal gaps and adaptation can be improved with a higher level of thinking and training.

Not owning a microscope at the time, I agreed to explore this idea and accepted the position. I trained, calibrated, and practiced with the dental students to quickly see the value. Within a few short months, I had integrated dental microscopy into my dental practice.

Does the Microscope Replace Loupes?

Other dentists, who have not adopted dental microscopy, often ask me, “What does the microscope replace in your practice, and does it replace your loupes?” The answer is simple. Using a dental microscope doesn’t necessarily replace loupes but higher magnification increases proficiency and precision. I often prepare with my loupes and finish my preparations under higher magnification to improve smoothness, adaptation, and finish lines.

The viewing capabilities of the microscopes provide a range of higher magnification beyond some loupes with no eye muscle strain. Under dental microscopy, I can magnify my viewing field from 4X power to 10X power and sometimes as high as 25X power.

The Microscope Has Changed How I Practice

Utilizing a dental microscope has changed how I practice dentistry, improved my overall health in ergonomics, and is now an invaluable part of my practice as I strive to serve my patients with higher-level dentistry.

Using the microscope, I routinely minimize marginal gaps in my preparations to increase the longevity of restorations for my patients.

The completely upright binocular, parallel vision provides less strain to my posture, my neck, and head position.

My patients can view what I see with the microscope and gain an elevated understanding. Together we can partner better in making collaborative decisions to improve their dental health in the best way possible.

Why I Use a Dental Microscope

I am of the belief that when we see better, we can do better. I want to do my best for my patients. The dental microscope provides an elevated level of magnification, illumination, ergonomics, and patient education so I can deliver the highest care. After adapting to its usage and experiencing its benefits, I recommend it highly to other dentists. If you have access to one to try it–and put in the effort to learn how to use it, I think you’ll rapidly want one of your own.

Discover more on how to build a thriving dental practice with The Essentials Series at Pankey. This comprehensive 4-part course starts with Essentials 1, diving deep into the core principles that will transform your approach to patient care and practice management. 

Seating dental restorations with resin-based cement can be daunting. The process is extremely technique sensitive and requires multiple steps. One of the things I learned years ago is to keep a small cup of acetone or ethanol on the tray table when I am seating restorations using resin-based cement.

All our resin materials have a solvent in them. That solvent is often ethanol or acetone. The solvent disrupts the chemistry, spreads out particles, and stops the resin from polymerizing. So, we can use a solvent to prevent the resin from setting and turn it completely into a liquid then wipe it away. Now we can go back to our steps to clean the ceramic, selenate the ceramic, etch the tooth, apply the dental adhesive, and freshly seat the restoration in the same appointment.

Recently, I was in the process of seating veneers. I prepped #6 and loaded the resin. As I raised the veneer, I realized it was for #11 instead of #6. So, I dropped the veneer in the little cup of acetone on my tray. I soaked a 2×2 in the solvent and completely wiped the resin off tooth #6 and completely wiped the resin off the back of veneer #11. Then, I took a deep breath and was ready for a do-over.

This was the first time I had to use that little cup of solvent in over 15 years, but I was delighted it was on my tray table. Time and again we have thrown that little cup away—for years and years, and now I have experienced firsthand why that cup of solvent is always “at the ready” when I seat restorations using resin-based cement.

Here at Pankey, we are committed to helping you through any of the questions you might have while practicing dentistry. I recommend starting your advanced dental education journey with our Essentials 1 course. You will gain essential knowledge and skills, enabling you to build a solid understanding of fundamental concepts in dentistry. From fundamental principles to essential clinical techniques, The Essentials Series will lay down the groundwork for a successful dental practice and further specialization. 

As I’ve been giving presentations about business systems to dentists, I’ve discovered that there are six prevalent myths surrounding 401k retirement plans. In Parts 1 and 2 of this series, I hope to help dentists who are also small business owners develop a better understanding of what is possible.

Myth 4: It’s Possible for a 401(k) Plan to Be Free

The reality is that a 401(k) plan is never free. Equitable, for example, has a specific retirement plan for dentists. They claim to have a plan with no direct costs for dentists. What they do is take a part of the participants’ total investment to cover the costs. In most cases, the person paying the highest percentage of the fee is the dentist because the dentist puts the largest amount into the fund. As a dental practice owner, I don’t want the costs to come from my account. Instead, I want my business to cover the costs because the fees are tax deductible for the business and my retirement funds accumulate to their greatest potential.

When someone is marketing a free plan, be aware that there is no free plan and the costs are going to come out of your account, just as much or more as any participant’s account in the plan and those costs are not going to be tax deductible on personal taxes. In the case of Equitable, about 20% of your earnings are being siphoned off for fees and this has a significant drag on your net accumulation.

Myth 5: Being a 401(k) Fiduciary Is Risky

The first responsibility of being a plan sponsor is that you have the fiduciary responsibility. No one else can assume that responsibility. I believe you can meet your fiduciary responsibilities rather simply by doing the following.

The 6 Fiduciary Responsibilities Are to:

1. Meet financial investment responsibilities.
2. Meeting administrative responsibilities.
3. Pay only reasonable expenses from plan assets.
4. Deposit employee contributions timely.
5. Maintain adequate ERISA fidelity bond coverage.
6. Select and monitor 401(k) service providers.

You do need to maintain fidelity bond coverage, and $50,000 to $100,000 of bond coverage costs $200 to $300 per year. I do not think this is expensive and I think it is not difficult to fulfill your fiduciary responsibilities.

Myth 6: Switching to a Low Cost 401(k) Provider Is Difficult

An existing 401(k) plan cannot be simply terminated and then you start a new one. You must go through the following four steps, but this is easy to do.

The 4 Steps in the Conversion Process Are:

1. Asset transfer
2. Document preparation
3. Investment selection
4. Participant enrollment

Here are two examples of vetted companies that I believe provide low-cost plans with robust features. The first is 401Go.com. It provides advisor-led retirement plans for small businesses. This company is very easy to work with, has payroll integration, and you can set convert your plan quickly.

The second company is EmployeeFiduciary.com. This company has incredibly low establishment and conversion fees—some of the lowest in the industry. With Employee Fiduciary, you have access to 30,000 share classes and 377 fund families. These include low-cost options like Vanguard, Fidelity, and Schwab index and exchange-traded funds. You can also elect to include a self-directed brokerage account from TD Ameritrade, which allows you to invest in any fund on the market.

I hope this instills some curiosity in understanding your existing 401(k) plan. Examine your fees and your options if you were to convert your plan. I encourage you to do this because fees can significantly drag down your investment accumulation over time.

If you are interested in taking a deeper dive into financial freedom, I highly encourage you to sign up for Mastering Business Essentials. This course is the blueprint for running a dental practice with long-term growth.