By Lee Ann Brady, DMD 

When a crown comes off and we are going to put it back in the mouth, we need to remove the old resin cement that is inside the crown. What is the best way to go about this? 

First, we need to know if the crown is made of zirconia or lithium disilicate. If you have a radiograph of that restoration, you can tell immediately which one of those two things it is. If you don’t, you can always attempt to X-ray it. (That’s what I do.) Alternatively, you can assume the crown is made of lithium disilicate, which is the more technique-sensitive material when it comes to removing cement. 

For crowns confirmed to be zirconia, employing 30-micron aluminum oxide air abrasion effectively clears out the old resin cement. Subsequently, re-etching the inside of the zirconia prepares it for reseating. For crowns presumed to be lithium disilicate, this approach should be avoided to prevent crack propagation. 

In the case of lithium disilicate crowns, two alternative methods can be employed: 

1. The crown can be placed in a porcelain oven to liquefy and evaporate the old resin. However, caution must be exercised to avoid rapid heating of the hydrated ceramic that has been in the oral environment. Rapid dehydration will introduce cracks and lead to crown fracturing. 

1. An alternative method involves using a brown silicone point in a high-speed handpiece, adjusted to lowest speed. A brown silicone point at slow speed effectively removes resin without damaging ceramic. 

How will you know when all the resin has been removed? When etching lithium disilicate, whether using red 5% hydrofluoric acid or Monobond Etch & Prime from Ivoclar Vivadent, any remaining resin will be evident because the dye sticks to it after the etching solution is rinsed off.  

By Lee Ann Brady, DMD 

For addressing the access hole of a screw-retained implant crown, my preferred method involves applying Teflon tape over the hole followed by temporary filling material, such as Telio Inlay from Ivoclar Vivadent. 

I emphasize to patients the importance of maintaining accessibility to the screw for potential adjustments without jeopardizing the integrity of the ceramic crown. Hence, immediately after seating the crown, I ensure no adjustments are needed before doing the filling. 

Patients are scheduled for a final post-op appointment with the surgeon after the restoration is in place. If there are no issues requiring crown removal, the Teflon tape and Telio Inlay may remain indefinitely, monitored during hygiene recall appointments. As long as the temporary filling remains intact, replacement is unnecessary. 

In cases where the Telio Inlay dislodges but the Teflon tape remains intact, I inform the patient of our plan to reapply the temporary filling. However, if repeated dislodgment occurs, leading to inconvenience, we consider transitioning to a permanent filling. In such instances, fresh Teflon tape is applied, and the access hole is filled with composite that precisely matches the crown’s color. 

Even if years pass and the Telio Inlay needs replacement, I opt for a temporary filling for ease of identification if removal is necessary. Only if frequent filling replacements prove bothersome do I consider switching to a permanent filling because I prioritize easy retrievability of the screw. 

Why Use an Essix Retainer Versus a Flipper During Dental Implant Therapy 

Lee Ann Brady, DMD 

When it comes to choosing a provisional during implant therapy in the anterior aesthetic zone, we have two removable options. One is called a “flipper.” It’s an interim partial denture composed of an acrylic base and a denture tooth. The other is an Essix retainer.  

There is no question that both options are taxing for the patient for the three to five months that the patient is edentulous and must deal with having this removable device to replace the tooth. So, I always tell my patients that they are going to have to manage the provisional for that time, but it’s worth it because, in the end, they have replaced the tooth with an implant with all the benefits of an implant versus an alternative prosthetic solution. 

In my practice, I use Essix retainers in nearly 100% of the cases. Why? Because an Essix retainer is tooth-borne. The pressure is placed on the teeth and not on the surgical site. In the case of a flipper, the prosthesis is primarily tissue-borne with a little pressure placed on the adjacent teeth. We really don’t want any pressure on the surgical site while it is healing. Pressure can induce biological problems in bone grafts and connective tissue, which affect the long-term outcome. From an aesthetic perspective, the most challenging thing about anterior implant aesthetics is replicating the size, shape, and position of the tissues of the alveolar ridge and papilla. I want to do everything I can to eliminate pressure on the healing tissue. 

In my practice, we do Essix retainers that don’t have a full solid tooth in them. Instead, we simply paint flowable on the facial so that there’s zero pressure anywhere around that surgical site after extraction, after grafting, and after implant placement.  

In addition to explaining the improved outcomes associated with using an Essix retainer, I assure my patients that the retainer will be more comfortable to wear than a denture and be easily removed by them for eating, for drinking liquids other than water that are likely to stain the retainer, for teeth cleaning, and for cleaning the prosthesis. When out in public, such as in a restaurant, patients may carefully eat while wearing the Essix retainer.  

One of the things that I take the opportunity to do every year in January is evaluate my fees. I am disciplined about this because the cost of doing business goes up every year.  

Whether it is a low inflationary time when the cost of doing business has gone up 1-1.5%, or it is more like the recent period when the cost of doing business has gone up 7-10%, our profitability is going to decrease if we don’t adjust our fees. When profitability decreases, usually the dentist’s compensation decreases.  

The Fee-by-Fee Way 

We can go through our fee schedule, fee by fee, and raise them individually. Dentists who do this are concerned that they will lose patients if they raise certain fees, for example, their fees for regular recall exams and dental cleanings. Dentists who take the fee-by-fee approach tend to believe patients are less price sensitive to the cost of restorative dentistry and appliances. Some dentists cover the increasing costs of Hygiene by increasing the fees for their restorative procedures. 

The Global Way 

Alternatively, we can do a global fee increase that raises every fee by the same percentage. This is my preferred way. To select the rate, I will look at my 2023 end-of-year profit and loss statement (from my accountant) and compare it to my 2022 end-of-year profit and loss statement. Did I make a profit in 2023? Was it higher or lower than in 2022? I don’t want to make less profit year to year.  

I will also look hard at my practice’s operating expenses in 2023 compared to 2022. I expect 2023 will be significantly higher because we have gone through high inflation in 2023 that none of us could have reliably predicted at the end of 2022.  

For example, if overhead was 65% in 2022 and jumped to 68% in 2023, I must increase my fees by at least 3%, plus a percentage I anticipate will cover overhead increases in 2024. If my profitability decreased in 2023, I also would want to compensate for that loss in the future. (Our “healthy business” goal each year is to maintain and hopefully increase profitability.) 

To arrive at the final percentage that I will raise my fees across the board, I will factor in the raises I want to give my team and myself in 2024, and the other expenses I know (or anticipate) will go up.  

The Global Way Is Easier 

If we do piecemeal fee increases, it becomes a complicated set of mathematics to determine if we will recapture last year’s decrease in profitability, cover next year’s increase in overhead, and hopefully increase our profitability over the next year. If you want to be cautious, you can blend the two approaches. Do a global increase and then go back and look at the price-sensitive fees you are concerned about and lower just those. This is the Modified Global approach. 

Evaluate Your Fees Early in 2024 

Annual evaluation of our fee is a must-do, and I don’t think there has ever been a better time to raise fees in all the years I have practiced. We live in a time when everything costs more. Patients understand that our overhead costs have increased. They know we are running a business and want us to stay in business to be there for them. 

I encourage you to use a system of thinking to figure out which fees you will raise and how much you will raise them. I advocate for the global approach or the modified global approach. Ask your accountant to give you profit and loss statements for 2022 and 2023. If you need help with your evaluation, ask your accountant or practice management consultant to assist you. 

Deprogramming of the lateral pterygoid muscle is generally done by placing something in the anterior that eliminates posterior occlusal contact. I have two “go-to” deprogrammers. One is a leaf gauge or what is often referred to as a Lucia jig, and the other is a little device developed by Dr. Keith Thornton, who invented the TAP appliance. This second favorite is called a “Pankey Bite Stop” and is sold at The Pankey Institute store.

Using a Leaf Gauge

Every time you have a leaf gauge in the patient’s mouth and the patient is instructed to slide their jaw forward, then back and squeeze, the back teeth can’t touch. As the elevator muscles fire, they pull the condyle up into centric relation, stretching the lateral pterygoid and eliminating proprioception across the teeth.

I try to find the first point of contact on the forward motion and ask the patient to slide back and squeeze. By the time I do this 10 to 15 times, the pterygoid muscle has fully deprogrammed.

Using a leaf gauge to do occlusal deprogramming works especially well when the patient is already sleeping in a quick splint at night or wearing a full coverage appliance or an anterior-only appliance that has done the deprogramming for us.

Using a Pankey Bite Stop

I use a Pankey Bite Stop when I judge a leaf gauge will not suffice. The device is relined with Bite Ridge, placed over the upper incisors, and left to set. The patient is instructed to “sit on it.” I usually set a timer for 15 minutes. My instructions to my patient are not to try to touch their teeth together. The teeth may or may not touch. I instruct them to relax and try to NOT think about their teeth.

Using this device, you do not need to have the patient move forward, back, and squeeze if you allow 15 minutes. Because the posterior teeth do not touch, the proprioceptive message that normally tells the patient’s brain to activate the pterygoid muscles is eliminated and the lateral pterygoid starts to release.

What if the patient needs more?

With some patients, I realize that they will need to sleep in a QuickSplint for a couple of weeks. In our Essentials One course at Pankey, we use the Quicksplint as an overnight deprogrammer to allow us to capture very accurate diagnostic records. In my practice, we use this device as a durable deprogrammer, in addition to all the other things that it does. They are easy to fabricate chairside. You can read more about their use here. In our Essentials One course at Pankey, we use the Quicksplint as an overnight deprogrammer to allow us to capture very accurate diagnostic records. In my practice, we use this device as a durable deprogrammer, in addition to all the other things that it does.

Team members can become a bit tunnel-visioned. Their day-to-day work life and CE are focused on topics related to their niched responsibilities, which puts them on an island of their own. One of my hopes is that all my team members — including hygienists, dental assistants, and administrative team members — will learn about all we do in our dental practices.

Faculty meetings at The Pankey Institute always invigorate my thinking about the Institute’s curriculum and the teaching I do with my own team members. Freshly energized by the last faculty meeting, I am writing my thoughts to hopefully inspire the many of you who are not faculty but, like us, have enthusiasm for leading your teams to a broad and deep understanding of the dentistry you practice.

In my own office, one of the things I look for in hiring is team members who are interested in learning, interested in dentistry and are even passionate about dentistry. They want to know as much about it as they possibly can. And one of the things I pay attention to is providing opportunities for them to learn about the many aspects of dentistry.

For example, I want my hygiene team to understand what happens in the restorative operatory. They don’t often get to see me working with a patient because they are busy with their own patients. But when they see a beautiful veneer case that we’ve done, I would love for them to have some background in the considerations and decisions that went into that treatment…the knowledge, the technique, the materials, and even the patient’s experience during treatment.

When hygienists see our patients, they may think something could appear better, for example, a crown margin. It helps them put what they are seeing in perspective if they have some understanding of the techniques, materials, and complexity. And I want to know the questions and concerns that occur in their minds as they do their hygiene exams. I also want them to understand the dentistry we offer in our practice so they can better answer questions and advocate for a treatment plan that hasn’t moved forward.

I want them to take CE that elevates their hygiene skills. I also want them to be fully integrated into our team and understand everything that happens in our office, so we can all work collaboratively to create more effective outcomes for our patients.

Accomplishing this requires that we set aside time and take advantage of open time. In my office, I regularly review a variety of cases with my clinical team before, during, and after treatment. This involves more than meetings in my consultation room. Sometimes, it involves chairside observation and conversations. Most of my patients are eager learners who appreciate the chairside teaching that I do with my team members. They are simultaneously learning and coming to a greater understanding of their dentistry.

I often hear that dentists return to their practices after a Pankey Institute continuum course or seminar with the inspiration to share what they learned with their teams—the enthusiasm for learning spills over naturally in the week following the dentist’s CE. Take advantage of that energy at that moment, and while you are excited make a commitment to continue sharing your knowledge on a regular basis, interesting case by interesting case.

In your dental practice, it’s important to create a restorative partnership with your assistants, hygienists & front office team. Make the handoff between your team seamless, build a stronger team & create lasting patient connections. Check out our three Pankey Team Courses that are coming up: Team Series.

We use the words “multilayer” and “multilayered” to describe lots of different materials from different manufacturers. If your lab tells you they use multilayered zirconia on a restoration or abutment, do you know what you are getting?

One of the ways we use the word multilayered is to describe a puck of zirconia that has two different types of zirconia.

Some of the pucks are a layer of 3y (the strongest but least aesthetic zirconia) with a layer of 5y (the weakest but most aesthetic zirconia). The laboratory technician puts the restoration design in the puck so that the 5y is on the facial of the restoration where you can see it and the 3y is on the incisal edge and lingual.

There are also pucks that are 4y zirconia layered with 5y zirconia. The 4y zirconia is a middle grade of both strength and aesthetics. In this case, the 5y is on the facial and the 4y is on the incisal edge and lingual.

Thus, there are two different ways to mix strength and aesthetics in one puck of zirconia and both variations are called “multi-layered.”

Complicating this even more, we use “multi-layered” to describe layers of chroma gradient or translucency. The laboratory technician can put the design pattern in the puck to achieve different gradient effects, but the restoration is all of one strength (one type of zirconia).

One of the challenges today with zirconia is that there is no place on a laboratory prescription to specify one of these varieties, and it needs to be clarified when communicating with your lab technician. Ask what your lab technician means by “multilayered zirconia,” and communicate clearly the multilayering you want used.

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

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. 

In our office, we routinely take our patients’ blood pressure, and we have a variety of cuffs. Most commonly, both hygienists use one of the convenient, digital wrist cuffs. A few months back, they noticed a trend of higher BP readings than they thought were appropriate. We wondered if the wrist cuffs were giving us accurate readings. We did a little research and I decided to reach out to my own primary care physician to ask her advice.

I learned two important things about taking blood pressure:

1. My physician recommended that we give our patients three to five minutes sitting up in the dental chair, relaxed, and not moving. While pleasant chitchat to reduce anxiety might help, we were advised to steer away from asking any medical history questions and other questions that might produce a bit of anxiety before taking the patient’s blood pressure.
2. One of the challenges with wrist cuffs is that the cuff is supposed to be at the level of the heart. In a dental chair, the patient is likely to rest their arm on their leg unless we instruct them to do otherwise. She advised that we have the patient take the arm that is wearing the cuff and place it across their chest to hold it at the level of their heart. To be at heart level, the hand shouldn’t come up to the shoulder but be horizontal with the elbow.

My physician asked me if we have arm cuffs that go above the elbow. I told her that we have two digital arm cuffs. She said she prefers using the arm cuffs herself because they tend to be more accurate than a wrist cuff, especially in picking up subtle variations.

This great information has enabled us to take blood pressure readings with more confidence and would be valuable to share with your team members who measure blood pressure. 

In your dental practice, it’s important to create a restorative partnership with your assistants, hygienists & front office team. Make the handoff between your team seamless, build a stronger team & create lasting patient connections. Check out our three Pankey Team Courses that are coming up: Team Series.