A while ago, I had the opportunity to repair a small bubble in an old composite restoration, and I got to thinking you might like to know how I use air abrasion to do this type of repair.

I don’t know how many times you see this, but I frequently see small holes in old composite restorations. In many cases, the margins look good. Everything looks good about the restoration except where there was an air bubble when the composite was placed and now there is a little hole on the occlusal surface. Food can get trapped and staining can occur in the hole, but the hole doesn’t descend into the tooth. And sometimes I see a little gap on the margin of an old composite with staining or early decay. In both cases, I don’t want to remove the entire restoration.

I use a lot of air abrasion in my practice, and in particular, I find it is wonderful for repairing old composite. I have the EtchMaster® from Groman. It’s a little handpiece that is super easy and convenient. It makes using air abrasion chairside something you will want to do every day.

Use 50-micron aluminum oxide air abrasion to clean out the stain, etch the old composite, and etch the tooth. If any tooth structure is to be etched, this air abrasion is a replacement for phosphoric acid. So, in one easy step, you have prepped the tooth and the composite. A plus of this technique is that local anesthetic is not needed if the hole does not extend into the tooth.

Now you can go in and use your dentin adhesive and replace your repair composite. Today, dentin adhesives contain MDP or PMMA which is the chemistry we need for the new composite to bond to the old composite. If I were to repair a composite restoration with a handpiece and a burr, I would not get the same bonded interface between the new resin and the old resin.

For both ease, patient comfort, and the best bond, I choose to treat previously polymerized resin with air abrasion and then some sort of resin that contains either MDP or PMMA.

Here I share abridged excerpts from my newest book The Porch: A Dental Fable to illustrate why the new patient exam is sacred time that sets the stage for trust.

In this story, Tom Parker, DDS has been invited to shadow a second-generation dentist by the name of Paul Wilson, who has been in practice many years in a small town in upstate New York. Paul is a close friend of Tom’s mentor Henry, and both Paul and Henry have been immersed in opening the eyes of dentists to the possibility of practicing in an intentionally virtuous way that is enriching for both patients and dentists.

Upon arrival at Paul’s dental office, Tom notes that Paul displays photos of his family and dogs, pictures related to his love of skiing and golf, and pictures that indicate he is as a person of prominence in his community. Tom feels like he is back in time to another era.

Paul tells Tom the first patient is a new one so Tom will see what a blank slate looks like for the doctor and patient. When Paul is finished, he escorts Tom into his private office and asks him what he thinks so far.

“To be honest, Paul, you did it just the way Henry taught me.”

“Okay, but what didn’t you see. You know, what was invisible to you?”

“What do you mean?”

“I mean the intangibles. The things we can’t see or touch or even explain sometimes — like love. Let me explain what the positive psychologist Barbara Fredrickson calls the cocoon of self-absorption. Most of us spend our days focused on ourselves. It’s just our default…Frederickson says love appears ‘anytime two or more people, even strangers connect over a shared positive emotion, be it mild or strong.’ The doctor-patient relationship is a dyad in which love can be present…The virtues of love, empathy, kindness, compassion, and gratitude take time.”

“I think Henry mentioned that trust is spelled T.I.M.E.”

“Yes, we like to teach that. And that is why we ritualize the comprehensive examination, so we can leave the cocoon of self-absorption and become other-focused. That is why we ritualize slow dentistry.”

“Slow dentistry…I like that. I also noticed that the first thing you did was thank Gloria for coming in.”

“Congratulations, Tom, good observation. Gratitude is another virtue that is most important for our well-being. Being grateful rather than feeling entitled or taking others for granted is important. My dad taught me that years ago. Every morning he would greet his team and tell them how thankful he was for them being with him. Science tells us that gratitude is a great way to improve our health, happiness, and general well-being. So, I ritualize my greeting, but I really do mean it. I must earn the right to treat them. Did you notice how much attention I was paying to Gloria? It’s a tricky thing. It’s more than just listening.”

“Yes, I have seen active listening demonstrated before, but what you were doing was different.”

“I’m sure Henry has told you there is no instant pudding. We all need to work on our attention. Love is attention. It’s the highest form of love there is. When we learn to pay attention with no expectation of reward, with no agenda, this is the rarest form of generosity. People can spot bogus attention in a heartbeat. Your wife and kids know when you’re not paying attention. Patients know, too. That is why we make the examination sacred time without interruption.

“People want to feel that they are the only one in the room. I always begin with a very open-ended question, for example, ‘What you are going through with your health?’ or ‘What is it that made dental care a priority now?’ I don’t keep a list of questions. I use different ones. Some land well. Others fall flat, but I keep trying, always looking for levels of comfort. The point is to not just acknowledge their presence but to truly notice their presence. This takes another level of awareness. We need to learn their stories. We need to learn their goals, not only their dental goals but their overall health and wellness goals. They want to know that we are here for them in every way.”

Tom’s face lights up in an Aha moment as he realizes love is operationalized through attention that is selfless. The examination is sacred time in which we pay attention – with no expectation of reward.

Have you ever had a night guard or other full coverage dental device come back with contact only in the posterior or heavy in the posterior? It is a fairly common phenomenon. And it is a big challenge when doing two-jaw hybrid surgery and placing the temporary restorations on the day of the surgery.

I became aware of this big challenge when my oral surgeon came across the parking lot one day to discuss the upper and lower hybrid case of one of our mutual patients. This was the first hybrid case we would be doing together. He had been using a company with a software platform that does his implant planning and digital setup, and then produces his surgical guides and provisional restorations. It can even produce the final restorations. He related to me that when he tries in the initial prostheses, he always finds they are heavy in the posterior.

So, I asked him, “When they ask you for records, what do you send them?” He said they request either an upper and lower scan, or upper and lower BPS impressions, or upper and lower models. They also want a bite record and a shade. As he went down the list, something was missing that has to do with heavy posterior contacts.

Whether it is premade upper and lower provisional restorations when you are doing extractions, implants, and hybrids — or it is a nightguard you get back from the lab or Invisalign trays that you receive from Invisalign, there are occasions when we find prostheses are heavy on the posterior contacts. Sometimes there are no anterior contacts. That’s because, across the board, prostheses need to be fabricated knowing the arc of rotation, which is the distance between the hinge axis at the center of the condyle and the upper anterior teeth.

A full arch impression taken without a facebow transfer, either hand articulated or with a bite registration only over the prepared teeth, only provides the same information about maximum intercuspal position as a triple tray. If we mount the full arch impressions on a simple hinge articulator, the articulation used does not represent the arc of rotation. If we are digitizing the impressions for a digital system, we also are missing this essential piece of diagnostic information. We must have impressions mounted on an articulator with a facebow or dental-facial analyzer (DFA).

I explained this to my oral surgeon who became concerned he would not be able to deliver this information to the implant planning company he was using. But this story has a happy ending. He called the company to learn if they could use articulated models mounted with a DFA or facebow. It turns out they much prefer this! And they told him the specific articulator systems for which they have corollaries in the digital world. If he sends the models mounted on any of these, they can digitize them and know the arc of rotation.

Those who have been in my presentations have heard this many times before. The more esthetic and functional information we send to the laboratory the higher will be our ability to efficiently manage the functional and esthetic issues of the case precisely. A lesson we can learn from this story is the value of conversing with the specialists on our interdisciplinary teams and in our interdisciplinary study clubs about the importance of capturing and communicating the arc of rotation. If a laboratory is not requesting this information, have a conversation with the laboratory.

The primary purpose of Panadent’s DFA or any of the earbow/facebow systems is to capture this critical piece of information we call the arc of rotation. There is other information these systems capture but the arc of rotation is critical in establishing proper occlusion. I’ve written about Panadent’s DFA in a previous blog. For an in-person, hands-on lesson in the dento-facial analyzer, we invite you to attend our Essentials 1 Pankey course. You can also watch this video for a quick refresher.

Excerpt from an essay first published in the Journal of the American College of Dentists, Fall 2011

The introduction to dental ethics and professionalism began very early in my dental career. Upon graduation from the University of Florida College of Dentistry in December of 1979, I was fortunate to receive a few awards and honors. One was a full scholarship to the L.D. Pankey Institute for Advanced Dental Education in Miami, Florida, to attend the institute’s beginning course, Continuum I. Pankey’s goal in offering scholarships to recent dental graduates had the intention of attempting to “catch them early” in their dental career and provide solid fundamental concepts of clinical dentistry and practice administration, as well as life and practice philosophy.

In the summer of 1980, only a few months out of dental school, I attended the institute for the first time. During my C-I week, my class and I were honored to listen to two presentations by Dr. L.D. Pankey. One of Dr. Pankey’s presentations concerned creating life balance as a dentist and the ethical practice of dentistry. In his lecture he offered his definition of what a professional, particularly one in the healthcare professions, should be.

Dr. Pankey’s definition of a professional was “an individual who possesses a specialized body of knowledge and skill, and who chooses to use that knowledge and skill for the benefit of another individual, prior to self-interest.” When Dr. Pankey said that the professional dentist “ought” to provide service to those they served prior to self-interest, he really hit me between the eyes. This challenge caused me more than ever to consider the reasons I had pursued a career in the profession of dentistry.

In my introspection, I had to admit that almost every reason I had for seeking a dental career had to do with my perception of what becoming a dentist could do for my family and me. Factors such as, personal income, community respect, self-esteem, and continual learning were the primary reasons I could identify for seeking a career in dentistry. Dr. Pankey’s definition forced me to look again at my intentions at their very core as to service to those individuals who chose to give me the greatest of all professional gifts: trust.

This experience was my introduction to dental ethics and professionalism. The principle of service “prior to self-interest” remained on my mind and heart during my daily interactions with my patients. Clinical decisions for my patients began to focus on the two ethical questions that must be answered in all clinical decision making: What should we do? and Why should we do it?

Most of us are placing implant crowns, using screw retained crowns. If the crown needs to be recovered, or the screw needs to be changed or tightened, the restoration can be removed by accessing the screw through the screw channel.

One of the main advantages of screw-retained crowns is the ease of retrieval. I have discovered two ways to make retrieval easier for myself, which involve the colors of the Teflon tape and composite I use.

1. Now I have colored Teflon tape on hand, and when I place the screw, I put colored tape on top of the screw instead white tape. If I need to remove the composite, I more readily see my gray or yellow tape than I would white tape.
2. I also like to use a composite color that is not be an exact match with the implant crown. This way I can easily see the material to be removed to access the screw channel… if I need to remove the crown.

If you plan ahead to have colored Teflon tape on hand, you can do what I do. Teflon tape is available in multiple colors at Home Depot and other hardware stores.

The question of whether it is better to have a rough or smooth tooth preparation for indirect restorations pops up from time to time, and dentists relate to me they have heard conflicting opinions.

I go to the research literature to become better informed when questions arise, and this is one question research has answered convincingly for me.

What is the impact of texture on the predictability of your restorations?

When we think about the surface texture of a tooth preparation, there are two considerations.

1. How does the surface texture have an impact on bond strength or retention of an adhesively placed restoration? Do coarser surface textures on preps increase bond strength, or is it exactly the opposite?
2. How does the surface texture impact the accuracy of a VPS or Polyether impression and therefore the fit of the restoration?

It turns out that smoother is better.

If you go to the literature and look up the research studies in PubMed, you will find there is a high correlation between high bond strength and extremely smooth surface texture. To achieve an extremely smooth surface texture, multiple studies used carbide burs that are in the same shape that we use in doing crown and veneer preparations.

The other piece of the puzzle (the second consideration) has to do with the contact angle of VPS or Polyether impression materials and the tooth preparation. The smoother the preparation surface is, the more accurate the impression will be. The more accurate the impression is, the more accurate the die will be. And the more accurate the die is, the more accurate the fit of the final restoration will be.

So, in both categories, bond strength for adhesives and accuracy of physical impressions, smoother preps win over coarser preps.

Mastery sits atop L. D. Pankey’s Ladder of Competency. The question is how does one achieve mastery? Once again it has been reduced to “Just Do It.” But there is more science.

In his 1953 paper, The Achievement Motive, Harvard psychologist David McClelland wrote an original thesis about mastery. Psychologists Deci and Ryan (authors of Self-Determination and Intrinsic Motivation in Human Behavior) acknowledged that this thesis may have described an intrinsic driver even more important than autonomy. They called it competence, but it is now known as mastery.

The pursuit of mastery has been the subject of numerous scholars and authors from Theresa Amabile and Robert Greene to George Leonard. Most agree that mastery is the desire to get better at what we do. It is the need to continually get better, to improve, and to make progress. It is the royal road to growth and flourishing and the opposite of languishing and drudgery (the low rung on Pankey’s Ladder of Competency).

The Process/Progress of Mastery Is Pleasurable

Working toward worthy goals is pleasurable. Making progress produces the neuro-chemical dopamine. According to Dan Pink, author of the popular book Drive, the single biggest motivator by far, is making progress in meaningful work.

At my lowest point in dentistry, I felt stuck…hopeless. My work had lost its meaning. Today we call that burnout. Remember those Thursday mornings I mentioned in Part 1 of How to Move Toward Independence in Dentistry? Those Thursday mornings turned on the light of hope.

We need the freedom to chase mastery. That freedom comes from autonomy. Without the intrinsic driver of autonomy, it is difficult to sustain the drive necessary to achieve mastery. This is based on our biology, not just some story, fairy tale, or business myth.

So, after scheduling Thursday mornings to practice autonomously, applying the Pankey Institute lessons I needed to learn and make second nature, I slowly put the complex elements of comprehensive, relationship-based dentistry together. I started with the comprehensive examination and built on that by learning all the components from mounting of models to the nuances of advanced occlusion. It took time…but driven by dopamine and progress, slowly I was installing my model practice.

Behavioral Skills and Technical Skills Are Both Important

In time I came to realize that learning the softer behavioral skills were just as important as the technical, so I learned about case presentation. Through the years I learned new skills like digital photography and PowerPoint. This is the essence of mastery. I am retired now. Looking back, I see how that the moment Dr. Becker suggested implementing the “Pankey Morning” changed my life.

There Is a Way to Enjoy Dentistry

Today things are different than when I was a young. There is pressure to go right into corporate dentistry or practice in a way that is built on extrinsic motivators. Many of the newer models of practice are an assault on autonomy, and many dentists don’t realize the root of their unhappiness for years.

My new book, The Porch, is a fable about a dentist who is losing his autonomy and breaks down. By finding a mentor and keeping his eyes on the ultimate prize, he goes from despair to hope. The book provides lessons the young dentist learns along a path of mastery, with the leadership and support of other colleagues.

Pankey Institute instructors, mentors, and colleagues inspired and encouraged my personal path. As I recall, many of them started on their personal fee-for-service journey, like I did, with focus on changing and mastering a new approach to patient examination, education, and leadership — one new patient at a time, one morning per week.

Our constantly growing Pankey Institute community has stayed “on the porch” of conversation, like the Stoic philosophers under the stoa, to grow in shared wisdom over 50 years. This wisdom is never outdated, even as dentistry has changed. There is a way to enjoy dentistry. My mission is to keep writing and awakening hope.

Happiness for me in dentistry was always doing my best for patients who appreciated and wanted the best dentistry. When third parties began to heavily impact the care patients wanted and my ability to do my best, my happiness disappeared, and burnout set it.

Independence to me meant removing myself and leading my patients away from insurance dependence. The Pankey Institute showed me the way to do this, and I was able to start restoring my happiness one patient at a time, until I was finally once again “fee for service.” Whether you can do this in part or in whole, you will achieve more dentistry and have a greater impact on more lives.

I first attended The Pankey Institute in the late eighties. I was at the lowest point of my career. Admittedly times were a bit easier for a young dentist back then, but in many fundamental ways they were the same. On the first morning at the Institute, I remember feeling overwhelmed. I was focused on the herculean task of creating the practice of my dreams. Every moment of that first week tested my competence and potential to succeed. I kept comparing myself with other students as I paid attention and diligently took notes.

Later in the week, Dr. Irwin Becker was discussing how to schedule patients so we would have time to practice what we were learning. I returned home and secured every Thursday morning for practicing “the Pankey way” which included a lot of new techniques for me and my staff. Dr. Becker was more correct than he even knew when he recommended that we “just do it.”

The Science of Motivation

About the same time, during the eighties, two psychologists, Edward Deci and Richard Ryan from the University of Rochester were beginning to formulate their now groundbreaking Self Determination Theory of Human Motivation. Their advice also came down to “Just Do It.” Years later, while studying positive psychology, I was gratified that I took Dr. Becker’s advice; otherwise I may not have had an accomplished and fulfilling career.

Deci and Ryan defined motivation as the “energy required for action.” How many times do we attempt to accomplish a worthy goal but run out of steam? We need drive. Installing a fee-for-service practice is difficult…if we dare to do it. It requires resources like drive and energy.

Deci and Ryan noted extrinsic drives are the material rewards we are all familiar with, as well as status and recognition. The intrinsic drives are passion, curiosity, and purpose. They found intrinsic motivation is more effective in every tested situation, except when basic needs haven’t been met (think Maslow’s Hierarchy of Needs). They also found that autonomous work overrides controlled work because autonomy is aligned with our intrinsic drives.

Autonomy as an Intrinsic Driver Works

When we are the masters of our own destiny, we are also more focused, productive, optimistic, resilient, creative, and healthy. In retrospect, this is what I found on those Thursday mornings. When I was focused on doing a comprehensive, relationship-based new patient exam, to the best of my ability and focused on leading the special person before me to greater understanding and health without thoughts about personal gain… putting another first and giving them the gift of my time… I felt most alive and well myself.

I started with the comprehensive examination and built on that by learning all the components from the mundane mounting of models to the nuances of advanced occlusion. For those of you starting to implement a fee-for-service practice model, success can be measured one morning a week and one patient at a time. Your intrinsic motivation will carry you forward to expand your “Pankey style” approach to a greater and greater percentage of your patients.

Beyond Scheduling One Special Morning…Return to “The Porch”

My latest book, The Porch: A Dental Fable, tells the story of a young dentist who is led in mentoring relationship — by a retired dentist and an expanding group of encouraging colleagues who meet regularly on a porch. He discovers and practices a new philosophical and behavioral approach to practice that transforms his life. I’ll keep blogging on this theme, but between blogs, you might want to pick up the book and discover the richness of a life in dentistry based on intrinsic drive. If you have sampled The Pankey Institute offerings and been inspired, then stay on “the porch” of its philosophical approach, courses, study clubs, and collegial gatherings. Continuously sharing and supporting one another is what put me on the never-ending, meaningful, highly satisfying Road of Mastery…and never again to experience burnout.

This blog is a precursor for the long lecture I will do on this topic at the 2021 Pankey Symposium.

Over the last decade, there have been major changes in how we do things in our laboratory (Niche Dental Studio), but from small cases to full mouth and hybrid cases, traditional Prosthodontic protocols still guide everything we do. These foundational processes provide a structural/philosophical approach for all our cases.

It’s a philosophical approach to diagnosis and treatment that you have been learning in your Pankey Institute courses. It’s an approach that extends from your dental practice into our lab, so our lab becomes part of your practice.

What are the key principles of this philosophy or approach?

• We will use optimal diagnostic protocols, communication, technology and methods to deliver custom prostheses as efficiently as possible while not compromising on the quality of the products.
• We will do our best to deliver products that meet or exceed your expectations for optimal function, comfort, and natural esthetics.

Here are some of the things that we do the same and some we do differently than we did ten years ago.

Feldspathic ceramics still produce the most natural appearance.

In the past everything we made was made by hand, and it was the prosthodontic protocols of this handwork that enabled us to have success using CADCAM technology today. And while today’s CADCAM dentistry is great, it does not replicate the results of restorations made by hand. A machine can’t mill “infinity margins.” Monolithic materials used in milling do not contain multiple levels of opacity.

To blend perfectly with Nature, restorations must still be made by hand, and in our laboratory, feldspathic veneers are still our “go to” type of restoration for central incisors. Layered feldspathic ceramics not only look the best but also are the best for marginal integrity. The restoration on number 8 below is an example.

For fit and finish, these types of anterior restorations are still the prosthodontic foundation of our Niche Dental Studio.

We still aim to replicate natural teeth.

Another foundational attribute of prosthodontic protocols is to replicate nature. Part of our success has been how much time and effort we have put into studying natural teeth and helping Pankey Institute trained dentists distinguish themselves by using restorations that are exquisitely made to appear natural and blend in the patient’s smile.

Today’s patients desire natural esthetics once they understand the elements of what makes teeth appear natural. If a patient seems stuck on a cosmetic dentistry meme of the past and requests whiter, brighter, straight teeth that will not blend in their smile, a conversation with your patient that illustrates tooth, smile, and facial esthetics will be appreciated by your patient and distinguish you as a caring, exacting dentist.

To create restorations that appear natural and don’t “jump out,” we do the following things:

• Increase the “value” of the color but not enough to create harsh contrast.
• Play with the levels of the incisal embrasures and the translucency.

These prosthodontic protocols can be implemented by you, too, while doing composite build-ups.

We use new technology to optimize communication.

From the ceramist’s perspective, I don’t want to see just close-up images of teeth. I want to see the patient. For many of our cases, we see the patient in our lab. Local patients come in for a consultation. We consult with other patients via Skype or Facetime. Seeing the entire smile, the entire face in natural interaction, aids us in doing our best.

 Modern 3D technology has changed how labs communicate visually with doctors and their patients. We’re constantly sending 3D screen shots back and forth with our doctors so they can check out the design and show them to a patient. An image like this one is confusing to patients. So, we’ve been able to integrate those screen shots into a photo of the patient to create a virtual image the patient grasps more easily.

CAD technology allows us to work more efficiently, but we still hand-finish restorations.

In our laboratory, we mill a lot of lithium disilicate crowns for clients. Prior to milling the lithium disilicate, we like to mill the restorations in wax. The milling quickly does 80% of the model creation and gives us the opportunity to hand finish the other 20% as we traditionally would. We can now put all our esthetic and creative efforts into finishing the case. We also mill temporary restorations from IOS data without hand modifying them.

Using IOS and CAD has made the lives of our clients much easier. For example, in the past, with full mouth cases, we did a lot of wax-ups when raising verticals. The doctors found working with matrixes too time consuming. They preferred working with eggshells and would reline them. Little problems would creep in when seating these eggshells. Perhaps, the cant was a little off or the vertical wasn’t raised accurately. With 3D imaging, it is far easier, because now we can do our full mouth wax-ups, scan them, and print the eggshells from scans with full palatal rest and retro-molar rest. There is now only one definitive way to seat the eggshells.

This is just a taste. There is so much to share.

To see how we do actual cases, in detail, go to the free Pankey Webinar: Prosthodontic Protocols for the Modern Dental Team. There you will see how our modernized approach, guided by traditional prosthodontic processes, becomes an extension of your treatment goals. I look forward to sharing more with you at the 2021 Pankey Symposium.

I was at the Ontario Dental Society meeting giving a presentation on occlusion, and I was asked one of the most common questions I receive when discussing anterior-only appliances: “What about tooth movement, either eruption or intrusion? Isn’t that a risk with these devices?” The answer is, yes there are risks, as with everything we do. Let’s consider the risks and how we can minimize and avoid them.

There are many types of anterior-only appliances, temporary and long term. Popular temporary anterior bite splint appliances are QuickSplint® and the Best-Bite™ Discluder from WhipMix®. NTI-tss Plus™ from NDX® National Dentex Labs is designed as a permanent anterior only and then there are the Kois Deprogrammer, Spear style deprogrammer, Lucia jigs, regular deprogrammers, Dawson B-Splints and so on. They are designed so that when the patient bites in MIP, they only touch on the front. When the patient goes into any excursive position (right, left, forward or back), they can only touch in the anterior—plastic to plastic or teeth to plastic.

We love anterior-only appliances because of their efficiency and effectiveness in eliminating posterior contact and allowing TMJ muscles to optimally relax. But we do worry about tooth movement, so how do we evaluate the risk and how do we minimize it?

There are a couple of pieces to this puzzle. We know that super eruption of the back teeth may occur if the appliance is worn more than ten hours a day, consistently over many days, even weeks, in a row. This means the risk is minimal with nighttime wear only for eight hours a night. Since we do not want patients to wear these types of appliances 24 hours a day, a patient in acute pain might be best helped with an anterior-only appliance for nighttime and a different type of appliance for daytime.

There is also a risk of lower tooth intrusion. There are two ways to deal with that. One is to make sure they have contact from canine to canine to distribute forces. Another is to make the upper anterior discluder against an appliance on the bottom that is called “a slider.” This is essentially a thicker version of an Essix retainer on the bottom to distribute the forces. I have made these appliances for many years and have not observed a problem in my own practice. I had one patient with significant deprogramming who could only touch on her first point of contact, but that was not due to tooth movement. It was because of total elimination of her masticatory muscle memory.

If you are concerned about tooth movement, I recommend making the upper discluder on a full arch Essix and then put the patient in a full arch lower Essix (lower slider) that will distribute the forces. That will prevent the problem of super eruption and should significantly minimize potential for intrusion, even though you only have midpoint contact. This is a great way to moderate the risks of tooth movement for patients who are going to wear an anterior-only appliance long term.

I would like to add, that any time you put a patient on appliance therapy, you need to see them for post-op appointments. You need to verify the appliance is working—that their signs and symptoms are going away or minimizing. And, you need to check their occlusion and mandibular position. So, I always plan multiple follow up appointments and include those in the appliance therapy fee. Even when the patient and I think everything is going great and they are wearing their appliance only at night long term, I ask them to bring their appliance to every Hygiene appointment for professional cleaning. This reminds us to ask how things are going with their appliance and gives me the opportunity to check their occlusion and make sure there are no negative consequences of the therapy. I also tell my patients to call if they notice any change in their bite. “We need to have you come in and check that right away.”