There may be times when you see an unfamiliar brand of material on the tray before you. If you do notice, it’s likely because the brand of this particular material has come to matter to you.

You know the brand you prefer is predictably reliable, and you have worked with it a lot.

A while back, I went to take a Centric Relation bite record for a patient so we could fabricate an occlusal appliance. After I dried the upper teeth and reached for the bite registration silicone, I realized it was an unfamiliar material in the gun. While trying to complete the procedure, I rotated the gun to read the label. Sure enough, it was bite registration silicone, but not a brand I had used before.

After the procedure was completed and the patient dismissed, I found a few minutes to talk to my assistant that handles ordering. She has been very effective in managing supplies and an incredible team member. I started with a simple question that I hoped would not sound accusatory. “That was a new bite registration material I haven’t used before.” She was pleased to say the brand was less expensive and they were having a special, so it was even less expensive than usual.

Now many of you might think all bite registration silicone is created equally, and I learned my assistant thought so as well. Her cost-saving thought process works well for many for the things we use in the office where I don’t have a brand preference, such as 2 x 2 gauze. However, I do have a strong brand preference for bite registration silicone. They are not all the same hardness, and they do not all have the same set time or moisture tolerance. This was not the staff member’s fault because I had never communicated this to her.

This has prompted me to take a moment, sit with my staff and go through the materials we order and identify any other places where my preferences are very brand specific. While doing this, I explain why I have each preference.

From time to time, I try new materials and brands of materials, adopt some and reject others. My preferences change. Therefore, I offer this little story to remind myself and to suggest to others that we periodically review with our teams the brands we like, the ones we don’t like, and the ones we would like to try.

One of my goals with composite restorations is to do as much of the forming and shaping prior to picking up a curing light as I can.

The material is easy to sculpt before it is cured, and access to the surface of the tooth is easier with hand instruments. Once I have placed all the composite and have a dense fill, I remove as much of the excess sitting above the final occlusal surface as I can. With this step accomplished, I turn my attention to creating the occlusal anatomy.

My OptraSculpt handle and disposable tips from Ivoclar Vivadent are perfect for this. The various tip shapes allow me to create incline planes, occlusal grooves and the curve of the marginal ridges into the occlusal embrasures. This process often removes and shapes the composite. My assistant holds a two by two that has been moistened with rubbing alcohol to remove the excess off the end of the instrument. I can place a different shape on each end of the instrument, or I can interchange them as I need them.

Using a series of disposable tips enables me to work without the composite sticking. This has reduced the necessity for meticulous management of expensive instruments which frequently need replacement. And, I resist the desire to use dentin adhesive or an unfilled resin on the instrument to reduce sticking.

Indirect restorations are the mainstay of most general practices.

Deciding whether to take triple tray or full arch impressions is a process that represents the classic dilemma we all face. It feels like we are deciding between “quality” and “economics”. In truth I think there are “quality” and “economic” pros and cons to both types of impressions.

From an economic perspective triple tray impressions are a straightforward decision.

A triple tray and the VPS to take it represent about $10 in materials compared to two full arch trays, VPS material, facebow and bite registration at a cost of about $25 in materials. Additionally a very important economic factor is productive chair time. A triple tray impression should take about 5 minutes of chair time, whereas full arch impressions and all the accompanying records take approximately 15 to 20 minutes.

The balance to the chair time on the front end is the chair time required to seat and adjust the case. In order to do an accurate comparison of the seat appointment we need to discuss the technical risks and benefits of the two approaches. We are going to assume on the front end that both techniques are done with proper retraction and accurately represent the prep and margins. A triple tray impression captures the occlusal information at maximum intercuspal position extremely accurately, but it is the only functional position they can replicate.

Full arch impressions taken without a facebow transfer, either hand articulated, or with a bite registration only over the prepared teeth only give the same information about maximum intercuspal position to the laboratory as a triple tray.

The advantage to taking full arch impressions is that they can be mounted with a facebow transfer and allow the laboratory to see the interaction of the teeth in excursive and end to end positions. A facebow records the relationship of the maxillary arch to hinge axis in all planes of space, and then transfers this information to an articulator. It can also be used to communicate esthetic information about the relationship of the incisal and occlusal plane to the horizon if the bow is leveled when the record is taken.

So the ultimate difference between a triple tray and full arch impressions is the addition of functional information about excursive movements and end-to-end positions. This requires taking a facebow record, and can be increased in accuracy by setting the condylar elements on a semi-adjustable articulator either with a protrusive bite record or an end to end retracted photograph. Using either technique the most accurate bite record is always captured with the unprepared teeth in full occlusal contact. So the decision between the two approaches really depends on the functional and esthetic risk factors of the case. The more esthetic and functional information we send to the laboratory the higher our chances of managing the esthetic and functional issues of the case precisely.

Chair-side air abrasion has numerous advantages, especially today when we use adhesive retention so much of the time.

The advantages for many years have been outweighed by the logistic challenges. With the advent of small, lightweight, easy to use air abrasion handpieces this is no longer true. When I became aware of the etchmaster I was skeptical, but I am now a believer and use air abrasion int he operatory all day long.

The Clinical Applications

One of the first things that many of us will utilize air abrasion for is to “etch” zirconia restorations for bonding during final seating. The only way to prepare the inside of a zirconia restoration is with 30-50 micron aluminum oxide. The particle size and type is critical. The ideal pressure is 1 bar (15psi). Next on my list is to clean tooth preparations prior to bonding and cementation. To me there is no better way to assure the removal of temporary cement and prepare a tooth for maximal adhesive retention than with 30 micron aluminum oxide.

My list goes on as I have started to prepare small class one cavity preparations using small glass beads in my chair-side unit. Cleaning out the occlusal grooves prior to a sealant and etching un-prepped enamel for anterior esthetic composite margins are other uses. In addition sodium bicarbonate can be used to remove stain. Now that I have a convenient, easy to use unit, I find more and more reasons everyday.

Air Abrasion Made Easy

When I first began to experiment with air abrasion the biggest challenge was the equipment and managing the logistics.  The Etchmaster is a small 3 to 4 inch attachment that connects to either a 3 or 4 hole line on your unit. The pressure is precisely controlled, for great clinical outcomes, and it means the patients mouth is not full of powder when you are done. The powders come in pre-filled tips that slide into the top of the hand-piece. You can choose from a variety of sizes and particle types and sizes. This means no more filling a reservoir with powder, wondering if you have too little or too much. It also means not wondering what particle type and size is in the reservoir the next time you go to use the unit.

Have you explored the clinical advantages of air abrasion? How has this been beneficial in your practice?

One of the most common questions I get is about the use of a category of materials we refer to as prep scrubs, prep wetting agents or desensitizers.  The question is usually do they actually make a difference, and are they worth the cost. The answer is “yes” and “yes”.

There are 4 things we are trying to accomplish: prevent sensitivity, antimicrobial activity, moisten dentin for bonding, reduce bond degradation over time. The prevention of sensitivity is caused in two ways. The first is the inclusion of HEMA in products like Gluma from Kulzer. The HEMA occludes the dentinal tubules and prevents fluid movement that triggers a pulpal response. The second is the anti-microbial activity of either glutaraldehyde (GLUMA) or chlorhexidine (Consepsis by Ultradent). Fewer bacteria left behind int he dentin means lower chances of a pulpitis that causes sensitivity or the ultimate need for a root canal.

Both chlorhexidine and glutaraldehyde also minimize the production of MMP’s (Matrix Metal Proteinases) the biologic process responsible for bond degradation. This means our bonded restorations last longer before we see marginal breakdown, leakage and secondary caries. The last function is to moisten the dentin to allow optimal penetration of the primer in our dentin adhesives. This means better hybrid zone development and better bonds and sealing of dentinal tubules.

So the answer to do they have benefit is a resounding yes. I have used Gluma on every tooth I have prepared for many years. I consider it extremely cost effective as I am not sure how to put a price on greater restorative longevity and less patient dissatisfaction due to sensitivity or post operative issues. The true cost should be about $2 a prepared tooth if dispensed properly, so that’s hard to argue with.

One of the challenges we face today in dentistry is managing tissue health during the time period our patients are in provisonal restorations. This has become even more critical as we have incorporated more resin bonding techniques to seat indirect restorations. Isolation is critical to the long term success and can be challenging after multiple weeks in a bisacryl provisional.

We all stress oral hygiene to our patients during this time period, but let’s be honest there are barriers to optimal tissue health at the seat appointment. One barrier is often patients are fearful that their hygiene procedures will displace the provisional. This fear has them brush less vigorously, floss less or not at all, and even sometimes avoid that part of their mouths completely. Even when patients are undeterred int heir hygiene the provisional itself is often a barrier. Contacts can be less then optimal and increase interproximal food impaction. The Bisacryl itself, tends to hold and attract plaque due to a different surface texture even when finely polished.

Given the barriers and the goal of super healthy tissue, Chlorhexidine varnish (Cervitec Plus by Ivoclar) has become one of my favorite products. We are all familiar with the incredible anti-microbial effects of chlorhexidine, and also the reasons we dislike it. Cervitec does not have a bad taste, does not cause the typical brown staining, does not effect the patients taste buds, and they don’t have to remember to use it. Cervitec plus is a clear liquid applied with a micro-brush. At the end of any appointment where we have placed a provisional my assistants will coat the gingival margin with Cervitec as the last step before the patient leaves.

I have been using this as a critical step in my restorative procedures for over 5 years now, and I swear by it. I see almost perfect tissue health at seat appointments, and it is rare for me to struggle with isolation due to poor tissue management.

Current digital splint technology requires workarounds to make it a feasible option for clinically exceptional dentistry. In Part 1 of this series, I described the challenges and opportunities of digital dental technology and explained some details of my preferred protocol. Here, I continue this explanation:

An Effective Digital Splints Protocol

In my practice, I mount digitally printed models using a centric relation record and a protrusive record for condylar inclination adjustments. This is just like we have done in the past with stone models. 

The lab technician can transfer this into the computer exactly as we have it in our hands. They do this with the use of a tabletop scanner. It’s important to note that the technician can now register original files for the impressions into position for the best accuracy. The greatest benefit today is the accuracy of these original scans (20-30 microns). 

The design portion comes next in this process. Communication with the technician can be done in real time online. My technician and I have been working with different settings in the software that give me the best chance of skipping the reline procedure patients don’t enjoy. 

I can also evaluate and do final adjustments on the mounted digital models and analog articulator. We have been successful about 80% of the time getting a splint that is rock solid and has an intimate fit on the occlusal surfaces. This is critical for fine-tuning adjustments and fracture resistance. 

If it ends up as an ill-fitting or loose-fitting splint, we can still reline just like we always have because it is a milled PMMA material (as dense as a denture tooth). 

Areas of Improvement for Digital Splints

My opinion at this time on digital splints is mixed:

Pro: We can produce a very high quality PMMA splint that lasts longer and generally gives the patient a better experience.

Con: We still need digital counterparts to essential analog skills that provide for all situations. 

Pro: I believe we will have printed materials that outperform current milled materials in the near future (this will lower the cost to produce splints). 

Con: It is frustrating that we are not getting better support from companies selling us  expensive equipment.

I am proud to be part of the Pankey family because our community encourages the use of technology to enhance good dentistry. 

White and brown spot lesions on the anterior teeth can be very distressing for the patient and a frustration for clinicians. Normally, they are decalcification or deposits on the teeth from fluoride or other minerals.

They do not require restoration. We are hesitant to do this and sacrifice good tooth structure, but esthetically they can really bother patients. They reduce a patient’s confidence in their smile. Recently, I have found a solution to this clinical situation that meets both the patient’s esthetic demands and my desire to be conservative.

Reversing Lesion Color on Anterior Teeth

Icon, from DMG America, is a translucent resin infiltrate that reverses the color of the lesion. It brings the tooth back to its natural color, requires no tooth preparation, and protects the tooth from further decalcification or progression into a carious lesion.

After we isolate with a rubber dam, the tooth is etched with a special etchant included in the kit. The protocol requires a longer etching time then we are accustomed to with other procedures.

After each etching procedure, we rinse and dry the tooth. Then we apply a special drying agent that allows us to evaluate the final result prior to proceeding with the resin.

If the tooth color has not yet been optimized, the etchant is applied again. This can be repeated up to five times. Once we have completed the etching process and confirmed the result with the drying agent, the resin is applied and then cured.

The entire procedure is done without any anesthesia and is very comfortable for the patient. Icon can be used on the facial and also on interproximal areas.

The resin is not visible on an x-ray, so the kit comes with a card to give the patient. This is so that if they see another dental office in the future, they are aware that the interproximal areas will still appear decalcified on an x-ray but have been fully infiltrated with resin.

I really enjoy offering this incredible, conservative esthetic service to my patients.

Pankey dentists have been instrumental in changing the face of dentistry and launching inspiring innovations that advanced patient care. This post is a continuation of my first blog on the history of Dr. Henry Tanner.

Developing the Tanner Appliance

Dr. Tanner always credited Dr. Ricketts for encouraging him and giving him permission to continue learning what patients were doing with their teeth. They were both using full arch lower appliances, although at that time, Henry simply called his a nightguard. For approximately 15 years, he made that nightguard on a single lower cast and then would adjust it in the mouth.

Some years later at The Pankey Institute, under Dr. John Anderson’s leadership, Dr. Tanner introduced his appliance to Dr. Parker Mahan. Dr. Mahan had a Ph.D. in anatomy, was a full time professor at the University of Florida Dental College, and was a world renowned authority on head and neck pain.  

How Dr. Tanner Changed Dentistry

With the full support and encouragement of Drs. Anderson and Mahan, Henry started teaching about his nightguard using mounted casts. Dr. Anderson initially named it a TANG (Tanner Appliance Night Guard).  

Dr. Tanner always said, “Don’t ever have anything named after you. Whenever people misuse it, then your name is attached.” Over the years, the Tanner appliance has become known as an anatomic appliance. It is extremely individualized, based on the patient’s unique joint, condyle, and tooth anatomy.

The goals are even bilateral centric relation contacts, non-interfering posteriors, and smooth anterior guidance. Dr. Tanner was always curious to see how little could be done to the person’s own unique occlusion to accomplish all those goals. Patient discovery and engagement are keys to Tanner appliance therapy.

Dr. Tanner passed away in 2003. His appliance and his life’s work live on.

Curious what dental materials the Pankey community is currently raving about? 

Sometimes, when you feel bored or uninspired at the practice, you could benefit from trying out new materials. This type of change can simultaneously up your clinical game and get you excited about work again.

Check out the suggestions from 5 Pankey dentists below for inspiration:

Materials Pankey Dentists Love

Dr. Mark Kleive

“My favorite new material is the air abrasion hand piece from Groman Dental – Etchmaster. It’s simple, no big equipment, still a bit of mess, but very precise.”

Dr. Mike Crete 

“My favorite new ‘tool’ in my toolbox is CBCT. In the last two years, I have had a major shift in my diagnostics and treatment planning by using 3D imaging. Although I do not have a scanner in my own office, the specialists that I have a great working relationship with do have them and it has become a great adjunct to our diagnostic and treatment planning process.

Dr. Lee Ann Brady

“My recent favorite is Cervitec Plus, Chlorhexidine varnish. It is an incredible antimicrobial adjunct for high caries risk patients. It reduces the bacterial count for 3-5 months and is applied at their hygiene visits. It is also great for around temporaries to create fabulous tissue health when seating restorations.”

Dr. Jennifer Davis

“My top two favorite materials lately:

(1) Not a new thing, but it still amazes me. Use of MicroPrime, a Gluma product,  after etching my composite preps. The amount of post-operative sensitivities and/or root canal procedures that come from my office now is amazingly low. Wish I had the foundation for a research study.

(2) I am loving using products to stain provisionals to custom match a tooth to the dentition. I use Protemp as my provisional material most times. They make such limited shades, though. Therefore, I stain with either Cosmodent tints, Creative Color, or Kerr-Kolor in white.”

Dr. Michelle M. Lee

“Not a material, but my mind has been blown with microscopes in the last month from the training I’ve been getting at Penn. It’s just been such a great experience and taken dentistry to the next level in terms of detail, finish, and marginal integrity. I have been loving learning more about this, as well as the integration of microscopes and dentistry with digital workflow! Fun stuff!”

What new or old favorite material are you excited about? We’d love to hear from you in the comments!