By Lee Ann Brady, DMD 

Balancing Benefits and Risks in Restorative Dentistry 

As restorative dentists, our commitment to providing high-quality, lasting care is unwavering. Ideally, we’d offer our patients restorative solutions that last a lifetime without needing repair or replacement. However, in reality, no restoration is permanent, so balancing the benefits and potential risks is essential in choosing the right solutions for each patient. 

What Makes Resin-Bonded Bridges Unique? 

Among restorative options, resin-bonded bridges may not be the first to come to mind, yet they serve as a unique solution for specific cases. Resin-bonded bridges are known for their conservative approach—they don’t require extensive alteration of the surrounding teeth and can often be placed without surgical intervention. For young patients, in particular, this minimally invasive option has a range of benefits. 

Preserving Alveolar Ridge Development in Young Patients 

One of the reasons resin-bonded bridges are favorable for younger patients is their flexibility in preserving the natural development of the alveolar ridge. By delaying more permanent options, such as implants, patients can avoid the potential complications related to ridge development and aesthetics that could arise years later. These bridges also offer an unobtrusive alternative, especially for patients who need a solution but may not be ready for an implant due to age or other factors. 

Setting Realistic Expectations with Patients 

Recommending a resin-bonded bridge requires a balanced approach to patient communication. These bridges are more likely to become loose over time, demanding a higher level of care and caution from patients. They must be aware of dietary limitations, avoiding hard or sticky foods that could disrupt the bond. Educating patients on the longevity and maintenance requirements of resin-bonded bridges helps set realistic expectations while ensuring they understand the care involved. 

A Conservative Yet Valuable Solution 

Despite their potential for detachment, resin-bonded bridges remain a valuable choice when the clinical situation calls for it. They offer patients a pathway to maintain oral functionality and aesthetics without the invasiveness of traditional restorative methods. Especially in younger individuals or those with adjacent unrestored teeth, this solution balances the need for stability with the importance of conserving natural tooth structure. 

Up Next in Part 2 

Part 2 of this series will discuss how resin-bonded bridges compare with other restorative options, such as traditional fixed bridges and implants. By understanding these options more fully, we can better guide our patients toward the solution that best fits their unique needs and preferences. 

By Daren Becker, DMD 

A 16-year-old girl presented with the worst case of ectodermal dysplasia I had ever seen.. She was missing all of her lower teeth except for her 12-year molars. She presented with a lower denture (made by a previous dentist) on two temporary implants in the canine position.  She had only a few maxillary teeth that were malformed; some of these were still her primary teeth.  The appearance of her smile made her look like she was a 9 year old child. 

She was embarrassed by her smile and realized she would need implants and restorative dentistry down the road. At the time, she was too young. Our hearts went out to her. 

Another dentist had recommended direct bonding, which certainly could have worked, but I thought that we could get a better aesthetic result for her with significantly less time in the chair. So, we captured preclinical digital impression scans with our iTero scanner and along with Matt Roberts at CMR Dental Lab in Idaho, we designed a digital wax-up for an improved occlusion and smile. From there, we had milled PMMA (Polymethyl Methacrylate) overlays created that we direct bonded onto the existing dentition as a long-term temporary solution. We did not need to prep any teeth, and we quickly gave her a broad beautiful smile that looked natural and age appropriate. 

She was in tears. We were in tears. Her mom and sister were in tears. It was the best day ever! 

Soon after, she got a part as an extra in a series filmed here in Georgia, and is thinking about a career in acting. Seeing her life change with simple, comfortable clinical procedures has been priceless. 

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.

I’m a restorative dentist with a passion for occlusion. I’m a firm believer that our patients deserve our best efforts to eliminate deleterious stomatognathic forces that impact comfort, function, smile aesthetics, and whole health. So, I encourage all dentists to wrap their minds around the area of “occlusion” and become immersed in hands-on, mentored courses to better diagnose and treat their patients.

In teaching at The Pankey Institute, I often hear clinicians view occlusion as a great, big mystery, and yes, sometimes misery. At each stage of my developing interest, knowledge, and skill, I have found my passion for occlusion grows and results in better clinical management and outcomes with my patients. When a well-planned full mouth equilibration is completed, the patient’s elation over how their “bite feels” cannot be matched in dentistry.

So, What’s So Hard About Occlusion?

L. D. Pankey was said to say that occlusion is getting the posterior teeth to touch all at the same time with light contact, and when you bite firmly, neither the joint nor the teeth should move. In addition, when you move your jaw left, right, or forward ONLY the front teeth should touch. He would chuckle and say, “So what’s so hard about Occlusion?”

Another way to think about it is that the jaw operates like a tricycle; the two little wheels are the joints, and the big wheel is the front teeth. To have a smooth ride, the steering mechanism and the joints shouldn’t have any notches in them!

Where My Journey in Occlusion Began

Although occlusion was integral to my dental school education, it really wasn’t until I went to the Pankey Institute that my real journey in occlusion began. While I went through the Continuums at the Institute, I joined several technical study clubs. Under the direction and encouragement of Drs. Richard A. Green and Herb Blumenthal, I explored many facets of Occlusal Therapy and TMD.

My View Today

Today I see the occlusion/bite as a potentially significant factor in the balance and harmony of the patient’s whole health. Integrative dental health involves looking for the impact of “other” on the entire body, as my colleague Dr. John Droter states it. The airway, myofunctional impact, and the body’s posture and structural integrity may influence how the teeth come together. If the teeth are chipping, breaking, or intermittently sensitive, it could be the bite. Headaches can be directly associated with the bite. Establishing occlusal harmony – getting rid of “any notches” in the steering mechanism and joints, is a process best tested with a finely balanced bite appliance.

Today I see occlusion as a case-by-case riddle. Every patient is an individual, and their occlusal management is customized accordingly. When solving each patient’s riddle, I’m trying to see how harmony can be re-established in the system of joints, muscles, and teeth. I utilize a bite appliance as a mechanism to test out an occlusal scheme for the patient. Once harmony is achieved, the challenge is to wax and plan the case to mirror the harmony established on the appliance.

For each patient, I’m also trying to figure out how the patient responds to appliance therapy to determine the best treatment modalities or modality. Is the treatment limited to the dentition or is intervention in the joint appropriate?

Either way, my governing philosophy is to make the fewest changes to the dentition while producing the best result for the patient. For some patients, this could be full mouth rehabilitation and for others simply equilibration and/or orthodontics.

Beyond the Teeth and Joints

We are a closed loop from head to toe, and the influence of the stomatognathic system on the “whole” body is best not ignored. Research shows that the teeth, jaws, and tissue affect different areas of the body, impacting for example head, neck, heart, pulmonary, and gastrointestinal health.

In establishing harmony between the dentition and joints, we are calming the musculature. In my mind’s eye, I see occlusal harmony calming the whole system.

Is Pankey Essentials (E1) Right for You?

Dentists who participate in E1 invariably say it is both an inspiring and practical course, and they want to come back for E2.

In E1, you will receive enormous encouragement to stay inquisitive and engaged in learning. You will gain insights that impact all aspects of dental practice, and when it comes to occlusion, you will be immersed in a combination of presentations and hands-on exercises coached by experts. The Pankey Institute excels at removing “the misery” out of occlusion by coaching you as you perform exams on colleagues, do diagnostic work ups, and practice making occlusal changes with models, wax, and appliances in the Pankey lab.

“Patients, who seek your care, want the best care you can give them. I believe the Pankey Essentials continuum is one of the best continuums on the planet to learn how to solve occlusal puzzles. Without this “essential” development, we are not the best physicians we can be.” –Kevin Muench DMD

Why Occlusal Appliance Therapy Is My First Step Prior to Ortho, Equilibration, or Restorative

Occlusal changes on an appliance are easy and reversible. An appliance can immediately reduce elevator muscle activity and give the patient relief. The patient also experiences what changes to their tooth contacts could provide for them long term. We can test the changes that would be made by ortho, equilibration, and/or restorative.

As reviewed in Part 2 of this series, our goals are to stabilize the joint anatomy and reduce the activity of the elevator muscles because those muscles are what overload the joints and teeth. We also want to slow down the rate of damage to the dentition and move that rate back to a more age-appropriate pace. We also may need to reorganize a patient’s occlusion to manage occlusal forces to ensure restorations that last.

Removing Posterior Contacts Does Not Work for Every Patient

Over my years of clinical practice, I have found that changing the occlusion does reduce functional risk for most patients. But we all have patients with perfect occlusion who present with TMD symptoms. We have some patients who continue to parafunction after we move them into immediate posterior disclusion.

Studies show that proprioception causes the elevator muscles to engage in only 80 to 85% of the population. This means that when the brain receives the signal that teeth are touching, the brain elevates the masseter muscles in 80 to 85% of people. Tooth contact is the trigger. Because this proprioception does not occur for 15 to 20% of the population, it is not the universal trigger for excessive loading.

Over my years in clinical practice, I have learned there is nothing I can do that is 100% dependable to stop a patient from para-functioning. Some of my patients continue to excessively load after posterior contacts are removed. Their functional risk does not diminish.

If we cannot reduce elevator force and redistribute force enough on an occlusal appliance to eliminate or at least relieve TMD symptoms, then occlusal therapy via ortho, equilibration, or restorative will not satisfactorily help the patient. We will need to turn to other forms of therapy.

Other modalities I use are BOTOX to deactivate muscles, massage therapy, and physical therapy. There are also systemic medications, cold lasers, and TENS therapy we can use to reduce the activity of the muscles or reduce inflammation in the muscles and joints. Sometimes one modality will alleviate symptoms for a while and when symptoms return, we can try it again or try another modality.

An Exercise to Identify the Patients Who May Not Benefit from Occlusal Therapy

You can do what I call a poor man’s EMG on yourself by placing your hands on your masseter muscles. Put your back teeth together, clench and release, clench and release, clench and release to see how much masseter activity you have. Then move your teeth into protrusive edge to edge and try to clench a little bit, making sure your back teeth do not touch. If you now have a posterior tooth touching in the edge-to-edge position, then put a pencil or pen between your front teeth to separate your back teeth.

With no back teeth touching and contact on the centrals, try to clench and release two or three times while feeling your masseters. Most of you will find your masseters do not move or move a lot less when no back teeth are touching. Some of you, even with your back teeth separated, can still clench in protrusive and can still increase the muscle activity almost the same amount as when your back teeth touch.

I do this exercise with my patients, but when they move into protrusive, I put a bite stop over their front teeth or have them bite on a Lucia jig we have lined for their bite registration. If you do this test with your patients, you can use an EMG or feel the muscle activity with your hands.

If the patient can still generate almost the same force or the same force with their back teeth separated, you have identified one of the around 15% of people who might not benefit significantly from occlusal therapy. You’ve also identified someone who might not do well on an anterior-only appliance because, if they can generate that same force on just two teeth, they are at risk for those teeth becoming sore and moving.

Interested in Learning More?

The Pankey Institute Essentials courses and multiple focus courses include hands-on exercises and over-the-shoulder training designed to help dentists develop mastery in reducing functional risk and treating TMD symptoms.

Many times, we need to increase the vertical dimension of occlusion (VDO) to put teeth where they should be esthetically and restore teeth that are severely worn from attrition or erosion. If you are concerned that changing VDO will cause joint or muscle pain, put your mind at rest. My experience is that it won’t. If you are concerned it will cause pain, put that thought aside too. My experience is that it won’t.

We want to change the vertical dimension only as much as we needed to accomplish the esthetic and functional goals of the case. That will minimize the effect changing VDO may have phonetics.

Phonetics May Be a Challenge

Vertical dimension has impact on two phonetic sounds in particular—F, S and V. F and V are similar. When we say them, we touch the edge of our upper central incisors just on wet-dry line on the inside of our lower lip. Saying F and V has to do with mandibular lip position, and the patient learns to adjust that position when VDO is changed. In my experience, they adjust to this in two to four weeks. They learn to accommodate a new mandibular position that touches the lower lip more gently.

S is a totally different sound. People say S in one of three different ways.

1. Some people make the sound S by making a small air space that’s between their upper and lower incisors edge to edge.
2. Some people make the sound S by making that same small air space but with their lower incisal edges just lingual to their upper incisal edges.
3. Some people make the sound S by making that same small air space but with their lower incisal edges just labial to their upper incisal edges. And those are our Class 3 occlusion patients.

The air space needs to be a precise amount of distance. If you have too little space, the patient lisps. If you have too much space, the patient spits or sprays saliva. Neither of which the patient is happy about. If the patient is totally edentulous, the patient may adapt to the new VDO of their prostheses, but patients rarely adapt to correct their pronunciation of S if they have a new VDO on natural teeth. This means we need to be careful about altering VDO.

The only way to test if a patient will have a lisp or other phonetic challenge is to test the VDO with provisionals, not with a removable bite splint.

Correcting Lisps Created by Anterior Restoration

How much air space do patients need to pronounce S without a challenge? They need about 100 microns to not lisp or spray saliva. To correct for too large or too small a space, I learned the following trick I hope you find helpful.

Madam Butterfly Silk is about 94 microns thick. I have the patient sit up and hold the silk between their upper and lower incisors with a Miller forceps. While the articulator silk is between the teeth, I have the patient count from 60 to 70. As they count the entire series of numbers, they relax into the process and red ink is transferred to their incisal edges if the space is smaller than 94 microns. If we see red marks, including on the canines, we need to increase the air space. My experience is that it takes four to six passes with the articulator silk and patient counting from 60 to 70 to adjust the airspace sufficiently. As you are doing this, the patient experiences the positive benefit of the lisp going away. I then tell the patient to go home and “observe how you sound. Ask others how you sound. We may need to do a little more refinement.”

If the patient lisps edge to edge, I shorten the lower incisal edges because upper incisors are esthetic. If the patient says S with the lower incisors lingual and they have red marks on their lower lingual and on their upper labial, I pick the upper or lower incisors and make adjustments where they are structurally and esthetically least impactful. If they are Class 3 and say S with their lower incisors, labial to their upper incisors, I always adjust the lingual marks on the lower incisors.

All restorative materials have wear properties. We need to understand both how they wear and survive in the oral environment and how they impact opposing natural teeth.  

The wear of enamel is the basis for comparison.

Despite what we sometimes see clinically, enamel is highly resistant to wear (attrition and abrasion), with average annual wear rates of 30-40 microns. The range is from as low as 15 microns to as high as 100+ microns, and there is variability depending on the tooth position in the arch.  

Unlike enamel, which basically all has the same structure and properties, composites come in many different formulas. The chemical and physical properties of the material have a direct impact on its wear resistance and impact on other teeth. Some examples of this include: 

• Size, shape, and hardness of filler particles 
• Quality of the bond between filler particles and polymer matrix 
• Polymerization dynamics of the polymer 

These same properties affect the other physical and handling properties of the material and have to be balanced to create a composite that works clinically.  

Creating improvements in the physical properties of composites has eliminated the high degree of wear in non-contact areas we witnessed years ago. The loss of restorative material gave the appearance of fillings losing their shape and contour. Today our primary concern is in areas of direct occlusal contact.  

One approach might be to avoid using composite that has direct occlusal contact.

I would say this is not only not practical but not necessary. We have a variety of materials available today, with a range of handling and physical properties, and wear rates that are between 30-200 microns a year.  

We need to choose a composite based on things like wear versus polish–ability, anterior versus posterior, and the properties of the particular material we are using. In addition, we can manage the occlusion to maximize the success of the natural teeth as well as the composite. 

When we nose breathe, our tongue is elevated against the anterior portion of the palate and held there with gentle pressure. This position mechanically pulls the base of the tongue forward increasing the size of the airway. At the same time, the gentle pressure and movement of the tongue to this position helps to strengthen the tongue and keep it strong. A strong tongue is less likely to collapse backwards and obstruct the airway, so nose breathing is important for airway.

There is also great research today that breathing through your nose promotes better health. It creates higher levels of oxygenation of the blood, it cleans and humidifies the air for better lung health. Studies also show that mouth breathing suppresses the immune system and can have other adverse health effects. To this end, one of the current trends is to work with patients to train them to nose breath, including using a mouth taping technique.

A simpler way that may be effective is to use behavior modification and have people actively work on nose breathing. Many of the step tracking devices today can be set to vibrate every 15 minutes, to remind the person to move. I use this to remind people who parafunction to check if their teeth are touching, and for mouth breathers so they can check-in and nose breath instead.

I believe that some wear is normal. I base this on the fact that I have very few if any patients who are in their seventies or eighties and still have mamelons on their incisors. Wear is a concern when the amount of tooth structure being lost is out pacing the patient’s age.

In Part 1 of this series, I wrote about determining when wear leaves the physiologic category and becomes something we need to discuss with patients. Both attrition and erosion can cause severe tooth wear, but they pose different long-term risks. Once we have a sense of the cause of tooth wear, we can partner with the patient to treat the damage and manage the progression.

These are the guidelines for discerning attrition from erosion.

Attrition is the loss of tooth structure caused when the patient rubs two tooth surfaces together. You will observe:

· Matching facets on upper and lower teeth

· Facets on tooth surfaces that occlude

· Enamel and dentin worn evenly

Erosion is caused by the presence of acid from issues like GERD and eating disorders. You will observe:

· Facets that may or may not match on upper and lower teeth

· Facets on tooth surfaces that are not in occlusion

· Dentin cupped out and wearing faster than enamel

· Tooth structure wearing around restorations that remain unchanged

Note that attrition can be seen in addition to erosion, often giving us a false sense of how much the patient truly parafunctions, as the etched tooth structure wears away more easily.

I ask the question “Is wear normal?” at almost every lecture I do on occlusion. Usually the response is a small number of mumbled replies. A good follow up question is “How many eighty-five-year-old patients have you seen with mamelons?” I hope you are thinking not many, if any at all. So, yes, tooth wear of some amount is normal. A combination of attrition, erosion and abrasion cause all of us to lose enamel over a lifetime.

Is the wear advancing at a pathological rate?

The more important question is when is the wear age-appropriate and when is it advancing at a pathologic rate? We don’t have the data to know how many millimeters of enamel loss is appropriate at every decade of life. In order to help with this answer in my office, I play a mental game. With the picture of the patient’s current wear in mind and a knowledge of their age, I imagine if the wear continues at the same rate at what age their teeth will be in jeopardy or need restorative dentistry to be saved. I then reveal this estimate to the patient.

You can document wear over time in three ways.

I believe it is important that I help my patients understand the process and the options for protecting their teeth. To quantify the amount of wear that is happening, we take a measurement from the CEJ to the incisal edge of several teeth with wear. We take the measurement on the mid-facial and record it on the patient’s perio chart. At subsequent appointments we can now repeat these measurements and have clear data that the process is continuing. Another great way to document tooth wear is with photography. With repeat photographs, we and the patient can see the change over time. Today with digital impressions and software we can scan the arch, and then compare scans months or years later and get a precise measurement of the change.