The best dentists I know mastered the art of examination and discovery first. They learned to understand their patients’ conditions and how they relate to one another.

Leadership Through Discovery & Complexity

In that process of discovery, highly competent dentists learn to navigate complexity by confidently using reference points. These guide their understanding of what they discover. They train their eyes to see the details of esthetics, tooth structure, function, and periodontal type and status. Their fingers learn to feel the dynamic nature of the patient’s functional system.

They use every available form of imaging and records that add meaning to their discovery. Ultimately, they intentionally, systematically, and thoroughly develop a diagnosis that can determine the treatment plan. They manage complexity by moving toward simplicity.

Absolute and relative reference points serve as guides in designing the optimal scheme for the patient. When the patient’s teeth, gingiva, bone, functional scheme, and esthetics have been lost, those reference points tell you where to start and where to end. They both establish and limit what needs to be created.

Managing Complex Cases

Dentists at this level possess a very sound understanding of the dental functional system and a very detailed understanding of dental esthetics. They specially focus on how these two systems relate to one another.

They also understand their role in coordinating, guiding, and leading their interdisciplinary team in managing the complex case. To be certain, every member has a strong voice in developing and executing the treatment plan. Leadership in knowing your work really becomes visible in this process.

Someone has to decide where the case is going and how it is going to get there. There are many voices in the process, but at the end of the day that someone has to be you the leader, who also happens to be the first and final designer of the beautiful smile that is being restored to health.

Clinical competence is a requirement of a successful practice. If people are going to seek you out rather than just going to someone who is contracted with their benefit provider, they need a reason. Clinical results are clearly one of those reasons.

Leadership Through Knowing Your Work

That being said, how well do you know your work? How well does your team know their work? Do the specialists and technicians that you work with make you better? Becoming highly competent in clinical dentistry begins with a decision. Have you made it?

If you have, are you maintaining that decision in the midst of all the resistance that you encounter as you try? Leadership, at its core, is about making a decision and maintaining that decision in the midst of pressure to do otherwise. Your clinical competence begins with a decision to be competent. How well it continues and develops depends on how important being highly competent is to you.

8 Complex Skills of Clinical Dentistry

Although clinical dentistry is not always complex, it requires a variety of complex skills. This includes:

1. Examination, Diagnosis, and Treatment Planning
2. Spatial Relationships & Esthetics
3. Biologic Principles
4. Local Anesthesia
5. Tooth Preparations
6. Provisionalization
7. Materials Application
8. Patient Management

You can add many more to my list. All of these skills are important in uniquely different ways. This is why continuing education and professional development in dentistry is so vital.

It is just plain difficult to develop so many skills and move them toward competence and mastery. Dentistry is both extremely rewarding and extremely demanding. So how are we going to develop competence that is moving toward mastery?

We need a plan that develops specific habits. We need the habits to serve our WHY. We need great teachers, leaders, and institutions that help us pursue the limits of our possibilities. It is a journey that never ends as long as we are given the gift of caring for another human being.

Approaching implant reconstruction as an all or nothing situation ignores the reality of future patient needs. Often it is too expensive for patients, who will not be able to proceed fully with treatment. They then receive only part of the complete treatment plan.

For example, with an edentulous arch the difference between a lower denture with two implants and locators as opposed to five implants with a fixed restoration is significant.  Alternately, it’s common for patients with two implants and a lower denture with locators to be dissatisfied with their function and esthetics. They may wish to move to a fixed restoration if they can now afford it. But does the clinical situation make this possible?

Implant Treatment Planning for the Future

It’s a good idea to create a treatment plan for a patient that doesn’t eliminate their ability to select different treatment in the future that could lead to improved esthetics, health or function. Certain planning decisions must be applied when placing implants to ensure necessary spacing and vertical room for a fixed restoration.

Ideally, the plan would include fixe fixtures between the mental foramina for a fixed restoration. If the patient currently wants a removable with two implants, the ideal placement can be planned for five. The 2 and 4 spots can then be used for placement of fixtures with locators.

This gives enough room for three potential implants later on that are spaced correctly. Though the placement choice can be based on a clinician’s preference for where locators would be, the 1 and 5 locations allow for ideal placement of five future fixtures. Still, many patients will have two fixtures between the mental foramina that negatively impact proper spacing for a fixed restoration. On top of this, the lower ridge position is another important factor to consider. It must be managed to account for vertical space.

The end of 2017 is wrapping up a solid year of incredible dental blogs from our talented Pankey contributors. Our posts featured everything from techniques for occlusion and orthodontics to practice management and leadership.

There are tons of useful tips and plenty of information for dentists at every stage of their career on the Pankey Gram. Here, we’re compiling five pieces of sound advice from blogs in 2017 that are sure to get you excited for another year of practicing dentistry your way.

As Pankey dentists, we continue to strive for greater learning and growth in our professional and personal lives. Revitalize your hunger for education with these thought-provoking tips:

5 Clinical Tips From 2017 Pankey Blogs

1. Consider physiologic changes that occur over a lifetime when planning restorative dentistry.

In his blog on ‘Adult Growth of the Dental Arch,’ Dr. Roger Solow explored the slow craniofacial growth that can affect dentistry throughout a patient’s life.

2. Set splint therapy fees in such a way that you can actually make money off them.

In his blog, ‘How to Set Splint Therapy Fees,’ Dr. James Otten described how to individualize splint therapy fees and more accurately estimate therapeutic time.

3. Think like an orthodontist when advising patients on post-ortho care.

In her blog, ‘How Long Should Patients Wear Their Retainers Post-Ortho?’, Dr. Lee Ann Brady laid out important considerations for dealing with questions about retainers.

4. Recognize when patients are in denial and practice empathy toward them.

In her blog on communication, ‘From Denial to Acceptance and Action,’ Mary Osborne RDH enlightened with a description of patient denial in dentistry.

5. Improve you protocol for restorations by adding another dental assistant.

In his blog, ‘6-Handed Bonding,’ Dr. Mike Crete made his case for why an extra dental assistant can benefit dentists dealing with adhesive dentistry and tricky restorations.

And there you have it folks. Best wishes for 2018! 

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.

The Carolina bridge is an all-porcelain bonded pontic that can be used as an interim prosthesis and for many other valuable purposes.

In my last blog, I discussed why I love the Carolina bridge and its many applications as a restorative alternative. Now, I’ll provide an overview of the design and how to begin a case using the bridge.

Carolina Bridge Design

The design of the Carolina bridge bypasses problems found in Maryland bridges and adhesion bridges. The all-porcelain Carolina bridge is very esthetic because there is no metal substructure. There is also incredible light penetration.

Maryland bridges, on the other hand, are not esthetic due to the the graying created by metal wings. All-porcelain pontics, such as the Carolina bridge, often can be used when tooth anatomy comes before or restricts the prep and placement of a Maryland-type bridge. Also, it is easier to repair the proximal resin composite retaining connectors of Carolina bridges.

Carolina Bridge Case Technique

A case that illustrates a Carolina bridge technique is one where an adolescent patient presented with a missing maxillary right lateral incisor. A team consisting of a periodontist, an orthodontist, an endodontist, and a restorative dentist determined that a dental implant would be the best treatment once the patient reaches maturity.

The team decided to orthodontically submerge the endodontically treated root to best preserve the bony site for implant placement. They selected a Carolina bridge as the best interim prosthesis because the occlusal relationship was favorable and there was sufficient crown length of the abutment teeth.

At the first appointment, shade selection was determined and an elastomeric impression was made of the anterior segment. A working case, an impression of the opposing arch, and a bite registration were created. An all-porcelain pontic was fabricated of feldspathic porcelain by the laboratory. At the second appointment, the involved abutment teeth were fully cleaned and rinsed.

The pontic was trial positioned to assess the shade accuracy and the adaptation of the pontic to the residual ridge. Once the accuracy of the shade and fit was verified, the pontic was readied for cementation.

A silane coupling agent was placed on the etched proximal surfaces of the porcelain pontic to improve the bond strength. Preparation of the abutment teeth was done by lightly roughening the proximal surfaces with a coarse, flame-shaped diamond stone. At this point, the pontic was ready for bonding into the edentulous space.

Dr. Heymann will be a featured lecturer at the Pankey 2018 Annual Meeting in Nashville, TN.

The Carolina bridge is a novel all-porcelain bonded pontic. It requires no significant tooth preparation, making it an outstanding option as an interim prosthesis.

Numerous bonded bridge designs have been advocated over the years for the temporary or permanent replacement of missing teeth. Both metal and all-porcelain designs of bonded bridges are popular, each with varying degrees of success.

All of these designs involve some degree of tooth preparation, which makes them irreversible in nature. This is where the Carolina bridge comes in. The key to success with a Carolina bridge is the availability of adequate surface area interproximally to ensure optimally strong resin composite connectors.

Utilizing an ultraconservative all-porcelain bonded bridge for the interim replacement of single incisors relies on clear understanding of indications, contraindications, and clinical technique.

I Love the Carolina Bridge & Here’s Why

The Carolina type of bonded bridge provides benefits like ease of placement, esthetic vitality (no metal substructure), ease of connector repair, and a totally reversible nature.

Patients best suited for an all-porcelain bonded Carolina bridge are young adolescents with missing maxillary incisors. In these cases, an all-porcelain bonded pontic is an excellent interim prosthesis because of its totally reversible nature.

The abutment teeth can be returned to their original condition simply through removal of the bonded pontic and the resin composite connectors.

The Carolina bridge can also be used as a restorative alternative in cases where a more permanent fixed prosthesis is impractical or unaffordable. This might be a result of the patient’s age, medical condition, or economic status.

Additionally, patients with missing lateral incisors and in whom the remaining edentulous space is too small for an implant are often excellent candidates for an all-porcelain bonded pontic of this type. By slightly lapping the adjacent teeth, an esthetically acceptable prosthesis can be obtained.

In my next blog, I’ll talk about the design of the Carolina bridge and illustrate my technique for implementing it in appropriate cases. 

Dr. Heymann will be a featured lecturer at the Pankey 2018 Annual Meeting in Nashville, TN

The truth can be hard to face: Something is wrong with the design of these provisionals … We may be working on a broken provisional and feel the deep frustration that comes with knowing something went awry.

I challenge you, in these moments, to reframe the ‘problem’ as a mystery to be solved. You are the clinical detective who needs to work backwards a la Sherlock Holmes to figure out ‘whodunit.’

Mystery of the Broken Anterior Provisional

Remaking and adjusting an anterior provisional from the upper right to the upper left canine (for the second time) is a horror story in the making. Before you allow that narrative to take over and call the lab to have them rush the case back, remember to rely on your intuition and technical expertise.

You may not be able to call the lab because you haven’t taken final impressions. Either way, let the provisionals tell you what the flaw in the design is, rather than believe you can run the solution show.

A good first place to look and listen for answers is the occlusion. For example, if the patient reports that they wake up with headaches after you’ve placed the provisionals, you would want to look closely at envelope of fucntion. Is the patient heavy on the centrals and laterals? If so, you can begin the process of adjusting.

Methods of the Dental Detective

As you examine the issue, you may find other clues, such as that the patient is catching on the incisal edge in their return stroke from protrusive. You continue to adjust, beveling edges for a smoother transition. You leave the guidance shared between the canines and centrals, keep it smooth, but even this doesn’t stop the patient from breaking the provisional.

If you’ve ever seen or read a good detective story, you know this isn’t the time to quit. When things seem most opaque, the detective is usually at a breaking point where the parts might finally start to fit together. Once they do this, the flood gates open and they rush toward the explanation.

You will reach this point while adjusting again. In response to what you’ve learned, you begin to shallow the patient’s guidance and share protrusive with the premolars. You decide to shorten lower anteriors and increase overjet by proclining the restoration. Here, you’ve come to the solution. You need to work it out on an articulator perhaps and then go back to the mouth.

The main lesson is that we have the most to learn from cases that don’t go perfectly. Plus, it would get pretty boring if there were no dental mysteries left to solve …

We have a remarkable heritage at Pankey. Around the 1950’s and 1960’s, four innovations converged to permanently change the dental profession worldwide. Pankey dentists were part of the creation of all of them.

In my last post, I talked about the invention of the sit-down chair. Now, I’ll dive into time and motion studies, high speed air-driven rotary handpieces, and the “washed-field’ evacuation technique. These innovations had a significant impact on the future of dentistry.

Pankey Innovators of Modern Dentistry

Time and Motion Studies

These studies evaluated and changed how dentistry was delivered, e.g. four-handed dentistry, ergonomics, efficiency, etc. My father, Dr. John Anderson was a large part of that along with men from the east coast. Don Coburn from Canada was also a major time and motion researcher and later became a strong supporter of the Institute. My dad wrote several articles in the Dental Clinics of North America about office design related to time/motion principles.

High Speed Air-Driven Rotary Handpieces

Before the 1960’s, belt driven handpieces were the norm. Dr. Henry Tanner was at Bethesda at that time working with engineers designing this new high-speed technology. This too was reluctantly received by the profession at first but now one can’t imagine doing dentistry without it. Dr. Tanner was on the faculty at the Institute and you can find his portrait in Master’s Hall.

“Washed-field” Evacuation Technique

This is the type of high volume vacuum system we use each and every day today. It replaced the workhorse cuspidors used by everyone in the 50’s and early 60’s. The new water-cooled high-speeds needed this innovation for pulpal health and prepping efficiency. To my surprise, there are still cuspidors being used in operatories to this day. Elbert Thompson of Salt Lake City, Utah was the dentist that created a consumer friendly system of high volume evacuation. He was a friend of Dr. Pankey and an integral associate of these other innovators.

What Pankey history do you admire? We’d love to hear from you in the comments! 

Click Here for When Ceramic Debonds: Part 1

A Methodical Process for Examining the Frustrating Reasons Behind Why

One of the most disheartening and emotionally upsetting situations is when a ceramic restoration debonds. Our ability to act constructively in the moment is key to our future case success.

In Part 1 of this series, I explained why it’s important to acknowledge your frustration without letting it control you. I also outlined the beginning of a methodical thought process that will help you figure out why ceramic debonds.

The following steps assume you’ve already looked at the resin and determined if the ceramic was prepared, cleaned, or conditioned properly.

Completing Your Investigative Process When Ceramic Debonds

You have a different set of explanations for what happened if all of the resin cement is on the ceramic and the tooth is clean.

Clean the tooth thoroughly to remove all trace of the temporary cement. The issue may have occurred when the enamel and dentin were etched, regardless of whether you used a total etch or a self etch technique.

Next, ask yourself about the amount of enamel you have versus the amount of dentin. This involves taking a second look at the prep, because secondary dentin can be quite problematic when bonding.

Another area you may need to reconsider is your technique for dentin adhesive. Did you accurately follow the steps? Could poor isolation have led to a contaminated tooth during the process?

Lastly, sometimes there is some resin on the tooth and some on the ceramic. In this case when resin is in both places, you can benefit from rethinking the occlusal forces on the tooth and the functional design. Your patient may have higher functional risk or you might have lacked complete precision while adjusting the final occlusion. A good clue that you’ll find resin on the tooth and the ceramic is if it fails under load.

You can better target your problem solving and decrease the risk of the same technical issue recurring in the future by identifying where the resin is located. Follow the thought process in this series and you’re well on your way to smoother cases.

How do you respond when ceramic debonds? Please let us know your thoughts in the comments!