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.

Before I come up with a treatment plan, I always do certain things in a certain order. That structure has allowed me to feel confident that I can treatment plan any case that walks into my office. That structure, or process, affects how I approach my exam, make my diagnosis, and ultimately make my treatment plan.

The process begins by looking at the following five areas during the patient exam. I gather information in each of these areas in the following order:

1. The patient parameters of the case
2. The aesthetic parameters of the case
3. The functional parameters of the case
4. The restorative parameters of the case
5. The biologic parameters of the case

The first area I look at is the patient. What is the patient interested in? What are the patient’s circumstances, temperament, and dental health objectives? What is the patient’s current understanding of their dental health? How does that compare to my perception of their dental health? After answering these questions, I then move on to the four technical areas.

The first technical area I look at is the aesthetics of the teeth, gingiva, skeletal structure, and face. I then look at function, including the jaw joints, muscles, occlusion, and airway. The third area I look at is the restorative parameters of tooth structure, missing teeth, and the restorative materials and restorative techniques previously used in the mouth. And finally, I look at the biologic parameters, including caries, periodontal, and endo.

When I do my examination, I want information gathered in all five of these areas. When I sit down to do my exam diagnosis and treatment planning, I have all of that information in front of me and I’m going to always consider the five areas in the same order as I proceed with diagnosis and begin treatment planning.

When I plan the stages of treatment that will occur, the treatment sequence is in the order that is most appropriate for the case. For example, if the patient has a biologic health condition, perhaps, the need for a root canal or significant perio inflammation, I’m going to treat that condition at the front end of the treatment sequence, and not in the order in which I gathered information and reviewed it. The most appropriate treatment sequence will be the order in which I need to do restorative procedures to most predictably achieve the total best outcome.

Although my “structured approach” may not be the same as yours, I thought sharing mine with you could be of benefit to you. By establishing a process in which you gather and consider information in all five areas (Patient, Aesthetics, Function, Restorative, and Biologic), you will have all the information you need to consistently do diagnosis and treatment planning with efficiency and confidence.

For more information on this topic, I encourage you to take Treatment Planning and Case Presentation with me on June 11th – June 12th. This is a phenomenal way to solidify your knowledge and spend two days in sunny Key Biscayne, FL.

There is a practice in Ohio I recently work with, in which the dentist and a young hygienist were having a chat about the idea of restorative partnership. When she first heard the idea, her reply was beautiful. She said, “Oh you want me to learn about treatment planting,” and I thought that was just the coolest thing ever because that is what we get to do when we think about developing patients over time. We are planting ideas…planting seeds that we can grow.

When I was still working as a hygienist, I found I was good at talking with patients about what was going on in their mouths… what I saw… what the possibilities were. And I even enjoyed dreaming with patients about what their mouth could be like if they chose to do dentistry proactively rather than reactively. So, it is interesting to me how many hygienists become nervous about the idea of talking about dentistry with patients.

This nervousness exists because we have been taught in and out of hygiene school that it is illegal for hygienists to diagnose. This one barrier has become an incredible obstacle to having conversations about current conditions and possibilities with patients. It does not need to be this way.

When I think about restorative partnership, now, I think of it as treatment planting! The doctor diagnoses and discusses the potential of treatment with the patient. And during recall appointments, the hygienist has amazing opportunity to plant seeds during encouraging conversations. A restorative partner deeply appreciates the developmental path that dental patients are often on and looks for opportunities to plant seeds of awareness, curiosity, and of course, possibilities.

Wouldn’t it be cool if a patient came in one day and said, “You know, we’ve been talking about this idea of comprehensive care… we’ve been talking about the idea of restoring this quadrant… and I want to go ahead with it.” Wouldn’t it be exciting if suddenly what you have been talking about blooms like a beautiful flower?

If you have been thinking about having a conversation with your team members about restorative partnership, starting the conversation around “planting seeds” would be enormously helpful. Think about looking at cases together…creating learning opportunities in your office, where you can start sharing more of your knowledge about what it takes to work in a patient’s mouth, examining photographs together and talking about what you see, talking about the implications and consequences of not having treatment done, and what the benefits could be of thinking about treatment.

The restorative choice is always in the patient’s hands, and what I find to be most exciting about the restorative partnership is the partnership that we, as dental professionals, get to develop with our patients.

When working with participants at The Pankey Institute, I help them analyze dental cases to assess the risk for joint and muscle problems. I often hear, “The patient is not reporting any pain.” Yet, the dental records indicate the patient is at high risk of experiencing pain.

I have discovered a question to ask my patients that reveals their personal pain tolerance. “When you have a headache or muscle pain, at what level of pain do you take an Advil?” Some patients say at level 1 or 2. Others say not until it is a 12. Patients are all up and down the scale.

This one question leads to the patient’s self-discovery about how they perceive pain and potentially tolerate abnormal pain when they are “diseased.” Further conversation helps the patient understand symptoms they have been dismissing indicate abnormalities that can be “treated” for a healthier, longer-lasting dentition and more comfortable life.

And this brings me back to how we diagnose and plan treatment in general. Sometimes the questions we ask our dental patients aren’t structured to get us the information we are hoping for. If we gather inaccurate impressions from their responses to our questions, we go down the wrong path clinically. Asking more powerful, well-crafted questions allows us to better know the patient and get more complete information to better understand their situation.

I had a patient in a provisional on tooth #7, and he called to tell me he ate the crown. When he came in, I checked his occlusal marks in MIP, and there was a nice coupling with the opposing tooth. He was not hitting the tooth at all in protrusive, in right and left, and in crossover. He had not used floss and had not chewed on something sticky that would pull the provisional off. So, I put articulating paper between his teeth and used my iPhone to video him as he chewed like he was chewing food. What I discovered in the video is that he had a functional interference. He had broad strokes on the provisional whenever he was in his chew stroke.

I sent the video to the lab with the hope that the new information could be used to make a crown that would protect the tooth from breaking or becoming loose. This patient was adamant about not wanting orthodontics. I was able to show him why equilibrating his opposing tooth would be beneficial and he accepted equilibration.

Having run into this problem once, I am now checking for functional interferences with more patients by having them do “the chew test.”

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.

When we identify patients, whose dental esthetics has been negatively impacted by altered passive eruption, our treatment plans are apt to include altering the gingival esthetics. One of the things we are tasked with is determining where we want the tissue to be.

We start by determining if the incisal edge is correctly positioned in the face.

For example, by looking at a lips at rest photograph and a full face image for my patient with altered passive eruption, we can see that the patient’s incisal edges are correctly positioned. If they were not properly positioned, we would next plan the position for the incisal edges.

Tooth proportion becomes the next building block in the planning puzzle. We know that beautiful anterior teeth are usually between 70-80% width to length ratio. This variability allows us to accommodate other clinical considerations, as well as patient preference. As a starting point, I begin with 75% and then look at the other parameters.

If the patient has excessive gingival display, and one of the hoped for outcomes is to minimize the amount of gingiva, we can alter the drawing to increase the length and then evaluate the esthetic result.  On the other hand, if there is excessive sulcus depth, we can place the proposed gingival margin within the confines of the sulcus and assess the esthetic result.

Patient Involvement

I create template drawings, like the one below, in Keynote on my Mac computer, but drawings also can be done in PowerPoint. I then sit down with my patient, insert a retracted teeth apart patient photo behind the drawing, and together we move the lines until the patient is happy with where the pink will be.

Once we have the final proposal, the next step is to determine the possible treatment options to gain the intended result. The information can easily be transferred to a wax-up or used to create a snap on trial smile.

How to Create and Use Templates

In Keynote or PowerPoint, take a retracted teeth apart photo of a beautiful, near perfect smile. Put it into the presentation software. Blow the image up to 200%. Using the free form drawing tool, trace the outline of the upper six anteriors. Take the photo out and save the presentation as a named template.key or template.ppt file.

When you want to do proposal drawings with your patient, open up the template, insert the patient’s photo and save the file with the patient’s name. You can copy and paste the tooth outlines onto any of the patient’s photos to propose gingival changes. If you pre-draw and save outline templates for various tooth sizes (ratios), you can quickly show options to your patient.

It can be an incredibly frustrating clinical situation, when you have been meticulous about preparing a posterior tooth, (most commonly a molar) for a crown and things aren’t predictable. Using your burs you created depth cuts to ensure adequate occlusal clearance. After the impression you allow your assistant to fabricate the temporary only to have them come get you. Why? Because the temp is thin or perforated on the occlusal. When you go back to check, and have the patient bite, sure enough the opposing tooth is touching your prep.

A common reason that this happens is because we just prepared away the patient’s first point of contact in centric relation. The lateral pterygoid muscle in coordination with the elevator muscles has a learned pattern of firing that bring the mandibular teeth into maximum intercuspal position. This “learned” position is programmed by the patient’s first point of contact when the condyles are seated. For some patients when we remove this contact, and therefore the message that was programming the muscles to locate MIP, they release quickly. When the muscles release and the condyles seat, the occlusion is now totally different than MIP was moments before.

One solution that I considered briefly was to no longer work on molars! Alas, not a great business strategy.

Removing this frustration is about understanding which patients are at risk. Identifying risk begins with the exam, whether we are discussing caries or occlusion. There are several key factors that alert me to this potential issue. I start by identifying the patient’s first point of contact and clarifying if it is on the tooth we are about to prepare. If I am going to prepare FPC away, then I look at the magnitude and direction of the patient’s slide, or the difference between this position and MIP. If the difference is small (1-2mm), then even if their condyle does seat the occlusal difference will not cause an issue for clearance. So large slides (3mm or greater) could cost approximately 1mm of clearance on the prepared tooth. Other factors include whether they have a history of occlusal changes or more than one MIP they can find.

Understanding the risk, still leaves us with the question of how to proceed. That is a longer conversation for another post. However, if we proceed as we would before, at least knowing the risk we can explain this to the patient ahead of time, and help them understand how we would manage it if it happens.

Learning from one another is one of the top benefits of dental continuing education.

One of the things that I value about continuing dental education is the opportunity to spend time with other dentists.  I always learn something I can bring back to my office. Recently while lecturing at Midwestern Dental School to the faculty, on of the faculty members told me about a new way to stabilize lower models when mounting, and was even kind enough to give me some samples.

Stabilizing a lower model during mounting with centric relation records is critical to the accuracy of the mounting.

Over the years I have tried about every idea possible to optimize mounting the lower model. If the model moves in the bite registration due to pressure during mounting, tipping or shrinkage of the stone it interferes with the accuracy of the mounting. To overcome this I have tried hot glue, compound, rubber bands, hanger wire bent into a V and probably many more.

We realized the Fleximount was incredible the first time we used it. Sold by WhipMix and developed for their articulator systems, I will say I have used it on other systems, and as long as there is a knob on the upper member of the articulator it works fantastic. The Fleximount is trapped inside the stone, so they are disposable. The lower model is held with even pressure directly against the upper( if mounting in MIP) or the bite record, therefore no tipping forces are present as with other stabilizer systems. Because it stays in the stone, you can walk away and let it come to a complete set, instead of having to stand and remove the stabilizer while the mounting stone is still somewhat soft. Both of these features result in a very accurate mounting.

Once the stone is set you simply cut away the rubber band material that is not inside the mounting stone. Now you can finish and groom the lower mounting.