A patient presented to my practice with upper and lower implant hybrids and a long history of fracturing. I myself struggled with needing to replace her dentures regularly up until the point I decided something had to change.

Parafunction, Occlusion, and a Low Smile Line

The patient clearly needed some type of intervention. I looked at mounted models and evaluated her history of extreme parafunction to determine what we should do next. She had been restored in her hybrids with canine guidance and relatively steep anterior guidance. In light of all these factors, I recommended resetting the upper hybrid, opening her vertical, and both shallowing and balancing her occlusion.

These adjustments would hopefully make a big difference in her ability to maintain dentures for longer periods of time. There wasn’t much space to open vertical, but with the little we had we managed to lengthen the time between fractures from months up to once a year. That was a huge achievement on its own, but we knew we could do more. We had also made her an occlusal appliance that went over her upper hybrid. She consistently wore it, which was beneficial.

I shared this story with Wiand of Wiand lab and he was able to give me an important breakthrough. He asked me how high her smile line was and I told him it was very low. He had an idea that made all the difference. We took upper and lower impressions of the hybrids, bite records, facebow, fixture level impression on the upper arch, and gathered shade information.

Wiand lab removed everything from the original bar. Then, I had them send the entire case to Gold Dust Dental Lab. There, they waxed the upper to full contour over the bar. After this, the case was returned to Wiand, where an injection-molded composite was used to fabricate a one-piece upper over the patient’s original bar.

This seems to have finally done it for keeping my patient out of the dental chair. No maintenance has been necessary since. By relying on the advice of my fantastic partners in both dental labs, I was able to help a tricky patient. The lesson here is that patients who are hard on their teeth will be hard on restorations. Similarly, implants aren’t going to magically resolve issues for occlusally high-risk patients.

It’s impossible to go through a dental career without continuously encountering cases that challenge our clinical skills. Nor do I think that would be a good thing, as stagnation and complacency can lead down a slippery path to less optimal dental care. Even an expert has something more to learn.

The case I’m going to discuss here is a perfect example of why collaboration is so important in the dental practice. No matter how much I think I know about the techniques for tricky restorations, I’m always surprised by how much there truly is left to understand or adjust.

It’s important to rely on our peers and lab partners for case breakthroughs and insights. They can see things from a different perspective and give you exactly what you need to provide an exceptional outcome for patients. Even just the act of talking through impressions on a patient’s circumstances can lead to unexpected realizations.

A Case of Fracture, Wear, and Parafunction

This case frustrated me for quite a while before I understood how to solve it. The patient presented with upper and lower implant hybrids from another dentist. An examination revealed the problem she had visited my office for, which was fracturing of the upper right lateral denture tooth.

She was no stranger to the irritation of fractures. She shared with me that she had a long history of wearing down and fracturing her teeth. I was immediately interested in taking the time to understand the cause of this consistent fracturing.

The patient had multiple single unit implants placed for replacement of individual teeth. Her condition then worsened to the point where she had her remaining teeth removed. Implants were used for dentures with locator attachments, but this didn’t last long. The problem persisted and resulted in the need for more implant placements.

Upper and lower hybrids were created, yet still she went through 4-5 replacements of upper lateral and canine denture teeth. After seeing me, she and I had to replace upper anterior denture teeth several times over the course of a year. That meant removing the hybrid and replacing the screws each time.

To be continued …

Consistent case acceptance is a skill it can take years to develop. Part of the reason it can seem so challenging is that a patient’s true motivations may not be clear from the outset. We have to hone that sixth sense that can tell us what information or guidance would truly speak to a patient.

Two aspects of case acceptance in particular often go ignored because they either seem too obvious or are just not as fun to dive into: offering individualized options and making sure patients understand insurance.

Individualized Options for Case Acceptance

You may think the concept of individualized options is a no brainer, but that isn’t necessarily the case from a patient’s perspective. If you’re willing to provide this extra level of specificity, you can put many ‘maybe’ patients right into the ‘yes’ category.

We accept that car and other big purchases are often paid in installments, so why not do the same with a large investment like dentistry? Offering financing or other piecemeal payment options to patients is a game changer. It also makes comprehensive dental care accessible to a broader demographic. That in and of itself is valuable.

When dealing with patients, break the payment options down into easily understandable terms. Tell them the total fee, but decrease the stress by making it clear that there are different ways they can arrange to pay, including pre-pay, pay as you go, and Care Credit. Using a term like Care Credit is helpful because everyone is familiar with the idea of credit. When they ask for more information, you can lay out the details of payment plans.

Understanding Insurance for Case Acceptance

The real role of insurance is a mystery to most patients. Some may deliberately avoid understanding it because of how convoluted and frustrating it can be. They may have an entitlement mindset complete with the belief that the only healthcare they can indulge in is the kind covered by insurance.

Before you ever even look in a patient’s mouth, my advice is to have the insurance talk in low-stress language. Explain the actual definition of insurance and describe how dental insurance functions more as a maintenance plan. Use analogies to clarify the fact that just like with car insurance, its more of a backup fund than a way to pay for necessary yearly interventions such as a new tire or oil changes.

During an occlusion-focused hygiene exam, there are certain things the hygienist should pinpoint. This will help them develop a deeper relationship with the patient as well.

A Hygiene + Occlusion Exam

What the hygienist should look for:

1. “Can you eat/drink cold things comfortably?”
2. Subtle wear facets – those shiny spots on the edges of teeth.
3. Chipping of the edges of teeth. Can you get the patient to line up an incisal “chip” with a sharp edge of a lower front tooth?
4. Fremitis – that subtle shimmying of an upper front tooth when you gently place your fingernail on the facial of a maxillary incisor and ask the patient to grind side-to-side and front-to-back.
5. NCCL – could that be from clenching or orthodontic expansion? Both/and?
6. Persistent marginal inflammation that could be a sign of clenching (or an imbalanced bite).

The hygienist’s role is to raise patient awareness –  to “discover” changes that can be brought to the doctor’s attention for long-term protection of the patient’s teeth.

The doctor’s arrival for an exam is the time that real skill and teamwork begins. The hygienist takes the lead and informs the doctor what they (hygienist and patient together) have been discovering/discussing.

Many times, the most significant questions come when I am behind and feeling rushed. Our goal, practiced for years, is for me to get in and out of the hygiene room in under 5 minutes. Therefore, our total goal together is to encourage the patient to schedule another appointment for a more thorough evaluation of any changes/discoveries.

The hygienist then supports and reassures the patient about the need for a more thorough understanding to protect their teeth and eating for a lifetime. They confirm the uniqueness of a full understanding of teeth, harmonizing bite forces, and oral-systemic health and well-being.

“This is what sets our office apart. Together we strive for the best in your total oral health prevention.”

A well-thought-out and choreographed hygiene appointment can truly establish you in the relationship-based sector of dental care.

When a patient has periodontitis, they suffer from a destructive inflammatory infection that significantly impacts their oral health and damages their periodontal structures. Understanding how occlusion impacts or worsens this damage is key to helping these patients prevent unnecessary trauma.

Periodontitis and Occlusal Trauma

Even before the 1960s, there was research linking occlusal trauma and progression of periodontal disease. More recent research has found that this link isn’t as strong as once thought. Still, a relationship has been identified between the extent of damage and whether the patient has an occlusal interference.

One crucial aspect of periodontitis is that it is unique to every patient. This means we have to be careful not to apply a blanket approach to all patients or rely too heavily on past data that may not help us treat our current patient. Their individual susceptibility to periodontitis must be assessed based on their distinct risk factors.

The Relationship Between Occlusion and The Periodontium

For each tooth, occlusal experience matters and may be one of the reasons that loss of attachment worsens. A 2001 study by Harrel and Nunn found that there was a correlation between amount of periodontal damage and existence of occlusal interference. Perhaps more interesting, they also found that changing the occlusion had a positive impact on the periodontal issue.

Even in light of this research, the relationship between occlusion and periodontium is hotly contested. Regardless of one’s opinion on this matter, there’s no denying that the periodontium is effected by occlusal force. When there is no occlusal loading, there may be over-eruption or drifting of the tooth. On the other hand, when the force is appropriate, the periodontium is healthy and stable.

We must remember that there is a spectrum of susceptibility to periodontitis. For those who are very susceptible and also have teeth experiencing occlusal trauma, the latter only serves to worsen the situation.

Amidst all the details that must be managed day in and day out at a dental practice, I’d like to bring to light something I find super important that is often neglected. Let me begin by asking a question: When is the last time you took a good look at your perio probes? I mean a really good look!

My guess is you will find different shapes, sizes, colors, materials, ages, and markings. Maybe this doesn’t seem like the worst tragedy in the grand scope of the world, and yet, having even two different probes in the office can set the stage for lack of continuity in your patient diagnoses. 

Why Perio Probes Matter

It does seem like there are as many choices in probes these days as there are stars in the sky, so how can you make the best decision when it comes down to buying?

Although I do recognize the need and desire to have options, at the end of the day I encourage you to consider which probe provides the LEAST probable chance of creating error. Although I have used (and observe people using) a huge variety of probes, my favorite by far is the UNC-15. Due to markings at every mm up to 15, there is virtually no guesswork in capturing and documenting data with a high level of accuracy.

As you make the decision of exactly which probe you will use exclusively in your practice, please also consider calibrating all dentists and hygienists on an ongoing basis. It is typically easy to notice that probing techniques will vary from person to person. Watching and learning from each other with the ultimate goal of having everyone in agreement about how you will probe is invaluable.

Lastly, remember that an accurate periodontal diagnosis can only be made when a comprehensive periodontal assessment is completed and documented. Your probe is designed to be used for measuring pocket depths, recession, bleeding, pus, and attached gingiva. Oh, and don’t forget to check for mobility and furcations while you’re at it.

Here’s to a future of more accurate and calibrated perio probing in your office!

When the tongue can’t function properly (especially the middle portion), a cascade of events can happen. This is a very important point because many assess proper tongue function by mobility alone, but this does not uncover a posterior tongue restriction.

Assessing a tongue by how far a child or adult can move it is simply not enough. The middle portion of the tongue must be addressed because it is the biggest driver in normal development.

Tongue Restriction or Dysfunction

Following the Functional Matrix theory, if there is a tongue restriction or dysfunction while in utero and the tongue cannot reach the palate, the facial muscles will be the biggest factor shaping the palate. This  results in a high, vaulted palate at birth.

In infancy, a lack of function may lead to an inability to nurse properly or create a proper seal. This can be worsened by a high vaulted palate. If the palate is not stimulated, oxytocin release is limited and the facial muscles continue to be the largest influence on the shape of the palate. Symptoms of this problem can show up in both mom and baby immediately or a few days after birth. They can include: 

• Swallowing too much air resulting in: gassiness, reflux, spitting up, colic, getting “full” on air, or not draining breast, which leads to frequent feedings.
• Increased effort needed to eat, so falling asleep when nursing, short nursing sessions, and poor sleeping/frequent waking.  
• Excessive non-nutritive sucking/thumb sucking to stimulate palate and release oxytocin.
• Incorrect latch, which can be painful and lead to cracking/bleeding nipples or not fully draining breast, which leads to mastitis, etc.  

So many times, a “simple” answer to these problems would be switching to bottles or special formula and/or reflux medications instead of addressing the real issue. This is all too often missed by the medical field. When the underlying dysfunction goes untreated because the symptoms have been pacified by those treatments, the dysfunction continues and more symptoms develop.

The function or dysfunction of a tongue can lead to more health issues than many realize. Recent research has linked tongue dysfunction to a myriad of issues such as skeletal and bite changes. These issues can also lead to sleep apnea and TMD among other things. 

The evolution of recent thought is that sleep apnea and TMD are chronic “end stage” diseases whose roots develop early in life. Interventions as early as birth may help prevent or at least curb the severity of these diseases.

Exploring Tongue Function

The tongue is used not only for speaking, swallowing, and tasting, but also for other less obvious functions. The most important may be the tongue’s function of protecting the airway. When touching the palate, the tongue releases oxytocin, which has a calming effect.

The tongue is a large factor in normal growth and development of the face including the nasal and oral spaces. The Moss functional Matrix theory in essence states that the soft tissues will dictate how the hard tissues form. Or, in other words, form follows function.

According to this theory, the tongue will influence development of the palate, nasal cavity, and overall facial form. It then stands to reason that normal function is important for normal facial growth and development.

Development of Swallowing Patterns

The normal function of a tongue begins at the 18th week in utero when the fetus begins swallowing. Infants are born with a congenital suckling/swallowing reflex. At birth, the infantile swallowing pattern (called a “Tooth apart” pattern) is characterized by positioning of the tongue between the gum pads and the jaw slightly apart.

Stabilization of the mandible is from facial muscles and the interposed tongue. The middle portion of the tongue must lift and touch the roof of the mouth to create a seal when nursing and also release oxytocin.

Then, as teeth erupt, children change to a transitional swallow pattern. They will fluctuate between the infantile tooth apart pattern to an adult tooth together pattern. In the tooth together pattern, the teeth are together and the tongue is to the roof of the mouth.

This transition may be altered if the tongue cannot learn the proper position. An altered swallow pattern such as a tongue thrust may occur. Issues that can alter swallower pattern can be a tongue tie, poor or hyperactive muscle tone, a high vaulted palate, delayed non-nutritive sucking habits, or essentially anything that will not allow the tongue to reach the proper spot.

To be continued …

The Pankey Institute has positively changed how I practice dentistry. My work–life ‘flow’ would not be what it is today if I had not integrated the philosophy and dental training. As Dr. LD Pankey said: “A tooth never walked in the door.”

I too have integrated my own personal touch at the practice and have said, “We don’t treat strangers in our practice.” I get a little chuckle from patients at times when I say this. I also get a warm and welcoming look because they can connect with those words. This statement is an invitation that helps them open up.  

Better Cases From a Better Practice Philosophy

My training at Pankey and learning about LD Pankey’s Practice Philosophy has given me insight into how to create, formulate, and execute my own. I strive to live that philosophy with my dental team and my patients. We have created a practice culture that allows me to do many comprehensive cases.

I integrate concepts of restorative dentistry that have resulted in a rewarding outcome for both the patient and dentist. Appreciation and gratitude from the patient along with pride and care from the team have continued to fuel me to deliver the best dentistry with my best self.

It all starts with a comprehensive exam. For the case shown in these pictures, I utilized a thorough examination complete with understanding, listening, and hearing what the patient’s goals were. This was followed by a focus on airway, occlusion, TMJ, and restorative and esthetic goals. Digital photography, mounted study casts, evaluation of occlusion, wax up, and communication with the patient and the laboratory enabled me to create a smile that the patient was very comfortable with both in function and in form.  

Treatment consisted of an occlusal equilibration to improve occlusal interferences, which had caused fremitus on #7 and instability in occlusion and discomfort. I placed a porcelain crown on #8 and veneers on #7, 9, and 10. The patient was also given take home whitening trays.  

The patient’s final comments were: “I love my new smile and my bite is comfortable” and “Oh, did I tell you that since the dental work was completed, my jaw has felt more relaxed and comfortable?”

The question of what makes something ‘aesthetic’ or pleasing to the eye is one that often plagues dentists. We are so concerned with our patients’ perceptions of beauty that it is always on our mind.

The sense of aesthetics is an innate quality that we all carry. This sensibility is intertwined with our own internal creativity and curiosity, as well as our desire to create. Many people conflate a particular affinity for aesthetics with a lesser ability in other more technical areas, but in reality these are not mutually exclusive.

As dentists, we balance the technical and the aesthetic every single day. It can be challenging to handle the needs of both these areas in concert.

A Pankey Take on Aesthetics

Dr. Pankey had a particularly eloquent way of describing aesthetics. He clearly had a great appreciation of the world. This is why he combined his appreciation for aesthetics with the needs of dentistry, which resulted in multiple insights about the complexities of aesthetic dentistry.

Dr. Pankey’s aim was to learn the ins and outs of dental aesthetics to maximize quality of patient care. He had a vision of organizing all of the information he had acquired and making it available to more dentists.

The S Curve

An important tenant of dental aesthetics is the ‘S’ shaped curve that visually stimulates a sense of beauty. This has to do with the way it moves the eye and creates a flowing movement. The curve is a common aesthetic aspect of teeth and tissue, especially in the tips of every papilla to the zenith point.

We see the S shape as a result of the emergence profile or the angle of the entrant line of each tooth. Contour also plays a role in this specific part of the smile’s appearance. All in all, it’s important to pay attention to this aesthetic nuance in your work.

What do you think is the most important consideration for aesthetics in dentistry?