When we ask patients what they really want, we can drastically improve our case acceptance. 

In my last blog, I talked about the path that led me to start asking patients: “Is there anything about the way your teeth look that you would like to change?”

Surprisingly, this one sentence has transformed my practice. The answers often surprise me. Countless patients with chipping, crowded, discolored teeth respond without hesitation, “Nope!” and many others with what I think are quite lovely smiles respond with a laundry list of things they would like changed.  

Transforming Your Dental Practice

Now that I wait for patients to tell me what they want, I no longer waste time on case work-ups that never turn into productive treatment. And because I found a way to zero in on the cases that I like doing the most, I have transformed my practice into one where I get to do more of the procedures that give me a higher level of satisfaction and happen to also be quite profitable.  

My message is this: First, figure out what your dream practice looks like. I think the best way to do this is to pursue high quality continuing dental education, get a great foundation in comprehensive dentistry, and find the areas you like most.  

Second, figure out how to do more of those things. Find ways to give patients permission to ask you for that treatment. If you love treating TMD, allow patients to uncover problems that will get them excited about the treatment you can provide to alleviate their pain. If you love seeing infants with tongue-ties, include questions on your new patient paperwork about breastfeeding. If you love placing implants, make sure your patients know you can provide them with long-term solutions for missing or hopeless teeth.  

Now that’s not to say that all I do all day is esthetic dentistry. I do plenty of posterior composites and single-unit crowns. However, having some challenging esthetic cases in progress, the ones that give me a lot of gratification and really do change lives make dentistry so much more enjoyable.  

Define your dream practice and eventually you may find yourself living it.  

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

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

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

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

Materials Pankey Dentists Love

Dr. Mark Kleive

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

Dr. Mike Crete 

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

Dr. Lee Ann Brady

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

Dr. Jennifer Davis

“My top two favorite materials lately:

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

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

Dr. Michelle M. Lee

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

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

Ever since I started my AEGD residency following dental school, I have loved continuing education. I’ve always sought new courses, new educators, new techniques. But for me, the most impactful educational experience was taking The Essentials courses at The Pankey Institute.

Not only did I learn about the complex temporomandibular and masticatory system, perhaps more importantly, I gained the skill and confidence I needed to tackle complex esthetic cases and truly found my sweet spot in dentistry.

Finding My Way in Dentistry

I am a bread and butter general dentist. However, my favorite cases are the ones that have the capacity to change someone’s smile, to make them not only healthier and more beautiful, but most importantly, improve their confidence. Once I gained these skills I wanted to implement them into my practice as soon as possible, but unfortunately I tripped over a few stumbling blocks before I found the right way to do that.

I remember one particular patient I had who really could have benefitted from some esthetic dentistry. I spent hours mounting the case, cropping and organizing photos, even waxing up anterior teeth on a model to show him the dramatic esthetic improvement I could make to his smile. That patient was engaged and listened to everything I had to say.

He came back for his second consult, asked questions, but at the end of the day never pursued treatment. I learned a valuable lesson in that case and numerous others. When I stopped presenting the treatment I thought patients needed and instead let them tell me what they wanted, I started closing cases.

As a part of my comprehensive exam, after the radiographs, the periodontal probings, the hard and soft tissue exam, and often clinical photography, I simply ask the patient, “Is there anything about the way your teeth look that you would like to change?”

To be continued…

Why You Should Determine Value Before Chroma and Hue When Matching Shades for Composites

The true artistry of the dental profession tends to show itself in many of the more challenging requirements of cosmetic dentistry. One of these areas where we can express our esthetic skills is in shade matching for composites. The struggle arises in understanding the various properties of natural-looking teeth and determining what visual aspects to match first.

 Composites 101: Defining ‘Shades’ and Their Components

Before you can begin to choose which aspects of a natural ‘shade’ to preference, it’s integral to delve into the nature of these complex components.

Reflectiveness and translucence combined determine the appearance of a tooth. Reflective properties are especially important for shade matching because this is the true definition of ‘value.’ Value tends to be defined as the coloring on a range of white to grey, but it’s actually a measure of tooth reflectiveness.

Other esthetic qualities of dentin and enamel include ‘chroma’ and ‘hue.’ A classic numeric scale of 1 (lowest) to 4 (highest) is used to judge chroma, which simply refers to the intensity of a color. Hue, on the other hand, is generally deconstructed into the letters A, B, C, and D. These indicate the names of color.

‘Shade’ is simply the end result when all three parameters of value, intensity, and hue are viewed together. The key lesson here is that these parameters must be matched separately. To achieve the best case outcome, you must rank them according to importance.

Should You Shade Match for Value, Chroma, or Hue First?

This is where things get tricky and we start to juggle multiple considerations at once.

Layering is paramount because dentin shades and light properties differ in composites versus real dentin. This is also true for enamel shades. Added to these differences is the fact that dentin and enamel do not have the same amounts of reflectiveness and translucence. Basically, you have dentin and enamel discrepancies between composites and real teeth in addition to the discrepancies that exist between dentin and enamel.

Precision will impact the final appearance of the tooth, so it’s important that you layer composites to get around these discrepancies. The composite materials selected should match for value before chroma and chroma before hue. Because final value is a blend of the individual values of every composite layer, you must consider that each layer is not going to be representative of your intended value. They build on one another to create life-like reflectiveness and translucency.

A Method You Can Use for Determining Value in Composites

My favorite method for constructing an esthetically superior value is to start the appointment with layering. I plan what composite shades I want to combine ahead of time and work efficiently so that inevitable teeth dehydration doesn’t affect my results.

I layer the materials on the labial of the adjacent tooth in their final thicknesses and photograph the outcome. This allows me to see if my chosen combinations match my esthetic goals and troubleshoot if the composite doesn’t disappear against the tooth. When I’m not happy with the look, I easily pop the composite off the tooth and re-do the process. I only begin to contemplate chroma and hue once I’ve matched the value.

How do you troubleshoot shade matching issues in your esthetic cases? We’d love to hear your perspective in the comments!