You can gather accurate functional and esthetic information using the Panadent Dento-Facial Analyzer for restorative cases. I’ve found this tool particularly effective compared to alternatives such as the Facebow or stick bite.

If you haven’t done so yet, make sure to check out the introduction to this series on the Dento-Facial Analyzer. It includes background information, armamentarium, and key reasons why the device can elevate patient care.

Without further ado, the Dento-Facial Analyzer technique:

Essentials of Dento-Facial Analyzer Technique

Once you have the white disposable plate – which is actually the piece you will send to the lab once the record is captured – snapped onto the Dento-Facial Analyzer, use VPS tray adhesive to lightly coat the plastic tray. You are only going to do this from about the canine position posteriorly because you aren’t going to put silicone on the anterior portion of that bite plate.

Next, attach the vertical reference bar to the Dento-Facial Analyzer. Without bite registration on it, take it to the patient’s mouth and seat the central incisors exactly against the white plastic in the front labially.

Verify that you can hold this level to the horizon in two planes of space and that you can touch the patient’s teeth. If not, you might need to build up the posterior.

If you’ve verified this, put bite silicone on the plate from the canine position back, then seat it again, making sure the central incisors are seated labially against the white plastic …

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I’ll round up this fun technique with Part 3 in the series coming soon.

For a hands-on lesson in the Dento-Facial Analyzer from our talented educators, check out our Essentials 1 Pankey course. Also, watch this video for a quick refresher or pre-course overview.  

QuickSplint has many functions in general practice, but it is also a great resource overall in both diagnostics and restorative dentistry. It’s ideal for patients who grind, those with endodontic issues, and anyone needing a restoration.

QuickSplint to Improve the Patient Experience

Many dentists see patients who have wear on their teeth but don’t think they grind at all. They might have said that they used to grind their teeth, but they believe they don’t anymore. You can use the QuickSplint as a learning experience where the patient is able to recognize the cause of the attrition.

It’s nice to rely on this quick, easy, and inexpensive device. Go ahead and have the patient sleep in it for a little while. The QuickSplint will then reveal whether or not they are clenching and grinding. After the proof is clearly demonstrated, you can have an impactful conversation with your patient.

Another option for QuickSplint use is as a means for handling parafunction and restorative materials selection. Today, we talk a lot about posterior materials when we are doing crowns on first or second molars. Are we going to use high strength ceramics or traditional PFM restorations? Instead of guessing about the patient’s parafunctional risk and how much load they will place on the restoration, you can easily get that information with a QuickSplint.

Additionally, you can use the QuickSplint as a post-op device after an endodontic procedure. You can reduce a patient’s discomfort significantly in less than three minutes and also help the tooth heal without occlusal pressure. You then won’t have to take the entire occlusal table off the problem tooth. This can even work during pre-op for a patient whose tooth appears to need endodontic treatment.

In our Essentials One course at Pankey we use the Quicksplint as an overnight deprogrammer to allow us to capture very accurate diagnostic records.

Do you use QuickSplint in your dental practice? Tell us your best tips for using this handy little tool!

Replacing a failed restoration starts with a careful examination of the patient’s needs, desires, and current oral health. My patient in this case presented with a six unit anterior bridge, decay, and many esthetic issues. After an esthetic evaluation and comprehensive exam, it was time to move on to treatment planning.

Failed Restoration: Treatment Plan

To treatment plan this case, I relied on an advanced facially-generated treatment planning system for communicating with the rest of the team. Communication is essential to a reliable outcome.

First, a diagnostic work-up was generated. Then, the interdisciplinary team together developed a final treatment plan and sequence, with the incisal edge position of the upper right central as reference.

We chose orthodontic extrusion of the upper teeth to handle proclination in the anterior and the gingival discrepancy. Additionally, we treatment panned the maxillary right canine for over-extrusion by 2 mm. This was done to achieve adequate restorative ferrule through crown lengthening, not to mention re-treatment endodontic therapy with post and core.

We talked about implant therapy, but ultimately it was not a workable solution. Root proximity on the upper right and the gingival tissues meant it wasn’t ideal as a first option. For the final treatment, we decided on placing a six unit anterior bridge. I then discussed the outcome with the patient and she decided conservative therapy for the posterior esthetics of direct composite veneers was best. This enabled us to create consistent contour and shade.

Next up was the lab, which made a pre-orthodontic wax-up based on periodontal surgery and planned tooth movement. I gave them the proper information by using PowerPoint and digital photography with the proposed tooth positions. After this, the post and core endodontic re-treatment was done for the upper right canine.

To be continued…

What’s your approach to treatment planning? 

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.

Forty five years ago, in the fall of 1972, the first class at The Pankey Institute was held. It’s easy to forget how much things have changed in the world of dental continuing education. Read on for an enlightening reminder of how far dentistry has come in the last few decades … 

Pankey History: Dr. Henry Tanner

Dr. John Anderson and Dr. Loren Miller each had sold their private practices and dedicated their careers to the creation of the Institute. In 1974, Dr. Anderson asked Dr. Henry Tanner to be assistant director of education. Dr. Tanner had been head of fixed prosthodontics at USC School of Dentistry and had made several significant contributions to dentistry.  

Many years earlier, Dr. Tanner had rebuilt the occlusion of Dr. Anderson, who then described Henry as “the finest restorative dentist in the world.” Dr. Henry Tanner is most often associated with the development of the Tanner Appliance.  

Dr. Tanner vividly recalled the first time he made a lower full arch appliance for a woman who was having severe head and face pain. She and her husband went to the hospital emergency room and she was given morphine and Demerol, yet she was not having much relief.

During an emergency visit at his office, Dr. Tanner made an acrylic wafer, placed it directly in her mouth, had her touch it gently with her upper teeth, and asked her to mold it with her tongue. After the acrylic got rubbery, he took it out of her mouth, let it harden, and refined it. She was out of pain the next day.

Within weeks of that experience, Dr. Tanner met a well-recognized orthodontist, Dr. Bob Ricketts, who was taking laminagraphs (sectional x-rays) of his splint patients to monitor condylar position and bony healing in the joint.  

To be continued ...

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 …

Splint therapy can be one of the best services we offer our patients, but plan poorly and your headaches will greatly increase as you decrease your patient’s.

We all want to provide our best stuff for our patients, yet sometimes we can find ourselves in a quagmire of complexity and not getting reimbursed for our efforts.

Through the years I’ve seen this scenario play out in my own practice and many others because we lack structure around our fees for splint therapy. If ever there was an example of the failure of unit fees to provide appropriate care and reimbursement, the one size (fee) fits all approach in splint therapy will leave you clenching and grinding.

How to Individualize Splint Therapy Fees

To be equitable for patient and practice, fees for splint therapy must be individualized. To do this, you’ll need to have a good idea of what your production per hour goals are and utilize that as a basis for your fee.

For example, if I have an anterior deprogrammer that requires very little follow up to simply protect the dentition and calm muscle, the fee would consist of a lab fee (I charge this fee even if I make it in house), the time for insert, and the amount of time for follow up, usually one or two short appointments.

For more complex TMD therapy I like to look at it this way: take the same basic fee structure illustrated above and add time for insertion (allow yourself enough time, knowing mandibular/condylar position is likely to change as you adjust), then add for follow up appointments based on your diagnosis and complexity.

Estimating Therapeutic Time

Here are some of the factors I consider when estimating the “therapeutic time.” I’ll routinely add time and/or appointments based on whether it involves:

1) an occluso-muscle disorder

2) an intracapsular disorder

3) the amount of degenerative change in the condyle disc assembly

4) the chronic or acute nature of the problem (acute problems I feel are generally harder to manage)

5) the presence of pain, both quantitative and qualitative

6) the duration of pain and complexity of pain pattern (pain emanating from multiple sources)

7) the behavioral and psychological dynamics involved with the patient

In closing, I’d remember to under-promise and over-deliver in direct proportion to the complexity of the problem. Evaluate, diagnose, and treat wisely and you’ll achieve pain reduction and stability for both you and your patient!

How do you structure fees for splint therapy in your practice? We’d love to hear from you in the comments!