Aug 292014

Healing Cap WebIf your goal is to create optimal tooth and gingival esthetics, than the answer in my book is YES. Probably one of the most common questions i get is why the lab can’t simply go from a fixture level impression to the final restoration and create optimal gingival position and contours. The answer is simple, you are asking them to guess as to how the patients tissue will respond to the facial contour of the abutment and crown over time. Guessing inherently includes risk, the patients gingival health, tissue thickness, healing since fixture placement, and more. So asking your technician to sculpt a model and create the final contour from the fixture to the gingival margin is about your personal tolerance for risk assumption, and how you will deal with things when the result doesn’t meet your expectations or the patient’s expectations.Implant Temp 1 Web

As someone who is fairly risk averse, loves predictability and loves to meet or exceed expectations anterior implant provisionals are routine in my office. The timing for placing an implant provisional is about the beliefs of the person placing the fixture and the person doing the restorative. Either way my clinical experience has cemented the importance of this stage of treatment int he esthetic zone. So what do implant provisionals do?

  • Provide for complete an optimal tissue maturation and healing
  • Provide interproximal and facial subgingival shape for development of papilla and free gingival margin placement
  • Allow alteration of the shape of the abutment and crown as needed to optimize gingival esthetics
  • Offer the patient a non-removable restoration during the healing phase
  • Allow creation of a custom impression coping and soft tissue model

Implant Temp WebI fabricate most of my implant provisionals, but you can also partner with your lab and have them do this. In my upcoming hands on workshop Implants Live:Mastering Implant Success, participants will get a chance to make a custom provisional and see one made by Gold Dust Dental Lab. You are correct if you are thinking the shape of the provisional is a guess. The difference is you are guessing on plastic, and can evaluate the outcome and change the shape of the provisional easily to alter the tissue position. Making these same alterations on the final abutment and crown is laborious and sometimes costly, and send a very different message to the patient.


Aug 272014

questionsBy Mary Osborne

Everyone has an opinion about what a fair fee is in dentistry today. Patients think they know what it should be (usually less than what it is.) Insurance companies have their opinions about what our care, skill, and judgment is worth. Consultants and other experts have statistics, comparisons, and formulas that promise to provide the right answer. In my conversations with dentists and their teams I hear their concern about a changing health care model and changing economic model. They see that systems and structures of the past may be less relevant in the future. As I look at an emerging and evolving health care model I have been working with what I think of as a formula for health: the health and well being of our patients, and the financial health and viability of our practices.
CSJ + PO + FF + MOP = Health
Care, Skill and Judgment + Preferred Outcomes + a Fair Fee + the Method of Payment = Health
As I said in earlier articles on this formula, the first part of the equation is the only part completely within our control. Our care, skill, and judgment represent what we bring to the equation. The next part, the Preferred Outcome, has to do with the values our patients bring to the process. The next part, a Fair Fee is where the two intersect. There are two primary models that have traditionally been used in dentistry:
1. What the market will bear. Many offices rely on comparisons with other practices to determine their fees: Conversations with other dentist; reports from local and national surveys; fee schedules from insurance companies. All provide information about what others are charging for various procedures and offer insights into what patients are accustomed to paying. If practices agree to be preferred providers in a given plan they accept the fees stated in their agreement as fair for those patients. For other patients practices can set their fees either higher or lower depending on where they choose to position their practice in the marketplace.

2. Overhead and profitability. Another method for determining fees is to assess what it costs to run the business, add the profit you want to make, then figure out the average amount you need to generate per hour to achieve that. Once you know the amount you need to generate per hour you can base your fees on how much time it takes to provide each service.

Both of the above methods have been used with some success for many years and will continue to have some relevance, but they are inadequate in mapping the future. A more philosophical definition of a fair fee — a fee that allows the dentist to feel well rewarded, and that the patient is happy to pay — seems more appropriate. This definition can include the other two methods, but requires greater and greater creativity as we move into new models of health care.

Creative Communication: Our patients’ ability to find value in our services is directly related to our ability to show them how what we offer can alleviate their fears and meet their hopes and dreams. As decisions about how to pay for health insurance moves from employers to patients, they will become more savvy consumers. Some will base their choices only on cost, and some will become more discerning. We have an opportunity to help them become more discerning. Where is the potential in your practice to help patients who already value your practice become more discerning?

Creative use of Resources: New models for providing services are emerging in every sector of the economy. Convenient scheduling, use of technology, and personalization of service are increasing in value. Patients and health care providers alike desire flexibility and efficient use of time. The time is ripe with opportunities to make our work more enjoyable and more rewarding in every way. How could you alter your current model to make better use of your facility, your time, or your energy?

Creative Staffing: What are the aspects of care that must be done by a dentist or hygienist, and what ways can others provide a high level of care?. The traditional positioning of administration, hygiene and assisting can open up to a more flexible, innovative model. Hiring takes on new dimensions. As we look for ways to be more efficient we can also find ways for work to be more fulfilling for highly skilled and talented employees. Look at your current staffing model. Ask yourself if there is one team member whose skills could be better used somewhere else in the practice. How could you use those gifts and talents more productively someplace else?

Creative Mix of Services: I already see practices developing all inclusive plans for patients that are not dependent on insurance codes. As rigid structures and systems become less relevant opportunities open up for attention to what really enhances health; comprehensive fees that focus on results more than on procedures. Where can you begin to develop one fee for a service that falls outside of the traditional model? Learn to communicate one values based fee to hone your skills for models of the future.

The level of each practice’s care, skill, and judgment determines the fee we deserve to receive, but it does not mean that we are entitled to any given fee. We are responsible for how we use our resources; for how we structure our mix of services; and for how we choose, utilize, and grow our team. The more confident we are in our ability to manage those variables, the more likely we are to help our patients see the value of our care. Regardless of the model of practice we choose, it will always be our responsibility to convince enough people to choose enough of what we have to offer to allow our practices to thrive.

Jul 152014

adhese-universalThe recent launch of Ivoclar’s Adhese Universal adds to the growing category of materials known as “Universal Adhesives”.  In general when I hear the word universal I assume it is a product that can be used for all possible applications and with a single set of instructions. I have learned over the years not to assume in dentistry what the word universal applies and make sure I understand the specifics. This new group of materials is no different. There are multiple manufacturers with “Universal Adhesives” on the market, and each one has a different set of procedures it includes with different recommended directions. So with that what are the advantages of using a “Universal Adhesive”? Continue reading »

Jul 092014

Cartridge CouplerWasted material is wasted money. Over the years I have tried to analyze the remaining impression material or bite registration in cartridges and make the decision whether there is enough remaining material to accomplish our goals. If not time to use a whole new cartridge. We have also loaded two separate guns and used the remaining material, switched guns to finish loading the impression tray or taking the bite. This approach uses two tips, another way to increase costs.

Recently we became acquainted with a product called Lock-n-Reload. The blue plastic connectors fit on to the end of the cartridge of material, and allow you to attach a second cartridge of material. Using the gun you move the remaining material from cartridge one into the second combining the contents. The now empty cartridge and connector are thrown away and you can get full use out of the material. The connectors are manufactured by a company called IndiGreen Innovations at and is available from most of the major dental distributors.

Jul 012014

Teflon Tape Block Out WebVinyl Polysiloxane and Polyether impression materials are stiff enough that material that locks under a bridge pontic or through a large gingival embrasure can make removal of the impression from the mouth difficult to near impossible. On the other hand Alginate used int he same situations can tear easily or be dislodged from the tray causing distortion that renders the resulting model inaccurate. Continue reading »

May 272014

Woman's Eye and World GlobesBy Mary Osborne

For more years than I care to admit I told patients they should brush their teeth; they should floss their teeth; they should come in for regular exams and cleanings. I did that kindly, gently, with compassion and with the best of intentions. Still, I had patients who were not effective at removing deposits and who did not keep their scheduled appointments. I wondered why they didn’t listen to me.
I have come to understand that personal hygiene is, well, personal. Most adults believe they have good enough hygiene. They feel judged and insulted when they are told their hygiene is not good enough. When people feel insulted their defenses go up.  When they feel a need to defend their actions they are likely to get attached to those actions; to justify them; to resist any change. Continue reading »

May 122014

Imacon Color ScannerLast week we had a team meeting on Wednesday. This is something we do about every 4-6 weeks. We block out the entire afternoon, order in lunch for everyone and plan some valuable time together. It is amazing to me how often these meetings turn into logistics discussion about the radio station, uniforms or how we are handling sterilization. I am even willing to admit sometimes they degrade into “gripe” sessions. When this happens I wonder why we continue to schedule these as they seem more stressful than helpful.

One of our goals is to have these meetings be positive and  beneficial. There are many levels of benefit we can get, from clinical or technical development, resolving systems based issues, resolving conflict and becoming a more cohesive team. Last week at our meeting one of our team members requested that everyone bring in photos of themselves over a span of years. The suggestion was met with mixed reviews. The day before the meeting at the morning huddle she reminded everyone to bring their photos and some groans were heard. Continue reading »

Apr 302014

Image converted using ifftoanyI think all of us have patients in our offices who chronically complain of a bad taste or bad smell in their mouths. Some of these patients perceive this themselves, and others have feedback from others. I’m discussing the patients who have excellent oral hygiene, have tried brushing or scraping their tongues, do not need scaling & root planing and still the problem persists. I can only imagine that this is distressing whether it is a continual bad taste or smell for the people who experience it. Recently I have come across a fabulous solution I can offer these patients. Continue reading »

Apr 152014

Full Coverage ApplianceMany times I get asked if there is a connection between the vertical dimension of an occlusal appliance and it’s effectiveness. The answer is “yes” and “no”. There is scientific evidence that supports that the activity of the elevator muscles decreases as we open the vertical dimension of occlusion. The next questions to ask, are how the amount of vertical change affects the amount of muscle activity reduction and the duration of this affect. One of our goals in appliance therapy is to reduce the activity of the elevator muscles. This reduction directly affects the signs and symptoms associated with muscles, like headache as well as having a positive impact in reducing joint loading which is a percentage of the total force applied. With this in mind the fact that the muscle activity of the elevator muscles decreases as we open vertical dimension is most likely one of the reasons appliance therapy works in helping our patients feel better.  It may also contribute to why during appliance therapy of short duration we see less evidence of attrition. It may not be that the person has stopped or reduced the amount of parafunction occurring, but that they are applying less force and therefore not notching the appliance significantly. Continue reading »

Mar 312014

RingInPlace_03.RGB_color.0620_0We are all on the search for the perfect matrix system. Our hope would be to find one system that works every time. Working would be defined as sealing the margins of the prep so we have minimal to no excess to finish off, replicating the original shape of the tooth, and creating tight interproximal contacts.  My experience is that there isn’t any one system that works in every clinical situation. Exceptional results are dependent on having multiple matrix systems and choosing the appropriate one based on the tooth preparation. Continue reading »