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.

Elevator muscle activity decreases as we begin to open vertical, but beware that at some point the force starts to rise again until we approach maximum opening. The range of decreased activity seems to be more than 1mm of opening and less that the patients vertical dimension of rest. The other challenge to be aware of is that studies have shown this reduction in elevator muscle activity to be transient, and that the body adapts and the muscle force returns to baseline even at the new VDO. This phenomenon means that we can not count on only the effect of changing VDO to provide therapeutic benefit for our patients. Long lasting benefits come from designing an appliance at the appropriate condylar position and with the optimal occlusal design based on that patient’s joint, muscle and dental condition.

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 »

Mar 182014

http://www.dreamstime.com/royalty-free-stock-photos-dental-mirror-patient-mouth-teeth-reflection-image26818748This quarter’s e-newsletter looked at the concept of completing comprehensive exams for new patients and fitting this in to your practice philosophy and current circumstances.



Sometime in the past I think I heard that all “good” dentists completed a comprehensive exam on every new patient at the first appointment. In truth a rigid interpretation of this idea in a private practice setting can be overwhelming and a barrier to changing and improving your new patient experience.

Right after dental school in the 80’s I believed I gave a comprehensive exam to all of my patients, and it included dentition charting, necessary x-rays, and periodontal screening. As I went through more advanced continuing education, my comprehensive exam grew to include a comprehensive periodontal exam, joint & muscle exam and digital photography. Continue reading »

Mar 042014

Shrink Wrap Provisionals WebFabricating provisionals for anterior veneers can be one of the most challenging of our clinical procedures. For some it is such a challenge that they hesitate to offer veneers to their patients. There are three methods of fabrication: indirect, direct and shrink-wrap. The indirect approach requires fabrication of a model of the preps on which the provisionals are made. The model does, however, allow the bisacryl to be trimmed on the model without the challenge of holding the fragile provisionals. Direct fabrication, forms the bisacryl on the preps in the mouth. This technique has both the challenge of timing the removal of the bisacryl and then trimming in your hands without breaking. Shrink wrap provisionals are formed directly on the teeth and then trimmed and polished int he mouth. The technique challenge is int he handling of the matrix and flash of bisacryl without damaging tissue or preparations. Continue reading »

Feb 252014

ChecklistSeveral years ago I became familiar with a great book called “The Checklist Manifesto” by Atul Gawande and began incorporating some of the ideas into my practice. I am hopeful that the concept of using checklists is becoming more popular in dentistry. The cover story of this month’s Journal of The American Dental Association is entitled “Designing a Safety Checklist for Dental Implants”, so maybe the idea is catching on. The book uses a system incorporated by airplane pilots to minimize risk and increase the successful and safe completion of flights, a checklist. This idea was then incorporated into hospital and medical protocols with dramatic results and improved patient outcomes.

The basic premise is that as our worlds and systems become more and more complex, the answer to success is as old and simple as having a checklist and a system to use it every time.  The more complex a task becomes the easier it is to forget or overlook any single step. In addition the more calamitous it can become on  the result when a step is skipped. For many of us we think these complex and multi-step systems are too complicated and sophisticated to breakdown into a checklist, but in truth everything can be.

So could checklists help improve patient outcomes, or the simple day to day operations of your office? We use checklists in our office for complex procedures like bonding in porcelain veneers, where skipping the step of applying silane can cause the restorations to fall off prematurely. We also use checklists for office systems like cleaning and servicing the vacuum suction, or restocking our procedure kits. One of the challenges of using checklists is not ever letting yourself think you no longer need them. No matter how long you have done a process, or how many times, we are all capable of not getting all the steps. A simple distraction can cause you to lose your train of thought or place and then pick up one step too far ahead. Checklists give us certainty that we are true to the process and reassurance that we will produce successful outcomes.

So, where can you implement a checklist?

Feb 142014

communicationThanks Mary Osborne for another great post!!

There is quite a buzz in dentistry today about all of the tools at our disposal for presenting treatment to patients. Digital dental photography, Power Point, and computer generated patient education systems offer technologically sophisticated and visually appealing images. But I want to talk today about a resource to engage and encourage your patients that I believe is underutilized in presenting treatment: your team.

I want to suggest a simple exercise you can do in your practice which will increase the ability of everyone on your team to answer questions and help your patients see the value of the treatment you recommend for them. Continue reading »

Feb 052014
Silicone Matrix Web

Matrix of Model with Gingival Channel

Making a silicone matrix to fabricate provisional has several goals and they include accurate replication of the model being used to form the matrix and efficiency in fabricating the provisional. One of the most time-consuming components of fabricating a provisional is trimming the excess material away from the margins and embrasures.Recently I learned an addition to my silicone matrix technique that is no doubt my new favorite trick. The technique is designed to fabricate a silicone matrix for use with “shrink wrap” provisional where they are intentionally locked on. In this technique as all the trimming is completed in the mouth it is critical to reduce the excess both for purposed of time as well as reducing he risk of damaging preps during intraoral trimming of the bisacryl. Continue reading »

Jan 282014

Screw Retained WebLast week at the Seattle Study Club Symposium I was talking with a group of the other presenters and we were all remarking how implant restorations have come full circle back to screw retained. It is funny if you think about the fact that in the early years everything we did was screw retained. Then over the years the pendulum swung to people doing almost exclusively cement retained. Now we have the option to choose between these two alternatives and the pendulum is swinging back as we realize that a large number of implant failures are due to cement that was left behind. As with anything in dentistry there are risks and benefits of each option. One of the primary things to realize is that this is a treatment planning decision and needs to be discussed ahead of time between the restoring dentist and the surgeon. Continue reading »

Jan 232014
e-max bridge

e-max bridge

One of the most important factors when considering using an all-ceramic material like zirconia or lithium disilicate (e-max) is the presence of adequate space for the connectors. Fabricating an all ceramic bridge with connectors that are too small based on the strength of the material is a recipe for premature failure. It is common to see fractures of the porcelain right through the connectors. Connector size is determined by measuring the height from gingival to incisal or occlusal as well as the width measured from buccal to lingual. Some patients present with insufficient inter-occlusal space to gain the appropriate height of the connectors recommended. The shape of the interproximal connector is typically an oval or a circle.  In areas of increased load or tension it is reasonable to consider increasing the connector size. Continue reading »

Jan 162014

pulp TesterThe sensitivity or responsiveness of a dental pulp is a key indicator to vitality. Over the years people have developed varying methods to test the responsiveness of teeth including cold, heat and electricity. The first thing to think about are the qualities of a pulp responsiveness test.