The Dawson Academy Blog

Increasing the Predictability of Anterior Restorations

Leonard A. Hess, DDS
Associate Faculty Member
The Dawson Academy


Every clinician is on a constant journey.  We all must continuously learn and hone our craft.  Every year thousands of dentists trust the Dawson Academy to help them on their path.  One topic that interests many restorative dentists is anterior indirect restorations, and how to do them better. 

Improving a smile is one of the fastest ways to make a person happy, as their life is often changed for the better.  But a pretty smile must also function properly.  Changing the anterior teeth with disregard to function can lead to broken restorations, uncomfortable speech, and muscular disharmony.  Here are a few commonly overlooked ingredients to “cooking up” a beautiful and functional smile.

Incisal Edge Position:  The incisal edges must be placed in the proper position vertically and horizontally.  The teeth must be long enough esthetically, but must also work with the patients anterior guidance and envelope of function.

Photographs:  The Dawson Academy consistently teaches the necessity of a complete set of diagnostic photographs.  Photos are needed for treatment planning, patient education, lab communication, and documentation.  Their importance cannot be overstated. 

Preparation Design:  One often neglected step in case planning is the creation of reduction stents.  The lab must have adequate reduction for esthetics and material requirements.  Remember, if the lab needs 0.6mm of reduction and you only gave them 0.4mm that is a 33% error!

Laboratory Communication:  Predictability comes from giving the proper information to the lab.  It isn’t their job to decide all the variables involved in anterior reconstruction.  And the lab certainly shouldn’t be put into the position of guessing length and incisal edge position.   

Predictable results come from a consistent approach.  As a practicing clinician I always find myself reviewing the Dawson Academy fundamentals that help me succeed.  

Avoid Subprime Results in Your Practice

Measure What's Really Important and Accomplish What Really Matters

by Larry M. Guzzardo  

 

In his groundbreaking book, Thriving on Chaos, Tom Peters proclaims, “What gets measured gets done.” He further explains, “Develop simple systems that encourage participation and understanding by everyone.” In other words, measure what’s important. Create measures of what is happening in your practice and empower staff to take action to achieve improvement. Keep what you track simple, paring it down to a few essential statistics that can capture the vitality of your practice at a glance. Anything you want to improve should be measured and monitored regularly.

 

Determine What is Important.

Determine what is important to the lifeblood of your practice, but don’t ignore non-financial measures, such as laboratory quality control, adherence to hygiene departmental protocol, or patient satisfaction. Ultimately, the staff will consider what you track as important. By not paying attention, you won’t be able to react until it is too late, keeping you from getting things done, making you appear indecisive, and preventing you from delivering on promises and commitments—which is certainly not the formula for a winning team. However, too many offices operate without any real direction, having a direct impact on employee development and practice progress. As a result, individual staff members may form cliques and resort to uncoordinated efforts to get things done.

 

Avoid Inaction.

So, what causes this inability for dentists to take action? Usually, the failure to put the right people in the right jobs leads to problems in the workforce. Oddly enough, doctors admit to knowing there are performance issues with certain staff members, but they choose to ignore it, hoping the employees can resolve it on their own. To make matters worse, the rest of the staff is aware of problematic employees, but the doctor usually does not seek their advice to address the matter. When a staff member is underperforming, ignoring the problem is bound to make it worse. Strong leaders encourage and stretch the abilities of talented staff.

Once the decision has been made to challenge your staff, you must commit to tracking their progress in detail through regularly scheduled review sessions that conclude with comprehensive constructive Actions Plans that outline the employee’s goals until the next review session (usually six months). Effective leaders begin by focusing on clear and specific goals. With clear goals, effective doctors implement them in a way that appears simple, but produces profound effects. At the end of every staff meeting or employee review, doctors should create an Action Plan. Note exactly what is supposed to be done by whom and by when. Then, discuss the steps that should be taken and how you will assist them. You can then review this agenda before you adjourn and make it the first thing you review the next time you meet. As simple as it may seem, this process is the first step in learning to get things done. It is the doctor who brings these habits into a practice where they did not exist before. Now under your renewed direction, the whole tone of the office changes as staff members prepare for meetings differently.

 

Embrace the Routine.

Sure, keeping track of assignments, following up on them, and evaluating progress seems boring, but it’s a routine you should learn to embrace. In underperforming practices, many dentists find no reward in continually improving systems and procedures. They rant, “Why can’t the staff just do this by themselves?” They’re afraid of being seen as too controlling. However, Dr. Dawson teaches us that where there are no controls, you will find control freaks. Ironic, but true, especially if there is no way to determine progress, meaning dentists must constantly check and recheck. This waste of time keeps the doctor from focusing on the staff and patient care. Time-efficient doctors who are engaged in what is happening in their practice are hungry for information, including information about daily and hourly production, collections, bad accounts, the schedule, incomplete treatment, hygiene therapy, supplies, equipment, and even the facility. They never want to be the last to know. They use meetings as an opportunity to have their staff bring data to them to be evaluated. By incorporating measures and tracking results, staff can self-monitor their progress and offer solutions to problems, facilitating their ability to understand the goals and vision of the practice. Developing measures and monitors saves time and allows the doctor to lead the practice and work toward fulfilling commitments and promises.

 

Larry M. Guzzardo who has co-authored two books, “Powerful Practice” and “Getting Things Done,” conducts in-office practice management consultations exclusively for dentists to enhance trust, create organization, increase profits, and develop patient relationships that last. Larry has presented numerous workshops, including “Winning Patient Acceptance,” “Business Communication Systems,” and “The Leadership Challenge.” Larry can be reached at 800-782-5770 or www.larrymguzzardo.com if you have further questions.

Alumni Membership Privileges

The Dawson Academy's Alumni Association: Membership Has Its Privileges

Although American Express may have coined the phrase “membership has its privileges,” The Dawson Academy has adopted a similar philosophy regarding membership within its Alumni Association. Designed to give our students a special experience that extends beyond the classroom, the Alumni Association is your gateway to information needed to implement the Dawson principles in your own dental practice. From developing the best treatment plan to viewing podcasts conducted by Dawson Academy faculty members, our alumni network is designed to help you grow your practice by providing the knowledge you seek. The following are just a few examples of the resources you will find:

Blogs. Here you can find regular, ongoing articles, press releases, and information about both The Dawson Academy and the dental industry in general. From discussions about growing your practice to the latest dental technology, this blog will provide you with the information your practice needs to thrive. What’s more, we welcome you to comment on the blogs and engage in conversation with your fellow Dawson alumni.

Podcasts. Podcasts have quickly become one of the most integral forms of communication. Realizing this, we provide these video segments to reinforce the lessons learned in our seminar series and hands-on courses, and introduce new ideas that may energize your practice. Generally ten minutes or less, these podcasts provide you with the opportunity to stay on top of your dental game.

Discounts. In our struggling economy, very few people aren’t interested in saving money. That’s why we’re proud to offer all alumni network members a 40 percent tuition savings for all seminar auditing and a 10 percent discount for all bookstore purchases.

Links to You Tube Page. Video is now one of the premier communication options available, and The Dawson Academy is pleased to present our You Tube page, which will provide videos that address current issues, technologies, materials, and even member questions.  And best of all, this information is delivered directly to your desktop computer.

Seminar Dates and Locations. In our continuing effort to meet the demands of our students, The Dawson Academy is pleased to partner with Henry Schein Dental to now offer courses throughout the United States. Founded on our two organizations’ shared belief in continuous learning, the initiative will help combine advances in technology with a sound clinical approach—and here is where you will be the first to know our latest course dates and locations.

Message Boards. Similar to our blog, the message boards provide you with the opportunity to engage in discussion with your fellow alumni members. However, this time you get to choose the topic.

As you can see, there is a wealth of information to be found on our alumni network. We welcome you to log into the site with the account activation code listed on the manual from your latest session and browse the site. You’ll soon see that it’s an invaluable resource for any complete dentist who is looking to grow his practice.

The Bite Record Directive: The Need to Properly Record Centric Relation

When it comes to developing a successful treatment plan, few things are as important as the need for accurate, usable bite records. In fact, Dr. Peter Dawson believes that one of the biggest—but yet easily fixable—flaws most dentists make is not verifying that the intended joint position is both achieved and recorded accurately. Not only does this oversight lead to frustration, wasted time, and errors in treatment planning, not properly recording your patients’ centric relations can and will cause unacceptable grinding on new restorations. That’s why it’s imperative for complete dentists to take the time and effort needed to ensure they attain accurate, usable bite records.

First and foremost, it’s important to remember that the preciseness of the determination of centric relation can easily be lost if not matched by the preciseness of the intraocclusal bite record combined with an acceptable facebow record. What’s more, some dentists will argue that it’s nearly impossible to repeatedly find centric relation. However, tests have proven that centric relation can be reproduced on mounted casts to needlepoint accuracy. And best of all, it’s a process that can be learned in just a few hours time. But, you must be certain to stay clear of the following problems that may impact the accuracy of your bite records:

·         Improper manipulation

·         Lack of guidance or verification of centric relation

·         Flimsy bite-recording materials

·         Too-deep indentations in the bite material

·         Use of easily distorted, soft waxes

·         Nonexistent indentations in the bite record

·         Unstable bite-recording materials that may warp or distort

Despite all these possible problems that may impact the accuracy of any bite record, it still remains the best way to accurately verify a patient’s centric relation. That’s why you should keep the following five criteria in mind as you make an intraocclusal bite record:

·         The bite record must not cause any movement of teeth or displacement of soft tissue.

·         It must be possible to verify the accuracy of the interocclusal record in the mouth.

·         The bite record must fit the casts as accurately as it fits the mouth.

·         It must be possible to verify the accuracy of the bite record on the casts.

·         The bite record must not distort during storage or transportation to the laboratory.

When attempting to verify centric relation, all five of the above criteria should be met, especially if you choose to take a wax bite record, easily the most popular method of recording centric relation. The following will illustrate how:

1.       Choose the right type of wax. Although wax is the most popular method for recording CR, it is also the most easily abused. That’s because the quality of the wax can have a profound impact on the quality of the records. For example, the wax must be soft enough so the teeth do not move during recording. What’s more, once the wax is cooled it must remain brittle hard, so no damage can be done to the wax during transport or mounting. The right kind of wax should break with a snap when it is bent.

Although you are certainly free to choose whichever wax you like, Dr. Dawson highly recommends Delar wax, which is a brittle-hard wax that is supplied in wafers that are thicker at the front for more even penetration by the teeth from back to front.

2.       Soften the wax. Since the wax is so hard, it will be necessary for you to soften it through the use of a small torch, being careful not to overheat the wax. Be sure to flame both sides of the wax carefully, striving to attain a slight shine on both sides of the wax. You’ll then want to allow a few seconds just for the heat to penetrate the wax.

3.       Insert in the mouth. Once the wax has been softened to a slight sheen, you’ll want to begin the actual process of recording the bite. Insert the wax into the patient’s mouth and place it against the upper arch, pressing against the arch to ensure you indent the wax with the teeth.

4.       Manipulate the mandible. Now that the wax has been comfortably placed into the patient’s mouth against the upper arch, ask your assistant to hold the wafer in place to free your hands for mandible manipulation into centric relation.

5.       Verify centric relation. Once the wax has been seated against the upper arch and you have had the chance to place your hands on the lower jaw for manual manipulation, you’ll want to make sure the joints are properly seated. Take the time here to load test your patient to ensure the joints are in the appropriate placement.

6.       Have the patient close into the wax. Maintain firm, upward pressure on the condyles as the patient closes into the wax. If not, patients may have a tendency to protrude at the start of closing into anything between the teeth.

7.       Check the premolars. At this point, you want to make sure the first premolars have made a definite indentation in the wax. This step will help make sure that the posterior teeth will recorded with indentations that will hold the casts in a stable relationship with the bite record.

8.       Remove the wax and begin trimming it. While the wax is still warm, you want to remove it from the patient’s mouth and begin trimming it back to the indentations of the buccal cusp tips so the fit of the bite record can be verified in the mouth. You’ll also want to make sure that you have made a perfect tooth-wax-tooth fit by checking for voids or cracks between the teeth and the bite record.

9.       Verify the bite record. Now is the moment of truth. Submerge the wax into a glass of cold water to return it to a brittle-hard state. Then, return the wax to the mouth and seat the condyles and load test the patient for verification of centric relation. Hold the condyles firmly in centric relation while the mandible hinges to bring the teeth into maximal contact with the bite record. Make sure that both sides of the arch contact simultaneously with no premature contact or deflection into the hard wax. Finally, make sure that there are no voids between the teeth and the wax at complete closure.

10.   Check for soft tissue impingement. You’ll now want to examine the bite record to that it is not being effected by any soft tissue. If there is any soft tissue contact at gingival margins, take this opportunity to trim these sections back. If you find that the wax is difficult to manipulate, feel free to re-soften the wax with the torch once again. However, be certain to only warm the wax where the indentation of the teeth has been made. You can then re-insert the wax and place it back against the upper teeth and mandible, closing the patient into it to adjust it as necessary. Once inserted, it should extend directly across the arch without touching any palatial tissue.

11.   Store in water. Now that you have verified centric relation and made an accurate bite record, you’ll want to store the wax until you use. The easiest way to do this is to float it in a cup of water in a sealed plastic container, such as a Tupperware jar. One of the more common mounting problems can be attributed to casts that haven’t been carefully handled.

Although some may argue that taking a wax bite record is the most time-consuming process for verifying centric relation, chances are that they’re not doing it properly. In fact, the wax bite technique is the simplest and fastest way to record centric relation. What’s more, it is also the most accurate way to mount casts, because the casts fit neatly into the record with very little movement.