Today we move between the digital and the analog world to accomplish the goals of aesthetic dentistry. A mock-up is a key tool in helping patients want aesthetic dentistry and visualizing what the changes will accomplish.

Lots of us have learned from masters like Dr. Susan Hollar how to hand-lay composite on the patient’s teeth so the patient can see their possible new smile. This trial smile technique is a fabulous way to motivate patients. It’s also a great way for us to learn what might be possible.

For many dentists, that technique is not natural for us, and it takes chair time. Another way we can model possible changes is through digital technology. In our office, we are using digital smile design as follows.

1. We do our initial records, which includes facial photos and an intraoral scan using our digital impressions intraoral scanning system.

2. Either on the software in our office or at the lab, a 3-D version can be designed of what the new smile approximately could look like.This doesn’t have to be a definitive wax-up. Remember, we call it a diagnostic work-up. In fact, this is oftentimes where we discover the need for gingival changes and/or orthodontic procedures in order to achieve the desired outcome. I find this extremely helpful in communicating with the patient as I can show them what the compromised outcome would be if they choose not to correct the gingival levels or align the teeth if that is in fact appropriate.

We’ve learned it is very efficient to collaborate with the lab, the lab creates the 3-D design, and the lab emails us the STL digital file of the design. Alternatively, the lab can send printed models, matrices, or even milled/printed PMMA shells of the design.

3. On the 3-D printer in our office, we print the model from the STL file.

4. We make a matrix from that, either in a suck down material or a putty matrix, and we take that to the mouth, fill it with our temporary material (usually bisacryl), and seat it right onto the teeth.

5. After letting it set, removing the matrix, and peeling off excess material, the patient is wearing their trial smile. This last step takes all of two minutes.

Using this process enables us to do the lab work between appointments, and when the patient returns, they can very quickly preview the possibilities.

It is a wonderful communication tool, because the patient can look in their own mouth, not at a picture of someone else, not at pictures of other shapes of teeth, and say, “I like that,” or “I thought they would be shorter (longer, fatter, narrower…).” You can go in with your handpiece and reshape the temporary material or add material with flowable to make something more pronounced.

Patient participation in the tweaking of the design draws the patient into deeper engagement with and commitment to the smile they want. Now, we can scan the corrected and approved trial smile while it is in their mouth and take photos to send to the lab to help them as we move into the definitive design phase, including working out the occlusion and function.

On day one of the 2019 Annual Pankey Meeting, Dr. Gary Severance and Angela Severance will explore how digital technology continues to expand the opportunities dental professionals have to know their work and to provide better dentistry and ultimately better care.  Preliminary to this presentation, we share this quote with you.

“Be not the first to try the new or the last to leave the old aside.”

This is a statement from Dr. L.D. Pankey in his 1985 interview with the International College of Dentists. As a well-read and literary man, Dr. Pankey was familiar with Alexander Pope, an 18th-century English poet who is best known for his satirical verse and translation of Homer. Because Pope is the second-most frequently quoted writer in The Oxford Dictionary of Quotations (after Shakespeare), it is highly likely Dr. Pankey was inspired by the following famous couplet from Pope’s Essay on Criticism.

Be not the first by whom the new are tried,
Nor yet the last to lay the old aside.

We offer this conjecture, because Pope’s couplet is often used across the professions in the context of evaluating and adapting to technological change.

Pushing Forward Mindfully

Dr. Pankey was on the forefront of the technological and methodological changes that rapidly occurred in dentistry during the 1950s and onward. He was internally driven to be and do his best for his patients and profession. He urged dentists to “know your work” to provide better dentistry and ultimately better care.

Digital technology in dentistry has advanced to address special needs, just as Dr. Pankey advanced in his systems of thought and practice to address special needs. He did this mindfully.

His genius, in concert with those of Dr. Arvin Mann and Dr. Clyde Schuyler, had produced the “P.M.S. Technic.” They had selected the best of the procedures that had been developed by outstanding practitioners in their special fields and assembled them into a system that functioned well for addressing full mouth rehabilitation. They applied their intelligence to “try” new techniques and new materials. They gained knowledge through carefully doing their best for patient, after patient. They then stepped out to share what worked successfully for them. Along the way, Dr. Pankey was mindfully developing his philosophy of practice. He intentionally set out to learn from many great minds, and the composite of principles he lived by and generously shared through his lectures, publications, and ceaseless conversations with other dentists have rippled into our lives today.

Learn, Converse, Lead with Confidence

As a community, you can share your knowledge, immerse in conversation, and lead with confidence. The L.D. Pankey Institute from its beginning was a radical departure from dental school settings of the day. The Institute pioneered a training clinic with overhead cameras and closed-circuit TV, anatomical simulators (which had heretofore only been developed for training in medical schools), and it’s characteristic “hands on” learning process. The Institute’s founding leaders conceived of novel ways to fulfill their goals. But—building the unique learning environment and learning process involved tens of thousands of hours of research, thought, and conversation. A group of “top” minds in dentistry worked together to close the gap between what was known (the science) and what was practiced.  Adaptation to emerging digital technology is no different.

Current digital splint technology requires workarounds to make it a feasible option for clinically exceptional dentistry. In Part 1 of this series, I described the challenges and opportunities of digital dental technology and explained some details of my preferred protocol. Here, I continue this explanation:

An Effective Digital Splints Protocol

In my practice, I mount digitally printed models using a centric relation record and a protrusive record for condylar inclination adjustments. This is just like we have done in the past with stone models. 

The lab technician can transfer this into the computer exactly as we have it in our hands. They do this with the use of a tabletop scanner. It’s important to note that the technician can now register original files for the impressions into position for the best accuracy. The greatest benefit today is the accuracy of these original scans (20-30 microns). 

The design portion comes next in this process. Communication with the technician can be done in real time online. My technician and I have been working with different settings in the software that give me the best chance of skipping the reline procedure patients don’t enjoy. 

I can also evaluate and do final adjustments on the mounted digital models and analog articulator. We have been successful about 80% of the time getting a splint that is rock solid and has an intimate fit on the occlusal surfaces. This is critical for fine-tuning adjustments and fracture resistance. 

If it ends up as an ill-fitting or loose-fitting splint, we can still reline just like we always have because it is a milled PMMA material (as dense as a denture tooth). 

Areas of Improvement for Digital Splints

My opinion at this time on digital splints is mixed:

Pro: We can produce a very high quality PMMA splint that lasts longer and generally gives the patient a better experience.

Con: We still need digital counterparts to essential analog skills that provide for all situations. 

Pro: I believe we will have printed materials that outperform current milled materials in the near future (this will lower the cost to produce splints). 

Con: It is frustrating that we are not getting better support from companies selling us  expensive equipment.

I am proud to be part of the Pankey family because our community encourages the use of technology to enhance good dentistry. 

The new challenge facing us in dentistry is how to incorporate technology into our daily practice. Digital splints specifically are a subject I have been working on for about a year. 

We have had the technology available to mill a splint out of acrylic for a few years now. However, we have not had a good protocol that meets all our needs. 

Digital Splints: Challenges

Some of the problems we face are as follows:

1) Lack of digital articulators that make all of the movements we are able to with semi adjustable articulators, such as crossover transitions. 

2) Absence of centric relation record mountings in software on a computer.

3) No rotational path insertion we can achieve from relines in the mouth. 

4) Few materials that are as good or better than we have now.

I believe we are well on our way to solving these issues. The biggest problem I see is something Dr. Pankey was dealing with many years ago. He talked about how the majority of dentists are indifferent to good comprehensive care dentistry. Therefore, most of the manufacturers of our dental equipment and software are catering to a majority that does not share our own clinical demands. 

These companies give me answers like, “That sounds great doc but who will I be able to sell that to?” I think we have to find workarounds for now that will encourage development in these technologies. Keep in mind, all of the workarounds I will explain are in line with what we teach at the Pankey Institute. 

Digital Splints: Opportunities

We also need systems we can duplicate and teach without compromising the quality of care or experience for patients. I believe there is great potential for higher quality materials and great fitting splints without relines. These two potentials alone can create more value and better experiences for patients.

Today I have a protocol that is some digital and some analog. I intraoral scan our impressions with the TRIOS scanner. I believe most of the scanners on the market today work very well and produce very accurate files that can be printed into models. I also use the TRIOS because it communicates very well with the 3SHAPE units most labs use. 

Now that I have files and models I have to mount them. This is our first problem to solve. I still use an analog facebow or facial analyzer. I mount these models on an articulator like the Denar Mark 330 because this is an articulator model programmed into the 3SHAPE software. 

To be continued…

(Link to Digital Bite Splints: Part 1)

If you’re hesitant to start testing out digital bite splints in your practice, read on to learn why one dentist prefers them for improved efficiency and accuracy.

In Part 1 of my thoughts on this topic, I explained the features I love when working with a lab to create digital bite splints. These bite splints have an incredible fit and allow for customizable retention. Below, I round out the rest of my perspective on why they’re a great option for many dentists.

Occlusal Schemes and Adjusting the Digital Bite Splint Design

I’ve played with different occlusal schemes for digital bite splints. I have utilized:

1. A universal flat plane appliance (upper or lower).

2. An anatomic retainer-type appliance we designed to have a little more detail.

3. One anterior repositioning appliance. It was created for a patient who had some recent trauma. We were trying to keep them from seating all the way for a short period of time.

The idea is that you can design the occlusal scheme any way you want. After we send the scan in and the lab does the initial design, they can send us back screenshots that show us what the design is.

When we look at those screenshots, we can make comments on them. If there’s a lot of change – if we want to shallow the guidance, steepen the guidance, or make it thicker/thinner – we can actually go online live with the lab as they enact the changes. We can watch it happen in real time.

Increasing Efficiency by Reducing Chair, Lab, and Adjustments Time

Digital bite splints are a nice, new way to do things. Personally, I think we’re getting a better result. It’s certainly saving us a ton of time, both in terms of lab time (model work time) and chair time because the patient doesn’t need a lot of reline time. Of course, keeping the nasty acrylic out of the mouth is another significant benefit.

You don’t have to spend a lot of time adjusting. The occlusal adjustments are nominal. If we get the records right with the scan, there is very little in terms of adjustments. In fact, that might be the downfall for some of us because we lose a portion of time for the patient to experience things. Sometimes, I’ll spend more time adjusting than I need to. I ensure the patient is engaged and experiencing what an even bite might feel like relative to their natural occlusion. But, in this case, I wouldn’t have to devote that time if I didn’t need to.

Digital bite splints are also really dense. Breakage is going to be a minor problem. They’re going to hold up and last a long time.

What technology are you considering using in your practice? Please leave your thoughts in the comments!

The future of dentistry is here: digital bite splints. I’ve used bite splint therapy in my practice successfully for years. I was comfortable with my preferred traditional process until I learned I could work more efficiently and more accurately with the latest technology.

There is no reason to fear implementation of a digital workflow in your practice. In this two part series, I’m going to lay out the reasons why I’ve chosen to switch to digital bite splints for goals like protecting teeth and restorations, deprogramming muscles, and treating TMD.

They’re the productivity solution you didn’t realize you needed.

Less Effective Splint Fabrication Methods

My past process for fabricating occlusal splints (bite splints) was traditional. It included making records, alginate impressions, facebow, mounting, and several bite records (protrusive and centric). We would design and fabricate with cold cure acrylic that we would make by hand, then adjust and modify as needed.

That process works great, which is why most dentists use it. Alternately, some dentists send them off to the lab and have the same process done, possibly in a cured acrylic. But the outstanding process we have transitioned to in my practice is a completely digital designed and fabricated bite splint.

Why I Love the Digital Bite Splint Fabrication Process

The first step for a digital bite splint is to do an intraoral scan of the patient’s dentition. Any scanner can be used. We then send the scans to a restorative lab, where a software package specifically made for appliance design is utilized. The lab designs the appliances to our specifications and then they are milled out of a solid block of acrylic. This leads to an amazingly dense result that polishes unbelievably well.

The fit is incredible because we can get such an accurate scan with no distortion. With an impression, we usually have distortion of the alginate, distortion of the stone, or distortion of the acrylic as it sets, which is why we have to reline them. I have only had to reline two CAD/CAM designed and milled splints since we’ve been doing them. These bite splints are easy to adjust and it’s easy to read the dots on them. They just drop right in with almost no adjustment needed.

You can also dial in the retention on the software, so we’ve played with it a little bit to figure out what we want in terms of retention. We’ve got it just about right where they’re not too loose and not too tight. They have a nice snug fit that’s stable and retentive enough, but doesn’t squeeze the teeth too much.

Keep your eye out for Part 2 of this digital bite splint blog series. Next week, I’ll describe how we play with different occlusal schemes and work with the lab on customization in real time.

What advancements in dental technology are you hesitant to implement in your practice and why? We’d love to hear your thoughts in the comments!

(Link to Digital Bite Splints: Part 2)