Caring for a Dental Leaf Gauge 

Lee Ann Brady, DMD 

In the Pankey Essentials courses, we use dental leaf gauges to train dentists in how to feel for the first point of occlusal contact, as a method for occlusal deprogramming, and as a tool for articulating models on an articulator in centric relation. Dental leaf gauges not only assist us in diagnosis and treatment planning but also in enabling our patients to discover the nature of their occlusion as we help them understand how malocclusion can manifest in TMD symptoms, parafunction, tooth damage, and more. 

In our Essentials 1 course, I am sometimes asked how to take care of leaf gauges, so I thought I would share my answer.  

Although they don’t last forever, dental leaf gauges do last a long time and you can autoclave them between uses. When you sterilize them, the leaves become sticky, so I separate them like a hand of cards before putting the gauge in the autoclave bag and separate them again when I take them out of the bag just before going to the mouth. 

Over time, with use, a leaf gauge will start to look a little beat up. I’m looking at one now. The Teflon screw that holds it together has turned color from going through the autoclave. I can see some ink stains from Madame Butterfly silk. It’s at the point where I think it looks too grungy to keep using. Although it might continue functioning for quite some time, I’m going to toss it and use a new one. After all, they are relatively low cost with a high return on investment.  

I’ve never seen a dental leaf gauge break after many trips through the autoclave. I tested cold sterilizing one and discovered the chemistry in the ultrasonic cleaner started to make the leaves brittle and they came out stickier than when autoclaved. So, my preference (and the protocol in my practice) is to bag them and put them through the autoclave. 

Seated Condylar Position

I know even the mention of the words centric relation probably has some readers bristling, as this is a much argued over topic. With that said the research by Lundeen and Gibbs at the University of Florida shows that we do seat our condyles into the fossa during the chewing stroke. This seated condylar position is often used as a reference position to treat patients whether as part of reorganizing their occlusion to alleviate TMD symptoms or for restorative or orthodontic treatments.

Centric Relation & Parafunction

The next question is do people seat their condyles other than during normal function as part of the chewing stroke. I believe the answer is yes. One of the pieces of evidence is the number of patients that I have with wear facets that correspond exactly to their first point of contact with their condyles seated. These same patients do not mark this area with articulating paper in intercuspal position or when following their excursives.

I took the photo with this post in my office. The patient has no other wear facets. #31 has a small, less than .5mm combination sealant/occlusal composite on this tooth. The distal wear facet does not touch in intercuspal position or excursives, but will mark using a leaf gauge to seat the condyles as the first point of contact. This facet marks in both the arc of closure and a power wiggle or abbreviated excursive movement from this first contact. #31 is also split from the gingival margin on the distal over the marginal ridge and right to the margin of the composite. I have seen and restored multiple examples just like this. In my experience when the crown comes back from the lab we will be able to adjust it in without issue, but the patient will report it feels high, or it will become chronically sensitive. The solution will be to either adjust this crown in both intercuspal position and centric relation, or incorporate an equilibration with the restorative care.

My belief is this patient parafunctions in centric relation.

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!

A patient presented to my practice with upper and lower implant hybrids and a long history of fracturing. I myself struggled with needing to replace her dentures regularly up until the point I decided something had to change.

Parafunction, Occlusion, and a Low Smile Line

The patient clearly needed some type of intervention. I looked at mounted models and evaluated her history of extreme parafunction to determine what we should do next. She had been restored in her hybrids with canine guidance and relatively steep anterior guidance. In light of all these factors, I recommended resetting the upper hybrid, opening her vertical, and both shallowing and balancing her occlusion.

These adjustments would hopefully make a big difference in her ability to maintain dentures for longer periods of time. There wasn’t much space to open vertical, but with the little we had we managed to lengthen the time between fractures from months up to once a year. That was a huge achievement on its own, but we knew we could do more. We had also made her an occlusal appliance that went over her upper hybrid. She consistently wore it, which was beneficial.

I shared this story with Wiand of Wiand lab and he was able to give me an important breakthrough. He asked me how high her smile line was and I told him it was very low. He had an idea that made all the difference. We took upper and lower impressions of the hybrids, bite records, facebow, fixture level impression on the upper arch, and gathered shade information.

Wiand lab removed everything from the original bar. Then, I had them send the entire case to Gold Dust Dental Lab. There, they waxed the upper to full contour over the bar. After this, the case was returned to Wiand, where an injection-molded composite was used to fabricate a one-piece upper over the patient’s original bar.

This seems to have finally done it for keeping my patient out of the dental chair. No maintenance has been necessary since. By relying on the advice of my fantastic partners in both dental labs, I was able to help a tricky patient. The lesson here is that patients who are hard on their teeth will be hard on restorations. Similarly, implants aren’t going to magically resolve issues for occlusally high-risk patients.

It’s impossible to go through a dental career without continuously encountering cases that challenge our clinical skills. Nor do I think that would be a good thing, as stagnation and complacency can lead down a slippery path to less optimal dental care. Even an expert has something more to learn.

The case I’m going to discuss here is a perfect example of why collaboration is so important in the dental practice. No matter how much I think I know about the techniques for tricky restorations, I’m always surprised by how much there truly is left to understand or adjust.

It’s important to rely on our peers and lab partners for case breakthroughs and insights. They can see things from a different perspective and give you exactly what you need to provide an exceptional outcome for patients. Even just the act of talking through impressions on a patient’s circumstances can lead to unexpected realizations.

A Case of Fracture, Wear, and Parafunction

This case frustrated me for quite a while before I understood how to solve it. The patient presented with upper and lower implant hybrids from another dentist. An examination revealed the problem she had visited my office for, which was fracturing of the upper right lateral denture tooth.

She was no stranger to the irritation of fractures. She shared with me that she had a long history of wearing down and fracturing her teeth. I was immediately interested in taking the time to understand the cause of this consistent fracturing.

The patient had multiple single unit implants placed for replacement of individual teeth. Her condition then worsened to the point where she had her remaining teeth removed. Implants were used for dentures with locator attachments, but this didn’t last long. The problem persisted and resulted in the need for more implant placements.

Upper and lower hybrids were created, yet still she went through 4-5 replacements of upper lateral and canine denture teeth. After seeing me, she and I had to replace upper anterior denture teeth several times over the course of a year. That meant removing the hybrid and replacing the screws each time.

To be continued …