Louis Malcmacher DDS MAGD Printer Friendly Version

Perfect Imperfections
by Dr. Louis Malcmacher. DDS MAGD

In past years, in our minds we have separated cosmetic dentistry from the traditional dental treatment. But now, in essence it is all one and the same. We see this routinely in every general dental practice. Let’s take a brief look at the history of cosmetic dentistry based on this thought. 

At one time, cosmetic dentistry was thought to be just for those “elite” dentists who would only make a “perfect” smile for patients. There was, and still is, discussion in dentistry whether or not this should become a specialty unto its own. Associations and organizations were created solely dedicated to cosmetic dentistry, and these were important in communicating to the dental industry that cosmetic dentistry was here to stay. There are still so many courses that are dedicated to the perfect smile, and this certainly helps elevate cosmetic dentistry to the position that it is in today.

But where were patients in all of this? In the past, cosmetic dentistry was not only for elite dentists, but also it turns out for elite patients. How many patients can really afford the “best dentistry,” when “best dentistry” is defined by bright white teeth in a perfectly straight smile? What about cosmetic dentistry for the general dentist who has everyday patients? That has certainly been the key to integrating cosmetic dentistry into mainstream dentistry. Products like Cristal Veneers by Aurum Ceramics with their no/minimal preparation approach appeals greatly to dentists and patients alike. Are the cosmetic results perfect? The bigger question really should be, do they need to be perfect? Many patients are happy with certain aspects of their smile and only want the teeth made white with minimal change in size and shape. Many patients are more than pleased with results when the teeth inclination and the midline may not have been perfect.

The question that I want you to think about is this - are perfectly straight and white teeth really esthetic, either by themselves or at all? One of the first lessons we as dentists learned in the dental school denture lab is this: when setting the teeth in wax for a try-in, don’t make the teeth look too straight, because perfect looking teeth look unnatural and fake. Now here we are doing exactly that in patient’s mouths in the name of cosmetic dentistry. 

Now that we are entering the realm of total facial esthetics with the advent of Botox and dermal fillers in dentistry, we have taken a fresh look at facial esthetics - which integrates the teeth with all the soft tissues around them, like lips and cheeks. We have finally stopped disassociating the teeth from the rest of the face. In other words, we need to stop being so teeth-centered and if we really are going to go ahead and give our patients great looking smiles, we need to consider all of the soft tissue around the mouth and indeed the entire face. What we really know about total facial esthetics is that people’s faces are not perfect and in fact, some of the most famous beautiful people in the world have faces that are characterized by slight imperfections.

Now, if we go ahead and put perfect teeth into an imperfect face, is that really esthetic? The answer is obviously no, perfect teeth many times look very fake because unless the patient has a perfect face, these can stand out abnormally. They may look great in the retracted photographs that dentists adore, but in a full face photograph - which is the view that really matters to people other than dentists - these perfect teeth may not fit in at all. 

Most esthetic smiles and faces that you see and admire every day fall under the term I like to use called perfect imperfections. In other words, rarely does a perfect smile fit into a person’s face. It’s the little characterizations such as a slight rotation, a slight inclination of a tooth, a little bit of gradual shading and the characterization of the surrounding soft tissue depending upon the patient’s facial features which will look much more esthetic than trying to force perfect teeth into a imperfect face. This is what total facial esthetics has really come to teach us.  You need to look far beyond the teeth to get patients a great looking smile. We need to view the full face of the patient in order to give us direction as to what the teeth should look like and what is truly esthetic for each individual patient.         

Dr. Louis Malcmacher is a practicing general dentist in Bay Village, Ohio, an internationally known lecturer, dental consultant and author, and is President of the American Academy of Facial Esthetics. Interested in knowing more about how to truly enjoy dentistry? Click here.

Interested in having Dr. Malcmacher speak to your dental society or study club? Click here. To reach Dr. Malcmacher, email him at DrMalcmacher@thedentistsnetwork.net or call 1.800.952.0521.

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Dr. Ryan Swain Printer Friendly Version

The “Sweet Spot” For Dentists And Patients
by Ryan Swain, DMD

Early in my career I grasped on to a certain mindset that I have since learned was erroneous. I thought that I needed to convince each patient to proceed with the dental work that I believe they needed. I viewed case presentation as though I was the attorney and the patient was the jury; my job was to win the case. I believed that if I won the case and convinced the patient, they would proceed with the treatment that I was recommending for them.

How many times have you presented a treatment plan and hoped that you showed the right photos and used the right verbal skills in order to get the patient to “say yes?” Some of us even create fancy PowerPoint presentations with spinning letters and flying photographs... all in an attempt to get the patient to “say yes” to our recommendations.

I had an epiphany a few years ago after I took my car to a local mechanic. I usually despise taking my car to a mechanic because it is hard for me to know if the recommendations that he gives me are trustworthy. I’m sure many of you feel the same way. You take your car in and they tell you things like, “You need a new transmission” or “Your brakes are shot and you need completely new brakes.” In my experience, most mechanics aren’t like dentists. They don’t take out a small camera and take pictures of the existing problems with the car. They don’t put together clever PowerPoint presentations to convince us that the problems really do exist. Most mechanics tell us what we “need” and stare blankly at us until we say something… but they are expecting us to submit to their “automotive authority” and proceed with their recommendations.

When I took my car to a local mechanic a few years ago, I had a different experience that really resonated with me. After diagnosing my car problems, this particular mechanic, whom I had never worked with before, came into the waiting room and told me what he thought was wrong with my car and explained his recommendations. But, he didn’t stare blankly at me after this. He said something bold and clear that has stuck with me.

He said, “Dr. Swain, I’m assuming that you want your car to run properly and function safely but you want to spend as little money as possible to accomplish those goals. Is that correct?” In awe I responded, “Yes, that’s right.” He continued, “Dr. Swain, you have my word that I will only make recommendations that will allow you to obtain your goals and I will always make my recommendations based on the knowledge that you want to spend your money wisely.” I was blown away by his simple and effective approach. I proceeded with his recommendations and he quickly earned my trust as the months went by. We reached “the sweet spot” where he could be honest with me and I could trust him as the automotive expert.

Through this experience I realized that my patients want the same thing from me… the ability to trust me as the expert. With the PowerPoint presentations and photos that I had been using to “convince” patients to say yes, I had essentially been trying to educate patients to the point where they became “the expert” and would agree that my recommendations were appropriate. Even with great patient education, patients still aren’t able to make an expert decision about whether or not they need an implant or a root canal. They come to us because we are the experts. When I take my car to the mechanic, I don’t want to be responsible for making the decisions because I don’t have enough knowledge of automobiles to make good decisions. I want to trust my mechanic and our patients want to trust us.

I’ve discovered that the best way to implement this idea is to be very candid with patients, just like the mechanic had been open and candid with me. We should tell patients that they can trust us because we have their best interests (and their wallets) in mind when we make our treatment recommendations. Some patients will never meet us in “the sweet spot” but many will. It is our responsibility to communicate to patients that they should trust us, and then it is our duty to make ethical and accurate recommendations.

This approach has saved me and my team a tremendous amount of time and it reduces stress for everyone - including the patient. We still understand the importance of patient education, but we use it as a tool to inform them about the treatment they will be receiving rather than as a tool to convince them to “say yes.” Ultimately, I realized that patients want to put their trust in the hands of a reliable expert and I needed to own that role. If you can grasp the attitude shift that I’m recommending, I hope that you too are able to move into “the sweet spot” with your patients.

Dr. Ryan Swain is a graduate of the University of Florida College of Dentistry. He practices in Rochester, NY and focuses on Short Term Ortho and other conservative cosmetic dental procedures. He is president and chief clinical instructor for Six Month Smiles. Dr. Swain is a pioneer in the field of Short Term Ortho and constantly on the forefront of GP orthodontics. He has trained dentists internationally and prides himself on de-mystifying orthodontics for GPs. 

Dr. Swain can be reached at Drswain@thedentistsnetwork.net

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Chris J. Lampert, DMD Printer Friendly Version

The Art of Patency
by Chris J. Lampert, D.M.D

The most important objective of endodontic instrumentation is the removal of all pulp tissue, debris, and bacteria from the root canal system. The only way to achieve this fundamental endodontic principle is to establish patency from the canal orifice to the canal terminus. This principal is true regardless of your philosophy on where the obturation material should end. If you cannot achieve patency (finding the main portal of exit), then you cannot clean the entire canal space. There are no exceptions.

Reaching patency allows other endodontic objectives to be achieved. Gauging the apex, creating a continuous tapered canal shape, proper cone fitting, and using an electronic apex locator for length determination all require a patent canal. The two objectives of this article are to explain why negotiation files fail to reach the canal terminus and to describe solutions to the most common problems associated with patency.

There are two main reasons that file advancement stops during canal negotiation. Recognizing the cause will allow you to employ the proper solution. A file either meets binding resistance along its length, called longitudinal binding, or an impediment at its tip. An impediment at the file tip can either be a ledge, a curve, a ledge and a curve, a blockage, compacted pulp tissue, or a bifurcation. The best way to determine why a file will not advance is to use the “smaller file test.” If you started with a size 10 file (which is the preferred negotiating file) and the 10 file no longer advances, decrease in file size to an 08 file. If the 08 file advances further than the 10 file, then the file was binding along its length and not at its tip. If the 08 file will not advance any further than the 10 file, then both files are being impeded at the tip.

Overcoming Longitudinal Binding
The solution to longitudinal binding is to open up the canal by using larger files to increase the canal diameter. This is accomplished by using two or three larger files alternating with a 10 file. For example, use a 15 file to where it goes, then a 10 file, then a 20 file to where it goes, then a 10 file, then a 25 file to where it goes, then a 10 file. This method is continued until the 10 file is patent or until the 10 file reaches a tip impediment. This file sequence increases the canal diameter and allows the 10 file to advance further with each alternating use. Using a 10 file in between the larger files helps prevent ledge formation and clears debris. Use caution not to force the larger files because this will lead to a ledge. In that case, you will have two things working against you.

A second option for overcoming longitudinal binding is to use a small tip sized .04 tapered rotary instrument to enlarge the coronal part of the canal. I prefer to use a 20/04 rotary instrument inserted until it meets resistance. This is much faster than using the hand file method described above.

Overcoming A Tip Impediment
This is probably the most important clinical skill needed to consistently negotiate canals to their terminus. To negotiate a tip impediment, a 10 file with a curved tip (the last 1-2 mm) is used in a circumferential “tip walking” motion until the tip slips past the impediment. Circumferential “tip walking” involves the repeated motion of inserting the file until it stops, slightly withdrawing the file, rotating a few degrees, and reinserting the file. At some point the file tip will align with the canal opening and slip past the impediment. This process could take many attempts and require curving the file tip multiple times, but it is successful at overcoming a tip impediment.

Once patency is established, great care must be taken to maintain it. This is accomplished by passing a patency file (10 file) out the apex by .5 to 1.0 mm.  Using a patency file after every 2-3 instruments will ensure the canal path is clear of debris and the canal terminus is patent. Achieving patency on every canal takes patience and persistence, but it will greatly improve the success of your endodontic treatment.

Chris J. Lampert, DMD maintains a fulltime Endodontic practice in Portland, Oregon, and is involved with research, testing, and development of new endodontic products. Dr. Lampert received his DMD from Oregon Health and Sciences University and his Endodontic post-graduate degree from Boston University. 

Dr. Lampert can be reached at drlampert@thedentistsnetwork.net

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