No, Bite on Your BACK Teeth – Part One

Teeth Photos
Don’t get mad at the patient; in this case he can’t bite on his back teeth. (The images are not underexposed; his teeth are really this dark). This is the result of long term snore guard appliance wear.

He has been in a snore appliance every night for five years. He noticed some changes in his bite almost immediately but was always able to get back on his back teeth. It slowly changed until he can no longer touch his back teeth.

This is a well-documented sequela of snore guard or forward-positioning appliances and should always be discussed with the patient before making the appliance. Most sleep physicians suggest a sleep study for patients whose snoring is a problem, and if therapy is indicated will prescribe CPAP before a snore guard.

If CPAP fails or the patient can’t tolerate the mask, then a forward-positioning appliance may be indicated. The consequences, of course, should always be discussed prior to beginning treatment.

Stay tuned for my next blog when we talk about treating this condition.

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Being One with the Moment

2010 Olympic TorchesBy now I’m sure you’ve heard about the technical glitch that occurred during the opening ceremonies of the Olympics here in Vancouver. After eight years of meticulous preparation and countless rehearsals, the show proceeded flawlessly for two hours—until the climactic moment when, with the world watching, one of the four hydraulic pillars that would form the centerpiece for the Olympic flame failed to emerge from the floor.

Of course nobody ever wants to encounter critical failures at critical times, but the truth is, it’s how you respond to sudden challenges like this that define you. The producers, directors, technical crew, and performers during that moment must have felt extreme pressure, but because they had been preparing and practicing for so long, they were calm enough and confident enough to quickly review the facts and improvise a solution. Call it street smarts, call it court sense—everyone involved was attuned to the situation and intensely in the moment. Everyone was wearing earpieces, so they were advised of the problem and the revised plan, and they responded so professionally that many people in attendance were unaware that a problem had occurred.

We all face moments like this (though usually not on a world stage). A patient you thought for sure was going to accept your treatment advice surprises you with objections and questions. Unexpected complications arise in a routine procedure. These are your defining moments, and you should treasure them for the opportunity they give you to challenge yourself and to grow. Most great breakthroughs—and most reputations—are built on obstacles overcome. If everything went smoothly and easily all the time, there would be no notable achievements. And the more advanced your clinical mastery becomes, the deeper you go with your case preparation, and the more confident you can be when a defining moment rises up to test you.

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Centric Relation Bite Record Tips

As a follow-up to the Protrusive Record Technique blog, Lee shares tips and techniques for obtaining stable bite registrations.

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Weird Stuff I Get to See

This bridge has been in place for about 20 years. The patient is beginning a comprehensive course of treatment and we are getting ready for ortho so I cut off the old bridge to reprovisionalize and see how the tissue responds. We just want to be sure that we can move teeth with healthy tissue.

The bridge popped off easily and I noted that there was no cement in the canine abutment in the prosthesis. It fit very poorly, thus the cause of the inflammation. I just didn’t expect the inflammation to look like this!

This tissue had grown under the crown and had completely covered the preparation.  It was difficult to laser it away and then provisionalize. It did, however, result in a much healthier situation!

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A Gold-Medal Homecoming

I’m back in my old hometown of Vancouver for the Olympics and what a phenomenal experience it is to come back to a place I know so well and see it so transformed. Everything I love about the city and its people—the deeply-rooted multiculturalism, the welcoming attitude, even the dazzling physical setting—are amplified and infused with new energy. Just walking the old familiar streets, now teeming with people and alive with an air of celebration, is electrifying.

It’s all part of the transcendent power of the Olympics. Say what you want about the over-commercialization and politicizing of the Olympic Games—they do bring the world together in a way few events can. The competitors parading into the opening ceremonies, proudly bearing their countries’ colors; the anticipation of records to be broken; the years of preparation coming down to one moment—often one fraction of a second; the ecstatic cheers for a winning performance; the camaraderie even among opposing athletes—to be here in the midst of it all is to really feel what it means to be inspired.

I’ll be making a few blog posts from here during the Olympics, but for now I’ll leave you with this thought: Why not bring some of that energizing Olympic spirit to the practice with you every day? Of course you can’t replicate the pageantry and the lavish ceremonies on the scale of the Olympics. But you can embrace the ideals of an Olympic competitor. You can give everything you’ve got to prepare yourself for success. You can step into your operatory the way a skier approaches a starting gate—with intense focus and awareness for the stakes involved. You can make each day a day of celebration and expectation. As any world-class athlete will tell you, the physical execution is only part of it—a large part of success comes from choosing the right mental attitude.

It is the attitude of champions.

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Protrusive Record Technique

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Treatment Planning Roadblock

If you come to a point in treatment planning where you can’t make a decision about what to do, it’s usually because you’re not supposed to make it. If there are two (or more) ways to accomplish the outcome and you find yourself going back and forth, take it to the person who should make the decision – the patient.

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Perimo-what?

PerimolysisSee the little cupped out area in the mesiobuccal cusp of the molar? Until very recently, I didn’t know why it was there. As I write this I am sitting in the Treating the Worn Dentition seminar and Frank just talked about the cause.

We frequently see these cupped out areas on the lower posterior teeth, even in young people. They occur as a result of a process called perimolysis.

Perimolysis occurs when acid comes in contact with a tooth surface, etching the enamel and thereby making it brittle. In many cases the acid comes from stomach acid, especially in young people who can have acid reflux at a young age, and which later disappears as they get to their teens.

When the enamel is etched and then rubbed, as in tooth brushing, the brittle etched enamel is crushed and rubbed away by the brush or by rubbing against another tooth. That rubbing results in progressive loss of tooth structure and a resultant “pothole” in the most susceptible area of the tooth.

This is just one of hundreds of take home for Monday concepts that I hear in this seminar. I love listening to it over and over again because I always learn something.

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What Do I Do with This?

Have you ever looked into a patient’s mouth and been confronted with dentition that invoked awe, puzzlement, confusion, intimidation, perhaps even despair? You’re not alone. Frank introduces treatment planning the “what do I do with this?” case series.

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A Reminder About the Process

I was speaking to a patient recently and I asked if she wanted to do something about her “gummy smile.”

“What gummy smile?” she responded, and then asked for a mirror.

Oops.

I’m constantly reminded that there is a wide variation in beauty and that every individual gets to decide what that is for them. By the way – the patient had not come in asking about esthetics and I had failed to engage her in a process to see what I saw. Had I done that (which IS what we teach here at Spear Education), her response would undoubtedly have been different. In fact, had I engaged her in the process, I might have discovered that her smile and her grandmother’s were nearly identical (she REALLY loved her grandmother), and not even asked the question.

It’s about them, not about me.

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