2

CONTENTS

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3

2

12

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6

IN THE NEWS

© Aurum Ceramic Dental Laboratories LLP (2012).Reproduction of this work in whole or in part by any means whatsoever is strictly prohibited

without the express written consent of Aurum Ceramic Dental Laboratories LLP. All rights reserved.

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Except where specifically stated otherwise, views expressed in this newsletter are the opinions of the individual contributors and do not reflect the views of Aurum Ceramic Dental Laboratories LLP.The information contained herein is not intended to be comprehensive and readers are advised to rely exclusively upon their own skill and judgement and to inquire further before acting on the information.

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In The News —Now Available!Esthetic Restorative Options

Advanced Esthetics —Building The Veneer PracticeThrough Marketing.The Top 10 “Consensus” Approach

Advanced Esthetics —Aurum’s Cristal Veneers®Examples of Clinical Situations

Consultants Corner —3 Easy StepsEmpower Your Team To Educate YourPatients About VeneersSherry Blair

Innovative Implant SolutionsDr. Jim Reid

Denture —AE (Advanced Esthetic) Dentures®

Stunning Esthetics - UnrivalledPrecision - Exceptional FunctionGary Wakelam

Neuromuscular Dentistry —The Difference a Millimeter Can MakeCorrecting a Pathologic Joint Positionusing Mandibular Torque and a FixedOrthosisDr. Michael Adler

3

ADVANCED ESTHETICS

The most recent American Academy ofCosmetic Dentistry State of the CosmeticDentistry Industry survey (conducted inOctober-November 2011 with 1,068respondents) illustrates that many dentistsexpect increasing revenues from cosmeticdentistry through 2012. There can alsobe no question that veneers continue to bea key part of the cosmetic dental practice

with 85% of respondents offering fulland/or no/minimum prep veneers.Further, as reported in the DentalProducts Report 2010 DPR CosmeticSurvey, 57% of clinicians stated thatveneers were one of the most profitablecosmetic services they offer in theirpractice.

Many dental practitioners and teamsask “how do we ensure they are partici-pating in this area of dentistry mosteffectively”? A review of the materials

published over the last few years indi-cates that a wide range of leading

speakers and clinicians havewritten extensively on that

very topic. Certainlythere are differences inthe approaches butthere is also a cer-tain commonalityto the advicepresented. The pur-pose of this articleis to synthesize thatadvice and topresent a general

roadmap of currentmarketing best

practices for expandingyour cosmetic veneerpractice and creatingbeautiful smiles foryour patients.

Marketing theCosmetic VeneerPractice

The fallacy often outlinedis that marketing cosmetic

dentistry is some sort ofhigh-pressure sales activity.

For those successful at buildingtheir cosmetic practices and

sharing their expertise, nothingappears to be further from the

truth. In addition, while many practi-tioners believe that any discussion of“marketing” focuses on an externalactivity, most of the authors lead with a

discussion of what should occur withinthe practice as a starting point. Theirkeys are: set up an integrated marketingsystem, stick to it, allow time for it towork, monitor its success and adjust asrequired. In fact, once outlined, you areprobably doing many of the aspects now– it just requires a new focus andemphasis. While each practitioner mustevaluate what they feel comfortable within their own practice, here are 10 keyareas to consider from the literature tocreate a marketing structure andculture:

1. Have specific targets in termsof patients and treatment optionsMarketing works best when it is specificand targeted. The task is to identify yourtarget audience who want improvedsmiles: those interested inside andoutside of your practice.

The State of the Cosmetic DentistryIndustry survey illustrated the changingdemographic of the cosmetic dentistrypatient. Males continue to increase as apercentage of the total patient mix (now60% female and 40% male) while therehas also been a noticeable increase inthe percentage of younger patients (20years of age or less) from 5% in 2007 to17% in 2011. Certainly, the 31 to 50 yearold age group continues to dominate themarket but the younger segment hasbecome a powerful force. Beyond that,what type of patient do you want? Therewill always be those who will shop for‘best price’ dentistry. Ask yourself, “Isthis the market I wish to capture?” It’snot the number of patients, but ratherhaving the right patients that value whatyou can offer. Focus your attention onways to reach the people who need andwant the dentistry you want to deliver.

2. Plan the effortExpanding your cosmetic dentistryservices should be a seamless, stress-free experience. Developing a compre-hensive written marketing strategy and

Building The Veneer PracticeThrough Marketing.The Top 10 “Consensus” ApproachCompiled by Eric P. Jones & Associates Inc. Marketing Group

implementation plan will help make it so.By determining these aspects step-by-step, you will naturally start to take anorganized, systematic approach to yourmarketing.

3. Take advantage of CEopportunitiesThere are many courses offered in cos-metic dentistry training today coveringveneers, bonding cosmetic restorations,and tooth whitening. Keeping abreast ofthe latest techniques will not only keepyour skills current but also simplify theirimplementation in the practice.

4. Create a strong messageMost patients have no idea what you cando for them. It is important to make surethat your current patients, as well aspotential patients, understand youreducation, experience, and expertise incosmetic dental procedures. At the sametime, make your messages simple, mean-ingful and all about benefits for thepatient. Share your experience when itcomes to smile makeovers. Don’t beafraid to show examples of subtlechanges. The literature states that morepatients can relate to subtle improve-ments than dramatic transformations.Finally, don’t be afraid to ask for action.Offer them “a complimentary, no-obliga-tion assessment to determine if veneersare for you. Call today!”

5. Choose media that reaches yourtarget audiencesFor your marketing efforts to be success-ful, you have to reach the correct people.Sounds simple, but it may be the biggesterror practitioners make according to theliterature. You have to be where targetedcurrent and potential patients are lookingfor information: print ads, websites (withbefore and after photos and testimoni-als), email newsletters and Blasts, blogs,social media (Facebook, Twitter,LinkedIn), direct mail, word of mouth,press releases, speaking engagements.Whichever “mix” of these options youchoose, make sure it reaches your targetaudience in terms of age and gender andmake sure you are comfortable with ityourself. For example, if you are uncom-fortable with public speaking, perhapsyou wish to select other options to start.If you think you would like to do a blog,make sure it is updated regularly or noone will visit it.

One effective way to reach youngerpatients seeking veneers, for example, isvia the internet (website, social media

and email). The AACD found a 25 pointincrease in the use of internet by patientswho are seeking information and bene-fits on cosmetic dentistry.

Don’t forget about regular pressreleases to all the local newspapers,magazines and websites. An on-goingprogram featuring new procedures,offers and “success stories” can havegreat value. The key – make sure it is“new”, interesting and well-written tocut through the clutter, not “advertise-ments”. Higher awareness pays off inmore visits to your website, higher read-er rates on your newsletters, direct mail,etc. and more potential patient inquiries.

6. Don’t forget about InternalMarketingDon’t just look outside, internal market-ing can be a powerful tool “promoting tothe converted” – patients who know you,your staff, your practice and still want amore self-confident smile. Start by regu-larly informing, educating and motivatingeach patient about the new, excitingtechnologies available today.

Further, don’t be afraid to ask forreferrals. Internal marketing relies onreferrals from existing patients and staffto bring in new patients. Why not givepatients something to take with themthat they can pass along to their friendsor family members? Everyone shouldleave your office with promotional, edu-cational, and referral-inducing materials.

7. Put someone in the practice incharge of the effortPractitioners are busy people. Most can-not find the time to properly promote theoffice themselves. Find a well-qualifiedinternal marketing coordinator who canwork on that task specifically, keepingeveryone on track, driving the programand implementing the planned marketingstrategies effectively.

8. Have the tools in place,including a well-prepared teamShow your patients what’s possible visu-ally! Have portfolios of smile makeovercase photos, before and after procedures,and testimonials readily available, bothonline and in print throughout the office.Have brochures, photos/posters andvideos in the office reception area andoperatories. Have demonstration modelsavailable showing aesthetic restorations.Encourage smile previews using eithercomputer imaging or a chairside mock-up. Have a solid smile evaluation formdesigned and administered. Most

important, make sure you have aknowledgeable team with excellent com-munication skills and a sincere belief inyour talents and artistic skills. Empoweryour team to take the initiative whenthey see the opportunity and talk aboutthe incredible restorative and estheticcare you provide. Staff members need tobe educated, excited about what it meansfor your office to offer veneers and will-ing to have conversations with patientsabout cosmetic dentistry.

9. Don’t “sell”, co-diagnose withyour patientsCosmetic dentistry is really “want”based, not necessarily “need” based.That doesn’t mean you need to “sell”.Instead, “inform, educate and motivate”your patients on the veneer options avail-able, in terms they can relate to. Theyneed to understand the rationale behindyour suggested treatment plan and“what’s in it for them”.

Gather input from patients so you caneffectively co-diagnose theircosmetic needs. Don’t assume we knowwhat they want. Take notes – this notonly helps you “listen” but conveys thatyou really care and are interested in theiropinions. Create the comfort level thathelps patients confide the changes theywould like to have done without feelingembarrassed or under duress.If they don’t want change, so be it. Thepressure to take action should comefrom a desire to resolve their perceivedchallenges, not from the dental team. Actas a consultant, offering understandingand solutions.

10. Stick to it. Be consistent forbest long-term resultsMarketing, whether internal or external,has the greatest impact when it isconsistent, well thought out andrepeated …multiple times . . . to getyour patients to remember and think ofyou when they’re ready to move forwardwith veneers. The old saying “out ofsight, out of mind” has never been moreapplicable than when a hit and missmarketing strategy has been employed.

4

Aurum’s Cristal Veneers®Examples of Clinical Situations

Indication 1. Young Patients

Clinical Situation:Patient desired a fuller smile and toclose the spaces in the anterior.

Case Planning Tips:Young patients will likely need to havetheir veneers replaced at some pointlater in their life. The minimal removalof tooth structure and the strength ofthe bond to enamel instead of dentinwill prevent compromises later, andincrease the life of the veneers. Minimalpreparation veneers can be removedwithout difficulty and be replaced manyyears later.

Treatment Plan:Minimal reduction was needed toremove any areas on the teeth thatwere protrusive to the plane of thedesired arch form. These areas werereduced and marked (in green) on theconsultation model.

ADVANCED ESTHETICS

Required reduction.

Indication 2. Lengtheningshort/worn teeth. Improving toothshape

Clinical Situation:Short or worn teeth. Unattractive toothshape.

Treatment Plan:The Consultation model was reducedand marked. The incisal edges wererounded off and the facial surfacesreduced to bring them back into theplane of the desired arch form.

Initial situation.

Initial situation. Lateral view.

Lateral view. Required reduction.

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Reviewed by Dr. Louis Malcmacher

Indication 3. Closing Spaces

Clinical Situation 1:Diastema

Case Planning Tips:If the space is less than 1 mm, the teethwill need to be reduced on the inter-proximal surfaces to allow enoughthickness of porcelain to wrap around inthe contact areas. Moderately preppinginto the interproximals to removeundercuts will also allow the veneers todraw from the dies and preparationsduring lab procedures, during try-inand at final placement.

Treatment Plan:The diastemas between the teeth wereopened up to 1 mm and any undercutswere removed from the interpromimalsurfaces on the consultation model.

Prepped consultation model. Lateral view.

Indication 4. Making aged teethlook youthful

Clinical Situation:Short, aged teeth.

Treatment Plan:To create longer and more youthfulteeth, minimal reduction was done to theincisal edges on the Consultation modelto round off sharp edges. Any bulbousareas on the facial of the teeth werereduced and marked.

Clinical Situation 2:Diastema

Treatment Plan:Consultation model prepped interproxi-mally to open the diastemas to 1 mmand to remove the undercuts.

NOTE: For every 1 mm of space, we sug-gest taking margin in ½ mm subgingivalinterproximal to help create a new papillaand a nice proximal emergence profile.

Initial situation. Required reduction.

Prepped consultation model. Prepped consultation model. Lateral view.

Initial situation. Required reduction.

Prepped consultation model. Lateral view.

Required reduction.Initial situation.

7

Required reduction.

Indication 5. Minor tooth positionimprovements (correcting rotationor overlap)

Clinical Situation:Misaligned Lateral

Treatment Plan:Minimal reduction was completed onthe consultation model and marked.The tooth that was out of alignmentneeded to have significant reductiondone to bring it back into the plane ofthe arch form. Then the bulbous areason the other teeth were modified tobring them back into the plane of thedesired arch form.

NOTE: If teeth are in a lingual aspect,we suggest prepping the tooth fromlingual to allow for proper arch form.This will prevent thick incisal edges.

Indication 6. Shade change /Brighten shade

Clinical Situation:This patient was happy with the overalllength and shape of their teeth butwanted a brighter whiter smile.

Treatment plan:The entire facial surfaces of the teethbeing veneered were reduced between0.5 and 0.8 mm. The preps wererounded into the interproximals. Thisprep will allow enough porcelain,without being too bulky, to block out ormask the undesirable color of thepatients teeth underneath and to ensurethe veneer covers the whole facialsurface into the interproximals so nounderlying color shows at the edges ofthe veneer.

Required reduction.

Initial situation. Incisal view of misaligned lateral.

Side view of misaligned lateral. Side view of misaligned lateral.

Required reduction.

Initial situation.

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Required reduction.

Required reduction.

Required reduction.

Indication 8. Post orthodontictreatment

Clinical Situation 1:Not all post ortho cases are the finalstep to finishing a smile. Veneers orrestoration may be needed to fill in theremaining spaces, modify the naturalshape and length of the teeth and evenout or change the shade of the teeth.

Treatment Plan:Minimal reduction was needed toremove any areas on the teeth that wereprotrusive to the plane of the desiredarch form. These areas were reduced onthe consultation model. This patient hadtetracycline staining so with having thepatient bleach their teeth, porcelainshade selection and the right choice ofshade for the cement, the new desiredshade can be achieved.

Indication 7. Correcting teeth inlingual version

Clinical Situation:Teeth are in lingual version

Treatment Plan:To create a fuller smile, minimalreduction was needed to remove anyareas on the teeth that were protrusiveto the plane of the desired arch form.These areas were reduced and markedon the consultation model.

Clinical Situation 2:Post orthodontic case with relapseresulting in an open anterior bite.

Treatment Plan:Minimal reduction was needed toremove any areas on the teeth that wereprotrusive to the plane of the desiredarch form. The incisal edges wererounded off. These areas were reducedon the consultation model.

After bonding Aurum’s Cristal Veneers®/Restorations,Aurum Ceramic recommends that the patient should protect their new smile

with a nightguard.Contact your closest Aurum Ceramic Dental Laboratories LLP

(see page 2 for contact information) for full details.

Initial situation.

Initial situation. Side view of missing bicuspid.

Side view of missing bicuspid.

Initial situation.

9

CONSULTANTS CORNER

Sherry Blair, Dental Management Consultant

Step One: Educate Your Team.Spend time in making sure that EVERYteam member is aware of the process ofthe veneer procedures. You have to cre-ate value and trust with your team mem-bers first so they can, in turn, pass that onto the patient. Sure your assistants under-stand the process, but do your hygien-ists? Your hygienists spend more timewith your patients than you do. Youradministrator spends a good part of theirday answering questions on the phoneand taking that all important “first phonecall” from that potential veneer patient. Itwould be a lot like me asking you to sell acar but you don’t get to know the make ormodel of that car or for that matter, youdon’t even get to know what bells andwhistles are on it.

Step Two: Have Educational ToolsReadily Available.Be prepared with lots of visual aids. Setup and regularly update your before andafter albums. If you haven’t yet completedenough cases of your own, purchase onethat has already been prepared. Have

several before models also on hand fordemonstration, along with wax ups ofthose same models. Don’t forget toinstruct staff to allow patients to hold andstudy the models themselves as this hasbeen proven to be a powerful asset inunderstanding the treatment proposedand eventual plan acceptance.

Create a smile evaluation form (seeFigure 1 as a general example) to beused in addition to the patients photos.By filling this out, patients become moreaware of all aspects of the appearance oftheir teeth and how they feel about theirsmile themselves. Having to writesomething down always leads to morethoughtful responses than justverbalizing.

You will need several sets of each ofthese items: at least one for each of thehygiene operatories and one for the con-sult rooms. Remember your hygienisthas a limited time to discuss this treat-ment with a patient. If they have to get upand leave the room to go get these tools,it will compromise the outcome, asopposed to having it at their fingertips.

3 Easy Steps

An additional before and after photoalbum for your reception area would alsobe beneficial. A hint for the receptionroom album - instead of placing it on atable in the room, place it in one of themost popular chairs in the room. Yourreceptionist can tell you which chair mostpatients will go to if there is no one elseseated in the reception room. By placingthe album in the chair, non-verbally weare telling the patients that this book is apopular item because clearly it has beenlooked at before. Otherwise, it would justbe on the table.

Also make sure that each teammember is familiar with the cases in thebefore and after album and can use themaccording to the individual patients situa-tion. If I have a 60 year old female in thechair that wants longer, whiter teeth I’mnot going to turn to a photo of a 40 yearold male where we have straightenedtheir teeth with veneers. I will find asimilar case and go to that photo.

However, of all the tools you haveavailable, nothing is as powerful as yourcamera. An actual visual representation ofthe patients before and after situation isone of the most powerful ways ofobtaining interest and then acceptance.Whether it is a new patient or an existingpatient in for their continuing care visit,commit to taking a photo of everypatient’s smile. Then, for those that haveexpressed concerns about their smile,consider showing them quickly on-screenhow their smile might be improved. Ofcourse, before considering this, you haveto make sure your schedule allows timeto make this happen.

Step Three: Use The CorrectVerbiage.Keep it casual, never pushy. No one likesto be sold to. Have your hygienist lettheir patients know that “we are updatingour records and would love for you to fillout this form (smile evaluation) so wecan make it a permanent part of yourfile.” When looking at the patients smilephotos with them, never ask them “Is

Empower Your Team To EducateYour Patients About Veneers

10

11

As Director of the Dynamic Team Program at theLas Vegas Institute, Sherry Blair shares her morethan 37 years of experience managing each andevery system within the dental practice. Sherryhas combined her acquired knowledge and per-sonal experience to create an inspired, effectiveand motivated curriculum that refines the systemssurrounding the patient’s total experience in adental practice. Sherry’s extensive exposure tomost forms of practice management and dentalsystems, as well as her strong focus on patientsatisfaction, make her uniquely qualified toenhance the effects of any dental practice.

there anything that you want to changeabout your smile?” Remember we smilewith our entire face; we smile with ourlips, our eyes, our cheeks. A patient mayhave had lots of compliments on theirsmile because their eyes beam whenthey smile, or they have a very cutedimple when they smile. Instead wewant to ask them in a casual way “Idon’t suppose there’s anything aboutthe appearance of your teeth you wouldwant to improve on?”

If an existing patient that is in fortheir continuing care visit shows somekind of interest, have your hygienistreschedule that patient for a consultwith you to “see if they are a candidatefor the procedure.” I have seen us makethe mistake of trying to “close” on a15-20 thousand dollar case when the

patient was just in to “get their teethcleaned.” Besides wreaking thehygienist schedule, we may appeardesperate and/or pushy to our patients.

Ask the patients lots of questions toco-diagnose with them what their newsmile will look like to them. Their wordscreate pictures in their minds. Thosepictures create emotions. People buy onemotions. “You said you want themlonger.....how much longer?” “Youmentioned whiter.....are you wantingHollywood white or a more naturalwhite?” Tell other patients emotionalstories about how it changed their lives.Emotions are the key when it comes toelective procedures.

In ConclusionIn addition to the three easy steps out-

lined in this article, you have to makesure that you WALK THE TALK. I haveyet to see a Doctor and/or Team mem-ber that have had veneers, if indicated,done, and not become a walking, talkingbillboard in the practice.

Don’t get discouraged. Statisticsshow us that it will take approximatelytwenty “No’s” to get to one “yes.” It’seasy, after 15 “no’s” to simply think thatthis isn’t working; no one really wantsthis and give up. It is the practice thatcan accept rejection the best that is themost successful practice. It is abouttruly adopting the saying of “some will,some won’t, next.”

Most of all make sure that whateveryou choose to say, say it with passion.Know and believe that you can trulychange a patient’s life and that passionwill shine through.

When I see a picture of myself, the first thing I notice about my smile is:

Something I often notice about other smiles I consider attractive is:

*PLEASE MARK AN “X” BY THE STATEMENTS BELOWTHATYOU AGREEWITH.

I wish the color of my teeth were whiter.

I wish I had a broader smile.

I think some of my teeth are too small.

I think some of my teeth are too large.

I wish my teeth were straighter.

I think my gums show too much when I smile.

I think my smile shows too much space between some of my teeth.

Because I am not totally pleased with my smile, I sometimes hesitate to smile.

I have often wished I could change some of the features of my smile.

I feel as though I don’t really know all of the options available for enhancingmy smile.

Concerns over what the end result might look like, have been a factor in mynot having aesthetic dentistry in my own mouth.

Concerns over fees have prevented me from taking advantage of some of theavailable options to enhance my smile.

SMILE ANALYSIS

Figure 1.

Plan to Attend:

“Helping the TeamUnderstand theBusiness of Dentistry”with Sherry Blair

Spokane, WA, October 26, 2012

For more information or courses inyour area, check out “Register for CE”on our homepage at www.aurumgroup.comor contact the Aurum Ceramic DentalLaboratories Continuing EducationDepartment at 1-800-363-3989or email: ce@aurumgroup.com.

Dates subject to change. Please call toconfirm course dates.

12

INNOVATIVE IMPLANT SOLUTIONS

This male patient had always had many and varied dentalproblems and been undergoing periodontic treatment for years.Finally, he decided he wanted to resolve his dental issues. Aftersome discussion, we arrived at the conclusion that an implant-based solution was the best one for him.

In early 2010, we commenced treatment by extracting hisremaining dentition and placing both upper and lower denturesfor the healing phase. Eight 13 mm Nobel Biocare implants wereplaced in July 2010, four in the upper arch and four in lowerarch. Another healing period followed per routine with severalrelines of his previously placed dentures. In November 2010, wetook impressions for his initial fixed prosthesis starting withrestoring his upper arch. We took a bite, impressions and had afixed prosthesis for the lower arch fabricated in early 2011. Then,the adventure began!

Our original laboratory created the prostheses using some sortof milled Titanium bar, affixed denture acrylic and artificial teethand called it a “fixed appliance”. The lower prosthesis broke inJuly, which was only the beginning of a series of problems. It wasalmost an endless loop. If we re-fabricated the bar with a suffi-cient thickness of acrylic to stand-up to the stresses of mastication,the patient lost all phonetics, esthetics and was unable to clean

underneath it properly. If we resolved those issues, the teethwould fall off and the bar fractured. Finally, the incumbent labgave up and we went to the Implant Team at Aurum Ceramicfor a solution.

Our first step was to determine his comfortable jaw positionthrough a full K-7 Myobite work-up. We then applied the LasVegas Institute’s Golden Proportion to get a proper relationshipalong with occlusion and esthetics. With this confirmed, finalimpressions were taken and the process of crafting the finalrestorations began.

The Aurum Ceramic Implant Team crafted several wax-upsfor try-ins and acceptance by the patient and then developed aninnovative approach to resolving our difficulties. We decided toproceed with Aurum Ceramic’s exclusive EASI-ACCES™ system,where upper and lower understructures are combined withporcelain-to-metal overstructures in each arch. With the Easi-ACCES™ technique, the screw access holes on the overstructuresare placed on the lingual rather than the occlusal, in effecthiding them from view.

Just as important, both the under- and overstructures are fullyand easily recoverable in the event of any difficulty. For example,if there was a fracture in the porcelain at any time in the future,

Upper understructures in position. Note the screw holes on the lingual ready to retain the overstructures.

One upper overstructure highlighting lingual screw access. Other upper overstructure being placed. Note male and female precisionattachments.

A very happy patient!

that section can now be unscrewed and sent to the laboratory forquick repair. Finally, the design of the Easi-ACCES™ frame-works results in vastly improved access regarding hygiene.

Three PFM-type framework understructures were created intotal. The lower arch understructure was a fully cast horseshoewith an UCLA-type attachment that screwed directly to theimplants. For the upper arch, two understructures were created,each affixed with screw-retained abutments. These were all usedto anchor porcelain-to-metal overstructures. For the lower arch afull horseshoe overstructure was also employed anchored by fourscrews. For the upper arch, two separate overstructures were

fabricated, connected with a precision attachment. This combina-tion gave the support, and flexibility, needed (i.e., while not beingentirely rigid) across the Sagittal plane.

Everything fit beautifully and provided a terrific final result –both aesthetically and avoiding all the problems that had plaguedour previous solution. The patient was extremely happy with thelook and feel of his new restorations (as you can see in his Afterphotograph) – particularly with how easy they were for him tomaintain.

Dr. Jim Reid

Restorations fabricated by Aurum Ceramic.

Dr. Jim Reid graduated fromthe University of Albertawith a D.D.S. in 1978. Aftergraduation, he set up inprivate in Calgary, AB andhas continued for 34 years

(the last 30 in his current

location) with an emphasis ongeneral and implant dentistry. Dr.Reid has attended a range of courseson laser dentistry and has completedthe Core 1 curriculum at the LasVegas Institute for Advanced DentalStudies. He is now planning to attend

Core 3 as his current clinical interestsare focused more on posteriordentistry at this point. Dr. Reid is amember of the CDA, ADA, and theCalgary & District Dental Society.

Final result – upper arch. Final result – lower arch.

Final upper and lower restorations in position.

13

AE (Advanced Esthetic)Dentures®

Gary Wakelam, RDT, CDT

Stunning Esthetics - Unrivalled Precision -Exceptional Function

Available Free of Charge, this checklistsaves you time and keeps your cases onschedule by ensuring all necessarycomponents are prepared and shippedto the laboratory.

Denture Expertise you can rely onOur AE Advanced Esthetic Team® havethe knowledge, proven technicalabilities and creativity to deliverunsurpassed Advanced Esthetic resultson every AE Denture – every time. Formore information, call your closestAurum Ceramic laboratory TOLL FREE.

Every practice has patients that areasking for a superior, premium denture.Now you can bring your denture artistryto life while offering your edentulouspatients dramatic improvements indenture esthetics and function withAE (Advanced Esthetic) Dentures®,exclusively from Aurum Ceramic DentalLaboratories!

Where form follows function andscience meets art!By blending the latest in technique andtechnology, our AE Denture Team® ofcosmetic denture specialists haveperfected unique techniques that createpicture-perfect smiles, smiles that morethan satisfy your most demandingcosmetic patient. Each AE (AdvancedEsthetic) Denture® takes into accountthe subtle variations of natural dentitionand contours of natural tissue thatmakes each patient unique.

Crafted with care and qualityBlending the latest in technique andtechnology, every AE (AdvancedEsthetic) Denture® provides the opti-mum bite position and is fabricated withSR-Ivocap® or Eclipse® and your choiceof top quality artificial teeth. Only ourAE (Advanced Esthetic) Denture®

offers:• Special mounting & bite positioning

based on H.I.P. plane on semiadjustable Stratos articulator.

• Set-ups in lingualized occlusion forbetter stability and function.

At Aurum Ceramic, our attention todetail and personalized patient-dentist-technician communication systemsensure that even the most challengingcase proceeds accurately and smoothly.

Our exclusive AE (AdvancedEsthetic) Dentures® Checklist Pad is aprime example of how we are able tostreamline the AE Denture Process.

(See Page 2 for locationand contact information)

Restore Your Patients’Youthful Look WithAE (Advanced Esthetic)Dentures®

• Dramatic improvement in denturefunction.

• Remarkably natural, estheticallypleasing.

• Incorporates subtle variations ofnatural dentition and contours ofnatural tissue that make each patientunique.

• Provides optimum bite position.

• Fabricated with SR-Ivocap®orEclipse®and your choice of topquality artificial teeth.

• Exclusively from Aurum Ceramic.

DENTURE

14

NEUROMUSCULAR DENTISTRY

euromuscular dentists are oftencriticized as dentists who justopen the bite but what happens

when we open the bite and maybe thingsdon’t go exactly as planned? The patientmay still be suffering from symptoms,restorative treatment gets delayed andthe patient begins losing confidence inthe dentist. What happens when thepatient is your father!

My father, and long-time patient, hada severe traumatic painful episode in hisleft TMJ while eating an Italian hamsandwich on a French baguette. I haveto be specific because my father takeshis food very seriously. I say thisbecause even after he experienced acrunching gravely pain in his left joint,

The Difference a MillimeterCan MakeCorrecting a Pathologic Joint Positionusing Mandibular Torque and a Fixed Orthosis

he was able to finish the sandwich.My father was well aware of my neu-

romuscular dental practice. He calledfrom New York and told me he could nolonger bring his teeth together normally.The pain was more dull than sharp. Heexperienced pain while chewing on bothsides or tearing with his front teeth. Thepain was strongest when first clampingdown on food, but then lessened withsubsequent chewing. He kept getting adull ache when he pushed the jaw on theright side of the face to the left. Uponopening and closing his mouth, he couldhear bone rubbing against bone in theleft TMJ. When he opened his mouth aswide as possible he sometimes felt theleft TMJ catch, occasionally the right

also. There was no pain or discomfort inthe right joint. Opening the mouth wideto bite on food produced an ache, butdoing the same maneuver without fooddid not. Directly after the initial event,there was a change in his bite. Uponwaking in the morning he could closehis teeth on the right side so that theymet. However, soon after he would notbe able to close down on the right sidewithout difficulty, he would only hit onthe left. So chewing food on the rightside became a problem. (Figure 1 and 2)

We used the Myotronics K-7 to evalu-ate his function. EMG of resting musclegroups showed elevated levels in histemporal and cervical group. After 60minutes, there was an improvement of

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Figure 1. Figure 2.

Dr. Michael Adler

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Figure 5 - Extensive degenerative changes now in left joint. Figure 6 - Condyle directly against the eminence.

Figure 4 - Left condyle riding against articular eminence.Figure 3 - Boney degeneration and joint compression.

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resting EMG’s but the left cervicalgroup remained elevated. His clenchscores remained low both with andwithout cotton rolls between his teeth.There was excess freeway space andunstable occlusion along with dyskine-sia. He had difficulty opening and wasable to force himself to open to approxi-mately 37 mm. The Sonography showedcrepitus on both sides. The existinganterior vertical dimension was 16 mmwhen measured from tooth numbereight to twenty five. There was an ante-rior/posterior discrepancy of 4.0 mm inthe saggital plane and 2.0 mm in thefrontal plane in scan 4/5. The Myobitewas taken at 18.8 mm to construct aremovable orthotic. The scans are anintegral part of the diagnosis and treat-ment to discuss the scans in detailwould require a lot more time.

The I-CAT scan without the orthosisshows boney degeneration and jointcompression. There is space betweenthe condyle and the eminence, althoughthere was still pain. (Figure 3) It wouldhave been helpful to have the I-CAT inan open position especially when weconsider his Sonography with late crepi-tus. That might have revealed greaterdysfunction in his left TMJ as we willsoon see. You can really begin to

second guess yourself and be self criticalwhen things are not going as planned.

When I placed my father in a neuro-muscular removable orthotic there waslittle improvement. In fact, the painmight have been slightly worse in theleft TMJ although he was now onMyo-trajectory. The Myo-centric bite hadbrought him down and forward, but hisI-CAT scan revealed a disturbing fact.(Figure 4) The left condyle was ridingagainst the articular eminence in theMyo-bite position. We tensed and tensedand tensed in fact we tensed so much…once for about five hours while I wastreating other patients in my office andcompletely forgot about him. Could wefind a bite position that would relieve hispain within his joint? My father neverreally complained of muscular painthroughout this experience.

Repeated evaluations with the K-7system showed that the orthotic was onMyo-trajectory. This created a dilemma;every Myo-bite taken left him in a boneto bone situation on the left side. Weoriginally began with a removableorthotic to attempt to alleviate his condi-tion. However, his bite relationship with-out the orthotic did not leave him with afunctional occlusion to eat with. Wemade the decision to change to a fixed

orthotic with a new Myo-bite. (Figure 5)As you can see there were extensivedegenerative changes now in the leftjoint as time went on. (Figure 6) We cansee the condyle directly against theeminence and the formation of jointmice or calcified bodies and bone frag-ments floating within the joint space. Hisopening became even more limited.

It was getting very hard to believethat things were going to get better.Was surgery going to be the onlyoption? Was my father going to have tolive with pain and suffering? He wastraveling from New York to Coloradoonce a month for treatment. Theproblem had really hit home and thepressure was building.

When we looked at his originalradiograph, things almost looked betterbefore treatment. Without the orthotic,he was in constant pain with no bite. Hewas in pain with the orthotic on Myo-centric trajectory but at least he couldchew. Could his issues be related to theorthogonal axis of his cervical neck?Repeated tens of spinal accessory nerveXI showed no improvement or change inthe Myo-trajectory, it was always thesame. My father had no history of painor cervical neck symptoms. I began tothink about his dental history, the

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Figure 7. Figure 8.

Figure 9. Figure 10 - Left condyle moved dramatically, joint mice gone.

chronic break down of the left posteriorteeth and subsequent crowning oneafter the other over the years.

The intra-oral signs were there longbefore his symptoms. (Figures 7 and 8)There was a loss of vertical dimension,occlusal wear of anterior teeth andabfractions, tori, lingual version of lowerbicuspids, fractured teeth and deep bite.My father explained that he had chewedice for years. As a teenager, when hiswisdom teeth were removed, he beganchewing almost exclusively on the leftside after pain on the right. He contin-ued this habit throughout his life untilrestored in a neuromuscular bite. Thefact that we had crowned almost theentire left side as these teeth fracturedover the years was interesting. Then hebegan fracturing the right side as well. Ibegan placing crowns on the right side,one tooth after another. In August 2006,my father began complaining of pain intooth number 31. There was a distalfracture extending through the pulpalfloor to the mesial. I placed a crown onnumber 31 and sent him home to NY.Shortly after the pain worsened and anendodontist determined the tooth wasfractured through the root system. Heremoved the tooth and placed a bonegraft. We placed an implant in the

extraction site in August 2007. Now myfather had lost his posterior stop on theright side, setting him up for catastroph-ic failure. One month after the implantwas placed with a healing abutment attissue height, my father ate his infa-mous ham sandwich. The years of grad-ual loss of posterior vertical dimension,first on one side then the other, hadfinally taken their toll. As medical pro-fessionals we are told to “do no harm”.Well, a whole lot of harm was done hereover the years… one crown at a time.

Perhaps the years of pathologic mus-cle function combined with the degener-ation within his joints was preventingme from finding the ideal functionalposition. The atrophy of the system wasnot allowing TENS to correct the X/Yplane. If the torque created by theocclusal breakdown had led to this prob-lem then maybe torquing the occlusionthe opposite way might correct him. Ithought let’s give it a try. The destruc-tion of his teeth on one side of hismouth and then the other had createdtorque in his mandible. He was tensingat home with a BNS-40; so I called himand had him TENS with two Popsiclesticks or tongue depressors tapedtogether and held between his teeth.First placed on one side and then the

other to see if there was any difference.He also adjusted the balance of theTENS to one side or the other to see if itwould release the condyle on the leftside. He noticed no difference.

On his next trip, I decided to alter hisorthotic. It seemed to make sense thatwe needed to torque the left side torotate the condyle away from the bone.If I torqued the right side it would seemto jam the condyle back into the emi-nence. We began with one hour ofTENS. Then I began adding to the leftside. I first re-measured my anterior andposterior vertical dimensions, becausethey had to be exact. I confirmed themeasurements three times before start-ing. I added a small amount of compos-ite resin to tooth number 19 since itwould give me the most secure stop. Ilightly pulsed him once with the TENSunit into the material and cured it. Ichecked my measurements and I hadindeed increased the vertical on the leftside by one millimeter. I then addedresin to the second molar and the bicus-pids, increased the gain, pulsed himhard into the material and then lightcured it. He was now hitting right on thetips of all cusps on the left posterior witha one millimeter increase. There wasnow no contact on the right side. I

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cranked the tens unit up until he washitting hard and then altered the bal-ance so the right side was only pulsing.I tensed him for another hour or so in aZero Gravity chair. I then sat him up,balanced the pulse of the Myomonitorand checked his bite. (Figure 9) He wasnow hitting on both sides … Harder onthe left but some on the right. I decidedto leave him like that and let his ownmuscle function do the work. That nighthe noticed no difference in the pain hewas experiencing while eating. I waslucky I could monitor the patient thisway. I was able to watch every bite. He

seemed like he was opening a little widerwhile eating. My father grabbed a rawcarrot and crunched through it withoutcomplaining. I was afraid he was going tofracture the orthotic. The next day wetensed for one hour and began checkingthe bite. He was now hitting on bothsides. With a slight adjustment to theright side and adding a little resin to thecusp tips of his right first bicuspid, hewas now hitting evenly again.

My father returned to NY. I calledhim regularly for a week and asked howhe was doing. My father could not tellme if he was improving so I stoppedcalling. Two weeks later my fatherphoned… he realized he was completelyout of pain. He has been out of pain eversince.

Three months later he flew out andwe started with new I-CAT scans. Theresults were amazing. (Figure 10) Hisleft condyle had moved dramatically, thejoint mice were gone. The K-7 scansshowed great improvement in function.He was now able to open wide enough torestore him. He was on Myotrajectory.My father has had no recurrence of painsince adjusting his orthotic by correct-ing the torque. (Figure 11) We thenrestored to the new position using theLVI protocol for full mouth reconstruc-tion. (Figure 12) My father remains painfree. What a difference one millimetercan make!

Dr. Michael Adler graduated from GeorgetownUniversity Dental School in 1987. He went intoPublic Service on a Navajo Reservation aftergraduation, later going into private practice inBoulder, CO. Initially focusing on General andCosmetic Dentistry, Dr. Adler has seen hispractice evolve strongly towards Neuromusculartreatment over the past few years. He has takenextensive Post Graduate Training at the LasVegas Institute for Advanced Dental Studiesincluding CORE I – VII; Occlusion I - III; Anteriorand Posterior Aesthetics; Bonding; K-7 Training;CARP; TMD: Developmental Diagnosis;Neuromuscular Orthodontics I - III; PediatricOrthodontics; the Physiologic Approach toTreating OSA and Full Mouth Reconstruction.

Dr. Adler has also completed the neuromus-cular orthodontics curriculum and attained hisLVI Fellowship in 2010. He is a Fellow of theICCMO and a member of the AACD, IACA, ADAand the Colorado Dental Association.

Full face before.

Full face after.