Embrace Progress The Standard of Care (Records, Anyone?) by Dan Grob, DDS, MS, editorial director, Orthotown magazine

I am often amused at the number of writers, speakers and practitioners proclaiming that the new standard of care is having a CBCT machine.

I will agree, in many instances the ability to visualize radiographic images in 3-D helps to direct care in the correct location and apply the force to a predictable direction. Often after a panoramic, I take a cone beam for clarification of issues that arise in the 2-D X-ray. Why not on everyone, you ask? Probably habit, convenience and inability to smoothly link into my office software system. But, I'm getting there.

In the desire to offer the latest in treatment, we're gradually implementing and adapting to these new diagnostic methods. But what about the old ones? I am a bit miffed by the lack of comprehensive treatment planning in the dental field. Remember, we are supposed to be soliciting (begging) general practitioners for patients when they—after complete treatment planning—determine that we could be of service to their patients (or practice). I, like so many of you, am believing this so less and less every year.

Prompted by some second opinions, I'd like to opine about what I've seen lately in a couple of patients (or, in the case of most of these patients, what I've not seen). The most egregious was a comprehensive cosmetic patient in his 60s desiring a great smile even though he had worn and defective full crowns, a cross bite and resultant lateral shift. He was offered clear aligner therapy and after a couple of years was no different than when he started, as shown by the mounted diagnostic casts made at his initial exam.

This is in addition to a patient I met at the gym who had every one of her upper teeth recently veneered or crowned, all four lower molars with full coverage and lower anterior crowding confined to the 10 anterior teeth. After inquiring about her lower crowding, she was offered, once again, clear-aligner therapy.

Two general dentists recently approached me after treating themselves with clear-aligner therapy. Both had interceptive contacts, shifting bites and lack of proper tip, torque and interincisal angle before my visit. Both were evaluated, had modified treatment plans and were done or in treatment. These examples are not intended to trash aligner therapy.

Sleep apnea patients with posterior open bites are becoming the latest challenge—at least in my arena. I have about six patients who, after receiving sleep appliances (paid for by insurance, of course), had bites so bad that they were willing to put the CPAP machine back on and get their teeth aligned.

All the instances above were initiated by the general dentist without proper documentation such as cephalometric X-rays, photos or diagnostic casts. To be clear, I have an interest in articulation and the effects on dentition and restorative care. As a prosthodontist in my first life, I was intrigued and compelled to understand the intricacies of hinge axis, side shift, guidance and the like. But even without a gnathological upbringing, when in the field of dentistry was the goal of restoring to a reproducible, predictable point lost—or worse yet, when was the idea of registering some sort of beginning point tossed out?

I know that the articulation fanatics will claim that all patients must be restored to an anatomically registered hinge axis. I am also aware of the group of dentists who subscribe to muscular positions being the goal. Quite honestly, there is room for both!

However, in the situations mentioned, no position was recorded.

Seems to me that if we're undertaking complete mouth rehabilitation (which we are doing), there should be a record of where we started to help us decide where we will end.

I was trained in the 1980s when Roth and Rickets were at it, comparing and arguing in favor of one method or another. I was part of a practice mounting absolutely every patient on semi-adjustable articulators and continued that practice until recently.

I don't believe it is necessary to perform this procedure on every patient. However, for a tremendous learning experience—and to visualize what's going on with our mechanics—we must evaluate what may have led to the current malocclusion. To prepare for aligning the teeth, there is nothing better than taking the time to dust off the articulator and face bow and see how the teeth are meshing in a 3-D manner.

So here are some thoughts for articulation evaluation in the same day start world in which we live and practice:

• After the initial evaluation and proposed treatment plan, make a habit of gathering casts for mounting and display on adults with worn dentition, restorations, or other evidence of shifting bites.
• Take impressions of children with severe cross bites, protrusions or transpositions.
• Offer to have them return for discussion if they have not committed to starting at the evaluation appointment.
• If they are headed for a second or third opinion, this delay of the start gives you one more shot at collecting thoughts and visual aids if necessary.
• At the band-and-bond appointment, we share with the patient the results of the cast evaluation. Often, a shift, slight or major Class II tendency is discovered, which may on occasion necessitate a modification to the treatment plan.

How do you store them, you ask? We photograph them and create an image template in our management program. Often, I even send images with aligner prescriptions for technicians to visualize what is going on. Patients are given their casts after we are finished.

With all the technological advancements in our profession, I have yet to see anything that replaces the articulator mounting of diagnostic casts. Much like the manual paper and pencil checklists that I was made fun of using a couple of years ago, the ease of collection and the ability to delegate and manipulate face bow-mounted casts are essential tools in my practice tool box.