Diagnostic

• Dental Examination
  Every new patient exam requires a quiet Columbo or Sherlock Holmes voice in the back of the examining doctor’s head: What is really going on here? What’s missing?
• X-rays
  How can the general dentist become aware of this kind of ramus length discrepancy in his patients? An article in The Angle Orthodontist (2006, 76, pp. 388-393) examined whether the use of panoramic x-rays in the dental office might be a reliable way to spot these problems of unequal ramus length. In a review of a study entitled, “Validity of Panoramic Radiographs for Measuring Mandibular Asymmetry,” by Kambylafka, et al, the subject was carefully studied. Without going into great detail here, I will simply state that the authors found that the panoramic x-ray, commonly found in many dental offices, was consistently unreliable for determining ramus length and for comparing the lengths of the two sides. This was due to inherent unreliability of the equipment itself, and frequent operator error.
• Oral Cancer Screening
  Shall I pretend that I know how you do your new patient exam, Doctor? No; but I’d be willing to wager. Recline the dental chair, ask the patient to open, look at existing restorations (hoping you see a defective one that you can diagnose for replacement), check for obvious carious lesions with an explorer, spot check periodontal pocket depths or perhaps even do careful six point probe scores, note obvious recession. Maybe an oral cancer screening. Done. Takes about five minutes.

Preventive

• Teeth Cleaning

Restorative

• Fillings
• Veneers
  What can I say about bond failure under porcelain veneers? That it is aggravating to both patient and dentist? Of course.
• Crowns
  Doctors, do you leave your crowns just out of occlusion? Have another look. – William F. Halligan, DDS – Raymond Carpenter, DDS
• Bridges
• Dental Bonding
  “That’s right. Actually, taking any tooth structure away was too much in your case. There never was a problem with the teeth or the bite as far as I can tell. It was a displaced disc. When the joint is corrected and the pain goes away, I’ll have to see how much tooth structure needs to be added. I think it could mean a couple of crowns and composite bonding.”
• Restorative Dentistry
  My focus for many years was the TMJ. Although imaging the TMJ requires a larger data volume than simply imaging the dentition, I found that the ability to image the joints had implications beyond TMJ therapy. Since the joint, as stated by oral surgeon Mark Piper, is the foundation of occlusion, I think it is mandatory for dentists considering extensive restorative dentistry to evaluate the health and status of the TMJs. After completion of a full-mouth restoration is not the time to discover that the foundation of occlusion is unstable or even pathological.

Endodontics

• Root Canal Treatment
  Abram had had root canal treatment on a lower molar two to three weeks prior to his visit with me. The day after the endodontic procedure, he could not open his mouth. Okay, we’ve all seen that before. Trismus after an inferior alveolar block isn’t that uncommon. Give it a few days, some ibuprofen, maybe ice or heat packs and the patient will be fine. But a few days later, Abram wasn’t ok. He could not open his mouth and he was in tremendous pain.

Periodontics

• Periodontal Surgery
  Mrs. P, a 45 year-old woman with an unremarkable medical history was referred to me for TMJ and occlusal evaluation by her prosthodontist. She had had periodontal surgery involving all the upper teeth the previous year and now was in the process of full mouth reconstruction. Most upper teeth already had final restorations in place, although a few were still in nicely done provisionals.

Prosthodontics

• Dentures
  One look at her profile and the accordion-like folds in her upper and lower lips and I think she’s right. I think she’s over-closed. Joint imaging shows both mandibular condyles well posterior to centric relation. So the lady is correct. I explain that I’ll do an acrylic appliance that will fit over her existing denture and we’ll work with it to provide better comfort and then she’ll need to have one of the dentures re-done.

Implants

• Dental Implants
  And timing of tooth contacts? Forget about it. Marking paper cannot tell you. Is that important? For implant restorations it can be critical. T-scan will tell you the exact timing of every tooth contact.

Oral and Maxillofacial Surgery

• Oral Surgery
• Osseous Surgery
  The main concern of both the patient and her restorative dentist was continued periodontal breakdown, especially involving the first and second molars on the upper right. Periodontal pockets measuring 7 mm or more had been corrected with osseous surgery but now, a few months later, those defects were back and there was talk of possible extraction and implant placement.
• Tooth Extractions

Orthodontics

• Orthodontics
  A young man came to see me yesterday with complaints of pain when chewing, jaw clicking and limited opening. He’d had prior orthodontics 10 years before but was sure that had nothing to do with his current problem.
• Braces
  Dr. Halligan Botox should not be your first line remedy for TMJ pain, despite some claims to the contrary. While I do have a handful of patients who are receiving regular injections of Botox and doing well, I have two primary objections: First, I consider Botox a band aid that simply reduces muscle contraction pain without necessarily discovering the cause. And second, Botox often fails to reduce muscle spasm enough to effectively address the pain. A new patient I saw just yesterday illustrates the point. Renee W. a 40 year-old new mom with complaints of jaw pain, clicking, and pain when chewing said she had suffered years of occasional pain beginning in her teenage years. A few months ago, she stated that she had even locked closed once, although with physical therapy she had been able to open and that severe limited opening had not recurred. She has also had recent Botox injections into the masseter muscles on both sides and this has provided some relief. And so you might logically say, let’s just do Botox every few months for the rest of her life. While that might be appropriate, I’d like to find out why she has the symptoms. What is the cause? Since this is a TMJ focused practice, one of our first steps is to obtain joint images. I was somewhat surprised to see that Renee had textbook perfect joint alignment with excellent disc spacing and condyles well centered in the glenoid fossae. She also had normal range of motion. “So, you’re telling me that these problems have been going on for years. Did you have braces as a youngster?” I asked her. “Yes.” “And your problems started then or shortly after?” “Well, I guess so. I don’t remember exactly when it started, but it has been years. It’s just been getting worse lately.” If her joints look normal, where else should we look? How about occlusion?

General

• Cosmetic Dentistry
  Bill Dickerson, at LVI, has raised the level of esthetic dentistry done in this country and around the world as no other one person has done. Color mapping, the idea that cosmetic dentistry doesn’t just mean making the anteriors white, proper proportions, attention to the potential dark corridor that may remain after your cosmetic restorative dentistry, are all concepts that many dentists have first learned from Bill.
• General Dentistry
  The true closed lock: One of the consequences of a total anterior disc displacement is the true closed lock. This is a relatively rare situation. In fact, during many years in general dentistry, I never saw even one. Now that my practice is primarily focused on TMJ problems, I see these patients fairly often. In fact, I’ve seen and unlocked as many as three in one day.