Opening the VDO is Simple and Fast: Gives You Prosthetic Convenience and is Good For Your Patients!

You're listening to the Phil Klein Dental Podcast. So we've all seen patients with a worn dentition, which has essentially reduced their vertical dimension of occlusion. Is this a big deal? Well, every patient is different, but in many cases, a reduced VDO can cause problems. It affects the patient's occlusal equilibrium, i.e. their envelope of motion. It can cause TMJ issues and even sleep disorders. And with a reduced VDO, when it comes to preparing a single crown, we're often challenged with little occlusal clearance, forcing us to over-reduce the crown prep. This, of course, leads to a prosthesis that has compromised retention. So how can we explain this all to our patient, and what is the simplest way to open up the VDO prior to doing your restorative dentistry? To tell us all about it is our guest, Dr. Stephanie Vondrak. Dr. Vondrak owns and operates a private practice in Elkhorn, Nebraska. She has pursued over 600 hours of postdoctorate education in TMD, occlusion, orthodontics, and sleep apnea, including the Panky Institute, the Schuster Center, and the American Academy of Craniofacial Pain. We'll be introducing Dr. Vondrak in a moment, but first, we all know that to achieve healthy, beautiful smiles, we sometimes need to align the teeth. and to do so, aligner therapy is a great option. So why not set your practice apart with 3M Clarity Aligners Flex? Designed for comfort, Clarity Aligners Flex feature a thin, flexible design, yet they deliver excellent force persistence over a two-week period. Plus, they resist scratching and stains, and they're backed by a dedicated clinician team providing support every step of the way. With a variety of affordable case type options, single or dual arch, Clarity Aligners Flex offer a great value to your patients and practice. To learn more, visit 3m.com slash clarity dash aligners dash flex. Dr. Vondrak, thanks for joining us on our show. Well, thank you for having me. I appreciate it. I'm glad we talked on a previous podcast because I got to learn about some of the things you're doing in your office clinically with vertical dimension of occlusion. So you were very nice to agree to come back and do a podcast episode dedicated to this because I think it's really interesting the way you use composites and so forth to build up the occlusion. So to begin this podcast, what does it mean to you when you say open the vertical dimension of occlusion? Great question. So when I'm looking at a patient where we all see a lot of patients that have wear on their teeth, and so when you see that the anatomy of the teeth has really been worn down, then you know they've lost vertical dimension. So what I mean by that is the height between the nose and the chin. the top jaw to the bottom jaw is reduced because the anatomy, the teeth is gone. And I think from a clinical setting, just to think about it from that perspective, if they have a lot of wear, they've lost vertical dimension. They've lost some of that height. So tell us what happens to the whole envelope of function and occlusion when a patient starts losing VDL, mainly from, I assume, missing teeth and or a worn dentition. What actually is going on and why is it so important that we address this from getting worse and even correcting it? Yeah, I mean, I would say that when you lose the anatomy of the teeth, it's kind of the wild wild west is the best way to put it. Because now when you go to chew, that normal envelope of function you mentioned is now off the table. The easier way to think about it is when you go to chew, they're going to have to be more of a horizontal side to side motion to be able to break the teeth down. The tongue isn't going to function the same way as effectively either in this setting. When you have the anatomy of the teeth, we're meant to have that vertical, that envelope of function that's more of like an oval shape where the cusp tips actually break down the food. So we'll see things that happen to the patient like gastric reflux gets worse because they're swallowing bigger boluses of food when they don't have any anatomy on their teeth because you don't have the tips to break the food down. So there's all sorts of a series of things that can happen when you lose that anatomy. And I would say it becomes less class one and almost class two sometimes, because when the teeth get flat, the jaw tends to kind of slide back a little bit. So when it does that, that again, it impacts the airway. And there's all sorts of a series of effects that happen when the teeth get really flat. Does that make sense? Yeah. But the idea is to take some of the forces off of the molars on the lateral movement, right? Because they are going to put more stress on the... The whole idea is just to balance the forces. So when you lose that dimension, yes, I just don't think you can say that it's always the molars or always the incisors because it's going to depend upon, you know, I look at a lot of supplementary x-rays. It's going to depend upon, you know, their actual skeletal makeup as to exactly where those forces are. The easier way to think about it is they're just not balanced. And when they're not balanced, they tend to be destructive. The other thing that I find is that when you lose that anatomy and the forces aren't balanced, the patients tend to clench and grind more. I feel like there's a lot of proprioception that happens in the mouth. And when the brain can't sense exactly where to bite, if the teeth are flat, you can bite all over the place. You get all sorts of negative feedback when you're swallowing and chewing and doing all of these things. So when I talk to patients about the vertical dimension of occlusion, I'm trying to help them understand that, hey, this lost anatomy is your body telling us that this system is not functioning properly. When I go to do your dental work. I want to put it in the best functioning system possible because then it's going to last the longest. And so when I talk to them in that way, I think they can kind of follow because a patient's never going to know what you mean if you say vertical dimension of occlusion. But if you say, hey, this is what a tooth should look like. This is what the anatomy of your tooth does look like. And that's the result of movements that aren't helping you actually break down your food and digest it properly. Then patients are more interested and will, hey, I'd rather have that fixed. before you do my crown or before you fix another tooth, then afterwards. Right. So there are some huge benefits of using composite on the tips of those cusps to open the VDO. So tell us about that. Absolutely. So, you know, when you think about lost VDO, and I think about it in dental school, you might think full mouth rehab right off the bat, because that's kind of how they would talk about it with kind of the prosthodontic way in dental school. Well, not all of these patients need a full mouth rehab, especially if their posterior teeth um don't have restorations on them or just have like occlusals you have all this nice enamel around there so i use composite i build up the cusp tips i generally do the lower arch if possible um and i'll do all of the posteriors in one visit so i'll isolate like the right side for example i'll add on my buckle cusp tips because we obviously want the buckle to be contacting the opposing um central fossa so i'll build up those buckle cusp tips on the right and get that even. And then when I go to add to the left, it's really easy because as my composite is still soft, I can have them tap a couple of times and their upper teeth will help mold exactly where I need it to be. So I can usually add to all the posteriors in an hour. It's pretty easy. They're not numb. You just make sure it's isolated. Your bond to enamel is so much stronger than your bond to dentin. So when you're doing all of those teeth at one time, it's rare that I have several of them come off. What I always tell the patient is that if you're going to chip one of these, it's going to happen in the first two weeks. And I would say maybe 50% of the patients chip like one spot in the first two weeks. So I usually have them back after two weeks. And I don't usually add back to that chip. I usually polish it out a little. And I tell the patient their body equilibrated themselves a little bit right there. And that's it. And I've done this for over 10 years. I've never redone all of the composites before. They've all stayed on. There's been times where I've had to add to them, especially if the patient doesn't wear their nighttime appliance. But I've never had it where they just all broke off at once or something like that. It's a really effective treatment. And what's the typical amount of material that you're putting on? in millimeters are we talking about two millimeters on average two to three um yeah that's probably about right i mean honestly um I don't take a specific measurement. I love looking at the anatomy of a tooth and trying to get a tooth back to its biological tooth form. So a lot of it, I think there's a little bit of an art to it when you're looking at how you want to rebuild that. You have to look at the opposing arch also because if the maxillary teeth are worn really, really bad, I've also had cases where I've then added to the lingual cusp tips of the upper posteriors also if I need to increase it a little bit more or if they have like an airway issue. But probably... two millimeters is probably about right. Yeah, and I was going to ask you that. How do you determine whether to build up the buckle cusps of the lower or the lingual cusps of the upper? Do you plan this out prior to the visit with models? I do. I photograph everything. everything. My front office will laugh. I'll be like, Dr. Vondrak, you took 200 pictures today. I'm like, well. So I photograph everything that I do. And then I'm always double checking things. And so I can do so much diagnosis from having good photos and your x-rays. And I do all my treatment planning from my desk versus chair side. So before I go back there, I've already looked at it and I know exactly where I'm going to add. Depending on the patient, sometimes I might think I need to add to bottom and top. But sometimes I might just start with the bottom. I like the bottom if possible, unless there's a whole bunch of crowns that you can't get both sides even because it's just easier access. And if you think about when you do a full mouth rehab, the way I was taught or I always do it is I always do the lower first because you get your foundation to build your upper. So it's just nice to start with the lower and know you have that nice level occlusal plane. So even if you're just doing a single crown, by doing this kind of VDO, rejuvenation, if you want to call it, or opening the VDO, it's really prosthetic convenience, right? Because the amount of reduction that you'll need to do on your tooth preparation will be minimized by opening up the VDO. A hundred percent. That is exactly right. We'll be getting back to Dr. Vondrak in a moment. 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So think about a case that comes into a general dental practice all the time. They need a crown on tooth number 15. You're looking at tooth number 15 and there's hardly any clinical crown height to that tooth. And you're thinking, oh my gosh, when I go to do this crown, what's going to retain it? You know, you can only drop the margin so far. Well, if you look and the rest of the teeth are worn and you open the VDO with composite, now you hardly have to even take off the occlusal. You just need a margin all the way around. Then you maintain that tooth and you maintain more enamel. It works very well. And you're less likely to have that crown come off than you are if you hadn't opened the vertical, if that makes sense. Yeah, totally. I think it's a tremendous service that you do for the patient prior to doing that crown. So we've discussed the benefits of opening the VDO for restorative purposes just now. But in speaking with you, it's also obvious that you have found additional health-centered benefits for these patients. So let's talk about the health-centered benefits by increasing or opening the VDO. Sure. So as you know from when we've talked before, I'm a health -centered dentist, which means I help every patient become as healthy as they wish to be. Given that being my philosophy, I'm always talking to patients about all sorts of things with their overall health. So I've already mentioned that when teeth are worn and there's a loss of vertical, a lot of times you can get where you can't break down food as well. So then you can have digestion issues and you can see acid erosion in the mouth because of acid reflux. You can also see it with airway issues. And so if you think about it, if the jaw is more collapsed and we all know when we go to sleep at night, our chin kind of falls back and the muscles relax. If you lose that vertical, you're more likely to impact the airway when you're sleeping than if that vertical is maintained. So I'm not saying that you can cure sleep apnea or anything like this by doing this composite work, but it will help you and help your patient to help stabilize where they swallow and where they bite in an increased vertical to prevent some of those airway issues. Or I don't know if you can say totally prevent, but it helps them not be as bad. if that makes sense. So that's definitely another benefit. There's aesthetic benefits and then definitely digestion and how they break down food. So how do you handle that as far as building up those cusps? What kind of treatment? Is that just considered a one surface composite? So that's going to, you know, it's going to be up to the individual practitioner, but I can tell you how I do it. This isn't something where if I, you could charge per tooth, but I, like I said, I can do all of these eight teeth in one hour and I want the patient to accept. Let's say I'm doing that single crown on 15. My life is a heck of a lot easier and it's a heck of a lot better for the patient if they do this first. So if I charge, really it's an occlusal buckle kind of composite. If I charge a two surface composite for all those teeth, that can be a pretty big number. So I generally pick one fee and I'll say, I'm going to charge you. x for my hour of time and i don't submit that to insurance it's a fee for service procedure i tell the patient here's what it would look like if i used your insurance and i had to charge full fee and here's here's how what i'm going to do for you because this is something that i can provide a lot of insurance companies aren't going to necessarily reimburse if they don't see decay even though this is a huge service for the patient so i have kind of negated that problem by just having one fee for all of those teeth for that time that I see them and their one follow-up. So Dr. Vondrak, I know we have a podcast coming up on TMJ disorders, but for this one, tell us how opening the VDO has an effect on patients that might very well have TMJ problems. Oh, I'm so glad you asked that because I didn't mention that earlier. So when you think about losing that space between the top jaw and the bottom jaw and that anatomy is lost, and I told you the jaw slides back a lot. Well, if the jaw slides back, then the condyle, that part of our mandible, slides back. So there's more pressure on the disc. So I do see, that's why with clenching and grinding and these forces, we start seeing TMJ symptoms, popping and clicking of the jaw joint, some of these problems arise. So when we build the anatomy and open that BDO with composite, we've now lessened the pressure on those joints and the pressure on that disc. So that's also another positive effect for the patient. So there's no doubt, Dr. Vondrak, that your efforts to learn more through really high-end... high-end continuing education programs that you've participated in over the years have really helped you grasp the whole concept of VDO and many of the other niches that you're involved with in dentistry that tie directly into composites for that matter. What recommendations would you have for our listeners to learn more about VDO and other areas of dentistry that's so related to the occlusion? That's a great question. We are so lucky in dentistry because there are so many great mentors out there, great teachers out there to be able to take courses. I've taken from a variety of places. You know, I've been to the Panky Institute. I've been to the Dawson Center. I've done a lot of these, you know, bigger continuing education classes. I've done some great courses on composite through the American Academy of Cosmetic Dentistry as well. So I think that if you go online and you start looking, Kois, Spear, all of them, there's a lot of really, really good ideas out there on how to do it. You're going to be able to come across things that resonate with you that will help you be able to then take these services and translate into your practice. Excellent discussion, Dr. Vondrak. I'm very happy to have you on the show. I think you made some excellent points today about VDO and how to approach the patient and how to use composite and why it's important to keep an eye on the VDO and especially prior to restorative work. Great stuff. Thank you so much for your contributions. And we look forward to having you on future podcasts and webinars soon. Thank you so much. If you're enjoying this podcast, please leave a review or follow us on your favorite podcast platform. It's a great way to support our program and spread the word to others. Thanks so much for listening. See you in the next episode.