Dr. Lee Ann Brady

Dr. Lee Ann Brady

Dr. Lee Ann Brady lives in Phoenix, Arizona with her husband Kelly and three children Sarah, Jenna and Kyle. She owns Desert Sun Smiles Dental Care, a private restorative practice in Glendale, Arizona. Outside of her private practice, Dr. Brady is the Director of Education for The Pankey Institute, recognized for hands-on education programs focused on occlusion and restorative dentistry. She is the founder and lead curator of Restorative Nation, a supportive learning community for dentists.

picture of teeth with arrows pointing to the Interdental Papilla

Interdental Papilla: Esthetic Considerations 

By: Lee Ann Brady DMDTopic originally appeared on Pankey.org: Dr. Brady allowed permission for igniteDDS to share…

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lady holding retainers with questions about post orthodontic care

Post-Orthodontic Questions for Retainers 

By: Lee Ann Brady DMDTopic originally appeared on Pankey.org: Dr. Brady allowed permission for igniteDDS to share…

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predictable veneers

Predictable Veneers: The Art of Shrink Wrap Provisionals

By: Lee Ann Brady DMDTopic originally appeared on Pankey.org: Dr. Brady allowed permission for igniteDDS to share…

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broken provisionals

Cracking the Case: Understanding Broken Provisionals

By: Lee Ann Brady DMDTopic originally appeared on Pankey.org: Dr. Brady allowed permission for igniteDDS to share…

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A Dentist's Perspective on Retainer Wear Time

A Dentist’s Perspective on Retainer Wear Time

By: Lee Ann Brady DMDTopic Originally Appeared on PankeyGram.org Patients tend to want to spend as little…

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centric relation

Do Patients Parafunction In Centric Relation?

By: Lee Ann Brady DMDArticle Originally Appeared on PankeyGram.org Seated Condylar Position I know even the mention…

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My Favorite Occlusal Deprogrammers

My Favorite Occlusal Deprogrammers

By: Lee Ann Brady DMDTopic Originally Appeared on PankeyGram.org Deprogramming of the lateral pterygoid muscle is generally done…

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when your occlusal clearance disappears

When Your Occlusal Clearance Disappears

By: Lee Ann Brady DMDTopic Originally Appeared on PankeyGram.org It can be an incredibly frustrating clinical situation…

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By: Lee Ann Brady DMD I ask the question “Is wear normal?” at almost every lecture I do on occlusion. Usually the response is a small number of mumbled replies. A good follow up question is “How many eighty-five-year-old patients have you seen with mamelons?” I hope you are thinking not many, if any at all. So, yes, tooth wear of some amount is normal. A combination of attrition, erosion and abrasion cause all of us to lose enamel over a lifetime. Is the wear advancing at a pathological rate? The more important question is when is the wear age-appropriate and when is it advancing at a pathologic rate? We don’t have the data to know how many millimeters of enamel loss is appropriate at every decade of life. In order to help with this answer in my office, I play a mental game. With the picture of the patient’s current wear in mind and a knowledge of their age, I imagine if the wear continues at the same rate at what age their teeth will be in jeopardy or need restorative dentistry to be saved. I then reveal this estimate to the patient. You can document wear over time in three ways. I believe it is important that I help my patients understand the process and the options for protecting their teeth. To quantify the amount of wear that is happening, we take a measurement from the CEJ to the incisal edge of several teeth with wear. We take the measurement on the mid-facial and record it on the patient’s perio chart. At subsequent appointments we can now repeat these measurements and have clear data that the process is continuing. Another great way to document tooth wear is with photography. With repeat photographs, we and the patient can see the change over time. Today with digital impressions and software we can scan the arch, and then compare scans months or years later and get a precise measurement of the change. What is causing the wear? I believe that some wear is normal. I base this on the fact that I have very few if any patients who are in their seventies or eighties and still have mamelons on their incisors. Wear is a concern when the amount of tooth structure being lost is out pacing the patient’s age. I wrote about determining when wear leaves the physiologic category and becomes something we need to discuss with patients. Both attrition and erosion can cause severe tooth wear, but they pose different long-term risks. Once we have a sense of the cause of tooth wear, we can partner with the patient to treat the damage and manage the progression. These are the guidelines for discerning attrition from erosion. Attrition is the loss of tooth structure caused when the patient rubs two tooth surfaces together. You will observe: • Matching facets on upper and lower teeth • Facets on tooth surfaces that occlude • Enamel and dentin worn evenly Erosion is caused by the presence of acid from issues like GERD and eating disorders. You will observe: • Facets that may or may not match on upper and lower teeth • Facets on tooth surfaces that are not in occlusion • Dentin cupped out and wearing faster than enamel • Tooth structure wearing around restorations that remain unchanged Note that attrition can be seen in addition to erosion, often giving us a false sense of how much the patient truly parafunctions, as the etched tooth structure wears away more easily. Occlusal Therapy Why Occlusal Appliance Therapy Is My First Step Prior to Ortho, Equilibration, or Restorative Occlusal changes on an appliance are easy and reversible. An appliance can immediately reduce elevator muscle activity and give the patient relief. The patient also experiences what changes to their tooth contacts could provide for them long term. We can test the changes that would be made by ortho, equilibration, and/or restorative. Our goals are to stabilize the joint anatomy and reduce the activity of the elevator muscles because those muscles are what overload the joints and teeth. We also want to slow down the rate of damage to the dentition and move that rate back to a more age-appropriate pace. We also may need to reorganize a patient’s occlusion to manage occlusal forces to ensure restorations that last. Removing Posterior Contacts Does Not Work for Every Patient Over my years of clinical practice, I have found that changing the occlusion does reduce functional risk for most patients. But we all have patients with perfect occlusion who present with TMD symptoms. We have some patients who continue to parafunction after we move them into immediate posterior disclusion. Studies show that proprioception causes the elevator muscles to engage in only 80 to 85% of the population. This means that when the brain receives the signal that teeth are touching, the brain elevates the masseter muscles in 80 to 85% of people. Tooth contact is the trigger. Because this proprioception does not occur for 15 to 20% of the population, it is not the universal trigger for excessive loading. Over my years in clinical practice, I have learned there is nothing I can do that is 100% dependable to stop a patient from para-functioning. Some of my patients continue to excessively load after posterior contacts are removed. Their functional risk does not diminish. If we cannot reduce elevator force and redistribute force enough on an occlusal appliance to eliminate or at least relieve TMD symptoms, then occlusal therapy via ortho, equilibration, or restorative will not satisfactorily help the patient. We will need to turn to other forms of therapy. Other modalities I use are BOTOX to deactivate muscles, massage therapy, and physical therapy. There are also systemic medications, cold lasers, and TENS therapy we can use to reduce the activity of the muscles or reduce inflammation in the muscles and joints. Sometimes one modality will alleviate symptoms for a while and when symptoms return, we can try it again or try another modality. An Exercise to Identify the Patients Who May Not Benefit from Occlusal Therapy You can do what I call a poor man’s EMG on yourself by placing your hands on your masseter muscles. Put your back teeth together, clench and release, clench and release, clench and release to see how much masseter activity you have. Then move your teeth into protrusive edge to edge and try to clench a little bit, making sure your back teeth do not touch. If you now have a posterior tooth touching in the edge-to-edge position, then put a pencil or pen between your front teeth to separate your back teeth. With no back teeth touching and contact on the centrals, try to clench and release two or three times while feeling your masseters. Most of you will find your masseters do not move or move a lot less when no back teeth are touching. Some of you, even with your back teeth separated, can still clench in protrusive and can still increase the muscle activity almost the same amount as when your back teeth touch. I do this exercise with my patients, but when they move into protrusive, I put a bite stop over their front teeth or have them bite on a Lucia jig we have lined for their bite registration. If you do this test with your patients, you can use an EMG or feel the muscle activity with your hands. If the patient can still generate almost the same force or the same force with their back teeth separated, you have identified one of the around 15% of people who might not benefit significantly from occlusal therapy. You’ve also identified someone who might not do well on an anterior-only appliance because, if they can generate that same force on just two teeth, they are at risk for those teeth becoming sore and moving. Interested in Learning More? Join me at The Pankey Institute with The Essentials Series. Starting with Essentials 1, this series offers a comprehensive and structured approach to dental education. Participants will gain essential knowledge and skills, enabling them to build a solid understanding of fundamental concepts in dentistry. From fundamental principles to essential clinical techniques, this series lays the groundwork for a successful dental practice and provides a strong platform for further specialization.

Occlusal Wear: Is It Advancing? How Fast?

By: Lee Ann Brady DMD I ask the question “Is wear normal?” at almost every lecture I…

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dental assistant thinking about how to earn more money

Help…My Dental Assistant Wants More Money!

By Ronda Holman | February 26, 2024

By: Ronda Holman Hi dear reader, my name is Ronda Holman and I have been sitting across from a dentist for a living for the last 25 years. I thought it might be time to make some written confessions as to what I have been guilty of over the years and how my dentist was…

load test tmjs

Dentists: Why Should You Load Test the TMJs?

By Dr. Leonard Hess, DDS | February 23, 2024

By: Dr. Leonard A. Hess, DDSClinical Director, The Dawson AcademyThe Article Originally Appeared on TheDawsonAcademy.com Properly loading the joints tells you several things about the root cause of some patients’ problems. This will also determine how functionally stable the patient is. Let’s start with the first item. 1. Indicate if the Joint is Healthy You’re going to…

dental fuel

The Secrets to Success: Advice from Dental Assistant Ronda Holman

By Ronda Holman | February 19, 2024

Interviewer: Tanya Sue Maestas, DDSInterviewee: Ronda HolmanEdited By: Candy Velez – CRDH, BSDH In this interview, dental assistant Ronda Holman shares invaluable insights on the often-overlooked power of patience and communication in the dental office. The Importance of Patience In the dynamic realm of dentistry, Ronda Holman underscores the significance of patience for both dental…

changing vertical dimension

Changing Vertical Dimension: When is it Safe?

By Dr. Leonard Hess, DDS | February 16, 2024

By: Dr. Leonard A. Hess, DDSClinical Director, The Dawson AcademyThe Article Originally Appeared on TheDawsonAcademy.com If you follow The Dawson Academy protocols, altering the vertical dimension is going to be the exception rather than the rule. We can work with the vast majority of patients vertical dimension and still fulfill the five requirements for occlusal stability and get a…

buyer beware numbers can lie in a dental practice acquisition

Buyer Beware: Numbers Can Lie in Dental Practice Acquisitions

By David Rice | February 13, 2024

By: Dr. David Rice In the world of dental practice acquisitions, potential buyers often find themselves navigating through a sea of financial data and performance metrics. The numbers presented can be a powerful tool in decision-making, but they can also be deceiving. As a new dentist buyer, it’s crucial to understand the web of factors…

Reducing the Tax Burden When Selling a Dental Practice

Reducing the Tax Burden When Selling a Dental Practice

By Bruce Bryen | February 12, 2024

An innovative approach to reducing the tax burden for the buyer and seller when a dental practice is sold that has used conventional financing for its acquisition. By: Bruce Bryen When the principal payments on the loan are paid by the buyer of a dental practice, they become subject to tax. The seller knows that…

How Does the Occlusal Plane Relate to the Anterior Teeth? By: Dr. Leonard A. Hess, DDS Clinical Director, The Dawson Academy The Article Originally Appeared on TheDawsonAcademy.com One of the most common mistakes I see in occlusal restorations is also the easiest mistake to observe. It is interference of the posterior teeth with the anterior guidance. A perfected occlusion allows the anterior teeth to contact in centric relation simultaneously and with equal intensity with the posterior teeth. This harmony of contacts occurs with complete seating of the condyles at their most superior position, which is bone braced. This means that there is an ideal distribution of compressive contact starting at the TMJs, and continuing all the way through front tooth contact. This is the contact distribution that we want for centric relation. When the jaw moves from centric relation, in a perfected occlusion only the anterior teeth contact. All posterior teeth distal to the cuspids should immediately separate. This is called “posterior disclusion”. Separation of the posterior teeth should occur, whether the jaw moves forward, left, or right from centric relation. The reason that posterior disclusion is such a desired effect is that the moment the posterior teeth separate, almost all of the elevator muscles shut off. This reduces the horizontal forces against the anterior teeth which are carrying all the forces in protrusive or lateral movements of the mandible. it also reduces the loading forces on the TMJ’s. But even more importantly, it is impossible to wear or overload the posterior teeth if they cannot rub. Keep Reading: How to Use Splints in Your Treatment Plan

How Does the Occlusal Plane Relate to the Anterior Teeth?

By Dr. Leonard Hess, DDS | February 9, 2024

By: Dr. Leonard A. Hess, DDSClinical Director, The Dawson AcademyThe Article Originally Appeared on TheDawsonAcademy.com One of the most common mistakes I see in occlusal restorations is also the easiest mistake to observe. It is interference of the posterior teeth with the anterior guidance. A perfected occlusion allows the anterior teeth to contact in centric…

dentist disability insurance

Dentist Disability Insurance: You Probably Won’t Read This…

By Todd Doobrow, CFP | February 7, 2024

Your ability to earn income should be protected – in the most meaningful way for you and your family.  By: Todd Doobrow, CFP Maybe you will read this…who knows what piques your interest? If you do stick with us, here is a crazy story for you. I have a buddy who always dreamt of owning a…

not bringing work home with you

Not Bringing Work Home With You

By Savanah Craig | February 5, 2024

You have a long career ahead of you, setting limitson how much work you bring home with you can prevent you from burning out.  By: Savannah Craig Arguably most people entered the dental profession to help people and to make a difference in the lives of those around us, particularly our patients. As members of…

3 Fatal Flaws of Denture Design

By Dr. Kimberly Daxon, D.D.S. | February 2, 2024

Overcoming these 3 common flaws will give you very happy patients! By: Dr. Kimberly Daxon, D.D.S.The Article Originally Appeared on TheDawsonAcademy.com There are three main areas that need attention when designing complete denture prostheses. When these three things are not accomplished, it can lead to misfits and patient dissatisfaction. I see it all the time….