Chairside - Glidewell Dental Labs

Chairside® 

A Publication of Glidewell Laboratories • Volume 3, Issue 3 

One-on-One 

An Interview with 

Dr. Brock Rondeau 

Portrait Photography 

In a Busy Dental Practice 

Minimal-Prep Veneer 

Photo Essay 

Building the 

Edentulous Impression 

Dr. Michael DiTolla’s 

Clinical Tips

Contents 

9 Dr. DiTolla’s Clinical Tips 

This month’s tips include a translucent temporary 

cement that is a must-have when working with thin 

provisionals. The days of having to see the outline 

of your prep through the veneer are over. Polishing 

porcelain intraorally is a daily occurrence in most 

dental offices, and CeraGlaze ® makes the process 

simple and effective. For larger restorative cases we 

spotlight Marcaine ® , one of the secrets to happy patients. 

Finally, LuxaGlaze ® helps give your temporaries 

the same “wet-glazed” look that the final ceramic 

restorations have. 

14 Minimal-Prep Case Photo Essay 

With all the talk of prep versus no-prep veneers, I 

thought it might be prudent to make sure we don’t 

forget about the most versatile veneer of them all— 

the minimal-prep veneer. By definition (mine anyway), 

a minimal-prep veneer is one that does not 

break through the enamel anywhere on the prep. 

It is conservative and allows more corrections than 

no-prep veneers, making it the best of both worlds 

unless the patient insists on no-preps. 

25 Incorporating Portrait Photography Into 

a Busy Dental Practice 

I took a class from Dr. Tony Soileau years ago on this 

very topic, and you see the results in this magazine 

and other dental magazines such as the AACD journal. 

Tony’s approach is so simple, there is literally no 

additional equipment required besides a camera and 

a parking lot. This is easier than it looks and can be 

100 percent delegated to staff. 

32 One-on-One with Dr. DiTolla 

Dr. Brock Rondeau taught me how to do ortho 15 

years ago, and it was probably the most comprehensive 

continuing education experience of my career. 

Brock said a lot of things back then that I considered 

controversial, but research has shown that he 

was right on track. It might sound over the top that 

parents want their kids to have two-phase ortho, but 

I am here to tell you it is the truth. Consider getting 

involved in the most conservative of all esthetic 

dentistry—two-phase orthodontics. 

Cover photo by Sharon Dowd 

Cover illustration by Wolfgang Friebauer, MDT 

Contents 1

Editor’s Letter Publisher 

Jim Glidewell, CDT 

I am happy to see you guys liked the Dr. Paul Homoly interview 

in the last issue as much as I did! I received more 

voicemails, e-mails and comments at lectures from that 

article than any other we have ever published. I will be 

doing an interview with him later this year where he will 

incorporate profitability numbers into that same discussion. 

The preliminary phone conversation we had about 

it was fascinating. 

We have another great interview in this issue from another 

clinician I have looked up to for a long time, Dr. 

Brock Rondeau. Like the Homoly interview, you need to 

stick with this one as all of the loose ends get tied up 

into one package that may be a revelation for some of 

you as it was for me years ago when Brock trained me. 

I began treating the children in my practice with twophase 

orthodonic treatment as Brock has been doing for 

decades, and the results were as nice as Brock said they 

would be. 

The most amazing thing to me about doing ortho in my 

practice was that the same parents who didn’t have the 

money to replace the 35-year-old crowns in their mouth 

could afford to start both of their kids in ortho treatment 

with me! Their children’s ortho was a much higher priority 

than replacing their own crowns. 

I never really enjoyed working on kids until I had children 

of my own. Even then, once I knew how to talk to 

kids, I still didn’t really like doing operative on them. My 

least favorite thing was how the orthodontist charging the 

patient $5,000 for ortho would send the kid back to my 

office for $400 worth of extractions to remove the first 

bicuspids! Brock’s flier came in the mail the next day, and 

seven months later I started my first ortho case. Whether 

or not you ever decide to provide two-phase ortho to your 

patients, Brock’s interview is a fascinating look into the 

interconnectedness of orthopedics, orthodontics, TMD 

and sleep apnea. 

The bottom line: I would rather do two-phase ortho on 

my daughter when she was 10, than do 10 veneers on her 

when she is 20. 

2 

Editor’s Letter 

Yours in quality dentistry, 

Dr. Michael DiTolla 

Editor in Chief, Clinical Editor 

mditolla@glidewelldental.com 

Editor in Chief 

Michael DiTolla, DDS, FAGD 

Managing Editors 

Jim Shuck 

Mike Cash, CDT 

Creative Director 

Rachel Pacillas 

Clinical Editor 

Michael DiTolla, DDS, FAGD 

Copy Editor 

Melissa Manna 

Magazine Coordinators 

Sharon Dowd 

Lindsey Lauria 

Graphic Designers 

Jamie Austin, Deb Evans, Joel Guerra, 

Phil Nguyen, Gary O’Connell, Rachel Pacillas 

Staff Photographers 

Sharon Dowd 

Kevin Keithley 

Illustrators 

Wolfgang Friebauer, MDT 

Ad Representative 

Lindsey Lauria 

(lindsey.lauria@glidewelldental.com) 

If you have questions, comments or complaints regarding 

this issue, we want to hear from you. Please e-mail us 

at chairside@glidewelldental.com. Your comments may be 

featured in an upcoming issue or on our Web site. 

© 2008 Glidewell Laboratories 

Neither Chairside Magazine nor any employees involved in its publication 

(“publisher”), makes any warranty, express or implied, or assumes 

any liability or responsibility for the accuracy, completeness, or usefulness 

of any information, apparatus, product, or process disclosed, or 

represents that its use would not infringe proprietary rights. Reference 

herein to any specific commercial products, process, or services by 

trade name, trademark, manufacturer or otherwise does not necessarily 

constitute or imply its endorsement, recommendation, or favoring 

by the publisher. The views and opinions of authors expressed 

herein do not necessarily state or reflect those of the publisher and 

shall not be used for advertising or product endorsement purposes. 

CAUTION: When viewing the techniques, procedures, theories and materials 

that are presented, you must make your own decisions about 

specific treatment for patients and exercise personal professional judgment 

regarding the need for further clinical testing or education and 

your own clinical expertise before trying to implement new procedures. 

Chairside ® Magazine is a registered trademark of Glidewell Laboratories.

Contents 

47 Building the Edentulous Impression: 

A Layering Technique Using Multiple 

Viscosities of Impression Material 

Final impressions for removable prosthodontics are 

a whole different world from final impressions for 

fixed prosthodontics—they have nearly nothing in 

common. If you are like me, you take hundreds of 

fixed final impressions for every removable final impression 

you take. I was doing some personal review 

of current techniques for my own benefit when I 

found this article from Dr. Joseph Massad, which I 

knew could help all of us achieve better removable 

results. 

54 Practice Management: The Dangers of 

Denial 

I was reading the AGD Impact magazine last month 

when I stumbled upon this article. It is the first time 

I ever remember reading a firsthand account of a 

dentist with oral cancer. Our family had an aunt with 

oral cancer and we witnessed her slow painful demise, 

including the removal of most of her tongue. 

It’s a 30 second exam that can mean so much to 

someone’s life, and I thought you would find this 

story to be a real eye-opener. 

59 Clinical Technique: 

Impression Taking—Is it a Lost Art? 

Hopefully I will never let an issue of Chairside 

go by without reminding dentists that we 

could all be taking better crown and 

bridge impressions. Dr. Michael Miller 

has been featured in these pages before 

and, as one of my mentors, will 

be in future issues as well. If you have 

never seen the Techniques portion of his 

REALITY book, you are missing one of 

the great accomplishments in dentistry. 

Michael is what I strive to be, a qualityconscious 

realist when it comes to techniques, 

and in this article he discusses the fixed 

impression technique. 

Contents 3

Letters to the Editor 

“Dear Dr. DiTolla, 

With how many ounces and for how long 

do you have the patient swish with Cyclone?” 

- Dr. Mitchel L. Friedman, Lincroft, NJ 

Dear Mitchel, 

Thanks for the Cyclone question. For 

those that don’t know, Cyclone is a 

powerful liquid topical anesthetic 

that we use in the office. My assistants 

use it with patients who are 

concerned about gagging prior to 

taking study models or final crown 

and bridge impressions, especially if 

they are full arch impressions. I have 

also seen them use it before an FMX 

on patients who are concerned with 

gagging to help them get all the necessary 

views. 

On the hygiene side, my hygienists 

use Cyclone when someone doesn’t 

need root planning but still has sensitive 

prophies, and we’d like them 

to be more comfortable. I have also 

seen it used prior to perio probing a 

sensitive unanesthetized patient. We 

fill up a Dixie cup two-thirds of the 

way and ask the patient to swish for 

60 seconds prior to spitting into a 

hand-held cuspidor. It gives good an- 

4 

Letters to the Editor 

esthesia on all oral tissue including 

the buccal and lingual gingival, the 

tongue and the soft palate. Cyclone 

is available from Steven’s Pharmacy 

at 800-352-3784 or www.stevensrx. 

com. 

- Dr. DiTolla 


This past week has not been great for 

me in obtaining adequate anesthesia on 

the mandibular molars using the block. I 

use the X-tip often, but it causes discomfort 

unless a lower block and long buccal 

are already somewhat working. I remember 

an issue of Chairside in which you 

mentioned you were planning to go to a 

course featuring anatomy that would help 

you with lower block anesthesia success. 

I am curious if the course proved valuable 

and if it has helped with mandibular anesthesia 

success. Also, do you have any 

recommendations as to good courses to 

take for improving the techniques for lower 

blocks? I find this part of dentistry the 

most frustrating.” 

- Dr. Julian Drew, Raleigh, NC 

Dear Julian, 

I feel your pain! I have experienced 

missing blocks in batches too, and 

the more dentists I talk to the more I 

realize we are not alone. 

The course I attended was designed 

to teach the Gow-Gates technique, 

which is a great way to anesthetize 

a quadrant. 

However, a couple 

of things got in the 

way of me becoming 

a Gow-Gates 

convert. 

The first was the 

realization that 

the Rapid AnesthesiaTechnique 

(outlined 

in the last issue of 

Chairside and online at www.glidewell-lab.com) 

could be trusted to reliably 

anesthetize mandibular molars 

at a 99.9 percent success rate. I suppose 

this isn’t surprising, as this is 

the type of injection I always go to 

when my lower block isn’t working. 

The second thing, which goes handin-hand 

with the Rapid Anesthesia 

Technique, was the discovery of the 

STA System from Milestone Scientific 

(www.stais4u.com). In addition to 

being designed specifically for PDL 

injections (like the one I use in the 

Rapid Anesthesia Technique), it also 

has the ability to give multiple carpules 

of anesthesia without removing 

the needle. That is a big deal 

for me! I always wondered why the 

standard carpule was 1.8 cc and no 

one could give me a good answer. I 

have heard Dr. Stanley Malamed say 

for years than one carpule is not sufficient 

for the average adult when 

giving a lower block! 

When using the STA System for a 

lower block, I use the first carpule to 

painlessly get the 27-gauge needle to 

the hub. Without having to remove 

the needle from the tissue, my assistant 

exchanges the empty carpule for 

a full one. Many times I will have put 

a third carpule in while I continue to 

tap the tip of the needle against the 

bone. My success rate has gone way 

up since I started this technique, in

no small part to being able to give 

more anesthetic with “just one shot” 

from the patient’s point of view. I 

hope that helps, Julian! 

- Dr. DiTolla 


Do you have a DVD on Profound topical 

and the injections that might follow for 

molars? Thanks!” 

- Dr. Tina Donahue, San Francisco, CA 

Dear Tina, 

Here is a link for the online DVD: 

www.glidewell-lab.com/educational/ 

videos/index.html. It is the “Rapid 

Anesthesia, Reverse Preparation & 

Two-Cord Impression Technique” 

video; it is the second one down in 

the left-hand column. Also, I just did 

a photo-essay detailing the technique 

in our Chairside Magazine, which 

should be arriving in your office any 

day now. It can also be viewed online 

at: www.chairsidemagazine.com. 

- Dr. DiTolla 


I keep hearing stories about it being difficult 

to cut off zirconia-based restorations. 

Is this true, and what is the best way to cut 

them off?” 

- Dr. Mike Hamm, Minneapolis, MN 

Dear Mike, 

Compared to cutting off a PFM, cutting 

off a zirconia crown (e.g., Cercon 

® from Dentsply Ceramco, 3M ESPE Lava , or Prismatik Clinical 

Zirconia from Glidewell Laboratories) 

is quite challenging. I have cut 

many units off as part of our material 

testing at the laboratory, and I have 

learned a few things. 

First of all, you better have the right 

burs on hand. I prefer the Zir-Cut 

burs from Axis Dental, and chances 

are it will take more than one bur 

to get through the zirconia coping. 

I use the biggest tapered Zir-Cut bur 

Axis makes to help get through the 

tenacious coping. 

Secondly, it helps to have an electric 

handpiece—there is no such thing 

as too much torque when cutting 

through zirconia. Cut with plenty of 

water and air to keep the tooth cool. 

Lastly, be careful while putting pressure 

on the bur to cut through the 

coping. It is natural to lean into the 

bur since it is cutting so slowly, but 

you need to be careful since once 

you break through the zirconia you 

can go flying into the tooth. 

Cutting off zirconia-based bridges is 

even worse, so for now I am sticking 

with PFM bridges unless a patient 

absolutely demands otherwise. 

I hope this helps! 

- Dr. DiTolla 


Can veneers be removed with a laser without 

damage and then rebonded? I have a 

patient whose original veneers keep popping 

off because they were not bonded 

properly at delivery. I have rebonded three 

of six and was hoping to rebond the remaining 

three veneers prior to her going 

off to college. If time permits a brief 

conversation, e-mail and/or referral to a 

journal article, it would be greatly appreciated.” 

- Dr. William Lucas, Richmond, VA 

Dear William, 

Unfortunately, no. I know of no way 

to remove a veneer without destroying 

it, unless they fall off like the 

three you mentioned. The laser shatters 

the veneers into many pieces as 

it pops them off the teeth. It sounds 

like your best alternative is to let the 

other three veneers fall off, which admittedly 

is not a great option. Short 

of replacing the veneers, I am afraid 

I have no solution. 

- Dr. DiTolla 

WRITE US 

Chairside Magazine welcomes 

letters to the editor, which may 

be featured in an upcoming 

issue or on our Web site. Letter 

should include writer’s full 

name, address and daytime 

phone number. To contact us: 

e-mail (chairside@glidewell 

dental.com), mail (Letters to 

the Editor, Chairside Magazine, 

Glidewell Laboratories, 4141 

MacArthur Blvd., Newport 

Beach, CA 92660) or call (888- 

303-4221). 

Letters to the Editor 5

Contributors 

6 

Contributors 

Michael C. DiTolla, DDS, FAGD 

Dr. Michael DiTolla is Director of Clinical Education & Research at Glidewell Laboratories in Newport 

Beach, Calif. Here, he performs clinical testing on new products in conjunction with the company’s R&D 

Department. Glidewell dental technicians have the privilege of rotating through Dr. DiTolla’s operatory 

and experience his commitment to excellence through his prepping and placement of their restorations. 

He is a CR evaluator and lectures nationwide on both restorative and cosmetic dentistry. Dr. DiTolla has 

several clinical programs available on DVD through Glidewell Laboratories. For more information on 

his articles or to receive a free copy of Dr. DiTolla’s clinical presentations, call 888-303-4221 or e-mail 

mditolla@glidewelldental.com. 

Joseph J. Massad, DDS 

Dr. Joseph Massad is currently the Director of Removable Prosthodontics at the Scottsdale Center for 

Dentistry in Arizona, and presently holds faculty positions at Tufts University School of Dental Medicine 

in Boston, the University of Texas Dental School at San Antonio, and the Oklahoma State University 

College of Osteopathic Medicine. In addition, Dr. Massad served from 1992-2003 as an associate faculty 

at the Pankey Institute in Florida. Dr. Massad is a Fellow of the American College of Dentists and the 

International College of Dentists. To contact Dr. Massad, call 888-336-8729, visit www.gdit.us or www. 

joemassad.com, or e-mail using the contact message form at www.joemassad.com. 

Michael B. Miller, DDS 

Dr. Miller graduated from the University of Maryland School of Dentistry in 1974, and completed a 

general practice residency at the Veterans Administration Hospital in Houston in 1975. He is a Fellow 

of the Academy of General Dentistry, a Founding, Accredited Member and Fellow of the American Academy 

of Cosmetic Dentistry, and has memberships in the International Association of Dental Research, 

Academy of Dental Materials, and Academy of Operative Dentistry. Dr. Miller is founder of the National 

Children’s Oral Health Foundation, which is dedicated to fostering the development of local dental 

health and education facilities for children who do not currently receive any type of care. In addition, 

he is co-founder, president and editor-in-chief of REALITY Publishing, which he runs while maintaining 

a dental practice in Houston. Contact Dr. Miller at www.realityesthetics.com or by e-mail at mmiller@ 

realityesthetics.com.

Brock Rondeau, DDS, IBO, DABCP 

Dr. Brock Rondeau is a general dentist specializing in orthodontic, orthopedic and TMJ problems. A 

1966 graduate of Dalhousie University Dental School in Halifax, Nova Scotia, Dr. Rondeau is recognized 

as a leader in the orthodontic profession. In addition to being the first Canadian named the American 

Association of Functional Orthodontics Man of the Year – 1988, Dr. Rondeau is also a Diplomat of 

the International Board of Orthodontics, a past president and senior instructor for the International 

Association for Orthodontics, and a member of the American Association of Functional Orthodontics, 

International Association for Orthodontics, Academy of General Dentistry, London & District Dental 

Society, the Academy of Dental Sleep Medicine, the Ontario and Canadian Dental Associations, and 

the American Academy of Craniofacial Pain. For more information on Dr. Rondeau’s courses, visit 

www.rondeauseminars.com, e-mail brondeau@rondeauseminars.com, or call 877-372-7625. 

Tony Soileau, DDS 

Dr. Tony Soileau is a general dentist from Lafayette, La. His practice focuses on restorative rehabilitation 

and cosmetic enhancements. Dr. Soileau has been a faculty member of the Institute of Oral Art and 

Design (IOAD) in Tampa, Fla., and the Pacific Aesthetic Continuum (PAC~Live) in San Francisco. He is 

a member of the ADDA, LDA, ADA, AGD, AACD, and has Fellowship in the Academy of Comprehensive 

Esthetics. Dr. Soileau has published more than 50 articles on esthetic dentistry, as well as incorporating 

technology into a general dentistry practice, in leading dental journals such as Dentistry Today, CERP, 

Inside Dentistry, Dental Economics, and PPAD. To learn more about his techniques and articles, visit 

www.tonysoileau.com, e-mail tony@smilesbysoileau.com, or call 337-234-3551. 

Contributors 7

Dr. DiTolla’s 

CLINICAL TIPS 

PRODUCT ....... TempBond Clear 

CATEGORY ...... Dual Cure Resin-Based Cement 

SOURCE .......... Kerr Corporation 

Orange, CA 

800-537-7123 

www.kerrdental.com 

Many of us tend to take temporary cements for granted, 

but I will always remember the first time I realized 

I need more than one. I had just placed some 

anterior temporary crowns on a patient with a typical 

temporary cement that happened to be yellow. And 

right through the chairside temps my assistant had 

made, I could see the outline of the preps staring back 

at me. I was horrified! The temps were a little thinner 

than usual and the yellow temp cement was showing 

through. I explained to the patient what was happening 

and promised I would figure out a solution as 

soon as I could. Two phone calls later a dentist friend 

told me about TempBond Clear, and today I would 

not practice esthetic dentistry without it. Whether it’s 

temps that end up being a little thin after reshaping 

them, or underneath thin temporary veneers, having a 

translucent temporary cement is critical. It also works 

well for inlays and onlays, and since it is a resin-based 

cement it is dual-cured as well. 

– ARTICLE by Michael DiTolla, DDS, FAGD 

– PHOTOS by Sharon Dowd 

Dr. DiTolla’s Clinical Tips 9

10 

Dr. DiTolla’s Clinical Tips 


CLINICAL TIPS 

PRODUCT ....... LuxaGlaze ® Light-Cured Varnish 

CATEGORY ...... Provisional Crown & Bridge Glaze 

SOURCE .......... Zenith/DMG 

Englewood, NJ 

800-662-6383 

www.zenithdental.com 

I had an instructor in dental school who told me not to 

make my temporary crowns look too good or patients 

will never come back for the permanent crown. Huh? 

First of all, if you collect all the money at the prep appointment 

you don’t have to worry about the patient 

not coming back. Does anyone really want to spend 

$1,000 on a temporary? How many patients really 

are so in love with the look of their temps that they 

decide, “Forget that fancy porcelain one, I’m sticking 

with the superior esthetics of this plastic one!” Needless 

to say, I strive for gorgeous temps, and LuxaGlaze 

is a great way to make your temps look like glazed 

porcelain. Paint a thin layer on, cure for 10 seconds, 

and admire. If your patient doesn’t come back for the 

permanent crown, it’s either because you give lousy 

injections or your breath stinks. Great looking temporaries 

keep patients coming back to you for more 

restorative dentistry.


CLINICAL TIPS 

PRODUCT ....... CeraGlaze ® Ultimate Porcelain 

Polishing Set (RA/Latch) – LS-506 

CATEGORY ...... Porcelain Polishing Logic Set 

SOURCE .......... Axis Dental 

Coppell, TX 

800-355-5063 

www.axisdental.com 

Nobody knows more about how to effectively smooth 

porcelain than your dental laboratory. Oddly enough, 

dentists don’t seem to consult with their laboratories 

when it comes to polishing ceramic materials. Most 

dentists think if they send a restoration back to their 

lab for “reglazing” that the lab will paint on the glaze 

and run it back up in the oven. The truth is there’s too 

great a risk that the restoration will fracture when 

this happens, and the lab is able to achieve nearly 

identical results with polishing wheels. We use the 

CeraGlaze Ultimate Porcelain Polishing Set here at 

the lab, and the key is that we use it in a high torque 

electric handpiece. Polishing ceramics outside of the 

mouth is an easy enough task, but it becomes more 

difficult when it needs to be done post-cementation. 

With my KaVo ELECTROtorque handpiece and the different 

shapes in the CeraGlaze Logic Set, there is no 

area in the mouth that I can’t polish to a high glazelike 

shine. 

Dr. DiTolla’s Clinical Tips11

PRODUCT ....... Marcaine ® 


CLINICAL TIPS 

CATEGORY ...... Local Anesthetic 

SOURCE .......... Cooke-Waite Anesthetics 

Rochester, NY 

800-933-8031 

www.kodakdentalsystems.com 

It’s about time Marcaine gets a little love! I write a 

lot about how much I like Septocaine ® because I use 

it in the Rapid Anesthesia Technique, however, that 

technique is for single mandibular molars or two adjacent 

mandibular molars. There are many cases, of 

course, that either still require lower blocks or are in 

the maxilla. Most of the cases I do are three to five 

crowns at a time, and the more teeth you prep the better 

the chance there will be more than one surprise 

you have to contend with, which always lengthens the 

treatment time. Marcaine gives you pulpal and soft tissue 

anesthesia that typically lasts two to three times 

longer than lidocaine—in many patients lasting up to 

seven hours. Typically on a larger case the patient will 

be with us for three to four hours, and I don’t want 

the local anesthetic to wear off on the drive home. We 

encourage the patient to take 800 mg of ibuprofen 

before leaving the office so that it kicks in as the Marcaine 

wears off. 

Septocaine is a registered trademark of Septodont. 

Dr. DiTolla’s Clinical Tips13

minimal-PREP Case 

Photo Essay 

– ARTICLE & CLINICAL PHOTOS by Michael DiTolla, DDS, FAGD – COVER PHOTO by Sharon Dowd 

14 

Minimal-Prep Case Photo Essay

have really come around to no-prep veneers. As our technicians and the ceramics have improved, I have been 

getting much better results on a much wider variety of cases. There are still those cases, however, where some 

minimal enamelplasty can make a big difference in final esthetics. I usually have a conversation with the patient 

to determine if they are set on no-prep veneers or open to minimal-prep veneers. It’s a little ironic because no-prep 

patients don’t want their teeth touched, but it would be impossible to ever remove the veneers without prepping tooth 

structure. I am comfortable with both and I welcome patient input when planning these cases. 

Figures 1-3: This 32-year-old female patient wanted to 

improve her smile but did not have much luck with vital 

bleaching. A previous dentist had placed some direct 

composite veneers on the upper and lower anterior teeth, 

but most had broken off or worn away. These photos are 

used to judge macroesthetic issues, such as smile line, 

and whether there are gingival issues that need to be addressed. 

Figures 4-6: The retracted views of her smile show there 

are small islands of composite still attached to the teeth 

in random areas. There is some composite on the lower 

teeth as well, but the patient can only afford to treat the 

upper arch at this time. These photos are used to evaluate 

esthetic issues related to the interdigitation of the upper 

and lower anterior teeth such as overbite, overjet and 

crossbites. 

Figures 7-9: The addition of a black background makes it 

easier to see specific esthetic issues. Tooth rotations, gingival 

embrasures, shade issues and incisal translucency 

are much easier to see when the lower teeth are not visible 

and the contraster is in place. 

Figure 10: It is not until you see this occlusal photo that 

you can begin to determine whether this is going to be a 

no-prep or minimal-prep veneer case. Since most dentists 

Figure 1 Figure 2 

do not take photographs, they must wait until the lab 

pours the model and views it from this angle. Based on 

this view, we decided to do minimal-prep veneers. 

Figure 11: Based on Fig. 10, we decided minimal reduction 

was needed on teeth 7, 9 & 11. My definition of a 

minimal-prep veneer is one that requires enamel removal 

for optimum esthetics but exposes no dentin. Part of a 

minimal-prep veneer is patient approval for removal of 

the tooth structure. I’ve had many minimal-prep patients 

who wanted no-prep veneers. While it compromises esthetics 

somewhat, I cannot force the patient to value esthetics 

over conservation of tooth structure. 

Figure 12: Teeth 7 & 9 require facial reduction to improve 

the esthetic result of the final restorations, while tooth 11 

only needs reduction to the distal third of the tooth. It is 

surprising how often the distal third of the canines have 

rotated facially, which throws off the overall esthetics of 

a smile. Ideally, the distal third of the canines should not 

even be visible from a straight on smile view. 

Figures 13-14: I had the laboratory make a putty wash reduction 

guide for me to ensure I would reduce the teeth 

only as much as needed. The lab has taken the study 

model and reduced it in the areas we agreed upon, duplicated 

the model, and then waxed it up to ensure they 

Minimal-Prep Case Photo Essay15

Figure 3 

Figure 5 

Figure 7 

reduced enough. The putty wash matrix can then be fabricated 

with prep windows in it. 

Figure 15-18: The putty wash matrix is placed on the unprepared 

model to check for fit. The putty has been cut 

back by the lab to be flush with the tooth structure after 

it is prepped, based on the preparation they did on the 

study model. In other words, the matrix is used to determine 

not only the boundaries of where the teeth should 

be prepped but how deep as well. In this sense, it acts 

as a reduction coping since it is an aid for how much 

tooth to reduce. Keep in mind that because the prelimi- 

16 

Minimal-Prep Case Photo Essay 

Figure 4 

Figure 6 

Figure 8 

nary preps were done on a stone model, the technician 

has no idea where the enamel will end. If your goal is to 

remain in enamel, this is a call you have to make chairside, 

even if the prep guide indicates you need to prepare 

more tooth structure. A surgical skin marker (available 

from most dental dealers) is used to mark the perimeter 

of the preparation area while the matrix is in the mouth, 

and the matrix is then removed. 

Figure 19: A coarse 856-025 diamond bur from Axis Dental 

(Coppell, TX) is used to perform the necessary reduction. 

I prefer to use a coarse diamond so that when I

Figure 9 

Figure 11 

Figure 13 

dry off the tooth to check my reduction, it will be obvious 

where the reduction has taken place. Teeth 7, 9 & 11 

are prepped with water for comfort and then air dried to 

check reduction. The matrix is placed back on to check 

depth of facial reduction. 

Figure 20: A dry close-up of prepared teeth 7, 9 & 11. Even 

after using a coarse grit bur it is difficult to tell exactly 

where the preparation was done, which is why the putty 

matrix makes minimal reduction more accurate. There is 

still some composite left on the incisal edge of tooth 9, 

and I decide to leave it in place since the incisal third of 

Figure 10 

Figure 12 

Figure 14 

the veneer tends to be slightly thicker than the gingival 

third. I would also like the veneers on teeth 8 & 9 to be 

the same thickness in the incisal third. 

Figure 21: I like to prep these types of veneers with a 

coarse bur, but I do not like to leave a coarse surface 

on the tooth while the lab fabricates the veneers. Since 

I don’t do temporaries in veneer techniques unless I expose 

dentin, there are no temps on this patient. However, 

if you leave a coarse diamond finish on the facial surfaces 

of these teeth they will pick up a ton of stain in the interim. 

A fine grit 856-018 diamond bur from Axis Dental 


Figure 15 

Figure 17 

Figure 19 

is used to smooth the prepped areas. 

Figures 22-23: The fine grit diamond does a fairly good 

job of smoothing the enamel to the point where it won’t 

pick up stains from food and coffee, but the teeth still 

look somewhat dull and you can tell something was done 

to them. As a final step, I use a OneGloss ® cup from Shofu 

(San Marcos, CA) in my KaVo electric handpiece at 30,000 

rpm with a light touch to put a shine on the prepared 

areas. Since we are bonding the veneers into place, there 

is no reason to leave things rough to achieve mechanical 

retention at the seat appointment. 

18 


Figure 16 

Figure 18 

Figure 20 

Figure 24-28: Having essentially performed enamelplasty 

and subsequent smoothing of the tooth structure, we are 

ready to take the final impression. Just because you do a 

no-prep or minimal-prep case does not absolve you from 

taking a great full arch impression. In no-prep and minimal-prep 

cases, I do not place a retraction cord since I 

want to have to have the margin right at the gingival margin. 

Keep in mind that nearly all minimal-prep cases will 

have no reduction in the gingival third. As such, there will 

be no margin to finish to, much like with a no-prep case. 

Since both types of veneers are going to have a small 

speed bump at the gingival margin, I do not want to place

Figure 21 

Figure 23 

Figure 25 

them subgingivally. Even though I skip cord packing or 

placement of Expasyl (Kerr Corporation, Orange, CA), I 

still take the impression as though it were a crown and 

bridge impression. I begin syringing the material at the 

last tooth to receive a restoration at the gingival margin, 

and I work my way around the arch at the gingival margin 

until I reach the last tooth to be restored. I then cover the 

facial surfaces of all the teeth to be restored, and place 

the tray my assistant has filled with heavy body material. 

You would not believe how many no-prep and minimal– 

prep impressions arrive at the lab with bubbles at the 

gingival margin from not using this technique. It may be a 

Figure 22 

Figure 24 

Figure 26 

no-prep case, but it’s still a $10,000 case! Slow down and 

do it correctly. 

Figure 29: As always for a 10-unit case, we are using a custom 

tray to take a full arch polyvinylsiloxane impression. 

It only took me 15 years to get into this habit, and now 

I hate taking impressions without custom trays. Incidentally, 

there was no local anesthesia used at this appointment, 

although the patient has the ability to request it. If 

a patient is on the fence, I ask them to swish with Cyclone 

(Steven’s Pharmacy, Costa Mesa, CA) or I place Profound 

Lite (Steven’s Pharmacy) to give them strong topical anes- 


Figure 27 

Figure 29 

Figure 31 

thesia without administering an injection. 

Figure 30-32: Here are the veneers on the day of cementation. 

Like many patients who had stopped smiling because 

they don’t feel comfortable with their smile, she 

will have to learn to smile again. That is not just an expression 

either; some patients literally need to practice 

smiling in front of a mirror if they have been hiding their 

smile with their hand or lips. 

Figure 33-35: The retracted view is one the patient will 

never see, but it is a useful clinical view for us. Without 

20 


Figure 28 

Figure 30 

Figure 32 

full preparation it is impossible to get total control of the 

esthetics of the case but, as you can see, we were able to 

address most of them. We certainly were able to address 

all the issues the patient was concerned with, which is a 

major determinant in esthetic success. 

Figure 36-38: I call this case a minimal-prep case because 

we performed minimal preparation on teeth 7, 9 & 11. On 

the other hand, we did not prep the other seven teeth that 

we worked on, so it might actually be more of a no-prep 

case. Perhaps a mixed-veneer case would be the best way 

to describe it.

Figure 33 

Figure 35 

Figure 37 

Figure 39: Compare this to Fig. 10. The minimal 

prep we did on teeth 7, 9 & 11 did a good job of 

bringing the facial aspects of those teeth back into 

ideal archform. Tooth 10 is now thin faciolingually 

because of its lingual positioning. Had we done minor 

ortho prior to the veneers, as we do in other 

cases, this could have been corrected. 

Figure 34 

Figure 36 

Figure 38 

Figure 39 


Incorporating Portrait 

PhotograPhy 

Into A Busy Dental Practice 

– ARTICLE & PHOTOS by Tony Soileau, DDS 

Incorporating Portrait Photography Into a Busy Dental Practice25

26 

Incorporating Portrait Photography Into a Busy Dental Practice 

Portrait photography, especially of your own patients, is 

a great way to demonstrate how cosmetic dentistry can 

help one attain a beautiful smile. Whether through your 

own photography or pictures you have purchased, patients 

are more accepting of cosmetic dental procedures 

when they see the amazing results others have achieved. 

Even better, when you incorporate portrait photography 

into your dental practice, you can use these portraits for 

external marketing in both print and television markets. 

These snapshots also make a wonderful place to display 

testimonials from your patients. 

■ Digital Cameras 

Digital cameras have all but eliminated the need for hiring 

a professional photographer to document your best 

cosmetic restorations. The latest SLR digital cameras (the 

ones that look and feel like a 35 mm camera) have made 

the art of taking professional portraits very easy. Even a 

dentist or staff member who has never taken a photograph 

can take amazing portraits with just the touch of 

a button. This is because a computer that does most the 

work drives the camera for you. 

Digital cameras follow the same trends as the rest of the 

computer market. Each year the cost continues to fall, 

while the quality and image size of the picture grows. A 

professional level SLR digital camera with a macro lens 

and ring flash can now be purchased for less than $3,000. 

At the time of writing this article, my favorite digital camera 

is the Canon EOS 40D Digital SLR camera with the 

Canon 100 mm macro lens and MR-14EX E-TTL Macro 

Ring Lite Flash.

■ alloCate time 

As with any new technique or service introduced into a 

dental practice, a certain amount of time must be allocated 

for adaptation. Determine the amount of time to set 

aside by deciding the overall value of the procedure and 

the desired outcome. 

For a busy dental practice, incorporating new procedures 

can be very frustrating to the dental team, as well as patients. 

The purpose of this article is to introduce some 

simple techniques for incorporating portrait photography 

into a practice that maintains a busy schedule and tight 

budget. In this article, I will share with you how to take 

amazing portraits with a digital camera setup for dentistry. 

I will also discuss locations in which to take the 

photos, including a very unattractive parking lot! What’s 

more, every image in this article can be achieved without 

special lenses or studio lighting. The only equipment I 

will use to take these photographs is the Canon EOS 40D 

Digital SLR camera, the Canon 100 mm macro lens, and 

the parking lot behind my office. Flash, external lighting, 

filters and reflectors will not be used. That’s not to 

say that a studio setup shouldn’t be used—I have all of 

this equipment, as well as several cameras and different 

lenses (and I love using them)—but I want this article to 

demonstrate that you do not need to purchase expensive 

equipment or have years of experience to take beautiful, 

captivating portraits. 

In my practice, we typically schedule one-hour photo 

shoots. During this short time frame, we will take portraits, 

edit the images, print several photos, and ask the 

model to write a testimonial. I spend 10-30 minutes taking 

the portraits, and my team spends the remaining time 

with the model to select the best images. 

“In this article, I will share with you how 

to take amazing portraits with a digital 

camera setup for dentistry. I will also 

discuss locations in which to take the 

photos, including a very unattractive 

parking lot! What’s more, every image 

in this article can be achieved without 

special lenses or studio lighting.” 


■ Know Your Camera 

The digital camera I am using is the Canon EOS 40D Digital 

SLR camera. It is a 10-megapixel camera. It saves each 

image at an average of 3.5 megabytes compressed; uncompressed 

the image averages 24-30 megabytes. This is 

large enough to print 13x19 images and more than sufficient 

to print 8x10 photos. The camera can also be set 

to capture images to a smaller file size for clinical use. I 

usually set my camera to medium size for all clinical shots 

and large size for images used in marketing or dental 

publications. 

While I do have an assortment of lenses to choose from, 

I want to demonstrate how a basic dental setup is all you 

need to take amazing portraits. Although it is nice to have 

a variety of lenses and studio equipment at your disposal, 

they are not necessary if you learn how to use the camera 

to its fullest ability. This means you must think about your 

camera setup in ways it was not designed for. The Canon 

100 mm lens is a good example. This lens was designed 

to take images at a very close distance, such as flowers, 

insects and teeth. However, it is also an amazing portrait 

lens. The lens is a macro lens, meaning it is designed 

to focus on very close objects. When using this lens for 

portrait photography, the background is blurry and the 

model is in perfect focus. Because of the way the lens is 

designed, you need to maintain five to six feet of space 

between you and your subject so the model fits inside the 

viewfinder. This distance often necessitates the need to 

take photos outside or in a hallway. 

28 

Incorporating Portrait Photography Into a Busy Dental Practice

■ Camera settings 

I set my camera to AV (aperture priority) mode. By using AV mode, I only have to set the f-stop according to how 

blurred out I want the background. The camera picks the best shutter speed so the picture is perfectly exposed (not 

too bright or too dark). I start by setting the ISO setting for my camera to 400. The ISO setting controls how sensitive 

the camera’s computer chip is to light. If it is late in the day and the sun is going down or if I am in the shadow of a 

building, the camera chooses a slow shutter speed to let in additional light. A shutter speed under 1/90 causes a blurry 

image. If the shutter speed is set below 1/90, I increase the ISO setting. By increasing the ISO setting, I am making the 

camera “more sensitive” to light so it can choose a faster shutter speed. As I am not using a flash, I evaluate my shots 

for two criteria: depth of field and brightness of the image. Depth of field refers to: how blurry is the background? This 

is set by the f-stop, which refers to: how open is the front of lens? The higher the f-stop number, the “more closed” the 

lens aperture or opening. An f-stop setting of 32 means the aperture of the lens is barely open and little light can get 

in. The higher the f-stop number, the more depth of field the image has. So a setting of 32 means the image has little 

light but everything is in focus. An f-stop setting of 2.8 means the lens aperture is wide open; light pours in making the 

image very bright. A small f-stop number also means the background is very blurry and out of focus. Remember that I 

am in an unattractive parking lot, so I do not want any of the background to be in focus. And, even if I was shooting 

next to a beautiful background, I want the focus to be on my model and her smile. So I choose to blur the background 

in most situations. This is why I prefer to use a macro lens for my portraits. It lets me shoot in any setting. Cars in a 

parking lot become colored blobs and brick walls become a reddish textured background. 

The brightness of an image depends on three settings: my f-stop, shutter speed, and ISO setting. If I set my f-stop to 11, 

the aperture (the size of the opening of the lens) is partially closed. This keeps the image from being too bright, but the 

depth of field is greater. The best thing about digital cameras is they have a monitor to let you view the images as they 

are stored on the card. This provides immediate feedback on how the images look. I can evaluate them as I go, which 

eliminates the wait of the photos being developed and then later realizing I missed critical shots. 


■ Portrait PhotograPhY teChnique 

I begin every session by taking chest shots of the model. This means I have from the top of her head to her chest in 

the viewfinder. Standing about six feet away from her, I start with the f-stop set to 6.7 and the camera picks the shutter 

speed. I then look at the monitor to see how the image looks. The image varies depending on a variety of factors, 

including if it is sunny, the amount of clouds in the sky, if she is standing in a shadow, etc. My first few shots are just 

to get the settings right for that particular day. I usually do not have to worry about the image being too bright or too 

dark because the camera picks the ideal shutter speed. I just make sure the image is not blurry because of a slow shutter 

speed and that only the model is in focus, not the background. I spend about 10 seconds taking two to four pictures 

to get the settings right. 

Once the settings are right, I take 15-25 images with the model in different poses at varying camera angles. I may have 

her move around to different spots, shaded areas, etc., and make changes to my settings as needed. Remember that I 

get to view my images as I take them so I know how I am doing. 

Next, I take a series of close-up shots. I stand closer to the model so I am just two feet away. The goal is to get just her 

face in the viewfinder. I incrementally raise my f-stop number to about 11. At this distance, an f-stop of 6.7 would focus 

on just the tip of her nose or chin or whatever was closest to the lens; her smile would be slightly out of focus. As soon 

as the camera settings are in place, I again ask the model to go through different poses, and I take about 15-25 shots. 

Once we complete the close-up shots, we are finished with our session. We now have 30-50 portraits to select from, 

which took just 10-15 minutes of the scheduled one-hour appointment. 

30 

Incorporating Portrait Photography Into a Busy Dental Practice

■ Printing 

After the 10-15 minute photo session, my model and I go 

back inside to edit and print my images. I start by transferring 

the images from the compact flash card to my 

server. It is much faster to edit and print them from my 

server than the compact flash card. I like to edit the photos 

using ThumbsPlus ® (Cerious Software). It is an $80 

program that can be purchased online at www.thumbsplus.com. 

For such inexpensive software, it is very easy 

to use and has some amazing functions for printing and 

editing. I also use Adobe ® Photoshop ® (Adobe Systems 

Incorporated) to create all my print ads. But for the purposes 

of basic editing and printing, I find ThumbsPlus the 

easiest to use. 

I start editing by resizing the portrait according to the 

size of paper I will print to. All the portraits displayed 

in my office are printed to A3 (13x19) size. Rarely do I 

ever have to adjust color or brightness tones of the image. 

Because I use a professional level SLR, the color is very 

accurate from the beginning. I then digitally stamp the 

image with my logo and signature. This is really easy to 

do with ThumbsPlus and lets anyone viewing the portrait 

know this is our work. 

For printers, I prefer the Canon PIXMA Pro9000. The Canon 

PIXMA Pro9000 costs less than $500. It is incredibly 

fast, even at the higher dpi settings. It is also very quiet. 

This makes it a great ink jet printer for your practice if 

located near the front desk, where staff members talk on 

the phone and interact with patients all day. 

The quality of a print is determined by the paper choice 

as much as the printer settings. I want my prints equal to 

35 mm prints so I use the best paper, even though it may 

cost a little more. Keep in mind I use high quality paper 

only for portraits displayed on the wall. 

There are two basic types of paper to choose from when 

printing photographs: a matte (satin) finish paper or a 

glossy finish paper. Both have advantages and disadvantages 

over the other. A glossy finish gives you the most 

detail; however, glare from bright office lights may obscure 

the portrait from certain viewing angles. A matte finish 

may not reproduce the subtlest details, such as individual 

eyelashes, but it can be viewed from any angle. I prefer to 

use a matte finish for photos displayed in my office. My 

favorite matte finish is IPC Olmec Satin finish 260-gram 

paper. For glossy paper, Pictorico Pro Glossy Film has to 

be seen to be believed. It is so shiny the paper looks wet, 

and the detail it reproduces is amazing. 

Once I choose which paper to use, I set my printer setting 

or “printer profiles”. I match the printer setting to the 

paper size I’ve selected—in this case size A3. I then select 

my paper preference, and this tells the printer to make 

each drop of ink as large as possible to give my print the 

most color saturation. The prints come out of the printer 

completely dry and can be autographed immediately by 

my model. We give them a Sharpie marker and ask them 

to write as much of a testimonial as they like. 

So, in less than one hour we have taken 50 portraits, edited 

the images, printed one 13x19 image for me, and 

several for the model. In addition, the model has written 

a testimonial for display on my wall. 

■ DisPlaYing 

After the model has signed the printed image, I mount it 

to a one-fourth inch foam board for display. I use inexpensive 

glue sticks and foam board from Office Depot. 

The print is glued to the foam board and allowed to dry 

for 30 minutes. The print is then cut out with a straight 

edge (a metal ruler) and a #15 scalpel. Lastly, I hang it on 

my wall where it is visible to everyone visiting the office. 

The entire print mounted and ready to display has cost no 

more than $4.50 and took just one hour and 30 minutes to 

create. The final result is an incredible marketing piece that 

is completely of our own design and displays the quality of 

our services. We also have a testimonial to share with other 

patients. And because the model is someone from the local 

community, it is so much more powerful for new patients 

than would be a stock image I bought online. 

Many of Dr. Tony Soileau’s techniques and articles can be found on his Web site, 

www.tonysoileau.com. He may also be contacted by phone at 337-234-3551. 

“The entire print mounted and 

ready to display has cost no more 

than $4.50 and took just one hour 

and 30 minutes to create.” 


32 

20 Questions with Dr. Brock Rondeau

20Questions with Dr.Brock Rondeau 

– INTERVIEW of Brock Rondeau, DDS, IBO, DABCP 

by Michael DiTolla, DDS, FAGD 


– CLINICAL PHOTOS by Brock Rondeau, DDS, IBO, DABCP 

There are a few important people I have met in dentistry who 

have done more than change the way I practice, they have 

changed the way I look at how a patient’s multiple dental prob- 

lems may share a common origin. The first time I took Brock’s 

course I had a hard time believing what he taught me; it was 

so far from what I learned in dental school. I took the course a 

second time when I was ready to begin some ortho cases and 

never looked back after that. Almost 20 years later, I see every- 

thing Brock taught me is accurate, effective, and that mothers 

love two-phase treatment as much as he said they would. En- 

joy this interview, and I hope you will consider taking Brock’s 

course. Even if you don’t want to treat these cases, you owe it 

to your patients to learn how to diagnose them. 

20 Questions with Dr. Brock Rondeau33

The most common type of orthodontic problem 

dentists see is the Class II skeletal malocclusion. 

Historically, this type of malocclusion 

was treated with first bicuspid extraction and 

headgear to retract anterior teeth. This type 

of “retractive” treatment failed to take into account 

the effect it would have on the patient’s 

face and resulting profile. With the use of twophase 

orthodontics and functional appliances, 

the goal is to achieve pleasing faces as well as 

esthetic smiles. 

34 

20 Questions with Dr. Brock Rondeau 

Question 1: I’d like to start by just letting people hear a little bit 

about your background. I took your comprehensive ortho course 

15 years ago and started doing ortho, and you’re still the only 

general practitioner I know who treats solely orthodontic cases 

and TMD cases—and now snoring and sleep apnea as well. It’s 

really interesting to speak with someone who is a GP but has decided 

to do only ortho. Why don’t you tell us a little about your 

background and how you got started and how it ended up that 

you decided to treat only ortho patients. 

Brock Rondeau: A long time ago, I read Napoleon Hill’s 

book—he’s a billionaire—titled “Think and Grow Rich” (Highroads 

Media). And in the book, I remember what he said. He 

said, “Find out what people want and give it to them. If you 

want to be rich and successful, find out what people want and 

give it to them.” And I think what happened was, I looked at 

the profession and saw that there was a lot of mothers coming 

in with their kids and asking me what we can do with these 

crooked teeth, these crooked jaws, the problems these kids 

were having. And then I would refer them out to the orthodontists 

in my area. 

You know, 30 years ago they were not treating kids early. 

And the orthodontist was telling the mother, “Let’s wait until 

all their permanent teeth have grown in.” The mothers would 

say, “Well, that doesn’t sound sensible. You just told me we’ve 

got to treat cavities when they’re small, and pockets in the 

gums when they’re small. And now you’re telling me you’re 

going to wait until my child is 13 to begin treating these problems? 

He’s got crooked teeth and a problem with self-esteem 

because he hates how his smile looks.” 

Then I took a course in orthodontics. It seemed like a niche 

I could get into and something I’d be interested in doing as 

well. And the other thing that really interested me in those 

days was the fact the staff did all the work! I was really encouraged 

by that. So, I thought, I can do my general dentistry 

in one room, I can have a hygienist doing perio in another 

room, and I can have another hygienist in the other room doing 

orthodontics—and all I have to do is go in and tell her 

what to do. So that’s the way the course was sold to me—that 

the staff does most of the work and you can just be kind of a 

supervisor. In most orthodontic offices, the staff really does 

do a large part of the work. The orthodontist or the general 

dentist does the thinking and the diagnosis, and the staff actually 

does most the work. So that appealed to me. Then I got 

into it and I really did like it. I really liked helping the kids, 

particularly with the functional issues. These little kids come 

in with narrow jaws, and I knew that if I didn’t extract or develop 

the arches that the cuspids were going to come in like 

fangs. And then if I sent that case to some orthodontist, they 

would recommend bicuspid extractions. But from the courses 

I took from Dr. [James A.] McNamara and Dr. [Donald] Woodside, 

I realized if you expand or develop those arches you 

can prevent extractions of teeth. So, the mothers were very 

receptive to that. And then, of course, I took Dr. John Witzig’s 

courses many years ago, and he showed the use of functional

appliances to bring the jaws forward. I thought that was great because the profiles 

were fantastic—the patients looked great. These little kids would come in 

with their nose coming through the door five minutes before their chin, and 

then you put these functional appliances in and the jaw comes forward and 

the kids look great. 

I didn’t realize in those days that functional appliances would have such a 

significant influence on the temporomandibular joint. We really didn’t even 

discuss TMJ very much back then. But then, it was kind of funny. I remember 

a mother once said to me, “You know, my little girl had headaches before you 

put that appliance in, and that appliance stopped the headaches. Could you 

put one in for me?” And I said, “These appliances really aren’t for adults, these 

are for children—growing children.” All the literature said they were for growing 

children. But again, I had taken courses from Dr. Brendan Stack, who’s 

probably one of the world’s best on TMJ, and he had shown some cases using 

adults. So I said, well you know what, Brendan did it so maybe I’ll do it. I 

remember telling the mother, “I’m not even going to charge you,” which you 

never should do, and I said, “I’m going to put this appliance in and see what 

happens.” And lo and behold it worked! It brought the jaw forward, the condyle 

came down and forward, it decompressed the joint, and she got rid of her 

pain. Then I said, “Gee, this really is something,” because what I was taught 

to do in dental school was push the jaw up and back, and that didn’t work. I 

was also taught in dental school to use flat plane splints. Well, flat plane splints 

make the jaw go distally and that’s not good if the jaw is already back too far. 

So functional appliances seemed to be the answer. I first started doing children 

with functional appliances, and then gradually built a practice where I now do 

adult TMD/ortho cases. It’s been quite an evolution. 

Anybody getting into this, Mike, I would advise them to gradually add this to 

their general practice. Don’t try to switch over immediately. Learn your skills. 

See if you like it. Most of these patients are in your practice already; most of 

those kids are in your practice because 70 percent of all children have some 

form of malocclusion. And, you and I have talked about this previously, mothers 

really want their kids to be treated and will pay to have their kids treated. 

Q2: So, Mom takes her kid to the orthodontist and the orthodontist says, “Well, let’s 

not do anything until she’s 13 or 14.” And you mentioned Mom would be upset. I 

think most dentists would say, “Well, I don’t understand why.” But the reason is, for 

most of these cases, Mom doesn’t want her kid to look ‘ugly.’ And she’s got malocclusions, 

the teeth are crooked and this poor kid has to go to school and be made fun 

of. And it’s really not that Mom is so worried about the ortho aspect of this per se, 

she’s more worried about how her child looks, right? 

BR: Of course. Self-esteem is a big thing. I was lucky I never had buck teeth. 

But I see these kids come in with buck teeth and they really are very shy. 

They’re shy and they don’t have a normal personality and they’re just not like 

typical children. And the minute you fix that malocclusion and you put a functional 

appliance in and get that jaw forward, they look like all the other kids 

and their whole personality changes. It’s just remarkable. Plus, if they did have 

headaches or earaches or any other TM dysfunction, it brings the jaw forward 

and you relieve all that. And, you open up the airway. So the kid is breathing 

better and sleeping better. 

It’s interesting—a lot of kids have sleep apnea because of large tonsils and 

adenoids. You and I talked about that when you took my course 15 years ago. 

And getting those tonsils and adenoids out has a significant improvement on 

the child’s ability to learn because the pituitary gland secretes a growth hor- 

“The proper size to the 

maxillary arch is the key 

to patients being able to 

breathe through their nose. 

Because when you expand 

the maxilla, you enlarge the 

nasal cavity transversely. 

When you expand the max- 

illa, the palate drops. That 

makes the nasal cavity 

larger vertically. When you 

just expand the maxilla, 

you are providing the best 

service possible for any pa- 

tient. If I could do one thing 

for every patient, that’s 

what I would do.” 


36 


mone. And if children don’t get to the deep stage of sleep, which they don’t 

when they have sleep apnea or when they’re snoring, they don’t grow properly. 

So these kids’ growth is stunted, they wet the bed, and many of them develop 

ADHD—attention deficit hyperactivity disorder. And again, the medical 

profession will prescribe medication for that—Ritalin—to try and calm them 

down. But that’s just treating the symptom while the cause of the problem is 

a blocked airway, which is due to the tonsils and adenoids. Get those out and 

these kids do beautifully. 

Q3: I remember when I took your course 15 years ago that you used to get into 

arguments with the medical community because you could not find an ENT to 

take out the tonsils and adenoids for those reasons. They thought you were crazy. 

Rather, they wanted to wait for six bouts of tonsillitis before they resorted to taking 

them out. In the last 15 years, has that changed much, are ENTs now more willing 

to listen to a dentist? 

BR: Well, it’s three times now, three infections a year requiring antibiotics 

before they will typically remove tonsils and adenoids. My way around it is I 

have an overnight sleep study I give to kids. If I can show that these children 

have sleep apnea, they have to take them out. And I have no problem at all 

when they have sleep apnea. In fact, an ENT wrote me a letter the other day 

and said, “This patient’s tonsils aren’t large.” I took a picture of the tonsil and 

put it on an 8x10 photo and sent it to him—it looked like an apple, it was so 

big. The guy said in the response, “Wow, I guess they are pretty big.” So, I still 

send a copy of the ceph that shows the airway constriction, but most of the 

ENTs don’t learn how to read a ceph. General dentists look at cephs, orthodontists 

look at cephs, but ENTs don’t. But I think it’s getting better. I do have 

some ENTs who will definitely take them out for me, and I have articles to give 

dentists who take my courses to help educate ENTs. I find that everything is 

education—there is not enough communication between the medical profession 

and the dental profession. 

Q4: Well, if the ENT said the tonsils weren’t big enough to come out at this time and 

then you took a photograph and sent it back to him and he said, “Wow, those are 

big,” what was he basing his assessment that they weren’t very big on if he didn’t 

look at them visually? 

BR: You have to keep in mind that the tonsils go up and down. Say the child 

is allergic to dairy products. If they have a lot of dairy products, they’ll get 

really big. And then when they go off dairy products for three or four days, 

maybe they’ll shrink. They also get larger with colds, but we won’t take them 

out if they get large with a cold because it’s part of the immune system. But if 

they’re consistently blocking the airway and causing snoring and sleep apnea 

and all kinds of other health problems, then we definitely get those out. It also 

encourages mouth breathing. 

Q5: So the bottom line is that a patient can have enlarged tonsils and make an appointment 

to go see an ENT, and maybe the first appointment is 10 days later, and 

when the patient shows up they’re back to their normal size and the ENT will say, 

“I don’t know what you’re talking about.” 

BR: That can happen, that can definitely happen sometimes. So we bring them 

in several times—maybe once every two weeks—and we watch them. And 

we also see if they’re mouth breathing. If they’re mouth breathing because 

of large tonsils blocking the airway that is a problem because malocclusions 

have been linked to mouth breathing. Because when the tongue sits low in the 

mouth, it doesn’t go up to the roof of the mouth when you swallow. Every time 

you swallow the pressure from the tongue doesn’t spread out the maxilla, so

the upper maxilla constricts. When the maxilla is constricted 

you get crossbites, and you also get the mandible going distally. 

The cause of the Class II malocclusion has long been 

studied from every angle. It was established in the 1900s that 

the cause of the Class II malocclusion was mouth breathing, 

which caused constriction of the upper arch and forced the 

mandible to go posteriorly to help the patient occlude better. 

We really have to get to the cause of these problems, and we 

have to fix these airway problems early. 

Q6: One of the eye-opening things I learned in your class 15 years 

ago is that, when a child swallows 2,000 times a day—when that 

tongue presses up against that anterior portion of the palate—it 

helps to expand the upper jaw. And until I learned that from you 

and I started reading some of Dr. Brendan Stack’s work on how 

the skull itself was constantly expanding and contracting, I had 

always thought of the mouth and the skull as being in a fixed, 

concrete state. I never realized just how fluid and how dynamic 

things were. But it’s amazing how just through swallowing and 

the tongue pressing on the anterior palate, it really shapes the 

maxilla to the ideal shape and size, doesn’t it? 

BR: Absolutely, it’s key. The proper size to the maxillary arch 

is the key to patients being able to breathe through their nose. 

Because when you expand the maxilla, you enlarge the nasal 

cavity transversely. When you expand the maxilla, the palate 

drops. That makes the nasal cavity larger vertically. When you 

just expand the maxilla, you are providing the best service 

possible for any patient. If I could do one thing for every 

patient, that’s what I would do. And that’s usually my first 

step. Expanding the maxilla creates enough room for all the 

permanent teeth to fit. It makes more room for the tongue so 

the patient can speak properly. Having a proper size maxilla 

allows the mandible, sometimes on its own, to come forward 

and help correct the Class II malocclusion. It will certainly 

correct the Class II Division II malocclusion if you expand 

the maxilla and torque those anteriors out. And many times, 

the mandible comes forward on its own. A lot of these kids, 

the malocclusions can really be corrected long before their 

permanent teeth have even erupted. It’s so easy to work with 

kids with fixed removable functional appliances when they’re 

actively growing. The mothers will happily bring them in, the 

mothers will pay your fee, and everybody appreciates what 

you do. You see the kids get healthier and better looking, and 

it’s very rewarding for doctor and staff. In fact, I’ll tell you one 

thing: you’ll never get any of my hygienists to go back to perio. 

They are orthodontic hygienists who I have trained, and 

they would never go back to perio—they love what they do. 

Q7: When I took your course, I mistakenly thought treating adults 

would be easier than treating kids. Boy was I wrong! And it wasn’t 

until I started doing some cases that I realized it was much easier 

to hop in and do this type of dentistry on kids. 

Today I saw a patient, an adult female, and I thought of you 

because she had her four bicuspids extracted. As I looked at this 

patient from the side, her face looked very flat. It looked like some- 

Phase 1 of two-phase orthodontics is orthopedics 

and Phase 2 is orthodontics. Most of us 

were only taught about orthodontics in dental 

school, and for most of us that education was 

inadequate. Straightening teeth with orthodontic 

brackets, wires and elastics becomes more 

of a finishing technique than the sole purpose 

of treatment. The teeth can almost always be 

straightened, but orthopedics needs to begin 

in the mixed dentition. Without even seeing his 

straight teeth, look at the huge improvement to 

this patient’s profile and facial appearance. 


Most of the time, these malocclusions are 

caused by a mandible that is under-developed 

in relationship to the rest of the face. Often, 

you can confirm if this is the case by having 

the patient slide their mandible forward and 

observing the effect it has on the patient’s profile, 

which is often a very pleasing effect. Many 

times this is all Mom needs to see to agree to 

treatment. 

38 


body had hit her in the mouth with a baseball bat—just a very 

flat face from the base of the nose down to the chin. And as I examined 

her intraorally, I noticed a diastema between the cuspids 

and second bicuspids. Is this something that you see routinely, 

this kind of relapse after four bicuspid extractions? 

BR: What’s happening there is the patient probably has temporomandibular 

joint dysfunction and the condyles are probably 

back too far. And what’s happening is, all night long the 

lower jaw is coming forward and the lower anteriors are pushing 

all those teeth forward and it’s causing that space to open 

up. It takes place over a number of years, it may take five or 

ten years to do it, but that is what’s happening. We see that a 

lot. I’m not saying you can’t take out bicuspids because there 

are specific cases where it’s a good idea. But I think in the 

past far too many bicuspids were taken out. In fact, I took out 

too many bicuspids more than 30 years ago. And I tell my patients 

that I’m doing it a little bit better today because 25 years 

ago I didn’t like my bicuspid extraction results either. I was 

looking at facial profiles that looked very flat. When I started 

using functional appliances, I was developing beautiful faces. 

I think anybody doing cosmetic dentistry has to think about 

creating a good foundation before you do cosmetic dentistry. 

Cosmetic dentistry is the roof in the house, but it helps to 

have a good foundation of orthodontics to build it. 

Q8: You make a great point. The cosmetic dentistry we do at the 

lab is highly invasive and typically needs to be redone every seven 

to 10 years. And a lot of times we’re taking some, or all, of the 

enamel off the teeth to achieve our results. If you truly want to 

achieve esthetic success in the most conservative way, you have 

to be comfortable with diagnosing and/or treating orthodontics. 

And frankly, the only reason—with the exception of tetracycline— 

that porcelain veneers even exist is because of dentistry’s failure 

to diagnosis orthodontics early enough in children. 

BR: I agree, but I think the orthodontic profession has to take 

partial blame for this. They historically waited a long time to 

initiate treatment. But if you look at the orthodontic society’s 

Web site today, they are recommending children be screened 

by age seven. So a lot of orthodontists are now switching their 

practices to early treatment. I remember something you said 

at the end of my course. You said that patients should take 

a class action lawsuit out against the dental schools for their 

failure to train dentists to diagnose or treat an orthodontic 

case. You said we learn fixed and removable prosthodontics, 

we learn periodontics, we learn endodontics. All the other 

specialties are taught to us in dental schools except for ortho. 

The orthodontists basically taught us to refer patients out and 

discouraged us from doing it. 

By the way, Mike, this doesn’t happen in just North America. 

I’ve taught in many places across the world—Hong Kong, Poland, 

Australia, England, Scotland—and everywhere I’ve been 

it’s the same story. I just think that dental schools have to 

change. It was interesting because I just spoke to an orthodontist 

in South America who actually took my course many

years ago in Atlanta. And he told me all general dentists in South America do 

functional appliances. They don’t do braces, they don’t do fixed braces, but 

they do functional appliances. They develop arches, they fix airway problems, 

and they bring the lower jaws forward when they’re deficient. They just treat 

the kids orthopedically. Because remember, orthopedics is to fix the bone 

problems and orthodontics is to fix the tooth problems. So I think we need to 

get better at orthopedics. 

Q9: So once the South American GPs finish the orthopedic portion of the case, they 

send the patients to the orthodontist to do the fixed braces? 

BR: That’s right. 

Q10: That actually makes a lot of sense, doesn’t it? 

BR: It does. I mean, the orthodontist could certainly do that and teach that. 

But again, only orthodontists who do that kind of treatment should be in the 

dental schools teaching. What I feel is, any orthodontist who starts getting 

into teaching GPs seriously gets so much slack from his colleagues that it just 

makes it very uncomfortable for him. But I’m lucky because in Las Vegas every 

year at my big meeting, I’m able to invite some world-class orthodontists who 

really want to share their knowledge and help the entire profession. I invited 

an orthodontist to speak once and he said, “Well, I’m not very popular if I 

come to your meeting.” And he designed this fantastic appliance, a wonderful 

appliance, which I use a lot in my practice. And I asked him: “Did you design 

that appliance to help just orthodontists and their patients? Or did you design 

that appliance to help everybody? All the patients in the world?” I said, “I want 

you to think about that. I’m going to call you back in three days, and I’m going 

to ask you if you’re going to speak at my convention.” I called him back 

three days later, and he said, “You know what, you got to me. You’re right—I 

designed this appliance for everyone, not just orthodontists. And every general 

dentist who’s competent should be able to use this appliance to help their 

patients.” I thanked him very much, and he came on the program, and he was 

a big success. 

Q11: I feel like I got a pretty darn good education at UOP; I got to do six veneers 

back in 1988 while I was in my last year there. However, my big beef with dental 

school is that when I think back on my ortho education, it seems like it was about 

14 minutes long. I remember we had some ridiculously difficult wire-bending task 

to complete. And basically, the take home message was: “See, ortho is tough. Don’t 

even think about doing it: Refer.” My point always was, if we received that little 

knowledge—we didn’t even know barely enough to diagnose, let alone treat—and 

if we got that poor of an education in endo or perio or anything else there would 

be a class action lawsuit by the American people because you’d have to go to another 

country to have a root canal since none of us were taught how to do endo. 

I know there’s a limited amount of time to teach dental students, but this is pretty 

important stuff. Not that any of it’s not important stuff, but I could easily make an 

argument that learning how to do functional orthodontics is just as important as 

learning how to do dentures! 

BR: That’s right. Well, my course is eight days long. At the end of those eight 

days—obviously there are four manuals that go with it and some lab work— 

but at the end of those eight days, I’ve got dentists doing simple cases. They’re 

graduating and they’re coming out doing simple cases. You know, if you added 

eight days to any orthodontic curriculum, which you could easily do, you 

could reduce some of the information on other courses and get general dentists 

to have a basic understanding of what they’re doing to help patients. 

“I don’t mind selling, but 

I’d rather just present the 

case and have them say 

yes. It’s just so much more 

professional. And I don’t 

have to sell ortho—it sells 

itself. I mean, all mothers 

want their children to have 

straight teeth; they want 

them to be healthy.” 


40 


Seventy percent of kids have some type of malocclusion. That’s a huge number 

of children in your practice that could benefit. And you don’t have to do any 

external marketing—they’re right there and they trust you. All those patients 

in your practice trust you and like you and they will listen to you. 

Q12: Most dentists don’t seem to enjoy working on kids. Most GPs want to have 

an all-adult practice that they can do crown and bridge on. They don’t like doing 

fillings on the kids because that doesn’t bring in a lot of money. It’s really pleasing 

when you get to work on kids without a needle, without a handpiece, and the 

same parents who couldn’t afford two crowns on themselves can suddenly afford 

the same $2,000 for their kids. Have you noticed that, that parents are much more 

willing to spend money on their kids than themselves? 

BR: Yes, from one room to the other. I remember one time I suggested a 

crown, it was $1,000 and the mother said, “I can’t afford that.” Her little girl 

was in the next room having a prophy and a cleaning and fluoride treatment, 

and I walked in and said, “Geez, she’s got a narrow jaw here. She’s got 

a crossbite in the back. You know, that’s going to be about $1,500. Plus the 

orthodontic records, that’s going to be around $2,000.” And the mother said, 

“Well, when do we take the records?” And, of course, I said, “Do you mind telling 

me why you just couldn’t afford the crown for $1,000?” She said, “Children 

are different. My child gets whatever she needs. We will find the money, and 

we’ll pay it on time.” I said, “Of course. We’ll set up a payment plan for you. 

You pay so much a month.” And she said, “Well, we’re going to get that done. 

There’s no question.” 

Now we’re into a situation where the U.S. is in a recession. You and I talked 

about that a couple of days ago. You said elective dentistry in the lab is down 

a bit. Well, I can tell you my practice is not down. We’re averaging about six 

new patients a day in ortho, TMD and sleep apnea—we’re just really humming 

along. And each one of those patients could be a significant amount. If you 

do just functional appliances, it is about $2,000. But if you do the entire ortho 

case, it’s about $6,000 in my office. There’s a lot of demand for health. There’s 

a lot of demand for someone who can do a case without extracting permanent 

teeth. And there’s a lot of patient demand to use functional appliances in order 

to avoid orthognathic surgery, in cases where it’s appropriate. 

Q13: Isn’t it funny how when it comes time to tell adults about their proposed treatment, 

we get into case presentation and how to educate your patient to get them to 

say yes. If you have a patient who needs $6,000 worth of crown and bridge, you 

have to really kind of put on a sales cap to convince them this is the right thing for 

them to do. And you’re saying that you tell the same patient their kid needs $6,000 

worth of ortho and they’ve already got their checkbook out of their pocket! 

BR: It’s great. I don’t mind selling, but I’d rather just present the case and 

have them say yes. It’s just so much more professional. And I don’t have to sell 

ortho—it sells itself. I mean, all mothers want their children to have straight 

teeth; they want them to be healthy. And I think if you talk about the airway 

and you talk about the breathing and you talk about the sleep apnea and you 

talk about the healthy temporomandibular joint, you talk about all the things 

that functional appliances deliver, and more room for your tongue to speak, all 

of the things you can do for their kids, mothers say, “You know what, I want 

to be in your practice.” And then, that builds my general practice because they 

want to switch from their dentist to me. That’s because their general dentist 

said wait till 13 and the orthodontist said wait till 13, and the mother said, 

“It doesn’t makes any sense.” And mothers are smarter nowadays. They talk. 

I mean, they go to soccer practice, they go to church, and they go to the gro-

cery store, everywhere, talking to other women. And if one 

woman has been to my practice or to another practice that 

does functional appliances or early treatment, that’s where 

those mothers are going to head. 

Michael DiTolla: There is absolutely a secret society of women 

that men don’t know about because men are typically at work. 

But it’s true: if you’re off for a day and you take your kid to soccer 

practice, you see this. And the number one priority in these 

mothers’ lives is making sure their kids are healthy and that they 

look good. 

BR: I had a referral today from that. The guy came in and I 

said, “Well, how did you find us?” And he said, “My next door 

neighbor comes to you and really likes you.” We had another 

consultation with someone else, and I said, “Are you coming 

here because you didn’t like what he said?” And he said, “No, 

no, you were just so highly recommended we had to meet 

you.” So, word of mouth spreads. And if you do a good job 

with these patients—I mean, it’s the same as any business 

or any practice—you’re going to get referrals. And we get 

referrals. I’m really happy with that. We do treat our patients 

well. 

Q14: And just as a little bit of disclosure, when I first took your 

course, the eight day course, I went back and—as most dentists 

are—I was afraid to do my first ortho case, like most dentists 

are terrified to place their first implant. So I didn’t do any ortho 

cases right away. Then, when it came time where I had some 

patients lined up, I had forgotten a lot from the course. And you 

were generous enough to let me come back and audit the course 

a second time. When I came back the second time having done 

some screenings and records, I knew what questions to ask and 

I was ready to go. So once I took the course a second time, I was 

able to go back and start treating these kids with a bigger degree 

of confidence. Are you still letting attendees audit the course like 

that after they take it the first time? 

BR: Absolutely. If they want to take it again, they can take it 

for half price. If they bring someone with them, they come 

free. But what I’ve just done, Mike, is my Internet course. I’ve 

already got 30 people lined up just to know how much I’ll 

charge. And I’m going to be very fair to the first 50. I’m going 

to give a deal to the first 50 and then it’ll go up, up, up. And 

that is going to be a really good way to learn because there’s 

going to be a 20-minute session and then there’s going to be 

a test at the end of every 20 minutes. And then you’re going 

to get hours of continuing education. Plus you’re going to get 

notes. I think the Internet is a really good way to learn. So 

maybe they won’t have to retake the course. Maybe they take 

it once and then if they take the Internet course, it’s a nice 

review and they can do it in their home. They won’t have to 

travel. Nowadays, you have to deal with the hassle of airfare 

and air travel, the cost of gas and hotels and everything else. 

Q15: Also, Space Maintainers ® Laboratory had a big part in why 

I started to do ortho cases because I was really nervous. Even af- 

In two-phase orthodontics, Phase 1 is the orthopedic 

stage in which the jaws are developed 

to correct skeletal malocclusions and create 

room for the permanent teeth. In a patient that 

is still growing, it is possible to accelerate the 

growth of the mandible to catch up with the 

maxilla with a functional appliance such as the 

MARA appliance. When the patient tries to 

bite down into a Class II relationship, the arms 

on the appliance guide the mandible forward 

into a Class I relationship. Patient compliance 

is assured because the MARA appliance is cemented 

into place. 


These are the upper and lower components of 

the standard Twin Block appliance, one of the 

functional appliances referred to in the interview. 

Twin Blocks are ideal for treating children 

with skeletal Class II malocclusions while 

developing the maxillary arch simultaneously. 

Twin Blocks can be made as fixed or removable 

appliances based on the child’s expected compliance. 

42 


ter the second time I was nervous to start some of these cases. And 

it was right at the time Space Maintainers came out with something 

called The Second Opinion, where you send all the patients 

orthodontic records to them and you get a 120-page “cook book” 

on how they suggest to treat each patient. I did that for the first 

10 or 15 patients I treated. And then once I realized everything 

was just like you said it was going to be in the course, I tapered 

off The Second Opinion for the easier cases. Do you think that 

type of hand holding is a good idea for the GP who’s doing his 

first few cases? 

BR: Absolutely. They are a great lab. They’ve got a lot of good 

education materials, brochures, and they have great people 

on the telephone to help you with cases when you call in. 

And they also have The Second Opinion. And, as you mentioned, 

when dentists come to my courses they’re allowed 

to bring cases, models and photographs—all the things we 

teach you how to do with the records in the course and the 

X-rays—and I now have assistant instructors at the courses. 

And the assistant instructors and I review cases at no charge. 

We’re there to make sure everything goes well. You know, I’ve 

never had anyone successfully sued who took my course and 

I’ve trained 10,000 dentists. Anybody who follows my system 

and takes the records the way they’re supposed to and who 

doesn’t do the difficult cases we teach them not to do. 

Q16: Give me a typical timeline for one of these two-phase ortho 

cases. Let’s say an 8-year-old patient comes in with a Class II 

malocclusion. 

BR: What I would do is put in an appliance to widen the upper 

arch. That would take about four months. Then I would 

probably put in a Twin Block , which would move the lower 

jaw forward. That would take about seven months. And then 

I would probably modify the Twin Block into a Twin Block 

2, and hold her there until she’s maybe 10 years old. She just 

wears the appliance for another six months. So treatment time 

so far would be 17 months. And I wouldn’t have to see her 

every month because the appliance works almost by itself, so 

I’d see her every two months. And the mother would pay me 

about $200 a month and I’d check her for about five minutes. 

We’ll spend more time cleaning up the room and getting it 

ready for the next patient than actually seeing the patient. I 

just make sure to check the appliance, make sure it’s not hurting, 

and adjust the appliance accordingly. Turn the screws or 

whatever you have to do. Then, I would just wait until all the 

rest of the permanent teeth erupted. And many times when I 

do that, you deal with 80 percent of the malocclusion. Then 

when the permanent teeth erupt, I might only be in fixed 

braces for nine months. So I would tell the patient, “Look. My 

usual fee is $6,000. Let’s do Phase 1 for $2,000. If you have to 

do Phase 2, the most I would probably charge you is $4,000.” 

And then if the patient comes back, you say, “Look, I’ve got a 

conscience. I really can’t charge you $4,000, I’ll only charge 

you $3,500 because it’s only going to take me six months.” 

The mother’s quite happy. But I say, “Because I’m losing so 

much money on this case, you have to refer me to at least

two more patients.” And believe it or not, the mothers say, “Okay. I will.” It’s 

just unbelievable… they do. So then, wouldn’t that be nice if you had a child 

where you could treat early and wear these appliances for 17 months, which 

are no trouble for the kids to wear. 

Q17: And isn’t it surprising how if you personalize the appliances for the kids, with 

a flower or a team logo, they are more apt to wear them? 

BR: Oh yes, absolutely. And I tell them, “Make sure you take this and show it 

to everybody else in your class and see if anybody else has one—because I 

think you’re the only person in the world who’s got it.” So then they’re showing 

the appliance off. And you are right: you personalize it, which Space Maintainers 

will do for you. They’ll send you a chart and let the kids pick the color 

they want, which is fun for the kids. 

My office is a very upbeat office, and I’ve got to do a lot of consultations all 

day. And I hear laughter all day. You just hear kids laughing and their parents 

laughing and everybody’s having a good time, which is different from some 

dental offices. And quite frankly, I’m not tired. We see 60 patients a day but it’s 

not tiring because I’m doing sleep apnea and some TMD cases. I’m also getting 

some very difficult patients referred to me by some general dentists who take 

my courses—they send me all the tough ones and they do the easy ones—so 

it takes me a little longer to do some of those cases. So we can really only do 

about 50 a day, but it’s just a pleasant way to practice. I’m so happy I got into 

ortho; I really feel I’m helping a lot of patients and it’s very rewarding. 

When I look back, I think I was thinking of the money. I was thinking I can 

get a room going in ortho and I don’t have to be in there that much. We can 

generate some income there that’s nice and helps the bottom line and helps 

me feed my family. But eventually, when I sat back down to think about it, it’s 

more about the personal satisfaction. After a while, you have enough money 

and you really want to feel that you’re doing something good for your patients. 

And I feel I’m significantly improving the health of my patients. I believe that 

most dentists went into the profession to help people, I really do. And I’m not 

saying that when you put on 10 veneers that you aren’t improving their smile 

and their self-esteem, but I am improving their health as well. Especially when 

I treat snoring or sleep apnea. We really don’t have time to talk about that today, 

but maybe someday we can talk a little bit about snoring and sleep apnea 

because that’s another huge area of growth for any practice. 

Q18: Fifteen years ago, I don’t think you were talking much about snoring and 

sleep apnea. How did you get started with that? 

BR: Well, I started noticing that an awful lot of my patients who were Class 

II malocclusions and had TMJ problems were also snoring and sleep apnea 

patients. I started reading about how bad sleep apnea is for your health. Forty 

percent of patients who have heart attacks have sleep apnea. Forty to 60 percent 

of diabetics have sleep apnea. Over 50 percent of patients who have a 

stroke have sleep apnea. GERD—gastroesophageal reflux disease—is also associated 

with sleep apnea. So all these medical problems are being caused by 

sleep apnea. I thought, if I don’t deal with the sleep apnea, how can I make 

my patients healthier, number one? I need to open up the airway because a 

lot of these patients are depressed, or they’re depressed because they’re not 

getting much sleep and they’re tired all the time, or they’re depressed because 

they’re in pain since their jaw is back too far. So the same patient who has 

sleep apnea is the TMD dysfunction patient. Because when your jaw is back, 

your condyles are back pressing on your nerves and blood vessels. And when 

“After a while, you have 

enough money and you re- 

ally want to feel that you’re 

doing something good for 

your patients. And I feel 

I’m significantly improving 

the health of my patients. 

I believe that most dentists 

went into the profession to 

help people, I really do. And 

I’m not saying that when 

you put on 10 veneers 

that you aren’t improving 

their smile and their self- 

esteem, but I am improving 

their health as well.” 


“I would encourage den- 

tists to broaden their ho- 

rizons because there’s a 

tremendous need for early 

diagnosis for kids. There’s 

a tremendous need to learn 

about TMD. Most dentists 

are scared stiff of TMD— 

they don’t want to get near 

it. But snoring and sleep 

apnea is a much shorter 

learning curve, you can 

learn that in a much shorter 

period of time.” 

44 


your jaw is back, your tongue is back blocking your airway. When the tongue 

partially blocks the airway it’s snoring. But snoring is not dangerous to your 

health—just bad for your relationships. Probably 50 percent of my patients 

are coming in from their wives telling them, “Get in there. Otherwise, you 

are in a different bedroom and we’re going to get divorced…or something.” 

The other 50 percent are stopping breathing. They have been to the medical 

doctor who sent them to a sleep center for a polysomnogram—an overnight 

sleep study—and they’ve been diagnosed with sleep apnea. And the medical 

profession likes the CPAP machine, which is the thing that goes over the nose 

and looks like Darth Vader and blows air up your nose all night. A lot of patients 

can wear it, but a lot of patients can’t. So the patients who can’t wear it 

would come to me and say, “Look. I can’t wear this medical device but I’ve got 

the problem; can you help me?” And recently, the American Academy of Sleep 

Medicine came out with a statement that said: “For mild to moderate cases of 

sleep apnea, oral appliances are the treatment of choice.” So, when I read that 

in 2006 I realized, Mike, that we are now getting the backing of the medical 

profession to make oral appliances for the mild cases and slightly moderate 

cases. But for severe cases, we send them to the medical profession for the 

CPAP machine. It’s been a huge benefit to my practice, and now I really feel 

I’m treating all patients. 

If I could just tell you one quick story: I had a patient today who came to me 

five months ago for snoring and sleep apnea. I examined her and I found her 

jaw went back, she had an overjet of 7 mm. Her tongue was back too far blocking 

the airway and she had sleep apnea. Then I examined her TMJs and found 

that she had temporomandibular joint dysfunction. She had headaches every 

day, she was on three medications a day, and she was very, very sick. She was 

very tired all the time because of sleep apnea, tired all the time because of the 

medication, and just really a very unhappy lady. So here’s a patient with an 

orthodontic problem. Here’s a patient with temporomandibular joint dysfunction 

and signs of sleep apnea. That’s why I’m doing all three, because they’re 

all related. I said to the patient, “I’m going to put you in a MARA appliance, 

which is going to bring your jaw forward. I am hoping that when I do I’m going 

to solve all three problems.” 

Today she told me in front of another patient that since I put the appliance 

in, her headaches are gone. Her sleep apnea is gone, her snoring is gone, and 

she’s just a different person. She’s off medication. She did admit to me that 

she’s had two headaches in five months, but they were so minor she could 

take over-the-counter Tylenol. Just those two small headaches in five months, 

and she said she used to have them all the time constantly, migraines, everything. 

And she was on three pain medications daily, 24-hours a day. She said, 

“I’m 60 years old and I feel like I’m 40.” 

Q19: That is amazing because I think it really gets to the heart of what you’re doing. 

And that’s why you’ve always gotten me excited about this. Because when we 

put veneers on a patient, every once in a while we’ll get a patient whose self-esteem 

was really hurt by their smile. So, when they see their new teeth for the first time 

they might cry because of the esthetic improvement. But we’re doing an esthetic improvement—and 

that’s fantastic—but what you’re doing on some of these patients 

is a massive quality of life improvement. And you’re taking somebody who lived in 

pain with these headaches on a daily basis and removing those—you must end up 

being a hero to a lot of these patients. 

BR: (Laughs). It’s terrific, but you’ve got to make the right diagnosis, you 

have to take full records, and you have to learn what you’re doing. There are 

courses everywhere for dentists to take. Dentists can take good courses—not

just mine—there are lots of good courses they can take. But I 

would encourage dentists to broaden their horizons because 

there’s a tremendous need for early diagnosis for kids. There’s 

a tremendous need to learn about TMD. Most dentists are 

scared stiff of TMD—they don’t want to get near it. But snoring 

and sleep apnea is a much shorter learning curve, you can 

learn that in a much shorter period of time. 

Q20: So you’re teaching the ortho courses, and now you’re teaching 

snoring, sleep apnea and TMD courses as well? 

BR: I am, and attendance on those courses is maybe 15 or 20 

dentists. They’re not like the ortho courses that usually have 

40 dentists because more people are interested in treating 

kids orthodontically with these appliances. And that’s probably 

a good way to start. That’s the basics. I would encourage 

dentists to take the ortho course first and then see if they like 

the science of sleep apnea or TMD. But I’ve transitioned a lot 

of dentists into those courses and most of the dentists going 

to those courses have taken my previous courses, and their 

practice is rolling along. What I’ve told them works, they are 

happy with the results, they feel good about what they’re doing 

for patients, and they just want to get better. 

MD: For dentists who are interested, what is your Web site so they 

can look into getting more information? 

BR: It is www.rondeauseminars.com. 

MD: I just wanted to say that since the first time I took your course 

you’ve struck me as a really open-minded dentist, somebody who 

is willing to speak the truth whether it’s popular or not. And while 

the things you said 15 years ago made me shake my head a little 

bit then, I look to you now and I think you should feel somewhat 

vindicated—they appear to be true and the research backs it up. 

And certainly my own clinical experience backs it up as well. You 

taught me how to be a better dentist and make my patients happier 

and make them healthier at the same time, AND make more 

money. And there is nothing wrong with that. I want to thank you 

for your time today. You shared some really important ideas with 

our dentists, and I look forward to doing this again with you in 

the future. 

BR: Thanks a lot, Mike. It’s really a pleasure to talk to you 

again. 

To contact Dr. Rondeau, e-mail brondeau@rondeauseminars.com or call 877-372- 

7625. 

The functional appliances presented in this article are courtesy of Space Maintainers ® 

Laboratory (Chatsworth, CA, 800-423-3270). 

The top picture is a functional appliance called 

a Bionator. Popular in Europe for decades, it 

continues to grow in the U.S. and Canada as an 

effective appliance in both mixed and permanent 

dentition. The Bionator corrects Class II 

skeletal malocclusions with growth and forward 

movement of the mandible, and can be used to 

open the bite or close an anterior open bite. 

On the bottom is a fixed functional appliance 

called a Rick-A-Nator . Cemented to the maxillary 

first molars with ortho bands, it consists 

of an anterior bite plane lingual to the maxillary 

anterior teeth. It is an ideal appliance for minor 

mandibular advancement (

Building the 

Edentulous 

Impression 

A Layering Technique 

Using Multiple Viscosities 

of Impression Material 

– ARTICLE by Joseph Massad, DDS 

– COVER PHOTO by Sharon Dowd 

– CLINICAL PHOTOS by 

Joseph Massad, DDS 

In a recent Internet survey (n=701), dentists reported 

that many edentulous patients complained of poorfitting 

dentures (Dental Economics Survey Primary 

Research, October 2005). The patients perceived looseness 

or movement of the denture and generalized soreness. 

To provide a more detailed and customized impression 

of the edentulous patient, a procedure using both 

the static and functional concepts of impression making 

in one application will be described. 

The Static Impression Technique is used to create an accurate 

impression of undisturbed and uncompressed tissue. 

1,2 The Functional Impression Technique explains the 

need to make an impression based on the differing degrees 

of tissue function. 3-5 

“The soft tissue 

overlying the 

residual ridges 

should be 

assessed using 

a blunt instrument 

to determine the 

relative amount 

of displacement 

or mobility.” 

Building the Edentulous Impression47

Evaluation and Classification of Tissue Quality 

After a thorough patient history has been obtained, the 

intraoral and extraoral structures should be evaluated 

closely. Inspecting intraoral tissue will permit the clinician 

to determine the character and mobility of the overlying 

soft tissue. Classifying the tissue after examination based 

on the differences between tissue character and mobility 

will give the clinician a simple method for selecting the 

appropriate viscosity to make the impression. 

The clinician uses tactile manipulation to assess the character 

of the tissue overlying the bony support in the 

edentulous arches and classifies the tissue as coarse and 

fibrotic, average, or thin and fragile. For example, if a 

patient’s tissue quality is determined to be coarse and fibrotic 

covering the residual ridges, it is generally thought 

that the patient is able to tolerate a removable complete 

prosthesis better than if the supporting tissue is classified 

as thin and fragile. 

The soft tissue overlying the residual ridges should be 

assessed using a blunt instrument to determine the relative 

amount of displacement or mobility. After tactile assessment, 

the tissue can then be classified and recorded 

as one of the following: attached, low mobility, low displacement; 

average, clinically acceptable displacement; 

or high mobility, high displacement. Soft tissue that is 

categorized as attached and less mobile quality overlying 

the alveolar ridge generally results in better adaptation of 

the removable prosthesis. Conversely, soft tissue quality 

that is categorized as high mobility and high displacement 

typically represents a clinical condition that is more 

difficult to manage and prepare for well-fitting complete 

dentures 6 (Figure 1). 

Materials 

It has been demonstrated that the type of impression materials 

used for making the final impression can have a 

critical effect on the pressures produced during the impression 

making procedure; therefore, tray modifications 

have less significant influence when the amount of pressure 

produced needs to be controlled. 7 

48Building 

the Edentulous Impression 

Figure 1: The tissue character can be assessed using digital/tactile 

evaluation. 

Figure 2: The patient or a dental assistant can help provide adequate 

tissue retraction when building the impression. In this instance, a patient 

is shown holding cheek retractors in preparation for the procedure. 

Figure 3: Use the high viscosity PVS impression material to create 

tissue stops in the stock impression tray.

In an attempt to select the most appropriate material 

for the technique, a review of the types of impression 

materials was completed. Materials considered included 

plaster, impression compound, zinc oxide eugenol, alginate, 

polysulfide, polyether, condensation silicone, and 

polyvinylsiloxane (addition-reaction silicone). Next, the 

important characteristics required to make a simultaneous 

static and functional impression were recorded 8-10 

(Table 1). 

Plaster 

Viscosity 

Border Wash 

Table 1 

Co-lamination 

between 

Viscosities* 

Hydrophilicity 

Light NO YES NO YES 

High Tear 

Strength 

It is important to use an impression material that maintains 

dimensional stability during removal and reinsertion 

while making an impression that must be seated beyond 

anatomical undercuts. 8 This requires a material with a 

high percentage of recovery from deformation. 8 It is also 

important that the clinician be allowed to apply varying 

viscosities sequentially and simultaneously that will set 

to form a homogeneous mass of impression material, regardless 

of the viscosity used. The materials selected for 

this technique must exhibit high tear strength (resistance 

to tearing) across the multiple viscosities used in this procedure. 

8,9 Impression 

NOT 

Heavy YES NO NO NO NO NO 

SENSITIVE SENSITIVE 

CONSTANT 

Compound 

Zinc Oxide Light & 

NOT 

NO YES NO NO NO NO 

CONSTANT 


Euqenol Medium 

Alginate Light & 

NOT 

NO YES NO YES NO YES CONSTANT 


Heavy 

Light & 

Polysulfide 

YES NO NO YES YES 

SOMEWHAT 

Heavy 

YES 


CONSTANT 

Polyether Multiple 

YES YES 

YES CONSTANT 

SLIGHTLY NOT 

YES WEAK 

WEAK 

YES 

YES 


Condensation Light & 

WEAK NOT NOT NOT 

YES YES YES NO YES 

CONSTANT 

Silicone Medium 

YES 


Polyvinyl 

NOT NOT 

Multiple YES YES YES YES** YES YES CONSTANT 


Siloxane 

* When applied separately but not simultaneously 

** With surfactant added 

The use of the multiple viscosities of impression 

material should be such that there is a co-lamination 

between the layers of material and an anatomically cor- 

NO 

Engage Working and 

Undercuts Setting Time Patient 

NO 

Operator 

NOT 

CONSTANT SENSITIVE SENSITIVE 

Figure 4: After creating tissue stops in the tray, add high viscosity PVS 

onto the tray flanges and border mold to define the vestibular areas. 

Figure 5: The maxillary master cast is highlighted to demonstrate the 

anatomical features that should be reproduced in the final impression. 

Figure 6: The mandibular master cast is highlighted to demonstrate the 

anatomical features that should be reproduced in the final impression. 


“Based on the characteristics 

of the materials reviewed, 

polyvinylsiloxane materials 

appear to meet all the 

requirements that support 

use of this layering 

impression technique.” 

rect and detailed reproduction that captures all aspects of 

the edentulous arches. 

Based on the characteristics of the materials reviewed 

(Table 1), polyvinylsiloxane (PVS) materials appear to meet 

all the requirements that support use of this layering impression 

technique. The impression material used to demonstrate 

this technique is a hydrophilic, polyvinylsiloxane 

material and a specially designed disposable edentulous 

tray. The authors chose Aquasil Ultra PVS (Dentsply Caul, 

Milford, DE). Other polyvinylsiloxane materials available 

are Clone Bite and Chromaclone PVS Super Light (Ultradent 

Products, South Jordan, UT), Imprint (3M ESPE, St. 

Paul, MN), and Extrude ® (Kerr Corporation, Orange, CA). 

Clinical Application 

For optimal intraoral access, appropriate lip and cheek retraction 

is made to assist the clinician during the impression-making 

procedures of the maxillary and mandibular 

arches (Figure 2). The high viscosity PVS impression material 

with low strain in compression is used initially to 

create tissue stops before proceeding (Figure 3). The low 

strain property of the material during compression helps 

reduce tissue movement or rebound after polymerization 8 

and helps to create predictable tissue stops when reinserting 

the tray during subsequent steps. The tissue stops 

create adequate tissue relief for the impression material, 

help to reposition the impression intraorally, center, and 

stabilize the tray on the edentulous residual ridge. The tissue 

stops provide the clinician with a predictable position 

50Building 

the Edentulous Impression 

Figure 7: Multiple viscosities of PVS impression materials are being dispensed 

in the maxillary tray. In this instance, the ultra low viscosity is 

applied to the premaxilla area, which had been evaluated as loose and 

having a spongy character upon tactile evaluation. The low viscosity was 

applied to the mid-maxillary area where the tissue exhibited average tissue 

character and average mobility. 

Figure 8: Multiple viscosities of PVS materials are being dispensed in the 

mandibular tray. In this instance, the ultra low viscosity was applied to the 

anterior mandibular area because of fragile, loose, unsupported tissue. 

The low viscosity was applied to the posterior mandibular areas where 

the tissue was of average mobility and average tissue character.

on tray reinsertion, helping to prevent over-seating the 

tray during functional border molding. 

The impression tray is removed and excess impression 

material is trimmed. High viscosity PVS is then added to 

the borders of the maxillary impression tray, then border 

molded. The medium viscosity PVS is placed on the 

borders of the mandibular impression tray, then border 

molded. Each tray is border-molded separately within the 

stated setting times (Figure 4). The high viscosity PVS used 

in this study captured anatomical details such as frena 

and the vestibular sulcus throughout and extended sufficiently 

to capture the postpalatal area in the border-molding 

procedure for the maxillary arch. For the mandibular 

arch, it is important to preserve and maintain all frena, 

vestibular sulcus, retromylohyoid space, and the retromolar 

pads (Figures 5 and 6). 

Dry the impression and place the appropriate viscosity 

impression material onto the basal seat (load-bearing 

area) as a thin, “wash” impression; the appropriate viscosity 

of impression material selected is based on evaluation 

of the tissue character and mobility classification (Figures 

7 and 8). For example, the premaxilla and anterior mandibular 

areas displayed poor tissue character and mobility, 

which required the extra light viscosity material, while 

the posterior maxillary and mandibular arches displayed 

average tissue character and mobility, which suggested 

the need for low or average viscosity PVS material (Figures 

9 and 10). The clinician should inspect the accuracy of the 

impressions to ensure that all tissue details have been 

captured before pouring the master cast. 

To preserve and protect the peripheral detail of the vestibular 

borders of the impressions, each final impression 

is boxed using the alginate boxing method. It is extremely 

important to maintain the peripheral borders of both the 

maxillary and mandibular impressions when boxing and 

to avoid over-trimming the master cast, which could compromise 

anatomical details of the vestibular borders (Figure 

11). The selection and use of an appropriate dental 

Figure 9: The final impression of the edentulous maxillary arch shows 

use of four viscosities of PVS impression material, as defined by the various 

colors. The high viscosity was used initially to create the base tissue 

stops and to border mold the vestibular areas. 

Figure 10: The final impression of the edentulous mandibular arch 

shows use of three viscosities of PVS impression materials, as defined 

by the various colors. The high viscosity was used initially to create the 

base tissue stops and to border mold the vestibular areas. 


stone is made in consideration of selecting one with controlled 

expansive/contractive properties 9 (Figure 12). 

An evaluation of the adequacy of the bond between the 

various viscosities of impression material was performed. 

Four different viscosities of impression material were 

used to build and complete the final impression (Figure 

13). High viscosity (green), medium viscosity (purple), 

low viscosity (teal), and ultra low viscosity (orange) 

impression materials were used to record the maxillary 

impression used in this clinical situation. The high viscosity 

material was used to create the tissue stops and 

border molding, each being applied and allowed to set 

separately. The remaining three viscosities were applied 

sequentially in the predetermined areas of the tray, reinserted 

intraorally, and allowed to set simultaneously. 

After the material set and the impression was removed, 

the impression was sectioned longitudinally using a sharp 

blade to demonstrate the various layers of impression materials 

used and the relation to the anatomical area reproduced 

intraorally (Figure 13). Note the approximation of 

material layers and co-lamination of the various viscosities 

in the cross-sectional view, evident in the thinly layered 

sections. 

Based on informal testing, it was found that the different 

viscosities, applied and allowed to set simultaneously, 

could not be separated. However, the materials that were 

applied in separate layers (such as in a dual technique) 

exhibited more than adequate adhesion to each other and 

could only be separated with difficulty after several attempts. 

It should be noted that adhesion between impression 

layers was enhanced when the layers were dried before 

placing the subsequent layer. Even in the presence of 

slight moisture contamination, the co-lamination between 

layers was sufficient to pour and create the master cast. 

Conclusion 

Making acceptable final impressions when fabricating 

complete dentures is an important requirement for the 

successful treatment of an edentulous patient. Diagnosing 

the tissue condition and classifying the edentulous arch 11 

should be determining factors when selecting an impression 

technique for a specific patient. 

52 

Building the Edentulous Impression 

Figure 11: The final impressions are boxed to create a dense master 

cast and to preserve the peripheral flanges carefully created intraorally.

The layering technique presented in this article represents 

an alternate impression technique for the clinician 

who thoroughly understands the basic principles in complete 

prosthodontics and has the clinical ability to evaluate 

and assess intraoral tissues of the edentulous patient. 

The clinician can use multiple viscosities of an impression 

material and a stock edentulous tray (in this example, a 

well-designed disposable edentulous impression tray) to 

border mold and create an impression of the edentulous 

arch efficiently and accurately, as an effective clinical solution 

for the contemporary practice of treatment of the 

edentulous patient. 

To contact Dr. Massad, call 888-336-8729, visit www.gdit.us or www.joemassad. 

com, or e-mail using the contact message form at www.joemassad.com. 

References 

1. Bohannan HM. A critical analysis of the mucostatic principle. J Prosthet Dent. 

1954; 4:232-241. 

2. Addison Pl. Mucostatic impressions. J Am Dent Assoc. 1944;31:941-946. 

3. Pendelton CE. The positive pressure technique of impression taking. Dent Cosmos. 

1931;73:1045-1056. 

4. Frank RP. Controlling pressures during complete denture impressions. Dent 

Clin North Am. 1970;14:453-470. 

5. Boucher CO. A critical analysis of mid-century impression techniques for full 

dentures. J Prosthet Dent. 1951;1:472-491. 

6. Massad JJ, Golijan KR. A method of prognosticating complete denture outcomes. 

Compendium. 1994;15:900-909. 

7. Masri R, Driscoll CF, Burkhardt J, et al. Pressure generated on s simulated oral 

analog by impression materials in custom trays of different designs. J Prosthodont. 

2002;11:155-160. 

8. Anusavice, KJ. Phillips’ Science of Dental Materials, 10th ed. Philadelphia, PA: 

Saunders; 1998. 

9. Albers, HF. Impressions. A Texbook for Technique and Material Selection. 2nd 

ed. Santa Rosa,CA: Alto Books; 1990. 

10. Ferracane, JL. Materials in Dentistry Principles and Applications. 2nd ed. Philadelphia, 

PA: Lippincott Williams and Wilkins; 2001. 

11. McGarry TJ, Nimmo A, Skiba JF, et al. Classification system for complete 

edentulism. The American College of Prosthodontics. J Prosthodont. 

1999;8:27-39 

Reprinted from Compendium: Massad J, Lobel W, Garcia LT, et al. ‘Building The 

Edentulous Impression: A Layering Technique.’ 2006; 27(8):446-452. Copyright 

©2006, with permission from AEGIS Publications, LLC. 

Figure 12: The master casts have been poured, allowed to set completely, 

and trimmed. Note the peripheral flanges have been preserved 

as the boxing procedure creates a “land area” around the periphery of 

the anatomical areas of the impression. 

Figure 13: The sectioned impression shows the multiple layers of impression 

material in cross-section. 


I 

The 

Dangers 

of Denial 

am a dentist with oral cancer. Even worse, I’m a dentist who ignored his oral cancer. In spite of playing tennis every 

Tuesday with a physician friend, having many patients who are doctors and staff members who could have checked 

a bulge in my neck, I ignored it. 

I don’t know why I didn’t act sooner. After all, I’m a doctor, and I have always told my patients to take their health 

seriously. But I guess I’m human first. You see, I had missed just one day of work in 24 years of dentistry and, like 

my dentist-father before me, I never thought there could be anything wrong with me. Somewhere inside I must have 

thought I could be immune from the very disease I try to help patients prevent. 

But reality started to hit me in December 2006. One morning, dressing for work, I went to button my shirt before putting 

on my tie. The collar was tight. I assumed I was getting fatter, or older, or possibly both. But upon further examination 

I noticed a swollen gland to the right of my Adam’s apple. I was fighting an infection, I thought. I ignored it—for 

six months. 

54 

The Dangers of Denial

One day I asked my hygienist to check my neck. She 

suggested I have a doctor look at it right away. I didn’t. 

Then, a few weeks later, I took my nine-year-old son in 

for a routine checkup and asked his pediatrician (who is 

also my friend) to check the lump. She gave me “the look” 

that I won’t soon forget. Three days later I was diagnosed 

with a superball-size mass at the base of the tongue, with 

a secondary tumor in my lymph node the size of a baseball 

and the culprit of the bulge. The radiologist said he 

didn’t think it was squamous cell carcinoma, one of the 

most dangerous cancers. I agreed, thinking back to my 

days in dental school 25 years ago, when I first learned 

about it. The next day the cancer was biopsied, and it was 

squamous cell carcinoma, stage IV, the worst. I fell to the 

floor hysterically crying, swearing I was ready to die if 

that was God’s plan. But how could this be happening to 

“ 

Three days later I was diagnosed with 

a superball-size mass at the base 

of the tongue, with a secondary tumor 

in my lymph node the size of a 

” 

baseball 

and the culprit of the bulge. 

me? I wasn’t ready to leave my two boys, Jamie and Ryan, 

my beautiful wife Anne Marie, my friends and family. I 

was devastated. 

The next few weeks were a daze. Every day was another 

doctor, another test. At one point we went to a doctor’s 

office and everyone seemed to know me. I had no idea 

why. My wife informed me this was the third time at this 

office in the last two weeks. I didn’t remember being 

there before. 

Then one day Jamie, my 11-year-old son, and I went for a 

walk. I asked him if he had any questions about my illness. 

He said, “Well, it’s not like you have cancer or anything, 

right, Dad”? I said, “Yes, Jamie, it is cancer.” He hugged 

me for a few seconds and then went into this lengthy 

explanation of why cancer isn’t something to be so afraid 

of anymore. That there have been so many advances in 

treatment, and many people live very long and healthy 

lives after their diagnosis. Before that conversation all I 

could think of was the 22 percent five-year survival rate 

I had read about on the Internet. I will never forget how 

brave he was, how inspiring, and how right. 

Today I’m still trying to figure out why I ignored that 

lump, what made me think I was so different. Mostly, 

though, I focus on the gift of my cancer. I’m inspired to 

change the dental world. Studies suggest that only 20 to 

50 percent of dentists do oral exams. Why would a dentist 

worry more about finding a cavity than cancer? So I’ve 

dedicated myself to reaching out to my colleagues, and 

my patients, imploring them to give and get oral cancer 

screenings. These days with special equipment we can actually 

find precancerous lesions. And the sooner we find 

something, the better the outcome. 

Like Lou Gehrig, I consider myself to be the luckiest man 

on the face of the earth. Or, at least, the luckiest person 

coming out of the 10th floor at Beth Israel’s Head and 

Neck Cancer ward. Unlike others there I kept my tongue 

and vocal cords. Outside of a lengthy scar on my neck (I 

tell people it’s from protecting my wife in a bar fight), the 

loss of my taste buds and salivary gland function (which 

doctors hope, but can’t guarantee, will return in a few 

months), and some numbness in my fingers and toes from 

chemo and radiation treatments, I’m fine. I’ve suffered 

The Dangers of Denial55

through six chemo treatments and 33 radiation sessions. 

I survived a week in the hospital, including surgery and 

radiation implant therapy, where I was in isolation for 

48 hours, except for occasional 15-minute visits from my 

parents, my sister and my wife, who also have been so 

brave and inspiring. 

Recently I returned from a trip to the Yankee Dental Conference 

in Boston, Mass., where I had the honor of lecturing 

to more than 350 dentists about cosmetic dentistry, 

and included the necessity of oral cancer screening, and 

the use of a new device called a VELscope to help detect 

oral cancer sooner. My mentor and friend, Dr. Gerard Kugel, 

told our mutual students, “If you don’t do oral cancer 

screening you don’t deserve to be a dentist.” I couldn’t 

agree more. 

I believe I know why God didn’t let me lose my ability 

to speak. I’m on a mission. I’m here to spread the word 

about oral cancer (which has increased in incidence by 11 

percent in the last year). Next month my office will have 

an open house oral cancer screening day. Perhaps I will 

be able to get other dentists to do the same. 

Today, at 51, I’m a better dentist. I’m a better husband, a 

better dad, probably a better man. And I appreciate every 

minute of this fragile life so much more. 

Larry Hamburg, DDS, lives in Poughkeepsie, NY. 

From Newsweek Web Exclusive, Feb 6 ©2008 Newsweek, Inc. All rights 

reserved. Used by permission and protected by the Copyright laws of the United 

States. The printing, copying, redistribution, or retransmission of the Material 

without express written permission is prohibited. 

56 

The Dangers of Denial 

“ 

Like Lou Gehrig, I consider 

myself to be the luckiest 

man on the face of 

the earth. Or, at least, 

the luckiest person 

coming out of 

the 10th floor at 

Beth Israel’s Head 

” 

and Neck Cancer ward.

Title of article

If you walk around just about any dental laboratory 

today, you will no doubt find a large number of impressions 

for which a vivid imagination is required 

to find the margins of the preparations they are 

supposed to have recorded. But finding the margins 

(and the rest of the preparation) is exactly what we 

are asking our technicians to do. Otherwise, our 

full-coverage restorations will have only a slight 

chance of fitting the preparations adequately. After all of 

the new products that have been introduced recently to 

make impression taking less treacherous, how is it that 

many dentists still struggle with this procedure? Let’s review 

the latest developments and I’ll give you my take 

on them. 

To stop the bleeding and retract the tissue, “all-in-one” 

products such as Expasyl (Kerr Dental, Orange, CA), 

Magic FoamCord ® (Coltene/Whaledent, Inc., Cuyahoga 

Falls, OH), and GingiTrac (Centrix, Shelton, CT) are being 

touted as being gentle, fast, and effective. These types 

of products are supposed to relieve us from the drudgery 

of having to utilize the dreaded retraction staple (namely, 

the cord), but the sad fact is their performance leaves a 

lot to be desired. 

– ARTICLE by Michael B. Miller, DDS 


– CLINICAL PHOTOS by Michael DiTolla, DDS, FAGD 

Impression taking 

Is it a lost art? 

“I learned a long 

time ago that paying 

attention to the 

soft tissue before 

prepping subgingivally 

is the single most 

important aspect of 

impression taking.” 

Impression Taking — Is It a Lost Art?59

Impression taking 

Then there are diode lasers that promise to stop bleeding 

in its tracks and, at the same time, provide direct access 

to the margins by strategically and atraumatically zapping 

the tissue. But do we really want to do this unless there 

is no other option? 

The newest impression materials are supposed to somehow 

find their own way to the margins—regardless of 

whether you have been able to control bleeding—due 

to their being hydrophilic (that is, absorbing the blood) 

or hydrokinetic (that is, moving the blood). While these 

properties may be of some minimal value, the latest impression 

materials are not capable of overcoming aggressive 

preparations that chew up the tissue. And without 

proper retraction, even these new impression materials 

still will be unable to find their own way subgingivally to 

register the margins. 

The increasing overuse and/or abuse of closed mouth 

impression trays also can sabotage even the best of impression 

materials. Even though the newest trays such 

as QUAD-TRAY Xtreme (Clinician’s Choice, New Milford, 

CT) and Gripper (Discus Dental, Culver City, CA) offer 

improved designs, it is my opinion that these trays should 

be limited to one or two teeth. Unfortunately, some manufacturers 

are producing these trays in sizes that permit 

impressions of even long-span bridges, which encourages 

dentists to use them for these types of restorations. 

I believe we need to get back to basics for our patients’ 

sake. I learned a long time ago that paying attention to 

the soft tissue before prepping subgingivally is the single 

most important aspect of impression taking. In other 

words, move the tissue out of the way before that coarse 

diamond you so proudly wield as the ultimate tooth reduction 

implement traumatizes the tissue beyond recognition 

and makes it hemorrhage profusely. This usually 

means using an aforementioned product many dentists 

consider to be old-fashioned and a nuisance to place— 

namely, the retraction cord. 

60 

Impression Taking — Is It a Lost Art? 

“Unfortunately, some 

manufacturers are 

producing these trays in 

sizes that permit 

impressions of even 

long-span bridges, 

which encourages 

dentists to use them 

for these types 

of restorations.”

Nevertheless, here are my steps 

to logical impression taking: 

1. Place a single cord in the sulcus of a tooth to be prepared 

subgingivally before venturing into this forbidden 

territory. The size of the cord should fit the tooth 

and should require only minimal packing pressure to 

place it. When you have finished placing the cord, the 

tissue should be moved laterally enough to allow your 

preparation diamond to enter the sulcus without any 

tissue contact. Note: You may not even have to prepare 

the tooth subgingivally if you are placing a metal-free 

restoration and using a clear resin cement for cementation. 

Not only are supragingival or equigingival margins 

easier to prepare and healthier for the tissue, they 

also facilitate impression taking and simplify the luting 

protocol. 

2. Use an impression tray that fits both your restoration 

and, of course, the patient’s mouth. For one or two posterior 

teeth, a closed bite tray can be adequate, although 

I still prefer a stock plastic tray in most instances. For 

three or more preparations, especially if the distal-most 

teeth are involved, I strongly suggest using a full arch 

tray. And don’t forget custom trays that can be fabricated 

relatively quickly using Triad (Dentsply Trubyte, 

York, PA). For some patients with unusual anatomic 

features, a custom tray can be the difference between 

capturing the impression the first time and having to 

retake it. 

3. After prepping the tooth, you may need to place a second 

cord to ensure that your margin will be fully accessible 

to the impression material. If you place a second 

cord, I suggest leaving it in place for at least five 

minutes. Just for hemostatic assurance, I usually dip 

the cord in an aluminum chloride medicament such as 

Hemogin-L (Dux Dental, Oxnard, CA). 

4. Select an impression material whose syringe viscosity 

has exemplary flow and wetting out characteristics, 

Impression Taking — Is It a Lost Art?61

such as Aquasil Ultra XLV (Dentsply Caulk, Milford, 

DE) or Imprint 3 Light Body (3M ESPE, St. Paul, MN). 

As previously mentioned, these materials will not automatically 

record a subgingival margin under less than 

optimal conditions but they will swing the success pendulum 

in your favor. However, if the tissue condition 

truly is compromised, a polyether such as Impregum 

Soft or Permadyne (both 3M ESPE) still has the best 

chance of overcoming the adversity of the situation. 

5. When it is time to take the impression, have the syringe 

material ready to inject as soon as you remove the cord. 

If you can see your margins after just removing the top 

cord, leave the bottom cord in place. But access, it also 

needs to be removed. Inject the syringe material using 

a fine tip placed in the retracted sulcus and continue 

coating the rest of the preparation. Then seat the tray 

filled with heavy body material as quickly as possible— 

we have found in our tests that many of the working 

times stated by manufacturers are grossly overstated. 

6. Time the impression from the beginning of mixing and 

don’t remove it until the timer beeps. Even then, feel 

the accessible tray material. If it still feels soft, let it 

dwell in the mouth for another minute or so. The time 

needed to retake an impression that was removed prematurely 

is far greater than the time it would take to let 

it complete its set for an additional minute or so. Having 

to retake an impression is one of my least favorite 

tasks, so I go out of my way to get it right the first 

time. Patients also disdain having to endure retakes. Although 

no technique works every time, the steps I have 

outlined should help you in this messy endeavor. 

Until digital impressions become commonplace, we are 

stuck with this task whether we like it or not. 

For more information about this article, contact Dr. Michael Miller at mmiller@ 

realityesthetics.com or visit www.realityesthetics.com. 

Reprinted with copyright permission from the Academy of General 

Dentistry. Copyright © 2007 by the Academy of General Dentistry. All rights 

reserved. 

62 

Impression Taking — Is It a Lost Art? 

Is it a lost art?

“I had a feeling this 

cowhorn forcep wouldn’t work.” 

Dr. John F. McNeal 

Manassas, VA 

1st place winner of a $500 lab credit 

“More carrots. Less carrot cake.” 

Dr. Stephen L. Kirkpatrick 

Olympia, WA 

2nd place winner of a $100 lab credit 

“Bovine socket graft? 

Doc, I’d rather eat dirt!” 

Dr. Holt Gray 

Birmingham, AL 

3rd place winner of a $100 lab credit 

“Why the long face? It’s only an extraction.” 

Dr. Aria Irvani 

Lake Forest, CA 

Honorable Mention 

“If this guy hurts me, I’m going to give him some ‘rightsided’ 

‘choice dialogue’ right up his ‘advocate’ butt.” 

Dr. Jerry Vinduska 

Marion, KS 


“My lip’s been doing that since the frenectomy.” 

The Chairside ® 

Caption Contest Winners! 

Dr. Odalis Hernandez 

West Palm Beach, FL 


“And I thought my mother-in-law had a big mouth...” 

Dr. Dennis Mohney 

Miami Lakes, FL 


Congratulations to Dr. John F. McNeal, Dr. Stephen L. Kirkpatrick and Dr. Holt Gray, winners of the Vol. 3, Issue 2 Chairside Caption Contest. These 

captions were chosen among thousands of entries submitted to Chairside Magazine when asked to add a caption to the picture shown above. Winning 

entries were judged on humor and ingenuity. 

64 

Contest Results

“Send us 

a case or 

the woman 

gets it.” 

The Chairside ® 

Caption Contest 

Send your captions for the above photo, including your name and city of practice, to: chairside@glidewelldental.com. By submitting 

a caption, you are authorizing Chairside Magazine to print your name in a future issue or on our Web site. You may also submit your 

entries online at www.chairsidemagazine.com. 

The winner will receive $500 in Glidewell credit or a $500 credit towards their account. The 2nd and 3rd place winners will receive 

$100 in Glidewell credit or a $100 credit towards their account. Entries must be received by December 1, 2008. The winners will be 

announced in the Winter issue of Chairside Magazine.

Chairside - Glidewell Dental Labs

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