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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

“Dear 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

“Dear 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

“Dear 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

“Dear 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

Dr. DiTolla’s

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.


Dr. DiTolla’s

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 ®

Dr. DiTolla’s

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

Minimal-Prep Case Photo Essay17


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

Minimal-Prep Case Photo Essay

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-

Minimal-Prep Case Photo Essay19


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

Minimal-Prep Case Photo Essay

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

Minimal-Prep Case Photo Essay21


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.”

Incorporating Portrait Photography Into a Busy Dental Practice27


■ 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.

Incorporating Portrait Photography Into a Busy Dental Practice29


■ 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.”

Incorporating Portrait Photography Into a Busy Dental Practice31


32

20 Questions with Dr. Brock Rondeau


20Questions with Dr.Brock Rondeau

– INTERVIEW of Brock Rondeau, DDS, IBO, DABCP

by Michael DiTolla, DDS, FAGD

– PHOTOS by Sharon Dowd

– 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.”

20 Questions with Dr. Brock Rondeau35


36

20 Questions with Dr. Brock Rondeau

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.

20 Questions with Dr. Brock Rondeau37


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

20 Questions with Dr. Brock Rondeau

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.”

20 Questions with Dr. Brock Rondeau39


40

20 Questions with Dr. Brock Rondeau

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.

20 Questions with Dr. Brock Rondeau41


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

20 Questions with Dr. Brock Rondeau

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.”

20 Questions with Dr. Brock Rondeau43


“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

20 Questions with Dr. Brock Rondeau

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

SENSITIVE SENSITIVE

Euqenol Medium

Alginate Light &

NOT

NO YES NO YES NO YES CONSTANT

SENSITIVE SENSITIVE

Heavy

Light &

Polysulfide

YES NO NO YES YES

SOMEWHAT

Heavy

YES

SENSITIVE SENSITIVE

CONSTANT

Polyether Multiple

YES YES

YES CONSTANT

SLIGHTLY NOT

YES WEAK

WEAK

YES

YES

SENSITIVE SENSITIVE

Condensation Light &

WEAK NOT NOT NOT

YES YES YES NO YES

CONSTANT

Silicone Medium

YES

SENSITIVE SENSITIVE

Polyvinyl

NOT NOT

Multiple YES YES YES YES** YES YES CONSTANT

SENSITIVE SENSITIVE

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.

Building the Edentulous Impression49


“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.

Building the Edentulous Impression51


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.

Building the Edentulous Impression53


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

– PHOTOS by Sharon Dowd

– 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

Honorable Mention

“My lip’s been doing that since the frenectomy.”

The Chairside ®

Caption Contest Winners!

Dr. Odalis Hernandez

West Palm Beach, FL

Honorable Mention

“And I thought my mother-in-law had a big mouth...”

Dr. Dennis Mohney

Miami Lakes, FL

Honorable Mention

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.

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