A Publication of Glidewell Laboratories • Volume 3, Issue 3
An Interview with
Dr. Brock Rondeau
In a Busy Dental Practice
Dr. Michael DiTolla’s
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
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
Cover photo by Sharon Dowd
Cover illustration by Wolfgang Friebauer, MDT
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
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.
Yours in quality dentistry,
Dr. Michael DiTolla
Editor in Chief, Clinical Editor
Editor in Chief
Michael DiTolla, DDS, FAGD
Mike Cash, CDT
Michael DiTolla, DDS, FAGD
Jamie Austin, Deb Evans, Joel Guerra,
Phil Nguyen, Gary O’Connell, Rachel Pacillas
Wolfgang Friebauer, MDT
If you have questions, comments or complaints regarding
this issue, we want to hear from you. Please e-mail us
at email@example.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.
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
54 Practice Management: The Dangers of
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
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
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
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-
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.
- 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
- Dr. Julian Drew, Raleigh, NC
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
However, a couple
of things got in the
way of me becoming
The first was the
the Rapid AnesthesiaTechnique
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
- Dr. Tina Donahue, San Francisco, CA
Here is a link for the online DVD:
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
- 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
- Dr. Mike Hamm, Minneapolis, MN
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
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
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
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:
dental.com), mail (Letters to
the Editor, Chairside Magazine,
Glidewell Laboratories, 4141
MacArthur Blvd., Newport
Beach, CA 92660) or call (888-
Letters to the Editor 5
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
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@
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 firstname.lastname@example.org, 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 email@example.com, or call 337-234-3551.
PRODUCT ....... TempBond Clear
CATEGORY ...... Dual Cure Resin-Based Cement
SOURCE .......... Kerr Corporation
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
Dr. DiTolla’s Clinical Tips
PRODUCT ....... LuxaGlaze ® Light-Cured Varnish
CATEGORY ...... Provisional Crown & Bridge Glaze
SOURCE .......... Zenith/DMG
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
PRODUCT ....... CeraGlaze ® Ultimate Porcelain
Polishing Set (RA/Latch) – LS-506
CATEGORY ...... Porcelain Polishing Logic Set
SOURCE .......... Axis Dental
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
Dr. DiTolla’s Clinical Tips11
PRODUCT ....... Marcaine ®
CATEGORY ...... Local Anesthetic
SOURCE .......... Cooke-Waite Anesthetics
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
Septocaine is a registered trademark of Septodont.
Dr. DiTolla’s Clinical Tips13
– ARTICLE & CLINICAL PHOTOS by Michael DiTolla, DDS, FAGD – COVER PHOTO by Sharon Dowd
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
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
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-
Minimal-Prep Case Photo Essay
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
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
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
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.
Minimal-Prep Case Photo Essay
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
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
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
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
Minimal-Prep Case Photo Essay
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 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.
Minimal-Prep Case Photo Essay21
Into A Busy Dental Practice
– ARTICLE & PHOTOS by Tony Soileau, DDS
Incorporating Portrait Photography Into a Busy Dental Practice25
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,
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
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.
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.
Incorporating Portrait Photography Into a Busy Dental Practice
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.
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
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
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
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
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
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
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
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
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.
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
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.”
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
BR: Thanks a lot, Mike. It’s really a pleasure to talk to you
To contact Dr. Rondeau, e-mail firstname.lastname@example.org or call 877-372-
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 (
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
a blunt instrument
to determine the
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).
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
the Edentulous Impression
Figure 1: The tissue character can be assessed using digital/tactile
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
Light NO YES NO YES
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.
Heavy YES NO NO NO NO NO
Zinc Oxide Light &
NO YES NO NO NO NO
Alginate Light &
NO YES NO YES NO YES CONSTANT
YES NO NO YES YES
Condensation Light &
WEAK NOT NOT NOT
YES YES YES NO YES
Multiple YES YES YES YES** YES YES CONSTANT
* 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-
Engage Working and
Undercuts Setting Time Patient
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,
appear to meet all the
requirements that support
use of this layering
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).
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
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
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.
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.
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
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.
1. Bohannan HM. A critical analysis of the mucostatic principle. J Prosthet Dent.
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.
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.
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.
8. Anusavice, KJ. Phillips’ Science of Dental Materials, 10th ed. Philadelphia, PA:
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.
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
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
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
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
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
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
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.
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
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
Is it a lost art?
“I learned a long
time ago that paying
attention to the
soft tissue before
is the single most
important aspect of
Impression Taking — Is It a Lost Art?59
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.
Impression Taking — Is It a Lost Art?
producing these trays in
sizes that permit
impressions of even
dentists to use them
for these types
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
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
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
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
1st place winner of a $500 lab credit
“More carrots. Less carrot cake.”
Dr. Stephen L. Kirkpatrick
2nd place winner of a $100 lab credit
“Bovine socket graft?
Doc, I’d rather eat dirt!”
Dr. Holt Gray
3rd place winner of a $100 lab credit
“Why the long face? It’s only an extraction.”
Dr. Aria Irvani
Lake Forest, CA
“If this guy hurts me, I’m going to give him some ‘rightsided’
‘choice dialogue’ right up his ‘advocate’ butt.”
Dr. Jerry Vinduska
“My lip’s been doing that since the frenectomy.”
The Chairside ®
Caption Contest Winners!
Dr. Odalis Hernandez
West Palm Beach, FL
“And I thought my mother-in-law had a big mouth...”
Dr. Dennis Mohney
Miami Lakes, FL
Congratulations to Dr. John F. McNeal, Dr. Stephen L. Kirkpatrick and Dr. Holt Gray, winners of the Vol. 3, Issue 2 Chairside Caption Contest. These
captions were chosen among thousands of entries submitted to Chairside Magazine when asked to add a caption to the picture shown above. Winning
entries were judged on humor and ingenuity.
a case or
The Chairside ®
Send your captions for the above photo, including your name and city of practice, to: email@example.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.