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Contents<br />

9 Dr. DiTolla’s Clinical Tips<br />

I introduce my two new bur kits for Axis <strong>Dental</strong>,<br />

one especially for the adjustment and polishing of<br />

BruxZir ® Solid Zirconia and the other for all other<br />

ceramic materials. Also highlighted are the uber-topical<br />

PFG Light and the paradigm changing Vertise <br />

Flow.<br />

14 One-on-One with Dr. DiTolla<br />

I still think that every new dentist should be issued a<br />

copy of REALITY the day they graduate from dental<br />

school. It is an exhaustive encyclopedia with topnotch<br />

photographs on how to successfully accomplish<br />

all the esthetic procedures we weren’t taught in<br />

dental school. Plus, is there such a thing as a perfect<br />

product? We discuss this and more with REALITY<br />

Publishing’s Dr. Michael Miller.<br />

27 Twelve Alternatives to the<br />

Traditional Inferior Alveolar Nerve Block<br />

Does any dentist like giving lower blocks? Dr. Stanley<br />

Malamed has shown it is the most common injection<br />

that we miss on a regular basis, and it is pretty low<br />

on our patient’s list of painless injections, as well. Is<br />

there a better way to achieve mandibular anesthesia?<br />

Dr. William Forbes explores some alternatives to the<br />

traditional inferior alveolar block.<br />

35 Clinical Predictability with<br />

Dual-Arch Impressions:<br />

Plastic Trays Are Not the Answer<br />

If you could catch a glimpse of our shipping department,<br />

you might notice that nearly 90 percent of the<br />

incoming impressions are double-arch impressions.<br />

And while double-arch impressions can be the most<br />

accurate impression available in dentistry today, your<br />

tray of choice has a lot to do with how good your results<br />

will be. Dr. Leendert “Len” Boksman explains.<br />

COVER PHOTO by Sharon Dowd<br />

COVER ILLUSTRATION by Wolfgang Friebauer, MDT<br />

Contents 1

Contents<br />

40 The Risk of the Metal-Free Practice<br />

When I graduated from LVI in 1995, I remember<br />

hearing that many dentists wanted to drop metal<br />

from their practices completely. It’s not that difficult<br />

to find a dentist who has stopped doing amalgams,<br />

but to drop metal completely, including cast gold?<br />

Dr. Frank Spear shares his thoughts on the risks of<br />

going metal-free.<br />

47 The Rise of <strong>Dental</strong>town ® :<br />

An Interview with Dr. Howard Farran<br />

I spoke to Dr. Howard Farran, owner of Today’s<br />

<strong>Dental</strong> and founder of <strong>Dental</strong>town, about the recession,<br />

how it has affected his practice, and what he<br />

has done to combat these effects. We also talk about<br />

<strong>Dental</strong>town.com, which is in my opinion the best<br />

place in dentistry for dentists to talk shop.<br />

62 Utilizing Digital Treatment Planning and<br />

Guided Surgery to Restore Fully Edentulous<br />

Arches with the All-on-4 Technique<br />

As you might recall, I took advantage of <strong>Glidewell</strong>’s<br />

Inclusive ® Digital Treatment Planning Services to<br />

place my first surgical implant, practically stress free!<br />

In this clinical case, one of our customers, Dr. Irfan<br />

Atcha, utilizes these same services to take advantage<br />

of the Nobel Biocare All-on-4 technique. If you have<br />

never seen a full-arch restored on just four implants,<br />

check this out.<br />

2<br />


Publisher<br />

Jim <strong>Glidewell</strong>, CDT<br />

Editor in Chief<br />

Michael DiTolla, DDS, FAGD<br />

Managing Editors<br />

Jim Shuck<br />

Mike Cash, CDT<br />

Creative Director<br />

Rachel Pacillas<br />

Clinical Editor<br />

Michael DiTolla, DDS, FAGD<br />

Copy Editors<br />

Melissa Manna<br />

Kim Watkins<br />

Magazine Coordinators<br />

Sharon Dowd, Lindsey Lauria<br />

Graphic Designers<br />

Jamie Austin, Deb Evans, Joel Guerra,<br />

Phil Nguyen, Gary O’Connell, Rachel Pacillas<br />

Staff Photographers<br />

Sharon Dowd, Kevin Keithley<br />

Illustrators<br />

Wolfgang Friebauer, MDT, Phil Nguyen<br />

Ad Representative<br />

Lindsey Lauria<br />

(lindsey.lauria@glidewelldental.com)<br />

If you have questions, comments or complaints regarding<br />

this issue, we want to hear from you. Please e-mail us at<br />

chairside@glidewelldental.com. Your comments may be<br />

featured in an upcoming issue or on our Web site:<br />

www.chairsidemagazine.com.<br />

© 2010 <strong>Glidewell</strong> Laboratories<br />

Neither Chairside Magazine nor any employees involved in its publication<br />

(“publisher”), Chairside makes Magazine any nor warranty, any employees express or involved implied, in or its assumes publica-<br />

Neither<br />

tion any liability (“publisher”), or responsibility makes any for warranty, the accuracy, express completeness, or implied, or or assumes usefulness<br />

liability of any or information, responsibility apparatus, for the accuracy, product, completeness, or process disclosed, or useful-<br />

or<br />

any<br />

ness represents of any that information, its use would apparatus, not infringe product, proprietary or process rights. disclosed, Reference or<br />

represents herein to any that specific its use would commercial not infringe products, proprietary process, rights. or services Reference by<br />

herein trade name, to any trademark, specific commercial manufacturer products, or otherwise process, does or not services necessarily<br />

constitute name, trademark, or imply its manufacturer endorsement, otherwise recommendation, does not or necessar-<br />

favoring<br />

by<br />

trade<br />

ily by constitute the publisher. or imply The its views endorsement, and opinions recommendation, of authors or expressed favoring<br />

by herein the do publisher. not necessarily The views state and or reflect opinions those of of authors the publisher expressed and<br />

herein shall not do be not used necessarily for advertising state or or reflect product those endorsement of the publisher purposes. and<br />

shall CAUTION: not be When used viewing for advertising the techniques, or product procedures, endorsement theories purposes. and materials<br />

that When are presented, viewing the you techniques, must make procedures, your own theories decisions and about ma-<br />

CAUTION:<br />

terials specific that treatment are presented, for patients you and must exercise make personal your own professional decisions about judgment<br />

regarding treatment the for need patients for further and exercise clinical personal testing professional or education judg-<br />

and<br />

specific<br />

ment your own regarding clinical the expertise need before further trying clinical to implement testing or new education procedures. and<br />

your own clinical expertise before trying to implement new procedures.<br />

Chairside is a registered trademark of <strong>Glidewell</strong> Laboratories.<br />

Chairside ® Magazine is a registered trademark of <strong>Glidewell</strong> Laboratories.<br />

Editor’s Letter<br />

Welcome to the “Tell it like it is” issue! It’s not the official<br />

theme of this issue, but we just happen to have<br />

three renowned “truth-tellers” in this latest installment of<br />

Chairside ® Magazine. With all of the products, clinical and<br />

otherwise, available in dentistry today, it is necessary to<br />

have respected leaders help us navigate through the sea<br />

of advertising in which we are swimming.<br />

Dr. Michael Miller has been telling it like it is in the pages<br />

of REALITY since 1986. Michael has had to invent tests<br />

of his own over the years in order to fill the void left by<br />

standard testing methods, and REALITY is filled with the<br />

truth-be-told results. Additionally, since Michael focuses<br />

on esthetic products, his testing facility is the only one<br />

that tests for characteristics such as fluorescence…that<br />

way you’ll know if your patients’ new veneers will turn<br />

neon white under a black light in a nightclub.<br />

Dr. Frank Spear gives his two cents on the concept of a<br />

metal-free practice on page 40. Frank is a pretty levelheaded<br />

guy, with a knack for taking complicated restorative<br />

dentistry and making it easy to understand. He also takes<br />

esthetics seriously and does not shy away from using allceramic<br />

restorations when indicated; however, Frank’s article,<br />

“The Risk of the Metal-Free Practice,” makes a good<br />

case for holding onto PFMs for the time being.<br />

Dr. Howard Farran has been a personal friend for nearly<br />

20 years. Howard, more than anyone else in dentistry, has<br />

never been afraid to speak his mind, even when it got him<br />

in hot water with the American <strong>Dental</strong> Association. Howard<br />

still points out when organized dentistry or practice<br />

management gurus get hypocritical about their approach<br />

to clinical dentistry, and he shares some of those insights<br />

in our interview on page 47.<br />

In these politically correct times, I find it refreshing to<br />

hear clinicians comment on products, techniques and<br />

philosophies without kowtowing to a particular manufacturer<br />

or institute, and without worrying about offending<br />

another prominent clinician. I hope you enjoy their<br />

candid opinions!<br />

Yours in quality dentistry,<br />

Dr. Michael DiTolla<br />

Editor in Chief, Clinical Editor<br />

mditolla@glidewelldental.com<br />

Editor’s Letter 3

Letters to the Editor<br />

“Dear Dr. DiTolla,<br />

I am a fourth year dental student at the<br />

University of Florida and I love watching<br />

your clinical videos from <strong>Glidewell</strong>. I<br />

am interested in trying out your Reverse<br />

Preparation Technique bur block. Roughly<br />

how many uses can you get out of each<br />

bur on typical crown and bridge cases before<br />

it starts getting dull and need to be<br />

replaced?”<br />

- Anis Elkhechen, <strong>Dental</strong> Student, University<br />

of Florida<br />

Dear Anis,<br />

Nice to hear from you! Well, the workhorse<br />

bur is the 856-025 and I probably<br />

get three or four preps out of it. If<br />

I do the occlusal reduction with the<br />

football bur instead of the 856-025,<br />

I can get more uses out of the 856-<br />

025. I order the 856-025 in batches of<br />

100 and just rotate it into the Reverse<br />

Preparation Kit as needed. I use the<br />

depth cutters slowly with light pressure<br />

to keep them from clogging and<br />

dulling quickly. I hope that helps!<br />

- Dr. DiTolla<br />

“Dear Dr. DiTolla,<br />

I’m not sure if I’ve come to right place to<br />

contact you on an educational level. I’m<br />

graduating this year and have recently<br />

been watching your clinical videos, which<br />

I love! They are outstanding and very educational.<br />

I wanted to ask you a couple of<br />

questions. If you find the time to answer<br />

them, I would appreciate it.<br />

1) For porcelain (non-metal) restorations<br />

I’ve been taught a shoulder margin is required.<br />

Should I use a flat end bur for the<br />

90-degree shoulder or is it appropriate to<br />

use a rounded torpedo bur?<br />

2) You use a round bur in one of your videos<br />

to prepare the finish line for a veneer.<br />

Is it ok if I stick with a round-ended taper<br />

bur?<br />

3) We work with light body and heavy body<br />

silicone two-stage impression for preps.<br />

After the putty impression, my teachers<br />

make grooves and channels in the impression.<br />

Is this necessary and what is the<br />

point really? Why do you take both phases<br />

at once?<br />

4) With regards to the retraction cord, will<br />

we leave the retraction cord for the first<br />

stage and remove it for the light body<br />

stage? I’m not really sure when to leave<br />

the retraction cord in or take it out. I always<br />

assumed to leave it in for however<br />

long was required, then take it out and<br />

take the impression whether it’s one stage<br />

or two. What are your views?<br />

Thank you very much, and if you manage<br />

to answer any I am grateful.”<br />

- Alidad Daftari, <strong>Dental</strong> Student, London,<br />

United Kingdom<br />

Dear Alidad,<br />

Thanks for your kind words! To answer<br />

your questions...<br />

1) For porcelain restorations, it is<br />

preferable to have a rounded internal<br />

line angle rather than a 90-degree<br />

shoulder. The KR burs will achieve<br />

this, and my favorite, the 856-025,will<br />

do it as well. Both of these burs are<br />

not quite as pointed as a torpedo<br />

bur.<br />

2) Yes, of course you can use a round<br />

end taper bur for your margin formation.<br />

I just find it really fast and<br />

easy to use the 801-021 bur and then<br />

use the round end taper (856-025) to<br />

blend the margin with the rest of the<br />

axial reduction.<br />

3) The relief that your teachers are<br />

having you put in the putty material<br />

is to ensure the entire preparation<br />

is surrounded with light body material<br />

from the tray being able to seat<br />

completely. I don’t use putty at all,<br />

actually; I use medium body as my<br />

syringe material and heavy body in<br />

the tray. Using putty is simply a costsaving<br />

method that leads to more<br />

problems than it is worth. Taking a<br />

simultaneous impression where both<br />

materials set together prevents several<br />

different problems from occurring<br />

and is the preferred method for<br />

taking quality impressions, although<br />

they may be slightly more expensive.<br />

4) I refuse to take two-stage impressions.<br />

It makes no sense to me. I<br />

pack two different retraction cords:<br />

a size 00 cord goes in the sulcus first<br />

while I am preparing the tooth, and<br />

the second cord (size 2 typically)<br />

goes in when I am done with the<br />

preparation. The size 2 cord stays in<br />

for eight to 10 minutes and then is<br />

removed, leaving the 00 cord in the<br />

sulcus while I syringe the medium<br />

body material around the tooth. At<br />

the same time my assistant expresses<br />

heavy body material into the tray<br />

and then I seat that in the patient’s<br />

mouth. The 00 cord is removed either<br />

after the impression or after the<br />

temps are cemented.<br />

- Dr. DiTolla<br />

4<br />


“Dear Dr. DiTolla,<br />

I am concerned with not sealing exposed<br />

dentin, even for a short period of time.<br />

With dentinal tubules numbering in the<br />

tens of thousands per square millimeter<br />

and bacteria numbering in the billions in<br />

the oral cavity, not sealing this with some<br />

sort of temporary luting agent for any period<br />

of time seems unwise. Dr. Charlie Cox<br />

and others have shown the seal is the deal<br />

to prevent pulpitis, whether temps break<br />

or not. Do you agree? I am obviously an<br />

endodontist. I do a lot of RCTs on previous<br />

virgin teeth from “veneers,” 15 out of 20<br />

on one patient — all teeth virgin to start<br />

with and then necrotic with radiolucencies<br />

within three to six months, with the dentist<br />

making her (a 24-year-old) a long-term<br />

dental cripple. I see you do try to emphasize<br />

that you are not prepping into dentin<br />

as much, but most dentists need to have<br />

the idea of protecting the pulp jammed<br />

into their brains. Remember, whatever you<br />

tell them will get applied to almost any restorative<br />

situation!”<br />

- Anonymous<br />

Dear Anonymous,<br />

I am concerned with not sealing exposed<br />

dentin as well; it has always<br />

been a shortcoming to the prepped<br />

veneer/shrink-wrap temp technique.<br />

As time went on, I began to apply a<br />

bonding agent to the dentin prior to<br />

temporization, even though I knew<br />

it could theoretically affect fit. I personally<br />

have a case where I prepped<br />

10 virgin teeth for veneers into the<br />

dentin as I was taught, and three of<br />

them ended up needing endodontic<br />

therapy. After that case, I drew a<br />

mental “line in the sand” and decided<br />

not to expose dentin unless I<br />

could care for it properly. Fortunately,<br />

at the same time we introduced<br />

Prismatik ThinPress ceramic material,<br />

which made 0.3 mm veneers a<br />

reality and made it unnecessary to<br />

remove all of the facial enamel.<br />

Are we really being conservative if<br />

we are able to prepare teeth less, but<br />

protect them less during provisionalization<br />

and subject them to possible<br />

pulpal death? Conservatism needs to<br />

apply to the pulpal tissues as well as<br />

the enamel, and today I believe that<br />

by removing only enamel for my veneers<br />

(and many times no enamel on<br />

half the teeth), I may make a small<br />

sacrifice in the pursuit of ultimate esthetics<br />

to protect the long-term health<br />

of the teeth. I doubt many patients<br />

would say they want lobe development<br />

and incisal translucency in their<br />

veneers, even if it meant that some of<br />

their teeth might need endo.<br />

- Dr. DiTolla<br />

WRITE US<br />


Visit www.chairsidemagazine.com<br />

and click on “Contact Us.”<br />


<strong>Glidewell</strong> Laboratories,<br />

ATTN: Chairside Magazine,<br />

4141 MacArthur Blvd.,<br />

Newport Beach, CA 92660.<br />



For clinical tips, past issues of<br />

Chairside Magazine and more:<br />

www.chairsidemagazine.com. For<br />

product info or to request a DVD:<br />

www.glidewelldental.com.<br />



Call 888-303-4221.<br />

Letters should include writer’s full name,<br />

address and daytime phone number. All<br />

correspondence may be published and<br />

edited for clarity and length.

Contributors<br />

Michael C. DiTolla, DDS, FAGD<br />

Dr. Michael DiTolla is Director of Clinical Education & Research at <strong>Glidewell</strong> Laboratories in Newport<br />

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

Department. <strong>Glidewell</strong> dental technicians have the privilege of rotating through Dr. DiTolla’s operatory<br />

and experience his commitment to excellence through his prepping and placement of their restorations.<br />

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

several clinical programs available on DVD through <strong>Glidewell</strong> Laboratories. For more information on<br />

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

mditolla@glidewelldental.com.<br />

Irfan Atcha, DDS, DICOI, DADIA<br />

Dr. Irfan “Ivan” Atcha graduated from the University of Illinois College of Dentistry in 1996. Today, he<br />

owns a private practice in Dyer, Ind., that focuses on general, cosmetic, sedation and implant dentistry.<br />

In addition, Dr. Atcha is the owner of the Center of Implants, Sedation and Cosmetic Dentistry and the<br />

No Dentures Chicago <strong>Dental</strong> Implant Center. He is a Diplomate of the International Congress of Oral<br />

Implantologists and American <strong>Dental</strong> Implant Association and board of director member of the American<br />

<strong>Dental</strong> Implant Association. A leading expert on dental implantology, occlusion and TMJ, Dr. Atcha<br />

specializes in one-day implants and lectures across the U.S. on his dental implant techniques, including<br />

the All-on-4 technique. Contact Dr. Atcha at www.NoDenturesChicago.com, dratcha@sbcgobal.net or<br />

888-416-4109.<br />

Bradley C. Bockhorst, DMD<br />

Dr. Bradley Bockhorst is known for his unique perspective, which incorporates both clinical and industrial<br />

backgrounds. After receiving his dental degree from Washington University School of <strong>Dental</strong><br />

Medicine, Dr. Bockhorst served as a Navy <strong>Dental</strong> Officer. Dr. Bockhorst has held positions as Director of<br />

Marketing and Education for several leading implant companies. He is currently Director of Clinical<br />

Technologies at <strong>Glidewell</strong> Laboratories, where he oversees Inclusive ® Digital Implant Treatment Planning<br />

Services and acts as editor in chief and clinical editor of Inclusive magazine. A member of the<br />

CDA, ADA, the Academy of Osseointegration, International Congress of Oral Implantologists and the<br />

American Academy of Implant Dentistry, Dr. Bockhorst continues to lecture internationally while maintaining<br />

a private practice in Mission Viejo, Calif. Contact him at 800-521-0576 or inclusivemagazine@<br />

glidewelldental.com.<br />

Leendert Boksman, DDS, BS, FADI, FICD<br />

Dr. Leendert “Len” Boksman graduated from the University of Western Ontario Schulich School of Medicine<br />

and Dentistry (formerly Faculty of Dentistry) in 1972. After private practice in Burlington, Ontario,<br />

Canada, Dr. Boksom returned to his alma mater as Associate Professor of Operative Dentistry in<br />

1979. He completed his BS in 1984 and was awarded a Fellowship in the Academy of Dentistry International.<br />

In 1987 he returned to private practice full time. Dr. Boksman was the first International Editorial<br />

Board Member of REALITY magazine and consulted for 3M ESPE and Caulk/DENTSPLY for more<br />

than 20 years. Presently, Dr. Boksman is Adjunct Clinical Professor at the Schulich School of Medicine<br />

and Dentistry while maintaining a private practice in London, Ontario. He is also a paid part-time consultant,<br />

acting as Director of Clinical Affairs, to Clinical Research <strong>Dental</strong> Incorporated and Clinician’s<br />

Choice. Contact Dr. Boksman at lboksman@clinicalresearchdental.com or 519-641-3066, ext. 292.<br />

6<br />


Howard Farran, DDS, MBA, MAGD<br />

Dr. Howard Farran is a noted international lecturer on faster, easier, more efficient dentistry. A 1987<br />

graduate of UMKC School of Dentistry, Dr. Farran continued his pursuit of higher education at the ASU<br />

W. P. Carey School of Business (MBA, ’99). Dr. Farran’s impact on dentistry has been widespread. He<br />

is founder and editor of <strong>Dental</strong>town, Hygienetown and Orthotown, which collectively are mailed to 38<br />

countries and more than 215,000 dental professionals. In addition, Dr. Farran is the author of several<br />

dental practice management articles and multiple video series. With experience in all aspects of practice<br />

management, including business planning, operations, finance, e-commerce and Internet marketing,<br />

Dr. Farran continues to capture audiences worldwide with his seminar titled “The Virtues of Profitable<br />

Dentistry.” Contact Dr. Farran at www.dentaltown.com, 480-893-2273 or howard@todaysdental.com.<br />

William C. Forbes, DDS<br />

Dr. William Forbes is a graduate of the University of Michigan School of Dentistry. He maintained a<br />

solo practice in general dentistry in Dover-Foxcroft, Maine, for 27 years, during which he was adjunct<br />

professor at the School of Nursing and School of <strong>Dental</strong> Hygiene at the University of Maine. In 1998,<br />

he concluded his dental practice and joined the faculty at the University of Detroit Mercy School of<br />

Dentistry. Today, Dr. Forbes is course director for all anatomy courses at the dental school, including<br />

courses for dental students, dental hygiene students, and residents in endodontics, periodontics and<br />

AEGD. He is also an adjunct professor of human anatomy, in the Anatomy and Cell Biology Department,<br />

at Wayne State University School of Medicine. To contact Dr. Forbes, e-mail forbeswc@udmercy.<br />

edu or call 313-494-6643.<br />

Michael B. Miller, DDS<br />

Dr. Michael Miller graduated from the University of Maryland School of Dentistry in 1974, and completed<br />

a general practice residency at the Veterans Administration Hospital in Houston in 1975. He is a<br />

Fellow of the Academy of General Dentistry, a Founding, Accredited Member and Fellow of the American<br />

Academy of Cosmetic Dentistry, and has memberships in the International Association of <strong>Dental</strong><br />

Research, Academy of <strong>Dental</strong> Materials and Academy of Operative Dentistry. Dr. Miller is founder of<br />

the National Children’s Oral Health Foundation, which is dedicated to fostering the development of local<br />

dental health and education facilities for children who do not currently receive any type of care. In<br />

addition, he is Co-Founder, President and Editor-in-Chief of REALITY Publishing, which he runs while<br />

maintaining a private practice in Houston, Texas. Contact Dr. Miller at www.realityesthetics.com or<br />

mmiller@realityesthetics.com.<br />

Frank Spear, DDS, MSD<br />

Dr. Frank Spear is one of the premier educators in esthetic and restorative dentistry in the world today.<br />

He earned his dental degree and an MSD in Periodontal Prosthodontics from the University of Washington.<br />

Dr. Spear is an affiliate professor in Graduate Prosthodontics at the University of Washington and<br />

maintains a private practice in Seattle limited to esthetics and fixed prosthodontics. He is also founder<br />

and director of Spear Education. Dr. Spear has received the Christensen Award for Excellence in Restorative<br />

Education, the American Academy of Cosmetic Dentistry Achievement Award, the Saul Schluger<br />

Memorial Award for Excellence in Diagnosis and Treatment Planning, and the American Academy of<br />

Esthetic Dentistry President’s Award for Excellence in <strong>Dental</strong> Education. To learn more about Dr. Spear<br />

or Spear Education, visit www.speareducation.com or call 866-781-0072.<br />

Contributors 7

Dr. DiTolla’s<br />


– ARTICLE by Michael DiTolla, DDS, FAGD<br />

– PHOTOS by Sharon Dowd<br />

PRODUCT........ PFG Light<br />

CATEGORY...... Topical Anesthetic<br />

SOURCE.......... Steven’s Pharmacy<br />

Costa Mesa, CA<br />

800-352-3784<br />

www.stevensrx.com<br />

I have written before about PFG gel, and how it has<br />

allowed me to do lots of gingival recontouring and<br />

other soft tissue procedures without the need for<br />

local anesthesia. It has also allowed me to virtually<br />

eliminate lower blocks from my day-to-day practice.<br />

What I didn’t realize was that PFG gel also comes in<br />

a Light version that is a perfect pre-injection topical<br />

anytime it is being placed in the vestibule or on unattached<br />

gingiva.<br />

It’s not that PFG Light works better than regular PFG<br />

gel; it’s the fact that it works just as well with half the<br />

strength of ingredients! Anytime we can achieve the<br />

same clinical results with half the medication, it is a<br />

step in the right direction. On attached gingiva I still<br />

use the regular PFG gel for things such as my Rapid<br />

Anesthesia Technique, packing cord on the palatal<br />

and minor laser recontouring of gingiva. For uses on<br />

unattached gingiva, such as a pre-injection topical for<br />

maxillary teeth or lower blocks, to numb oral ulcers<br />

or to remove sutures, I use PFG Light.<br />

Do your patients a favor and strive for completely<br />

painless dentistry!<br />

Dr. DiTolla’s Clinical Tips 9

Dr. DiTolla’s<br />


PRODUCT........ Porcelain Adjusting & Polishing Set<br />

CATEGORY...... Polishing Kit<br />

SOURCE.......... Axis <strong>Dental</strong><br />

Coppell, Texas<br />

800-355-5063<br />

www.axisdental.com<br />

It might be the most common question I get from<br />

dentists: What is the best way to adjust and polish<br />

ceramic materials? It started me down a long path<br />

of testing and retesting different burs and polishing<br />

methods. I tried adjusting with carbide burs, as I<br />

was taught, and then tried a myriad of diamond<br />

grits as well, observing the roughness of the surface<br />

under magnification. Finally, I would test the polishers<br />

to see which ones most effectively removed the<br />

scratches and restored a high shine. The winners<br />

are in the Porcelain Adjusting & Polishing Set! The<br />

fine grit diamonds reshape porcelain without destroying<br />

it, and the diamond-impregnated polishers are<br />

highly effective at smoothing the surface to be kind<br />

to opposing dentition.<br />

10 www.chairsidemagazine.com

Dr. DiTolla’s<br />


PRODUCT........ Vertise Flow<br />

CATEGORY...... Flowable Composite<br />

SOURCE.......... Kerr Corporation<br />

Orange, CA<br />

800-537-7123<br />

www.kerrdental.com<br />

There are some truly breakthrough moments in dentistry,<br />

when something becomes so easy to do that it<br />

almost becomes fun. I remember having that feeling<br />

when I switched from lateral condensation to obturators,<br />

and from hand files to engine driven files. Well,<br />

Vertise Flow from Kerr provides another one of these<br />

breakthrough moments.<br />

For the last 20 years, the routine in direct composite<br />

restorations has been: prep tooth, etch, rinse, dry,<br />

bond, cure, apply composite, cure. I’m happy to report<br />

that Kerr has changed that workflow, and it now<br />

reads: prep tooth, place Vertise Flow, cure. Done! It<br />

seems a little mind-boggling, but Vertise Flow is an<br />

etch, bonding agent and flowable composite, all in one<br />

syringe. From sealants to small class 1 restorations,<br />

from a class 2 liner to a simple crown build-up material,<br />

Vertise Flow does not disappoint.<br />

Dr. DiTolla’s Clinical Tips11

Dr. DiTolla’s<br />


PRODUCT........ BruxZir ® Adjustment & Polishing Set<br />

CATEGORY...... Bur Kit<br />

SOURCE.......... Axis <strong>Dental</strong><br />

Coppell, Texas<br />

800-355-5063<br />

www.axisdental.com<br />

When we were initially testing BruxZir Solid Zirconia,<br />

it became clear that we were going to need some<br />

new diamonds to be able to effectively contour, adjust<br />

and polish these restorations. I still remember the<br />

first few zirconia-based restorations I had to remove,<br />

and how it was nearly impossible with the wrong<br />

burs. With BruxZir the entire restoration is made of<br />

zirconia, so it is imperative to use burs designed for<br />

this material. The diamonds and polishers in the<br />

BruxZir Adjustment & Polishing Set are ideal for adjusting<br />

and polishing zirconia, and the diamonds also<br />

work extremely well if you ever need to cut off a zirconia<br />

crown.<br />

Waterlase YSGG is a registered trademark of BIOLASE Technology, Inc.<br />

12 www.chairsidemagazine.com

14 www.chairsidemagazine.com

– INTERVIEW of Michael B. Miller, DDS<br />

by Michael DiTolla, DDS, FAGD<br />

– PHOTOS by Sharon Dowd<br />

I was pretty happy when I heard that REALITY was<br />

going to publish a book again this year. REALITY<br />

offers objective online product reviews for dentists.<br />

As much as I read online, there are select<br />

publications where I still enjoy the printed version<br />

better, mainly those with high-quality photography<br />

or where it’s fun to jump around the book. REAL-<br />

ITY fits the bill for me on both of those notes. The<br />

candid nature of the Rants & Raves section of the<br />

book is proof that Co-Founder, President and Editor-in-Chief<br />

Dr. Michael Miller does not bow to any<br />

manufacturers, he simply tells it like it is. Enjoy this<br />

latest installment with Dr. Miller.<br />

Interview with Dr. Michael Miller15

Dr. Michael DiTolla: Let me start by welcoming you back. I don’t<br />

know how many times we’ll end up interviewing you for Chairside<br />

® , but I always find you and your publications to be an enormous<br />

source of practical information for practicing esthetic dentistry,<br />

or any type of dentistry. It’s always nice to check back in<br />

with you and see what’s going on. The first thing I’d like to say<br />

is that I have the 2009 REALITY book sitting in front of me right<br />

now, and it is really great to see this in book form. You know, I’m<br />

44 years old, I still read a newspaper, but I don’t want to read RE-<br />

ALITY on my Amazon Kindle reader just yet. There’s still something<br />

substantial about having an actual book. Tell our readers<br />

why you decided to publish REALITY in book form again.<br />

Dr. Michael Miller: Well, thanks again for the opportunity to<br />

appear in Chairside Magazine. I know it’s widely read, and I<br />

appreciate having the chance to tell you a little bit about our<br />

new book and why we decided to publish it again.<br />

“<br />

The genesis of many<br />

of these tests is based<br />

on what I have experienced<br />

as a clinician for<br />

33 years, finding out<br />

about my own patients<br />

and then getting e-mails<br />

and postings on the RE-<br />

ALITY Web site from all<br />

”<br />

of our members.<br />

Back in 2006, we stopped publishing the annual edition of<br />

REALITY with the thought that the strong trend in publishing,<br />

whether it’s dental or otherwise, was to minimize print and<br />

maximize online content. The reasons for this are pretty obvious.<br />

Print is expensive. Paper is expensive. Printing is time<br />

consuming. It’s very labor intensive. And shipping is expensive,<br />

especially internationally. It was our thought that because<br />

the entire publishing world was moving online — except for<br />

novels, and I know Kindle and other types of electronic book<br />

devices you can even read novels and other fun stuff; but for<br />

business-to-business communication, we thought that putting<br />

all of our information on a database that anyone could access<br />

from anywhere in the world would be the way to go.<br />

However, over the years we received many notices from our<br />

members that they missed the book. They still wanted to open<br />

it up and smell and touch the pages. Obviously we want to<br />

get our information out, no matter how people get it. We’re<br />

willing to do whatever they want. The people spoke and we<br />

responded. It took us a while to do it because we felt like we<br />

needed to give the online presence a fair chance. And we still<br />

are dedicated to keeping the online database as our primary<br />

vehicle for information, since there’s more information there<br />

than we’re able to put in the book — just for dollars and<br />

cents reasons. If we make REALITY as big as we used to, we<br />

would have to charge double what we charge today because<br />

of the cost of paper and everything else that goes into putting<br />

together a book. The database will still be in place, but there<br />

was definitely a voice out there telling us the book was necessary.<br />

So, we went back into the book business.<br />

MD: Well, I think it’s a great idea. I love having this copy in front<br />

of me and being able to grab 40 or 50 pages and flip to another<br />

section. I do a lot of stuff online, but I think it is more the<br />

interface that needs to change before a book like REALITY will<br />

feel as comfortable online as it does in your hand. Being able<br />

to hold this book and turn the pages is still more meaningful<br />

to me than reading it digitally, because of how quick you can<br />

jump around.<br />

16 www.chairsidemagazine.com

It’s impressive how in-depth you review each product. From fluorescence to the runniness of flowable<br />

composites, you think of pretty much everything to test. What I like specifically about how you review<br />

products is that you have something negative to say about everything. On one hand it makes me think<br />

you’re a curmudgeon; but on the other hand, I like that for even the best products you’re able to find one<br />

or two little things that need improvement. To me, it gives it an aura of credibility. You’re not so in love<br />

with a product that you’re not going to look at it with a somewhat critical eye.<br />

MM: Obviously, there is no one perfect product, where everything about it is great. There’s no<br />

perfect product period. So, I think it’s very important — and this is my philosophy anytime I give<br />

anyone advice — to let dentists know what’s good about a product and what’s not so good about a<br />

product. And then it’s up to each individual dentist to decide whether the pros outweigh the cons<br />

for his or her practice. There may be some aspects, like you mentioned fluorescence. Well, the testing<br />

of fluorescence of dental materials is something we pioneered a number of years ago, testing<br />

them live in a real human being. That is the only way you can really test fluorescence. Prior to our<br />

doing that, fluorescence was tested on the benchtop with little discs or using extracted teeth. But<br />

extracted teeth do not fluoresce like vital teeth in someone’s mouth.<br />

MD: So, let me ask you this: When you go to test the fluorescence of a composite, you actually take a staff<br />

member and you’ll take whatever composite it is and then cover the entire facial (without etching of<br />

course) of tooth #8 or 9 and then take him in and do the fluorescence test?<br />

MM: The way we do this is not a secret. We publish how we do all of our tests. We’re not into the<br />

secrecy deal. And anyone who wants to come by, whether a manufacturer or a visitor in the city,<br />

is always welcome. We just ask they call to make an appointment. But the point is that with fluorescence,<br />

we make 1 mm thick veneers out of whatever product we’re testing, whether it’s ceramic<br />

or composite. Even if it’s not meant for veneers, we still make a veneer out of it because it’s the<br />

only calibrated way of doing this. So we make these veneers, they’re exactly 1 mm thick, and we<br />

place them in a live model’s mouth, usually on one central incisor. And we assess the fluorescence<br />

compared to the rest of the model’s teeth, which are unrestored natural teeth. We look at them in a<br />

specially built black light box, which we built ourselves because there wasn’t anything on the market<br />

that you could buy like this. And at that point, we just look in there and see how it fluoresces<br />

compared to natural teeth.<br />

MD: I’m really grateful you do that. I think most dentists probably remember the first time a patient came<br />

back to them and said, “I went dancing at a club with a friend of mine, and my teeth looked black.” Or<br />

“My teeth looked white.” Or “My teeth looked purple.” To have a patient come back and say that after<br />

you’ve just placed ceramic veneers is pretty terrifying because it’s not something that ever occurs to the<br />

average dentist. It’s certainly not taught in dental school.<br />

MM: Yeah, absolutely. The genesis of many of these tests is based on what I have experienced as<br />

a clinician for 33 years, finding out about my own patients and then getting e-mails and postings<br />

on the REALITY Web site from all of our members. In terms of fluorescence, if a doc has a patient<br />

population where the patients don’t care about fluorescence, then whether the material fluoresces<br />

or not should not play a part in the selection of a specific material. On the other hand, if a doc is<br />

practicing in one of the media centers — like L.A., where you are, or New York, for instance —<br />

where a significant number of patients are in front of the camera and exposed to different lighting<br />

conditions, then the fluorescence of a product is a major aspect, as you just alluded to. So, when<br />

we talk about the pros and cons or the rants and raves of a product, it’s because we feel the need<br />

to point them out, even though not all of them will apply to every practice.<br />

MD: The last time we spoke I asked about what was exciting in dentistry, and you actually brought up<br />

ergonomics and loupes. I love loupes and have been wearing them for years. It got me thinking that there<br />

are companies out there selling clinical microscopes that can be mounted above the chairs and offer even<br />

more magnification than loupes. What are your thoughts on microscopes? Have you had the opportunity<br />

to practice with them?<br />

MM: There are several categories of products for which manufacturers believe it is unnecessary<br />

to provide us with an instrument for evaluation. Clinical microscopes is one of those categories.<br />

Interview with Dr. Michael Miller17

More than likely, the reason for this — at least what I’ve been able to glean in talking to manufacturers<br />

— is that items like this are relatively expensive. While they’ve certainly been marketed to<br />

endodontists, oral surgeons and periodontists, they have not been heavily marketed to the general<br />

dentist. By the way, we don’t buy these products. To buy everything we evaluate is totally out of<br />

our budget, so we do depend on manufacturers to provide us evaluation samples. A product like a<br />

microscope, my feeling is the manufacturers are just concerned that our evaluation will not come<br />

out in their favor. They are hesitant to give us the item because they know the minute they do,<br />

they have no control over the evaluation. It is what is it. One thing about microscopes is that even<br />

though on the surface it looks like a great idea — and as you just said, I’m a big fan of all kind of<br />

ergonomic aids for dentists, especially for my age group — microscopes, from what I’ve been able<br />

to glean from folks who use them, may not be applicable to doctors practicing general dentistry,<br />

family dentistry. And that’s another reason that none of these companies have allowed us to evaluate<br />

them. Due to these reasons, we have not yet seen a microscope.<br />

MD: That makes sense. Let me run a newer idea by you, something that is certainly new to us at the laboratory.<br />

This actually started about a year and a half ago during a discussion with one of the REALITY<br />

editorial team members, Dr. David Baird. We spoke to him at the time about unbreakable all-ceramic<br />

crowns, and he mentioned how he’d been restoring some cases with full-contour zirconia crowns. Essentially<br />

the zirconia understructure that’s under a restoration (i.e., Lava , 3M ESPE; St. Paul, MN),<br />

no porcelain is stacked on it; it’s just a full-contour zirconia crown. And at the Chicago meeting, Dr.<br />

Baird sent us over to the Zircon Zahn booth to talk to those folks. We went over there and we were pretty<br />

impressed by what we saw. We liked the idea of an unbreakable all-ceramic. Number one on my dental<br />

wish list has always been a cast gold material that comes in a shade A2. And of course, that’s never quite<br />

been available. So Dr. Baird mentioned this and talked about patients of his who had broken all-ceramic<br />

crowns and PFM crowns, and how he was now restoring some teeth with these all-zirconia crowns. He<br />

sent us some examples and we found this very interesting.<br />

We have since started to make and place these full-contour zirconia crowns, which we are calling<br />

BruxZir ® Solid Zirconia, in employees’ mouths here at the lab. We recently made BruxZir crowns and<br />

bridges available to dentists as well. In fact, we tell dentists that we see BruxZir as an alternative to placing<br />

cast gold in a patient who simply won’t accept it, or the dentist wants to place a metal occlusal and<br />

the patient won’t accept it. What we’ve been led to believe from Dr. Baird and Dr. John Sorenson is that<br />

the wear of opposing teeth is not so much related to how hard the material is as opposed to how smooth<br />

it is. And I’ve been impressed with how smooth you can actually polish full-contour zirconia. Esthetically,<br />

you’re not going to mistake this for IPS e.max ® (Ivoclar Vivadent; Amherst, NY) or IPS Empress ®<br />

(Ivoclar Vivadent) — clearly it does not have the translucence of enamel and doesn’t necessarily look like<br />

a natural tooth. But neither does cast gold. This is a new area for us and it looks somewhat promising. I<br />

don’t know if you’ve had the chance to do any restorations like this, but what might your feelings be on<br />

a concept like BruxZir?<br />

MM: I did receive something just the other day from <strong>Glidewell</strong> on these full-contour BruxZir allzirconia<br />

crowns, and my kneejerk reaction was, “Wow, what a great idea!” Because obviously, like<br />

you just said, on that lower second molar in a patient who doesn’t have much space and you can’t<br />

reduce, you can’t get much clearance in that area. In the old days, most of us would tell the patient,<br />

“Well, we need to do gold back there because there’s not enough room for ceramic, you’re probably<br />

going to get the nutcracker effect, who knows how long it’s going to last,” so on and so forth.<br />

I think it is a great idea. The zirconia crowns that I’ve done, mainly Lava, have been tremendously<br />

successful in terms of strength, although we have had maybe one or two of the veneering porcelains<br />

chip off in certain circumstances. Especially in bruxers, regardless of whether they’re wearing<br />

their nightguards or not.<br />

It doesn’t surprise me that Dr. David Baird would come up with this type of innovative solution.<br />

Even though he doesn’t get the amount of press as some of the other ceramic-type gurus around<br />

the world, Dr. Baird is a tremendous dentist and thinker and laboratory technician. He was way out<br />

on the bleeding edge of bonded porcelain before many of us were out of diapers, so it doesn’t surprise<br />

me that he would have that idea. Quite frankly, I’m really excited that you guys have come out<br />

with this. After I saw that BruxZir ad I went through my patient base, thinking about all the patients<br />

18 www.chairsidemagazine.com

I could have done that on, had I thought of it. So, I think innovative<br />

solutions with ceramics, especially with something like<br />

zirconia, obviously you’re not going to get the depth of color.<br />

Not unlike a monochromatic CEREC ® (Sirona <strong>Dental</strong> Systems;<br />

Charlotte, NC) type crown, which you can’t expect to look as<br />

good as a really nice crown made in the lab. But as long as<br />

the patient understands the old “inform before you perform”<br />

issue and understands both the pros and cons (here we go<br />

again with the raves and rants), then I think that solutions like<br />

this are great. And I applaud you guys for doing it.<br />

MD: Well, thank you. Again, we’re just following an idea that Dr.<br />

Baird started. He’s restoring entire mouths, he’s putting a small<br />

layer of veneering porcelain on anterior teeth, but he’s pushing<br />

the envelope even farther than we’re willing to do now. At <strong>Glidewell</strong>,<br />

we envision a patient study model where you tell the patient,<br />

“We don’t have enough interocclusal space here to do a<br />

typical crown. Here are your three choices.” And you show them<br />

a PFM with metal occlusal, a cast gold crown, and a full-contour<br />

BruxZir Solid Zirconia crown to kind of point out the zirconia<br />

and that it’s a good crown for bruxers. Let the patient decide<br />

between these three. Even though, like I said, it doesn’t look as<br />

good as other traditional all-ceramics, in the patient’s mind it<br />

probably looks better than cast gold or a PFM with a silver or<br />

gold metal occlusal on it. So thank you for those kinds words, we<br />

certainly appreciate that.<br />

Another product that I love and I know you’ve reviewed, but we’ve<br />

never talked about, is electric handpieces. I don’t think I could go<br />

back to using an air turbine after using an electric handpiece for<br />

the last seven or eight years. The reason I converted is because I<br />

thought that I could prep faster, but my biggest reason for liking<br />

them now is the ability to turn the handpiece way down. Turn<br />

the speed down and the water off and be able to finish a margin.<br />

Once I started working here in the laboratory and the technicians<br />

were staring at my preps, I took it a lot more personally that,<br />

“Wow, I did not give them a very good margin.” The ability to put<br />

in a fine grit diamond, turn the speed down to 6,000 rpms, turn<br />

the water off and with light pressure dial in a perfect margin is<br />

fantastic. The other thing I never realized about electric handpieces<br />

is that they make me a lot more efficient in polishing ceramics<br />

intraorally after I might adjust the occlusion, compared to<br />

with an air turbine. We actually reprinted one of your articles in<br />

Chairside about that, can we even really polish ceramic materials<br />

intraorally? That’s a great question, but I know I can do a much<br />

better job with an electric handpiece than I can with a traditional<br />

one. I just would not want to go back and practice without them.<br />

How do you personally feel about electric handpieces?<br />

MM: We’ve seen a lot of electric handpieces here, and I personally<br />

have used probably close to a dozen models over the<br />

years. There are only two issues with electric handpieces: the<br />

weight and the cost. Everybody today needs to talk about cost.<br />

You cannot just say, “Well, you know, you’re going to make<br />

more than that.” I’ve never really understood that concept.<br />

When you buy something you need to be able to justify its<br />

cost on a day-in, day-out basis. With an electric handpiece, the<br />

Interview with Dr. Michael Miller19

costs are still higher than they are with a regular air turbine.<br />

Being 60 years old and starting to suffer some musculoskeletal<br />

type issues, especially a little bit with my hand, holding an<br />

electric handpiece — which typically weighs double or even<br />

triple what an air turbine weighs — can get a little bit tiring<br />

and even aggravate some of these musculoskeletal issues. So,<br />

at 44 years old, you’re not in that category yet. But for older<br />

dentists or even female dentists out there — and I’ll probably<br />

have some folks criticize me for this statement — but they<br />

probably don’t have the hand strength required. It is a fact<br />

that women dentists are smaller and don’t typically have the<br />

musculature of male dentists. Holding a heavier handpiece<br />

can be a real issue. So, I think that there are some electric<br />

handpieces that are lighter, but there is no electric handpiece<br />

lighter than an air turbine handpiece. To me, that is the biggest<br />

downside. On the other hand, the issue you brought up<br />

about being able to turn down electric handpieces, calibrating<br />

the speed, is a tremendous advantage. And from a polishing<br />

perspective, you’ll be interested to know that if you read the<br />

directions from manufacturers of polishing instruments (including<br />

polishing discs, which I use a ton of), some of the<br />

optimal speeds are around 30,000 rpms. If you’re using the<br />

typical slow-speed air handpiece, it’s rare that they will go up<br />

that high. To optimize these functions, you really need to use<br />

an electric handpiece. Having said that, I do think that there’s<br />

a safety issue. And certainly if you use a disc with a very sharp<br />

edge on it or a rubber-type polisher with diamond particles,<br />

or any instrument at a high speed in the mouth, not only is<br />

the soft tissue at risk but so is the tooth. Especially with rubber-type<br />

instruments, you can build up a lot of heat as you go.<br />

If you use any of these instruments at a higher speed and you<br />

do turn off the water, there can be some adverse affects to the<br />

tooth or soft tissue. So even though electric handpieces have<br />

many advantages over air handpieces (just like we’ve pointed<br />

out in REALITY), the individual doctor has to define for him<br />

or herself whether the extra weight is going to be an issue.<br />

Because when we’d done our speed test — calibrated prepping<br />

tests in our laboratory — electric handpieces are really<br />

not significantly faster than the better air turbine handpieces.<br />

Speed of cutting preps is really not that big of an issue. Neither<br />

is the noise factor; a lot of electric handpiece manufacturers<br />

advertise that their electric handpieces are much quieter.<br />

But when you actually test this in a calibrated way, you find<br />

the decibel ratings from an electric handpiece rotating at the<br />

same speed as an air turbine is not that much quieter at all.<br />

MD: I’ve got the KaVo ELECTROtorque (KaVo USA; Lake Zurich,<br />

IL), and it doesn’t seem quieter, per se, but it is less “whiney.” It’s<br />

not the same pitch as the air turbine that has driven generations<br />

of people to fear dentistry from hearing that kind of sound. To<br />

me it’s not a speed thing; it’s one of those things I do because it’s<br />

a quality thing. And in my hands, I can do a better margin on a<br />

crown when I turn the speed way down to 5,000 or 6,000 rpms<br />

with a diamond in there and turn the water off. That’s something<br />

I learned from Dr. Bill Strupp, only he did it with an air<br />

turbine and I find it a lot easier to do with a high torque electric<br />

handpiece. But I’m glad you brought up dentists with the muscu-<br />

20 www.chairsidemagazine.com

loskeletal issues, and maybe even female dentists, because I tend to make electric handpieces a blanket<br />

recommendation. I hadn’t really taken into account that there might be some groups that do struggle a<br />

little bit with the weight of the handpiece when you’re holding it day-in and day-out. Just because I don’t<br />

notice it doesn’t mean that other people won’t.<br />

MM: The ELECTROtorque is a great handpiece, but it weighs close to 8 ounces. Most air turbines<br />

weigh about 3.5 ounces, and some of them weigh as little as 2 ounces. It may not sound like a<br />

lot but it is. When you hold them side-by-side it’s different. Now, there is the titanium electric<br />

handpiece from NSK (NL400 Brushless Electric Handpiece System; Kanuma, Japan), which is sold<br />

here in the U.S. by Brasseler USA (Savannah, GA). That one is lighter; I believe it’s a little less than<br />

6 ounces.<br />

MD: Have you ever held the Cadent iTero , the digital impression system? That will cause you to cramp,<br />

so I get what a heavy instrument feels like. I guess I notice the diameter more than the heaviness, but<br />

you’re right. I’m kind of in that group where one wouldn’t expect necessarily to experience those musculoskeletal<br />

issues yet, so I appreciate you bringing this up.<br />

As a mail order lab, one of the things we struggle with is the dentist taking correct shades. We don’t do<br />

pick-up or delivery, so everybody sends his or her case to us — which used to have a certain stigma associated<br />

with it until IPS Empress got big and dentists wanted to use technicians like Matt Roberts, CDT,<br />

and Lee Culp, CDT. Unless you were in their hometowns, you had to send things via FedEx. So that helped<br />

dissipate the stigma of using a technician that was farther away. And one of the challenges of working<br />

with dentists like this is trying to get a correct shade. Because dentists oftentimes determine the shade<br />

themselves, and they do not take a photograph with the shade tab in place next to the tooth to give us<br />

an idea of how the shade tab really matches the tooth and what the particular characterizations of that<br />

tooth are. So a part of my efforts is to try and come up with a better system for dentists who are in Pennsylvania<br />

or Texas or wherever, to communicate with us about how those shades should look. I’ve kind<br />

of settled upon dentists taking a digital photograph after using the VITA Easyshade ® Compact (Vident;<br />

Brea, CA) to get the shade of the adjacent tooth. And there are times when it works very well and times<br />

it doesn’t work as well, when the tooth has already been restored. But I’d like to hear your thoughts on<br />

the Easyshade Compact, as well as the best way for a dentist to work with a laboratory in terms of mail<br />

order and getting the shade correct.<br />

MM: Over the years we’ve looked at a lot of these little shade computers; some of them have been<br />

real simple and some of them have been very complex. Probably the most accurate one, although<br />

pricey, is the ShadeVision (X-Rite; Grand Rapids, MI). I haven’t really communicated with X-Rite<br />

recently on the ShadeVision, so I’m not sure of its overall availability status; we did not include it<br />

in our book this year. We did, however, include the Easyshade Compact. We did our first preview<br />

article and it is probably the most extensive first preview article that we’ve done on a product in<br />

recent years. Personally, I was really excited about this instrument when I first got it. I took it out<br />

and it was small and lightweight, and it just looks cool. I’m big on design; I’m always impressed<br />

by great design, no matter what it is — whether it’s a dental instrument or a building. So, I really<br />

liked the way this thing looked, and when I delved into it I thought that Vident and VITA had really<br />

done their homework.<br />

The first case I used it on was in a patient’s mouth where I was doing a crown on an upper first<br />

premolar, tooth #5. She had an old porcelain veneer that I had done 20 years ago on #6, on the<br />

canine right next to it. She also had an old ceramometal bridge, which I did not do, from #2 to #4.<br />

So this #5 was in between different types of ceramic restorations. In her upper arch she did not<br />

have any unrestored natural teeth; they were all restored. On her lower arch she did have a few<br />

natural unrestored teeth. So when I used it, we took probably 100 different scans in her mouth with<br />

all the different settings on the Easyshade Compact. You can take a setting on a natural tooth, you<br />

can use a test setting for a shade guide, and labs can take a setting on a finished restoration and<br />

compare it to the shade taken in the mouth. And even though there was some consistency, there<br />

was also quite a bit of inconsistency. So, in some instances, VITA is on the right track. They have<br />

the retail price down to about $2,300 right now. And whenever you go to a trade show they always<br />

have specials, so you may be able to get this particular device for under $2,000. It’s not cheap but<br />

it’s certainly not the ShadeVision, which is a much larger and more complex instrument that, last<br />

Interview with Dr. Michael Miller21

time we checked, was priced at more than $7,000. Two thousand dollars is better than $7,000, but<br />

it’s still not cheap. That said, I think this type of instrument is useful in some instances but not in<br />

all instances. And that’s the real bugaboo: if you’re going to spend $2,000 on a device but you can’t<br />

use it in restored mouths — or at least you can’t use it consistently, you still need to take a picture<br />

next to a shade guide — then it becomes an issue of whether this is really what you should be doing.<br />

I don’t have the answer to that. Like I said, every doc needs to read the preview in our book<br />

and decide whether it’s good enough to serve his or her purposes or whether they are going to<br />

wait a little bit longer.<br />

As far as digital photography, I know we also evaluated some new cameras from Nikon and Canon<br />

that are being sold by PhotoMed. And one of the digital set-ups that PhotoMed has is this long<br />

bracket with two point flashes on it that takes better, more in-depth images of teeth from the facial.<br />

It’s not good for mirror shots or any type of occlusal shots, but from the facial you get more<br />

characterized digital images using this set-up than you can with the typical ring-type flash that’s on<br />

most digital cameras today.<br />

MD: Another one of my favorite products that I saw you guys covered this year is the Demi LED<br />

Light Curing System (Kerr; Orange, CA), from Demetron ® , which is the curing light that I use. I like<br />

this curing light a lot because it’s cordless, it’s easy to use, and the controls are well laid out — not<br />

because of the five-second cure. You’ve been doing dentistry for 33 years, and it’s over 20 for me,<br />

so we both remember the days when everything was cured 40 to 50 seconds and there was no such<br />

thing as over-curing. So I’m not obsessed with the promise of a five-second cure, I just like the light.<br />

Do you find that dentists are really looking for this or is this a manufacturer thing, thinking that<br />

dentists want to be able to cure everything in five seconds?<br />

MM: The Demi LED Curing Light is a 5-star product. There’s no doubt that it’s a great product. Ergonomically,<br />

this is Kerr’s first entrée into the more wand-type design compared to the gun design.<br />

For the more mature among us, who’ve been around for a long time, we’ve just gotten used to using<br />

gun devices. So going to a wand was not natural. But the Demi is a great light, especially the<br />

way they present it where you can get the two lights almost for the price of one. I know that Kerr<br />

just came out with some kind of special, I’m not sure if it’s a two-for-one deal, but there’s some kind<br />

of special deal that when you buy a Demi, you get something extra. What I like about the Demi is<br />

you can still use different tips. And I’m a big fan of using different sized tips to match the clinical<br />

situation. If you’re doing a premolar, you don’t need an 11 mm tip. And if you’re doing children,<br />

many times you don’t need anything but an 8 mm tip. On the other hand, if you’re doing veneers,<br />

crowns, and so on, you’re going to need 11 mm or even 13 mm, because otherwise you’re going to<br />

have to overlap your cures. It’s one of my theories that the reason veneers come back years later<br />

with brown lines around their margins is not so much that the adhesive was not working or the<br />

cement was lousy, I just think that that portion of the veneer was not cured properly. Our tests<br />

show very definitively, besides the curing time, that as you go to the outside periphery of tips the<br />

power goes down significantly.<br />

MD: Oh really? Because I was going to say, isn’t the gingival margin of a veneer one of the easier places<br />

to access? And the ceramic is probably thinner there than it is in other areas of the veneer. But you’re saying,<br />

just because you have the curing light lined up and the periphery of the tip is at the periphery of the<br />

veneer, it’s not curing as significantly there as you think it is compared to the middle of the tip.<br />

MM: Absolutely. We do hardness tests for composite based on three different areas of curing tips:<br />

the center, halfway between the edge and the center, and then about 0.5 mm in from the edge. In<br />

most curing tips, the hardness of composites goes down significantly, maybe as much as 50 percent<br />

depending on the light and the tip, as you get to within 0.5 mm of the edge of the tip. If you have<br />

an 11 mm tip, for instance, and you’re curing a veneer on an 11 mm tooth, then it’s quite possible<br />

the margin is not being properly cured. By the way, not all 11 mm tips are really 11 mm. You need<br />

to take a look at where the fiber-optic bundle ends. So, the fact is you may not be blasting that<br />

marginal area on a veneer like you are the middle of it. Which means to cure it properly, you either<br />

need to use a larger tip and actually place part of the tip on the soft tissue or near the soft tissue,<br />

being careful not to burn it. Or you need to overlap your cures and actually move your curing light<br />

tip slightly gingival. Again, if you’re using a turbo-type tip, these tips get very hot. And if you put<br />

22 www.chairsidemagazine.com

it directly on gingival tissue, even though the patient might<br />

be numb, later on you may find yourself with the patient<br />

complaining about some slight burns on their tissue. Even if<br />

you can’t see it, it burns. My favorite aspect of the Demi LED<br />

Curing Light is that it accepts different size tips. The curing<br />

time is one of those things that we’ve investigated extensively.<br />

We do more tests on curing time than probably anyone else<br />

out there, and we have shown categorically that you cannot<br />

cure composite in five seconds. I don’t care what composite<br />

it is, you cannot cure in five seconds. It’s even difficult to<br />

cure most composites, even if you’re right on top of it, in 10<br />

seconds. And if you’re trying to cure composites, say, at the<br />

bottom of a proximal box, that’s even more difficult because<br />

you’re maybe 6 to 8 mm away from that composite. In many<br />

instances, forget even 20 seconds, you are not going to adequately<br />

cure the composite in those areas. But this is one area<br />

where we know absolutely, positively that you cannot cure<br />

most composites faster than 20 to 40 seconds per increment,<br />

and you cannot cure them any deeper than 2 to 3 mm. These<br />

claims of curing 5, 6, 7, 8 mm, they are an absolute figment<br />

of the manufacturer’s imagination. You need to test them the<br />

way they need to be tested and that’s with real teeth, which<br />

is the way we do it.<br />

MD: And that means the manufacturers are not following your<br />

protocol when doing this. Even though they are fully aware and<br />

they all probably subscribe to REALITY, they still continue to do<br />

their testing on their own terms?<br />

MM: It’s not on their terms. There are some standardized testing<br />

methods specifically for depth of cures by the International<br />

Standards Organization (ISO). The ISO method is using a<br />

split metal ring where you fill it up with composite to the tune<br />

of 10 mm. Then you cure the composite from the top. You<br />

break the ring open. You scrape off the uncured composite at<br />

the bottom. And then you measure the height of the resulting<br />

cylinder, and you take 50 percent of that height. And, presumably,<br />

that’s the depth of cure. I have never understood where<br />

that test came from. Who developed the test? Who thought of<br />

it? Where is the clinical relevance? Even though I’m primarily<br />

a clinical dentist, I’ve spent many hours in our research lab.<br />

And in talking to many other very smart researchers over the<br />

years, nobody seems to know who developed that test.<br />

We test depth of cure in a modified Class II preparation in a<br />

real tooth. And we test it by way of hardness using a calibrated,<br />

computerized hardness machine. We test the difference in<br />

hardness between top hardness and different depths along<br />

the proximal box. We use 80 percent Delta as our guideline,<br />

meaning that anytime a composite falls below an 80 percent<br />

hardness reading from the top to the bottom, we declare that<br />

as probably beyond what you’d want to use clinically. Now,<br />

I have to admit that this 80 percent rule is another one of<br />

these rules that no one has actually proven in the mouth. On<br />

the other hand, common sense tells us, “Why would I want<br />

something cured only 50 percent?” I always ask docs when<br />

I go out and lecture: If you were going to do a restoration<br />

“<br />

A product like a microscope,<br />

my feeling is<br />

that manufacturers are<br />

just concerned that our<br />

evaluation will not come<br />

out in their favor. They<br />

are hesitant to give us<br />

the item because they<br />

know the minute they<br />

do, they have no control<br />

over that evaluation. It<br />

”<br />

is what is it.<br />

Interview with Dr. Michael Miller23

in your own mouth, would you not want the composite (or<br />

whatever it is that you’re curing) to be as hard as possible?<br />

As the hardness goes up the degree of cure goes up, and that<br />

means the composite is not only stronger but is less likely to<br />

discolor. It’s more likely to be wear resistant. We all shoot for<br />

a higher percent, but that’s somewhat unreasonable. Nobody<br />

would ever do a restoration if they went for 100 percent down<br />

deep. So we go for 80 percent, and that’s where we come up<br />

with our curing times.<br />

“<br />

It is a fact that women<br />

dentists are smaller and<br />

don’t typically have the<br />

musculature of male<br />

dentists. Holding a<br />

heavier handpiece can<br />

”<br />

be a real issue.<br />

MD: You’re making a great argument for indirect restorations.<br />

MM: Absolutely. But I have to tell you, when you’re using a<br />

dual cure cement with indirect restorations, not all dual cure<br />

cements cure the same way based on whether they were light<br />

initiated or they just chemically cure. So there are red herrings<br />

out there in virtually everything that we do. Same thing<br />

goes with core build-ups. There are just so many things when<br />

you actually walk into a research lab and sit down at a lab<br />

bench. I have to tell you: Since our research lab opened in<br />

1998, I have done thousands and thousands of different tests<br />

myself, as has as our research team, and it opens up your<br />

eyes tremendously. It’s like you with the dental lab: Unless<br />

you’re actually in there and you see the way restorations are<br />

being made, you see the trials and tribulations of the laboratory<br />

technicians when they sit down at a lab bench and try to<br />

fabricate a restoration from an impression where they have<br />

to use their imagination for where the margins are. There are<br />

so many things out there, and it’s amazing to me how many<br />

restorations still succeed even in light of these issues.<br />

MD: It’s funny. When we get an impression where you can’t see<br />

the margin at all, we’ll call the doctor and say, “Look, we can’t<br />

see the margin. We really need a new impression.” The doctor<br />

will hem and haw and say, “Just do your best.” And it always<br />

makes me laugh. It’s like, “‘Do your best?’ Well, you didn’t do your<br />

best and now we’re supposed to do ours?” When did “Do your<br />

best” become the theme in this case because obviously the best<br />

wasn’t done in the operatory. And you’re right; it makes it difficult.<br />

That’s my passion: making it easier for dentists to produce<br />

quality dental restorations. Finding ways, finding techniques,<br />

finding something where they can reduce the proper amount and<br />

not have to get the patient back in and re-prep and re-impress.<br />

But it’s got to take into consideration time, effort, what kind of<br />

equipment they’re going to need, all that stuff—because we don’t<br />

practice in a vacuum. That’s why I find the REALITY book and<br />

the Techniques Guide so valuable. I know that our lab customers<br />

would agree as well because it’s chock full of advice and recommendations,<br />

and you guys are doing tests I don’t even see other<br />

people doing.<br />

As we close this, I’d like to give you an invitation, Michael. The<br />

next time a patient comes in with a broken PFM or a broken restoration,<br />

we would love to make a BruxZir Solid Zirconia crown<br />

for you. In fact, what we’ve done actually with our first dentists is<br />

when they ask for a cast gold crown, we just include one of these<br />

for free. Or if it’s a PFM crown that needs a metal occlusal, we’ve<br />

24 www.chairsidemagazine.com

included BruxZir for free and said, “Hey, do us a favor. Try this other one and see what you think. Give<br />

the patient a mirror and see which one they like.” And we were afraid because our motto for that product<br />

is “More brawn than beauty.” We’re trying to be real upfront and say: Hey, we know this doesn’t necessarily<br />

resemble a natural tooth. This isn’t about esthetics. This is about you putting a tooth colored crown<br />

in and not having the patient come back in a year and a half with it broken and wanting to know who’s<br />

going to pay for this. We were rather surprised that dentists were happy with it. We were NOT surprised<br />

that the patient picked the tooth colored crown over the gold because we’ve known that patients aren’t big<br />

fans of gold. If you have cause to replace a broken PFM or something like that, we’d love to have you send<br />

it to us and we’ll make you a couple different crowns, in case you choose not to cement the BruxZir. But<br />

enough of my yapping, I want to thank you for your time and once again for all the valuable information.<br />

I really appreciate you taking the time to share this with our readers today.<br />

MM: It’s always fun, it’s a real pleasure. I never fail to be amazed when I see the DVDs that <strong>Glidewell</strong><br />

sends out all the time, in every way trying to overcome the difficulties that dentists have in<br />

their everyday practices. I think your personal effect on what goes on at <strong>Glidewell</strong> is definitely<br />

appreciated by masses of dentists out there. For such a large lab, you do a great job and I really<br />

applaud you. I’ll definitely take advantage of that offer. As you were saying that, I’m going through<br />

my mind here envisioning a number of patients that I could call in and do that on. So, it sounds<br />

great. I’ll definitely take you up on that.<br />

MD: Thanks again, Michael, I really appreciate it.<br />

MM: Thanks, Mike, for the opportunity.<br />

To contact Dr. Michael Miller or to learn more about REALITY Publishing Company,<br />

visit www.realityesthetics.com or e-mail mmiller@realityesthetics.com.<br />

Cadent iTero is a trademark of The Cadent Company.<br />

Interview with Dr. Michael Miller25

12<br />

Alternatives to the<br />

Traditional Inferior<br />

Alveolar Nerve Block<br />

– ARTICLE by William C. Forbes, DDS<br />

– CLINICAL PHOTOS by Michael DiTolla, DDS, FAGD<br />

– COVER PHOTO by Sharon Dowd<br />

– ILLUSTRATIONS by Phil Nguyen<br />

Abstract<br />

In the case of the difficult-to-anesthetize patient, the inferior alveolar nerve can be particularly challenging. In<br />

those patients, other approaches may be necessary to achieve profound anesthesia. This article presents techniques<br />

that may be utilized in those efforts. The clinician can change his target slightly, or increase the dosage<br />

of anesthetic. Accessory innervation by lingual and mylohyoid nerves sometimes needs to be addressed.<br />

Some standard alternative approaches are Gow-Gates and Varizani-Akinosi injections. Intraosseous and intraligamentary<br />

injections should be considered. For lower anteriors, infiltration and incisive nerve blocks can<br />

be effective. Slight changes in armamentarium, such as increasing the needle gauge, can be helpful.<br />

Twelve approaches that can be used instead of, or as an adjunct to, the traditional Halstead injection are described.<br />

Occasionally in dental practice, a patient will present for whom it is difficult to achieve profound anesthesia with<br />

the standard inferior alveolar nerve block. In those patients, other approaches to blocking this nerve may be necessary.<br />

This article describes 12 techniques for those efforts.<br />

In the traditional (Halstead) technique for the inferior alveolar nerve block, the operator approaches the injection site<br />

with the barrel of the syringe over the contralateral second premolar. The needle is placed just lateral to the pterygo-<br />

Twelve Alternatives to the Traditional Inferior Alveolar Nerve Block27

mandibular raphe, approximately halfway up its length. The<br />

operator inserts the needle about three-quarters of the length<br />

of a long needle, or until bone is touched (Fig. 1). At this point<br />

the operator will aspirate, then inject almost a full cartridge<br />

of local anesthetic solution. The presence of the lingula, just<br />

anterior to the mandibular foramen, makes it advisable to approach<br />

the foramen from the contralateral side.<br />

1. Inject higher and deeper. The operator should bear in mind<br />

the shape of the pterygomandibular space (Fig. 2). Viewed<br />

from the operator’s perspective, the space is triangular in<br />

shape, with its base (the lateral pterygoid muscle) superior,<br />

and its apex (the attachment of the medial pterygoid muscle<br />

to the angle of the mandible) inferior. One should also<br />

remember the position of the inferior alveolar nerve as it<br />

runs down the lateral side of the medial pterygoid muscle<br />

and enters the mandibular foramen: It approaches the mandible<br />

superiorly and posteriorly. If we can contact the nerve<br />

anywhere along its length with anesthetic, it will interrupt<br />

transmission on the nerve and effect profound anesthesia.<br />

Therefore, if a second attempt is necessary, most operators<br />

will aim their needle higher and deeper. One must<br />

also consider the fact that in some cases, nerves enter<br />

smaller canals in addition to the mandibular canal, on<br />

the medial side of the ramus of the mandible. Most of<br />

these canals are located in a superior or superior/posterior<br />

position relative to the mandibular foramen (Fig. 3). 1<br />

Medial<br />

Pterygoid<br />

Muscle<br />

Figure 1<br />

Lateral<br />

Pterygoid<br />

Muscle<br />

Considering these facts, one would be advised to err on<br />

the side of being slightly higher and deeper than the site<br />

of the mandibular foramen. This leads to the popular rule<br />

of thumb for the inferior alveolar nerve block: If your first<br />

attempt fails, make your second attempt higher and deeper.<br />

Both for the sake of the inferior alveolar nerve itself,<br />

and for the sake of the alternative canals like those in Fig.<br />

3, this is good advice.<br />

2. Increase the anesthetic dose in the difficult-to-anesthetize<br />

patient. The healthy patient can tolerate several cartridges<br />

of anesthetic without encountering problems. Since the<br />

potential volume of the pterygomandibular space is about<br />

5 ml, that amount of anesthetic will come close to filling<br />

the entire space. As a practical matter, it is impossible<br />

to do so, owing to the immediate dispersion of the solution<br />

into other tissue spaces and resorption of solution<br />

into the myriad blood vessels. However, injecting two cartridges<br />

of solution initially in rapid succession has proven<br />

of some benefit in some difficult-to-anesthetize patients.<br />

Pterygomandibular<br />

space<br />

Figure 2<br />

The Council on <strong>Dental</strong> Therapeutics of the American <strong>Dental</strong><br />

Association recommends a maximum dose of lidocaine,<br />

with or without a vasoconstrictor, of 2 mg/lb or 4.4 mg/<br />

kg. 2 Therefore, two cartridges in rapid succession is well<br />

within acceptable limits.<br />

28 www.chairsidemagazine.com<br />

Figure 3

3. Inject parallel to the ramus, at the depth of 18 mm. The<br />

mandibular foramen is usually found at or slightly below<br />

the level of the deepest concavity of the coronoid notch.<br />

Therefore, an injection at the level of the deepest concavity,<br />

as palpated with the operator’s thumb, will, with the average<br />

patient, place the anesthetic very close to the foramen.<br />

The usual approach is the Halstead method, described<br />

above, but an alternative approach to the same spot is as<br />

follows: Insert the needle close to, and parallel to, the medial<br />

surface of the ramus instead of approaching from the<br />

contralateral side. Three problems may arise in the mind<br />

of the operator with the parallel approach. These include<br />

how to avoid the temporal crest (Fig. 4), how to compensate<br />

for the flare of the ramus of the mandible (Fig. 5), and<br />

how deep the needle should be inserted before injecting.<br />

An examination of a mandible will demonstrate the<br />

internal oblique ridge of the ramus, passing diagonally<br />

down toward the lingual aspect of the third molar<br />

(Fig. 3). This ridge must be avoided by penetrating<br />

the mucosa 10 mm medial to the coronoid notch.<br />

The careful operator can determine the flare of the ramus<br />

(Fig. 4) by placing the thumb in the coronoid notch and<br />

the index finger on the posterior surface of the ramus. In<br />

this way, one can feel the front and back of the ramus and<br />

determine its flare. The needle penetrates the mucosa 10<br />

mm medial to the coronoid notch (to avoid the temporal<br />

crest), and is inserted as if aiming for the operator’s index<br />

finger. The average depth of the penetration should be 18<br />

mm. Since the conventional 25-gauge long needle is 34 to<br />

38 mm long, and the conventional 27-gauge long needle is<br />

36 mm long, 3 one should insert the needle approximately<br />

half the length of a long needle, then aspirate and inject.<br />

Figure 4<br />

Angle of<br />

flare<br />

Figure 5<br />

4. Anesthetize the mylohyoid/lingual nerves. Close examination<br />

of the dried skull will reveal several distinct foramina<br />

on the lingual side of the body of most mandibles. These<br />

foramina can allow branches of the mylohyoid and lingual<br />

nerves to penetrate the bone, bringing sensory innervation<br />

to the pulps of some mandibular teeth (Fig. 6). Anesthetizing<br />

these branches can be a simple matter of injecting just<br />

under the mucosa, just lingual to the body of the mandible,<br />

in the area of the tooth to be anesthetized. Care should<br />

be taken to make the site of mucosal penetration close<br />

to the mandible, to avoid such structures as the lingual<br />

nerve and Wharton’s duct, which lie more medial (Fig. 7).<br />

In most cases, a successful inferior alveolar nerve block<br />

will anesthetize the mylohyoid and lingual nerves as well,<br />

because these nerves pass in close to the mandibular foramen.<br />

Presumably, even if these two nerves give off branches<br />

to the lingual side of the body of the mandible, these<br />

nerves will have been anesthetized at the mandibular foramen,<br />

proximal to the branching, and no problems will<br />

arise. However, there are some cases in which the lingual<br />

Figure 6<br />

29<br />

Twelve Alternatives to the Traditional Inferior Alveolar Nerve Block

and mylohyoid nerves branch from the mandibular nerve<br />

at some distance proximal to the mandibular foramen,<br />

and do not pass close to the foramen. Fibers from these<br />

unanesthetized lingual and mylohyoid nerves might enter<br />

the lingual side of the body of the mandible and bring<br />

pulpal innervation to the lower teeth. In these cases, anesthetizing<br />

as described above should solve the problem.<br />

The transverse cervical nerve, a branch of the cervical<br />

plexus of nerves, carries sensory fibers and sends branches<br />

very close to the inferior border of the mandible. Considering<br />

the tiny foramina near the inferior border of the body<br />

of the mandible, some clinicians have implicated branches<br />

of the transverse cervical nerve in bringing sensory pulpal<br />

innervation to the mandibular teeth. 4 This proposal has<br />

been largely disputed; in any case, an injection like the<br />

one used to combat mylohyoid and lingual nerve involvement<br />

should anesthetize fibers from the transverse cervical<br />

nerve as well.<br />

5. Anesthetize the retromolar pad. Accessory innervation is<br />

possible by anomalous branches of the inferior alveolar<br />

nerve entering the ramus in the retromolar pad area, usually<br />

from a site slightly buccal to the crowns of the molar<br />

teeth (Fig. 8). These can be readily anesthetized with an<br />

injection in the retromolar area, similar to the long buccal<br />

nerve block (Fig. 9).<br />

6. Utilize the Gow-Gates or Varizani-Akinosi technique.<br />

The Gow-Gates technique 5 has a very high success rate<br />

in experienced hands, and eliminates most of the problems<br />

of accessory innervation described above, because<br />

it approaches the mandibular nerve very high in the<br />

pterygomandibular space, proximal to the place where<br />

mandibular nerve branches into mylohyoid, lingual and<br />

inferior alveolar nerves. Many clinicians who are accustomed<br />

to the traditional (Halstead) injection are uncomfortable<br />

with using extra-oral landmarks for an intraoral<br />

injection, but once these psychological barriers are conquered,<br />

the Gow-Gates can be very effective. Dr. Stanley<br />

Malamed writes that Gow-Gates can be effective 99<br />

percent of the time in experienced hands (Fig. 10, 11). 3<br />

The Varizani-Akinosi block 6 requires lining up the syringe<br />

parallel with the occlusal table of the maxillary teeth at the<br />

height of the muco-gingival junction of the upper teeth.<br />

The target for this injection is below that of the Gow-Gates<br />

injection, but above that of the Halstead injection. This<br />

injection has the added advantage of being able to be performed<br />

with the patient’s mouth closed (Fig. 12, 13).<br />

7. The intraosseous injection. Intraosseous injections 7 are<br />

often used for anesthesia of individual teeth when other<br />

methods have proven ineffective. Through the use of special<br />

kits, this injection places anesthetic in the cancellous<br />

bone of the alveolar ridge. Soft tissue infiltration anesthesia<br />

at the site is necessary before penetrating the bone.<br />

30 www.chairsidemagazine.com<br />

Figure 7<br />

Figure 8<br />

Figure 9

In most cases, intraosseous anesthesia produces immediate<br />

profound anesthesia of the tooth. This profound anesthesia<br />

can be fleeting, perhaps as short in duration as 15<br />

minutes, because of rapid diffusion of the anesthetic, and<br />

rapid absorption by the circulatory system. Vasoconstrictors<br />

do not markedly prolong anesthesia by this technique<br />

and can lead to palpitations. 8<br />

8. Make the intraligamentary injection. The intraligamentary<br />

injection (variously called intraperiodontal, periodontal<br />

ligament, PDL injection) 9 requires special armamentaria as<br />

well. Through the use of a syringe made specifically for<br />

this injection, anesthetic is placed into the periodontal ligament<br />

for about 5 mm on the mesial and the same distance<br />

on the distal of the tooth. A small amount of anesthetic<br />

(0.25 ml) is injected very slowly to minimize discomfort. 8<br />

9. Use the incisive nerve block. The judicious use of the<br />

incisive nerve block can effect profound pulpal anesthesia<br />

from the midline as far back as the mandibular second<br />

premolar. The injection is relatively painless, and the landmarks<br />

are reliable and consistent. The target, the mental<br />

foramen, is located either buccal to the apex of the second<br />

premolar, or buccal to a spot between the apices of the first<br />

and second premolars. Often, the foramen can be palpated<br />

before giving the injection. Injecting into the foramen<br />

will give pulpal anesthesia to the midline of the mandible.<br />

The operator can increase the effectiveness of the injection<br />

by digitally pushing the anesthetic into the hole after<br />

injecting. After injecting one-half to three-quarters of a<br />

cartridge, there will be a “bubble” of mucosa at the injection<br />

site. The operator should slowly and gently “mash”<br />

the solution into the mental foramen, until the “bubble”<br />

is no longer there, which usually takes about 30 seconds.<br />

This will greatly enhance pulpal anesthesia in the area.<br />

Target area for<br />

Gow-Gates<br />

injection<br />

Figure 10<br />

Figure 11<br />

Many practitioners continue to refer to the incisive nerve<br />

block as the “mental block,” perhaps because the target is<br />

the mental foramen. The mental nerve is the branch of the<br />

inferior alveolar nerve that exits the mental foramen and<br />

provides soft tissue anesthesia only. If one is anesthetizing<br />

for pulpal anesthesia, one must get anesthetic solution into<br />

the foramen, and in contact with inferior alveolar and incisive<br />

nerves.The procedure is correctly called the incisive<br />

nerve block.<br />

10. Use a 25-gauge needle. Larger-gauge needles have<br />

some distinct advantages. There is less deflection in<br />

the tissues with the larger gauge, leading to greater accuracy<br />

in hitting the target. Intravascular injections are<br />

less frequent, because positive aspirations are more<br />

clearly seen by the operator. 3 With fewer intravascular<br />

injections, the solution stays in the immediate area<br />

of the injection and is more accessible to the nerve.<br />

Malamed 3 reports that injections with larger-gauge needles<br />

are as comfortable as those with smaller-gauge needles.<br />

Figure 12<br />

Target area for the<br />

Varizani-Akinosi<br />

nerve block<br />

31<br />

Twelve Alternatives to the Traditional Inferior Alveolar Nerve Block

11. Infiltrate lower anteriors. Although the operator will find<br />

it futile to infiltrate the mandible in most areas for pulpal<br />

anesthesia of the lower teeth, the lower incisors can be<br />

quite readily accessed in this way. A small amount (1/4 cartridge)<br />

of anesthetic injected just submucosally, buccally at<br />

the level of the apex of the teeth will diffuse through the<br />

cortical plate of bone, which is quite thin in that area in<br />

most patients (Fig. 14). Infiltration injections can be placed<br />

lingually as well, where the thickness of bone is even less<br />

in most patients. A very small amount of solution (1/4 cartridge)<br />

is sufficient (Fig. 15).<br />

12. Try articaine. Articaine, because it diffuses through tissues<br />

very well, has the potential to diffuse through the<br />

pterygomandibular space and to reach the target nerves<br />

well. In addition, a great deal of consistent anecdotal evidence<br />

credits Septocaine (articaine) with the ability to infiltrate<br />

mandibular teeth for pulpal anesthesia. These injections<br />

are made buccally and lingually to the target tooth,<br />

similar to the injection made to anesthetize the lingual and<br />

long buccal nerves. Articaine has been associated with an<br />

increased incidence of paresthesia of the tongue and lip<br />

following anesthesia of the mandibular arch. 10<br />

Figure 13<br />

Target area for the<br />

Varizani-Akinosi<br />

nerve block<br />

Conclusion<br />

Twelve suggestions are given for treating patients who experience<br />

pain with treatment despite the conventional (Halstead)<br />

injection. Depending on the preference of the operator,<br />

one or more of these alternative approaches may be effective,<br />

even with the difficult-to-anesthetize patient.<br />

Dr. William Forbes is course director at University of Detroit Mercy School of Dentistry<br />

and adjunct professor of human anatomy at Wayne State University School of Medicine.<br />

To contact Dr. Forbes, e-mail forbeswc@udmercy.edu or call 313-494-6643.<br />

Figure 14<br />

References<br />

1. Lang, J. Clinical anatomy of the masticatory apparatus and peripharyngeal spaces.<br />

New York: Thieme Medical Publishers;1995:32.<br />

2. Council on <strong>Dental</strong> Therapeutics of the American <strong>Dental</strong> Association: Accepted<br />

dental therapeutics, 40th ed. Chicago: American <strong>Dental</strong> Association;1984.<br />

3. Malamed, S. Handbook of local anesthesia. 4th ed. St Louis: Mosby;1997:86,203.<br />

4. JADA 1992; 1233:69-73; Br Dent J 1976;140:237-239.<br />

5. Gow-Gates GAE. Mandibular conduction anesthesia: A new technique using extraoral<br />

landmarks. Oral Surg 1973;36:321-328.<br />

6. Vazirani SJ. Closed mouth mandibular nerve block: A new technique. Dent Dig<br />

1960;66:10-13.<br />

7. Kleber, CH. Intraosseous anesthesia: Implications instrumentation and techniques.<br />

JADA 2003;134:487-91.<br />

8. Jastak JT, Yagiela JA. Regional anesthesia of the oral cavity. St. Louis: Mosby;<br />

1981:165-6.<br />

9. Walton RE, Abbott BJ. Periodontal ligament injection: A clinical evaluation. JADA<br />

1981;103:571-5.<br />

10. Haas, DA, Lennon, D. A 21-year retrospective study of reports of paresthesia<br />

following local anesthetic administration. J Can Dent Assoc 1995;61:319-20,323-<br />

6,329-30.<br />

Figure 15<br />

32 www.chairsidemagazine.com

When a full-arch impression<br />

is taken, the heavy<br />

body has to support the<br />

light body, but by necessity,<br />

it has to have the ability to<br />

flex significantly to allow<br />

withdrawal of the impression<br />

from the oral cavity.<br />

Figure 1: QUAD-TRAY Xtreme.<br />

Many dual-arch trays currently being used for dual-arch<br />

impressions are plastic. Accuracy of our impressions is<br />

compromised when these plastic dual-arch trays flex as<br />

the impression is taken, which results in consistent discrepancies<br />

of 180 to 210 microns. 4 This flex can be caused<br />

by the high side walls of the plastic trays hitting the palatal<br />

tissues, maxillary tuberosities or tori present in the<br />

patient’s oral cavity. Flex can also occur due to outward<br />

pressure on the plastic tray when there is interference<br />

in the retro-molar pad area. The very act of swallowing<br />

during the impression procedure can cause the tongue<br />

to repeatedly displace the lingual wall of the tray during<br />

polymerization, creating distortion. As well, the thicker<br />

rheology of high viscosity impression materials can cause<br />

the plastic tray to flex away from the tooth preparation. 5<br />

Therefore, when the tray is removed, the plastic memory<br />

of the tray will create an inward pressure, and depending<br />

on the stiffness of the heavy body used, the dies can be<br />

distorted mesio-distally, creating marginal fit problems as<br />

well as interproximal contact issues.<br />

The answer is to use a metal tray, which eliminates flex.<br />

The QUAD-TRAY ® Xtreme (Clinician’s Choice; Brookfield,<br />

CT) (Fig. 1), as reviewed by Dr. Gordon Christensen, 6<br />

is designed to complement the dual-arch impression technique<br />

and to eliminate the distortion that is common with<br />

plastic dual-arch impression trays. Because the tray is fabricated<br />

from aluminum, the tray has no elastic memory<br />

to create distortion in the final impression. As well, the<br />

low sidewalls cannot cause distortion due to axial roll or<br />

outward flex, and the design incorporates a wide arch,<br />

very thin retro-molar area and is adjustable. Therefore,<br />

when combined with the correct heavy body PVS impression<br />

material, the impression is dimensionally accurate<br />

and stable for an indefinite period of time. Using a “technique<br />

designed” specific heavy body is critical to success.<br />

If a clinician desires reproducible accuracy and consistent<br />

results, the impression material used with a dual-arch tray<br />

should be stiffer than the material that is used for fullarch<br />

impressions, which are supported by a walled tray<br />

that encompasses the entire arch.<br />

When a full-arch impression is taken, the heavy body has<br />

to support the light body, but by necessity, it has to have<br />

the ability to flex significantly to allow withdrawal of the<br />

impression from the oral cavity. Since the dual-arch impression<br />

is essentially a “platform” with no circumferential<br />

walls like a traditional tray, the heavy body must be<br />

Figure 2: Inflex with AFFINITY Light Body High<br />

Flow.<br />

36 www.chairsidemagazine.com

formulated differently to maximize predictability in our<br />

crown & bridge prostheses. It has to be very rigid when<br />

polymerized, since it essentially takes on the function<br />

of a tray to support the light body. It also has to be very<br />

stiff to resist the deformation forces of pouring up the<br />

model in the laboratory. In a recent American <strong>Dental</strong> Association<br />

Professional Product Review 7 , the ADA makes<br />

the recommendation that heavy bodies, which demonstrate<br />

a strain in compression of less than 2 percent (a<br />

very stiff impression material), would work well with a<br />

closed bite tray. In my office, for dual-arch impressions<br />

I use AFFINITY Inflex impression material (Clinician’s<br />

Choice), which I’ve found has a very low strain in compression<br />

(high stiffness) while still demonstrating the flow<br />

necessary to give reproduction of detail. As well, when<br />

using the matching light body, the rheology of this heavy<br />

body material has been formulated to allow for all of the<br />

preparation to be captured in light body, rather than just<br />

the gingival collar, resulting in a more accurate fit, with<br />

less strain on the physical characteristics of the cementing<br />

medium (Fig. 2, 3).<br />

With such a stiff material, when the impression is set, the<br />

final impression is held against the prepared arch and the<br />

patient is asked to open. Once the opposing arch has been<br />

released from the impression, the impression is then carefully<br />

rocked from side to side to remove. It must be noted<br />

that the patient should not clench during this procedure,<br />

as occlusal prematurities on teeth adjacent to the preparation<br />

can cause these teeth to move during the impressioning,<br />

creating an inaccuracy. Put a hand on the masseter,<br />

and when the clinician feels the masseter tighten, make<br />

sure the patient releases the pressure but holds the bite<br />

lightly. Since the patient cannot always close accurately,<br />

especially when anesthetic has been injected, a reference<br />

point should be marked anteriorly before anesthesia.<br />

Use a small marker to indicate the midline and anterior<br />

overbite before the injection takes place, with the patient<br />

guided back to this position during the impression.<br />

The original QUAD-TRAY Xtreme has been used to provide<br />

excellent impressions because of its rigid metal construction,<br />

memory-free aluminum design, impingement<br />

preventing sidewalls, wide arch and thin distal bar. A new<br />

addition to the QUAD-TRAY family is the QUAD-TRAY<br />

XL. (Fig. 4), which provides the same benefits but in a<br />

full-quadrant design. It extends to the dental midline, has<br />

a perforated, tapered buccal/facial wall and a slotted lin-<br />

Figure 3: Note amount of impression material past the margin.<br />

Accuracy of our impressions<br />

is compromised when these<br />

plastic dual-arch trays flex<br />

as the impression is<br />

taken, which results in<br />

consistent discrepancies<br />

of 180 to 210 microns.<br />

Figure 4: New QUAD-TRAY XL tray will full-quadrant design.<br />

Clinical Predictability with Dual-Arch Impressions Plastic Trays Are Not the Answer37

gual wall that helps to lock in the impression material without impinging on the palate. By using the QUAD-TRAY XL,<br />

the practitioner can provide the laboratory with even more information for precision and accuracy in creating crown<br />

and bridge prostheses.<br />

The clinical success of the dual-arch impression is dependent on the combination of proper metal tray and “technique<br />

driven” impression material. Laboratories see far too many plastic trays with obvious burn through of hard or soft tissues,<br />

reflecting a probable distortion, but the fear of losing clients often dissuades them from returning the case for<br />

a new impression. What the laboratories, of course, cannot see is the possible mesio-distal discrepancies caused by<br />

memory flex of the plastic tray. In an era where economic turmoil is a reality, neither the laboratory nor the clinician<br />

can afford the time, frustration, the cost of remakes or the time taken to “adapt” an ill-fitting prosthesis.<br />

Dr. Leendert “Len” Boksman is Adjunct Clinical Professor at the Schulich School of Medicine and Dentistry and maintains a private practice in London, Ontario,<br />

Canada. He is also a paid part-time consultant to Clinical Research <strong>Dental</strong> Incorporated and Clinician’s Choice. Contact Dr. Boksman at lboksman@clinicalresearchdental.com<br />

or 519-641-3066, ext. 292.<br />

References<br />

1. Thornton LJ. A survey of disposable articulators. Gen Dent. 2002 Jan-Feb;50(1):72-6.<br />

2. Boksman L. Point of Care: How do I minimize the amount of occlusal adjustment necessary for a crown? JCDA July/Aug 2005;71(7):494-95.<br />

3. Cox JR. A clinical study comparing marginal and occlusal accuracy of crowns fabricated from double arch and complete arch impressions. Aus Dent J 2005;50:90-<br />

94.<br />

4. Carrotte PV et al. The influence of the impression tray on the accuracy of impressions for crown and bridgework – an investigation and review. Br Dent J<br />

1998;185:580-585.<br />

5. Cho GC., Chei WWL. Distortion of disposable plastic stock trays. J Prosth Dent 2004;92;354-358.<br />

6. Christensen G. Dual-arch Impression Summary Clinicians Report June 2008 Vol 1. Issue 6 (also published in JADA 2008 Aug:1123-1125).<br />

7. ADA Professional Product Review Vol. 2 Issue 3 Elastomeric Impression Materials.<br />

Reprinted with permission from <strong>Dental</strong>town Magazine: Boksman L. Clinical predictability with dual-arch impressions: plastic trays are not the answer. <strong>Dental</strong>town<br />

2009;10(9):18-21. Copyright ©2009 <strong>Dental</strong>town.com, LLC. Printed in the USA.

As a practicing prosthodontist for nearly 30 years, the reality<br />

of clinical failure is something I know too well. Whether it<br />

is a failed endo on a critical tooth in a reconstruction, failed<br />

implant, broken solder joint, or the topic of this editorial – the failure<br />

of a dental material – all failures evoke multiple challenges for the<br />

practitioner. First, there is the patient’s frustration. Regardless of how<br />

long the restoration was present, most patients are not pleased when<br />

a restoration needs to be redone. Next, there is frustration for the<br />

office because failures usually mean that an emergency visit is added<br />

to the schedule in order to solve the problem in the short term. And<br />

then there is the frustration for the practitioner, not only at having<br />

to redo your own work but also of having to deal with what may be<br />

an irritated patient. And finally, of course, there is the big question<br />

of how to handle the finances.<br />

It is not the purpose of this editorial to focus on how or why you<br />

financially manage your failures. However, I believe for many of us it<br />

is how long the restoration functioned successfully that determines<br />

what we may or may not charge the patient. Generally, if we are talking<br />

about less than three years of service, there would be minimal<br />

to no charge for the redo – unless you really do not like the patient<br />

and want them out of your practice.<br />

What I do think is relevant to this editorial is the cost to the office<br />

of redoing restorations that failed early, at no charge. For the sake<br />

of simplicity, let us assume that you placed a maxillary first molar<br />

crown on a patient and charged them $1,000. Let us also assume<br />

that your office has an overhead in the 65 percent range, as many in<br />

the country do. Therefore, your net profit on the crown was $350.<br />

Now, 18 months later, the distal marginal ridge of the crown fractures,<br />

requiring the restoration to be redone. Assuming you choose<br />

to redo the restoration at no charge, as many would do, let us see<br />

what it will cost you. If you have a busy practice and full schedule,<br />

you will have to take up a productive space where you could have<br />

been doing a new crown on someone else to redo the broken one.<br />

Assuming you have not raised your fees, you just gave up $1,000 of<br />

production to make time to redo the broken crown. But it is actually<br />

much worse than that because you also have to pay the office overhead<br />

and the laboratory fee to redo the broken crown, which costs<br />

you $650. If you add up the $1,000 you did not produce with the<br />

$650 you had to pay, the single broken crown redone at no charge<br />

could cost you $1,650 in gross revenue. Suffice it to say that redoing<br />

failed dental work at no charge is a recipe for financial disaster in<br />

the office. So, am I saying that you should charge for all redos? Not<br />

at all, as I believe that doing so can be a public relations disaster.<br />

Instead, what I am saying is that it is critical to look at methods for<br />

minimizing the risk of failure, and for this editorial specifically, the<br />

risk of dental materials.<br />

The Risk of the Metal-Free Practice41

To discuss the risks of different dental materials, it is important to<br />

identify which teeth are at the greatest risk of early restorative failure,<br />

usually fractures. This is easy, as the research is overwhelming;<br />

posterior teeth, particularly the first and second molars, are at the<br />

highest risk of failure. This is also simple to understand when we<br />

recognize that the average occlusal forces generated on molars are<br />

nine times higher than on an incisor. Which brings us to the point<br />

of this editorial: why take potential dental material risks if you do<br />

not have to?<br />

The answer to that question is not as simple as it may seem. We, as<br />

dentists, are an intense and emotional group of people who want to<br />

feel we are providing the most current and best care possible for our<br />

patients. Often, this focuses on dental materials or new technologies.<br />

In addition, we do not want to feel left behind by our colleagues if<br />

they are doing something we perceive as more current than what we<br />

are doing. To this end, we sometimes make ill-informed decisions<br />

about dental material choices without adequate evidence to support<br />

those choices. In addition, as a profession, we have a history of following<br />

the speaker at the podium in making our choices. Over the<br />

last 10 to 20 years, we have had a greater influx of young speakers<br />

than ever before who are starting to speak and are desiring to present<br />

a new message different from, perhaps, the status quo, which by<br />

itself is not a bad thing; it is only when that message involves suggesting<br />

techniques or materials with only a short-term history that<br />

the risks to the practitioners in the audience increases.<br />

Let me give you some of my own personal history to illustrate what<br />

I mean. In 1986, I listened to legendary dental ceramic Willi Geller<br />

lecture in Chicago. To this day, I believe he is truly one of the best,<br />

if not the best, technician dentistry has known. He was presenting<br />

on “Willi’s Glass,” a crown he had developed that used one of the<br />

few all-ceramic systems of the day, “Dicor,” as a coping and overlaid<br />

it with “Vitadur-N” aluminous porcelain. The Dicor gave the fit as it<br />

was a cast glass, and the Vitadur-N gave the beauty of layered porcelain.<br />

The crowns he presented were easily the most beautiful I had<br />

ever seen in dentistry. I came back to Seattle and told my technician<br />

that we would now use Willi’s Glass as our standard anterior crown,<br />

which we did. The esthetic results were stunning, making all my<br />

metal ceramic restorations look like poor substitutes.<br />

Examples of other<br />

product disasters<br />

in our profession<br />

abound over the<br />

last 25 years.<br />

Several of the ceromers<br />

bonded to<br />

metal or fiber that<br />

were supposed to<br />

replace metal ceramics<br />

for crowns<br />

and bridges at the<br />

end of the 1990s<br />

come to mind.<br />

But there was a problem: nobody had conducted in vitro or clinical<br />

studies on Willi’s Glass. And there was another problem: I had<br />

started lecturing nationally in 1983, and by 1987 what do you think<br />

I was telling the audience they should use and had no failures<br />

and was beautiful? The problems started in about 1989, when the<br />

mismatched coefficient of expansion of the Dicor coping and the<br />

Vitadur-N started to show up as crowns cracking or experiencing<br />

bulk failure. Now remember, by then I had been doing them for<br />

three years. In short, by 1991, I had been replacing multiple Willi’s<br />

42 www.chairsidemagazine.com

Glass crowns monthly for no charge, a huge financial burden on<br />

my practice. Was Willi Geller wrong for presenting the material in<br />

Chicago? Not at all. He made it clear that it was a new concept without<br />

research. The problem was my exuberance at using something I<br />

thought was so exciting and esthetic that I jumped in with both feet<br />

without considering the consequences.<br />

The question you<br />

have to ask is<br />

whether the success<br />

rate on posterior<br />

teeth is worth<br />

the esthetic gain on<br />

molars compared<br />

with using products<br />

such as gold or<br />

metal ceramics that<br />

have success rates<br />

of 97 to 99 percent<br />

on molars at<br />

10 to 15 years.<br />

Examples of other product disasters in our profession abound over<br />

the last 25 years. Several of the ceromers (composite) bonded to<br />

metal or fiber that were supposed to replace metal ceramics for<br />

crowns and bridges at the end of the 1990s come to mind. In fact,<br />

the worst case of material failure I ever heard of was a student in one<br />

of my workshops, whose laboratory had convinced her to quit doing<br />

metal ceramics and switch exclusively to a ceromer bonded to metal<br />

process. Eighteen months after the switch, more than 50 percent<br />

of the restorations failed because of veneering material fractures.<br />

All were replaced at no charge. And yet, used as inlays and onlays,<br />

without metal or fiber, some of those products have an excellent<br />

track record.<br />

Even today, we are practicing in a time when “zirconia” products<br />

were going to replace the need for metal in our practices because of<br />

the strength of the zirconia framework. In fact, the frameworks have<br />

been exceptional, with very little reported framework failures. But<br />

I hear countless stories of very high rates of veneering material failures,<br />

particularly marginal ridge failures on molars compared with<br />

what practitioners have seen with more traditional systems. And, as<br />

is often the case, some clinicians and laboratories are having almost<br />

no failures. Currently, researchers are looking at framework design,<br />

framework adjustment prior to veneering, framework surface treatment<br />

prior to veneering, bond strength of the veneering ceramic to<br />

the framework, and strength of the veneering ceramic itself as potential<br />

causes for these increased rates of failure. This tells me that<br />

there are technique and material variables that we do not understand<br />

yet that are producing the problem. If we did understand them, we<br />

would be able to stop the problem.<br />

Therefore, should you not be using zirconia-based restorations? I<br />

believe that that depends upon you and your laboratory’s success<br />

rate with them. If you have not had veneering porcelain fractures in<br />

the several years that zirconia has been out, the obvious answer is to<br />

continue using them. If you have had frequent problems then stop<br />

using them and switch to a different material, or switch to a laboratory<br />

that does not have failures with them.<br />

This really brings me to the heart of this editorial. What do you<br />

gain from the risk you take in choosing among different restorative<br />

materials? In choosing an all-ceramic restoration, the gain is always<br />

an esthetic one, or in a small group of patients, the lack of having<br />

metal in their mouth. Is this risk worth it? In the anterior portion of<br />

the mouth, I would definitely say yes. This would include the pre-<br />

The Risk of the Metal-Free Practice43

molars, as well. On the molars, the risk has to be tempered by the<br />

facts. I mentioned some not-so-great materials over the last 25 years,<br />

but there have been some incredible performers as well, perhaps<br />

none better than pressed ceramic. It has enabled large numbers of<br />

technicians to produce esthetic restorations at a much higher level<br />

than they ever could with metal ceramics. And because it can often<br />

be done supragingivally, it has eliminated the challenge of managing<br />

and perfecting subgingival margins for the dentist, and benefited<br />

the patient as well. Its long-term clinical performance on premolars<br />

forward has been exceptional. My friend Dr. Mauro Fradeani, a gifted<br />

clinician, published 11-year results of 98.9 percent success in the<br />

anterior. But even in his hands, the success rate on posterior teeth<br />

for the same period was 86.6 percent. The question you have to ask<br />

is whether the success rate on posterior teeth is worth the esthetic<br />

gain on molars compared with using products such as gold or metal<br />

ceramics that have success rates of 97 to 99 percent on molars at 10<br />

to 15 years. Realize that a success rate of 86.6 percent means that<br />

over 11 years, 13 of every 100 restorations done had to be replaced,<br />

as opposed to a gold or metal ceramic replacement rate of one to<br />

three per 100 restorations.<br />

In conclusion, I want to be clear that this is not an editorial about<br />

avoiding all-ceramic restorations, nor using only metal ceramic or<br />

gold restorations. I believe we have to evaluate each patient, their<br />

occlusal relationships, occlusal behaviors, esthetic demands, and<br />

their willingness to accept risks of failure in exchange for esthetics,<br />

to make an informed decision on which restorative materials we<br />

use. For myself, the majority of what I do is all-ceramic from second<br />

premolar forward. If the patient shows little to no evidence of wear<br />

on the molars, I will probably use all-ceramic restorations on these<br />

teeth as well, if the patient has high esthetic demands. But if the patient<br />

shows risk factors such as significant tooth wear, or wants the<br />

maximum longevity from the restorations, I will not hesitate to use<br />

gold or metal ceramics as my material of choice.<br />

Dr. Frank Spear is founder and director of Spear Education. He is also an affiliate professor in<br />

the graduate prosthodontics program at the University of Washington and maintains a private<br />

practice limited to esthetics and fixed prosthodontics in Seattle. To learn more about Dr. Spear<br />

or Spear Education, visit www.speareducation.com or call 866-781-0072.<br />

If the patient shows<br />

little to no evidence<br />

of wear on the molars,<br />

I will probably<br />

use all-ceramic<br />

restorations on<br />

these teeth as well,<br />

if the patient<br />

has high esthetic<br />

demands. But if the<br />

patient shows risk<br />

factors such as significant<br />

tooth wear,<br />

or wants the maximum<br />

longevity from<br />

the restorations, I<br />

will not hesitate to<br />

use gold or metal<br />

ceramics as my<br />

material of choice.<br />

44 www.chairsidemagazine.com

®<br />

An interview with Dr. Howard Farran<br />

– INTERVIEW of Howard Farran, DDS, MBA, MAGD<br />

by Michael DiTolla, DDS, FAGD<br />

The Rise of <strong>Dental</strong>town: An Interview with Dr. Howard Farran47

Dr. Michael DiTolla: Welcome, Howard. I’ve known you a while and I have to say, of all your accomplishments,<br />

I think the most impressive one I’ve seen is your vision for what has become <strong>Dental</strong>town ® . I really think<br />

that for somebody who hated computers — I mean, I used to laugh at you for your inability to use computers<br />

—, and for somebody who fancied himself as being very low tech, you really hit the nail on the head with<br />

dentaltown.com.<br />

Back in the day, you talked about how great it would be for a dentist in Topeka, Kan., to be able to ask a question<br />

about how to treat a case and have somebody in New York answer his or her question. It sounded like a<br />

flight of fancy, but you turned out to be absolutely correct. <strong>Dental</strong>town is probably the best way in dentistry<br />

for dentists to exchange information and to learn new tips and techniques. Give me an update on what’s going<br />

on with <strong>Dental</strong>town these days.<br />

Dr. Howard Farran: <strong>Dental</strong>town just continues to grow and grow and grow. The total number of registered<br />

users on the site now is 114,699. There are 192 countries in the world, and we have dentists registered<br />

from 172 countries. As I lecture around the world, it’s just amazing to see dentists in Australia,<br />

New Zealand, Hong Kong, Singapore, Ireland and the United Kingdom get excited about <strong>Dental</strong>town.<br />

They’re having a blast being able to talk to colleagues around the world.<br />

In 1994 when Netscape went public, I couldn’t understand what all the hype was about. I kept looking<br />

at this stock that blew up 30,000 percent and checked out the Internet, but at the time I thought it was<br />

pretty useless. One day I realized that I could use the Internet to connect all the dentists on one Web<br />

site. I wanted it to be like an AA meeting, where anybody could go and say, “Hey, I’m Dr. Farran and I<br />

have a problem: I’m getting sensitivity under my fillings.” And then some other dentist, for free, who’s<br />

been there and done that, can sit there and offer solutions and product names to help fix my problem.<br />

I thought by now we’d probably have 1,000 registered dentists, when in reality we will surpass 115,000<br />

registered dentists next month. It’s growing by about 1,000 dentists per month, with 20 percent of that<br />

being international. <strong>Dental</strong>town has become a household name because when a dentist has a problem,<br />

he or she can’t really ask the hygienist or assistant or receptionist or spouse; and they view the dentist<br />

across the street as a competitor. So instead they can go online. And you know, our motto at dentaltown.com<br />

is “No dentist ever has to practice solo again.”<br />

MD: Yeah, because even if a dentist did pick up the phone to call a friend, and we’ll use your example of sensitivity<br />

on direct composites, the friend may not be doing them or may not really have a good answer because<br />

they don’t use the same products or the friend doesn’t do many of them. The beauty of <strong>Dental</strong>town is you put<br />

something out there and not only do you get one piece of advice, but you’re going to get 20 responses from<br />

20 parts of the country from 20 dentists who went to 20 different dental schools and have seen 20 different<br />

lectures and tried 20 different composites. That is really powerful.<br />

HF: Yes, absolutely. And then to have a fun and friendly debate over which product is the best. I mean,<br />

there are 100 ways to cook a hamburger, and there are 100 different ways to do a filling. A lot of major<br />

companies have a large number of products, and it’s fun to watch dentists debating over which one is<br />

the best.<br />

That brings us to the Townie Choice Awards ® . We spoke previously about product evaluation and how<br />

the world used to be according to one person or another, and people would hang on every limb they<br />

said. And some of those speakers might only do esthetic dentistry or root canals or the like. We set up<br />

the Townie Choice Awards so that dentists can vote on the best products every year. The several thousand<br />

dentists that vote are the ones who are buying these products and lab services with their own<br />

48 www.chairsidemagazine.com

money. They’re practicing in the trenches of real-world, wet-glove dentistry and they’re just voicing<br />

what’s worked for them and what hasn’t. And I want to congratulate you, Mike, because last I heard<br />

<strong>Glidewell</strong> Laboratories has won 18 Townie Choice Awards.<br />

MD: Yes, thank you. In fact, we just ran an advertisement that shows Jim <strong>Glidewell</strong> holding all 18 Townie<br />

Choice Awards. We do take this honor seriously because the Townie Choice Awards represent the voice of dentists<br />

nationwide – these dentists are not paid to make a statement about our products. To us, it is validation<br />

that we are doing something right.<br />

HF: Yes. It’s a great thing. And back to your question about what’s new at <strong>Dental</strong>town: We started<br />

doing free online Continuing Education (CE). That’s been a major hit. We’ve had 260,000 course views<br />

in the first year, all for either AGD credit or ADA credit. A lot of the State Boards of <strong>Dental</strong> Examiners<br />

are allowing online CE credits as opposed to sitting in a lecture. Why the shift? For starters, lectures are<br />

expensive. They’ll say it’s $195 for the doctor, but what they don’t tell you is you have to shut down<br />

your office for a day. That could be several thousand dollars. And then you have to drive someplace or<br />

stay in a hotel.<br />

At <strong>Dental</strong>town, we break down our courses into really nice one- to two-hour courses. You can sit<br />

there at the end of the day, after dinner, after the kids go to bed, make yourself a bowl of microwave<br />

popcorn and sit in front of your computer and learn. You don’t have to take notes because you can<br />

always just go back to that class; you could take it a hundred times if you wanted to. The courses we<br />

have are on everything from dentistry to fillings to root canals to implants. It’s amazing how successful<br />

that’s been.<br />

MD: You mentioned earlier the international aspect of <strong>Dental</strong>town, and I can tell you we absolutely see that<br />

with our educational programs as well. We send every one of clinical and educational DVDs to U.S. dentists,<br />

but we stream them online as well. When you look at views per country, it’s pretty amazing to see what the<br />

Internet has done for the international dental community. For example, just yesterday I got an e-mail from a<br />

dentist in Moldova who has watched all of our videos and loves them.<br />

Shifting gears, I was around when you had your first dental practice and you had a concept for morphing<br />

your dental practice into what is now Today’s <strong>Dental</strong>, one of the most consumer-friendly practices that had<br />

ever been put together. It’s been awhile, probably eight or nine years, since I’ve had the chance to see your<br />

practice. But since nearly everybody reading this interview has a general dental practice, tell us a little bit<br />

about Today’s <strong>Dental</strong>. How has it changed over the years?<br />

HF: Well, Today’s <strong>Dental</strong> has changed tremendously over the years. I think the biggest change has been<br />

technology. Remember hand-dipping X-rays back in 1987, and then finally coming up with a developer<br />

like the AT-3000?<br />

MD: I think it was the AT-2000, unless you had one that was a thousand better.<br />

HF: And now we’re completely digital. I think digital X-rays are even more consumer friendly than the<br />

intraoral camera picture. You can sit there and take a bitewing and blow it up to an 8x10 piece of paper<br />

and then put it up on a clip board and get a red pen and circle right where the cavity at the contact of<br />

the adjacent tooth.<br />

MD: You know what’s funny? I just read something that said considering all the great things about digi-<br />

The Rise of <strong>Dental</strong>town: An Interview with Dr. Howard Farran49

tal X-rays (and it’s hard to find anything negative about them), that it’s only been adopted by 37 percent<br />

of dentists.<br />

HF: Yeah, and that’s just crazy because when you take bitewing X-rays and try to put that on a viewbox<br />

and educate the patient, it’s just a lose-lose situation. You’ve got this viewbox with light constricting<br />

your retina while your pupils are supposed to be dilating to see these little cavities; and the patient<br />

doesn’t own it — they don’t have mastery over their own X-ray.<br />

At Today’s <strong>Dental</strong> we print the X-rays out and give a copy to the<br />

patient every single time. And like I said, we can put that X-ray<br />

on a clipboard and show them that there are two types of cavities.<br />

There’s a flossing cavity right in between the teeth and then you<br />

can circle an existing flossing cavity, and you can trace out the<br />

nerve and show them that this cavity only needs to go another<br />

millimeter or two before it turns into a root canal. And when you<br />

talk about flossing cavities instead of a MO or a DO, something<br />

the patient doesn’t understand, well they understand a “flossing”<br />

cavity because the patient knows more than anyone that they’re<br />

not flossing. And then you can circle the pit and fissure fillings on<br />

the teeth and get out your laser Diagnodent and have them hold<br />

it for educational purposes and go around the pits and fissures<br />

and write down the numbers over 30 on another 8x10 sheet of<br />

paper so now they’ve got their digital X-rays. They can see, “Wow,<br />

I have 10 existing fillings, and it sounds like with this laser I’ve<br />

got two more.” And then we’ll go around the mouth and show<br />

them that they have nine fillings that are in between the teeth<br />

where the floss goes. And not only do they have two new flossing<br />

cavities, one of them is under an existing flossing filling. So,<br />

you can just tell this person, “Look, you’re not flossing at all and<br />

you haven’t been for the last 10 years.” That really, really sells<br />

dentistry because they can master — anybody can master — and<br />

see the black dot that’s printed out on the 8x10 piece of paper. It<br />

makes treatment plan acceptance go through the roof. I also still<br />

use intraoral cameras to take pictures of broken down teeth to<br />

show patients there’s not enough tooth structure to hold a filling<br />

and a crown or when an onlay is needed.<br />

“<br />

Why do half the general<br />

dentists in Europe place<br />

implants and in the<br />

United States it’s 5 percent?<br />

Your European<br />

brothers can do this in<br />

England and Germany<br />

and France. Why can’t<br />

you do this in the<br />

United States? ”<br />

The other notable change is going completely paperless. In the past, if a patient were to call the office<br />

and say, “I’ve still got pain from that wisdom tooth extraction, can I have more pain pills?” or something<br />

like that, the receptionist would never have the time to get up out of the chair and make notes<br />

in the chart. When they came in later for a suture removal, I wasn’t aware that this person was in pain<br />

for six or seven days. Now that we’re paperless, every conversation is entered at the computer. All the<br />

receptionist has to do is just type in the patient’s name and put in the clinical notes. It’s amazing how<br />

many times patients call the office with questions about this or that, or maybe they call up and say, “I<br />

don’t want a deep cleaning, I just want a regular cleaning. Why do I have to have a deep cleaning?” And<br />

then the hygienist sees in the notes that the patient is coming in for their first quadrant or two of root<br />

planing. Then she goes over it again, and she can get out a mirror or go back to the intraoral camera<br />

or go back to the digital X-ray and show them bone loss. So, I think technology has been the single<br />

50 www.chairsidemagazine.com

iggest thing that has affected dentistry. And I think it’s quite frightening that two-thirds of dentists<br />

don’t utilize digital X-rays.<br />

MD: Do you think it’s mainly just the cost of getting into the system?<br />

HF: Yes.<br />

MD: And do you think that’s a valid point for a dentist to say, “Look, I just don’t want to spend the money.”<br />

Do you think they’re overpriced?<br />

HF: No, I don’t think they’re overpriced because I think they make you go so much faster. You’re doing<br />

a root canal and you’ve got Apex Locator technology. You can snap a real quick digital X-ray and have<br />

it on-screen instantly. Do you remember going back and putting in 12 X-rays for an FMX and having<br />

them come out and figure out which one goes where? That was a 15-minute ordeal, and bitewings<br />

were a 10-minute ordeal. Now, instead of spending 10 minutes in the dark room, a hygienist has 10<br />

more minutes in the operatory for education. You know, “doctor” is a Latin word coming from docere,<br />

meaning “to teach.” Now the hygienist can be a doctor and spend more time teaching with an intraoral<br />

camera, having the patient hold a mirror and he or she shows them the bleeding gums. I think this<br />

technology pays for itself just in speed. That’s why I always get upset with dentists when they’re strictly<br />

fee-for-service; meanwhile, a third of their patients want them to take a PPO. These fee-for-service<br />

dentists don’t accept PPO because they can get $1,100 for a crown and PPO only pays $700. To this I<br />

say, change your technique and get more efficient! Instead of spending 90 minutes doing a crown, try<br />

doing it in 45 minutes. Try getting the technology. Try Septocaine instead of Lidocaine to numb them<br />

up faster. Pack your cord before you prep the tooth so you don’t nick the gums . Push the gums down<br />

and outward, and if you don’t nick the gums you won’t have to spend 10 minutes dealing with bleeding<br />

or hemorrhage or sulcular fluid. And so you know, Septocaine over Lidocaine, packing cord first and<br />

taking your preliminary impression using impression materials that set up faster. A dentist who can do<br />

a $700 crown in 45 minutes is doing $1,500 in 90 minutes, as opposed to the other dentist who’s losing<br />

patients because he’s charging too much. During a time of recession, people are shopping around and<br />

they’re calling to find out how much your crowns are.<br />

MD: And that’s how I got into single-tooth anesthesia, for example. I use PFG gel (Steven’s Pharmacy; Costa<br />

Mesa, CA) and the Milestone STA System (Milestone Scientific; Livingston, NJ), and I don’t give that many<br />

blocks unless I’m working on an entire quadrant. I mean, 90 seconds after I start this injection, I’ve got<br />

profound anesthesia and I’m ready to prep the tooth. That shaves off waiting eight to 10 minutes for a lower<br />

block, maybe missing it, having to give it again. It’s such a great feeling to set down the anesthetic syringe<br />

and pick up the handpiece and get to work. And part of it is quality, too: The efficiency allows you to do better<br />

work. You have a little extra time to clean up the prep at the end if you need to. Or like you were talking<br />

about with digital X-rays – one of my favorite things with digital X-rays that I would never do before is take<br />

a picture to check the interproximal margins of a crown before cementing it. In the old days, it was so inefficient<br />

to shoot a bitewing and wait for it to develop prior to cementation. I would rather just cement it on<br />

and then cut it off six months later if there was an open margin. But today, the ability to have my assistant<br />

try a crown in, check contacts and occlusion, take a digital X-ray and have the image up there three seconds<br />

later to verify the interproximal fit is a huge deal to me. It not only increases efficiency because I’m not going<br />

to have to redo a crown later that’s got an open margin, but the quality goes up as well. Efficiency can really<br />

lead to better quality.<br />

HF: Absolutely. Efficiency does lead to quality — there’s been a lot of research on it. Like, for instance,<br />

The Rise of <strong>Dental</strong>town: An Interview with Dr. Howard Farran51

an endodontist will do a root canal in an hour. Compare the quality of that to someone who takes three<br />

one-hour appointments. A dentist who requires three one-hour appointments to do molar root canals<br />

doesn’t know what he or she is doing, is not focused, doesn’t have the equipment needed, doesn’t have<br />

engine driven nickel titanium files, isn’t using a Root ZX, isn’t using technology.<br />

I think it’s a fact in dentistry that the faster you are, the better you are. I mean look at the oral surgeon,<br />

who will take out all four wisdom teeth in seven to 10 minutes after they’re numb or the patient is put<br />

to sleep. And then you have a general dentist who will spend an hour trying to get out one wisdom<br />

tooth. And the oral surgeon has got all kinds of toys and technology and handpieces that make his or<br />

her job so much easier, and the general dentists doesn’t invest the time or the money to get the technology<br />

needed to be that efficient.<br />

MD: Speaking of technology, do you ever see the chairside CAD/CAM milling units being a challenge to the<br />

dental laboratory industry and replacing the dental laboratory in the eyes of American dentists?<br />

HF: I don’t, because I think a lot of dentists are using CAD/CAM mills more to replace large fillings with<br />

inlays and onlays. I think badly broken down teeth are still by and large being replaced by crowns and<br />

bridges and putting things on implants. So no, I don’t see it as being a threat to the dental laboratory<br />

business. The other thing is the dental industry in ‘08 did $98 billion during this horrible recession; it<br />

was scheduled to do about $101 billion, so that’s only about 3 percent down. Dentistry just continues<br />

to grow, at about twice the rate of the GDP of America. That’s why health care went from 1 percent of<br />

GDP in 1900 to 14.7 percent in the year 2000. Here we are 2009 and this year it’s expected to be 17.5<br />

percent of the GDP. Same thing with removables. People were saying that this was the end of dentures<br />

and removables, and it’s a lost art and no one is getting them anymore. But don’t forget there are 30<br />

million illegal immigrants in the U.S., and they are the ones who will keep removables going strong.<br />

You’ve got people coming into this country who have never seen a dentist in their life and can’t afford<br />

to have full-mouth reconstruction with root canals and crowns and bridges going for removable. So,<br />

I think dentistry is extremely diverse. There’s room for everyone, there’s room for all the specialties.<br />

There’s pretty much room for growth in all sectors.<br />

MD: Let me ask you about something that came up last year. There was a news report on crowns made in<br />

China that were found to have high levels of lead in them. It was kind of funny in the sense that there is really<br />

no porcelain glaze available on the market today that doesn’t contain at least a microscopic amount of<br />

lead. So it’s really not a China thing, and it was hard to tell whether this issue was just xenophobia or what.<br />

But Walmart has certainly proved to become a successful company selling predominantly, if not exclusively,<br />

items imported from China. Why is it, do you think, that the American public had such a knee-jerk reaction<br />

to crowns being made in China?<br />

HF: Well, I think it’s funny. You know, many dentists drive cars made in Germany or Japan, whether it<br />

be a Lexus or an Infiniti or a Mercedes-Benz or a Porsche or a Jaguar – and that’s not a problem because<br />

it’s Japan and Germany and we won that World War. Japan’s the second-biggest economy in the world.<br />

In 1998, the entire world’s economy was $50 trillion dollars, and America’s economy was $14 trillion of<br />

that, Japan was $5 trillion of that, Germany was $3 trillion, China was only $2.6 trillion and the United<br />

Kingdom was $2.4 trillion.<br />

When it comes to imports, China is a communist country, and that just stirs great emotion. No one<br />

complains that they’re using materials that are made in Germany, whether it be Sirona or Ivoclar or<br />

whoever. No one cares about importing stuff from the United Kingdom. It was an extremely emotional<br />

52 www.chairsidemagazine.com

esponse. However, I want to point out that America doesn’t make a single television, ever. If I asked<br />

a group of dentists, “What make is your TV?” they’ll say “Sony” or “Hitachi.” Well, why is having a Sony<br />

television and a BMW and shopping at Walmart not bad? America doesn’t have any textiles mills either.<br />

So you’re either running around naked, or your importing clothes from India or China. Name a textile<br />

company in America. That was Warren Buffett’s great insight. He bought the 10 textiles called Berkshire<br />

Hathaway, and they were draining so much money trying to improve their textile mills that he just took<br />

all that money and returned it to the shareholders. And with all that profit, he just started buying other<br />

companies. And he said America’s too high-cost to make textiles; we’re not a country where everyone is<br />

going to be sitting on a sewing machine making shirts and pants. So, I think the response to the crowns<br />

with lead made in China was extremely emotional.<br />

MD: For the average dentist, it really does come down to value. I believe that if you can give the average<br />

dentist, for a fair price, a crown that drops into place, contacts are good, occlusion is good, esthetics are acceptable<br />

— I don’t think they care if it’s made in California, China, or Sri Lanka by a team of 12 monkeys. I<br />

think it’s all about the final result. And I agree with you that it’s emotional.<br />

So, are you saying that if you could get a crown from China for the same price, or maybe a little cheaper than<br />

one you got in the U.S., you would not have a problem doing that?<br />

HF: I would not have a problem doing that. Another thing I’d like to point out is this: American labs<br />

have issued price increases for a long time. However, the insurance companies don’t give us dentists a<br />

price increase. I think Jim <strong>Glidewell</strong> is the Herb Kelleher of dentistry. For those unfamiliar with Herb<br />

Kelleher, he is founder of Southwest Airlines. And he once said, “Everyone calls up to check what the<br />

price is to fly from L.A. to Las Vegas, but no one ever calls up and asks what meals we’re going to serve.”<br />

So Herb just stripped out all the cost he could, limited it to one type of airplane, a Boeing 737, so he<br />

could limit his parts and overhead, and got rid of the meals and doesn’t do layovers, just flights point to<br />

point. And what Herb has done is given people the freedom to fly. So when Grandma wants to go visit<br />

her granddaughter for her First Communion, she, with Southwest Airlines, can actually afford to fly to<br />

see her granddaughter’s First Communion. And that’s what <strong>Glidewell</strong> Laboratories has done. By keeping<br />

an eye on costs, you’re giving the middle-income and lower-middle-income people the freedom to<br />

save their teeth.<br />

MD: And you know what our newest project is? Yesterday I cemented our first model-less PFM crown. We did<br />

not make a stone model for this crown. I took a digital impression in the mouth, I sent the information to<br />

the laboratory and they made a model-less PFM crown for me. You can do this with all-ceramics, obviously<br />

CEREC ® has been doing this for decades, but a lot of dentists are skeptical of all-ceramic crowns because they<br />

break or they’d rather cement them into place because of post-operative sensitivity concerns. So we made the<br />

first model-less PFM. It’d be like if your CEREC machine was able to spit out a PFM crown at the end of milling.<br />

And we’re realizing that by not making the model, not having to produce it all here, not having to have<br />

the dentist ship us the case via FedEx because it’s going to be digitally transmitted, that by being able to send<br />

out a tiny little envelope with a crown in it instead of a big box with a heavy model in it, we’re going to be<br />

able to save $20-$25 dollars per crown. We then pass that savings along to the dentist, so the crown will be<br />

$20-$25 cheaper if you’re okay without a model. To me, that’s a great example of what you just explained<br />

— stripping away the unnecessary to make it more affordable for the dentist who hopefully can make more<br />

dentistry available to more patients.<br />

HF: That is fantastic because we’re in a recession, and people are keeping an eye on their overhead and<br />

where they’re spending their money. In fact, we’ve had to adjust Today’s <strong>Dental</strong> for a recession.<br />

The Rise of <strong>Dental</strong>town: An Interview with Dr. Howard Farran53

MD: In what ways?<br />

HF: Well, I think there are four basic things that have to be done during a recession. Number one is to<br />

cut costs, whether that be cheaper crowns or supplies or reduced labor costs. For example, if you’re<br />

having a central sterilization person stand around all day and there are open holes in your schedule,<br />

You’ve got to lay people off. The second thing is you’ve got to double or triple your marketing budget.<br />

It’s just amazing to me how people will not be coming into the dental office and the dentist is not aggressively<br />

trying to replace those people. Advertising is so lucrative. You’ve got two big facts staring<br />

you in the eye: One is that 50 percent of the population didn’t go to the dentist last year, so that’s fertile<br />

territory to market to. And then number two: it’s a fact that 8 percent of Americans moved. So you might<br />

say, well, my neighborhood is mature and there’s not a lot of new growth, but you still have turnover in<br />

houses and you still have people not going. And some of these marketing things are no-brainers, like<br />

1-800-DENTIST. They charge $1,500 a month and guarantee you 15 new patients, and a new patient, if<br />

you take an FMX on them that is $100. If I were to walk a dentist into a stadium and say, “You can have<br />

any patient in this stadium for your practice if you give them a free FMX, how many patients do you<br />

want?” the dentist would say, “I’ll take them all.” Then join 1-800-DENTIST. There’s other great marketing<br />

places: There’s newpatientsinc.com with Howie Horrocks. There’s dentalpostcards.com, where all<br />

you have to do is call them up, give them your ZIP code and a credit card number and they’ll drop the<br />

direct mail piece the next day.<br />

MD: And how much more willing would that dentist be to do those free FMXs just to get those new patients if<br />

he had digital radiography?<br />

HF: Exactly. And then the third thing I’d say is you’ve got to add new products and services. You know,<br />

you used to refer out all your endo, maybe it’s time you started learning some endo.<br />

MD: You know what I just did for the first time two months ago?<br />

HF: What’s that?<br />

MD: A crown that matched! (laughs) No, I surgically placed my first implant for a missing lower molar, and<br />

I did it with the Inclusive ® Digital Implant Treatment Planning Services we have here at the laboratory. They<br />

made a surgical guide for me. It’s like a bite splint, it snaps onto the teeth. There’s also a hole in it — about<br />

5 mm long so that the drill can’t go in at the wrong angle or can’t go in too deep. Howard, it was the easiest<br />

$1,200 procedure I’ve ever done. And that’s probably at the low end for Newport Beach. And it’s easier than<br />

prepping a crown. You look at prepping a crown and you start with this whole tooth and you need to threedimensionally<br />

be able to imagine what it’s going to look like 2 mm shrunk down and not have any undercuts.<br />

All I did here, and I didn’t even lay a flap, I used a tissue punch through the surgical guide and then used<br />

each drill down to the depth and then placed the implant right through it. It was the most fun I’ve had and it<br />

was certainly the easiest high-dollar production procedure I’ve done in the last 10 years.<br />

HF: Right. And you know, there’s an interesting thing about that. I mean, why do half the general<br />

dentists in Europe place implants and in the United States it’s 5 percent? Your European brothers<br />

can do this in England and Germany and France. Why can’t you do this in the United States? Or take<br />

orthodontics. You’re telling me you can’t even do Invisalign ® (Align Technology; Santa Clara, CA)? I<br />

mean Invisalign, they do all the work for you. You can’t do minor tooth movement? Another one is<br />

a crown lengthening procedure. I mean how many impressions do you get at <strong>Glidewell</strong> Laboratories<br />

where you’re looking at the impression thinking, man that patient should’ve had crown lengthening. So<br />

54 www.chairsidemagazine.com

they’re sitting there pumping Epinephrine in with the ligamajet<br />

trying to stop the bleeding and they’re jamming cords down into<br />

the attachment for this subgingival margin. Like you were talking<br />

about digital impressions. You can’t take a digital impression if<br />

there’s blood or fluid.<br />

MD: No way. Especially not if it’s 3 mm subgingival like we see in<br />

some cases. And even if it does turn out perfect, the margin is a millimeter<br />

away from the bone, and now it’s a periodontal nightmare,<br />

not a periodontal and restorative nightmare.<br />

HF: And insurance companies pay about 80 percent of crown<br />

lengthening, which is about $750 a quadrant. All you need is a<br />

scalpel and some sutures and a bur. It’s just amazing how, with<br />

crown lengthening, not only do most dentists not do it, they won’t<br />

even refer it out!<br />

MD: And why don’t they refer it? I think they don’t want to lose<br />

the production of doing the crown that day. That’s how shortsighted<br />

it is.<br />

HF: Yes, I absolutely agree with that.<br />

MD: And they don’t want the periodontist using up the patient’s insurance<br />

benefits for that year instead of the crown.<br />

HF: Yeah.<br />

“<br />

Insurance companies<br />

pay about 80 percent<br />

of crown lengthening,<br />

which is about $750 a<br />

quadrant. All you need<br />

is a scalpel and some<br />

sutures and a bur. It’s<br />

just amazing how, with<br />

crown lengthening, not<br />

only do most dentists<br />

not do it, they won’t<br />

even refer it out! ”<br />

MD: Which is not a decision made in the patient’s best interest, and<br />

it’s very short-term planning. You put a crown on a patient today<br />

that has a 3 mm subgingival margin and you got the money, but<br />

you’re going to have to redo it and your hygienist on is going to say,<br />

“Wow, everything on this patient looks good here on recall except for<br />

the margin on this crown on tooth #30. It’s purple and it won’t stop bleeding.” Or, worst-case scenario, the<br />

patient moves to another city and the dentist looks at it and says, “The tissue around this crown looks horrible,<br />

who did this?”<br />

HF: Right. And that would be 8 percent of your patients. So 8 percent of your crowns in any given year<br />

move to another house somewhere in another city.<br />

MD: Yeah, and now you’re not just having to fool your hygienist, you’re having to fool a dentist in another<br />

city, right? And then a peer review board. I saw President Obama on television the other day talking about national<br />

health care, and there’s some question about whether or not dentistry would be covered in this health<br />

care plan. I’m interested to hear what your take would be on the government getting into dental care?<br />

HF: Well, the government is broke. They’re $14 trillion in debt. They’re projected revenues vs. costs<br />

over the next 20 years is negative $50 trillion. The bottom line is, Obama would like to do everything.<br />

I’m sure he’d like to buy everybody a new car if he had the money. He has a big heart, but he’s not<br />

going to have the money. And when we look around the world of the 40 richest countries in the world,<br />

The Rise of <strong>Dental</strong>town: An Interview with Dr. Howard Farran55

ased on GDP per person, we’re the only one that doesn’t have universal health care. But a lot of these<br />

countries that cover dentistry are getting out of it as fast as they can because they have to cut costs.<br />

They’ve already got 60 percent taxes and they still are broke. So I don’t think that America can afford<br />

to get involved in dentistry. And if they do, it would only be for disadvantaged, poor children under<br />

the age of 18.<br />

MD: Yeah, that’s what I saw. It would be for patients under 21, basically in high-needs categories. I’m interested<br />

to know if you or any of the dentists at Today’s <strong>Dental</strong> still routinely place amalgams? You and I got out<br />

of dental school and started in this profession when the word on the street was that amalgams were evil and<br />

soon to be banned, but amalgams make up a big part of bread-and-butter dentistry. That was 15 years ago.<br />

Where are you today in regards to amalgams?<br />

HF: Well, Today’s <strong>Dental</strong>, I think we did our last one in 1990. So it’s been 20 years. The reason I got out<br />

of them had nothing to do with mercury, because I’ve read a lot of mercury research, and mercury in<br />

a silver filling is ionically bound to silver and copper and nickel and tin. And it’s an insoluble salt. And<br />

when you swallow an old amalgam, the next day, your body just disposes of it. It doesn’t get absorbed.<br />

But when you start finding mercury in brain tissue or things like that, it’s ethyl mercury or methyl mercury,<br />

which is basically coming out of seafood because of burning coal. In 1950 the oceans were 1 part<br />

per million mercury and after a half-century burning coal, now it’s 4 parts per million of mercury in<br />

the ocean. So I don’t like mercury in coal, but in the mouth I find it fine. The only reason I don’t do it<br />

is because if I asked 100 blind patients, would you rather have a black filling or a white filling, they’re<br />

always going to take the white filling. And we did it back in 1990, that was a real economic boom,<br />

because all the other dentists were doing silver fillings, and they didn’t like them and they didn’t like<br />

them in their kids’ teeth. They’d come in and say, “Look what this dentist did!” And the kid would smile<br />

and there would be a metal crown that still said “B4” on the side of it and a couple black fillings here<br />

and there, and that just kills self-esteem. We did it for business reasons, not health care reasons. But I<br />

think an amalgam lasts longer than a composite. I mean, the research is extremely clear on that. How<br />

could a heavy metal not last longer than a piece of plastic?<br />

MD: Yeah, and plastic versus porcelain, even. You look at the difference with composite inlays versus porcelain.<br />

You’ve got a pool, you look at the ceramic tile, it does pretty good. But anything that’s plastic around the<br />

pool, you can see it just gets beat up in the presence of constant moisture. I don’t think there’s any doubt that<br />

plastic doesn’t do as well as metal or glass when it comes to being submerged 24/7. So, if a dentist in Kansas<br />

e-mails you and asks if he or she should stop doing amalgams, is there an easy “yes or no” answer? Or do you<br />

need to know more about his or her practice before giving advice?<br />

HF: Why not have a two-chair level? Why not have an MOD amalgam for $150 and an MOD composite<br />

for $200? Let’s call it market segmentation. That’s why GM has Chevy and Pontiac and Oldsmobile and<br />

Buick and Cadillac. How much do you want to spend? Want a basic car? We’ll sell you a Chevy. Want all<br />

the bells and whistles? We’ll sell you a Cadillac. But when they ask me which one lasts longer, I always<br />

tell them the Chevy.<br />

MD: Right. You know back in the day, too, we heard a lot about concepts like dropping insurance. And I’m<br />

sure you remember we were being told by some of our clinical gurus that it was time to drop insurance — become<br />

free and independent of the insurance companies. Tell me how Today’s <strong>Dental</strong> views the dental insurance<br />

industry.<br />

HF: Well, first of all, the majority of all those speakers didn’t even have practices. Secondly, I think the<br />

56 www.chairsidemagazine.com

only people that can get away with no insurance are running monopolies in small towns with 3,000<br />

people and they’re the only dentist. But when you get into a competitive market, a metropolitan area, if<br />

you don’t take insurance, you’re insane. And that’s another thing we did to cut costs with digital X-rays<br />

and being paperless. We can shoot out the insurance claim right when we check out the patient. Remember<br />

back in the old days when you had paper charts and on Fridays you would do insurance billing?<br />

That’s all gone. And what we do with every single person that comes in, we have a person — our<br />

insurance coordinator — who physically calls the insurance company and has a sheet that they fill out.<br />

That sheet basically covers all the technical questions of insurance coverage so that when we do the<br />

financial arrangement, we can say with extremely great confidence exactly what that insurance person<br />

is going to pay. I mean, Mom loves her benefits. I’ve heard, “Yeah, my husband works in construction,<br />

and he used to be in this small company and they didn’t have dental benefits. I’ve been egging him to<br />

get on to this bigger company because they have benefits. I’ve been waiting three years for this.” And<br />

they bring their insurance coverage in and they’re all proud and they want to use it. I mean, why not<br />

have someone else pay for half of your crown?<br />

MD: That seems to me the more rational thing to do. It always scared me when I heard people recommending<br />

to dentists that they get rid of insurance: “We know it’s going to be really difficult, but do it and it’ll be the<br />

best decision you ever made.”<br />

HF: I think it’s anti-consumer. You know, Mike, deep down inside we all have to be a public dentist,<br />

too. We all have to do charity cases in our office for free when, you know, some girl has been beaten<br />

up by her husband, she’s living in a shelter and she can’t get a job because she’s missing tooth #8. I<br />

can’t tell you how many of those I’ve done. Sure, we have upper-class people who can pay cash for<br />

all of their dentistry. But we also have middle-class people barely making ends meet, especially in this<br />

economy today where we have 10 percent unemployment. But what about the lower class, whether it’s<br />

good times or bad. I think cutting costs and offering, when you treatment plan, cost alternatives. You<br />

can do a low-cost partial or you can do a high-cost bridge, implant and a crown. I think by treatment<br />

planning market segmentation so these people can have choices and then having financing available<br />

like CareCredit ® , is being extremely public health dentist oriented. That’s why they fluoridated the City<br />

of Phoenix water. I got here and I thought it was just an atrocity that there were 2,000 dentists doing<br />

dentistry in Phoenix and the water wasn’t even fluoridated. So, I spent every Friday for two years trying<br />

to get the water fluoridated and finally got the City Council to pass it 8-1, and I got the Public Health<br />

Dentist of the Year Award (’95). And I’ll tell you what, that’s a greater achievement than anything else<br />

I’ve ever done.<br />

MD: Yeah, that is pretty important because of who you’re helping there. When you get right down to it, I don’t<br />

know many middle-class families who drink tap water. I think the middle class believes tap water is evil.<br />

Meanwhile, in a city like Phoenix, if you assume the inner-city kids are drinking tap water, the people who<br />

have the least amount of access to dentistry now have the most amount of access to the free fluoride. And<br />

they’re the ones who can’t afford dentistry and need the stronger teeth, versus the middle-class kids drinking<br />

essentially distilled water and ending up with interproximal decay.<br />

HF: Yeah, and that’s why I participate in PPOs. I’m not a fee-for-service dentist; I’m a production-perhour<br />

dentist. I can go in there and do $1,000 an hour; I don’t care if you give me $700 for a crown on<br />

a PPO or $700 cash. And I might do that PPO crown and in that same appointment do another two<br />

fillings. Two things on that: A lot of dentists don’t want to numb up the other side of the mouth and<br />

they’ll make two appointments out of it, and then right next door to them in a dental building is an<br />

oromaxillofacial surgeon who spends his entire life numbing up all four quadrants of the mouth. When<br />

The Rise of <strong>Dental</strong>town: An Interview with Dr. Howard Farran57

you sit there and slash your prices by joining a PPO, which is the fourth thing dentists need to do in a<br />

recession, it is that you just need to work harder. You can’t numb up with Lidocaine and then go in your<br />

break room and get a cup of coffee and then go in your private office and sit there and start playing<br />

around on <strong>Dental</strong>town. You need to stay in there and work.<br />

MD: Are you saying <strong>Dental</strong>town is bad for your practice?<br />

HF: Well, you know when you’re in your practice, the private office<br />

has never made you a dime.<br />

MD: You did make the point that if you’re taking <strong>Dental</strong>town CE, it<br />

should be at home in your underwear with some microwave popcorn,<br />

not at the office.<br />

HF: I want to say something else about PPO, another public health<br />

dentist thing. Most of the people with PPO can’t afford to get<br />

their teeth fixed any other way. And if you, once again, concentrate<br />

on production-per-hour and quit concentrating on fee-forservice<br />

and get faster and more efficient and do better dentistry,<br />

you can make a fortune on PPOs, especially since you know half<br />

of your competitors across the street don’t touch them.<br />

Also, I want to say one more thing about marketing. Let’s say that<br />

you’re a slow dentist, and you’re just never going to get faster.<br />

You know, a PPO might discount your fee 20 percent, but why<br />

not spend 3 percent on marketing. It’s always amazing to me that<br />

a dentist will sign a PPO and give up 20 to 30 percent of their fee<br />

but won’t spend 3 percent on marketing to retain new patients,<br />

half of which have no insurance at all.<br />

MD: So how have you guys done through this recession?<br />

“<br />

We joined a couple<br />

PPOs and we started<br />

advertising our daylights<br />

out and just really<br />

bumped up our new<br />

patient flow to replace<br />

all the people who<br />

didn’t have the money<br />

to come in or were<br />

moving away. ”<br />

HF: We grew 8 percent this year.<br />

MD: Well, there you go.<br />

HF: Just doing what I’m talking about. And the best example, Mike, of this how to handle a recession<br />

is to go back to March of 2000 when the NASDAQ was at 5,045 and then the whole bubble popped<br />

and the stocks came crashing down — the Internet stocks. Remember all those Internet stocks that<br />

went from $50 per share to pennies per share? Look at Michael Dell. He’s only 45 years old and he’s<br />

a multibillionaire. And when that recession hit, what did he do? He did all four things that we’re talking<br />

about. He cut costs; he tripled his marketing budget. Remember the Dell Dude on every television<br />

channel: “Hey, dude, you need a Dell.” Full-page ads in every magazine. And then, number three, he<br />

added new products and services, he started selling servers and other different devices. And he grew<br />

his earnings every quarter all the way through that recession by just cutting costs, tripling his marketing<br />

budget, adding new products and services and slashing his prices. I mean, who would’ve guessed<br />

in the year 2009 that today you could buy a Dell laptop with everything needed for $750? In the year<br />

2000, that laptop was almost was $5,000.<br />

58 www.chairsidemagazine.com

At Today’s <strong>Dental</strong>, we joined a couple PPOs and we started advertising our daylights out and just really<br />

bumped up our new patient flow to replace all the people who didn’t have the money to come in<br />

or were moving away. We got a slew of new patients and did a lot of hard work on them and did a lot<br />

of dentistry and added new products and services like Invisalign. I got my Diplomat in International<br />

Congress for Implantology; I got my Fellowship in the Misch Institute; I’ve been really trying to build<br />

an implant practice within my practice.<br />

MD: How’s that going?<br />

HF: Great, great. I mean it’s kind of funny, but upper-middle-class people do not like to have two teeth<br />

filed down for a bridge.<br />

MD: Is it just the upper-middle class? I’m not sure anybody likes the idea of having two teeth ground down to<br />

a nub, as they so often put it.<br />

HF: Yeah, I like it when you prep lower anteriors for a crown. What do you have left, a rice kernel?<br />

MD: Yeah. It’s a good thing the impression takes four minutes to set because that gives you time to start praying<br />

that the preps won’t be in the impression, as you stare down at the pulp chambers. Can you see where<br />

a service like Inclusive Digital Implant Treatment Planning with the surgical guide for implants would be<br />

helpful, or do you think it’s overkill to have every patient go out for a scan?<br />

HF: No! You cannot overkill on the diagnostics and placement of implants. I mean, you’ve got nerves,<br />

you’ve got sinuses, and you’ve got the mental foramen. I think you have to overkill on diagnosing and<br />

treatment planning and, once again, need to be fast and efficient. You were talking about your implant<br />

and how fast it went, and it’s because you were using technology. For implants you need high technology.<br />

MD: That’s how I felt. It was fast because basically there had been so many safety precautions built into it that<br />

I could go fast. It was fun, it was fast and the feeling of not grinding those two adjacent teeth down was so<br />

nice. What a great feeling. Have you ever done a case where you remove a three-unit bridge and instead of<br />

placing a new one, you place an implant and two single crowns there?<br />

HF: Yes.<br />

MD: And that’s a great feeling, too, isn’t it? Just knowing the patient can floss in between there and you’ve<br />

created a healthy periodontal situation?<br />

HF: Right. And as I look back at some of my slides from like 1990, Mike, I remember some of these<br />

horseshoe bridges I was so proud of, like 14-unit roundhouse bridges, where someone was missing five<br />

or six teeth in the arch. But then you watch that over the next 10 or 20 years, and one tooth looks bad,<br />

and what happens? You lose the whole case. I think that times have really changed and implants are a<br />

big part of that. Once again, why are half of the dentists in Europe placing implants and only 5 percent<br />

in the U.S.? Because they are scared by the oral surgeon and periodontist, who both claim you have to<br />

be an oral surgeon or a periodontist to surgically place an implant. The fact is periodontists had zero<br />

implant training in their periodontal program because they graduated 10 or 20 years ago.<br />

MD: Well, Howard, is there anything else you can think of that we didn’t bring up or that you’d like to<br />

talk about?<br />

The Rise of <strong>Dental</strong>town: An Interview with Dr. Howard Farran59

HF: Yes. I’d like to say this: In 1945 when Pearl Harbor was bombed, 99.9 percent of Americans had<br />

never heard of General Patton or General MacArthur. And then the United States rounded up 6 million<br />

boys and told Patton to go get Nazi Germany and MacArthur to go get Japan. And those two men, because<br />

of the gravity of the situation, they rose to the occasion and they achieved their destiny. If there<br />

wouldn’t have been a World War, they could have never achieved their destiny. When times are tough,<br />

like they are now during this “Great Recession,” and things aren’t going to be easy for another year,<br />

year and a half, maybe even two to three years, now is your time to rise to the occasion — to be Gen.<br />

Patton, to be Gen. MacArthur. Don’t sit back in your private office and be a wimp and whine about the<br />

economy and cry to your spouse at night. Stand up and lead. Stand up and start marketing. Stand up<br />

and start taking CE — take it for free on <strong>Dental</strong>town, go to some courses, learn how to place implants,<br />

start doing Invisalign, join a PPO where you have to work harder. Just rise to the occasion and achieve<br />

your own dental destiny.<br />

MD: Those are great words of inspiration. But you must run into dentists who really don’t want to do what<br />

you’ve just said. They don’t want to have to be a leader and don’t want to have to run a business. What’s the<br />

most common question you get from dentists at lectures or via e-mails? Is there one thing that dentists hit you<br />

with all the time that you can almost count on getting at least once a week?<br />

HF: Yes. That is staff problems.<br />

MD: I wonder if most dentists in America are nodding their heads yes in agreement.<br />

HF: Yep, that’s the most common question I get. How do you deal with dysfunctional staff? And the<br />

answer is so easy: You fire them as fast as you can. But they just don’t seem to have the guts or the<br />

perseverance or they’re scared that fired employees are going to talk bad about them around town. But<br />

building a winning team is probably THE single most important thing you can do in any business. I<br />

mean Southwest Airlines hires on attitude and trains for skill. All the other airlines want an impressive<br />

resume showing skill; Southwest Airlines wants a happy, personable person.<br />

MD: And I would guess that Southwest Airlines would pride themselves on hiring on attitude, but I would assume<br />

that they are definitely going to fire based on attitude as well, right?<br />

HF: Right.<br />

MD: I mean, you might not be the sharpest employee there, but as long as you’re happy, outgoing and you look<br />

like you love to work there and love the customers, then you’ll be okay.<br />

HF: Absolutely.<br />

MD: Alright. Well, Howard, thanks for your time, I really appreciate it. We’re going to direct everyone, if they<br />

haven’t already, to go to dentaltown.com, log on, get an account. It’s free. Find out what you’ve been missing.<br />

What you’ve been missing, which is only the best post-graduate education you could ever hope to get in dentistry.<br />

It’s almost “<strong>Dental</strong> School 2.0.” Now you’re not just learning from part-time instructors, you’re learning<br />

from other full-time, wet-finger dentists who have been in the same trenches you have been in and may have<br />

some answers to the problems you’ve had. So again, thank you for creating something like <strong>Dental</strong>town, Howard,<br />

and I look forward to seeing you on there.<br />

HF: Thank you very much for your time, Mike. This has been a real honor.<br />

Dr. Howard Farran is a noted international lecturer on faster, easier, more efficient dentistry. As founder and editor of <strong>Dental</strong>town, Hygienetown<br />

and Orthotown, which collectively are mailed to 38 countries and more than 215,000 dental professionals, Dr. Farran’s impact on dentistry<br />

has been widespread. For more information about <strong>Dental</strong>town, visit www.dentaltown.com. Contact Dr. Farran at howard@todaysdental.com or<br />

480-893-2273.<br />

60 www.chairsidemagazine.com

Utilizing Digital Treatment Planning and Guided Surgery to<br />

Restore Fully Edentulous Arches with the All-on-4 Technique<br />

by Irfan Atcha, DDS, DICOI, DADIA<br />

We now have access to technologies that<br />

greatly enhance our abilities to restore our<br />

patients with high precision in a shortened treatment time<br />

utilizing a minimally invasive surgical procedure. This<br />

case report will demonstrate several of these technologies.<br />

Utilizing <strong>Glidewell</strong> Laboratories’ Digital Treatment<br />

Planning Services allowed me to easily integrate these<br />

technologies into my practice.<br />

There are several treatment planning software programs<br />

on the market. These programs allow you to virtually plan<br />

your cases utilizing CT scans. Scanning the patient with<br />

an appliance (Radiographic Guide) that has the teeth to<br />

be replaced in the ideal positions allows you to digitally<br />

plan the case from both the surgical and prosthetic perspectives,<br />

making it a truly restoratively-driven process.<br />

Because Nobel Biocare implants were to be placed, the<br />

NobelGuide System (Nobel Biocare; Yorba Linda, CA)<br />

was utilized for this case. The case was planned following<br />

the All-on-4 technique. 1-5 This design involves tilting the<br />

distal implant on each side of the arch distally in order to<br />

improve the anterior-posterior spread and provide posterior<br />

support for the prosthesis. Using stereolithography,<br />

a Surgical Template was produced to transfer the digital<br />

plan to the clinical setting. An immediate screw-retained<br />

provisional restoration was delivered at the time of surgery<br />

through a flapless procedure.<br />

This technology can be used to completely rehabilitate<br />

a fully edentulous patient by placing the implants<br />

and delivering maxillary and mandibular provisional<br />

restorations in one appointment. These cases require<br />

meticulous attention to detail and must be staged<br />

correctly. I had restored more than 20 individual arches<br />

using the All-on-4 protocol prior to restoring both arches<br />

in one appointment. Working with <strong>Glidewell</strong> Laboratories<br />

and utilizing its Digital Treatment Planning Services<br />

allowed me to make the major planning decisions presurgically.<br />

62 www.chairsidemagazine.com

Pre-surgical work-up and<br />

digital treatment planning<br />

The patient was a young male who had been<br />

edentulous for some time. His chief desire was<br />

to have a fixed restoration. Due to the amount<br />

of ridge resorption, screw-retained dentures<br />

were the restoration of choice.<br />

Standard procedure was used to determine<br />

the ideal positions of the teeth. Impressions<br />

and bite blocks were used to fabricate and articulate<br />

the study models. A wax try-in was<br />

done to finalize the set-up.<br />

Figure 1: A panoramic view of the planned implants.<br />

Radiographic Guides were fabricated and the<br />

patient was sent for a CT scan. The DICOM files<br />

of the three scans (patient with Radiographic<br />

Guide, then maxillary and mandibular Radiographic<br />

Guides alone) were uploaded and sent<br />

along with my Digital Rx to <strong>Glidewell</strong>’s Digital<br />

Treatment Planning Department.<br />

Following a Web-based conference, the plan<br />

was finalized. Due to the size of the implants<br />

that could be placed and the patient profile,<br />

six implants were planned in the maxilla: four<br />

in the anterior and two angled distally paralleling<br />

the anterior walls of the maxillary sinuses<br />

(Fig.1-3).<br />

Figure 2: A digital plan of the implants and Anchor Pins<br />

is created.<br />

The mandibular plan included four implants:<br />

two in the lateral incisor regions and two angled<br />

distally to improve the anterior-posterior<br />

spread.<br />

Continue reading on page 6 in Inclusive ® Magazine<br />

or online at www.inclusivemagazine.com.<br />

Figure 3: The implant parallels the anterior wall of the<br />

sinus.<br />

This article by Dr. Irfan Atcha is available in its entirety in the enclosed<br />

Inclusive ® Magazine or online at www.inclusivemagazine.com. Here<br />

you will find a variety of articles, clinical videos and case studies, all<br />

of which are related to the exciting profession of implant dentistry.<br />

Utilizing Digital Treatment Planning and Guided Surgery to Restore Fully Edentulous Arches with the All-on-4 Technique63

“Hold still while<br />

I inject some<br />

comic relief.”<br />

Timothy C. Fish, DDS<br />

Greenfield, MA<br />

1st place winner of a $1,000 lab credit<br />

“Yes, I am<br />

the only dentist<br />

in your insurance<br />

company’s network.”<br />

Bernard Park, DDS, FAGD<br />

Colchester, CT<br />

2nd place winner of a $200 lab credit<br />

“Want to hear something<br />

funny? Before I entered the<br />

Witness Protection Program<br />

I was known as The Bruiser.”<br />

Eric Hanson, DDS<br />

Deer Park, NY<br />

3rd place winner of a $200 lab credit<br />

Honorable Mentions<br />

“Too bad I am reduced to shopping at the dollar store for a cheap pair of loupes!”<br />

Edwin S. Porter, DDS<br />

Charlotte, NC<br />

“Ah, c’mon, Senator! You need the same healthcare as the rest of us.”<br />

Craig Hays, DDS<br />

Mesquite, Texas<br />

The Chairside ®<br />

Caption Contest Winners!<br />

Congratulations to winners of the Vol. 4, Issue 4 Chairside Caption Contest. The winning captions were chosen from thousands of entries<br />

both e-mailed and submitted online (www.chairsidemagazine.com) to Chairside Magazine when asked to add a caption to the picture<br />

shown above. Winning entries were judged on humor and ingenuity.<br />

64 www.chairsidemagazine.com

The Chairside ®<br />

Caption Contest<br />

Send your captions for the above illustration, including your name and city of practice, to: chairside@glidewelldental.com.<br />

By submitting a caption, you authorize Chairside Magazine to print your name in a future issue or on our Web site. You may<br />

also submit your entries online at www.chairsidemagazine.com.<br />

The 1st place winner of this issue’s Caption Contest will receive $500 in <strong>Glidewell</strong> credit or a $500 credit towards their<br />

account. The 2nd and 3rd place winners will each receive $100 in <strong>Glidewell</strong> credit or a $100 credit towards their account.<br />

Entries must be received by March 22, 2010. The winners will be announced in the spring issue of Chairside Magazine.

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