One-on-One An Interview with Dr. Paul Homoly Simply Beautiful A ...

Chairside® 

A Publication of Glidewell Laboratories • Volume 4, Issue 3 

<strong>One</strong>-on-<strong>One</strong> 

An Interview with 

Dr. Paul Homoly 

Page 18 

Simply Beautiful 

A Reconstruction 

of a Class II Malocclusion 

Page 41 

Clinical Techniques in Prosthodontics 

Relationship of the Periodontium 

to Impression Procedures 

Page 34 

Economics of a Dental Website 

An Interview with Glenn Lombardi 

Page 56 

Dr. Michael DiTolla’s 

Clinical Tips 

Page 9

Contents 

9 Dr. DiTolla’s Clinical Tips 

In this issue I take a look at the VITA Linearguide 

3D-Master, the ubiquitous Richwil Crown & Bridge 

Remover, the new strawberry-flavored Expasyl from 

Kerr, and the QUAD-TRAY ® Xtreme from Clinician’s 

Choice. 

14 Curing Lights – Does a 

Five-Second Cure Really Work? 

I don’t buy curing lights based on manufacturer’s 

claims of cure time; I buy them based on ease of 

use. It’s an old habit, but I still cure for 40 seconds 

regardless of what manufacturers say—and Dr. Michael 

Miller has tests to back this up. 

18 <strong>One</strong>-on-<strong>One</strong> with Dr. DiTolla 

When you or your staff discusses case fees with patients, 

at what point do you start to sweat? Dr. Paul 

Homoly and I had a great discussion about this topic, 

and why prosperity lingers at the cultural fringe 

of dentistry. 

34 Clinical Techniques in Prosthodontics: 

Relationship of the Periodontium 

to Impression Procedures 

I have been looking forward to having Dr. John Kois 

in Chairside ® since our very first issue, and this great 

impression article shows why he is a restorative master. 

Put simply, an impression is the easiest way to 

tell how much a dentist cares about his or her patients. 

41 Simply Beautiful: A Venus ® Reconstruction 

of a Class II Malocclusion 

I never get tired of looking at Dr. Bob Lowe’s cases. 

They are always real world cases that don’t take 15 

visits with special articulators, and they always turn 

out looking beautiful while respecting biology. 

Cover photo by Kevin Keithley 

Cover illustration by Wolfgang Friebauer, MDT 

Contents 1

Editor’s Letter 

Dentists always want to know what their hygienists are 

allowed to do while they are not in the office. In California, 

direct supervision requires the dentist to be in the 

office, and one of the things that requires direct supervision 

is placement of subgingival topical anesthetic. So the 

placement of PFG gel in the sulcus (formerly Profound, 

Steven’s Pharmacy), for example, would need me in the 

building. Having the patient rinse with DYC (formerly 

Cyclone, Steven’s Pharmacy) topical rinse, however, does 

not. Score one for DYC rinse. 

My assistant, Jennifer, is an RDAEF, and the list of extended 

functions has been increased for 2010. Existing 

RDAEFs (like Jennifer) will need to attend a dental school 

based board approved CE program to perform these 

new functions, but check out the list of what they can 

do above and beyond a standard RDA license. These all 

require direct supervision: 

• Cord retraction of gingival tissue for impression 

procedures 

• Size and fit endodontic master points and accessory 

points 

• Cement endodontic master points and accessory points 

• Take final impressions for permanent indirect 

restorations 

• Take final impressions for tooth-borne removable 

prosthesis 

• Place, contour, finish and adjust all direct restorations 

• Adjust and cement permanent indirect restorations 

Wow! That is pretty progressive, and I would be interested 

to hear your feelings on this list. 

Will these changes be implemented in your state soon? 

Do you like the idea of assistants being able to do so 

much? Much like our training in dental school, their 

license makes them a safe beginner, and it will take a lot 

of on-the-job training before they can complete these duties 

with a high level of confidence. 

2 

Yours in quality dentistry, 

Dr. Michael DiTolla 

Editor in Chief, Clinical Editor 

mditolla@glidewelldental.com 

www.chairsidemagazine.com 

Publisher 

Jim Glidewell, CDT 

Editor in Chief 

Michael DiTolla, DDS, FAGD 

Managing Editors 

Jim Shuck 

Mike Cash, CDT 

Creative Director 

Rachel Pacillas 

Clinical Editor 

Michael DiTolla, DDS, FAGD 

Copy Editor 

Melissa Manna 

Magazine Coordinators 

Sharon Dowd 

Lindsey Lauria 

Graphic Designers 

Jamie Austin, Deb Evans, Joel Guerra, 

Phil Nguyen, Gary O’Connell, Rachel Pacillas 

Staff Photographers 

Sharon Dowd 

Kevin Keithley 

Illustrators 

Wolfgang Friebauer, MDT 

Phil Nguyen 

Ad Representative 

Lindsey Lauria 

(lindsey.lauria@glidewelldental.com) 

If you have questions, comments or complaints regarding 

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

chairside@glidewelldental.com. Your comments may be 

featured in an upcoming issue or on our Web site: 

www.chairsidemagazine.com. 

© 2009 Glidewell Laboratories 

Neither Chairside Magazine nor any employees involved in its publication 

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

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

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

represents that its use would not infringe proprietary rights. Reference 

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

trade name, trademark, manufacturer or otherwise does not necessarily 

constitute or imply its endorsement, recommendation, or favoring 

by the publisher. The views and opinions of authors expressed 

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

shall not be used for advertising or product endorsement purposes. 

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

that are presented, you must make your own decisions about 

specific treatment for patients and exercise personal professional judgment 

regarding the need for further clinical testing or education and 

your own clinical expertise before trying to implement new procedures. 

Chairside ® Magazine is a registered trademark of Glidewell Laboratories.

Contents 

49 Creative Uses for Topical Anesthetic 

I have to hand it to you guys; you are a pretty creative 

bunch when it comes to figuring out ways to 

perform dental procedures without giving local anesthetic 

injections! 

50 The Effect of Low Level Red Laser Light 

on the Healing of Oral Ulcers 

Look up contrarian in the dictionary and you will 

probably find a picture of Dr. Ellis “Skip” Neiburger 

there! In his second article for Chairside, Skip does a 

clinical study to see if a red laser pointer (e.g., from 

Radio Shack) can speed the curing of aphthous ulcers. 

56 The Economics of a Dental Website 

Internet marketing is vastly different from other 

types of marketing in your ability to contact your 

target market so specifically. I wanted more information, 

so I contacted Glenn Lombardi from Officite to 

get the lowdown on Google ® advertising. 

64 Chairside ® Photo Contest – 

Name That Picture! 

In lieu of our quarterly Chairside Caption Contest is 

the Chairside Photo Contest. Can you correctly identify 

the six images for a chance to win a $500 lab 

credit? 

Contents 3

Letters to the Editor 

“Dear Dr. DiTolla, 

I just received my issue of Chairside ® , 

Volume 4, Issue 2. In the article ‘Elective 

Cosmetic Dental Treatment: <strong>One</strong> Dentist’s 

Philosophy Concerning “When to Treat,”’ 

Fig. 8 and Fig. 14 and the commentary 

by Dr. Lowe on his rationale for treatment 

of the gingival tissues is, in my opinion, 

not consistent with other articles in the 

same Chairside issue. Dr. Strupp’s and 

Drs. Pulliam and Melker’s articles and cases 

go the great lengths to manage periodontal 

and gingival tissue properly. 

Under Fig. 14, Dr. Lowe mentions: ‘The 

marginal tissues are still immature and 

the sulcular environment is such that 

bonding restorations could be difficult.’ I 

agree with his observation based on the 

photo in Fig. 14, yet he proceeds to bond 

the restoration using chemical means 

to dry up the sulcular fluids. This is inconsistent 

with the statement by Drs. 

Pulliam and Melker in the caption on page 

50: ‘Currently, the gingival complex is a 

vital aspect of any restorative treatment 

plan.’ 

Dr. Lowe shows the final three-day post 

delivery slides in Figs. 19-23 (page 21), 

which show an ‘immediate result.’ Again, 

in my opinion, the management of the 

tissues in this case is the issue—not the 

lab prosthetics. In my experience, the 

4 

www.chairsidemagazine.com 

gingival tissue will not remain healthy in 

this case because there is and will be 

consequences from the manner in which 

the tissues were handled, as well as how 

the contours and margins were prepared. 

I would like to see a six-month pre-prophylaxis 

photo of this case.” 

- George V. Duello, DDS, MS, FACD 

St. Louis, MO 

Dear Dr. Duello, 

I appreciate your comments regarding 

the case I presented in the recent 

issue of Chairside. I am familiar 

with Dr. Strupp and his protocols. 

Personally, I follow the protocols 

of Drs. John Kois, Frank Spear, and 

Dennis Tarnow in regard to perio 

prosthetic management of the gingival 

tissues during restorative therapy. 

On anterior teeth, I place the restorative 

margins, as recommended by 

Dr. Kois, 3 mm from the bony crest 

on the facial aspect and 4 mm from 

the bony crest on the interproximal 

aspect. The bony crest position is 

determined by sounding from the 

free gingival margin to the bony 

crest prior to tooth preparation. I 

am sure that you assume there was 

no regard for biologic width when 

viewing the laser sculpting on Fig. 

8. This sculpting was performed to 

allow the laboratory to correct the 

emergence angle of the restoration 

from the margin and avoid creating 

a ledge of porcelain to close the diastema. 

I assure you that the preparation 

margins were placed 4 mm from 

the bony crest in the interproximal 

area. Normally, I would perform the 

gingival sculpting, place provisional 

restorations to nurture the healing 

and contour of the proximal gingiva, 

and then make master impressions 

after healing. 

The other aspect of this case that you 

are not aware of is that the patient 

was a long distance “fly-in” patient 

that I saw for a preparation visit and 

delivery visit only. I did not have the 

ability to have multiple visits with 

this patient. I will tell you that I have 

several years of experience using lasers 

and following Dr. Kois’ perio by 

the numbers protocol. I have taken 

master impressions prior to surgery 

in the same visit and have several 

years of follow-up on many cases 

to show what Drs. Kois and Tarnow 

say is true: if the restorative margin 

is placed in the appropriate position 

relative to the bony crest, biologic 

width and gingival health will be reestablished. 

This particular patient 

has been under the care of her local 

dentist for several years since the 

case was delivered. I do not have pictures 

to show follow-up, unfortunately, 

since I have not seen her personally, 

but her dentist has reported to 

me that the case has remained stable 

both gingivally and prosthetically. 

Again, I appreciate your concern for 

the tissue management in this case, 

but I assure you that it is important 

to me as well. For years, I had followed 

a protocol of six months in 

provisional restorations after surgery. 

But now, in select patients (and this 

was not a surgical perio case), these 

cases can be managed, in my opinion, 

by careful margin placement 

with respect to the bony crest and allowing 

the tissues to mature around 

precisely fit and polished porcelain 

restorations, rather than ill-fitted 

plastic temporaries that after several 

months don’t fit as well and harbor 

bacteria. Remember, as well, that 

there is more than one way to gain 

a successful result when doing what 

we do. No one doctor has the corner 

on the “best protocol” to follow. 

It is the end result that matters, not 

so much how you get there. I assure 

you that the gingival health around 

this patient’s restorations, from all 

reports from her dentist, is excellent. 

Thanks again for your letter. 

- Dr. Robert Lowe


I am a general dentist in Wisconsin considering 

the use of a compounded topical 

anesthetic. I have read several articles you 

have written on Cyclone and Profound. 

Can you tell me if there is a specific technique 

that should be used when trying to 

get pulpal anesthesia from the topical to 

avoid an injection (such as with pedo)? 

Would the topical be syringed into the 

sulcus as opposed to the soft tissue over 

the injection site? Also, are there patients 

or situations where these compounds are 

contraindicated? Are there certain teeth/ 

areas where pulpal anesthesia seems to 

be more effective from your experience? 

Thank you for any suggestions.” 

- Paul S. Petroll, DMD, Pulaski, WI 

Dear Paul, 

When I use PFG gel (formerly known 

as Profound) for pedo teeth (like 

when extracting my kids’ primary 

teeth), I place it with a cotton tip applicator 

on the facial and palatal tissue 

from the free gingival margin to 

the apical extent of where I thought 

the tooth was. If using it for pulpal 

anesthesia, I place it in the vestibule 

in the area I would expect the apex 

to be. 

The only time I place it in the sulcus 

is prior to a PDL injection, which 

I like to do with the STA System. 

With the combination of PFG gel and 

the STA System, I can finally give 

painless injections almost anywhere 

in the mouth—so I am actually less 

hesitant to give injections to nervous 

patients, especially since this combination 

allows me not to give lower 

blocks anymore. 

PFG gel is contraindicated in any patient 

who has had a reaction to any of 

the ingredients—any of the “caines.” 

I haven’t seen one yet; most of what 

I hear from patients is related to epinephrine 

in a local anesthetic. With 

my PFG/STA System technique, I use 

only one-half to two-thirds of a carpule 

of Septocaine ® , which has half 

the epi of typical 2 percent lidocaine 

with 1:200,000 epi. 

PFG gel seems to work best for teeth 

where the alveolar bone is thinnest. 

In areas where it is thick or the teeth 

are multi-rooted, an injection will be 

necessary if the procedure requires 

pulpal anesthesia. PFG gel is available 

through Steven’s Pharmacy 

(stevensrx.com) and the STA System 

can be purchased through Milestone 

Scientific (www.stais4u.com). To see 

this technique, go to www.glidewelldental.com 

and watch the Rapid Anesthesia 

video. I hope that helps! 

- Dr. DiTolla 


I just purchased a STA System. I noticed 

on one of your educational videos on Single 

Tooth Anesthesia that you used a PDL 

injection into buccal furcation on lower 

molars. Can this be used with the STA 

System rather than the two lingual injections, 

and can you bend the needle at 45 

degrees to give the injection? Thanks.” 

- Douglas C. Stoker, DDS, Henderson, NV 

Dear Doug, 

That is exactly how I use the STA 

System: in the buccal furcation, with 

the needle bent at a 45-degree angle. 

I bought my STA System the week 

after that DVD was finished, so it 

doesn’t show up there, but it is used 

in the most recent DVDs. The folks 

at Milestone Scientific like the lingual 

injections better, but I start with the 

buccal and move to the MB or ML if 

I don’t get the pressure I am looking 

for in the furcation. That said, 

the people at Milestone are pretty 

smart and have some good reasons 

for preferring the lingual. But I don’t 

have any problems on the buccal 

and, therefore, I have no reason to 

change! Let me know how it goes. 

- Dr. DiTolla 

WRITE US 

Chairside Magazine welcomes 

letters to the editor, which may 

be featured in an upcoming 

issue or on our Web site. Letter 

should include writer’s full 

name, address and daytime 

phone number. To contact us: 

e-mail (chairside@glidewelldental.com), 

mail (Letters to 

the Editor, Chairside Magazine, 

Glidewell Laboratories, 4141 

MacArthur Blvd., Newport 

Beach, CA 92660) or call (888- 

303-4221). 

Letters to the Editor 5

Contributors 

Michael C. DiTolla, DDS, FAGD 

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

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

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

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

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

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

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

mditolla@glidewelldental.com. 

Paul Homoly, DDS, CSP 

Dr. Paul Homoly is a world-class leader in dental education. After practicing comprehensive restorative 

dentistry for 20 years, Dr. Homoly earned the highest designation in professional speaking—Certified 

Speaking Professional (CSP)—and is the first and only dentist in the world to earn this designation. As 

an acclaimed educator for more than 25 years, he is best known for his innovative and practical approach 

to dentistry. An accredited member of the ADA, Dr. Homoly is an active author who contributes 

to dental journals worldwide, including a monthly column in Dental Economics. Dr. Homoly is president 

of Homoly Communications Institute located in Charlotte, N.C., and can be reached at 800-294- 

9370, www.paulhomoly.com, or by e-mail at paul@paulhomoly.com. 

John C. Kois, DMD, MSD 

Dr. John Kois received his DMD from the University of Pennsylvania School of Dental Medicine and a 

MSD/Certificate in Periodontal Prosthodontics from the University of Washington School of Dentistry. 

He maintains a private practice limited to prosthodontics in Tacoma and Seattle and is an affiliate 

professor in the Graduate Restorative Program at the University of Washington. Dr. Kois continues to 

lecture worldwide, is reviewer for the International Journal of Prosthodontics, and is on the Editorial 

Advisory Board for The Compendium of Continuing Education in Dentistry. A member of the American 

Academy of Restorative Dentistry and the American Academy of Esthetic Dentistry, Dr. Kois continues to 

work with restorative dentists at the Kois Center, a didactic and clinical teaching program. To contact 

Dr. Kois, call 206-515-9500 or visit www.drkois.com. 

Glenn Lombardi 

Glenn Lombardi is President of Officite LLC, a leading national provider of customized Websites and 

search engine marketing solutions to the dental community, with over 4,200 clients worldwide. Glenn is 

a frequent speaker at National Dental Association and State Association meetings, including the Academy 

of General Dentistry and DC Dental. His speaking topics focus on Websites, search engines and how 

to incorporate the Internet into your practice to attract new patients and increase case acceptance. For 

more information about the services offered by Officite, call 888-748-2746 or visit www.officite.com. To 

contact Glenn, e-mail GLombardi@officite.com or call 800-908-2483. 

6 

www.chairsidemagazine.com

Robert A. Lowe, DDS, FAGD, FICD, FADI, FACD 

Dr. Robert Lowe graduated magna cum laude from Loyola University School of Dentistry in 1982 and 

was a Clinical Professor in Restorative Dentistry until its closure in 1993. Since January of 2000, 

Dr. Lowe has maintained a private practice in Charlotte, N.C. He lectures internationally and publishes 

in well-known dental journals on esthetic and restorative dentistry. Dr. Lowe maintains fellowships in 

the AGD, ICD, ADI, ACD, was 2004 recipient of the Gordon Christensen Outstanding Lecturers Award, 

and in 2005 was awarded Diplomate status on the American Board of Esthetic Dentistry. To contact Dr. 

Lowe, call 704-364-4711 or e-mail boblowedds@aol.com. 

Michael B. Miller, DDS 

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

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

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

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

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

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

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

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

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

at mmiller@realityesthetics.com. 

Ellis Neiburger, DDS 

Dr. Ellis “Skip” Neiburger graduated from the University of Illinois College of Dentistry in 1968. After 

postgraduate research in Oral Pathology and Forensic Dentistry at the US Armed Forces Institute of Pathology, 

Skip pursued a career as a paleopathologist. He has been curator of anthropology at the Lake 

County Museum for 17 years. Dr. Neiburger’s research on ancient anatomy and occlusion has taken 

him throughout the world, and his studies have been widely published in the areas of prehistoric pathology, 

dental computing and clinical dentistry. He is editor and vice president of the American Association 

of Forensic Dentists, and has written five books on dentistry. Dr. Neiburger has a general practice 

in Waukegan, Ill., and may be contacted at 847-244-0292 or by visiting www.drneiburger.com. 

Rena T. Vakay, DDS 

Dr. Rena Vakay received her DDS degree from Georgetown University Dental School in Washington, D.C. 

She maintains a private practice in restorative dentistry in Alexandria, Va., and is a clinical instructor 

at the Kois Center in Seattle, Wash. Dr. Vakay is editor in chief of the Journal of Excellence for the 

Kois Center and is a member of the Editorial Advisory Board for The Compendium. Her memberships 

to various professional organizations include the American Academy of Restorative Dentistry and the 

American Academy of Cosmetic Dentistry, for which she is an Accredited Member and former Board of 

Director. Dr. Vakay is presently on the Board of Directors for the Arts at Mason, George Mason University, 

Fairfax, Va. To contact Dr. Rena Vakay, call 703-256-7700 or visit www.renavakay.com. 

Contributors 7

Dr. DiTolla’s 

CLINICAL TIPS 

– ARTICLE by Michael DiTolla, DDS, FAGD 

– PHOTOS by Sharon Dowd 

PRODUCT........ VITA Linearguide 3D-Master 

CATEGORY...... Shade Guide 

SOURCE.......... Vident 

Brea, CA 

800-828-3839 

www.vident.com 

Dentists really seem to be in love with the VITA Classical 

Shade Guide, not that it is necessarily their fault. 

The VITA Classical is the shade guide that every dentist 

has used since day one, except for the few of us 

old guys who remember the Bioform shade guide that 

was a mile long. Despite VITA coming out with better 

shade guides, such as the Linearguide 3D-Master seen 

here, dentists still want to stay with the familiar, even 

if it might be more difficult to use. The Linearguide 

3D-Master makes accurate shade taking simple, with 

two quick steps that are faster for me than the VITA 

Classical system. First, grab the portion with the six 

tabs and determine the closest value to the tooth to 

be matched. This is very straightforward and hard to 

get wrong. If the value number happens to be 3, take 

out set 3 of the hue/chroma tabs and pick the closest 

one. Here in the lab I can tell you most of the missed 

shades are due to incorrect values, and the Linearguide 

3D-Master is a big step in the right direction for 

correcting that problem. 

Dr. DiTolla’s Clinical Tips 9


CLINICAL TIPS 

PRODUCT........ Richwil Crown & Bridge Remover 

CATEGORY...... Crown and Bridge Removal 

SOURCE.......... Almore International, Inc. 

Portland, OR 

800-547-1511 

www.almore.com 

Richwil Crown & Bridge removers go by many other 

names; the most common is probably the “Jujubee’s 

thingy.” You won’t be in practice long before you need 

some Richwil’s. Whether it’s a crown with tight contacts 

or an inlay with near vertical walls, you are going 

to have trouble removing a restoration that is only 

being tried-in at that point, and you better hope you 

have some of the “sticky green cubes” around. Simply 

hold it under warm tap water for a minute or two, 

push it onto the occlusal surface of the restoration 

you want to remove, have the patient bite down until 

the Richwil compresses about half way, and spray it 

with some cold water or air. After cooling, have the 

patient pop open, and it’s time to cement. You may 

only need them a couple of times per year, but you 

need them! 

10 www.chairsidemagazine.com


CLINICAL TIPS 

PRODUCT........ Strawberry-flavored Expasyl 

CATEGORY...... Retraction Cord Alternative 

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

Orange, CA 

800-537-7123 

www.kerrdental.com 

If you read this magazine or watch our DVDs, then 

you know that I am a big fan of the two-cord impression 

technique. But there are simply times when placing 

the second (top) cord is dangerous due to thin, 

friable tissue or a lack of attached gingival. Cordpacking 

should not resemble perio surgery, but if you 

stick to the two-cord technique in all situations (some 

maxillary first bicuspids and lower anteriors come to 

mind), you might end up damaging the epithelial attachment. 

In these cases, I go with Expasyl on top 

of the bottom size 00 cord, and rinse it out after two 

to three minutes. I also love Expasyl for those times 

when the tissue is irritated next to a crown seat. I 

place the Expasyl with the patient biting on a cotton 

roll, rinse two minutes later, and cement into a bloodfree 

site thanks to its aluminum chloride styptic properties. 

What’s more, with its new strawberry flavor, 

patients will never complain about the taste. 

Dr. DiTolla’s Clinical Tips11


CLINICAL TIPS 

PRODUCT........ QUAD-TRAY ® Xtreme 

CATEGORY...... Impression Tray 

SOURCE.......... Clinician’s Choice 

New Milford, CT 

800-265-3444 

www.quadtray.com 

The QUAD-TRAY Xtreme is definitely on my list of 

products that I wouldn’t want to practice without. I’m 

not sure what took so long to get it onto these pages—perhaps 

I have just started to take it for granted. 

Maybe it’s because it gets covered with impression material 

pretty quickly and is not heard from again. But 

from the looks of the double-arch tray cases coming 

into the laboratory, many of you like it as well, since 

almost one-third of our incoming cases are taken with 

the QUAD-TRAY Xtreme. Clinician’s Choice improved 

the original QUAD-TRAY by making the distal bar 

25 percent thinner to help make room for the retro 

molar pad, a big problem area for plastic double-arch 

trays. A shorter lingual wall keeps the tray free from 

the patient’s anterior teeth, another common cause of 

plastic double-arch tray distortion. The QUAD-TRAY 

Xtreme is now the #1 selling aluminum double-arch 

impression tray in the world, and has been my exclusive 

double-arch tray for the last seven years. Try one 

and you won’t go back to plastic! 

Dr. DiTolla’s Clinical Tips13


Curing Lights 

Does a Five-Second 

Cure Really Work? 

– ARTICLE by Michael B. Miller, DDS 

– PHOTO by Sharon Dowd 

“ 

A leading manufacturer of curing lights even goes 

so far as to state that its light will cure many popular 

hybrid composites to depths of 5.5-7.4 mm 

— in five seconds ! 

That would be great, if only it were true.” 

Curing Lights15

If you have seen the marketing propaganda for the latest whiz-bang curing lights, you’ve no doubt found claims of superfast 

performance and incredible depths of cure. A leading manufacturer of curing lights even goes so far as to state 

that its light will cure many popular hybrid composites to depths of 5.5–7.4 mm—in five seconds! 

That would be great, if only it were true. This article will give you information that should make you stop and think 

before following this misleading claim. 

First, to understand how these claims can even be stated at all, you need to know something about how depth of cure 

(DOC) is measured. Although there are various ways to accomplish this task, a simple International Standards Organization 

(ISO) scrape test may be the most popular, since it is quick and expedient. 1 In this test, a stainless steel cylinder is 

essentially filled with composite and cured from one of the open ends. The uncured material on the bottom is scraped 

away and the height of the resulting cured material is measured. The DOC is stated as 50 percent of this height. 

Contrast that method to the way DOC is measured in the REALITY Research Lab (RRL). We use a modified Class II preparation 

in a real extracted human tooth. The tooth is secured in an Ultradent bond strength testing jig (Ultradent Products, 

Inc., South Jordan, UT) that has been modified for this purpose. A section of stainless steel matrix, similar to those 

used clinically by most dentists, provides the surface against which the composite is cured in this Class II preparation. 

“ 

Despite its snooze-inducing potential, curing 2 mm increments of 

composite for 40 seconds remains the gold standard, especially when 

your light is not in direct contact with the restorative material. ” 

After filling the preparation and curing the material, the restored tooth is removed from the jig and the DOC is measured 

using a sophisticated digital hardness testing device. Hardness is the parameter we use to determine how well a 

composite has cured deep into the preparation. A similar test is used to gauge how well flowable composites are cured 

on the gingival wall of Class II proximal boxes. 

The results from the RRL are definitive and categorically reject the 5-second and even 10-second curing claims coming 

from light manufacturers. Unfortunately, in clinical situations, undercured composite is very difficult—if not impossible—to 

diagnose, even years after the restoration has been placed. Who is to say that the gradual yellowing of a restoration 

was caused by undercuring? It might have happened even had the restoration been cured properly. What about a 

fractured marginal ridge in a Class II restoration? Would it have fractured if the material’s strength had been maximized 

by thorough curing? 

It’s my position that clinicians should do anything and everything within their power to increase the probability that 

their restorations will be as durable and long-lasting as possible. Longer curing will skew the success rate in your favor. 

Why do you think indirect restorations are blasted with intense light for extended periods? 

Despite its snooze-inducing potential, curing 2 mm increments of composite for 40 seconds remains the gold standard, 

especially when your light is not in direct contact with the restorative material. This would be the situation when you 

are incrementally restoring a Class II preparation. Once you have built up the restoration and the restorative material is 

very close to the light tip, you can reduce your curing time to 20 seconds, assuming that you are using a relatively translucent 

hybrid composite. Reducing curing time does not work with microfills, which are notoriously difficult to cure. 

The allure of curing restorations for only 5-10 seconds may be hard to resist, but our data clearly and definitively indicates 

that you will be shortchanging your patients if you allow this primrose path. In the final analysis, how long would 

you want a restoration to be cured if you were the patient? 

To contact Dr. Michael Miller, visit www.realityesthetics.com or e-mail mmiller@realityesthetics.com. 

References 

1. Fan PL, Schumacher RM, Azzolin K, Geary R, Eichmiller FC. Curing-light intensity and depth of cure of resin-based composites tested according to international 

standards. J Am Dent Assoc 2002;133(4):429-434. 

Reprinted with permission of the Academy of General Dentistry. Copyright ©2009 Academy of General Dentistry. All rights reserved. 


18 www.chairsidemagazine.com 

I

Interview with Dr.Paul Homoly 

– INTERVIEW of Paul Homoly, DDS, CSP 

by Michael DiTolla, DDS, FAGD 

– PHOTOS by Sharon Dowd 

Interview with Dr. Paul Homoly19

Michael DiTolla: Welcome back, Paul! Today, the topic we are going to discuss is prosperity. 

Paul Homoly: Mike, this topic goes back to our previous article when we talked about the cultural 

center of dentistry. The cultural center of dentistry, of course, is the pursuit of clinical excellence. 

A big part of that cultural center is the concept of patient education. These are central core beliefs 

that we have as an industry, as a profession, that what we’re about is producing and sustaining 

clinical quality. And as a part of that, a way to advance that, is educating our patients. These are 

strong beliefs that drive our behavior. 

The cultural fringe—that is, what’s not at the center but what plays at the edges—is the concept of 

prosperity, the concept of understanding patients, and the concept of influencing patients. To say 

that prosperity is not at the center of the culture of dentistry is a pretty accurate statement. We don’t 

learn about the concept of prosperity in dental school. There are even some states in this country 

that don’t give continuing education credits for practice management courses or financial planning 

courses. I just got off the phone with one of the leaders of the Academy of General Dentistry, and 

he said that one of the topics that draws the poorest attendance are courses on practice management 

focused on dentists running more a successful practice. So, today, I really want to go after 

the concept of prosperity. 

Prosperity is about having the energy to succeed. Prosperity is about combining a willful act with 

an aspect of hope thrown in. And that prosperity not only means financial success, but prosperity 

in all aspects of our life. And a big part of the pursuit of prosperity is how we talk about it— 

language is symbolic. How we think and how we talk largely shapes our experiences. 

To start this article, I’d like to ask you to put yourself in the mindset of an average general dentist. 

Let’s say that your collections are $900,000 to a million dollars a year. Would you say that’s about 

normal, Mike? What’s your sense there? 

MD: I don’t know…that sounds a little high. I would say $800,000 might be closer to the average, but 

that’s just a guess. 

Describe the type of 

dental care you love providing: 

Technical - Cosmetic, Implant, 

Orthodontics, TMJ, Periodontics 

Total treatment fee 

(including all specialist fees) 

PH: Okay, put yourself in that position—you’re an average 

dentist and your annual collections are $800,000. 

Here’s what I would like for you to do: think about the 

ideal case, one that you really enjoy treating. Think 

about it in terms of the technical characteristics. Is it 

a crown and bridge case, a combination restorativeperio 

case, a cosmetic case? Think about this ideal 

case and ask yourself, what is the total treatment fee 

for this case? Take into account all fees, including specialist 

fees. For example, if you enjoy doing implant 

dentistry, but you don’t do the implants, you do the 

prosthetics, your ideal treatment fee would include the 

specialist fees to do that case. Same thing with perio, 

same thing with ortho. So, think about that for just a 

few seconds. You’re the average general dentist; what 

type of case do you enjoy doing most? Describe it to 

me technically. Then give me a sense of the total treatment 

fee. 

MD: I would like to do a case that’s a combination of 

restorative dentistry and elective dentistry. I really like 


eplacing old crowns on 7 through 10 and then no-prep veneers on 4, 5, 6 and 11, 12, 13. The fees on that are probably 

going to be…we’ll say, $800 for the crown or $3,200 for four of those, plus $800 for each of the veneers. So the total case 

is going to be $8,000, give or take some ancillary services. 

PH: Okay, so we’ll call it a $8,000 fee. That’s the average guy. Now, let’s ask the same question to the above-average 

dentist. Let’s look at a dentist who’s been to the institutes, who owns all the adjustable articulators, CEREC ® units, 

belongs to a restorative study club or Seattle study club, has been in dentistry for a full 15-plus years and understands 

occlusion, perio, and cosmetics really well. Maybe the dentist is a Fellow or Master in the AGD. What’s an 

ideal case for a dentist like this? 

MD: Well, this dentist is probably going to enjoy the challenge of a multi-disciplinary case. That’s going to require a couple 

of implants here or there, certainly some cosmetic work around a few teeth, restorative work on some other teeth, probably 

changing the bite to improve function. A couple of teeth may need to have some endo retreats. If you look at all the fees 

combined, you’re probably in the neighborhood of $20,000 to $30,000 for a complete mouth. 

PH: Okay, we’ll call it $25,000. So, we got the average fee for the average dentist’s ideal case, between $3,000 and 

$8,000. We have the ideal case for the more advanced dentist at $25,000. Mike, what I’d like for you to do now is 

look at that slide I sent you (Page 23). 

The Crossover Zone is an illustration of the cultural behavior of dentists relative to talking about money. What this 

chart shows is that in the culture of dentistry the higher the fee, the greater our discomfort is in discussing that fee. 

For example, let’s say the fee is $1,000. You notice that line is in the comfort zone. The horizontal line that goes 

through the center of the chart, parallel to the horizontal axis, is the dividing line between a dentist being comfortable 

discussing the fee and the dentist being uncomfortable discussing the fee. This is not the patient reaction. This 

is how the practitioner feels when he or she is discussing the fee. So at the $1,000 level, the dentist feels comfortable 

talking about the fee. This is just an example now, Mike. So $1,000, you’re comfortable; $2,000, you’re comfortable; 

$3,000, you’re comfortable; $4,000, your knees are beginning to shake a little bit; $5,000, you’re beginning to 

breathe hard; and at $6,000, you are now in the zone of discomfort. You see how that works? 

MD: At $10,000, you are visibly sweating. 

PH: You’re visibly sweating and you show it in your body language. You’re breathing hard, you’re not making eye 

contact with the patient. 

MD: You’re trying to use a lot of dental technical terms and not really giving them answers to questions that they have. 

PH: Exactly. Hiding behind your visual aids—all of that. Now, I showed the scale from $1,000 to $10,000; it could 

be $1,000 to $50,000. This illustration is for diagrammatic purposes only. Now, I’d like for you to wear your average 

general practitioner hat again, go back to that average dentist. Where do you cross over? That is, at what fee do you 

go from comfortable to uncomfortable? As you’re quoting the fee—you’re the average dentist now, Mike—where 

does it get uncomfortable? Where is the Crossover Zone? 

MD: Probably right around $4,000. 

PH: Okay. And put your hat on as far as the dentist whose ideal treatment plan would be $25,000. Where are you 

crossing over? Where’s this AGD Master, graduate of the Pankey Institute, graduate of the Dawson Center, owner of 

the articulators, CEREC units, lasers—where is this dentist crossing over? 

MD: Well, he or she is still a dentist, albeit a very intelligent one. But intelligence isn’t the issue here. I’m going to say this 

dentist gets uncomfortable at the same spot—$4,000. 

PH: You’re exactly right. 


MD: We are, after all, just humans and dentists. 

PH: You’re exactly right. 

MD: I don’t know that any amount of technical training can get you to the point where this stuff no longer affects you, or 

these numbers no longer affect you. I can guess where you’re heading with this—something along the lines of patient education 

can’t make patients ready. Clinical education for the dentist, and the pursuit of clinical excellence, does not mean 

that you can ignore what’s going on inside your own head when you go present these numbers to a patient. 

PH: Exactly right. I’ve been teaching this in seminars for decades, and what’s amazingly consistent is the Crossover 

Zone among dentists. Now, there’s two numbers. Let’s look at the first number. The first number when I do this 

exercise, dentists are usually going to be in that $4,000 to $6,000 range. They go off to the institutes and learn to 

treatment plan implants instead of partial dentures, veneers instead of three-surface composites. They learn to take 

cases that they would typically treatment plan for $3,000 to $4,000 at $10,000 to $12,000. How much more comfortable 

is the dentist quoting that treatment plan? 

MD: The dentist actually might be doubly comfortable because it’s a bigger number. But he or she is also now quoting 

a fee for something performed very few times, as opposed to quoting a fee for a partial denture that they’ve done 

many times. 

PH: You bet. And that’s exactly what happens—dentists come back with new technical knowledge that’s helped 

their hands but hasn’t helped their hearts. They haven’t changed on the inside; they haven’t embraced the concept 

of prosperity. That’s the point of the article. 

MD: Well, they would have gone to a practice management course, but organized dentistry has sent them the not-so-subtle 

message that it’s not very important—you don’t get any recognized credits for going to that. 

PH: Right, that’s why this concept of prosperity is on the fringe. And why take something that’s on the fringe when 

you can take something that is at the cultural center? Typically, what I see, Mike, is that the treatment plan fee for 

the ideal case is anywhere from two to five times greater than the dentists’ Crossover Zone. And that creates a tremendous 

amount of stress with the practitioner. A great exercise for your readers is to teach the Crossover Zone to 

their team. The dentist will explain the concept of the Crossover Zone, like I did to you, then each team member 

working independently, not as a group—it can’t be a group, it has to be as individuals, with a piece of paper and a 

pencil. And the dentist explains the Crossover Zone and asks the team point blank, “Where do you crossover? What 

number do you get nervous about?” And then the team needs to immediately write the number down. They can’t 

be talking to each other. Once they start talking to each other, then you get this community think and you don’t 

get real numbers. 

MD: Exactly, write it down on a piece of paper, and it should be a private vote. You know everybody is going to have different 

numbers. And you know that most of your dental staff, if they went to the physician or veterinarian and got a $5,000 

to $6,000 fee quote, would be blown away, too. So, it’s probably happening with staff members in your office. 

PH: Sure, and I like the idea of a secret ballot. They write the number down and they hand it to the dentist. Then, 

the dentist takes these numbers and averages the team crossover, okay? He looks at all the numbers, adds them up 

(he does not include his own), and averages them. What you get is an office crossover number—that is the prosperity 

culture of your practice. These are the beliefs that are driving the discretionary behavior, Mike. These are the 

beliefs that when Suzanne, the dental assistant, is sitting next to Mrs. McBucks, the lady with the big diamond rings 

who rolls her eyes about the fee. And the dental assistants and other staff often times have the opportunity to discuss 

fees in the absence of the doctor. It’s that prevailing culture and the practice that will largely determine what 

that dental assistant says, how they say it, and how they deliver the message. Does that make sense? 

MD: Yes, it does make sense, and I’m beginning to realize that this is may be more of a make or break moment than hav- 


ing the dentist quoting the fee. What happens when the dentist is gone and the dental assistant, who’s 

perceived as a peer, reacts to whatever the patient says about the fees? 

PH: Ha, you bet. It’s like going into a restaurant, Mike. Let’s say you and I go to a restaurant, we 

look at the menu, and we’re not sure what to order. When the waitress comes I ask her, “How is 

your salmon today?” She kind of shakes her head, and says, “You know what…if you want fish, 

I would go with the mahi-mahi. But the salmon, I don’t think it’s as fresh today as it usually is.” 

You’re going to believe that because the waitress is in direct contact with the customers. But when 

the chef comes out and you ask that same question, he might say, “Oh, it’s a miracle. It’s wonderful!” 

Well, he doesn’t interact with the customers, the waitress does. And in many ways, the dental 

assistant, the dental hygienist, and the dental receptionist offer that second party endorsement and 

Comfort 

Discomfort 

Describe the type of 

dental care you love providing: 

authentication of what is really going on in the office. So you’re right on. It’s the culture that prevails 

in your practice that’s largely going to determine how much stress is surrounding money. 

MD: Not only that but the waitress told me the truth about the salmon, and then gave me her opinion, 

so I trust that. Almost as if the dental assistant were to acknowledge, “That is a lot of money, however…” 

that kind of thing. I also don’t see the waitress being emotionally connected to the end product, taking it 

personally how it’s cooked or not cooked. It just happens that the mahi-mahi is better than the salmon, 

whereas the chef (i.e., the dentist) is emotionally connected to it. That’s one of the reasons my dental assistant 

tries in all restorations without me in the room. I don’t want to put any pressure on the patient to 

look at the mirror and go, “Wow, these look fantastic” because I just said how fantastic they look. I want 

them to have an authentic conversation with my dental assistant with me out of the room. Then, there’s 

no pressure for them to say what they think I want them to say. 

Technical - Cosmetic, Implant, 

Orthodontics, TMJ, Periodontics 

Total treatment fee 

(including all specialist fees) 

PH: Ah, very wise, very wise. So then, what’s the impact of having the culture of your dental practice 

where the crossover number is lower than the treatment plans you’re presenting? Number one is 

increased stress. Number two is erosion of confidence—as stress prevails, more and more patients 

are going to refuse treatment because they sense the stress in the dentist and team members. When 

dentists don’t give off an aura of confidence when talking about money, people become suspicious 

and that’s when they leave. To have a lower crossover number than your treatment plan is an avenue 

to lose patients. Once dentists realize this, 

often unconsciously, they stop quoting fees 

above this Crossover Zone. That is, the dentist 

pulls back on treatment plans and starts offering 

care based on what is comfortable, not 

so much on what the patient needs or what 

the patient can pay. That, over time, will lead 

to cynicism. The dentist will begin to believe 

that the population they serve is a bunch of 

low-lifes with low dental IQ, and they don’t 

value you or your dentistry. And, ultimately, 

that will lead to surrender. Dentists will say: 

“Dentistry isn’t what I thought it would be. 

I’ve missed the boat. I’m too old to change. If 

it weren’t for the damned insurance companies, 

then this would be great. This economy 

is ruining my practice...” Everything kind of 

swirls down the drain and the sense of prosperity 

is replaced with a sense of desperation. 

And as an opinion leader and consultant in 

dentistry, Mike, this is something that I see all 

Crossover Zone 

$100 Fee 

$10,000 


“The Crossover Zone is an 

illustration of the cultural 

behavior of dentists relative 

to talking about money. 

What this chart shows is 

that in the culture of dentistry 

the higher the fee, 

the greater our discomfort 

is in discussing that fee.” 

the time. This domino effect that goes from stress, to erosion of confidence, 

to loss of patients, to avoidance of treatment plan, to cynicism, and ultimately 

ends in surrender. We see it all the time. 

Let me give you a few more scenarios that can occur around this Crossover 

Zone. Let’s look at what happens when the doctor is crossing over significantly 

higher than the team. By the way, when I average Crossover Zones’ from the 

teams—and this is again a decade of empiricism, a decade of doing this and 

averaging the number from literally hundreds of practices—most teams cross 

over between $6,000 to $6,500 dollars. I don’t know why that is, Mike. 

MD: That is a really narrow zone…that is pretty amazing. 

PH: It is amazing to me, and I see it consistently when I do workshops. 

MD: All these dental team members with different family backgrounds, different 

schooling, different training and work experience, and they all tend to cross over 

within $500 of each other. Amazing! 

PH: It is, Mike. When the dentist crosses over significantly higher, three to five 

times or more than the staff, it really erodes the staff’s confidence in the presence 

of patients. The staff members don’t want to be alone with patients when 

they’re talking about money because the staff members are very uncomfortable 

with the fees. On the other hand, when the team crosses over higher than 

the doctor that is also a disaster. Why? Well, take the scenario where, let’s say, 

the team is paid on performance and a monthly bonus is involved based on 

collection. The doctor is doing some crown and bridge, all of a sudden—BAM! 

Tooth explodes and now you have a root canal, post, build-up and crown that 

weren’t in the original treatment plan. The doctor’s going to need to go in 

there and increase the fee. He or she’s already crossed over on this case, and 

adding additional fees becomes very uncomfortable. So, the dentist tells the 

dental assistant, “We’re not going to charge for this. We’re not going to charge 

for that.” And that gets communicated to the front desk. What do you think 

that does to the morale relative to the pay-for-performance bonus system? 

MD: Considering that their bonuses are based on collections, it’s like the dentist 

just opened up their purse and took money out of their wallet. It’s just a total lack 

of team effort and self-sabotage, team-sabotage, you name it. 

PH: Yeah, you bet. Really, the foundation of what we’re talking about is becoming 

aware of our own aspect of prosperity. When I was probably a little 

older than kindergarten age, my mother said to me, “C’mon, we’re going to 

walk to Little Town.” Little Town was a little shopping center about three miles 

from our house in suburban Chicago. We walked down York Road, a busy twolane 

highway, because my mom didn’t drive. So, we walked down York Road 

to a little shopping center, and before she went inside the store she said, “Wait 

outside for me here, I’m going to be a little while.” There was a hobby shop 

right across the street, so I went in the hobby shop while my mom went to this 

other store. When she came out, I met her, and as we walked home she burst 

into tears. This was the first time I’d ever seen my mother cry. 

I didn’t know then why she was crying, but I learned several years later. At 


the time, my grandfather, my mom’s dad, was committed to the Cook County Sanitarium for tuberculosis. He didn’t 

have any insurance so my mom’s brother, my Uncle Frank, went to all the brothers and brothers-in-law—my mom 

had six brothers and three sisters—and asked each family for $200 to $300 to spring Grandpa out of the sanitarium. 

Well, my dad was a carpenter and my mom was a housewife and we had four kids, we had a 900 square foot home, 

we were very modest in our lifestyle. We didn’t have $200. I later found out that when my mom took me down to 

Little Town, the store she walked into was called Household Finance. You could get a little signature loan. My mom 

borrowed $200 and it scared the living hell out of her, and that’s why she burst into tears. The reason for the story 

is that money has always been a very highly emotional issue in my family. My family—my mom, my dad, my uncles 

and aunts do not have any prosperity consciousness at all. They are blue-collar workers; they lived from check to 

check. Money was always frightening to them and a source of continual stress. I grew up in that environment, and 

I still have a little bit of York Road in me. And you know what? So does everybody else. So do all dentists, so do 

all team members. Money is one of the cultural things that we inherit from our parents. How we perceive money is 

one of the things we inherit from our family. 

MD: Well, I remember once lecturing actually to a group of therapists—this was something that I was doing through 

a dentist friend—and I mentioned to one of the therapists about people having issues when they come to the dentist. 

And he said, “Well, we see people all day about all kinds of issues. What do you think is the biggest issue we see people 

for?” I said, “Probably related to marriage?” He said, “Yes.” And I said, “Probably sex?” And he said, “No, this one’s 

not even close to sex.” When I couldn’t guess what it was, he said, “Money. If you think people are messed up when it 

comes to their thinking about sex, wait till you get two people together in a marriage and you try to bring up money and 

what you should do with it.” He said everything else pales in comparison to how people struggle with how they feel 

about money. 

PH: (Laughter) Well, that doesn’t go away when they go into the dental office does it? 

MD: No, it doesn’t, it might even get worse. 

PH: Sure, and it doesn’t go away when you go to dental school or the institute, or if you’re a dental hygienist or 

dental assistant. It follows us. But what are we going to do about it? Well, what we want to do is raise our Crossover 

Zone. Look at that chart, Mike (Page 23). I’ve got that person crossing over at $5,000. What do you think the impact 

on his practice would be if we could get him to cross over at $10,000? 

MD: I think he would certainly diagnose more completely, more ideally, and really let the patient come to decide about 

the suitability—I’m speaking like you now, Paul (laughter). There are a lot of dentists I talk to who don’t like to diagnose 

more than two crowns at a time because they hate rejection. They end up doing the case piecemeal instead of getting the 

patient’s input. So obviously it would lead to an increase in production and collections in their practice, an increase in 

professional satisfaction, an increase in the strength of the team if they are getting bonuses on collections, and probably 

an increase in the satisfaction of patients. 

PH: You bet. And put on top of all that an increase in the standard of care in that office. The cultural center being 

clinical quality is now well-served, isn’t it? 

MD: Yes, it is. 

PH: So this fringe item that we’ve been talking about, prosperity, has a direct and immediate impact on our cultural 

center. It cannot and should not be ignored. It is as important to clinical quality as is the quality of our impression 

material, the quality of the lab we use, the quality of the die stone, the quality of the alloy and our diagnosis. And 

yet dentistry still has its head in the sand when it comes to issues that are non-clinical, that are related to what impacts 

standard of care. If a dentist crosses over at $5,000, chances are this dentist is going to treatment plan a lot of 

cases that are in the $3,000 to $4,000 range and be successful with them. If the dentist then increases the Crossover 

Zone and crosses over at $10,000, he or she is going to do a lot of cases in the $7,000 to $9,000 range and do them 

pretty well, you know what I’m saying? 


MD: Exactly, and you know it’s funny because it dawns on me that organized dentistry’s Crossover Zone is practice 

management, and that’s right where organized dentistry gets uncomfortable—because God forbid our members have a 

practice where they are happy and successful and can pursue clinical excellence without worrying about the balance in 

the checkbook on a month-to-month basis (laughter). 

PH: Let’s put together a to-do list. Let’s get real dentists oriented and put together a list of ways we can increase the 

Crossover Zone or how to decrease the Crossover Zone. What behaviors will increase it, and what behaviors will 

decrease it? Here are some good pointers on increasing the Crossover Zone. Really, at the heart of it is—an increase 

in the Crossover Zone means becoming more comfortable with higher fees and the dentist becoming conscious 

about protecting his or her confidence. Typically what this means, Mike, is that the dentist needs to put themselves 

in collaboration with people who think abundantly. I belonged to an entrepreneurial group for 10 years—we met 

once a quarter. No one was a dentist. There were car dealers, restaurateurs, financial services people, attorneys, a 

wide range of people. And these were people who were building their business. Everyone thinks differently, and 

it’s great to be around people like that. 

Find mentors, find someone who is doing what you want to do, and do what they’re doing. A big part of increasing 

your confidence, and protecting your confidence, is the issue that we were talking about at the beginning of this. 

First, you must protect your physical health—that is if you’re overweight, if you lost vitality, if you’re not active, that 

has a depressive emotional effect on you. <strong>One</strong> of the ways to get a good start on increasing your Crossover Zone is 

to hang out with people who have high Crossover Zones and collaborate with them. Here’s a good way to decrease 

your Crossover Zone—watch a lot of daily news and TV. That is a great way to get depressed—I had to shut it off 

the other night. Check the stock market everyday. Get in there and watch the fluctuation and just watch your blood 

pressure change. Stay isolated and don’t be collaborative and remain inactive. Those activities will cause a general 

depression and will actually shrink your Crossover Zone. 

The second way to increase your Crossover Zone is to offer the patient a choice following your initial exam. We 

touched on this, Mike, in our article on left and right-side patients (Chairside Magazine, Volume 3, Issue 2). A choice 

dialogue is a dialogue that you’ll enter into following the exam. For example, a patient named Kevin comes in 

for a consultation and explains to you he’s got a dark front tooth, his daughter is getting married and he’d like 

to get the dark front tooth improved. He also mentions that he wears a partial denture, although he’s not 

having a big problem with it right now—it just comes out in conversation. You do an exam, and tooth no. 7 has got a 

large mesial incisal composite; it’s been in there for 15 to 20 years, otherwise the tooth is healthy. However, his partial 

denture, the abutment teeth are mobile, he’s got periodontal disease, he’s got occlusal disease, he’s got loss of 

vertical dimension. Kevin’s case/ideal treatment plan would be a $27,000 treatment plan. Now, what do you do as a 

practitioner? Do you get into Kevin with a big treatment plan or do you get into Kevin by offering him something simple, to 

begin building a relationship? The recommendation I’m going to make here, as far as increasing the Crossover 

Zone, is that the initial examination be a short one, Mike. Instead of insisting that all new patients go through your 

complete examination process—which for those of us who have been to the institutes and are pursuing higher 

levels of dentistry includes study models, photographs, full-mouth radiographs, panoramic X-rays, oral cancer 

screening, a periodontal screening, occlusal analysis, DNA analysis, CAT scan—think about putting them 

through a simple initial exam. You can still do the oral cancer screening exam and the periodontal screening exam, 

but really focus on the condition that’s responsible for this guy not being happy with his teeth. And then once you 

see that condition and get a sense of his overall health, then offer the patient a choice relative to the therapeutic 

range. For example, after I did a simple initial examination on Kevin, I might say to Kevin something like, “Kevin, I 

can understand that you’re not happy with the appearance of this front tooth, especially with your daughter’s 

wedding coming up. Before we decide on anything, I want you to know that you have a choice today: we can focus on 

getting you to look good for the wedding or, in addition to that, would today be a good time for us to look at all 

your teeth and perhaps plan for a lifetime of good dental health? Which would be better for you today?” 

Now, that’s a choice dialogue, Mike. And what that does—it allows you to understand what the patient is ready 

for. When you understand what the patient is ready for, and then deliver it, it increases their confidence in 

this relationship. 


Now, when I teach this choice dialogue, I get some pushback from practitioners 

who say, “Yes, but if you just offer them simple care, if you just fix 

that front tooth, then you’re going to miss out on the opportunity to completely 

treatment plan their mouth and provide complete dentistry.” And at 

that point, they give me a lecture about how they pride themselves on practicing 

comprehensive dentistry and recommending comprehensive care to all 

their patients. Well, I don’t see where that is such a badge of honor. I want 

you to think about the advantages of a patient like Kevin. Let’s say you have a 

patient like Kevin who has a potential full-mouth reconstruction. What are the 

advantages of doing something simply on him first? Number one, if I’m going 

to fix just one tooth on him, Kevin is going to experience my touch, my hands. 

Kevin is going to experience the fact that I’m a good listener, that I’ve given 

him a choice. He is going to experience my office, my team, my punctuality, 

my process, etc. Kevin is going to see an outcome—a tangible outcome very 

early in our relationship. He’s going to become a happy guy, and there’s tremendous 

advantage to that because it builds confidence on the patient’s part 

towards us. 

MD: It’s like test-driving a car before buying it. Who buys a car without getting the 

opportunity to test-drive it? The patient wants to test-drive you, his dentist. 

PH: Absolutely true. So the myth is, let’s do complete exams on everyone 

and that way we can showcase our comprehensiveness and thoroughness and 

how much we care. I don’t take that point-of-view at all. My point-of-view is 

to showcase what you can do in the mouth. When you do, and can make a 

patient happy, that sends a much stronger message of value than any examination 

you could ever do. Kevin is much happier walking out with a shiny front 

tooth that matches his other teeth, as opposed to the complete examination 

process. He gets more value out of having something simple done initially. 

That right there will inspire the patient’s confidence in you and then you will 

be more confident as a practitioner, which increases your Crossover Zone. 

Does that make sense, Mike? 

MD: Absolutely, it does. 

PH: The way to decrease your Crossover Zone is to insist that all new patients 

go through complete examinations. It is impossible to build a relationship 

with a patient through a procedure they don’t want. 

MD: Especially because the culture of clinical excellence states that the patient 

will be impressed by the fact it is the most thorough examination they’ve ever had, 

where in reality their anger level may just be rising higher and higher because this 

is not what they had in mind. 

PH: Right. And when you look at the concept of examination, there’s really 

two examinations going on at the initial appointment. There’s the one that 

we do, but there’s another one going on—it’s the one that the patient’s 

doing. I think it’s much more important that we pass their examination than 

submit them to ours. I can make that patient satisfied and give that patient 

a sense of value. And then, I have earned the right to influence that patient 

another day. 

“When I average Crossover 

Zones’ from the teams— 

and this is again a decade 

of empiricism, a decade of 

doing this and averaging 

the number from literally 

hundreds of practices— 

most teams crossover between 

$6,000 to $6,500 

dollars. I don’t know why 

that is, Mike.” 


“If a dentist crosses over 

at $5,000, chances are this 

dentist is going to treatment 

plan a lot of cases 

that are in the $3,000 to 

$4,000 range and be successful 

with them. If the 

dentist then increases the 

Crossover Zone and crosses 

over at $10,000, he or 

she is going to do a lot 

of cases in the $7,000 to 

$9,000 range and do them 

pretty well.” 

MD: Right, because the patient is the only one in this relationship with the ability 

to decide whether or not any of this is going to happen. We can’t force it on them. 

They really are the ones interviewing us and making a decision whether or not this 

relationship is going to move forward. 

PH: Exactly right. The second way to increase the Crossover Zone is to get 

really clear about what’s going on with the patient’s life as far as their life circumstances. 

I call it understanding the patient’s fit issues. Fit issues are those 

life circumstances that include their budget and their life and their time and 

their hobbies—it’s all of the contemporary life events that are going on in 

people’s lives. Mike, right now in my life, my fiancée and I are buying a house 

down the street here. It’s springtime now, we just put the boat in the water. I 

got stereo speakers I’m working on one side, my exhaust gas sensors weren’t 

working, I had a tear in my part of the vinyl that covers the windshield. I’ve 

got my television studio. I’m doing work with you. I have a lot of complexity in 

my life right now. And it would be very difficult to carve out three to five hours 

every other week to have my mouth reconstructed right now—it would be a 

tough thing. And the more we can understand the life circumstances of our 

patients, understand these fit issues, the better we can enter into a dialogue 

about those issues. 

Again, Mike, we touched on this last time. I called it an advocacy position or 

advocacy dialogue. That is, I’ve got a patient in this chair. Let’s say this guy is 

Kevin again. I fixed Kevin’s front tooth and he is happy. I say to him, “Kevin, 

listen, enjoy the wedding. However, I want you to come back here and let me 

take a real good look at your mouth. The reason I’m saying that, Kevin, is that 

while I was fixing your front tooth, I noticed that you have other conditions 

in your mouth that we really can’t ignore. I noticed some teeth that move, I 

noticed some gum infection, I noticed that your bite isn’t quite right. And it’s 

my responsibility as a dentist to let you know these things. You’re not obliged 

to treat anything right now, but I’m really bound by good dentistry and dental 

ethics to make sure you understand that. Kevin, I’d really appreciate it if you’d 

come back and let me do a complete examination so you understand what 

your needs are.” 

So, Mike, it’s really important for the reader to know that I’m not just treating 

some chief complaint and then ignoring the patient. I’m treating the chief complaint, 

I’m making them happy, I’m building my confidence, they’re building 

their confidence, but now I’m asking the patient to return. And prior to that 

complete examination, I’m going to engage the patient in a conversation about 

what’s going on in their life, and I’m going to understand. I’m going to find out 

about that new house they’re buying, about that boat. Why? Because it’s called 

a conversation. That’s not in the culture of dentistry. That’s another thing that 

we need to have—stronger verbal and conversational skills. Learning how to 

bring dialogue out of a person, how to get another person to tell you a story 

about their life. It’s within these dialogues that we’ll understand what the patient’s 

fit issues are. When we understand the fit issue, Mike, it’s absolutely key 

in increasing the Crossover Zone. Why? Because it gives me the confidence to 

quote fees that may be beyond my Crossover Zone. When I understand the fit 

issue, I can integrate it into my treatment plan with the patient. For example, 

let’s say Kevin’s treatment plan is $20,000 and I’m crossing over at $10,000. 


But I understand Kevin has two boys in college and is remodeling his house. Now, when I present care to Kevin, I 

want to present the fit issue along with the treatment plan. I’m going to say something like this: “Kevin, first of all, 

I understand that you have two boys in college right now, that you’re really proud of that, you’re spending a lot of 

time visiting them. I also know that you’re remodeling your home and I just remodeled a part of mine, and I know 

all about that process. I want you to know that we can help you with your care. What I’m not sure is how that fits 

into your life right now. Do we do your care right now or later? Or a little bit at a time?” You see, what I’m doing 

here is I’m not allowing that patient’s fit issues to get in the way emotionally with me. What I’m doing is almost 

subordinating my treatment plan to what this patient has going on in their life. What that does for me is increase my 

Crossover Zone because I’m telling this patient when you’re ready, we’ll be here—it’s very authentic and it’s based 

on my understanding of that patient’s fit issue. 

MD: Interesting. I can also picture a scenario where a young dentist right out of school might have a pretty low Crossover 

Zone, like $1,500, whereas a 60-year-old patient who owns his own business might actually have a higher Crossover Zone, 

where anything under $4,000 they just kind of sneeze at. 

PH: Well, I think you’re correct there, Mike. I think patients have Crossover Zones. We all kind of have an idea or 

intrinsic value of what we’re willing to pay for something. We’re getting estimates right now on painting the inside 

of the house. And you know, I looked at the house—there are four bedrooms, a big rec room, a porch, kitchen and 

a dining room—and I’m thinking, “What is it going to take to paint this place?” It seems like it should be about 

$5,000 or $6,000 to paint the whole place. So I walk in with an expectation rattling around in my head. I have a 

Crossover Zone related to cars. I don’t want to spend more than $60,000 on a car, I just don’t put the value there. 

I’d rather put it in the boat…you know what I’m saying? 

MD: That’s different in the sense that you know what the car is going to cost before you get to the lot. I mean you don’t know 

it to the exact penny, but when you have somebody over to get an estimate on painting and you’re thinking it’s going to be 

$4,000 or $5,000 and they throw out a number like $12,000, there’s an opportunity for you to be stunned, right? 

PH: Right. Sure. You know, the Crossover Zone is largely caused, but not completely caused, by the dentist who 

typically doesn’t know how to respond when the patient says, “No, I can’t afford it,” or “Gosh, I had no idea it would 

be that expensive.” I mean, would there be a Crossover Zone, Mike, if we knew the patient would say yes? 

MD: No, not at all! If we knew the patient would say yes, we’d probably have to double the number of dentists because 

everybody would be doing the ideal treatment and only be able to see about a third of patients currently in their practice. 

PH: Sure. So, if there’s no Crossover Zone, if we knew the patient would say yes, then it’s not about the money. It’s 

about the patient’s negative reaction to the money… you see that? If we know the patient is going to say yes, that 

is if you quote $10,000 dollars and they say “Yippee! When can we start?” there is no Crossover Zone. But what if 

you had fear of the patient screaming when you say $10,000, demanding to know, “What makes it so expensive?” 

The dentist doesn’t have the answer to that question, which is what creates a lot of anxiety and results in a low 

Crossover Zone. So, it’s more so about the dentist’s feeling than it is about the patient’s feeling. 

MD: Absolutely, and it’s about the dentist’s confrontational tolerance and not wanting to be rejected. It really almost goes 

back to the dentist’s reason for becoming a dentist—so that he or she didn’t have to go into sales. 

PH: (laughter) Right, right! So the whole issue of advocacy—that is, understanding the patient’s life circumstances 

and then asking the patient whether the treatment plan fits the life circumstances now or later or a little bit over 

time—really helps ease the anxiety of the Crossover Zone. A way to decrease the Crossover Zone is just continue 

to pursue excellence. It’s the whole blind pursuit of saying, “Listen, I’m going to give you the best treatment plan. 

Whether you’re my brother or my mother or my wife, this is what I would do. And this is the very best, and we use 

the best this, and we have the best lab…” It’s that head-in-the-sand way that will continuously drive the Crossover 

Zone down, because treatment planning and offering care in the absence of knowing the patient’s fit is always an 

invitation for stress on you and your patients. 


MD: Now, when you have that staff meeting and you find out what everybody’s Crossover Zone is, if you happen to have 

one employee who is at $23,000, does she immediately become your financial coordinator? 

PH: Well, I’d certainly think about it. It’s like a basketball game. If the game is tied and there’s three seconds on 

the clock, who’s going to take the final shot? Your best shooter, right? It’s the same thing in the dental practice. 

You find out who is really comfortable talking about money. And you know what? It may not be your treatment 

plan coordinator. If my treatment coordinator is crossing over at $1,200, I’m going to have to re-purpose her, find 

another place for her in the practice, replace her. But it becomes extremely critical that the person who is doing 

the treatment planning, or doing financial arrangements, has an extremely high Crossover Zone. Diagnostically, you 

can’t live without knowing that. 

MD: Agreed. 

PH: Another major aspect of the Crossover Zone is what goes on in the dental hygiene room. And this might be the 

most important thing of all that we talk about here. Most practices are filled with complex care patients who have 

not completed their treatment. They might have gotten part of their treatment done, but there are a lot of practices 

with many patients who have literally millions of dollars worth of dentistry to be done in their mouth. And every six 

months, the hygienist revisits with those patients on an ideal basis. Now, what are the hygienists saying? Well, the 

patient needs some crown and bridge, right? And the typical—again, I’m not trying to beat up the hygienist here, 

I’m just telling you what I know to be true—patient needs some crown and bridge, patient comes in for six month 

recall, and the hygienist says, “Are you ready for the crown and bridge work?” Patient says no. Six months later, 

“Are you ready for the crown and bridge work?” Patient says no. Six months later, “Are you ready for your crown 

and bridge work?” Patient says no. Six months later, patient says, “Don’t mention the crown and bridge work!” Six 

months later, broken appointment. Compound that with courses dentists can send their hygienists to that teach 

them how to sell dentistry out of dental hygiene. I think the dental hygienists are kind of caught in the middle 

between the patient and the doctor they work for. And dental hygienists often times have extremely low Crossover 

Zones relative to complete care dentistry. 

So, what can a dental hygienist do to increase her Crossover Zone? How can she become more comfortable talking 

about money? This is a major issue in most offices, Mike. When the dentist offers care to a patient and the patient 

is not ready for that care, it’s really important that the dentist understands the fit issue behind why the dentistry is 

not appropriate this time. This goes back to the previous point that I made about understanding the patient’s life 

circumstances. If I recommend to Kevin full-mouth dentistry, I understand he has boys in college. He tells me he’d 

like to get work done but he has to wait because the kids are in college. That fit issue is then documented in Kevin’s 

patient record. And six months later when Kevin comes back in, the hygienist should revisit the fit issue before she 

revisits the condition. So Kevin comes in, sits in the chair, and the hygienist asks, “Any changes in your medical 

history? Any changes in your dental history?” “Nope.” “Kevin, how are the boys doing at school? Are they still there? 

Tell me what they’re up to.” What we’re going to do is revisit the fit issue. Then after I revisit the fit issue, I’m going 

to reflect back on it. “Kevin, considering your boys are still in college, is this a good time for us to revisit the 

recommendations that Dr. Homoly made for you last time?” Do you see how that works? You’re asking the patient, 

“Is now a good time?” That is testing readiness, Mike. That is something you and I have talked about in all three articles 

we’ve done. The hygienist tests for readiness, and she doesn’t feel out on the limb as far as recommending an 

expensive treatment plan the patient can’t afford—which makes hygienists feel uncomfortable or embarrassed. So, 

the hygienist revisits the fit issue before she revisits the condition. And listen to what I’m saying carefully here: I’m 

not saying that she shouldn’t revisit the condition, but rather that she should revisit the fit issue prior to revisiting 

the condition. The other side of that would be just to put the patient in the chair and educate the hell out of them 

based on their conditions. And that oftentimes ends up with the patient being educated right out of the practice. 

MD: Yes, because you did the same thing to them last time with no regards for suitability. They are probably willing to accept 

it once, that you’re going to do that, but if you go in there again and try to do that without taking into account their 

suitability and their life circumstances, then yeah, at some point, it’s that whole thing about don’t try to teach a pig to sing. 

You keep reminding them they don’t have any money. 


PH: Right. After a while it just feels like nagging. Overeducating the patient, 

relying too highly on patient education on a patient who isn’t ready, feels like 

sales pressure. And that’s how you lose them. Last point here about the Crossover 

Zone, Mike; let’s start with the dentist. The dentist needs to get his own 

financial house in order. That means meeting with a financial planner who 

can get the demons out of the dentist’s life relative to money. If there are back 

taxes due, if there is no savings, if there are labs sending cases COD because 

you’re three months late on your lab bill—all of that has a huge depressive 

effect on the Crossover Zone. Often times, dentists end up treatment planning 

patients based on their own ability to pay, not on the patient’s ability to pay. 

My recommendation—and it might be that maybe this is the first recommendation 

that a dentist should do—is to get a financial services specialist, and 

take your own medicine as far as how we treat patients comprehensively. Get 

a comprehensive examination and diagnosis and treatment plan of your own 

financial health, and build it into the culture of your family and your team. If 

you have team members who are struggling financially, team members who 

are involved in financial issues that are toxic to their mental health, it’s not 

unthinkable for them to get help also; that can be a huge benefit of working 

for you. It could be a huge tool for you to build long-term loyalty with staff. 

And maybe you hire a financial planner to come in and to work with different 

team members as far as getting their credit cards figured out or restructuring 

their debt, or one of a hundred things that financial planners can do to ease 

some of the demons flowing related to money. 

“The myth is, let’s do complete 

exams on everyone 

and that way we can showcase 

our comprehensiveness 

and thoroughness and 

how much we care.” 

I believe that the concept of prosperity needs to be a companion cultural icon 

right next to clinical quality, because prosperity and clinical quality are joined 

at the hip, Mike. When a dentist is prosperous and profitable, then that dentist 

can afford a good facility, pay great wages, hire great people, afford the finest 

materials, get good equipment, use the best laboratories, can afford to take 

time off for rejuvenation—and all of that has a dramatic and immediate impact 

on the clinical quality. The topic of prosperity should not be on the fringe, but 

it should be at the center of what we do in our continuing education efforts 

in dentistry. 

MD: Wow, that’s a nice wrap-up right there. And that certainly is again against 

the grain, because, it’s as we’ve mentioned before—the dental community is so ingrained 

with nothing but clinical excellence as the end-all, be-all to a happy career. 

And I think you’ve laid out a pretty good case today for why that’s not necessarily 

true. And this leads us into a good fee discussion for next time. You’ve suggested 

before that while a crown fee of $900, for example, works really well for one, two 

or three crowns, it does not work beyond three crowns. I know that’s going to be a 

great interview and a great topic for discussion. Thanks again, Paul! 

PH: It was my pleasure, Mike. 

To contact Dr. Paul Homoly or to purchase his book “Making It Easy for Patients to Say ‘Yes,’” call 800-294- 

9370, visit www.paulhomoly.com, or e-mail paul@paulhomoly.com. 

CEREC is a registered trademark of Sirona Dental Systems, Inc. 


When planning esthetic anterior restorations, 

many concerns arise regarding gingival tissue 

architecture. After potentially traumatic 

impression procedures, how confident are we in predicting 

the final form of the tissue? 

Developing an understanding of three key concepts enables 

the clinician to predict the gingival tissue architecture 

with more certainty: 

1. Biology of the periodontal interface. 

2. Relationship of gingiva to the osseous crest. 

3. Relationship of the preparation finish line to 

the osseous crest. 

Figure 1: Histologic components vs. clinical dentogingival 

complex. 

■ Biology of the Periodontal Interface 

Anatomically, the dentogingival complex is comprised 

of three components: the connective tissue attachment, 

the junctional epithelium, and the depth of the sulcus. 1,2 

The average measurement of each is difficult to assess 

clinically (Figure 1). 3,4 When probing the sulcus, the 

probe can easily penetrate through the junctional epithelium. 

The junctional epithelium is attached in a tight 

approximation by hemidesmosomes. This attachment is 

only a few layers of cells in thickness, so the measurement 

that usually is considered the depth of the sulcus 

can be the sulcus depth plus the depth of the junctional 

epithelium. The most reliable measurement is the total 

of the entire dentogingival complex, which is from the 

osseous crest to the free gingival margin. 5 

To make an accurate measurement to the osseous 

crest—sounding to bone—the tooth must be anesthetized. 

A periodontal probe (flat-ended so it will not slip 

on the bone) is placed into the sulcus. Resistance will 

be met when the probe reaches the connective tissue 

attachment. The probe is kept in contact with the root 

surface and then it is pushed hard to the osseous crest. 

This sounding to the osseous crest will represent the 

measurement of the total dentogingival complex. 

Figure 2: Osseous crest relationship. 

■ Relationship of Gingiva to the Osseous Crest 

The gingival relationship to the osseous crest is always 

equal to or greater than the underlying osseous scallop, 

which is parallel to the cementoenamel junction. Before 

tooth preparation, two reference measurements should 

be established for placing the intracrevicular finish line 

by using the periodontal probe. The first measurement 

should be on the facial aspect of the tooth; the second 

should be on the interproximal surface. These two mea- 

Figure 3: Initial metal ceramic crowns on teeth 7-10. 

Clinical Techniques in Prosthodontics35

In the normal osseous crest, the 

“ 

facial margin of the preparation 

should be 2 mm to 2.5 mm 

coronal to the osseous crest, 

or 0.5 mm to 1 mm apical to 

the free gingival margin. 

” 

surements, which should be of the entire dentogingival 

complex, will be the guide for placing the finish line of 

the preparation. 

Ideally, for anterior teeth, the facial measurement should 

be approximately 3 mm, and the interproximal measurement, 

when adjacent teeth are present, approximately 

4 mm. This relationship is considered a normal crest 6 

and exists on the facial and interproximal surfaces of 

normal sized teeth in about 85 percent of patients (Figure 

2). With this gingival-to-osseous crest relationship, if 

the tissue is traumatized with any type of clinical procedure, 

it will heal in a similar fashion. 7 The healing will 

return to normal 85 percent of the time. 8 

If the depth of the osseous crest to the gingival margin 

is greater than 3 mm facially and 4 mm interproximally, 

it is considered a low crest and exists on the facial and 

interproximal surfaces of normal sized teeth in about 

13 percent of patients. The low osseous crest and thin 

tissue biotype pose the most variation for final gingival 

position. 9 Black holes and recession are most likely with 

this situation. If the gingival depth to the osseous crest 

is less than 3 mm facially and 4 mm interproximally, the 

osseous architecture is considered a high crest and exists 

in about 2 percent of patients. High crests are most 

susceptible to biologic width violations. 

Figure 4: Normal crest 3 mm on facial. 

Tissue biotype affects the stability of the tissue in all 

levels of osseous architecture. Thick biotype reduces 

the risk of recession and black holes. Thick biotype and 

a low osseous crest will yield pocket depth formation. 

■ Preparation Finish Line to the Osseous Crest 

In the normal osseous crest, the facial margin of the 

preparation should be 2 mm to 2.5 mm coronal to the 

osseous crest, or 0.5 mm to 1 mm apical to the free 

gingival margin. The interproximal margin of the preparation 

should be located 3 mm coronal to the osseous 

crest or 1 mm apical to the interproximal papilla. In 

this relationship, how the gingiva will reestablish itself 

to create an intracrevicular finish line can be predicted 

after the impression. 

Figure 5: Normal crest 4 mm on interproximal. 

With low crests, the facial margin of the preparation 

should be a minimum of 2 mm from the osseous crest, 

and the interproximal margin more than 1 mm away. 

With high crests, the facial and interproximal margin 

of the preparation should be at the level of the free 

gingival margin or no deeper than 0.5 mm. A high crest 

is most susceptible to biologic width violations. If the 

margin of the preparation is deeper than 0.5 mm, the 


isk of violation of biologic width increases. This usually 

happens in the interproximal region or line angles 

of anterior teeth where the margin is placed too horizontally. 

10 The osseous crest is thicker at the line angles 

and will not resorb, although the finish line has been 

placed into the biologic width area relative to the osseous 

crest. 11 Inflammation begins interproximally and 

proceeds to the facial surface of the tooth. 12 

If the violation of biologic width occurs on the facial or 

lingual surfaces, resorption is more likely. 13 Recession 

usually follows on the facial surface when there is a 

combination of thin osseous crest and thin tissue type. 

This could result in an esthetic problem. Recession is 

less likely to occur where the biotype is thick or the line 

angles of the osseous crest are intact. 

Figure 6: Finish line location 0.5 mm-1 mm apical 

to undistorted free gingival margin. 

Some situations may dictate the need to avoid finish 

line placement parallel to the scallop of the gingiva. 

Risk of violation of biologic width increases with these 

circumstances. Surgical or orthodontic intervention may 

be a consideration when potential violation of biologic 

width occurs in the esthetic zone. Accurate determination 

of whether there is a normal, low, or high osseous 

crest can only be made before placement of the retraction 

cord. 

■ Clinical Technique 

The following clinical protocol demonstrates how these 

periodontal concepts work with impression making. 

For the purposes of this article, the following system, 

using silicone material and retraction cord, is very predictable. 

14 

Figure 7: Primary cord placed. 

1. For more than two preparations, pre-medicate the 

patient with two tablets of 15mg Propantheline 

(induces dry field). 

2. Anesthetize the teeth (Figure 3). 

3. Probe to the osseous crest both facially and interproximally 

(Figures 4 and 5). 

4. Prepare the tooth relative to the osseous crest—follow 

the scallop of the gingiva and locate the finish 

line (Figure 6). 

5. Place the primary cord. To minimize any bad taste, 

use a dry Ultrapak ® cord. a Use 00 cord for a normal 

crest and 000 cord for a low or high crest. A 

high crest will have minimal room for the cord. 

For a low crest, it is best to minimally manipulate 

the tissue to prevent tissue changes (Figures 7 and 8). 

Figure 8: The primary cord in the junctional epithelium. 


6. Facially, extend the preparation margin to the 

coronal aspect of the primary cord. The margin 

will be about 0.5 mm into the sulcus when the 

restoration is completed. With a normal crest, 

never allow facial tooth structure to show coronally 

to the primary cord (Figure 9). 

7. Interproximally, extend the preparation to the 

free gingival margin, except in low crest situations. 

Extending the preparation will develop a 

scallop. 

Figure 9: Refine facial finish line apical to free 

gingival margin with Brasseler KS1 super coarse 

diamond or KS6 medium grit tapered diamond 

(Brasseler USA, Savannah, GA). 

8. Place ferrous subsulfate circumferentially around 

tooth directly onto the primary cord (Figure 10). 

9. Place the secondary cord. Depending on the tissue 

thickness, use either Ultrapak #1 or #2. When 

the secondary cord compresses into the primary 

cord and pushes it into the connective tissue fibers, 

Sharpey’s fibers may provide some resistance 

to the cord. Use the largest cord possible 

to ensure tissue deflection; however, larger cords 

cause more distortion (Figures 11 and 12). Leave 

the secondary cord in for at least four minutes. 

10. Cleanse with Superoxol. b This is an optional step. 

11. Microabrade the preparations with the PrepStar . c 

12. Remove the secondary cord only (Figure 13). 

13. Place lip retractors d and large dry tips. e 

Figure 10: Tissue management gel in place (ferrous 

subsulfate). 

14. Block undercuts of any bridgework. 

15. Completely dry the preparations. 

16. Set timer to seven minutes. 

17. Fill the tray with Star VPS Ultra Heavy #80062 c 

material, then load a syringe with Star VPS Ultra 

Light #80060 c material. 

18. Flow the Star VPS Ultra Light material around the 

tooth preparations two to three times, then flood 

the preparation and adjacent occlusal surfaces 

with the light material. 

19. Insert the tray before the timer reaches four minutes 

and 30 seconds. Remove the impression after 

the timer has reached zero. 

Figure 11: Secondary cord in place. 

20. Disinfect the impression, read, and package in a 

laboratory bag. 


The keys to impression making with respect to the osseous 

crest and gingival response are: 

• Normal crest situations are not generally technique 

sensitive. The two-cord technique is best. The tissue 

will be distorted, but it will heal and return to the 

normal relationship. 

• Low osseous crests are very sensitive. The thin biotype 

tissue should be manipulated as little as possible. 

A small cord should be used with light pressure. 

The tissue may distort and not predictably return to 

the original level. 

Normal crest situations are 

“ 

not generally technique sensitive. 

The two-cord technique is best. 

The tissue will be distorted, but 

it will heal and return to the 

normal relationship. 

” 

• High osseous crests are moderately technique sensitive. 

Retraction may be limited to one small cord. 

High crests are most prone to biologic width violations, 

which lead to chronic long-term inflammation. 

■ Discussion 

The gingival level will not be accurately represented in 

the stone cast because the retraction cord displaced the 

gingiva laterally and apically. If preoperative sounding 

to the osseous crest has been accomplished, it is unnecessary 

for the gingiva to be accurately represented 

in the study cast. The osseous crest is critical in determining 

where the papilla will ultimately be. Now, the 

dentist can predict where the contact should begin on 

the restorations. 

If the above impression technique is followed, the gingiva 

in a normal crest will be displaced 0.5 mm to 1 

mm apically and approximately 0.4 mm laterally. 15 If the 

preoperative osseous crest was normal, the laboratory 

technician can begin the contouring of the contact of 

the crown 1 mm from the interproximal margin of the 

die. The beginning of the contact will then be located 

4 mm from the osseous crest because the interproximal 

margin of the preparation was located 3 mm from the 

bone. Predicting that the tissue will return in a normal 

crest situation enables the technician to place a contact 

area for an anterior restoration at the correct starting 

point (Figure 14). 

At try-in, the papilla may still be distorted from traumatic 

manipulation. The dentist may now see a black 

hole even in a normal crest. The papilla will fill into 

the interdental space if the technician was guided 

as to where to begin the contact. If the technician is 

not guided, the embrasure space may be overclosed and 

the gingival tissue will be compressed. Chronic inflammation 

and cervical facial fullness will occur. 

Figure 12: Diagram depicting cord placement into 

connective tissue attachment and further distorting 

free gingival margin apically. 

Figure 13: Removal of the secondary cord shows 

displaced tissue without bleeding. 


Low and high osseous crests can be as predictable as 

normal crests if the tissue is minimally manipulated. Low 

crests are the most susceptible to gingival recession and 

loss of papilla. If the gingival tissue is irreversibly lost, 

the technician can compensate by changing the form 

and size of the teeth with tooth-colored porcelain so 

that there will be no black holes. Tissue-colored porcelain 

can be used if no tooth size change is planned. 

Figure 14: Lab communication includes apical position 

of contact point 1 mm coronal to interproximal 

finish line. 

The impression is the foundation for the final restorations 

(Figure 15). In addition, the laboratory should be 

given an occlusal record, preoperative mounted study 

casts, and the base tooth shade. Diagnostic Wax-Ups, 

study casts of the patient’s provisionals, and preoperative 

extraoral and intraoral views with the shade tab are 

excellent adjuncts to use on a routine basis. 

To contact Dr. John Kois, visit www.drkois.com or call 206-515-9500. Dr. 

Rena Vakay can be contacted at www.renavakay.com or by phone at 

703-256-7700. 

■ References 

Figure 15: Final Procera ® crowns (Nobel Biocare, 

Yorba Linda, CA). 

1. Gargiulo AW, Wentz FM, Orban B: Dimensions and relations of the dentogingival 

junctions in humans. J Periodontol 32:261-267, 1961. 

2. Vacek JS, Gher ME, Assad DA, et al: The dimensions of the human dentogingival 

junction. Int J Periodontics Restorative Dent 14(2):154-165, 1994. 

3. Maynard JG Jr, Wilson RD: Physiologic dimensions of the periodontium significant 

to the restorative dentist. J Periodontl 50(4):170-174, 1979. 

4. Ingber JS, Rose LF, Coslet JG: The “biologic width”—a concept in periodontics 

and restorative dentistry. Alpha Omegan 70(3):62-65, 1977. 

5. Kois JC: Altering gingival levels: the restorative connection. I. Biologic variables. 

J Esthet Dent 6(1):3-9, 1994. 

6. Coslet JG, Vanarsdall R, Weisgold A: Diagnosis and classification of delayed 

passive eruption of the dentogingival junction in the adult. Alpha Omegan 

70(3):24-28, 1977. 

7. Ingraham R, Sochat P, Hansing FJ: Rotary gingival curettage—a technique for 

tooth preparation and management of the gingival sulcus for impression taking. 

Int J 

a. Ultradent Products, Inc., South Jordan, UT 

b. Sultan Chemists, Inc, Englewood, NJ 

c. Danville Engineering, San Ramon, CA 

d. Washington Scientific Camera Company, Sumner, WA 

e. Microcopy, Kennesaw, GA 

Reprinted with permission from AEGIS Publications, Inc: Kois JC, Vakay RT. 

Relationship of the Periodontium to Impression Procedures. Compendium. 

2000;21(8):684-692. Copyright ©2009. All rights reserved. 


porcelain products. Its manufacturer reports that the uniform 

leucite structure seen in Venus porcelain allows a smoother 

surface, with the clinical advantages of easier adjustment and 

intraoral polishing to a consistently high luster. A multiple 

fitting process during manufacturing allows consistent shading, 

bottle-to-bottle, which is an important feature, whether 

fabricating full-mouth restorations, restoring a few teeth, or a 

quadrant or arch at a time. The following case report features 

Venus porcelain and Venus stacked on zirconium in the functional 

and esthetic ceramic rehabilitation of a Class II postorthodontically 

treated patient. 

Figure 1: Preoperative full-smile view of a post-orthodontically 

treated Class II malocclusion. Note how the roots of the 

maxillary central incisors had to be inclined distally to create 

proximal contact. As a result, there is a “black triangle” that 

can never be filled with gingival papillae, because the contact 

is too far incisally to the interproximal crestal bone. 

Diagnosis and Treatment Planning 

The patient presented for a comprehensive examination after 

more than two years of orthodontic treatment to correct a 

Class II malocclusion (Figure 1). The limitations of orthodontic 

tooth repositioning are evident, based on the final treatment 

positions (Figures 2–5). This case was an orthodontic retreatment—the 

first premolar extractions and the first-time orthodontics 

had been performed several years previously. Without 

corrective skeletal surgery, the patient was left with the following 

conditions: 

• A deep overbite and the inability to retract the maxillary anterior 

segment sufficiently enough to close the diastemata 

(interproximal spaces) without inclining the incisors palatally. 

Figure 2: A preoperative oblique view of the patient’s smile 

reveals other esthetic problems. The maxillary central incisors 

are inclined too far in the palatal direction, and there is still a 

diastema present distal to the maxillary canine. 

• A Bolton’s discrepancy, due to the extracted first premolar 

teeth, leaving the orthodontist unable to close the spaces 

distal to the maxillary cuspids, due to inadequate mesialdistal 

widths of the remaining teeth and the excessive arch 

length. 

From a dental perspective, most of the posterior teeth had 

received large restorations that were breaking down and were 

in need of repair and/or replacement. The short cervico-incisal 

heights of the posterior teeth and the limited inter-arch 

space created a problem in reducing the posterior dentition 

enough occlusally (1.5 mm to 2.0 mm) to create adequate 

space for restorative materials. Based on the need for posterior 

dental rehabilitation, the deep overbite, and the anterior 

spacing, it was decided that the patient would need a porcelain 

rehabilitation to conservatively “resurface” anterior teeth 

and close the interproximal spaces. At the same time, the vertical 

dimension of occlusion would be opened, or recaptured 

(approximately 3 mm), to gain occlusal space for the posterior 

reconstruction and correction of the deep overbite (100 

percent overbite). The patient also desired to have a more 

youthful, whiter smile. 

Because the platinum foil remains in the feldspathic restora- 

Figure 3: View of a retracted full preoperative smile. Note the 

100 percent overbite in the CO position. 

Figure 4: A maxillary full-arch preoperative occlusal view 

shows that most of the maxillary posterior teeth have large 

restorations and short clinical crowns. 


tions, it is not possible to assess marginal integrity, proximal 

contact, or color of the anterior teeth. 

To accomplish these goals, it was decided to use a feldspathic 

porcelain on the anterior teeth, so that the preparation 

could be performed in a more conservative manner, with zirconium 

crowns on the posterior dentition for esthetics and 

strength. 1,2 

Figure 5: A mandibular full-arch preoperative view. Prosthetic 

restoration of vertical dimension will require full-coverage 

restoration of anterior and posterior teeth. 

Figure 6 : A Diagnostic Wax-Up was created by the laboratory 

technician to act as a template for the provisional reconstruction. 

Treatment Methodology 

Diagnostic Wax-up 

At the first visit, preoperative photographs, maxillary and 

mandibular impressions for a Diagnostic Wax-Up, a facebow 

with interocclusal records, and full-mouth digital X-rays 

were taken. The dental technician poured up the models and 

mounted the case on a semi-adjustable articulator (Denar ® , 

Teledyne Water Pik; Fort Collins, CO). The completed Diagnostic 

Wax-Up is shown in Figure 6. To create sufficient 

posterior space to develop normal cervico-incisal heights for 

the clinical crowns, the dental technician had to open the 

pin on the articulator by 3 mm. This procedure allows 

the height of the posterior teeth to be corrected, decreases 

the overbite of the maxillary anterior teeth, and allows 

the mandibular anterior teeth to be visible during maximum 

intercuspation. 

Figure 7: A silicone matrix is used as a preparation guide in 

the reduction of the maxillary teeth during the preparation 

phase of treatment. 

Figure 8: The maxillary arch provisional restorations are 

shown in place as a plastic matrix filled with a bisacrylic provisional 

material placed over the mandibular preparations, and 

the patient is instructed to close into light occlusal contact. 

Provisional Stent 

A silicone matrix was made from the maxillary wax-up, to 

be used as a provisional stent. Another matrix was made and 

the facial portion was cut away, allowing the palatal outlines 

of the corrected tooth forms to remain. When placed in position, 

this stent can be used as a preparation guide to aid in the 

reduction of teeth during the preparation process (Figure 7). 3 

Once the tooth preparation was completed, a bisque acrylic 

provisional material (LuxaTemp ® , Zenith DMG; Englewood, 

NJ), was dispensed into the maxillary stent and then 

placed over the maxillary preparations for approximately two 

minutes. When the provisional material is set, it can be removed 

from the matrix, carved, and polished. It is then 

placed upon the maxillary preparations, while the mandibular 

teeth are prepared. A clear plastic provisional stent is 

made from a plaster duplicate of the mandibular wax-up, 

filled with bisque acrylic, and placed over the mandibular 

preparations (Figure 8). The clear plastic stent was used rather 

than a silicone matrix, so that the patient could close into 

centric occlusion (CO), while the provisional material polymerized. 

Figures 9 through 11 are views of the completed provisional 

restorations. 

Simply Beautiful: A Venus Reconstruction of a Class II Malocclusion43

Evaluation 

All eccentric movements of the mandible from the CO position 

should result in immediate disclusion, due to anterior 

guidance and canine disclusion. The patient was now to be 

evaluated for eight to 12 weeks at the restored vertical dimension 

of occlusion. Any muscle tenderness or abnormal 

occlusal wear of the provisional restorations might require 

the provisional occlusion (occlusal vertical dimension) to be 

lessened toward the preoperative position. The patient tolerated 

the change in vertical dimension well, and no adjustments 

were required to the provisional restorations. Figure 12 

demonstrates the “occlusal lock” position, formed when the 

provisional stamp cusps are properly interdigitating in their 

respective opposing fossae. The prepared maxillary and mandibular 

teeth can be seen in the position of CO, and incisal 

reduction is then verified and corrected, if necessary. 

Figure 9: The view of provisional restorations at full smile. 

Compare to the preoperative view at full smile in Fig. 1. 

“ 

The second molars were 

left unprepared to 

preserve a reference to the 

preoperative position. ” 

Figure 10: Occlusal view of the maxillary full-arch provisional 

restorations six weeks after placement. Note the lack of accelerated 

occlusal wear, due to the balanced occlusion; and 

anterior guidance, built into the provisional restoration. 

The gingival tissues surrounding all preparations were then 

readied for the registration of master impressions. First, interpapillary 

injections of 2 percent lidocaine with 1:50,000 

epinephrine were used buccally and lingually to aid in retraction 

and for sounding around preparations for marginal 

correction, as it relates to the crestal bone position. As recommended 

by Kois. 4 the restorative margin should be located no 

closer than 3 mm incisally (occlusally) from the crestal bone 

on the facial surfaces of all teeth, 4 mm interproximally for 

anterior teeth, and 3 mm for posterior teeth. 

Figure 11: A six-week post-placement view of the mandibular 

provisional restoration. Note that the second molars are left 

unprepared to serve as a record of the preoperative occlusal 

vertical dimension. These teeth will be restored after the 

reconstruction is completed. 

Sounding 

Sounding is a technique to measure the dentogingival complex 

(gingival sulcus, connective, and epithelial attachments) 

by pushing the periodontal probe parallel to the long axis 

of the root, until the tip stops on the osseous crest. A no. 00 

retraction cord (UltraPak ® , Ultradent; South Jordan, UT) was 

placed circumferentially around each preparation. <strong>One</strong> can 

sound to the osseous crest by placing the periodontal probe 

between the retraction cord and the tooth. The restorative 

margin can then be corrected to the appropriate position and 

Figure 12: The “occlusal lock” in the provisional restoration. 

Note the cusp-fossae relationship, established in the provisional 

restorations, and the amount of space between the 

maxillary and mandibular anterior teeth allocated for restorative 

material. 


smoothed, using a rotary diamond instrument. A no. 1 cord 

was then placed above the no. 00 cord for each preparation. 

Interocclusal Records 

Figure 13: As the provisional restorations hold the vertical 

dimension of occlusion, a “prep-to-prep” anterior centric 

relation/occlusion record is made. 

Figure 14: An anterior bite record of “provisional-to-prep” is 

made in centric relation/occlusion. 

After the retraction was completed, the no. 1 cord was removed, 

and the no. 00 was left in place. The light-bodied 

impression material was then syringed into the retracted sulci. 

The impression tray was filled with heavy-bodied impression 

material and placed over the teeth. 5 After master impressions 

were made, a facebow registration was taken of the maxillary 

preparations, using an earbow (Denar ® Slidematic Facebow, 

Whip Mix Corp.; Louisville, KY). Interocclusal records in CO 

were taken, a sextant at a time, while the remaining provisional 

restorations maintained the vertical dimension of occlusion 

position. 

The first series of interocclusal records was taken “prep 

to prep” (Figure 13), using a polysiloxane bite registration 

material (Registrado X-tra, Voco; Cuxhaven, Germany). 

A second series of interocclusal records was taken 

“provisional to prep” (Figure 14). These records allow the 

dental technician to cross-mount models of the provisional 

restorations with the prepared teeth, which will aid in 

design and fabrication of the definitive restorations. 6-10 

Figure 15: The bisque-bake try-in. Remember that anterior 

color cannot be evaluated at this point, since the platinum foil 

remains in place until the case is completed. 

Figure 16: View of the “occlusal lock” in ceramic during the 

bisque-bake try-in. Compare to Fig. 12. Cross-mounting in 

the laboratory, using the proper interocclusal records, and a 

facebow transfer has allowed a high degree of accuracy in 

the first bake. 

Bisque Try-in 

“ 

There is a natural 

texture, translucency, 

and cervico-incisal 

blend of color. ” 

The purpose of the bisque-bake try-in is to evaluate occlusion, 

marginal integrity, proximal contacts of the posterior 

ceramic restorations, and anterior ceramic contours. Because 

the platinum foil remains in the feldspathic restorations, it is 

not possible to assess marginal integrity, proximal contact, or 

color of the anterior teeth. These parameters will be refined 

by the ceramist during the finishing process and evaluated at 

the delivery appointment. Figure 15 shows the case at bisquebake 

try-in, with the patient’s dental arches lightly closed in 

CO. The precision of the occlusion on the first closure is due 

primarily to the accurate interocclusal records and crossmounting 

with the provisional restoration models. 


A thin articulating medium (AccuFilm ® , Parkell; Edgewood, 

NY) was introduced between the posterior teeth without anterior 

restorations in place to evaluate the “occlusal lock.” (Note 

the provisional occlusal lock in Figure 12.) The anterior restorations 

were removed, since the platinum foil does not permit 

complete marginal seating of the restorations. The AccuFilm 

would mark centric prematurities and was left on the teeth 

for the ceramist to adjust during the finishing process (Figure 

17). 11 A periodontal probe was used to verify the position of 

the gingival papillae at the proximal facial line angle of 3 mm 

incisal to the crest of the alveolar bone (Figure 18). This would 

ensure that a “black triangle” would not be created and that 

the gingival papillae would fill the gingival embrasure space 

completely. 

Figure 17: The maxillary bisque-bake try-in from the 

occlusal view after recording the first occlusal contacts 

with articulation paper. 

Finishing and Glazing 

The restorations were then sent back to the ceramist for finishing 

and glazing. Figures 19 through 21 show the finished 

Venus restorations for the case from various views. Note the 

natural appearance of the ceramic and how well the posterior 

zirconium restorations blend and match the feldspathic 

anterior restorations. Also note that the vertical dimension 

of occlusion, based on the unprepared second molars, was 

opened posteriorly approximately 3 mm. The second molars 

were left unprepared to preserve a reference to the preoperative 

position; they will be prepared and restored at a 

later date. 

Figure 18: The osseous crest is sounded to 3 mm at 

the facial proximal line angle. This verifies that the gingival 

tissue (papillae) will fill the gingival embrasure completely. 

Cementation and Delivery of Final Restorations 

The cementation process was begun with the maxillary arch. 

The maxillary central incisors were evaluated individually 

for marginal fit and together for the mesial proximal contact. 

Since these restorations were made of Venus feldspathic porcelain, 

the preparations were etched with 37 percent phosphoric 

acid for 15 seconds, thoroughly rinsed, and air-dried. 

A desensitizer (AcquaSeal B, AcquaMed Technologies; Chicago, 

IL) was applied to the preparations, and the excess was 

removed with a high-volume suction. A fifth-generation bonding 

agent (OptiBond ® Solo Plus, Kerr; Orange, CA) was applied 

to the preparations, air-thinned, and light-cured. A resin 

cement (NX3 Nexus ® Third Generation, Kerr) was syringed directly 

from its auto-mix syringe into the restorations, and they 

were placed on the preparations. The excess resin cement 

was removed from the margins, using an artist’s brush (#2 

Keystone, Patterson Dental; St. Paul, MN). The adjacent lateral 

incisor restorations were seated on their respective preparations 

to ensure proper positioning of the central incisors, and 

the central incisor restorations were then “flash-cured” into 

position. This procedure allows most of the remaining resin 

cement to be cleaned away with a small scaler prior to the 

Figure 19: A full-arch occlusal view of the finished restorations. 

Figure 20: A full-arch facial view of the completed reconstruction 

in CO. 


completion of the cure. This “two-by-two” procedure is followed 

until all the anterior restorations on the maxillary arch 

are placed. 

Figure 21: A buccal view of the reconstruction in CO 

shows the Class I molar and Class II canine relationship, 

established by the ceramist. 

Figure 22: Retracted facial view of the completed fullarch 

maxillary reconstruction in CO, against the mandibular 

provisional restorations. 

The posterior zirconium restorations (Venus stacked on zirconium) 

were evaluated individually for marginal fit, and then 

seated to evaluate the collective fit. They were then cemented, 

one by one, using self-etching resin cement (Maxcem , 

Kerr). Figure 22 shows a retracted full-facial view of the cemented 

maxillary arch in CO, opposing the provisional mandibular 

restorations. The same protocol was used to cement 

the mandibular restorations, as previously described. 12 Figures 

23 through 27 show the definitive restorations following 

delivery. Note the gingival health and natural appearance of 

the Venus restorations, even though the patient requested a 

“bright smile.” 

The gingival zenith positions above the maxillary anterior 

teeth are correct, the central incisor being slightly apical to 

the lateral incisor, and the canine at the same level or slightly 

apical to the central incisor. Note that the zenith position on 

the mandibular right central incisor is incisal to the left central 

incisor. The patient opted not to have this gingival zenith 

level surgically corrected since it did not show in his smile 

(see Figure 27). 

Figure 23: The mandibular reconstruction delivered 

and seated. Note the degree of occlusal accuracy when 

compared to Fig. 22. 

Summary 

This article has presented a detailed case report of full-arch 

corrective and restorative procedures using Venus porcelain. 

As noted at the full-smile final postoperative view, there is 

a natural texture, translucency, and cervico-incisal blend of 

color. The gingival papillae fill in the embrasure spaces well. 

The patient was pleased with the restoration and will enjoy it 

for many years to come. 

Acknowledgment 

The author would like to acknowledge the ceramic artistry of 

Vincent DeVaud, CFC, MDT, in the fabrication of this beautiful 

Venus reconstruction. 

To Contact Dr. Bob Lowe, call 704-364-4711 or e-mail boblowedds@aol.com. 

Figure 24: Full-arch occlusal view of the completed 

maxillary reconstruction. 


References 

1. Rufenacht CR. Structural esthetic rules. In Fundamentals of Esthetics (chapter 4). 

Hanover Park, IL: Quintessence Pub.; 1990. 

2. D’Amico A. The canine teeth: Normal functional relation of the natural teeth of 

man. J So Calif Dent Assoc 26(1-6):6-208, 1958. 

3.Lowe RA. Methodical tooth preparation for predictable esthetic excellence. Esthetic 

technique. Contemp Esthet & Rest Pract 2(4 suppl.):3-10, 2002. 

4. Kois JC. Altering gingival levels: The restorative connection. Part 1: Biologic variables. 

J Esthet Dent 6(1):3-9, 1994. 

5. Lowe RA. Mastering the art of impression making. J Inside Dent pp. 38-39, 2006. 

6. Lowe RA. Predictable techniques for successful multiple unit dental restruction. 

Cont Esthet & Rest Pract (June):2-13, 2004. 

7. Shavel HM. The art and science of complete-mouth occlusal reconstruction: A 

case report. Int J Period & Rest Dent 11(6):439-459, 1991. 

8. Lowe RA. Provisionalization: Mastering the morphology. Dent Prod Report 

(Aug):56-58, 2003. 

9. Lowe RA. Predictable fixed prosthodontics: Technique is the key to success. Compend 

(special issue) 23(2):4-12, 2002. 

10. Shavell HM. Mastering the art of tissue management during provisionalization and 

biologic final impressions. Int J Perio & Rest Dent 8(3):25-43, 1988. 

11. Boucher LJ. Occlusal articulation. Dent Clin No Amer 23:157-241, 1979. 

12. Lowe RA. Dr. Robert A. Lowe discusses dental cements. The Dalin Exchange. Dent 

Econ (Oct):2-4, 2006. 

Figure 25: Full-arch occlusal view of the completed mandibular 

reconstruction. 

Reprinted with permission of The Journal of Cosmetic Dentistry. Copyright ©2009 

American Academy of Cosmetic Dentistry. All rights reserved. 

Figure 26: Full-arch retracted facial view of the completed 

reconstruction. 

Figure 27: A full-smile view of the Venus reconstruction. Note 

the natural beauty, incisal translucency, and the vitality of this 

ceramic rehabilitation. 


Creative Uses for Topical Anesthetic 

– ARTICLE by Michael DiTolla, DDS, FAGD 

Itry to be as pain-free as possible 

in all aspects of dentistry. Once 

the patient and I know that we 

have profound pulpal anesthesia, we 

can relax. This helps me to do the 

best dentistry I can for that particular 

day. To achieve that type of profound 

anesthesia in a painless fashion is the 

pinnacle of patient-friendly dentistry. 

For years, I have been using a strong 

topical to achieve a painless injection. 

At my lectures, dentists have told me 

about their uses for this topical gel. 

PFG gel, formerly Profound, is a 

custom-compounded topical anesthetic 

available by prescription from 

a compounding pharmacy in California 

(Steven’s Pharmacy; 800-352-3784 

or www.stevensrx.com). I use this gel 

in conjunction with the STA System 

(Milestone Scientific) to give what I 

think is the most painless injection 

available in dentistry today. 

Like most of you, I see many patients 

who need only one crown done in 

a lower quadrant. For these patients, 

I no longer give lower blocks. I selectively 

anesthetize individual lower 

molars. Patients absolutely love this 

technique. I like it too because I do 

not have to give lower blocks and 

then wait for them to work, or deal 

with the 15 to 20 percent of times 

when I do not achieve complete anesthesia. 

On those occasions when I do not 

achieve complete anesthesia, I resort 

to this technique. By doing so, 

I cut out the middleman (the lower 

block) and get right to immediate 

and profound anesthesia for mandibular 

molars. (For more on the Rapid 

Anesthesia Technique, visit www. 

glidewelldental.com and click on the 

Video Gallery tab.) 

A few months ago, I went through 

my e-mails to chronicle the interesting 

ways dentists are using PFG gel. 

Certainly, the most common use is as 

a preanesthetic topical anesthetic. I 

use PF Lite, formerly Profound Lite, 

if placing the topical in the vestibule. 

I use PFG gel if the topical is being 

placed on attached tissue. 

As a preinjection topical, a small 

amount is applied to a cotton-tipped 

applicator, which is placed on moist 

mucosa for 60 seconds and then 

rinsed off. A few patients might feel 

a pinch when the needle is inserted 

through taut tissue. 

❯ A dentist in Michigan wrote to me that 

he uses PFG gel to place mini-implants 

without an injection. As he pointed out, 

there are no nerve endings in bone. He 

said that, with the small diameter of 

the implant, there is much less vibration 

during placement. He places 

PFG gel on the alveolar tissue for 

three to five minutes prior to placement 

of the mini-implant. 

❯ An orthodontist in Washington recontours 

tissue with a diode laser without 

having to give an injection. Of course, 

he won’t give an injection. That’s why 

he became an orthodontist! He places 

PFG gel on the excess tissue with a 

syringe for approximately four minutes, 

then rinses and removes the 

excess tissue. This orthodontist also 

has done three or four labial frenectomies 

with just the gel. 

Several dentists mentioned placing 

PFG gel on the palatal tissue to pack 

cord rather than giving the palatal 

anesthesia. A couple of dentists mentioned 

that, on endodontically treated 

teeth, they do not need local anesthesia. 

These dentists use the gel around 

the entire prep to pack cord without 

an injection. 

A dentist in Minnesota places the gel 

around a tooth that needs a rubber 

dam clamp to extend subgingivally. 

This dentist also uses it for all primary 

tooth extractions to avoid injections. 

This is something I did with my three 

children when they did not want me 

to touch their loose teeth. 

A dentist in California uses the gel in 

the syringe to anesthetize dry sockets 

prior to removing and repacking a 

dressing. This same dentist also places 

the gel on sutures to be removed, 

in order to make the appointment 

more comfortable for the patient. 

Several hygienists wrote to say that 

they use the gel as part of scaling and 

root planing procedures, in states 

where hygienists are not allowed to 

give anesthesia. They also mentioned 

using it for deeper pockets on patients 

who are otherwise having just 

a prophy. 

For patients who are sensitive during 

prophies, we have them rinse with 

DYC rinse, formerly Cyclone, for 60 

seconds. This anesthetizes all of the 

patient’s tissues. DYC is available 

from the same compounding pharmacy 

as the gel. 

Creative Uses for Topical Anesthetic49

■ The Effect of Low Level 

ed Laser Light 

on the Healing of Oral Ulcers ■ 

Note: Photos have not been edited, enhanced or retouched other than placing arrow figures. 

– ARTICLE & PHOTOS by Ellis Neiburger, DDS 


❚❙❘ Abstract 

Low-level laser light at 30-second exposures 

(fluence=0.34J/cm 2 ), from a 

red laser light pen (1.4mw, 680nm), 

increased the healing rates of a variety 

of intraoral ulcers in 69 general 

practice patients. Patients demonstrated 

that a single exposure to this 

light reduced 88 percent of mostly 

painful aphthous lesions to comfortable 

epithelized levels within two 

days. This compares more favorably 

than untreated lesions, which took 

five to 10 days for similar resolution. 

This study concludes that treatment 

of lesions using low-level laser exposures 

(the laser pen) is an effective 

and inexpensive method of oral 

ulcer treatment. 

Figure 2: Epithelialized 

and comfortable 

lesion (Fig.1) 

two days after 

30-second red laser 

pen treatment. 

Figure 1: Inflamed, 

painful aphthous 

lesion on lip. Notice 

the red border and 

yellow, serous center 

of the lesion. 

❚❙❘ Introduction 

Laser treatment of oral ulcers has 

been a recognized method of treatment 

for more than 20 years. 1-8 Different 

types of lasers, power intensities 

and light wavelengths have been 

used with a variety of success. 3,4,8 <strong>One</strong> 

of the most common lasers in use today 

is the red penlight laser. It operates 

at or below 5 milliwatts (mw) 

of power and produces light in the 

630-690 nanometer (nm) wavelength 

range. 2,5 These small, low-level lasers 

(LLLs) are readily available in numerous 

retail stores (e.g., dollar, department, 

hardware, office supply) for as 

little as one dollar. They are used as 

“ 

pointers, toys and play devices for 

pet owners. 4 

Lasers produce a coherent wavelength 

of red light, which encourages 

catalytic changes increasing the 

metabolism of reproducing epithelial 

and fibroblastic cells: the cells 

involved in mucosal and epidermal 

wound healing. 1-5 By exposing most 

lesions to the optimum levels of laser 

radiation, healing is enhanced several 

times greater than what is seen in 

The use of a single 30-second exposure 

of red laser light from a common

first record basis in a busy suburban 

private practice. Each lesion was recorded 

as to size, nature, sensitivity 

and duration. Most lesions were 1-3 

mm in diameter and clinically diagnosed 

(e.g., aphthous stomatitis, herpetiform, 

trauma). 

Any lesion presenting a rounded ulcer 

was included in the sampling. 

The CONTROL group’s lesions (100) 

were left untreated; however, the patient 

was told, by this author, that the 

“sore” would heal “within a week or 

so.” The LASER group’s lesions (69) 

received a single, 30-second exposure 

from a laser (OD China brand, 

generic penlight laser purchased at a 

local dollar store for $1) producing 

680nm wavelength light at approximately 

1.4 mw of power as measured 

by a Meterologic Instruments, Inc. 

(Blackwood, NJ) photometer, Model 

45-230. The laser spot size was 3 mm 

in diameter. Large lesions, greater 

than 3 mm in diameter, received a 

second exposure next to the first 

so that all areas of the lesion were 

equally radiated. This resulted in a 

fluence (exposure) of 0.34J/cm 2 for 

each patient. 

Figure 3: Aphthous 

ulcer on upper lip. 

Patient complained 

of pain and oblong 

tissue destruction 

area (arrow). 

The patients were told that the laser 

light would “quickly heal the sore.” 

All patients were called the following 

day(s) for symptoms and to schedule 

an exam appointment. Half the 

sample did not present themselves 

for the post-treatment exams personally 

but reported over the phone that 

the “sore was/was not healed” (e.g., 

painful). Those who returned to the 

dental office were evaluated as to the 

extent of epithelization, resolution of 

tissue redness, tenderness and eating 

comfort. The appearance of full surface 

epithelization, a lack of tissue 

redness, and no sensitivity were the 

conditions necessary to classify the 

lesion as “healed.” For those who did 

not come for subsequent visits, their 

observations as to the “disappearance” 

of the “sore” and absence of 

tenderness were considered “healed.” 

Either the lesion was considered 

healed or it was not. There were no 

gradients involved in this classification 

or distinction as to whether the 

lesion was diagnosed as aphthous, 

herpetiform, etc. 

Since the purpose of this study was 

to determine if the laser exposure 

Figure 4: Healing 

ulcer (Fig. 3) 

reported as asymptomatic 

by the 

patient (arrow). This 

photo was taken 

one day after laser 

treatment. 

was beneficial to the patient, the patient’s 

evaluation, substantiated by 

a percentage of confirming clinical 

exams (50 percent), was considered 

sufficient evidence as to the degree 

of wound healing. The reported 

comfort levels of the lesions examined 

on days after treatment closely 

correlated, in the degree of healing, 

to those patients who reported their 

symptoms and lay observations over 

the phone. 

❚❙❘ Results 

The data from the two groups (CON- 

TROL, LASER) were compared and 

statistically analyzed (p

peared to be completely coated with 

epithelium (a variety of thicknesses) 

and did not hurt during normal function, 

then I considered the wound 

“healed,” though deeper epithelium 

and fibrous tissue had not made its 

full histological restoration. As mentioned 

above, only half the patients 

in the two groups participated in 

post-treatment exams. The other half 

of the patients were interviewed by 

phone (e.g., “Did the lesion appear 

covered? Was it comfortable?”). 

<strong>One</strong> day after laser exposure, 49.3 

percent of the LASER group’s lesions 

had resolved sufficiently to be classified 

as “healed.” After two days, 37.7 

percent were “healed.” After three 

days, another 2.9 percent of lesions 

healed, followed by 4.3 percent on 

the fourth day. The remaining 5+ 

percent of lesions healed within the 

next three days. The larger lesions, 

and those which were reinjured (epithelium 

scraped off), were associated 

with longer healing times. 

All patients reported pain as the 

main symptom of their lesions. An 

open ulcer, especially in the mouth, 

was quite painful in 100 percent of 

the patient sample. No mention as to 

the expectation of comfort (reduced 

pain) was made to the patients in 

an effort to reduce the placebo effect. 

When I asked, just after treatment, 

“How do you feel?” (I did not 

mention “pain” or “comfort”), twenty 

percent of the patients volunteered 

that their pain was “gone.” On the 

following day (24 hours later), 73.3 

percent of the patients reported absence 

of pain. On the third day post 

treatment, 6.7 percent of the patients 

reported to be pain-free. Over 90 percent 

of the patients reported to be 

comfortable (pain-free) one day after 

laser exposure. This contrasted significantly 

with findings in the CON- 

TROL group, 90 percent of whom 

complained of some pain for at least 

five days. The LASER group had individuals 

who reinjured their lesions 

during biting and eating. These patients 

understandably had a longer 

recovery period. 

“ 

The important issue in this study is whether 

the oral lesions, no matter what their cause, 

could be helped, from the patients’ viewpoint 

(i.e., elimination of pain and infirmity), by 

laser exposure. This study substantially 

demonstrates a positive effect of low-level 

laser treatment. Though perception of pain 

and ‘comfort’ can be influenced by the placebo 

or waking hypnosis effect (up to 33 percent), 

the results of this study exceed this level 

of positive response and demonstrates that 

laser treatment for intraoral lesions is real 

and not simply psychological. ” 

❚❙❘ Analysis 

This study analyzed 100 CONTROL 

and 86 LASER patients who had intraoral 

lesions from a variety of different 

causes. The most common 

were single aphthous stomatitis cases 

with a smattering of herpetic and 

trauma induced ulcers. The use of 

a single 30-second exposure of red 

laser light from a common

Figure 5: Traumatic 

lesion of upper 

lip (arrow). Note 

the bite defect 

indenting the tissue. 

Patient complained 

of pain. 

❚❙❘ Acknowledgements 

Special thanks to Andent, Inc., for permission to 

reprint the photos contained in this article. 

To contact Dr. Ellis Neiburger, call 847-244-0292 or 

visit www.drneiburger.com. 

❚❙❘ References 

1. Pinheiro, A., Cavalcanti, E. et al. Low-level laser 

therapy in the management of disorders of the 

maxillofacial region. J. Clin Laser Med Surg. 

1997;15(4):181-183. 

2. Neiburger, E. Rapid healing of gingival incisions 

by the Helium Neon diode laser. J. Mass Dent 

Soc.1999 Spring;48(1):8-13,40. 

Figure 6: Lip lesion 

(Fig. 5) showing 

epithelization, 

filled-in defect and 

demonstrating no 

pain two days after 

a single 30-second 

laser treatment. 

because Food and Drug Administration 

(FDA) clearance has remained 

in the off-label arena and few, if any, 

commercial firms are willing to do 

the expensive testing needed to get 

FDA approval (est. cost: $250,000+). 

If a prospective firm wanted to market 

its laser product it would reflect 

the costs of testing, insurance and 

regulation, and could not compete 

economically with equivalent lasers 

purchased at dollar store prices. Why 

would the clinician pay several hundred 

dollars for a commercially FDA 

approved low-level laser when one 

of identical qualities would be available 

in retail outlets for $1? Thus, we 

have no commercial low-level lasers 

available except in cases where high 

wattage, expensive dental lasers are 

used at powered-down fluences. 1,4,6 

Unlike more powerful laser systems 

(>5mw), normal LLL exposure is 

safe and does not require any safety 

equipment for staff or patient. Brief 

exposures to the retina and other organs 

have no record of producing serious 

injury, though long periods of 

exposure to the eyes (5+ seconds) can 

be irritating. 3,5 Excessive exposure of 

lesions to LLL will not increase healing, 

but may retard the rapid healing 

effects of optimal exposure (e.g., 30 

seconds). 1-6 

Low-level laser treatment is easy to 

do, safe, low cost per treatment (laser 

& batteries), painless and effective. 

Patients who have continuous 

oral sore problems may be advised 

to treat their own lesions using their 

own lasers under proper supervision 

(e.g., periodic exams). This treatment 

can reduce much pain and cost over 

a patient’s lifetime. All practitioners 

should use low-level lasers. 

❚❙❘ Summary 

This study demonstrated that lowlevel 

laser therapy using a red laser 

pointer significantly reduced pain 

and increased the rate of healing in 

a variety of commonly experienced 

intraoral lesions. The ease of use and 

insignificant expense of this effective 

therapeutic device suggests that all 

practitioners become “laser dentists” 

and provide this mode of treatment 

to their patients. 

3. Casigila, J. Recurrent aphthous stomatitis: etiology, 

diagnosis and treatment. Gen Dentistry 2002 

Mar:157-165. 

4. Amorim, J.,de Sousa, G. et al. Clinical study of 

the gingival healing after gingivectomy and lowlevel 

laser therapy. Photomed Laser Surg. 2006 

Oct;24(5):588-594. 

5. Lask, G., Lowe, N. Lasers in Cutaneous and 

Cosmetic Surgery. 2000. Churchill Livingstone, 

Pa.:17-18. 

6. Ozcelik, O., Haytac, C. et al. Improved wound 

healing by low-level laser irradiation after gingivectomy 

operations. J. Clin Periodontology 2008 

Mar;35(3):250-254. 

7. Sciubba, J. Herpies simplex and aphthus 

ulcerations:presentation, diagnosis and management-an 

update. Gen Dent 2003 Nov:510-516. 

8. Scully, C., Porter, S. Recurrent aphthous stomatitis: 

current concepts of etiology, pathogenesis 

and management. J.Oral Path Med 1989 

Jan;18(1):21-27. 

Copyright ©2009 Ellis Neiburger. All rights reserved. 


■ The Economics 

of a Dental Website 

– INTERVIEW of Glenn Lombardi 

by Michael DiTolla, DDS, FAGD 

“ In a down economy when most dentists are cutting back on their 

marketing budget, for less than a thousand dollars—a $100 or $200 

a month budget—you can advertise specifically to people looking 

for dental services in your neighborhood. ” 


“ It’s not running an ad that goes to 40,000 people in your area 

looking for the 40 patients in need of a snoring device. It’s marketing 

specifically to the patient looking for a specific service at the 

exact moment they search. Plus, you can track every dollar spent 

to see what your return on investment is by keyword. ” 

The Economics of a Dental Website57

Michael DiTolla: Glenn, we know that dentistry and the economy, as a whole, are currently seeing some challenging 

times. Dentistry, in general, is slowing down because dentists are prepping fewer crowns and bridges, and elective procedures 

have slowed down, too. So, I can understand a dentist thinking that this would be a good time to lower overhead. 

<strong>One</strong> of the first things that a dentist might cut is marketing, but I’m not sure that’s a great idea—unless you are considering 

a phone book ad, which might cost $8,000 to $10,000. Talk to me a little bit about the economics of a Website and 

why, in trying economic times, a Website is a worthwhile investment. 

Glenn Lombardi: Well, like you said, when the economy slows down, and your practice starts to slow down, doctors 

look at their appointment books and begin to see openings. But that’s actually the time when they should beef up their 

marketing. Most dentists—when they are fully booked and everything’s going great and referrals are just walking in the 

door—don’t have the time to think about marketing. So, when things do slow down, it is actually the ideal time to pick 

up your marketing to potential patients in your area. If you look at all the options available to a dentist, from direct 

mail to advertising to the phone book, the dentist sits there and says, “Okay, I have limited funds and I am in a down 

economy. What is going to have the highest probability of producing new patients? What is the best value available for 

my limited budget?” And that’s where a Website can become very productive in two ways. 

Number one, Officite offers a Website package that gets dental practices online with an attractive, highly visible Website 

for under $1,000. Number two, dentists can advertise their practice or for specific services in their local area through 

Google AdWords and Yahoo! ® sponsored results programs, which are pay-per-click programs. That means you only 

pay for the patients who click on your ad and go directly to your Website. In a down economy when most dentists are 

cutting back on their marketing budget, for less than a thousand dollars—a $100 or $200 a month budget—you can 

advertise specifically to people looking for dental services in your neighborhood. 

MD: And with the Google AdWords, can you advertise for specific dental services? For example, if I provide snoring and 

sleep appliances, can I advertise specifically to those types of patients? 

GL: Yes, that’s a great example. In that scenario, you want to attract a specific type of patient that you know is going to 

require a specific service offering that will generate a specific revenue flow for the practice. So, if a patient is having an 

issue with sleep apnea or snoring, the first thing they are going to do is Google “snoring” or “sleep apnea.” If you type 

“sleep apnea” into Google right now, on the left side and scrolling down you’re going to see results related to Websites 

about sleep apnea information. But, if you look at the “Sponsored Links” at the top and on the right, there are numerous 

links highlighting messages such as “Stop Snoring Immediately! Sleep Apnea Treatment Available.” Here’s one that 

says, “LVI Dentist Offering Sleep Apnea Solution.” 

This localized search marketing technology offers dentists a new opportunity to market specifically to patients who live 

or work in their practice area. Here’s how it works: 

First, the dentist selects a radius around his or her office— 

a five, ten or 25-mile radius near their practice. Any time 

a person within this defined radius types in the words 

“sleep apnea” or “snoring,” your practice ad and link will 

pop-up on the top or right of the search results. Let’s say 

your ad reads: “Dentist Treating Sleep Apnea,” and contains 

copy specifically talking about the keyword that was 

entered by the consumer for the search. When patients 

outside your defined radius type in the same keywords, 

the search engine knows the location of the patient’s computer 

by their IP address, and thus shows your ad only to 

those patients inside your designated radius. 

The power of this new search technology is at the exact 

moment when a prospective patient is looking for treatment 

related to sleep apnea or snoring, your ad and a direct 

link to your practice Website is displayed. When the 

patient clicks on your ad, it takes them to a specific 

landing page on your Website that talks about sleep 

apnea and educates the patient—all within one click 

from their original search results page. The page 


could describe the causes of sleep apnea, what possible solutions might be used, and what appliances are available. 

The key is to have a call to action or special offer that entices the patient to either call or e-mail the office. 

From this landing page, you will be able to track how many people e-mail or call the office by using a “smart” phone 

number—which is a different phone number than your actual office phone number, but points to your office phone 

number so you can track and record each call. At Officite, we use this new technology and landing page process to track 

every click, dollar spent, e-mail, phone call and new patient revenue associated with your ad. And because the dentist 

designates a monthly budget for terms such as “sleep apnea” and “snoring,” it’s easy to track their return on investment 

for every marketing dollar spent. 

An example would be this: let’s say you get 50 clicks per month on your Google AdWords campaign. You can easily 

track which page each of the 50 patients visited, and then count how many take advantage of your offer and either 

e-mail or call the office. From there, you can track how many patients schedule an appointment and the services rendered 

to each patient. What’s really powerful about the program is that it’s the only advertisement opportunity available 

that, at the exact moment a patient looks for a specific service in your practice area—such as sleep apnea or snoring—, 

allows you to market your practice and drive patients directly to your Website. 

MD: That is pretty amazing because if I place a snoring or sleep apnea ad in Orange Coast magazine, one of the big 

magazines out here, and I spend a ton of money to put a full page ad in there, the people who are interested in sleep 

apnea may or may not ever see that ad in that magazine. In fact, the chances are probably pretty low that they do. But 

for a patient who doesn’t know much about sleep apnea, or any topic for that matter, dental or otherwise, they go to the 

Internet—the encyclopedia has become a relic, a museum piece. You go to the Internet to get information on the topics 

that you don’t know about. And it’s pretty amazing that right at that moment, when they enter a single word or phrase 

to learn more about sleep apnea, your name pops up right in front of them. And, as you mentioned, it’s local. I just typed 

in sleep apnea when you told me to, and it pulled up two doctors right here in Newport Beach. 

GL: Exactly. Each dentist is going to get different results based on their location. And that’s based on the new local 

search capability that Google offers. The local dentist can now compete with the national companies for patients in their 

area. For patients who work or live in your area, you can now market specifically to them using exact terms, whether 

it be veneers, Invisalign ® or snoring devices—whatever your practice specialty. 

And it’s not a shotgun strategy either. That’s the beauty of this focused marketing solution. You’re not sending out 

10,000 direct mail pieces and crossing your fingers that 30 people are looking for your services. It’s not running an ad 

that goes to 40,000 people in your area looking for the 40 patients in need of a snoring device. It’s marketing specifically 

to the patient looking for a specific service at the exact moment they search. Plus, you can track every dollar spent to 

see what your return on investment is by keyword. 

MD: To be able to reach patients right at that moment 

when they have enough interest to sit down and search 

the Web is really amazing. That’s got to be a marketing 

person’s dream. You mentioned veneers. For that example, 

I’m sure you can have “no-prep veneers” be your keywords. 

There are companies out there that will sign up for a steep 

monthly fee, which is much more expensive than what 

you’re talking about, to become one of their approved noprep 

veneer doctors where you can get referrals from them. 

But instead you can use Officite and Google AdWords, set 

this up on your own, and have people who Google “no-prep 

veneers” be directed to your Website. 

GL: That’s a great example. Three to five years ago, the 

only available option to dentists for marketing their practices 

on the Internet was to join one of these directory 

sites and be listed in your area with 10 other docs, or 

maybe a hundred dentists. 

The good news is that times have changed, and 

Google has become the number one directory on 


Earth. Now, you don’t have to join numerous directories and be listed with ten other docs in your area. You can now 

be listed with your own ad and link to your Website right in Google—and not in a directory. It’s a great way for you to 

market directly to the local patient searching for a specific service without paying a directory service to be listed with 

everybody else in your area. 

MD: And as opposed to the “old school” Yellow Pages ad, where you listed every single thing that you did—extractions, 

crowns, bridges, veneers, all these things that the average patient may or may not be interested in,—you now have the 

ability to advertise specifically for the procedures that the doctor likes to do. There are usually two or three, maybe four, 

procedures that the doctor really enjoys doing—the things that really make the practice fun and make it fulfilling to be 

a dentist. So, beyond just the production and collection of numbers that come from these procedures, this type of specific 

targeted marketing really stands to make dentists much happier in their own practice. 

GL: Yes, that’s true. The key to this whole marketing process is that the Website enables you to do 24/7 marketing. For 

example: it’s 2 a.m. and a spouse wakes up because his or her partner is snoring. The spouse goes online to find a solution 

for this problem. With a Google AdWords campaign, you now have an opportunity to market to them at 2 a.m in 

the morning. Sure, your practice isn’t open at 2 a.m., but you are offering the patient the ability to learn about possible 

solutions for snoring on your Website and to take action by e-mailing your practice directly. It is truly 24/7 marketing! 

Like you said, Dr. Michael, with an ad or a postcard there’s only so much you can tell them because of limited space. 

But with a Website, you have the opportunity to expand on the topic and offer in-depth information about a specific 

service. You can show pictures of different appliances. If it’s a cosmetic procedure, you can display before and after 

photos. You have a much better chance at educating the patient right then, when they’re interested, which both attracts 

them to the practice and increases your case acceptance. 

MD: I recently had to find a dermatologist for the first time in my life. I asked a couple friends for a recommendation, 

and one person liked their dermatologist but couldn’t remember the name. I did a Google search to find the person and 

I found that some of the dermatologists had Websites and others didn’t. The one that I ended up going to had a Website, 

had pictures of the doctors, included a picture of the staff—and I got the feeling by looking at their Website that I kind 

of got to know who they were. I don’t know how much you can judge a business by pictures, but it made me feel more 

comfortable; and that’s the person that I ended up going to. Have you noticed those same kinds of things with respect 

to dental patients as they are looking to find a new dental office to go to, if they move to a new area, or something like 

that? 

GL: Yes, you have a much higher probability just from a referral standpoint. While everybody recommends a dentist 

to a friend, the patient still may not be comfortable just going off of that referral. So, the Website is there to further 

educate them, make them feel more comfortable, show them more pictures of the practice both outside and inside 

the office, tell them a little bit about yourself on the Website—all of that helps the patient feel more comfortable. Let’s 

face it: You know there’s a reason a good percentage of 

the population doesn’t go to the dentist regularly. It’s the 

“fear factor.” Your Website is only going to help them feel 

more comfortable and increase the odds that they’ll set up 

an appointment. 

MD: Yes, that’s fantastic. I’m amazed that you can get 

this kind of presence on the Internet so quickly. I mean, 

it sounds affordable at $995. How long is the turnaround 

time for someone to establish a presence on the Internet? 

GL: Well, it’s amazing. Our clients typically have their Websites 

up within a day, if not hours. And that’s completely 

customized with all their information, logos, photos, everything 

uploaded and ready to go. Then to set up a Google 

AdWords campaign, a local search campaign like I talked 

about, also takes minutes. We can get a practice up and 

running within 30 to 45 minutes. 

MD: That’s another huge advantage over an “old 

school” example, like the Yellow Pages ad. <strong>One</strong> of the 

things I love about the Internet is that the next day, or 


a couple of days after this information gets submitted to Officite, you’re up on the Internet. You have a site that’s just as 

legitimate and just as visible—maybe more so than somebody who’s had a Website for five years. 

GL: That’s right. And the beauty of Google AdWords and this pay-per-click strategy is that if you’re willing to spend 

more money than competitors in your area, you can be listed number one or two fairly quickly. The other nice thing 

is, unlike the Yellow Pages where you pay $8,000 and your ad starts in March and goes to the following February, with 

this pay-per-click strategy you can pause your campaign budget at anytime. 

So, if you see great results spending $200 a month, you can increase it to $400 or $500. We have some doctors spending 

$2,000 a month on pay-per-click advertising because they are getting a high return with new patients. Some 

of our doctors get 80 or 90 new patients running their pay-per-click campaign, so it works. And if for some reason 

it’s not effective in your area, you can turn it off tomorrow. You’re not committed to some multi-thousand dollar 

investment. 

MD: Wow, that’s fantastic. Yes, with the Yellow Pages ad, you are doing it half a year ahead of time and you’re committing 

for the whole year. I mean, I’m 44 years old, so I’m neither young nor old, but I can’t even think of the last time I 

used the Yellow Pages. In fact, the environmental waste of delivering it to everybody’s front porch…I mean, maybe people 

still use it to order pizza, but I ordered Domino’s the other day on my TiVo (laughter). I don’t know if the Yellow Pages 

are even relevant for that anymore. I guess if your target market is patients 70 and older, the Yellow Pages might still be 

a good idea, but for everybody else… 

GL: Anybody else…whenever I speak at events, that’s one of the questions I ask early in the presentation. I always ask, 

“Who remembers where their phonebook is at home?” Not many people raise their hands. We’ve gone from talking 

about how everybody is going to have a computer in their house to now—not only does everybody have two or three 

computers, but also they are online 24/7. That’s convenience; the world has changed since we moved from dial-up to 

broadband. You know, that was the big switch, when everybody switched from using AOL to using their local cable or 

Yahoo! or Gmail or whatever it is, to access the Internet and their e-mail. Everybody is online 24/7 now, so if you need 

something—if you want to know the weather or buy a camera—the first place you’re going is online. And then from 

there, you may still go out to shop for it. But everybody is using the Internet as their number one resource for looking 

things up. 

MD: I just think it’s such a sophisticated way to market a dental practice because you can have a very classy looking 

Website. And let’s face it: not long ago, your only marketing choices were the Yellow Pages and the ValuPak (or whatever 

coupon book), where you’re going to be in there with the dry cleaner and the new Chinese restaurant (laughter). I mean, 

how classy was that? You can be a lot more elegant and sophisticated on a Website, don’t you think? 

GL: Agreed. You can have different photos, whether they 

are stock photos or photos of your patients, the imagery 

and colors, the logos—you can make it look much more 

professional than you can with just a regular ad. And you 

can separate yourself from the noise. That’s a great way to 

differentiate yourself, to brand your practice. If you have 

certain colors or a look and feel to your practice, you can 

incorporate that into your Website. So again, the first time 

a patient goes to your Website and sees a certain branding 

and feel and look, when they walk into your office and 

get that same feeling it only enhances that experience. 

Anything’s possible with the Website. 

MD: For those doctors whose practice is a little slow right 

now, they may think, “Well, it’s going to be too late for me to 

market.” That might be true with the old style of marketing. 

But if you’re slow right now in June and you want 

to be busier for July, it sounds like a Website and 

Google AdWords campaign can be up and running 

in just a few days, which translates into literally getting 

new patients next week. Is that correct? 


GL: That’s correct. It’s one of the few marketing vehicles available to a dentist that can be up and running within a few 

hours and, like you said, generate new patients for their practices by next month. 

MD: Well, I’m a huge believer in the power of the Internet. I’m a huge believer in the power of Officite, as I’ve seen with 

the traffic from my own Website that I have with you guys. So I’m giving a big recommendation to the dentists out there. 

If they’ve tried to market their practice before with a marketing company or with the Yellow Pages or with coupons, or 

they’ve just avoided it completely because they didn’t think it was classy, it’s a different world today with the Internet. I 

encourage every dentist to get in touch with Officite so that they have an opportunity to see that you can be professional 

online. 

Even if a dentist is not going to go out and actively market, I think that if you don’t have a presence on the Internet today 

it looks suspicious. If a prospective patient can’t even find a picture of what your practice looks like and what you 

and your staff look like, I find that to be somewhat skeptical. At least, it’s a sign that you’re probably not technologically 

relevant when it comes to…who knows what? Maybe even the equipment that you have in your office. 

So, if dentists want to get in touch with you guys, Glenn, what’s the best way for them to do it? 

GL: They can either call us at 888-748-2746 or go to our Website, www.officite.com. 

<strong>One</strong> last note for you: I’m just online looking this up, there’s a tool on Google to see how many times a word was 

typed into Google last month. And the word “dentist,” or other forms of it, was searched more than 10 million times 

in the month of April. And the words “sleep apnea” or “snoring” were also entered over a million times last month in 

Google. 

MD: That’s in the US? 

GL: That’s in the US. And anybody can do that. Just go to Google and type in “keyword AdWords tool.” And you should 

get a link that says “Google AdWords: Keyword Tool.” Click on that, and then enter one keyword or phrase per line. 

Type “dentist.” Next you have to enter the security word. Then hit keyword ideas and it’ll give you a list. 

MD: So, these are all different. I like the fact that 40,000 people entered “dental dentist.” I’m not even sure what they are 

going for there. “Best dentist”—12,000 people. 

GL: If you actually click on search volume by April, it recalculates it. Now scroll down the list and you’ll start to see a 

lot of towns in searches, like Chicago dentists and things like that. In fact, what town do you live in? Newport Beach? 

You can actually search your own town. Your terms won’t always appear, but most of the time it does. So, you can see 

which keyword terms are performing well and use those words to refine your campaign results. 

MD: I like the fact that dentists can do this themselves, so 

they can see that we’re not lying (laughter). That’s perfect. 

We’ll do it a couple times this year and beat it in them. 

But anytime they can play around on the Internet and see 

what we’re saying is true, I think it’s kind of neat that we 

can show them on a sidebar what to do. Thanks, Glenn! 

To contact Officite, call 888-748-2746 or visit www.officite.com. Contact Glenn 

Lombardi at 800-908-2483 or GLombardi@officite.com 

Google and AdWords are trademarks of Google, Inc. 

Yahoo! is a registered trademark of Yahoo! Inc. 

Officite is a registered trademark of Officite, LLC. 

Invisalign is a registered trademark of Align Technology, Inc. 


“Only a sophomore and already 

the family wants free dentistry.” 

Craig Hays, DDS 

Mesquite, TX 

1st place winner of a $500 lab credit 

“No, I’m not a 

dentist, but I stayed 

in a Holiday Inn 

Express last night!” 

Edward J. Gottlieb, DDS 

Williston Park, NY 

2nd place winner of a $100 lab credit 

“Hey, do you remember 

the time when you shot 

me with a BB gun?” 

Ted H. Spence, DDS 

Exmore, VA 

3rd place winner of a $100 lab credit 

The Chairside ® 

Caption Contest Winners! 

Congratulations to winners of the Vol. 4, Issue 2 Chairside Caption Contest. The winning captions were chosen from thousands of entries 

both e-mailed and submitted online (www.chairsidemagazine.com) to Chairside Magazine when asked to add a caption to the picture 

shown above. Winning entries were judged on humor and ingenuity. 


Chairside ® Photo Contest 

a 

b 

c 

d 

w 

e 

f 

In lieu of our quarterly Chairside Caption Contest is the Chairside Photo Contest! Here’s how to participate: look at all six images (a-f) 

and tell us what you think the image is. Then send your answers, including your name and city of practice, to: chairside@glidewelldental.com. 

You may also submit your answers online at www.chairsidemagazine.com. By submitting your answers, you authorize 

Chairside Magazine to print your name in a future issue or on our Web site. 

The winner of the Chairside Photo Contest will receive $500 in Glidewell credit towards their account. Entries must be received by 

September 14, 2009. The winner will be announced in the Fall issue of Chairside Magazine.

One-on-One An Interview with Dr. Paul Homoly Simply Beautiful A ...

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